Reports From the Field

Clinician Telephone Training to Reduce Family Tobacco Use: Analysis of Transcribed Recordings

Journal of Clinical Outcomes Management. 2016 February;23(2)

References

1. U.S. Department of Health and Human Services. The health consequences of involuntary tobacco smoke: a report of the Surgeon General. 2006.

2. Rauh VA, Whyatt RM, Garfinkel R, et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol 2004;26:373–85.

3. Polanska K, Hanke W, Ronchetti R, et al. Environmental tobacco smoke exposure and children’s health. Acta Paediatr Suppl 2006;95:86–92.

4. American Academy of Pediatrics, Committee on Substance Abuse. Tobacco’s toll: implications for the pediatrician. Pediatrics 2001;107:794–8.

5. U.S. Department of Health and Human Services. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2007.

6. Wilson KM, Klein JD, Blumkin AK, et al. Tobacco-smoke exposure in children who live in multiunit housing. Pediatrics 2011;127:85–92.

7. Taylor SM, Ross NA, Cummings KM, et al. Community intervention trial for smoking cessation (COMMIT): changes in community attitudes toward cigarette smoking. Health Educ Res 1998;13:109-22.

8. Winickoff JP, Healey EA, Regan S, et al. Using the postpartum hospital stay to address mothers’ and fathers’ smoking: the NEWS study. Pediatrics 2010;125:518–25.

9. American Academy of Pediatrics, Section on Tobacco Control. Policy statement: Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics 2015;136:1008–17.

10. Winickoff JP, Nabi-Burza E, Chang Y, et al. Implementation of a parental tobacco control intervention in pediatric practice. Pediatrics 2013;132:109–17.

11. Ossip DJ, Chang Y, Nabi-Burza E, et al. Strict smoke-free home policies among smoking parents in pediatric settings. Acad Pediatr 2013;13:517–23.

12. Winickoff JP, Park ER, Hipple BJ, et al. Clinical effort against secondhand smoke exposure: development of framework and intervention. Pediatrics 2008;122:e363–e75.

13. Nabi-Burza E, Winickoff JP, Finch S, Regan S. Triple tobacco screen: opportunity to help families become smokefree. Am J Prev Med 2013;45:728–31.

14. Winickoff JP. Pediatrician-led program increases provision of smoking cessation support, boosts quit rates among parents. Innovations in Medicine 2011. Accessed 24 Nov 2015 at https://innovations.ahrq.gov/profiles/pediatrician-led-program-increases-provision-smoking-cessation-support-boosts-quit-rates.

15. Fiore MC, Bailey WC, Cohen SJ. Treating tobacco use and dependence. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.

16. Winickoff JP, Nabi-Burza E, Chang Y, et al. Sustainability of a parental tobacco control intervention in pediatric practice. Pediatrics 2014;134:933-41.

17. Moore D, Aveyard P, Connock M, et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systematic review and meta-analysis. BMJ 2009;338:b1024.

18. Aveyard P, Wang D, Connock M, et al. Assessing the outcomes of prolonged cessation-induction and aid-to-cessation trials: floating prolonged abstinence. Nicotine Tob Res 2009;11:475–80.

19. Asfar T, Ebbert JO, Klesges RC, Relyea GE. Do smoking reduction interventions promote cessation in smokers not ready to quit? Addict Behav 2011;36:764–8.

20.Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med 1998;339:673–9.

21. Abroms LC, Ahuja M, Kodl Y, et al. Text2Quit: Results from a pilot test of a personalized, interactive mobile health smoking cessation program. J Health Commun 2012;17 Suppl 1:44-53.

22. Curry SJ, Ludman EJ, Graham E, et al. Pediatric-based smoking cessation intervention for low-income women: a randomized trial. Arch Pediatr Adolesc Med 2003;157:295–302.

23. Orleans CT, Schoenbach VJ, Wagner EH. Self-help quit smoking interventions: effects of self-help materials, social support materials, social support instructions and telephone counseling. J Consult Clin Psychol 1991;59:439–48.

24. An LC, Zhu SH, Nelson DB, et al. Benefits of telephone care over primary care for smoking cessation: a randomized trial. Arch Intern Med 2006;166:536–42.

25. Warner DO, Klesges RC, Dale LC, et al. Clinician-delivered intervention to facilitate tobacco quitline use by surgical patients. Anesthesiology 2011;114:847–55.

26. Creswell, JW. Qualitative inquiry and research design: choosing among five approaches. 2nd ed. Thousand Oaks, CA: Sage; 2007.

27. Sandelowski M. Focus on research methods: whatever happened to qualitative description. Res Nurs Health 2000;23:334–40.

28. Winickoff JP, Hipple B, Drehmer J, et al. The clinical effort against secondhand smoke exposure (CEASE) intervention: A decade of lessons learned. J Clin Outcomes Manag 2012;19:414–9.

29. Clark T, Sinclair R. The costs and benefits of acting as a research site. Evid Policy A J Res Debate Pract 2008;4:105–19.

30. Zhu S, Melcer T, Sun J. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305–11.

31. Gilpin EA, Messer K, Pierce JP. Population effectiveness of pharmaceutical aids for smoking cessation: what is associated with increased success? Nicotine Tob Res 2006;8:661–9.

32. Cokkinides VE, Ward E, Jemal A, Thun MJ. Under-use of smoking-cessation treatments: results from the National Health Interview Survey, 2000. Am J Prev Med 2005;28:119–22.

33. Winickoff JP, Tanski SE, McMillen RC, et al. Child health care clinicians’ use of medications to help parents quit smoking: a national parent survey. Pediatrics 2005;115:1013–7.

34. Kaiser Family Foundation. Status of state action on the medicaid expansion decision. Available at http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

35. U.S. Department of Health and Human Services. The health consequences of smoking- 50 years of progress: a report of the Surgeon General. 2014.

36. American Academy of Pediatrics, Section on Tobacco Control. Policy statement: Public policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics 2015;136:998–1007.

37. Collins BN, Levin KP, Bryant-Stephens T. Pediatricians’ practices and attitudes about environmental tobacco smoke and parental smoking. J Pediatr 2007;150:547–52.

38. Leininger LS, Finn L, Dickey L, et al. An office system for organizing preventive services: a report by the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems. Arch Fam Med 1996;5:108–15.

39. Swartz SH, Hays JT. Office-based intervention for tobacco dependence. Med Clin North Am 2004;88:1623–41.

40. Bordley WC, Margolis PA, Stuart J, et al. Improving preventive service delivery through office systems. Pediatrics 2001;108:E41.

41. Schoen C, Osborn R, Huynh PT, et al. On the front lines of care: primary care doctors’ office systems, experiences, and views in seven countries. Health Aff (Millwood) 25:w555–w71.

42. Rigotti NA, Quinn VP, Stevens VJ, et al. Tobacco-control policies in 11 leading managed care organizations: progress and challenges. Eff Clin Pract 2002;5:130–6.

43. Curry SJ. Organizational interventions to encourage guideline implementation. Chest 2000;118(2 Suppl):40S–6S.

44. Berg M, Meijerink Y, Gras M, et al. Feasibility first: developing public performance indicators on patient safety and clinical effectiveness for Dutch hospitals. Health Policy 2005;75:59–73.

45. Gandhi TK, Puopolo a L, Dasse P, et al. Obstacles to collaborative quality improvement: the case of ambulatory general medical care. Int J Qual Health Care 2000;12:115–23.

46. Mol A. Proving or improving: on health care research as a form of self-reflection. Qual Health Res 2006;16:405–14.

The principal investigator presented information, clarified points in the video, explained the materials, and asked questions and elicited relevant experiences from the project leader. In addition to teaching the project leader about the tobacco control strategies used in CEASE, the peer-to-peer calls prepared the project leader to train the rest of their own practice clinicians and staff in the CEASE intervention.

Whole Office Training Calls

Each practice’s local project leader led the whole office training calls, but CEASE study staff were on the call to introduce themselves to office staff, answer any questions that staff may have raised that the project leader could not answer, give information about data collection, and to generally support the implementation of the CEASE intervention and research program. During this call, the project leader watched the video with the group and tailored the training for his or her practice, focusing on issues of relevance for patients and staff.

Training Calls as Research Data

As many practices struggle with research burden [29], finding innovative and unobtrusive methods of collecting data is especially useful for research teams and participating practices. During both calls, clinicians and staff were asked open-ended questions to learn about their concerns regarding intervention implementation, share their own experiences with tobacco and tobacco control, and explore practice-specific methods to address family smoking. CEASE staff used this opportunity to help practices tailor the intervention to the local setting, such as by offering quitline enrollment sheets in another language. Clinician and staff answers to open-ended questions provided qualitative data for this manuscript.

Results and Discussion

The research team used training call data to explore clinician and staff concerns and desires related to family-centered tobacco control. The most common themes were: (1) prescribing, dosing, and insurance coverage of NRT, (2) motivation for and methods to help families become tobacco-free, and (3) the impact of the CEASE intervention on the day-to-day operations of the practice.

Nicotine Replacement Therapy

Prescribing or recommending NRT is one of the best ways to help families become tobacco-free and is a crucial component of the CEASE intervention [30–32]. Through the telephone trainings, clinicians and staff were trained to prescribe NRT using pre-printed prescription sheets, presented information about the effectiveness of NRT for smoking cessation, and referred to an information sheet on NRT to answer other questions as needed.

During the calls, it became clear that the pediatric clinicians were interested in prescribing NRT to help smokers quit, but lacked the skills and knowledge to do so:

I’m writing all this down [about NRT], because I don’t know any of this. (IN peer-to-peer)

Is 4 mg the strongest the gum comes in? (NC whole office)

This lack of knowledge may be a barrier to prescribing NRT in the pediatric setting. A national survey revealed that while smoking parents would accept prescriptions for NRT from their child’s doctor, very few received a prescription [33]. The calls provided an opportunity to have clinicians’ questions about NRT be answered by a pediatric tobacco control expert.

Clinicians were interested in helping parents stop smoking with medication, but were worried about access to medication; one of the most common questions voiced was not about how or why to prescribe NRT but how to help low-income parents get NRT for free or low-cost.