Tobacco TacticsTobacco TacticsSonia A. Duffy, Ph.D., R.N.Sonia A. Duffy, Ph.D., R.N.

VA Ann Arbor Healthcare SystemVA Ann Arbor Healthcare System

The University of MichiganThe University of Michigan

Tobacco Tactics TeamTobacco Tactics Team Sonia Duffy, Ph.D., R.N., Principal InvestigatorSonia Duffy, Ph.D., R.N., Principal Investigator Jeffrey Alexander, Ph.D., ConsultantJeffrey Alexander, Ph.D., Consultant Frederic Blow, Ph.D., M.A., ConsultantFrederic Blow, Ph.D., M.A., Consultant Deborah Caplan, M.S., N.P., C.D.E., Co-InvestigatorDeborah Caplan, M.S., N.P., C.D.E., Co-Investigator Timothy Carmody, Ph.D., Co-InvestigatorTimothy Carmody, Ph.D., Co-Investigator Stephen Chermack, Ph.D., M.A.., Co-InvestigatorStephen Chermack, Ph.D., M.A.., Co-Investigator Gregory Dalack, M.D., Co-InvestigatorGregory Dalack, M.D., Co-Investigator Lee Ewing, M.P.H., Project ManagerLee Ewing, M.P.H., Project Manager Petra Flanagan, Pharm.D., Tobacco Cessation CoordinatorPetra Flanagan, Pharm.D., Tobacco Cessation Coordinator Amanda Fore, M.S., R.N., Research NurseAmanda Fore, M.S., R.N., Research Nurse Karen Fowler, M.P.H., Data AnalystKaren Fowler, M.P.H., Data Analyst Judy Heath, M.S., R.N., Research NurseJudy Heath, M.S., R.N., Research Nurse Christopher Hermann, M.S.N., N.P.-C., Co-InvestigatorChristopher Hermann, M.S.N., N.P.-C., Co-Investigator Thomas Hicks, D.N.S., R.N., C.S., Co-InvestigatorThomas Hicks, D.N.S., R.N., C.S., Co-Investigator Carrie Karvonen-Gutierrez, M.P.H., Data AnalystCarrie Karvonen-Gutierrez, M.P.H., Data Analyst Pamela Reeves, M.D., Co-Principal InvestigatorPamela Reeves, M.D., Co-Principal Investigator David Ronis, Ph.D., Co-Investigator/StatisticianDavid Ronis, Ph.D., Co-Investigator/Statistician Patricia Smith, Ph.D., ConsultantPatricia Smith, Ph.D., Consultant Richard White, M.S.N., R.N., Nurse ChampionRichard White, M.S.N., R.N., Nurse Champion

Tobacco Tactics Nurse Tobacco Tactics Nurse ChampionsChampions

Denise CrawfordDenise Crawford Bryan FacioneBryan Facione Sarah PalmateerSarah Palmateer Melissa PowersMelissa Powers Ruth RileyRuth Riley Mary Jane RothMary Jane Roth Diane Sobecki-RyniakDiane Sobecki-Ryniak

Cecilia SosnowskiCecilia Sosnowski Sylvia WallaceSylvia Wallace Charles WashingtonCharles Washington Richard WhiteRichard White Lori WilsonLori Wilson Patrick WoznyPatrick Wozny

BackgroundBackground Tobacco use continues to be the leading cause Tobacco use continues to be the leading cause

of morbidity and mortality in the United States. of morbidity and mortality in the United States. Over 400,000 Americans die every year from Over 400,000 Americans die every year from

diseases caused by tobacco. diseases caused by tobacco. More deaths are caused each year by tobacco More deaths are caused each year by tobacco

use than by all deaths from HIV, illegal drug use, use than by all deaths from HIV, illegal drug use, alcohol use, motor vehicle injuries, suicides, and alcohol use, motor vehicle injuries, suicides, and murders combined.murders combined.

Actual Causes of Death in the Actual Causes of Death in the United States United States

EvidenceEvidence Our 2004 pilot data showed at least 70% of Our 2004 pilot data showed at least 70% of

inpatient veteran smokers were motivated to quit, inpatient veteran smokers were motivated to quit, yet only 17% stated they received cessation yet only 17% stated they received cessation services during their hospitalization.services during their hospitalization.

Efficacious smoking interventions are available.Efficacious smoking interventions are available. Smoking cessation services in the VA are Smoking cessation services in the VA are

historically provided via outpatient groups which historically provided via outpatient groups which reach few smokers.reach few smokers.

Inpatient cessation programs have been shown Inpatient cessation programs have been shown to be highly efficacious. to be highly efficacious.

More EvidenceMore Evidence Nurse-administered cessation interventions have Nurse-administered cessation interventions have

been shown to be more efficacious than been shown to be more efficacious than interventions delivered by non-nurses.interventions delivered by non-nurses.

Lack of knowledge is the number 1 reason Lack of knowledge is the number 1 reason nurses do not provide smoking interventions.nurses do not provide smoking interventions.

A VA study by Anne Joseph showed that it took 5 A VA study by Anne Joseph showed that it took 5 attempts for a cessation counselor to contact a attempts for a cessation counselor to contact a patient.patient.

Why Nurses?Why Nurses? Nurses are the largest group of front-line providersNurses are the largest group of front-line providers Nurses have access to patientsNurses have access to patients Nurses have rapport with patientsNurses have rapport with patients Nurses are trained in patient education and health Nurses are trained in patient education and health

behaviorbehavior Nurses can incorporate cessation interventions into Nurses can incorporate cessation interventions into

routine careroutine care Nurses can relate detrimental effects of smoking to Nurses can relate detrimental effects of smoking to

patient’s conditionpatient’s condition Nurses can work with physicians to order medicationsNurses can work with physicians to order medications

ObjectiveObjective The objective of this Service Directed The objective of this Service Directed

Project (SDP) is to implement and evaluate Project (SDP) is to implement and evaluate an inpatient, nurse-administered, an inpatient, nurse-administered, evidence-based Tobacco Tactics program evidence-based Tobacco Tactics program for general inpatients in the three largest for general inpatients in the three largest VISN 11 hospitals. VISN 11 hospitals.

MethodsMethods

Patients admitted to the Ann Arbor and Patients admitted to the Ann Arbor and Detroit VAs receive the Tobacco Tactics Detroit VAs receive the Tobacco Tactics intervention, while patients admitted to the intervention, while patients admitted to the Indianapolis VA receive usual care cessation Indianapolis VA receive usual care cessation groups.groups.

Tobacco Tactics toolkits for nurses and Tobacco Tactics toolkits for nurses and patients were developed and training patients were developed and training sessions have been implemented.sessions have been implemented.

Toolkit for NursesToolkit for Nurses

One contact hour for trainingOne contact hour for training PowerPoint presentation on behavioral and PowerPoint presentation on behavioral and

pharmaceutical interventionspharmaceutical interventions Pharmaceutical and behavioral protocolsPharmaceutical and behavioral protocols Pocket card “Helping Smokers Quit: A Guide Pocket card “Helping Smokers Quit: A Guide

for Clinicians” developed by the U.S. for Clinicians” developed by the U.S. Department of Health and Human Services Department of Health and Human Services Public Health Service and Tobacco Free Public Health Service and Tobacco Free NursesNurses

Computerized template for nurse Computerized template for nurse documentationdocumentation

Contents of Nurse Training Contents of Nurse Training PowerPointPowerPoint

The Five A’sThe Five A’s Pharmaceutical management Pharmaceutical management Behavioral Behavioral management management CPRS documentation CPRS documentation Case studiesCase studies

The Five A’sThe Five A’s

AskAsk if they smoke if they smoke AdviseAdvise to quit to quit AssessAssess motivation to change motivation to change AssistAssist if willing to quit if willing to quit ArrangeArrange for follow-up for follow-up

Pharmaceutical ManagementPharmaceutical Management Recommend nicotine replacement (patch, gum, or lozenge) if:Recommend nicotine replacement (patch, gum, or lozenge) if:

Never used patch, gum, or lozenge before.Never used patch, gum, or lozenge before. Used patch, gum, or lozenge successfully in the past (smoke-free Used patch, gum, or lozenge successfully in the past (smoke-free

> 3 months).> 3 months). Recommend bupropion if:Recommend bupropion if:

Failed nicotine replacement monotherapy in the past (smoke-free Failed nicotine replacement monotherapy in the past (smoke-free <3 months). <3 months).

Patch, gum, or lozenge intolerant (i.e. rash, etc.).Patch, gum, or lozenge intolerant (i.e. rash, etc.). History of depression or currently has depressive symptoms.History of depression or currently has depressive symptoms.

Recommend combination nicotine replacement (patch, gum, or Recommend combination nicotine replacement (patch, gum, or lozenge) and bupropion if:lozenge) and bupropion if:

Failed nicotine replacement and bupropion monotherapy in the Failed nicotine replacement and bupropion monotherapy in the past.past.

Recommend varenicline if:Recommend varenicline if: Intolerance or treatment failure to nicotine replacement and Intolerance or treatment failure to nicotine replacement and

bupropion.bupropion.

Behavioral ManagementBehavioral Management Assess if patient interested in quitting.Assess if patient interested in quitting. If patient not interested, leave brochure at bedside.If patient not interested, leave brochure at bedside. If patient interested, leave brochure and arrange for patient to If patient interested, leave brochure and arrange for patient to

view videotape.view videotape. After videotape, provide patient with patient manual to read if After videotape, provide patient with patient manual to read if

able.able. Using patient manual, assist patient with behavioral Using patient manual, assist patient with behavioral

intervention including:intervention including: Self assessmentSelf assessment Smoker typeSmoker type Smoking costsSmoking costs Handling cravingsHandling cravings Relapse preventionRelapse prevention Medication optionsMedication options

Along with patient, identify and arrange for cessation Along with patient, identify and arrange for cessation medications (see pharmaceutical protocol).medications (see pharmaceutical protocol).

Arrange for follow-up calls.Arrange for follow-up calls.

Documentation – CPRSDocumentation – CPRS InpatientInpatient

Nursing Admission Nursing Admission Assessment Assessment

InterdisciplinaryInterdisciplinaryTreatment Plan (ITP)Treatment Plan (ITP)

√ √ Smoking CessationSmoking Cessation Follow template questionsFollow template questions

Shared TemplatesShared Templates Education TemplatesEducation Templates Tobacco Education Tobacco Education

InpatientInpatient Select note title Select note title (i.e.. patient education)(i.e.. patient education)

OutpatientOutpatient Clinical RemindersClinical Reminders Shared TemplatesShared Templates

Education TemplatesEducation Templates Tobacco Cessation Tobacco Cessation

OutpatientOutpatient Select note titleSelect note title

Template varies depending Template varies depending on who is completing iton who is completing it Able to prescribe Able to prescribe

medication / NOT able medication / NOT able to prescribe medicationto prescribe medication

Documentation TemplateDocumentation Template

Physician ComponentPhysician Component 5-minute overview of the intervention was given to 5-minute overview of the intervention was given to

medical students and residents each month.medical students and residents each month. Physicians were counseled to advise patients, Physicians were counseled to advise patients,

“Quitting tobacco use is the most important thing “Quitting tobacco use is the most important thing you can do to protect your health.”you can do to protect your health.”

Work with nurses and prescribe pharmaceuticals Work with nurses and prescribe pharmaceuticals based on patient assessment, history, based on patient assessment, history, and protocol.and protocol.

Toolkit for PatientsToolkit for Patients

Brochure Brochure VideotapeVideotape Tobacco Tactics manualTobacco Tactics manual PharmaceuticalsPharmaceuticals 1-800-QUIT-NOW help line1-800-QUIT-NOW help line

BrochureBrochure

VideotapeVideotape Smoking: Getting Ready to Quit (2Smoking: Getting Ready to Quit (2ndnd

edition) by Milner-Fenwickedition) by Milner-Fenwick VHS/DVDVHS/DVD

Tobacco Tactics ManualTobacco Tactics Manual

PharmaceuticalsPharmaceuticals(Protocol described earlier)(Protocol described earlier)

Nicotine replacement therapy (patch, gum, or Nicotine replacement therapy (patch, gum, or lozenge) lozenge)

BupropionBupropion Combination nicotine replacement (patch, gum, Combination nicotine replacement (patch, gum,

or lozenge) and Bupropionor lozenge) and Bupropion Varenicline Varenicline

Restricted template for initial prescribing and Restricted template for initial prescribing and renewalsrenewals

1-800-QUIT-NOW1-800-QUIT-NOW

The plastic 1-800-QUIT-NOW cards, which The plastic 1-800-QUIT-NOW cards, which connect smokers with the State-supported connect smokers with the State-supported quit line, are the most rapidly used piece quit line, are the most rapidly used piece of the Tobacco Tactics toolkit.of the Tobacco Tactics toolkit.

Evaluation of Tobacco Tactics Evaluation of Tobacco Tactics

Formative evaluationFormative evaluation focuses on the focuses on the process process and allows for tailoring the intervention to the and allows for tailoring the intervention to the needs of the VA.needs of the VA.

Summative evaluationSummative evaluation focuses on outcome and focuses on outcome and determines 6-month cessation rates. Smokers determines 6-month cessation rates. Smokers in all facilities (experimental and control) are in all facilities (experimental and control) are surveyed and given mailed cotinine tests.surveyed and given mailed cotinine tests.

SustainabilitySustainability: Once nurse trainers are : Once nurse trainers are withdrawn from the units, sustainability and withdrawn from the units, sustainability and summative evaluation will be conducted.summative evaluation will be conducted.

Formative EvaluationFormative Evaluation

In Ann Arbor, 333 healthcare professionals In Ann Arbor, 333 healthcare professionals have attended Tobacco Tactics training, of have attended Tobacco Tactics training, of which 284 were nurses. which 284 were nurses.

In Detroit, 185 healthcare professionals In Detroit, 185 healthcare professionals have been trained (to date), of which 135 have been trained (to date), of which 135 are nurses and trainings are still in are nurses and trainings are still in progress.progress.

Formative EvaluationFormative Evaluation

In Ann Arbor, the intervention has In Ann Arbor, the intervention has disseminated rapidly.disseminated rapidly.

Units not targeted including psychiatric, Units not targeted including psychiatric, substance abuse, and outpatient clinics also substance abuse, and outpatient clinics also became interested.became interested.

Manuals Used by Month Manuals Used by Month (6/21/2007 – 4/30/2008)(6/21/2007 – 4/30/2008)

As trainings increased, the number of As trainings increased, the number of materials for patients disappeared and units materials for patients disappeared and units where materials were stagnating were given where materials were stagnating were given extra attention.extra attention.

0

10

20

30

40

50

6/21-7/19

8/17-9/17

10/10-11/5

12/12-1/9

1/30-2/27

3/31-4/30

Number of Manuals Used by Month

Performance MeasuresPerformance Measures

Under Performing Meets Target

 

Year2007

Year 2008

  Q4 Q1 Q2 Q3 Q4

Counseling-Heart Failure 43% 100% 100% 88% 83%

Counseling-AMI 88% 100% 100% 100% 67%

Counseling-Outpatient 30% 85% 74% 79% 72%

Referral to Cessation Program-Outpatient

- 95% 84% 93% 91%

Staff Confidence in Training Staff Confidence in Training 274 nurses and 32 other participating staff were given 274 nurses and 32 other participating staff were given

surveys one to two months after participation in the surveys one to two months after participation in the training. training.

Those who were satisfied or extremely satisfied with the Those who were satisfied or extremely satisfied with the training were more confident in their abilities to provide training were more confident in their abilities to provide smoking cessation interventions and to think it was smoking cessation interventions and to think it was important to provide such services on their units.important to provide such services on their units.

Those who strongly agreed they had a good Those who strongly agreed they had a good understanding of the elements of the smoking cessation understanding of the elements of the smoking cessation intervention were also more confident in their abilities to intervention were also more confident in their abilities to provide smoking cessation interventions and to think it provide smoking cessation interventions and to think it was important to provide such services on their units.was important to provide such services on their units.

As nurses began to see the implementation of their As nurses began to see the implementation of their suggestions to improve the intervention, they became suggestions to improve the intervention, they became increasingly motivated to implement the intervention. increasingly motivated to implement the intervention.

Volunteer Phone CounselingVolunteer Phone Counseling Telephone counseling has been shown to Telephone counseling has been shown to

enhance quit rates, yet nurses did not have time enhance quit rates, yet nurses did not have time to do it.to do it.

Hence, volunteers were trained to provide Hence, volunteers were trained to provide telephone follow-up counseling and peer support telephone follow-up counseling and peer support to patients 2, 14, 21, and 60 days post-to patients 2, 14, 21, and 60 days post-discharge. discharge.

Documentation is a paper check list with some Documentation is a paper check list with some prompts for counseling. prompts for counseling.

Volunteers are extremely enthusiastic about Volunteers are extremely enthusiastic about providing follow-up calls. providing follow-up calls.

Volunteer Data Volunteer Data

From April – September 2008, volunteers made From April – September 2008, volunteers made 617 calls to 111 patients. 617 calls to 111 patients.

Calls across all time points: Calls across all time points: No tobacco used since discharge: 63No tobacco used since discharge: 63 Yes, still smoking, not in last 24 hours: 35Yes, still smoking, not in last 24 hours: 35 Yes, still smoking but interested in quitting: 77Yes, still smoking but interested in quitting: 77 Yes, still smoking, do not want to quit: 11 (6 Yes, still smoking, do not want to quit: 11 (6

withdrew)withdrew)

Provision of ServicesProvision of ServicesPre

InterventionDuring

InterventionPost

Intervention

% % %

Received individual counseling to quit

Experimental 16.9 (n=29) 13.0 (n=7) 20.9 (n=18)

Control 17.2 (n=5) 24.1 (n=7) 29.6 (n=8)

Received nicotine patch

Experimental 37.8 (n=65) 33.3 (n=19) 41.7 (n=35)

Control 37.9 (n=11) 33.3 (n=10) 33.3 (n=9)

Received nicotine gum

Experimental 4.8 (n=8) 7.3 (n=4) 13.1 (n=11)

Control 10.3 (n=3) 6.7 (n=2) 15.4 (n=4)

Provision of Services (cont.)Provision of Services (cont.)Pre

InterventionDuring

InterventionPost

Intervention

% % %

Received other medications to help quit smoking

Experimental 11.6 (n=20) 9.3 (n=5) 24.1 (n=20)

Control 17.2 (n=5) 17.2 (n=5) 11.5 (n=3)

Received hand-out materials to help quit smoking

Experimental 47.4 (n=81) 50.0 (n=27) 58.6 (n=51)

Control 58.6 (n=17) 65.5 (n=19) 55.6 (n=15)

Received video about quitting smoking

Experimental 6.4 (n=11) 3.7 (n=2) 14.0 (n=12)

Control 6.9 (n=2) 10.0 (n=3) 3.7 (n=1)

Tobacco Tactics CampaignTobacco Tactics Campaign Novel and strategic campaign strategies are needed to Novel and strategic campaign strategies are needed to

compete with the enticing messages produced by tobacco compete with the enticing messages produced by tobacco advertisers. advertisers.

Since pictures speak louder than words, social marketing Since pictures speak louder than words, social marketing techniques were used to develop the image-based VA techniques were used to develop the image-based VA Tobacco Tactics program logo and campaign character. Tobacco Tactics program logo and campaign character.

A graphic design firm was hired to develop a logo for our A graphic design firm was hired to develop a logo for our Tobacco Tactics program and a character for our tobacco Tobacco Tactics program and a character for our tobacco cessation manual.cessation manual.

Three rounds of surveys have been conducted with patients Three rounds of surveys have been conducted with patients and staff at the Ann Arbor and Detroit VAs to obtain feedback.and staff at the Ann Arbor and Detroit VAs to obtain feedback.

Consumer feedback was communicated to the graphic Consumer feedback was communicated to the graphic design firm and iterations of the logo and character were design firm and iterations of the logo and character were developed. developed.

Example Logos & CharactersExample Logos & Characters

Tobacco Tactics CampaignTobacco Tactics Campaign After successive iterations, the character was narrowed down to a drill After successive iterations, the character was narrowed down to a drill

sergeant or bulldog. sergeant or bulldog.

61% preferred the drill sergeant and 34% preferred the bulldog (61% preferred the drill sergeant and 34% preferred the bulldog (N=95).N=95). However, several participants stated that their drill sergeant told them to However, several participants stated that their drill sergeant told them to

“smoke 'em if you got 'em.”“smoke 'em if you got 'em.” Thus, we chose the bulldog as our final product.Thus, we chose the bulldog as our final product.

Tobacco-Free Campus (Ann Tobacco-Free Campus (Ann Arbor)Arbor)

ChampionsChampions LeadershipLeadership Potential implementation January 1, 2009Potential implementation January 1, 2009

Data from Tobacco-Free SurveyData from Tobacco-Free Survey

397 staff responded to the survey. 397 staff responded to the survey. Over 75% of staff are favorable or very Over 75% of staff are favorable or very

favorable of the Ann Arbor VA becoming favorable of the Ann Arbor VA becoming tobacco-free.tobacco-free.

Over 61% feel it is important or very Over 61% feel it is important or very important to relocate the smoking shelters. important to relocate the smoking shelters.

About 70% feel it is important or very About 70% feel it is important or very important to offer employee assistance to important to offer employee assistance to quit using tobacco. quit using tobacco.

Data from Tobacco-Free SurveyData from Tobacco-Free Survey

15% of staff are current tobacco users.15% of staff are current tobacco users. Approximately 18% are thinking of quitting Approximately 18% are thinking of quitting

in the next 30 days, 33% within the next 6 in the next 30 days, 33% within the next 6 months, and 49% are not currently months, and 49% are not currently thinking of quitting. thinking of quitting.

About 45% are interested in tobacco About 45% are interested in tobacco cessation services provided by the VA, cessation services provided by the VA, with the most interest in medications and with the most interest in medications and take-home workbook/video.take-home workbook/video.

Qualitative data from Qualitative data from Tobacco-Free SurveyTobacco-Free Survey

Eliminate smoking near main entrance (27)Eliminate smoking near main entrance (27) Enforce policy (18)Enforce policy (18) Smoking is a personal choice (16) Smoking is a personal choice (16) Move or improve smoking shelters (10)Move or improve smoking shelters (10) Ban would decrease staff productivity (7)Ban would decrease staff productivity (7) Include patients in the ban (6)Include patients in the ban (6) Get rid of vending machines/Obesity (6) Get rid of vending machines/Obesity (6) Change the law (5) Change the law (5)

Tobacco Tactics WebsiteTobacco Tactics Website

SHP (short term project) was granted to SHP (short term project) was granted to develop the program into a website. develop the program into a website.

Two veterans from out of state have called Two veterans from out of state have called and asked to participate in the study. and asked to participate in the study.

Website Screen ShotWebsite Screen Shot

Message from General McCaffrey Message from General McCaffrey

Website Screen ShotWebsite Screen Shot

Summative EvaluationSummative Evaluation

In progressIn progress

SustainabilitySustainability

Nurse training has been incorporated into Nurse training has been incorporated into new nurse employee orientationnew nurse employee orientation

Tobacco Tactics module added in LMSTobacco Tactics module added in LMS Video shown on hospital education Video shown on hospital education

channel two times/day channel two times/day Patient education materials kept in patient Patient education materials kept in patient

education library education library

Initial Barriers to ImplementationInitial Barriers to Implementation

Improve CPRS documentation Improve CPRS documentation Lack of support from physicians Lack of support from physicians Difficulty locating Tobacco Tactics resourcesDifficulty locating Tobacco Tactics resources Patient’s condition may not be appropriate for Patient’s condition may not be appropriate for

intervention which suggests the need for intervention which suggests the need for cessation interventions at various points in cessation interventions at various points in treatment.treatment.

Hiring difficulties in Indianapolis and Detroit Hiring difficulties in Indianapolis and Detroit

Facilitators to ImplementationFacilitators to Implementation

Template placed in Nursing Admission Template placed in Nursing Admission Assessment Assessment

Brief overview of the intervention was Brief overview of the intervention was given to interns and residents each monthgiven to interns and residents each month

Materials were clearly labeled and made Materials were clearly labeled and made visible on each unit; monthly email visible on each unit; monthly email reminders were sent to staff reminders were sent to staff

Units decided best time for intervention Units decided best time for intervention (e.g. Inpatient Psych and ICU’s) (e.g. Inpatient Psych and ICU’s)

Facilitators to ImplementationFacilitators to Implementation

There was great concern that nurses There was great concern that nurses would not have the time to do this.would not have the time to do this.

This was not true. Once trained, nurses This was not true. Once trained, nurses were enthusiastic about the intervention.were enthusiastic about the intervention.

Nurse champions were invaluable Nurse champions were invaluable

Continued Barriers to Continued Barriers to ImplementationImplementation

Getting training to be mandatory Getting training to be mandatory Tobacco-free environmentTobacco-free environment Acceptance of creative aspects of patient Acceptance of creative aspects of patient

education materialseducation materials Passing over the program – lack of much Passing over the program – lack of much

FTE to administerFTE to administer

Conclusion: The nurse-based Tobacco Conclusion: The nurse-based Tobacco Tactics intervention can be successfully Tactics intervention can be successfully

implemented in the VAimplemented in the VA

Opportunities for National Opportunities for National DisseminationDissemination

Why your dog really goes Why your dog really goes outside…outside…

Questions?Questions?

Sonia A. Duffy, Ph.D., R.N.Sonia A. Duffy, Ph.D., R.N.Ann Arbor VA HSR&D (11H)Ann Arbor VA HSR&D (11H)

P.O. Box 130170P.O. Box 130170

Ann Arbor, MI 48113-0170Ann Arbor, MI 48113-0170

Ph: (734) 845-3608Ph: (734) 845-3608

bump@umich.edubump@umich.edu