# Presentation: 477273

## Tobacco Tactics

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

## 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

## 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

## 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.

## Actual Causes of Death in the United States 

## 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.

## 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.

## 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 patient’s condition
- Nurses can work with physicians to order medications

## 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.

## 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.

## 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

## Contents of Nurse Training PowerPoint

- The Five A’s
- Pharmaceutical management
- Behavioral management
- CPRS documentation
- Case studies

## The Five A’s

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

## 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 > 3 months).
- Recommend bupropion if:
- Failed nicotine replacement monotherapy in the past (smoke-free <3 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.

## 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.

## Documentation – CPRS

- _Inpatient_
- Nursing Admission Assessment
- Interdisciplinary
- 	Treatment Plan (ITP)
- √ 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

## Documentation Template

## 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.

## Toolkit for Patients

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

## Brochure

## Videotape

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

## Tobacco Tactics Manual

## 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

## 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.

## 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.

## 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.

## Formative Evaluation

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

## 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.

## Performance Measures

|  | Under Performing |  | Meets Target |
| --- | --- | --- | --- |

|   | Year
2007 |                Year 2008 |  |  |  |
| --- | --- | --- | --- | --- | --- |
|   | Q4 | Q1 | Q2 | Q3 | Q4 |
| Counseling-Heart Failure | 43% | 100% | 100% | 88% | 83% |
| Counseling-AMI | 88% | 100% | 100% | 100% | 67%   |
| Counseling-Outpatient | 30% | 85% | 74% | 79% | 72%  |
| Referral to Cessation Program-Outpatient | - | 95% | 84% | 93% | 91% |

## 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.

## 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.

## 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)

## Provision of Services

|  | Pre Intervention | During Intervention | Post Intervention |
| --- | --- | --- | --- |
|  | % | % | % |
| Received individual counseling to quit |  |  |  |
| Experimental | 16.9 (n=29) | 13.0 (n=7) | 20.9 (n=18) |
| Control | 17.2 (n=5) | 24.1 (n=7) | 29.6 (n=8) |
| Received nicotine patch  |  |  |  |
| Experimental | 37.8 (n=65) | 33.3 (n=19) | 41.7 (n=35) |
| Control | 37.9 (n=11) | 33.3 (n=10) | 33.3 (n=9) |
| Received nicotine gum  |  |  |  |
| Experimental | 4.8 (n=8) | 7.3 (n=4) | 13.1 (n=11) |
| Control | 10.3 (n=3) | 6.7 (n=2) | 15.4 (n=4) |

## Provision of Services (cont.)

|  | Pre Intervention | During Intervention | Post Intervention |
| --- | --- | --- | --- |
|  | % | % | % |
| Received other medications to help quit smoking  |  |  |  |
| Experimental | 11.6 (n=20) | 9.3 (n=5) | 24.1 (n=20) |
| Control | 17.2 (n=5) | 17.2 (n=5) | 11.5 (n=3) |
| Received hand-out materials to help quit smoking  |  |  |  |
| Experimental | 47.4 (n=81) | 50.0 (n=27) | 58.6 (n=51) |
| Control | 58.6 (n=17) | 65.5 (n=19) | 55.6 (n=15) |
| Received video about quitting smoking  |  |  |  |
| Experimental | 6.4 (n=11) | 3.7 (n=2) | 14.0 (n=12) |
| Control | 6.9 (n=2) | 10.0 (n=3) | 3.7 (n=1) |

## 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.

## Example Logos & Characters

## 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 (N=95).
- 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.

## Tobacco-Free Campus     (Ann Arbor)

- Champions
- Leadership
- Potential implementation January 1, 2009

## 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.

## 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.

## 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)

## 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.

## Website Screen Shot

## Message from General McCaffrey 

## Website Screen Shot

## Summative Evaluation

- In progress

## 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

## Initial Barriers to Implementation

- Improve CPRS documentation
- Lack of support from physicians
- Difficulty locating Tobacco Tactics resources
- Patient’s 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

## 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 ICU’s)

## 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

## 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

## Conclusion: The nurse-based Tobacco Tactics intervention can be successfully implemented in the VA 

## Opportunities for National Dissemination

## Why your dog really goes outside...

## 
Questions?

Sonia A. Duffy, Ph.D., R.N.
Ann Arbor VA HSR&D (11H)
P.O. Box 130170
Ann Arbor, MI 48113-0170
Ph: (734) 845-3608
bump@umich.edu

**Questions?**
- Sonia A. Duffy, Ph.D., R.N.
- Ann Arbor VA HSR&D (11H)
- P.O. Box 130170
- Ann Arbor, MI 48113-0170
- Ph: (734) 845-3608
- bump@umich.edu