Tobacco Dependence Treatment Training -- J. Taylor Hays, M.D.


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Presentation by J. Taylor Hays, M.D., a Global Bridges co-investigator and professor of medicine at Mayo Clinic, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

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  • Time to relapse at week 52, by treatment group.The model controlled for age (HR, 1.00 [95% CI, 0.99 to 1.01]; P = 0.65), sex (HR, 0.96 [CI, 0.77 to 1.19]; P = 0.69), and level of nicotine dependence. Nicotine dependence level predicted relapse from weeks 0 to 8 (HR, 1.83 [CI, 1.35 to 2.48]; P < 0.001) but not from weeks 9 to 24 (HR, 0.91 [CI, 0.61 to 1.36]; P = 0.65) or weeks 25 to 52 (HR, 1.04 [CI, 0.60 to 1.70]; P = 0.90). The HRs were stable and uniform over the intervals (P = 0.80). A residual decline in abstinence after 24 weeks occurred, but the decline was statistically equivalent across treatment groups. HR = hazard ratio; μR = restricted mean number of weeks to relapse (included censored observation times).* Participants at risk for relapse.
  • Tobacco Dependence Treatment Training -- J. Taylor Hays, M.D.

    1. 1. Tobacco Dependence Treatment Training What should we teach? How should we teach it? J. Taylor Hays, MD Professor of Medicine Mayo Clinic Rochester, MN USA
    2. 2. Learning Objectives Recognize evidence based treatment components for tobacco dependence Describe the gaps between physician knowledge and practice regarding tobacco dependence treatment Describe best approaches to educating health professionals in tobacco dependence treatment
    3. 3. Outline Brief background Review evidence based treatment Knowledge-practice gaps for tobacco dependence treatment Instructional approaches for health professionals Competency-based training
    4. 4. 438,000 Deaths Attributable to Cigarette Smoking United States Heart disease Other diagnoses Lung cancer Stroke Other Chronic lung cancers diseaseCM862644-4
    5. 5. Tobacco Is a Risk Factor for 6 of the World’s 8 Leading Causes of Death Hatched areas indicate proportions of deaths related to tobacco use.
    6. 6. Tobacco Use: An Escalating Epidemic 8 10 7 By 2030: •Leading cause of deathmillions of deaths 6 •10 million annual deaths 5 due to tobacco 4 •70% of those deaths will 4.9 3 occur in developing 2 countries 1 0 2000 2030 Developed Countries Developing Countries
    7. 7. Evidence Based Treatment
    8. 8. Eisenberg MJ, et al. CMAJ 2008; 179:135-144
    9. 9. West R, Zatonski W, Cedzynska M, et al. NEJM 2011;365:1193-2000.
    10. 10. Combination NRT Compared With Single Agent NRT  Nicotine patch + short-acting NRT Patch provides steady baseline NG, NL NNS, NI respond to urges  Withdrawal may be improved  Overall abstinence rates at 6 mos. better OR 1.35 (95% CI 1.11-1.63)* *Cochrane Database of Systematic Reviews 2009 1
    11. 11. Adherence to NRT TreatmentBalmford J, et al. Nicotine & Tobacco Research 2011;13:94-102•Only 28.6% of NRT users completed the recommended 8 weeks oftreatment•Most quit prematurely because they believed the medication was notworking, had unwanted side effects or believed that they no longer neededtreatment. 1
    12. 12. Nicotine patch 8 vs 24 weeks: RCT of 568 adult smokersSchnoll R A et al. Ann Intern Med 2010;152:144-151 ©2010 by American College of Physicians 1
    13. 13. Behavioral Treatment 1
    14. 14. Effect of Contact IntensityCessation by intensity of person-to-person contactContact* O.R. Cessation%None 1.0 10.9Minimal 1.3 13.4Brief 1.6 16.0Counseling 2.3 22.1*minimal<3mins; brief >3 to <10mins; counseling > 10mins. 1
    15. 15. Effectiveness Based on Total Contact Time Time (min) OR Abstinence % None 1.0 11.0 1-3 1.4 14.4 4-30 1.9 18.8 31-90 3.0 26.5 91-300 3.2 28.4 > 300 2.8 25.5 1
    16. 16. Effect of ProvidersSmoking cessation by type of providerType O.R.* Abstinence %Self-help 1.1 10.9NonMD 1.7 15.8M.D. 2.2 19.9Multiple 2.5 23.6 *odds ratio 1
    17. 17. Benefits of Counseling Boost motivation to quit- Motivational Interviewing techniques Discuss barriers to quitting Review coping strategies Discuss other big challenges to quitting Living with other smokers Cautions about use of alcohol Post-cessation weight gain 1
    18. 18. Gaps Between Knowing and Doing 1
    19. 19. JAMA 2001;285:2643-2648Smoking prevalence by birth cohort among physicians in Japan 1
    20. 20. JAMA 2001;285:2643-2648AttitudeAction 2
    21. 21. •41% of male MD’s are smokers•Most MD’s believe they shouldoffer help and advise quitting•Fewer than 10% take activesteps to help a smoker quit Am J Prevent Med 2007;33:15-22 2
    22. 22. Teaching Health Professionals 2
    23. 23. Adult Learners Motivated to learn Goal directed •Increase knowledge and skills •Change attitudes and beliefs Self-directed– control nature, timing and direction of the process Build on established foundation– a “two-edged” issue 2
    24. 24. Training Experts Performance of experts continues to improve as they engage in more complex cognitive tasks and deliberate practice of skills.•Performance is most closelyrelated to specialized trainingand years in practice.•Without specialized trainingand practice skills decline. Ericsson KA. Acad Med 2004;79:S70-S81 2
    25. 25. Competency Based Training Competency- a skill performed to a specific standard Competencies clearly identified Assessment criteria are clear (knowledge, skill, attitude, practice) Instruction targets each competency Learners progress at their own rate Varied instructional methods (traditional, groups, reading, remote, asynchronous) 2
    26. 26. ATTUD Competencies1. Tobacco Dependence Knowledge and Education Provide clear and accurate information about tobacco use, strategies for quitting, the scope of the health impact on the population, the causes and consequences of tobacco use2. Counseling Skills Demonstrate effective application of counseling theories and strategies to establish a collaborative relationship, and to facilitate client involvement in treatment and commitment to change3. Assessment Interview Conduct an assessment interview to obtain comprehensive and accurate data needed for treatment planning4. Treatment Planning Demonstrate the ability to develop an individualized treatment plan using evidence-based treatment strategies5. Pharmacotherapy Provide clear and accurate information about pharmacotherapy options available and their therapeutic use6. Relapse Prevention Offer methods to reduce relapse and provide ongoing support for tobacco-dependent persons7. Diversity and Specific Health Issues Demonstrate competence in working with population subgroups and those who have specific health issues8. Documentation and Evaluation Describe and use methods for tracking individual progress, record keeping, program documentation, outcome measurement and reporting9. Professional Resources Utilize resources available for client support and for professional education or consultation10. Law and Ethics Consistently use a code of ethics and adhere to government regulations specific to the health care or work site setting11. Professional Development Assume responsibility for continued professional development and contributing to the development of others 2
    27. 27. Learner Outcomes Changed attitudes, values, habits Knowledge base enlarged and enhanced Practice skills (information gathering, counseling skill, treatment planning) 2
    28. 28. Competency Based Training Rigotti NA, et al. Addiction 2009; 104:288-296 2
    29. 29. Training CapacityRigotti NA, et al. Addiction 2009; 104:288-296 2
    30. 30. Summary Strong evidence base for tobacco dependence treatment… we know what works There are large gaps between evidence base and the knowledge and practice of physicians… we do not practice what works Competency based training using varied instructional methods must be widely deployed to build capacity and expertise 3