To evaluate the impact of a tobacco cessation training program on pharmacists' confidence, skills, and practice-change behaviors.
Wisconsin during 2002–2003.
25 community pharmacists.
A continuing education training program was developed and implemented using home and live training components consisting of the national tobacco cessation guidelines, including the 5A's counseling process. The home study component included lectures and readings in CD-ROM format. Consistent with self-efficacy theory, the live training was based on exercises that included modeling, rehearsal, and feedback to learners.
Main outcome measures
Knowledge assessment, pre- and postsurveys assessing confidence and skill levels, and service provision indicators.
Self-efficacy and perceived ability to counsel patients to quit using tobacco improved significantly after the combined program. No significant change in confidence or perceived skills occurred following home study alone, suggesting value in using a combination of teaching strategies (problem solving, modeling, rehearsal, and feedback). Of participants, 92% received a passing knowledge score and 75% attempted to implement a tobacco cessation service posttraining; more than 50% assisted patients up to 1 year posttraining. A relationship between self-efficacy and service provision was found when practice settings were considered.
This program increased pharmacists' knowledge and self-efficacy to counsel patients on tobacco use. Further, the majority of pharmacy participants attempted to implement a tobacco cessation service.
Self-efficacy; continuing education; counseling (patient); tobacco cessation
The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized.
To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings.
Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention.
Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices’ mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK.
This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit.
clinicaltrials.gov NCT00627185; http://clinicaltrials.gov/ct2/show/NCT00627185 (Archived by WebCite at http://www.webcitation.org/5c5Kugvzj)
Smoking cessation; Internet; general practice, dental; randomized controlled trial; health services research
This paper describes the follow-up interventions and results of the work place tobacco cessation study.
To assess the tobacco quit rates among employees, through self report history, and validate it with rapid urine cotinine test; compare post-intervention KAP regarding tobacco consumption with the pre-intervention responses and assess the tobacco consumption pattern among contract employees and provide assistance to encourage quitting.
Settings and Design:
This is a cohort study implemented in a chemical industry in rural Maharashtra, India.
Materials and Methods:
All employees (104) were interviewed and screened for oral neoplasia. Active intervention in the form of awareness lectures, focus group discussions and if needed, pharmacotherapy was offered. Medical staff from the industrial medical unit and from a local referral hospital was trained. Awareness programs were arranged for the family members and contract employees.
Statistical Analysis Used:
Non-parametric statistical techniques and kappa.
Forty eight per cent employees consumed tobacco. The tobacco quit rates increased with each follow-up intervention session and reached 40% at the end of one year. There was 96% agreement between self report tobacco history and results of rapid urine cotinine test. The post-intervention KAP showed considerable improvement over the pre-intervention KAP. 56% of contract employees used tobacco and 55% among them had oral pre-cancerous lesions.
A positive atmosphere towards tobacco quitting and positive peer pressure assisting each other in tobacco cessation was remarkably noted on the entire industrial campus. A comprehensive model workplace tobacco cessation program has been established, which can be replicated elsewhere.
Contract employees; focus group discussions; tobacco cessation; urine cotinine; workplace
Smoking cessation services in the Department of Veterans Affairs (VA) are currently provided via outpatient groups, while inpatient cessation programs have not been widely implemented.
The objective of this paper is to describe the implementation of the Tobacco Tactics program for inpatients in the VA.
This is a pre-/post-non-randomized control study initially designed to teach inpatient staff nurses on general medical units in the Ann Arbor and Detroit VAs to deliver the Tobacco Tactics intervention using Indianapolis as a control group. Coupled with cessation medication sign-off, physicians are reminded to give patients brief advice to quit.
Approximately 96% (210/219) of inpatient nurses in the Ann Arbor, MI site and 57% (159/279) in the Detroit, MI site have been trained, with an additional 282 non-targeted personnel spontaneously attending. Nurses’ self-reported administration of cessation services increased from 57% pre-training to 86% post-training (p = 0.0002). Physician advice to quit smoking ranged between 73–85% in both the pre-intervention and post-intervention period in both the experimental and control group. Volunteers made follow-up telephone calls to 85% (n = 230) of participants in the Ann Arbor site. Hospitalized smokers (N = 294) in the intervention group are reporting an increase in receiving and satisfaction with the selected cessation services following implementation of the program, particularly in regards to medications (p < 0.05).
A large proportion of inpatient nursing staff can rapidly be trained to deliver tobacco cessation interventions to inpatients resulting in increased provision of services.
implementation research; smoking cessation; veterans
This paper is a report of a study conducted to examine the effects of a brief training in the treatment of tobacco use and dependence on the tobacco use intervention-related knowledge and attitudes of nurses.
Nurses are the largest group of healthcare providers and they have an extended reach into the population of tobacco users. Thus, increasing the number of nurses who deliver brief evidence-based interventions for tobacco use and dependence, such as that prescribed by the Public Health Service Clinical Practice Guideline in the United States of America, is likely to expose more tobacco users to evidence-based treatments and lead to more successful quit attempts. However, effective training is key to improving provider proficiency in delivering evidence-based interventions for tobacco use and dependence.
A 1-hour didactic training was delivered to 359 nurses from 2006 to 2007, including 54 Advanced Practice Nurses, 250 Registered Nurses and 55 Licensed Practical Nurses. Pre-and post-training tests assessed attitudes, knowledge and behaviors. Paired samples t-tests were used to compare pre- and post-test results.
Statistically significant increases on nearly all measures were achieved, with registered nurses and licensed practical nurses realizing the largest gains.
Given the overwhelming impact of tobacco use on patients, all nurses should be provided with training in the delivery of brief, evidence-based interventions for tobacco use. As the most trusted healthcare provider group with a strong reach into the tobacco using population, nurses would have a large potential impact on the prevalence of tobacco use if they were adequately trained to provide interventions.
Training; nurses; treatment; tobacco; dependence; smoking cessation; primary health care
Tobacco use adversely affects oral health. Tobacco use prevention and cessation (TUPAC) counselling guidelines recommend that healthcare providers ask about each patient's tobacco use, assess the patient's readiness and willingness to stop, document tobacco use habits, advise the patient to stop, assist and help in quitting, and arrange monitoring of progress at follow-up appointments. Adherence to such guidelines, especially among dental providers, is poor. To improve guideline implementation, it is essential to understand factors influencing it and find effective ways to influence those factors. The aim of the present study protocol is to introduce a theory-based approach to diagnose implementation difficulties of TUPAC counselling guidelines among dental providers.
Theories of behaviour change have been used to identify key theoretical domains relevant to the behaviours of healthcare providers involved in implementing clinical guidelines. These theoretical domains will inform the development of a questionnaire aimed at assessing the implementation of the TUPAC counselling guidelines among Finnish municipal dental providers. Specific items will be drawn from the guidelines and the literature on TUPAC studies. After identifying potential implementation difficulties, we will design two interventions using theories of behaviour change to link them with relevant behaviour change techniques aiming to improve guideline adherence. For assessing the implementation of TUPAC guidelines, the electronic dental record audit and self-reported questionnaires will be used.
To improve guideline adherence, the theoretical-domains approach could provide a comprehensive basis for assessing implementation difficulties, as well as designing and evaluating interventions. After having identified implementation difficulties, we will design and test two interventions to enhance TUPAC guideline adherence. Using the cluster randomised controlled design, we aim to provide further evidence on intervention effects, as well as on the validity and feasibility of the theoretical-domain approach. The empirical data collected within this trial will be useful in testing whether this theoretical-domain approach can improve our understanding of the implementation of TUPAC guidelines among dental providers.
Current Controlled Trials ISRCTN15427433
Although smoking rates in the United States (US) are high, healthcare systems and clinicians can increase cessation rates through application of the US Public Health Service tobacco treatment guideline (2000, 2008). In primary care settings, however, guideline implementation remains low. This report presents the results from an assessment of patient tobacco use, quit attempts, and perceptions of provider treatment before (2004) and after (2010) guideline implementation.
By use of a systems approach, the Louisiana Tobacco Control Initiative integrated evidence-based treatment of tobacco use into patient care practices in Louisiana's public hospital system. This prospective study, designed to collect data at 2 time points for the purpose of evaluating the effect of the 5A protocol (ask, advise, assess, assist, and arrange), included 571 and 889 adult patients selected from primary care clinics in 2004 and 2010, respectively. Chi-square analyses determined differences between survey administrations, along with direct standardization of weighted rates to control for confounding factors.
Patient reports indicated that provider adherence to the 5A clinical protocol increased from 2004 to 2010. Significant (P<0.001) improvements were observed for the assess (39% vs 72%), assist (24% vs 76%), and arrange (8% vs 31%) treatment variables. Patient-reported quit attempts increased, along with awareness of cessation services (from 19% to 70%, P<0.001), while use of cessation medications decreased (from 23% to 5%, P<0.002).
Following implementation of the guideline, significant improvements were noted in patient reports of provider treatment and awareness of cessation services.
Guideline adherence; physician's practice patterns; smoking cessation
Quitting smoking is the most effective intervention to reduce mortality in patients with coronary artery disease who smoke. Guidelines for the treatment of tobacco dependency recommend that health care institutions develop plans to support the consistent and effective identification and treatment of tobacco users. The University of Ottawa Heart Institute (Ottawa, Ontario) has implemented an institutional program to identify and treat all smokers admitted to the Institute.
The objectives of the present paper are to describe core elements of this program and present data concerning its reach and effectiveness.
The goal of the program is to increase the number of smokers who are abstinent from smoking six months after a coronary artery disease-related hospitalization. Core elements of the program include: documentation of smoking status at hospital admission; inclusion of cessation intervention on patient care maps; individualized, bedside counselling by a nurse counsellor; the appropriate and timely use of nicotine replacement therapy; automated telephone follow-up; referral to outpatient cessation resources; and training of medical residents and nursing staff. Program reach and effectiveness were measured over a one-year period.
Between April 2003 and March 2004, almost 1300 smokers were identified at admission, and 91% received intervention to help them quit smoking. At six-month follow-up, 44% were smoke-free.
Hospitalization for coronary artery disease provides an important opportunity to intervene with smokers when their motivation to quit is high. An institutional approach reinforces the importance of smoking cessation in this patient population and increases the rate of smoking cessation. Posthospitalization quit rates should be a benchmark of cardiac program performance.
Coronary disease; Health care delivery; Prevention; Smoking
The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange), and 2) assess ED nurses’ and physicians’ perceptions of smoking cessation counseling.
The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians, and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses’ and physicians’ self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable linear regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.
Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted OR = 2.0, 95% CI = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5), and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians. ED nurses’ self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in “pros” and “cons” attitudes toward smoking cessation in either ED nurses or physicians.
Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.
In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity-based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients.
To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients.
A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived from international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article.
The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients’ lives.
Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.
Behavioural intervention; Smoking cessation; Tobacco
This study documented the tobacco use among male diabetes patients in a clinic-based population of urban India, patient reports of physician cessation messages and patients’ perception of tobacco use as a risk factor for diabetes complications. All the 444 male diabetes patients who attended three public sector hospitals in Thiruvananthapuram district, Kerala, were surveyed to ascertain their tobacco use as well as the frequency and content of quit messages received from health staff. A significant proportion (59%) of diabetes patients were tobacco users prior to diagnosis and more than half of them continued to use tobacco, many daily, even after diagnosis. Of the 100 current smokers, 75% were asked about their tobacco use at the time of diagnosis; of those, 52% were advised to quit. However, a lack of patient awareness existed regarding the linkages of smoking and diabetes complications. Notably, 52% of patients did not associate smoking with diabetes complications. Given the magnitude of tobacco use among diabetics, there is clearly a need for more proactive cessation efforts. The times of illness diagnosis, illness flare-ups and emerging illness complications are teachable moments when patients are primed to change their behavior and more motivated to quit tobacco.
Smoking cessation counseling by health professionals has been effective in increasing cessation rates. However, little is known about smoking cessation training and practices in transition countries with high smoking prevalence such as Armenia. This study identified smoking-related attitudes and behavior of physicians and nurses in a 500-bed hospital in Yerevan, Armenia, the largest cancer hospital in the country, and explored barriers to their effective participation in smoking cessation interventions.
This study used mixed quantitative and qualitative methods. Trained interviewers conducted a survey with physicians and nurses using a 42-item self-administered questionnaire that assessed their smoking-related attitudes and behavior and smoking cessation counseling training. Four focus group discussions with hospital physicians and nurses explored barriers to effective smoking cessation interventions. The focus group sessions were audio-taped, transcribed, and analyzed.
The survey response rate was 58.5% (93/159) for physicians and 72.2% (122/169) for nurses. Smoking prevalence was almost five times higher in physicians compared to nurses (31.2% vs. 6.6%, p < 0.001). Non-smokers and ex-smokers had more positive attitudes toward the hospital’s smoke-free policy compared to smokers (90.1% and 88.2% vs. 73.0%). About 42.6% of nurses and 26.9% of physicians reported having had formal training on smoking cessation methods. While both groups showed high support for routinely assisting patients to quit smoking, nurses more often than physicians considered health professionals as role models for patients.
This study was the first to explore differences in smoking-related attitudes and behavior among hospital physicians and nurses in Yerevan, Armenia. The study found substantial behavioral and attitudinal differences in these two groups. The study revealed a critical need for integrating cessation counseling training into Armenia’s medical education. As nurses had more positive attitudes toward cessation counseling compared to physicians, and more often reported having cessation training, they are an untapped resource that could be more actively engaged in smoking cessation interventions in healthcare settings.
Smoking cessation; Smoke-free hospital policy; Survey research; Qualitative research; Healthcare professionals; Physician smoking; Armenia; Transition economies
OBJECTIVE—To review the evidence base underlying recommended cessation counselling for pregnant women who smoke, as it applies to the steps identified in the Agency for Healthcare Research and Quality's publication, Treating tobacco use and dependence: a clinical practice guideline.
DATA SOURCES—Secondary analysis of literature reviews and meta-analyses.
DATA SYNTHESIS—A brief cessation counselling session of 5-15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials, significantly increases rates of cessation among pregnant smokers. This low intensity intervention achieves a modest but clinically significant effect on cessation rates, with an average risk ratio of 1.7 (95% confidence interval 1.3 to 2.2). There are five components of the recommended method—"ask, advise, assess, assist, and arrange".
CONCLUSIONS—We recommend these evidence based procedures be adopted by all prenatal care providers. The use of this evidence based intervention is feasible in most office or clinic settings offering prenatal care and can be implemented without inhibiting other important aspects of prenatal care or disrupting patient flow. If implemented widely, this approach has the potential to achieve an important reduction in a number of adverse maternal, infant, and pregnancy outcomes and to reduce associated, excess health care costs.
Keywords: smoking cessation; pregnancy
Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations.
This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis.
Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95%CI = 2.13-9.88).
Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.
The vast majority of individuals receiving substance abuse treatment also use tobacco, which suggests that smoking cessation is an important clinical target for most clients. Few studies have measured the extent to which addiction treatment counselors address clients’ tobacco use. In this study, we examined counselors’ implementation of brief interventions that are consistent with the US Public Health Service’s clinical practice guideline, Treating Tobacco Use and Dependence, when counselors are engaging new clients in treatment. We hypothesized that counselors’ implementation of tobacco-related brief interventions is associated with organizational and counselor-level factors. Data were collected from 2,067 counselors via mailed surveys. Implementation of recommended brief interventions during intake was significantly lower among counselors reporting greater barriers to smoking cessation services within their organizational context. Perceived managerial support for smoking cessation services was positively associated with implementation. Counselors with greater knowledge of the PHS guideline and who believed in the positive impact of smoking cessation interventions on sobriety reported greater implementation. Relative to counselors who have never been tobacco users, current tobacco users reported significantly lower implementation of these brief interventions. These findings suggest that attempts to increase the implementation of best practices in substance abuse treatment may require attention to organizational contexts and the individuals responsible for implementation.
implementation research; smoking cessation brief interventions; counselors
Although tobacco cessation training is included in many health profession programs, it is not yet routinely incorporated into chiropractic education. The purpose of this study was to assess the feasibility of incorporating a problem-based learning tobacco cessation activity into a lecture course for chiropractic students.
Seventy-two students were assigned to participate in two 1-hour lectures on health promotion counseling and tobacco cessation followed by an experiential student-driven lab session using standardized patients at various stages of dependency and willingness to quit. The intervention was based on the transtheoretic model and the “5 A's” of counseling (ask, advise, assess, assist, arrange). Outcomes were assessed via (1) questionnaires completed by the standardized patients regarding the students' use of the 5A's, and (2) questionnaires completed by the students using a 5-point Likert scale of “strongly disagree” to “strongly agree” on the acceptability of this method of learning. Descriptive statistics were computed.
Sixty-eight students (94%) completed the activity, spending a median of 2.5 minutes with patients. Over 90% addressed 4 of the 5A's: 99% asked patients if they were smokers; 97% advised them to quit; 90% assessed if they were willing to quit; and 99% offered assistance in quitting. Only 79% arranged a follow-up visit. Overall, students expressed a positive response to the experience; 81% said it increased their confidence in being able to advise patients, and 77% felt it would be valuable for use in their future practice.
This active learning exercise appeared to be a feasible way to introduce tobacco counseling into the curriculum.
Chiropractic; Education Assessment; Learning, Problem-Based; Tobacco Cessation
Objective: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres.
Design: Pre- and post-trial.
Setting: Fourteen community health centres in Rhode Island.
Subjects: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up.
Interventions: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building.
Outcome measures: Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit.
Results: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points.
Conclusions: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.
Cigarette Smoking is the leading cause of preventable mortality and morbidity in the United States. Healthcare providers can contribute significantly to the war against tobacco use; patients advised to quit smoking by their physicians are 1.6 times more likely to quit than patients not receiving physician advice. However, most smokers do not receive this advice when visiting their physicians. The Morehouse School of Medicine Tobacco Control Research Program was undertaken to develop best practices for implementing the “2000 Public Health Services Clinical Practice Guidelines on Treating Tobacco Use and Dependence” and the “Pathways to Freedom” tobacco cessation program among African American physicians in private practice and healthcare providers at community health centers. Ten focus groups were conducted; 82 healthcare professionals participated. Six major themes were identified as barriers to the provision of smoking cessation services. An intervention was developed based on these results and tested among Georgia community-based physicians. A total of 308 charts were abstracted both pre- and post-intervention. Charts were scored using a system awarding one point for each of the five “A’s” recommended by the PHS guidelines (Ask, Advise, Assess, Assist, Arrange) employed during the patient visit. The mean pre-intervention five “A’s” score was 1.29 compared to 1.90 post-intervention (P < 0.001). All charts had evidence of the first “A” (“asked”) both pre- and post-intervention, and the other four “A’s” all had statistically significant increases pre-to post-intervention.
The results demonstrate that, with training of physicians, compliance with the PHS tobacco guidelines can be greatly improved.
Five “A’s”; Smoker; Smoking cessation; Training physicians; Tobacco
Tobacco is a significant risk factor for oral diseases. Dental care providers have the opportunity to inform patients about the risks associated with tobacco use and refer them to tobacco cessation resources. Although dental teams usually ask their patients about their tobacco use, most do not provide tobacco cessation counseling.
This project involved four staff-model dental clinics and four contracted network dental clinics. Project goals were to 1) describe current practice patterns of tobacco cessation intervention, 2) increase the use of steps for treatment, known as the 5 As, recommended by the U.S. Public Health Service, 3) increase referrals to a tobacco helpline, and 4) increase use of pharmacotherapy for tobacco dependence treatment. The project included training and program support (e.g., sharing of project data, weekly newsletters, discussion at clinic meetings). Results indicate that this approach to addressing tobacco dependence in a dental clinic setting can effectively change dental provider knowledge and action.
Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.
A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.
While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.
Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.
OBJECTIVE—To describe the development and preliminary results from a community based certification model for training in tobacco cessation skills in Arizona.
DESIGN—A programme evaluation using both quantitative pre-post measures and qualitative methods.
SETTING—Arizona's comprehensive tobacco control programme of state funded, community based local projects and their community partners providing tobacco treatment services for geographically, socioeconomically, and ethnically diverse communities.
INTERVENTION—A three tiered model of skills based training emphasising Agency for Health Care Policy and Research guidelines, and utilising a training of trainers approach to build community capacity. Certification roles addressed basic tobacco cessation skills, tobacco cessation specialist, and tobacco treatment services manager.
PARTICIPANTS—Initial target audience was community based local project personnel and their community partners, with later adoption by community organisations unaffiliated with local projects, and the general public.
MAIN EVALUATION MEASURES—Process measures: participant satisfaction, knowledge, skills, and self-efficacy. Outcome: participant demographics, community organisations represented, post-training, cessation related activities.
RESULTS—During the model's implementation year, 1075 participants attended certification training, 947 participants received basic skills certificates and 82 received specialist certificates. Pre, post, and three month measures of self efficacy showed significant and durable increases. Analysis of participant characteristics demonstrated broad community representation. At post-training follow up, 80.9% of basic skills trainees had performed at least one brief intervention and 74.8% had made a referral to intensive services. Among cessation specialists, 48.8% were delivering intensive services and 69.5% were teaching basic skills classes.
CONCLUSIONS—Initial experience with Arizona's state wide, community based model for certification of tobacco cessation skills training suggests this model may be a promising method for broad, population based diffusion of evidence based tobacco cessation guidelines.
Keywords: tobacco cessation; certification; population based; training
Tobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains.
A 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature.
Internal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, α = 0.86), capability (13.3% of variance, α = 0.83), and opportunity (10.0% of variance, α = 0.71).
This study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions.
The objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved.
This effectiveness study will be a quasi-experimental design of six Michigan community hospitals of which three will get the nurse-administered Tobacco Tactics intervention and three will provide their usual care. In both the intervention and usual care sites, research assistants will collect data from patients on their smoking habits and related variables while in the hospital and at thirty days and six months post-recruitment. The intervention will be integrated into the experimental sites by a research nurse who will train Master Trainers at each intervention site. The Master Trainers, in turn, will teach the intervention to all staff nurses. Research nurses will also conduct formative evaluation with nurses to identify barriers and facilitators to dissemination.
Descriptive statistics will be used to summarize the results of surveys administered to nurses, nurses’ participation rates, smokers’ receipt of specific cessation services, and satisfaction with services. General estimating equation analyses will be used to determine differences between intervention groups on satisfaction and quit rates, respectively, with adjustment for the clustering of patients within hospital units. Regression analyses will test the moderation of the effects of the interventions by patient characteristics. Cost-effectiveness will be assessed by constructing three ratios including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved.
Given that nurses represent the largest group of front-line providers, this intervention, if proven effective, has the potential for having a wide reach and thus decrease smoking, morbidity and mortality among inpatient smokers.
Dissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217
Smoking; Cessation; Inpatient
Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm.
To study hospital workplace culture relevant to tobacco use and control as part of a mixed‐methods research project that investigated hospital‐based registered nurses' integration of cessation interventions.
The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient‐care documents on 16 adult in‐patient wards.
The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence.
Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.
tobacco control; cessation strategies; hospitals; nursing; ethnography
To determine the tobacco-related knowledge, attitudes, and practice behaviors among US pediatric dentists.
A survey was conducted in 1998 among a national, random sample of 1500 American Academy of Pediatric Dentistry members. Chi-square tests and logistic regression with odds ratios (ORs) and 95% confidence intervals assessed factors related to pediatric dentists' tobacco control behaviors.
Response was 65% for the survey. Only 12% of respondents had prior tobacco prevention/cessation training. Of those untrained, 70% were willing to be trained. Less than two-thirds correctly answered any of four tobacco-related knowledge items. Over one-half agreed pediatric dentists should engage in tobacco control behaviors, but identified patient resistance as a barrier. About 24% of respondents reported always/often asking their adolescent patients about tobacco use; 73% reported always/often advising known tobacco users to quit; and 37% of respondents always/often assisting with stopping tobacco use. Feeling prepared to perform tobacco control behaviors (ORs = 1.9–2.8), a more positive attitude score (4 points) from 11 tobacco-related items (ORs = 1.5–1.8), and a higher statewide tobacco use prevalence significantly predicted performance of tobacco control behaviors.
Findings suggest thatraining programs on tobacco use and dependence treatment in the pediatric dental setting may be needed to promote tobacco control behaviors for adolescent patients.