Change the Way You View Smoking

In an era when tobacco cessation programs are being cut from tight budgets, we need to be intentional and creative with tobacco cessation opportunities. According to Dr. Steven Schroeder of the Smoking Cessation Leadership Center at the UCSF School of Medicine, changing the way we view tobacco dependence is necessary to reduce tobacco use and save lives. If we all work together to increase the cessation rate from 2.5 percent to 10 percent, we can save 1.2 million additional lives!

Why is it difficult for people with diabetes to quit smoking? Is it because they fear that they will crave food, gain weight, and find it more difficult to control their blood sugar?  Is it because they are at an increased risk for depression, making it harder to quit? I believe that it is because tobacco dependence is a chronic disease and that quitting successfully requires ongoing medical management and support. Until healthcare providers focus on tobacco dependence, we won’t see tobacco rates decline. As a diabetes educator, I ask all my patients with diabetes if they use tobacco and include cessation support in their care plan.

Cigarette smoking continues to be the leading preventable cause of death in the United States, from both direct exposure and secondhand exposure. What are we doing wrong? I think that healthcare providers are frustrated with their lack of success and have focused their attention on other issues. For most people, it can take many attempts to finally quit, but each attempt increases their chance of success.  Another concern for healthcare providers is the recent evidence suggesting that tobacco use may be an independent risk factor for type 2 diabetes.  Now is the time to regroup and revitalize our tobacco cessation efforts.

We need to utilize every resource at our disposal to improve tobacco cessation.  A critical, often over-looked tool is medication. When I recently made a presentation to over 90 nurses, very few of them knew how to educate their patients about nicotine replacement therapy. They didn’t know that nicotine gum should not be chewed, but rather “parked” between cheeks and gum most of the time. They didn’t know that nicotine isn’t absorbed when swallowed. Nor did they know that nicotine absorption is reduced if the patient drinks coffee, beer, soda, or milk within 15 minutes before or after the medication. I challenge all diabetes professionals to educate themselves regarding tobacco cessation medications to help support their patients.

Medication often fails because patients don’t receive adequate instruction. Pharmacists distribute over-the-counter medication, but many do not know how to adequately instruct patients on the correct technique.

Another tool to help support tobacco cessation is the electronic medical record. At Sutter Medical Foundation, listing “tobacco dependence” on the problem list generates a health maintenance “field” for ongoing tobacco cessation counseling.  Every provider has access to this information during all routine visits. In addition, every encounter includes a question on verifying tobacco use status.

Let’s strive to incorporate tobacco dependence treatment into the Chronic Care Model of care. I encourage all providers to ask every patient, at every visit, about tobacco use.  Let’s train all support staff to document tobacco use status in the medical record.  Let’s implement workflows that encourage staff to advise all patients who use tobacco to consider quitting. Let’s have resources available, such as quit line phone numbers, so that we can refer all patients to cessation services.  Even if the patients are not ready today, they will have the information they need when they do make the decision to quit.  The more we encourage, the greater the potential success.

Sutter Medical Foundation has partnered with the California Diabetes Program and the California Smokers’ Helpline to implement a system-wide tobacco cessation intervention. We plan to train all medical assistants to be tobacco cessation “promoters” by implementing the “Ask, Advise, Refer” 30-second intervention with every patient, at every visit. 

By implementing simple changes, we hope to improve the health of people with diabetes and improve the quality of care that patients receive.  Studies have shown that even if they are not ready to quit, people are more satisfied with healthcare providers who offer tobacco cessation support.  There is more information in this issue of Diabetes Health, with links to resources. I encourage you to be tobacco cessation promoters with your patients, other staff members, and your family and friends.

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