ICHS Alison Shigaki MD APPEAL National Conference

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Comprehensive Tobacco Cessation in a Community
Clinic

• ICHS / Alison Shigaki MD / APPEAL National
  Conference

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Objectives

• Describe two policy changes that can be made in a
  community clinic setting.
• Explain why the development of a tobacco database
  is important and how it can be used.
• Discuss five ways in which a cessation program
  can be culturally tailored.

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• Our mission is to provide culturally sensitive,
  accessible, affordable and comprehensive primary
  care services to Asian and Pacific Islanders
  (API) and other members of the community
• Established in 1975
• Operates the International District Clinic and
  Holly Park Clinic in 2003, 9,590 unduplicated
  medical patients were seen 48.7 were Chinese,
  23.4 Vietnamese, 7.6 Filipino, 5.9 Korean,
  1.8 Mien, 1.6 Cambodian, and 1.1 Pacific
  Islander

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Tobacco use in the API Community

• API community appears to have a low prevalence
  of tobacco use
• Data is misleading

• Aggregated data- severity of the tobacco problem
  among API men is obscured by the low prevalence
  of tobacco use in API women.
• Selection biases-telephone surveys conducted in
  English exclude recent immigrants who are not
  proficient in English but who represent a
  significant proportion of the API population.
• Studies conducted in native languages demonstrate
  that smoking prevalence is higher among persons
  with limited English language proficiency and
  more recent immigrants.

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Tobacco Use API Men in USA
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Approaching Cessation as a Whole Picture

• Obtain an understanding of the group(s) you are
  providing cessation services to prior to
  implementing services
• Collect data on your target population(s)
• Get community input/feedback prior to
  implementing a program
• Remain flexible, continue to modify based on your
  findings and the community needs

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Cultural Factors Affecting Smoking and Quitting
in Chinese and Vietnamese Men

• Focus group findings
• Lack of knowledge about the health effects of
  tobacco and ETS
• Cultural expectations for men to smoke both in
  the personal and business world
• Smoking cigarettes is strongly associated with
  drinking coffee tea
• Loneliness is associated with cigarette use
• Family influence was important in the quitting
  process.
• Quitting for the health of ones wife and
  children was a motivating factor
• Many Chinese participants felt you could not quit
  cold turkey

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Documenting tobacco use and SHS exposure in the
clinic setting

• Tobacco as a Vital Sign and Smoking Stickers

• Used at each visit since 2001.
• Can be used by Medical, Dental, WIC, Nutritionist
  etc.
• Reminder for providers and support staff to
  provide counseling, tobacco prevention materials.
• Updates tobacco and SHS status at each visit.

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Documenting tobacco use and SHS exposure in the
clinic setting

• Provider Chart Reviews
• Providers or support staff document Tobacco and
  SHS status when reviewing patient charts for the
  next day.
• Tobacco status CCurrent, FFormer, NNever
• ETS status and document who/where or -
• Another mechanism for providers to remember to
  provide brief counseling for their patients.

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ICHS Tobacco Database
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American Legacy Foundation Grant
Purpose To develop a culturally competent
Tobacco Cessation Program for Chinese and
Vietnamese men

• Develop a culturally competent cessation
  curriculum
• Run cessation classes for Chinese and Vietnamese
  men in Cantonese, Mandarin, and Vietnamese
• Collect data from cessation group participants

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Development of a culturally competent cessation
curriculum

• Modified existing cessation curriculum based on
  Train the Trainer Model
• Utilized focus group and pilot cessation class
  findings for curriculum development
• Worked with graphic designer to begin developing
  cover designs
• Held focus groups to get feedback on curriculum
  and cessation booklet design
• Focus groups conducted in Cantonese, Mandarin,
  and Vietnamese (2 in each language)

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Focus Group Feedback
Cover Bright colors (orange/blue), big
lettering. Picture of families and children
signifies the next generation Use red to indicate
no smoking Smoking makes people around
uncomfortable. It is impolite. Title Should be
clear and direct (i.e. Tobacco endangers health,
tobacco is harmful to health, smoking is a
gradual suicide) Use inspirational person i.e.
movie star or writer. HealthGold Quitting for
your familys Happiness Quit smoking
method/program How you can quit smoking for good.
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Focus Group Feedback cont.

• Curriculum is low literacy and easy to understand
• Font size is large enough
• Culturally appropriate pictures and issues (i.e.
  tai chi exercise, symbol of
  longevity)
• Emphasize health, family, money saved, and role
  model for their children as reasons to quit
• Emphasize the benefits of quitting children,
  elderly, future generations
• Target whole family, particularly the women who
  will likely make their spouses quit smoking
• Need counter smoking images
• Would like to see pathological graphics
• More images to make it attractive
• The health effects are slow thus not many people
  realize it.
• Emphasize self determination-thats the most
  important fact

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remember
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Tobacco Cessation Classes

• Cessation classes last for 6 weeks
• Rolling admission basis
• Open to clinic patients and community members
  over the age of 18 years old
• Classes last for 1 1/2 hours and are led by a
  bicultural/bilingual instructor
• NRT patches are provided for participants if
  needed

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Data Collection

• Demographic questionnaire administered when
  participants enter cessation program
• Survey questionnaire administered at start and
  finish or cessation program, and at 6 months, and
  1 year upon completion of class
• Stages of Change, behavioral modifications, level
  of addiction (Fagerstrom), and depression level
  are being followed through the survey
  questionnaire
• Also looking at quit rate, number of cigarettes
  smoked, and CO level

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Focus on Second Hand Smoke (SHS)

• Due to low numbers of participants shifted focus
  to SHS
• Recruited patients through educating family
  members
• Developed SHS and Your Family Brochure
• Placed ads in community based newspapers

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Focus on Second Hand Smoke cont.
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Telephone Survey

• Needed to assess what individual community
  members felt their cessation needs were
• Developed a 24 question survey (14 questions
  apply to what HELPED to quit smoking and 14
  questions apply to what WOULD help)
• Target group Chinese and Vietnamese adult males
  who are current and former smokers
• Information will be used to modify cessation
  program further

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Conclusion

• Important to develop a culturally competent
  cessation program from the ground up vs top down
• Do research on the target community that you are
  working with prior to implementing a new program
• Get input and feedback from community members in
  order to pre-test the materials and make needed
  changes
• Remain flexible in the planning, develop, and
  implementation of the program
• Evaluate the intervention