SPECIAL SESSION: Development, Implementation, and Dissemination of the Nurse-Administered Tobacco Tactics Intervention

Description/Overview: Introduction Smoking cessation services are often provided by outpatient groups or 1-800-QUIT-NOW telephone lines. Yet these groups and telephone lines reach less than 10 percent of smokers. Nurses are ideally positioned to deliver smoking cessation interventions because they have repeated access to the patient during diagnosis, treatment, and follow-up, can relate the consequences of smoking to the patients’ medical illness, can initiate physicians' orders for medications, and generally have good rapport with their patients. While a meta-analysis showed that nurse-administered cessation interventions are efficacious, they are seldom implemented due to lack of training and time. This presentation will discuss the development, efficacy and effectiveness testing, and dissemination of the Tobacco Tactics intervention highlighting concepts that can be applied to developing, testing, and disseminating other nursing interventions. Efficacy Testing Relatively few smoking cessation clinical trials have focused on smokers with cancer, and most studies were under-powered. Only two, one by PI Duffy, were found to be efficacious. PI Duffy conducted a randomized controlled trial (N = 184) to test the efficacy of the Tobacco Tactics intervention among head and neck cancer patients in a Department of Veterans Affairs (VA) (IIR 98-500) and foundation-sponsored study. There was a significant difference in six-month smoking cessation rates, with 47% quitting in the intervention group compared to 31% quitting in the usual care group (p < 0.05). Ninety percent of participants said they would recommend the intervention and its manual to someone else dealing with similar issues. Patients in the study said: “If a person reads and studies the manual, it can’t help but change his or her life.” “The program did what I was trying to do for 20 yrs.” “Reinforced the fact that I was not unique in my reactions to cancer, smoking and moods.” As with many efficacy studies, the intervention was not maintained and ended when the trial ended. Effectiveness Testing Next, the Tobacco Tactics intervention was packaged into a toolkit for inpatient nurses and smokers in the VA (SDP 06-003). Reach: Compared to the usual care site, patients in the intervention sites reported an increase in receipt and satisfaction of selected cessation services, particularly medications (p < 0.05). Effectiveness: Six-month quit rates improved from pre- to post-intervention in Ann Arbor (p = 0.004) and Detroit (p < 0.001), both of which serve a large African American population, compared to the Indianapolis control site (n = 1,070). Adoption and Implementation: A total of 369 (74%) targeted nurses and 282 non-targeted personnel were trained in the Tobacco Tactics intervention. Nurses’ self-reported administration of smoking cessation services increased from 57% pre- to 86% post-training (p = 0.0002). The intervention was incorporated into new nurse training, and maintenance was high; the programs remain in place three years after the study ended. The intervention was exported to another VA via satellite broadcast, where it has continued to be implemented two years after the study ended and the program is currently being exported other VAs. Based on this work, a recently completed National Institutes of Health (NIH)-supported study (U01HL105218) tested the dissemination of the Tobacco Tactics intervention in the inpatient setting among five community hospitals outside the VA. Of all targeted nurses, 76% (n = 1,028) were trained. Reach: Among the 1,370 smokers, there were significant pre- to post-intervention increases in the intervention hospitals in self-reported receipt of print materials (p < 0.001). Effectiveness: In the intervention hospitals, pre- to post-intervention six-month quit rates significantly increased from 5.7% to 16.5% (p < 0.001), while there were no changes in quit rates in the control hospitals. Adoption: In the intervention hospitals, 76% (n = 1,028) of targeted nurses and 317 additional staff participated in the training, and 90% were extremely/somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing counseling, medications, handouts, and video (p < 0.05) and decreased barriers to providing smoking cessation services (p < 0.001). Maintenance: Nurses continued to provide the intervention after the study ended. At the end of the study, the nurses in the control hospitals were also trained. An e-mail from a nurse follows. “…just a few short hours after I was in your tobacco tactics class on Monday... I was taking care of a patient who smoked a pack a day and had wanted to quit for a long time. I sat down with her and told her how important it was for her health to quit smoking (yes, I used the phrase)! She agreed and said that she really wanted to quit but that she wasn't ready because she needed help. I reminded her that she wasn't going to be smoking while she was here (we had her on a nicotine patch) and that now would be a great time to quit. She agreed and said how she has her son's wedding coming up in December and she would love to be smoke-free by then. I explained how that would be an excellent goal and that she might as well start now! She looked at me, smiled, and said, "let's do it!" I gave her the Tobacco Tactics book and the 1-800-quit now card and she spent the rest of the evening looking through the book! She told the day shift RN during bedside report that I had convinced her to quit smoking and that she was going to stick with it! YAY!” Employing Technology Tobacco interventions are needed to address blue collar workers who have high smoking rates. This study tested the efficacy and usage of the web-enhanced Tobacco Tactics intervention targeting Operating Engineers (heavy equipment operators) compared to the 1-800-QUIT-NOW telephone line. Operating Engineers (N=145) attending one of 25 safety training sessions from 2010 through 2012 were randomized to either the Tobacco Tactics website with nurse phone counseling and access to nicotine replacement therapy (NRT) or to the 1-800-QUIT-NOW telephone line which provided an equal number of phone calls and NRT. Using an intent-to-treat analysis, the Tobacco Tactics website group showed significantly higher quit rates (n=18, 27%) than the 1-800-QUIT NOW group (n=6, 8%) at 30-day follow-up (p=.003), but this difference was no longer significant at 6-month follow-up. There were significantly more positive changes in harm reduction measures (quit attempts, number of cigarettes smoked per day, and nicotine dependence) at both 30-day and 6-month follow-up in the Tobacco Tactics group compared to the 1-800-QUIT-NOW group. Compared to participants in the 1-800-QUIT NOW group, significantly more of those in the Tobacco Tactics website group participated in the interventions, received phone calls and NRT, and found the intervention helpful. The web-enhanced Tobacco Tactics website with telephone support showed higher efficacy and reach than the 1-800-QUIT-NOW intervention. Longer counseling sessions may be needed to improve 6-month cessation rates. Next Steps In 2014, for the first time Surgeon General’s report “The Health Consequences of Smoking–50 Years of Progress” (SGR) specifically associated smoking with adverse health outcomes in cancer patients. Given the new conclusions, the SGR stated that it is imperative to address smoking among cancer patients. Recent similar reports have been endorsed by the American Association for Cancer Research (AACR), American Society of Clinical Oncology (ASCO), and National Comprehensive Cancer Network (NCCN) guidelines. Since it is the expectation that Cancer Centers provide the best cancer care in the US and the world, providing smoking cessation services is of huge public relations and public health value and should not be delayed. Hence, the next steps are to adapt the Tobacco Tactics intervention to treat the particular needs of cancer patients who have unique reasons for continued smoking including, having increased psychological distress associated with treatment, high nicotine dependence, guilt and/or shame over continued smoking, a large social network of smokers, lack of social support and resources, and elevated alcohol use. An alternative intervention is referral to existing services already available from NCI, such as Smokefree.gov, the booklet “Clearing the Air,” Quitline at 1–877–44U–QUIT (1–877–448–7848), SmokefreeTXT, and LiveHelp Chat Service. These two interventions will be compared in six cancers. Conclusion This presentation will show how a nurse-based intervention was developed, tested, implemented and disseminated with variety of smokers in multiple settings. A variety of research designs at each stage were utilized. Concepts of patient and stakeholder engagement as well as theoretical frameworks were used to accomplish these goals.