Academic Strategies to Influence Evidence-Based Tobacco Cessation Practices

Janie Heath PhD, APRN-BC, FAANAssociate Dean Academic Programs & Professor of Nursing

University of Virginia, School of NursingFormer Associate Dean of Academics College of Nursing & Director, Tobacco Cessation Nursing Faculty Practice Group

Georgia Health Sciences University

Why Make Tobacco Control an Academic Initiative 46 million adults smoke (18.4%

of population) GEORGIA = 19.5% prevalence VIRGINIA = 16.4%

1200 individuals DIE every day in U.S. because of tobacco use(450,000 / yr) GEORGIA = 10,000 / yr VIRGINIA = 9200 / yr

Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010. Morbidity and Mortality Weekly Report 2011;60(33):1207–12 [accessed 2012 June 3].

Why Make Tobacco Control an Academic Initiative It’s our MISSION

Improve health and reduce the burden of illness in society by discovering, disseminating, and applying knowledge of human health and disease

It’s our EXPERTISE It’s our PASSION

Why Make Tobacco Control an Academic Initiative

It’s all about OPPORTUNITY to promote health!

Major Responsibilities Chief Academic Officer (CAO) for Accreditation and Outcomes

Assessment CAO, Curriculum/Program development CAO, Regulation of Academic/Student Affairs & Contracts

Academic/Enterprise-wide Engagement Strategic Planning New Financial Model: Responsibility Based Budget University Assessment

Recent Funding PI, HRSA DNP Acute Care APN Grant ($950,000) – 3 year Ntl Panel, AHA, Effects of Smokeless Tobacco; Circulation 9/10 Co-I, NIH, AA Family Intervention for Smoking Cessation – 5 year

Student Reach with Tobacco Control – Rx for Change EDU

BSN - 361 students Traditional RN-BSN

MSN - 244 students Clinical Nurse Leader Primary Care NP Acute Care NP and CNS PMH NP and CNS Health Mgmt Systems Public Health Nursing

Leadership

Post MS Certificate - 21 students NP, CNS, Wound Ostomy Care

DNP - 38 students PhD - 48 students Doctoral exchange – 11

students TOTAL Projected UVA Tobacco

Control Reach: 2012 Fall Enrollment = 723 students

Our MODEL for Optimal EBP Tobacco Cessation Outcomes

Provide Training:Nsg EDUNsg CE

Provide Systems Support:Priority in

Organizations

Provide ResearchFunding:

OrganizationsFederal

EnsureAccountability:

LicensureCertification

CessationInterventions=

Standard ofNsg Practice

RaiseAwareness:

GrassrootsState

NationalInternational

Heath, J., Andrews, J. (2006). Translation of tobacco cessation interventions into clinical practice. Nursing Research, 55(4): S44-S50.

The REAP Framework National coalition of nurse educators established to help

disseminate resources and information through a REAP framework for tobacco control

R = RESEARCH E = EDUCATION A = ADVOCACY P = PRACTICE

Founder: Dr. Janie Heath (MCG) Co-Founders: Dr. Jeannette Andrews, Medical University of South

Carolina and Dr. Claudia Barone, University of Arkansas Medical Sciences

www.nurses4tobaccocontrol.org

Georgetown University

Medical College of Georgia

University of Arkansas

Vanderbilt University

Medical University of South Carolina

University of Virginia

Research

Education

Advocacy

Practice

Application of REAP through Academic Partnerships

Research: Workforce Development

To evaluate the effect of an advanced practice nurse driven EDU INTERVENTION to improve the effectiveness of tobacco cessation interventions among… Acute Care Cardiology &

Pulmonary Providers PMH APRN Providers Maternal Child Providers

Application of the Theory of Reasoned Action

10

Schematic drawing of Theory of Reasoned Action’s relationship to tobacco cessation interventions (TCI) adapted from Fishbein and Ajzen (2010)

Overview of Studies

Pretest – Posttest; Descriptive Correlational Designs

Convenience Samples in large academic medical centers with healthcare providers

Fishbein-Azjen Theory of Reasoned Action Framework

INTERVENTION- Rx for Change Clinician Assisted Tobacco Cessation* (www.rxforchange.edu) a 1 Hour Interactive DVD Education Session

43 item survey

Overview of Selected Findings

KnowledgeScores

TRA BeliefsChange

IntentionScores

Amole, J., Heath, J., McLear, B,, & Thomas, J. (2012). Optimizing tobacco cessationstrategies through an online continuing education program. Nursing Clinics of North America. 47: 71-79

Heath, J., Kelley, J., Andrews, J., Crowell, N., Corelli, R., Hudmon, K.S. (2007).Evaluation of a tobacco cessation curricular intervention among acute care nurse practitioner faculty member. American Journal of Critical Care, 16(3):284-289.

Heath, J. & Amole, J. (podium). Tobacco Control and Mental Illness: Breaking Barriers through NP Education, Practice and Research. The 36th Annual Meeting of National Organization of Nurse Practitioner Faculties, Washington, DC; 4/17/10

Self-Confidence

Correlations

Alices, M, Manghram, D, Heath, J., Bennett, S. & Joshua, T ( poster). Tobacco Cessation Interventions among Acute-Care Providers in Respiratory Units. The National Teaching Institute and Critical Care Exhibition Conference, Chicago, IL; 5/4/11.

Education Research

To evaluate the effect of the Rx for Change

Clinician Assisted Tobacco Cessation Curriculum Intervention among pre-licensure interdisciplinary healthcare students Nursing, Dental Hygiene &

Respiratory Therapy COMMIT - CNLs

Rx For Change Clinician Assisted Tobacco Cessation Curriculum –

Based on USPHS Guideline and extensively reviewed by experts in tobacco control Comprehensive > 350 CD-slides, ancillary

handouts, evaluation measures, case studies

Selected Modules Epidemiology Forms of tobacco Genes & tobacco use Pathophysiology Nicotine addiction Pharmacotherapy Counseling techniques

Access at www.rxforchange.ucsf.edu

Rx for change

Authors:Karen Hudmon RPh, DrPHRobin Corelli PharmD

Education Intervention:

Overview of Studies

Pretest – Posttest; Descriptive Correlational Designs

Convenience Samples in large academic medical centers with students

Fishbein-Azjen Theory of Reasoned Action Framework

INTERVENTION- Rx for Change Clinician Assisted Tobacco Cessation* (www.rxforchange.edu) a 3 Hour Interactive Education Sessions

43 item survey

Overview of Selected Findings

KnowledgeScores

TRA BeliefsChange

IntentionScores

Self-Confidence

Correlations

Kelley, J., Heath, J., Crowell, N. (2006). Using the Rx for change tobacco curriculum in advanced practice nursing education. Critical Care Nursing Clinics of North America,18(1): 131-138.

Inglett, S., Schumacher, A., Kiernan, B., & Heath, J. (poster). The Effect of a Service Learning Project on CNL Student’s Knowledge, Confidence, Beliefs, & Intentions to Intervene with Tobacco Dependent Women. 26th Annual SNRS Conf, New Orleans, LA,

2/18/12

Inglett, S, Heath, J. (podium). Factors Influencing Undergraduate Nursing Students Intentions to Integrate Tobacco Cessation in Daily Practice. 5th Annual Uniting Practice, Education, and Research Conference, Beta Omicron & Pi Lambda Chapters, Sigma Theta Tau International, Augusta, GA; 2/23/10

Inglett, S., Schumacher, A., Kiernan, B., & Heath, J. (poster). Predictors for Intentions to Intervene with Tobacco Dependent Women: A CNL Student Learning Project. 16th Annual Graduate Research Day, Georgia Health Sciences University, Augusta, GA

4/18/12

Advocacy Outcomes

Tobacco Free Campus Initiative

College of Nursing faculty leadership

Student leadership Service learning activities

for students March of Dimes project

Media coverage The Augusta Chronicle Local TV Stations

Great American Smoke Out

~30 pre-licensure /yr ~5 post-licensure /yr ~ 4 faculty / yr

Kick Butts Campaign ~18 pre-licensure / yr ~ 3 post-licensure / yr ~ 2 faculty /yr

Employee Wellness Health Fair

~22 pre-licensure / yr ~ 4 post-licensure / yr ~ 2 faculty / yr

Service Learning Outcomes for Students

GHSU NSG, Respiratory Therapy & Dental Hygiene

Circle Of Motivated MOMs for Infants to be Tobacco-free (COMMIT)

March of Dimes 12 mth funding

Recruit 24 tobacco dependent women of child bearing age to participate in a 6 wk evidence based tobacco cessation program & follow up

Service Learning Outcomes for Students

GHSU NSG and 3rd yr Pharmacy Students

Practice Outcomes

To evaluate the effect of an advanced practice nurse driven tobacco cessation clinic on health and cessation outcomes among

GHSU employees, staff, faculty and students

Heath et al (2012). The impact of the Georgia Health Sciences University Nursing Faculty Practice on Tobacco Cessation Rates, Nurs Clin N Am (47) 1-12.

PMH participants

Funding per Tobacco Free CampusInitiative: University, Health System & Physician

Practice Group

Nursing Faculty Practice Group (NFPG) and Tobacco Control @ GHSU

How We Got There…

Administrative support Dean Lucy Marion has

long history of promoting faculty practice

All GHSU SON faculty receive 0.2 work effort for practice

New Facility 3700 Square foot; full

services from laboratory space to 5 exam rooms

NFPG and Tobacco Control @ GHSU

How We Got There…

Faculty interest and expertise

22 members (33%) of NFPG in active practice

7 members (10%) of NFPG with tobacco control expertise

Financial incentive 9% Dean’s fund, 9%

Chair’s fund, 37% practice, 45% faculty

NFPG and Tobacco Control @ GHSU

Nov 29th, 2006 Town Hall Announcement; Nov 15th, 2007 Tobacco Free Campus

How We Got There…

Our Providers Medical Evaluation and Management

Janie Heath PhD, NP; Margo Henderson DNP, NP; Lovoria Williams MSN, NP; Pam Cromer MSN, NP

Collaborating Physician: Dr. Sara Young –MCG-HI Family Medicine

Behavioral Counseling Nursing - Sharon Bennett DNP, CNS;

Margaret Tuck MSN, CNS: Jack Amole DNP, CNS;

Allied Health – Susan Whiddon MS, RT Our Staff

Jim Hawkins, NFPG Manager Nita Sakovitz & Candice Yates, Clinic

Coordinator

Plus STUDENTS!

The NFPG Tobacco Cessation Clinic

GHSU Tobacco Cessation Program

~ weekly group sessions for 6 wks x 2 hours each

~ individual sessions for 4 wks x 2 hours each

~ telephone follow up 3mths, 6mths & 12mths

CLINICAL MEASURES:Objective:

Weight Blood Pressure Heart Rate Carbon Monoxide (CO)

Subjective (Self Report): Medical & Tobacco History Average Daily Cigarettes Fagerstrom Level of Dependence

Scale CES-D Depression Scale Readiness to Quit Ladder Motivation to Quit Scale Confidence to Quit Scale Medication Tolerance

NFPG Tobacco Cessation Clinic

EBP Treatment for Tobacco Dependence

Counseling + Pharmacotherapy = Best Outcomes

27

The PHYSICAL

The EMOTIONAL

The BEHAVIOR

Physical addiction of cravings & withdrawals

Role of cigarettes in life—pleasure, stress, social

Automatic learned behavior with cigarettes

A Successful Approach to Break the Cycle of Tobacco Dependence

Adapted from Legacy’s GSD&M Presentation 12/5/03

EBP Treatment for Tobacco Dependence

0

20

40

60

80

100

Male n = 72 (45%)

Female n = 88 (55%)

NFPG Tobacco Cessation Clinic Outcomes

Heath et al (2012). Nurs Clin N Am (47) 1-12.

N = 160 completed program; 2007 - 2009

0102030405060708090

100

Married 53%

Divorced 15%

Other 5%

Single 29%

NFPG Tobacco Cessation Clinic Outcomes

Heath et al (2012). Nurs Clin N Am (47) 1-12.

Demographic findings: n = 160 completed program; 2007-2009

020406080

100120140160

African American 18%

Caucasian 79%

Other 1%

Asian 3%

NFPG Tobacco Cessation Clinic Outcomes

Heath et al (2012). Nurs Clin N Am (47) 1-12.

Demographic findings: n = 160 completed program; 2007-2009

NFPG Tobacco Cessation Clinic Outcomes

0

50

100

150

200H&Ps

Completed Program

Start and Completion of Program: 2007 - 2009

x178 Evaluated

x160 Completed

Heath et al (2012). Nurs Clin N Am (47) 1-12.

Variable Mean SD Range

Tobacco Hx

22.75 11.32 2 – 50 yrs.

# of QUIT Attempts

4.22 3.86 1 - 25

Fagerstrom 4.20 2.09 0 - 10123/178 (93.89%) attempted to quit before

NFPG Tobacco Cessation Clinic Outcomes

151 (85%) received Chantix as part of treatment at the NFPG Tobacco Cessation Clinic Heath et al (2012). Nurs Clin N Am (47) 1-12.

n = 160 completed program; 2007-2009

NFPG Tobacco Cessation Pharmacotherapy Outcomes

0

50

100

150

91% treated with medication (145/160) as mono-therapy or combination therapy: x6 NRT patch, x3 NRT gum, x5 NRT lozenge, x2 NRT inhaler; x4 Zyban; x138

Chantix; x15 No meds

050

100150

Chantix Start Pack

Chantix Continuation Pack

Heath et al (2012). Nurs Clin N Am (47) 1-12.

NRT

Zyban

Chantix 11%

3%

95%

75%

0 20 40 60Pharmacotherapy Outcomes: Chantix Side Effect Profile

NFPG Tobacco Cessation Clinic Outcomes

Vivid Dreams 34%

Nausea 34%

Flatulence 5%

Other 8%

Sleeplessness 13%

HA 3%

Constipation 3%

Comparison to Pfizer’s Phase 2 Trials of Chantix: Nausea = 30%; Insomnia = 18%Chantix Prescribing Information 2008 Insert, Pfizer, New York, NY

0102030405060708090

100

1st Qtr

Group Session Quit Rate

Individual Session Quit Rate

Collective Quit Rates

Tobacco QUIT Rates @ End of 6 wk / 4 wk Treatment per Self Report & Carbon Monoxide Validation

64%

55%

66%

NFPG Tobacco Cessation Clinic Outcomes

0102030405060708090

100

1st Qtr

Follow Up Self- Report 3 mths

Collective Tobacco QUIT Rates (no response = lost to follow up and/or assumed to relapse)

22%36%

16%

NFPG Tobacco Cessation Clinic Outcomes

Follow Up Self- Report 6 mths

Follow Up Self- Report 12 mths

NFPG Tobacco Cessation Clinic Outcomes

Analysis

Readiness toQuit Scorep = .0034

QUIT RATES at End of Tx, 3, 6 and 12 mths compared to…

Number of Group Sessions

p = .0001

If Married p = .0312

Number of Individual Sessions

p = .0001

0 20 40 60PMH Tobacco Cessation Outcomes: 27 of 39 (69%) QUIT

Quit Rates for Mental Illness and/or Substance Abuse

Multiple PMH Disorders 3/9 (33%)Depression 17/22 (77% - QUIT at 6 wk tx)

Substance Abuse 2/2 (100% - QUIT at 6 wk tx)

Bipolar 0/2 (0% - QUIT at 6 wk tx)

Anxiety 5/6 (83% - QUIT at 6 wk tx)

Demographics: n = 39 with PMH Disorders (0.8%)

Variable Mean SD Range

Tobacco Hx

21.85 14.0 3 - 60

# of QUIT Attempts

4.72 3.69 1 - 15

Fagerstrom 4.59 2.05 1 - 1039/39 (100%) attempted to quit before

NFPG Tobacco Cessation Clinic Outcomes for Mental Illness and/or Substance Abuse

Demographics: n = 39

CES-D 15.92 10.06 3 - 42

NFPG Tobacco Cessation Clinic Outcomes for Mental Illness and/or Substance Abuse

Series10

102030 Yes QUIT

EOTNo QUIT EOT

Series10

20

40PrivateGroup

Series10

102030 EOT

3mths6mths12mths

79% on Chantix (31/39) 81% on Chantix (25/31)

85% Group Session (33/39) QUIT Rates: EOT 69%, 3mths 10%; 6mths 12%; 12mths 7%

Academic Strategies to Influence Evidence-Based Tobacco Cessation Practices WORK!!!

REAP into action for…

Happy & Healthy EMPLOYEES/Patients!

…and COUPLES..!

THANK YOU

Janie Heath PhD, APRN-BC, FAANJanie.heath@virginia.edu