The Vulnerability in Smoking

Looking at individuals who smoke as a vulnerable population.

In 2012, smoking attributed to 45,400 deaths in Canada which correlates to 18 percent of all deaths in 2012 (Noakes, 2017). The World Health Organization, states smoking is responsible for more than 5 million deaths annually (Health Canada, 2017). According to Health Canada in 2021, nearly five million Canadians smoked and about 48,000 Canadians die from tobacco use every year (CBC Radio, 2021). Smoking is known to cause many different disease processes. Smoking primarily leads to cancer, cardiovascular diseases, and respiratory diseases such as chronic obstructive pulmonary disease (COPD) (Health Canada, 2017). The direct cost of smoking to health care accounted for $6.5 billion. Yet people continue to smoke.

Social Determinants of Health in Smokers (Brady, 2020):

• Low socioeconomic status

• Poor education

• Low income

• Race/ethnicity

• Cultural characteristics

• Social marginalization (e.g., lesbian, gay, bisexual, and transgender communities, people with mental illness and substance use disorders)

• Stress

• Lack of community empowerment

• Unequal distribution of resources and services

These are just some of the main social determinants of health (SDoH) that are found in smokers. The two biggest SDoH for these individuals is education and income. Smoking is strongly correlated with individuals with low education and low income (Brady, 2020).

Social Ecological Model of Health (SEM) of Smokers:

Individual Level:

Low socioeconomic status plays a huge role in the individual level of SEM. Many individuals who smoke have low levels of education and low income. At the individual level, Pierce and Kealey (2021) recommend tobacco education and tobacco free schools. Education will provide individuals with the knowledge needed to make an informed decision on whether to smoke or not. Additionally, creating an environment that promotes anti-tobacco beliefs and behaviors is also very instrumental in smoking cessation (Pierce and Kealey, 2021).

Interpersonal Relationships Level:

An individual’s relationships play a huge role in whether they will smoke or not. It is noted that individuals with parental and peer smokers in their lives have exponentially increased odds of smoking (Australian Government, n.d.). Additionally, nicotine exposure during childhood plays a major role in enabling smoking behavior (Australian Government, n.d.). Promoting smoke-free homes could help prevent individuals from smoking (Pierce and Kealey, 2021).

Organizational Level:

An individual’s surroundings heavily influence an individual’s smoking. Many individuals are more likely to smoke depending on the organizations they belong too. A major organization that an individual is apart of and is connected to is their job. Our job plays a huge role in our identity and makes up a major part of our lives. It is noted that physically demanding jobs are linked with heavy smoking. Work that involves high physical exertion is associated with heavy smokers, roughly 2.5 times more than people whose job involves low physical exertion (IWH, 2019). Creating smoke-free work places may help create an environment that promotes smoking cessation.

Community level:

Adults that live in rural areas smoke at a higher rate compared to adults that live in urban areas. This relates back to a lack of education and low income (Australian Government, n.d.). In these communities, smoking is more common and socially acceptable. These individuals believe that smoking is okay and ignore the negative effects associated with smoking. Creating communities that promote smoking cessation will help deter individuals from smoking.

Societal/Policy level:

The introduction of policies that deter smoking can increase smoking cessation rates. A common recommended policy is increasing taxes on tobacco products (Pierce & Kealey, 2021). Additionally, increasing insurance coverage for medical treatments such as pharmaceutical treatments and behavioral coaching can help increase smoking cessation (Pierce & Kealey, 2021). Changes in policies that promote smoking cessation can lead to creating a society that encourages people to be tobacco free.

As a respiratory therapist, smoking is considered very harmful and bad. At the hospital I work at majority of these individuals develop COPD. With COPD being a chronic disease, many of these patients are non-complaint with medications and have frequent visits to the hospital. As a result, COPD costs the health care system an estimated 1.5 billion dollars annually (Canadian Institute for Health Information, n.d.). A personal trend that I am noticing is that education for these individuals is severely lacking. There are various factors for the lack of education but a large reason in my opinion is the fact that many individuals do not want to waste their time providing smoking cessation education. Many nurses and RTs feel like their words are falling on deaf ears and that these individuals have no desire to quit. RTs and nurses prefer to rather treat and discharge these patients. I can understand and relate to these frustrations as a health care provider. Seeing the same patients come in and out of the hospital for exacerbations can be very demoralizing. Smoking is an extremely difficult habit to break and it takes multiple failed attempts before an individual will kick the habit (Pierce and Kealey, 2021). Re-enforcing smoking cessation is vital because you never know when an individual will be open to the idea of quitting unless you attempt to provide them with education. I feel like opportunities to capitalize on these moments when these types of patients have a desire to quit are being missed. As a result, theses cycles of COPD exacerbations and hospitalizations continue and are not broken. Thus, continuing the financial burden placed on the Canadian health care system.

References:

Australian Government. (n.d.). Factors influencing smoking levels among high smoking prevalence groups. The Department of Health. Retrieved March 22, 2022 from https://www1.health.gov.au/internet/publications/publishing.nsf/Content/smoking-disadvantage-evidence-brief~factors-smoking-levels#:~:text=Research%20has%20identified%20a%20range,pressure%20and%20stress%3B%20(28)

Brady, K. (2020). Social Determinants of Health and Smoking Cessation: A Challenge. The American Journal of Psychiatry, 177(11), 1029-1030 https://ajp.psychiatryonline.org/doi/epub/10.1176/appi.ajp.2020.20091374

CBC radio. (2021). How the pandemic impacted vaping and smoking rates — and why it showed vaping is 'here to stay'. CBC Radio. Retrieved March 22, 2022 from https://www.cbc.ca/radio/whitecoat/how-the-pandemic-impacted-vaping-and-smoking-rates-and-why-it-showed-vaping-is-here-to-stay-1.6068729

Canadian Institute for Health Information. (n.d.). COPD: A focus on high users — Infographic. Canadian Institute for Health Information. Retrieved March 22, 2022 from https://www.cihi.ca/en/copd-a-focus-on-high-users-infographic

Health Canada. (2017). The Costs of Tobacco Use in Canada, 2012. Government of Canada. Retrieved March 22, 2022 from https://www.canada.ca/en/health-canada/services/publications/healthy-living/costs-tobacco-use-canada-2012.html

Institute for Work & Health. (2019). Examining the link between working conditions and tobacco-smoking habits. Institute for Work & Health. Retrieved March 22, 2022 from https://www.iwh.on.ca/summaries/research-highlights/examining-link-between-working-conditions-and-tobacco-smoking-habits

Newsy. (2017). Most smokers have low socioeconomic status. Retrieved March 22, 2022 from https://www.youtube.com/watch?v=6dJ-5Zz6JF4

Noakes, S. (2017). Smoking costs 45,400 lives, $16.2B in a year, study finds. CBC News. Retrieved March 22, 2022 from https://www.cbc.ca/news/business/smoking-economic-cost-1.4357096#:~:text=Those%20costs%20include%20health%20care,the%20economy%20continue%20to%20rise.

Fighting Chronic Diseases

A comparison between British Columbia and Quebec.

In 2000, Canada chronic diseases accounted for $99.1 billion with $31.6 billion being associated in direct costs (BC Ministry of Healthy Living and Sport, 2010). These numbers have only risen and it is estimated that chronic diseases account for $190 billion annually with $68 billion of it being in direct costs (Chronic Disease Prevention Alliance of Canada, 2018). Most of the direct costs are due to chronic diseases that can be prevented and mitigated. Currently in Canada, 44% of adults 20+ have at least one common chronic condition (Health Canada, n.d.). Additionally, 10% of these individuals are affected by Chronic Obstructive Pulmonary Disease (COPD) (Health Canada, n.d.).

Working as a Respiratory Therapist, COPD is a chronic disease that I encounter very frequently. In British Columbia (BC) alone, approximately 138,500 individuals aged ≥ 45 years in BC have been diagnosed with COPD (Government of BC, n.d.). This is roughly 6% of British Columbians aged ≥ 45 years (Government of BC, n.d.). In the Fraser health, the health authority I work in roughly 30, 000 people live with COPD (Fraser Health, n.d.).These numbers however may not represent the true number of people living with COPD as many individuals go undiagnosed.

Chronic Disease is an issue that is plaguing all of Canada. As our population ages, chronic disease management has become an increasingly more focused area in health care. Each province has implemented their own strategies to combat chronic disease through various preventive and management methods. Below I will highlight how BC and Quebec tackle chronic diseases. I will specifically elaborate how each province conducts chronic disease surveillance, management and obtain funding.

Chronic Disease surveillance:

For the surveillance of Chronic disease management, BC uses The Population & Public Health Program. This program collects, analyzes, and shares data about health status and chronic diseases in BC (BCCDC, n.d.). In Quebec, the Quebec Integrated Chronic Disease Surveillance System (QICDSS) was created for Chronic Disease surveillance. The database was created by linking five health administrative databases (Blais et al, 2014). The QICDSS allows the surveillance of the following chronic diseases: diabetes, cardiovascular diseases, respiratory diseases, osteoporosis, osteoarticular diseases, mental disorders and other related disorders (Blais et al, 2014.).

Chronic Disease management:

British Columbia Core Functions of Public Health Framework (CF Framework) identified the need for twenty-one core public health programs. The CF Framework highlighted the areas of health improvement; disease, disability and injury prevention; environmental health; and health emergency management (Kothari et al, 2013). It is the responsibility of the various health authorities for implementation and quality of their programs. Health authorities are expected to develop programs/services and conduct a performance improvement plan for each core program (Kothari et al, 2013). Although in BC, the provincial government has established a provincial wide program called The Chronic Disease Self-Management Program for individuals suffering from chronic diseases. It is a six-week program that focuses on patient education (Government of British Columbia, n.d.). The program is tailored to the individual’s specific chronic disease and is available in various languages (Government of British Columbia, n.d.).

Additionally, many of the various health authorities in BC provide their own chronic disease management programs. Fraser health, the health authority I work in for instance has; Asthma Education Program, Chronic Pain Clinic, Community Dialysis, Community pain program, COPD Self-Management Program, Diabetes Education, Home Hemodialysis, Inflammatory Arthritis Rehab Clinic, Kidney Care Centre, Lung Health, Multiple Sclerosis Clinic, Peritoneal Dialysis, Positive Health Services, Pulmonary Rehabilitation Program, Renal Vascular Access Clinic and Stroke Prevention Clinic (Fraser Health, n.d.). For example, the COPD Self-management program provides education and tips on how to better manage chronic obstructive pulmonary disease (COPD) condition at home. Patients are given education on medication review, breathing exercises, controlling shortness of breath and other COPD relevant information (Fraser Health, n.d.). Similarly, Providence Health has many chronic disease management programs. The COPD outpatient clinic in providence health aim to optimize care in COPD patients according to best clinical practice in a multidisciplinary setting (Providence Health, n.d.). The team is composed of a respirologist, a respiratory therapist, a dietitan, physiotherapist and patients are referred by physicians (Providence Health, n.d.). Additionally, the increasing number of individuals living with chronic diseases has led Providence Health to establish the Rapid Access to Consultative Expertise (RACE). The RACE program is a telephone advice line where family physicians can call and choose various specialty services and be routed directly to a specialist for real-time advice (Providence Health, n.d.).

The Ministère de la Santé et des Services sociaux (MSSS) of Quebec has made the prevention and management of chronic diseases a priority. The government has developed and disseminated their strategy for the prevention and management of chronic diseases to all health and social services agencies (ASSS) in Quebec (Ahmed et al, 2015). Quebec uses the Chronic Care Model (CCM) framework for the management of chronic diseases like the rest of Canada. It has been adopted by the MSSS’s strategy for the prevention and management of chronic diseases (Ahmed et al, 2015). As a result, Quebec has made Family Medicine Groups (FMGs) one of the cornerstones of its chronic disease management reforms (Health Canada, 2007). The FMG is composed of family physicians working in close collaboration with nurses to provide a wide range of services to clients who enroll voluntarily (Health Canada, 2007). The services offered are tailored to the individual health status of registered patients. The program offers disease prevention, health promotion, medical assessment, diagnosis and treatment of acute and chronic conditions (Health Canada, 2007).

Funding:

Both BC and Quebec utilized the Primary Health Care Transition Fund (PHCTF). The PHCTF provides funds to all the provinces and territories for the development and implementation of new models of public health care delivery (Health Canada, 2007). The fund was created with an increase emphasis on health promotion, disease and injury prevention, and chronic disease management (Health Canada, 2007). Currently, majority of funding for programs in both provinces comes from the provincial government. Quebec uses the Fonds de recherche du Québec—Santé (FRQS), the provincial funding agency (Ahmed et al, 2015).

As illustrated above, both these Provinces have prioritized efforts to deal with the increasing prevalence of chronic disease. Each province uses their own methods to conduct chronic disease surveillance and management. BC and Quebec both use similar methods for obtaining funding. Although, both provinces use different methods, they share a similar commitment to helping individuals deal with and combat chronic diseases.

References:

Ahmed, S., Ware, P., Visca, R., Bareil, C., Chouinard, M. C., Desforges, J., Finlayson, R., Fortin, M., Gauthier, J., Grimard, D., Guay, M., Hudon, C., Lalonde, L., Lévesque, L., Michaud, C., Provost, S., Sutton, T., Tousignant, P., Travers, S., Ware, M., … Gogovor, A. (2015). The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting. BMC research notes, 8, 571. https://doi.org/10.1186/s13104-015-1514-0

BC Centre for Disease Control. (n.d.). Population & Public Health Surveillance. BCCDC. Retrieved March 8, 2022 from http://www.bccdc.ca/our-services/programs/population-public-health-surveillance

BC Ministry of Healthy Living and Sport. (2010). Model Core Program Paper: Chronic Disease. BC Ministry of Healthy Living and Sport. Retrieved January 23, 2022 from https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/public-health/healthy-living-and-healthy-communities/chronic_disease-model_core_program_paper.pdf

Blais, C., Jean, S., Sirois, C., Rochette, L., Plante, C., Larocque, I., Doucet, M., Ruel, G., Simard, M., Gamache, P., Hamel, D., St-Laurent, D., & Emond, V. (2014). Quebec Integrated Chronic Disease Surveillance System (QICDSS), an innovative approach. Chronic diseases and injuries in Canada, 34(4), 226–235. https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-34-no-4-2014/quebec-integrated-chronic-disease-surveillance-system-qicdss-innovative-approach.html

Centers for Disease Control and Prevention (CDC). (2019). Chronic Disease. Retrieved March 8, 2022 from https://www.youtube.com/watch?v=c91ggTlEGv8

Centers for Disease Control and Prevention (CDC). (2017). Self-Management Education: Managing Chronic Conditions Beyond Medications. Retrieved March 8, 2022 from https://www.youtube.com/watch?v=de2llrEajvU

Chronic Disease Prevention Alliance of Canada (2018). 2018 pre-budget submission to the House of Commons Standing Committee on Finance. Chronic Disease Prevention Alliance of Canada. Retrieved January 23, 2022 from https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR9073636/br-external/ChronicDiseasePreventionAllianceOfCanada-e.pdf

Fraser Health Authority. (n.d.). Chronic Disease Management. Fraser Health. Retrieved March 8, 2022 from https://www.fraserhealth.ca/Service-Directory/Services/chronic-disease-management

Fraser Health Authority. (n.d.). COPD Self-Management Program. Fraser Health. Retrieved March 8, 2022 from https://www.fraserhealth.ca/Service-Directory/Services/chronic-disease-management/copd-self-management-program

Fraser Health. (n.d.). Chronic Obstructive Pulmonary Disease (COPD). Fraser Health. Retrieved March 8, 2022 from https://www.fraserhealth.ca/health-topics-a-to-z/copd#:~:text=COPD%20is%20a%20lung%20disease,last%20year%20in%20the%20province.

Government of British Columbia. (n.d.). Chronic Condition Care. Government of British Columbia. Retrieved March 8, 2022 from https://www2.gov.bc.ca/gov/content/family-social-supports/seniors/health-safety/disease-and-injury-care-and-prevention/chronic-condition-care

Government of British Columbia. (n.d.). Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management. Government of BC. Retrieved from March 8, 2022 from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/copd#:~:text=Approximately%20138%2C500%20individuals%20aged%20%E2%89%A5,Columbians%20aged%20%E2%89%A5%2045%20years).&text=Many%20individuals%20have%20unrecognized%20COPD%20and%20remain%20undiagnosed.

Health Canada. (2007). Chronic Disease Prevention and Management. Retrieved March 8, 2022 from https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/primary-health-care/chronic-disease-prevention-management.html#f2

Health Canada. (n.d.). Prevalence of Chronic Diseases Among Canadian Adults. Health Canada. Retrieved March 8, 2022 from https://www.canada.ca/en/public-health/services/chronic-diseases/prevalence-canadian-adults-infographic-2019.html

Kothari, A., Gore, D., MacDonald, M., Bursey, G., Allan, D., Scarr, J., & Renewal of Public Health Systems Research Team (2013). Chronic disease prevention policy in British Columbia and Ontario in light of public health renewal: a comparative policy analysis. BMC public health, 13, 934. https://doi.org/10.1186/1471-2458-13-934

Providence Health. (n.d.). Chronic Disease Management. Providence Health Retrieved March 8, 2022 from https://www.providencehealthcare.org/chronic-disease-management

Providence Health. (n.d.). COPD Clinic. Providence Health. Retrieved March 8, 2022 from https://www.providencehealthcare.org/copd-clinic

Telehealth: Will it stay or will it fade?

Telehealth Services is revolutionizing the way we access health care.

2020 will forever be considered a year full of exponential change. COVID-19 and all its mutations redefined the world we lived in. Office jobs turned into work from home. Personal protective equipment (PPE) went from recommended to mandatory. Being sick required self-isolating instead of powering through a shift at work. Propaganda questioning the science behind vaccines were amplified through the use of the internet and social media. The world drastically changed and so did health.

2020 and 2021 saw a drastic increase in digital health. Digital health encompasses telehealth, centralized electronic health records, wearable sensors, cloud technology, machine learning, and artificial intelligence (Hamoni et al, 2021). Interest and the use of telehealth services specifically grew within Canadians due to COVID-19 lockdowns and stay-at-home orders (Hamoni et al, 2021). Prior to the pandemic, in 2018–2019, clinicians conducted only 8% of their clinical visits virtually (Mohammed et al, 2021).

Majority of the use of telehealth was used to aide in the disparity of access to healthcare in northern rural parts of Canada. These individuals benefited from telehealth services as it created opportunities for cost-effective and accessible care closer to home. Telehealth provided timely care, reduced the cost of health care and increased accessibility as individuals in rural areas didn’t need to travel to larger urban settings (Jong et al, 2018).

Some services that are being provided by telehealth in rural Canada are (Jong et al, 2018):

•Preoperative assessments and postoperative care for surgery

•Management of fractures and dislocations

•Assistance with procedures and surgeries via more experienced colleagues

•Daily remote hemodialysis rounds

•Tele-oncology

•Point of care ultrasound with the aid of an untrained person and led remotely via video by an experienced health provider

•Speech pathology

•Dietary consult

•Physiotherapy consult

•Professional development

•Supervising learners in remote communities

However in 2020, with the COVID-19 pandemic, this percentage increased to approximately 60% in Canada (Mohammed et al, 2021). And in this current climate of health care and the uncertainty of the pandemic, telehealth is here to stay and is the future of health care delivery.

Telehealth services or telemedicine is an alternative to in-person consultations with healthcare professionals. Telehealth services are conducted through electronic communications such as audio or video calls, text messages and emails (Hamoni et al, 2021). Telehealth allows patients to meet with healthcare providers from the comfort of their own homes. Additionally, telehealth allows for patients to meet with health care professionals that whom would normally require distant travel to meet with for an appointment (Hamoni et al, 2021).

Benefits (Mohammed et al, 2021):

• Higher patient satisfaction

• Better access to care

• Overall cost savings

• Access to specialist care

Challenges (Mohammed et al, 2021):

• Digital competency among both healthcare providers and patients

• Affordability and accessibility of technology required

• Internet access

Since the pandemic, the healthcare system has endorsed several different virtual modes to increase clinical interactions with patients (Mohammed et al, 2021). The drastic implementation of telehealth services has resulted in many beneficial outcomes. It has been noted to have higher patient satisfaction, better access to care, decrease in costs and increased access to specialist care (Mohammed et al, 2021). However, telehealth still has plenty of limitations. Limitations are often seen around digital competency in both health care providers and patients (Mohammed et al, 2021). Individuals’ familiarity with the vast range of technologies within telehealth can be vastly different. Some individuals are highly literate in telehealth while others are very illiterate. Education in telehealth is strongly need to support the growth of telehealth services. Additionally, affordability and accessibility of telehealth technology is required (Mohammed et al, 2021). Mohammed et al (2021) states that this is often seen as a huge barrier within individuals with poor income. These individuals do not have the means to access and buy equipment necessary to participate in telehealth services (Mohammed et al, 2021). Additionally, limitations around internet access is an issue for individuals (Mohammed et al, 2021). Depending on the individual, connectivity issues regarding internet access may be due to their geographical location (Jong et al, 2019). Conversely, an individual’s internet access may be due to their income. Patients with low income may prioritize food and shelter over obtaining internet access (Jong et al, 2019). Thus limiting their access to telehealth services.

Telehealth should not replace traditional methods of delivering health care however, it does have its own place within health care in Canada. I believe telehealth has a place in rural areas where travel is an issue, for simple routine check ups, prescription refills, obtaining requisitions for bloodwork/x-rays, referrals for specialist etc. I still believe that in some instances physical assessments are still warranted and are unavoidable. Telehealth should be used as an aide to support the delivery of health care. Replacing some aspects with telehealth will help ease accessibility in our health care system. It will help replace wait times, increase convince for patients, reduce travel time, decrease emergency room hospitalizations and overall cost burdened by our health care system in Canada.

References:

Bloomberg Markets and Finance. (2020). Telehealth Is Booming During Covid Pandemic. Is it Here to Stay? Bloomberg. Retrieved April 1, 2022 from https://www.youtube.com/watch?v=j6htr4SxA08

Hamoni, R., Matthews, M., and Watson, M. (2021). Digital Transformation: The Next Big Leap in Healthcare. Information and Communications Technology Council (ICTC). Retrieved March 28, 2022 from https://www.ictc-ctic.ca/wp-content/uploads/2021/08/ICTC_Report_DigitalTransformation_August-12.pdf

Jong, M., Mendez, I., & Jong, R. (2019). Enhancing access to care in northern rural communities via telehealth. International journal of circumpolar health, 78(2), 1554174. https://doi.org/10.1080/22423982.2018.1554174

Mohammed, H. T., Hyseni, L., Bui, V., Gerritsen, B., Fuller, K., Sung, J., & Alarakhia, M. (2021). Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use. PloS one, 16(6), e0253665. https://doi.org/10.1371/journal.pone.0253665