Smoking Cessation and Use in Logan County, CO

Smoking cessation and use in Logan County, CO

Sara Quale

8/10/14

MPH 584/Community Health

Dr. Kelly Wheeler

Table of Contents

Introduction 1

Literature Review 4

Physician intervention and quit attempts 4

Behavioral counseling 5

Nicotine replacement therapies 6

VMOSA 10

Innovation 13

Evaluation 14

References 16

14

Fifty years ago, the U.S. Surgeon General released a report that for the first time saw the federal government link smoking to illness including cancer and heart disease (Surgeon General, 2014). The document laid the groundwork for public health initiatives to prevent smoking-related morbidity and mortality, but continued efforts are needed. Tobacco still ranks as the number one actual cause of death in the United States (McKenzie, Pinger & Kotecki, 2012). Tobacco also is linked to premature birth, low infant birth weight, and higher infant mortality (HealthyPeople.gov, 2014). In 2008, cancer, heart disease, and lung diseases were the top three most common causes of death (McKenzie et al, 2012).

Secondhand smoke also has been shown to cause heart disease and lung cancer, as well as illnesses in children and infants including asthma, respiratory infections, ear infections and sudden infant death syndrome (HealthyPeople.gov, 2014). There is no level where you can be exposed to secondhand smoke without risk (HealthyPeople.gov, 2014).

Cigarette smoking causes about 480,000 deaths annually including those from secondhand smoke (CDC, 2014). It causes premature death as well with the life expectancy of a smoker at least 10 years shorter than for nonsmokers (CDC, 2014). In terms of economics, costs due to tobacco are over $289 billion annually (U.S. Department of Health and Human Services, 2014). The productivity loss from premature death due to smoking is more than $150 billion annually; direct medical care for adults that is attributed to smoking is more than $130 billion (U.S. Department of Health and Human Services, 2014).

The Centers for Disease Control and Prevention identified “tobacco” as one of the Winnable Battles for which the agency has set actionable targets and expectations to reach those targets in a short time period (CDC, 2013). The overall goal in this battle is to prevent the start of tobacco use, promote quitting and preserve smoke-free environments (CDC, 2014). The Winnable Battle hopes to reduce the percent of adults who smoke cigarettes to 17% (CDC, 2014). One of the strategies effective in moving toward this goal is providing access to proven tobacco use cessation treatment including counseling and medication to all smokers (U.S. Department of Health and Human Services, 2014, p. 19). The U.S. Surgeon General’s report also recommends expanding smoking cessation for all smokers in primary and specialty care clinics by having medical provider systems find standard processes of care for effective treatments (U.S. Department of Health and Human Services, 2014, p. 19).

Logan County, Colorado, population of 22,709 is a rural, agricultural county in the northeastern part of the state (U.S. Census 2010, n.d.). About 92% of the population is white and 16% is Hispanic or Latino (U.S. Census 2010, 2014). The median value of a home in Logan County is $121,200 compared with $236,800 in Colorado, and the per capita money income in the past 12 months was $22,815 in the county compared with $31,039 across the state (U.S. Census 2010, 2014). The median income was $41,369 in Logan County compared to $58,244 statewide, and Logan County had 15.9% of its population living below the poverty level (U.S. Census 2010, 2014).

In 2008-2010 29.1% of adults 18 and older in Logan County reported that they currently smoked cigarettes (CDPHE, 2010). The average rate of smoking in Colorado is 17%, and in the top performing counties of the United States is 14% (Robert Wood Johnson Foundation, 2014). A goal of Healthy People 2020 aims to reduce illness, disability and death related to tobacco use and exposure to second hand smoke (HealthyPeople.gov, 2014).

Currently the Northeast Colorado Health Department partners with Colorado QuitLine to offer support, coaching sessions, nicotine replacement therapies and tips online or by telephone (NCHD, n.d.).

Addressing smoking cessation in Logan County will require the effort of a diverse group of community representatives. That group includes local primary care physicians, members of the Northeast Colorado Health Department, area health insurance representatives, representatives from the Sterling Chamber of Commerce and representatives from the Northeastern Junior College as well as current smokers. Together they can identify barriers as well as opportunities for improvement in smoking cessation programs.

Literature Review

As previously stated smoking is the nation’s number one actual cause of death and is known to have negative health consequences including increased risks for cancers to nearly every part of the body (American Cancer Society, 2014). Lung cancer is the leading cause of cancer death in the United States for both men and women and it is the most preventable form of cancer death in the world (American Cancer Society, 2014). The costs attributed to smoking were between $289 billion and $332.5 billion annually between 2009 and 2012 (American Cancer Society, 2014).

This literature review explores evidence-based best practices in a clinical care setting and whether a combination of telephone counseling, pharmacotherapies and in-person sessions is more effective that using single tactics for tobacco cessation.

Physician intervention and quit attempts To improve the overall success of tobacco cessation, public health professionals must increase the number of people who attempt to quit smoking (quit rates) as well as the number of successful attempts to quit smoking (CDC, 2014, p. 41). State tobacco control programs can influence the number of quit attempts through population-based programs. Clinical providers can help by making patients aware of the tobacco cessation programs that are covered under health insurance (CDC, 2014, p. 41). Studies have shown that tobacco interventions delivered consistently and effectively require a coordinated approach involving health care professionals as well as the insurers and health care administrators.

Patients who smoke expect that their health care provider will ask them about smoking habits and attempts to quit (CDC, 2014, p. 42). As more than 80% of smokers see a health care provider annually, integrating a routine conversation about smoking cessation into the clinic visit is an important first step in improving attempted quit rates for smokers (CDC, 2014, p. 42). A patient’s family and personal health history and information about previous attempts to quit smoking play a key role in determining how to proceed. The Fagerström Test for Nicotine Dependence (FTND) is used to determine the level of dependence on nicotine (Chaney & Sheriff, 2012). Physical exams also provide information about the current health status that can influence treatment options. All smokers should be provided with information about smoking cessation treatments at an office visit (Chaney & Sheriff, 2012).

An additional tool to begin treatment discussions uses the five As: ask, advise, assess, assist and arrange (Chaney & Sheriff, 2012). Ask the patient about smoking habits, advise him or her to quit, assess whether the patient is ready to quit, assist the patient with treatment options and arrange for further visits to check on progress (Chaney & Sheriff, 2012).

Behavioral counseling In considering health behavior theories that apply most appropriately to smoking cessation, the Precaution Adoption Process Model allows for a smoker to evolve through a series of distinct classes toward action and maintenance of a health behavior (DiClemente, Salazar & Crosby, 2013, p. 121). This theory also incorporates the five As mentioned above. The distinction in the PAPM from other theories or models of behavior change comes in the beginning when a person may be entirely unaware or not feel threatened by a particular health behavior (DiClemente et al, 2013, p. 121). Acknowledging this highlights the importance of repeated conversations between a physician and patient to make the patient aware of specific health threats and the benefits available through behavior change. The seven stages of PAPM are illustrated in Figure 1.

Figure 1 Stages of the Precaution Adoption Model. Source: Adapted from “Health Behavior Theory for Public Health,” by R. DiClemente, L. Salazar & R. Crosby, 2013, p. 121. Copyright 2013 by Jones & Bartlett Learning, LLC.

Counseling provides smokers with a support to help them develop skills needed to address withdrawal symptoms and failures (Chaney & Sheriff, 2012). Smokers who had one visit to a physician to get information about smoking cessation and then participated in lifestyle coaching with a nurse practitioner at 6 months demonstrated a better quit rate than smokers who only saw the physician for a single visit (Abdullah & Simon, 2006). The intervention group saw a 14% quit rate compared to 9% among the group that only saw the physician (Abdullah and Simon, 2006).

Nicotine replacement therapies Receiving physician advice and counseling in conjunction with using a nicotine replacement therapy is another approach to smoking cessation. Smokers in the control group that received only advice from a physician had a quit rate of 8.16% compared 15.41% among smokers that saw the physician, received NRT, a manual and met with clinic staff 2-4 weeks after the intervention (Abdullah and Simon, 2006).

A combination of approaches may be more successful than NRT alone because other determinants for smoking also are involved. The other aspects that would be addressed through behavior counseling include the habit and conditioning associated with smoking, the role of the cigarette as an object and the psychosocial aspects of smoking (Fagerström, 2011, p. 76). In his commentary to propose a renaming of the Fagerström Test of Nicotine Dependence, Karl Fagerström, PhD, asserts that people become conditioned to the routine of smoking, the feel of a scratch in their throats, the psychosocial benefits of the activity of smoking in interpersonal situations and simply lessening their anxiety by having something to do, which is smoke (Fagerström, 2011, p. 76).

Methods for improving success rates include dealing with weight gain, managing withdrawal symptoms, dealing with failure and following the recommendations and treatments (Abdullah & Simon, 2006). Weight gain while trying to quit is attributed to an increase in eating combined with a decreased metabolic rate which can be addressed by NRT (Abdullah & Simon, 2006). Implementing a plan to manage withdrawal symptoms when they are at their peak – typically the first few days of quitting – will help sustain success (Abdullah & Simon, 2006). People trying to quit also must be cognizant of the difficulty of the task. About 70% of smokers have tried to quit and failed at least once (Abdullah & Simon, 2006). This can be overcome with the proper support, treatments and adherence to the plan of treatment, however.

Tobacco cessation programs can be assisted by the structure of the health care clinic including automated reminders and the use of mid-level providers. A provider reminder system in a practice electronic medical record can be used to automatically screen the patient history for smoking information and alert physicians to initiate conversations (CDC, 2014, p. 42). Physician assistants, medical assistants or nurse practitioners can continue the conversation by delivering lifestyle behavior change information and instructions on self-help techniques such as online and telephone-based resources (CDC, 2014, p. 42). Health care organizations that use electronic medical record systems achieve an 80% level of screening and treatment intervention than organizations that do not have those systems (CDC, 2014, p. 43). The network can use the information to set reminders to patients about when a patient is due for an appointment, screening or other administrative function (Institute of Medicine, 2014, p. 15).

Including information on the social and behavioral determinants of health including smoking behaviors in the electronic medical record can benefit the clinical utility as the behavior relates to the diagnosis and treatment plan (Institute of Medicine, 2014, p. 14). A randomized controlled trial comparing the effect of brief advice delivered by physicians to assessment only and to repeated, computer-generated letters to smokers showed statistically significant differences with the best results for long-term stability of the early interventions coming from the tailored letters (Meyer, Ulbricht, Baumeister, Schumann, Rüge, Bischof, ... John, 2007). The tailored letters or a one-session intervention with a practitioner both were effective in lowering the proportion of current smoking compared to no intervention (Meyer et al, 2007). The letters appeared to be as effective as a brief advice session with a practitioner (Meyer et al, 2007).

Health care reform measures will influence how smoking cessation practices are employed through a need for better cost-efficacy, (Hughes, 1996). Insurers and the government agencies responsible for the health care costs of smokers will want programs that can produce fast and effective results along with proof that the programs help smokers who were unable to quit on their own. These third-party payers will want to use a combination of therapies and interventions run by non-physician providers such as nurses (Hughes, 1996). Lack of time for physicians also will force health experts to find new ways to approach smoking cessation including time-saving counseling approaches that cover a broader patient base (Meyer et al, 2007).

Smoking rates in Logan County are higher than the state average and fail to meet the Healthy People 2020 goal, (CDPHE, 2010; Robert Wood Johnson Foundation, 2014). To achieve the Healthy People 2020 goal, clinical practices can implement a combination of physician interaction with the patient using proper screening, mid-level provider lifestyle behavior coaching and NRT. Using electronic medical system reminders for physicians and staff to identify, address and remind in clinically-indicated cases will increase the number of quit attempts and ultimately successful quits.

Vision, Mission, Objectives, Strategies and Actions

The Vision Because Logan County’s 29.1% rate of current smokers compares poorly to the average of 17% across the state of Colorado (CDPHE, 2010; Robert Wood Johnson Foundation, 2014), and smoking is known to be the leading actual cause of death in the country (McKenzie et al, 2013), the vision of this program for Logan County is to create a community free from smoking-related illness and death. An additional challenge posed by targeting this county is the disparity in health among rural and urban residents. The combination of economic issues, cultural and social differences, lower educational attainment and transportation needs due to living in remote areas creates health disparities (National Rural Health Association, 2007).