CHAMPLAIN CVD PREVENTION
STRATEGIC PLANNING 2013-2016
EXPERT TASK GROUP RECOMMENDATIONS
REGIONAL INTEGRATED SMOKING CESSATION
STRATEGY
FINAL REPORT
JUNE 2012
EXPERT TASK GROUP MEMBERSHIP
Name
Title & Organization
Hilda Chow (Co-chair)
Program Manager, Chronic Disease and Injury Prevention, Ottawa Public Health
Dr. Robert Reid (Cochair)
Deputy Chief, Prevention and Rehabilitation Centre, University of Ottawa Heart
Institute
Donna Pettey
Director of Operations, Canadian Mental Health Association
Dr. Sophia Papadakis
Program Director, Champlain CVD Prevention Network/ Primary Care Smoking
Cessation Program, University of Ottawa Heart Institute
Manager, Quit Smoking Program, University of Ottawa Heart Institute
Debbie Aitken
Kerri-Anne Mullen
Robyn Hurtubise
Network Manager, Ottawa Model for Smoking Cessation, University of Ottawa
Heart Institute
Tobacco Manager, Eastern Ontario Health Unit
Richard Hayter
Director of Community Relations, Eastern Ontario Building and Construction
Trades Council
Suzie Joanisse
Regional Coordinator, Regional Cancer Program
Barbara Hollander
Senior Coordinator, Smoker’s Helpline
Yves Decostes
Tobacco Program Coordinator, Leeds, Grenville and Lanark District Health Unit
Perveen Gulati
Pharmacist, Ottawa-Carleton Pharmacists’ Association
Debbie Tirrul
Nurse Practitioner, Somerset West Community Health Centre
Danielle Simpson
Analyst, Champlain Cardiovascular Disease Prevention Network
1
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
TABLE OF CONTENTS
1.0 The Case for Action .................................................................................................................................... 3
2.0 Methodology ............................................................................................................................................... 4
3.0 Environmental Scan ................................................................................................................................... 5
4.0 A New Vision for Cessation Services in Champlain ............................................................................... 8
5.0 Strategy Components .............................................................................................................................. 15
6.0 Performance Management Plan .............................................................................................................. 17
7.0 Resource Plan ........................................................................................................................................... 17
8.0 Leadership and Partner Roles ................................................................................................................. 18
9.0 Impact & Return on Investment .............................................................................................................. 19
10.0 Risk Assessment .................................................................................................................................... 19
Exhibit 1: Number and Percentage of Smokers in the Champlain Region ............................................... 20
Exhibit 2: Champlain Smoking Cessation Services: 2011-12 Reach, Efficacy, and Funding Source ... 21
Exhibit 3: Environmental Scan ...................................................................................................................... 22
Exhibit 4: Swot Analysis ................................................................................................................................ 28
Exhibit 5: Estimated Reach by Setting ......................................................................................................... 29
Exhibit 6: Regional Smoking Cessation Strategy Logic Model ................................................................. 30
Exhibit 7: Standardized Metrics for Cessation Services ............................................................................ 31
References ...................................................................................................................................................... 32
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
1.0 THE CASE FOR ACTION
There are 157,000 residents who smoke daily in the Champlain Region


There are more than 220,000 smokers in the Champlain region, including 157,000 daily smokers.1
The City of Ottawa has one of the lowest rates of smoking in the province, with a rate of daily smoking of
12%. However, the Eastern Counties, Renfrew Districts, and Leeds, Grenville and Lanark all have
smoking rates above 25%.1 See Exhibit 1 for Smoking Prevalence Statistics.
The burden of tobacco use on morbidity and mortality in Ontario is extensive:





Tobacco use is the leading preventable cause of death in Ontario.2
Tobacco use will kill half of all long-term users.3
In 2002, tobacco was responsible for an estimated 13,224 deaths in
Ontario and 37,209 deaths nationally.4
Each year in Ottawa, almost 1,000 smokers and nonsmokers die
prematurely of tobacco related illness.2
Tobacco-related deaths resulted in 184,304 potential years of life lost
(PYLL) in Ontario and 515,607 PYLL for all of Canada. PYLL are the
years of life lost due to premature mortality related to smoking.4
Tobacco use is a very powerful modifiable CVD risk factor:


157,000 Champlain
residents smoke
daily
Tobacco use will kill
half of these
residents if they do
not quit.
Individuals who smoke are two to four times more likely to develop
heart disease and/or stroke compared to non-smokers.3 As such,
tobacco use is tied with hypertension as the most powerful risk factor
for preventing CVD.5
Moreover, tobacco use accounts for 80 - 90% of all chronic obstructive pulmonary disease and 30% of all
cancer deaths.3,6
Tobacco use is a key driver of health care spending:






Tobacco use costs the Ontario economy an estimated $1.6 billion in health care costs each year. 7,8
The direct health care costs resulting from tobacco use account for the second largest share of the total
costs in Ontario.4
Smokers have higher hospitalization rates than non-smokers, average at least twice the number of
hospital bed-days, and evidence documents a causal relationship between tobacco-use and adverse
surgical outcomes.3, 9
Research has shown that tobacco-related disease was responsible for over 10% of hospital days in
2002.4
Tobacco-related illness accounted for 782,520 days of acute care hospital stay in Ontario and 2,210,155
acute care hospital days for all of Canada.4
Hospitalization costs amounted to an average of $38.2 million per year for smoking attributable
hospitalizations of Ottawa residents from 2008 to 2010.
Table 1: Economic Costs of Tobacco Use for the Year 20022
Champlain*
Deaths per year
1,128
Acute hospital days per year
66,784
Direct health care costs ($ millions)
132
Other direct costs ($ in millions)
2.85
Indirect costs: productivity losses ($ in millions)
378
Total** ($ in millions)
517
Ontario
13,224
782,520
1,553
33.4
4,440
6,057
Canada
37,209
2,210,155
4,360
87.0
12,470
16,996
**Calculated based on published data for Ontario per using modeling for per capita estimates; *Cost components may not add to totals due to rounding.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
2.0 METHODOLOGY
A multi-sector expert task group, representing stakeholders from primary care, hospitals, mental health, public
health, community agencies and pharmacy, assembled to create the Regional Smoking Cessation Strategy.
In developing the regional smoking cessation strategy, the group met a total of 6 times. The following steps were
undertaken:

Step 1: Environmental Scan: Building off an existing scan of smoking cessation services by Ottawa
Public Health, and CCPN, a comprehensive scan was completed to capture the current level of smoking
cessation services in the Champlain region.

Step 2: Asset and Gap Analysis: Reviewed the current assets and gaps in services in the Champlain
region; Reviewed best practice programs; Identified areas for collaboration to increase efficiencies within
the smoking cessation system.

Step 3: Developed Areas of Focus: Developed recommended areas of focus for the strategy, including
resource requirements and technology development.
ANNUAL DEATHS IN CHAMPLAIN CAUSED BY SMOKING
1,128
HOSPITAL DAYS IN CHAMPLAIN RELATED TO SMOKING
66,784
ANNUAL HEALTH CARE COST AS A RESULT OF SMOKING
$132 MILLION
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
3.0 ENVIRONMENTAL SCAN
Smoking Cessation is a highly cost effective intervention:



Smoking cessation is one of the most cost effective interventions available.10
The cost per life year saved is between $2000-4000 which is superior to most other preventative and
medical interventions available in 2012.11-14
Data indicates that a light, moderate, or heavy smoker who quits between the ages of 40 and 44 may
reduce their healthcare costs by $25,842, $45,118 or $79,300, respectively 15
Cessation services currently reach less than 5% of the overall
population of smokers:


There are a total 23 smoking cessation programs operating in
the Champlain region.
In 2011-12 over 8,000 Champlain residents took part in a formal
smoking cessation program – representing 5% of the overall
population of smokers in the region. Exhibit 2 provides a
summary of the reach and efficacy of cessation services.
LESS THAN 5% OF
SMOKERS IN
CHAMPLAIN USED A
SMOKING CESSATION
SERVICE IN 2011-12
Most smokers want to quit but are not using evidence-based
interventions:



Sixty percent of smokers want to quit, 40% will make at least one attempt to quit each year, but only 5%
will be successful without assistance.16
Less than 20% of smokers use evidence-based support with quitting.17
High rates of nicotine addiction are reported by almost 60% of smokers. 18
Investment in Prevention & Tobacco Control is a priority in Ontario’s Health Action Plan:



The rising costs in health care spending in Ontario require an increase emphasis on proven interventions
for reducing hospitalizations and health care utilization.
Ontario’s Health Action Plan released in 2012 identified Tobacco Control as a provincial priority.
The Ministry of Health and Long Term Care are presently finalizing the Smoke-Free Ontario Strategy
which may provide new resources and supports for cessation.
Champlain Partners have made Smoking Cessation an organizational priority:





Ottawa Public Health has committed to a three year Smoking Cessation Strategy to expand the reach of
cessation services in coordination with the CCPN.
In 2012, the Eastern Ontario Health Unit launched a new smoking cessation program committing
resources to address the high rates of tobacco use in Eastern Ontario.
The Champlain LHIN has identified Smoking Cessation as a priority in its 2009-2012 Integrated Health
Services Plan.
The University of Ottawa Heart Institute considers smoking cessation a key priority area and places
significant resources in the operation of four large smoking cessation programs that serve our community.
Health care providers in hospitals, Family Health Teams, and Community Health Centres in the region
have partnered to make smoking cessation a priority in their organization.
Building on a history of leadership in tobacco control in Canada:


The Champlain Region has been a leader in Tobacco Control in Canada for more than two decades.
The City of Ottawa was the first Canadian city to introduce smoke-free spaces policies in Canada, has
supported community health centres with cessation services in vulnerable populations, and through the
exposé Program developed a provincially recognized program to tackle tobacco use among high school
students.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY




The University of Ottawa Heart Institute has been providing leadership in addressing tobacco use in
clinical settings for more than two decades. The UOHI has supported the rollout of the Ottawa Model to a
network of more than 140 hospitals and primary care settings across Ontario and Canada and operates a
large smoking cessation program for Champlain residents.
As part of the 2007-2012 CVD Prevention Strategy - The Ottawa Model for Smoking Cessation (a
systematic approach for addressing tobacco use in clinical settings) was introduced in all 23 hospitals in
Champlain; 15 Family Health Teams; and 14 Outpatient clinics.
The Champlain LHIN was the first health authority in Ontario to include a smoking cessation performance
indicator in hospital accountability agreements.
Most recently in 2012, Ottawa Public Health joined several other Canadian cities in passing progressive
outdoor smoke-free spaces by-laws.
See Exhibit 3 for detailed summary of Environmental Scan.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
3.1 MOST SIGNIFICANT ISSUES TO BE ADDRESSED

Reach of existing smoking cessation programs and services is less than 5% of the population of smokers.

Higher rates of smoking outside of the City of Ottawa and in subpopulations within the City of Ottawa.

High prevalence of smoking among individuals with Mental Health Illness, lower socio-economic status.

Lack of knowledge among public of existing cessation services.

Lack of understanding of how to best reach high risk populations.

Uncoordinated delivery of cessation services in the region and communications.

Difficulty assembling accurate data on reach and outcomes for existing regional cessation services.

Ability to counsel and prescribe evidence-based quit smoking medications is limited in many current
cessation programs, e.g. worksites, etc.
3.2 MOST SIGNIFICANT OPPORTUNITIES

Smoke-Free Ontario Strategy renewal and funding support:
o Availability of cost-free NRT to Family Health Teams and Community Health Centres.
o MOHLTC funding for expansion of Ottawa Model into Ontario 10 Community Health Centres
o MOHLTC pilot funding for cloud project to integrate data collection among multiple cessation
providers.
o MOHLTC worksite demonstration project funding.

Interest among large smoking cessation providers in the region in coordinating expansion of cessation
services (UOHI, EOHU, OPH, LHIN, RCC, LG&LHU).

Leadership from the Eastern Ontario Building and Trades Union to address cessation among union
members.

Ontario Smoker’s Helpline resources.

Cancer Care Ontario’s plan to invest in Smoking Cessation and availability of local funds.

Expansion of OMSC to outpatient settings in particular cancer treatment centres.

Expand reach of OMSC within The Ottawa Hospital.

Redesign the delivery of smoking cessation sevices through the local Ottawa community coalition called
A.C.E.S.S (Accessible Chances for Everyone to Stop Smoking)Linkages to Canadian Mental Health
Association.
See full SWOT analysis in Exhibit 4.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
4.0 A NEW VISION FOR CESSATION SERVICES IN CHAMPLAIN
A JOINT ACTION PLAN FOR AN INTEGRATED CESSATION SYSTEM IN CHAMPLAIN
Although the Champlain District and the City of Ottawa in particular have demonstrated significant leadership
being first to introduce progressive smoke-free policies and innovative service delivery models to address tobacco
use in schools and health care settings – we must continue to focus on tobacco control efforts in order to improve
public health, address inequalities and address rising health care costs.
To do this we will implement a Joint Action Plan involving the CCPN, Ottawa Public Health, Eastern Ontario
Health Unit, the University of Ottawa Heart Institute, large employers and unions, regional hospitals, family
medicine, and voluntary sectors. This strategy builds on existing assets and will strengthen our ability to help
more residents quit smoking.
THE VISION
More Champlain residents make an aided quit attempt using evidence-based cessation services.
TARGETS
To increase the number of Champlain residents who make an aided quit attempt using evidence-based cessation
interventions to 15,000 by 2016.
Secondary targets include reducing regional variation in tobacco use and success with quitting measured at 6months.
Indicator
Adults who currently smoke (daily)
2012 (Baseline)
2016 Target
12.8%
11.8%
Regional Disparity (daily)
Ottawa: 12% were daily smokers
Eastern Counties: 21%
Gap = 9%
Reduce gap to 8%
Number of aided quit attempts
8,000 / year (5%)
15,000 / year (10%)
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
ANTICIPATED OUTCOMES
The three year Joint Action Plan will result in an integrated smoking cessation system in Champlain by 2016
which serves to:
1. Encourage more tobacco users to make a quit attempt and promote cessation services
2. Offer choice in how to quit with support
3. Remove barriers to accessing cessation services
4. Address gaps in underserviced populations
5. Create a skilled workforce of regional cessation service providers
6. Increase the availability of cost-free medications to smoker’s willing to make a quit attempt
7. Actively engage worksites and health professionals in the delivery of cessation interventions.
8. Improve information systems and gather high quality metrics on reach and efficacy of cessation services,
and
9. Introduce system efficiencies.
See logic model in Exhibit 6.
STRATEGY COMPONENTS AND PRIORITY ACTIVITIES
Our focus will be on building on existing programs (OMSC in hospital and primary care) as well as expanding into
sub-populations with higher smoking rates (individuals with mental illness and blue collar worksites). All of the
priority areas will be linked and supported through the development of common outcomes, training, resources and
a centralized smoker’s registry. See section 5 for description and page 11 for full description of priority activities.
The recommended Joint Action Plan contains six strategy components:
1. Improvement Information Systems and Metrics
2. Cessation Service Delivery Network
3. Partner with Employers and Unions to deliver Innovative Worksite Smoking Cessation Program
4. Expand Reach of OMSC in Champlain Hospitals and Outpatients Clinic
5. Expand Reach of OMSC in Primary Care
6. Mental Health & Vulnerable Populations Strategy
CESSATION SERVICE MODELS TO BE ADOPTED





Brief Intervention in Clinical Settings (1-time)
Individual Cessation Treatment (4 weeks – 6 months)
Group Cessation Programs (4-8 weeks)
Telephone-based Cessation Support (4-weeks – 6 months)
Web-based Cessation Support (Self-help and Smoker’s Helpline)
AREAS NOT PRIORTIZED FOR 2013-2016
Extensive consultation was undertaken to derive these five priority areas. However, the task group did feel that
there were specific populations which necessitate further program development and focus. Pregnant women and
young adults and youth were two such areas. Although they are not a focus of the current strategy, they will
remain on the longer list of long-term priorities for smoking cessation.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
JOINT ACTION PLAN FOR A SMOKING CESSATION SYSTEM IN THE CHAMPLAIN REGION
STRATEGY COMPONENTS /
RECOMMENDATIONS
1) IMPROVED INFORMATION
SYSTEMS & METRICS
1. Create common evaluation
indicators and systems
GOAL / ACTIVITIES
Goal: Support collection of high quality metrics among regional cessation service
providers and support coordinated delivery of cessation services among providers.
1.1 Introduce a common set of performance indicators (see Exhibit 7)
1.2 A centralized database should be created to support the tracking of indicators across
smoking cessation service providers and allow for triage of patients from one service to
another electronically.
1.3 Track performance metrics on a bi-annual basis for all smoking cessation service
providers in the Champlain District.
KEY
PARTNERS
FUNDING
PRIORITY
RANK
Service
Delivery
Partners
UOHI
In-kind
High
OPH
In-kind
TBD
1.4 Create a Champlain Report Card which will compile all of the region’s performance
metrics
2) CESSATION SERVICE
DELIVERY NETWORK
2A. Provide training and
establish a knowledge
translation network in
cessation service delivery in
Champlain
2B. Share common tools and
resources
Goal: Create the capacity in the Champlain region to deliver high quality cessation services
to more Champlain residents.
2.1 A smoking cessation specialist training and certification program should be offered
twice annually which will ensure all service providers in the Champlain District are
trained in evidence-based interventions to support cessation (based on the TEACH
training, delivered locally, with local experts, covering regional program information
and integrating TEACH program content).
2.2 Develop and implement a regional training program to train physicians, nurses, nurse
practitioners, occupational health nurses, etc., on best practice smoking cessation
counselling. As more health professionals are trained, capacity to deliver smoking
cessation programs is increased (link to Ottawa Smoking Cessation Conference).
2.3 Adopt regional protocol for the delivery of cessation services across all smoking
cessation programs in Champlain to ensure that all providers are delivering consistent,
evidence-based smoking cessation services.
2.4 A regional protocol for the prescribing, titration, and monitoring of the first line quit
smoking medications should be introduced into the protocols of all service providers in
Champlain District based on the University of Ottawa Heart Institute’s protocols.
2.5 A medical directive should be created that will expand the scope of nurses and other
qualified health professionals to prescribe the first line quit smoking medications
according to this protocol.
PH, UOHI,
TEACH
In-kind
PH, UOHI
TBD
Very High
TBD
UOHI and
MOH’s
PH, UOHI
TBD
OPH, UOHI
TBD
10
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
STRATEGY COMPONENTS/
RECOMMENDATIONS
2C. Creation of a regional
communications campaign
2D. Increase access to costfree/low-cost quit smoking
pharmacotherapy for
Champlain residents
2E. Expand Services through
the creation of Regional
Cessation Centres
3) PARTNER WITH EMPLOYERS
& UNIONS TO DELIVER
INNOVATIVE WORKSITE
CESSATION PROGRAM
3A. In partnership with the
Eastern Ontario Buildings and
Trade Union conduct a pilot
program in three worksites
GOAL / ACTIVITIES
KEY
PARTNERS
UOHI, PH
FUNDING
TBD
TBD
TBD
TBD
2.9 A regional communications plan should be developed to promote cessation services
among members of the general public interested in quitting smoking as well as those
participating in targeted cessation programs (ie. Worksites). The campaign will
advertise one phone number and/or website at which point, patients will be directed to
services in their area.
2.10 Ensure Champlain providers optimally access government funded quit smoking
medications.
2.11 Advocate for greater access to cessation medications for populations without access,
specifically mental health and outpatient populations.
2.12 Work with partners to ensure gaps in access are addressed within the partnership.
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
2.13 A network of satellite cessation clinics should be operated in communities with the
Champlain District with high rates of tobacco use in partnership with public health,
primary care, hospitals, mental health agencies, and worksites. Clinics should be
modeled after the UOHI Quit Smoking Program for one-on-one treatments and Public
Health Group Cessation Programs.
Goal: To decrease the number of smokers within the construction and trades workers,
hospital employees, and municipal workers who smoke through the provision of evidencebased smoking cessation programs.
PH, UOHI,
Cessation
Service
Providers
3.1 Develop detailed pilot program plan and resources. The worksite cessation program
should be peer driven and involve both a communications strategy to motivate quit
attempts among employees, as well as access to low-cost pharmacotherapy and several
cessation service formats (group, one-on-one, self-help) to smokers ready to quit and
those interested in reduce to quit approaches.
3.2 Launch worksite promotional campaign to increase the motivation of employees and
union members to make an aided quit attempt and repeat in regular cycles.
3.3 Pilot new approaches to reach and engage employees who work in an outdoor
environment that does not lend itself to conventional cessation services to participate
in workplace cessation programs.
EOBTU,
OPH, EOPH,
LLG, RDPH,
UOHI,
Employers
PH, EOBTU,
Employers
PH, EOBTU,
Employers
2.6 A common set of patient and health professional materials should be developed and
introduced by smoking cessation service providers in Champlain
2.7 A regional website should be created as a resource for community members, health
professionals in obtaining evidence-based information about quitting smoking and
cessation services in the region.
2.8 Create one phone number for information on cessation services and triage.
TBD
MOHLTC
Application
for $100,000 +
In-kind
PRIORITY
RANK
Very High
(cont’d)
High
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
STRATEGY COMPONENTS/
RECOMMENDATIONS
3B. Develop Plans for Broader
Worksite Program Rollout
4) EXPAND REACH OF OMSC IN
CHAMPLAIN HOSPITALS AND
HIGH RISK OUTPATIENT
CLINICS
4A. Continue the expansion of
the OMSC inpatient program
into more units within
Champlain LHIN hospitals
4B. Expand OMSC into High
Risk Out-Patient Clinics
GOAL / ACTIVITIES
KEY
PARTNERS
FUNDING
3.4 Coordinate the delivery of cessation services to employees ready to quit including selfhelp materials, telephone based support, group, and one-on-one treatment options.
PH, UOHI,
OHN
3.5 Support access to low-cost quit smoking medications.
Partners
3.6 Assist construction industry employers, employees and unions to adopt smoke-free
worksites policies.
OPH, PH
3.7 Conduct an evaluation of the workplace smoking cessation intervention in 1 year’s time.
3.8 Examine pilot program results and develop a detailed plan for rollout to additional
worksites with a focus on blue collar, health care, and government workplaces.
OPH
PH, UOHI,
Unions,
Employers
3.9 Implement plan to rollout support to additional worksites.
Goal: Increase the number of smokers being reached by Champlain LHIN hospitals.
TBD
TBD
4.1 Provide outreach facilitation for Champlain hospitals, including onsite training and
program evaluation.
UOHI
4.2 Hospital smoking cessation inter-professional task groups and coordinators to meet
regularly with UOHI facilitators to review performance, discuss program delivery
models, and adaptation to improve uptake.
UOHI
Secured
MOHLTC to
2016
Secured
MOHLTC to
2016
4.3 Provide cost-free or subsidized quit smoking medications to patients in the pre-surgical
period and to those being discharged from hospital.
UOHI
Unfunded
4.4 Adapt OMSC and implement in the TOH pre- surgical clinic, followed by other presurgical areas.
UOHI
TBD
4.5 Adapt OMSC and offer other service format (group, one on one, self help, telephone
based support) in regional cancer program.
RCC, UOHI,
PH, SHL
TBD
PRIORITY
RANK
High
(cont’d)
TBD
High
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
STRATEGY COMPONENTS/
RECOMMENDATIONS
GOAL / ACTIVITIES
KEY
PARTNERS
FUNDING
PRIORITY
RANK
5) EXPAND REACH OF OMSC IN
PRIMARY CARE
Goal: Expand Ottawa Model for Smoking Cessation to Family Health Teams and
Community Health Centres in Champlain
5A. OMSC Primary Care
Leadership & Regional
Efficiencies
5.1 Establish FHT/CHC Leadership Group for Coordinating Regional Cessation Programs and
Monitoring Program Outcomes (sub-committee of FHT Leadership Table established by
CCPN).
5.2 Establish annual regional benchmarks and automate performance reporting for OMSC
in FHTs and CHCs using EMR linkages.
UOHI &
Leadership
Table
UOHI &
Leadership
Table
UOHI,
Leadership
Table, CAMH
UOHI & FHTs
In-kind
High
5.5 To expand the OMSC intervention to an additional 5 FHTs/FHOs in the Champlain LHIN.
5.6 Develop sustainability plan for telephone-based follow-up of FHTs patients making quit
attempt.
5.7 Support all interested CHCs in Champlain to apply to be a OMSC partner CHC as part of
the 2012, 2013 Smoke-Free Ontario application process.
UOHI & FHTs
UOHI, SHL,
FHTs
CHCs, UOHI,
LHIN
Unfunded
Unfunded
5.8 To conduct an assessment of resource gaps for counselling and follow-up support and
develop an action plan to address identified gaps.
5.9 To adopt the OMSC intervention into the CHCs in the Champlain region.
CHCs, UOHI, ,
SHL
UOHI, CHCs,
SHL
CHC, UOHI,
CAMH
UOHI & PH
Unfunded
5.3 Work collectively to streamline data collection activities with CAMH STOP Program and
examine follow-up models to improve efficiencies.
5B.Expand the OMSC into more
Family Health Teams
5C.Expand OMSC and
Cessation Services in
Champlain CHCs
5D. Support the delivery of
brief interventions
5.4 Sustain the OMSC in the 15 FHTs in Champlain and expand to additional FHTs in the
region including bi-annual meetings with FHT cessation task force and development of
QI plan; provision of training, materials and expert support.
5.10 Support Champlain CHCs involvement in the CAMH STOP program (cost-free NRT) and
delivery individual and group counselling services.
5.11 Host regional training workshops to train healthcare professionals and smoking
cessation champions outside of Family Health Teams using the ESCAPE Program and
Tools and promote referral to community resources.
In-kind
In-kind
Unfunded
In-kind
Secured
MOHLTC
CAMH,
MOHLTC
MOHLTC
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
6) MENTAL HEALTH &
VULNERABLE POPULATIONS
STRATEGY
Goal: Develop a regional strategy aimed at helping people with mental illness, living in
poverty and/or with substance use issues to access smoking cessation resources,
ultimately helping more people quit smoking.
6A. Develop skills training
&knowledge exchange
opportunities
6.1 Scan training opportunities in the Champlain region to ensure that a strong mental
health component is included as part of all training opportunities. Work collaboratively
with leaders from the mental health community to develop content and resources.
6.2 Integrate a strong mental health component into current UOHI training programs &
insert strong tobacco cessation component within existing and appropriate mental
health training opportunities.
6.3 Increase knowledge exchange and training between regional smoking cessation experts
and community health agencies that serve individuals with severe mental illness.
6.4 Train 10 organizational 'champions’ within the mental health service sector of the
Champlain LHIN each year on smoking cessation principles through the UOHI's 2 day
Ottawa Model of Smoking Cessation Sessions
6.5 Advocate for greater access to provincially funded cessation medication for those with
mental illness.
6B. Adapt, deliver and evaluate
the Ottawa Model for Smoking
Cessation for use by Mental
Health Service Providers
6.6 Work collectively to streamline data collection activities with CAMH STOP Program and
examine follow-up models to improve efficiencies and assist providers who are unable
to continuously follow their patients.
6.7 Prepare a research grant which would support the implementation of a systematic,
evidence-based tobacco cessation intervention for those with severe mental illness.
Smoking
Cessation
Network,
CMHA
CMHA, UOHI
In-kind
CMHA, PH,
UOHI
In-kind
UOHI
TBD
AMHNC,
Smoking
Cessation
Network,
CAMH
CAMH,
Leadership
Table, CAMH
CMHA
In-kind
High
TBD, in-kind
In-kind
Research
Grant
14
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
5.0 STRATEGY COMPONENTS
Strategy Component 1: Improved Information Systems and Metrics
A key issue identified in the environment scan was the lack of comparable data on program reach and efficacy
among cessation providers in Champlain and the lack of information systems to support coordinated care among
service providers.
GOAL:
Support collection of high quality metrics among regional cessation service
providers and support coordinated delivery of cessation services among
providers.
Strategy Component 2: Cessation Service Delivery Network
A key gap identified as part of the environmental scan was the lack of cohesion and communication between
smoking cessation programs in the region. For example, if a patient quits smoking while in hospital, their quit
attempt may falter upon discharge as their family physician may not be aware of this attempt, their medication
may not be continued, and they may not receive the necessary follow-up support they require. Creating a
centralized smoker’s registry which could link and share information between the various smoking cessation
programs could provide a level of integration unseen before in the field of smoking cessation.
GOAL:
Create the capacity in the Champlain region to deliver high quality cessation
services to more Champlain residents.
Strategy Component 3: Partner with Employers and Unions to Deliver Innovative
Worksite Smoking Cessation Program
Worksites have been underutilized in Canada as a channel for reaching smokers. The Conference Board of
Canada estimates the total cost per smoking employee is now $3,396, due to decreased productivity and
increased absenteeism.25 Blue collar workers have high rates of tobacco use which are estimated to be between
30%-60% as compared to 12-18% in the general population. In the Champlain region champions have been
identified from within the Eastern Ontario Building and Trades Union and the City of Ottawa to support the
delivery of cessation services to union members and employees. This union serves more than 25,000 members
and offers a unique opportunity to develop and execute an innovative worksite cessation program.
Workers who smoke and identify as ready to quit will be provided a menu of three levels of support for making a
quit attempt. The services offered will include a) ‘Quit Kits’ with self-help resources, b) ‘Quit Kits’, a faxed referral
to Smokers’ Helpline for active follow-up, and the option to use cost-free nicotine replacement therapy (NRT) c) A
4 week group or one-on-one cessation counselling service with cost-free NRT.
GOAL:
To decrease the number of smokers within the construction and trades workers,
hospital employees, and municipal workers who smoke through the provision of
evidence-based smoking cessation programs.
15
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Strategy Component 4: Expand Reach of OMSC in Champlain Hospitals and High Risk
Outpatients Clinics
The Ottawa Model for Smoking Cessation (OMSC) has gained national recognition for its implementation of a
systematic approach to identifying and treating smokers in the hospital setting. The OMSC has been adopted by
23 of the 23 hospitals in the Champlain region as well as many outpatients units. Given the effectiveness of the
intervention, there is an opportunity to increase the reach of the program by expanding the current inpatient and
outpatient programs. The Regional Cancer Program has provided leadership as part of their provincial mandate to
address tobacco use and will provide leadership to the introduction of the OMSC in outpatient Cancer Clinics.
GOAL:
Increase the number of smokers being reached by Champlain LHIN hospitals
and expand reach to pre-admission units and regional cancer program.
Strategy Component 5: Expand Reach of OMSC in Primary Care
Approximately 90% of Ontario residents visit a primary care clinic each year, and primary care is the first point of
contact most people have with the healthcare system.16 In this setting, 12% and 30% of patients smoke.16
Currently, physicians do a better job asking about a patient’s smoking status, than they do offering advice to quit
smoking and offering follow-up.16 The Ottawa Model for Smoking Cessation in Primary Care was developed and
tested in 2009-2010 and has been shown to be effective in increasing rates at which providers deliver evidencebased cessation treatments, patient quit attempts, and, among those ready to quit cessation rates. The Ottawa
Model for Smoking Cessation is very well suited to the primary care environment with multi-disciplinary teams
available such as Family Health Teams. Currently, 15 of the 23 Family Health Teams (FHTs) in the Champlain
region have adopted the model and 5 other primary care teams. In the City of Ottawa, the A.C.E.S.S. program is
the most widely used program in the Community Health Centre (CHC) environment. The program is currently
being revised however, due to the low reach and high dropout rate of the program. The adoption of the Ottawa
Model in the CHC setting is feasible due to the allied healthcare staff of the CHCs. The Smoke-Free Ontario
Strategy made cost-free nicotine replacement available in 2012 to FHTs and, in 2013 to Community Health
Centres.
GOAL:
Expand Ottawa Model for Smoking Cessation to Family Health Teams and
Community Health Centres in Champlain
Strategy Component 6: Mental Health & Vulnerable Populations Strategy
In 2005, 9.7% of the general population in the Champlain LHIN (111,280) was diagnosed with a mood disorder,
an anxiety disorder or schizophrenia. This is a population that accesses health care primarily through the
emergency departments and in the Champlain LHIN, there is a high rate of repeat visits within 30 days of an
emergency department visit.
Survey data has determined that over 70% of Canadian Mental Health Association Ottawa clients and close to
100% of Ottawa Inner City Health clients smoke. Both organizations serve individuals with severe mental illness
who are homeless and/or vulnerably housed. Up to 85% of individuals with severe mental illness continue to use
tobacco products and 40% of these individuals smoke more than 40 cigarettes a day. 22 This has contributed to
such an astounding inequitable distribution of negative health outcomes this it is now estimated that individuals
with severe mental illness die 20 years earlier than the general population, with 60% of these deaths due to
cardiovascular, respiratory, and infectious disease.23 Despite the high rates of tobacco use, the environmental
scan showed a lack of accessible and appropriate smoking cessation treatment options for those with mental
health illness. There is also a lack of organizational knowledge and systemic support to create sustained action
utilizing consistent evidenced based approaches.
GOAL:
Develop a regional strategy aimed at helping people with mental illness, living in
poverty and/or with substance use issues to access smoking cessation
resources, ultimately helping more people quit smoking.
16
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
6.0 PERFORMANCE MANAGEMENT PLAN
Indicators
Process
Number of patients registered to the centralized smokers’ registry
Number of worksites implementing the smoking cessation program in the Champlain LHIN
Number of mental health services implementing a smoking cessation program in the Champlain LHIN
Number of hospitals implementing the OMSC in the Champlain LHIN
Number of outpatient clinics implementing the OMSC in the Champlain LHIN
Number of Family Health Teams implementing the OMSC in the Champlain LHIN
Number of Community Health Centres implementing the OMSC in the Champlain LHIN
Number of health care professionals trained in best practice smoking cessation guidelines in the
Champlain LHIN
Outcome
Number of smokers identified and offered treatment in the Champlain LHIN
Reach in priority populations and between geographic areas.
Impact
Number of smokers quit at 6-months
Improvement in 6-month quit rate attributable to cessation intervention
7.0 RESOURCE PLAN
The costing for the strategy recommendations was completed as part of the expert panels work. The following
provides preliminary estimates of a base budget for the six strategy components.
Item
Improved Information Systems and
Metrics
Cessation Service Deliver Network
Year One
($)
Secured Funding
Gap
Year Two
($)
Secured
Funding
Gap
Year Three
($)
Secured Funding
Gap
0
20,000
0
10,000
0
10,000
0
150,000
0
250,000
0
250,000
0
0
100,000
0
200,000
Worksite Smoking Cessation Program
100,000
Hospital and High Risk Outpatient
Clinics
550,000
0
550,000
0
550,000
0
200,000
100,000
100,000
200,00
100,000
200,000
0
25,000
0
100,000
0
100,000
850,000
295,000
650,000
660,000
Grand
Total
650,000
760,000
Primary Care Program
Mental Health and Vulnerable
Populations
Totals
3,865,000
17
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
8.0 LEADERSHIP AND PARTNER ROLES
Ottawa Public Health and the University of Ottawa Heart institute have offered to be the co-lead for this strategy.
Further conversations with each partner will identify their specific role in the strategy. The named organization for
each element will be required to embed their plan within their annual planning framework and report progress
through a Tobacco Control Strategy Implementation Group. The following partner organization will play active
roles in execution of the strategy:
Partner
University of Ottawa Heart Institute
Ottawa Public Health
Eastern Ontario Health Unit
Leeds, Grenville & Lanark District Health Unit
CCPN
Smoker’s Helpline
Canadian Mental Health Association
Regional Cancer Program / Ottawa Breast Cancer Clinic
Ottawa-Carleton Pharmacists’ Association
Ottawa Inner City Health
Building and Construction Trades Council
Construction Companies (Aecon, Ellis-Don, Bellai Brothers Construction Ltd etc.)
18
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
9.0 IMPACT & RETURN ON INVESTMENT
By reaching an expected 15,000 smokers, we can expect that approximately 4,500 individuals will quit smoking.
This will decrease the percentage of smokers in Champlain region by 1% and will result in an estimated cost
savings of over $117 million in lifetime health care costs.
Expected
Reach by
2016
Component
Integration of Smoking Cessation Service
Network
Worksite Smoking Cessation Program
Hospital & Specialty Clinic Smoking Cessation
Primary Care Smoking Cessation Program
Mental Health Smoking Cessation Program
Total
Expected
Number of
Quits
Expected
Savings in
Health Care
Spending
1,500
500
$12,921,000
1,500
450
$11,628,900
7,000
2,100
$54,268,200
4,000
1,200
$31,010,400
1,000
300
$7,752,600
15,000
4,550
$117,581,100
*Expected number of quits is calculated by taking the expected reach and multiplying it by 20% quit rate for community based
program and 30% quit rate for other program which is the average quit rate of the OMSC programs. Expected savings in
health care spending was calculated by multiplying the expected number of quits by $25,842 15, which is the health care cost
savings for a light smoker who quits between the age of 40 and 44.
*Please note these numbers are estimates.
10.0 RISK ASSESSMENT
There are potential risks to the engagement of this strategy. The risks and mitigation strategies are listed below.
Type of Risk or Barrier
Risk Level
Insufficient staff for the project
Likely
Demand for program exceeds capacity
Likely
Grant funding is not received from the
MOHLTC
Likely
Programs are not able to sync with the
centralized smokers’ registry
Likely
Mitigation Strategy
CCPN and its partners will seek to secure
resources from Network partners,
government, and industry sources.
The sharing of resources and programs
will ensure that partners are familiar with
all programs in the region. Therefore, if
one program has too much demand,
patients can be referred to other partner
programs.
CCPN and its partners will seek
additional in-kind partner contributions.
Program components may need to be
scaled back accordingly.
Further technological development time
and resources will be required to ensure
that a solution can be established
19
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 1 – Number and percentage of smokers in the Champlain region
All Smokers (Daily
and Occasional)
Daily Smokers
(>12 years)
Male
Female
Champlain
221,568 (18.0%)
(15.2, 20.9)
157,000 (12.8%)
(10.5, 15.1)
178,486
(14.5%)
137,865(11.2%)
City of Ottawa
128,841(14.67%)
(11.0, 18.2)
82,952 (9.4%)
(6.7, 12.1)
95,307
(10.8%)
71,480
(8.1%)
Eastern Counties
51,954 (26.1%)
(21.1, 31.1)
41,205 (20.7%)
(16.1, 25.3)
42,798
(21.5%)
39,613
(19.9%)
Renfrew Counties
27,178 (26.8%)
(20.5, 33.1)
22,716 (22.4%)
(16.5, 28.4)
28,293
(27.9%)
17,746
(17.5%)
Leeds, Grenville &
Lanark
12,477 (26.0%)
(20.5, 31.5)
10,125 (21.1%)
(15.6, 26.7)
13,053
(27.2%)
7,198
(15.0%)
Region
Source: Atlas of Cardiovascular Health in the Champlain Region 2011
20
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 2 – Champlain Smoking Cessation Services: 2011-12 reach, efficacy, and funding source
Program Name
Organization
Region
# of Sites
Reach 2011-12
Quit Rate
Funding Source
Smokers’ Helpline Call Volume**
Canadian Cancer Society
Provincial
N/A
327
3
Not collected
Canadian Cancer Society
Smoker’s Helpline Online Registration
Canadian Cancer Society
Provincial
N/A
1,075
Not collected
Canadian Cancer Society
OMSC Inpatient Hospital Program
Ottawa Heart Institute
Regional
23 hospitals
4,608
29.4% at 6-months
MOHLTC
OMSC Outpatient Hospital Program
Ottawa Heart Institute
Regional
15 units in 4
hospitals
-
MOHLTC
OMSC Primary Care Program
Ottawa Heart Institute
Regional
15 FHTs, 1
CHC, 4 FHGs
563
(2010-2011)
872 Quit Plan Visits
2180 brief advice
31.1% at 60 days
Ottawa Heart Institute Quit Smoking Program
Ottawa Heart Institute
City of Ottawa
1
185
Not available
UOHI base budget
Ottawa Public Health Dental Program
Ottawa Public Health
City of Ottawa
4
N/A
Not collected
Ottawa Public Health
A.C.C.E.S. Program
Ottawa Public Health
City of Ottawa
11
381
Not collected
Ottawa Public Health
Leave the Pack Behind
U of Ottawa, Carleton University, Algonquin
College, La Cité Collégiale
City of Ottawa
4
N/A
Not collected
Provincial Funding
Dr. Lena’s Adolescent Smoking Cessation Clinic
Clinic for Adolescents (Dr. Lena’s clinic)
City of Ottawa
1
200
Not collected
OHIP (counseling is
covered)
Kick Butt for 2
St. Mary’s Home, Salvation Army Bethany
Hope Centre, Youville Centre
City of Ottawa
3
42
Not collected
Ottawa Public Health &
Nicotine Anonymous
Nicotine Anonymous
City of Ottawa
1
N/A
Not collected
Nicotine Anonymous
Seventh Day Adventist Church
Seventh Day Adventist Church
City of Ottawa
1
N/A
Not collected
Workplace Health Workshop (Jan-March 2012)
Ottawa Public Health
City of Ottawa
1
12
Not collected
Ottawa Public Health
Prenatal Cessation Support
Ottawa Public Health
City of Ottawa
various locations
397
Not collected
Ottawa Public Health
Tobacco Team: phone line, youth, self-help kits
Ottawa Public Health
City of Ottawa
2,147
Not collected
Ottawa Public Health
Royal Ottawa Hospital Drop-in Cessation Program
Royal Ottawa Hospital
City of Ottawa
Various
locations
1
N/A
Not collected
Base funding
EOHU Quit Smoking Program
Eastern Ontario Health Unit
Eastern Ontario
6
277
Not collected
EOHU
Smoking is a Drag
Seaway Valley CHC
Eastern Ontario
1
Not available
Not collected
Quit Smoking Program
Renfrew County and District Health Unit
Renfrew County
1
Not available
Not collected
Strengthening the Forces
Canadian Forces (Petawawa)
Renfrew County
1
205
Not collected
Base Funding & CAMH
STOP
Renfrew County and District
Health Unit & CAMH STOP
Study
Federal Government
Quit Smoking Program
Leeds, Grenville & Lanark District Health Unit
LL&G
1
Not available
Not collected
LL&G Health Unit
Brockville General Hospital
LL&G
1
Not available
Not collected
-
96
11,306
-
Brockville Cardiovascular Program Smoking Cessation
TOTAL
-
HSFO secure until 2013
Brockville General Hospital
Foundation Office
-
* Note: Numbers are only for those programs that collected attendance numbers at the program.; ** The Smokers’ Helpline Call Volume is for new calls only. Source: Environmental
scan of programs undertaken by the Regional Smoking Cessation Task Group
21
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 3: ENVIRONMENTAL SCAN
EVIDENCE-BASED SMOKING CESSATION INTERVENTIONS
There are four key components to an evidence-based smoking cessation intervention regardless of the
setting. They are:
1) Intervention to motivate quit attempt
2) Behavioural Counselling
3) First Line Quit Smoking Pharmacotherapy
4) Follow-up Support over 2 to 6 months
MOTIVATING A QUIT ATTEMPT
There are several well-established interventions for increasing the motivation of an individual who smokes
to quit (see Table 2).19 Among the most powerful interventions are policies to increase the price of
tobacco products and smoke-free space policies both of which have been executed in the province of
Ontario. Other proven strategies include brief advice from a clinician, availability of cost-free
pharmacotherapies, mass media campaigns and incentives such as quit and win contests.
A health professional’s advice to quit has been shown to increase a smoker’s motivation to quit and long
term success with quitting.20 Patients with a smoking related illness have been shown to quit at higher
rates than those who do not.
Table 2.0: Summary of Best Practice Smoking Cessation Interventions
Intervention
Efficacy
Price (taxation, contraband availability)
***
Smoke-Free Spaces Policies
**
Mass Media & Targeted Promotional Campaigns
**
Health Professional Advice to Quit
***
Quit and Win Contests
**
Health Scare (Personal or other)
***
Availability of Cost Free Pharmacotherapy
**
22
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
INCREASING SUCCESS WITH QUITTING
The United States Treating Tobacco Use and Dependence, Clinical Practices Guideline on Tobacco
Control is a highly regarded resource on evidence-based practice for smoking cessation.20
Smokers who stop smoking with support are four times more likely to stop successfully compared with
smokers who stop without any form of support (See Table 3). Success is higher among patients who are
motivated to make a quit attempt. Counselling and medication are effective when used by themselves for
treating tobacco dependence. The combination of counselling and medication, however, is more effective
than either alone. Thus all individuals making a quit attempt should be encouraged to use both
counselling and medication. Those receiving counselling in addition to pharmacotherapy are up to four to
six times more likely to quit than those attempting to quit without support.20
Table 3: Effects of pharmacotherapy and behavioural counselling on smoking cessation
outcomes
No behavioural
treatment
Brief Intervention
Longer advice,
multiple sessions
No medication or
placebo
Control condition
(CC)
2 x CC
3 x CC
Medication
2 x CC
4 x CC
6 x CC
Behavioural Counselling
Individual, group, and telephone counselling are effective, and their effectiveness increases with
treatment intensity.20 Patient preference is an important factor in determining which mode of delivery is
most effective.
Outcomes by format of cessation service
Format Number
Estimated odds ratio (95% C.I.)
Estimated abstinence rate (95% C.I.)
No format
1.0
10.8
Self-help
1.2 (1.02–1.3)
12.3 (10.9–13.6)
Proactive telephone counselling
1.2 (1.1–1.4)
13.1 (11.4–14.8)
Group counselling
1.3 (1.1–1.6)
13.9 (11.6–16.1)
Individual counselling
1.7 (1.4–2.0)
16.8 (14.7–19.1)
Source: Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update.
The optimal dose of counselling is not clear however there is evidence that brief interventions are
effective and that additional benefit occurs with up to 90 minutes of follow-up support.
23
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Treatment Outcomes by amount of contact time
Total amount of contact time
Estimated odds ratio (95% C.I.)
Estimated abstinence rate (95% C.I.)
No minutes
1.0
11.0
1–3 minutes
1.4 (1.1–1.8)
14.4 (11.3–17.5)
4–30 minutes
1.9 (1.5–2.3)
18.8 (15.6–22.0)
31–90 minutes
3.0 (2.3–3.8)
26.5 (21.5–31.4)
91–300 minutes
3.2 (2.3–4.6)
28.4 (21.3–35.5)
> 300 minutes
2.8 (2.0–3.9)
25.5 (19.2–31.7)
Source: Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update.
Effectiveness and estimated abstinence rates for number of person-to-person treatment sessions
Number of sessions
Estimated odds ratio (95% C.I.)
Estimated abstinence rate (95% C.I.)
0–1 session
1.0
12.4
2–3 sessions
1.4 (1.1–1.7)
16.3 (13.7–19.0)
4–8 sessions
1.9 (1.6–2.2)
20.9 (18.1–23.6)
> 8 sessions
2.3 (2.1–3.0)
24.7 (21.0–28.4)
Source: Treating Tobacco Use and Dependence, Clinical Practice Guideline, 2008 Update.
First Line Pharmacotherapies
Three first line pharmacotherapies are available which have been shown to increase long term success
with quitting by 2 to 3 fold.20 The extended use (beyond 10-12 weeks) of pharmacotherapies and high
dose of Nicotine Replacement Therapy (NRT) has been shown to increase success with quitting
compared to standard treatment regimes.20 This is particularly true for smokers with higher levels of
nicotine addiction which is presently 60% of the population of smokers in Champlain.21
Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that
all insurance plans include the counselling and medication identified as effective in the Guideline as
covered benefits.
24
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
3.1 THE PROVINCIAL CONTEXT
The implementation of a regional smoking cessation strategy is opportunely timed to align with the current
renewal of the Ontario Smoke-Free Strategy. The Ontario Smoke-Free Strategy is implementing the
recommendations of the Tobacco Strategy Advisory Group (TSAG) published in October 2010. The
strategy will focus on increasing efficiencies within the system by having groups such as CAMH,
Smoker’s Helpline and the Ottawa Model for Smoking Cessation work together to integrate their services,
particularly in the hospital setting.
The University of Ottawa Heart Institute has secured funding from the Ontario Smoke-Free Strategy to
support the sustainability of the Ottawa Model for Smoking Cessation in the Champlain LHIN and other
hospitals in Ontario.
The Ontario Smoke-Free Strategy also places an emphasis on increasing NRT access to Family Health
Teams (FHTs) and Community Health Centres (CHCs). Our proposed strategy includes working with
FHTs and CHCs to increase the number of patients who make a quit attempt and increase the number of
patients who use pharmacotherapy with their attempt.
The Ontario Drug Benefit (ODB) plan has added smoking cessation pharmacotherapy to the list of drug
benefits. The cost of pharmacotherapy is a barrier for some people who want to quit smoking and
therefore, this new addition will allow those residents who qualify for the ODB plan to access smoking
cessation pharmacotherapy at no cost.
The Ontario Smoke-Free strategy also encourages smoking cessation programs to be developed for
target groups that are at high risk for tobacco-related disease, or have decreased access to tobaccocessation services, to provide services that address their specific needs. The mental health component of
our strategy is strategically aligned with the Ontario strategy to ensure that those with mental health
issues in our region are receiving the appropriate care.
25
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
3.2 THE LOCAL CONTEXT
PREVALENCE OF TOBACCO USE IN CHAMPLAIN
Regional Disparities
The Champlain region has a wide variation in smoking rates. The City of Ottawa enjoys one of the lowest
smoking rates in the province, however, if you travel 30 minutes outside of Ottawa in any direction, you
will find that the smoking rate is dramatically higher. Interestingly, given the large population of Ottawa,
there still remain more smokers in Ottawa than in the outlying regions. See Exhibit 1.
Vulnerable Populations
Within the Champlain region, certain sectors of the population also have disproportionately higher rates of
smoking. Vulnerable populations include trade workers, low-income, blue collar, GLBT, francophone,
aboriginals, individuals with mental health illness.
SMOKING CESSATION SERVICES IN CHAMPLAIN
An environmental scan was undertaken to review the current level of cessation services in the Champlain
region. See Exhibit 2 for a summary of reach, efficacy, and funding source for all cessation services
identified.
ASSETS & STRATEGIC ALIGNMENT
Ottawa Public Health Smoke-Free Outdoor Spaces Policy and Smoking Cessation Strategy
In April 2012, a new smoke-free by-law was passed by the City of Ottawa which prohibits smoking in all
outdoor areas on municipal properties including parks, playgrounds, beaches, sports fields, and outdoor
areas around City facilities. The by-law also prohibits smoking on outdoor restaurant, bar and food
premise patios. As a consequence of this amendment, Ottawa Public Health expects to see a renewed
interest in quitting smoking and has recently released a quit smoking strategy which aims to provide
education about the by-law and expanded support to smokers who want to quit. The CCPN has been
working closely with the leadership team at Ottawa Public Health to coordinate an integrated smoking
cessation plan as part of our shared interest in this area.
Eastern Ontario Health Unit Smoking Cessation Strategy
The EOHU has a smoking cessation strategy entitled My Time 2 Quit which aims to provide participants
with the tools to achieve a healthier tobacco-free lifestyle, through a combination of counselling and
Nicotine Replacement Therapy (NRT) products. The strategy links patients who are being discharged
from the hospital with this community-based program. Participants may participate in telephone
counseling and/or group sessions. Participants also receive 1 $15 voucher to be used towards the
purchase of NRT products every time they attend a group session (to a maximum of 10 vouchers). The
EOHU smoking cessation strategy has partnered with the Ottawa Model for Smoking Cessation to ensure
timely follow-up with participants.
Community-Based Programs
Community based programs are being delivered in each of the four public health regions. As noted in
Exhibit 3, there are 17 community programs in place throughout the Champlain region. These programs
service a variety of clientele and are offered through a variety of service models, including group sessions
and one-on-one counselling. With these types of programs, it is more difficult to ascertain exactly how
26
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
many participants are being reached and have quit smoking as attendance and abstinence rates are not
tracked uniformly across all programs.
ACESS Program
The Accessible Chances for Everyone to Stop Smoking (ACESS) program is a coalition of community
agencies and Ottawa Public Health serving Ottawa. ACESS delivers smoking cessation services by
coordinating with community health centres, community resource centres and some community agencies
in Ottawa. The program is offered free of charge and includes eight and four week quit smoking
programs. The participants also have access to transportation and child care costs (through the
partnering centres. Nicotine Replacement Therapy is offered by participating centre based on their
medical directives. Individuals can register themselves and participate in a once per week group
counselling for a maximum of eight-weeks to increase their chances of quitting. This program is currently
being reviewed.
University of Ottawa Quit Smoking Program
The University of Ottawa Heart Institute has since 1998 offered a quit smoking program which is open to
all residents in the Champlain region.
Ottawa Model for Smoking Cessation
In the first five years of the CCPN’s operating plan, the Ottawa Model for Smoking Cessation was one of
6 priority initiatives. The Ottawa Model for Smoking Cessation is currently operating in 23 of the 23
hospitals in our region. In addition, the OMSC has been included as part of the hospital accountability
agreements in our region. Since 2006, over 26,622 hospitalized smokers in the Champlain LHIN have
been provided the OMSC intervention, resulting in more than 7,827 quitters at 6 months post-discharge.
A recent analysis of the OMSC in a cardiac hospital showed a 355% return on investment. 24
The success of this model has spurred the adoption of the model into speciality clinics and in primary
care. The program has expanded into outpatient clinics which see an extremely large volume of patients
per year. There is further opportunity to expand the model into more specialty clinics such as the Cancer
Clinic at the Ottawa Hospital. In Family Health Teams (FHTs), the main program being used is the
Ottawa Model which has been adopted by 15 of the 21 FHTs in the Champlain LHIN as well four other
large primary care teams in the region. Since its inception, the primary care physicians involved in the
program have advised over 6,300 patients to quit smoking in the Champlain LHIN and 2,500 have made
a quit attempt with the support of their primary care provider.
The Champlain Local Health Integration Network
The OMSC is now included in the accountability agreements of all Champlain LHIN hospitals. First
developed in the hospital setting, the model has grown to serve specialty clinics and the primary care
setting.
Ontario’s Smoker’s Helpline
Smoker’s Helpline also provides counselling services to those wanting to quit smoking. Smokers are able
to receive assistance both through phone counselling or the web. Over 3,000 patients received phone
calls from the program or registered on the website in the Champlain region between October 2009 and
September 2011.
27
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 4: SWOT ANALYSIS
Strengths
 Smoking identified as a priority in Champlain
LHIN Integrated Health Services Plan
 Ottawa Smoke-Free Outdoor Spaces By-Law
and OPH Cessation Strategy
 University of Ottawa Heart Institute Quit
Smoking Program
 Partnership Building and Trades Union to
support Worksite Cessation services
 Smokers’ Helpline – call in and fax referral
program
 Availability of cost free Nicotine Replacement
Therapy among Family Health Teams and
Community Health Centres in region.
 Ottawa Model for Smoking Cessation
Network of 23 hospitals
 Renewal of MOHLTC funding for Hospital
OMSC Network for 2011-12
 Champlain LHIN Hospital Accountability
Agreement to support Smoking Cessation
 Ottawa Model for Smoking Cessation Primary
Care Model
 Family Health Team Leadership to support
coordination of activities
 Eastern Counties Cessation strategy
 OPH ACESS Program
 TCAN
Weakness
• Reach of existing smoking cessation programs
and services is less than 5% of the population of
smokers
• Lack of awareness among smokers of existing
smoking cessation services
• Low demand in existing cessation services by
smokers in region.
• Difficulty assembling accurate data on reach and
outcomes for existing regional cessation services
• Varying quality of existing smoking cessation
programs
• Lack of coordinated communication strategy
• Size of skilled cessation workforce in region
• Reach of the OMSC in some partner hospitals is
sub-optimal in particular the Ottawa Hospital
• Linking of inpatients to outpatient resources
(transfer between programs)
• Access to cost-free pharmacotherapy & follow-up
for hospitalized patients and other groups
• Lack of active cessation efforts in community
pharmacies
• Lack of sustained funding for NRT
Opportunities
 Emphasis of Ontario’s Health Action Plan on
Prevention and Smoking Cessation
 Smoke-Free Ontario Strategy Renewal may
provide new resources and supports for
cessation
 Introduction of Ontario Drug Benefit Plan
coverage for Varenicline and Bupropion
(effective September 2011).
 MOHLTC funding for expansion of Ottawa
Model into Ontario 10 CHCs
 Cancer Care Ontario’s Plan to Invest in
Smoking Cessation ($35,000)
 Expansion of cessation services into high
reach settings (See Exhibit 5).
 Intervention focused on chronic disease
populations.
 Expansion of OMSC to outpatient settings in
particular cancer treatment centres,
outpatient settings, community health
centres, other primary care settings
Threats
• Hardening of smokers
• High rates of smoking in specific sub-populations
(mental health illness, low SES, blue collar
workers)
• Lack of understanding of how to best reach high
risk populations
• Annual renewal of funding for OMSC
• Lack of sustainable funding for OMSC FHTs
• Where smoking will be prioritized in 2013-2016
LHIN Integrated Health Services Plan
• Funding renewal of NRT to CHCs and FHTs
through CAMH
28
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 5 - ESTIMATED REACH BY SETTING
Worksites
Number of
employees
Building and Trades Union
25,000
City of Ottawa
5,000-9,000
Hospitals*
10,000
Federal Government
10,000
Ottawa Carleton District School Board
7,200
*Data based on employees at Ottawa Hospital only
Worksites
Smoking Prevalence
Potential Reach
30-40%
15%
15%
15%
15%
7,500
1,125
1,500
1,500
1,080
Source: City of Ottawa, Major Employers in the City of Ottawa, 2006.
Health Care Settings
Program Setting
Outpatient Hospital
Inpatient Hospital
Breast Cancer Clinic
Long Term Care
Home Care
Units
23
23
1
64
26
Smoking Prevalence
15%
15%
15%
Unknown
Unknown
Potential Reach
50,000-75,204
20,000
2,550
Unknown
Unknown
Units
21
12
800
Smoking Prevalence
22%
30%
15%
Potential Reach
34,940
18,000
70,000
122,940
Source: CCPN Partners
Primary Care
Practice Type
FHTs
CHCs
Primary Care
Combined
Source: Champlain Family Health Team Survey
29
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 6: Regional Smoking Cessation Strategy Logic Model
Strategic Component
Improved
Information
Potential Reach
Short-term Outcomes
Medium Term Outcomes
1,500
Decrease
smoking
related
morbidity
Systems & Metrics
Cessation Service
Delivery Network
1,500
Worksite Smoking
Cessation Program
OMSC in
Hospitals
High risk outpatient clinics
7,000
Inpatient hospital program
Primary Care
Long-term Outcomes
To increase the
number of
Champlain
residents who
make an aided quit
attempt using
evidence-based
cessation
interventions to
15,000 by 2016
Increase in the number
of Champlain residents
who:
1) Make a quit attempt
2) Use behavioural
support
3) Use pharmacotherapy
4) Quit smoking
Family Health Teams
4,000
Decrease
smoking
related
mortality
Increase quality
of life
Decrease
health care
utilization
Community Health Centres
Mental Health
and Vulnerable
Populations
Increase
productivity
1,000
30
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
Exhibit 7: STANDARDIZED METRICS FOR CESSATION SERVICES
Category
Indicator
Program / Organizational Process




# of staff trained in smoking cessation
# of staff trained as a smoking cessation specialist
# of sites (e.g. worksites, FHTs, hospital units)
# of clients reached
Client Level - Descriptive









Age
Gender
Years of Education
Postal Code
Time to first cigarette in the morning
Number of cigarettes smoked per day
Years smoking
Presence of smoking related illness (specify)
Presence of anxiety, depression, mental health illness (Y/N)
Client Level - Process




Delivery Model for Counselling (one-on-one, phone, group, web)
Number of sessions completed
Pharmacotherapy Type (NRT, Varenicline, Bupropion, none)
Cost free pharmacotherapy provided (Y/N)
Client Level - Outcome
 # of quit attempts at 1, 2, and 6-months**
 7 day point prevalence abstinence measured at 1, 2 and 6 months**
31
EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY
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EXPERT TASK GROUP RECOMMENDATIONS REPORT –REGIONAL INTEGRATED SMOKING CESSATION STRATEGY