Nurse Practitioners' Knowledge, Attitudes, and Clinical Practices Regarding Treatment of Tobacco Use and Dependence

Article Outline

• Abstract
• Methods
  • Procedure
  • Participants
  • Measures
    • Knowledge variables
    • Attitude variables
    • Clinical practice variables: the 5 As
    • Demographic and practice variables
• Results
  • Subjective and Objective Knowledge of Tobacco Use and Treatment
  • Attitudes Toward Tobacco Use and Treatment
  • Clinical Practices Regarding Treatment of Tobacco Use and Dependence: The 5 As
    • Ask
    • Advise and assess
    • Assist
    • Arrange
  • Correlates of Clinical Practices Regarding Treatment of Tobacco Use and Dependence
    • Ask
    • Advise
    • Assess
    • Assist
    • Arrange follow-up
• Discussion
• Acknowledgment
• References
• Copyright

Abstract 

This article describes knowledge, attitudes, and clinical practices regarding treatment of tobacco use and dependence reported by nurse practitioners (NPs) interested in learning about evidence-based practices. Researchers analyzed baseline data from 193 licensed NPs prior to participating in Providers Practice Prevention: Treating Tobacco Use and Dependence. Results revealed domains where participants practiced in accordance with clinical practice guidelines and some areas where additional education and support may be necessary. NPs have a tremendous opportunity to reduce tobacco-related morbidity and mortality by addressing tobacco use, making it vitally important to support their implementation of evidence-based strategies.

Keywords:  advanced practice nursing , continuing education , evidence-based practice , tobacco

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Approximately 440,000 deaths each year in the United States are attributable to tobacco use¹—the leading cause of preventable deaths in this country. Kentucky has the highest rate of tobacco-related mortality,² while being a leading producer of tobacco products. It leads the nation with a smoking prevalence of nearly 30%,³ while the U.S. smoking rate is just above 20%.⁴ In Kentucky alone, the consequences of smoking are accountable for an estimated $1.2 billion spent on health care costs while another $2.3 billion are related to lost productivity.²

While primary prevention of tobacco use is admittedly the most effective approach to preventing morbidity and mortality linked to tobacco, it has also been demonstrated that tobacco cessation can prevent the development or exacerbation of a variety of health conditions.⁵ The United States Public Health Service (USPHS) clinical practice guideline, Treating Tobacco Use and Dependence (TTUD-CPG),⁶ summarizes evidence-based approaches that help tobacco users quit, and is directly relevant to tobacco control efforts advocated for nurse practitioners (NPs).⁷ Over 70% of smokers visit a health care setting each year,⁸, ⁹ providing an opportunity for NPs to counsel patients on tobacco cessation. The TTUD-CPG indicates that brief 3-minute interventions can significantly increase smoking cessation rates.⁶, ⁹, ¹⁰ If 100,000 health care providers were to help only 10% of their patients to stop smoking, the number of smokers could decrease by an additional 2 million per year.¹¹

Because of the considerable burden of tobacco-related illness in Kentucky, a self-study continuing education program was developed by the Kentucky Cancer Program (KCP) to promote the use of evidence-based tobacco cessation strategies. Providers Practice Prevention: Treating Tobacco Use and Dependence (PPP-TTUD) was based on the TTUD-CPG,⁶, ¹² and included 3 primary components. First, the PPP-TTUD kit consisted of a motivational/testimonial video including prominent medical, dental, nursing, and public health professionals from across Kentucky. Second, the kit included the TTUD Quick Reference Guide,¹³ which highlights evidence-based-practices' tobacco treatment, including a variety of assessment strategies, pharmacologic approaches, and counseling interventions. Third, the kit included a number of tobacco cessation-related practice aids such as patient education materials, pharmacotherapy prescription guides, and chart reminders addressing a patient's tobacco use status. At the heart of the program, it advocated implementation of the 5 As and encouraged providers to address tobacco use at every visit. Specifically, the 5 As include ask, advise, assess, assist, and arrange.

Health care professionals are to ask about their patient's history of tobacco use to systematically identify all tobacco users at every visit. If a patient reports tobacco use, professionals advise all tobacco users to quit and subsequently assess their willingness to do so. It is then recommended that health care professionals assist patients in quitting tobacco use, using available evidence-based approaches to treatment and then arrange follow-up to prevent relapse.

Reviews have suggested that nurses may be the most important health care providers for implementation of tobacco cessation programs because they are the largest provider population.¹⁴, ¹⁵ They can influence national health objectives regarding the treatment of tobacco use and dependence because they have the most direct contact with patients in diverse settings¹⁵ and they have tremendous public trust.

A few studies have explored knowledge, attitudes, and practice behaviors of NPs regarding smoking cessation, but have commonly analyzed data from nurses as a single group, or combined NP data with physicians or physician assistants. Hall and colleagues¹⁶ surveyed a random sample of 152 practicing nurses and found that the majority (83%) had an overall positive attitude toward delivering smoking cessation advice. However, these nurses also perceived several barriers to implementing cessation techniques. Almost one-third (28%) felt that discussing smoking was not an appropriate use of their time, and 23% felt that their cessation advice was not effective.

Kviz and colleagues¹⁷ found that NPs were more likely to employ successful cessation techniques than other nurses. The authors measured smoking cessation attitudes and practices of 145 health care providers in a health maintenance organization. Results showed that MDs and NPs were more likely than nurses to conduct smoking cessation activities such as asking and advising patients.¹⁷ It was suggested that perhaps MDs and NPs felt they had more responsibility to advise and assist in smoking cessation practices because they are primary care providers, and build a more in-depth patient-provider relationship than RNs or LPNs. Furthermore, Block and colleagues¹⁸ found that NPs and physician assistants (PAs) were more likely than other health care providers to assess patient tobacco use. Overall, NPs and PAs consistently responded more favorably throughout this study when assessing knowledge and attitudes toward smoking cessation.

Given the central role of NPs in health care delivery and their attention to disease prevention, it is important to study their knowledge, attitudes, and practices regarding treatment of tobacco use and dependence. It is important to direct research efforts specifically toward NPs to facilitate development of interventions to promote or reinforce maintenance of evidence-based tobacco cessation strategies in accordance with the TTUD-CPG. The primary aim of this study was to describe knowledge, attitudes, and clinical practices among NPs in Kentucky regarding treatment of tobacco use and dependence. The secondary aim was to explore associations between background characteristics, knowledge, and attitudes with clinical tobacco-cessation practices.

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Methods 

Procedure 

Recognizing a need for greater awareness and implementation of evidence-based tobacco-cessation strategies by health care providers in Kentucky, the Kentucky Cancer Program and collaborating faculty at the University of Louisville James Graham Brown Cancer Center developed the PPP-TTUD program with support from the Kentucky Department for Public Health Tobacco Prevention and Cessation Program. Invitation letters describing the self-study program were distributed to all Kentucky-licensed advanced registered nurse practitioners (ARNPs) other than nurse anesthetists. The letter recounted the opportunity to participate in the PPP-TTUD program. The University of Louisville institutional review board approved the protocol, and analysis is based solely on pre-program (baseline) surveys.

Participants 

Of 1717 potential participants, 356 (21%) requested the program kit and 193 returned and completed the survey (54% completion rate). Participants were predominantly female (94%), practiced in a rural setting (58%), and reported an average of 8.6 (± 8.86) years of practice (Table 1).

Table 1. Demographic and Practice Characteristics of the Sample (n = 193)

Measures 

Survey questions addressed 4 domains: objective and subjective knowledge, attitudes, clinical practices, and demographics. The survey was developed in collaboration with survey methodologists and experts in nursing, tobacco control, public health, and cancer prevention.¹⁹

Five subjective self-assessment items measured perceived knowledge of tobacco interventions. Three subjective knowledge items used a 4-point scale: 1 (not very comfortable) to 4 (very comfortable) rating comfort levels when discussing cessation, helping patients develop a plan, and recommending appropriate pharmacological treatments. The fourth question assessed level of knowledge regarding pharmacotherapy using a scale from 1 (not very knowledgeable) to 5 (very knowledgeable). The last subjective knowledge item assessed TTUD-CPG awareness based on stages of change.²⁰, ²¹

Eight objective items assessed knowledge of tobacco-use prevalence and TTUD-CPG-recommended practices using a multiple-choice format and were scored dichotomously (correct/incorrect). A total objective knowledge score was calculated by totaling correct responses.

Provider attitudes toward smoking cessation were assessed with questions derived from the validated Risk Behavioral Diagnosis Scale.²² Participants responded using a scale from 1 (strongly disagree) to 4 (strongly agree) to questions measuring perceived susceptibility of smoking as a threat to patient morbidity and mortality, perceived seriousness of tobacco health consequences, perceived self-efficacy to implement tobacco-cessation interventions, and 2 items measuring response efficacy regarding tobacco cessation in general, and brief interventions. The last question assessed perceived barriers to implementing evidence-based tobacco-cessation strategies.

Eight face-valid questions were developed from the TTUD-CPG 5 As.⁶ These items remain consistent with the updated guidelines.¹² Three questions addressed whether participants ask every patient to identify tobacco use status, how status is determined, and frequency of asking. A fourth question measured how often participants advise patients to quit, using a scale from 1 (never) to 5 (always). A fifth question measured when a tobacco user's willingness to quit using tobacco was assessed. The 5-point scale was used again in the sixth item to measure how often certain methods were applied to assist tobacco users who are willing to quit using tobacco. Another assist item (assist with referral) was used to evaluate referrals to cessation resources. The eighth item measured what types of follow-up were arranged.

Demographic and practice information was collected in the last survey section. Table 1 shows sample details.

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Results 

Subjective and Objective Knowledge of Tobacco Use and Treatment 

Approximately half (52%) of participants reported that they had never heard of the TTUD-CPG, while 31% had heard of the guideline but never read it. Only 4% reported having previously read the guideline and routinely followed its recommendations. As shown in Figure 1, most were either somewhat (34%) or very comfortable (65%) discussing cessation with patients. Similarly, many NPs were somewhat comfortable (43%) helping the patient develop a tobacco-cessation plan. Additionally, 40% were somewhat comfortable and 38% were very comfortable recommending pharmacological agents. This was qualified by modest ratings of pharmacotherapy knowledge (M = 3.43 ± 1.04).

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• Figure 1. 

  Percentage ratings of comfort with tobacco-cessation treatment practices (n = 189).

Results indicated a mean knowledge score of 5.0 (± 1.34). A high percentage of participants (89%) chose “identifying tobacco status at every visit” as a TTUD-CPG-recommended practice. There were 2 items that seemed challenging for participants: only 46% correctly identified the percentage of unaided attempts to quit smoking that fail (90% to 95%), and 30% correctly identified the percentage of current smokers that express a desire to stop smoking (70%).

Attitudes Toward Tobacco Use and Treatment 

Participants strongly agreed with the importance of discussing tobacco use with patients (97%), the seriousness of tobacco's health consequences (99%), and that tobacco cessation in general is effective in reducing morbidity and mortality (93%). However, fewer agreed that a brief, 3-minute intervention would be effective for tobacco cessation (36% strongly agreed). Additionally, only 22% strongly agreed that they possessed self-efficacy to treat nicotine dependence. As shown in Table 2, over half reported that patient priority (60%) and time (58%) were barriers to implementing smoking cessation strategies during each visit.

Table 2. Barriers to Tobacco Cessation Treatment Practices (n = 189)

Clinical Practices Regarding Treatment of Tobacco Use and Dependence: The 5 As 

Almost 80% of participants reported that they identify tobacco-use status for every patient, and 88% reported almost always, or always, asking each patient about tobacco use. Few reported recording tobacco use as a vital sign (17%) at every visit, but only 4% had no routine method and 2% did not ask patients about tobacco use. Asking verbally during patient examination (88%) and utilizing a health history form (48%) were also commonly reported.

Participants indicated that they almost always (59%) or always (22%) advised patients to quit tobacco use. However, only 26% reported that they assessed the patient's willingness at every visit, followed by 22% that assessed during routine check-up or physicals, and 12% at the initial visit.

As shown in Figure 2, assist methods most often cited were providing practical counseling (54%) and encouraging patients to use current social support (56%). Nearly 25% of participants reportedly did not offer patients any type of cessation assistance.

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• Figure 2. 

  Frequency of assisting patients willing to quit tobacco use (n = 189).

NPs commonly referred patients to cessation support groups or classes (60%), but other referral resources were used much less often: individual therapy (21%), cessation websites (17%), telephone quit-lines (6%), and inpatient cessation programs (3%). Almost 25% of NPs reported not using outside referrals.

The method most often reported by participants for arranging follow-up with patients was scheduling a return visit (50%). This was followed by 36% who reported not arranging follow-up, with other methods being rarely reported.

Correlates of Clinical Practices Regarding Treatment of Tobacco Use and Dependence 

Three variable sets were correlated with recommended practices and the 5 As: demographic characteristics, knowledge factors, and attitudinal variables (Table 3).

Table 3. Correlates of Clinical Practices Regarding Treatment of Tobacco Use and Dependence (n = 189)

For these analyses, the ask variable was operationalized as participants who identified tobacco-use status among their patient population (n = 151, 80%). Asking was significantly associated (P < 0.05) with greater TTUD-CPG awareness, comfort discussing cessation, greater perceived severity of tobacco use, greater self-efficacy, and tobacco-cessation response efficacy.

Greater frequency of advising tobacco users to quit (M = 4.03 ± 0.65) was associated with greater TTUD-CPG awareness, more comfort discussing tobacco cessation, developing a cessation plan, a stronger belief that brief cessation interventions are efficacious, and fewer perceived barriers.

The assess variable was operationalized as whether a participant assessed a tobacco using patient's willingness to quit smoking at every visit (n = 51, 26%). Assessing at every visit was associated with greater TTUD-CPG awareness, greater self-reported pharmacotherapy knowledge, more comfort discussing cessation, more comfort developing a cessation plan, more comfort recommending pharmacotherapy, greater self-efficacy, and fewer perceived barriers.

The assist variable was computed by calculating a mean score of 6 different assist approaches (M = 3.43 ± 0.73). Greater assistance with tobacco cessation was associated with greater TTUD-CPG awareness, greater self-reported pharmacotherapy knowledge, more comfort discussing cessation, more comfort developing a cessation plan, more comfort recommending pharmacotherapy, greater self-efficacy, and a stronger belief that brief cessation interventions are efficacious.

The assist with referral sources variable was operationalized as to whether participants referred patients to any additional cessation resources (n = 48, 25%). Use of referral sources was associated with greater TTUD-CPG awareness, more comfort developing a cessation plan, and self-efficacy.

The arrange follow-up variable was operationalized as to whether a participant endorsed using any type of follow-up (n = 70, 36%). Arranging follow-up was associated with greater TTUD-CPG awareness, self-reported pharmacotherapy knowledge, comfort discussing cessation, comfort with cessation planning, comfort recommending pharmacotherapy, self-efficacy, and the belief that cessation effectively reduces morbidity/mortality.

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Discussion 

To progress toward preventing morbidity and mortality associated with tobacco use, it is vital to understand how health care providers implement evidence-based treatments for tobacco use and dependence. This study explored knowledge, attitudes, and practices regarding evidence-based treatment for tobacco use and dependence (the 5 A's) among a sample of NPs practicing in Kentucky who have expressed interest in learning more about the topic.

In general, NPs' knowledge of tobacco-use statistics and tobacco cessation suggested a solid foundation of information, with 2 exceptions. Participants generally underestimated the number of unaided cessation attempts that fail and the percentage of tobacco users who have a desire to quit using tobacco. Despite this, NPs generally reported being comfortable discussing tobacco cessation with their patients. However, they reported less comfort providing more specific forms of assistance, such as developing cessation plans with their patients and recommending pharmacotherapy to assist with cessation. Clinically, this inconsistency may indicate that more training is needed for practitioners to develop these more advanced skills required to treat tobacco use and dependence effectively.

Participants strongly endorsed the importance of discussing tobacco use with patients, the seriousness of tobacco's health consequences, and the ability of tobacco cessation in general to reduce morbidity and mortality. However, fewer agreed that brief 3-minute interventions would be effective for tobacco cessation. Pessimism regarding efficacy of tobacco-cessation interventions has been described previously,¹⁶ but this specific result could be due to differences in perspective. Specifically, the TTUD-CPG adopts a public health stance on tobacco-cessation interventions, citing research demonstrating the efficacy of brief interventions that double cessation rates. However, these interventions are likely to achieve cessation rates around 8% to 10%. From the perspective of practicing NPs, doubling cessation rates from 4% to 8% may be clinically suboptimal, diminishing enthusiasm for brief interventions.

NPs reportedly believed that their patients viewed cessation as a low priority, and that they often had limited time to spend with patients, consistent with commonly reported time and priority barriers as challenges in health care.¹⁶ With greater focus on the often cyclical process of tobacco cessation, NPs might benefit from incorporating interventions that employ a chronic disease model approach. This approach recognizes that tobacco users may experience several periods of relapse and remission before permanent cessation is achieved,⁶ and emphasizes care that includes a brief intervention at each visit. While brief interventions may not achieve quit attempts immediately, these strategies can move patients along the path to cessation and facilitate future cessation attempts.²⁰

With regard to implementation of the 5 As, NPs in this study highlighted the importance of discussing tobacco use and planning a cessation strategy. Although NPs were likely to advise patients to cease their tobacco use, they were less likely to assess patient cessation willingness at each visit. Further, one-quarter of NPs reported that they did not assist with cessation and even fewer reported arranging follow-up for patients trying to cease tobacco use. This pattern is consistently identified in the literature¹⁷ and may be due to busy clinical practice routines, deterring efforts to enact more time-intensive aspects of providing assisting and arranging follow-up.

TTUD-CPG awareness was associated with implementation of all 5 As. This result clearly indicates that those providers who have been exposed to the guideline are more likely to report implementation of these evidence-based treatment practices. This creates optimism that continued promotion of the TTUD-CPG might enhance translation of these practices into clinical settings. In addition to TTUD-CPG awareness, comfort discussing tobacco cessation, developing a cessation plan, and provider self-efficacy were consistently associated with implementation of the 5 As. Given these findings, helping NPs build self-efficacy for tobacco cessation strategies should be a major goal of education and training. As has been demonstrated in numerous health behavior change domains, confidence in one's ability plays a central role.²³, ²⁴ Provider training might build on knowledge but place greater emphasis on creating confidence to implement the 5 As in diverse clinical settings to achieve a greater disease prevention impact.

A few study limitations should be considered. First, data regarding current practices are based on self-reports and are not validated against medical records or direct observation. Second, data are cross-sectional and provide only a snapshot of tobacco-cessation-related practices of NPs in the sample, which may not be representative of all NPs in Kentucky or the United States. Third, data were collected from a nonrandom sample of participants in a program offering training in evidence-based tobacco-cessation strategies. Fourth, this study was based on the 2000 version of the TTUD-CPG, not the latest 2008 version. However, recommendations regarding implementation of the 5 As remain consistent across both guidelines. Finally, it may have been helpful to collect information regarding NP prescription practices²⁵ given the availability of tobacco-cessation interventions that require a prescription.

In conclusion, these data provide the largest multidimensional description of knowledge, attitudes, and current practices regarding treatment of tobacco use and dependence among NPs. Although NPs have ample opportunities to counsel patients about tobacco cessation, more education and training is needed to achieve routine and effective implementation of evidence-based cessation practices. To achieve full implementation of the 5 As, targeted interventions should be developed that specifically promote self-efficacy, alongside basic knowledge of tobacco use and dependence. In addition to primary tobacco-prevention efforts, integration of evidence-based tobacco-cessation strategies into clinical practice provides the best opportunity for NPs to prevent illness and promote wellness.

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Acknowledgment 

This project was conducted with funding provided by the Kentucky Department for Public Health Tobacco Prevention and Cessation Program and the support of the Kentucky Medical Association.

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