Improving the health of Canadians: Why a certification program for tobacco educators is necessary.

Tobacco use disorder is recognized as a chronic, relapsing condition, listed in both the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (1) and the International Classification of Diseases (2). Tobacco cessation requires a comprehensive approach that combines motivational interviewing techniques, pharmacological options and client-centred education (3,4). Health care professionals currently provide a limited amount of support to their clients in tobacco cessation, even though support has been shown to be a significant factor influencing quit rates (5).

The Canadian Society of Respiratory Therapists’ smoking cessation position statement states respiratory therapists “advocate and encourage smoking cessation” (6). However, a joint statement of health care professional organizations, including the Canadian Society of Respiratory Therapists, indicates that health care professionals are not confident in providing tobacco cessation support due to “insufficient education” (7). This gap in education points to a need for additional training for respiratory therapists in tobacco cessation to further develop their competencies in this area.

The present commentary argues that a national, competency-based training and certification program will enable health care professionals to develop the skills and knowledge to support their clients through tobacco use disorder. A comprehensive approach to tobacco use prevention and cessation that is founded on the principles of client education will be reviewed as an effective means for reducing the burden of disease and suffering caused by tobacco use.

The fight against the use of tobacco is a personal one for the authors of the present commentary. We have lost family members, friends and clients to chronic obstructive pulmonary disease, cancer and heart disease caused by tobacco. The fight against tobacco has been ongoing and, while there is a decrease in the prevalence, tobacco continues to be the leading cause of death in Canada (8).

THE PROBLEM

According to the Canadian Tobacco, Alcohol and Drugs Survey (9), the overall smoking prevalence in 2013 was 15% (4.2 million smokers). Eleven percent (3.1 million) reported smoking daily while 4% (1.1 million) reported smoking occasionally. More males (16%) reported smoking than females (13%) (9). This prevalence translates to 59% of Canadians exposed to second-hand smoke, with 13% exposed on a daily basis (9). Tobacco use is a global epidemic, with more than one billion individuals who smoke worldwide (10).

The Conference Board of Canada estimated the economic cost of smoking to be $11.4 billion (0.68% gross domestic product) in 2010, due to lost productivity caused by unsanctioned breaks, absenteeism, short- and long-term disability, and premature mortality (11). Health costs related to tobacco use were estimated to be $4.4 billion direct costs with 2.2 million acute care hospital days in 2002 (12).

Tobacco use disorder is a complex disease that causes significant changes to the mental and physical health of an individual. Similar to other chronic disorders, clients who use tobacco require the highest levels of care. This is especially true because tobacco use causes or exacerbates a wide variety of other conditions. While the disorder can be treated, many health care professionals fail to provide adequate support to their clients due to lack of understanding of cessation methods, lack of institutional support and a reluctance to recommend pharmacotherapies (4). This support is a critical component of reducing smoking rates because interventions from health care professionals can increase cessation attempts (13). Unfortunately, support offered from different health care professionals varies substantially across disciplines, with 56% of clients being offered support from their physicians to only 14% being offered support from their pharmacists (8).

Tobacco use is not a simple problem that will yield to simple solutions. Health care professionals require motivational and educational skills to increase the likelihood that health care will offer support in tobacco cessation to their clients (14), as well as systems that encourage tobacco cessation counselling (15).

THE CLIMATE

National and international guidelines regarding the treatment of tobacco use disorder highlight the importance of training for health professionals who provide tobacco cessation counselling; such training results in significantly more interventions. Training is noted to be especially important for the acquisition of the counselling skills (eg, motivational interviewing, practical counselling, etc) that result in best outcomes (3,4,16).

Comprehensive training for health care professionals in tobacco cessation begins with nationally defined competencies, standards and practice guidelines that identify the required skills and knowledge for health care professionals providing this support. However, the 2011 Respiratory Therapy National Competency Profile does not mention tobacco cessation, prevention or protection support (17). Similarly, only passing mention of tobacco support is found within the competency profiles or entry-to-practice guidelines of other health care professions such as nurses and pharmacists (17,18). This suggests that tobacco cessation training is a small component of entry-to-practice training for health care professionals, and presents a significant gap between what health care professionals need to support clients who use tobacco and the training that they receive.

THE SOLUTION

In 2013, the Public Health Agency of Canada announced the funding of an initiative from the Canadian Network for Respiratory Care (CNRC) to develop a national program to support the training and certification of health care professionals (19). CNRC is a national nonprofit organization and registered charity that is well known to members of the respiratory community through its Certified Asthma Educator and Respiratory Educator programs (20). Through its certified educators and member organizations, CNRC works to improve the quality of life for Canadians and their families living with respiratory diseases and tobacco use disorder, by developing, promoting and advocating the highest standards of education in health promotion and care.

This new program included the development of a new credential, the Certified Tobacco Educator (CTE), and an associated comprehensive training program based on a nationally validated set of competencies for health care professionals providing tobacco prevention and cessation support. There are two competency documents that outline the knowledge, skills and abilities required for health care professionals providing tobacco prevention and cessation support, which include foundational health education as well as tobacco prevention and cessation. The foundational health education competencies include:

health promotion, including education and behaviour change models and theories;

communications, including motivational interviewing;

educational interventions;

resource management;

professional practice; and

program evaluation.

The tobacco education competencies include:

the tobacco epidemic;

tobacco use disorder and chronic diseases;

tobacco prevention, protection and cessation;

assessment;

interventions;

client-centred approach (ie, diverse populations); and

tobacco programs and systems (21).

This unique approach of including competencies in health education along with tobacco prevention and cessation ensures that health care professionals who complete the training programs and successfully challenge the CTE examination are offering evidence-informed care based on the principles of client-centred care and client education.

More than 100 Canadian health care professionals from diverse disciplines including respiratory therapy, nurses, pharmacists and social workers have already gained this credential.

To qualify to challenge the CTE examination, candidates must have a degree or diploma in a recognized health care profession, with a scope of practice that includes counselling. Candidates must successfully complete CNRC-accredited foundational health and tobacco education courses based on the nationally validated competencies. Training providers include: Alberta Health Services, the Training Enhancement in Applied Cessation Counselling and Health (TEACH) Project (Centre for Addiction and Mental Health, Toronto, Ontario), the Ontario Pharmacists Association, Pear Healthcare Solutions, RespTrec (Lung Association of Saskatchewan) and Vancouver Coastal Health (22–27).

CTEs must recertify every five years by submitting documentation that shows a combination of teaching and learning hours totaling 500 h over the five-year period or by re-taking the examination. Recertification ensures that CTEs will keep their tobacco knowledge and skills up to date.

The Canadian guidelines, the WHO and the United States Surgeon General recommend a systems approach that includes a varied approach, from brief advice for all who use tobacco to intensive counselling by trained practitioners for improved long-term cessation rates (3,16,28). Because counselling has a dose response and has been recommended to promote long-term cessation, its addition is important in the success of the system (16,28). Current models (eg, The Ottawa Model for Smoking Cessation, Alberta’s Tobacco Free Future Program, Ask, Advise, Connect model in Texas [USA]) have demonstrated success, especially when the model links individuals seamlessly to intensive counselling (29–31). For educators who want to evaluate their organization, the CTE training program provides information on program evaluation, as well as advocacy and support for systemization of tobacco programs.

Doctors, nurses, midwives, dentists, pharmacists, chiropractors, psychologists and all other professionals dedicated to health can help people change their behaviour. They are on the frontline of the tobacco epidemic and collectively speak to millions of people.

THE CALL

The tobacco epidemic is an issue that concerns all health care professionals. This new program helps to address the need for a more comprehensive training program for health care professionals offering tobacco prevention and cessation support. The CTE credential, the first of its kind in Canada, is a mark of excellence for health care professionals demonstrating their significant knowledge, skills and abilities in tobacco prevention and cessation to their clients and peers. By treating tobacco use disorder as a chronic disease using appropriate evidence-based interventions, we can help take away the self-blame and guilt that many of our clients who use tobacco feel.

We can do more to help our clients quit. Together we can do more to take on tobacco!