Academic Strategies to Influence Evidence- Based Tobacco Cessation Practices Janie Heath PhD, APRN-BC, FAAN Associate Dean Academic Programs & Professor of Nursing University of Virginia, School of Nursing Former Associate Dean of Academics College of Nursing & Director, Tobacco Cessation Nursing Faculty Practice Group Georgia Health Sciences University

Why Make Tobacco Control an Academic Initiative 46 million adults smoke (18.4% of population)  GEORGIA = 19.5% prevalence  VIRGINIA = 16.4% 1200 individuals DIE every day in U.S. because of tobacco use (450,000 / yr)  GEORGIA = 10,000 / yr  VIRGINIA = 9200 / yr Centers for Disease Control and Prevention. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010. Morbidity and Mortality Weekly Report 2011;60(33):1207–12 [accessed 2012 June 3].Vital Signs: Current Cigarette Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010

Why Make Tobacco Control an Academic Initiative It’s our MISSION  Improve health and reduce the burden of illness in society by discovering, disseminating, and applying knowledge of human health and disease It’s our EXPERTISE It’s our PASSION

Why Make Tobacco Control an Academic Initiative It’s all about OPPORTUNITY to promote health! Major Responsibilities  Chief Academic Officer (CAO) for Accreditation and Outcomes Assessment  CAO, Curriculum/Program development  CAO, Regulation of Academic/Student Affairs & Contracts Academic/Enterprise-wide Engagement  Strategic Planning  New Financial Model: Responsibility Based Budget  University Assessment Recent Funding  PI, HRSA DNP Acute Care APN Grant ($950,000) – 3 year  Ntl Panel, AHA, Effects of Smokeless Tobacco; Circulation 9/10  Co-I, NIH, AA Family Intervention for Smoking Cessation – 5 year

Student Reach with Tobacco Control – Rx for Change EDU  BSN students  Traditional  RN-BSN  MSN students  Clinical Nurse Leader  Primary Care NP  Acute Care NP and CNS  PMH NP and CNS  Health Mgmt Systems  Public Health Nursing Leadership  Post MS Certificate - 21 students  NP, CNS, Wound Ostomy Care  DNP - 38 students  PhD - 48 students  Doctoral exchange – 11 students TOTAL Projected UVA Tobacco Control Reach: 2012 Fall Enrollment = 723 students

Our MODEL for Optimal EBP Tobacco Cessation Outcomes Provide Training: Nsg EDU Nsg CE Provide Systems Support: Priority in Organizations Provide Research Funding: Organizations Federal Ensure Accountability: Licensure Certification Cessation Interventions= Standard of Nsg Practice Raise Awareness: Grassroots State National International Heath, J., Andrews, J. (2006). Translation of tobacco cessation interventions into clinical practice. Nursing Research, 55(4): S44-S50.

The REAP Framework National coalition of nurse educators established to help disseminate resources and information through a REAP framework for tobacco control  R = RESEARCH  E = EDUCATION  A = ADVOCACY  P = PRACTICE Founder: Dr. Janie Heath (MCG) Co-Founders: Dr. Jeannette Andrews, Medical University of South Carolina and Dr. Claudia Barone, University of Arkansas Medical Sciences

Georgetown University Medical College of Georgia University of Arkansas Vanderbilt University Medical University of South Carolina University of Virginia R esearch E ducation A dvocacy P ractice Application of REAP through Academic Partnerships

R esearch: Workforce Development To evaluate the effect of an advanced practice nurse driven EDU INTERVENTION to improve the effectiveness of tobacco cessation interventions among…  Acute Care Cardiology & Pulmonary Providers  PMH APRN Providers  Maternal Child Providers

Application of the Theory of Reasoned Action 10 Schematic drawing of Theory of Reasoned Action’s relationship to tobacco cessation interventions (TCI) adapted from Fishbein and Ajzen (2010)

Overview of Studies Pretest – Posttest; Descriptive Correlational Designs Convenience Samples in large academic medical centers with healthcare providers Fishbein-Azjen Theory of Reasoned Action Framework INTERVENTION- Rx for Change Clinician Assisted Tobacco Cessation* ( a 1 Hour Interactive DVD Education Sessionwww.rxforchange.edu 43 item survey

Overview of Selected Findings Knowledge Scores TRA Beliefs Change Intention Scores Amole, J., Heath, J., McLear, B,, & Thomas, J. (2012). Optimizing tobacco cessation strategies through an online continuing education program. Nursing Clinics of North America. 47: Heath, J., Kelley, J., Andrews, J., Crowell, N., Corelli, R., Hudmon, K.S. (2007). Evaluation of a tobacco cessation curricular intervention among acute care nurse practitioner faculty member. American Journal of Critical Care, 16(3): Heath, J. & Amole, J. (podium). Tobacco Control and Mental Illness: Breaking Barriers through NP Education, Practice and Research. The 36 th Annual Meeting of National Organization of Nurse Practitioner Faculties, Washington, DC; 4/17/10 Self- Confidence Correlations Alices, M, Manghram, D, Heath, J., Bennett, S. & Joshua, T ( poster). Tobacco Cessation Interventions among Acute-Care Providers in Respiratory Units. The National Teaching Institute and Critical Care Exhibition Conference, Chicago, IL; 5/4/11.

E ducation Research To evaluate the effect of the Rx for Change Clinician Assisted Tobacco Cessation Curriculum Intervention among pre-licensure interdisciplinary healthcare students  Nursing, Dental Hygiene & Respiratory Therapy  COMMIT - CNLs

Rx For Change Clinician Assisted Tobacco Cessation Curriculum – Based on USPHS Guideline and extensively reviewed by experts in tobacco control  Comprehensive > 350 CD-slides, ancillary handouts, evaluation measures, case studies Selected Modules  Epidemiology  Forms of tobacco  Genes & tobacco use  Pathophysiology  Nicotine addiction  Pharmacotherapy  Counseling techniques Access at R x for change Authors: Karen Hudmon RPh, DrPH Robin Corelli PharmD Education Intervention:

Overview of Studies Pretest – Posttest; Descriptive Correlational Designs Convenience Samples in large academic medical centers with students Fishbein-Azjen Theory of Reasoned Action Framework INTERVENTION- Rx for Change Clinician Assisted Tobacco Cessation* ( a 3 Hour Interactive Education Sessionswww.rxforchange.edu 43 item survey

Overview of Selected Findings Knowledge Scores TRA Beliefs Change Intention Scores Self- Confidence Correlations Kelley, J., Heath, J., Crowell, N. (2006). Using the Rx for change tobacco curriculum in advanced practice nursing education. Critical Care Nursing Clinics of North America,18(1): Inglett, S., Schumacher, A., Kiernan, B., & Heath, J. (poster). The Effect of a Service Learning Project on CNL Student’s Knowledge, Confidence, Beliefs, & Intentions to Intervene with Tobacco Dependent Women. 26 th Annual SNRS Conf, New Orleans, LA, 2/18/12 Inglett, S, Heath, J. (podium). Factors Influencing Undergraduate Nursing Students Intentions to Integrate Tobacco Cessation in Daily Practice. 5th Annual Uniting Practice, Education, and Research Conference, Beta Omicron & Pi Lambda Chapters, Sigma Theta Tau International, Augusta, GA; 2/23/10 Inglett, S., Schumacher, A., Kiernan, B., & Heath, J. (poster). Predictors for Intentions to Intervene with Tobacco Dependent Women: A CNL Student Learning Project. 16 th Annual Graduate Research Day, Georgia Health Sciences University, Augusta, GA 4/18/12

A dvocacy Outcomes  Tobacco Free Campus Initiative College of Nursing faculty leadership Student leadership  Service learning activities for students March of Dimes project  Media coverage The Augusta Chronicle Local TV Stations

Great American Smoke Out ~30 pre-licensure /yr ~5 post-licensure /yr ~ 4 faculty / yr Kick Butts Campaign ~18 pre-licensure / yr ~ 3 post-licensure / yr ~ 2 faculty /yr Employee Wellness Health Fair ~22 pre-licensure / yr ~ 4 post-licensure / yr ~ 2 faculty / yr Service Learning Outcomes for Students GHSU NSG, Respiratory Therapy & Dental Hygiene

Circle Of Motivated MOMs for Infants to be Tobacco- free (COMMIT) March of Dimes 12 mth funding Recruit 24 tobacco dependent women of child bearing age to participate in a 6 wk evidence based tobacco cessation program & follow up Service Learning Outcomes for Students GHSU NSG and 3 rd yr Pharmacy Students

P ractice Outcomes To evaluate the effect of an advanced practice nurse driven tobacco cessation clinic on health and cessation outcomes among  GHSU employees, staff, faculty and students Heath et al (2012). The impact of the Georgia Health Sciences University Nursing Faculty Practice on Tobacco Cessation Rates, Nurs Clin N Am (47)  PMH participants Funding per Tobacco Free Campus Initiative: University, Health System & Physician Practice Group

Nursing Faculty Practice Group (NFPG) and Tobacco GHSU How We Got There…  Administrative support Dean Lucy Marion has long history of promoting faculty practice All GHSU SON faculty receive 0.2 work effort for practice  New Facility 3700 Square foot; full services from laboratory space to 5 exam rooms

NFPG and Tobacco GHSU How We Got There… Faculty interest and expertise 22 members (33%) of NFPG in active practice 7 members (10%) of NFPG with tobacco control expertise Financial incentive 9% Dean’s fund, 9% Chair’s fund, 37% practice, 45% faculty

NFPG and Tobacco GHSU Nov 29 th, 2006 Town Hall Announcement; Nov 15 th, 2007 Tobacco Free Campus How We Got There…

Our Providers  Medical Evaluation and Management Janie Heath PhD, NP; Margo Henderson DNP, NP; Lovoria Williams MSN, NP; Pam Cromer MSN, NP Collaborating Physician: Dr. Sara Young – MCG-HI Family Medicine  Behavioral Counseling Nursing - Sharon Bennett DNP, CNS; Margaret Tuck MSN, CNS: Jack Amole DNP, CNS; Allied Health – Susan Whiddon MS, RT Our Staff  Jim Hawkins, NFPG Manager  Nita Sakovitz & Candice Yates, Clinic Coordinator Plus STUDENTS! The NFPG Tobacco Cessation Clinic GHSU Tobacco Cessation Program ~ weekly group sessions for 6 wks x 2 hours each ~ individual sessions for 4 wks x 2 hours each ~ telephone follow up 3mths, 6mths & 12mths

CLINICAL MEASURES: Objective:  Weight  Blood Pressure  Heart Rate  Carbon Monoxide (CO) Subjective (Self Report):  Medical & Tobacco History  Average Daily Cigarettes  Fagerstrom Level of Dependence Scale  CES-D Depression Scale  Readiness to Quit Ladder  Motivation to Quit Scale  Confidence to Quit Scale  Medication Tolerance NFPG Tobacco Cessation Clinic

EBP Treatment for Tobacco Dependence Counseling + Pharmacotherapy = Best Outcomes

27 The PHYSICAL The EMOTIONAL The BEHAVIOR Physical addiction of cravings & withdrawals Role of cigarettes in life— pleasure, stress, social Automatic learned behavior with cigarettes A Successful Approach to Break the Cycle of Tobacco Dependence Adapted from Legacy’s GSD&M Presentation 12/5/03 EBP Treatment for Tobacco Dependence

Male n = 72 (45%) Female n = 88 (55%) NFPG Tobacco Cessation Clinic Outcomes Heath et al (2012). Nurs Clin N Am (47) N = 160 completed program;

Married 53% Divorced 15% Other 5% Single 29% NFPG Tobacco Cessation Clinic Outcomes Heath et al (2012). Nurs Clin N Am (47) Demographic findings: n = 160 completed program;

African American 18% Caucasian 79% Other 1% Asian 3% NFPG Tobacco Cessation Clinic Outcomes Heath et al (2012). Nurs Clin N Am (47) Demographic findings: n = 160 completed program;

NFPG Tobacco Cessation Clinic Outcomes H&Ps Completed Program Start and Completion of Program: x178 Evaluated x160 Completed Heath et al (2012). Nurs Clin N Am (47) 1-12.

VariableMeanSDRange Tobacco Hx – 50 yrs. # of QUIT Attempts Fagerstrom /178 (93.89%) attempted to quit before NFPG Tobacco Cessation Clinic Outcomes 151 (85%) received Chantix as part of treatment at the NFPG Tobacco Cessation Clinic Heath et al (2012). Nurs Clin N Am (47) n = 160 completed program;

NFPG Tobacco Cessation Pharmacotherapy Outcomes 91% treated with medication (145/160) as mono-therapy or combination therapy: x6 NRT patch, x3 NRT gum, x5 NRT lozenge, x2 NRT inhaler; x4 Zyban; x138 Chantix; x15 No meds Chantix Start Pack Chantix Continuation Pack Heath et al (2012). Nurs Clin N Am (47) NRT Zyban Chantix 11% 3% 95% 75%

Pharmacotherapy Outcomes: Chantix Side Effect Profile NFPG Tobacco Cessation Clinic Outcomes Vivid Dreams 34% Nausea 34% Flatulence 5% Other 8% Sleeplessness 13% HA 3% Constipation 3% Comparison to Pfizer’s Phase 2 Trials of Chantix: Nausea = 30%; Insomnia = 18% Chantix Prescribing Information 2008 Insert, Pfizer, New York, NY

Group Session Quit Rate Individual Session Quit Rate Collective Quit Rates Tobacco QUIT End of 6 wk / 4 wk Treatment per Self Report & Carbon Monoxide Validation 64% 55% 66% NFPG Tobacco Cessation Clinic Outcomes

Follow Up Self- Report 3 mths Collective Tobacco QUIT Rates (no response = lost to follow up and/or assumed to relapse) 22% 36% 16% NFPG Tobacco Cessation Clinic Outcomes Follow Up Self- Report 6 mths Follow Up Self- Report 12 mths

NFPG Tobacco Cessation Clinic Outcomes Readiness to Quit Score p =.0034 QUIT RATES at End of Tx, 3, 6 and 12 mths compared to… Number of Group Sessions p =.0001 If Married p =.0312 Number of Individual Sessions p =.0001

PMH Tobacco Cessation Outcomes: 27 of 39 (69%) QUIT Quit Rates for Mental Illness and/or Substance Abuse Multiple PMH Disorders 3/9 (33%) Depression 17/22 (77% - QUIT at 6 wk tx) Substance Abuse 2/2 (100% - QUIT at 6 wk tx) Bipolar 0/2 (0% - QUIT at 6 wk tx) Anxiety 5/6 (83% - QUIT at 6 wk tx) Demographics: n = 39 with PMH Disorders (0.8%)

VariableMeanSDRange Tobacco Hx # of QUIT Attempts Fagerstrom /39 (100%) attempted to quit before NFPG Tobacco Cessation Clinic Outcomes for Mental Illness and/or Substance Abuse Demographics: n = 39 CES-D

NFPG Tobacco Cessation Clinic Outcomes for Mental Illness and/or Substance Abuse 79% on Chantix (31/39)81% on Chantix (25/31) 85% Group Session (33/39) QUIT Rates: EOT 69%, 3mths 10%; 6mths 12%; 12mths 7%

Academic Strategies to Influence Evidence-Based Tobacco Cessation Practices WORK !!! REAP into action for… Happy & Healthy EMPLOYEES/Patients! …and COUPLES..!

THANK YOU Janie Heath PhD, APRN-BC, FAAN