school nurse delivered tobacco cessation intervention for adolescents calling it quits
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School Nurse-delivered Tobacco Cessation Intervention for Adolescents: Calling it Quits. Lori Pbert, Ph.D. University of Massachusetts Medical School Diane Gorak, RN, BSN, MEd Massachusetts Department of Public Health Voula Osganian, MD Harvard Medical School. Learning Objectives.

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school nurse delivered tobacco cessation intervention for adolescents calling it quits

School Nurse-delivered Tobacco Cessation Intervention for Adolescents: Calling it Quits

Lori Pbert, Ph.D.

University of Massachusetts Medical School

Diane Gorak, RN, BSN, MEd

Massachusetts Department of Public Health

Voula Osganian, MD

Harvard Medical School

learning objectives
Learning Objectives
  • Understand the scope of the problem
  • Describe the 4-session school nurse-delivered tobacco cessation intervention
  • Describe the outcomes from a RCT evaluating the effectiveness of this intervention in reducing tobacco use among adolescents
  • Be able to adapt the intervention to your clinical setting
past month smoking among adolescents national youth risk behavior surveys 1993 2001
Past-Month Smoking Among Adolescents: National Youth Risk Behavior Surveys, 1993-2001






Percent Smoking in Past Month

Trends in Cigarette Smoking Among High School Students – U.S., 1991- 2001

MMWR:May 17, 2002

The earlier the onset of smoking, the more severe nicotine addiction is likely to be and the more difficult it will be to quit.1
  • Teens need only smoke a few times to develop the symptoms of nicotine addiction.2
  • Kessler: “Nicotine addiction begins when most tobacco users are teenagers, so let's call this what it really is: a pediatric disease.”3

1. Breslau and Peterson. Am. J. of Public Health. 1996; 2. DiFranza. NEJM. 2000; 3. Kessler. NEJM. 1996.

By age 17, one half of smokers have tried to quit and failed, 2/3 regret ever starting and nearly 40% express interest in some form of treatment for tobacco dependence.1
  • Approximately 75% of teenage daily smokers will smoke as adults.2
  • 1 in 3 teens who smoke will die of a smoking-related disease.3

1. CDC. MMWR. 1993; 2. Report of the Surgeon General. DHHS. 1989; 3. CDC. MMWR. 1996

why the school nurse
Why the School Nurse?
  • Accessibility and continuity of care: 70% seen yearly1
  • Adolescents feel it is the clinician's job to discuss health risk behaviors.2
  • Credibility
  • Can make a difference (?)

1. Igra, JAMA, 1993; 2. Steiner, J Fam Prac, 1996

health and social risks relevant to teens
Health and Social Risks Relevant to Teens
  • Decreased physical fitness and stamina
  • Retardation in the rate of lung growth and in maximum lung function
  • Below average overall physical health reported
  • Negative effect on lipid profile
  • Changes to appearance: wrinkles, yellowed teeth and fingers
  • Increased risk for developing depression and anxiety
benefits of quitting not smoking focus groups
Benefits of Quitting/Not Smoking (Focus Groups)
  • Increased athletic ability
  • Clean fingers, teeth, breath, clothes
  • Less sore throats, coughs and respiratory diseases
  • Premature facial wrinkling is minimized
  • No risk of cigarette burns
  • Save money
  • Not being manipulated by cigarette companies
  • Control/independence from cigarettes
school nurse work group
School Nurse Work Group
  • 15 school nurses/nurse practitioners from MA met 7 times in 2000 and 2001
  • Collaboration among DOE, MTCP, UMMS, and DPH School Health Unit
    • Dedicated members (80-90% attended all meetings)
school nurse work group cont
School Nurse Work Group (cont.)
  • Developed a process for systematically identifying students who use tobacco
    • Screener
    • Office system
  • Developed a brief intervention that school nurses can use to assist tobacco users to quit tobacco use
    • Literature review
    • Interviewed teens for input
    • Self help materials were shared
    • Intervention was piloted
school nurse work group cont11
School Nurse Work Group (cont.)
  • Developed student-level and organizational-level data collection instruments
    • Identified items used in literature
    • Sensitive to language in a school setting
  • Developed a process for the school nurses to identify community resources
overview of intervention protocol
Overview of Intervention Protocol
  • Based on the Agency for Healthcare Quality and Research (AHQR) clinical practice guideline (2000), Treating Tobacco Use and Dependence (5As: Ask, Assess, Advise, Assist and Arrange)
  • The American Academy of Pediatrics (AAP) endorses and accepts as its policy the AHQR guideline for adolescents who use tobacco
  • Modified based on focus groups and interviews with teens who smoke
intervention approach
Intervention Approach
  • Patient-centered/motivational interviewing
    • Ask open ended questions
    • Teen talks more than clinician
  • Build skills/self-efficacy
    • Problem - solving
  • Develop health knowledge
intervention protocol
Intervention Protocol
  • 4 individual sessions with school nurse
  • 30 minutes/session
  • Within 1 month period
visit 1
  • Identify pros/cons of using tobacco, summarize ambivalence
  • Clarify personal reasons for quitting
  • Identify anticipated problems
  • Learn from past quit attempts
  • Understand nicotine addiction
  • Review quit methods
  • Set a quit date
  • Identify triggers/brainstorm strategies
visit 2
  • Review pack wrap, identify concrete strategies to address each trigger
  • Develop plan for handling social siutations (friends, tobacco users in home)
  • Identify strategies for managing withdrawal symptoms
  • Share the 4Ds
    • delay
    • deep breathing
    • drink water
    • do something else
visit 2 cont
VISIT 2 (cont.)
  • Break the stress myth (smoking reduces stress); strategies to manage stress

Reality: smokers report greater overall stress and anxiety than nonsmokers and former smokers

  • Learn about weight gain and tips for minimizing
  • Elicit support from friends, family
  • Take control of environment
visits 3 and 4
VISITS 3 and 4

Assess how quit date went

If quit and maintained

  • Reinforce
  • Most difficult situations and how handled
  • Good things since quit
  • Anticipated problems in staying quit and strategies to deal

If quit and relapsed

  • Reinforce attempt
  • Length of quit
  • What went well
  • What led to relapse and how handle in future
  • Elicit recommitment to quit
  • Develop new plan
visits 3 and 4 cont
VISITS 3 and 4 (cont.)

If quit attempt not made

  • What got in the way and how handle when try again
  • Obtain recommitment to quit, set new quit date
  • Develop new plan
study objectives
Study Objectives
  • Overall Aim:
  • Conduct a randomized controlled school-based trial to evaluate the efficacy of a school nurse delivered tobacco cessation intervention for adolescents.
  • Primary Aim
  • Demonstrate a significantly greater decrease in tobacco use among students in the intervention compared to control schools.
study objectives23
Study Objectives
  • Secondary aims are to demonstrate a greater
    • reduction in the amount of tobacco use,
    • reduction in the frequency of tobacco use, and
    • decrease in the number of times students are suspended, received detention, or paid fines for tobacco use
study design
Study Design
  • Pair match on size, DPH funding type, and demographics
  • Randomize pairs
process data collection
Process Data Collection
  • Goals
    • document dose and fidelity of program implementation
    • document competing programs
    • assess school level support
  • Measures/Data Collection
    • student self-report of content of counseling sessions
    • school nurse questionnaires to assess support for the program and presence of other cessation programs
statistical analyses
Statistical Analyses
  • Students T-Test or Chi Square Tests of Association for comparison of student characteristics between conditions
  • Odds ratios were estimated using generalized estimating equation (GEE) logistic regression models with students clustered within school to account for within school correlations.
figure 1 proportion of students who quit smoking by condition at each time point
Figure 1: Proportion of Students Who Quit Smoking by Condition at Each Time-Point

OR=5.9 (3.6-9.6)

OR=7.3 (3.4-15.6)

Table 2: Adjusted Odd Ratios and 95% Confidence Intervals for Quitting Smoking in Intervention Compared to Control Schools at Each Time-Point
table 4 students self report of number of visits with school nurse in intervention schools
Table 4: Students’ Self-Report of Number of Visits with School Nurse in Intervention Schools

Number of Visits % of students

None 2%

1 Visit 9%

2 Visit 14%

3 Visits 15%

4 Visits 35%

> 5 Visits 25%

table 5 students self reported acceptability of the intervention
Table 5: Students’ Self-Reported Acceptability of the Intervention

Question % Responding

Very Moderate Somewhat

1. How well do you think the school nurse

understood how you feel about smoking? 64% 24% 10%

2. How well did the discussion with the

school nurse hold your interest? 42% 39% 17%

3. How comfortable were you discussing

smoking with the school nurse? 71% 20% 8%

4. How much did you like the booklet

provided to you? 11 % 32% 38%

table 9 school nurses report of smoking cessation activities during the past school year
Table 9: School Nurses’ Report of Smoking Cessation Activities During the Past School Year
summary and conclusions
Summary and Conclusions
  • A smoking cessation counseling intervention for adolescents can be feasible for school nurses to conduct in the school setting.
  • A school nurse delivered smoking cessation intervention is successful in assisting some students who are interested in quitting smoking to quit smoking in the short-term.
  • A school nurse delivered smoking cessation counseling intervention can be acceptable to adolescent smokers.
  • Lack of cotinine validation or an objective measure of smoking behavior.
  • Lack of longer term follow-up of smoking behavior to assess long term maintenance of quit rates.
  • Generalizability-conducted with a population of students interested in quitting and predominately white.
adapting the intervention to your clinical setting
Adapting the Intervention to Your Clinical Setting
  • Barriers and facilitators to incorporating the intervention into your clinical practice
nurses self reported barriers to conducting the intervention
Nurses’ Self-Reported Barriers to Conducting the Intervention
  • Lack of time to conduct a session or complete all sessions within the one month timeframe due to other responsibilities.
  • Lack of opportunity for uninterrupted sessions with the student due to other student issues.
  • Too difficult to fit the sessions into the school day of the student.