Academic Strategies to Influence EvidenceBased Tobacco Cessation Practices
Janie Heath PhD, APRN-BC, FAAN
Associate Dean Academic Programs & Professor of Nursing
University of Virginia, School of Nursing
Former Associate Dean of Academics College of Nursing & Director, Tobacco Cessation Nursing Faculty Practice Group
Georgia Health Sciences University
Why Make Tobacco Control an
Academic Initiative

46 million adults smoke (18.4%
of population)

GEORGIA = 19.5% prevalence
 VIRGINIA = 16.4%

1200 individuals DIE every day
in U.S. because of tobacco use
(450,000 / yr)

GEORGIA = 10,000 / yr
 VIRGINIA = 9200 / yr

Centers for Disease Control and Prevention. Vital Signs: Current Cigarette
Smoking Among Adults Aged ≥ 18 Years—United States, 2005–2010.
Morbidity and Mortality Weekly Report 2011;60(33):1207–12 [accessed
2012 June 3].
Why Make Tobacco Control an
Academic Initiative

It’s our MISSION



Improve health and reduce the
burden of illness in society by
discovering, disseminating,
and applying knowledge of
human health and disease
It’s our EXPERTISE
It’s our PASSION
Why Make Tobacco Control an
Academic Initiative
It’s all about OPPORTUNITY to promote health!
Major Responsibilities



Chief Academic Officer (CAO) for Accreditation and Outcomes
Assessment
CAO, Curriculum/Program development
CAO, Regulation of Academic/Student Affairs & Contracts
Academic/Enterprise-wide Engagement



Strategic Planning
New Financial Model: Responsibility Based Budget
University Assessment
Recent Funding



PI, HRSA DNP Acute Care APN Grant ($950,000) – 3 year
Ntl Panel, AHA, Effects of Smokeless Tobacco; Circulation 9/10
Co-I, NIH, AA Family Intervention for Smoking Cessation – 5 year
Student Reach with Tobacco Control –
Rx for Change EDU

BSN - 361 students


Traditional
 RN-BSN

MSN - 244 students






Clinical Nurse Leader
Primary Care NP
Acute Care NP and CNS
PMH NP and CNS
Health Mgmt Systems
Public Health Nursing
Leadership
Post MS Certificate - 21
students





NP, CNS, Wound Ostomy Care
DNP - 38 students
PhD - 48 students
Doctoral exchange – 11
students
TOTAL Projected UVA Tobacco
Control Reach: 2012 Fall
Enrollment = 723 students
Our MODEL for Optimal EBP Tobacco
Cessation Outcomes
Provide Research
Funding:
Organizations
Federal
Raise
Awareness:
Grassroots
State
National
International
Provide Training:
Nsg EDU
Nsg CE
Ensure
Accountability:
Licensure
Certification
Cessation
Interventions=
Standard of
Nsg Practice
Provide Systems
Support:
Priority in
Organizations
Heath, J., Andrews, J. (2006). Translation of tobacco cessation interventions into clinical practice. Nursing Research, 55(4): S44-S50
The REAP Framework

National coalition of nurse educators established to help
disseminate resources and information through a REAP
framework for tobacco control







R = RESEARCH
E = EDUCATION
A = ADVOCACY
P = PRACTICE
Founder: Dr. Janie Heath (MCG)
Co-Founders: Dr. Jeannette Andrews, Medical University of South
Carolina and Dr. Claudia Barone, University of Arkansas Medical
Sciences
www.nurses4tobaccocontrol.org
Application of REAP through Academic
Partnerships






Georgetown
University
Medical College of
Georgia
University of
Arkansas
Vanderbilt
University
Medical University
of South Carolina
University of
Virginia
Research
Education
Advocacy
Practice
Research: Workforce Development

To evaluate the effect of
an advanced practice
nurse driven EDU
INTERVENTION to
improve the effectiveness
of tobacco cessation
interventions among…



Acute Care Cardiology &
Pulmonary Providers
PMH APRN Providers
Maternal Child Providers
Application of the Theory of Reasoned Action
Schematic drawing of Theory of Reasoned Action’s relationship to tobacco cessation interventions (TCI) adapted from
Fishbein and Ajzen (2010)
10
Overview of Studies

Pretest – Posttest; Descriptive
Correlational Designs

Convenience Samples in large
academic medical centers with
healthcare providers

Fishbein-Azjen Theory of Reasoned
Action Framework

INTERVENTION- Rx for Change
Clinician Assisted Tobacco
Cessation* (www.rxforchange.edu) a
1 Hour Interactive DVD Education
Session

43 item survey
Overview of Selected Findings
Knowledge
Scores
Amole, J., Heath,
J., McLear, B,, &
Thomas, J.
(2012).
Optimizing
tobacco
cessation
strategies
through an online
continuing
education
program. Nursing
Clinics of North
America. 47: 7179
SelfConfidence
Correlations
Heath, J., Kelley,
J., Andrews, J.,
Crowell, N.,
Corelli, R.,
Hudmon, K.S.
(2007).
Evaluation of a
tobacco cessation
curricular
intervention
among acute care
nurse practitioner
faculty member.
American Journal
of Critical Care,
16(3):284-289.
TRA Beliefs
Change
Alices, M, Manghram, D,
Heath, J., Bennett, S. &
Joshua, T ( poster).
Tobacco Cessation
Interventions among
Acute-Care Providers in
Respiratory Units. The
National Teaching
Institute and Critical Care
Exhibition Conference,
Chicago, IL; 5/4/11.
Intention
Scores
Heath, J. & Amole, J.
(podium). Tobacco
Control and Mental
Illness: Breaking
Barriers through NP
Education, Practice
and Research. The
36th Annual Meeting
of National
Organization of Nurse
Practitioner Faculties,
Washington, DC;
4/17/10
Education Research

To evaluate the effect of
the Rx for Change
Clinician Assisted
Tobacco Cessation
Curriculum Intervention
among pre-licensure
interdisciplinary
healthcare students


Nursing, Dental Hygiene &
Respiratory Therapy
COMMIT - CNLs
Education Intervention:
Rx For Change Clinician Assisted Tobacco
Cessation Curriculum –
Rx for change

Based on USPHS Guideline and extensively
reviewed by experts in tobacco control
 Comprehensive > 350 CD-slides, ancillary
handouts, evaluation measures, case
studies

Selected Modules
 Epidemiology
 Forms of tobacco
 Genes & tobacco use
 Pathophysiology
 Nicotine addiction
 Pharmacotherapy
 Counseling techniques

Access at www.rxforchange.ucsf.edu
Authors:
Karen Hudmon RPh, DrPH
Robin Corelli PharmD
Overview of Studies

Pretest – Posttest; Descriptive
Correlational Designs

Convenience Samples in large
academic medical centers with
students

Fishbein-Azjen Theory of Reasoned
Action Framework

INTERVENTION- Rx for Change
Clinician Assisted Tobacco
Cessation* (www.rxforchange.edu) a
3 Hour Interactive Education Sessions

43 item survey
Overview of Selected Findings
Knowledge
Scores
Kelley, J., Heath,
J., Crowell, N.
(2006). Using the
Rx for change
tobacco curriculum
in advanced
practice nursing
education. Critical
Care Nursing
Clinics of North
America,18(1):
131-138.
SelfConfidence
Correlations
Inglett, S., Schumacher,
A., Kiernan, B., &
Heath, J. (poster). The
Effect of a Service
Learning Project on
CNL Student’s
Knowledge, Confidence,
Beliefs, & Intentions to
Intervene with Tobacco
Dependent Women. 26th
Annual SNRS Conf,
New Orleans, LA,
2/18/12
TRA Beliefs
Change
Inglett, S, Heath, J.
(podium). Factors
Influencing
Undergraduate
Nursing Students
Intentions to Integrate
Tobacco Cessation in
Daily Practice. 5th
Annual Uniting
Practice, Education,
and Research
Conference, Beta
Omicron & Pi Lambda
Chapters, Sigma
Theta Tau
International, Augusta,
GA; 2/23/10
Intention
Scores
Inglett, S., Schumacher,
A., Kiernan, B., &
Heath, J. (poster).
Predictors for Intentions
to Intervene with
Tobacco Dependent
Women: A CNL Student
Learning Project. 16th
Annual Graduate
Research Day, Georgia
Health Sciences
University, Augusta, GA
4/18/12
Advocacy Outcomes



Tobacco Free Campus
Initiative
 College of Nursing
faculty leadership
 Student leadership
Service learning activities
for students
 March of Dimes project
Media coverage
 The Augusta Chronicle
 Local TV Stations
Service Learning Outcomes for Students
Great American Smoke
Out



~30 pre-licensure /yr
~5 post-licensure /yr
~ 4 faculty / yr
Kick Butts Campaign



~18 pre-licensure / yr
~ 3 post-licensure / yr
~ 2 faculty /yr
Employee Wellness
Health Fair


GHSU NSG, Respiratory Therapy & Dental Hygiene

~22 pre-licensure / yr
~ 4 post-licensure / yr
~ 2 faculty / yr
Service Learning Outcomes for Students
Circle Of Motivated MOMs
for Infants to be Tobaccofree (COMMIT)


GHSU NSG and 3rd yr Pharmacy Students
March of Dimes 12 mth
funding
Recruit 24 tobacco
dependent women of child
bearing age to participate in a
6 wk evidence based tobacco
cessation program & follow up
Practice Outcomes
To evaluate the effect of
an advanced practice
nurse driven tobacco
cessation clinic on health
and cessation outcomes
among

GHSU employees, staff,
faculty and students

Funding per Tobacco Free Campus
Initiative: University, Health System & Physician
Practice Group

Heath et al (2012). The impact of the
Georgia Health Sciences University Nursing
Faculty Practice on Tobacco Cessation
Rates, Nurs Clin N Am (47) 1-12.
PMH participants
Nursing Faculty Practice Group (NFPG)
and Tobacco Control @ GHSU

How We Got There…

Administrative support



Dean Lucy Marion has
long history of promoting
faculty practice
All GHSU SON faculty
receive 0.2 work effort
for practice
New Facility

3700 Square foot; full
services from laboratory
space to 5 exam rooms
NFPG and Tobacco Control @ GHSU

How We Got There…

Faculty interest and
expertise



22 members (33%)
of NFPG in active
practice
7 members (10%) of
NFPG with tobacco
control expertise
Financial incentive

9% Dean’s fund, 9%
Chair’s fund, 37%
practice, 45%
faculty
NFPG and Tobacco Control @ GHSU
How We Got There…
Nov 29th, 2006 Town Hall Announcement; Nov 15th, 2007 Tobacco Free Campus
The NFPG Tobacco Cessation Clinic

Our Providers
 Medical Evaluation and Management



Janie Heath PhD, NP; Margo Henderson
DNP, NP; Lovoria Williams MSN, NP; Pam
Cromer MSN, NP
Collaborating Physician: Dr. Sara Young –
MCG-HI Family Medicine
Behavioral Counseling


Nursing - Sharon Bennett DNP, CNS;
Margaret Tuck MSN, CNS: Jack Amole DNP,
CNS;
Allied Health – Susan Whiddon MS, RT

Our Staff
 Jim Hawkins, NFPG Manager
 Nita Sakovitz & Candice Yates, Clinic
Coordinator

Plus STUDENTS!
GHSU Tobacco
Cessation Program
~ weekly group sessions
for 6 wks x 2 hours each
~ individual sessions for
4 wks x 2 hours each
~ telephone follow up
3mths, 6mths & 12mths
NFPG Tobacco Cessation Clinic

CLINICAL MEASURES:
Objective:
 Weight
 Blood Pressure
 Heart Rate
 Carbon Monoxide (CO)
Subjective (Self Report):
 Medical & Tobacco History
 Average Daily Cigarettes
 Fagerstrom Level of Dependence





Scale
CES-D Depression Scale
Readiness to Quit Ladder
Motivation to Quit Scale
Confidence to Quit Scale
Medication Tolerance
EBP Treatment for Tobacco Dependence
Counseling + Pharmacotherapy = Best Outcomes
EBP Treatment for Tobacco Dependence
A Successful Approach to Break the Cycle of Tobacco Dependence
The
PHYSICAL
The
BEHAVIOR
The
EMOTIONAL
Automatic learned
behavior with cigarettes
Role of cigarettes in life—
pleasure, stress, social
Physical addiction of
cravings & withdrawals
Adapted from Legacy’s GSD&M Presentation 12/5/03
27
NFPG Tobacco Cessation Clinic Outcomes
N = 160 completed program; 2007 - 2009
100
80
60
Female n = 88 (55%)
40
20
Male n = 72 (45%)
0
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Clinic Outcomes
100
90
80
70
60
50
40
30
20
10
0
Married 53%
Single 29%
Divorced 15%
Other 5%
Demographic findings: n = 160 completed program; 2007-2009
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Clinic Outcomes
160
140
120
Caucasian 79%
100
80
60
African American 18%
Asian 3%
40
20
Other 1%
0
Demographic findings: n = 160 completed program; 2007-2009
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Clinic Outcomes
200
H&Ps
150
Completed
Program
x178 Evaluated
100
x160 Completed
50
0
Start and Completion of Program: 2007 - 2009
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Clinic Outcomes
Variable
Mean
SD
Range
Tobacco
Hx
22.75
11.32
2 – 50 yrs.
# of QUIT
Attempts
4.22
3.86
1 - 25
123/178 (93.89%) attempted to quit before
Fagerstrom 4.20
2.09
0 - 10
n = 160 completed program; 2007-2009
151 (85%) received Chantix as part of treatment at the NFPG Tobacco
Cessation Clinic
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Pharmacotherapy
Outcomes
150
150
95%
100
50
Zyban
Chantix
11%
3%
0
Chantix
Start Pack
NRT
100
50
75%
Chantix
Continuation
Pack
0
91% treated with medication (145/160) as mono-therapy or combination therapy:
x6 NRT patch, x3 NRT gum, x5 NRT lozenge, x2 NRT inhaler; x4 Zyban; x138
Chantix; x15 No meds
Heath et al (2012). Nurs Clin N Am (47) 1-12.
NFPG Tobacco Cessation Clinic Outcomes
HA 3%
Constipation 3%
Flatulence 5%
Other 8%
Sleeplessness 13%
Vivid Dreams 34%
Nausea 34%
0
20 Outcomes: Chantix
40Side Effect Profile60
Pharmacotherapy
Comparison to Pfizer’s Phase 2 Trials of Chantix: Nausea = 30%; Insomnia = 18%
Chantix Prescribing Information 2008 Insert, Pfizer, New York, NY
NFPG Tobacco Cessation Clinic Outcomes
Group Session
Quit Rate
Individual Session
Quit Rate
Collective
Quit Rates
100
90
80
70
60
50
40
30
20
10
0
66%
64%
55%
1st Qtr
Tobacco QUIT Rates @ End of 6 wk / 4 wk Treatment per Self
Report & Carbon Monoxide Validation
NFPG Tobacco Cessation Clinic Outcomes
Follow Up
Self- Report 3 mths
Follow Up
Self- Report 6 mths
Follow Up
Self- Report 12 mths
100
90
80
70
60
50
40
30
20
10
0
36%
22%
16%
1st Qtr
Collective Tobacco QUIT Rates (no response = lost to follow up
and/or assumed to relapse)
NFPG Tobacco Cessation Clinic Outcomes
𝒙𝟐 Analysis
QUIT RATES at End of Tx,
3, 6 and 12 mths
compared to…
Readiness to
Quit Score
p = .0034
Number of
Group Sessions
p = .0001
Number of
Individual Sessions
p = .0001
If Married
p = .0312
Quit Rates for Mental Illness and/or Substance
Abuse
Substance Abuse 2/2
(100% - QUIT at 6 wk tx)
Bipolar 0/2
(0% - QUIT at 6 wk tx)
Anxiety 5/6
(83% - QUIT at 6 wk tx)
Multiple PMH Disorders 3/9
(33%)
Depression 17/22
(77% - QUIT at 6 wk tx)
0
20
40
60
PMH Tobacco Cessation Outcomes: 27 of 39 (69%) QUIT
Demographics: n = 39 with PMH Disorders (0.8%)
NFPG Tobacco Cessation Clinic Outcomes
for Mental Illness and/or Substance Abuse
Variable
Mean
SD
Range
Tobacco
Hx
21.85
14.0
3 - 60
# of QUIT
Attempts
4.72
3.69
1 - 15
39/39 (100%) attempted to quit before
Fagerstrom 4.59
2.05
1 - 10
CES-D
10.06
3 - 42
15.92
Demographics: n = 39
NFPG Tobacco Cessation Clinic Outcomes for
Mental Illness and/or Substance Abuse
30
Yes QUIT
EOT
20
10
No QUIT
EOT
0
79% on Chantix (31/39)
81% on Chantix (25/31)
30
EOT
Private
20
3mths
Group
10
6mths
40
20
0
85% Group Session (33/39)
0
12mths
QUIT Rates: EOT 69%, 3mths 10%;
6mths 12%; 12mths 7%
Academic Strategies to Influence Evidence-Based
Tobacco Cessation Practices WORK!!!
REAP into action for…
Happy & Healthy
EMPLOYEES/Patients!
…and COUPLES..!
THANK YOU
Janie Heath PhD, APRN-BC, FAAN
Janie.heath@virginia.edu