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Treating Tobacco Dependence: Interdisciplinary Perspectives ATTUD Interdisciplinary Committee October 16, 2013
Treating Tobacco
Dependence:
Interdisciplinary
Perspectives
ATTUD Interdisciplinary
Committee
October 16, 2013
ATTUD is an organization of providers
dedicated to the promotion of and
increased access to evidence-based
tobacco treatment for the tobacco user
A Needed Care Continuum
ATTUD represents over 40
disciplines and specialties
engaged in treating tobacco
addiction
Interdisciplinary Committee
• Represents the interests
of the many disciplines
that provide treatment
• Ensures the interests of
all professions and
disciplines are
represented
• Ensures that members
are treated with
respect regardless of
discipline
The committee will foster bi-
directional learning and information
sharing by: Enhanced linkage to national professional
organizations and
Building resources for ATTUD members
regarding the specialty roles various
disciplines play in treating tobacco
dependence and disseminating practical
guidance
Interdisciplinary Committee
Patient Vignette
Gloria
Gloria is a 45-year-old,
English speaking Latino
Medicaid coverage
GED-level education
Married, and her husband also
smokes
Fear regarding withdrawal symptoms
and weight gain
Husband is supportive but not
interested in quitting
Patient Description
Began smoking at age 15, and has
been a pack a day smoker for the last
15 years
First cigarette is immediately upon
awakening
Has had at least five past quit
attempts. All these attempts were
“cold turkey”
The longest abstinence was five
months
Her 18 year old daughter is now also
smoking
Patient Description
Has Type 2 diabetes
History of depression, and at one time was
hospitalized for severe depression and
thoughts of suicide
Currently taking trazodone at a stable
dose for the last year
Reports shortness of breath with exertion
but no chest pain
Has periodontal disease
Last dental exam also revealed the
presence of leukoplakia on the right
buccal mucosa
Patient Description
Multiple Case Perspectives
• Social Work
• Psychology
• Registered Nurse
• Dental Healthcare
• Respiratory Care
Social Work
Donna Richardson
Establishment of helping
relationship is critical to our
work
Trust
Cultural humility/ worth
of every individual
Self-determination
Demonstration of
competence/ ability to
find resources
Human kindness
Social Worker
Social Worker
Person in
Environment
Mental Health
Physical Health
Social Roles in
Relation to Others
Social Environment
Classic Family
Therapy Question:
Why now?
Social Worker
Therapeutic Change
40% extra therapeutic factors such as safe &
stable housing, secure employment,
adequate $, positive interactions & supports in
the community
30% Gloria’s experience of therapeutic relationship (non-judgmental, respectful,
honest, appears to care)
15% individual’s sense of hope and expectations for growth
15% techniques & skill of helper
Derived from Lambert & Barley, 2001
Psychology
Chad Morris
Psychology
Bio-psycho-social
approach
Assess psych history
Current and past
depression, suicidality
Rule-out bipolar disorder
Med levels affected by
smoking
Trazodone
Bupropion for depression
and cessation?
Psychology
During quit attempt
Monitor for depressive
symptoms
Differentiate between
expected withdrawal
and psych symptoms
Caffeine use?
Cognitive Behavioral
Therapy
Psychology
Education
Whole health perspective
e.g., Long-term association of smoking and
greater depression and anxiety
Support
husband
Has she found strategies to effectively
manage her diabetes?
Modeling for daughter
Registered
Nurse
Maria Feo
Nursing Nursing workforce is strategically situated to make an
impact on the leading cause of preventable mortality
and morbidity: tobacco use
Most trusted healthcare professional (Gallup, 2012)
Nurses have a long history of promoting health and
preventing illness
Evidence-based bio-psychosocial and holistic
approaches, and cultural awareness to care delivery
embedded in the nursing curriculum
Extensive access to clients in a variety of settings across the continuum of care
Nursing Tobacco-Related Disparities and Cultural Care
Ensure disparity issues remain primary concern in a
strategic plan
Remain culturally sensitive
Advocate and support funding on all levels
Refer to Quitline (multiple language counseling options)
Implement/ Support programs and interventions for
behavioral health clients
Collaborate closely with public health venues, coalitions,
and community support groups
Consider enlisting a (Latino) community outreach
coordinator
Nursing
Complete health history and physical assessment and a
(possible)family pedigree
Allow autonomy while encouraging self-management skills,
lifestyle modifications, and tobacco cessation
Referral to a Medicaid accepting PCP (preferably a PCMH)
and other eligible services(dental/counseling/NRT)
Plan of care to include patient/family education of
tobacco-related disease processes and interactions with
co-morbidities and medications
Careful integration and monitoring of pharmacotherapy if indicated
Recognize and validate Gloria’s concerns regarding withdrawal symptoms, depression, triggers, and weight gain
Nursing
Nurses are the largest workforce of healthcare providers and are advantageously poised to make a difference in ending a
fatal epidemic
Advocate for the tobacco-dependent population
Recognize tobacco dependence as a chronic disease
Nurses can influence change across the continuum of care
via collaborative relationships, establishment of evidence-
based protocols, policies, and population-health programs
to benefit communities served
Dental Healthcare
Provider Jill Loewen
Dentistry
Trusting relationships with our patients
Convenience- not to be referred or have to
go somewhere else
Opportunities for encouragement, support
and follow-up
Impact on oral health- more successful
treatments and outcomes
Health consequences usually seen orally first
Contributes to the quality of care and
comprehensive care
Dentistry For oral health, our focus:
Bad breath
Gum/periodontal disease (indicated for this case)
Sore throat/hoarseness
Reduced smell/taste
Unhealthy tissue (indicated for this case)
Delayed healing
Oral cancer
Throat cancer
Teeth staining
Poor response to dental treatment
Oral lesions/ sores on mouth, lips, or tongue
Additionally exposure to tobacco has been linked to
Doubling a child’s risk of caries in the primary dentition
An association with delayed and irregular tooth formation
Benefits to her oral health:
Decrease stains on your teeth and gums
Prevent bad breath
Lessen the amount of tartar and build-up
on your teeth
Reduce your risk of oral cancer:
Leukoplakia is a precancerous condition
that most likely will disappear with no
further tobacco use
Improve healing after a tooth extraction or
other oral surgery
Better response to periodontal treatment
and healthier gum tissue as an outcome
Risk for tooth loss decreased, with improved
periodontal condition (bone loss and tissue
inflammation minimized)
Dentistry
Dentistry
Dental practice in the 21st
century will increasingly
move from a restorative
orientation to one of broader
promotion of health and
well-being. It is
unconscionable to not
include aggressive tobacco
intervention in that new
paradigm.
28
Tomar 2001
Respiratory
Care
Practitioner
Susan Ryan &
Laura Van Heest
Respiratory Care Practitioner Working partnership with
clients, with high degree of
trust and mutual respect
Comprehensive knowledge
about health effects –
helping clients understand
‘cause and effect’ related to their health concerns
Able to explain concepts
such as relationships
between Carbon Monoxide
(CO) and stamina in lay
terms
Have coping skills ‘tool
kits’ that also help
improve work of
breathing and ADLs for
clients with pulmonary
disease
Able to provide social
support for chronically ill
clients by inclusion in
support groups
Trusted health team
members- recognized
expertise and good
rapport with physicians.
Respiratory Care Practitioner For Gloria, counseling from an RC perspective
would likely include exploring the importance of
improving her breathing and stamina, and
offering information and coping skills that help
manage both smoking urges and SOB
Offering information about possible added risk for
alpha-1 antitrypsin deficiency and COPD in some
Latinos might enhance Gloria’s commitment to
quit
Social support via pulmonary rehab and support
groups should Gloria have early COPD, asthma,
etc.
Respiratory Care Practitioner Value-added knowledge related to health care
problems important to the client.
Tie to health-related goals and desires, even
when faced with significant chronic health
problems.
RCPs can be especially effective working with clients concerned with:
COPD,
Lung CA,
Asthma,
Cystic fibrosis,
Alpha-1 antitrypsin deficiency,
Chronic bronchitis,
Bronchiectasis,
Secondhand smoke cardiac
and vascular disease
Concluding Thoughts
Concluding Thoughts
Healthcare has an increasing
prevention and wellness focus
Wellness is everyone’s responsibility,
and not the exclusive purview of any
one discipline
Tobacco use is a complex social,
environmental, and biological
problem… no single perspective is
sufficient
Comorbidity is the rule not the
exception
A “Call” for integrated systems of
care
“…never lose an opportunity of urging a
practical beginning, however small, for it is
wonderful how often in such matters the
mustard-seed germinates and roots itself.” ― Florence Nightingale
Interdisciplinary Committee
Angela Brumley-Shelton
Maria Feo
Frank Leone
Jill Loewen
Chad Morris
Donna Richardson
Susan Ryan
Laura Van Heest
www.attud.org
