Ohio providers develop action plans for new tobacco intervention, stage-based approach to tobacco services for people with mental illness and substance use disorders

Cleveland, OH—Representatives from nine community-based organizations and a state psychiatric hospital in Ohio attended a one-day training for "Tobacco: Recovery Across the Continuum (TRAC)," a stage-based motivational service model that helps people diagnosed with mental illness and/or substance use disorders reduce and eventually eliminate the use of tobacco products. The event was held in Cleveland on Thursday, October 1st and was attended by program managers, supervisors, direct-service providers, two psychiatrists, and an agency executive director, all of whom are currently implementing the TRAC model with technical assistance from the Center for Evidence-Based Practices (CEBP) at Case Western Reserve University, creator of the TRAC model.

Participants at the TRAC training event came from 11 Ohio communities (see sidebar). Presenters included Carlo DiClemente, Deb Hrouda, Ric Kruszynski, Patrick Boyle, and Christina M. Delos-Reyes, MD, who provided participants with practical information and useful strategies for implementing TRAC services, including the following:

  • Understanding the effects of tobacco products upon mental health and/or substance-related symptoms.
  • Understanding the effects of tobacco products upon pharmacological treatment for people with mental disorders.
  • Assessing tobacco use and diagnosing nicotine dependence among consumers.
  • Identifying intervention strategies and, thus, staff competencies (training and supervision) needed for each stage-of-change in the recovery process.
  • Enacting an organizational plan to implement, supervise, and monitor TRAC services.


Research shows that two-thirds of people diagnosed with a severe mental illness will accept help for quitting tobacco if it were made available to them. The TRAC model helps consumers in all stages of readiness change their tobacco use, not just those in the action stage who are ready to quit.

According to Deb Hrouda, MSSA ('94), LISW-S, project lead of TRAC and director of quality improvement at CEBP, the event was structured to help participants advance a TRAC implementation plan for their organizations over the course of the day.

"Our program-leader trainings are designed to combine traditional concrete knowledge and learning with focused planning of next steps," Hrouda says. "Participants have learned what the practice is and now work together as a group to enact a plan for how to do it. The group exercises help everyone learn from each others' successes and missteps. Everyone walks out with a plan for immediate next steps that they can bring back to their organizations and work with their trainers to implement."


Research shows that while the rate of tobacco use in the general population has declined steadily (to about 20 percent nationally), more than 75 percent of people diagnosed with a severe mental illness or substance use disorder consume tobacco products. The fact that the rate of tobacco use for this group has remained consistently high indicates that previous approaches have not been very effective. On the other hand, two-thirds of tobacco users say they would accept help with quitting if it were made available to them. This presents the perfect opportunity for an intervention designed to meet the needs of this underserved population.

This is why the CEBP at Case Western Reserve developed the TRAC model. It uses several core principles of the Integrated Dual Disorder Treatment (IDDT) model, an evidence-based practice for people with co-occurring severe mental illness and substance use disorders. TRAC also utilizes the Transtheoretical Model of Change (stages of change) and Motivational Interviewing, among other models and service approaches.

Hrouda emphasizes that the TRAC model helps consumers in all stages of readiness for tobacco change, not just those who are ready to quit (i.e., in the action stage of change). It utilizes consumer education and motivational strategies to connect with people in the pre-contemplation and contemplation stages—those who are either unaware of or ambivalent about the benefits of reducing and eliminating tobacco use—as well as those in the preparation, action, and maintenance stages.

Startling Facts

Research studies show that tobacco has numerous negative effects upon the health and well being of people with mental illness. Some examples including the following: 

  • People with severe behavioral health issues die, on average, 25 years earlier than their non-mentally ill peers from illnesses that are potentially tobacco-related.
  • Over 44 percent of cigarettes smoked in the U.S. are consumed by people with psychiatric disorders.
  • More than 70 percent of people with a mental illness and those that have substance use disorders also use tobacco (compared to less than 20 percent of people in the general population).
  • People diagnosed with schizophrenia spend an average of 27 percent of their income on tobacco products.
  • Tobacco interferes with the metabolism of many medications. Therefore, tobacco users often require higher doses of medication to get the intended therapeutic effect. In addition, with higher doses, there is potential for increased side effects.

Other Addictions

Hrouda emphasizes that nicotine dependence is a substance use disorder and encourages service providers to include it in their treatment plans, even if consumers are in the process of trying to reduce and/or eliminate the use of alcohol and other drugs. She cites a positive statistic from research. People with alcohol and other drug problems have up to a 25 percent increased likelihood of sustained abstinence when tobacco use is treated at the same time as other addictions. 


Presenters at the October 1st training event included the following:

  • Carlo C. DiClemente, PhD, professor of clinical psychology, University of Maryland-Baltimore County (UMBC), and co-creator of the Transtheoretical Model of Change, which identifies five stages of change (pre-contemplation, contemplation, preparation, action, and maintenance) that typically occur when individuals embark on a journey to kick the habit of tobacco use. Dr. DiClemente is also director of the Maryland Quitting Use and Initiation of Tobacco (MDQuit) Resource Center, which is dedicated to assisting providers and programs in reducing tobacco use among citizens across the State of Maryland. MDQuit is funded by the Maryland Department of Health and Mental Hygiene.
  • Deb Hrouda, MSSA (‘94), LISW-S, director of quality improvement, Center for Evidence-Based Practices, Case Western Reserve University, and project lead for TRAC.
  • Ric Kruszynksi, MSSA (‘93), LISW-S, LICDC, director of consultation and training, Ohio SAMI CCOE, Center for Evidence-Based Practices at Case Western Reserve University.
  • Patrick E. Boyle, MSSA ('89), LISW-S, LICDC, director of implementation services, Center for Evidence-Based Practices at Case Western Reserve University.
  • Christina M. Delos Reyes, MD ('01), medical consultant, Center for Evidence-Based Practices at Case Western Reserve University and the Center's Ohio SAMI CCOE initiative.