What is the single most preventable cause of disease, disability, and death in the United States? Tobacco use, according to the Centers for Disease Control and Prevention (CDC). The organization estimates that 443,000 people die in the United States prematurely every year from smoking or exposure to secondhand smoke, and an additional 8.6 million have a serious smoking-related illness.
Yet, the CDC also counts roughly 43.4 million US adult cigarette smokers. Of these, 70% report to the CDC that they want to quit. In Canada, smoking is an equally pervasive problem. In 2003, 21% of Canadians 15 years of age and older were smokers, according to Health Canada. The organization found about half of these smokers reported contemplating quitting or preparing to quit.
Unfortunately, contemplation or even effort does not always result in cessation success. Health Canada found that former smokers reported an average of 3.2 quit attempts before stopping for good.
In both the United States and Canada, research has shown that clinical intervention can help to increase smoker cessation success rates. A hospital-based smoking cessation program developed at the University of Ottawa Heart Institute (UOHI) in Ontario found cessation rates increased from 35% to 50% as a result of the initiative.
The National Hospital-based Smoking Cessation Network is now expanding with the help of the Horizon Health Network to 33 facilities throughout Canada. “Depending on the population, facilities can see anywhere from a 10% to 15% increase in cessation,” says David Arbeau, BTech, RRT, CAE, program manager for Horizon Health Network (formerly Regional Health Authority B) in New Brunswick, Canada.
The benefits of success can be felt throughout the health care system, resulting in healthier patient outcomes. “I think it’s quite obvious the burden tobacco has on the health care system with the increased prevalence of chronic diseases, respiratory diseases, cancer, stroke, heart disease—as well as the way it affects reproductive health, orthopedic surgery patients, post-op healing, wound healing, and bone healing,” Arbeau says.
The cessation effort involves the entire clinical team, but Arbeau believes that respiratory therapists can play a primary function. As the program has expanded, so have their roles. The expanded model permits RTs to participate in a leadership capacity as part of the team whose goal is to “identify and offer treatment to every admitted smoker using best practice guidelines.”
Admission—Half the Battle
The program is initiated during admissions and carries through treatment to follow-up 6 months after discharge. “The Heart Institute model was very nursing-based and obviously very successful,” Arbeau says. The model of the national network has successfully transferred some responsibilities to RTs. In both programs, patients are asked about their tobacco use during the admissions process by admissions nurses. If patients indicate having used tobacco in the past 6 months, they are asked about use during the past 7 days. “[The second question] provides a clearer picture of the patient’s usage,” Arbeau says. Patients who answer dishonestly are not pressed. “If they don’t provide an honest response, it’s obvious they are not ready to talk about quitting,” Arbeau says.
Responses are recorded in the patient record. Patients who do identify themselves as smokers receive follow-up from the bedside nurse, who delivers a brief message: “We think the best thing you can do for your health is to quit smoking. Are you interested in receiving some information?”
The Quit Kit
Patients expressing interest in cessation are given a “quit kit,” which includes self-directed tools as well as personalized advice and pharmacotherapy, if deemed necessary. “That’s done in consultation with the patient’s physician. Depending on how much they use, they may be given nicotine replacement therapy in the form of a patch, gum, inhaler, or a combination of a couple of those,” Arbeau says. Medications, such as Zyban or Chantix/Champix, may also be prescribed. Further support is provided in the form of counseling. “If patients indicate they’re ready to talk more about their quit history, what they’ve done before, or how maybe they need some motivation or confidence building, then they are referred to one of our tobacco cessation counselors, who are our respiratory therapists in the hospital,” Arbeau says. RTs seemed the natural choice because they see such a large volume of patients. “We see the impact that tobacco has on respiratory health particularly. With our background and skill set, RTs are primed to intervene with patients and encourage them to seek out learning opportunities,” Arbeau says. The effort does not present a significant workload burden. Bonne Quinlan, APN, network facilitator at the UOHI, is quoted in program materials as saying, “Smoking cessation counseling can be delivered as part of routine nursing care in less than 10 minutes.”
The 6-Month Checkup
Of course, 10 minutes of knowledge can be difficult to translate into an actual lifetime of quitting. Both the patients and their individual physicians are provided with follow-up instructions once the patient is discharged. Follow-up calls are made through the program using an interactive voice response system 6 months after the discharge date.
The time frame was based on research results and smoking stages. “Once patients move out of the 6-month smoke-free period, they are considered to be in the maintenance mode, which is a different stage of their change,” Arbeau says, acknowledging relapses can still occur at this point. Patients who do require further support are provided resources that may include the family physician.
Baselines and Results
The follow-up data that is gathered is also used to evaluate the success of the program, a step that requires that a baseline be measured before the initiative is implemented. “How many admissions out of 10 can the unit expect to be tobacco users?” Arbeau asks.
The answer, judged over a 4- to 6-week period, helps not only to measure effectiveness, but also to provide an indication of the smoking prevalence on a particular unit. “We know that prevalence could be lower or higher based on the specific patient population. For instance, we find a slightly higher prevalence among cardiac patients,” Arbeau says, adding it is important for a unit to know what its starting prevalence is before implementing the smoking cessation program.
Knowing the potential patient volume can help to adequately prepare hospital resources for successful implementation of the initiative. Preparation also includes an audit of the existing policies and procedures and customization of program steps to identify responsible individuals and develop standardized resources within the specific facility.
Admissions forms and patient-care maps are modified to incorporate smoking cessation questions and interventions. UOHI experts will work with clinical directors and nursing to make these changes, as well as to train the staff. “We’re doing mass frontline training open to nurses, dieticians, social workers, rehab staff—whoever has that encounter with patients who asks for the smoking status,” Arbeau says. The goal is to build capacity throughout the organization so everyone has the same information and is comfortable with the brief interventional step. Physicians and administrators can also participate. RTs, who perform the more intensive counseling, receive more comprehensive training. The education typically includes a 2- to 3-day workshop held at the UOHI, online coursework, and time with experienced UOHI nurse counselors on-site.
The Heart Institute is funding the program with a 3-year grant from Health Canada, which will help to establish the National Hospital-based Smoking Cessation Network in the facilities. Other organizations, such as Horizon Health Network, Pfizer Foundation (New York), and the Heart and Stroke Foundation of Canada (Saint John, New Brunswick), have also made commitments that include money, time, or other resources.
Arbeau notes that the program components or model might change to accommodate sustainability over the long-term (once federal funding has been used up), but that Horizon has committed to continue the programming in some form. “We may not have dedicated staff working full time, but we may integrate the model into respiratory therapy departments or develop a model that fulfills the requirements of the program but doesn’t require the creation of a lot of resources,” Arbeau says.
Currently, hospital inpatient counseling and medications are provided free of charge. “After that, it is the patients’ responsibility to continue the therapy in consultation with their physicians,” Arbeau says. Patients with smoking-related prescriptions (such as Zyban or Chantix/Champix) prior to admittance are asked to bring in their medications for their stay. “More times than not, however, patients are provided those therapies from the hospital formulary system,” Arbeau says.
Set Up for Success
The cost and other required resources are considered worth the expense because of the associated health care benefits of smoking cessation. Quitting can immediately and drastically reduce the risk of disease and the need for rehospitalization, according to UOHI. Subsequently, the program has been set up for success with components that research has shown to have a positive impact on quitting efforts.
According to UOHI and established literature, advice from a health professional increases cessation rates by as much as 30%, and the use of counseling and medications can double or triple the success rate. Inpatient programs are thought to offer an even greater opportunity for success since they provide a “teachable moment.” Most hospitalized smokers are in a good position to clearly recognize the health benefits of quitting smoking (or fear the health impact of continuing) and may be especially motivated. The smoke-free environment of medical facilities may also aid any effort to establish new patterns and quit.
“Hospital administrators like to see that we are making the health care system more effective and efficient and helping people make healthier choices. Helping patients with their nicotine dependence particularly has the greatest impact on their health and lessens the overall burden on the system,” Arbeau says. If patients can quit while they are ahead, everyone benefits.
Renee Diiulio is a contributing writer for RT. For further information, contact [email protected].