TB Program Smoking
Cessation Campaign The Multnomah County Experience
Amy D. Sullivan, PhD, MPH Communicable Disease Services Multnomah County Health Dept
After the session participants will be able to:
• Describe the development of materials for & implementation of smoking cessation efforts focused on TB cases
• Describe challenges to developing an effective smoking cessation program in the context of TB case management
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Learning Objectives
WHO/The Union Monograph (2007)
Evidence of associations between tobacco smoking &
TB-related health outcomes
Strong: Passive or active smoking Active disease
Moderate: Smoking Relapse & retreatment
Limited: Passive or active smoking Infection & Infectivity
Smoking Mortality
Insufficient: Smoking Disease severity, treatment default, etc.
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Background // TB & Tobacco Control
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Intervention Alternatives
High risk populations (shelter, refugee, etc.)
Persons with Latent TB Infection (LTBI)
General smoking cessation
↓
Decrease risk of
developing active TB disease
Persons with active TB disease
Focused smoking cessation
↓
Decrease risk for relapse & need for retreatment
Focused smoking cessation
↓
Decrease risk of transmission & TB-related mortality
• TB Case Management program
– Focus on persons who have TB
– Messages on transmission, relapse, mortality
• TB screening and LTBI treatment programs
– Focus on preventing TB Disease
Intervention Opportunities
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• Group effort in 2010
– State TB program; Multnomah County Communicable and Chronic Disease programs
– Develop messages and resources
– Update TB forms for documentation
– Train on counseling and new materials
• Roll-out late 2010/early 2011
Intervention Planning
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6
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Updated TB Forms // An Example
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BEFORE AND AFTER
What happened because of these changes?
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• Identify TB cases before (2010) and after (2013) roll out of smoking cessation counseling project; collect data on…
– Demographics
– TB disease
– Smoking status
– Cessation counseling
• Describe population & assess counseling practice
Smoking Cessation Counseling // Evaluate Before & After
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Evaluation Population
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5 Children
(2nd’ary smoke,
n=1)
Smoker/Hx of
smoking at Dx
n=11
Non-smoker
n=17
Smoker/Hx of
smoking at Dx
n=3
Non-smoker
n=5
Smoker/Hx of
smoking at Dx
n=2
Non-smoker
n=12
n=1 unknown status (died before interview) n=1 unknown status (left state)
Smoker
n=16
Non-Smoker
n=34
Total Cases >12 yrs old
N=52
Total Cases
N=57
Pulmonary
n=29
Pleural
n=8
Other Site
n=15
2010 Cases
N=31
2013 Cases
N=26(Closed by Jan 2015)
Population Description // By smoking status
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Smoker (N=16*)
Non-smoker (N=34)
Characteristic n (row %) n (row %) Total P-value
Year of report
2010 11 (37) 19 (63) 30 0.58
2013 5 (25) 15 (75) 20
Site of Disease
Pulmonary or Pleural 14 (39) 22 (61) 36 0.18
Other 2 (14) 12 (86) 14
Died
Yes 2 (50) 2 (50) 4 0.58
No 14 (30) 32 (70) 46
P-values calculated by Fischer's Exact Test or Wilcoxon Rank Sum
Population Description (cont’d) // By smoking status
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Smoker (N=16*)
Non-smoker (N=34)
Characteristic n (row %) n (row %) Total P-value
Gender
Male 15 (58) 11 (42) 26 0.00005
Female 1 (4) 23 (96) 24
Age
Under 30 years 4 (24) 13 17 0.75
30 - 55 yrs old 6 (38) 10 16
Over 55 years 6 (35) 11 17
Foreign born
Yes 11 (27) 30 (73) 41 0.12
No 5 (56) 4 (44) 9
Time since entry (mean years) 16 9 - 0.41
United States, US Territories, or Tribal Nation
Yes 7 (64) 4 (36) 11 0.02
No 9 (23) 30 (77) 39
P-values calculated by Fischer's Exact Test or Wilcoxon Rank Sum
Population Description (cont’d) // By year & smoking status
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2010 (N=30) 2013 (N=20)
Smoker (n=11)
Non-smoker (n=19) Smoker (n=5)
Non-smoker (n=15)
Characteristic n (%) n (%) n (%) n (%)
Smoking status reviewed at intake
Yes 8 (73) 17 (89) 5 (100) 15 (100)
No 2 (18) 0 - 0 0
Unknown 1 (9) 2 (11) 0 0
Smoking at time of diagnosis 6 (55) - 2 (40) -
Cessation Counseling // By smoking status, 2013
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2013 (N=20)
Smoker (n=5) Non-smoker
(n=15) Characteristic n (%) n (%) Cesssation counseling Ask 5 (100) 14 (93)* Advise 3 (60) - Assess, Assist, or Arrange 0 -
*Smoking cessation noted without step information for one case
• 5 persons reported smoking (current or past)
– 1 quit about one year before diagnosis
– 2 quit on their own at or around time of diagnosis
– 1 died shortly after diagnosis (unlikely smoking while hospitalized)
– 1 appears to have smoked throughout treatment
Smoker details // 2013 cases
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• 61 year old male, pulmonary TB (non-cavitary)
– 40 year smoker, ~1 pack per day; down to 2-4 cigarettes per day (unspecified time)
– Excess alcohol use
• Initial difficulties in case management
– Contact information / case management visits
• Cessation counseling
– Ask & Advise on first two visits
– Ask on most subsequent visits (one visit without documentation)
Case Study // Smoker who did not respond to counseling
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• Many cases stopped smoking around the time of diagnosis
– Possibly related to severity of symptoms
• Cases who continue smoking may have other risk factors – e.g., excess alcohol use – that can complicate case management
Challenges for Implementation // Qualitative assessment
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• Training was well-received
• Unclear if handouts were widely used
• Form changes improved documentation
• No client requested assistance to quit in years reviewed
– Anecdotal report of one client in last 5 years who requested Quit-line information
Summary
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QUESTIONS?
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