Abstract

Kentucky leads the United States in smoking prevalence as well as overall lung cancer morbidity and mortality. The United States Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence (TTUD), provides evidence-based recommendations for clinicians to promote tobacco cessation and reduce the burden of tobacco-related illness. The Providers Practice Prevention: Treating Tobacco Use and Dependence (PPP-TTUD) program is a self-study continuing education offering for practicing physicians, dentists, and psychologists in Kentucky. The program includes a 30-minute video and a clinician toolkit which provides information for clinicians and their patients regarding tobacco use assessment and counseling. As part of the offering, participants responded to three surveys of their knowledge, attitudes, and practices regarding tobacco cessation. Participants completed a practice survey (pre-test) prior to reviewing the program, a program evaluation (post-test) immediately following the program, and a follow-up survey (follow-up) one year after program completion. Of the 712 participants who completed the pre and post-tests, 427 (60%) also completed the follow-up questionnaire. Participants included 357 physicians, 275 dentists, and 75 psychologists, practicing in rural (39%), suburban (38%), and urban areas (19%), and representing a wide range of practice experience (1-54 years). Immediately following participation in the PPP program, participants reported dramatic increases in tobacco cessation knowledge, more confidence in their tobacco cessation skills, and greater intentions to adopt clinical practice guideline recommendations. Results of the follow-up survey showed that the intervention significantly promoted tobacco cessation practices among this group of clinicians, although the strength of the intervention lessened over time. Overall, the PPP-TTUD program appeared to promote the integration of the TTUD recommendations into the clinical practice of participating licensed health care providers. To enhance the effects of future interventions of this nature, researchers/educators might consider incorporating follow-up information to help clinicians maintain their initial motivation and knowledge, while expanding their skills in treating tobacco dependence.

Introduction

Tobacco Use is a Major Health Issue in Kentucky

• Smoking rates in Kentucky are the highest in the United States (32.6%).
  
• Kentucky also leads the nation in incidence (98 per 100,000) and mortality (79 per 100,000) from lung cancer.
  
• Approximately 1/3 of all tobacco users in the USA will die prematurely due to tobacco dependence.
  

Doctors Can Help Reduce the Burden of Tobacco

• 70% of smokers express a desire to quit smoking
  
• 70% of smokers visit a health care provider each year
  
• 90 – 95% of unaided attempts to quit smoking fail
  
• Brief interventions delivered by health care providers significantly increase long-term smoking abstinence rates.
  

Treating Tobacco Use and Dependence

• The Clinical Practice Guideline, Treating Tobacco Use and Dependence (2000) targets clinicians and other health care professionals, and provides recommendations, based on current research to promote smoking cessation.
  
• The Guideline contains strategies for effective treatment of nicotine dependence based on a systematic review of over 6000 tobaccorelated research articles.
  

Providers Practice Prevention: Treating Tobacco Use and Dependence

The program included:

• Motivational video (30-minute) featuring Kentucky doctors
  
• Clinician Toolkit
  
• TTUD Quick Reference Guide
  
• Clinical Office Tools
  
• Patient Education Pieces
  
• Reference Materials
  
• Two hours of Continuing Education credit
  

Method

Program Participation Accrual and Return Rates

Physicians: 357 of 870 (41%) who ordered the kit returned the initial surveys. 218 of these (61%) returned the follow-up survey.

Dentists: 275 of 456 (60%) who ordered the kit returned the initial surveys. 157 of these (57%) returned the follow-up survey.

Psychologists: 75 of 114 (66%) who ordered the kit returned the initial surveys. 50 of these (67%) returned the follow-up survey.

Other/Missing: 5 returned the initial surveys. 2 of these (40%) returned the follow-up survey.

Totals: 712 of 1430 (50%) who ordered the kit returned the initial surveys. 427 of these (60%) returned the follow-up survey.

Procedure

• Potential program respondents received information about the program through direct mailings, journal articles/newsletters, and conference announcements.
  

• Participants were asked to complete three study questionnaires:

• Baseline (T1: prior to program)
  
• Post-test (T2: immediately following program)
  
• Follow-up (T3: one year following program)
  

Measures

• Sociodemographic Characteristics of Participants
  
• Treatment Efficacy & Barriers to Cessation
  
• response efficacy, self-efficacy, barriers
  
• Clinical Practice (5 A’s)
  
• ask, advise, assess, assist, arrange
  
• Self-ratings of Knowledge & Comfort w/ Tobacco Cessation
  
• Knowledge Test
  
• tobacco use statistics and nicotine dependence treatment information
  
• Post-test Evaluation
  
• qualitative responses and program feedback
  

Results

Tobacco Cessation Attitudes & Skills
Tobacco Cessation Self-efficacy (on a scale of 1-4)
Pretest: 2.96
Posttest: 3.4
Follow-up: 3.23

Tobacco Cessation Response Efficacy (on a scale of 1-4)
Pretest: 3.07
Posttest: 3.56
Follow-up: 2.99

Comfort Recommending Pharmacotherapy (on a scale of 1-4)
Pretest: 2.8
Posttest: 3.34
Follow-up: 3.06

Self-rated Knowledge of Pharmacotherapy (on a scale of 1-5)
Prestest: 3.1
Posttest: 3.96
Follow-up: 3.6

• Higher numbers equal greater self-efficacy, response efficacy, comfort, and self-rated knowledge
  
• Three analyses demonstrated statistically significant linear and quadratic trends
  
• Response efficacy demonstrated a statistically significant quadratic trend only
  

Ask, Advise, Assess…

On a scale of 1-never to 5-always:

Frequency of Asking about Tobacco Use
Pretest: 3.69
Posttest: 4.4
Follow-up: 3.86

Frequency of Advising to Quit
Pretest: 3.82
Posttest: 4.31
Follow-up: 3.97

Percentage of Respondents who Endorsed Desired Response:

Assessing at Every Visit
Pretest: 22
Posttest: 57
Follow-up: 22

Use of "Vital Sign" Assessment
Pretest: 9
Posttest: 35
Follow-up: 12

Assist and Arrange

On a scale of 1-never to 5-always:

Refer to Tobacco Cessation Programs
Pretest: 65
Posttest: 95
Follow-up: 78

Frequency of Helping Develop a Cessation Plan
Pretest: 2.9
Posttest: 4.2
Follow-up: 3.1

Frequency of Recommending Pharmacotherapy
Pretest: 3
Posttest: 4
Follow-up: 3.3

Percentage of Respondents who Endorsed Desired Response:

Scheduling Tobacco Cessation Followup
Pretest: 45
Posttest: 95
Follow-up: 56

Discussion

• Participants reported dramatic positive changes in tobacco cessation knowledge, skills, and attitudes following participation in PPP-TTUD.
  
• Although many of these positive changes were maintained at one-year follow-up, the strength of
  the intervention lessened over time.
  
• Overall, PPP-TTUD enhanced integration of TTUD guidelines into the clinical practice of Kentucky health care providers.
  
• To promote long-term commitment to the TTUD guideline, the authors recommend providing followup materials to clinicians to help maintain positive clinical practices regarding the treatment of nicotine dependence.