- A nurse implemented smoking cessation strategies for cancer patients including brief interventions and referrals to a quitline with limited success. - Further initiatives were developed including educating nurses, establishing a nurse-led smoking cessation clinic, and conducting studies which found quit rates increased when patients had an active plan to quit and were admitted for treatment toxicity. - Eventually the cancer center became entirely smoke-free through policy changes, education, and communication strategies.

2. Cancer Treatment and
Care Innovations
Ingrid Plueckhahn RN MPH
Advanced Practice Nurse
Smoking Cessation Support

3. Innovation
• Identifying unmet needs
• Exploring how to address needs
• Using EBP to support processes
• Differing in approach
• Has an impact on patient outcome

5. Early Strategies
• Lung Cancer inpatient unit:
• Requesting support to quit smoking
• No clinical expertise to assist
• Liaised with Quit Victoria
– Proposal for Educating Nurses in EB
– Smoking Cessation Strategies
• Patients offered
• Brief inpatient intervention
• Referred to Quit Line

6. Evaluation
• “Quit Support” nurses
– Person dependant
– Variance of structured support
– Ambivalence amongst staff
– Quit referrals inconsistent
– More work to do!

7. CRF: UoM / PMCC
• Does continued smoking when a patient
has a cancer diagnosis have an impact
on their cancer outcome
• Literature Review
• Cancer patients
– Neglected population in smoking cessation
– Suffered adverse health consequences from
smoking
– Survivorship

8. Benefits of Quitting with a
Cancer Diagnosis
(Literature Review conducted through a Clinical Research Fellowship – Uni Melb):
• Decreased treatment complications
• Improved rates of complete response
• Less tumour resistance to cancer treatment
• Improved survival and relapse free survival
• Reduced rates of metastases
• Decreased second primary tumour rate
• Less aggravated weight loss
• Improved surgical outcomes
• Improved pain control
• Reduced infection rates
• Increased opportunities to continue anti cancer
treatments

9. Opportunity to quit
• Cancer diagnosis is an
opportunity for behavioural
change: “teachable moment”
• Patients are willing to modify
behaviour and are Motivated
• Disease site, stage, & smoking
history predict quitting

10. Identified stakeholders
• Executive support and
ratification
• Quit “Champions”
• Defined and included broad
stakeholders for
endorsement

11. Smoking cessation support
• What motivates?
• Routine clinical care then refer
• Quit support Champions
• Nurse led smoking cessation
support clinic
• Free Pharmacologic support
• Review of “smoking areas”

12. Smoking Cessation Strategy
• Inform Peter Mac community of the
harmful effects of tobacco smoke
• Highlight the benefits of quitting
• Denormalise the use of tobacco
• Research a smoking cessation program
in an acute cancer centre
• Protect from exposure to tobacco smoke
• Provide incentives to quit
• Totally Smoke Free Hospital

13. Strategy for Support
• Resourced a Nurse Co-ordinator
as project manager (.4 EFT)
• Annual Budget
• Policy development for Totally
Smoke Free hospital
• Guidelines for Pharmacologic
support – patients and staff

14. Staff & Med Record Survey
• 39% response rate
• 97% rated SCS as important
• 69% aware of benefits of quitting
• 53% made comments about
– Stopping smoking at entrances
– Need to make PMCC totally smoke free
• 7% were current smokers
• Review of Med Records (100) 35% - 100%

15. Pilot study
n=40
• Acceptability / Appropriateness and
Feasibility of smoking Cessation
Program for patients with a cancer
diagnosis:
– Patients found program acceptable
– Expected support
– Increased motivation and confidence quit
– Requested more than one session (20%)
– All made reduction in cpd with 35% quit (at
6 months)
– Quit line referrals unsuccessful

16. Progress
• Brochure development
• Quitting medications available
• Support for staff
• Nurse Led Smoking Cessation
Support Clinic attracted VACCs
funding

17. Designated Smoking Area
• Controversial! (Expensive)
• Exclusive – inpatients only
• Discouraged smoking elsewhere
• Safe environment staff and patients
• Minimise fire risk
• Minimise ETS
• Closed within a year!

18. Policy re- write
• Smoke Free hospital
• Smokers to leave hospital precinct
• Patients accept responsibility
– Not accompanied by staff
• Staff discouraged to smoke with or
in front of patients
• Staff de identified
• Voluntary

20. Policy Maintenance
• Orientation
• Staff encouraged to quit
• Cessation Counselling and support
• Clear delineation of boundaries
• Patients who smoke on property are
approached and informed of policy
• All staff are responsible to enact policy
• Melbourne City council engagement

22. Education strategy
• “Champions” educated at Quit Vic
• Forums / presentations
• all clinical streams / multidisciplinary
• non clinical groups
• Grand round presentations
• GP and wider clinical community
presentations
• Patient / Community Advisory
Committee

23. Prospective Study
Primary: To determine abstinence rate at 12
months
Secondary:
• Abstinence rate at 1, 3 & 6 months
• Point-prevalence abstinence rates at 1, 3, 6
and 12 months
• To compare the changes in QoL and distress
scores
• To determine the associations between patient/
treatment factors and prolonged abstinence
(Mileshkin, Plueckhahn, et al.2009)

24. Results
• n= 77 patients enrolled over 2 years
• Median age = 56 years (range 27 – 71), 61%
male
• 41 (58%) had a smoking-related cancer
• 24 (34%) were living with another smoker
• Mean age to start smoking = 16 (range 7-25)
• 25 (35%) heavy nicotine dependence
(Fagerstrom)
• 16 (23%) had reduced smoking
• 47 (66%) were planning to quit in the next
month

25. QUIT rates
Time-point Prolonged
abstinence rate
95% confidence
interval
1 month 53% (41 – 65%)
3 months 34% (23 – 47%)
6 months 28% (17 – 40%)
12 months 24% (14 – 36%)

26. Associations with successful
quitting
• Active plan to quit at baseline 49%
quit (p= 0.012)
• Hospital admission for treatment
toxicity 45% quit(p = 0.024)
• Having a smoking-related cancer
(33% vs 13% quit) p = 0.08
• No association with
• nicotine dependence
• distress or global QOL
• use of pharmacotherapy
• efficacy of anti-cancer treatment

27. 2007: Totally Smoke Free PMCC
• World Cancer Day (Feb 4) announced
• Totally Smoke Free on WNTD (May 31)
• Leadership in Cancer Prevention
• Statement about smoking & public health
• Policy review
• Reiterated voluntary compliance
• Senior Clinician engagement

28. Communication Strategies
• Key dates such as WNTD
• Brochure development
• Posters
• Web page alerts
• Grand Rounds
• Media releases
• Email signatures

30. 2009: “Ask” at registration
• Systematic collection of data
• All patients are asked smoking status
• Information transferred to “Verdi”
• Flag for clinicians
• to advise patients to quit
• refer for smoking cessation support
• Provides data for research

31. 2011: Pharmacy led study
• Examined
• Retrospective single arm
• n= 312
• Pack years
• Quit rates
• Findings
• 50% ever smoked / 12% current
• Ave pack years: 27.8
• Low clinic recruitment: (7.3%)
• 25% patients quit at 12 months, PP = 33% quit
• 66% (reduction or cessation)
• 43% seen in SCC had not disclosed
(Plueckhahn, Alexander, et al, 2011)

32. 2010: Superannuation funds
• Challenged for tobacco investments
• Met with CEO’s
• Business case
• Conflicts of interest
• Tobacco free folios
• Future fund: tobacco will be dumped
(>$250million worth of stocks)
• Continued pressure SF CEO’s
• (Dr. Bronwyn King)

33. VNSH membership
– Information sharing
– Compliance
– Smoking cessation strategies
– Education
– Engagement

34. Future…
• VNSH standards
• Repeat staff survey
• Pre admission clinic study
• VCCC plans (RMH / RWH)
• Automated referrals from
registration
• Indigenous community / VACCHO

35. Success factors
• Strong executive support
• Patient focused
• Senior clinician engagement
• Research practice
• Maintain high profile
• Education
• Communication

36. Finally
• Smoking cessation ABCD
• ASK
• Briefly advise
• Cessation treatment patient
focus
• Document