Program Details

Practice Type:	Promising
Program Name:	Smoking Cessation in the Public Health Setting
Organization:	Columbia-Boone County Health Department
Web site:
Overview:	This program addresses the need for low-cost smoking cessation options in a time when demand increased due to a newly adopted smoke-free worksite city ordinance. The program addressed the need to educate the public about the health hazards of secondhand smoke. Cigarette smoking is the leading preventable cause of premature death in the United States. Approximately 70% of smokers say they want to quit and about 40% try to quit each year, but only 4% to 7% succeed without help. Evidence shows that smokers who use NRT are more likely to quit than those who do not. Combining counseling and support with NRT significantly improves the cessation success rate. Evidence from the Clinical Practice Guidelines demonstrates that even an intervention lasting fewer than three minutes is effective. Goal: To reduce the impact of tobacco on chronic disease in Boone County Objectives: • Provide Brief Smoking Cessation Counseling training to nurses and others including Master of Public Health and pre-med students who will serve as counselors. This is in keeping with preparing our workforce through continuing education. It provides an innovative approach to the traditional smoking cessation classes. • Provide a low-cost smoking combination-therapy cessation opportunity to those who wish to stop smoking. Many communities do not have regular, consistent smoking cessation opportunities. Providing this service enables those who want to make a lifestyle change a reputable, affordable opportunity. • Educate those who came in for cessation services as well as attendees of FoodHandler classes as to the dangers of SHS. Each of the objectives were met. • All personnel were trained in the Brief Cessation Counseling method, including health department nurses and other interested staff, employee health personnel from colleges and worksites in Boone County, graduate and pre-med students. • A no-cost program was established using a combination therapy of individual counseling plus NRT, if desired. Eight weeks’ of patches were provided at no cost. • All cessation clients were educated about the health hazards of secondhand smoke. In addition a special educational DVD was produced and played before the start of FoodHandler classes. • An instruction manual was created and offered to local health departments at a number of local, state, and national meetings. It is available on our website, and it accompanies the training we have provided to a number of local health departments in Missouri.
Year Submitted:	2010
Responsiveness and Innovation:	The public health issue addressed is the need for smoking cessation, especially at the time a comprehensive smoke-free worksite ordinance was enacted. The Behavioral Risk Factor Surveillance Survey (BRFSS) reported an adult smoking rate of 26% in Boone County. The County Level Survey (CLS) reported that 75% of smokers intended to quit in the next six months. Education about health effects of secondhand smoke is an additional issue addressed in this practice. Our program provided the opportunity to speak to many individuals and to address the large numbers (4,000 per year) of attendees of Foodhandler classes. Secondhand smoke information was distributed in our WIC clinic and at all events we attended.Our community needs assessment revealed high numbers of smokers, the chronic diseases impacted by smoking, and the lack of smoking cessation resources. In addition, the local community coalition worked for three years prior to the initiation of our program to assess the level of interest in the community for a smoke-free worksite ordinance and the need for secondhand smoke awareness. The coalition polled all businesses for their acceptance of a possible ordinance, then used that information to educate the public, businesses, and city council members. During the same period of time the University of Missouri Department of Family and Community Medicine created the Campus-Community Alliance for Smoke-free Environments (CASE) which was comprised of highly motivated students interested in promoting smoke-free messages coupled with education about hazards of secondhand smoke. Using available evidence-based literature on the topic, the Health Department prepared for the need to educate the community and local businesses about an ordinance, should one be adopted. The Health Department also braced for a surge in demand for smoking cessation services. It was serendipitous that the Missouri Foundation for Health had decided to offer community-based smoking cessation grant opportunities at that time.The program squarely addresses the issue of providing low-cost smoking cessation at time of increased need by the public. The added benefit was the opportunity to educate the public and all those who intended to stop smoking about the hazards of secondhand smoke. The secondhand smoke issue was the highlight of the education and awareness effort in advance of adopting a smoke-free worksite ordinance. While the two issues seem dependent on each other, SHS truly became the health concern that drove awareness and the need to help people stop smoking. Most of the traditional smoking cessation options offer the seven-class series as a group. In our partnership with University of Missouri Department of Family and Community Medicine we learned of the Missouri Model for Brief Smoking Cessation Training used in a protocol for pregnant women. Drs Everett and Bullock adapted this model for use with the general public. Literature reviews and meta-analyses provided in Treating Tobacco Use and Dependence Clinical Practice Guideline provided level A (strong) evidence for two components we chose to use: NRT and Personal Counseling. Personal counseling: “Minimal interventions lasting less than three minutes increase overall tobacco abstinence rates.” “There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes.” We chose to provide the five-A’s counseling interventions in approximately 15-20 minute sessions. We chose to offer four intervention sessions over eight weeks to adequately address the length of time and the intensity that warranted the strong evidence rating by Clinical Practice Guideline. Another feature of our program was offering free NRT patches, which is usually not done on health departments due to the cost. The grant enabled us to pilot test the offering of free NRT. Upon completion of the project, it was decided by our clinical services to continue to provide some level of free NRT as part of the affordable smoking cessation services. One of the target audiences for education about secondhand smoke and the availability of the smoking cessation program was FoodHandler class. Our Division of Environmental Health trains approximately 4,000 people per year as food handlers in restaurants, bars, and other venues. We collaborated with the Communications Department of our city cable TV station to create a 10-minute educational video to be played before the start of each FoodHandler class. Finally, the use of students as counselors is truly innovative. Our ties with the Master of Public Health program at University of Missouri-Columbia (MU) and our partnership with the Wellness Resource Center also at MU, provide us a steady flow of highly motivated and bright undergraduate and graduate students with a passion for reducing tobacco use and who require clinical and research oriented community field experience. They have learned the Brief Counseling techniques well and have a caring attitude. In addition, they understand the value of data collection and are skilled in the use of Excel and other methods of data collection and analysis. The Health Department feels a strong responsibility to, whenever possible, provide training and experience for our future public health work force.This practice differs from other approaches to address smoking cessation in public health by: a) offering brief counseling at individual sessions over an eight-week period, b) using students to augment our counseling staff, and c) informing all participants in FoodHandler class about dangers of secondhand smoke. The uniqueness was enhanced by the relationships we had with faculty and students at MU, our collaboration with the City Communications Department in producing a video that is available to anyone who wants it, and in the Health Department’s multi-department (Administration, Nursing, Environmental Health, Communications) approach to addressing a chronic disease reduction issue. This is innovative for our target audience because they expect classes, rather than individual counseling. They were also pleasantly surprised by the students working as counselors. We had many positive comments about the program. Our smoking cessation program differs in two respects: 1) It used the Brief Counseling method instead of smoking cessation classes and 2) It made use of MPH and pre-med students to augment staffing, while providing them with public health training. 3) The program educated attendees of Foodhandler classes about secondhand smoke.The Health Department provides access to the program manual, offers consultation to local health departments that wish to initiate smoking cessation services. We will also provide, at no charge, the radio ads and SHS educational DVD to anyone who requests. We continue our strong relationship with the MU MPH program as a means of providing practical experience for students of public health and as a way of building the future public health workforce. Our ties with MU’s Department of Family and Community Medicine enable us to collaborate on tobacco education efforts in the community.
Agency and Community Roles:	The Columbia/Boone County Department of Public Health and Human Services (Health Department) secured the grant and initiated the smoking cessation program and assumed the lead role. The Health Department organized training events and maintained communication and updates to these participants. The Health Department hired and/or processed student internships and trained them as counselors. This required maintaining reports and evaluation to their academic institutions. The Health Department evaluated the practice by conducting an telephone follow-up survey with all participants and had the data analyzed. Results were reported to the Columbia/Boone County Board of Health and local, state, and national conferences. Our partners are: • University of Missouri Department of Family and Community Medicine: provided consultation and training in Brief Smoking Cessation Counseling • Campus-Community Alliance for Smoke-free Environments: provided motivated students with a passion for tobacco use reduction. They were trained and worked as counselors in our program. • University of Missouri Master of Public Health program: students served as interns and helped conduct evaluation and presentations. • Family Health Center ((FQHC): Their staff was trained and they conducted smoking cessation in their Center. They provided their records for our program evaluation • Columbia College: Their staff was trained and they conducted smoking cessation for staff and students. They provided their records for our program evaluation • City of Columbia Public Communications: helped produce and air secondhand smoke messages on cable TV; produced SHS educational DVD for FoodHandler class participants.
Costs and Expenditures:	In 2003, the Boone County adult smoking rate was 26%. While not the highest in the state, it was high by national standards. The lack of a comprehensive smoke-free policy reduces the incentive for smokers to stop smoking. With the enactment of a comprehensive smoke-free worksite community policy in 2006, the community including worksites, hospitals, and businesses felt the pressure to provide smoking cessation so make compliance easier for employees. Through a grant from the Missouri Foundation for Health, the Health Department initiated the program by hiring additional part time staffing, purchasing educational materials, NRT patches, and incentives. The total amount for the two-year start-up was approximately $229,000. In-kind contributions were in the form of grant management personnel and employee and student health personnel from our partnering agencies. The Health Department offered the training adapted by Drs. Kevin Everett and Linda Bullock of University of Missouri, whom we consider close partners in the cessation effort. Several major insurance firms as well as Columbia College, Stephens College, and the Federally Qualified Health Center (Family Health Center) sent their employee and student health staff and nurses to training. They then became partners in advertising the program and providing services in their own agencies, while providing the Health Department with records of their activities. The uniqueness of this program is the use of Brief Smoking Cessation Counseling instead of a seven-class series to enhance the cessation therapy. The Clinical Practice Guideline states that an intervention lasting fewer than three minutes is effective in treating tobacco use and dependence, when combined with NRT. We provided a number of resources for clients to use in addition to our counseling services. These included the following: • 1-800-QUIT-NOW • BecomeAnEx.org • American Lung Association’s Freedom from smoking online (FFSonline.org) • Nicotine Anonymous The Missouri Foundation for Health awarded the Health Department a two-year grant to start the program. This included staffing, materials, printing costs, incentives, and a full eight-week course of NRT patches for the clients. The cessation program continues to operate after the grant through purchases of limited quantities of NRT patches through clinic funds.
Implementation:	The public health issue addressed is the need for smoking cessation, especially at the time a comprehensive smoke-free worksite ordinance was enacted. The Behavioral Risk Factor Surveillance Survey (BRFSS) reported an adult smoking rate of 26% in Boone County. The County Level Survey (CLS) reported that 75% of smokers intended to quit in the next six months. Education about health effects of secondhand smoke is an additional issue addressed in this practice. Our program provided the opportunity to speak to many individuals and to address the large numbers (4,000 per year) of attendees of Foodhandler classes. Secondhand smoke information was distributed in our WIC clinic and at all events we attended.Our community needs assessment revealed high numbers of smokers, the chronic diseases impacted by smoking, and the lack of smoking cessation resources. In addition, the local community coalition worked for three years prior to the initiation of our program to assess the level of interest in the community for a smoke-free worksite ordinance and the need for secondhand smoke awareness. The coalition polled all businesses for their acceptance of a possible ordinance, then used that information to educate the public, businesses, and city council members. During the same period of time the University of Missouri Department of Family and Community Medicine created the Campus-Community Alliance for Smoke-free Environments (CASE) which was comprised of highly motivated students interested in promoting smoke-free messages coupled with education about hazards of secondhand smoke. Using available evidence-based literature on the topic, the Health Department prepared for the need to educate the community and local businesses about an ordinance, should one be adopted. The Health Department also braced for a surge in demand for smoking cessation services. It was serendipitous that the Missouri Foundation for Health had decided to offer community-based smoking cessation grant opportunities at that time.The program squarely addresses the issue of providing low-cost smoking cessation at time of increased need by the public. The added benefit was the opportunity to educate the public and all those who intended to stop smoking about the hazards of secondhand smoke. The secondhand smoke issue was the highlight of the education and awareness effort in advance of adopting a smoke-free worksite ordinance. While the two issues seem dependent on each other, SHS truly became the health concern that drove awareness and the need to help people stop smoking. Most of the traditional smoking cessation options offer the seven-class series as a group. In our partnership with University of Missouri Department of Family and Community Medicine we learned of the Missouri Model for Brief Smoking Cessation Training used in a protocol for pregnant women. Drs Everett and Bullock adapted this model for use with the general public. Literature reviews and meta-analyses provided in Treating Tobacco Use and Dependence Clinical Practice Guideline provided level A (strong) evidence for two components we chose to use: NRT and Personal Counseling. Personal counseling: “Minimal interventions lasting less than three minutes increase overall tobacco abstinence rates.” “There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes.” We chose to provide the five-A’s counseling interventions in approximately 15-20 minute sessions. We chose to offer four intervention sessions over eight weeks to adequately address the length of time and the intensity that warranted the strong evidence rating by Clinical Practice Guideline. Another feature of our program was offering free NRT patches, which is usually not done on health departments due to the cost. The grant enabled us to pilot test the offering of free NRT. Upon completion of the project, it was decided by our clinical services to continue to provide some level of free NRT as part of the affordable smoking cessation services. One of the target audiences for education about secondhand smoke and the availability of the smoking cessation program was FoodHandler class. Our Division of Environmental Health trains approximately 4,000 people per year as food handlers in restaurants, bars, and other venues. We collaborated with the Communications Department of our city cable TV station to create a 10-minute educational video to be played before the start of each FoodHandler class. Finally, the use of students as counselors is truly innovative. Our ties with the Master of Public Health program at University of Missouri-Columbia (MU) and our partnership with the Wellness Resource Center also at MU, provide us a steady flow of highly motivated and bright undergraduate and graduate students with a passion for reducing tobacco use and who require clinical and research oriented community field experience. They have learned the Brief Counseling techniques well and have a caring attitude. In addition, they understand the value of data collection and are skilled in the use of Excel and other methods of data collection and analysis. The Health Department feels a strong responsibility to, whenever possible, provide training and experience for our future public health work force.This practice differs from other approaches to address smoking cessation in public health by: a) offering brief counseling at individual sessions over an eight-week period, b) using students to augment our counseling staff, and c) informing all participants in FoodHandler class about dangers of secondhand smoke. The uniqueness was enhanced by the relationships we had with faculty and students at MU, our collaboration with the City Communications Department in producing a video that is available to anyone who wants it, and in the Health Department’s multi-department (Administration, Nursing, Environmental Health, Communications) approach to addressing a chronic disease reduction issue. This is innovative for our target audience because they expect classes, rather than individual counseling. They were also pleasantly surprised by the students working as counselors. We had many positive comments about the program. Our smoking cessation program differs in two respects: 1) It used the Brief Counseling method instead of smoking cessation classes and 2) It made use of MPH and pre-med students to augment staffing, while providing them with public health training. 3) The program educated attendees of Foodhandler classes about secondhand smoke.The Health Department provides access to the program manual, offers consultation to local health departments that wish to initiate smoking cessation services. We will also provide, at no charge, the radio ads and SHS educational DVD to anyone who requests. We continue our strong relationship with the MU MPH program as a means of providing practical experience for students of public health and as a way of building the future public health workforce. Our ties with MU’s Department of Family and Community Medicine enable us to collaborate on tobacco education efforts in the community.
Sustainability:	The strategic planning in our Health Department places a high priority on chronic disease prevention. Because tobacco use is the most preventable cause of disease and death, it is important to continue to offer some form of smoking cessation. Evidence indicates that brief counseling is very helpful, especially on conjunction with pharmacotherapy. Because the cost of buying patches is about half the cost of smoking, those who have a strong enough motivation to stop smoking can purchase patches and we can offer the counseling. With our clinic system in place, and by providing only a starter box of patches, the cost of the program can be significantly reduced and thereby, continued. Our continued relationship with MU's tobacco control efforts ensures our commitment on several levels. We continually partner with the CASE (Campus Community Alliances for Smoke-Free Environments) to ensure a public health support for their activities, and they provide academic resources for our cessation efforts, including highly motivated students. Our relationship with MU Department of Pulmonary Medicine provides public health input into the development of their clinic cessation efforts. The very nature of the declining acceptability of public smoking ensures a constant need to assist our citizens in avoiding or quitting this habit. The fact that one of the Health Department's primary foci of chronic disease prevention ensures our commitment to providing smoking cessation services at some level. Other agencies provide a steady stream of messages about the benefits of stopping smoking, therefore we do not need to spend money on advertising. An abundance of free information is available about hazards of smoking and secondhand smoke. Many free stop smoking resources are available such as Freedom From Smoking Online (American Lung Association), UCanQuit2.org, BecomeAnEx.org, and others. Free materials from U.S. Department of Health and Human Services provide clinical practice guidelines for health professionals, and planning guides, worksheets, and secondhand smoke educational materials that are quite satisfactory as aids for those who want to stop smoking. Many communities have a college nearby that can provide motivated students to assist with smoking cessation at little or no cost. With staff interest, a small amount of training, and all the free materials available, smoking cessation should be a sustainable service for many health departments.
Lessons Learned:

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