Provider Tools for Implementing a Smoking Cessation Program Optimus Health Care s Park City Primary Care Center, Bridgeport

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1 SEARCH Student Project / ClinQI Kimberly Tschetter Advisors: Maria Perez, PA-C and Howard Smith, PA-C June-July 2012 Provider Tools for Implementing a Smoking Cessation Program Optimus Health Care s Park City Primary Care Center, Bridgeport Background of Need: Tobacco use is the leading preventable health risk in the United States. 1 Smoking currently costs the U.S. healthcare system over $193 billion every year due to medical expenses and lost productivity. 1 Add in another $10 billion in costs for the effects of second-hand smoke. Nationally, over 19% of the population smokes tobacco, which comes out to over 43 million current smokers. 2 In Connecticut, just over 13% of the population smokes. 2 Millions of dollars are spent at national and state levels on anti-smoking campaigns every year. Despite these efforts, around 1000 people under the age of 18 start smoking each day. 1 Studies show that smoker s lives are cut short by 13 to 14 years 2. Each year, one out of every five deaths is due to smoking-related causes. 1 The negative health effects of smoking range from heart disease and stroke to emphysema and cancer. 3 The negative effects of second-hand include increased ear infections, severe asthma attacks, respiratory infections and sudden infant death syndrome. 3 Smoking is also the leading preventable risk factor for poor birth outcomes including low birth weight, pre-term births and perinatal deaths. 3 The good news is that 69% of current smokers report they want to quit. 1 52% of smokers made an attempt to quit in the past year. 1 Many smokers are afraid to quit for a variety of reasons including the fear of withdrawal symptoms such as cravings, insomnia, restlessness, anxiety, depression, difficulty concentrating and weight gain. While each person is different, studies show that smokers need the most support during the first few weeks after quitting tobacco. 4 People may use a variety of methods to deal with side effects, such as drinking plenty of water, staying away from caffeine and alcohol, chewing sugarless gum or sucking on sugarless candy, eating sunflower seeds or raw vegetables, brushing one s teeth, avoiding situations associated with smoking and getting more exercise. 4 Making multiple, small changes in a person s daily routine and staying positive are keys to quitting tobacco use. 5 Healthcare providers with direct patient contact have a unique role in helping people to quit smoking. Studies show that asking patients about tobacco use and encouraging them to quit at each visit increases the likelihood that a patient will attempt to quit smoking. 6 When consistent counseling is combined with smoking cessation products, cessation rates improve. 6 Objectives: The Community Health Center Association of Connecticut (CHCACT) is currently creating a standardized process for assisting patients with smoking cessation.

2 There are three main objectives aimed at improving the number of patients who quit smoking. These goals include: 1. Create a process to ensure that 100% of patients are assessed for tobacco use at each visit. 2. Create a standardized counseling process to be implemented at all CHCACT locations. 3. Offer smoking cessation counseling to at least 80% of all patients who smoke. This study was conducted to assist CHCACT with the second objective. As a part of the counseling process, patients will receive an informational handout that corresponds with their current stage of the quitting process. The second part of this project involved creating a convenient guide for providers with information about smoking cessation products and tips for identifying a patient s readiness to quit. Methods: The study placed each patient into one of three categories, depending on their smoking habits. The categories included: 1) Pre-Quit: The person has considered quitting, but is still smoking and has not yet set a Quit Date. Smokers who recently cut down on the number of cigarettes per day were also placed in this category. 2) Quit: The person has stopped smoking altogether. 3) Slip: The person quit smoking, but has recently slipped and had a few cigarettes. These three categories were modeled after the Stages of Readiness 2 : Precontemplation, Contemplation, Preparation, Action and Maintenance. The patient was then presented with three handouts, corresponding with the prescribed category. The handouts were adapted from the University of Pittsburgh's Smoking Cessation: Practical Skills for Healthcare Professionals Training Program. 5 Each handout was presented either in English or Spanish. The information presented in the Pre-Quit category focused on three different aspects of quitting: 1) 5 Ways to Get Started 2) What Does Smoking Do For To You 3) Give Quitting a Serious Try in a question and answer format The handouts for the Quit category looked at: 1) Feelings a person may encounter after quitting and ways to cope 2) Routines: Breaking the Cigarette Link 3) Preventing Temptation: Being Prepared

3 Finally, information in the Slip category addressed these issues: 1) Staying Smoke-Free in Tempting Situations 2) Don t Panic Learn From the Situation 3) What Can You Do Better Next Time? Before viewing the handouts, each person was read the following statement: I have a strong desire to live a smoke-free life. They rated this statement as: strongly agree, agree, neutral, disagree or strongly disagree. Patients were then asked the following set of questions: 1. Which handout most encourages you to quit smoking / to stay smoke-free? 2. Which handout contains the most realistic and practical suggestions for living a smoke-free life? 3. Which handout is the easiest to read and understand? 4. Looking at your favorite handout, would you hang it up at home or work to remind yourself to be smoke-free? 5. What is the single most important thing that encourages you to quit smoking / stay smoke-free? For the second part of the project, each provider at the clinic was asked their preference between a pocket guide to keep with them or a guide to hang up in their office. The guide contains basic prescribing information for bupropion (Zyban), vareniciline (Chantix), nicotine nasal spray and the nicotine inhaler. It also includes dosing information for over-the-counter nicotine replacement products such as the patch, nicotine gum and lozenges. Lastly, the guide describes the 5 A s of smoking cessation 7 : Ask the patient about their smoking habits. Advise them about the negative consequences of smoking. Assess the patient s willingness to quit. Assist with creating a smoking cessation plan. Arrange for a follow-up. Conclusions: For this study, 30 current and former smokers were surveyed. 13 people (45%) were in the Pre-Quit category, 9 people (30%) had already Quit, and 8 people (27%) had tried quitting and had Slipped but would all like to try quitting again. When presented with the statement about wanting to live a smoke-free life, 23 people (77%) strongly agreed, 4 people (13%) agreed and only 1 person (<1%) strongly disagreed. When asked about the single most important thing that encourages them to quit smoking / stay smoke-free, 26 out of 30 people (83%) said it was for health reasons, 3 people (13%) said it was for their family, and 1 person (<1%) said it was for financial reasons. For the Pre-Quit category, 7 out of the 13 people (53%) said they found handout #1 the most encouraging, 7 people (53%) said handout #1 was the most realistic

4 and practical, and 9 people (69%) said handout #1 was the easiest to read and understand. 12 people (92%) said they would hang it up at home or work. Smokers identified best with this handout because it presents a clear plan for quitting. The five steps include: 1. Plan Ahead 2. Pick Your Method 3. Create New Routines 4. Get Support 5. Think Positive People in the Quit category overwhelmingly preferred handout #2 about Routines and Breaking the Cigarette Link. 5 out of 9 people (56%) said it was the most encouraging and the most practical. 6 people (67%) thought handout #2 was the easiest to read and understand. All 9 (100%) said they would hang it up at home or work as a reminder to live smoke-free. People liked this handout because they could identify with times of the day when they smoke the most. Most reported craving a cigarette in the morning while having coffee and after the evening meal. We discussed ways to break the link between daily routines and smoking. For example, instead of sitting down to drink that first cup of coffee in the morning, wait until you get to work and have coffee in an environment where you cannot smoke. After dinner, do the dishes right away to keep yourself busy instead of smoking. Go for a walk in the evening and leave the cigarettes at home. Patients were encouraged to break as many behavioral links to smoking as possible. In the group of patients who recently slipped and had a cigarette after quitting, handout #2 titled, Don t Panic Learn From the Situation was the clear favorite. 4 out of 7 people (50%) choose this handout because it was the most encouraging, most practical and the easiest to read. 7 people (88%) would hang it up at work or home to encourage themselves to give quitting another try. People liked this handout the best because it was the most positive. It simply advised them to stop smoking, throw out any remaining cigarettes and recommit to living smoke-free. Do not panic and learn from the situation. Try to stay positive and plan what you will do differently the next time you have a craving. Patients were reminded that on average it takes 5 to 9 attempts to quit smoking for good. 1 One former smoker stated that he smoked for 20 years. It took him 9 attempts before kicking the habit for good. He has now been smoke-free for 10 years and feels much healthier. Patients who recently slipped found that stories such as this one encouraged them to try again. For the second part of this project, providers in the clinic overwhelmingly preferred a guide to hang up in their office with information about smoking cessation products and the 5 A s. Seeing this guide everyday will remind providers to ask about tobacco use at every visit and to offer counseling to all patients who desire to live a healthier, smoke-free life. As CHCACT works towards implementing a standardized counseling process, these patient handouts and the provider tools will hopefully encourage people to give quitting a try.

5 References 1. Centers for Disease Control and Prevention. Tobacco Control State Highlight Accessed June 26, 2012, statistics / state_data/ state _highlights/2010/index.htm. 2. Centers for Disease Control and Prevention. Smoking a Tobacco Use: State Data. Accessed June 26, 2001, / index.htm. 3. US Department of Health and Human Services (HHS), Public Health Service, Office of the Surgeon General. The health consequences of smoking: A report of the Surgeon General. Rockville, MD: HHS; Accessed June 26, 2012, 4. National Institutes of Health, National Cancer Institute (NCI). The role of the media in promoting and reducing tobacco use. Tobacco Control Monograph No. 19. Bethesda, MD: NCI; 2008 Jun. 5. University of Pittsburgh's Smoking Cessation: Practical. Skills for Healthcare Professionals Training Program. Accessed June 29, 2012, DocLibrary/Policy/Tobacco/Educational-Kit.aspx 6. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. American Journal of Preventive Medicine 2006;31(1) Okuyemi KS, Nollen NL, Ahluwalia JS. Interventions to Facilitate Smoking Cessation. American Family Physician Jul 15;74(2):