School Nurse-delivered Tobacco Cessation Intervention for Adolescents: Calling it Quits

1. School Nurse-delivered Tobacco Cessation Intervention for Adolescents: Calling it Quits Lori Pbert, Ph.D. University of Massachusetts Medical School Diane Gorak, RN, BSN, MEd Massachusetts Department of Public Health Voula Osganian, MD Harvard Medical School

2. Learning Objectives • Understand the scope of the problem • Describe the 4-session school nurse-delivered tobacco cessation intervention • Describe the outcomes from a RCT evaluating the effectiveness of this intervention in reducing tobacco use among adolescents • Be able to adapt the intervention to your clinical setting

3. Past-Month Smoking Among Adolescents: National Youth Risk Behavior Surveys, 1993-2001 36% 35% 35% 31% 29% Percent Smoking in Past Month Trends in Cigarette Smoking Among High School Students – U.S., 1991- 2001 MMWR:May 17, 2002

4. The earlier the onset of smoking, the more severe nicotine addiction is likely to be and the more difficult it will be to quit.1 • Teens need only smoke a few times to develop the symptoms of nicotine addiction.2 • Kessler: “Nicotine addiction begins when most tobacco users are teenagers, so let's call this what it really is: a pediatric disease.”3 1. Breslau and Peterson. Am. J. of Public Health. 1996; 2. DiFranza. NEJM. 2000; 3. Kessler. NEJM. 1996.

5. By age 17, one half of smokers have tried to quit and failed, 2/3 regret ever starting and nearly 40% express interest in some form of treatment for tobacco dependence.1 • Approximately 75% of teenage daily smokers will smoke as adults.2 • 1 in 3 teens who smoke will die of a smoking-related disease.3 1. CDC. MMWR. 1993; 2. Report of the Surgeon General. DHHS. 1989; 3. CDC. MMWR. 1996

6. Why the School Nurse? • Accessibility and continuity of care: 70% seen yearly1 • Adolescents feel it is the clinician's job to discuss health risk behaviors.2 • Credibility • Can make a difference (?) 1. Igra, JAMA, 1993; 2. Steiner, J Fam Prac, 1996

7. Health and Social Risks Relevant to Teens • Decreased physical fitness and stamina • Retardation in the rate of lung growth and in maximum lung function • Below average overall physical health reported • Negative effect on lipid profile • Changes to appearance: wrinkles, yellowed teeth and fingers • Increased risk for developing depression and anxiety

8. Benefits of Quitting/Not Smoking (Focus Groups) • Increased athletic ability • Clean fingers, teeth, breath, clothes • Less sore throats, coughs and respiratory diseases • Premature facial wrinkling is minimized • No risk of cigarette burns • Save money • Not being manipulated by cigarette companies • Control/independence from cigarettes

9. School Nurse Work Group • 15 school nurses/nurse practitioners from MA met 7 times in 2000 and 2001 • Collaboration among DOE, MTCP, UMMS, and DPH School Health Unit • Dedicated members (80-90% attended all meetings)

10. School Nurse Work Group (cont.) • Developed a process for systematically identifying students who use tobacco • Screener • Office system • Developed a brief intervention that school nurses can use to assist tobacco users to quit tobacco use • Literature review • Interviewed teens for input • Self help materials were shared • Intervention was piloted

11. School Nurse Work Group (cont.) • Developed student-level and organizational-level data collection instruments • Identified items used in literature • Sensitive to language in a school setting • Developed a process for the school nurses to identify community resources

12. Overview of Intervention Protocol • Based on the Agency for Healthcare Quality and Research (AHQR) clinical practice guideline (2000), Treating Tobacco Use and Dependence (5As: Ask, Assess, Advise, Assist and Arrange) • The American Academy of Pediatrics (AAP) endorses and accepts as its policy the AHQR guideline for adolescents who use tobacco • Modified based on focus groups and interviews with teens who smoke

13. Intervention Approach • Patient-centered/motivational interviewing • Ask open ended questions • Teen talks more than clinician • Build skills/self-efficacy • Problem - solving • Develop health knowledge

14. Intervention Protocol • 4 individual sessions with school nurse • 30 minutes/session • Within 1 month period

15. Demonstration of Intervention Protocol Visits 1 and 3

16. VISIT 1 • Identify pros/cons of using tobacco, summarize ambivalence • Clarify personal reasons for quitting • Identify anticipated problems • Learn from past quit attempts • Understand nicotine addiction • Review quit methods • Set a quit date • Identify triggers/brainstorm strategies

17. VISIT 2 • Review pack wrap, identify concrete strategies to address each trigger • Develop plan for handling social siutations (friends, tobacco users in home) • Identify strategies for managing withdrawal symptoms • Share the 4Ds • delay • deep breathing • drink water • do something else

18. VISIT 2 (cont.) • Break the stress myth (smoking reduces stress); strategies to manage stress Reality: smokers report greater overall stress and anxiety than nonsmokers and former smokers • Learn about weight gain and tips for minimizing • Elicit support from friends, family • Take control of environment

19. VISITS 3 and 4 Assess how quit date went If quit and maintained • Reinforce • Most difficult situations and how handled • Good things since quit • Anticipated problems in staying quit and strategies to deal If quit and relapsed • Reinforce attempt • Length of quit • What went well • What led to relapse and how handle in future • Elicit recommitment to quit • Develop new plan

20. VISITS 3 and 4 (cont.) If quit attempt not made • What got in the way and how handle when try again • Obtain recommitment to quit, set new quit date • Develop new plan

21. Evaluation Designand Results

22. Study Objectives • Overall Aim: • Conduct a randomized controlled school-based trial to evaluate the efficacy of a school nurse delivered tobacco cessation intervention for adolescents. • Primary Aim • Demonstrate a significantly greater decrease in tobacco use among students in the intervention compared to control schools.

23. Study Objectives • Secondary aims are to demonstrate a greater • reduction in the amount of tobacco use, • reduction in the frequency of tobacco use, and • decrease in the number of times students are suspended, received detention, or paid fines for tobacco use

24. Study Design • Pair match on size, DPH funding type, and demographics • Randomize pairs

25. Student Data Collection

26. STUDENT QUESTIONNAIRES OUTCOME and MODIFYING VARIABLES

27. Process Data Collection • Goals • document dose and fidelity of program implementation • document competing programs • assess school level support • Measures/Data Collection • student self-report of content of counseling sessions • school nurse questionnaires to assess support for the program and presence of other cessation programs

28. Statistical Analyses • Students T-Test or Chi Square Tests of Association for comparison of student characteristics between conditions • Odds ratios were estimated using generalized estimating equation (GEE) logistic regression models with students clustered within school to account for within school correlations.

29. Table 1: Characteristics of Participants at Baseline * p<0.01

30. Table 1: Characteristics of Participants at Baseline (cont) * p<0.01

31. Figure 1: Proportion of Students Who Quit Smoking by Condition at Each Time-Point OR=5.9 (3.6-9.6) OR=7.3 (3.4-15.6)

32. Table 2: Adjusted Odd Ratios and 95% Confidence Intervals for Quitting Smoking in Intervention Compared to Control Schools at Each Time-Point

33. Table 3: Students’ Self-Reported Receipt of the Intervention

34. Table 3: Students’ Self-Reported Receipt of the Intervention

35. Table 4: Students’ Self-Report of Number of Visits with School Nurse in Intervention Schools Number of Visits % of students None 2% 1 Visit 9% 2 Visit 14% 3 Visits 15% 4 Visits 35% > 5 Visits 25%

36. Table 5: Students’ Self-Reported Acceptability of the Intervention Question % Responding Very Moderate Somewhat 1. How well do you think the school nurse understood how you feel about smoking? 64% 24% 10% 2. How well did the discussion with the school nurse hold your interest? 42% 39% 17% 3. How comfortable were you discussing smoking with the school nurse? 71% 20% 8% 4. How much did you like the booklet provided to you? 11 % 32% 38%

37. Table 6: School Nurses’ Report of Intervention Implementation

38. Table 7: School Nurses’ Report of Intervention Acceptability and Feasibility

39. Table 8: School Nurses’ Report of Support for a Smoking Cessation Program

40. Table 9: School Nurses’ Report of Smoking Cessation Activities During the Past School Year

41. Summary and Conclusions • A smoking cessation counseling intervention for adolescents can be feasible for school nurses to conduct in the school setting. • A school nurse delivered smoking cessation intervention is successful in assisting some students who are interested in quitting smoking to quit smoking in the short-term. • A school nurse delivered smoking cessation counseling intervention can be acceptable to adolescent smokers.

42. Limitations • Lack of cotinine validation or an objective measure of smoking behavior. • Lack of longer term follow-up of smoking behavior to assess long term maintenance of quit rates. • Generalizability-conducted with a population of students interested in quitting and predominately white.

43. Adapting the Intervention to Your Clinical Setting • Barriers and facilitators to incorporating the intervention into your clinical practice

44. Nurses’ Self-Reported Barriers to Conducting the Intervention • Lack of time to conduct a session or complete all sessions within the one month timeframe due to other responsibilities. • Lack of opportunity for uninterrupted sessions with the student due to other student issues. • Too difficult to fit the sessions into the school day of the student.

45. Questions and Answers