Health Care Professional Training
in Smoking Cessation Counseling Techniques
Clean Air for Healthy
Children and Families
Edward G. Rendell, Governor
Calvin B. Johnson, M.D., M.P.H., Secretary of Health
Pennsylvania Chapter
American Academy of Pediatrics
In partnership with Pennsylvania Area Health Education Center (AHEC)
PA DOH Funding to Fox Chase
1989-1994
PA DOH Funding to PA AAP 1996-Present
Clean Air
Program
Adopted
1996
AAP Policy2001
Primary Contractors
2002
ACS1997
CPG, ACOG2000
Curriculum
Revised & Updated
2004, 2006
PA DOH Funding to AHEC to PA AAP 2005-Present
Program Development
Every clinician, who interacts with pregnant women, mothers, caregivers of young children, teens and others, will deliver effective smoking cessation advice and counseling.
Program Goal
Ensure that smokers are fully informed of the health risks associated with smoking and secondhand smoke
Motivate smokers to quit
Increase cessation attempts by delivering the 5 A’s/2 A’s and R brief smoking cessation counseling intervention
Increase successful cessation by providing effective counseling, pharmacotherapy, self-help materials, and referrals
Reduce the number of children and individuals who are exposed to secondhand smoke at home
CAFHCF Program Objectives
Today’s Learning Objectives
At the end of this training you should:
Understand the 5 A’s/2 A’s and R brief smoking cessation counseling intervention
Feel more confident in your ability to provide brief smoking cessation counseling
Be motivated to discuss smoking cessation with your patients and smoke-free environment with your patients
Develop a plan to implement the 5 A’s/2 A’s and R brief smoking cessation counseling intervention
What Is Your Office Doing Now?
In what ways do you feel your office is effective or ineffective?
What works well?
What do you feel your patients need?
What skills do you feel you are lacking to counsel patients?
What do you hope to gain from the training today?
Identify smokers and recent quitters
Counsel (5 A’s/2 A’s and R)
Patient education materials: self-help magazines, optional materials, etc.
Practice tools: documentation forms, stickers, etc.
Program Components
Integrating an evidence-based Intervention into practice
Practical Counseling
Problem solving Skills training Relapse prevention Stress management
Support by Providers Social Support Pharmacotherapy
Nicotine replacement Bupropion Varenicline
USPHSGuideline
Brief counseling is effective
sk about tobacco use
dvise to quit
ssess willingness
ssist in quit attempt
rrange for follow-up
CounselingIntervention
AA
AA
AA
AA
AA
AA
AA
RR
sk
dvise
efer
5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)
Community Resources 1-800-QuitNOW Rx Pharmacotherapy
*Can extend to 10-15 min. for all patients*Smoke Free Families recommends 10-15 min. for pregnant women
Fiore et al., (2000)Smoke Free Families recommends 5-15 minutes counseling in pregnancy
Efficacy of Various Levelsof Contact
10.9
13.4
16
22
0
5
10
15
20
25
Perc
enta
ge No Contact
Minimal Contact < 3 min.
Brief Counseling 3-5 min.
Counseling > 10 min.
Patient OutcomesTotals for cessation flow sheets through
12/31/97-06/01/06
QuitReductionRecent QuitterNo ChangeRelapse
20%
23%41%
3%
12%Smoking status self-reported by
patients
n= 9,882
Increase utilization of the 5 A’s
Every visit, every time
Reminder systems
Clinician education
Promote system change
Recommendations of Center for Disease Control
The scope of the problem
Comparative Causes of Annual Deaths in the U.S.
14
17
19
30
41
81
430
0 200 400 600
Drug Induced
Aids
Homicide
Suicide
Motor Vehicle
Alcohol
Smoking Related
# of Deaths(thousands)
USDHHS, CDC (TIPS): Comparative Causes of Annual Deaths in the United States
SmokingPrevalence
23
19
11
25
22
18
12 12
0
0
5
10
15
20
25
% Cur
rent
Smok
ers
US PA Healthy People2010 Goal
Men
WomenPregnant Women
2004 National Health Interview Survey {(MMWR 2005(54)44}2005 PA Behavioral Risk Factor Surveillance System PA DOH Vital Statistics Resident Live Births 2004 Table B-25National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.)
Smoking DuringPregnancy
35
25
15
108 7
0
5
10
15
20
25
30
35
% C
urre
nt S
mok
ers
LowIncome
HighIncome
Employment GradeUSDHHS, Smoking During Pregnancy-United States, 1990-2000. MMWR, 2004;53(39):911-915
Smoking During Pregnancy
High School> High School
< High School
National Vital Statistics Reports: Births: Final Data for 2003 (Martin, J. A. et al.), Table 31
Smoking Quit Rates DuringPregnancy
Approximately 30% of quitters relapse during their pregnancy
Many women who quit smoking during pregnancy plan to smoke again once the baby is born
70% of remaining quitters relapse within 12 months of delivery
PA Birth Certificate Data: % Pregnancy Smoking Status3 Mos. Prior 1st Trimester 2nd Trimester 3rd Trimester
White 25.5 18.5 15.7 15.1
Black 20.9 16.6 14.1 13.8
Hispanic 16.3 11.4 9.2 8.9
15-19 35.4 28.0 22.7 21.2
20-24 37.3 28.2 23.7 22.7
PA Department of Health, 2004 Vital Statistics Resident Live Births by Age (Table B-19A) and Race (Table B-19B)
“We’ve known for decades that smoking is bad for your health...the toxins from cigarette
smoke go everywhere the blood flows. There is no safe cigarette...the only way to avoid the
health hazards of smoking is to quit completely or to never start smoking.”
U.S. Surgeon General Richard H. CarmonaNews Release, 2004, SGR, The Health Consequences of Smoking
News Release 06/27/06, SGR, The Health Consequences of Involuntary Exposure to Tobacco Smoke
“The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It
is a serious health hazard that can lead to disease and premature death in children and
nonsmoking adults.”
The Debateis Over
The Life Cycle of the Effects of Smoking on HealthThe Life Cycle of the Effects of Smoking on Health
SIDsSIDsBronchiolitisBronchiolitisMeningitisMeningitis
InfancyInfancy
Low Birth WeightLow Birth WeightStillbirthStillbirthNeurologic ProblemsNeurologic Problems
In uteroIn utero
AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries
InfluencesInfluencesto Startto StartSmokingSmoking
Nicotine AddictionNicotine Addiction
CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD
AdulthoodAdulthood
AdolescenceAdolescence
ChildhoodChildhood
Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofAligne CA, Stodal JJ. Tobacco and children: An economic evaluation of the medical effects ofparental smoking. Arch Pediatr Adolesc Med. 1997;151:652parental smoking. Arch Pediatr Adolesc Med. 1997;151:652
Prenatal/Neonatal Outcomes 20-30% low birth weight infants
Fetal growth retardation
Spontaneous abortion
Fetal death
Pre-term deliveries
Ectopic pregnancies
Placenta previa and placental abruption
Lower APGAR
SHS and Children: Short TermHealth Effects Respiratory tract infections such as pneumonia & bronchitis
Decreased pulmonary function
Triggers asthma attacks
Ear Infection (Otitis Media)
Tooth decay
House fires
SHS and Children: Long TermHealth Effects Sudden Infant Death Syndrome (SIDS)
Asthma SHS accounts for 8-13% of asthma cases in children <15 years SHS exposure increases frequency of episodes and severity of symptoms 200,000-1 million asthmatic children are affected by SHS
Possible problems with cognitive functioning and behavioral development
More likely to become smokers
Risks for Women Who Smoke Reproductive health problems
Infertility Conception delay Pregnancy complications Menstrual irregularity Earlier menopause
Compromised immune system
Respond differently to nicotine
Cancer
Less likely to breast feed
Osteoporosis
Thrombosis with use of oral contraceptives
Adult Health Risks AssociatedWith Tobacco Use Cancer
Major cause of: lung, oral and nasal cavity, laryngeal, esophageal, bladder and cervical Increased risk for: pancreas, uterine, penile, kidney, liver, anal and stomach
Lung changes, COPD, Asthma
Cardiovascular & heart disease
Male & female reproductive problems
Digestive disorders
Rheumatoid arthritis
Impaired healing
Visual difficulties
Decline in hearing
Facial wrinkles
Tooth loss, plaque & staining
Dementia & Alzheimer’s
House fires
SHS and AdultHealth RisksNonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing;
Lung cancer 20-30%
Coronary heart disease (25-30%)
Acute respiratory problems
Other significant health risks as per the SGR: http://www.surgeongeneral.gov/library/secondhandsmoke
“There is no risk-free level of exposure to SHS. Breathing even a little SHS can be harmful to your health. Separating smokers from
nonsmokers, cleaning the air, and ventilating buildings cannot eliminate SHS smoke exposure that controls the health risks.”USDHHS, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A
Report of the SGR (2006).
What can be done?
SmokersWant to Quit
70% report wanting to quit
3 out of 4 smokers want to quit
Most have made at least one quit attempt
Smokers cite physician/clinician advice as important
Nicotine Addiction
Addiction
The repeated, habitual use of a substance that affects a person’s mood and the course is chronic, progressive, and ultimately fatal.
NicotineAddiction
Characterized by: Use stimulates the production of dopamine which changes brain chemistry and is associated with feelings of reward and pleasure
Need to use the substance to feel normal
The inability to control use resulting tolerance
Continued use regardless of the negative consequences
Being the most addictive drug
Impacting all areas of a person’s life – biopsychosocial effects
Addiction
1) Physical – A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug
2) Habit – The use is ritualistic and done without thought
3) Psychological – The belief that the user cannot function without the habit
3 Components3 Components
Recovery is possible when all 3 components are treated
The Process of BehaviorChange
Preparation
Preparation
Contemplator
Contemplator
RelapseRelapse
ActionAction
Maintenance
Maintenance
Ex-Smoker
Ex-Smoker
Pre-Contemplat
or
Pre-Contemplat
or
Prochaska and DiClemente, 1983
Relapse or Slip?
Relapse Slip
A return to baseline level of smoking Can occur at any stage, returning to Pre- Contemplation, Contemplation, Preparation or Action stages May recycle through the stage of change several times (6-8) before the change becomes truly established
An instance or several instances of smoking Avoid negative emotional reaction leading back to baseline level of smoking (one cigarette does not mean they are a smoker again)
Reframe the experience as a partial success versus a total failure
Learn from the experience and understand what happened
Develop optimism about continuing cessation or trying again
The Process of Behavior Changeand Pregnancy Pregnant women often are more open to change and can move through the stages of change differently than when they are not pregnant (The fetus can be a wonderful motivator)
May have more support to quit while pregnant
May not be socially acceptable to smoke in public if pregnant
Requirementsfor Change
X =
Motivation
(Should I?)
Self-Confide
nce(Can I?)
Commitment
(Will I?)
Motivational Interviewing/Consulting
A patient-centered counseling style for obtaining behavior change by helping patients explore and resolve
ambivalence
Motivational Interviewing/Consulting
Principles Express empathy to show you understand the person’s point of view
Develop discrepancy between smoking and future goals
Avoid arguing and confrontation be collaborative and friendly
Roll with the resistance and avoid argument
Support patient’s self-efficacy and belief in the possibility of making a change
sk about tobacco use
dvise to quit
ssess willingness
ssist in quit attempt
rrange for follow-up
CounselingIntervention
AA
AA
AA
AA
AA
AA
AA
RR
sk
dvise
efer
5 A’s (3-5 min.)* 2 A’s / R (1-3 min.)
Community Resources 1-800-QuitNOW Rx Pharmacotherapy
*Can extend to 10-15 min. for all patients*Smoke Free Families recommends 10-15 min. for pregnant women
sk: About Tobacco Use Ask or verify responses in a non-judgmental way: Identify smoking status
Counsel all smokers and recent quitters
Household environment Determine possible barriers to quitting Possible affects of SHS
If they smoke assess Nicotine dependence Patterns of use Past quit attempts
AA
Health Surveys
Chart Stickers
dvise: to Quit Advice to quit should be clear, strong and personalized while using a non-judgmental manner
Discuss the effects of smoking on the patient, fetus and children
Discuss the health benefits of quitting
Acknowledge the difficulty in quitting
AA
ssess: Willingness to Make a Quit Attempt Assess patient’s level of interest in quitting and intention to take action to quit
Ask key questions
AA
Assess: KeyQuestions
ssist: in Quit Attempt
Pre-Contemplation and Contemplation Stages(Unwilling to make a quit attempt)
The 5 R’s: Relevance to patient’s individual situation
Risks of smoking
Rewards of quitting smoking
Roadblocks or barriers to quitting
Repeat intervention at every visitIn successful interventions clinicians should be empathetic, promote patient choices, avoid arguments, listen, reflect and instill self-confidence
AA
Preparation Stage(Willing to quit)
Help the patient with a quit plan
Provide practical counseling
Provide social support Social support with treatment (Intra-treatment) Social support outside treatment (Extra-treatment)
Recommend pharmacotherapy
Provide supplemental materials (Quitline, groups)
ssist: in Quit AttemptAA
A combination of pharmacotherapy and intervention
a patient’s chance of successfully quitting smoking
Nicotine gum
Nicotine patch
Nicotine nasal spray
Nicotine inhaler
Bupropion SR (Zyban)
Lozenge
Varenicline (Chantix)
*Unless contraindicated
Pharmacotherapy* for Cessation
“If the increased likelihood of smoking cessation, with its potential benefits,
outweighs the unknown risk of nicotine replacement and potential
concomitant smoking, nicotine replacement products or other
pharmaceuticals may be considered.”
ACOG. (2005). Committee Opinion: Smoking Cessation During Pregnancy, Number 316.Concomitant = accompanying
Pharmacotherapy and Pregnancy
Handouts forPatients
Note: Most materials available in Spanish
Personalized Plan forPatients
Note: Most materials available in Spanish
PA DOH Free Quitline1-800-QUIT-NOW In partnership with the American Cancer Society
Intake 24 hours a day/7 days a week
Proactive referral (Fast Fax) versus Reactive referral (patient calls)
Develop a personalized plan for quitting
PA DOH Free Quitline1-800-QUIT-NOW Up to 5 follow-up scheduled counseling sessions (8 if pregnant)
Special counseling for pregnant smokers & available for teens
Offered printed materials, referrals, information on medications (NRTs)
English and Spanish; other languages as necessary
Confidential & HIPPA compliant
PA DOH Free Quitline
transitioning from1-877-724 -1090
to 1-800-QUIT-NOW 1-800-784-8669
Pre-Approved Tobacco Cessation Registry: Pennsylvania Department of Health http://www.dsf.health.state.pa.us (click on tobacco or Quit NOW (1-800-Quit-NOW) and follow prompts
Local tobacco coalitions, county websites, and county organizations or groups committed to smoking cessation
Quitline also refers to community resources
CommunityResources
See Appendix B of the Clean Air program manual for additional patient handouts and practice tools
OptionalMaterials
Clean Air Website: www.cleanairforhealthychildren.org
rrange: forFollow-Up Pre-Contemplation or Contemplation stage requires continual support and encouragement
Preparation stage: Follow-up within 1 week of Quit Date Ask at next visit about progress
Action or Maintenance stage: Praise success at quitting Problem solve challenges to maintaining abstinence
AA
Documentation Forms
19-year old
Smokes 16 cigarettes a day for past 3 years
Fights frequently with husband
Case Study #1 Sylvia
Pregnant with first baby
One prior quit attempt for a few days
Interested in effects on baby & children
*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources
1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* her in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.
Case Study#2 Linda
27-year old
Lives with her boyfriend who smokes
Smokes a pack a day for past 13 years
Has little interest in quitting
3 Children; 6, 4, and 2
Several prior quit attempts; one in last pregnancy for 1 month
Reluctant to set a quit date
*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources
1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* her in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.
Case Study#6 Lisa
17-year old
6 months pregnant, admitted to hospital for pre-term labor
Smokes a pack & a half a day and has smoked for 6 years
Boyfriend smokes
Hospitalized 4 days & medicated to stop contractions
Contraction free & being discharged
Enjoys smoking & has no interest in quitting
*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources
1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* her in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.
Case Study#8 John
32-year old father
Smokes a pack a day for past 14 years
John is sick with bronchitis
Has a son who has asthma
Concerned about stress with work & home life and avoiding weight gain
Had several prior quit attempts
Occasionally uses smokeless tobacco instead of cigarettes
Wife encourages him to quit
Not sure about trying again
*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources
1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* him in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.
Case Study#8 Grace
55-year old women
Has emphysema
Smokes a pack a day for the past 30 years
Has tried to quit several times in the past
Daughter and grandson lives with her
*Remember to discuss pharmacotherapy if appropriate**Refer to the Quitline (1-800-QUITNOW) and/or community resources
1. Ask about smoking status using a health history or survey.2. How will you Advise with a clear, strong, personalized message to quit smoking?3. Assess the patient’s stage of readiness to quit.4. To Assist* him in making a quit plan what might you include?5. What barriers or concerns about quitting would you address and would you do this?6. Arrange for follow-up via appointment, telephone, or referral.**7. Document the intervention in the patient chart.
Create A Quit Smoking Team Step 1. Develop administrative commitment
Step 2. Involve staff early
Step 3. Assign one coordinator
Step 4. Provide training
Step 5. Adapt procedures to your setting
Step 6. Monitor and provide feedback
Implementing into a Healthcare Setting
Implementation and Follow-Up Forms
HEDIS Health Employer Data Information Set
Survey of randomly sampled patients who were seen in the past year.
Used as a qualitative measure of practices to determine the level of care consistently given to patients.
Survey Questions
Have you smoked at least 100 cigarettes in your lifetime?
Do you now smoke cigarettes every day, some days or not at all?
How long has it been since you quit smoking?
In the past 12 months, on how many visits were you advised to quit smoking?
On how many visits was medication recommended or discussed?
On how many visits did your doctor or healthcare provider recommend or discuss methods or strategies to assist you with quitting?
JCAHO - Joint Commission of Accreditation of Hospitals
Diagnoses that are mandated to receive tobacco education counseling: At least 2 of 3 measures - congested heart failure; myocardial infarctions; community acquired pneumonia
Patients that have quit tobacco use one year prior to their admission
Interventions - advice to quit, assistance to quit, brochures, video, referral or tobacco cessation aids
Must be documented
Billing for Smoking CessationCounseling Always have your billing person/department
check with health plan benefits contact person to see what is covered and what codes they recognize
Also ask what page in billing manual you can find this information
Even if not reimbursed it is important to code to promote future coverage
ICD-9 Diagnostic Codes: Smoking Related COPD 491.2 Emphysema
492.8
Asthma 493.00
Diabetes 250
Chest Pain 786.50
Carcinoma: in situ/broncus, lung 231.2
Bronchitis 490
Cough 786.2 Toxic Effect/Tobacco 989.84
Tobacco Dependence/Disorder 305.1
Also can use ICD-9 Codes for medical procedures related to smoking co-morbidity.
Also can use ICD-9 Codes for medical procedures related to smoking co-morbidity.
ICD-9 Diagnosis Codes for Counseling Parents on Harms of SHS Sample codes for the child’s diagnosis Routine infant/child health check V20.2 Acute bronchiolitis due to respiratory synctial virus 466.11
Extrinsic asthma, with acute exacerbation 493.02
Sample codes associated with the parent’s smoking: Other specified personal history presenting hazards to health (exposure to tobacco smoke as a potential risk) V15.89 Toxic effects of tobacco 989.84
CPT Billing Codes Preventive Medicine Examination
New Patients: 99383-99387 Established Patients: 99393-99397 Pediatric under 1 year: 99381 Pediatric age 5-11: 99393 Higher level 99213 only if face to face counseling >50% of visit time
Tobacco Dependence Treatment Individual Counseling: 99401-99404 Group Counseling: 99411-99412
Psychiatric Therapeutic Procedures Outpatient: 90804-90809 Inpatient: 90816-90822
CPT code 99211: if nurse counsels and not physician
MedicalAssistance PA DOH pre-approved list Bulletins #99-02-02, 99-04-11, and
clarification #02-06 www.dpw.state.pa.us/omap Billing Code #S9075 Promise billing system if available If Health Choices provider discuss carve out in
contract? Medications are covered if patient has
prescription coverage but each plan may have “rules”Become a Pre-Approved Tobacco Cessation Provider by applying at PA Department of
Health Website:http://www.dsf.health.state.pa.us/health/cwp/view.asp?A=174&Q=236582
Clean Air Program Evaluation (optional) Pre & Post Training Evaluation Forms
Implementation Plan (initial practice assessment)
2, 6 & 12 Month Follow-Up of practice
Smoking Cessation Counseling Documentation Form
System change
Clean AirWebsite
Please visit us at our Website:www.cleanairforhealthychildren.org Request a training
Order and download materials
Participate and view teleconferences
Access resources and other links
Contact us
GoodLuck! Please feel free to contact:
Dottie Schell(484)446-3002
or (800)375-5217 (PA only)
Clean Air for Healthy Children Program
PA Chapter of the American Academy of Pediatrics
Rose Tree Corporate Center II
1400 N. Providence Road, Suite 3007
Media, PA 19063-2043www.paaap.org
The Real Reason Dinosaurs Became Extinct!
Adult Risks Associated WithTobacco Use
Lung Changes Lung cancer
Chronic cough, mucus, shortness of breath, wheezing
Cold & lung infections
Flu & pneumonia
Chronic Obstructive Pulmonary Disease (COPD) - chronic bronchitis and emphysema
Asthma
Adult Risks Associated WithTobacco Use
Cardiovascular & Heart Disease
Increases blood pressure & heart rate
Reduces blood & oxygen supply to body tissue
Blood clot formation
Damages blood vessels
Leads to stroke
Women using oral contraceptives have an increased risk for thrombosis
Adult Risks Associated WithTobacco Use
Cancer Major cause of: lung, oral cavity, laryngeal, esophageal, bladder and cervical
Increased risk for: pancreas, uterine, penile, kidney, anal and stomach
Digestive Disorders
Rheumatoid Arthritis
Adult Risks Associated WithTobacco Use
Reproductive Health Problems
Male impotence
Cervical and penile cancer
Impaired Healing Following surgery or disease
Broken bones (twice as likely)
Adult Risks Associated WithTobacco Use
Visual Difficulties Cataracts (twice as likely)
Macular Degeneration
Poorer night and peripheral vision
Adult Risks Associated WithTobacco Use
Other Risks Decline in hearing
Facial wrinkles
Tooth loss, plaque, staining and gingivitis
Dementia & Alzheimer’s (twice as likely)
House Fires
Step 1: Develop Administrative Commitment
Administrators and supervisors who are committed to providing smoking cessation
services to their patients
Consider requirements of
funding agencies or availability of
reimbursement for smoking cessation
services
Strengthened by mandates of institutional
governing boards or accrediting
agencies
Restricted by the allocation of limited resources such as
staff time
Effective problem solving for implementation of smoking cessation program
Step 2: Involve Staff Early Staff meeting:
Invite participation by all staff responsible for patient care at any level First with key staff members then with all front line staff
Meeting agenda to gain staff support: Overview of the 5 A’s smoking cessation counseling intervention Questions and answers Identify barriers to implementation at each step Develop Implementation Plan
Step 3: Assign One Coordinator One person should oversee implementation to ensure that tasks are not overlooked
The coordinator can: Answer questions Troubleshoot problems Arrange for training Monitor implementation
Step 4: Provide Training
5 A’s Smoking Cessation Counseling Intervention
Regional - 3 hours
Practice-Based – 1- 1.5 hours
Modules
Step 5: Adapt Procedures to Your Setting
Determine how the following will occur: Obtaining the smoking status of every patient/parent
Timing and delivery of the 5 A’s
Documenting the intervention in patient records
Follow-up with each patient and the PA AAP
Step 6: Monitor and Provide Feed Back A Periodic Review of the Program
Observe whether procedures are working as intended Determine if staff is completing assigned tasks Assess if documentation is complete and accurate Evaluate use of patient materials for distribution and inventory
Revise Program Procedures Anticipate revisions to original plan
Give Feedback to Staff and Administrators
Maintain staff enthusiasm Assure continued success
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