academic strategies to influence evidence-based tobacco cessation practices
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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
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