While a Cochrane Review showed that inpatient smoking cessation interventions that provide telephone follow-up are more efficacious than those without telephone follow-up, implementation of follow-up cessation telephone calls proved to be difficult in the VA (and other hospital systems) due to lack of resources, primarily personnel to provide this service. Hence, as part of the Tobacco Tactics intervention, we developed a novel program to train volunteers from Voluntary Services to provide telephone cessation counseling.
Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, the objective of this study was to conduct an in-depth evaluation of the volunteer telephone cessation counseling program that has been implemented and continues to be implemented at the Ann Arbor VA hospital as part of the Tobacco Tactics intervention.
Patients who are provided with the Tobacco Tactics manual as part of their inpatient hospitalization are automatically referred to the volunteer telephone cessation counseling program. To evaluate the program, 41 patients were surveyed, 25 were interviewed, 15 volunteer phone calls were observed, and 4 staff were interviewed including the volunteers that are providing the calls, the volunteer coordinator, and the tobacco cessation coordinator.
Means and frequencies were calculated for all variables. Bivariate relationships between number of times a veteran was reached by the volunteer and smoking outcomes as well as other covariates were calculated, using t-tests or F-tests for differences in means and Wald chi-square tests for differences in proportions. Interviews were transcribed and content analysis was conducted with the data from the interviews by two independent reviewers to determine the presence of certain words or concepts within the text. This data was then corroborated to determine the final themes or concepts from the analysis.
Of the 134 patients referred to the program over a 9 month period, 130 were reached at least once. Of the 134 participants referred, 31% (n=41) agreed to be surveyed. Survey responders were on average 60 years old, 98% male, 88% white, 68% unmarried, and more likely to be motivated to quit smoking than non-responders (p<0.001). Approximately 28% were highly nicotine dependent, 32% were hazardous drinkers, and 66% were depressed. Patients who were reached 3-4 times were more likely to have higher education (p<0.05) and less nicotine dependence (p<0.01) than those who were reached 0-2 times.
In terms of effectiveness, of those who responded to the 60-day follow-up survey, 32% (n=12) reported not smoking in the past 7 days and of those, 83% (n=10) reported not smoking in the past 30 days. Continuing smokers smoked an average of 13.6 cigarettes per day (SD=8.9). Those patients who were reached 3-4 times smoked fewer cigarettes compared to those who were reached only 0-2 times (p<0.05). While underpowered to determine significant differences, 7-day point-prevalence 60-day quit rates for those who were reached 3-4 times were double compared to those who were reached 0-2 times (67% versus 33%).
In terms of adoption, over a 9 month period, two volunteers spent approximately 1.5 hours each per week making 298 calls of which 127 reached respondents; most calls lasted 1-3 minutes. Study staff observed 15 phone calls and found that volunteers offered positive encouragement and suggested tips for handling thoughts about smoking and cravings to all patients. The volunteers were empathetic and understanding, particularly to patients who had a set-back and were smoking more cigarettes. In two instances, per protocol, the volunteers referred the patient to his/her doctor for medical advice.
In terms of implementation, approximately 65% of survey respondents thought that the support from the volunteers was helpful, 82% felt comfortable talking to the volunteer, 81% felt the number of times called was about right, 74% were satisfied with the calls, and 72% would recommend the calls to someone else who was trying to quit smoking. Patient interviews revealed that veterans were enthusiastic about the program and appreciate the support from the volunteers ("I live here all alone and I don't have very many people to talk to but like you know, you guys were cheering me on or vouching for me to quit"; "It made me feel like you know, there's people out there that really care about your health"). Patients thought the advice and tips about cravings were helpful, with one veteran saying "I had it [a cigarette] in my hand, getting ready to light it up, and after talking with her [the volunteer] I put it off for 2-3 hours before I smoked it." Common suggestions for improvement include more phone calls over a longer period of time, calling in the evening, and mailing literature to reinforce quitting.
According to staff, the greatest strength of the program is that it is "peer-to-peer" and veterans "realize someone cares about their tobacco cessation." The program gives volunteers the opportunity to participate in "more hands on [work] with veterans than mailings or entering survey results." As one volunteer stated, "I didn't serve [in the military] so this is my way of giving back." In terms of maintenance, the greatest organizational barriers to implementing the program are lack of space, a coordinator who can "own" the program, and restrictions on volunteers being able to document in CPRS.
Given new Joint Commission standards requiring inpatient cessation interventions with telephone follow-up, teaching volunteers how to conduct these calls is an option that is likely to be cost effective.
- Duffy SA, Ewing LA, Louzon SA, Ronis DL, Jordan N, Harrod M. Evaluation and costs of volunteer telephone cessation follow-up counseling for Veteran smokers discharged from inpatient units: a quasi-experimental, mixed methods study. Tobacco induced diseases. 2015 Feb 5; 13(1):4.