Development and Nationwide Dissemination of a Tobacco Curriculum for Health Professionals

1
Development and Nationwide Dissemination of a
Tobacco Curriculum for Health Professionals

• Karen Hudmon, DrPH, MS, BSPharm
• Purdue University College of Pharmacy
• Yale University School of Medicine

2
2004 Report of the Surgeon General
FOUR MAJOR CONCLUSIONS

• Smoking harms nearly every organ of the body.
• Quitting smoking has immediate as well as
  long-term benefits.
• Smoking cigarettes with lower machine-measured
  yields of tar and nicotine provides no clear
  benefit to health.
• Numerous diseases are caused by smoking.

U.S. Department of Health and Human Services. The
Health Consequences of Smoking A Report of the
Surgeon General, 2004.
3
Trends in Adult Smoking, by SexU.S., 19552005
Trends in current cigarette smoking among persons
aged 18 or older
20.6 of adults are current smokers
Male
Percent
22.1
Female
19.2
70 want to quit
Centers for Disease Control and Prevention. 1955
Current Population Survey 19652005 NHIS.
Estimates since 1992 include some-day smoking.
4
Smoking Prevalence Among Health Professional
Groups
5
Cigarettes
Each pack smoked costs society 7.18 in direct
and indirect costs. The only consumable product
that when used as intended will kill at least
half of its users.
Centers for Disease Control and Prevention.
Annual smoking-attributable mortality, years of
potential life lost, and economic costsUnited
States, 19951999. MMWR 200251300303.
Doll R, Peto R, Boreham J, Sutherland I.
Mortality in relation to smoking 50 years
observations on male British doctors. BMJ 2004
Jun 263281519.
6
LONG-TERM (?6 month) QUIT RATES for AVAILABLE
CESSATION MEDICATIONS
23.9
22.4
20.0
19.5
17.1
16.4
14.6
Percent quit
11.5
11.8
10.2
9.3
9.1
8.8
8.6
Data adapted from Silagy et al. (2004). Cochrane
Database Syst Rev Hughes et al., (2004).
Cochrane Database Syst Rev. Gonzales et al.,
(2006). JAMA and Jorenby et al., (2006). JAMA
7
Effective Methods for Quitting

• Pharmacotherapy
• Behavioral counseling

Combination therapy yields the highest quit rates.
Fiore et al. Treating Tobacco Use and Dependence.
Clinical Practice Guideline. USDHHS, PHS, June
2000.
8
The 5 As
www.surgeongeneral.gov/tobacco/
9
Meta-Analyses Estimated Abstinence and ORs,
Clinician Interventions
n 29 studies
2.2 (1.5,3.2)
Estimated abstinence at 5 months
1.7 (1.3,2.1)
1.1 (0.9,1.3)
1.0
Type of clinician
Fiore et al. Treating Tobacco Use and Dependence.
Clinical Practice Guideline. USDHHS, PHS, June
2000.
10
Helping Smokers Quit is a Clinicians
Responsibility
TOBACCO USERS DONT PLAN TO FAIL. MOST FAIL TO
PLAN. Clinicians have a professional obligation
to address tobacco use and can have an
important role in helping patients plan for
their quit attempts.
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The Clinicians Role in Promoting Cessation

• Tobacco users expect to be encouraged to quit by
  health professionals.
• Screening for tobacco use and providing tobacco
  cessation counseling are positively associated
  with patient satisfaction (Barzilai et al.,
  2001).

Failure to address tobacco use tacitly implies
that quitting is not important.
Barzilai et al. (2001). Prev Med 33595599.
12
The Clinicians Role in Promoting Cessation
(contd)

• Clinicians with smoking cessation training are
  more likely to intervene with patients who use
  tobacco than those who are not trained
  (Lancaster, 2000)
• WHO and USPHS all healthcare professionals,
  including students in health-care professional
  training programs, should receive education in
  the treatment of tobacco use and dependence.
• Numerous studies show that students in the health
  professions receive inadequate training for
  treating tobacco use and dependence.

13
Tobacco Education in Health Professional Schools

• Medical schools lt5 provide training for
  comprehensive tobacco cessation counselign
  (Ferry, 1999)
• Other professions median minutes taught
• Dental, 206 min
• Physician assistant, 145 min (preliminary data)
• Pharmacy, 170 min (increased to 270 min)

How much education is adequate?
14
Pharmacy faculty Perceived Importance for
Required Coursework
Percent
15
Educational Approach

• Training programs
• Health professional students
• Practicing clinicians
• Support staff

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Educational Approach (contd)
Three levels of expertise

• Minimal Ask-Advise-Refer
• 90-minute training
• Moderate The 5 As
• 6- to 8-hour training
• High Tobacco cessation specialist
• Certification

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Practitioner-Oriented Programs

• Arizona Certification Program
• http//bandura.sbs.arizona.edu/hcp/hcpMaterials1.h
  tml
• Mayo Clinic
• http//www.mayoclinic.org/ndc-rst/tts-certificatio
  n.html
• University of Medicine and Dentistry New Jersey
• http//www.tobaccoprogram.org/
• NAADAC (Association for Addiction Professionals)
• http//naadac.org/
• University of Mississippi
• http//actcenter.umc.edu/training.html
• University of Massachusetts
• http//www.umassmed.edu/behavmed/tobacco/

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Student-Oriented Programs

• Rx for Change Clinician-Assisted Tobacco
  Cessation
• All professions full version, slimmed-down
  version
• http//rxforchange.ucsf.edu
• PACE Boston University
• Medical
• http//www.teachtobacco.org/articles.html
• University of Minnesota
• Dental (dentists, hygienists)
• http//www1.umn.edu/perio/tobacco/
• Others

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Faculty-Oriented Programs

• Train-the-trainer programs
• Rx for Change Clinician-Assisted Tobacco
  Cessation
• http//rxforchange.ucsf.edu

Are our faculty prepared to teach tobacco
cessation counseling skills?
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Faculty Characteristics Rx for Change
Train-the-Trainer Program
Prior to attending this conference, had you
received formal training for ______ tobacco use
dependence?
Treating
Teaching
n 188
Percentage
21
Training Future Clinicians
22
Rx for ChangeVision and Curriculum Goals

• State-of-the-art training program
• Easily integrated into existing course structures
• Supported by evidence-based research
• TURN-KEY, SHARED PROGRAM
• Tobacco cessation curriculum for PharmD students
• California graduates qualified to intervene with
  all tobacco users
• Hands-on, skills-oriented training (self-efficacy)

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Rx for Change Overview

• Applicable to students and licensed clinicians
• 6- to 12-hour modular program
• MINIMUM is 6 hours
• Consensus panel WCOTOH 2000
• Major components
• Didactic lecture material
• Interactive, hands-on workshop

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Rx for ChangeCore Modules

• Epidemiology of Tobacco Use
• Pharmacology of Nicotine Principles of
  Addiction
• Drug Interactions with Smoking
• Assisting Patients with Quitting
• Hands-on Workshop
• Aids for Cessation
• Tobacco Trigger Tapes
• Role Playing Case scenarios (w/ video counseling
  sessions)

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Rx for ChangeOptional Lecture Modules

• Forms of Tobacco
• Pathophysiology of Tobacco-Related Disease
• Genes and Tobacco Use
• A History of Tobacco Control Efforts
• How to Get Involved
• Post-cessation Weight Maintenance

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Rx for ChangeExternal Review

• Neal Benowitz, MD
• Bruce Berger, PhD, RPh
• Li Cheng, PhD
• Timothy Cline, PhD
• Carlo DiClemente, PhD
• Stanton Glantz, PhD
• Taline Khroyan, PhD
• Marianne Paynter, PharmD
• Alexander Prokhorov, MD, PhD
• Frank Vitale, MA

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Students pre- and post-training self-ratings for
five components of comprehensive tobacco
cessation counseling Ask, Advise, Assess,
Assist, and Arrange (n 493)
Meansa (SD)
Ask about tobacco use
2.71 (1.16) 3.81 (0.82)
Advise to quit
2.01 (0.95) 3.61 (0.78)
All pre- versus post-training differences, p lt
0.001
Assess readiness to quit
2.10 (0.95) 3.82 (0.82)
1.84 (0.93) 3.74 (0.82)
Assist with quitting
1.82 (0.95) 3.71 (0.87)
Arrange follow-up
0
20
40
60
80
100
Percent of total responses
Corelli RL, et al., Prev Med, 2005.
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Evaluation Results (contd)
Percentage of pharmacy students who
97
Corelli RL, et al., Prev Med, 2005.
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Disseminating Rx for Change Student Pharmacists
Views
Do you believe that students at other U.S.
schools of pharmacy would benefit from receiving
the same, or similar, training?
99.2
Percentage
Corelli RL, et al., Prev Med, 2005.
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CALIF 6 schools 650 pharmacy students annually
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Disseminating a Tobacco Curriculum for Pharmacy
Schools Specific Aims

• Recruit 2 faculty from each US school of pharmacy
  for a 2-day train-the-trainer program in San
  Francisco
• Provide faculty participants with knowledge
  skills to implement the curriculum in their
  schools
• Attain a high level of implementation in pharmacy
  school curricula nationwide
• Evaluate the curriculum, using an approach that
  incorporates both process outcome measures

1
2
3
4
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Disseminating a Tobacco Curriculum for Pharmacy
Schools
Winter 2003
Summer 2003
Summer 2005
Summer 2004
Summer 2006
X X X
Trainings
O1 O2 O3 O4
Curriculum surveys

Student surveys
Ongoing for three academic
years
Ongoing throughout life of
grant
Web-site utilization
Ongoing throughout life of grant
External dissemination
98 participation in TTT programs n191
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Train-the-TrainerProgram Materials

• Rx for Change curriculum binder
• Faculty Coordinators Guide and supporting
  materials
• CD ROM (gt 300 slides)
• Instructors notes for each slide
• Ancillary handouts
• Tobacco Cessation Counseling Guidesheet,
  Pharmacologic Product Guide, Drug Interactions
  with Smoking, Tobacco Dependence Questionnaires,
  Cognitive Behavioral Coping Strategies, Tobacco
  Use Log, Withdrawal Symptoms, Patient Quit Plan
• Case scenarios (gt 30)
• Instructor guidelines, clinician info, patient
  info

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Train-the-TrainerProgram Materials (contd)

• Rx for Change videotape
• Introductory segment (F Vitale, U Pittsburgh)
• 15 tobacco trigger tapes instructor guide
• 6 videotaped counseling sessions (3 pharmacy, 3
  non-pharmacy)
• Clinical Practice Guideline (full, abbreviated)
• QuitKey unit (PICS, Inc.)
• Pharmaceutical products for trainings (pharmacy
  schools)
• Outreach tools
• CE programs 6 versions, w/ goals and objectives,
  handouts
• RxforChange web-site access

35
http//rxforchange.ucsf.edu
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Perceived Impact of the Train-the-Trainer Program
How do you rate your overall ability to teach
comprehensive tobacco cessation to your students?
n 188 p lt 0.001
Percent
Assessed post-training.
37
Rx for Change Faculty Participant Perceptions
Compatibility for integration
Comprehensiveness of content
Appropriateness of teaching methods
Confidence in skills for teaching RxFC
---- 67.1 ----
Likelihood of adoption in upcoming yr
0
20
40
60
100
80
Percent of total responses
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Pharmacy SchoolsImplementation, 2004-05

• 69 of 85 schools implemented (81)
• Median, 270 minutes of tobacco education
• 100 minutes (59) over baseline (2001-02)
• Nearly 8,000 students were exposed to all or
  portions of the program
• 89 integrated the program materials into the
  core (required) curriculum

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National EstimatesNumber of Students Trained
Number of students trained
Academic year
40
Rx for ChangeDissemination to Date
665
Number of licenses
Month and Year
41
Rx for Change Web-siteFILE DOWNLOADS
23,029
Number of downloads, in thousands
11,920
11,109
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Program Adaptations Ongoing collaborations

• UCSF Schools of Medicine, Nursing, Dentistry
• Georgetown University School of Nursing (J Heath)
• 80 acute care nurse practitioner faculty trained
• Psychiatric Residents (J Prochaska, UCSF)
• Globally Argentina, England
• GlaxoSmithKline

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• Way2Quit
• GlaxoSmithKline Initiative
• Rx for Change students are teamed with GSKs Rx
  for Change sales force in delivering
  community-based, individualized tobacco cessation
  interventions
• Facial age progression
• Lung function screening
• Carbon monoxide testing
• Smoking cessation counseling

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National Initiatives Engaging the Health
Professions
SMOKING CESSATION LEADERSHIP CENTER

• MISSION
• To increase the number of smokers who quit
• To raise the number of health professionals (and
  institutions) that help smokers quit
• To normalize smoking cessation assistance in the
  health professions, just as we are de-normalizing
  smoking in our society

Steven Schroeder, MD University of California San
Francisco
Via the Smoking Cessation Leadership Center,
collaborations are being established with
numerous health professional groups.
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New Initiatives

• Physician Assistants
• Respiratory Care Therapists
• Kaiser Permanente
• Its Quitting Time, LA!
• Community colleges
• Ask, Advise, Refer 3-hr, slimmed-down version
• Pharmacy Technicians, Dental Assistants,
  LPNs/LVNs (L Sarna)
• Cultural competence modifications (M Assemi)

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META-ANALYSIS Estimated Abstinence Rates and
ORs, Clinician Interventions
n 37 studies
2.5 (1.9,3.4)
2.4 (2.1,3.4)
Estimated abstinence rate at 5 months
1.8 (1.5,2.2)
1.0
Fiore et al. Treating Tobacco Use and Dependence.
Clinical Practice Guideline. Rockville, MD
USDHHS, PHS, June 2000.
47
Courtesy of Tina Brock, University of London