TOBACCO TACTICS: BRINGING THE PROGRAM TO THE SMOKER

1. Tobacco Tactics Manuals Used by Month during Intervention Period in the Ann Arbor VA, July 2007-May 2008 Tobacco Tactics Manuals Used by Month during Intervention Period in the Ann Arbor VA, July 2007-May 2008 TOBACCO TACTICS: BRINGING THE PROGRAM TO THE SMOKER Sonia A. Duffy, PhD, RN1,2; Lee A. Ewing, MPH2; Carrie A. Karvonen-Gutierrez, MPH2; David L. Ronis, PhD1,2;and the Tobacco Tactics Team 1University of Michigan; 2VA Ann Arbor Healthcare System, Center for Clinical Management Research SUMMATIVE (OUTCOME) EVALUATION BACKGROUND • In the Ann Arbor intervention site, smoking rates did not increase significantly largely because pre-intervention rates were unusually high. Sub-analyses show that the pre-intervention sample had significantly more heart patients than the post-intervention sample and heart patients are highly motivated to quit. • In the Detroit intervention site, 6-month cotinine verified quit rates went from 7.8% pre-intervention to 17.4% post-intervention compared to 8.9% quit rates during these periods in the Indianapolis control site. • Further sub-analyses show that the intervention seems to have the most benefit for motivated patients, i.e. those thinking of quitting smoking in the next 30 days. • Combining the Ann Arbor and Detroit sites, pre-intervention quit rates for psychiatric patients were 0% vs. 18.9% post-intervention (p=0.04) compared to 6.6% in the Indianapolis control site during the intervention period. • Smokers have an increased risk of morbidity and mortality resulting in twice as many hospital stays, longer hospital stays, and greater expenses per admission than nonsmokers. • Inpatient smoking programs are efficacious and have a high reach as they capitalize on a teachable moment, take advantage of cessation induced by hospital smoking bans, enroll a higher percentage of patients who smoke, and result in higher cessation rates. • The majority of smoking services in the Department of Veterans Affairs (VA) are provided by outpatient programs. Although efficacious, outpatient smoking cessation programs are poorly attended and few • smokers are reached. Inpatient cessation programs have not been widely implemented. FORMATIVE (PROCESS) EVALUATION • About 96% (210/219) of inpatient nurses in Ann Arbor, 57% (159/279) in Detroit, and an additional 282 non-targeted personnel attended training. • The intervention has disseminated to units initially not targeted including psychiatric, substance abuse, and outpatient clinics. • Nurses’ self-reported administration of cessation services increased from 57% pre-training to 86% post-training (p=0.0002). • Preliminary data analysis (N=1170) shows that those in the intervention group are reporting an increase in receiving and satisfaction with the selected cessation services, particularly in regards to medications compared to the Indianapolis control site (P=0.06). • Residents were given a brief overview of the program along with the medication algorithm during orientation. Physician advice to quit smoking (as reported by patients on their 6-month surveys) was high in both the pre-intervention and post-intervention period in both the experimental and control group, ranging between 74-82%. • Volunteers were trained to provide telephone follow-up counseling and peer support to patients 2, 14, 21, and 60 days post-discharge. In the Ann Arbor site only, during the intervention period, two volunteers made 1,776attempts (no more than 3 attempts per time point) to reach 270 patients of which 85% were reached at least once. An average of 2 follow-up calls per patient were made to 230 patients for a total of 552 patient contacts. • As more nurses were trained, the number of Tobacco Tactics manuals used on the units steadily increased as shown in Figure 1. OBJECTIVE • The objective of this study is to implement and evaluate the nurse-administered Tobacco Tactics program in the VA. METHODS • In this quasi-experimental implementation study, Ann Arbor and Detroit were the intervention sites and Indianapolis was the control site. • At the intervention sites, research nurses taught the intervention to staff nurses using the Tobacco Tactics nurse toolkit which includes: 1) one contact hour for training; 2) PowerPoint presentation on behavioral and pharmaceutical interventions; 3) pocket card “Helping Smokers Quit: A Guide for Clinicians”; 4) pharmaceutical and behavioral protocols; and 5) computerized template for documentation. • The patient toolkit includes: 1) brochure; 2) videotape; 3) Tobacco Tactics manual; 4) pharmaceuticals; 5) 1-800-QUIT-NOW help line; and 6) volunteer follow-up phone counseling. • At the Indianapolis control site, patients were referred to usual care outpatient groups. • Smokers in all facilities were surveyed at baseline and 6 months after discharge. SUSTAINABILITY • The program is now part of orientation for all new nurses. • A booster training module in the VA Learning Management System will provide ongoing continuing education to inpatient nurses. • Nurse champions from all of the units are responsible for sustaining the intervention. • Oversight of the program was transferred to the Tobacco Cessation Coordinator (a pharmacist). • Staff education was turned over to the nurse educators and patient education materials were assigned to Patient Care Services. Figure 1. Tobacco Tactics Manuals Used by Month during the Intervention Period at the Ann Arbor VA, July 2007 – May 2008 CONCLUSION • Since nurses constitute the largest number of front line providers, teaching nurses how to conduct smoking education may be the quickest and most efficient strategy to reach inpatient smokers. This study was supported by the Department of Veterans Affairs SDP 06-003.