Table 3.

Provider Perceptions of Key Factors Influencing Smoking Cessation Treatment Practices

Qualitative Themes	Illustrative Quote
Facilitators
Resources for providers to give patients (e.g. quit hotline number, community programs, specialist access) N=16 total, 8 internists, 8 psychiatrists	Internist: Well, the thing that makes it the easiest for me is having a behavioral psychologist down the hall. I mean, that’s a tremendous resource. And then in Oregon, having the Tobacco Quit Line readily available, and if that continues to maintain funding, of course, through tobacco taxes, that’s great. And then again, we have a large population of patients that are on Providence Health Plan because we’re a Providence affiliated hospital. And that particular health plan has pretty good smoking cessation telephone support. Psychiatrist: The availability of programs outside of – or in the community – is really important. Knowing about those programs is really important to me. I don’t think that most of these programs-- either they’re not doing a very good job of publicizing their program or we as clinicians don’t know how to find them because there are just very few of them it seems. I’ve been practicing for a while, and I can name you very, very few programs. For example, in [my city] there’s one that’s pretty popular. So, I know about that one, and I have known about that one for several years, and I tend to refer a lot of people there. But I don’t know of too many other programs around in the city.
Dual use of smoking cessation medications for patient illnesses N=12 total, 5 internists, 7 psychiatrists	Internist: For a depressed patient, I have seen that Wellbutrin works very well. And I think it hopefully gives them some energy too. And Wellbutrin is a great medicine. I really like that one, and the patients are benefit with that. So that’s good. Psychiatrist: Well, I tried it-- with my depressed patients, I always think of bupropion because it’s good for your depression and it helps them with their smoking. So that’s something that I offer to my depressed patients quite a bit.
Insurance coverage of smoking cessation medications N=11 total, 6 internists, 5 psychiatrists	Internist: I can provide what is covered. And usually, I work with the psychiatrist to try to do CBT and other things to help them if medications can’t be afforded. Psychiatrist: The state hospital is somewhat limited with resources. So, we do have nicotine patches. There’s bupropion available. I don’t think they provide Chantix on the formulary. Varenicline and the other forms of nicotine gum and candy, I believe you can obtain, but that’s what usually we have on the formulary. It’s usually patches.
Barriers
Smoking is utilized as a coping mechanism, and/or perceived as helpful by patients N=28 total, 12 internists, 16 psychiatrists	Internist: I think the main challenge is if-- there is a physical addiction for people with mental health issues and people without mental health issues. There is sometimes, or oftentimes, a nicotine addiction. Okay, so that’s already there. But the challenge with mentally impaired people is they have made that connection mentally that when they smoke they feel better. They feel calm. And I think it goes against their common sense to say, “Well, let me take away the cigarette,” because what they hear is, “Let me take away the thing that’s your friend. Let me take away the thing that makes you feel better. Let me take away your comfort stick.” Which would be their cigarette. I think that’s the hardest thing. Psychiatrist: The idea of taking away something that someone uses as a “crutch,” the only thing that gives them pleasure, can seem like it’s punitive or cruel even though it’s in the patient’s interest… The addictive process itself is so difficult to break with tobacco especially, the withdrawal phenomenon. The fact that a patient fools themselves to thinking that they need a cigarette to feel better when it’s really to treat their own withdrawal from the previous cigarette. They’re on this continuous loop of self-medicating their own withdrawal from tobacco.
Patient does not have a motivation to quit or is unwilling to try N=19 total, 11 internists, 8 psychiatrists	Internist: I try to assess where they are, because if they’re not engaged, then I think there’s really not a chance that they’re going to be successful. Psychiatrist: Oftentimes, the motivation to quit smoking isn’t particularly high because their overall kind of self-care, in terms of health, isn’t terrific. So yeah. So there’s a number of challenges there.
Inability to use certain smoking cessation medications due to interactions or side effects with other patient medications N=14 total, 7 internists, 7 psychiatrists	Internist: People with mental illness, they’re already on multiple medication for anti-psychotic or anti-depressant or anti-anxiety or any of them. And given the chemical medicines which I’m going to introduce, some always worry about drug-drug interactions. That’s number one. Psychiatrist: So if a person, for example, has bipolar disorder, then they’re more likely to get Chantix because I don’t want to give them-- I don’t want to add an anti-depressant like Bupropion into their treatment regimen.
Differences between patients with and without MI (Internists only)
Rate of smoking is greater among patients with and without MI N=15 internists	Internist: [Patients with a mental illness] have a bigger problem with smoking, absolutely. Especially bipolar and depressives.
Provider approach to treatment is different for patients with and without MI (e.g., different medications or counseling) N=15 internists	Internist: Yes. Depends on what mental illness they have. It’s a little bit different. The conversation’s a bit different with, for instance, with people with major depression, people with obsessive-compulsive. It depends on their underlying mental illness. My conversation’s a little more cautious, and it’s tailored to individual mental health patients.
The level of difficulty to quit is greater for patients with and without MI N=11 internists	Internist: I think this is difficult for the patients with mental illness to quit smoking. Smoking is difficult to quit anyway. This is one of the addictions which is so difficult, and I think with mental illness is a bigger challenge. Sometimes I think they don’t realize. I think one of their problems is it doesn’t go in their head that what they are doing for themselves. I think it’s understanding, especially in the general population and more in the mental illness, that they don’t get it. So we have to work extra hard for those patients.