The American Association for Respiratory Care (AARC) is a national professional organization with a membership of 40,000 respiratory therapists who treat patients with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma. Through our work, we support more than 170,000 practicing respiratory therapists (RTs) across the country. RTs are an integral part of the healthcare system, providing care for patients with a myriad of pulmonary diseases, including chronic obstructive pulmonary disease (COPD) asthma, bronchitis, emphysema, cystic fibrosis, and acute respiratory distress syndrome. We also provide therapy for patients suffering from Parkinson’s disease, amyotrophic lateral sclerosis, and sleep apnea. Finally, we provide care for patients suffering from trauma and provide support for premature infants. In essence, we work with patients of all ages and are trained in pulmonary medicine to provide therapeutic care for patients suffering from pulmonary disease or conditions that impair breathing.
Definition of Smoking:
Within the proposed framework, we believe that the definition of smoking needs to be redefined to include not only traditional burned tobacco products such as cigarettes, cigars, and pipes but also heat-not-burn tobacco products (for example, IQOS) and e-cigarettes.1 Broadening the definition will ensure, as HHS develops policies and programs to support smoking cessation, that all types of inhaled products are considered.
Goal 4 Comments: Increase Access to and Coverage of Comprehensive HighQuality Cessation Treatment
As it pertains to the RFI, we believe that RTs and their role in patient care fit squarely into the administration’s framework under Goal Four; Increase Access to and Coverage of Comprehensive High-Quality Cessation Treatment. RTs play an integral role in assisting people with smoking cessation. Given that smoking exacerbates many pulmonary conditions and may even lead to those conditions developing in the first place, a respiratory therapist is in a unique position to counsel and educate patients on stopping smoking.2 According to studies, smoking cessation rates increase when two or more providers ask about the use of tobacco use when compared to one provider and not being asked at all.3 Understanding this, the AARC has created a training course to educate RTs about smoking cessation and to provide the skills necessary to begin such a discussion with patients. Talking to patients about smoking cessation may be a difficult task, and therefore this training program provides information about how to handle this topic while educating the RTs about the epidemiology of tobacco use, principles of addiction, assisting patients with quitting smoking, as well as training regarding the use of pharmacotherapy. 4 As we noted previously, simply by the very nature work that they perform, RTs are on the front lines of treating patients who smoke. When patients are referred to RTs, this increases access to cessation treatment and, with that, an opportunity to begin a smoking cessation program. COPD is most often caused by cigarette smoking, which is responsible for eight of every ten COPD-related deaths.5 According to the 2020 Surgeon General’s report, smoking cessation reduces the risk of many adverse health
1 Heat-not-burn products use tobacco, whereby the tobacco is heated to produce an aerosol that is subsequently inhaled. E-cigarettes use liquid nicotine that is heated and then inhaled.
2 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
3 An L. C., Foldes S. S., Alesci N. L., Bluhm J. H., Bland P. C., Davern M. E, … Manley M. W. (2008). The impact of smoking-cessation intervention by multiple health professionals. American Journal of Preventive Medicine, 34, 54– 60. 10.1016/j.amepre.2007.09.019.
4 AARC Tobacco and Smoking Cessation Training; https://www.aarc.org/education/online-courses/smokingcessation-training/
5 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Accessed May 17, 2023
effects, including those associated with COPD.6 For those patients who continue to smoke, there is little chance that their condition will improve. We believe that patients should be counseled to stop the use of cigarettes and shown that when smoking stops, their lives and condition will improve. RTs are the experts that can provide this care and assist patients in accessing smoking cessation programs. One of the broad strategies noted in Goal Four includes collaboration with varying types of stakeholders, including insurers, community providers, healthcare facilities, and states. We would encourage you to consider the AARC and its members as experts in the treatment of conditions exacerbated by smoking and in smoking cessation treatments, and as such, we would like to partner with HHS in an advisory capacity by participating in any expert panels or advisory committees that are developed out of the proposed framework. Additionally, we are available for both private and public meetings to discuss this topic and would welcome collaboration with the agency.
Other Comments:
Goal 1: Eliminate Smoking- and Cessation-Related Disparities
AARC supports the policies in this RFI and would suggest that the agency create a more specific policy to support building capacity. The following are important concepts for the agency to consider when implementing systems approaches to support smoking cessation:
- Ensure that all patients are screened for smoking before inpatient admission.
- Provide counseling by a trained tobacco treatment specialist.
- Resources for cessation, including treatments as needed, are provided on-site prior to an inpatient discharge. We believe that to create real change and to increase positive patient outcomes, smoking and the use of tobacco products need to be addressed at the outset of treatment or an inpatient admission and then followed up upon discharge. To ensure that the framework drives progress, AARC suggests that of the system changes we note above, all should be measured in some capacity to create accountability and to measure the success of the systems change that the framework is hoping to drive.
Goal 3: Strengthen and Sustain Cessation Services and Supports
As we have noted throughout, we believe that RTs are the backbone of safe, evidence-based treatments for respiratory conditions and smoking cessation. We believe that State and local cessation programs and smoking treatment activities may be guided by respiratory therapists, trained tobacco specialists, and other trained community partners. Through this type of collaboration, smoking cessation programs may be created with input from experts in the field. 6 U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.
https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
Also, we support strategies that would ensure funding and resources are spread among local and statewide organizations and that the funds and resources are available to those best positioned to help with this cause, including RTs, public health professionals, and trained tobacco specialists.
Additional Goals and Broad Strategies for Consideration:
The framework should include creating a policy that addresses those affected by second-hand smoke, including those who live with smokers and those who are exposed to smoking simply by living in an apartment complex that allows smoking or other areas. Children are often exposed to smoke by riding in cars with smokers, and we believe that this should be addressed in the framework as well.
Job Growth for Respiratory Therapists:
We would also like to note that according to the US Bureau of Labor Statistics (USBLS), respiratory therapists now number in the hundreds of thousands, with approximately 135,900 practicing in the US as of 2021.7 RTs projected job growth from 2021-2031 is 14%, much faster than the average for all occupations, which is 5%.8 The USBLS states that there are approximately 9,400 job openings for RTs projected each year over the next ten years. Given the growing demand for RTs’ services, AARC recommends that HHS invest in programs to support their training, whether through a grant program or other mechanism to allow for those 9,400 job openings to be filled, thereby increasing access to smoking cessation treatment and programs.
If you have questions or would like to talk to us about the important work we are doing, please contact Miriam O’Day, Senior Vice President of Government Affairs, AARC (Miriam.oday@aarc.org.) and Kay Moyer, Director of Regulatory Affairs, CRD Associates (kmoyer@dc-crd.com). We look forward to working with the agency on these critical issues.
