Integrating Tobacco Cessation into a Student Health Center setting

1. Integrating Tobacco Cessation into a Student Health Center setting PCCHA Annual Meeting October 14, 2014Seattle, WA

2. Presenter Mark Shaw, M.S. Director of Health PromotionUniversity of Washington Seattle campus

3. Goals for workshop 1) Brief review of motivational interviewing concepts 2) Opportunity for learning key “MI” phrases to use with tobacco using patients/clients 3) Describe an effective process of referral of tobacco using patients/clients (including mental health) 4) Discussion of the use of electronic medical record for making referrals 5) Identify new possible sources of funding for a tobacco cessation program

4. University of Washington • Institution Profile • Largest public university in Northwest region of US • 28,570 Undergraduates • 11,648 Graduates/Professional • Main campus in Seattle and 2 ‘branch’ campuses (Tacoma and Bothell)

5. Range of Services • Primary care clinics Specialty care clinics • Primary CareMental Health • Family HealthPhysical Therapy • Women's HealthSports Medicine • Travel • Immunization Clinic • Health Promotion • Other services: Consulting Nurse,Radiology, Pharmacy, & Lab (all on site)

6. Scope of the problem • National College Health Assessment shows that 14% of students use tobacco (last 30 days) • Extrapolating this figure to the UW-Seattle campus: approximately 5,630 students are tobacco users • Adding faculty and staff… another 4,366 use tobacco • No shortage of clientele! Total = 9,996

7. Prior to establishment of formal tobacco cessation program • Patients occasionally referred to see Health Promotion Director (me) • This took either a phone call, email message, or brief visit to my office by the provider • What I didn’t grasp…they ‘live’ in EMR much of the day, around seeing patients

8. Prior to establishment of formal tobacco cessation program • Net result was that very few patients were referred (1-2/month) • Part of the reason was that the patient was not always asked about tobacco use during visit (focus on presenting issue with limited time) • Also, influence of how the topic was discussed

9. Compare and Contrast these 2 phrases • 1) “I think you should quit using tobacco products; it’s one of the best things you can do for your health.” • 2) “How do you feel about your tobacco use right now? Have you been thinking about making any changes lately?”

10. Compare and Contrast these 2 phrases • 1) Studies do show the power of ‘the white coat effect’ (provider bringing up tobacco use during a patient visit) in increasing quit attempts • 2) Gets at the Stages of Change model, and whether the person is READY to consider making a change to their tobacco use

11. Stages of Change model • Stage One: Pre-contemplation • Stage Two: Contemplation • Stage Three: Preparation • Stage Four: Action • Stage Five: Maintenance Developed by Prochaska and DiClementi, 1982

12. Response to questions depend on where the patient “is at” in Stages of Change • Pre-contemplators won’t say “Where do I sign up?” (‘Hand signal’ instead!) • Contemplators may doubt that they will succeed • “Preparers” may never get to a ‘quit date’

13. “Motivational Interviewing 101” • Express empathy (reflective listening vs. judgment) • Roll with resistance (reduces tension in interaction) • Develop discrepancy (between current behavior and personal goals/values) • Avoid arguments (gently diffuse defensiveness) • Support self-efficacy (optimism about ability to succeed) William R. Miller, 1982

14. Key components of “MI” • Autonomy (patients are responsible for their choices) • Collaboration (work ‘with’ person, not ‘forcing them’) • Evocation (Patients talk about change, not provider) • Ask open-ended questions

15. Some phrases to use to open the conversation • “What are some good things about using tobacco? • “What are some not-so-good things about using tobacco? • “What are some good things about quitting your use of tobacco?” • “What are some not-so-good things about quitting your use of tobacco?”

16. Some phrases to use to open the conversation • Assessing the patient’s readiness to change • “On a scale of 1-10, what is your desire to quit using tobacco?” • “On a scale of 1-10, how confident are you in your ability to stop using tobacco?” • If someone answers with a low number to either question, you can ask “How come it’s not 10?”

17. Some phrases to use to open the conversation • “What would you like to do about your tobacco use?” (even if reply is “nothing,” leave open the opportunity to discuss in the future) • If some readiness to quit is displayed… “What do you think has to change?” • “How are you going to deal with this?”

18. How it can proceed with a tobacco cessation program in place (such as "Tobacco Talk”) • For Contemplators ‘and beyond’… “We have a program here for those who are thinking about making changes. You don’t have to be wanting to quit to use it. Would you be interested in talking to someone about your tobacco use?”

19. Course of action depending on response to question • If ‘Yes,’ provider can initiate a referral to the tobacco cessation program… ‘Someone from Tobacco Talk’ will get in touch with you shortly.’ • If ‘No,’ provider doesn’t make a referral, but gives the patient information about the program… ‘OK, here is some information; if you change your mind, feel free to contact them directly.’

20. Making the referral • 1) If there is someone in your health center that can provide tobacco cessation services: Notify them of the patient’s interest in talking about their tobacco use, and provide contact information At UW, the referral is now done via Electronic Medical Record; much easier for providers to use this method.

21. Making the referral • 2) If there is not someone in your health center that can provide tobacco cessation services: Seek resource elsewhere on campus (such as Health Promotion in Student Life, Mental Health Clinic, or a community resource). Release of information authorization would be needed if provider makes referral.

22. Importance of discussing tobacco use with mental health clients • Smoking Prevalence is Much Higher Among People with a Mental Illness • Nationally, nearly 1 in 5 adults (or 45.7 million adults) have some form of mental illness, and 36% of these people smoke cigarettes. • 31% of all cigarettes are smoked by adults with mental illness. • 40% of men and 34% of women with mental illness smoke. Source: CDC

23. Why tobacco use isn’t always discussed with mental health clients • Nicotine has mood-altering effects that put people with mental illness at higher risk for cigarette use and nicotine addiction. • Some therapists are more focused on treating the mental illness of their patients (the ‘primary problem’) • Some providers may not consider smoking to be a problem, or ignore it (my previous experience in substance abuse treatment centers).

24. What could mental health professionals do to improve this situation? • Find out if your clients use tobacco. • If they do smoke, use MI approach to see if they are interested in cessation. • Make quitting tobacco part of an approach to mental health treatment and overall wellness. • Tailor cessation focus as needed to address the unique issues this population faces.

25. Other groups to reach out to about tobacco cessation • GBLT students • International students (especially those from the Pacific Rim and men from the Middle East) • Students from a lower Socio-economic status Outreach to these sub-groups can be done via student clubs and organizations (i.e.., at UW: the Queer Center, FIUTS, MAPS program).

26. How “Tobacco Talk” got started at UW’s student health center Guess one of the options below: • I found $100,000 on the street, in large bills! • We got a $100,000 grant from the King County Tobacco Prevention Program • I was approached by a Native American tribe that operates a casino about a 3-year gift worth $100,000

27. How “Tobacco Talk” got started at UW’s student health center • In the state of Washington, tribes that operate a casino are required by the state to donate a small % of their profits to fund… • Tobacco cessation programs • Gambling treatment programs If your state has tribal casinos, look into this option!

28. Our program logo

29. Questions/Comments ??? If you would like an electronic copy of these slides, pick up one of my business cards or send me an email message…

30. Contact Information • Mark Shaw • mshaw@u.washington.edu • (206) 616-8476 • hallhealth.washington.edu/healthpromotion