Implementation of the Tobacco Tactics program in the Department of Veterans Affairs

How can hospitals change practice to better implement smoking cessation interventions? A systematic review

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Tobacco Use and Tobacco Treatment Referral Response of Patients With Cancer: Implementation Outcomes at a National Cancer Institute-Designated Cancer Center

PURPOSE

Smoking after a cancer diagnosis is linked to cancer-specific and all-cause mortality, among other adverse outcomes. Yet, 10%-20% of US cancer survivors are current smokers. Implementation of evidence-based tobacco treatment in cancer care facilities is widely recommended, yet rarely accomplished. This study focuses on the early outcomes of a population-based tobacco treatment program integrated within an National Cancer Institute-designated cancer center.

METHODS AND MATERIALS

The sample consists of 26,365 patients seen at the cancer center during the first 18 months of program implementation. The study is a retrospective chart review of patients' tobacco use and, among current users, patients' treatment referral response.

RESULTS

More than 99% of patients were screened for tobacco use. Current (past month) use was observed in 21.05% of patients; cigarettes were the most popular product. Only 17.22% of current users accepted a referral for tobacco treatment; among current users who declined, the majority were not ready to quit (65.84%) or wanted to quit on their own (27.01%). Multiple demographic variables were associated with tobacco use and treatment referral response outcomes.

CONCLUSION

Despite cancer diagnosis presenting a teachable moment for tobacco cessation, patients with cancer may not be ready to quit or engage with treatment. Clinically proven strategies to increase motivation, prompt quit attempts, and encourage treatment use should be key components of tobacco treatment delivery to patients with cancer.

Overcoming Challenges in Multisite Trials

BACKGROUND

Conducting multisite studies has many challenges, including determining the geographic distance between sites, ensuring effective communication, monitoring intervention and data integrity, handling institutional policy variations, seeking institutional review board approval with unique site needs or complex subcontracts, and planning for additional costs.

OBJECTIVES

This article discusses common challenges in conducting multisite studies and identifies strategies to overcome these challenges using real-world examples from the literature, the authors' research studies, and their personal experiences.

METHODS

A summary of articles on multisite trials conducted within the past 10 years was explored to uncover common challenges in conducting multisite trials. To enrich the context, exemplars from authors' works are included. Based on literature and experience, strategies to combat challenges are summarized.

RESULTS

Unique issues related to multisite studies include site selection, use of epicenters/coordinating centers, hiring/managing staff, fidelity monitoring, institutional review board approval, statistical considerations, and approaches to authorship.

CONCLUSION

Addressing challenges a priori can improve scientific rigor, reproducibility, and evidence from multisite studies. Given the benefits to scientific rigor, reproducibility, and design, findings from multisite studies are more likely to provide evidence to transform clinical practice and influence policy.

Smoking Ban in Psychiatric Inpatient Unit: An Iranian Study on the Views and Attitudes of the Mental Health Staff and Psychiatric Patients

Although the move to smoke-free mental health inpatient settings is an internationally common and popular trend, these policies are neither implemented nor supported by any national program in Iran. This study investigates the attitude of mental health staff and psychiatric patients toward smoking cessation in 2 psychiatric inpatient units (psychosomatic and adult general psychiatry) in the Taleghani general hospital in Tehran. One hundred and twenty participants of this cross-sectional study consist of 30 mental health staff and 90 psychiatric patients. An eight-item questionnaire was used for collecting information. Both staff and patients expressed a positive attitude towards smoking cessation. Patients favoured the implementation of these policies and expressed a more positive attitude towards the feasibility. Sixty-three percent of patients and 57% of staff were opposed to smoking in the units. Seventy percent of patients reported the smoke-free ban as a feasible policy compared to 45% of staff who did the same. The implementation of the smoke-free policy has more support in both staff and patients than the continuation of smoking in psychiatric units. There is a need for an ongoing education and training for mental health care providers, in order to have a successful implementation of smoke-free policy.

Design and implementation of decision support for tobacco dependence treatment in an inpatient electronic medical record: a randomized trial

Tobacco dependence treatment for hospitalized smokers results in long-term cessation if treatment continues at least 30 days post-discharge. Health information technology may facilitate ongoing tobacco dependence treatment after hospital discharge. To describe the use and impact of a new decision support tool and order set for inpatient physicians, addressing tobacco dependence treatment for hospitalized smokers, embedded in an electronic health record (EHR). In a cluster-randomized trial, 254 physicians were randomized (1:1) to either receive or not receive the decision support tool and order set, which were embedded in the Epic (Madison, WI) EHR used at 2 hospitals in a single city. When an adult patient was admitted to a medical service, an electronic alert appeared if the patient was coded in the EHR as a smoker. For physicians randomized to the intervention, the alert linked to an order set to prescribe tobacco treatment medications and refer the patient to the state tobacco quitline. Additionally, "tobacco use disorder" was added to the patient's problem list, and an e-mail was sent to the patient's primary care provider (PCP). In the control arm, an alert fired with no screen visibility. Generalized estimating equations were used to model the data. Since August 2013, the alert has appeared for 10,939 patients (5391 intervention, 5548 control). Compared to control physicians, intervention physicians were more likely to order tobacco treatment medication (35 vs. 29%, P < 0.0001), populate the problem list with tobacco use disorder (41 vs. 2%, P < 0.0001), and make a referral to the state smokers' quitline (30 vs. 0%, P < 0.0001). In addition, intervention physicians sent an e-mail to the patient's PCP 4152 (99%) times. Designing and implementing an order set and alert for tobacco treatment in an EHR is feasible and helps physicians place more orders for tobacco treatment medication, referrals to the state smokers' quitline, and e-mails to patients' PCPs. Data on cessation outcomes are pending.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT01691105).

Impact of a webcast on nurses' delivery of tobacco dependence treatment

AIMS AND OBJECTIVES

To evaluate an educational programme about nurses' role in tobacco dependence treatment, and its webcast component, on the long-term impact of increasing the frequency of nurses' self-reported changes in practice related to delivery of smoking cessation interventions.

BACKGROUND

Healthcare professionals' knowledge about evidence-based tobacco dependence treatment using the 5As framework (Ask about tobacco use, Advise users to quit, Assess willingness to quit, Assist in making a quit plan and Arrange for follow-up, including referral to a quitline) is essential to increase smoking cessation rates in the United States.

DESIGN

A 6-month pre-post design.

METHODS

A convenience sample of nurses (N = 283) from Kentucky and Louisiana was provided access to the webcast and printed toolkit. Responses from those who completed an online survey at baseline, and at 3 or 6 months postimplementation of the educational programme were included in an analysis of changes in the consistent (always/usually) delivery of the 5As plus referral to the quitline.

RESULTS

After 3 months, the intervention had a significant impact on increasing nurses' reports of consistently providing the 5As to patients who smoked, which was largely sustained at 6 months. Nurses who viewed the webcast were three times more likely to refer smokers to a quitline at 3 months; and four times more likely at 6 months than those who did not.

CONCLUSIONS

An online educational programme, plus printed toolkit about tobacco dependence treatment increased nurses' delivery of smoking cessation interventions over time. This study provided preliminary evidence that including a webcast in a nurse-targeted educational programme could significantly increase the proportion of nurses who referred smokers to a quitline beyond the benefit of access to printed materials and web-based resources.

RELEVANCE TO CLINICAL PRACTICE

Distance learning is a feasible mechanism for enhancing nurses' involvement in tobacco dependence treatment and promoting evidence-based clinical practice.

"Let Me Get You a Nicotine Patch": Nurses' Perceptions of Implementing Smoking Cessation Guidelines for Hospitalized Veterans

Many hospitalized smokers do not receive guideline-recommended tobacco treatment, but little is known about the perceptions of inpatient nurses with regard to tobacco treatment. We used a sequential explanatory mixed methods design to help explain the findings of an academic detailing intervention trial on the inpatient medicine units of four Veterans Affairs (VA) hospitals. We surveyed 164 nurses and conducted semistructured interviews in a purposeful sample of 33 nurses with different attitudes toward cessation counseling. Content analysis was used to inductively characterize the issues raised by participants. Emerging themes were categorized using the knowledge-attitudes-behavior framework of guideline adherence. Knowledge-related and attitudinal barriers included perceived lack of skills in cessation counseling and skepticism about the effectiveness of cessation guidelines in hospitalized veterans. Nurses also reported multiple behavioral and organizational barriers to guideline adherence: resistance from patients, insufficient time and resources, the presence of smoking areas on VA premises, and lack of coordination with primary care. VA hospitals should train inpatient staff how to negotiate behavior change, integrate cessation counseling into nurses' workflow, develop alternative referral mechanisms for post-discharge cessation counseling, and adopt hospital policies to promote inpatient abstinence.

Implementation of the Tobacco Tactics intervention versus usual care in Trinity Health community hospitals

Background

Guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework, a National Institutes of Health-sponsored study compared the nurse-administered Tobacco Tactics intervention to usual care. A prior paper describes the effectiveness of the Tobacco Tactics intervention. This subsequent paper provides data describing the remaining constructs of the RE-AIM framework.

Methods

This pragmatic study used a mixed methods, quasi-experimental design in five Michigan community hospitals of which three received the nurse-administered Tobacco Tactics intervention and two received usual care. Nurses and patients were surveyed pre- and post-intervention.

Measures included reach (patient participation rates, characteristics, and receipt of services), adoption (nurse participation rates and characteristics), implementation (pre-to post-training changes in nurses' attitudes, delivery of services, barriers to implementation, opinions about training, documentation of services, and numbers of volunteer follow-up phone calls), and maintenance (continuation of the intervention once the study ended).

Results

Reach: Patient participation rates were 71.5 %. Compared to no change in the control sites, there were significant pre- to post-intervention increases in self-reported receipt of print materials in the intervention hospitals (n = 1370, p < 0.001). Adoption: In the intervention hospitals, all targeted units and several non-targeted units participated; 76.0 % (n = 1028) of targeted nurses and 317 additional staff participated in the training, and 92.4 % were extremely or somewhat satisfied with the training. Implementation: Nurses in the intervention hospitals reported increases in providing advice to quit, counseling, medications, handouts, and DVD (all p < 0.05) and reported decreased barriers to implementing smoking cessation services (p < 0.001). Qualitative comments were very positive (“user friendly,” “streamlined,” or “saves time”), although problems with showing patients the DVD and charting in the electronic medical record were noted. Maintenance: Nurses continued to provide the intervention after the study ended.

Conclusions

Given that nurses represent the largest group of front-line providers, this intervention, which meets Joint Commission guidelines for treating inpatient smokers, has the potential to have a wide reach and to decrease smoking, morbidity, and mortality among inpatient smokers. As we move toward more population-based interventions, the RE-AIM framework is a valuable guide for implementation.

Trial registration

ClinicalTrials.gov, NCT01309217

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0511-6) contains supplementary material, which is available to authorized users.

Effectiveness of the Tobacco Tactics Program in the Trinity Health System

INTRODUCTION

This study determined the effectiveness of the Tobacco Tactics intervention.

DESIGN/SETTING/PARTICIPANTS

This was a pragmatic, quasi-experimental study conducted from 2010 to 2013 and analyzed from 2014 to 2015 in five Michigan community hospitals; three received the Tobacco Tactics intervention, and two received usual care. Smokers (N=1,528) were identified during hospitalization, and sent surveys and cotinine tests after 6 months. Changes in pre- to post-intervention quit rates in the intervention sites were compared with usual care control sites.

INTERVENTION

The toolkit for nurses included: (1) 1 continuing education unit contact hour for training; (2) a PowerPoint presentation on behavioral and pharmaceutical interventions; (3) a pocket card entitled "Helping Smokers Quit: A Guide for Clinicians"; (4) behavioral and pharmaceutical protocols; and (5) a computerized template for documentation. The toolkit for patients included: (1) a brochure; (2) a cessation DVD; (3) the Tobacco Tactics manual; (4) a 1-800-QUIT-NOW card; (5) nurse behavioral counseling and pharmaceuticals; (6) physician reminders to offer brief advice to quit coupled with medication sign-off; and (7) follow-up phone calls by trained hospital volunteers.

MAIN OUTCOME MEASURES

The effectiveness of the intervention was measured by 6-month 30-day point prevalence; self-reported quit rates with NicAlert(®) urinary biochemical verification (48-hour detection period); and the use of electronic medical record data among non-responders.

RESULTS

There were significant improvements in pre- to post-intervention self-reported quit rates (5.7% vs 16.5%, p<0.001) and cotinine-verified quit rates (4.3% vs 8.0%, p<0.05) in the intervention sites compared with no change in the control sites. Propensity-adjusted multivariable analyses showed a significant improvement in self-reported 6-month quit rates from the pre- to post-intervention time periods in the intervention sites compared to the control sites (p=0.044) and a non-statistically significant improvement in the cotinine-verified 6-month quit rate.

CONCLUSIONS

The Tobacco Tactics intervention, which meets the Joint Commission standards for inpatient smoking, has the potential to significantly decrease smoking among inpatient smokers.

TRIAL REGISTRATION

This study is registered at www.clinicaltrial.gov NCT01309217.

Two Years in the Life of a University Hospital Tobacco Cessation Service: Recommendations for Improving the Quality of Referrals

BACKGROUND

Hospitalization, when patients may be more receptive to quitting, provides an opportunity to provide tobacco cessation services for patients who otherwise might not seek help. Although specialized tobacco cessation services are shown to be effective if evidence-based treatment, including follow-up, is completed, resources are limited and guidelines are needed, and few smokers complete all treatment steps. Experience drawn from an analysis of two-year implementation data from the Oregon Health & Science University (OHSU) Tobacco Cessation Consult Service is presented.

METHODS

Data for 5,827 smokers discharged from OHSU University hospital between January 2011 and December 2012 were analyzed to determine patient characteristics and identify predictors of completing each of four treatment steps: consult ordered, consult completed, follow-up arranged, and follow-up completed.

RESULTS

Smokers were younger and male (p<0.0001) and significantly different with respect to insurance class, admission type, history of mental disorders, primary discharge diagnoses, and length of stay (p<0.0001) than nonsmokers. Predictors of having a tobacco consult order were admission for elective medical procedures; orders for medications to treat withdrawal; history of mental health/substance use disorders; primary diagnoses of cardiovascular, endocrine, gastrointestinal, or pulmonary disease; and longer hospitalizations. Smokers admitted through the emergency department had the lowest rates of follow-up completion and abstinence. Admission for an elective surgery was the only predictor of completing all treatment steps through followup (p≤0.05).

CONCLUSIONS

This study adds important information about how hospitalized smokers respond to each step of tobacco treatment in a real-world setting and offers strategies for improving referrals.

Fidelity monitoring across the seven studies in the Consortium of Hospitals Advancing Research on Tobacco (CHART)

BACKGROUND

This paper describes fidelity monitoring (treatment differentiation, training, delivery, receipt and enactment) across the seven National Institutes of Health-supported Consortium of Hospitals Advancing Research on Tobacco (CHART) studies. The objectives of the study were to describe approaches to monitoring fidelity including treatment differentiation (lack of crossover), provider training, provider delivery of treatment, patient receipt of treatment, and patient enactment (behavior) and provide examples of application of these principles.

METHODS

Conducted between 2010 and 2014 and collectively enrolling over 9500 inpatient cigarette smokers, the CHART studies tested different smoking cessation interventions (counseling, medications, and follow-up calls) shown to be efficacious in Cochrane Collaborative Reviews. The CHART studies compared their unique treatment arm(s) to usual care, used common core measures at baseline and 6-month follow-up, but varied in their approaches to monitoring the fidelity with which the interventions were implemented.

RESULTS

Treatment differentiation strategies included the use of a quasi-experimental design and monitoring of both the intervention and control group. Almost all of the studies had extensive training for personnel and used a checklist to monitor the intervention components, but the items on these checklists varied widely and were based on unique aspects of the interventions, US Public Health Service and Joint Commission smoking cessation standards, or counselor rapport. Delivery of medications ranged from 31 to 100 % across the studies, with higher levels from studies that gave away free medications and lower levels from studies that sought to obtain prescriptions for the patient in real world systems. Treatment delivery was highest among those studies that used automated (interactive voice response and website) systems, but this did not automatically translate into treatment receipt and enactment. Some studies measured treatment enactment in two ways (e.g., counselor or automated system report versus patient report) showing concurrence or discordance between the two measures.

CONCLUSION

While fidelity monitoring can be challenging especially in dissemination trials, the seven CHART studies used a variety of methods to enhance fidelity with consideration for feasibility and sustainability.

TRIAL REGISTRATION

Dissemination of Tobacco Tactics for hospitalized smokers. Clinical Trials Registration No. NCT01309217.Smoking cessation in hospitalized smokers. Clinical Trials Registration No. NCT01289275.Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial. Clinical Trials Registration No. NCT01305928.Web-based smoking cessation intervention that transitions from inpatient to outpatient. Clinical Trials Registration No. NCT01277250.Effectiveness of smoking-cessation interventions for urban hospital patients. Clinical Trials Registration No. NCT01363245.Comparative effectiveness of post-discharge interventions for hospitalized smokers. Clinical Trials Registration No. NCT01177176.Health and economic effects from linking bedside and outpatient tobacco cessation services for hospitalized smokers in two large hospitals. Clinical Trials Registration No. NCT01236079.

Effectiveness of the tobacco tactics program for psychiatric inpatient veterans: an implementation study

BACKGROUND

The objective of this study was to evaluate the effectiveness of the inpatient, nurse-administered Tobacco Tactics program for patients admitted for psychiatric conditions in two Veterans Affairs (VA) hospitals compared to a control hospital.

METHODS

This is a subgroup analysis of data from the inpatient tobacco tactics effectiveness trial, which was a longitudinal, pre- post-nonrandomized comparison design with 6-month follow-up in the three large Veterans Integrated Service Networks (VISN) 11 hospitals.

RESULTS

Six-month self-reported quit rates for patients admitted for psychiatric conditions increased from 3.5% pre-intervention to 10.2% post-intervention compared to a decrease in self-reported quit rates in the control hospital (12% pre-intervention to 1.6% post-intervention). There was significant improvement in self-reported quit rates for the pre- versus post-intervention time periods in the Detroit and Ann Arbor intervention sites compared to the Indianapolis control site (P=0.01) and cotinine results were in the same direction.

CONCLUSION

The implementation of the Tobacco Tactics intervention has the potential to significantly decrease smoking and smoking-related morbidity and mortality among smokers admitted to VA hospitals for psychiatric disorders.

Evaluation and costs of volunteer telephone cessation follow-up counseling for Veteran smokers discharged from inpatient units: a quasi-experimental, mixed methods study

Background

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate the volunteer telephone smoking cessation counseling follow-up program implemented as part of the inpatient Tobacco Tactics intervention in a Veterans Affairs (VA) hospital.

Methods

This was a quasi-experimental, mixed methods design that collected data through electronic medical records (EMR), observations of telephone smoking cessation counseling calls, interviews with staff and Veterans involved in the program, and intervention costs.

Results

Reach: Of the 131 Veterans referred to the smoking cessation telephone follow-up program, 19% were reached 0–1 times, while 81% were reached 2–4 times. Effectiveness: Seven-day point-prevalence 60-day quit rates (abstracted from the EMR) for those who were reached 2–4 times were 26%, compared to 8% among those who were reached 0–1 times (p = 0.06). Sixty-day 24-hour point-prevalence quit rates were 33% for those reached 2–4 times, compared to 4% of those reached 0–1 times (p < 0.01). Adoption and Implementation: The volunteers correctly followed protocol and were enthusiastic about performing the calls. Veterans who were interviewed reported positive comments about the calls. The cost to the hospital was $21 per participating Veteran, and the cost per quit was $92. Maintenance: There was short-term maintenance (about 1 year), but the program was not sustainable long term.

Conclusions

Quit rates were higher among those Veterans that had greater participation in the calls. Joint Commission standards for inpatient smoking with follow-up calls are voluntary, but should these standards become mandatory, there may be more motivation for VA administration to institute a hospital-based, volunteer telephone smoking cessation follow-up program.

Trial registration

ClinicalTrials.Gov NCT01359371.

Differences in risk perception and quit rates among hospitalized veteran pipe smokers, cigarette smokers, and dual users

OBJECTIVE

This study examined differences in perception of risk, hospitalization quit rates, and 6-month quit rates between pipe smokers, cigarettes smokers, and those who smoke both in the Department of Veterans Affairs.

METHODS

Before implementing the Tobacco Tactics intervention (among 811 smokers), smoking quit rates were determined (among N = 465 patients with 6-month follow-up data available) in three Midwestern hospitals during 2006-2010.

RESULTS

Pipe smokers were less likely to believe that they needed to quit tobacco, that quitting would be difficult, and that quitting tobacco was important to their health. Eighty-five percent of pipe smokers remained tobacco free throughout their hospital stay compared with 59% of dual smokers and 60% of cigarette smokers (p < .10). Twenty-three percent of pipe smokers remained tobacco free at 6 months compared with 19% of dual users and 7% of cigarette smokers (p < .10).

CONCLUSION

Although pipe smokers had higher spontaneous quit rates than dual smokers and cigarette smokers, the perception of the risk of smoking was less among pipe smokers suggesting a need to expel the myths surrounding pipe smoking and increase cessation efforts.

Implementing smoking cessation guidelines for hospitalized veterans: effects on nurse attitudes and performance

BACKGROUND

A minority of hospitalized smokers actually receives assistance in quitting during hospitalization or cessation counseling following discharge. This study aims to determine the impact of a guideline-based intervention on 1) nurses' delivery of the 5A's (Ask-Advise-Assess-Assist-Arrange follow-up) in hospitalized smokers, and 2) nurses' attitudes toward the intervention.

METHODS

We conducted a pre-post guideline implementation trial involving 205 hospitalized smokers on the inpatient medicine units at one US Department of Veterans Affairs (VA) medical center. The intervention included: 1) academic detailing of nurses on delivery of brief cessation counseling, 2) modification of the admission form to facilitate 5A's documentation, and 3) referral of motivated inpatients to receive proactive telephone counseling. Based on subject interviews, we calculated a nursing 5A's composite score for each patient (ranging from 0 to 9). We used linear regression with generalized estimating equations to compare the 5A's composite score (and logistic regression to compare individual A's) across periods. We compared 29 nurses' ratings of their self-efficacy and decisional balance ("pros" and "cons") with regard to cessation counseling before and after guideline implementation. Following implementation, we also interviewed a purposeful sample of nurses to assess their attitudes toward the intervention.

RESULTS

Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A's composite score was higher after guideline implementation (3.9 vs. 3.1, adjusted difference 1.0, 95 % CI 0.5-1.6). More patients were advised to quit (62 vs. 48 %, adjusted OR = 2.1, 95 % CI = 1.2-3.5) and were assisted in quitting (70 vs. 45 %, adjusted OR = 2.9, 95 % CI = 1.6-5.3) by a nurse during the post-implementation period. Nurses' attitudes toward cessation counseling improved following guideline implementation (35.3 vs. 32.7 on "pros" subscale, p = 0.01), without significant change on the "cons" subscale.

CONCLUSIONS

A multifaceted intervention including academic detailing and adaptation of the nursing admission template is an effective strategy for improving nurses' delivery of brief cessation counseling in medical inpatients.

The development of the tobacco tactics website

BACKGROUND

Web-based cessation interventions have been shown to reduce tobacco use, be more efficacious than self-help booklets, be more efficacious if they provide tailored messages, and enhance quit rates in conjunction with nicotine replacement therapy.

OBJECTIVE

The objective of this study was to usability test and pilot test the Tobacco Tactics website for veterans.

METHODS

Both formative and summative evaluations were used across three small successive studies to develop and test the Tobacco Tactics website for veterans, which was based on a prior face-to-face smoking cessation intervention. Once the website was developed, the research team and Web developers usability tested the website with 5 veteran smokers and former smokers. Feedback from the veterans was collected as they navigated each webpage, then used to revise the website. In pilot study 1, 9 veteran smokers were provided access to the website, and given a baseline and 30-day follow-up survey. In pilot study 2, 18 veteran smokers, who were also motivated to quit smoking, were recruited and randomized to either the Tobacco Tactics website plus nicotine replacement therapy or to the 1-800-QUIT-NOW telephone line.

RESULTS

As a result of usability testing, more than 27 modifications were made to improve the website. In pilot study 1, 50% (3/6) veterans who entered the website had cut down on the number of cigarettes and 83% (5/6) found the website enjoyable, easy to read, easy to navigate, and would recommend the website to others. In pilot study 2, which included only smokers motivated to quit and also offered nicotine replacement therapy, seven-day point prevalence abstinence at 30-day follow-up was 40% (4/10) in the intervention group compared to 13% (1/8) in the control group.

CONCLUSIONS

These preliminary results are promising and suggest the need for wider-scale testing of the Tobacco Tactics website for veterans.

Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs

Research on the validity of self-report tobacco use has varied by the population studied and has yet to be examined among smokers serviced by the Department of Veterans Affairs (VA). The purpose of this study was to determine the predictors of returning a biochemical urine test and the specificity and sensitivity of self-reported tobacco use status compared to biochemical verification. This was a sub-analysis of the larger Tobacco Tactics research study, a pre-/post-non-randomized control design study to implement and evaluate a smoking cessation intervention in three large VA hospitals. Inpatient smokers completed baseline demographic, health history and tobacco use measures. Patients were sent a follow-up survey at six-months to assess tobacco use and urine cotinine levels. A total of 645 patients returned six-month surveys of which 578 also returned a urinary cotinine strip at six-months. Multivariate analysis of the predictors of return rate revealed those more likely to return biochemical verification of their smoking status were younger, more likely to be thinking about quitting smoking, have arthritis, and less likely to have heart disease. The sensitivity and specificity of self-report tobacco use were 97% (95% confidence interval=0.95-0.98) and 93% (95% confidence interval=0.84-0.98) respectively. The misclassification rate among self-reported quitters was 21%. The misclassification rate among self-reported tobacco users was 1%. The sensitivity and specificity of self-report tobacco use were high among veteran smokers, yet among self-report quitters that misclassification rate was high at 21% suggesting that validating self-report tobacco measures is warranted in future studies especially in populations that are prone to misclassification.

Health behaviors predict higher interleukin-6 levels among patients newly diagnosed with head and neck squamous cell carcinoma

BACKGROUND

Health behaviors have been shown to be associated with recurrence risk and survival rates in patients with cancer and are also associated with interleukin-6 (IL-6) levels, but few epidemiologic studies have investigated the relationship of health behaviors and IL-6 among cancer populations. The purpose of the study is to look at the relationship between five health behaviors, viz.: smoking, alcohol problems, body mass index (BMI; a marker of nutritional status), physical activity, and sleep and pretreatment IL-6 levels in persons with head and neck cancer.

METHODS

Patients (N = 409) were recruited in otolaryngology clinic waiting rooms and invited to complete written surveys. A medical record audit was also conducted. Descriptive statistics and multivariate analyses were conducted to determine which health behaviors were associated with higher IL-6 levels controlling for demographic and clinical variables among patients with newly diagnosed head and neck cancer.

RESULTS

While smoking, alcohol problems, BMI, physical activity, and sleep were associated with IL-6 levels in bivariate analysis, only smoking (current and former) and decreased sleep were independent predictors of higher IL-6 levels in multivariate regression analysis. Covariates associated with higher IL-6 levels were age and higher tumor stage, whereas comorbidities were marginally significant.

CONCLUSION

Health behaviors, particularly smoking and sleep disturbances, are associated with higher IL-6 levels among patients with head and neck cancer.

IMPACT

Treating health behavior problems, especially smoking and sleep disturbances, may be beneficial to decreasing IL-6 levels, which could have a beneficial effect on overall cancer treatment outcomes.

Why do cancer patients smoke and what can providers do about it?

Despite the widespread dissemination of information about the health risks associated with smoking, many cancer patients continue to smoke, which results in a decreased quality of life, an increased probability of cancer recurrence, and a decreased survival time. Efficacious interventions are available to assist cancer patients to quit smoking, yet smoking cessation interventions are often not implemented. This review describes how clinicians, administrators, insurers, and purchasers can encourage a culture of health care in which tobacco cessation interventions are implemented consistent with evidenced-based standards of care. Implementing efficacious tobacco cessation interventions can reduce morbidity and mortality among cancer patients.

Dissemination of the nurse-administered Tobacco Tactics intervention versus usual care in six Trinity community hospitals: study protocol for a comparative effectiveness trial

Background

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.

Methods/Design

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.

Discussion

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.

Trial registration

Dissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217

Development of the Tobacco Tactics logo: From thumb prints to press

Background

The purpose of this study was to describe the development and evaluation of the image-based Veterans Affairs (VA) Tobacco Tactics program logo and campaign character using principles of social marketing.

Methods

Four cross-sectional surveys with open- and closed-ended questions were used to gather participant demographic information, smoking behavior, and feedback on the development and evaluation of the Tobacco Tactics program logo and campaign character. The first 3 surveys were conducted with 229 veterans, visitors, and staff to obtain feedback for the final logo and character choice. The fourth survey was conducted with 47 inpatient veteran smokers to evaluate the Tobacco Tactics manual which was illustrated with the logo and campaign character. Descriptive statistics and bivariate analyses comparing demographic characteristics and tobacco use variables to opinions about the pictures for each round of testing were computed.

Results

After three rounds of testing to modify the logo and character choices based on participant feedback and survey data, the bulldog logo was chosen to represent the VA Tobacco Tactics program as it was viewed as strong and tough by the majority of participants. About 80% of the participants rated the manual highly on items such as logo, color, and pictures/illustrations. Almost 90% said they would recommend the manual to someone trying to quit smoking.

Conclusion

Social marketing techniques that include consumer feedback to develop appealing tobacco cessation campaigns can increase consumer engagement and enhance the development of compelling tobacco cessation campaigns to compete with the influential marketing of tobacco companies.

Ethnicity predicts perceptions of smoking and smoking cessation among veterans

The objective of this study was to determine if race/ethnicity predicts motivation to quit smoking and preferences for cessation services among smokers serviced by a primarily psychiatric Veterans Affairs hospital. A self-administered survey was given to a convenience sample of smokers (n=146) at the Battle Creek Veterans Affairs Medical Center. Univariate, bivariate and multivariate regression analyses were calculated to determine the association between race/ethnicity and motivation to quit smoking. Forty-two per cent of the sample was non-white. Non-white patients smoked significantly less cigarettes per day as compared with white patients (P=0.002). In the multivariate analyses, compared with whites, non-whites had 3.5 times greater odds of thinking that quitting smoking was extremely/very important to health (P= 0.01), 4.0 times greater odds of thinking of quitting using tobacco products in the next 30 days (P=0.004) and 3.4 times greater odds of being interested in receiving smoking cessation services (P=0.007). Yet, non-white patients were less likely to be interested in intensive nurse counselling and cessation medications. As the number of non-whites continues to increase in the military, novel strategies may be needed to capitalize on the high motivation to quit smoking and preference for non-traditional interventions among non-white smokers treated in Veterans Affairs hospitals.

Secondary prevention in the intensive care unit: does intensive care unit admission represent a "teachable moment?"

OBJECTIVES

Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a "teachable moment." Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate.

DATA SOURCES

A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search.

SUMMARY

Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical intensive care unit population.

CONCLUSIONS

Intensive care unit admission represents a "teachable moment" for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical intensive care unit patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.

Health behaviors of Operating Engineers

Operating Engineers (heavy equipment operators in construction) may be at particular risk for heart disease and cancer related to their exposure to environmental dust and smoking, the sedentary nature of their job, and long hours of exposure to the sun. The aim of this study was to characterize the health behaviors of Operating Engineers. This cross-sectional survey from a convenience sample of Operating Engineers (N = 498) used validated instruments to measure smoking, drinking, diet, exercise, sleep, and sun exposure. Univariate and bivariate analyses to detect differences by age were conducted. The sample scored significantly worse on all five health behaviors compared to population norms. Those who were older were less likely to smoke and chew tobacco and more likely to eat fruits and vegetables. Many were interested in services to improve their health behaviors. Health behavior interventions are needed and wanted by Operating Engineers.

Implementation research: a critical component of realizing the benefits of comparative effectiveness research

Comparative effectiveness research (CER) holds the promise of improving patient-centered care and increasing value in the healthcare system. Achieving these goals, however, depends on effectively implementing the findings of CER. In this article, we draw on lessons from implementation research and our experience in the Veterans Administration (VA) healthcare system to offer recommendations about what is needed to support implementation of CER. There is no single strategy for successful implementation. Implementation efforts must take into account the nature of the evidence, the type of change being implemented, the clinical context in which the findings are being applied, and the specific barriers and facilitators to implementing new practices. The experience of the VA illustrates the importance of taking a systems approach that aligns numerous elements of the healthcare system--guidelines, decision support, performance measures, financial incentives, coverage and benefits policy, and health information technology--to support implementation:. We illustrate these principles with an example of implementing a new model of evidence-based depression care.