A wealth of evidence confirms that tobacco smoking is a major risk factor for the development of cardiovascular disease, including but not limited to stroke. Overall, patients who smoke exhibit at least double the risk for stroke, compared to patients who do not smoke, and associated treatment is costly. Although the VA monitors tobacco cessation counseling as performance measures in both inpatient and outpatient settings, currently there are no existing tobacco cessation programs that are systematically delivered to veterans admitted with stroke.
Lifestyle changes, particularly smoking cessation, are cost-effective interventions that can substantially reduce the incidence of an initial stroke as well as recurrent stroke. This project aims to conduct developmental formative research to characterize the current VA procedures for the management of tobacco cessation in veterans admitted with stroke or TIA, enabling the application of theory-based methods in planning an effective tobacco cessation intervention for veterans admitted with stroke or TIA.
Specifically, we will (a) conduct in-depth interviews with key informants (clinical and administrative) in VA settings, (b) conduct four focus groups with previous patients with stroke and their family members (n=48 participants, total), and (c) administer written surveys to previous patients and their family members (n=600 surveys, total). This broad range of informants is necessary to characterize the issue fully and to gain a clear understanding of the capacity (strengths, weaknesses) of both target populations-the healthcare providers and the patients/families-for the intervention. This information will be applied in a subsequent grant application, to operationalize a theory-based intervention that will target both the healthcare providers within the VA system and the patients/family. Given our "ground-up" approach, which addresses the needs of key stakeholders, we anticipate that our resulting intervention will witness high levels of adoption as well as ultimate success in promoting cessation among veterans admitted with stroke or TIA.
Our goal in this formative stage is to obtain the necessary data for development of a feasible and effective tobacco cessation service intervention. We envision that next steps will be to submit a VA Merit Review application. Importantly, the results of the proposed RRP will inform the Stroke QUERI's efforts in secondary stroke risk factor management among veterans with stroke.
VISN Key Informant Interviews
Most key informants discussed that the smoking status of the patient is recorded in the computerized medical record and that they utilize the nurse clinical reminder to query patients at specific time points. All facilities interviewed reported access to nicotine replacement (e.g. gum, patches), and specific medications. Very few facilities reported having an inpatient program; however, one facility reported that the smoking cessation nurse met each hospitalized patient who was a current smoker at the bedside to counsel on smoking cessation. Most facilities offered a support group and group classes in the outpatient setting. One facility reported that their smoking cessation program used a stage of change model, and this program was working well. None of the facilities reported implementing any special procedures in terms of smoking cessation for veterans who smoke and had a stroke.
Five themes emerged from the analysis: existing helpful resources for cessation, existing unhelpful resources, barriers and facilitators to cessation, desired resources for quitting, and association of stroke/TIA with tobacco use. Pharmacotherapy and support from medical providers were perceived as helpful whereas group programs and flyers were perceived as unhelpful. Barriers to quitting included boredom and lack of social support; facilitators included social support and the cost of tobacco products. Vocational and rehabilitation programs were highly desirable resources for quitting. Participants did not perceive their stroke/TIA to be associated with tobacco use.
Surveys of Veterans and Spouses/Significant Others
Among veterans, most survey respondents were male (92.6%), white (69.7%), and married (45.9%). More than half were current smokers at the time of survey.
When asked perceptions regarding what works for smoking cessation, no single option ranked higher than a 5 (on a 10-point scale ranging from 1=does not work at all to 10=works extremely well). Medications ranked highest at 4.9, followed by a friend or buddy to quit together (3.6), a program to learn new hobbies (3.4), and massage, hypnosis, or acupuncture (3.3). Trends were similar among the spouses/partners. Veterans indicated that if they were to quit, they would be most likely to use a medication (5.3), followed by massage, hypnosis, or acupuncture (3.3) and a friend or buddy (2.9) (scale responses range from 1=not at all likely to use to 10=extremely likely to use).
Finally, when asked about access to methods for quitting, veterans did not feel that the available methods were easy to access: medications=5.6, group programs for quitting=3.3, telephone counseling=2.5, and written handouts or pamphlets=3.3 (scale responses range from 1=not at all easy to access to 10=extremely easy to access). Spouses/partners had similar trends, but the mean scores were lower, indicating more difficult access.
In both the focus groups and the survey, pharmacotherapy was perceived as one of the most helpful factors in smoking cessation, but when veterans were asked if they were likely to use medication to quit smoking, responses did not indicate a high likelihood. In general, veterans did not appear to have confidence in any of the methods that were presented (pharmacologic or nonpharmacologic). We also found, in both the focus groups and the survey, that veterans did not perceive a strong relationship between tobacco use and their cerebrovascular events. In contrast, participants did understand the risk of tobacco use with cardiovascular events. In focus groups, many participants mentioned that their smoking was associated with chest pain (angina) and/or a heart attack but very few reported that smoking could be related to stroke/TIA. This suggests that communication about risk of continued tobacco use following stroke/TIA is inadequate, and interventions that help medical providers to communicate the risk associated with tobacco use and stroke are needed. During any rehabilitation program, our data supports the stroke rehabilitation guidelines suggesting that rehabilitation providers have the opportunity to educate patients about stroke/TIA risk factors and help them to quit smoking and reduce exposure to second-hand smoke, to reduce their risk for secondary events. Moreover, rehabilitation providers have the opportunity to connect stroke survivors to vocational rehabilitation programs and stroke support groups.
- Zillich AJ, Hudmon KS, Damush T. Tobacco use and cessation among veterans recovering from stroke or TIA: a qualitative assessment and implications for rehabilitation. Topics in Stroke Rehabilitation. 2010 Mar 1; 17(2):140-50.