Tobacco Tactics

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Tobacco Tactics

• Sonia A. Duffy, Ph.D., R.N.
• VA Ann Arbor Healthcare System
• The University of Michigan

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Tobacco Tactics Team

• Sonia Duffy, Ph.D., R.N., Principal Investigator
• Jeffrey Alexander, Ph.D., Consultant
• Frederic Blow, Ph.D., M.A., Consultant
• Deborah Caplan, M.S., N.P., C.D.E.,
  Co-Investigator
• Timothy Carmody, Ph.D., Co-Investigator
• Stephen Chermack, Ph.D., M.A.., Co-Investigator
• Gregory Dalack, M.D., Co-Investigator
• Lee Ewing, M.P.H., Project Manager
• Petra Flanagan, Pharm.D., Tobacco Cessation
  Coordinator
• Amanda Fore, M.S., R.N., Research Nurse
• Karen Fowler, M.P.H., Data Analyst
• Judy Heath, M.S., R.N., Research Nurse
• Christopher Hermann, M.S.N., N.P.-C.,
  Co-Investigator
• Thomas Hicks, D.N.S., R.N., C.S., Co-Investigator
• Carrie Karvonen-Gutierrez, M.P.H., Data Analyst
• Pamela Reeves, M.D., Co-Principal Investigator
• David Ronis, Ph.D., Co-Investigator/Statistician
• Patricia Smith, Ph.D., Consultant
• Richard White, M.S.N., R.N., Nurse Champion

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Tobacco Tactics Nurse Champions

• Denise Crawford
• Bryan Facione
• Sarah Palmateer
• Melissa Powers
• Ruth Riley
• Mary Jane Roth
• Diane Sobecki-Ryniak

• Cecilia Sosnowski
• Sylvia Wallace
• Charles Washington
• Richard White
• Lori Wilson
• Patrick Wozny

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Background

• Tobacco use continues to be the leading cause of
  morbidity and mortality in the United States.
• Over 400,000 Americans die every year from
  diseases caused by tobacco.
• More deaths are caused each year by tobacco use
  than by all deaths from HIV, illegal drug use,
  alcohol use, motor vehicle injuries, suicides,
  and murders combined.

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Actual Causes of Death in the United States
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Evidence

• Our 2004 pilot data showed at least 70 of
  inpatient veteran smokers were motivated to quit,
  yet only 17 stated they received cessation
  services during their hospitalization.
• Efficacious smoking interventions are available.
• Smoking cessation services in the VA are
  historically provided via outpatient groups which
  reach few smokers.
• Inpatient cessation programs have been shown to
  be highly efficacious.

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More Evidence

• Nurse-administered cessation interventions have
  been shown to be more efficacious than
  interventions delivered by non-nurses.
• Lack of knowledge is the number 1 reason nurses
  do not provide smoking interventions.
• A VA study by Anne Joseph showed that it took 5
  attempts for a cessation counselor to contact a
  patient.

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Why Nurses?

• Nurses are the largest group of front-line
  providers
• Nurses have access to patients
• Nurses have rapport with patients
• Nurses are trained in patient education and
  health behavior
• Nurses can incorporate cessation interventions
  into routine care
• Nurses can relate detrimental effects of smoking
  to patients condition
• Nurses can work with physicians to order
  medications

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Objective

• The objective of this Service Directed Project
  (SDP) is to implement and evaluate an inpatient,
  nurse-administered, evidence-based Tobacco
  Tactics program for general inpatients in the
  three largest VISN 11 hospitals.

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Methods

• Patients admitted to the Ann Arbor and Detroit
  VAs receive the Tobacco Tactics intervention,
  while patients admitted to the Indianapolis VA
  receive usual care cessation groups.
• Tobacco Tactics toolkits for nurses and patients
  were developed and training sessions have been
  implemented.

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Toolkit for Nurses

• One contact hour for training
• PowerPoint presentation on behavioral and
  pharmaceutical interventions
• Pharmaceutical and behavioral protocols
• Pocket card Helping Smokers Quit A Guide for
  Clinicians developed by the U.S. Department of
  Health and Human Services Public Health Service
  and Tobacco Free Nurses
• Computerized template for nurse documentation

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Contents of Nurse Training PowerPoint

• The Five As
• Pharmaceutical management
• Behavioral management
• CPRS documentation
• Case studies

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The Five As

• Ask if they smoke
• Advise to quit
• Assess motivation to change
• Assist if willing to quit
• Arrange for follow-up

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Pharmaceutical Management

• Recommend nicotine replacement (patch, gum, or
  lozenge) if
• Never used patch, gum, or lozenge before.
• Used patch, gum, or lozenge successfully in the
  past (smoke-free gt 3 months).
• Recommend bupropion if
• Failed nicotine replacement monotherapy in the
  past (smoke-free lt3 months).
• Patch, gum, or lozenge intolerant (i.e. rash,
  etc.).
• History of depression or currently has depressive
  symptoms.
• Recommend combination nicotine replacement
  (patch, gum, or lozenge) and bupropion if
• Failed nicotine replacement and bupropion
  monotherapy in the past.
• Recommend varenicline if
• Intolerance or treatment failure to nicotine
  replacement and bupropion.

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Behavioral Management

• Assess if patient interested in quitting.
• If patient not interested, leave brochure at
  bedside.
• If patient interested, leave brochure and arrange
  for patient to view videotape.
• After videotape, provide patient with patient
  manual to read if able.
• Using patient manual, assist patient with
  behavioral intervention including
• Self assessment
• Smoker type
• Smoking costs
• Handling cravings
• Relapse prevention
• Medication options
• Along with patient, identify and arrange for
  cessation medications (see pharmaceutical
  protocol).
• Arrange for follow-up calls.

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Documentation CPRS

• Inpatient
• Nursing Admission Assessment
• Interdisciplinary
• Treatment Plan (ITP)
• v Smoking Cessation
• Follow template questions
• Shared Templates
• Education Templates
• Tobacco Education Inpatient
• Select note title
• (i.e.. patient education)

• Outpatient
• Clinical Reminders
• Shared Templates
• Education Templates
• Tobacco Cessation Outpatient
• Select note title
• Template varies depending on who is completing it
• Able to prescribe medication / NOT able to
  prescribe medication

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Documentation Template
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Physician Component

• 5-minute overview of the intervention was given
  to medical students and residents each month.
• Physicians were counseled to advise patients,
  Quitting tobacco use is the most important thing
  you can do to protect your health.
• Work with nurses and prescribe pharmaceuticals
  based on patient assessment, history,
  and protocol.

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Toolkit for Patients

• Brochure
• Videotape
• Tobacco Tactics manual
• Pharmaceuticals
• 1-800-QUIT-NOW help line

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Brochure
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Videotape

• Smoking Getting Ready to Quit (2nd edition) by
  Milner-Fenwick
• VHS/DVD

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Tobacco Tactics Manual
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Pharmaceuticals(Protocol described earlier)

• Nicotine replacement therapy (patch, gum, or
  lozenge)
• Bupropion
• Combination nicotine replacement (patch, gum, or
  lozenge) and Bupropion
• Varenicline
• Restricted template for initial prescribing and
  renewals

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1-800-QUIT-NOW

• The plastic 1-800-QUIT-NOW cards, which connect
  smokers with the State-supported quit line, are
  the most rapidly used piece of the Tobacco
  Tactics toolkit.

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Evaluation of Tobacco Tactics

• Formative evaluation focuses on the process and
  allows for tailoring the intervention to the
  needs of the VA.
• Summative evaluation focuses on outcome and
  determines 6-month cessation rates. Smokers in
  all facilities (experimental and control) are
  surveyed and given mailed cotinine tests.
• Sustainability Once nurse trainers are withdrawn
  from the units, sustainability and summative
  evaluation will be conducted.

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Formative Evaluation

• In Ann Arbor, 333 healthcare professionals have
  attended Tobacco Tactics training, of which 284
  were nurses.
• In Detroit, 185 healthcare professionals have
  been trained (to date), of which 135 are nurses
  and trainings are still in progress.

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Formative Evaluation

• In Ann Arbor, the intervention has disseminated
  rapidly.
• Units not targeted including psychiatric,
  substance abuse, and outpatient clinics also
  became interested.

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Manuals Used by Month (6/21/2007 4/30/2008)

• As trainings increased, the number of materials
  for patients disappeared and units where
  materials were stagnating were given extra
  attention.

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Performance Measures
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Staff Confidence in Training

• 274 nurses and 32 other participating staff were
  given surveys one to two months after
  participation in the training.
• Those who were satisfied or extremely satisfied
  with the training were more confident in their
  abilities to provide smoking cessation
  interventions and to think it was important to
  provide such services on their units.
• Those who strongly agreed they had a good
  understanding of the elements of the smoking
  cessation intervention were also more confident
  in their abilities to provide smoking cessation
  interventions and to think it was important to
  provide such services on their units.
• As nurses began to see the implementation of
  their suggestions to improve the intervention,
  they became increasingly motivated to implement
  the intervention.

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Volunteer Phone Counseling

• Telephone counseling has been shown to enhance
  quit rates, yet nurses did not have time to do
  it.
• Hence, volunteers were trained to provide
  telephone follow-up counseling and peer support
  to patients 2, 14, 21, and 60 days
  post-discharge.
• Documentation is a paper check list with some
  prompts for counseling.
• Volunteers are extremely enthusiastic about
  providing follow-up calls.

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Volunteer Data

• From April September 2008, volunteers made 617
  calls to 111 patients.
• Calls across all time points
• No tobacco used since discharge 63
• Yes, still smoking, not in last 24 hours 35
• Yes, still smoking but interested in quitting 77
• Yes, still smoking, do not want to quit 11 (6
  withdrew)

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Provision of Services
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Provision of Services (cont.)
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Tobacco Tactics Campaign

• Novel and strategic campaign strategies are
  needed to compete with the enticing messages
  produced by tobacco advertisers.
• Since pictures speak louder than words, social
  marketing techniques were used to develop the
  image-based VA Tobacco Tactics program logo and
  campaign character.
• A graphic design firm was hired to develop a logo
  for our Tobacco Tactics program and a character
  for our tobacco cessation manual.
• Three rounds of surveys have been conducted with
  patients and staff at the Ann Arbor and Detroit
  VAs to obtain feedback.
• Consumer feedback was communicated to the graphic
  design firm and iterations of the logo and
  character were developed.

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Example Logos Characters
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Tobacco Tactics Campaign

• After successive iterations, the character was
  narrowed down to a drill sergeant or bulldog.
• 61 preferred the drill sergeant and 34
  preferred the bulldog (N95).
• However, several participants stated that their
  drill sergeant told them to smoke 'em if you got
  'em.
• Thus, we chose the bulldog as our final product.

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Tobacco-Free Campus (Ann Arbor)

• Champions
• Leadership
• Potential implementation January 1, 2009

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Data from Tobacco-Free Survey

• 397 staff responded to the survey.
• Over 75 of staff are favorable or very favorable
  of the Ann Arbor VA becoming tobacco-free.
• Over 61 feel it is important or very important
  to relocate the smoking shelters.
• About 70 feel it is important or very important
  to offer employee assistance to quit using
  tobacco.

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Data from Tobacco-Free Survey

• 15 of staff are current tobacco users.
• Approximately 18 are thinking of quitting in the
  next 30 days, 33 within the next 6 months, and
  49 are not currently thinking of quitting.
• About 45 are interested in tobacco cessation
  services provided by the VA, with the most
  interest in medications and take-home
  workbook/video.

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Qualitative data from Tobacco-Free Survey

• Eliminate smoking near main entrance (27)
• Enforce policy (18)
• Smoking is a personal choice (16)
• Move or improve smoking shelters (10)
• Ban would decrease staff productivity (7)
• Include patients in the ban (6)
• Get rid of vending machines/Obesity (6)
• Change the law (5)

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Tobacco Tactics Website

• SHP (short term project) was granted to develop
  the program into a website.
• Two veterans from out of state have called and
  asked to participate in the study.

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Website Screen Shot
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Message from General McCaffrey
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Website Screen Shot
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Summative Evaluation

• In progress

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Sustainability

• Nurse training has been incorporated into new
  nurse employee orientation
• Tobacco Tactics module added in LMS
• Video shown on hospital education channel two
  times/day
• Patient education materials kept in patient
  education library

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Initial Barriers to Implementation

• Improve CPRS documentation
• Lack of support from physicians
• Difficulty locating Tobacco Tactics resources
• Patients condition may not be appropriate for
  intervention which suggests the need for
  cessation interventions at various points in
  treatment.
• Hiring difficulties in Indianapolis and Detroit
  

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Facilitators to Implementation

• Template placed in Nursing Admission Assessment
• Brief overview of the intervention was given to
  interns and residents each month
• Materials were clearly labeled and made visible
  on each unit monthly email reminders were sent
  to staff
• Units decided best time for intervention (e.g.
  Inpatient Psych and ICUs)

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Facilitators to Implementation

• There was great concern that nurses would not
  have the time to do this.
• This was not true. Once trained, nurses were
  enthusiastic about the intervention.
• Nurse champions were invaluable

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Continued Barriers to Implementation

• Getting training to be mandatory
• Tobacco-free environment
• Acceptance of creative aspects of patient
  education materials
• Passing over the program lack of much FTE to
  administer

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Conclusion The nurse-based Tobacco Tactics
intervention can be successfully implemented in
the VA
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Opportunities for National Dissemination
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Why your dog really goes outside
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• Questions?
• Sonia A. Duffy, Ph.D., R.N.
• Ann Arbor VA HSRD (11H)
• P.O. Box 130170
• Ann Arbor, MI 48113-0170
• Ph [phone]
• bump_at_umich.edu