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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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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