RTs seem the logical choices to head smoking cessation programs, but does their training equip them for this role?
Are respiratory therapists the best choice for providing smoking cessation information and intervention? The natural initial response to that question is “Yes, of course.” Respiratory therapists have the specialized training and experience it takes to evaluate a patient’s smoking history, discuss respiratory anatomy and physiology, and teach patients about the pathophysiology of smoking-related lung disease. Both the US Department of Labor’s Bureau of Labor Statistics and the American Association for Respiratory Care include smoking cessation counseling in their definitions of “respiratory therapist.”
But I think we are seriously deluding ourselves if we assume that RTs are the de facto go-to guys when it comes to smoking cessation, and we need to make a sincere and objective self-evaluation of our qualifications. Unfortunately, there is no one specialty within the health care team that has been consistently and adequately trained in smoking cessation. We are well educated and experienced in treating the outcomes of smoking, and we are prepared to manage the diseases and medical conditions caused by smoking. Whether addressing an acute exacerbation of COPD in the emergency department, helping identify a lung cancer via bronchoscopy, or designing a weaning protocol for a chronic lung patient on a ventilator, our training and experience ensure that our patients who have smoking-related disease will receive the best of care.
But when it comes to integrating smoking cessation protocols into our plan of care, we still have a lot of work to do. For one thing, most respiratory therapists received little or no training in smoking cessation when they were students in school, and we are not alone in our lack of education. Such training in medical and nursing schools has been similarly lacking. Research has documented that tobacco intervention training in US medical schools is seriously inadequate. In one study, only 21% of practicing physicians said they received adequate training to help their patients stop smoking. A study in JAMA1 documented that 69% of medical schools surveyed did not require clinical training in smoking cessation techniques and that 31% of the schools averaged less than 1 hour of instruction per year in these techniques.
Our day-to-day patient care naturally focuses on providing the necessary treatment regimes to address the patient’s medical condition, with minimal focus on the cause of the condition. After all, no one is admitted to the hospital specifically for nicotine dependence or because they require smoking cessation support. So we treat the condition and ignore the cause. Once upon a time, when a patient indicated a desire to quit smoking, our typical response was to wish them the best of luck. That is no longer good enough.
Every respiratory therapist needs to become familiar with the Ask, Advise, and Refer regime to assess each patient’s readiness to quit, and directly refer them to immediately accessible support. For example, every state has a quit line that can be accessed by simply calling (800) QUITNOW. Every respiratory therapist should at least be able to provide their patients with that phone number. In addition, we need to:
Integrate smoking cessation into hospital patient care protocols so that providing assessment and support is not a hit-and-miss affair.
Provide respiratory therapists the tools, the time, and the training to become effective at supporting our patients’ desire to quit. Patients who say they don’t want to quit should receive information about the benefits of quitting.
Employ a specially trained respiratory therapist at every hospital to serve as a smoking cessation coordinator, providing both inpatient and outpatient smoking cessation counseling, and to serve as an instructor and resource for the entire health care team.
Integrate tobacco dependence education throughout each year of medical, nursing, and respiratory school curricula, including specific training in nicotine addiction, smokeless tobacco intervention, cultural issues, nicotine replacement therapy, and emerging pharmaceutical developments.
Quit smoking. It is difficult for clinicians to give credible cessation advice when their lab coat smells like an ashtray.
It is a mistake to think that RTs can go it alone in providing comprehensive smoking cessation support. The most effective programs involve several different health care professionals, including physicians, respiratory therapists, nurses, and social workers. They work together to coordinate and plan for the screening, intervention, and counseling necessary to help patients quit. Respiratory therapists should be leading the way, but I have actually heard RTs and respiratory department heads say, “Let nursing do it.” That attitude has to change.
There is a widespread belief among both administrators and clinicians that smoking intervention is ineffective because patients do not typically quit as the result of a single 3-minute intervention. This is a result of a fundamental misunderstanding of the quitting process and of how to measure success. Long-term smoking cessation success is an arduous journey consisting of many little steps. Our goal is to assess where the patient is on the continuum of change, and facilitate a step in the right direction. If we encounter a patient who is in a precontemplative stage and get him to simply begin thinking about quitting, that is a huge success. Patients who indicate a strong desire to quit, are ready to set a quit date, and are entering the action phase need extra assistance. That is why an on-site smoking cessation coordinator is so valuable.
Although smoking remains the number-one preventable cause of death and disability, most clinicians still have not integrated smoking cessation support into their patient care routines. Seventy percent of the 46 million smokers in the United States say they would like to quit; no other clinical intervention can offer a larger potential benefit than smoking cessation support. Isn’t it time we gave our patients the kind of comprehensive help they deserve?
To begin making a difference in your individual patient care practice or to integrate smoking cessation protocols into your hospital policy, the place to start is at the Centers for Disease Control and Prevention Tobacco Information and Prevention Source (TIPS) Web site, www.cdc.gov/tobacco/index.htm. It includes the Clinical Practice Guidelines that every hospital should employ, and a mother lode of resources for smoking cessation. Respiratory therapists can either demonstrate leadership now, or lose an important opportunity to expand our scope of practice. Are respiratory therapists the best clinicians to provide smoking cessation information and intervention? The answer to that is up to us.
John A. Wolfe, RRT, CPFT, is a clinical specialist at North Colorado Medical Center, Greeley, Colo, and a member of the RT’s advisory board.
1. Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. JAMA. 1999; 282(9):825-829.