SEARCH STUDENT PROJECT KIMBERLY TSCHETTER JUNE-JULY 2012

Transcription

1 SEARCH STUDENT PROJECT 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, CT

2 WHAT IS SEARCH? Student/Resident Experiences And Rotations in Community Health SEARCH aims to retain health care professionals, who have experience and training in Connecticut, within the system of 14 federally qualified health centers (FQHCs). Assists Connecticut s FQHCs in providing high quality health care and social services to the area s underserved populations SEARCH brings students from different health professions into underserved areas to gain experience in hopes of turning them into culturally competent providers

3 SEARCH PROJECT COMPONENTS Background of Need Project Objectives Project Methods Conclusions

4 BACKGROUND OF NEED: WHY IS IT SO IMPORTANT TO ASSIST PATIENTS WITH SMOKING CESSATION? Tobacco use is the leading preventable health risk in the United States. Smoking currently costs the U.S. healthcare system over $193 billion every year due to medical expenses and lost productivity. Nationally, over 19% of the population smokes tobacco. (43 million people). In Connecticut, just over 13% of the population smokes tobacco.

5 HEALTH RISKS ASSOCIATED WITH SMOKING TOBACCO Studies show that smoker s lives are cut short by 13 to 14 years. Each year, one out of every five deaths is due to smokingrelated causes. Negative health effects of smoking include heart disease, stroke, emphysema, poor oral health and cancer. The negative effects of second-hand smoke include increased ear infections, severe asthma attacks and respiratory infections. Smoking is also the leading preventable risk factor for poor birth outcomes including low birth weight, pre-term births and perinatal deaths.

6 WE KNOW THAT PEOPLE SHOULD QUIT. DO THEY WANT TO? The good news is that 69% of current smokers report they want to quit. 52% of smokers made an attempt to quit in the past year. Many smokers are afraid to quit for a variety of reasons: Fear of withdrawal symptoms such as cravings Insomnia Restlessness Anxiety and Depression Difficulty concentrating Weight gain

7 WHAT ROLE DO HEALTHCARE PROVIDERS PLAY? 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. When consistent counseling is combined with smoking cessation products, cessation rates improve.

8 PARK CITY PRIMARY CARE CENTER Primary Medical Care Obstetrics and Gynecology Chiropractic Pediatrics Behavioral Health WIC Dental Geriatrics Asthma Treatment Podiatry

9 Patients served in 2011: 51,698 Park City Age 18 and under: 21,028 (40% of all patients) Age 65 and older: 2,755 (5% of all patients) Males: 21,132 (41%) Females: 30,566 (59%) Patients best served in a language other than English: 16,557 (32%)

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11 OBJECTIVES The Community Health Center Association of Connecticut (CHCACT) is creating a standardize process for assisting patients with smoking cessation. There are three main objectives aimed at improving the number of patients who quit smoking. 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.

12 SUMMARY OF PROJECT As a part of the counseling process, patients will receive an informational handout that corresponds with their current stage of the quitting process. This project tested different patient handouts at the Park City location. 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.

13 METHODS The study placed each patient into one of three categories depending on their smoking habits. 1) Pre-Quit: Patient 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: Patient has stopped smoking altogether 3) Slip: Patient quit smoking, but has recently slipped and smoked a few cigarettes

14 STAGES OF READINESS The three categories were modeled after the Stages of Readiness : Pre-contemplation Contemplation Preparation Action Maintenance Each patient was then presented with three handouts from the Pre-Quit, Quit or Sip category. The handouts were adapted from the University of Pittsburgh's Smoking Cessation: Practical Skills for Healthcare Professionals Training Program. mhttp://

15 PRE-QUIT HANDOUT #1 Quit Smoking: 5 Ways To Get Started 1. Plan ahead. Choose a date to stop smoking. Give yourself enough time to create a plan. Ask advice from other people who have quit. Write down how often you smoke and under what circumstances. Be aware of your triggers. You can come up with strategies to overcome them. 2. Pick your method. No single approach works for everyone. You may need to try a few strategies at once. Make sure you address both your physical dependence on nicotine as well as your emotional triggers. 3. Create new routines. Since smoking is a part of your day, you will need to form new habits. Chew gum instead of taking a drag after lunch or play a computer game in place of your cigarette break. Avoid situations associated with lighting up. 4. Get support. You are the only one who can make yourself stop smoking, but surrounding yourself with friends, family and fellow quitters can help you get through tough days. Pick someone who really wants you to kick the habit and make him or her your go-to person when a craving hits. 5. Think positive. Know that each day you get through without smoking is an accomplishment! Keep yourself inspired to stick with it by reminding yourself of your reasons for quitting. You are strong enough to make this a lasting life change!

16 PRE-QUIT HANDOUT #2 What Does Smoking Do For To You? Mary thinks that smoking makes her cool and attractive. What is so attractive about yellow teeth, bad breath, body odors and clothes with burn holes? Helen feels that smoking keeps her thin. Even though some people do gain weight when they quit, is it worth the increased risk of getting cancer, heart disease or emphysema to keep off a few extra pounds? Jack feels that cigarettes get rid of stress. How could a cigarette fix a flat tire, stop the baby from crying, solve a problem with the boss or help you pay your bills? Frank is afraid to even try to quit because he thinks the cravings will be too much to handle. There are many excellent nicotine replacement products on the market now. They will help you get off nicotine slowly and comfortably. Rhonda feels that cigarettes are her best friend. Think about it! What kind of friend would steal your money, destroy your health and take away your self-esteem?

17 PRE-QUIT HANDOUT #3 SMOKING CIGARETTES IS A SERIOUS PROBLEM Give Quitting a Serious Try. You CAN quit smoking! Hundreds of people do it every day. Here are some suggestions for things you can do while you are considering becoming smoke-free: Become aware of your smoking. Where and when do you smoke the most? Of all the cigarettes you smoke, how many do you really enjoy? Pay attention to any smoke-related health problem you have. Are you coughing or wheezing? Are you short of breath? Make a list of the negative effects smoking has on your life: Now make a list of all the benefits of quitting: If you have tried to quit in the past and then started smoking again, why not try again now? Remember that many people need several tries before they actually quit for good. Learn from past mistakes and use those lessons when you try again to quit. This will help you quit once and for all. Keep trying! You CAN do it!

18 QUIT HANDOUT #1 I Quit Using Tobacco and Now I am Feeling Depressed *Call a friend *Listen to music or go for a walk *Use prayer or meditation Insomnia *Avoid caffeine after 6 P.M. *Read in bed *Allow minutes of quiet time before bed Irritability, Frustration or Anger *Take a walk or exercise *Talk to a friend or relative about how you feel *STOP, close your eyes, breathe in deeply through your nose and out through your mouth Difficulty Concentrating *Take breaks *Do important tasks when you are the most alert Restlessness *Try squeezing a rubber ball or stress reliever *Chew sugarless gum, sugarless candy or raw vegetables *Work on a hobby and take one day at a time Increased Appetite or Weight Gain *Choose healthy foods *Walk for minutes a day *Drink lots of water Tell Yourself Positive Things! I m Getting Healthier! I m Feeling Better! I m Confident in Myself!

19 QUIT HANDOUT #2 Routines: Breaking the Cigarette Link Each time you smoke a cigarette, you link the cigarette with whatever you are doing. For example, when you drink coffee or after you eat, you smoke a cigarette. After smoking for years, these links become very strong. Breaking all links is a very important part of quitting smoking. In the morning As soon as you get up, tell yourself how exciting it will be to go through another day without cigarettes. Change the order of your morning routine. If you usually have your coffee first before you shower, then shower first. If you usually shave before breakfast, then have breakfast first. In the Car Choose a slightly different route for routine trips. Listen to a talk radio station or an audio book. This will keep your mind occupied. Remove cigarettes from your car and clean out the ashtrays. At Work Change your work environment as much as you can. Keep busy during breaks. Do word games or read. Go for a walk if you can. Make a list of all the things you ll do with the money you will save each month by not smoking! Stay away from smoking areas. Avoid taking breaks at the same time as your smoking friends. In the Evening Keep yourself busy! Do projects you have been putting off. Begin an exercise program. Walking each day for 20 minutes is a great way to start. Keep a Quitting Calendar. Say to yourself, I am proud that I made it through another day without smoking!

20 QUIT HANDOUT #3 Preventing Temptation: Being Prepared When you quit smoking, you will probably be tempted to smoke from time to time. Just about every new smoker is. Temptations are most likely to occur when you are in a situation in which you used to smoke. You may feel temptations for several months after you quit. Changing your routines will remove many of these temptations and will help keep the urge to smoke from sneaking up on you. Relaxation Technique FIND a quiet place where no one will bother you SIT in a comfortable chair or lie on the floor THINK of a sound or a short word that you can say over and over to yourself CLOSE your eyes LET yourself relax BEGIN to breathe deeply and slowly, taking air in through your nose and letting it out through your mouth. As you do, say your special word over and over to yourself DO this for fifteen minutes each day DON T WORRY if you have trouble clearing your mind the first few times you do this. Just like everything else, it will become easier as you practice.

21 SLIP HANDOUT #1 Now that you have quit smoking, here are some suggestions to help you maintain your new freedom from cigarettes. What Tempts you to Smoke? Tempting Situation: Coping Techniques: Tempting Situations and Winning Ways To Cope

22 SLIP HANDOUT #2 So You Have Recently Smoked One or Two Cigarettes What can you do? If you are still smoking, STOP. If you bought a pack of cigarettes and still have some, throw them out! Make a commitment not to get cigarettes from friends or family. DO NOT PANIC. Learn from the situation. What was I doing when I smoked? Where was I? What was I feeling? Why did I smoke? Plan what you will do differently next time you feel the need to smoke. Stay positive. Talk with a friend about it. They may be able to help. If you are using nicotine replacement products, make sure you are using them correctly. Review your smoking cessation information. Talk to your doctor or nurse if you have questions. Refocus your efforts. Keep doing what works best for you. Hint: If you are using nicotine replacement gum or lozenge, use a piece instead of smoking next time you are in the same situation where you last craved a cigarette.

23 SLIP HANDOUT #3 SO YOU HAVE STARTED SMOKING AGAIN What can you do? Do not be too hard on yourself! Most people try more than once before they quit completely. Learn from your mistakes and try again. Learn what you can do differently next time to avoid smoking. Think about your attempt to quit. Make notes to yourself about it... What are the easiest situations for me to deal with when I am trying not to smoke? What are the hardest situations for me to deal with when I am trying not to smoke? What was I doing the first time I smoked a cigarette after quitting? What techniques worked for me to quit smoking? What techniques did NOT work for me to quit smoking? DO NOT GIVE UP! Renew your attempt to quit smoking. Choose a new Quit Date. Use this experience to make your next attempt a success. My New Quit Date:

24 METHODS 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: Which handout most encourages you to quit smoking / to stay smoke-free? Which handout contains the most realistic and practical suggestions for living a smoke-free life? Which handout is the easiest to read and understand? Looking at your favorite handout, would you hang it up at home or work to remind yourself to be smoke-free? What is the single most important thing that encourages you to quit smoking / stay smoke-free?

25 METHODS The second part of the project included a Provider Guide to Smoking Cessation. 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 OTC nicotine replacement products and prescribing information for bupropion (Zyban), vareniciline (Chantix), the nicotine inhaler and nicotine nasal spray. Ask about tobacco use The guide also describes the 5 A s of smoking cessation Identify and document tobacco use status for every patient at every visit. Advise to quit In a clear, strong and personalized manner, urge every tobacco user to quit. Assess willingness to make a quit attempt Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. Arrange follow-up For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at this time, address tobacco dependence and willingness to quit at their next clinic visit.

26 CONCLUSIONS

27 CONCLUSIONS

28 CONCLUSIONS

29 CONCLUSIONS Pre-Quit category Handout #1 7 out of the 13 people (53%) said they found it the most encouraging 7 people (53%) said it was the most realistic and practical 9 people (69%) said it 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 presented a clear plan for quitting.

30 PRE-QUIT HANDOUT #1 Quit Smoking: 5 Ways To Get Started 1. Plan ahead. Choose a date to stop smoking. Give yourself enough time to create a plan. Ask advice from other people who have quit. Write down how often you smoke and under what circumstances. Be aware of your triggers. You can come up with strategies to overcome them. 2. Pick your method. No single approach works for everyone. You may need to try a few strategies at once. Make sure you address both your physical dependence on nicotine as well as your emotional triggers. 3. Create new routines. Since smoking is a part of your day, you will need to form new habits. Chew gum instead of taking a drag after lunch or play a computer game in place of your cigarette break. Avoid situations associated with lighting up. 4. Get support. You are the only one who can make yourself stop smoking, but surrounding yourself with friends, family, and fellow quitters can help you get through tough days. Pick someone who really wants you to kick the habit and make him or her your go-to person when a craving hits. 5. Think positive. Know that each day you get through without smoking is an accomplishment! Keep yourself inspired to stick with it by reminding yourself of your reasons for quitting. You are strong enough to make this a lasting life change!

31 CONCLUSIONS Quit category Handout #2 5 out of 9 people (56%) said it was the most encouraging and the most practical 6 people (67%) thought it 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 the times of the day when they smoked the most. Most reported craving a cigarette in the morning while having coffee and after the evening meal. Patients were encouraged to break as many behavioral links to smoking as possible.

32 QUIT HANDOUT #2 Routines: Breaking the Cigarette Link Each time you smoke a cigarette, you link the cigarette with whatever you are doing. For example, when you drink coffee or after you eat, you smoke a cigarette. After smoking for years, these links become very strong. Breaking all links is a very important part of quitting smoking. In the morning As soon as you get up, tell yourself how exciting it will be to go through another day without cigarettes. Change the order of your morning routine. If you usually have your coffee first before you shower, then shower first. If you usually shave before breakfast, then have breakfast first. In the Car Choose a slightly different route for routine trips. Listen to a talk radio station or an audio book. This will keep your mind occupied. Remove cigarettes from your car and clean out the ashtrays. At Work Change your work environment as much as you can. Keep busy during breaks. Do word games or read. Go for a walk if you can. Make a list of all the things you ll do with the money you will save each month by not smoking! Stay away from smoking areas. Avoid taking breaks at the same time as your smoking friends. In the Evening Keep yourself busy! Do projects you have been putting off. Begin an exercise program. Walking each day for 20 minutes is a great way to start. Keep a Quitting Calendar. Say to yourself, I am proud that I made it through another day without smoking!

33 CONCLUSIONS Slip category Handout #2 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. Patients were reminded that on average, it takes 5 to 9 attempts to quit smoking for good. One former smoker stated that he had 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.

34 SLIP HANDOUT #2 So You Have Recently Smoked One or Two Cigarettes What can you do? If you are still smoking, STOP. If you bought a pack of cigarettes and still have some, throw them out! Make a commitment not to get cigarettes from friends or family. DO NOT PANIC. Learn from the situation. What was I doing when I smoked? Where was I? What was I feeling? Why did I smoke? Plan what you will do differently next time you feel the need to smoke. Stay positive. Talk with a friend about it. They may be able to help. If you are using nicotine replacement products, make sure you are using them correctly. Review your smoking cessation information. Talk to your doctor or nurse if you have questions. Refocus your efforts. Keep doing what works best for you. Hint: If you are using nicotine replacement gum or lozenge, use a piece instead of smoking next time you are in the same situation where you last craved a cigarette.

35 CONCLUSIONS For the second part of this project, providers in the clinic overwhelming 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 at EVERY VISIT who desire to live a healthier, smoke-free life.

36 Provider Guide to Smoking Cessation THE 5 A S MODEL FOR TREATING TOBACCO USE AND DEPENDENCE Ask about tobacco use Advise to quit Assess willingness to make a quit attempt Assist in quit attempt Arrange follow-up Identify and document tobacco use status for every patient at every visit. In a clear, strong and personalized manner, urge every tobacco user to quit. Is the tobacco user willing to make a quit attempt at this time? For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at this time, address tobacco dependence and willingness to quit at their next clinic visit.

37 OTC: Short Acting Nicotine Gum < 25 cig./day, start with 2mg gum >24 cig./day, start with 4mg gum Max 24 pieces per day Class C Nicotine Lozenge First cig. >30 minutes after waking, 2mg lozenge First cigarette <30 minutes after waking, 4mg lozenge Max 5 lozenges per 6 hours, no more than 20 per day Class C Nicotine Mini Dissolves 3 times faster than the lozenges First cig. > 30 minutes after waking, 2mg lozenge First cig. <30 minutes of waking up, 4mg lozenge Max 5 lozenges per 6 hours, no more than 20 per day Class C OTC: Long Acting Nicotine Patch One patch lasts 16 hours, take patch off at night >10 cig. per day: 21mg patch for 6 weeks 14mg patch for 2 weeks 7mg patch for 2 weeks <10 cigarettes per day 14mg patch for 6 weeks 7mg patch for 2 weeks Class D Prescription: Short Acting Nicotine Inhaler One cartridge contains 10mg of nicotine, 4mg is delivered Use 6 to 16 cartridges daily for 12 weeks. Max 16 cartridges/day Self taper over 6 to 12 weeks (if needed), Class D Nicotine Nasal Spray 0.5mg per spray Use one spray in each nostril per dose 1 to 2 doses per hour for weeks 1 to 8, self taper weeks 9 to 14 Max 5 doses per hour or 40 per day Fastest relief from withdrawal symptoms, Class D Prescription: Daily Medication Varenicline (Chantix) Covered by Medicaid Chantix should be taken after eating and with 8 oz. of water 12-week prescription includes 1 Starting Month Box and 2 Continuing Month Boxes Starting Box: 0.5 mg once per day (days 1-3) 0.5 mg twice per day (days 4-7) 1 mg twice per day (days 8+) Do not take nicotine replacement or smoke along with Chantix Class C Bupropion (Zyban) Start 150mg QD for three days (Sustained Release) Increase to 150mg BID for 7 to 12 weeks Suicidality risk in young adults with major depressive disorder Decreases seizure threshold May be combined with nicotine replacement therapy Class C

38 THANK YOU! All patient handouts were available in English and Spanish. A special thanks to fellow PA student and friend Jennifer Gonzalez for the MANY hours she spent translating all nine handouts into Spanish.

39 RESOURCES OPTIMUS pdf Centers for Disease Control and Prevention. Tobacco Control State Highlight Accessed June 26, 2012, statistics / state_data/ state _highlights/2010/index.htm. Centers for Disease Control and Prevention. Smoking a Tobacco Use: State Data. Accessed June 26, 2001, / index.htm. 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, 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. University of Pittsburgh's Smoking Cessation: Practical. Skills for Healthcare Professionals Training Program. Accessed June 29, 2012, DocLibrary/Policy/Tobacco/Educational-Kit.aspx 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):