Everybody has smelled them, many smoke them, and some are able to quit. The American Heart Association estimates that 46 million American adults are smokers, a number that was double in 1965.

While the number of smokers appears to be dwindling in America, cigarette use remains a controversial subject in today’s society, frequently sparking a heated debate between those that do engage in the act and those that do not. Smokers often feel unjustly targeted and discriminated against as more states pass smoking legislation to ban smoking in bars, restaurants, and public places.

Unfortunately for them, research has exposed the dangers of tobacco use for decades and do not sympathize with smokers or the inequity they feel at the passing of such laws. The World Health Organization cites 5.4 million deaths every year across the globe because of tobacco use. Private choices aside, second-hand smoke, also known as passive smoking, proves similarly dangerous; the EPA estimates that it is responsible for about 3,000 lung cancer deaths annually among non-smokers in the U.S. and increases the risk for heart disease.

Despite all of this knowledge, many people start or continue their smoking habit. Ultimately, physicians and healthcare providers are not responsible for the choices that individuals make about their health, but they can act as a first wave of intervention. This role remains unfulfilled though, as it seems that those in the medical community shy away from the topic in their interaction and are slow to identify or motivate their patients that do smoke to stop.

Physicians consider tobacco use a personal choice and feel that they might be breaching societal norms if they approach it. “They just see it as he’s a smoker; it’s his right and he should be able to,” says Iyaad Hasan, MSN, CNP, CTTS, director and chief clinician of the Tobacco Treatment Center at the Cleveland Clinic in Ohio.

Unfortunately, this silence continues to keep patients in the dark about important resources – like comprehensive tobacco treatment centers – to help them quit.
 
Smoking Cessation Programs vs. Tobacco Treatment Centers

Only one in five physicians offer any kind of cessation program, and usually, it’s just not enough. These kinds of programs only focus on one aspect of quitting, either by addressing behavioral alteration or just prescribing medication without any support system. Another issue in smoking cessation programs is that once the patient has overcome their addiction and finished the program, follow-up is not maintained and individuals may fall off the wagon.

Tobacco treatment centers, like the one at the Cleveland Clinic, stand apart from smoking cessation programs. Treatment centers offer comprehensive care in behavioral, cognitive, and pharmacological intervention, as well as online or through other intensive counseling services, in all forms of tobacco addictions.

Nicotine-replacement therapy, prescribed use of smoking cessation medicine (such as Chantix or Zyban), group or one-on-one counseling, and online forums are many of the ways these centers help their patients stay tobacco-free.


Lynda Goodfellow, EdD, RRT, program director of Respiratory Therapy at Georgia State University’s College of Health & Human Sciences agrees with comprehensive intervention.

“I have seen in the past where a respiratory therapy department or therapist will put together a very good smoking cessation or behavioral modification program, but long-term, this addiction needs more to break than just behavior modification,” she says.

“You can’t just have the medicine, and then you just can’t have the behavioral modification,” she argues, “You really need both to have a true success.”  Hasan also adds that patients can double their success rate when their treatment includes both kinds of intervention.

Up in Smoke

Medical indifference to smoking, as a social problem, and poorly designed smoking programs are not the only issues that contribute to non-intervention. Seventy percent of the people that smoke want to quit, but misjudging addiction, expensive treatment fees and prescriptions, physician accountability, and limited time are all factors that keep patients smoking and keep healthcare providers quiet on the subject.

For example, even if a patient does have access to a comprehensive treatment plan or clinic, they may not be able to afford it. According to Goodfellow, “They either have no insurance or their insurance simply does not cover it.”

Hasan sees another trend. “A lot of the responsibility and the accountability on the provider side has been taken away. [Healthcare providers feel] that many people have quit in the past and therefore, anybody can do it. A lot of our products are over-the-counter, so many patients feel empowered enough that they can do it themselves.”

Along with these circumstances, sometimes physicians and healthcare providers simply don’t know how or when to approach the subject. “They’re just not equipped with how to go there. One thing, they just may not have the medical knowledge. And, the whole conversation sort of ends right there,” says Goodfellow. She also points out that previous sour experiences with defensive patients can discourage medical professionals from even asking in the future.

Hasan notes that time constraints are a big obstacle for doctors, saying, “I always tell my docs, ‘How many times have you had a smoker walk in and walk out and you wish you had done something?’ And they’ll tell me, “I wish I had the chance. I wish I had the time. I really want to do something.’ “

Airway Experts

Whatever the underlying cause is that undermines communication and treatment, one thing remains important: early intervention is key in detecting fatal tobacco-related complications. Lung cancer, heart disease, chronic pulmonary disease, and stroke are some of the illnesses caused or aggravated by smoking tobacco.

Inpatient providers, especially respiratory therapists, frequently interact with individuals suffering from such diseases and witness the severe effects of smoking on lung health. Because of this, respiratory therapists play a unique and important role in screening smokers. Goodfellow insists that respiratory therapists should ask all of their patients if they smoke. If the patient does, the therapist needs to “open up the floodgates to generate a conversation about it.”

Hasan also recognizes the critical role that respiratory therapists and other inpatient caregivers play. Though his staff consists of nurse practitioners, he relies on respiratory therapists from the main campus at the Cleveland Clinic to be frontline advocates for the treatment center.

For the future, Hasan says, “Respiratory therapy is going to become a big part of our clinic,” adding that there are plans to work collaboratively with the respiratory and pulmonary therapy departments from the institute to continue to make their patients aware of the treatment clinic.

A Model of Success

Hasan has set a good example in overcoming the problems and complexities of tobacco intervention at the Cleveland Clinic. He says, “It was not a challenge, but an actual culture change on how we approached our physicians, nurse practitioners, respiratory therapists, etc.,” to make the time to motivate and question their patients, repetitively, about the necessity of quitting.

He even urges his patient service representatives to ask individuals as they check-in if they smoke, then refer them to the tobacco center.

And if tobacco treatment isn’t covered under the patient’s insurance or is otherwise unaffordable, the clinic offers income-dependent financial assistance. He hopes that referrals to the clinic will trickle down to other providers and other areas so that they can use or emulate the resource, too.


Hasan is also forging new ground in the services offered by tobacco treatment centers with the help of the Cleveland Clinic. “Being a part of the Wellness Institute, we can refer our patients to many people within the system. Many individuals need stress management, so we hook them up with the right type of counselor,” he says.

Aside from stress, smokers also fear other secondary complications, such as weight gain. He hopes to begin programs that address the special needs of smokers in the future, such as weight management, women groups, pregnancy groups, and even programs for teens. “We want to move into covering the lifespan of a smoker,” he says.

Going Forward

Both Goodfellow and Hasan urge those in the medical field to become proactive and passionate about getting their patients to quit. Even if a patient is not ready to stop now, repeated exposure to the message will jumpstart the thought process that might lead them to quit. Many are doing their part, but more needs to be done. Awareness of resources and time constraints continue to be the main obstacles in getting providers to speak to individuals, but it doesn’t need to be.

Hasan admits that the physicians working in the Cleveland Clinic and surrounding areas have it a little easier when speaking about cessation programs and treatment plans, since that they have a resource right there on their campus. However, even if one isn’t locally available, there are several other options. He recommends that physicians and healthcare providers take advantage of the programs offered by the American Lung Association, the 1-800-QUIT-NOW telephone line, and other local resources.


It may also seem that talking with patients or providing them with resources is just not enough. Some might fear that it won’t make a difference, so it isn’t worth their time. Goodfellow feels that this type of thinking causes those in the field to become desensitized to smoking, ultimately fueling the other obstacles, and preventing treatment.

Respiratory therapists are particularly prone to this kind of burnout, she warns, because of their firsthand experiences with smokers and lung health. Hasan also sees how this might happen, but believes differently.

He recounts a treatment experience six months ago with an elderly man that smoked for 70 years. Hasan drew motivation from the patient, who had previously suffered a heart attack and needed to quit. Together with this motivating factor, the right medication, and intense behavioral counseling, the patient has remained smoke-free. At that man’s age, many people would say, “What’s the point?” and give up their attempt to intervene.

To this, Hasan says: “He gains a lot of benefit by stopping smoking at that age. He can gain years of life – not just one year – years. Most smokers don’t plan to fail; they fail to plan. Let them know there is a plan. It only takes one minute to talk. And one minute is not really a lot of time.”     

For more information about the Cleveland Clinic Tobacco Treatment Center, please visit: www.clevelandclinic.org/tobaccoclinic.

For more information about treatment options, local resources, and facts about tobacco, please visit:

The American Lung Association, www.lungusa.com

The AAFP’s Ask & Act Tobacco Cessation Program, http://www.aafp.org/online/en/home/clinical/publichealth/tobacco.html

— Kelly Olsen is a staff writer for Therapy Times. Questions and comments can be directed to kolsen@therapytimes.