Transcript for Episode 76: Smoking Cessation

NASW Social Work Talks Podcast

Announcer:
This episode is sponsored by ECINS, the world's most collaborative case management system.

Greg Wright:
Welcome to Social Work Talks podcast. I am Greg Wright. Almost 60 years ago, the U.S. surgeon general warned that smoking could cause lung cancer and chronic bronchitis. Yet today, 40 percent of adult Americans continue to smoke, and smoking is linked to more than 480,000 deaths a year. How can social workers help people stop smoking? Today, we talk about this with a social worker, Taslim van Hattum, senior director of a practice improvement at the National Council for Behavioral Health. Welcome to Social Work Talks, Taslim.

Taslim van Hattum:
Hi, Greg. Thanks so much for having me today. I'm doing fantastic and looking forward to just talking about this critically important public health and social work issue.

Greg Wright:
A lot of folks smoke. So what are the reasons why people smoke, and why is this such a hard habit to break?

Taslim van Hattum:
Yeah, so it's a really fantastic and complex question. And some of this really needs to be talked about in the context of addiction. And then some of it might really be talked about in the context of a habit, and where the two of those intersect.

But if we really want to start talking about some of the reasons why individuals start smoking, as a social worker and then someone who works in public health and healthcare, I also think we need to think about this as an equity issue as well.

And so when we think about some of the reasons why individuals start smoking, there's a couple of pretty big reasons. Number one, there's pretty significant targeted and predatorial marketing by big tobacco. And we know that despite the overall rate of cigarette smoking amongst adults decreasing, we know that there's pretty significant disparities in different populations, whether that's based on having a mental health issue, a substance use issue, your race or your socioeconomic status or your educational level. And so we know folks, they're targeted based on that with marketing.

We also know that there's some pretty significant linkages and a dose response relationship between the high rate of ACEs (or adverse childhood experiences) or traumas that someone might experience, and a dose response relationship to that adverse childhood experience to early initiation of tobacco use, adult use, the amount of adult use and then the duration of adult commercial combustible tobacco use. So it's not something that we talk about a lot but the other few big reasons I think are also what we think about as limited access to high quality care, the ability to really make sure that individuals are accessing the highest quality of care to get to those best clinical outcomes around sub courting cessation. So those are some of the bigger, larger issues.

And then we also know that, as social workers certainly, that the social determinants really impact those overall rates. So everything from of course 30 percent of the activities being our health behaviors, but also, like I said, those other factors like the social and economic factors, physical environment, access to care and then access to really high quality clinical care to support cessation.

Greg Wright:
Are you saying that a person, if they have experienced a trauma as a child, that that might make you more likely to be a smoker later?

Taslim van Hattum:
There is a dose response relationship, so correct. If you have exposures or a higher adverse childhood experience score, that risk accumulates as your ACE score increases so that you do have a higher risk of those four things I mentioned, early initiation of tobacco use, the adult tobacco use, the duration of use meaning you're likely going to smoke longer as an adult, and then the amount that you use. And I think this is pretty important because you can think about this in two ways. You can think about this, there's going to be some individuals who smoke whether or not there are adverse childhood experiences in the world, and this smoking can be caused by genetics or access to cigarettes, or learning to smoke as a young person because potentially the adults around you smoke. But these are the individuals who tend to quit when they're presented with information through high quality clinical care about the dangers of smoking.

But then we have another group of individuals who have much higher exposure to adverse childhood experiences, or what you and I might colloquially call childhood trauma. And as you are exposed to that, the risk of smoking increases into adulthood.

Greg Wright:
If there was more anti-smoking education, if there was more mental healthcare at a young age, we might actually prevent folks from ever picking up this habit later on.

Taslim van Hattum:
Yeah, I think you're exactly right. So really thinking about prevention of early childhood trauma and strong public health education from childhood all the way on through adulthood, and then really fantastic access to high quality clinical care where you're getting those cessation interventions.

Greg Wright:
A person who is smoking, are they smoking to feel calmer, to feel more at ease? Is it a way to address anxiety?

Taslim van Hattum:
Oftentimes, we know that we are presented with smoking as something that helps to calm us, make us less anxious, and really provide us with potentially a coping mechanism to deal with that. But what we actually know is that tobacco and many of the chemicals that are in commercial combustible cigarettes are extremely detrimental to anxiety, depression, and PTSD, and how that shows up. So what we're oftentimes seeing is a pretty complex relationship between those two, but there is nothing within cigarettes or the chemicals within them that actually do assist with depression or anxiety. And actually, in most cases, they serve to further exacerbate those symptoms.

Unfortunately, we oftentimes will say, "I feel anxious. Let me smoke a cigarette. Oh, it seems like those symptoms are decreased." But what we're actually decreasing often times is that withdrawal from cigarettes versus our actual anxiety. We know that smoking really possesses these three unique factors that make it a reinforcer for at risk individuals, and due to these effects, individuals with trauma or anxiety trying to quit have more frequent relapses, and that's of course like the perceptions around pleasure and the positive effect, the perceptions or the oftentimes false inform that we've been given around anxiety reduction, and then the distress termination. But those actually most commonly are simply the distress termination of withdrawal from nicotine, not actually the distress termination of your preexisting anxiety.

Greg Wright:
A bait and switch in other words, is what's happening.

Taslim van Hattum:
Absolutely.

Greg Wright:
We've had our conversations so far about our mental health end of it, but what about our physical health? How does smoking affect you?

Taslim van Hattum:
I think it's fantastic that you even grounded us in that 1964 US surgeon general report, and that first report really sought to examine the health consequences of tobacco use in our country. And it changed the American perception, healthcare and public health and social work attitudes around tobacco use and then, as you said, found that tobacco was a cause of chronic bronchitis, a cause of lung cancer and many other ones. But it's worth saying that 50 years later, almost 60 years later from that report, we continue to have critical findings that are emerging.

We know that smoking harms nearly every organ in the body. We know it causes diseases and is extremely bad for your health, we know that quitting smoking can make you more healthy right away and in the short and in the long term, so it has these critical short and long term benefits that have been extensively studied. We know that the exposure to secondhand smoke causes cancer, respiratory issues, heart disease, and then of course the list of diseases caused by smoking in addition to I believe between 10 and 12 different cancers continues to grow. So we know that tobacco use and commercial combustible cigarette smoking is still the leading cause of death in our country and these are all preventative deaths. And then we also know in addition to that, smoking harms people of every age, race, socioeconomic status, including unborn babies, infants, children, adolescents, adults, and even seniors.

Greg Wright:
What I have never understood is that this information is out there, there are striking ads on television of folks who have had a major detrimental health impact due to smoking. So this info is out there, yet people keep doing it and they don't quit, and I never understood that.

Taslim van Hattum:
Part of this is because we continue to think a little bit about tobacco use and smoking cigarettes just in that really specific traditional addiction discourse, which is that tobacco use is just about your individual personal behaviors. It's a habit that you have chosen as an individual. And I think oftentimes as a social worker, I sort of zoom out and really think about that holistic social determinants of health and health equity model that says that about 30 percent of this is my personal behaviors. And we can really seek to address that through specific clinical interventions, the use of NRTs counseling and other FDA approved methods like pharmacological supports. But there's these other things that we've started talking about today, which is the other 70 percent of the determinants of health that really impact our health behaviors and that's of course, again, that access to high quality clinical care so that you're given this health information that you've talked about, you understand the cause and the effect.

And then of course some really big social and economic factors that we don't often talk a lot about, but it's really important to know that of the people in the United States that still continue to smoke, disadvantage is the most common denominator. And if you face disadvantages, and I can talk a little bit about what those are, your liability around smoking and the risk of smoking increases. Our disparities in tobacco use can be explained by individuals that have more disadvantage being more likely to both start smoking and less likely to quit smoking.

Greg Wright:
And the disadvantages are?

Taslim van Hattum:
And I frame this lightly because I might say we could use a couple of different words, which I think is important. Vulnerabilities or disadvantages, so individuals with lower socioeconomic status or a poverty status, individuals that lack health insurance, individuals with low educational levels. So the rate of tobacco use in our country with someone with a GED is 40 percent, but it's about 4 percent with someone with a graduate education, so it's a pretty big disparity. And then of course additional vulnerabilities around individuals with disability or ability limitations, sexual orientation, serious psychological distress or mental health and substance use issues, and then race and ethnicity.

Greg Wright:
Are you saying that if you are a person of color or an LGTQIA person, that you are more likely to smoke?

Taslim van Hattum:
You are, but also thinking about this as you're more likely to be targeted by big tobacco around predatory marketing, you're more likely to have less supportive clinical and community health services around intervention, many of the interventions that are being presented to you have not been tested or studied with vulnerable populations as much as they have been with what I would say who we usually test the majority of our interventions on in this country, so generally, middle class, white and overwhelmingly male. And then you are also less likely to have the additional support or the additional privileges around socioeconomic status, education and health insurance coverage, which all deeply impact your risk as well as the interventions that are provided to you to support cessation.

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Greg Wright:
Before we go into a social worker side of all of this, I want to talk about vaping. Because a lot of folks who I know who are vapors claim, "Oh, this isn't as bad as if I was a combustion smoker."

Taslim van Hattum:
So it's absolutely a myth and there's a couple reasons why this is a myth and why we should really be talking about e-cigarettes, vaping and the way in which we're also really thinking about this. And the number one reason why we should be talking about this is because similar to combustible commercial cigarettes, which is generally what we just call cigarettes and smoking in this country, we know that what makes ends so addictive is a combination of three factors. It's advertising, the addition of flavors and nicotine. And we also know that the primary ingredient of nicotine, whether it's in a commercial combustible cigarette or in an e-cigarette or vaping or ENDS (or electro nicotine delivery system), it's still nicotine, which is a highly addictive substance. Which means that you're still engaging in nicotine dependency and addiction, regardless of whether it's an e-cigarette or another nicotine source.

And so nicotine containing electronic cigarettes produce brain changes similar to that caused by combustible cigarettes or nicotine lozenges, and researchers have found that when regular users of e-cigs quit e-cigarettes and then resumed vaping, they exhibited the same changes in brain function that were linked to relief from symptoms of withdrawal and studies using combustible cigarettes. So we know that that nicotine dependency and addiction develops in the same way. We also know that there's additional vulnerabilities based on those same categories, and then we really know that individuals with depression and anxiety are about twice as likely to try e-cigarettes and about three times as likely to use them.

We know there's pretty dangerous emerging trends with young people using electronic cigarettes in our country. And then, while we know that research is still emerging on all of the disparities, we do know that if you start using ENDS or vapes, we know that you are more likely to use combustible commercial cigarettes. And so we know that opening up a nicotine pathway or a nicotine addiction lends itself to, even if you start with a vape, you're more likely to end up on commercial combustible cigarettes.

Greg Wright:
Wow. So why should social workers be involved in a cessation end of this? Why should a social worker be involved, Tas?

Taslim van Hattum:
This is a fantastic question and it's one that I'm deeply passionate about, because I believe that social workers have this really critical opportunity to both change the individual interpersonal interactions that folks have around health and mental health care, but also simultaneously can deeply impact those social determinants of health that we talked about. Some of the big reasons why we should be talking about tobacco cessation as social workers is because it's a profound equity issue. We know that there's individuals of different race, class, access and mental health status that are more likely to be exposed and then marketed to and then not provided services, so we know it's a huge equity issue. And then as social workers, we know it's a big quality of care issue. And then it's ultimately about providing the best clinical and community based services to our clients and our patients for the best clinical outcomes.

So if we're a social worker and we know that there are strong environmental and interpersonal interventions to really help individuals prevent really profound morbidity and mortality, we are really wanting to ground in those as social workers. And some examples of that are of course just like adopting tobacco-free facilities and supporting individuals around that, thinking about integrating tobacco treatment into mental health care. Everything from nicotine replacement therapies, those FDA approved NRTs and other pharmacological supports. Really engaging peer models as an evidence based methodology, utilizing the quit lines and other evidence based interventions, and then as social workers, we have this really incredible ability to think beyond cessation to overall recovery.

Greg Wright:
How do you train a social worker to intervene? How are you actually getting out the word to empower and train the social work profession?

Taslim van Hattum:
Thankfully at the National Council for Mental Wellbeing, we are a Washington, DC, based advocacy organization and much of our work is really at the intersection of providing high quality behavioral healthcare. So that's mental health and addiction supports, and we do this in a variety of different ways. We advocate for policies to really ensure equitable access to high quality services and then we seek to really build the capacity of mental health and substance use treatment organizations. In addition to that, we are funded by the Center for Disease Control and Preventions, Office of Smoking and Health and the Division of Cancer Prevention and Control. And we're funded through them to specifically engage in one of eight CDC national networks to eliminate cancer and tobacco disparities in priority populations.

And much of that work really centers on providing resources, tools, and trainings to help clinical providers as well as social workers and all other mental health and substance use providers in thinking about how to reduce tobacco use and cancer amongst individuals, specifically with mental health and substance use issues. Both at the organizational and systems level, so everything from, how do you take your facility tobacco free, to what evidence based interventions should be using in your clinical services, to what are the ways that you might be engaging in developing and running tobacco cessations support groups as a social worker? And then of course, developing out toolkits, other training opportunities and practice change initiatives where we support social workers across the country in how to reduced tobacco use with individuals with mental health and substance use issues.

Greg Wright:
We are in a pandemic. It's still ongoing. How has that affected how folks are smoking? Is it making it a worse issue and how has it affected the way that social workers and other mental health providers can actually get out cessation information?

Taslim van Hattum:
What you're bringing up is such an important issue right now, because what we're facing is this collision of two public health crises, COVID-19 and addiction simultaneously. And then I'd be remiss if I didn't just say we're talking about, within addiction, this preexisting respiratory condition from vaping and smoking tobacco. And then in COVID-19, we have this virus that really directly affects respiratory health. So this is sort of a perfect, like I said, collision of two public health crises. And we know that unfortunately, the state of smoking during COVID-19 is that unfortunately, we have seen some increases in tobacco use and nicotine, just talking about what we mentioned earlier as this being a main tool to falsely manage stress and anxiety. And that's really real, right?

We are in a pandemic, there's an incredible amount of stress and anxiety, and we know that motivation to quit really varies. But we also know that it's an incredible opportunity to really engage in that motivation to quit conversation because we know the desire to quit owing to that association with a respiratory condition around COVID-19 has increased due to, of course, the fears and anxiety around health concerns from COVID-19. And so we know that there's some incredible opportunities, really specifically right now.

We know there's been some seismic shifts in the entire field, everything from in person to telehealth, and really seeking to build out organizational capacity for telehealth around smoking cessation, thinking about how we can increase client access, really meet the needs of new clients. And then think about how telephone and telehealth technology can be used to address access issues for certain populations, maybe for homeless individuals or individual individuals who are in rural health settings or senior citizens, or folks that need a bit more higher touch and really would like to be accessing services.

There's a couple of really incredible opportunities. We also know that there's some real incredible opportunities to reopen behavioral health facilities or mental health and substance use facilities as tobacco free facilities. Every single hospital in our country is tobacco free, it's a tobacco free campus or healthcare facility. But unfortunately, only about 50 percent of our mental health facilities are tobacco free in our country. So thinking about how we utilize space and outdoor space for social distancing and reduce the risk overall of COVID-19 amongst clients who use tobacco by going tobacco free is pretty important right now.

And then the only other thing that I'd really love to highlight and uplift is the National Council for Mental Wellbeing in partnership with the SAMHSA Center of Excellence For Tobacco Free Recovery that's run by the University of California, San Francisco's Smoking Cessation Leadership Center has developed an incredible campaign called I COVID Quit, and it's really recognizing that there's never been a better time to quit smoking. COVID-19 has really taught us about how vulnerable our bodies and our lungs can be, and we want to just do everything to prevent disease, but also really think about providing individuals with more resources around cessation. I would highly encourage folks to check out the I COVID Quit campaign, which is also a campaign from the National Partnership for Behavioral Health and Tobacco Use to support individuals around their cessation journey during COVID-19

Greg Wright:
Taslim, this has been a wonderful conversation. I've learned a great deal as a layman. Is there anything else that you would want to add to this conversation before we let you go?

Taslim van Hattum:
Many individuals who currently smoke report a deep desire to quit smoking. A lot of the time when we think about tobacco cessation, we think about resistant clients or individuals who don't want to quit. But we know that seven out of 10 smokers want to quit smoking. And we know that they can when provided with access to the best possible clinical care and cessation supports.

And so we know that this number one cause of death and contributor to death continues to be a preventable health condition or a preventable health outcome, and we know that social workers play such an important role in continuing the good of providing the best clinical care to the best of your ability to your clients.

Greg Wright:
Taslim, thank you for all of the wonderful work that you are doing out there on this issue. Thanks for being our guest.

Taslim van Hattum:
Thank you so much for having me.

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