Carol Ripley-Moffitt

Smoking As a Vital Sign: Prompts to Ask and Assess Increase Cessation Counseling

Background: Strategies to improve smoking cessation counseling in clinical settings are critical to supporting smokers’ attempts to quit. This study evaluates the impact of adding 2 smoking-related vital sign questions in an electronic medical records system on identification, assessment, and counseling for patients who smoke: “Current smoker?” and “Plan to quit?” Methods: Baseline data and data after intervention were collected through record review of 899 randomly selected patient visits across 3 outpatient clinics. Results: From before to after intervention, identification of smokers increased 18% (from 71% to 84%; P < .001), and assessment for a plan to quit increased 100% (from 25.5% to 51%; P < .005). Among all smokers, cessation counseling increased 26% (from 23.6% to 29.8%; P = .41). Significantly more smokers who received the assessment for a plan to quit received cessation counseling (46% vs. 14%, P < .001). Regression analysis showed that patients receiving an assessment for plan to quit were 80% more likely to receive cessation counseling (OR 0.209; 95% CI, 0.095–0.456). Conclusions: Physician-documented counseling rates are significantly higher when patients are asked about smoking and assessed for a plan to quit. Two questions that ask about smoking status and assess plans to quit may provide prompts to increase the likelihood that patients who smoke receive cessation counseling.

Safe babies: a qualitative analysis of the determinants of postpartum smoke-free and relapse states.

This qualitative study explores smoking cessation during pregnancy and the factors that contribute to remaining smoke-free and relapsing. Ninety-four women attending prenatal clinics in central North Carolina who had quit smoking before 30 weeks gestation were enrolled in an observational study that included a face-to-face interview at 4 months postpartum. Results were analyzed for common themes in the two groups: those who remained smoke-free and those who had relapsed. Fetal health motivated pregnant women to quit smoking, while stress, socializing with smokers, cravings, and easy access to cigarettes tempted women to smoke. Women who remained smoke-free postpartum overcame temptations by continuing to acknowledge the health benefits of not smoking and having a strong internal belief system, significant social support, negative experiences with renewed exposure to cigarettes, and concrete strategies for dealing with temptations. For women who relapsed postpartum, factors having the greatest influence on relapse included easy access to cigarettes, lack of social and financial support, insufficient resources for coping with the challenges of childrearing, physical addiction, reliance on cigarettes as a primary form of stress management, and feelings of regret, shame, or low self-esteem. Recommendations for relapse prevention include assessing women who quit during pregnancy for low or high risk of relapse and offering comprehensive interventions and case management for those at higher risk to address the physical, mental, behavioral, and social contexts leading to relapse.

Tobacco Use Treatment at the U.S. National Cancer Institute’s Designated Cancer Centers

INTRODUCTION Tobacco use is a leading cause of cancer, and continued use after cancer diagnosis puts patients at greater risk for adverse health outcomes, including increased risk for cancer recurrence. This study surveyed National Cancer Institute (NCI)-designated Cancer Centers to assess the availability of tobacco use treatment (TUT) services. METHODS Directors and oncology providers of 58 NCI-designated Cancer Centers received invitations to participate in an online survey. The questionnaire asked about attitudes, awareness, policies, and practices related to TUT; barriers to treatment provision; and factors likely to increase services. RESULTS All 58 Cancer Centers participated. Twelve (20.7%) Centers reported no TUT services for their patients. Of the remainder, 34 (58.6%) reported a TUT program within their Center and 12 (20.7%) reported external TUT services in their health care system or affiliated university. Only 62% of Centers reported routinely providing tobacco education materials to patients, just over half reported effective identification of patient tobacco use, and less than half reported an employee dedicated to providing TUT services or a clear commitment to providing TUT services from Center leadership. The 34 centers with internal TUT programs reported significantly greater services and administration support for TUT Services. CONCLUSIONS These data demonstrate a national need for Cancer Centers to embrace and incorporate recommended standards for TUT. Tying TUT services to NCI recognition and providing stable funding for TUT services in Cancer Centers could lead to better health outcomes, treatment efficacy, and satisfaction for all U.S. Cancer Centers and their patients.

Influence of a Tobacco-Free Hospital Campus Policy on Smoking Status of Hospital Employees

Purpose: To examine the influence of a tobacco-free hospital campus (TFHC) policy on employee smoking behavior. Design: Questionnaires immediately prior to, 6 months after, and 1 year after implementation of a TFHC policy. Setting: University-affiliated hospital system. Subjects: A cohort of smokers and recent quitters. Measures: Smoking status, quit attempts, influence of TFHC policy. Analysis: Descriptive. Results: From 2024 employees who responded to an initial online survey prior to implementation of a TFHC policy, 307 respondents reported either current smoking or quitting smoking within the past 6 months. Of these, 210 (68%) agreed to follow-up surveys at 6 and 12 months post-policy implementation. At each of the three times, between 15% and 18.5% of the cohort reported not smoking, with at least 48% of those not smoking reporting 6 to 12 months continuous abstinence. Sixty percent or more of those who reported quit attempts or not smoking indicated that the TFHC policy was influential in their efforts. Conclusions: A TFHC policy may lead to increased employee smoking quit attempts and successful cessation. Health care facilities should broaden smoking restrictions to include the entire workplace campus, not only to reduce exposure to environmental tobacco smoke, but also to increase tobacco cessation.

Tobacco use and dependence treatment: a critical component of cancer care.

Failure to address tobacco addiction in patients with cancer is unjustified at best and negligent at worst. Recently, a patient nearing completion of her breast cancer treatment came to our Nicotine Dependence Program. When asked why she wanted to quit, she said that she did not want to go through breast cancer again. She had wanted to quit before beginning chemotherapy, but her physician advised against it, thinking that quitting during treatment would be too stressful. Several concerns help to explain why oncology providers sometimes hesitate to address tobacco use with their patients. Some question the wisdom of engaging in smoking cessation during active cancer treatment. Patients are already overwhelmed and the prospect of coping with withdrawal symptoms and attending additional appointments feels like too much. Some providers are unfamiliar with tobacco cessation medications; others fear that these medications may cause side effects, potentially interfering with cancer treatment. Some question the utility of intervention; if cancer diagnosis did not make the patient quit, then nothing will. Oncology providers who do want to incorporate smoking cessation into cancer care may initially find little institutional support. A comprehensive system may not exist to identify tobacco users and educate providers and patients about effective interventions. Clinicians who do advise patients to quit may not know where to refer them for additional resources and ongoing support. The function of a cancer center is to screen patients, diagnose cancer, and provide comprehensive treatment. Smoking cessation, if provided at all, is often viewed as an ancillary service, outranked in terms of prominence and resources by nutrition, mental health, education, acupuncture, and massage. This is surprising given that quitting smoking is proven to reduce a patient’s chance of a future cancer diagnosis. Research demonstrates that failure to address tobacco addiction in patients with cancer is unjustified at best and negligent at worst. Smoking causes cancer (Kuper, Boffetta, & Adami, 2002). Continued smoking among individuals who have cancer causes more cancer. Patients who continue to smoke after diagnosis experience decreased recurrence-free survival (Fleschner et al., 1999; Stevens, Gardner, Parkin, & Johnson, 1983) and increased risk for a second primary tumor (Do et al., 2004; Johnson, 1998; Richardson et al., 1993; Tucker et al., 1997). Smoking is associated with complications in patients receiving radiation (Eifel, Jhingran, Bodurka, Levenback, & Thames, 2002; Rugg, Saunders, & Dische, 1990) and may also impact the metabolism of chemotherapy (Hamilton et al., 2006; van der Bol et al., 2007). Continuing smokers experience diminished quality of life across multiple physical, psychological, and social domains (Garces, Yang, et al., 2004) and are more likely to report higher pain scores than nonsmokers or former smokers (Daniel et al., 2009). Surgical procedures cost more and do not work as well for tobacco users because of complications such as delayed healing, wound dehiscence, and postoperative infections (Al-Sarraf et al., 2008; Kearney, Lee, Reilly, DeCamp, & Sugarbaker, 1994; Krueger & Rohrich, 2001). Given the adverse outcomes associated with continued smoking, cancer di-

Use of Expired Air Carbon Monoxide Testing in Clinical Tobacco Treatment Settings

&NA; Carbon monoxide (CO) testing is considered an easy, noninvasive, and objective contribution to the assessment of smoking behavior, as CO is rapidly absorbed into the bloodstream when lit cigarettes or cigars are inhaled. CO testing is a medically important billable outpatient service that can contribute to sustainability of face to face tobacco use treatment services by clinicians. This article reviews research on the clinical use of CO testing to provide biomedical feedback in assessing smoking behavior, educating smokers on tobacco health effects, assisting with treatment planning, and as a motivational tool to encourage people to become tobacco free. Further research can focus on how to best incorporate CO testing into clinical practice, including more research on outcomes and methods to ensure that insurers reimburse for testing and improved ways to use CO testing to initiate attempts to quit tobacco use, to maintain cessation, and to prevent relapse.

Patient Care Outcomes of a Tobacco Use Registry in an Academic Family Practice

Purpose: While the potential benefit of a chronic disease registry for tobacco use is great, outcome reports have not been generated. We examined the effect of implementing a tobacco use registry, including a decision support tool, on treatment outcomes within an academic family medicine clinic. Methods: A chart review of 200 patients who smoked and attended the clinic before and after registry implementation assessed the number of patients with clinic notes documenting (1) counseling for tobacco use, (2) recommendations for cessation medication, (3) a set quit date, (4) referrals to the on-site Nicotine Dependence Program (NDP) and/or QuitlineNC, and (5) pneumococcal vaccine. Data from the NDP, QuitlineNC, and clinic billing records before and after implementation compared the number of clinic-generated QuitlineNC fax referrals, new scheduled appointments for the NDP, and visits coded for tobacco counseling reimbursement. Results: Significant increases in documentation occurred across most chart review variables. Significant increases in the number of clinic-generated fax referrals to QuitlineNC (from 27 to 96), initial scheduled appointments for the NDP (from 84 to 148), and coding for tobacco counseling (from 101 to 287) also occurred when compared with total patient visits during the same time periods. Patient attendance at the NDP (52%) and acceptance of QuitlineNC services (31%) remained constant. Conclusions: The tobacco use registrys decision support tool increased evidenced-based tobacco use treatment (referrals, medications, and counseling) for patients at an academic family medicine clinic. This novel tool offers standardized care for all patients who use tobacco, ensuring improved access to effective tobacco use counseling and medication treatments.

Evaluation of a Direct Mailing Campaign to Increase Physician Awareness and Utilization of a Quitline Fax Referral Service

Research has shown that fax referral services play an important role in linking people who are ready to quit tobacco use with effective cessation support provided through telephone-based quitlines. While many states have implemented fax referral services to assist health care providers in connecting their patients to quitlines, few published studies delineate optimum ways to promote this service to providers, particularly the role of direct mail educational campaigns. This is one of the first studies to evaluate the effectiveness of a small-scale educational and promotional campaign designed to increase health care providers’ awareness and utilization of a state tobacco cessation quitline fax referral service. The campaign included a direct mailing to 6,197 health care providers in North Carolina. The mailing consisted of a large tube, in the shape of cigarette, with enclosed fax referral promotional materials. An 8-month follow-up survey was mailed to a 10% random sample of family physicians, pediatricians, dentists, and orthodontists who were sent the promotional tube mailing. Valid surveys were returned by 271 providers (response rate = 46%). Forty-four percent of respondents remembered receiving the tube mailing, and 40% reported familiarity with the fax referral service. While only 3.5% of respondents reported referring a patient to the quitline using the fax referral service in the previous 6 months, almost one-third reported an intention to use the fax referral service in the future. The pilot promotional campaign increased awareness of the fax referral service more than service utilization. While increased utilization of the service by health care providers appears promising, additional research is needed on how to maximize educational and promotional campaigns that influence clinician fax referral behaviors. The results of this study can help guide the development of future fax referral promotional campaigns to increase clinician access to and utilization of state quitlines.

A minute for advocacy

What an unexpectedly rapid response to an online recommendation! Here’s how the scene unfolded on a hectic day: 11:40: surfing web for best nicotine replacement therapy (NRT) prices. 11:43: Discover following link after description of a nicotine replacement patch: “Additional Information CLICK HERE for Quit Assist website from Philip Morris USA” …

Using Lean Quality Improvement Tools to Increase Delivery of Evidence-Based Tobacco Use Treatment in Hospitalized Neurosurgical Patients

BACKGROUND Health care providers routinely undertreat tobacco dependence, indicating a need for innovative ways to increase delivery of evidence-based care. Lean, a set of quality improvement (QI) tools used increasingly in health care, can help streamline processes, create buy-in for use of evidence-based practices, and lead to the identification of solutions on the basis of a problems root causes. To date, no published research has examined the use of Lean tools in tobacco dependence. A 12-month QI project using Lean tools was conducted to increase delivery of evidence-based tobacco use treatment (TUT) to hospitalized neurosurgical patients. METHODS The study team developed a nicotine replacement therapy (NRT) and counseling protocol for neurosurgery inpatients who indicated current tobacco use and used Lean tools to increase protocol adherence. Rates of NRT prescription, referrals to counseling, and follow-up phone calls were compared pre- and postintervention. Secondary measures included patient satisfaction with intervention, quit rates, and reduction rates at 4 weeks postdischarge. RESULTS Referrals to counseling doubled from 31.7% at baseline to 62.0% after implementation of the intervention, and rates of nicotine replacement therapy (NRT) prescriptions during hospitalization and at discharge increased from 15.3% to 28.5% and 9.0% to 19.3%, respectively. Follow-up phone call rates also dramatically increased. The majority of satisfaction survey respondents indicated that counseling had a positive or neutral impact on stress level and overall satisfaction. CONCLUSION Lean tools can dramatically increase use of evidence-based TUT in hospitalized patients. This project is easily replicable by professionals seeking to improve delivery of tobacco treatment. These findings may be particularly helpful to inpatient surgical departments that have traditionally been reticent to prescribe NRT.