RC-2006-0007 Title: Increasing QUITPLANSM Helpline Utilization by Surgical Patients Applicant Organization: Mayo Clinic Rochester Principal Investigator: David Warner Amount of award: $517,397 Length of award: 36 months Type of award: Full Standard award ABSTRACT Despite the wide availability of effective tobacco cessation tools such as the QUITPLANSM services sponsored by MPAAT, there is a great need to increase the reach of these tools in the general population, as only a small percentage of eligible smokers currently elect to utilize these services. We believe that there is an excellent opportunity to do so in a population that has received little prior attention in the tobacco control literature — patients scheduled for elective surgical procedures. Each year, approximately 100,000 smokers undergo elective surgery in Minnesota. In addition to the fact that all these smokers contact the health care system, providing the opportunity to intervene, there are other reasons that surgery is a particularly opportune time for smokers to make a quit attempt. For example, because smoking increases the frequency of postoperative complications including pneumonia and wound infections, and even temporary abstinence from smoking reduces these complications, patients have a powerful additional incentive to quit. Furthermore, our prior work funded by MPAAT has shown that the forced abstinence that patients must maintain while in surgical facilities mitigates typical nicotine withdrawal symptoms, and that nicotine replacement therapy may be safe and effective in this population. This prior work also shows that very few surgical patients currently receive any type of tobacco cessation intervention, but has revealed some of the barriers to successful intervention. Busy practitioners, most of whom have little training or experience in tobacco interventions, simply do not have the time, skills, or motivation to consistently address tobacco use in their patients who seek attention for other medical problems. Very few surgical practices have ready access to referral to tobacco specialists, and patients may not have the interest, time, or resources to pursue such specialist treatment. One promising suggestion is that the recommended “5As” approach to brief clinician intervention, which has not been adopted widely in clinical practice, be further simplified to “ask, advise, and refer” — to resources such as QUITPLANSM; i.e., the clinician simply Assesses tobacco use, Advises the participant to stop smoking, and then Refers to a tobacco quitline. Although conceptually appealing from the standpoint of maximizing potential dissemination, this approach needs to be validated in clinical settings. In particular, the utilization of quitline resources is relatively low within the general population of smokers, and it remains to be determined whether provider referral will increase utilization. In preliminary work, we have identified several barriers to quitline utilization. These are primarily related to misconceptions regarding the content, cost, and configuration of these services, misconceptions that could be potentially addressed by information given by providers at the time of referral to these services. The overall goal of this proposal is to increase the utilization of the QUITPLANSM Helpline by surgical patients who smoke. Two specific aims will be pursued using a multidisciplinary research team. In the first aim, we will develop a practice-based intervention to promote QUITPLANSM Helpline utilization by surgical patients (SPECWIC AIM 1A), then develop methods to educate providers in its implementation (SPECWIC AIM 1B). In the second aim, we will perform a randomized clinical trial of this intervention in the Mayo Clinic Preorative Evaluation Clinic (POE), with the primary outcome being utilization of the QUITPLANSM Helpline (SPECIFIC AIM 2). This proposal thus aims to improve the reach and adoption of an existing tobacco cessation services in Minnesota. It specifically falls within Research Area II, Tobacco Cessation Services, and will address the full range of Minnesotans who require elective surgery. This is a diverse group that provides a representative sampling of the state population. The following is a brief overview of the proposed methodology. SPECIFIC AIM 1A.—Develop a practice-based intervention to promote QUITPLANSM Helpline utilization by surgical patients.--We will develop a brief (< 5 mm) practicebased intervention ensuring that patients scheduled for elective surgery are asked about tobacco use, advised to quit, and receive a blend of motivational interviewing, the removal of misperceptions about tobacco quit lines, and proactive recruitment of participants to quit line participation. The goal of this intervention will be to increase the proportion of surgical patients who utilize the QUITPLANSM Helpline. To develop the intervention we will use a validated participatory research approach, combining key informant interviews and focus groups. SPECIFIC AIM 1B.—Develop methods to educate providers regarding intervention delivery.-Having developed the intervention, we will develop means to educate the providers in the preoperative clinic who will deliver it, including the physicians and respiratory therapists. The development of the provider education component, both in content and mode of delivery, will rely heavily on the outcomes from the provider focus groups. We will use this information and the extensive experience of the investigative team in training other health care providers in tobacco intervention to develop the provider education. The method of education delivery will necessarily be determined by how best to economically present the clinically relevant material in a time frame that is acceptable to busy practitioners. We will also evaluate the effectiveness of the provider education. SPECIFIC AIM 2.—Evaluate the intervention in a surgical practice.—To evaluate the effectiveness of the intervention to promote QUITPLANSM Helpline utilization, we will perform a randomized clinical trial involving 300 smokers scheduled for elective surgery to test the hypothesis that the intervention devised in SPECIFIC AIM 1 will increase QUITPLANSM Helpline utilization. Subjects will be randomized to receive either the Helpline utilization intervention (specifically promoting the Helpline, including proactive referral) or a standard brief intervention that does not specifically encourage Helpline utilization (to clarify, the term “intervention” here refers to the action by the clinical provider to promote Helpline utilization, not the services provided b’ the Helpline itself). Helpline utilization and smoking behavior will be followed up to three months postoperatively. The primary outcome will be the rate of Helpline utilization, defined as the completion of at least one Helpline counseling session. The secondary outcome will be the 7-day point prevalence abstinence from smoking at three months postoperatively. By the conclusion of the grant period, we will have implemented and evaluated a brief practice- based smoking intervention strategy for surgical patients that leverages existing QUITPLANSM services to bring an effective smoking cessation intervention to more Minnesotans. If successful, the next step would be to disseminate this brief intervention into surgical practices throughout Minnesota and the nation. This work may also provide insight into how to increase the general reach of these valuable services by utilizing other practice settings, including primary care, patients hospitalized for other indications, dental offices, and others.