Cigarette use is more prevalent among veterans who have mental disorders than it is in the general population. Rates of tobacco use are also high among individuals who suffer from post traumatic stress disorder, addiction, and human immune deficiency disease. Approximately 22.7 million American veterans and their families are at risk of tobacco-related health problems. Concerned about heavy tobacco use among veterans, the U.S. Department of Veterans Affairs developed a Tobacco-Cessation Guideline to be used nationally. This guideline was updated in 2008 to include the '5A' mnemonic (ask, assess, advise, assist, and arrange) and is recommended for use by physicians, nurses, nurse practitioners, social service providers, and psychologists in Veterans Health Administration facilities when screening veterans for tobacco use. This doctoral capstone project involved evaluation of the Tobacco-Cessation Guideline by deploying a retrospective chart audit to assess implementation by first-line clinicians. Randomization of patient identifiers was used so that 18 Health Insurance Portability and Accountability Act patient identifiers were not recorded. The project was conducted at a Domiciliary and Residential Rehabilitation Treatment Program located in an urban area in the southern United States. Results of this project included raised awareness of first-line clinicians through electronic health record reminders, clinical outcome evaluations, and patient satisfaction surveys. These initiatives improved providers' effectiveness in documenting interventions, in addition to substantially improving the treatment progress made by each veteran. The sustainability of this effort will require long-term organizational commitment that will help to drive a change in practice and encourage positive attitudes toward tobacco cessation in the general population.

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BACKGROUND: This paper describes a pioneering effort to introduce tobacco cessation into India's undergraduate medical college curriculum. This is the first ever attempt to fully integrate tobacco control across all years of medical college in any low and middle income country. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as challenges that face implementation and steps taken to address them and to advocate for adoption by the Medical Council of India. METHODS: In-depth interviews were conducted with administrators and faculty in five medical colleges to determine interest in and willingness to fully integrate smoking cessation into the college curriculum. Current curriculum was reviewed for present exposure to information about tobacco and cessation skill training. A modular tobacco curriculum was developed, pretested, modified, piloted, and evaluated by faculty and students. Qualitative research was conducted to identify challenges to future curriculum implementation. RESULTS: Fifteen modules were successfully developed focusing on the public health importance of tobacco control, the relationship between tobacco and specific organ systems, diseases related to smoking and chewing tobacco, and the impact of tobacco on medication effectiveness. Culturally sensitive illness specific cessation training videos were developed. Faculty and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Students conducted illness centered cessation interviews with patients as a mandated part of their coursework. Systemic challenges to implementing the curriculum were identified and addressed. CONCLUSIONS: A fully integrated tobacco curriculum for medical colleges was piloted in 5 colleges and is now freely available online. The curriculum has been adopted by the state of Kerala as a first step to gaining Medical Council of India review and possible recognition.

Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalization and re-hospitalization. Smoking cessation leads to improved morbidity and reduced risk of death. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. Despite this, few Canadian hospitals have in place policies, protocols, and reminder systems that support the consistent and effective identification and treatment of tobacco users. The Ottawa Model for Smoking Cessation (OMSC), developed at the University of Ottawa Heart Institute (UOHI), is a systematic approach to identifying and treating smokers in the hospital setting. In order for health care funders and hospital administrators to begin supporting effective prevention interventions, like the OMSC, a compelling cost-effectiveness argument must be made. Few studies have looked at the downstream health, health care, and cost implications of such programs, particularly in the Canadian context and none using actual health care administrative data. In response to this gap, three studies were completed, applying theories and methodologies related to health services and population health research. Study 1: From the hospital payer’s perspective, what is the short-term (one year) and long-term (lifetime) cost-effectiveness of the OMSC intervention, as compared to a usual care condition, among high-risk smokers with chronic diseases? A cost-effectiveness analysis was completed based on a decision-analytic model to assess smokers hospitalized in Ontario, Canada for acute myocardial infarction, unstable angina, heart failure, and chronic obstructive pulmonary disease, their risk of continuing to smoke, and the effects of quitting on re-hospitalization and mortality over a one year period. Short- and long-term cost-effectiveness ratios were calculated. The primary outcome was one-year cost per quality-adjusted life year (QALY) gained. Study 2: What are the effects of the OMSC intervention on: 1) mortality, and 2) downstream health care utilization? An effectiveness study was completed comparing patients who received the OMSC intervention (n=726) to usual care controls (n=641). The study took place at 14 hospitals in Ontario. Baseline data was linked to Ontario health care administrative data. Unadjusted and adjusted competing-risks regression models were constructed, clustered by hospital, to compare the cumulative incidence of death, re-hospitalization, emergency department (ED) visits, and physician visits at 30 days, one, and two years following index hospitalization between groups. Study 3: From the health system perspective, what are the cumulative mean health care costs at 30-day, 1-year, and 2-year follow-up among smoker-patients that receive the OMSC compared to those that do not? What are the predictors of direct health care costs for patients that receive the OMSC compared to those who do not? Expanding on Study 2, a cost-analysis was completed to assess 30-day, 1-year, and 2-year health care costs between intervention and control groups. Costs were broken down by service type (e.g. inpatient, ED visits, laboratory, physician visits). To calculate cumulative mean costs, costs were grouped into the study’s 24 monthly intervals and weighted by the inverse probability of not being censored at the beginning of each month. Covariate-adjusted generalized linear models were performed for each of the 24 monthly intervals to determine the association between independent variables and health care costs.

Indiana University-Purdue University Indianapolis (IUPUI) / The United States spends more on healthcare than any other country in the world, but still trails most other countries when it comes to important health indicators. There has been an increasing recognition that in order to address this discrepancy, the U.S. health system must begin to address the underlying social determinants contributing to poor health outcomes. In light of this, the concept of “population health” has emerged as a framework and model for how to better address the social determinants contributing to unhealthy behaviors and increased rates of morbidity and mortality in the U.S. Various national initiatives, including reform related to how doctors and hospitals are paid, have been developed with the purpose of increasing the adoption of strategies to address population health among public and private organizations. In this dissertation I attempt to assess how these national policies are driving behavior and outcomes related to improving population health in private and public sectors. It is comprised of three papers focused on 1) a systematic review of literature to assess how hospitals are responding to policies that encourage them to form partnerships to address population health, 2) a quantitative analysis of how the Affordable Care Act has impacted population health by addressing tobacco use with policies to increase Medicaid coverage for tobacco cessation services, and 3) an empirical examination to identify hospital strategic partnerships to address population health and determine hospital and market characteristics associated with these partnerships. The main findings of this study indicate that while there is a growing amount of peer reviewed literature focused on hospital partnerships for population health there is still a need for more generalizable studies with rigorous study designs in this area; Medicaid Expansion as a part of the Affordable Care Act is associated with lower prevalence of tobacco use; and policies, such as Accountable Care Organization and Bundled Payment models, may be influencing hospitals to engage with a broad set of partners to support population health activities. Collectively these studies provide new evidence to suggest that national policies may be driving behavior in private and public sectors related to population health. / 2022-04-06

Little is currently known about the ability of electronic cigarettes to manage tobacco withdrawal symptoms and their abuse liability. In the current study eight conventional cigarette smokers completed nine within-subject study sessions. In the first session participants practiced using an electronic cigarette containing 16 mg/ml of nicotine over six 10-puff bouts. Remaining study sessions were comprised of four two-day blocks (one for each condition), which assessed measures of tobacco withdrawal symptoms and abuse liability following unrestricted cigarette smoking and 24-hour tobacco deprivation. Study conditions included an electronic cigarette with 0, 8, or 16 mg/ml nicotine concentrations, or preferred brand of conventional cigarette. Following 24-hours of tobacco deprivation, smoking conventional cigarettes ameliorated many of the self-report and physiological symptoms (decreased heart rate) associated with tobacco deprivation, while no attenuation of withdrawal symptoms was indicated following using electronic cigarettes, independent of nicotine dose. On abuse liability measures there were no significant changes following using an electronic cigarette (regardless of nicotine concentration), while conventional cigarettes engendered significant changes on abuse liability measures. Within the conditions of this study, first-generation electronic cigarettes had no measurable efficacy in ameliorating tobacco withdrawal symptoms and a reduced abuse liability compared to conventional tobacco cigarettes.

The use of tobacco has been a known contributing factor in the development of disease and death since the 1960s. Unfortunately, evidence-based tobacco cessation protocol is still not effectively being taught in healthcare curriculum as evidenced by the lack of clinical competencies in many institutions. The purpose of this study was to gain an in-depth understanding of the process dental hygiene program directors use to adopt and implement tobacco dependence information into their curricula. Gaining a clearer idea of how and why dental hygiene faculty diffuse tobacco curriculum may inform future dissemination efforts leading to improved adoption and implementation of evidence-based information in healthcare education. A total of ten, one hour interview data sets of US dental hygiene program directors were chosen for this study. They were selected from a possible 14 interviews collected from a larger research project consisting of 32 one hour interview data sets. A case study research methodology was used to guide the collection of interviews. The Diffusion of Innovation, Five Stages in the Innovation Process in Organizations (Rogers, 2003) was used as the theoretical framework to inform the extraction of themes and patterns. The analysis of interview data revealed that all ten program directors reported a similar process of: learning about tobacco cessation, discussing the topic in a faculty meeting, deciding what class the topic should be taught, and that cessation should be a part of the clinical experience. What was not evident from these interviews was how and why the evidence-based tobacco cessation guideline was reduced from five essential elements to minimal implementation by most of the ten schools. Though the process of how dental hygiene programs learn of and implement tobacco cessation into their curriculum, further research is needed to explore how faculty make decisions on content and level of clinical competencies when new innovations are introduced into their program.

Background: This article presents findings from qualitative interviews conducted as part of a research study that trained Acupuncture, Massage, and Chiropractic practitioners' in Arizona, US, to implement evidence-based tobacco cessation brief interventions (BI) in their routine practice. The qualitative phase of the overall study aimed to assess: the impact of tailored training in evidence-based tobacco cessation BI on complementary and alternative medicine (CAM) practitioners' knowledge and willingness to implement BIs in their routine practice; and their patients' responses to cessation intervention in CAM context. Methods: To evaluate the implementation of skills learned from a tailored training program, we conducted semistructured qualitative interviews with 54 CAM practitioners in Southern Arizona and 38 of their patients. Interview questions focused on reactions to the implementation of tobacco cessation BIs in CAM practice. Results: After participating in a tailored BI training, CAM practitioners reported increased confidence, knowledge, and motivation to address tobacco in their routine practice. Patients were open to being approached by CAM practitioners about tobacco use and viewed BIs as an expected part of wellness care. Conclusions: Tailored training motivated CAM practitioners in this study to implement evidence-based tobacco cessation BIs in their routine practice. Results suggest that CAM practitioners can be a valuable point of contact and should be included in tobacco cessation efforts.

Tobacco use among people with mental illness remain a significant problem in the western United States. At the project site, there is widespread tobacco use among patients with mental illness and lack of training for nurses to address the issue. The purpose of this project was to educate nurses working in the acute psychiatric setting about evidence-based tobacco treatment interventions. The practice-focused question addressed whether a tobacco education program would increase nurses' knowledge, confidence, and skills to provide tobacco treatment interventions to patients with a mental illness. Self-determination theory and the transtheoretical model of change provided the theoretical framework for the project. Evidence was obtained from a comprehensive literature search. The Psychiatry RX for Change education modules were used to implement the education intervention. Nine participants completed pre- and post-test knowledge-based questionnaires and the Skills and Confidence for Smoking Cessation Tool survey. Results from GraphPad t-test analysis indicated a statistically significant increase in perceived knowledge, skills, and confidence among nurses related to tobacco cessation treatment. The mean knowledge pre-test scores were 10.3 and the mean for the post-test score was 14.7. The mean on the pre-survey scores for the nine confidence questions was 16, and the mean on the postscores was 23. The mean obtained on pre-survey scores for the six skills questions was 11.0, and the mean obtained on the post-survey was 18.0. Findings support the use of tobacco education for nurses to improve tobacco treatment offered to patients. The implications of the project for positive social change are that results may be used to improve the quality of life and health outcomes for the patient population.

BACKGROUND: Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners' background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners. METHODS/DESIGN: The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention's impact on CAM practitioners' tobacco-related practice behaviors. Primary outcomes included CAM practitioners' self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients' readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients' actions to help someone else quit. DISCUSSION: CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners' tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.