REVIEW
Nurse practitioners, wake up and smell the smoke Gale Barr, MSN, CNP (Nurse Practitioner)1 , Nancy Houston-Miller, RN, BSN (Associate Director)2 , Iyaad Hasan, DNP, CNP (Director)3 , & Geoffrey Makinson, PhD (Senior Director, Epidemiology and Population Health)4 1
University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio Stanford University School of Medicine, Stanford, California 3 Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio 4 Pfizer, Inc., New York, New York 2
Keywords Smoking cessation; nurse practitioners; policy; education. Correspondence Gale Barr, MSN, CNP, University Hospitals Case Medical Center, Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106. Tel: +1 216-286-3468; Fax: +1 216 286 5779; E-mail: [email protected] Received: March 2013; accepted: May 2013 doi: 10.1002/2327-6924.12049 Disclosures The authors would like to thank Carol Southard for her contributions at the planning stage of the manuscript. Iyaad Hasan has received speaker honoraria from Pfizer. Geoffrey Makinson is an employee of and shareholder in Pfizer Inc. Editorial support was provided by Helen Jones, PhD, of UBC Scientific Solutions and funded by Pfizer Inc.
Abstract Purpose: With the focus of modern health care on preventive care, and the well-known benefits of smoking cessation on improving health and reducing healthcare costs, smoking cessation is a key focus of healthcare reform. To change the smoking habits of the U.S. population, two strategies are of particular importance to healthcare professionals: promoting tobacco-free environments in healthcare systems and expanding affordable and effective treatments. Data sources: Recent policy literature. Conclusions: Barriers to providing smoking cessation counseling most frequently cited by healthcare professionals are lack of training and poor reimbursement; however, recent legislation, for example, the Patient Protection and Affordable Care Act (PPACA), should make preventive services more available and affordable. Nurse practitioners (NPs) have vast experience in addressing health promotion and disease prevention, and are therefore well placed to lead this reform. However, despite consistently higher referrals of tobacco-dependent patients for smoking cessation interventions than any other group of healthcare provider, evidence suggests that NPs are not adequately trained to treat this addiction. Implications for practice: This article is a call to action for NPs to become familiar with the tobacco cessation policy changes affecting clinical practice, to become experts in tobacco treatment, and to take the lead in this healthcare reform initiative.
Introduction The focus of health care today and in the future is on high-quality preventive care. Helping Americans to lead productive lifestyles, limiting or delaying chronic diseases, and lowering healthcare costs are key targets for healthcare reform and the new models of care, for example, Medical Home and payment reforms such as accountable care. These advances have placed the focus on primary care providers to enable this wave of change throughout the U.S. health system. However, the shortage of primary care physicians has resulted in the necessary expansion of the nurse practitioner (NP) role. NPs have vast experience in addressing the needs of health promotion and disease prevention, and as such, the new healthcare reforms place these professionals in a prime 362
position for cultivating the next generation of Americans to become healthier individuals. One preventive measure that needs to be addressed by all parties involved in health care is smoking cessation. Smoking is known to be a major contributing risk factor for a variety of diseases including lung, throat, oral, and other cancers (U.S. Department of Health and Human Services, 2004), cardiovascular disease (Grassi et al., 2010), and chronic respiratory illnesses (Mannino, 2002), and the association between smoking cessation and reduced all-cause mortality is well established (Doll, Peto, Boreham, & Sutherland, 2005; Kenfield et al., 2010). Smoking cessation is a key focus of reform because of the overwhelming volume of research demonstrating that the use of smoking cessation services can improve health, prevent the occurrence of costly diseases, and reduce
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healthcare costs. The prevalence of smoking in adults has stayed at approximately 20% for several years, despite the ultimate goal of 12% having been set by Healthy People 2020 (Healthy People 2013). The failure to lower the prevalence of smoking in the United States has galvanized numerous organizations to renew their efforts to reduce this, the single most common cause of premature death and disability in the United States today. Starting in the early 1990s, California (and a few other states) initiated policy changes (including an increase in tobacco taxes) that have resulted in a current smoking rate of 12% in that state, meeting the objective set by Healthy People 2010 for the entire nation (Mannino, Caraballo, Benowitz, & Repace, 2001). However, smoking remains the leading cause of preventable mortality in the United States, with one in every five deaths being linked to the use of cigarettes (U.S. Department of Health and Human Services, 2010). This review article is a call to action for NPs to become familiar with the tobacco cessation policy changes affecting their clinical practice, to understand why this disease needs more attention, and to highlight ways to better equip future generations of NPs to change the future of smoking in the United States.
Policy changes and health care: Impact on smoking The decline in tobacco use in the United States during the past 40 years has been driven largely by four policy changes: (a) cigarette price increases through increased taxation; (b) comprehensive smoke-free policies extending to clean indoor air; (c) media/advertising campaigns to counter the pro-tobacco industry; and (d) greater access to affordable and effective treatments and services for smokers (Schroeder & Warner, 2010). It is estimated that if each U.S. state worked for 5 years on these initiatives, 5 million fewer individuals would smoke, thus preventing a large number of deaths (Centers for Disease Control and Prevention, 2006). Two of the aforementioned strategies are of particular importance to healthcare professionals: promoting tobacco-free environments (both indoors and outdoors) in healthcare systems, and expanding affordable and effective treatments for smokers. The policies related to these strategies and additional initiatives from national organizations are described below.
Healthcare systems promoting tobacco-free environments In 1992, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) launched an initiative requiring all accredited hospitals to ban indoor smok-
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ing, which subsequently led to the first industry-wide ban on smoking in the workplace (Longo et al., 1996). While this initiative resulted in a reduction in smoking among employees, it did not influence overall levels of smoking cessation (Longo et al., 1998). Immediately following the ban, 43% of hospitals initiated campus-wide prohibition of smoking in outdoor areas such as entranceways, grounds, and parking areas. Healthcare organizations have offered varying restrictions on the expanded JCAHO initiative: some dictate entire campus smoke-free policies without exception while others exempt defined populations of patients (e.g., those in psychiatric or longterm care) or allow physicians to override the policy; some organizations continue to designate outdoor areas for smoking. In 2002, the JCAHO began tracking performance data for patients with acute myocardial infarction (AMI), heart failure, or pneumonia who received smoking cessation counseling (Williams et al., 2005). In a recent analysis of 1916 hospitals, 45% had adopted a smoke-free campus policy. Those hospitals with smoke-free campuses were significantly (p < .001) more likely to report smoking cessation counseling for patients with AMI, heart failure, or pneumonia who smoked compared with hospitals that were contemplating a smoke-free campaign or those that had no smoke-free campus policy (Williams et al., 2009). However, these differences were small and reflected primarily the demographic attributes of the patient populations within hospitals rather than the hospital smoking policy (Williams et al., 2009). The Surgeon General’s 2006 report on “The Health Consequences of Involuntary Exposure to Tobacco Smoke” points out that workplace smoking restrictions decrease the number of cigarettes smoked by employees (U.S. Department of Health and Human Services, 2006).
Expanding treatments and services to smokers In addition to implementing strict indoor and outdoor smoking restrictions within workplace environments— including healthcare settings—there are numerous opportunities to improve upon and expand the availability of smoking cessation services. Barriers to the adoption of these services include: lack of insurance coverage for smoking cessation behavioral counseling and pharmacotherapies; lack of resources in many states to support ongoing quitlines; limited availability of services for Medicaid patients; limits on medication and counseling duration, and prior authorization for medications; and challenges posed by vulnerable populations including the mentally ill, substance abusers, and the poor (Abrams, Graham, Levy, Mabry, & Orleans, 2010; Warner, 2007). However, these barriers should not be a deterrent to 363
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focusing on those in greatest need within the healthcare system. As Rigotti has noted, the need for tobacco dependence treatment can no longer be ignored. She sets out a plan for all hospitalized patients, outlines the need for intervention, and provides an overview of the federal health policy developments that can lead to healthcare reform and new laws (Rigotti, 2011). The hospital is an effective environment for initiating and providing an entryway for smoking cessation counseling, but the resources required to enable effective relapse prevention are generally lacking. Furthermore, hospitals are currently not reimbursed for services provided to patients following discharge. However, this is changing, and in the future, healthcare systems will likely be rewarded for managing chronic disease and improving the long-term outcomes of patients. A recent meta-analysis of hospital-based studies showed that smoking cessation during hospitalization followed by relapse-prevention contact for more than 1 month increased cessation rates at 6 and 12 months with an odds ratio of 1.65 (Rigotti, Munafo, & Stead, 2008). No benefit was shown for interventions that included active counseling during hospitalization only.
Other policy changes In March 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law, the aim of which is to improve access to care and subsequent health outcomes. Under this law, for example, it is a requirement that state Medicaid programs cover comprehensive tobacco cessation treatments for pregnant women without a requirement for cost sharing (Healthcare.gov, 2011). Furthermore, the smoking rate among Medicaid recipients is 36%, compared with 21.6% of the general population, and accordingly, there is an even greater opportunity to reduce smoking through offering tobacco-related counseling in the Medicaid population (Centers for Disease Control and Prevention, 2007). Under the PPACA, private health insurance plans will also be required to cover 45 preventive services for adults graded “A” or “B” as recommended by the U.S. Preventive Services Task Force (Fiore et al., 2008). Because of the high certainty of substantial benefit, the list of preventive services includes tobacco cessation. Treatments will include those endorsed by the U.S. Public Health Service Tobacco Use and Dependence guideline, including FDA-approved medications and cost-effective counseling (Clinical Practice Guideline Treating Tobacco Use and Dependence 2008). As noted in a recent article, Maciosek and colleagues have identified several clinical services recommended by the U.S. Preventive Services Task 364
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Force that would produce medical net savings if utilization rates were increased to 90% of the U.S. population. Three services—tobacco use screening and assistance; discussion of daily aspirin use; and alcohol screening with brief counseling—contributed more than $1 billion each to net medical savings (Maciosek et al., 2006). The federal government—through the Health Information Technology for Economic and Clinical Health Act (HITECH)—is committing numerous resources to support the adoption and use of electronic health records. As part of another policy change, smoking status will be required as a coded field on electronic health records, and in order to qualify for incentive payments, reporting of data will be required not only of hospitals, but also by clinicians (Blumenthal & Tavenner, 2010).
Tobacco cessation as a priority for NPs The switch in focus of the healthcare provider role to wellness and preventive service is now stronger than ever. It is well known that many chronic diseases such as heart disease, cancer, and diabetes are preventable, yet they account for approximately three quarters of the current health spend. In covering recommended preventive services without charging a deductible, copayment, or coinsurance, the Affordable Care Act will make preventive services more readily available and affordable. Additional healthcare reform aspects and newer models of care also place a greater responsibility on healthcare providers to provide preventive care. The focus is simple: providers will get paid for the service that they provide based on how healthy they are able to keep their patients (and on the level of patient satisfaction with that service). Therefore, healthcare providers are being asked to treat and control disease, while integrating health promotion with disease prevention to maximize reimbursement. Health promotion and disease prevention has formed the core of the NP role since its inception in 1965. The vision at that time was that NPs would help to reduce healthcare costs and become providers in situations where resources were limited. The acceptance of NPs by other healthcare professionals and the public, coupled with greater political stature and self-regulation, has increased the scope of the work performed in this discipline. The Institute of Medicine (IOM) 2010 report on the future of nursing (Institute of Medicine of the National Academies, 2010) has reinforced the role of NPs in today’s healthcare practice. With policy change and newer models of care—for example, Accountable Care Organizations (ACOs)—the NP role offers the chance to play a key role in changing the future health prospects of millions of Americans. Results from a Pfizer-sponsored online survey of 3613 adult smokers, conducted from
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September 2006 through October 2010, show that of 76% of smokers who consulted a primary care physician, 45% did not have a discussion about smoking cessation with that provider. This equates to providers talking to just one in two smokers who entered their office. The list of obstacles stated by providers as barriers to their interaction with smokers included lack of time, fear of angering the patient, being of the opinion that the visit scope does not warrant that discussion, and a perception that the majority of patients do not want to quit. However, the two barriers most frequently cited are training and reimbursement. Most providers in practice today do not receive any form of training in relation to tobacco cessation. There have been recommendations by government and regulatory groups to introduce curricula that mandate the study of smoking cessation. If these changes are made, providers will gain improved confidence in their ability to provide counseling. However, the most likely reason why many providers do not focus on smoking cessation is poor reimbursement of the service. Codes (CPT 99406 and 99407) for smoking cessation counseling are available and may be accepted, but most U.S. health insurance plans (both public and private) do not provide coverage for tobacco addiction treatment. Hopefully, with the implementation of the new federal healthcare reform, providers will increase their impassioned focus on tobacco cessation and their patients will have a better chance of achieving disease control and healthy lives. There will be more coverage for Medicaid patients and stronger recommendations for private group and individual health plans to cover all recommended preventive services, including smoking cessation. As previously stated, obtaining reimbursement is becoming more a function of achieving and maintaining the best possible health status for patients. Commonly used metrics include glycated hemoglobin (Hb A1C), blood pressure, weight, and cholesterol (Fisher & Shortell, 2010). Currently, it appears that providers fail to realize the impact that smoking cessation can have on these metrics, and how in a business sense, they can get a better “return on investment” by helping a smoker to quit. Furthermore, the incidence and severity of chronic diseases in tobacco users are worse compared with nonsmokers; hypertensive smokers have a poorer cardiovascular risk profile than nonsmokers, despite receiving appropriate treatment; smokers have a 61% higher risk of cardiovascular events compared with nonsmokers when treated with statins for secondary prevention; and HbA1c levels in smokers can be increased from 9% to 34.5%, depending on nicotine exposure (Liu et al., 2011; Milionis, Rizos, & Mikhailidis, 2001). If healthcare providers increase their focus on tobacco cessation, patients would
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have a better chance of achieving disease control, and in the long run, better reimbursement would be achieved by healthcare providers taking this approach.
Recommendations for NP programs and education The need to provide care to some 50 million currently uninsured Americans will be a daunting task for healthcare reformers, as there will not be sufficient numbers of doctors to care for the volume of new patients. Even without reform, there is currently a 30% shortage of primary care physicians, with most new doctors choosing more lucrative specialties (Pickert, 2009). NPs could be a key to filling this gap, as they are capable of providing many of the same services more cost effectively. Furthermore, the NP role is focused on patient-centered care and preventive medicine. Despite the fact that tobacco abuse (and its contributory effect on a myriad of chronic diseases) remains the leading preventable cause of death in the United States, evidence suggests that NPs are not adequately educated to assist with the treatment of this addiction. Results from a cross-sectional survey, in which a questionnaire that measured tobacco content curricula was sent to 909 baccalaureate and graduate nursing program associate deans from institutions who were members of the American Association of Colleges of Nursing, revealed that only 1–3 h was spent on tobacco treatment in graduate nursing programs (Wewers, Kidd, Armbruster, & Sarna, 2004). In the past decade, the disciplines of medicine, dentistry, and pharmacy have integrated tobacco education into their curricula, whereas nursing has trailed behind (Heath & Crowell, 2007). Most nurses, who form the single largest group of healthcare professionals (over 3 million in the United States [Health Resources and Services Administration, 2010] and 17.3 million worldwide [Sarna, Bialous, Rice, & Wewers, 2009]) want to provide smoking cessation education, but they have not received the necessary information and/or skills training to provide effective interventions. There is an indication that nurses have achieved effective outcomes in a variety of clinical settings when they use tobacco-cessation interventions based on “best practice,” yet they fail to offer patients tobacco addiction treatment guidance. Also, as Heath et al. reported, nurses and NPs consistently refer a higher number of tobacco-dependent patients for smoking cessation interventions than any other group of healthcare providers (Heath, Andrews, Thomas, Kelley, & Friedman, 2002). NPs could be the profession to take the lead in becoming experts in tobacco treatment. However, they cannot take the lead in this endeavor until they are properly 365
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trained, and they cannot be properly trained until a number of changes occur. Our suggestions for change are as follows: 1. In-depth tobacco treatment education must be provided in each and every NP graduate program across the United States. We suggest a 5-day course in line with national standards of education for Tobacco Treatment Specialists (TTSs). This course should contain enhanced instructional methods including counseling roleplay with providers, which includes education on the parts of the brain involved in nicotine addiction and the brain reward center as it relates to nicotine receptors. This is important information to relay to smokers along with the mechanism of action of smoking cessation drugs, their side effects, and what they should expect when experiencing nicotine withdrawal. The cost of TTS certification training can range from $500 to $1000 per participant. To integrate TTS certification into NP education, the course could at first be elective, with the goal for it to become mandatory in the future. Funding for NP students to become certified TTSs would need to be secured through government or university grants. 2. In concert with The Association for the Treatment of Tobacco Use and Dependence (ATTUD), after attendance of the 5-day course on tobacco treatment, students would become certified TTSs. 3. NP licensure certifying agencies should include questions concerning tobacco treatment in their tests. 4. The NP, as a certified TTS, could be a new required area of expertise in NP education and practice. Although at present there is no national certification organization for TTSs, there are several training programs across the country with established standards and core competencies overseen by ATTUD. The requirements for this certification are 480 service hours focused on tobacco dependence treatment as part of direct patient care for those with a bachelor’s degree or 240 service hours for those with a graduate degree or higher. The applicant must be a nonsmoker and must also complete a 5-day TTS training program and achieve the pass score of 80% on examination. Graduate nursing faculty who complete the TTS certification could initiate collaboration between TTS training programs to offer NP students web-based training to become a certified TTS. 5. Select graduate nursing faculty who have completed the TTS certification can provide guidance to students, in addition to working alongside other TTSs. 366
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6. NPs working in primary care should have the ability to create a tobacco treatment clinic within their current practice and devote 1 day per week to tobacco treatment in patients. 7. NPs working within major medical centers should have the ability to develop NP-led tobacco treatment centers. These centers can become smokers’ “Refer to” place, and would thus help reduce the time constraints on nurses and the current low selfefficacy for providing smoking cessation counseling. Tobacco treatment centers should become a standard clinic in each hospital across the country. 8. Graduate schools of nursing should teach students how to start their own businesses and how to approach healthcare administrators of hospitals with the aim of starting an NP tobacco treatment center. 9. The delivery of smoking cessation interventions needs to become an indicator of quality nursing care. 10. The nursing profession must be held accountable for making necessary changes to ensure that they support nicotine addiction prevention and treatment into standard practice. 11. Nursing professional organizations need to do more to set standards for professional competency in tobacco treatment and control. 12. All advanced practice nurses (APNs) educators should be educated on the U.S. Public Health Service (USPHS) guidelines for tobacco dependence and should provide a copy to each and every graduate APN. 13. Continuing education for nurses should include education on brief cessation intervention and should, at least, include the basic “5A”s model for treating tobacco use and dependence. 14. Further research must be initiated and must focus on the role of APNs in smoking cessation. 15. NPs need to assume leadership roles in the field of nursing to lead the change in how nurses view tobacco treatment. Nurses have always been deeply committed to doing what is right for their patients, which has promoted the public’s respect. With our commitment to health promotion and disease prevention, NPs could be the profession to lead the country and world in breaking the deadly cycle of tobacco dependence.
References Abrams, D. B., Graham, A. L., Levy, D. T., Mabry, P. L., & Orleans, C. T. (2010). Boosting population quits through evidence-based cessation treatment and policy. American Journal of Preventive Medicine, 38, S351– S363.
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Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363, 501–504. Centers for Disease Control and Prevention. (2006). National Center for Health Statistics. National Health Interview Survey. Atlanta, GA: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/nhis.htm Centers for Disease Control and Prevention. (2007). Best practices for comprehensive tobacco control programs—2007. Retrieved from http://www.cdc.gov/tobacco/stateandcommunity/best practices/index.htm Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel. (2008). A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. American Journal of Preventive Medicine, 35, 158–176. Doll, R., Peto, R., Boreham, J., & Sutherland, I. (2005). Mortality from cancer in relation to smoking: 50 years observations on British doctors. British Journal of Cancer, 92, 426–429. ´ C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. Fiore, M. C., Jaen, J., & Wewers, M. E. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: Department of Health and Human Services, Public Health Service. Retrieved from http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163 Fisher, E. S., & Shortell, S. M. (2010). Accountable care organizations: Accountable for what, to whom, and how. Journal of the American Medical Association, 304, 1715–1716. Grassi, D., Desideri, G., Ferri, L., Aggio, A., Tiberti, S., & Ferri, C. (2010). Oxidative stress and endothelial dysfunction: Say NO to cigarette smoking! Current Pharmaceutical Design, 16, 2539–2550. Health Resources and Services Administration. (2010). The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC: U.S. Department of Health and Human Services. Retrieved from bhpr.hrsa.gov/healthworkforce/rnsurvey2008.html Healthcare.gov. (2011). Background: The affordable care act’s new rules on preventive care. Retrieved from http://healthcare.gov/law/about/provisions/services/background.html Healthy People.gov (2013). Objective TU-1.1. reduce cigarette smoking in adults. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020 /objectiveslist.aspx?topicid=41 Heath, J., Andrews, J., Thomas, S. A., Kelley, F. J., & Friedman, E. (2002). Tobacco dependence curricula in acute care nurse practitioner education. American Journal of Critical Care, 11, 27–33. Heath, J., & Crowell, N. A. (2007). Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty. Journal of Professional Nursing, 23, 189–200. Institute of Medicine of the National Academies. (2010). The future of nursing: Leading change, advancing health. Washington, DC: Institute of Medicine. Retrieved from http://www.iom.edu/Reports/2010/The-Future-ofNursing-Leading-Change-Advancing-Health.aspx Kenfield, S. A., Wei, E. K., Rosner, B. A., Glynn, R. J., Stampfer, M. J., & Colditz, G. A. (2010). Burden of smoking on cause-specific mortality: Application to the Nurses’ Health Study. Tobacco Control, 19, 248–254. Liu, T., Chen, W. Q., David, S. P., Tyndale, R. F., Wang, H., Chen, Y. M., Zhou, Q., Ling, W. H. (2011). Interaction between heavy smoking and CYP2A6 genotypes on type 2 diabetes and its possible pathways. European Journal of Endocrinology, 165, 961–967. Longo, D. R., Brownson, R. C., Johnson, J. C., Hewett, J. E., Kruse, R. L., Novotny, T. E., & Logan, R. A. (1996). Hospital smoking bans and employee smoking behavior: Results of a national survey. Journal of the American Medical Association, 275, 1252–1257.
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Longo, D. R., Feldman, M. M., Kruse, R. L., Brownson, R. C., Petroski, G. F., & Hewett, J. E. (1998). Implementing smoking bans in American hospitals: Results of a national survey. Tobacco Control, 7, 47–55. Maciosek, M. V., Coffield, A. B., Edwards, N. M., Flottemesch, T. J., Goodman, M. J., & Solberg, L. I. (2006). Priorities among effective clinical preventive services: Results of a systematic review and analysis. American Journal of Preventive Medicine, 31, 52–61. Mannino, D. M. (2002). COPD: Epidemiology, prevalence, morbidity and mortality, and disease heterogeneity. Chest, 121, 121S–126S. Mannino, D. M., Caraballo, R., Benowitz, N., & Repace, J. (2001). Predictors of cotinine levels in US children: Data from the Third National Health and Nutrition Examination Survey. Chest, 120, 718–724. Milionis, H. J., Rizos, E., & Mikhailidis, D. P. (2001). Smoking diminishes the beneficial effect of statins: Observations from the landmark trials. Angiology, 52, 575–587. Pickert, K. (2009). If a health-care bill passes, nurse practitioners could be key. Time U.S. Retrieved from http://www.time.com/time/nation/article/0,8599,1914222,00.html Rigotti, N. A. (2011). Integrating comprehensive tobacco treatment into the evolving US health care system: It’s time to act: Comment on “A randomized trial of Internet and telephone treatment for smoking cessation.” Archives of Internal Medicine, 171, 53–55. Rigotti, N. A., Munafo, M. R., & Stead, L. F. (2008). Smoking cessation interventions for hospitalized smokers: A systematic review. Archives of Internal Medicine, 168, 1950–1960. Sarna, L., Bialous, S. A., Rice, V. H., & Wewers, M. E. (2009). Promoting tobacco dependence treatment in nursing education. Drug Alcohol Review, 28, 507–516. Schroeder, S. A., & Warner, K. E. (2010). Don’t forget tobacco. New England Journal of Medicine, 363, 201–204. U.S. Department of Health and Human Services. (2004). The health consequences of smoking: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/reports/ U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/reports/ U.S. Department of Health and Human Services. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease. A report of the Surgeon General. Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of Surgeon General. Retrieved from http://www.surgeongeneral.gov/library Warner, K. E. (2007). Tobacco policy research: Insights and contributions to public health policy. In K. E. Warner (Ed.), Tobacco control policy (pp. 3–86). San Francisco: Jossey-Bass. Wewers, M. E., Kidd, K., Armbruster, D., & Sarna, L. (2004). Tobacco dependence curricula in U.S. baccalaureate and graduate nursing education. Nursing Outlook, 52, 95–101. Williams, S. C., Hafner, J. M., Morton, D. J., Holm, A. L., Milberger, S. M., Koss, R. G., & Loeb, J. M. (2009). The adoption of smoke-free hospital campuses in the United States. Tobacco Control, 18, 451–458. Williams, S. C., Morton, D. J., Jay, K. N., Koss, R. G., Schroeder, S. A., & Loeb, J. M. (2005). Smoking cessation counseling in US hospitals: A comparison of high and low performers. Journal of Clinical Outcomes Management, 12, 345–352.
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Nurse practitioners, wake up and smell the smoke Gale Barr, MSN, CNP (Nurse Practitioner)1 , Nancy Houston-Miller, RN, BSN (Associate Director)2 , Iyaad Hasan, DNP, CNP (Director)3 , & Geoffrey Makinson, PhD (Senior Director, Epidemiology and Population Health)4 1
University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio Stanford University School of Medicine, Stanford, California 3 Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio 4 Pfizer, Inc., New York, New York 2
Keywords Smoking cessation; nurse practitioners; policy; education. Correspondence Gale Barr, MSN, CNP, University Hospitals Case Medical Center, Seidman Cancer Center, 11100 Euclid Avenue, Cleveland, OH 44106. Tel: +1 216-286-3468; Fax: +1 216 286 5779; E-mail: [email protected] Received: March 2013; accepted: May 2013 doi: 10.1002/2327-6924.12049 Disclosures The authors would like to thank Carol Southard for her contributions at the planning stage of the manuscript. Iyaad Hasan has received speaker honoraria from Pfizer. Geoffrey Makinson is an employee of and shareholder in Pfizer Inc. Editorial support was provided by Helen Jones, PhD, of UBC Scientific Solutions and funded by Pfizer Inc.
Abstract Purpose: With the focus of modern health care on preventive care, and the well-known benefits of smoking cessation on improving health and reducing healthcare costs, smoking cessation is a key focus of healthcare reform. To change the smoking habits of the U.S. population, two strategies are of particular importance to healthcare professionals: promoting tobacco-free environments in healthcare systems and expanding affordable and effective treatments. Data sources: Recent policy literature. Conclusions: Barriers to providing smoking cessation counseling most frequently cited by healthcare professionals are lack of training and poor reimbursement; however, recent legislation, for example, the Patient Protection and Affordable Care Act (PPACA), should make preventive services more available and affordable. Nurse practitioners (NPs) have vast experience in addressing health promotion and disease prevention, and are therefore well placed to lead this reform. However, despite consistently higher referrals of tobacco-dependent patients for smoking cessation interventions than any other group of healthcare provider, evidence suggests that NPs are not adequately trained to treat this addiction. Implications for practice: This article is a call to action for NPs to become familiar with the tobacco cessation policy changes affecting clinical practice, to become experts in tobacco treatment, and to take the lead in this healthcare reform initiative.
Introduction The focus of health care today and in the future is on high-quality preventive care. Helping Americans to lead productive lifestyles, limiting or delaying chronic diseases, and lowering healthcare costs are key targets for healthcare reform and the new models of care, for example, Medical Home and payment reforms such as accountable care. These advances have placed the focus on primary care providers to enable this wave of change throughout the U.S. health system. However, the shortage of primary care physicians has resulted in the necessary expansion of the nurse practitioner (NP) role. NPs have vast experience in addressing the needs of health promotion and disease prevention, and as such, the new healthcare reforms place these professionals in a prime 362
position for cultivating the next generation of Americans to become healthier individuals. One preventive measure that needs to be addressed by all parties involved in health care is smoking cessation. Smoking is known to be a major contributing risk factor for a variety of diseases including lung, throat, oral, and other cancers (U.S. Department of Health and Human Services, 2004), cardiovascular disease (Grassi et al., 2010), and chronic respiratory illnesses (Mannino, 2002), and the association between smoking cessation and reduced all-cause mortality is well established (Doll, Peto, Boreham, & Sutherland, 2005; Kenfield et al., 2010). Smoking cessation is a key focus of reform because of the overwhelming volume of research demonstrating that the use of smoking cessation services can improve health, prevent the occurrence of costly diseases, and reduce
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healthcare costs. The prevalence of smoking in adults has stayed at approximately 20% for several years, despite the ultimate goal of 12% having been set by Healthy People 2020 (Healthy People 2013). The failure to lower the prevalence of smoking in the United States has galvanized numerous organizations to renew their efforts to reduce this, the single most common cause of premature death and disability in the United States today. Starting in the early 1990s, California (and a few other states) initiated policy changes (including an increase in tobacco taxes) that have resulted in a current smoking rate of 12% in that state, meeting the objective set by Healthy People 2010 for the entire nation (Mannino, Caraballo, Benowitz, & Repace, 2001). However, smoking remains the leading cause of preventable mortality in the United States, with one in every five deaths being linked to the use of cigarettes (U.S. Department of Health and Human Services, 2010). This review article is a call to action for NPs to become familiar with the tobacco cessation policy changes affecting their clinical practice, to understand why this disease needs more attention, and to highlight ways to better equip future generations of NPs to change the future of smoking in the United States.
Policy changes and health care: Impact on smoking The decline in tobacco use in the United States during the past 40 years has been driven largely by four policy changes: (a) cigarette price increases through increased taxation; (b) comprehensive smoke-free policies extending to clean indoor air; (c) media/advertising campaigns to counter the pro-tobacco industry; and (d) greater access to affordable and effective treatments and services for smokers (Schroeder & Warner, 2010). It is estimated that if each U.S. state worked for 5 years on these initiatives, 5 million fewer individuals would smoke, thus preventing a large number of deaths (Centers for Disease Control and Prevention, 2006). Two of the aforementioned strategies are of particular importance to healthcare professionals: promoting tobacco-free environments (both indoors and outdoors) in healthcare systems, and expanding affordable and effective treatments for smokers. The policies related to these strategies and additional initiatives from national organizations are described below.
Healthcare systems promoting tobacco-free environments In 1992, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) launched an initiative requiring all accredited hospitals to ban indoor smok-
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ing, which subsequently led to the first industry-wide ban on smoking in the workplace (Longo et al., 1996). While this initiative resulted in a reduction in smoking among employees, it did not influence overall levels of smoking cessation (Longo et al., 1998). Immediately following the ban, 43% of hospitals initiated campus-wide prohibition of smoking in outdoor areas such as entranceways, grounds, and parking areas. Healthcare organizations have offered varying restrictions on the expanded JCAHO initiative: some dictate entire campus smoke-free policies without exception while others exempt defined populations of patients (e.g., those in psychiatric or longterm care) or allow physicians to override the policy; some organizations continue to designate outdoor areas for smoking. In 2002, the JCAHO began tracking performance data for patients with acute myocardial infarction (AMI), heart failure, or pneumonia who received smoking cessation counseling (Williams et al., 2005). In a recent analysis of 1916 hospitals, 45% had adopted a smoke-free campus policy. Those hospitals with smoke-free campuses were significantly (p < .001) more likely to report smoking cessation counseling for patients with AMI, heart failure, or pneumonia who smoked compared with hospitals that were contemplating a smoke-free campaign or those that had no smoke-free campus policy (Williams et al., 2009). However, these differences were small and reflected primarily the demographic attributes of the patient populations within hospitals rather than the hospital smoking policy (Williams et al., 2009). The Surgeon General’s 2006 report on “The Health Consequences of Involuntary Exposure to Tobacco Smoke” points out that workplace smoking restrictions decrease the number of cigarettes smoked by employees (U.S. Department of Health and Human Services, 2006).
Expanding treatments and services to smokers In addition to implementing strict indoor and outdoor smoking restrictions within workplace environments— including healthcare settings—there are numerous opportunities to improve upon and expand the availability of smoking cessation services. Barriers to the adoption of these services include: lack of insurance coverage for smoking cessation behavioral counseling and pharmacotherapies; lack of resources in many states to support ongoing quitlines; limited availability of services for Medicaid patients; limits on medication and counseling duration, and prior authorization for medications; and challenges posed by vulnerable populations including the mentally ill, substance abusers, and the poor (Abrams, Graham, Levy, Mabry, & Orleans, 2010; Warner, 2007). However, these barriers should not be a deterrent to 363
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focusing on those in greatest need within the healthcare system. As Rigotti has noted, the need for tobacco dependence treatment can no longer be ignored. She sets out a plan for all hospitalized patients, outlines the need for intervention, and provides an overview of the federal health policy developments that can lead to healthcare reform and new laws (Rigotti, 2011). The hospital is an effective environment for initiating and providing an entryway for smoking cessation counseling, but the resources required to enable effective relapse prevention are generally lacking. Furthermore, hospitals are currently not reimbursed for services provided to patients following discharge. However, this is changing, and in the future, healthcare systems will likely be rewarded for managing chronic disease and improving the long-term outcomes of patients. A recent meta-analysis of hospital-based studies showed that smoking cessation during hospitalization followed by relapse-prevention contact for more than 1 month increased cessation rates at 6 and 12 months with an odds ratio of 1.65 (Rigotti, Munafo, & Stead, 2008). No benefit was shown for interventions that included active counseling during hospitalization only.
Other policy changes In March 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law, the aim of which is to improve access to care and subsequent health outcomes. Under this law, for example, it is a requirement that state Medicaid programs cover comprehensive tobacco cessation treatments for pregnant women without a requirement for cost sharing (Healthcare.gov, 2011). Furthermore, the smoking rate among Medicaid recipients is 36%, compared with 21.6% of the general population, and accordingly, there is an even greater opportunity to reduce smoking through offering tobacco-related counseling in the Medicaid population (Centers for Disease Control and Prevention, 2007). Under the PPACA, private health insurance plans will also be required to cover 45 preventive services for adults graded “A” or “B” as recommended by the U.S. Preventive Services Task Force (Fiore et al., 2008). Because of the high certainty of substantial benefit, the list of preventive services includes tobacco cessation. Treatments will include those endorsed by the U.S. Public Health Service Tobacco Use and Dependence guideline, including FDA-approved medications and cost-effective counseling (Clinical Practice Guideline Treating Tobacco Use and Dependence 2008). As noted in a recent article, Maciosek and colleagues have identified several clinical services recommended by the U.S. Preventive Services Task 364
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Force that would produce medical net savings if utilization rates were increased to 90% of the U.S. population. Three services—tobacco use screening and assistance; discussion of daily aspirin use; and alcohol screening with brief counseling—contributed more than $1 billion each to net medical savings (Maciosek et al., 2006). The federal government—through the Health Information Technology for Economic and Clinical Health Act (HITECH)—is committing numerous resources to support the adoption and use of electronic health records. As part of another policy change, smoking status will be required as a coded field on electronic health records, and in order to qualify for incentive payments, reporting of data will be required not only of hospitals, but also by clinicians (Blumenthal & Tavenner, 2010).
Tobacco cessation as a priority for NPs The switch in focus of the healthcare provider role to wellness and preventive service is now stronger than ever. It is well known that many chronic diseases such as heart disease, cancer, and diabetes are preventable, yet they account for approximately three quarters of the current health spend. In covering recommended preventive services without charging a deductible, copayment, or coinsurance, the Affordable Care Act will make preventive services more readily available and affordable. Additional healthcare reform aspects and newer models of care also place a greater responsibility on healthcare providers to provide preventive care. The focus is simple: providers will get paid for the service that they provide based on how healthy they are able to keep their patients (and on the level of patient satisfaction with that service). Therefore, healthcare providers are being asked to treat and control disease, while integrating health promotion with disease prevention to maximize reimbursement. Health promotion and disease prevention has formed the core of the NP role since its inception in 1965. The vision at that time was that NPs would help to reduce healthcare costs and become providers in situations where resources were limited. The acceptance of NPs by other healthcare professionals and the public, coupled with greater political stature and self-regulation, has increased the scope of the work performed in this discipline. The Institute of Medicine (IOM) 2010 report on the future of nursing (Institute of Medicine of the National Academies, 2010) has reinforced the role of NPs in today’s healthcare practice. With policy change and newer models of care—for example, Accountable Care Organizations (ACOs)—the NP role offers the chance to play a key role in changing the future health prospects of millions of Americans. Results from a Pfizer-sponsored online survey of 3613 adult smokers, conducted from
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September 2006 through October 2010, show that of 76% of smokers who consulted a primary care physician, 45% did not have a discussion about smoking cessation with that provider. This equates to providers talking to just one in two smokers who entered their office. The list of obstacles stated by providers as barriers to their interaction with smokers included lack of time, fear of angering the patient, being of the opinion that the visit scope does not warrant that discussion, and a perception that the majority of patients do not want to quit. However, the two barriers most frequently cited are training and reimbursement. Most providers in practice today do not receive any form of training in relation to tobacco cessation. There have been recommendations by government and regulatory groups to introduce curricula that mandate the study of smoking cessation. If these changes are made, providers will gain improved confidence in their ability to provide counseling. However, the most likely reason why many providers do not focus on smoking cessation is poor reimbursement of the service. Codes (CPT 99406 and 99407) for smoking cessation counseling are available and may be accepted, but most U.S. health insurance plans (both public and private) do not provide coverage for tobacco addiction treatment. Hopefully, with the implementation of the new federal healthcare reform, providers will increase their impassioned focus on tobacco cessation and their patients will have a better chance of achieving disease control and healthy lives. There will be more coverage for Medicaid patients and stronger recommendations for private group and individual health plans to cover all recommended preventive services, including smoking cessation. As previously stated, obtaining reimbursement is becoming more a function of achieving and maintaining the best possible health status for patients. Commonly used metrics include glycated hemoglobin (Hb A1C), blood pressure, weight, and cholesterol (Fisher & Shortell, 2010). Currently, it appears that providers fail to realize the impact that smoking cessation can have on these metrics, and how in a business sense, they can get a better “return on investment” by helping a smoker to quit. Furthermore, the incidence and severity of chronic diseases in tobacco users are worse compared with nonsmokers; hypertensive smokers have a poorer cardiovascular risk profile than nonsmokers, despite receiving appropriate treatment; smokers have a 61% higher risk of cardiovascular events compared with nonsmokers when treated with statins for secondary prevention; and HbA1c levels in smokers can be increased from 9% to 34.5%, depending on nicotine exposure (Liu et al., 2011; Milionis, Rizos, & Mikhailidis, 2001). If healthcare providers increase their focus on tobacco cessation, patients would
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have a better chance of achieving disease control, and in the long run, better reimbursement would be achieved by healthcare providers taking this approach.
Recommendations for NP programs and education The need to provide care to some 50 million currently uninsured Americans will be a daunting task for healthcare reformers, as there will not be sufficient numbers of doctors to care for the volume of new patients. Even without reform, there is currently a 30% shortage of primary care physicians, with most new doctors choosing more lucrative specialties (Pickert, 2009). NPs could be a key to filling this gap, as they are capable of providing many of the same services more cost effectively. Furthermore, the NP role is focused on patient-centered care and preventive medicine. Despite the fact that tobacco abuse (and its contributory effect on a myriad of chronic diseases) remains the leading preventable cause of death in the United States, evidence suggests that NPs are not adequately educated to assist with the treatment of this addiction. Results from a cross-sectional survey, in which a questionnaire that measured tobacco content curricula was sent to 909 baccalaureate and graduate nursing program associate deans from institutions who were members of the American Association of Colleges of Nursing, revealed that only 1–3 h was spent on tobacco treatment in graduate nursing programs (Wewers, Kidd, Armbruster, & Sarna, 2004). In the past decade, the disciplines of medicine, dentistry, and pharmacy have integrated tobacco education into their curricula, whereas nursing has trailed behind (Heath & Crowell, 2007). Most nurses, who form the single largest group of healthcare professionals (over 3 million in the United States [Health Resources and Services Administration, 2010] and 17.3 million worldwide [Sarna, Bialous, Rice, & Wewers, 2009]) want to provide smoking cessation education, but they have not received the necessary information and/or skills training to provide effective interventions. There is an indication that nurses have achieved effective outcomes in a variety of clinical settings when they use tobacco-cessation interventions based on “best practice,” yet they fail to offer patients tobacco addiction treatment guidance. Also, as Heath et al. reported, nurses and NPs consistently refer a higher number of tobacco-dependent patients for smoking cessation interventions than any other group of healthcare providers (Heath, Andrews, Thomas, Kelley, & Friedman, 2002). NPs could be the profession to take the lead in becoming experts in tobacco treatment. However, they cannot take the lead in this endeavor until they are properly 365
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trained, and they cannot be properly trained until a number of changes occur. Our suggestions for change are as follows: 1. In-depth tobacco treatment education must be provided in each and every NP graduate program across the United States. We suggest a 5-day course in line with national standards of education for Tobacco Treatment Specialists (TTSs). This course should contain enhanced instructional methods including counseling roleplay with providers, which includes education on the parts of the brain involved in nicotine addiction and the brain reward center as it relates to nicotine receptors. This is important information to relay to smokers along with the mechanism of action of smoking cessation drugs, their side effects, and what they should expect when experiencing nicotine withdrawal. The cost of TTS certification training can range from $500 to $1000 per participant. To integrate TTS certification into NP education, the course could at first be elective, with the goal for it to become mandatory in the future. Funding for NP students to become certified TTSs would need to be secured through government or university grants. 2. In concert with The Association for the Treatment of Tobacco Use and Dependence (ATTUD), after attendance of the 5-day course on tobacco treatment, students would become certified TTSs. 3. NP licensure certifying agencies should include questions concerning tobacco treatment in their tests. 4. The NP, as a certified TTS, could be a new required area of expertise in NP education and practice. Although at present there is no national certification organization for TTSs, there are several training programs across the country with established standards and core competencies overseen by ATTUD. The requirements for this certification are 480 service hours focused on tobacco dependence treatment as part of direct patient care for those with a bachelor’s degree or 240 service hours for those with a graduate degree or higher. The applicant must be a nonsmoker and must also complete a 5-day TTS training program and achieve the pass score of 80% on examination. Graduate nursing faculty who complete the TTS certification could initiate collaboration between TTS training programs to offer NP students web-based training to become a certified TTS. 5. Select graduate nursing faculty who have completed the TTS certification can provide guidance to students, in addition to working alongside other TTSs. 366
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6. NPs working in primary care should have the ability to create a tobacco treatment clinic within their current practice and devote 1 day per week to tobacco treatment in patients. 7. NPs working within major medical centers should have the ability to develop NP-led tobacco treatment centers. These centers can become smokers’ “Refer to” place, and would thus help reduce the time constraints on nurses and the current low selfefficacy for providing smoking cessation counseling. Tobacco treatment centers should become a standard clinic in each hospital across the country. 8. Graduate schools of nursing should teach students how to start their own businesses and how to approach healthcare administrators of hospitals with the aim of starting an NP tobacco treatment center. 9. The delivery of smoking cessation interventions needs to become an indicator of quality nursing care. 10. The nursing profession must be held accountable for making necessary changes to ensure that they support nicotine addiction prevention and treatment into standard practice. 11. Nursing professional organizations need to do more to set standards for professional competency in tobacco treatment and control. 12. All advanced practice nurses (APNs) educators should be educated on the U.S. Public Health Service (USPHS) guidelines for tobacco dependence and should provide a copy to each and every graduate APN. 13. Continuing education for nurses should include education on brief cessation intervention and should, at least, include the basic “5A”s model for treating tobacco use and dependence. 14. Further research must be initiated and must focus on the role of APNs in smoking cessation. 15. NPs need to assume leadership roles in the field of nursing to lead the change in how nurses view tobacco treatment. Nurses have always been deeply committed to doing what is right for their patients, which has promoted the public’s respect. With our commitment to health promotion and disease prevention, NPs could be the profession to lead the country and world in breaking the deadly cycle of tobacco dependence.
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