Respiratory therapy and tobacco: Exploring our role.

In the current issue of the Journal, we have curated a series of articles and commentaries on a longstanding public health issue: tobacco. Jason W Nickerson Tobacco use and smoking cessation have long been at the forefront of discussions of respiratory health, and tobacco is arguably one of the most significant contributors to respiratory-related morbidity and mortality. While remarkable gains have been made in reducing the prevalence of tobacco use among Canadians over several decades, the number of Canadians who continue to smoke remains stubbornly high. The public health consequences of this are extraordinary: chronic obstructive pulmonary disease, the most obvious consequence of prolonged cigarette smoking, is one of the leading causes of health service utilization, with staggering financial and social consequences. A considerable amount of work has been done by health promoters, addiction specialists, respiratory therapists and other health professionals to make the public aware of the harms of tobacco use and to manage its associated harms. Despite this, the complexity of the problem appears to present a rate-limiting step. Despite a desire to view the problem in the context of a binary solution – to smoke, or not to smoke – tobacco use is, in fact, the result of a constellation of linked problems embedded in the fabric of clinical medicine and population health. Great strides have been made to improve the management of people who smoke cigarettes, and there is growing recognition of the need to standardize and professionalize the training and accreditation that health professionals receive to provide smoking cessation services effectively. An article in the current issue describes the growth of this process in Canada and the move toward a standardized credential for smoking cessation providers, highlighting the need for these services to be evidence-based and accountable to patients and health systems. This achievement builds on the growth and expansion of models of smoking cessation provided in hospitals and in communities, which are increasingly becoming recognized as a standard of care for patients who smoke. These initiatives, combined with health promotion and other campaigns, comprise a significant advancement in reducing the number of individuals who smoke cigarettes. However, there are several unanswered questions that must be addressed to understand more comprehensively how best to continue to reduce the prevalence of tobacco use among Canadians: What are health professionals and patients to do about nicotine replacement therapies and other pharmacological agents that cost money and are rarely a publicly insured service outside of hospitals? How do we ensure that smoking cessation services are provided equitably across the population, ensuring that they are equally accessible to socioeconomically disadvantaged smokers, as well as to those with greater financial means? At what point does tobacco taxation become a punitive tax on those with an addiction, rather than a deterrent to tobacco use? Each of these questions, among others, points to a need to think of tobacco use not only as a medicalized problem, but as a complex social and societal one that lacks a clear solution. In public health, this might be termed a ‘wicked’ problem, not because of the implication that the problem is evil, but because of the lack of a linear, single solution to a constantly evolving problem (consider the emergence of electronic cigarettes) (1,2). What we hope the current issue brings is some renewed insight into a longstanding public health problem that affects us as respiratory therapists, who are responsible for educating, advocating and caring for patients who either currently use tobacco or have in the past. This issue intersects closely with the practice of respiratory therapy, yet the role of respiratory therapists as smoking cessation specialists or public health advocates has not been carefully described. This should change. What we also hope to foster through these articles and commentaries is the recognition that tobacco use is, in fact, a chronic relapsing disease that requires a coordinated approach to support individuals through programs ranging from educational to pharmacological interventions. This must, of course, be met with action at the population level to improve equitable access to these resources and services, ensuring that those who need them most have access. In short, we believe that this issue was an essential contribution to a discussion that has been ongoing for decades, and continues to have contemporary challenges and successes. More work remains, for certain, and it will be essential that respiratory therapists play a leading role in caring for patients who smoke, advocating for equitable access to comprehensive smoking cessation services and leading the public health discussion around reducing tobacco use.

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