November, 2005

1. Iowa Department of Public Health November, 2005

2. Tobacco Use in Iowa • Approximately 4,600 tobacco-related deaths annually • 20% of high school students are current smokers (2004 IYTS) • 20.3% of adults are current smokers (2004 IATS) • Annual health care costs directly caused by smoking - $937 million

3. Intervention Model for Patients Willing to Discuss Quitting • ASKabout tobacco use • ADVISEto quit • REFERpatient to cessation resources • This step relieves a practitioner of responsibility for the final 3 A’s (Assess, Assist, Arrange)

4. Step 1: Ask • Systematically ask every patient about tobacco use at every visit. • Determine if patient is current, former, or never tobacco user. • Determine what form of tobacco is used. • Determine frequency of use. • Document tobacco use status in the medical record.

5. Step 2: Advise • In a clear, strong, and personalized manner, urge every tobacco user to quit. • Tobacco users who have failed in previous quit attempts can be assured that most people make repeated attempts before they are successful. • Employ the teachable moment: link visit findings with advice.

6. Step 3: Refer • Assessif patient is willing to discuss quitting • Assistthose who are willing by providing information about Quitline Iowa • Use proactive referral • Request written permission to fax contact information to Quitline Iowa • Inform the patient that Quitline Iowa program staff will provide follow-up • Follow-up at next visit – repeat process if necessary

7. Fax Referral Program • Efficient method for referring patients who smoke to effective cessation services • Research indicates that physician referral of patients to smoking cessation programs is associated with a significantly higher participation rate than simply telling patients they should stop smoking • Alleviates some of the problems posed by limited time and resources • Takes the burden of initiating services off of the patient

8. How Fax Referral Works • HCP/clinician identifies patient as a smoker willing to discuss quitting • HCP/clinician educates patient on services of Quitline Iowa • Patient completes information on fax referral form providing consent for HCP/clinician to release information to Quitline Iowa to initiate counseling • Based on times provided by patient, Quitline Iowa staff contact patient to begin cessation counseling • Quitline Iowa provides feedback to HCP/clinician on status of patient – check-off box on fax referral form

9. Quitline Iowa Benefits • Effective, research-based cessation resource • Less time spent on tobacco cessation counseling during patient appointments • Increase in the number of patients who receive cessation counseling and who ultimately quit • No additional investment in materials, training, or other programs needed

10. What is Quitline Iowa? • Toll-free hotline available to all Iowans, including pregnant women and teens • Staffed 8 a.m. to midnight, seven days a week • Services in English & Spanish • Interpreters available for most other languages • TDD line, 1-866-822-2857 • Offers Comprehensive and Intensive counseling programs; tailored to client’s needs

11. Who Provides Quitline Iowa Services? • Operated by the Iowa Tobacco Research Center in the Department of Community and Behavioral Health, University of Iowa • John Lowe, DrPH, FAHPA, FAAHBDirector, ITRC • Mary Aquilino, Ph.D., MSN, FNPDeputy Director, ITRC • Funded by the Division of Tobacco Use Prevention & Control, Iowa Department of Public Health

12. Quitline Iowa Staff • Quitline Iowa currently employs 11 part-time counselors (FTE=2.93). • Graduate students in counseling psychology, rehabilitation counseling, health education, nursing and related fields • Professional therapists and educators • New counselors receive comprehensive training in treatment of tobacco dependence, motivational interviewing and cognitive behavioral therapy techniques. • Counselors receive continuing education through training sessions, monthly meetings and materials such as research articles and tip sheets. • Other staff include program coordinator, training coordinator/advanced counselor, program manager, research assistant and half-time database manager.

13. Quitline Iowa Services • Counseling treatment for tobacco users who want to quit • Information for friends, family and others concerned about someone’s tobacco use • Educational and self-help materials for anyone interested in quitting • Referrals to local tobacco cessation programs and services. • NRT coupon programs to provide financial assistance for smokers, available by county residency or health services providers

14. Transtheoretical Model and Stages of Change • PRECONTEMPLATION:Not thinking of quitting, does not see a problem • CONTEMPLATION: Examines smoking and potential to quit in a risk-reward analysis • PREPARATION:Makes a commitment to quit and develops a quit plan • ACTION: Has quit smoking (for under 6 months) and is implementing a quit plan • MAINTENANCE:Has been smoke free for an extended period of time (over 6 months) and all associated changes are consolidated into lifestyle Prochaska and DiClemente, (1984)

15. Quitline Iowa Cessation Programs • Comprehensive Program • Assess stage of change • Create quit plan if applicable • Mail materials • Follow up at 1, 2, 4 weeks • Intensive Program • Intake questionnaire • One-on-one counseling in up to 10 sessions • Excellent for heavy smokers

16. Effectiveness of Quitlines • Research indicates smokers who receive telephone cessation counseling double their chances of staying quit; e.g.: • Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone quitline for smokers. New England Journal of Medicine • Borland, et al., 2001. The effectiveness of callback counseling for smoking cessation: a randomized trial. Addiction • A meta-analysis of 27 studies of the efficacy of telephone quitlines indicates that proactive telephone counseling is more effective compared to interventions without personal contact, such as self-help materials. • Stead, et al., 2003—Cochrane Database of Systemic Reviews • A study of NRT added to quitline counseling indicates that the combination increases the likelihood of quitting. • Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine replacement therapy in a "real-world" setting.Preventive Medicine

17. Quitline Iowa Results • Quitline Iowa quit rates:

18. For More Information • Esther Baker, Program Coordinator • Phone: 319-384-4845 • Fax: 319-384-4841 • E-mail: esther-baker@uiowa.edu • Jeanie Kimbel, Training Coordinator • Phone: (319) 384-4842 • Fax: (319) 384-4841 • E-mail: jeanine-kimbel@uiowa.edu @ 2005 The University of Iowa. All rights reserved.