1. November, 2005 Iowa Department of Public Health

2. Tobacco Use in Iowa Approximately 4,600 tobacco- related deaths annually 20% of high school students are current smokers (2004 IYTS) 20.3% of adults are current smokers (2004 IATS) Annual health care costs directly caused by smoking - $937 million

3. Intervention Model for Patients Willing to Discuss Quitting ASK about tobacco use ADVISE to quit REFER patient to cessation resources This step relieves a practitioner of responsibility for the final 3 As (Assess, Assist, Arrange)

4. Step 1: Ask Systematically ask every patient about tobacco use at every visit. Determine if patient is current, former, or never tobacco user. Determine what form of tobacco is used. Determine frequency of use. Document tobacco use status in the medical record.

5. Step 2: Advise In a clear, strong, and personalized manner, urge every tobacco user to quit. Tobacco users who have failed in previous quit attempts can be assured that most people make repeated attempts before they are successful. Employ the teachable moment: link visit findings with advice.

6. Step 3: Refer Assess if patient is willing to discuss quitting Assist those who are willing by providing information about Quitline Iowa Use proactive referral Request written permission to fax contact information to Quitline Iowa Inform the patient that Quitline Iowa program staff will provide follow-up Follow-up at next visit – repeat process if necessary

7. Fax Referral Program Efficient method for referring patients who smoke to effective cessation services Research indicates that physician referral of patients to smoking cessation programs is associated with a significantly higher participation rate than simply telling patients they should stop smoking Alleviates some of the problems posed by limited time and resources Takes the burden of initiating services off of the patient

8. How Fax Referral Works 1. HCP/clinician identifies patient as a smoker willing to discuss quitting 2. HCP/clinician educates patient on services of Quitline Iowa 3. Patient completes information on fax referral form providing consent for HCP/clinician to release information to Quitline Iowa to initiate counseling 4. Based on times provided by patient, Quitline Iowa staff contact patient to begin cessation counseling 5. Quitline Iowa provides feedback to HCP/clinician on status of patient – check-off box on fax referral form

9. Quitline Iowa Benefits Effective, research-based cessation resource Less time spent on tobacco cessation counseling during patient appointments Increase in the number of patients who receive cessation counseling and who ultimately quit No additional investment in materials, training, or other programs needed

10. What is Quitline Iowa? Toll-free hotline available to all Iowans, including pregnant women and teens Staffed 8 a.m. to midnight, seven days a week Services in English & Spanish Interpreters available for most other languages TDD line, 1-866-822-2857 Offers Comprehensive and Intensive counseling programs; tailored to clients needs

11. Who Provides Quitline Iowa Services? Operated by the Iowa Tobacco Research Center in the Department of Community and Behavioral Health, University of Iowa John Lowe, DrPH, FAHPA, FAAHB Director, ITRC Mary Aquilino, Ph.D., MSN, FNP Deputy Director, ITRC Funded by the Division of Tobacco Use Prevention & Control, Iowa Department of Public Health

12. Quitline Iowa Staff Quitline Iowa currently employs 11 part-time counselors (FTE=2.93). Graduate students in counseling psychology, rehabilitation counseling, health education, nursing and related fields Professional therapists and educators New counselors receive comprehensive training in treatment of tobacco dependence, motivational interviewing and cognitive behavioral therapy techniques. Counselors receive continuing education through training sessions, monthly meetings and materials such as research articles and tip sheets. Other staff include program coordinator, training coordinator/advanced counselor, program manager, research assistant and half-time database manager.

13. Quitline Iowa Services Counseling treatment for tobacco users who want to quit Information for friends, family and others concerned about someones tobacco use Educational and self-help materials for anyone interested in quitting Referrals to local tobacco cessation programs and services. NRT coupon programs to provide financial assistance for smokers, available by county residency or health services providers

14. Transtheoretical Model and Stages of Change PRECONTEMPLATION: Not thinking of quitting, does not see a problem CONTEMPLATION: Examines smoking and potential to quit in a risk-reward analysis PREPARATION: Makes a commitment to quit and develops a quit plan ACTION: Has quit smoking (for under 6 months) and is implementing a quit plan MAINTENANCE: Has been smoke free for an extended period of time (over 6 months) and all associated changes are consolidated into lifestyle Prochaska and DiClemente, (1984)

15. Quitline Iowa Cessation Programs Comprehensive Program Assess stage of change Create quit plan if applicable Mail materials Follow up at 1, 2, 4 weeks Intensive Program Intake questionnaire One-on-one counseling in up to 10 sessions Excellent for heavy smokers

16. Effectiveness of Quitlines Research indicates smokers who receive telephone cessation counseling double their chances of staying quit; e.g.: Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone quitline for smokers. New England Journal of Medicine Borland, et al., 2001. The effectiveness of callback counseling for smoking cessation: a randomized trial. Addiction A meta-analysis of 27 studies of the efficacy of telephone quitlines indicates that proactive telephone counseling is more effective compared to interventions without personal contact, such as self-help materials. Stead, et al., 2003Cochrane Database of Systemic Reviews A study of NRT added to quitline counseling indicates that the combination increases the likelihood of quitting. Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine replacement therapy in a "real-world" setting. Preventive Medicine

17. Quitline Iowa Results Quitline Iowa quit rates: FY 2005 FY 2004 Smoke free for any period (24 hours or more) 73%58% Smoke free for 30 days or more 40%39%

18. For More Information Esther Baker, Program Coordinator Phone: 319-384-4845 Fax: 319-384-4841 E-mail: esther-baker@uiowa.eduesther-baker@uiowa.edu Jeanie Kimbel, Training Coordinator Phone: (319) 384-4842 Fax: (319) 384-4841 E-mail: jeanine-kimbel@uiowa.edujeanine-kimbel@uiowa.edu @ 2005 The University of Iowa. All rights reserved.