Tobacco Free Futures:

1. Tobacco Free Futures: Building Capacity for Brief Tobacco Intervention as a standard of care across Alberta health services Dr. Brent Friesen MD, FRCPC  Michelle Nummi BSc, BSc IIP Judy Corcoran, RN BN MSc Susan Canning BSc Alberta Health Services Background ABSTRACT The goal is the system wide implementation of an evidence informed health system tobacco cessation model to offer a seamless and integrated level of cessation support for all Albertans who use tobacco Tobacco Free Futures (TFF) is an integrated health systems 5As tobacco cessation model based on best practices. Alberta Health Services Tobacco Reduction Program uses the model to support tobacco cessation across a variety of health care settings within Alberta Health Services as well as affiliate and contracted service providers. At the end of TFF Project Phase 1 (2010-2013) about 30 sites/programs across the province had engaged with the initiative and were in various stages of implementation. The focus of TTF Phase 2 (2013-2014) was to transition from being a demonstration project to system wide implementation as an integral component of Alberta Health Services Tobacco Reduction Program. There is continued refinement of the implementation process to allow sites to work in a more efficient and self directed way given the potential demands to support implementation and sustainability of the model across all AHS sites (>400). These changes were necessary to increase the reach and sustainability of the program. Other program additions address different settings and populations. • Phase 1 (2010 – 2013) developed and tested a brief intervention cessation model with following key deliverables: • provincial practice guidelines and implementation process; • provincially approved patient documentation standards (paper and electronic); • patient and staff resources; and • health professional training including: implementation workshops, practice lead training and brief intervention training. • Phase 2 (2013 - 2014)increased capacity to support implementation across Alberta by: • development of the scale up plan and the transfer of on going responsibility to operations • refined existing & developed new resources that support implementation with less staff support from AHS’s Tobacco Reduction Program • developed sustainable training • updated TFF Guidelines and added new content to meet unique needs of specific populations. • established a TFF Network Community of Practice as ongoing support for all sites, especially those in the sustainability phase of implementation. Staff Preparation Initial Planning • Development of a communicationplan. • Scheduletrainingfor practice leads and frontline staff. • Engagementsite and physician leadership. • Formation of a steering committee. • Completion of a site policy assessment. • Identification of implementation timelines. UPDATED Brief Intervention Training Online for frontline health professionals NEW Podcast Series 10 part series about processes UPDATED Tobacco Free Futures Guidelines Resource for managers and steering committees Communication Tools Posters, window clings, memos etc.. UPDATED Tobacco Practice Lead Training Face to face for tobacco champions Resource Development Final Planning • Planning for sustainability. • Identification of staff roles and documentation standards . • Pharmacotherapy available with standardized orders. • Resourcesfor clients and healthcare professionals. Acknowledgement Support of Alberta Cancer Prevention Legacy Fund and Canadian Cancer Society Development of the model has been a collaborative process with contribution from many individuals and groups from across the province of Alberta. We have also benefited from the work that has been done nationally and internationally to inform practice guidelines. NEW Reporting Links to new TFF ACTION project CONTACT Patient Handouts Tobacco Reduction Program Alberta Health Services TRU@albertahealthservices.ca Phone: 780.422.1350 Website: www.albertaquits.ca NEW Community Of Practice Healthcare Professional Resources UPDATED Forms and Order Sets

2. Introduction to Tobacco Free Futures

3. About Tobacco Free Futures Program • Alberta based, evidence informed health systems tobacco cessation model. • Has been developed and tested in collaboration with healthcare teams and sites across AHS. • Supported through targeted funding from the Alberta Cancer Prevention Legacy Fund – April 1, 2010 to October 31, 2014. • AHS Tobacco Reduction Program is supporting sustainability of the program through phased transition from project funding. • Support the goals and strategic direction in Creating Tobacco-free Futures: Alberta’s Strategy to Prevent and Reduce Tobacco Use (2012-2022).

4. Tobacco Dependence in Healthcare Settings Brief Tobacco Treatment Implementing the Tobacco Free Futures Model Supports and Resources

5. Tobacco Dependence in Healthcare Settings

6. Impact of Tobacco Use and Exposure • Tobacco is the only consumer product that will kill at least one of every two of its regular users when used exactly as intended by the manufacturer.](Els 2008) • Tobacco use is the single greatest preventable cause of chronic disease and premature death. (WHO 2000) • In 2011, 17.3% of Canadians and 17.7% of Albertans aged 15 and over were identified as smokers. (CTUMS 2011) • In Alberta, tobacco use and exposure is responsible for about 30% of all cancer-related deaths. (ACB 2007) • The risk of hospitalization for current smokers aged 45 to 74 is 80% higher than non-smokers. (Wilkins et al 2009) • The overall cost to the Alberta healthcare system is $470.6 million per year. (ADDAC 2007) • Smokers aged 45-54 will stay in hospital on average 1.5 days longer; those aged 65 to 74 will stay an average 6 days longer.(Wilkins et al 2009)

7. Tobacco Dependence and Nicotine Addiction • A chronic relapsing condition. Not just a ‘bad habit’ or ‘lifestyle choice’. • Treatment must be comprehensive: • support for withdrawal • behavioural counselling • It is rare that tobacco users are successful with a first quit attempt. • Majority go through cycles of relapse and remission. Need to link to ongoing support.

8. Effects of Nicotine • Nicotine is the addictive agent in tobacco products. • Tobacco products are designed to maximize nicotine’s delivery to the brain. • Repeated exposure leads to physical addiction and behavioural dependence.

9. Effects of Nicotine • Tobacco users maintain a constant level of nicotine in their blood. • When level drops they will experience withdrawal symptoms. • Appears within 2 hours of last nicotine use, peaks in 24 to 48 hours and lasts from several days to weeks.

10. Effects of nicotine • Intensity of withdrawal symptoms can impact treatment outcomes

11. Receptive Advantage in Healthcare Settings • Every healthcare interaction with a person is a ‘window of opportunity’. • Most smokers want to quit. (Lung Association 2008) • Tobacco users who are hospitalized may be more motivated to make a quit attempt for health reasons.

12. Supporting Strategic Priorities • AHS strategic priorities are determined based on an identified need and a desire to improve the quality of care. • A systems-based approach to tobacco cessation supports current AHS strategic priorities.

13. Benefits of Treating Tobacco Use • Tobacco treatments are both clinically-effective and cost-effective relative to other medical disease prevention interventions. (Woolf 1999)

14. Linked System of Support • Ensures tobacco use is treated at every healthcare encounter across the continuum of care. (Modified Wagner Model , Wagner et al 2002) • Enhances provider-patient interaction in a seamless way that facilitates treatment.

15. Benefits of a Systematic Approach • Opportunity to increase rates of treatment delivery, quit attempts, and successful tobacco cessation.

16. Best Practice for Healthcare Settings

17. Brief Tobacco Intervention • Brief Tobacco Intervention can: • be done in less than 3 minutes. • at least double a person’s chances of quitting. • improve quality of life and increase lifespan. (Fiore 2008) • Important role of healthcare providers: support every client as part of daily practice. (Rigotti et al 2007)

18. ASK every patient about tobacco use in the last year. ASVISE to quit with personalized message. Advise of the Tobacco and Smoke-Free Environments Policy. ASSESS readiness to quit and interest in pharmacotherapy support for withdrawal. ASSIST with pharmacotherapy for withdrawal. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued pharmacotherapy. ask advise assess assist arrange

19. Benefits of a Systematic Approach • Efforts to integrate tobacco intervention into delivery of healthcare requires active involvement. Northern Lights Regional Health Centre - Ft. McMurray Northwest Health Centre – High Level St. Theresa General Hospital – Ft. Vermillion Royal Alexandra Hospital University of Alberta Hospital Glenrose Rehabilitation Mazankowski AB Heart Institute Misercordia Hospital Grey Nuns Hospital Stollery Children’s Hospital Rockyview General Hospital Peter Lougheed Centre South Calgary Health Campus Alberta Children’s Hospital Renfrew Recovery Centre Claresholm General Hospital Landers Treatment Centre Claresholm Centre MH&A All Zones Public Health Seniors Health

20. Implementing the Tobacco Free Futures Model

21. Evaluation & Sustainability • Communication • Training • Staff roles & Documentation • Pharmacotherapy • Staff & Patient Resources • Engagement • Steering Committee • Policy Assessment • Timelines 4 phases and implementation processes Initial planning Resource Deve’l Staff prep Final planning

22. Sustainability planning tool Chart review data collection tool Evaluation surveys - training Communication Tool Kit – posters, email templates Online training for frontline staff – 1 hour Tobacco Lead training – 5 hours Physician training Supplementary resources for staff – pocket guide, lanyard quick reference Standardized forms - Brief Intervention & Consult Standardized order sets – Inpatient and Discharge Variety of patient resources for patients/clients ready to quit and not ready to quit Posters and window clings Steering Committee Terms of Reference Communication Tools – emails and memo templates Implementation planning tool Resources available to support implementation Initial planning Resource Deve’l Staff prep Final planning

23. Specific Care Settings and Populations The TFF model is relevant and intended to be implemented across the continuum of care. Some specific care setting require further considerations. Existing guidelines document includes considerations for preoperative care, emergency/urgent care & home care. Recently completed guidelines include: public health, transitional and continuing care, and addictions & mental health settings Guidelines under development include: youth & families and reproductive years.

24. Supports and Resources

25. Resources & Supports for Management & Steering Committees A ‘how to’ manual to guide implementation. Consultative support for implementation, resource development, information sessions. Opportunity to network with other sites and to provide input into the program development. Workshops, webinars, conferences. One stop shop for all relevant information and resources: GUIDELINES TFF TEAM ADVISORY COMMITTEE WEBSITE OTHER

26. Moving Forward: Engage your site – support the formation of a steering committee. Learn from the experiences of others. Seek ongoing TFF support.

27. Dr. Brent Friesen Principal Investigator Susan Canning Manager TRP Michelle Nummi Project Manager ACPLF Judy Corcoran Program Coordinator Tasha Allen Team Lead TRP Anna Murphy Health Promotion TRP Christine Fetterly Health Promotion TRP Nana Gyennin Integration Lead ACPLF Jennifer Lindstron Program Coordinator Sarah Waters Program Consultant TRP Tobacco Free Futures Team

28. For Further Information Contact • Alberta Health Services Tobacco Reduction Program • TRU@albertahealthservices.ca • Phone 780 422 1350 • Website www.albertaquits.ca • ACKNOWLEDGEMENTS • Alberta Cancer Prevention Legacy Fund • Canadian Cancer Society