Evidence-based practice: Smoking Cessation Program SMOKING CESSATION Utilizing Evidence Based...

Evidence-based practice:Smoking Cessation Program

SMOKING CESSATION

Utilizing Evidence Based Guidelines To Establish An Appropriate Standard of Care For Persons With Severe And Persistent Mental Illness.

Donald N. Rose, MN, RN

Nancy Burke, MSN, RN

• Our beginnings – Integrated Health Care Centers

• an innovative model for advanced nursing practice • a community-focused collaboration

– UIC College of Nursing – http://www.uic.edu/nursing/index.html/

– Thresholds Psychiatric Rehabilitation – http://www.thresholds.org/

– Purpose of the centers• improve access to care for Thresholds members• provide integrated mental health and primary care



• Goals of the centers• To improve health outcomes

– through tailored, integrated care by APNs

• To provide high-quality clinical education– nurses, physicians, and allied health

• To develop evidence-based guidelines

– for integrated care of common problems

• To become financially self-sufficient– through APN reimbursement


• The Integrated Health Care Centers

Thresholds South

South side Chicago

Young Adult Program

North side of Chicago


• Our Integrated Health Care providers– psychiatric clinical nurse specialist faculty– nurse practitioner faculty– undergraduate and graduate nursing students


• Our Integrated Health Care services• Mental health care

– individual, group, and family therapy

• Primary health care– health histories and physical exams

– health screening and preventive care

– diagnosis and treatment of health problems such as colds and flu, diabetes, hypertension, STDs

• Health education groups – nutrition, exercise, stress, smoking cessation


Funding•Division of Nursing

– $1,226,435 Grant # 1 D11 HP 00152-01

–The content and conclusions are those of the author and should not be construed as the government’s official position.

•Robert Wood Johnson

•Chicago Community Trust

•Visiting Nurses Association-Chicago

•Washington Square Health Foundation


Objectives– To review and discuss recent literature regarding smoking

cessation for persons with severe and persistent mental illness.

– To discuss the socioeconomic and health related impact of smoking for this population.

– To discuss a pilot program designed to decrease smoking for persons with severe and persistent mental illness.


Goals of Objective 1– To review evidence based practice guidelines.

– To review existing smoking cessation programs for persons with SPMI.

– To describe pharmacological therapies utilized in smoking cessation programs.


Hierarchy of Levels of Evidence for Evidence-Based Practice

Level I– Strong evidence from at least one systematic review of multiple

well designed RCTs.

Level II– Strong evidence from at least one properly designed RCT of

appropriate size.

Level III– Evidence form well-designed trials without randomization, single group

pro-post, cohort, time series or matched case-controlled studies.


Hierarchy of Levels of Evidence for Evidence-Based Practice

• Level IV– Evidence form well-designed nonexperimental studies from more

than one center or research group.

• Level V– Opinions of respected authorities, based on clinical evidence,

descriptive studies, or reports of expert committees.

Moore, A., McQuay, H. & Gray, J. A. M. (1995)


• Public Health Service Guideline (2000) Treating Tobacco Use and Dependence– Every clinic should implement a tobacco-user

identification system.

– All health care systems should provide education, resources, and feedback to promote provider interventions.

– Clinical sites should dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations.


• PHS Guideline (2000) Treating Tobacco Use and Dependence– Hospitals should promote policies that support and provide

tobacco dependence services. – Insurers and managed care organizations (MCOs) should

include tobacco dependence treatments (both counseling and pharmacotherapy) as paid or covered services for all subscribers or members of health insurance packages.

– Insurers and MCOs should reimburse clinicians and specialists for delivery of effective tobacco dependence treatments and include these interventions among the defined duties of clinicians.


Smoking Cessation• Van Dongen, C. J., Kritz, P., Fox, K. A., & Haque, I.

(1999)– Conducted a Pilot Study on the implementation of a quit smoking

group for persons with SPMI.

• Van Dongen, C. J. (1999)– An Exploratory Study that examined the experience of smoking

and its effects on the lives of persons with SPMI.


Smoking Cessation • Lasser, K., Boyd, J., Woolhandler, S., Himmelstein, D.,

McCormick, D., & Bor, D. (2000) – A Population-Based Prevalence Study to assess rates of smoking

and tobacco cessation in adults with/without mental illness.

• Cataldo, J. K., & Talley, S. (2000) – Article reviewed the recently published PHS clinical practice

guidelines for related to smoking cessation.


Pharmacological Therapies

• Five first-line pharmacotherapies were identified that

reliably increase long-term smoking abstinence rates: – Bupropion SR.

– Nicotine gum.

– Nicotine inhaler.

– Nicotine nasal spray.

– Nicotine patch.


Pharmacological Therapies• Two second-line pharmacotherapies were identified as

efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective: – Clonidine.

– Nortriptyline.

• Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.


Goals Objective 2– To discuss the socioeconomic and health related impact of

smoking with the SPMI.

– To discuss the correlation between nicotine and psychotropic medications.


Socioeconomic Impact• The societal costs of tobacco death and disease approach

$100 billion. • Americans spend an estimated $50 billion annually on

direct medical care for smoking-related illnesses.• Lost productivity and forfeited earnings due to smoking-

related disability account for another $47 billion per year.• Research shows that delivering treatment to tobacco users

is cost-effective. – average cost per smoker for effective cessation

treatment is $165.61.


Physical Health Impact• One in every five deaths in the US is smoking related.

• Tobacco is responsible for more than 430,000 deaths each year.

• Increased risk for:– Cardiovascular disease– Lung disease– Chronic Obstructive Pulmonary Disease– Cancer


Physical Health Impact• Research data indicate that 60%-90% of individuals with

SPMI smoke as compared with a 25% smoking rate in the general population.

• Estimated 40%-50% anxiety or depression – Estimated 70%-90% chronic schizophrenia

• Data from Thresholds South indicate that 70% of the members smoke.


Nicotine & Psychotropic Medications• Smokers on psychotropic medications probably require

higher doses than nonsmokers due to effect of

hydrocarbons on liver enzymes. – Dalack & Glassman, 1992,

– Lohr, J. B. & Flynn, K. 1992.


Goals of Objective 3• To review Thresholds South focus group findings.

• To discuss how the smoking cessation program at Thresholds South:– Program design

– Assessment tools

– Implementation strategies

– Outcomes


Focus group findings• 70 % of Thresholds South members smoke

• Members were able to identify that smoking is a significant health issue


Program design• Nursing students in their mental health practica at

Thresholds South – Co-lead focus groups– Conducted staff/member needs assessment– Conducted literature reviews– Used a group project to formulate final written proposal– Collaborated with the onsite PCNS, FNP and clinical instructor.– Utilized Stages of Change model (Prochaska JO, DiClemente CC,

Norcross JC. In search of how people change. Am Psychol 1992;47:1102-4).


• Assessment tools– Addiction assessment

– Financial impact assessment

– Medication evaluation

– NRT evaluation


Implementation strategies• Program combined change model with activities in each

learning domain – Cognitive

– Affective

– Behavioral


Precontemplation stage• Goal: patient will begin thinking about change.

• Activities:– Education groups

– Assessments


Contemplation stage• Goal: patient will examine benefits and barriers to

change.

• Activities:– Journaling

– Smoking logs

– Collages

– Art projects

– Quit date


Action stage

• Goal: patient will take decisive action. • Activities:

– Sign contract

– Celebratory activities

– NRT implementation

– Weekly group

– Daily individual contact PRN


Maintenance stage• Goal: patient will incorporate change into daily lifestyle. • Activities:

– Support groups

– Education groups

– Exercise groups

– Nutrition groups

– RELAPSE PREVENTION


Outcomes• 12 to 15 started program including 3 staff members

• 2 staff members are still smoke free after 18 months

• 10 members signed quit contracts

• 5 used patch and/or medication and quit smoking for some period of time

• 4 quit program after 4 to 6 weeks

• 1 quit for three months and is again in the action stage


Clinical Considerations• Continual contact and support

• Students bring fresh ideas and enthusiasm each rotation

• Must be multifaceted using many activities

• Normalize all reactions, especially relapse

• Non-judgmental and encouraging approach

• More emphasis on the precontemplation stage and smoking reduction

• Several smoke free days per year


CONCLUSION • Challenges

– Incorporating the components of smoking cessation programs into everyday clinical practice (Cataldo & Talley, 2000).

– Smoking and smoking cessation should be part of the core curriculum and basic training of all health professionals (Rigotti & Thorndike, 2001).

– Further research is needed in the neurobiological and psychosocial aspects of smoking (Van Dongen, 1999) .

Evidence-based practice: Smoking Cessation Program SMOKING CESSATION Utilizing Evidence Based...

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