School Nurse-delivered Tobacco School Nurse-delivered Tobacco Cessation Intervention for Adolescents: Cessation Intervention for Adolescents:

Calling it QuitsCalling it Quits

Lori Pbert, Ph.D.Lori Pbert, Ph.D.

University of Massachusetts Medical SchoolUniversity of Massachusetts Medical School

Diane Gorak, RN, BSN, MEdDiane Gorak, RN, BSN, MEd

Massachusetts Department of Public HealthMassachusetts Department of Public Health

Voula Osganian, MDVoula Osganian, MD

Harvard Medical SchoolHarvard Medical School

Learning ObjectivesLearning Objectives

1.1. Understand the scope of the problem Understand the scope of the problem 2.2. Describe the 4-session school nurse-Describe the 4-session school nurse-

delivered tobacco cessation interventiondelivered tobacco cessation intervention3.3. Describe the outcomes from a RCT Describe the outcomes from a RCT

evaluating the effectiveness of this evaluating the effectiveness of this intervention in reducing tobacco use intervention in reducing tobacco use among adolescentsamong adolescents

4.4. Be able to adapt the intervention to your Be able to adapt the intervention to your clinical settingclinical setting

Past-Month Smoking Among Adolescents: Past-Month Smoking Among Adolescents: National Youth Risk Behavior Surveys, 1993-National Youth Risk Behavior Surveys, 1993-

20012001

Trends in Cigarette Smoking Among High School Students – U.S., 1991- 2001

MMWR:May 17, 2002

Percent Smoking in Past Month

0

5

10

15

20

25

30

35

40

1993 1995 1997 1999 2001

31%

35% 36% 35%

29%

The earlier the onset of smoking, the more The earlier the onset of smoking, the more severe nicotine addiction is likely to be and severe nicotine addiction is likely to be and the more difficult it will be to quit.the more difficult it will be to quit.11

Teens need only smoke a few times to Teens need only smoke a few times to develop the symptoms of nicotine addiction.develop the symptoms of nicotine addiction.22

Kessler: “Nicotine addiction begins when Kessler: “Nicotine addiction begins when most tobacco users are teenagers, so let's call most tobacco users are teenagers, so let's call this what it really is: a pediatric disease.”this what it really is: a pediatric disease.”33

1. Breslau and Peterson. Am. J. of Public Health. 1996; 2. DiFranza. NEJM. 2000; 3. Kessler. NEJM. 1996.

By age 17, one half of smokers have tried to quit By age 17, one half of smokers have tried to quit and failed, 2/3 regret ever starting and nearly and failed, 2/3 regret ever starting and nearly 40% express interest in some form of treatment 40% express interest in some form of treatment for tobacco dependence.for tobacco dependence.11

Approximately 75% of teenage daily smokers Approximately 75% of teenage daily smokers will smoke as adults.will smoke as adults.22

1 in 3 teens who smoke will die of a smoking-1 in 3 teens who smoke will die of a smoking-related disease.related disease.33

1. CDC. MMWR. 1993; 2. Report of the Surgeon General. DHHS. 1989; 3. CDC. MMWR. 1996

Why the School Nurse?Why the School Nurse?

Accessibility and continuity of care: 70% Accessibility and continuity of care: 70% seen yearlyseen yearly11

Adolescents feel it is the clinician's job to Adolescents feel it is the clinician's job to discuss health risk behaviors.discuss health risk behaviors.22

CredibilityCredibility Can make a difference (?)Can make a difference (?)

1. Igra, JAMA, 1993; 2. Steiner, J Fam Prac, 1996

Health and Social Risks Health and Social Risks Relevant to TeensRelevant to Teens

Decreased physical fitness and staminaDecreased physical fitness and stamina Retardation in the rate of lung growth and in Retardation in the rate of lung growth and in

maximum lung functionmaximum lung function Below average overall physical health reportedBelow average overall physical health reported Negative effect on lipid profile Negative effect on lipid profile Changes to appearance: wrinkles, yellowed Changes to appearance: wrinkles, yellowed

teeth and fingersteeth and fingers Increased risk for developing depression and Increased risk for developing depression and

anxietyanxiety

Benefits of Quitting/Benefits of Quitting/Not Smoking (Focus Groups)Not Smoking (Focus Groups)

Increased athletic abilityIncreased athletic ability Clean fingers, teeth, breath, clothesClean fingers, teeth, breath, clothes Less sore throats, coughs and respiratory Less sore throats, coughs and respiratory

diseasesdiseases Premature facial wrinkling is minimizedPremature facial wrinkling is minimized No risk of cigarette burnsNo risk of cigarette burns Save moneySave money Not being manipulated by cigarette companiesNot being manipulated by cigarette companies Control/independence from cigarettesControl/independence from cigarettes

School Nurse Work GroupSchool Nurse Work Group

15 school nurses/nurse practitioners 15 school nurses/nurse practitioners from MA met 7 times in 2000 and from MA met 7 times in 2000 and 20012001

Collaboration among DOE, MTCP, Collaboration among DOE, MTCP, UMMS, and DPH School Health UnitUMMS, and DPH School Health Unit– Dedicated members (80-90% attended all Dedicated members (80-90% attended all

meetings)meetings)

School Nurse Work GroupSchool Nurse Work Group (cont.) (cont.)

Developed a process for systematically Developed a process for systematically identifying students who use tobaccoidentifying students who use tobacco– Screener Screener – Office systemOffice system

Developed a brief intervention that school Developed a brief intervention that school nurses can use to assist tobacco users to quit nurses can use to assist tobacco users to quit tobacco usetobacco use– Literature reviewLiterature review– Interviewed teens for inputInterviewed teens for input– Self help materials were sharedSelf help materials were shared– Intervention was pilotedIntervention was piloted

School Nurse Work Group (cont.)School Nurse Work Group (cont.)

Developed student-level and organizational-Developed student-level and organizational-level data collection instrumentslevel data collection instruments– Identified items used in literatureIdentified items used in literature– Sensitive to language in a school settingSensitive to language in a school setting

Developed a process for the school nurses Developed a process for the school nurses to identify community resourcesto identify community resources

Overview of Intervention ProtocolOverview of Intervention Protocol

Based on the Agency for Healthcare Quality Based on the Agency for Healthcare Quality and Research (AHQR) clinical practice and Research (AHQR) clinical practice guideline (2000), Treating Tobacco Use and guideline (2000), Treating Tobacco Use and Dependence (5As: Dependence (5As: AAsk, sk, AAssess, ssess, AAdvise, dvise, AAssist ssist and and AArrange)rrange)

The American Academy of Pediatrics (AAP) The American Academy of Pediatrics (AAP) endorses and accepts as its policy the AHQR endorses and accepts as its policy the AHQR guideline for adolescents who use tobaccoguideline for adolescents who use tobacco

Modified based on focus groups and interviews Modified based on focus groups and interviews with teens who smokewith teens who smoke

Intervention ApproachIntervention Approach

Patient-centered/motivational Patient-centered/motivational interviewinginterviewing– Ask open ended questionsAsk open ended questions– Teen talks more than clinicianTeen talks more than clinician

Build skills/self-efficacy Build skills/self-efficacy – Problem - solvingProblem - solving

Develop health knowledgeDevelop health knowledge

Intervention ProtocolIntervention Protocol

4 individual sessions with school 4 individual sessions with school nursenurse

30 minutes/session30 minutes/session Within 1 month periodWithin 1 month period

Demonstration of Demonstration of Intervention ProtocolIntervention Protocol

Visits 1 and 3Visits 1 and 3

VISIT 1VISIT 1

Identify pros/cons of using tobacco, summarize Identify pros/cons of using tobacco, summarize ambivalenceambivalence

Clarify personal reasons for quittingClarify personal reasons for quitting Identify anticipated problemsIdentify anticipated problems Learn from past quit attemptsLearn from past quit attempts Understand nicotine addictionUnderstand nicotine addiction Review quit methodsReview quit methods Set a quit dateSet a quit date Identify triggers/brainstorm strategiesIdentify triggers/brainstorm strategies

VISIT 2VISIT 2 Review pack wrap, identify concrete strategies to Review pack wrap, identify concrete strategies to

address each triggeraddress each trigger Develop plan for handling social siutations (friends, Develop plan for handling social siutations (friends,

tobacco users in home)tobacco users in home) Identify strategies for managing withdrawal Identify strategies for managing withdrawal

symptoms symptoms Share the 4Ds Share the 4Ds

– delaydelay– deep breathingdeep breathing– drink waterdrink water– do something elsedo something else

VISIT 2 (cont.)VISIT 2 (cont.)

Break the stress myth (smoking reduces Break the stress myth (smoking reduces stress); strategies to manage stressstress); strategies to manage stressReality: smokers report greater overall Reality: smokers report greater overall stress and anxiety than nonsmokers and stress and anxiety than nonsmokers and former smokersformer smokers

Learn about weight gain and tips for Learn about weight gain and tips for minimizingminimizing

Elicit support from friends, familyElicit support from friends, family Take control of environmentTake control of environment

VISITS 3 and 4VISITS 3 and 4Assess how quit date wentAssess how quit date wentIf quit and maintainedIf quit and maintained

ReinforceReinforce Most difficult situations and how handledMost difficult situations and how handled Good things since quitGood things since quit Anticipated problems in staying quit and strategies to dealAnticipated problems in staying quit and strategies to deal

If quit and relapsedIf quit and relapsed Reinforce attemptReinforce attempt Length of quitLength of quit What went wellWhat went well What led to relapse and how handle in futureWhat led to relapse and how handle in future Elicit recommitment to quitElicit recommitment to quit Develop new planDevelop new plan

VISITS 3 and 4 (cont.)VISITS 3 and 4 (cont.)

If quit attempt not madeIf quit attempt not made What got in the way and how handle when try What got in the way and how handle when try

againagain Obtain recommitment to quit, set new quit dateObtain recommitment to quit, set new quit date Develop new planDevelop new plan

Evaluation DesignEvaluation Designand and

ResultsResults

Study ObjectivesStudy Objectives

Overall Aim:

Conduct a randomized controlled school-based trial to evaluate the efficacy of a school nurse delivered tobacco cessation intervention for adolescents.

Primary Aim

Demonstrate a significantly greater decrease in tobacco use among students in the intervention compared to control schools.

 

Study ObjectivesStudy Objectives

Secondary aimsSecondary aims are to demonstrate a greater are to demonstrate a greater– reduction in the amount of tobacco use,reduction in the amount of tobacco use,– reduction in the frequency of tobacco use, andreduction in the frequency of tobacco use, and– decrease in the number of times students are decrease in the number of times students are

suspended, received detention, or paid fines for suspended, received detention, or paid fines for tobacco usetobacco use

Study DesignStudy Design

72 High Schools•public schools in MA

•enrollment>=400•willing to be randomized

Usual CareN=34

Special Intervention5As Intervention

N=37

•Pair match on size, DPH funding type, and demographics•Randomize pairs

Student Data CollectionStudent Data Collection

Eligibility•Tobacco Use in past 30 days, and

•Interest in Quitting in next 2 weeks•Willing to participate

Baseline Survey

(N=577 Control / N=571 Intervention)

5As Intervention(4 visits within 1 month)•6-Week Follow-up survey

[554 (95%) Control / 506 (89%) Intervention]

•3-Month Follow-up survey

[525 (91%) Control / 498 (87%) Intervention]

Special Intervention Only

Recruit Students (goal 17 /school)

Usual Care

STUDENT QUESTIONNAIRES OUTCOME and MODIFYING VARIABLES

Variable

Baseline

6 Week F/UP

3 Month F/UP

Tobacco use in the past 30 days

Stages of Change

Gender

Race/ethnicity

Age of initiation of tobacco use

Previous quit attempts

Level of nicotine addiction

School performance

Parental permission to use tobacco

Accessibility of Tobacco

Family and friends tobacco use

Perceived social support to quit

Self-confidence to quit

Depression

Stress

Use of Nicotine Replacement Therapies (gum, patch, Zyban)

Process Data CollectionProcess Data Collection GoalsGoals

– document dose and fidelity of program implementationdocument dose and fidelity of program implementation

– document competing programsdocument competing programs

– assess school level supportassess school level support

Measures/Data CollectionMeasures/Data Collection– student self-report of content of counseling sessionsstudent self-report of content of counseling sessions

– school nurse questionnaires to assess support for the school nurse questionnaires to assess support for the program and presence of other cessation programsprogram and presence of other cessation programs

Statistical AnalysesStatistical Analyses Students T-Test or Chi Square Tests of Students T-Test or Chi Square Tests of

Association for comparison of student Association for comparison of student characteristics between conditionscharacteristics between conditions

Odds ratios were estimated using Odds ratios were estimated using generalized estimating equation (GEE) generalized estimating equation (GEE) logistic regression models with students logistic regression models with students clustered within school to account for clustered within school to account for within school correlations.within school correlations.

Table 1: Characteristics of Participants at BaselineTable 1: Characteristics of Participants at BaselineCharacteristic

Intervention (n=571)

Control (n=577)

Mean Age (years) 16.8 (1.1) 16.9 (1.1) % White 90% 86% % Black 2% 2% % Hispanic*

6% 10%

% with school performance about average or better

81%

80%

% with household member who uses tobacco

72% 70%

% with half or more friends who also use tobacco

89% 87%

% able to smoke at home 51% 51% % easy or very easy to get tobacco 98% 98%

* p<0.01

Table 1: Characteristics of Participants at Baseline (cont)Table 1: Characteristics of Participants at Baseline (cont)Characteristic

Intervention (n=571)

Control (n=577)

Mean # of days smoked cigarettes past 30 days 27 (7) 27 (7) Mean # of cigarettes smoked/day past 30 days 15 (11) 15 (12) Mean age first smoked a whole cigarette (yrs) 12 (2) 12 (2) Mean Nicotine Addiction Score (range 0-10)*

5.0(2) 4.7 (2.0)

% tried to quit in past 12 months 71% 70% % plan to quit in within next 30 days* 37% 68% % somewhat to very confident could quit permanently*

78% 70%

% with some to a lot of support to quit from family friends*

82% 69%

85% 61%

Mean depression score (range 0-20)

4.4 (4.0)

4.5 (4.0)

Mean stress score (range 28-140) 88.5 (21.2) 87.2 (22.6)

* p<0.01

Figure 1: Proportion of Students Who Quit Smoking Figure 1: Proportion of Students Who Quit Smoking by Condition at Each Time-Pointby Condition at Each Time-Point

0

0.1

0.2

0.3

0.4

0.5

6 weeks 3 months

Time

Pro

po

rtio

n W

ho

Qu

it S

mo

kin

g

Control

Intervention

OR=7.3 (3.4-15.6)

OR=5.9 (3.6-9.6)

Table 2: Adjusted Odd Ratios and 95% Confidence Table 2: Adjusted Odd Ratios and 95% Confidence Intervals for Quitting Smoking in Intervention Intervals for Quitting Smoking in Intervention Compared to Control Schools at Each Time-PointCompared to Control Schools at Each Time-Point

Model 6 weeks 3 months Adjusted for school

7.3 (3.4-15.6)

5.9 (3.6-9.6)

Adjusted for plans to quit, confidence to quit, support from friends, nicotine addition score

8.8 (3.7 -20.6)

6.3 (3.4-11.4)

Table 3: Students’ Self-Reported Receipt of the Table 3: Students’ Self-Reported Receipt of the Intervention Intervention

Key Component % YES

ask you what you like about smoking/using tobacco?

97%

ask what you do not like about smoking/using tobacco?

98%

ask you what your present reasons are for wanting to stop smoking/ using tobacco?

97%

ask you about prior quit attempts? 97%

discuss nicotine addiction? 94%

discuss different methods to quit such as quitting cold turkey or cutting back?

94%

Table 3: Students’ Self-Reported Receipt of the Table 3: Students’ Self-Reported Receipt of the Intervention Intervention

Key Component % YES

discuss your triggers to smoke/use tobacco and strategies for dealing with those triggers ?

97%

discuss social situations when you typically smoke/use tobacco or have an urge to smoke/use tobacco and how you will handle these situations?

97%

discuss withdrawal symptoms and ways to manage them (such as the 4 D’s)?

96%

discuss stress and ways you can reduce your stress? 95%

ask you who you would like to ask for support in your quit attempts and how they can best help you?

94%

ask you how you will reward yourself for quitting with the money you save?

91%

help you develop a personal quit plan? 96%

use the “Calling it Quits” booklet during visits? 95%

Table 4: Students’ Self-Report of Number of Visits with Table 4: Students’ Self-Report of Number of Visits with School Nurse in Intervention SchoolsSchool Nurse in Intervention Schools

Number of VisitsNumber of Visits % of students % of students

None None 2%2%

1 Visit 1 Visit 9%9%

2 Visit 2 Visit 14%14%

3 Visits 3 Visits 15%15%

4 Visits4 Visits 35%35%

>> 5 Visits 5 Visits 25%25%

Table 5: Students’ Self-Reported Acceptability of the Table 5: Students’ Self-Reported Acceptability of the

InterventionIntervention

QuestionQuestion % Responding% Responding

Very Moderate SomewhatVery Moderate Somewhat

1.1. How well do you think the school nurse How well do you think the school nurse

understood how you feel about smoking?understood how you feel about smoking? 64% 64% 24% 24% 10%10%

2.2. How well did the discussion with the How well did the discussion with the

school nurse hold your interest? school nurse hold your interest? 42% 42% 39% 39% 17%17%

3.3. How comfortable were you discussing How comfortable were you discussing

smoking with the school nurse?smoking with the school nurse? 71% 71% 20% 20% 8% 8%

4.4. How much did you like the booklet How much did you like the booklet

provided to you?provided to you? 11 % 11 % 32% 32% 38% 38%

Table 6: School Nurses’ Report of Intervention Table 6: School Nurses’ Report of Intervention ImplementationImplementation

Number of students enrolled completing required visits No Visits 15 (3%) 1 Visit 31 (5.4%) 2 Visits 58 (10%) 3 Visits 24 ( 4%) 4 Visits 443 (76%)

Time to conduct intervention visits (minutes)

First Visit 29 (8.3) Second Visit 21 (5.7) Third and Fourth Visits 15 (5.8)

Number of visits you think are needed to be successful 6.1 (3.8) visits

Table 7: School Nurses’ Report of Intervention Table 7: School Nurses’ Report of Intervention Acceptability and Feasibility Acceptability and Feasibility

.

Very

Somewhat Not at all

How helpful was the intervention protocol?

67%

33%

0

How effective was the intervention protocol?

25%

50%

25%

How receptive were your students to the intervention?

33%

67%

0

Table 8: School Nurses’ Report of Support for a Table 8: School Nurses’ Report of Support for a Smoking Cessation Program Smoking Cessation Program

Status Extremely

Moderately Somewhat

Teachers

Control

Intervention

5%

12%

13%

20%

50%

56%

Administrators

Control

Intervention

8%

17%

25%

29%

30%

37%

Table 9: School Nurses’ Report of Smoking Table 9: School Nurses’ Report of Smoking Cessation Activities During the Past School Year Cessation Activities During the Past School Year

.

Status Baseline Follow-up

Was smoking or tobacco use cessation counseling conducted with adolescents?

Control Intervention

49% 44%

39% 83%

Types of Sessions

Individual

Group

Both

Control Intervention

Control

Intervention

Control Intervention

21% 10%

26% 45%

53% 45%

44% 69%

13% 6%

44% 26%

Person Conducting Sessions

Yourself

Other school health nurse

Health Educator

Control Intervention

Control

Intervention

Control Intervention

55% 45%

10% 30%

40% 35%

56% 86%

13% 20%

31% 14%

Summary and ConclusionsSummary and Conclusions

A smoking cessation counseling intervention for A smoking cessation counseling intervention for adolescents can be feasible for school nurses to conduct adolescents can be feasible for school nurses to conduct in the school setting.in the school setting.

A school nurse delivered smoking cessation A school nurse delivered smoking cessation intervention is successful in assisting some students intervention is successful in assisting some students who are interested in quitting smoking to quit smoking who are interested in quitting smoking to quit smoking in the short-term.in the short-term.

A school nurse delivered smoking cessation counseling A school nurse delivered smoking cessation counseling intervention can be acceptable to adolescent smokers.intervention can be acceptable to adolescent smokers.

LimitationsLimitations Lack of cotinine validation or an objective measure Lack of cotinine validation or an objective measure

of smoking behavior.of smoking behavior.

Lack of longer term follow-up of smoking behavior Lack of longer term follow-up of smoking behavior to assess long term maintenance of quit rates. to assess long term maintenance of quit rates.

Generalizability-conducted with a population of Generalizability-conducted with a population of students interested in quitting and predominately students interested in quitting and predominately white.white.

Adapting the Intervention to Adapting the Intervention to Your Clinical SettingYour Clinical Setting

Barriers and facilitators to Barriers and facilitators to incorporating the intervention incorporating the intervention into your clinical practiceinto your clinical practice

Nurses’ Self-Reported Barriers to Nurses’ Self-Reported Barriers to Conducting the InterventionConducting the Intervention

Lack of time to conduct a session or complete all Lack of time to conduct a session or complete all sessions within the one month timeframe due to sessions within the one month timeframe due to other responsibilities.other responsibilities.

Lack of opportunity for uninterrupted sessions Lack of opportunity for uninterrupted sessions with the student due to other student issues.with the student due to other student issues.

Too difficult to fit the sessions into the school day Too difficult to fit the sessions into the school day of the student.of the student.

Questions and Questions and AnswersAnswers