Helping Our Patients Quit for Life
John A. Wolfe, RRT,
CPFT
Smoking cessation success is not easy, but RTs can make a
significant step toward that end simply by asking patients if
they want to quit.
mMy introduction to smoking cessation came in 1990 when I
was invited to assist in a teen smoking cessation program.
Like many people, I naively assumed that teenagers smoked
because they wanted to, and that they could readily quit
whenever they wished. I was completely unprepared for the
tears and tribulations of teenagers desperately trying, and
often failing, to kick the habit. I could see some of them
giving up on themselves. The successes made all the effort
worthwhile, however, and there was nothing more gratifying
than helping a teen smoker kick the habit with a clear
commitment to never smoke again.
Ten years ago, I created the opportunity to start an
employee smoking cessation program at the King Faisal
Specialist Hospital and Research Centre, in Riyadh, Saudi
Arabia. I researched the information that was then available
and found a lot of consensus among the programs I
investigated. Again I learned how hard it could be, even for a
committed adult, to conquer a nicotine addiction. More
recently, I became involved with the American Lung
Association’s Not On Tobacco (N-O-T) program. It is a
10-session comprehensive smoking cessation program
specifically geared to teens who want to quit, using the
latest tools and techniques, including cotinine testing, which
demonstrates the drop in physiologic nicotine levels when the
drug is eliminated. One of my favorite tools is a carbon
monoxide analyzer, which shows the CO level, in parts per
million, in the exhaled breath. Even an hour or more after the
last cigarette, smokers have a dramatically increased level of
CO in their blood (and hence their breath). It provides a
graphic demonstration of the immediate and measurable effect
of smoking on the cardiovascular system. Eyes begin to
open.
Most recently, I have been employed to perform pulmonary
function testing at our community hospital. You might assume
that I would consistently ask every smoker I evaluated if they
wanted to quit, and provide them with appropriate community
resources if they responded affirmatively. You would be wrong.
I quickly learned that positive intentions and experience in
smoking cessation were not immediately transferred into a
consistent and proactive system of assessment and support. I
also learned that I was not alone, and set about the task of
understanding and resolving the problem.
It comes down to this: The American health care system is
extremely well prepared to deal with the outcomes of smoking
and health. We have the equipment, expertise, and payment
codes to provide everything from emergency department
treatment to ventilator support and end-of-life palliative
care. We can provide nocturnal ventilatory support or perform
lung reduction surgeries and assess their efficacy. We can
provide increasingly sophisticated home oxygen systems to
people virtually anywhere. We can tell you exactly how much
impact a 60-pack-a-year habit has had on the FEV1 on any given
patient.
But when the same patients express an interest in smoking
cessation, we are often poorly prepared to support them or
refer them to available resources. Most embarrassingly, we
typically do not even ask patients if they want to quit. Why?
Because we lack the training, because we do not have
assessment and referral systems incorporated into our
protocols, and because we are not yet reimbursed for the
service.
Easy Answers
The bad news is that
physicians, nurses, and respiratory therapists do not receive
adequate training in smoking intervention. A survey of
“Tobacco Dependence Curricula in US Undergraduate Medical
Education” published in The Journal of the American Medical
Association showed that “Most medical schools (83/120 [69.2%])
did not require clinical training in smoking cessation
techniques, while 23.5% (27/115) offered additional experience
as an elective course. Thirty-one percent (32/102) of schools
averaged less than 1 hour of instruction per year in smoking
cessation techniques during the 4 years of medical school. A
minority of schools reported 3 or more hours of clinical
smoking cessation instruction in the third (14.7%) and fourth
(4.9%) years.”1 Sadly, only about half of current
smokers recall having been asked about their smoking status or
being urged to quit by a doctor.2 This lack of
consistent intervention may be due to a combination of
factors: a lack of formal training in effective cessation
techniques, a perceived lack of skills, frustration due to low
success rates, time constraints, lack of reimbursement, or
even a belief that smoking cessation is not an important
professional responsibility.2,3 And while providing
a comprehensive community smoking cessation program may not be
part of the mission of most health care providers, asking
patients if they want to quit and directing them to
appropriate resources should be.
For example, the current patient data algorithm used for
admitting patients into a health care system (or into a simple
spirometry database for that matter) includes questions
pertaining to the patient’s smoking history. We ask them if
they have ever smoked. If they answer “yes,” we obtain their
pack-year history and note whether they have quit. But we do
not, as a matter of policy, ask them if they want to quit. One
of the reasons for this may be that if they respond
affirmatively, we have no protocol for addressing their
request.
The good news is that tools and solutions are readily at
hand and relatively easy to implement. Health care systems do
not need to hire teams of consultants to study the issue and
recommend solutions. “Treating Tobacco Use and Dependence”
presents a comprehensive Clinical Practice Guideline thanks to
a Public Health Service-sponsored review of 6,000 articles by
a national panel of experts. Most important, it makes specific
recommendations for addressing the problem.
Major conclusions and recommendations include:
Tobacco dependence is a chronic condition that warrants
repeated treatment until long-term or permanent abstinence is
achieved.
Effective treatments for tobacco dependence exist and all
tobacco users should be offered those treatments.
Clinicians and health care delivery systems must
institutionalize the consistent identification, documentation,
and treatment of every tobacco user at every visit.
Brief tobacco dependence treatment is effective, and every
tobacco user should be offered at least brief treatment.
There is a strong dose-response relationship between the
intensity of tobacco dependence counseling and its
effectiveness.
Three types of counseling were found to be especially
effective: practical counseling, social support as part of
treatment, and social support arranged outside of
treatment.
Five first-line pharmacotherapies for tobacco
dependence—sustained-release bupropion hydrochloride, nicotine
gum, nicotine inhaler, nicotine nasal spray, and nicotine
patch—are effective, and at least one of these medications
should be prescribed in the absence of contraindications.
Tobacco dependence treatments are cost-effective relative
to other medical and disease prevention interventions; as
such, all health insurance plans should include as a
reimbursed benefit the counseling and pharmacotherapeutic
treatments identified as effective in the updated
guideline.4
The entire (and highly readable!) 66-page document is
probably sitting on the shelf of your respiratory therapy
department right now. It is in the October 2000 (Volume 45,
No. 10) of the Respiratory Care Journal.
An excellent place to begin fixing the problem is by
replacing the patient data algorithm described previously with
the one laid out in the Clinical Practice Guideline.
Appropriate smoking cessation resources are readily
available once we begin assessing patients’ readiness to quit,
and these need to be incorporated into the intervention
protocol. Even patients who do not indicate a desire to quit
should be provided with diplomatic nudging and the information
they need to begin thinking about the benefits of quitting.
Patients with diabetes or heart disease are lavished with
education and management resources. Why shouldn’t patients
afflicted with nicotine dependence be offered similar support?
And who better to provide that support than a properly trained
respiratory therapist? Further, hospitalized patients are an
essentially captive audience and may have gone days or weeks
without smoking.
“You Can Quit Smoking: Support and Advice From Your
Clinician” (US Department of Health and Human Services
publication ISSN 1530-6402) is an excellent tool to use at the
bedside for working with patients to create a smoking
cessation plan and introduce them to community resources. It
is in the public domain, which means it can be copied and used
just as quickly as your facility’s forms committee can approve
its use. It is available at: http://www.surgeongeneral.gov
/tobacco/tearsheeteng.pdf.
Quit kits are an effective way to assemble information
about successful quitting and coping strategies and both
national and community cessation support resources. Merely
handing patients a quit kit with tools and resources is a step
in the right direction. But ideally, clinicians should be
spending quality time with the patient to set a quit date,
develop an action plan, and provide for follow-up by a
community health nurse, cessation counseling program,
pulmonary rehabilitation, or other available resource.
Meanwhile, Medicare and private insurance companies need to be
pressured to cover the cost of the time and materials.
Failure Is Not An Option
We know that
smoking is responsible for more than 430,000 deaths each year
in the United States.5 It represents the number one
preventable cause of illness, and accounts for more than $50
billion in annual medical costs.6,7 Ironically, 70%
of smokers say they want to quit. Can we at least begin to
consistently ask our patients if they want to quit smoking and
provide them with guidance toward that end? To quote AARC’s
executive director, Sam P. Giordano, RRT, “Smoking cessation
interventions will move forward with or without us… . We like
to style ourselves as key players on the health care delivery
team. How can we earn that title if we’re not involved with
the elimination of the chief avoidable cause of illness?”
Let’s each do something today that will take us another step
closer to providing meaningful help to our patients who want
to quit.
John A. Wolfe, RRT, CPFT, is a contributing writer for
RT and a member of the editorial advisory board.
References
1. Ferry LH, Grissino LM,
Runfola RS. Tobacco dependence curricula in US undergraduate
medical education. JAMA. 1999;282:825-829.
2. Smoking
Cessation Clinical Practice Guideline Panel and Staff. The
Agency for Health Care Policy and Research Smoking Cessation
Clinical Practice Guideline. JAMA. 1996;275:1270-80.
3.
Manley MW, Epps RP, Glynn TJ. The clinician’s role in
promoting smoking cessation among clinic patients. Med Clin N
Am. 1992;76:477-94.
4. The Tobacco Use and Dependence
Clinical Practice Guideline Panel, Staff, and Consortium
Representatives. A Clinical Practice Guideline for Treating
Tobacco Use and Dependence: A US Public Health Service Report.
JAMA. 2000;
283:3244-3254.
5. Centers for Disease
Control and Prevention. Smoking-attributable mortality and
years of potential life lost—United States, 1984. MMWR Morb
Mortal Wkly Rep. 1997;46:444-451.
6. Miller LS, Zhang X,
Rice DP, Max W. State estimates of total medical expenditures
attributable to cigarette smoking, 1993. Public Health Rep.
1998;113:447-458.
7. Medical care expenditures attributable
to cigarette smoking—United States, 1993. MMWR Morb Mortal
Wkly Rep. 1994;43:469-472.