Not quite a year ago, Karen Yates found herself in the Emergency Department at University of Colorado Hospital. An ingrown toenail that had turned black caused so much pain in her feet and legs that she’d left her job as a cashier and waitress at Noodles and Company and driven home. She had a raging fever when she arrived at the ED, where she said providers had difficulty even taking her blood pressure.
“They couldn’t find a pulse anywhere,” Yates said. Yet that wasn’t Yates’s biggest concern when she spoke with vascular surgeon David Kuwayama, MD
“I told him I was dying for a cigarette,” she recalled. Kuwayama responded by telling Yates he planned to admit her to the hospital to work on the problems in her legs. She told him she’d feel better if she could go outside and smoke a cigarette.
“Dr. Kuwayama told me I could get in my truck and drive away or I could face this head on and the hospital would take care of me,” Yates said.
She didn’t go outside, a decision that saved her limbs and quite possibly her life. Kuwayama removed dozens of blood clots from Yates’s legs. When Yates awoke in a bed in Anschutz Inpatient Pavilion 1, Kuwayama told her she was lucky to be alive. “He said I’d made the right choice.”
Yates, 55, also decided during a week-long hospital stay to kick her 40-year, two-pack-a-day cigarette habit, and she’s stuck to it. She’s been smoke-free for nearly 11 months through her own determination and with the help of a state-funded inpatient smoking cessation program launched at UCH shortly after she was admitted.
The COMITT (Colorado Model of Inpatient Tobacco Treatment) program connected her with University of Colorado Cancer Center tobacco treatment specialist (TTS) Kathleen Moreira, who helped Yates identify her own motivation for quitting. Yates also received nicotine replacement therapy (NRT) and post-discharge follow-up calls that offered her additional support – if she wanted it.
Under the program, providers ask patients admitted to UCH about their smoking history. For patients who say they are currently using tobacco, the Epic electronic health record fires a best practice advisory for the attending physician to order NRT and a smoking cessation consult.
Since July 15, 2013, providers have ordered nearly 2,600 consults; close to 600 patients have enrolled in the COMMIT program and received additional smoking-cessation support, Moreira said.
In Yates, the program has both a success story and a cautionary tool. “I’m never going back to smoking,” she said in a phone interview, a vow she reiterated in a card with a handwritten note she sent to Moreira and her colleagues with the Cancer Center’s Prevention and Control Division. Yet her experience also illustrates the deep individual and organizational commitment needed to break the addiction to nicotine, a substance generally acknowledged to be among the most addictive and harmful on the planet.
“Karen is exceptional because of her desire to quit,” said Moreira. In addition to her lengthy smoking history, Yates deals with a number of smoking triggers: she’s out of work, is battling ongoing health problems, and her husband still smokes.
She also had trouble initially finding an appropriate NRT – a problem that by itself would have discouraged many other smokers, Moreira said. Yates is allergic to the adhesive on nicotine patches; lozenges left a distasteful white residue on her lips. Her dentures make chewing nicotine gum a challenge, but she’s adapted, supplementing it with hard candy to quell her cravings.
One of the keys to Yates’s success, Moreira said, is that she has developed her own strategies for “staying ahead of her smoking triggers.” She always has her nicotine gum with her, carries water and candy, and goes to another room when she smells smoke on her husband or sees his cigarettes lying on a table.
She’s also drawn on personal reserves. “I’ve prayed a lot,” Yates said. “I’ve told myself I’m bigger than this.” She regrets the consequences of her smoking even as she acknowledges that cigarettes were her nearly life-long “buddies,” constant companions through good times and bad times. “I’ve learned to live with both the pain of quitting and the happiness of quitting,” she said.
Yates has “reminders of an unhealthy life,” as she puts it. She nearly lost her legs during the ordeal last year and is still dealing with blood clots in them. She was diagnosed with chronic obstructive pulmonary disorder (COPD), is on two liters of oxygen, and “hacks up crap” from her lungs.
There is a valuable lesson in that painful experience, Moreira said. “What Karen stood to lose was great and specific,” she said. “If we can find a person’s personal story, it makes us more effective in helping them to quit.”
Finding an exit
The COMITT program strategy focuses on supporting smokers, not on judging them, Moreira stressed. The centerpiece is “motivational interviewing,” a technique designed to draw out the smoker’s individual reasons for wanting to quit and to identify the barriers that make it difficult to do so. The choice of accepting help with quitting or refusing it lies exclusively in the hands of the patient.
Whatever the situation, Moreira said, she approaches patients with compassion and expresses her desire to make them comfortable during their hospital stay. She is herself an ex-smoker – tobacco-free for seven years – who understands that even those who successfully quit smoking fail on average seven to 10 times.
“Trying to quit and failing a number of times can reduce confidence,” she said. “We talk about what worked in the past, coping strategies, and what took them back to smoking – the triggers and the circumstances.”
When Moreira knocked on the door of Yates’s hospital room, she found a patient still struggling to figure out what had happened to her through the fog of illness and surgery.
“I was wrapped up, with an IV and oxygen,” Yates recalled. She was overwhelmed and agitated by the procession of providers in and out of her room. But she hadn’t smoked in four days and heard her “inner self” telling her she needed to quit. Moreira told her she could help with that.
Yates left the hospital with the nicotine gum and the resolve to change her life. The COMITT program also includes interactive voice response calls designed to “check in” with the patient, Moreira said. Patients go through a series of automated prompts meant to determine if they need additional help. The first occurs three days after discharge, with three following in the first month and one a month for five months thereafter.
Moreira followed up with phone calls at Yates’s request. “We don’t want to be the smoking police,” Moreira said. “She needed support. It’s important to spend time reinforcing the motivation to quit and the coping mechanisms and strategy.”
The Cancer Center continues to evaluate the outcomes of the COMMIT program, said Talia Lyn Brown, a PhD epidemiology student with the Colorado School of Public Health’s Community Epidemiology and Program Evaluation Group. Brown said patients who received NRT before a TTS consult were four times more likely to enroll in the smoking-cessation program, which highlights the importance of that early intervention.
Moreira cited a couple of other success stories she’s had as a TTS but acknowledged the difficulty of making headway in the battle against an addiction that takes thousands of lives every year and consumes billions in health care costs.
It’s an effort that will proceed one individual at a time. “Everybody’s threshold for quitting is different,” Yates said. “I survived, and hopefully the next person will.”