key: cord-0948418-nhbx9rv0
authors: Lang, Adam Edward; Yakhkind, Aleksandra
title: “COVID-19 and Smoking: How and Why We Implemented a Tobacco Treatment Campaign”
date: 2020-06-17
journal: Chest
DOI: 10.1016/j.chest.2020.06.013
sha: c8af93756ada698fb54c6d4978c734f4f66b2fee
doc_id: 948418
cord_uid: nhbx9rv0

Abstract Smoking is associated with one out of five deaths in the United States. Multi-modality tobacco treatment increases rates of successful cessation by at least 20%. The COVID-19 pandemic has put a halt to many inpatient and outpatient medical visits deemed non-essential, including tobacco treatment. The transition to telehealth has been wrought with challenges. While data on the association between COVID-19 and tobacco products is mixed, the overall health consequences of tobacco point towards increased risk of morbidity and mortality associated with the virus. This leaves smoking as one of the few readily modifiable risk factors in an environment understandably not set up to prioritize cessation. A military health facility on Fort Eustis in Virginia runs a successful tobacco treatment program and adapted it to pandemic times. This paper describes the process and lessons learned from this initiative. The model is applicable and scalable to government and civilian health centers as healthcare adapts to a new normal.

predicted the 90-day mortality from viral pneumonias (including coronaviruses) in hospitalized 23 patients (7). While it is unclear to what extent the severity and management of these conditions 24 mitigate risk (1) , no other risk factors are as immediately modifiable as smoking. 25 26

Some researchers suggest a protective effect of smoking and COVID-19 based on 27 epidemiological data not controlled for age and comorbidities, and cell signaling hypotheses 28 based on animal data. While they have garnered media attention, they all conclude that the 29 cumulative risk of tobacco to the health of an individual outweighs the theoretical benefits (8, 9) . 30 31 The Centers for Disease Control and Prevention (CDC) and the World Health Organization 32 (WHO) recommend against smoking to reduce the risk of harm from the disease (10, 11). The 33

WHO has gone as far as to caution against reports that tobacco or nicotine may provide benefit 34 against COVID-19 as there is not sufficient evidence for this claim (11). Given the conflicting 35 information in the media and the challenges of coping with a pandemic, we felt it of utmost 36 importance to adapt tobacco treatment, promote its importance and continue to support our 37 patients in their efforts to quit during this unique time. Newport News, Virginia. It is an ambulatory care center that provides primary and specialty care 43 services to active duty service members, their families, and retirees. 44 45 A tobacco treatment program has been run by clinical pharmacy for over ten years. In 2019, it 1 grew to target specific populations within the active duty community in efforts to minimize 2 tobacco use and improve the health of the force. Educational products and live and video-based 3 programs were developed and implemented. The COVID-19 pandemic emerged in the midst of 4 these efforts, putting the program to a halt. The team quickly restructured their efforts in a way 5 that applied to social distancing orders. This process and what was learned from it is described 6 below. 7 8

There are three ways that a nicotine user can come to see a clinical pharmacist who manages 9

their tobacco treatment at MCAHC. They can self-refer, be referred by their primary care 10 provider, or be referred by a specialist. Prior to their appointment with the clinical pharmacist, 11 they must either see a psychologist for an appointment regarding nicotine use, attend a tobacco 12 treatment education class, or complete the Time to Quit online program. 13 14

When the pandemic was starting to be recognized in the US, the tobacco treatment program 15 responded. This online tool has been particularly useful during the pandemic, as psychologist appointments 30 may be limited and classes temporarily cancelled. 31 32

During the initial telehealth appointment, a concise nicotine use history was conducted 33 (Appendix 2). It assessed the type(s) and quantity of nicotine products used, length of use, 34 medical conditions that may limit medication options, triggers and times that the patient 35 normally uses nicotine products, and an overview of previous attempts to quit. This was followed 36 by a discussion of behavioral interventions and nicotine withdrawal symptoms. Medication 37 therapy options included varenicline, bupropion and nicotine replacement therapy (NRT) 38 patches, gum and lozenges. These have proven efficacy and safety as both monotherapy and in 39 combination with each other (13). At the end of the appointment, patients were provided with 40 discharge instructions through secure messaging or email (Appendix 3). 41 42

Patients had the option of obtaining their medications in one of three ways: through their local 43

Military Treatment Facility, through mail order, or through a retail pharmacy (coverage 44 dependent). The military treatment facility pharmacy had developed a drive through only 45 operation to reduce risk of viral spread. Patients were scheduled for at least two follow-up 46 1 ongoing concerns. 2 3 4

What was Learned and What to Consider with Future Campaigns 5 6

Fewer patients responded than was anticipated and the process was analyzed for how it can be 7

improved. The three main takeaways from the campaign are detailed below and summarized in 8 Table 1 . 9 10

Broadening Message Exposure 11 12

The timing and platform in which the message goes out to patients is important. A pandemic may lead to an even higher need for BH services to help with depression and 7 anxiety stemming from isolation from friends and family, financial hardship, and increased 8 stress. Normally, life stressors are staggered over time in a population. In a pandemic, everyone 9

experiences the same stressor at the same time. This may mean that the tobacco treatment 10 clinician has to take on an even greater role in the behavioral health aspects of their patients if 11 BH provider capacity is decreased. 12 13

While more free time may provide patients with motivation to quit, it may also be a deterrent due 14

to struggles with stress and isolation. Major life events may increase use in those already using, 15

cause former users to reinitiate use, and make it less likely for those that are using to quit. Self-16 efficacy is an important predictor of abstinence rates and outcomes are best when confidence in 17 quitting is reinforced by community or a provider (14). 18 19

Follow-up is key during a pandemic as the impact of population-wide social, psychological and 20

behavioral changes are uniquely challenging in the setting of isolation. At least three total 21 telehealth appointments should take place to provide effective care (15). Additional resources 22

such as quit lines (1-800-QUIT-NOW), text messaging programs, phone applications and online 23 services offer counseling support that can supplement the telehealth interaction (13, 15). Another 24 resource that augments patient-provider interactions is the Time to Quit program mentioned 25

above. It highlights the reasons people smoke, management of withdrawal symptoms, health 26 benefits of cessation and maintenance of motivation. 27 28

Resource Utilization and Practical Considerations 29 30

In a pandemic, physicians, nurse practitioners and physician assistants may be pulled from their 31 outpatient roles for acute care. A pharmacist trained in tobacco treatment is an ideal provider to 32 treat these patients. A standing order for varenicline, bupropion and various types of NRT by a 33 physician permits those medications to be available to patients even if they are seen by a 34 healthcare provider without prescribing privileges. 35 36 As response rates go up, providers have to prepare to handle an increased volume of telehealth 37

visits. As such, having as much of the essential visit logistics completed ahead of time as 38 possible would allow for more bandwidth for counseling and for more patients to be treated. 39

Support staff can call a patient prior to their visit to document pertinent history. Or, patients can 40 fill out a questionnaire through a secure messaging platform that details pertinent medical and 41 nicotine use history to the provider. 42 43

There is no single algorithm for tobacco treatment. The provider should recognize that, just like 44 with other chronic disease states, treatment is patient specific. Some patients may require two 45 21mg patches at once, some may need triple medication therapy, while others may not be able to 46 tolerate twice daily vareniciline or bupropion and need to take it once daily. Different approaches 1 work for different patients, so flexible dosing and treatment durations should be available for 2 patients depending on how their treatment progresses. 3 4

Another consideration is to limit virus exposure in this vulnerable population and respond to 5 patient fears. Patients may have heard that tobacco or nicotine could protect them from SARS-6

CoV-2, may be less likely to contact their providers for help with tobacco treatment if they don't 7 know that telemedicine is an option, or may be afraid to reach out as they see going to a provider 8 or a pharmacy as a risk to their health. 9 10

It is important to reach out to the patient in such times, inform them of the risks and the resources 11 available, which include telehealth (in the form of tobacco treatment as well as behavioral 12 health) and mail order prescriptions. No show and follow-up rates, which can be higher with 13

tobacco treatment compared to other appointments, may actually be reduced due to telehealth. 14 The telehealth appointment is generally initiated by the provider as opposed to being dependent 15 on the patient to show up at the clinic. 16 17

Lastly, providers have to adapt to telehealth technology and to scheduling remotely. The ideal 18 type of appointment depends on the patient population: Older patients may have less access to 19 audiovisual resources and the telephonic appointment may be the only option. As telehealth 20 expands, the abilities and needs of the patient must come first. Clinics are often faced with 21 questions about whether payors cover telehealth. Providers should be aware that the federal 22 government has eased restrictions on telehealth services during the pandemic, making them 23 much more accessible. An extensive guide on utilizing telehealth to support tobacco cessation 24 was created by the American Lung Association (21) . Long term, the widespread implementation 25 of telehealth may allow us to provide tobacco treatment to those in more rural areas that would 26 not have had the ability to follow-up on a monthly basis in person previously. 27 28 29

Review of the Literature 30 31

There is no template for telehealth, let alone tobacco treatment, during a pandemic. The literature 32 that does exist is in support of such an intervention. Smoking has innumerable adverse health 33 effects, and evidence points towards increased disease severity and worse outcomes in patients 34 who smoke and develop COVID-19 (1-3) . Also, the use of inhaled products or smokeless 35 tobacco requires the user to put their hands near their mouth, increasing risk of transmission of 36 disease (18). A better understanding of the interplay between smoking and COVID-19 can help 37

us learn more about the pathophysiology of each of them individually and identify targets for 38 possible therapies and interventions. In our review of the literature, we found that both severe 39 acute respiratory syndrome-related coronaviruses and smoking dysregulate the immune system, 40 cell signaling, coagulation and the cardiovascular system, which can cumulatively lead to poor 41 outcomes. 42 43

Immune Modulation 44 45

Cigarette smoke has been shown to upregulate inflammation through activation of NF-κB, TNF-1 α, interleukin-1beta, and neutrophils (19, 20) and downregulate successful immune function (21-2 24 ). This effect is proportional to increase in smoking and does not subside immediately after 3 discontinuation of use (25-27). Patients with SARS-CoV-2 have been shown to have elevated 4 levels of the inflammatory cytokines tumor necrosis factor-alpha (TNF-α), IL-2R and IL-6 upon 5 presentation and the virus causes lymphocytopenia (28, 29). 6 7

Cell Signaling and Viral Entry 8 9

The mechanisms that coronaviruses use to get into cells affect downstream signaling pathways 10 that may potentiate immune system dysregulation in parallel with smoking. SARS-CoV and 11

SARS-CoV-2 enter cells through cell wall proteins related to the renin-angiotensin system (RAS) 12

(30). The SARS-CoV spike (S) protein, once bound to ACE2, expeditiously downregulates 13 ACE2 expression (31) and it is presumed that SARS-CoV-2 has the same effect (30). 14 15

Rodent studies have shown a reduction in ACE2 expression with cigarette smoke and nicotine in 16 rats with pulmonary arterial hypertension due to smoking (32, 33 We describe the process through which we learned the steps that lead to a successful tobacco 3 treatment campaign in the setting of a pandemic. They include a standing order for medication 4 therapy, appropriately-timed campaign advertisement and efficient telehealth services, and the 5 availability of professionals with the skills to deliver efficacious behavioral treatments. While 6 discrete data on the interplay between smoking and coronaviruses is lacking, both tobacco and 7 COVID-19 contribute to lung injury, immune dysregulation, hypercoagulation, and 8

cardiomyopathy. Tobacco treatment runs the risk of being de-emphasized when the priority is 9

"essential" medical care. We argue that tobacco treatment is even more important during this 10 time and should be prioritized and adapted to the new healthcare environment .  11  12  13  14  15   16  17  18  19  20  21  22  23  24  25  26  27 28 29

• Smoking is the only immediately modifiable risk factor of COVID-19 disease severity. • Reports of the protective effects of smoking on COVID-19 are unfounded. Rather, both detrimentally affect immune system regulation, cell signaling, coagulation and heart function. • This should motivate both providers and patients to prioritize tobacco treatment as an essential medical intervention. • There is no data or template for tobacco treatment during a pandemic. • Our model used a standing order for medication therapy, media to spread an appropriately timed message, efficient telemedicine, redistribution of tasks between support staff and providers, and effective multidisciplinary behavioral interventions. • This model is applicable and scalable to health systems everywhere. 

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