Walking the Talk: Assisting Patients and Staff with Tobacco Cessation

1. Walking the Talk:Assisting Patients and Staff with Tobacco Cessation

2. Presenters Steve Riddle, BS Pharm, BCPS Quality Improvement Pharmacist Harborview Medical Center Clinical Assistant Professor UW School of Pharmacy sriddle@u.washington.edu Jeff Mero Executive Director Rural Healthcare Quality Network jeffm@awphd.org

3. Learning Goals • Gain understanding of tobacco dependence • Identify the “Readiness to Quit” stages • Learn the key elements of the “Brief Intervention” • Use tools like the 5 “A”s to evaluate and assist your patients • Develop and/or improve systems and processes for tobacco cessation

4. Comparing Causes of Death SAMMEC, CDC, 2002

5. Trends in Adult Smoking Trends in cigarette current smoking among persons aged 18 or older, by sex 25.2% Percent 22.5% of adults are current smokers 20.0% Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.

6. How Are We Doing?

7. Getting Started

8. Identify the Needs at Your Workplace Patient Needs • Assistance with “how to quit” • Resources • Outpatient support and follow up

9. Identify the Needs at Your Workplace (cont.) Institutional Needs • Meet patient needs • Defined, structured and sustained process that functions consistently and successfully • Cost-effective • Easily documented & measurable outcomes • Meets or exceeds performance measures

10. Identify the Needs at Your Workplace (cont.) Staff Needs • Education and tools to meet patient needs • Role definition • Sense of value

11. Staff Education & Awareness • Understanding tobacco addiction • Interventions that work • Debunking myths

12. Why Don’t They Just Quit?

13. Tobacco Addiction Pie Social Physical Emotional Behavioral Psychological

14. Tobacco Addiction Pie Physical • Nicotine dependence • “withdrawal”

15. Tobacco Addiction Pie • Routines and habits • After meals • Watching TV Behavioral

16. Tobacco Addiction Pie • View of Self • “I am a smoker” • “Smoking helps me” Psychological

17. Tobacco Addiction Pie • Coping and rewards • Stress / Anxiety • Celebration Emotional

18. Tobacco Addiction Pie Social • Norm in social group • Smoking is OK with friends, at work, etc.

19. Dopamine Norepinephrine Acetylcholine Glutamate Serotonin -Endorphin GABA Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension Neurochemical and Related Effects of Nicotine N I C O T I N E Benowitz.Nicotine & Tobacco Research 1999;1(suppl):S159–S163.

20. Depressed Mood Insomnia Irritability Frustration Anger Anxiety Restlessness Decreased heart rate Difficulty concentrating Increased appetite or weight gain Top 10 NicotineWithdrawal Symptoms

21. Mental Health and Withdrawal • Association between nicotine dependence, nicotine withdrawal and a history of major depression. • Three levels of nicotine withdrawal: mild (41%), moderate (36%) or severe (18%)

22. Mental Health and Withdrawal (cont.) • Symptoms that best distinguished smokers with severe withdrawal were characteristic of mood disorder. • Study subjects who experienced severe nicotine withdrawal, 84 percent reported a depressed mood after quitting cigarettes, 82 percent suffered with nervousness and 58 percent had insomnia.

23. Helping Smokers

24. Readiness to Change Model 40% Not ready to quit 40% Thinking about quitting Staying quit Relapse Ready to quit 20% Quitting

25. The Brief Intervention • A method with proven effectiveness… • Can vary from 30 seconds to 5 minutes • Multiple staff participation increases the quit rates (Cumulative Effect) • Consistency is crucial • Use the 5 “A”s or similar simple guides

26. Brief Interventions:The Five “A”s • Ask • Do you use tobacco? • Advise • Advise to quit • Personalize to patient disease states • Assess • Are you interested in quitting? • Willing to discuss quitting? • Assist • Address smoker’s needs, provide information, and access to help • Arrange • Follow-up as appropriate

27. Easy Steps for Care Providers “HMC Smoke-free” • Screen your patient for nicotine use • Determine the “Readiness to Quit” stage • Determine the patient’s needs • Provide appropriate resources

28. HMC Tobacco Use Screening Tool

29. Provide the Appropriate Resources • Strong quit message • Patient education materials • Stocked in your care area • Stored electronically? • Smoking cessation counseling • Community resources such as the Washington State Quit Line (877-270-STOP)

30. Example: The Strong Quit Message “MRS. JONES, I understand that you are not ready to quit smoking right now. As your _______ (nurse, doctor, etc) I just want to share with you that giving up smoking is probably the single most important thing you can do for your health. It is especially important now that you have/had a _____________ (heart attack, angina, CHF, stroke, etc) as smoking greatly increases the risk this condition will worsen or that other problems will arise. If you ever have questions about quitting there are a lot of resources available and I/we would like very much to help you with this. Do you have any questions for me at this time?”

31. Case Study • HA is a 64yo female admitted for evaluation of a possible heart attack. Her nurse, Mike, asks and discovers HA is a current smoker. Mike tells HA that smoking could increase the chance of a heart attack and ask if HA has considered quitting. HA says she has tried in the past and failed, but is now very serious about quitting as soon as possible. • Mike gives HA a patient info sheet on the dangers of smoking and wishes her luck with quitting.

33. Debunking Smoking Myths • Myth: “No one actually quits” • Fact: People quit all the time. Quit rates are highest in hospitalized patients. • Myth: “If I tell them to quit they will just get mad.” • Fact: Talking to smokers is easy if you approach in a helpful, nonjudgemental manner. • Myth: “I don’t know how to help anyone quit and it wouldn’t matter anyway.” • Fact: Quit rates double even with one-time simple interventions.

34. Tobacco Cessation Rates • Overall cessation rates = 2% • Additive increase with interventions… • Brief Intervention +2% = 4% • Behavioral Support +7% = 9%Spec • NRT with Intensive +8% = 10%Support • Tobacco Cessation +15% = 17%Program • *Cessation defined as 6-12 month abstinence

35. Making Changes in Processes and Systems

36. AHRQ Guidelines: Tobacco Use & Dependence • Tobacco dependence is a chronic condition and requires repeated intervention • Every tobacco user should be offered treatment, including drug therapy • Institutionalize the consistent identification, documentation, & treatment of every user • Treatments are both clinically and cost-effective relative to other interventions

37. Initial Assessment • Where are we now? • What are we doing well? • What are we not doing well? Take a walk-through!

38. HMC Initial Resources • Core group of highly motivated staff • Existing smoking cessation counseling in ambulatory areas • Current process usually ID smokers on admit • Leverage with CMS and JCAHO requirements • External Resources

39. Screen All Patients For Tobacco Use Identify Current & Previous Users Provide Resources to Patient Message/Advice,Counseling,Referrals Documentation HMC Tobacco Cessation Overview When? Who? Where? How?

40. Screening & Counseling • When? Inpatient Admit History • Who? Admitting RN • Where? Inpatient Care Area • How? Use of standardized screening tool Make identification of smoking status and cessation counseling routine

41. Awareness and Availability of Resources • Raise awareness of resources for patients and staff • Newsletters, posters, public displays, cafeteria promotion booths, attend key meetings • Make handouts and info readily accessible to staff, care givers, patients and families • Brochures in racks, admit packets • Develop system for maintaining stock • Intranet/Internet materials

42. Staff & Provider Support • Expect ALL healthcare professionals to intervene • Delegate specific roles to appropriate staff • General support from a variety of staff • MDs  Provide education, resources and feedback to promote provider interventions • Must address concerns about time and damaging patient relationships

43. Cessation Discharge:Planning for Patients Ready to Quit IF POSSIBLE • Counseling session at bedside by qualified and trained staff (or volunteer) • Provide pharmacotherapy as needed & appropriate AT MINIMUM • Outpatient referrals to smoking cessation programs • Follow-up phone calls from hospital staff and/or public health (1 - 2 weeks post-discharge)

44. Documentation Example Tobacco cessation intervention included… ⁣ Strong quit message and advice provided. ⁣ Written tobacco cessation materials provided. ⁣ Smoking Cessation Counseling provided, counselor notified or referral arranged to outpatient counseling.

45. Outcomes and Feedback • Don’t measure success by “quit rates”! • Use JCAHO/CMS criteria • Provide feedback regarding interventions to staff (% compliance with indicators, missed opportunities) • Reward and celebrate success with patients AND staff!

46. The Role of Medications Nicotine Replacement Therapy (NRT) Bupropion (Zyban) • None are effective on their own • Must combine with behavioral therapy to see improved quit rates • Person must realize that quitting requires a planned effort on their part

47. Resources • Washington Tobacco Quit Line • 1-877-270-STOP (7867) • Provides individuals with excellent kit • www.quitline.com • Institutional resources (posters, cards, etc) also available • Spanish: 1-877-2 NO FUME (or 1-877-266-3863)

48. Resources • Agency for Healthcare Research and Quality • Smoking Cessation Clinical Practice Guideline. JAMA.1996;275:1270-1280 • www.AHRQ.gov

49. What are the goals for your program? • Develop a system that accurately identifies all smokers and assesses their quit stage • Provide appropriate cessation message and resources • Connect smokers ready to quit to a smoking cessation program • Educate staff on the value of providing cessation messages • Develop a system for documentation

50. Questions?