Disclosures (5 years) Grants/Research Support: CAMH, Health Canada, - - PowerPoint PPT Presentation

Scaling Smoking Cessation in the Community:

TEN Years of Implementation

and Dissemination in Ontario, Canada.

Panel Presentations: TEACH Project: Ms. Rosa Dragonetti1 STOP Program: Dr. Laurie Zawertailo1,2 Indigenous Adaptation: Ms. Megan Barker1,2

1Centre for Addiction and Mental Health 2University of Toronto Toronto, Ontario, Canada

• Dr. Peter Selby1,2, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM

Disclosures (5 years)

Grants/Research Support:

• CAMH, Health Canada, OMOH, CIHR, CCSA, PHAC, Pfizer Inc./Canada, OLA,
• Medical Psychiatry Alliance, ECHO, CCSRI, CCO, OICR, Ontario Brain Institute,
• McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Shoppers Drug Mart,
• Bhasin Consulting Fund Inc., Patient-Centered Outcomes Research Institute

Speaking Engagements (Content not subject to sponsors approval)/Honoraria:

• Pfizer Canada Inc., ABBVie, Bristol-Myers Squibb

Consulting Fees:

• Pfizer Inc./Canada, Evidera Inc., Johnson & Johnson Group of Companies,
• Medcan Clinic, Inflexxion Inc., V-CC Systems Inc., MedPlan Communications,
• Kataka Medical Communications, Miller Medical Communications,
• NVision Insight Group, Sun Life Financial

Other: (Received drugs free/discounted for study through open tender process)

• Johnson & Johnson, Novartis, Pfizer Inc.

NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING

Tobacco Use

• 37-45k annual deaths in Canada
• 2 M of 5M smokers live in Ontario
• Mostly male, less than high school,

blue collar, working poor

• Comorbid mental illness and addiction

Challenge

• Untrained/uninterested workforce
• No coverage for smoking cessation
• Limited budget for cessation
• Tobacco control no balance,

population versus clinical responses

• Stigma- do it on your own!
• My clinic= 1000 patients annually

Funder question to me

Can you help us treatment smokers in Ontario?

Early models

• Proceed- precede model- Green for

Pregnets (www.pregnets.org)

• Greenhalgh
• KTA- Strauss
• Addiction and behaviour model

Society Behaviour and Biology: Making the Case for EBB interventions T.A. Glass, M.J. McAtee / Social Science & Medicine 62 (2006) 1650–1671

Integrated model

• Values based

– Compassion – Acceptance – Partnership – Evocation – Equity

Clinic Training and technical assistance Research (Bench to Public Health

$$$Multisource funding model

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Evaluation model

• R x E- Abhrams
• REAIM Glasgow
• Our addition to guide planning

REAIM/T+M

2005/06 Ontario Ministry of Health announced funding for smoking cessation. Our program would support a provincial cessation strategy. TRAINING AND CAPACITY BUILDING IMPLEMENTATION OF EVIDENCE-BASED INTERVENTIONS REDUCING INEQUITY: ADAPTATIONS

TEACH A Knowledge Translation/Training Program in Intensive Tobacco Cessation

Rosa Dragonetti1 MSc, RP, Myra Fahim1, Megan Barker1,2, MA, MSc, BEd, Mathangee Lingam1, Sheleza Ahad1 , Arezoo Ebnahmady1, PhD, Peter Selby1,2, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM

1Centre for Addiction and Mental Health 2University of Toronto Toronto, Ontario, Canada

Disclosures (5 years)

No disclosures

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Prevention Support System

Train Health Care Providers NDS creates program to build inter- professional capacity in evidence-based tobacco dependence among Ontario practitioners across disciplines and diverse healthy/social service settings.

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Adapted from Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Identify, Review, Select Knowledge Ongoing changes to knowledge (e.g., electronic devices, cannabis, etc) Adapt knowledge to local context Ongoing feedback from practitioners on issues specific to their settings (primary care, cancer, etc) Assess barriers to knowledge use 3 month follow ups/evaluation Listserv plus experts provide solutions/options Select, tailor, implement interventions From in-person to online Practice Leaders for local support Monitor knowledge use Evaluate outcomes 6 month follow ups Level 5 and 6 evaluation Sustain Knowledge Use Listserv, Education Rounds, Consultations, Toolkits, Videos, Advanced Issues conference, etc.

Knowledge Synthesis Knowledge Products & Tools

Selby P, et al BMJ Open. 2017 Nov 3;7(11)

Identify, Review, Select Knowledge

Screen for tobacco use Prescribe cessation medication Use a harm reduction approach Provide Cognitive Behaviourial Therapy Advocate for my clients

Adapt Knowledge to Local Context

Primary Care

Family Health Teams Community Health Centres Nurse-Practitioner Led Clinics

Addictions and Mental Health Public Health

Community Workshops

Assess Barriers to Knowledge Use

Funding Need more concrete clinical tools Need more practice Staff/peer resistance Organizational Support Time

Monitor Knowledge Use and Evaluate Outcomes

Pre- and Post-Course Assessments Formative Evaluations Summative Evaluation 3- and 6- month Follow-up Surveys Patient Outcomes and Interviews

Sustain Knowledge Use

TEACH Community of Practice

TEACH YouTube channel: http://www.youtube.com/ user/teachproject Monthly Webinars Trainer’s Toolkits Coaching by TEACH E-mail Listserv

Sustain Knowledge Use

826

TEACH Listserv subscribers

800+

Toolkits disseminated

111

Webinars

• ffered

5774

Practitioners trained

83%

Set practice goals

76% Offering cessation interventions (~38% response rate) 80.9% Engaging in knowledge transfer activities

6 Training Outcomes Community of Practice Outcomes

Significant increase in feasibility, importance, and confidence in changing practice (p<0.05)

From 37+ disciplines in 1300

• rganizations

Thank You!

Rosa.Dragonetti@camh.ca www.teachproject.ca www.nicotinedepenceclinic.com

The Smoking Treatment for Ontario Patients (STOP) Program: 10 Years of Implementation and Dissemination in a Variety of Clinical Settings

Laurie Zawertailo, PhD Senior Scientist, Nicotine Dependence Service, Centre for Addiction and Mental Health Associate Professor, Dept. of Pharmacology and Toxicology, University of Toronto Toronto, Ontario CANADA

Disclosures

• NO FINANCIAL DISCLOSURE
• GRANTS

– Pfizer Inc. Canada, Pfizer Global – Global Research Awards for Nicotine Dependence (GRAND Grant), Health Services Research Fund – Ontario Ministry

• f Health and Long-term Care, Canadian

Institutes of Health Research, Canadian Cancer Society Research Institute

• NO TOBACCO FUNDING

Smoking Treatment for Ontario Patients

• An evidence-based program examining the

effectiveness of different methods of providing cost- free smoking cessation treatment to Ontario smokers

• Goal: To decrease smoking prevalence in Ontario

What is the STOP Program?

STOP Program Goals

Increase access to free treatment for Ontario smokers Build practitioner and system capacity for delivering treatment

Decrease prevalence of smoking in Ontario

Revolutionize how smoking cessation treatment is delivered

In The Beginning…

• In 2005, we were awarded one-time funding from the government of

Ontario to distribute Nicotine Replacement Therapy (NRT)

• A pilot study was done in partnership with tertiary care centres (CAMH,

Ottawa Heart Institute & Thunder Bay Regional Cancer Centre)

• In January 2006 we conducted a 1-800 mass distribution of NRT to over

13,000 Ontarians – the first program of its kind in Canada.

• Due to the success and popularity of these pilot projects, the “STOP

Program” was born, and our funding has continued under the Smoke-Free Ontario strategy

History of STOP

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Tertiary-Care Centres Public Health Units Mass Distribution Community Pharmacies Community Health Centres 1st engagement STOP on the Road workshops with PHUs Internet-based Enrolment Family Health Teams 1st engagement Family Physicians Family Health Teams 2nd engagement Community Health Centres 2nd engagement Addiction Agencies Workplace Project Aboriginal Health Access Centres Nurse Practitioner-Led Clinics Hospital Project

Mass Distributions and Mail-Outs (Phone & Web-based Enrollment)

Using technology to enrol participants allowed virtually ANY eligible smoker in Ontario to access free NRT

46,994 participants across all regions

• f Ontario

STOP on the Road: Mobile Smoking Cessation Clinics

• Workshops held with Public Health Units across Ontario
• > 26,000 participants
• Able to reach underserved and sparsely-populated regions

Where are we now?

• Since 2012 we have been

focused on program development in primary care settings

• More intensive intervention
• Knowledge to action

framework in action 202,170 participants enrolled as of September 30, 2017

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Selecting Knowledge

The 5A’s is a model that presents the five major steps in providing a brief intervention in a health care setting:

» Ask » Advise » Assess » Assist » Arrange

Build on the 5A’s to offer more comprehensive treatment – Multiple visits (4 +) – Longer periods of time per visit (10 minutes +) Provided by any suitably-trained health provider, and is appropriate for any tobacco user willing to participate

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Assessing Barriers

Capacity Assessment Survey The first step in the site engagement process is completing a Capacity Assessment Survey to gauge interest and current capacity to implement the program

• Identifies any barriers to

implementation, knowledge gaps, and training needs

• Invitations were sent to all eligible
• rganizations; site recruitment is
• ngoing
• Currently over 300 orgs

implementing the program

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Program Development and Implementation

To increase capacity within organizations, we work collaboratively to develop a sustainable smoking cessation program.

1. Staff Training: Accredited training opportunities

– TEACH in-person or online comprehensive Core Course – Fundamentals of Tobacco Interventions (FTI) online course

2. Initial Discussion: Overall implementation plan 3. Operations Training: Program protocol 4. Provision of NRT and resources

Select, Tailor, Implement NO site visits!

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Monitoring Knowledge Use

• Bi-Weekly knowledge exchange teleconferences
• Continuous learning opportunities

– Lunch and Learn

• Ongoing coaching model

– videoconference case consultations

• Link with resources

– Pregnets – CANADAPTT guidelines – Smokers’ Helpline – STOP website

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Evaluation

• Participant follow-up surveys
• Third party independent program evaluation
• Data analysis, conference presentations and

peer-reviewed publications

• Site feedback reports

6-Month Quit Rates Achieved in STOP

5 10 15 20 25 30 35 40

Web-Based Enrollment Mass Distribution STOP on the Road Pharmacies Public Health Units Tertiary Care Centres Family Health Teams Community Health Centres Addictions Agencies STOP Model

% Abstinent among Survey Responders

Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009; 181(3-4):165-168.

Continuous K to A

• Identifying patient needs and

addressing gaps in care

– COMBAT – combining alcohol and tobacco treatment – Mood Management – addressing depressive symptoms in tobacco dependence and cessation

Summary

• Elements of successful implementation of

a smoking cessation treatment program in primary care settings include:

– High quality training in cessation interventions – Buy-in from government body that oversees these settings – A patient-driven intervention that includes individualized cost-free treatment – Ongoing QI

Acknowledgements

STOP Coordinators Principal Investigator

• Ryan Ting-a-Kee
• Peter Selby
• Carolyn Peters
• Eleanor Liu

Project Manager STOP RAs

• Aliya Noormahad
• Bianca Filoteo
• Camyl Gatchalian

Project Scientists

• Awet Sium
• Dolly Baliunas
• Virginia Ittig-Deland
• Nadia Minian
• Donya Mohammed
• Zara Masood
• Sarker Faisal
• Michelle Parker
• Rackell Levin

Balancing Fidelity with Fit:

Collaboratively Adapting Cessation Treatment Models to Improve Health Equity for Indigenous Communities

Megan Barker1,2, MA, Lisa Beedie3, BA, Ryan Ting-A-Kee1, PhD, Rosa Dragonetti1, MSc, RP, Peter Selby1,2, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM

1Centre for Addiction and Mental Health 2University of Toronto 3Cancer Care Ontario Toronto, Ontario, Canada

Disclosures

• bhasin consulting fund Inc. Fund for Inclusion

in Mental Health

• Canadian Institutes of Health Research (CIHR)

Travel Support

Acknowledging the Land

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Indigenous Peoples in Canada

First Nations Inuit Métis

• Linguistically, geographically, and culturally diverse.
• Live in urban, rural, and remote settings within Canada.
• The legacy of colonialization has had intergenerational

impact on individuals, families, and communities.

images provided courtesy of Cancer Care Ontario, Tungasuvvingat Inuit, and Métis Nation of Ontario

Commercial tobacco use rates among Indigenous Peoples in Canada are on average, twice as high when compared to other Canadians.

2X

• Up to 65% of Indigenous youth who

smoke report attempting to quit within the past 6 months.1

• 20.5% of First Nations youth report

trying to quit smoking to “live a healthier lifestyle.”2

1Greaves et al., 2012; 2Chiefs of Ontario, 2012

Interest in Quitting

STOP with Aboriginal Health Access Centres (AHACs)

Goal: Implement a culturally relevant and safe model for AHACs to provide free commercial tobacco cessation treatment with community members wanting to quit

• r reduce their commercial tobacco use.

What are AHACs?

• Aboriginal community-led

primary health care

• rganizations
• 10 across Ontario
• Service 66,000 clients/year

(Over 25% of FNIM populations in Ontario)

• Safe space for healing

Partnership and Engagement Circle

Centre for Addiction and Mental Health

(STOP & TEACH)

Cancer Care Ontario’s Aboriginal Tobacco Program

Engagement Circle of 56 Indigenous stakeholders

Guiding Principles

Relationships Respect Relevance Reciprocity Responsibility

Community-based Participatory Research Principles (CBPR)

Relationship Building and Trust

• Initial meetings (in-person)
• Follow up via e-mail and telephone
• Tailored implementation approach
• Community of Practice

– Ongoing support and engagement – Educational webinars (bi-monthly) – Yearly in-person meetings

Tailored Capacity-building

13.5 hour online course in Commercial Tobacco Interventions for First Nations, Inuit, and Métis Populations IT’S TIME Indigenous Tools and Strategies on Tobacco: Interventions, Medicines and Education (Inuit and First Nations)

Two-Eyed Seeing

When you force people to abandon their ways of knowing, their ways of seeing the world, you literally destroy their spirit and once that spirit is destroyed it is very, very difficult to embrace anything – academically or through sports or through arts or through anything – because that person is never complete. But to create a complete picture of a person, their spirit, their physical being, their emotions, and their intellectual being … all have to be intact and work in a very harmonious way.

• Mi'kmaw Elder Albert Marshall

Delivery of Care: Two-Eyed Seeing

A Flexible [Research] Model

• Acknowledging unethical history of research
• No standardized research protocol
• Follow-ups conducted by AHAC staff only
• No identifiable information collected from

participants or shared with CAMH

• Upholding and safeguarding OCAP Principles

7 FNIM Health Organizations, 16 sites, 5 AHACs, 690 community members enrolled

• Two online courses offered by TEACH.
• 203 healthcare providers trained.
• 4.46/5 overall satisfaction.
• Confidence in knowledge and skills increased significantly

post-training (p<.001).

• 66.4% set clinical practice goals.
• Disseminated to 246 individuals.
• Reviewed by 56 Indigenous stakeholders.
• New version to be released in Winter 2018.
• 11 healthcare providers completed an online survey and

rated the toolkit as 4.75/5.

• 13 Inuit living in Ottawa attended a pilot session and focus

group to evaluate the materials.

• Feedback Themes: Choice, flexibility, aligned with Inuit

Ways of Knowing, changed thinking about quitting.

Future Directions

Co-creating a community-driven, collaborative, and participatory research model aligned with OCAP principles

Wandersman, et al. (2008). Bridging the gap between prevention research and practice: The interactive systems framework for dissemination and implementation. American journal of community psychology, 41(3-4), 171-181.

Thank you! Chi-miigwech, nia:wen, Kinanâskomitin, ay-hay, qujannamiik, marsee, and merci.

Megan.Barker@camh.ca

REAIM Framework

R E A I M TIME IMPACT Model* Participants Quit Rate @ 6 months # of sites (%) Cost/Smoker (no meds) Medication Cost/smoker Years of Implementation Time (years) Impact/year (RxE/Time) Mass Dist 5/6 weeks of NRT 33,048 23% N/A $38 $146 2006, 2007,2009 1.00 14,871.60 Pharmacy (5 weeks NRT) 7,273 24% 98 $24 $140 2007 -2008 1.00 2,981.93 Zyban- Champix 12 weeks 918 27% N/A $104 $210 2009 -2011 0.14 2,754.00 Internet-based 5 weeks of NRT 7,856 30% N/A $18 $117 2008 0.96 1,964.00 Addictions 26 weeks NRT 10,428 28% ** 56(26%) $83 $239 2012 –present 4.08 792.32 CHCs 26 weeks NRT 13,140 27% ** 60(78%) $79 $235 2012 –present 4.75 719.24 FHTs 26 weeks NRT 63,389 34% ** 154(84%) $83 $235 2011 –present 5.33 4,400.36 NPLC 26 weeks NRT 1,139 26% ** 18(75%) $89 $198 2014 –present 2.17 167.96 AHACs 26 weeks NRT Stop on the Road 5 weeks of NRT 25,867 25% 32(89%) $51 $178 2007 –present 8.08 1,120.48

Thank You!

Peter.selby@camh.ca