# Presentation: 713835

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## Put It Out Rockland

- A successful smoking cessation program

- Una Diffley, MPH
- Public Health Education Coordinator
- Rockland County Department of Health
- 845..364.2127
- Diffleyu@co.rockland.ny.us

**Notes:**
PIOR is part of a comprehensive tobacco prevention, education and cessation program in the Health Education Division of the RCDOH.  

We also have a county-wide youth empowerment program, and we have partnered with many community and non-profit organizations in providing education and prevention programs on tobacco and second hand smoke.

## Historical Perspective

- County receives share of M.S.A. money in 2000(Master Settlement Agreement)
- Used MSA funds to develop a Comprehensive Tobacco, Prevention, Education and Cessation Program (based on “Program and Funding Guidelines for Comprehensive Tobacco Control Programs developed by CDC and Prevention’s Office on Smoking and Health.)
- MSA money securitized in 2003
- County government pledges to maintain funding for tobacco programs

**Notes:**
Funded originally with approximately $1.2 of MSA $ in 2000 that the county received. 

In 2003 the MSA funds were securitized by the county legislature, which prevented us from continuing to use these funds for programming purposes.  

We were fortunate to have a county executive, legislators and our commissioner who felt passionately about our programs and pledged continued funding. 

We presented a good argument for using the funds to reduce tobacco use now in order to reduce the future costs of tobacco-related diseases in the future. 

We have provided quarterly and annual reports to the legislature demonstrating our continued commitment and success in preventing youth from smoking, eliminating second hand smoke and helping people to quit smoking.

## Put It Out Rockland

- Goal:
- To achieve an adult smoking rate of 12% by 2010
- Objective:
- To provide direct cessation services and resources for residents of Rockland County, with special emphasis on households of undeserved populations.
- To provide nicotine replacement therapy to participants in smoking cessation programs, when appropriate** **

## Program Development

- 2 tobacco cessation specialists were hired
- Attended 5 day training at U Mass Medical School (Center for Tobacco Prevention and Control)
- Reviewed best practices
- The Put it Out Rockland Program was created and sponsored by the Rockland County Department of Health, which offered an 8 week behavior  modification program and included free nicotine replacement therapy.

**Notes:**

So with our funds, 2 tobacco cessation specialists were hired

Attended training at U Mass Medical School (Center for Tobacco Prevention and Control)

Reviewed best practices and successful program models.  Decided to develop a 8 week behavior modification program using NRT.

This program is free to all adults 18 years or older who work or reside in Rockland County

## Program Overview

**FACILITATOR GUIDE**
- Session Outline and Full Script
- Explanation of Record Keeping and Evaluation Procedures
- New Facilitators Trained By Observing Program Staff
**PARTICPANT GUIDE**
- Session Specific
- Group Activities and Educational Materials

**Notes:**
We wanted to insure quality control and that we had a program that could be duplicated.  

Many months were spent writing scripts for each session and program outlines for the facilitators.

 A Program Facilitators manual was developed with detailed explanations of how to keep records and evaluation procedures.  

In 2003-2004 we trained 3 additional facilitators, one of whom spoke spanish, in addition to english, and we modified the language in our program to make it LGBT friendly. 

The training for the new facilitators required that they observe one of our 2 DOH facilitators conduct all 10 sessions and they in turn would be monitored by these facilitators when they conduct their first program.

The participants receive handouts and educational materials specific to the content being covered during each session. 

## Integration for Success

- Nicotine Patch duration – 8 weeks is effective
- Treatment efficacy using one clinician type increases success by 18.3% (PHS Guidelines, 2000)
- Combination of Behavior Modification Therapy and pharmacotherapy (NRT) is more effective than either one alone (Treatment Strategies U. Mass Medical School TTST Manual)

**Notes:**
We wanted to develop a model program, that would insure the highest success rates possible using best practice guidelines.

The recommendation at that time was that an 8 week course of NRT was effective

A strong message about quitting smoking from a professional (i.e. M.D./Counselor/Nurse) was also important

And the combination of B Mod and NRT yields a higher quit rate than either one alone.

## AN “ENHANCEMENT” OF BEST PRACTICE

- Some smokers need longer course of treatment
- Duration tailored to meet individuals needs. (US Health & Human Services 10/2000)
- Combination of pharmacotherapies – Evidence suggests that combining the patch with either nicotine gum or lozenge increases long-term abstinence rates over those produced by a single form of NRT (US Dept Health Human Service PHS Guidelines, 2000)

**Notes:**
What we learned along the way from observation, our own program evaluation, and the literature was that some smokers, especially hard core smokers, needed a longer course of NRT treatment.

It became evident to us that we needed to tailor the dosing of NRT to meet the needs of our clients.

We also found that using a combination of NRT, i.e. the patch with gum or lozenges was beneficial to some.

## Nicotine Replacement Therapy

- Comprehensive Medical Eligibility Screening Procedure
- Nicotine Transdermal Patch, Nicotine Gum, Nicotine Lozenge
- Up to 10 weeks of NRT Provided Free to Medically Eligible Participants
- NRT Distributed Every Two Weeks

**Notes:**
Participants can call or register on line for our PIOR programs.

Registration includes completing an extensive NRT Medical Eligibility form to determine if there are medical contraindications to the use of NRT.  

We provide eligible participants with the patch, gum and/or lozenges.  

To insure that participants don’t come to the first weeks sessions just to receive a supply of free NRT, we distribute NRT in two week doses.

## Evaluation Methods and Highlights

- Continuous, Ongoing, and independent evaluation
- Pretest and post-test surveys
- 3, 6, and 12 month telephone follow-up
- Documentation of NRT usage
- Cessation rates calculated for program completers, and conservatively to include program dropouts
- Cessation rates calculated by NRT dosing schedule

**Notes:**
Worked closely with Independent Evaluator to garner “evaluative questions” that would capture smokers progress along a continuum, including a Pre and Post test. 

The program coordinator & evaluator also receive the weekly forms that the participants fill out indicating the type and amount of NRT they are using that week, and the degree of difficulty they are experiencing. 

Participants sign a permission form at the beginning of the program to allow our independent evaluator to conduct telephone follow-up surveys at 3, 6 and 12 months post treatment.  

## PIOR

- Over 3 years, over 869 smokers have participated in PIOR, with 624 (75%) completing the program.

## Year One Quit Rates

**Notes:**
In the first year quit rates were high, 86% at post test, 61% at 3 months, and 44% at 6 months. 

You see here two bars for 6 month quit rates. Notably one of the two facilitators observed that some smokers who were struggling needed patches beyond the 8-week prescribed dose.  

On her own, she began offering one or two more weeks of patches to those smokers, in effect, tailoring the dose to their needs.  

When we separated those people out, their 6-month quit rates were notably higher.  

The Health Dept., based on this experience and the most current literature, decided to offer longer duration of patch usage and subsequently combination therapy which added gum and lozenge with the patch for heavier smokers and those with a Fagerstrom score of 6 or more and those who reported greater difficulty in maintaining their non-smoking status.

## Tailoring Methodology

***Three methods:***
- Fagerstrom score
- Number of cigarettes smoked
- Weekly difficulty ratings
***Determine:***
-  Duration of patch use
-  Dosing of patches
-  Offer of combination therapy

**Notes:**
We decided to begin tailoring and this is the info we used to determine how to tailor NRT for the participant. 

A Fagerstrom score of 6 or higher,

Were initially smoking 25 or more cigarettes a day

How difficult they rated being smoke free each week (Una – you have sample forms in your binder IF asked)

This information will determine whether to step them down to a lower dose of Patch or maintain them on a higher patch mg for a longer period. 

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**Notes:**
The facilitators transfer all weekly program data onto this form which is sent to our Program Coordinator who determines the NRT dosing regimen based on the information provided.Name/ Fagerstrom (fg)/  Attendance (A)/  Difficulty (D)/ Cigarettes smoked C/

G/L (salmon color) gum given out

P (gray) Patch Strength per session

G/L (yellow) Gum or Loz consumed

Determined weekly
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Original Patch strength based on number of cigarettes consumed plus fagerstrom: 

>6 fg + >25 cigarettes = Combination therapy 21 mg patch plus choice of 4mg   gum or loz/ (amount of game/lozenge based on 1⁄2 of the number of cigarettes smoked over 20), (see red and orange on slide)
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Sample Patch Dosing
 >5 fg and 15+ cigarettes = 21 mg patch

<4 fg and 15 – 17 cigarettes smoked = 14 mg patch

10-14 cigarettes regardless of fagerstrom =14 mg patch

<10 cigarettes smoked = 7 mg patch
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Codes continued
 D = perceived difficulty in controlling urges  

 1 = impossible

 2 = very difficult

 3 = difficult

 4 = somewhat easy

 5 = very easy

## Three years of PIOR Quit Rates

**Notes:**
After three years of PIOR, combined data shows that both short and long term quit rates remain high with 85%  at post-program completion, 53% at 3 month, 41% at 6 months, and 46% at 12 months, parenthetically the 12 months picks up the number of people who made a 2nd quit attempt between 6 and 12 months.  

When we look at it this way, you might note that these quit rates appear to be slightly lower than the quit rates for year 1 alone.  

There are 2 issues, 1 is the recognition that all program people know and understand – that programs are dynamic things which involve people.  

In year 2 both of our professional facilitators had significant health issues and began training community facilitators.  

These things combined to produce slightly lower quit rates in year 2.  

Further, we examined the data by particular kinds of tailoring.

## Quit Rates by Type of NRT

**Notes:**
First we looked at quit rates by type of NRT and noted that tailored patch usage and combination therapy yielded approximately the same quit rates.

While combo quit rates appeared higher over the long-term, a few of our most addicted smokers noted to the interviewers that on occasion they were still chewing a piece of gum when they needed it suggesting that combo therapy may be particularly effective for these hardest core smokers.  

In fact, combo therapy was reserved for those people with the highest Fagerstrom scores and the highest number of cigarettes smoked (a Fagerstrom score of 6 or higher, plus smoking more than 25 CPD)

## Quit Rates by Patch Duration

**Notes:**
When we look at quit rates by patch duration the data begins to tell a more interesting story!  

This slide chart compares quit rates for participants who used the patch for 6, 8, or 10 weeks.  6-week patch users were those who decided on their own to discontinue patch use.  

8 and 10 week patch use was based on the Tailoring Method discussed earlier.  

At program completion there was no difference in success on the basis of patch duration. 

By 3 month follow-up those who did not complete at least 8 weeks of patch use were significantly more likely to begin smoking again and differences between 8 and 10 week patch use began to appear.  

By 6 months those with less than 8 weeks patch use continued to drop off and the difference between 8 and 10 weeks began to grow by 1 year follow-up.  

Those who used patches for 8 weeks or less were similar to each other, and those who used patches for 10 weeks had notably higher 12 month quit rates.  

It is particularly notable that longer term patch use is also correlated with heavier smoking at pre-test.

## Program Completion vs. Program Quit Rates

- In addition, data suggest that the program attracted heavy smokers who had never tried to quit before
- Smokers who smoked 35 or more cigarettes a day and/or who had never tried to quit were more likely than other smokers to drop out of the program in the early sessions
- However, the “novice quitters” who remained in the program were slightly more successful at quitting than other smokers at 6 months and 12 months and
- Those heavier smokers who stayed in the program benefited from the NRT tailoring and enjoyed slightly greater success over the long term.

**Notes:**
Note re: heavy smokers (those who smoked 25 or more cigarettes were equally successful as those who smoked 1-24, but those who smoked 35 or more were slightly <but not significantly> more successful than 1-34 at 6 months (49% vs. 40%), and 12 months (50% vs. 42%). 

## Smoking Rates and Related Attitudes

- The strong PIOR evaluation data have been shared with the County legislature, reported in the local media, and presented in various community venues to assure continued funding and community support.
- Assure continued funding through PIOR participants writing letters to legislators

## PIOR Success Story

- Charlie, 80+ years of age,
- Smoked 60 years
- Quit after his 2nd attempt
- A year after his last cigarette Charlie claims “he feels better            than he has in years.”

**Notes:**
The local newspaper has followed a particular smoker through the program and followed his progress over nearly two years, reporting every six months on his continued success. 

## PIOR a work in progress

- Three years of data demonstrate that PIOR is a successful smoking cessation program.
- DOH is committed to expanding its reach to reduce disparities in smoking rates.
- Materials have been translated into Spanish and French.
- PIOR facilitators from these communities have been trained.

**Notes:**
We are a work in progress.  We continue to look at the data

We trained a facilitator this year that speaks French/Creole

## Work in Progress

- The DOH has forged a relationship with ESL providers in the county to recruit non-English speaking smokers
- PIOR partnered with Steps to a Healthier NY in Rockland County in 2004 by incorporating Diabetes Risk Assessment into the program and referring participants to physicians and CDE’s
- Also has a exercise and nutrition/weight loss component in curriculum.

**Notes:**
We are working with ESL teachers at BOCES programs throughout the county to educate and reach out to non-english speaking residents with info on tobacco and our other steps messages.

As a partner in the Steps to a Healthier NY program, we have added the Diabetes self assessment risk test into our curriculum and refer ppts to physicians and Certified Diabetes Education classes

We also have a nutrition/weight loss component and encourage all participants to register for the RC Wallks program, which is part of the county’s Steps initiative.

## PUT IT OUT ROCKLAND AN AWARD WINNER!

- 2004 - The National Association Of County and City Health Officials (NACCHO) presents “MODEL PRACTICE”  award to Put It Out Rockland.

**Notes:**

In developing a program that integrated best practices and has a strong evaluation component,
In 2004 we received the “Model Practice” award.