Transcript Smoking Cessation Program

Evidence-based practice:
Smoking Cessation Program
SMOKING CESSATION
Utilizing Evidence Based Guidelines To Establish An
Appropriate Standard of Care For Persons With Severe And
Persistent Mental Illness.
Donald N. Rose, MN, RN
Nancy Burke, MSN, RN
Evidence-based practice:
Smoking Cessation Program
• Our beginnings
– Integrated Health Care Centers
• an innovative model for advanced nursing practice
• a community-focused collaboration
– UIC College of Nursing
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http://www.uic.edu/nursing/index.html/
– Thresholds Psychiatric Rehabilitation
– http://www.thresholds.org/
– Purpose of the centers
• improve access to care for Thresholds members
• provide integrated mental health and primary care
Evidence-based practice:
Smoking Cessation Program
• Goals of the centers
• To improve health outcomes
– through tailored, integrated care by APNs
• To provide high-quality clinical education
– nurses, physicians, and allied health
• To develop evidence-based guidelines
– for integrated care of common problems
• To become financially self-sufficient
– through APN reimbursement
Evidence-based practice:
Smoking Cessation Program
• The Integrated Health Care Centers
Thresholds South
South side Chicago
Young Adult Program
North side of Chicago
Evidence-based practice:
Smoking Cessation Program
• Our Integrated Health Care providers
– psychiatric clinical nurse specialist faculty
– nurse practitioner faculty
– undergraduate and graduate nursing students
Evidence-based practice:
Smoking Cessation Program
• Our Integrated Health Care services
• Mental health care
– individual, group, and family therapy
• Primary health care
– health histories and physical exams
– health screening and preventive care
– diagnosis and treatment of health problems such as colds
and flu, diabetes, hypertension, STDs
• Health education groups
– nutrition, exercise, stress, smoking cessation
Evidence-based practice:
Smoking Cessation Program
Funding
•Division of Nursing
– $1,226,435 Grant # 1 D11 HP 00152-01
–The content and conclusions are those of the author and should not
be construed as the government’s official position.
•Robert Wood Johnson
•Chicago Community Trust
•Visiting Nurses Association-Chicago
•Washington Square Health Foundation
Evidence-based practice:
Smoking Cessation Program
Objectives
– To review and discuss recent literature regarding smoking
cessation for persons with severe and persistent mental
illness.
– To discuss the socioeconomic and health related impact of
smoking for this population.
– To discuss a pilot program designed to decrease smoking
for persons with severe and persistent mental illness.
Evidence-based practice:
Smoking Cessation Program
Goals of Objective 1
– To review evidence based practice guidelines.
– To review existing smoking cessation programs for
persons with SPMI.
– To describe pharmacological therapies utilized in
smoking cessation programs.
Evidence-based practice:
Smoking Cessation Program
Hierarchy of Levels of Evidence for Evidence-Based
Practice
Level I
– Strong evidence from at least one systematic review of multiple
well designed RCTs.
Level II
– Strong evidence from at least one properly designed RCT of
appropriate size.
Level III
– Evidence form well-designed trials without randomization, single group
pro-post, cohort, time series or matched case-controlled studies.
Evidence-based practice:
Smoking Cessation Program
Hierarchy of Levels of Evidence for Evidence-Based
Practice
• Level IV
– Evidence form well-designed nonexperimental studies from more
than one center or research group.
• Level V
– Opinions of respected authorities, based on clinical evidence,
descriptive studies, or reports of expert committees.
Moore, A., McQuay, H. & Gray, J. A. M. (1995)
Evidence-based practice:
Smoking Cessation Program
• Public Health Service Guideline (2000)
Treating Tobacco Use and Dependence
– Every clinic should implement a tobacco-user
identification system.
– All health care systems should provide education,
resources, and feedback to promote provider
interventions.
– Clinical sites should dedicate staff to provide tobacco
dependence treatment and assess the delivery of this
treatment in staff performance evaluations.
Evidence-based practice:
Smoking Cessation Program
• PHS Guideline (2000)
Treating Tobacco Use and Dependence
– Hospitals should promote policies that support and
provide tobacco dependence services.
– Insurers and managed care organizations (MCOs)
should include tobacco dependence treatments (both
counseling and pharmacotherapy) as paid or covered
services for all subscribers or members of health
insurance packages.
– Insurers and MCOs should reimburse clinicians and
specialists for delivery of effective tobacco dependence
treatments and include these interventions among the
defined duties of clinicians.
Evidence-based practice:
Smoking Cessation Program
Smoking Cessation
• Van Dongen, C. J., Kritz, P., Fox, K. A., & Haque, I. (1999)
– Conducted a Pilot Study on the implementation of a quit smoking
group for persons with SPMI.
• Van Dongen, C. J. (1999)
– An Exploratory Study that examined the experience of smoking and
its effects on the lives of persons with SPMI.
Evidence-based practice:
Smoking Cessation Program
Smoking Cessation
• Lasser, K., Boyd, J., Woolhandler, S., Himmelstein, D.,
McCormick, D., & Bor, D. (2000)
– A Population-Based Prevalence Study to assess rates of smoking
and tobacco cessation in adults with/without mental illness.
• Cataldo, J. K., & Talley, S. (2000)
– Article reviewed the recently published PHS clinical practice
guidelines for related to smoking cessation.
Evidence-based practice:
Smoking Cessation Program
Pharmacological Therapies
• Five first-line pharmacotherapies were identified that
reliably increase long-term smoking abstinence rates:
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Bupropion SR.
Nicotine gum.
Nicotine inhaler.
Nicotine nasal spray.
Nicotine patch.
Evidence-based practice:
Smoking Cessation Program
Pharmacological Therapies
• Two second-line pharmacotherapies were identified as
efficacious and may be considered by clinicians if first-line
pharmacotherapies are not effective:
– Clonidine.
– Nortriptyline.
• Over-the-counter nicotine patches are effective relative to
placebo, and their use should be encouraged.
Evidence-based practice:
Smoking Cessation Program
Goals Objective 2
– To discuss the socioeconomic and health related impact of
smoking with the SPMI.
– To discuss the correlation between nicotine and psychotropic
medications.
Evidence-based practice:
Smoking Cessation Program
Socioeconomic Impact
• The societal costs of tobacco death and disease approach
$100 billion.
• Americans spend an estimated $50 billion annually on
direct medical care for smoking-related illnesses.
• Lost productivity and forfeited earnings due to smokingrelated disability account for another $47 billion per year.
• Research shows that delivering treatment to tobacco users
is cost-effective.
– average cost per smoker for effective cessation
treatment is $165.61.
Evidence-based practice:
Smoking Cessation Program
Physical Health Impact
• One in every five deaths in the US is smoking related.
• Tobacco is responsible for more than 430,000 deaths each
year.
• Increased risk for:
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Cardiovascular disease
Lung disease
Chronic Obstructive Pulmonary Disease
Cancer
Evidence-based practice:
Smoking Cessation Program
Physical Health Impact
• Research data indicate that 60%-90% of individuals with
SPMI smoke as compared with a 25% smoking rate in the
general population.
• Estimated 40%-50% anxiety or depression
– Estimated 70%-90% chronic schizophrenia
• Data from Thresholds South indicate that 70% of the
members smoke.
Evidence-based practice:
Smoking Cessation Program
Nicotine & Psychotropic Medications
• Smokers on psychotropic medications probably require
higher doses than nonsmokers due to effect of
hydrocarbons on liver enzymes.
– Dalack & Glassman, 1992,
– Lohr, J. B. & Flynn, K. 1992.
Evidence-based practice:
Smoking Cessation Program
Goals of Objective 3
• To review Thresholds South focus group findings.
• To discuss how the smoking cessation program at
Thresholds South:
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Program design
Assessment tools
Implementation strategies
Outcomes
Evidence-based practice:
Smoking Cessation Program
Focus group findings
• 70 % of Thresholds South members smoke
• Members were able to identify that smoking is a significant
health issue
Evidence-based practice:
Smoking Cessation Program
Program design
• Nursing students in their mental health practica at
Thresholds South
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Co-lead focus groups
Conducted staff/member needs assessment
Conducted literature reviews
Used a group project to formulate final written proposal
Collaborated with the onsite PCNS, FNP and clinical instructor.
Utilized Stages of Change model (Prochaska JO, DiClemente CC,
Norcross JC. In search of how people change. Am Psychol
1992;47:1102-4).
Evidence-based practice:
Smoking Cessation Program
• Assessment tools
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Addiction assessment
Financial impact assessment
Medication evaluation
NRT evaluation
Evidence-based practice:
Smoking Cessation Program
Implementation strategies
• Program combined change model with activities in each
learning domain
– Cognitive
– Affective
– Behavioral
Evidence-based practice:
Smoking Cessation Program
Precontemplation stage
• Goal: patient will begin thinking about change.
• Activities:
– Education groups
– Assessments
Evidence-based practice:
Smoking Cessation Program
Contemplation stage
• Goal: patient will examine benefits and barriers to change.
• Activities:
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Journaling
Smoking logs
Collages
Art projects
Quit date
Evidence-based practice:
Smoking Cessation Program
Action stage
• Goal: patient will take decisive action.
• Activities:
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Sign contract
Celebratory activities
NRT implementation
Weekly group
Daily individual contact PRN
Evidence-based practice:
Smoking Cessation Program
Maintenance stage
• Goal: patient will incorporate change into daily lifestyle.
• Activities:
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Support groups
Education groups
Exercise groups
Nutrition groups
RELAPSE PREVENTION
Evidence-based practice:
Smoking Cessation Program
Outcomes
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12 to 15 started program including 3 staff members
2 staff members are still smoke free after 18 months
10 members signed quit contracts
5 used patch and/or medication and quit smoking for some
period of time
• 4 quit program after 4 to 6 weeks
• 1 quit for three months and is again in the action stage
Evidence-based practice:
Smoking Cessation Program
Clinical Considerations
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Continual contact and support
Students bring fresh ideas and enthusiasm each rotation
Must be multifaceted using many activities
Normalize all reactions, especially relapse
Non-judgmental and encouraging approach
More emphasis on the precontemplation stage and smoking
reduction
• Several smoke free days per year
Evidence-based practice:
Smoking Cessation Program
CONCLUSION
• Challenges
– Incorporating the components of smoking cessation programs into
everyday clinical practice (Cataldo & Talley, 2000).
– Smoking and smoking cessation should be part of the core
curriculum and basic training of all health professionals (Rigotti &
Thorndike, 2001).
– Further research is needed in the neurobiological and
psychosocial aspects of smoking (Van Dongen, 1999) .