Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?


U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from

This report is free to download at:

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

The business of addiction treatment and health care

Whether it’s you suffering with addiction or a loved one, it’s easy to forget that at least in this country, treating the sick is a cash-money-business. This is true for health-care as well as for addiction treatment, and as the polls right before the passage of the recent health-care reform suggest, enough Americans like it this way that it’s likely not going to change in my lifetime.

I attended a networking event for Los Angeles area investors (LAVA) that focused on health-care and technology, especially in the post Obama Care era. Though they didn’t specifically talk about addiction, I brought the topic up and spoke to a few of the panelists after. Based on everything I read until now and what I heard this morning, there’s big change a-comin’ in the addiction treatment industry. Here’s where I think we’re heading and why:

1. Obama Care will add millions of new health-insurance clients to the mix, most of whom are exactly part of the vulnerable populations (poor, disadvantaged, less-educated) that more commonly need addiction treatment.

2. The Mental Health Parity and Addiction Equity Act passed in Congress a few years ago and now in effect means that all health-insurance policies that offer mental health and addiction treatment coverage have to include it at levels equal to those of standard physical care. This means billions of dollars added to the pool of money for addiction treatment. As of right now, the details about coverage of therapy, outpatient substance abuse treatment, and residential programs is being worked out, but it’s likely that all three will  benefit.

3. Health insurance companies want standardization of services, and for their money, they’re going to get it. Just like there’s a standard way to treat diabetes, addiction treatment is going to become standard among the larger providers that are going to begin doing serious billing with insurance companies. So while CBT, MI, and medications will see a lot of reimbursement there, we’ll have to see about mindfulness therapy, yoga, and other less conventional approaches. My guess is that the bigger 12-step centered providers will be part of the mix whether they offer residential or outpatient substance abuse treatment.

4. More people will get addiction treatment, especially now that the government is refocusing its efforts on the initial assessment for substance abuse problems being performed in primary-care physician offices. forget about 10% of 24 million addicts getting attention for their problem, I think we’re going to see something more like 25%-30% of 60 million people with substance abuse problem of varying degrees (not just full blown addicts) making use of the system.

5. Addiction treatment will focus more on outpatient substance abuse treatment than inpatient services. Not only do we not have the capacity to put everyone in residential treatment, but as we cast a wider net, a smaller percentage of individuals will need intense residential work. Hopefully this will mean that residential facilities will actually start adhering to NIDA recommendations and extend their average lengths of stay towards the 90 day minimum recommended.

That’s a lot of change, but I think it’s about time for all of this to happen. Addiction treatment has spent too much time as a small industry that doesn’t have much power behind it. We’re going to start seeing better results soon because people are going to want to get a piece of this pie, and in the U.S., that’s almost always the biggest motivator for change.

If you need help for yourself or a loved one make sure to try our Rehab-Finder or contact us directly!

Criminal health care – Why we should care.

For most people, the discussion of health care within the prison system is a philosophical one. Not for me.

Inmate health care is a disgrace

While in jail, I got to see the conditions firsthand. I saw the guy coughing his lungs out for days asking deputies to send him to the infirmary only to be laughed at. I saw him struggling to catch his breath night after night, gasping for air in between coughs, making it hard for everyone in the 200 person dorm to sleep. I saw him collapse onto the floor, blood dripping from his mouth and collecting as we all started screaming at the officers to send someone in. They did, finally, and we never saw that guy again. I hope he made it.

After many years of doing little, our government is finally recognizing that leaving inmates to die by attrition within their walled caves is inhumane. In California, there’s a plan to ease crowding and therefore relieve inmate health services to the point they can actually function. Maybe Arnold will do something worthwhile after all. Two birds.

What are prisons for?

The thing is that fiscally responsible conservatives can’t have it both ways. Incarceration is not cheap and as our prison population mushrooms it gets exponentially more expensive requiring support services, the construction of whole cities, and bigger, more secure prisons. The U.S. now has the more prisoners per capita than any other country in the world. Forget China’s human-rights violations, we’re imprisoning ourselves.

Prisons are meant to keep our most dangerous criminals away from society. They’re not meant to be the places where drug users die, or where thieves, cheaters, or dead-beat-dads, go to rot (I met them all there). At least not in my book. Addicts and heavy drug users need help, thieves most often need food or some rehab themselves, dead-beats need a good collection agency and a lien on their income. None of these things are performed in inmate housing facilities. All everyone is trying to do there is stay alive in the mess. Since when was the threat of imprisonment our national parenting device?

Why we should care

“Do onto others” is supposed to be our golden rule, right? Christians proclaim it feverishly, as do my fellow Jews, and as far as I can tell, all other religions have their own versions. Even moral atheists recognize that society functions better when people treat each other with respect. So let’s do it.

When someone is hurting so much from drug use, poverty, and discomfort that they’re willing to steal, let’s give them a hand rather than tossing them to the curb. If they do it repeatedly, let’s figure out a better way to help them. If they seem incapable of stopping, we can revisit this argument. My guess is that those initial steps will greatly reduce the frequency of crime in general. “Bad people” will forever exist in the world, evil will stick around, no doubt, but we can’t live our lives in constant fear of it, jailing anyone who seems to cross paths with it.

Anyway, that’s my opinion.

Drug use isn’t the problem – Addiction and the question of legalization or decriminalization

I don’t keep it a secret that I used to have a very serious drug problem. If you haven’t read it by now, my drug use started early on along with a whole bunch of high-school friends. They smoked weed, I wanted to fit in, and the rest is history.

But guess what? Most of them turned out fine.

Drug use versus addiction

Only about 3 of us ended up screwing up a major part of our lives because of our drug use. One friend died 8 years later from AIDS after finding out way too late about an HIV infection he got from shooting up heroin. Another dropped out of college and never made it back. I developed a massive habit that only grew bigger when I shifted from simply using drugs to selling them. Then I got arrested, served a year in jail and went to rehab. That sucked.

The thing is that I don’t think drugs were the source of our problem.

I’m pretty sure I’m going to get my own genetic code sequenced some time in the near future in order to certify this, but I think we all had way too much of the impulsive, rush-seeking in us to allow the rules of society to keep us down. If it wasn’t for the drugs, something else would have probably gotten us sooner or later. I know that, to date, my own love for speed (as in miles per hour) and motorcycles already got me in 3 pretty serious accidents.

What I know now is that once you start using drugs on a regular basis the issue of how you got there no longer matters. Your brain controls your behavior and when drugs control your brain, you’re out of luck without help.

Is the answer legalization or decriminalization?

I think legalization is a mistake. Making a drug legal gives the impression that the state sanctions its use. Heroin, cocaine, crystal meth, ecstasy, and yes, even marijuana cause problems for people. I think that sending any other message is dangerous.

It’s not a coincidence that most people with substance abuse problems in this country (about 15 million) are pure alcoholics. Want a guess at the second biggest group? The marijuana dependent group is about 5 million strong. The rest of the drugs pick up only a few millions in total. Any move towards the legalization of any new drugs will most likely increase their use and therefore the number of addicts.

Still, decriminalization could be the answer. I’ve been meaning to write a post about Portugal’s decriminalized system for a while and haven’t gotten around to it. The bottom line? People found with illegal drugs are given a ticket and sent before a committee. The more visits one has in front of the committee the more forceful the push towards treatment. Still, unless a drug user commits another crime aside from the  possession of drugs they aren’t sent to jail.

As it stand right now, 30%-40% of our prisoners are in for simple drug offenses. That means not only billions in wasted incarceration costs every year, but also billions and billions more useless dollars thrown away at future sentences, court costs, and more (health care, probation and on and on). As it stands now recidivism rates, especially within the addict population are at 70% or higher! Unless these people get treatment, they will go back to jail! It’s that simple. Really.

So what should we do?

Many people aren’t going to like my view point. Those of us in the addiction field are supposed to scream as loudly as possible that drug are bad and that their eradication should be a major goal of our system. I disagree. Sue me.

I think we need to put the money we’re putting into jailing drug addicts into treatment. Even if it saves no money in the present (it will) we’ll be seeing huge savings over time as less of these people go to jail, more of them earn wages and pay taxes, and less of them make wasteful use of other resources like emergency rooms and social services.

And guess what? It will make our society better. We’ll start taking care of our citizens instead of locking them up. We’ll be showing Americans that we believe they can overcome rather than telling them we’d rather see them rot in jail than help them. We’ll be cutting down the number of single parent households and along with them god only knows how many more seemingly endless problems.

That’s my story, an I’m sticking to it.

How does Obama’s health care reform affect substance abuse treatment for Medicare patients?

Co-Authored by: Jamie Felzer

Medicare and addiction?  Do you typically think of these things as related? After the recent passage of Obama’s health care system reform, those utilizing Medicare and other government-sponsored systems will obviously be affected.

Government sponsored substance abuse treatment

A recent study on substance abuse treatment services for people with Medicare found that those who were younger than 65, and with a disability or mental disorder, had a much higher prevalence of substance abuse. About 100,000 people that fit into this category.

When it comes to debating health care reform, the elderly are the ones that are most often discussed as being affected by the changes in Medicare.  However, there is also a large population of people who are not elderly but also rely on the government-provided health care (like those on Medicaid for instance).

Most often substance abuse treatment co-occurs with mental health disorders, especially in the younger group receiving Medicare services.  76% of the younger claimants received substance abuse and mental health services while for those over age 65, only 54% received both treatments.  However, putting these percentages into the broader picture, only 1% of the elderly Medicare claimants have a primary diagnosis of substance abuse while for the younger group that same classification represents 5.7% of their age group.

How the law will affect substance abuse treatment

Part of Obama’s new health care reform increases the amount of research conducted regarding Medicare/Medicaid patients and their service utilization.  This research will focus on areas of providers, new treatment methods, as well as payment options to best suit all claimants. This could prove very beneficial, especially for those patients seeking treatment for co-morbid disorders.

With the recent passage in Congress of mental health parity laws that are set to begin in 2010, the healthcare system’s overhall should allow substance abuse treatment and mental health services to finally catch up with the rest of the health-care world. American will be far better off for it.


Utilization of substance abuse treatment services under Medicare, 2001-2002. Journal of Substance Abuse Treatment. 36 (2009) 414-419

Holahan & Blumberg. An Analysis of the Obama Healthcare Plan. Urban Institute Health Policy Center.

Rx for reform: Spend on addiction treatment now, save later.

This was originally posted on

StatisticsThe debate about healthcare reform is raging with democrats and republicans seemingly entrenched in their positions on different sides. The overall question is simple: How do we reduce the cost of healthcare in this country without negatively affecting the quality of it?

US healthcare can be some of the most advanced and innovative in the world. Unfortunately, it can also leave nearly 46 million Americans with too little, or even no, coverage. With insurance companies caring more about the bottom line than about people’s health and well being (that is, along with safety, after all the stated job of the government, isn’t it?) individuals lose, or are not granted, coverage when they become unprofitable.

If you’ve seen Sicko, or a number of other productions dedicated to this problem, you know where this story leads: Bankruptcies, homelessness, and the destruction of families, due to cancers, genetically acquired maladies, and other chronic illnesses. This might be okay with some Americans, but it’s not okay with many of us.

Those who oppose reform are using the same scare tactics and generalities they normally resort too, warning us of the loss of our health coverage by this government takeover. If you’re told that regular checkups at the doctor will save you thousands in overall medical costs (and we all are), it would be silly to consider the co pay for the regular doctor visits an additional cost burden. In fact, those smaller payments are allowing you to avoid more expensive, and painful, procedures down the line.

The constant barrage of republican scare messages seems to ignore that simple fact. Spend more now to save money later has worked with thermostats, energy efficient appliances, consumer conveniences like AAA, and will work with a healthcare reform overhaul.

In the same way, treating drug addicts will reduce their burden on our healthcare system. Spending even tens of thousands of dollars on an individual that costs that much yearly in emergency room visits will reduce their total financial burden on society as long as it significantly reduces the number, and severity, of the healthcare visits they seek. And if we add to this and give coverage to the same group, many of whom are uninsured, and you’ve hit the jackpot.

Let’s clarify what costs we’re talking about:

  • With the average cost of an ER visit ranging from $200 to $2000, and an average of 13.3 ER visits per year for untreated addicts, we end up with costs ranging between $2600 and $26000 per year per addict in additional costs. Given the estimates of about 23 million addicts in the US, that takes us, even at the low end, to $60 billion more just for ER visits (the high end would leave us close to half a trillion).

Fortunately, addicts who enrolled in treatment had ER costs that were reduced by 20% and those who completed treatment reduced those costs by 50%!!!

All of this doesn’t take into account health costs associated with chronic illnesses and other indirect effects of addictions. Since these include heart disease (hypertension, stroke) cancers (lung cancer especially), and more (liver disease, kidneys, etc.) even the most conservative estimates would add additional billions of dollars in costs to our healthcare system annually.

As of right now, tax payers are left holding the tab for many of these services. California businesses and families alone shoulder a hidden health tax of roughly $1,400 per year on premiums as a direct result of subsidizing the costs of the uninsured**.  Similar numbers are available for other states, and our federal dollars subsidize even more of the overall healthcare system burden left behind by those who can’t pay for it.

Some suggest that we simply stop providing services to those who can’t afford them. The reality is that all we’ll end up with in that case are millions of people who will become hospitalized through our correctional system. If you need serious healthcare, you’ll do anything to get it. The US already holds the proud distinction of having more than 50% of the world’s prison population while only making up 5% of the overall population. I don’t know about you, but I’d rather lose that number 1 spot.

Addiction treatment may be expensive, but it’s far less expensive than the ER services I mentioned earlier. By allowing individuals to have coverage for those services, we’ll take away some of the burden those same individuals are currently placing on our system AND improve lives at the same time.

My last point has to do with the “pre-existing conditions” clause so many insurance companies love so much. As our understanding of many diseases, including addiction, improves, we’re finding genetic, environmental, and developmental effects on almost all conditions. If we don’t do something to eliminate such restrictions, we may all soon end up paying more that we could possibly be expected to afford because our genes show we have a slightly elevated risk for things like hypertension, arthritis, or yes, even addiction.

It’s time to change the conversation about this and take away the notion that any of us will lose anything in this reform effort. If you have money, you will always be able to get better treatment – this conversation isn’t about you. This entire debate should focus squarely on those who aren’t getting the medical services they deserve by their mere existence as human beings. Every other civilized society on earth recognizes this by now. It’s time for us to make our way out of the dark ages.

**Furnas, B., Harbage, P. (2009). “The Cost Shift from the Uninsured.” Center for American Progress.

Healthcare savings and alcohol and drug abuse treatment: Saving lives and money

Alcohol and drug abuse treatment can save health care moneyA recent paper put out by an initiative called Closing the Addiction Treatment Gap (CATG) talks about some of the cost savings benefits that go along with alcohol and drug abuse treatment. The numbers refer to current treatment methods, success rates, etc., so the savings should only go up as we become more successful and introduce longer, more chronic treatment methods (as I discussed here).

  • 2.3 Million hospital stays in 2004 we directly related to substance disorders.
  • Total medical costs were reduced 26 percent among patients that received addiction treatment.
  • Brief counseling alone allowed for a reduction of 20 percent in emergency department visits and 37 percent in days of hospitalization among a group of high-risk alcoholics.
  • Addiction contributes directly to many off our most pressing health issues: heart disease,
    cancer and stroke.
  • In one study, outpatient addiction treatment reduced total medical costs by 26%, inpatient health-care costs by 35%, and emergency room by 36% !!!

You can find the rest of the report on CATG’s website, but I think you’ll agree that alcohol and drug abuse treatment needs to be part of the discussion in our ongoing health-care debate. We can save billions of dollars and millions of life every year by making appropriate, effective, addiction treatment part of the reality of ongoing health care in America.

It’s the responsible thing to do. It’s the right thing to do.