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: /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.

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;
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.