Tobacco Training in Clinical Psychology Graduate Programs

Training and Education in Professional Psychology 2012 American Psychological Association 2012, Vol. 6, No. 2, 93 99 1931-3918/12/$12.00 DOI: 10.1037/a0027801 Tobacco Training in Clinical Psychology Graduate Programs JoAnn Kleinfelder, James H. Price, Joseph A. Dake, and Timothy R. Jordan University of Toledo Joy A. Price University of Toledo and Zepf Center, Toledo, Ohio The leading cause of preventable death for persons with mental health illnesses, as well as those who live in poverty, is cigarette smoking. These marginalized groups are some of the key groups that clinical psychologists are trained to work with to improve the quality of their lives. Therefore, the purpose of this study was to determine the extent of tobacco cessation training offered in the clinical psychology programs that would prepare clinical psychologists for helping patients who want to quit smoking. A valid and reliable 21-item questionnaire was sent to the population of 203 doctoral clinical psychology programs using a three-wave mailing process to assess tobacco cessation training. Clinical psychology directors returned 110 completed questionnaires for a response rate of 55.5%. The majority (80%) of the programs reported having never thought about offering formal smoking cessation training in their curricula. Only 17 programs (15.4%) currently provided formal smoking cessation education. The three leading barriers to offering smoking cessation education were not enough time (58.2%), not a priority (48.2%), and no interest by students (30.9%). These findings indicate that clinical psychology students are not receiving standardized smoking cessation education to assist in improving the well-being of their patients. This study provides evidence in support of smoking cessation education being incorporated into the existing curriculum guidelines for clinical psychology programs. Keywords: tobacco, training, curricula, smoking cessation, psychology JOANN KLEINFELDER, PhD earned her doctorate from the University of Toledo in Health Education and is an Instructor in Health Education and Public Health at the University of Toledo. Her research interests are tobacco cessation and control, health behavior change, issues in mental health and global disease prevention and control. JAMES H. PRICE, PhD, MPH earned his doctorate from Western Michigan University in science and health education. Currently he is Professor Emeritus of Health Education and Public Health at the University of Toledo, Toledo, Ohio. His primary research interests are in tobacco control issues and reducing risks from firearm violence. JOSEPH A. DAKE, PhD earned his doctorate in Health Education from the University of Toledo and currently serves as the Chair for the Department of Health and Recreation Professions at the University of Toledo. His area of research is primarily on adolescent health behaviors and school health education. TIMOTHY R. JORDAN, PhD earned his doctorate in Health Education from the University of Toledo and is Associate Professor of Public Health and Director of Undergraduate Public Health at the University of Toledo. His research areas include tobacco use prevention/cessation, chronic disease prevention and management, health behavior change, and adolescent health behaviors. JOY A. PRICE, MD, PhD earned her medical degree at the Medical College of Ohio, PhD at the University of Oklahoma and completed her residency in psychiatry at the University of Michigan. She is a practicing psychiatrist at the Zepf Community Mental Health Center, Toledo, Ohio. Her research interests are tobacco use in the mentally ill population. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to JoAnn Kleinfelder, Judith Herb College of Education, Health Science and Human Service, University of Toledo, Toledo, OH 43606. E-mail: jo.kleinfelder@utoledo.edu Over time, multiple reports have identified tobacco as the leading preventable cause of disease and death in the United States (Schroeder, 2008). It kills more people than alcohol, illicit drugs, HIV, suicide, homicide, motor vehicle accidents, and obesity combined (Centers for Disease Control & Prevention, 2005). Tobacco use is associated with approximately 440,000 deaths each year, or 18.1% of total United States deaths. Tobacco costs approximately $194 billion in annual health-related economic losses in the form of medical expenses and lost productivity and results in more than 5.6 million years of potential life lost (Centers for Disease Control & Prevention, 2008; Mokdad, Marks, Stroup, & Gerberding, 2004). These figures suggest that as much as 14% of personal care expenditures may be attributed to smoking. Relative to the general population, persons with mental illness have higher smoking rates. According to Leonard et al. (2001), approximately 60% of adults with mental illnesses smoke some form of tobacco compared with 21% for the general population (Centers for Disease Control & Prevention, 2009). Nicotine dependence has been reported to be most prevalent among individuals with a current drug use disorder (52.4%) or alcohol disorder (34.5%) and, to a lesser extent, in mood disorders (29.2%), anxiety disorders (25.3%), and personality disorders (27.3%) (Grant, Hasin, Chou, Stinson & Dawson, 2004). While persons with mental illness have a higher rate of smoking than the general population, certain mental illnesses are associated with higher rates of smoking than other mental illnesses. Specifically, persons with schizophrenia have the highest rate of smoking with estimated ranges from 58% to 90% (Beratis, Katrivanou & Gourzis, 2001; Combs & Advocat, 2000; Diwan, Castine, Pomerleau, Meador-Woodruff & Dalack, 1998; Herrán et al., 2000; McCreadie, 2002; Morris, Giese, Turnbull, Dickinson & Johnson-Nagel, 2006). Because of their high rate of smoking, persons with mental health problems tend to be at greater risk for developing smoking-related illnesses than persons with other health disorders and the general population (Els, 2004). In fact, smoking is the leading cause of 93

94 KLEINFELDER, PRICE, DAKE, JORDAN, AND PRICE preventable death in the mentally ill, responsible for about 200,000 deaths a year (Schroeder & Morris, 2010). On average, the chronically, mentally ill die 25 years earlier than the general population, and the leading cause is smoking (Schroeder & Morris, 2010). While some have questioned the efficacy of smoking cessation for those with mental illnesses, several studies have revealed that smoking cessation rates for mentally ill persons are often as successful as those for smokers without mental illness. The six-month abstinence rate is typically between 16% and 31% for the general population (Okuyemi, Nollen & Ahluwalia, 2006) and varies based on the type of treatments (education, counseling, referrals, and nicotine replacement therapy). Quit rates in the mentally ill at 8 to 24 months after smoking cessation treatment have been found to range from 11% to 25%, rates similar to the general population (Banham & Gilbody, 2010; Hall et al., 2006). Evidence-based smoking cessation interventions will most likely be incorporated into clinical practice if mental health professionals are adequately trained on the techniques to reduce nicotine addiction. Six published studies have reported that psychologists and psychiatrists felt untrained and unprepared to provide smoking cessation intervention to their clients (Leffingwell & Babitzke, 2006; Phillips & Brandon, 2004; Price, Sidani & Price, 2007; Sidani, Price, Dake, Jordan & Price, 2011; Wendt, 2005; Zvolensky, Baker, Yartz, Gregor & Leen- Feldner, 2005). While a small percentage of these respondents reported receiving formal training in smoking cessation, the majority reported that their education was informal. When psychiatrists and psychologists were asked to rate their perceived level of preparedness to counsel patients, 80% said they felt definitely unprepared (Zvolensky et al., 2005). At least one study found that licensed psychologists (38.1%) desired formal training in counseling patients regarding smoking cessation. (Wendt, 2005). Leffingwell and Babitzke (2006) surveyed 143 practicing licensed psychologists and found that 84% reported no tobacco assessment and/or intervention training. Zvolensky et al., (2005) reported similar findings that only 17% of psychiatrists and psychologists reported having received formal training in evidencebased smoking cessation during the past 3 years. Wendt (2005) found even fewer (11%) licensed psychologists received formal training in smoking cessation in the past 3 years. The primary purpose of the current study was to explore the tobacco and smoking cessation training in the curricula of doctoral clinical psychology programs. This study asked clinical program directors to identify perceived barriers to offering tobacco education in the curriculum. More specifically, answers to the following questions were sought. Do clinical psychology doctoral programs require training in smoking cessation? How many hours were devoted to the coverage of basic science topics, sociopolitical topics, and clinical science topics regarding smoking cessation in the clinical psychology doctoral programs? What are the perceived barriers to offering tobacco cessation education in the curriculum? Are there certain types of educational materials that would be helpful in offering smoking cessation education? Method Subjects Subjects were the population of directors of accredited clinical psychology doctoral programs. Clinical psychology programs included accredited PhD programs (n 149) and PsyD programs (n 54) identified by the American Psychological Association (APA). The APA provided the names and addresses of all doctoral program directors in 2009. Programs outside the coterminous United States and those without doctoral programs were not included in the survey. Several programs listed more than one codirector in the APA list of programs, and only one codirector was randomly selected for each of these institutions. Only clinical psychology programs were selected for this study because the graduates of these programs are often employed in jobs that provide direct services to clients with mental health issues. In addition, counseling psychologists had already been studied (Sidani, Price, Dake, Jordan & Price, 2011). Instrument The four-page, pencil-and-paper questionnaire was based on an existing instrument which had been used to assess content and time spent on tobacco education programs for other health professionals (Ferry, Grissino & Runfola, 1999; Price, Jordan, Jeffrey, Stanley, & Price, 2008; Price, Mohamed, & Jeffrey, 2008). The questionnaire consisted, in part, of items pertaining to the 5As (Ask, Advise, Assess, Assist, and Arrange) and 5Rs (Relevance, Risks, Rewards, Roadblocks, and Repetition) of smoking cessation. This brief clinical intervention was developed by the United States Public Health Service as guidelines for the treatment of tobacco use and dependence (Fiore et al., 2009). In addition, the questionnaire included perceived importance of smoking cessation education in the curriculum, the programs current status regarding the smoking cessation curriculum (based on Stages of Change theory: precontemplation, contemplation, preparation, action, and maintenance stages) (Prochaska & DiClemente, 1983), barriers to including more than 3 hours of smoking cessation education in the curriculum, graduate program content of smoking cessation education (i.e., basic science, clinical science and sociopolitical content), and how the graduate program evaluated students competence in applying smoking cessation counseling techniques. In addition, nine demographic and background questions were included to describe the program respondents. To establish content validity the questionnaire was forwarded to a panel of experts (n 6) who are recognized in the field of mental health, nicotine addiction, tobacco cessation education, or survey research who had recently published numerous articles in these areas. In addition, these experts are highly cited in their relevant fields of study. Minor wording changes to some items were made based on recommendations from the experts. The experts did not suggest any additional items nor did they recommend deleting items. Internal consistency reliability was assessed using Cronbach s alpha (Cronbach, 1951) on the final sample to measure the consistency in responses among the survey items for selected subscales (perceived barriers, basic science topics, sociopolitical topics, and clinical science topics). The results for the subscales were all high, ranging from 0.93 to 0.98.

TOBACCO TRAINING IN CLINICAL PSYCHOLOGY PROGRAMS 95 Procedure A three-wave mailing procedure was used. The time frame between the first and second mailings and between the second and third mailings was approximately two weeks each using published techniques to increase response rates (a signed cover letter personally addressed to each subject that explained the purpose of the study and assured of anonymity and confidentiality, the four-page smoking cessation education survey, a self-addressed, stamped return envelope and, a $1 bill incentive). No incentive was included in the second mailing. The third wave mailing consisted of a signed postcard requesting completion and return of the survey received in previous mailings (Price, Dake, Akpanudo & Kleinfelder, 2003). These aforementioned methods have been found to significantly increase response rates (Edwards et al., 2002; Hare, Price, Flynn & King, 1998; King, Peeler & Bernard, 2001). Data Analysis Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) 17.0 for Windows. Descriptive statistics such as means, standard deviations, proportions, and percentages were used to describe the general findings. Spearman rank order correlation coefficients, Mann Whitney U, and Kruskal- Wallis tests were calculated based on the type and distribution of the data. In other words, nonparametric analyses were conducted because the data did not meet one or more of the assumptions for parametric analyses (e.g., normal distribution of responses). Results Demographics and Background Characteristics Of the 203 questionnaires sent to directors of clinical psychology doctoral programs, 110 were completed for a response rate of 55.5% (31.5% wave 1, 16% wave 2 and 8% wave 3). The characteristics of the program directors provide readers the opportunity to assess whether there was bias in responding based on the demographics of the potential responding directors. An overwhelming majority of respondents were non-hispanic white (90.9%), male (68.2%), and held a PhD degree (97.3%) (see Table 1). A plurality were between the ages of 50 and 59 (40.0%) followed by those between 40 and 49 years (31.8%). With regard to smoking-related background information, the majority of respondents reported that they had never smoked (60.0%). About one third (35.5%) reported that they had a family member or close friend die from a smoking related illness. Most (70.9%) reported that they had no formal training in smoking cessation education. Stages of Change Model for Smoking Cessation Training The majority of clinical psychology directors (80%) placed their programs in the precontemplation stage. In other words, they had never seriously thought about providing such training. Only one in seven (15.4%) programs reported providing ongoing smoking cessation education for their students for a year or longer (action or maintenance stages). The rest of the programs (4.6%) were contemplating offering such training to their graduate students. Table 1 Demographics and Characteristics of Clinical Psychology Directors Item n (%) Sex Female 34 (30.9) Male 75 (68.2) Race/ethnicity White 100 (90.9) African American 1 (0.9) Hispanic 2 (1.8) Asian 1 (0.9) Other 2 (1.8) Highest degree Ph.D. 107 (97.3) PsyD 2 (1.8) Age 30 39 12 (10.9) 40 49 35 (31.8) 50 59 44 (40.0) 60 69 18 (16.4) Formally trained in smoking cessation Yes 32 (29.1) No 78 (70.9) Does your accrediting body require tobacco education in your curriculum? Yes 0 (0.0) No 107 (97.3) Not sure 3 (2.7) M SD Average number of years as director of this program or similar program? 6.42 6.45 Note. n ranges from 106 to 110. Barriers to Offering More Than Three Hours of Smoking Cessation Education Respondents were asked to indicate whether their program offered more than 3 clock hours of education on how to reduce smoking among patients. One in 10 psychology directors (10.0%) reported their programs offered more than 3 clock hours. Respondents whose programs did not include more than 3 clock hours of smoking reduction education were asked to check from a list of barriers what prevented them from offering this amount of education. Clinical psychology directors indicated that the most common barriers to offering more than 3 clock hours of smoking cessation education were having no time in the curriculum (58.2%), this education is not a priority in the curriculum (48.2%), no interest shown by students (30.9%), students can obtain this type of training on their own (29.1%), and that their accrediting body did not require tobacco education to be covered (23.5%). A statistically significant positive relationship (r.20, p.05) was found between the number of perceived barriers and the number of students who graduated in the clinical psychology programs in the past three years. Thus, the number of barriers identified increased as the number of graduates increased. Basic Science, Sociopolitical, and Clinical Science Topics All program directors were asked to indicate what topics were taught in their program related to tobacco, including small amounts

96 KLEINFELDER, PRICE, DAKE, JORDAN, AND PRICE of content in classes. Respondents were asked to indicate the amount of time they devoted to specific topics related to basic science, sociopolitical, and clinical science issues as they relate to tobacco use and cessation. Mean hours and standard deviations are detailed for coverage of basic science topics in Table 2. The two basic science topics most likely to be covered were nicotine withdrawal (53.6%) and cancer risks associated with tobacco use (49.0%). How to provide information about proposed tobacco policies to the public was the sociopolitical topic most likely to be covered by clinical psychology programs (13.6%). How to explain the economic consequences of tobacco to the public and policymakers was the second most likely topic to be covered (9.1%). Clinical psychology programs spent an average of 2.7 hours on clinical science topics. The most common clinical science topic covered was behavior change theories and models (73.6%) followed by relapse prevention techniques (56.4%). About one in three clinical psychology programs (31.0%) covered the 5A s. Likewise, about one in four programs (26.4%) addressed the 5R s method of smoking cessation counseling in their training programs. No statistically significant differences were found between the number of hours devoted to basic science topics, sociopolitical topics, or clinical science topics and geographic location of the institutions, the number of students graduated over the past three years, or the number of faculty teaching in the program. Importance of Including Smoking Cessation in the Curriculum Respondents were asked to indicate how important (Not at all Important, Somewhat Important, Important, and Extremely Important) it is to include smoking cessation education in the curriculum. A statistically significant difference ( 2 17.593, df 2, p.05) was found when comparing directors formal training in smoking cessation and importance of including smoking cessation education in the curriculum. Directors who reported no formal training were statistically significantly more likely to indicate that smoking cessation education was not at all important (34.3%) or somewhat important (28.7%) compared with those with formal training (6.5% and 14.8%, respectively). Age of the director, the number of years as director of their current program or similar program, the directors current smoking status, and whether a family member or close friend had died of a smoking related illness were not statistically significantly related to the perceived importance of providing tobacco education in the curriculum. Methods for Improving Smoking Cessation Educational Activities Respondents who indicated an interest in improving their smoking cessation educational activities were asked to check all that applied from a list of nine methods which would be helpful in fulfilling this need. The top methods identified by directors were specific educational print material to give to students (46.4%), website and/or Internet based educational services (45.4%), and a packaged curriculum that could be used by faculty (40.9%). Approximately one in four clinical psychology directors (21.8%) indicated having no interest in smoking cessation educational aids. Discussion The results of this study indicate that four of five doctoral clinical psychology programs (80%) offered no formal training for their students relative to smoking cessation techniques that could help reduce the prevalence of smoking in persons with mental illness. This finding corresponds to recent studies that reported that Table 2 Amount of Time Spent on Basic Science, Clinical Science, and Sociopolitical Tobacco Topics (Hours) M SD Basic science topics Cancer risks associate with tobacco use 0.3 0.39 Health effects of environmental smoke 0.2 0.34 Nicotine withdrawal symptoms 0.4 0.39 Other tobacco related diseases 0.3 0.37 Contents/chemicals in cigarette smoke 0.2 0.32 Risks of using smokeless tobacco 0.2 0.33 Sociopolitical topics How to provide information about proposed policies to the public 0.1 0.25 How to contact public officials to share views about tobacco policy issues 0.1 0.22 How to lobby a public policy-making body on tobacco issues 0.0 0.20 How to organize people for action on a tobacco policy issue 0.1 0.21 How to explain the economic consequences of tobacco to the public and policy makers 0.1 0.21 How to provide written reports, consulting, or research to public officials about tobacco issues 0.1 0.22 Clinical science topics Behavior change theories or models (e.g. Stages of Change, Health Belief Model) 0.9 0.60 Relapse prevention techniques 0.6 0.55 The 5A s method of cessation counseling (Ask, Advise, Assess, Assist and, Arrange) 0.2 0.42 How, when, and where to refer clients who smoke to smoking cessation programs 0.3 0.37 How to help high risk groups that have the greatest difficulty in quitting smoking 0.2 0.40 How to use pharmacological agents specifically for smoking cessation (nicotine replacement therapy, antidepressants, etc.) 0.3 0.37 The 5R s of cessation counseling (Relevance, Risks, Rewards, Roadblocks, and Repetition) 0.2 0.41 Note. n 110.

TOBACCO TRAINING IN CLINICAL PSYCHOLOGY PROGRAMS 97 psychologists and psychiatrists feel unprepared and untrained to provide smoking cessation interventions with their patients, and that no tobacco assessment and/or intervention training was included in their graduate programs (Leffingwell & Babitzke, 2006; Price, Sidani & Price, 2007; Wendt, 2005; Zvolensky et al., 2005). Specifically, only 13% of clinical psychologists have reported receiving training or education on the current United States Public Health Service (USPHS) recommendations for smoking cessation (Phillips & Brandon, 2004). A more recent study of clinical psychologists found that the majority identified professional journals (43%) or professional conferences (33%) as their primary sources of smoking cessation information (Akpanudo et al., 2009). Comments that smoking cessation topics are optional or electives, part of courses (i.e., pharmacology, behavioral medicine, substance abuse, health psychology, or community psychology), are not mandated, and some, but not all students receive this training suggest that there is no uniform training being provided based on specific standards, such as the United States Public Health Service (USPHS) recommendations, across clinical psychology programs. These findings are consistent with prior studies that have reported only a small percentage of practicing licensed psychologists (11% to 17%) received any smoking cessation training in their graduate programs (Wendt, 2005; Zvolensky et al., 2005). Leffingwell and Babitzke (2006) reported that the Table 3 American Psychological Association Curriculum Content Areas as They Relate to Smoking Cessation Training Biological aspects of behavior Understand the pathophysiology of tobacco use and the mechanisms of addiction (K) Understand the pathophysiology, mechanisms, and behavioral manifestations of nicotine withdrawal (K) Understand personal and family health risks associated with tobacco use (K) Be able to explain the beneficial effects of quitting smoking at all ages in terms of overall health, reduced risk of disease, and personal/social issues (K) Understand the pharmacological mechanisms of the full range of pharmacotherapy available for tobacco treatment, including the use of nicotine replacement and antidepressants (K) Understand the range of risks related to smoking during pregnancy (K) Understand the safety of using NRT and buproprion HCI in pregnant women (K) Affective aspects of behavior Understand the influences of the media on tobacco use, behavior, and attitudes toward them (K) Social aspects of behavior Understand barriers to smoking cessation, including weight gain, stress, and smokers in family and close social circles (K) Understand available over-the-counter medications (e.g. NRT) and their relative costs (K) Understand the major risks of environmental tobacco smoke exposure to children in the household (K) Individual differences in behavior Understand the prevalence of tobacco use among youths and adults, particularly among high-risk groups (e.g. mentally ill, low socioeconomic status) (K) Human development Know the medical literature regarding vulnerability to tobacco use and quick onset of addiction properties with early tobacco use (K) Know resistance skills to early onset of smoking with children and adolescents (K) Professional standards and ethics Understand the ethical importance of the role of clinical psychologists in assisting clients to obtain optimal health (e.g. not smoking) (K) Theories and methods of assessment and diagnosis Know how to use the transtheoretical model and its component stages of change, including readiness to quit smoking (S) Theories of methods of effective intervention Be aware of the evidence concerning effectiveness of practice systems (e.g. chart stickers, reminder systems) (K) Understand the basic principles of patient-centered counseling as it relates to smoking cessation (K) Know how to use the 5A s and 5R s for tobacco cessation treatment (S) Know how to asses and tailor the type of pharmacotherapy and the dose appropriate in individuals (S) Know at least 2 sources for patient referral for smoking cessation (K) Be aware of successful anti-tobacco initiatives outside the clinical setting, including legislative, policy, media, and partnership building (K) Understand that a high standard of care for smoking cessation depends on a team approach (K) Theories and methods of consultation Know how to provide information about proposed tobacco-related policies to the public (S) Know how to lobby a public policy-making body regarding tobacco issues (S) Theories and methods of evaluating the efficacy of interventions Be able demonstrate critical appraisal of intervention modalities (S) Know how to use biological assessments to confirm the success of smoking cessation interventions (S) Issues of cultural and individual diversity that are relevant to all of the above Understand the risks and benefits of smoking in common cultural groups and family structures (K) Attitudes essential for lifelong learning, scholarly inquiry, and professional problem-solving Student should value clinical psychologist s role in tobacco smoking prevention, assessment, screening, and treatment (A) Student should respect the importance of keeping current with evidence-based findings in tobacco smoking prevention and control (e.g. epidemiological, behavioral, clinical, and policy science) (A) Students should believe that smoking cessation interventions can be effective in reducing smoking among those with mental health problems (A) Note. K Knowledge; S Skill; A Attitude. Adapted from Tobacco control competencies for U.S. medical students, by A. C. Geller, J. Zapka, K. R. Brooks, C. Dube, C. A. Powers, N. Rigotti, J. O Donnell, and J. Ockene, 2005, American Journal of Public Health, 95, pp. 950 954. Copyright 2005 by the American Public Health Association. Adapted with permission.

98 KLEINFELDER, PRICE, DAKE, JORDAN, AND PRICE majority (84%) of licensed psychologists received no tobacco assessment and/or intervention training. In addition, any smoking cessation training that was reported consisted of informal and voluntary reading, attending workshops, and engaging in other unspecified training (Phillips & Brandon, 2004). Of concern is the finding that a plurality of directors from clinical psychology programs (41.5%) reported that including smoking cessation education in the curriculum was not important. This is not surprising because the majority of directors had not received any formal training in tobacco cessation. However, because clinical psychology program graduates will become professionals who are among the first to have contact with mentally ill patients, their roles in educating and providing tobacco cessation information, course of action, and referral are being compromised by a lack of adequate training. It is important to keep in mind the shifting role and preparation needs of clinical psychologists who work in health care settings as well as the need to integrate tobacco cessation interventions in specialty mental health settings. Therefore, smoking cessation education needs to be an important component of some graduate mental health courses. A majority of clinical psychology directors seemed open to the possibility of offering smoking cessation in the future because a majority (76.4%) indicated that they were interested in methods that could be used to improve smoking cessation training. Directors reported that printed material (46.6%), website education (45.5%), and a packaged curriculum (40.9%) would be helpful for improving their smoking cessation curriculum. This positive finding implies that many programs are at least receptive to finding ways to provide this training. Based on a review of the literature, we recommend that 6 clock hours of didactic course work and 3 clock hours of practicum experience in smoking cessation with patients would be a sufficient amount of time devoted to training doctoral clinical psychology and counseling students (Brown, Pfeifer, Gjerde, Seibert & Haq, 2004; Hymowitz, Schwab & Eckholdt, 2001; Kelley, Heath & Crowell, 2006). According to the American Psychological Association (2011) guidelines on competencies and understanding of course content in doctoral graduate clinical psychology programs, smoking cessation knowledge, attitudes, and skills could be integrated into some or all of the 12 content areas to comply with accreditation guidelines while covering an issue of critical importance to this population (see Table 3). These content areas were consensus areas agreed to based on independent evaluation of the APA guidelines by three doctoral trained professionals in the area of psychology and tobacco cessation. The inclusion of smoking cessation training in the graduate curriculum could be done in a focused manner or infused with possibly no more than 30 minutes of coverage in each course, depending on what works best for the particular program. This amount of time (9 clock hours) over a three year program should not significantly extend the length of the program for graduate students. This amount of time is negligible when spread over several years of doctoral training. Tobacco addiction training is more important for graduate students than many other demands on their time that finds their way into the curriculum. It should be noted that we found as the number of students increased, the directors perceived a greater number of barriers to offering smoking cessation training. It could be hypothesized that these programs may have had barely sufficient numbers of faculty to adequately address all of the educational competencies required by the APA. If so, then possibly the number of elective courses offered may have been reduced to compensate for the need to offer more sections of core required courses or to adequately supervise clinical experiences. Other potential explanations for this finding could be that a greater diversity of training occurs in larger programs and, thus, may have impacted curricular offerings. Also, larger programs may have had a different focus to their curricular offerings than did smaller programs. Finally, the potential limitations of this study need to be considered. First, because this study included only accredited programs, the results may not be generalized to nonaccredited programs. Second, even though the response rate was acceptable, to the extent that those who chose not to respond had different perceptions and practices regarding tobacco cessation education, this would represent a threat to the external validity of the findings. Third, all surveys relied on self-reporting, which is a potential threat to the internal validity of the findings because remembering accurately and a tendency to provide socially desirable responses can affect survey results. In addition, some directors may not have been aware of smoking cessation training provided in clinical electives or through practicum rotations. The aforementioned limitation seems unlikely because a recent study found that only 12% of mental health clinical psychologists had received formal training in their academic programs of study (Akpanudo et al., 2009). Finally, the monothematic nature of the survey could have caused some respondents to think about the topic in a unique manner, creating a threat to the internal validity of the findings. 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