POINT: Are advanced practice professionals more likely to achieve better tobacco cessation results than physicians? Yes

Hitsman, Brian; Baker, Amanda; King, Andrea

Title: POINT: Are advanced practice professionals more likely to achieve better tobacco cessation results than physicians? Yes
Creator: Hitsman, Brian; Baker, Amanda; King, Andrea
Relation: Chest Vol. 152, Issue 3, p. 466-469
Publisher Link: http://dx.doi.org/10.1016/j.chest.2017.03.031
Publisher: Elsevier
Resource Type: journal article
Date: 2017
Description: Despite that the prevalence of smoking among adults in the United States and many other high-income countries has reached historic lows (15.1% in the United States), smoking continues to be the single largest preventable cause of disease and premature death. The decline in smoking has not occurred equally across society. Rates remain much higher among certain groups, such as people living with mental health or substance use problems, or both. Consequently, there are major disparities in the incidence and prognosis of smoking-related respiratory diseases, including COPD. Specialty health-care settings such as those providing respiratory therapy offer a unique yet still untapped potential to address smoking behavior. As recommended in the 2008 US Public Health Service guideline for treating tobacco use and dependence, at every visit all patients should be assessed for smoking, advised to quit, and offered treatment consisting of behavioral counseling and pharmacotherapy. In general health-care settings, behavioral counseling added to medication improves smoking cessation outcomes. We believe that physicians can provide effective treatment and should continue to do so within the time they have available. However, we argue that advanced practice professionals (APPs), interpreted broadly to include behavioral health specialists such as psychologists, clinical social workers, and addiction counselors, are generally better suited than physicians to provide smoking cessation treatment in specialist settings and are likely to achieve better results. In this paper, we describe our rationale for this position based on provider and patient characteristics in the specialty respiratory clinic setting. Importantly, APPs are more likely to use a collaborative vs prescriptive counseling style, enhancing establishment of a good relationship with patients, the vast majority of whom may be unable or unwilling to commit to making an attempt at quitting in response to physician advice. In contrast, physicians are often more directive in their communication style and tend to provide specific advice for quitting smoking, not having the time or behavioral training to work on shaping behavioral change toward this goal. These types of interactions could potentially lead to reluctance on the part of the patient to be forthcoming in communication, fully disclose their smoking status or behavior, and form a therapeutic alliance. As some patients, including those with COPD, are susceptible to underreporting smoking status or smoking behavior, fostering a strong therapeutic alliance is essential to effective treatment. There are other advantages that make APPs uniquely qualified to address smoking (Table 1). First, their expertise in the psychological theory and skills involved in assessment and counseling render them uniquely qualified as front-line smoking cessation providers. Second, APPs are better equipped to customize patient care to incorporate the unique features of nicotine dependence with the psychological comorbidities that often accompany it. Smokers are more likely than nonsmokers to experience mood, anxiety, and alcohol/drug use disorders, and these comorbidities need to be taken into consideration. Smokers with COPD are especially likely to present with depression and anxiety, which may affect adherence to treatment and interfere with quitting smoking. Given their experience in treating a range of chronic behavioral conditions, APPs are more likely than physicians to view nicotine dependence as a chronic condition requiring long-term treatment and relapse prevention. As smoking usually begins in adolescence, it represents a longstanding addiction for many patients in the respiratory health setting. For these patients, optimal treatment may require a longer duration of treatment or adjunctive behavioral treatments that target smoking behavior in the context of psychological distress. Third, APPs may be more likely than physicians to be able to link behaviors that cluster together to enhance readiness to quit smoking. For example, strategies for stress, weight, and fatigue management include healthy eating and walking and other forms of exercise, all of which dovetail into treatment strategies for COPD and smoking cessation. Patients with COPD in particular may be better served by APPs, who are more likely to work with a patient across an extended period to foster motivation. APPs are also more equipped than physicians to work with patients on proximal goals, such as reducing the number of cigarettes smoked per day or considering their medication options, or both.
Subject: tobacco cessation; premature death; COPD
Identifier: http://hdl.handle.net/1959.13/1352662
Identifier: uon:30933
Identifier: ISSN:0012-3692
Language: eng
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