Table of Contents

• Abstract and Objectives
• Introduction
• Adverse Effects of Smoking
• Advantages of Smoking Cessation
• Assessment Tools
  Table 1: Fifth Vital Sign
  Table 2: Fagerstrom Scale
• Treatment Options
  Table 3: Pharmacological Therapy
• Practical Tips From the AHCPR Guidelines
• Summary
• Case Studies
  #1: Amy, 18
  #2: Mr. C, 65
  #3: Linda, 51
• References

The writers would like to thank Mary Ellen Wewers, PhD, RN, Audrey Gift, PhD, RN, Christine Wynd, PhD, RN, John Hansen-Flaschen, MD and David Rosenthal, MD for their valuable assistance in reviewing this program.

Abstract

The purpose of this article is to provide the staff nurse with an overview of the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation guidelines. The authors outline the practical components of the guidelines to enable nurses in any clinical setting to implement various smoking cessation strategies according to individual patient needs. Treatment options, including behavioral modification are discussed, including a comprehensive review of pharmacological therapy.

Objectives

1. Describe the impact of smoking as it relates to the number of deaths in United States.
2. State three (3) adverse outcomes of cigarette smoking.
3. Identify three (3) health related outcomes of smoking cessation.
4. Discuss three (3) current treatment options for smoking cessation.
5. List three (3) strategies for modifying smoking behavior.

Nursing Strategies for Smoking Cessation

Introduction

Smoking cigarettes is killing America! Tobacco use is the most preventable cause of premature death and disability in the United States. Tobacco kills more than 400,000 Americans per year by causing coronary heart disease, lung and other cancers, chronic obstructive lung disease including emphysema and bronchitis, acute respiratory infections and cerebral vascular accidents. (1) Despite these facts, 25% of adults in the United States — 28 million men and 23 million women — continue to smoke. Smoking is most prevalent in the age group of 25 - 44 year olds. There are alarming statistics revealing that approximately 90% of new smokers are teenagers. More than 3,000 adolescents under the age of 18 are starting to smoke every day! (2) Cigarette use is increasing on college campuses nationwide. (3) Other groups with higher rates of smoking include:

• people who have an educational level of high school or lower
• manual laborers
• military personnel
• certain minorities including African-Americans, Hispanics, Native Americans and Southeast Asians. (4)

Given these disheartening numbers, how can a staff nurse motivate patients to quit smoking and help to change these statistics? This continuing education article outlines the essentials of counseling for smoking cessation, whether it's in the inpatient acute care setting, the outpatient clinic, home care or the ICU!

Adverse Effects of Smoking

The long-term adverse effects of smoking are well documented. Nurses, however, realize that in the absence of symptoms, patients find it difficult to visualize themselves living with a chronic illness not yet present. Therefore, it may be useful to discuss the short-term symptoms of tobacco use affecting smokers. When a person smokes, the following physiological processes occur:

• an increased heart rate of 15-25 bpm (can present with tachycardia and chest palpitations)
• an increased blood pressure of 10-20 mm Hg
• corrosion of the lip and palate mucous membranes
• sensation of choking in the airways and shortness of breath
• carbon monoxide enters the system, depriving tissues of oxygen. (This may result in decreased energy level and exercise intolerance)
• a morning cough
• increased gastric acid flow which may lead to gastric ulcers
• periodontal disease
• increase in nervousness or anxiety levels
• impotence and infertility
• exacerbations of asthma
• premature skin aging

Discussing the above symptoms may help the patient appreciate the daily impact of smoking that will eventually result in the debilitating and deadly diseases identified in the introduction.

Advantages of Smoking Cessation

• Within two hours after smoking cessation, the blood pressure and pulse start to normalize and the body temperature of extremities increases.
• Within four hours after the last cigarette the CO (carbon monoxide) level returns to normal. (Carbon monoxide, the same poison that is present in exhaust fumes from cars and faulty furnaces, is present in the smoke from cigarettes and is readily inhaled.
• Within eight hours, indigestion and dyspepsia improve and the oxygen level in the blood increases.
• Within 24 hours, the chance of a myocardial infarction decreases and returns to baseline as a nonsmoker at one year.
• Within 48 hours, the nerve endings in the oropharyngeal area are stimulated and the sense of taste and smell improve. (This means home, car, and breath will smell better!)
• Within 72 hours, the bronchial tubes relax and a person feels less dyspneic; lung function and capacity increase. (The patient will feel better physically and have greater endurance in sports.)
• Within one to nine months, the cilia in the bronchus regain function, thereby decreasing the chance of developing bronchitis and emphysema. (Morning cough will gradually subside.)
• By 10 years, the chance of lung and other cancer decreases (but never reaches the level of a nonsmoker) and the chances of myocardial infarction, stroke, cancers of the larynx, oral cavity, pharynx, esophagus, bladder, or cervix, are reduced. The risk of smoking-related cancers decreases more slowly after smoking cessation than the risk for coronary artery disease.

Additional benefits of smoking cessation, especially important for youth, include the absence of bad breath, improved endurance in sports, more pocket money, and freedom from dependence on nicotine.

The "Take Home Message" includes the notion that positive changes occur in the body and mind when a person quits smoking and that the changes start immediately and continue on for years if the patient remains smoke-free. This subsequently leads to an improved daily functional status, a higher quality of life and a reduced death rate!

Assessment Tools

Now that the effects of tobacco use on patients is known, how does the nurse assess current tobacco use and nicotine dependence? Nurses represent the highest number of health care providers in the United States, and most nurses believe it is their responsibility to instruct patients about smoking cessation, but the percentage of nurses who counsel patients remains low. (6) Taylor et al. reported a nurse-managed smoking cessation intervention can increase cessation rates for hospitalized smokers. (7) In other studies, research conducted by Stillman at Johns Hopkins University described a model program for the hospitalized cardiac patient. (8) Wewers et al. at Ohio State University indicated that a nurse-managed smoking cessation intervention during diagnostic testing for lung cancer was successful in achieving short-term cessation. (9) Finally, Utz et al. at University of Virginia reduced smoking behaviors in a community-based program. (10) These are all examples of nurses making the difference in counseling their patients on tobacco use and cessation.

In the early 1990s, Fiore introduced the concept of the fifth vital sign; that is, considering a patient's smoking status along with blood pressure, pulse, temperature and respiratory rate. (11) This approach provides an important opportunity to gain information at each patient visit about the patient's tobacco status and an opportunity to promote smoking cessation. The AHCPR incorporated this 5th vital sign into the Clinical Guideline on Smoking Cessation (See Table 1) as a means to identify tobacco use at every patient visit. (12) Tobacco use is routinely assessed upon inpatient admission, but may only be assessed with initial ambulatory or home visits.

Table 1: Fifth Vital Sign

Fiore (1991). (11)

Once it is determined that the patient is a tobacco user, utilizing the Fagerstrom Scale will help to estimate dependency on nicotine (See Table 2). (13) This tool serves to provide feedback to both the patient and the provider on the level of nicotine dependence. A score of seven or greater is considered high. A higher score means that the patient who continues smoking is highly dependent on nicotine and more likely to experience withdrawal symptoms when they quit. By knowing this, the staff nurse can assist the patient to increase their awareness of possible effects that may be experienced, and how to plan his or her attempt to quit. A simple question to assess the patient's readiness to quit smoking is, "Can you see yourself smoke-free?"

Nicotine, a major ingredient in tobacco smoke, is addictive. (14) In addition to nicotine, there are approximately 5,000 other chemical compounds in tobacco smoke. These include acetone, ammonia, arsenic, carbon monoxide, cyanide, formaldehyde, methane, tar, and toluene. (15) The burning of tobacco is a thermal reaction involving multiple chemical reactions, releasing many of the above chemicals and their byproducts into the air when a cigarette, cigar or pipe is smoked. Many of these are known carcinogens. These are inhaled by the smoker and released to the air. This exposure to environmental tobacco smoke (ETS), often referred to as secondhand smoke, affects not only the smoker, but all those exposed to the smoke, including children and pets.

Table 2: Fagerstrom Scale (13)

The questionnaire that follows will help you estimate your physical dependency on nicotine. Each letter represents points 0, 1, 2 or 3. Enter your answer to each question on the line next to the question.

____1. How soon after you wake up do you have your first cigarette?

1. within 5 minutes (3)
2. 6-30 minutes (2)
3. 31-60 minutes (1)
4. After 60 minutes (0)

____2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, in cinema, etc.?

1. Yes (1)
2. No (0)

____3. Which cigarette would you hate most to give up?

1. the first one in the morning (1)
2. all others (0)

____4. How many cigarettes/day do you smoke?

1. 10 or less (0)
2. 11-20 (1)
3. 21-30 (2)
4. 31 or more (3)

____5. Do you smoke more frequently during the first hours after waking than during the rest of the day?

1. Yes (1)
2. No (0)

____6. Do you smoke if you are so ill that you are in bed most of the day?

1. Yes (1)
2. No (0)

A high score means that you are probably dependent on nicotine and you are likely to experience some withdrawal symptoms when you stop smoking. A score of 7 or greater is considered high. A score less than 7 suggests that you are less likely to encounter physical symptoms due to withdrawal from nicotine.

Reprinted with the kind permission of Dr. Karl-Olov Fagerström

Treatment Options

People quit smoking every day. There are more former smokers than current smokers. (16) Many smokers make an average of four to six quit attempts before they quit for good, but it is important to recognize that each quit attempt builds upon previous experience. An analogy can be made to learning to ride a bicycle. One may fall a few times, before riding smoothly. One or two falls does not mean that one will not learn to ride. Patients learn what worked for them, and what didn't. The authors like to think of these as practice for the final and permanent quit attempt. It is important to advise patients to quit, and do so in a kind, caring, nonjudgmental manner. Quitting can be difficult for the smoker. Most likely the patient will experience physical symptoms of nicotine withdrawal once he or she stops smoking. There are also many triggers or rituals the patient associates with his or her smoking habit, and despite the cessation of cigarettes, there will be continued presence of those triggers. Common triggers include: coffee, alcohol, completion of a meal, work breaks, smoking "buddies," etc., and all the other behaviors that are associated with cigarette use. Withdrawal from nicotine is easier if the patient is aware of his or her triggers, tries to avoid them, and knows how to better cope with them when they occur. A plan of action will help promote the patient's success in unlearning the rituals of his or her smoking behavior.

There are several effective approaches to smoking cessation. These include going "cold turkey," nicotine replacement therapy, (17) or the use of a newly released non-nicotine medication, such as Buproprion HCL (ZYBAN (®)). (18) A patient's desire to stop smoking is one of the most important indicators for successful cessation. Other tips that assist the patient in the quit process are:

• identify a support person
• advertise the quit attempt
• make the home smoke-free (this discourages a relapse)
• get rid of tobacco, matches, lighters, ashtrays, and all things associated with the cigarette habit.

Cold Turkey

Quitting "cold turkey" involves selecting a quit date. On that date, the smoker completely stops the use of any and all sources of tobacco. With the removal of the nicotine source, it is important for the patient to be aware that he or she will most likely experience withdrawal symptoms, which may last for a few days, but often up to two weeks. (19) The withdrawal symptoms are a response to nicotine deprivation and other aspects related to smoking, and may include irritability, fatigue, dizziness, difficulty concentrating and cravings for cigarettes. Encouraging the patient to drink plenty of water may assist with nicotine elimination.

Nicotine Replacement Therapy

Nicotine replacement products help to reduce the physical withdrawal symptoms that occur when the patient stops tobacco use. Over time, proper use of nicotine replacement therapy will help to wean the patient off nicotine. (17) Nicotine replacement therapy comes in the following forms: gum, patch, oral inhaler, and nasal spray. Please refer to Table 3 for more information. Nicotine replacement therapy should be started on the selected quit date, and only after your patient has completely stopped the tobacco source. Certain brands of these medications are now available over-the-counter, while some continue to be available by prescription only. The AHCPR guidelines caution the use of the nicotine replacement patch in patients within four weeks of a myocardial infarction. (12) The oral inhaler is the latest replacement product to be released and is meant to serve two purposes: providing nicotine replacement and also providing a substitute for the hand-mouth routine so commonly experienced by the smoker. The nasal spray has been found to provide the fastest delivery of nicotine due to rapid absorption through the nasal mucosa.

Table 3: Pharmacological Therapy

Buproprion HCL (Zyban (®), Welbutrin SR (®),)

This non-nicotine medication, Buproprion HCL, available for a number of years as an antidepressant, has been found to be effective in reducing the cravings smokers experience when they stop smoking. (18) The manner of its action is unknown, but it is thought to work on certain pathways in the brain that are involved in nicotine addiction and withdrawal. Buproprion HCL is available only by prescription and should be started approximately one week before the patient's quit date to achieve adequate drug levels in the bloodstream to prevent craving. This medication is taken once daily for three days and then increased to b.i.d. dosing for the duration of therapy, which is usually three months. It is crucial for patient success that this medication does not be discontinued if the patient is wavering to return to smoking once this medication is stopped. Current research is being done on duration of this therapy. A patient may also use this therapy along with nicotine replacement therapy for additional relief from nicotine withdrawal symptoms. Buproprion HCL is contraindicated in patients with a history of seizures or disorders that may promote seizure activity (alcoholism, unstable diabetes, altered metabolic state, such as in eating disorders), and also for patients currently taking MAO inhibitors, or one of the other Buproprion HCL preparations, such as Welbutrin SR (®).

Behavior Modification

The use of tobacco often becomes a learned behavior reinforced by the redundant triggers we discussed earlier. Patients who are aware of their triggers and develop a personalized quit plan will achieve more success in unlocking the rituals associated with their smoking habits.

Alternative options for smoking cessation also include: hypnosis, acupuncture and aversion therapy (smoking a large quantity of cigarettes until becoming ill). For the purposes of this article, these options will only be mentioned. Evidence to support their efficacy is insufficient at present.

Practical Tips From the AHCPR Guidelines (13)

Practical tips that can be incorporated into daily nursing practice include the 4 A's: 1. Ask, 2. Advise, 3. Assist, and 4. Arrange follow-up. This includes asking the patient about his or her smoking habit, advising that quitting is the most important health promotion activity for one's health, providing information on available medical therapies and behavior modification tips and arranging follow-up care either by telephone within two weeks or face to face at follow-up visits.

Summary

Motivating a patient to quit smoking is a challenging nursing intervention. Several factors must be taken into consideration, such as the patient's age, culture, occupation, education level and smoking history. Assessing the patient's nicotine dependence and smoking triggers are vital to recommending an appropriate action and individualized treatment plan. Assisting the patient with behavioral modification is a critical nursing responsibility. Nurses in all settings are key professionals to initiate and implement smoking cessation strategies for patients. Their impact on the decline of smoking related diseases and deaths can be significant.

Case Studies

Case Presentation #1

Amy is an 18-year-old college freshman who started smoking at age 13 with her friends. She started smoking one to two cigarettes when she was at school and gradually increased through her teens as a way to stay thin and be with her friends who also smoked. At age 18, she now smokes one pack per day, and doesn't see why "everyone is concerned." She doesn't notice any ill effects, in fact, it helps her calm herself when she's facing a big exam or getting ready for a date.

As Amy's nurse at her annual gynecology visit for birth control prescription, what strategies can be used to advise Amy about the hazards of smoking? What are some effective tips?

Actual health effects related to smoking include: relaxation vs. stimulation, bad breath and other tobacco related smells, premature wrinkles.

What are Amy's risk factors related to smoking?

Birth control pills are her risk factor.

What strategies can be implemented to assist her in making lifestyle changes? What smoking cessation techniques may be helpful to her?

Ask: Pattern of tobacco use, triggers, previous quit attempts.

Advise: Address her fear of weight gain, provide motivational information related to her current health status, self-help literature, and information regarding the dangers related to birth control use while using tobacco.

Assist: Teach her strategies to incorporate dietary and exercise lifestyle changes, teach problem solving/skills training to enhance coping with stress. Nicotine replacement therapy, such as a patch, may be appropriate in weaning from the nicotine. Buproprion HCL may be started, but realize that it takes approximately eight days to raise blood levels sufficiently to reduce/prevent craving.

Arrange: Schedule follow up telephone support. Refer for group support if she desires. Reinforce short term successes.

Case Presentation #2

Mr. C is a 65-year-old male presenting to the Emergency Department with chest pain. His past medical history includes controlled hypertension and Type II diabetes. He started smoking at age 18 and smokes one pack per day. He noticed recently that his legs ache when he walks any distance, and he gets short of breath walking up stairs. His mother and father both smoked until their seventies, and he never worried about how smoking might affect him. He has never had any quit attempts, and is unsure if he can quit now. His wife also smokes one pack per day. What should be suggested?

What are Mr. C's risk factors?

Hypertension, smoker, Type II diabetes, dyspnea and intermittent claudication are his risk factors.

As the nurse in the Emergency Department, what actions should be considered?

What strategies can be implemented to assist him with nicotine withdrawal while hospitalized? What smoking cessation techniques may be helpful to him?

Nicotine replacement therapy is contraindicated in this patient because of chest pain, and should not be initiated until a myocardial infarction has been ruled out. Buproprion HCL may be started, but realize that it takes approximately eight days to raise blood levels sufficiently to reduce/prevent craving.

Ask: Pattern of tobacco use, triggers, support systems, readiness to make changes.

Advise: Address his fear of lifestyle changes in the plan, including his wife in this process, encouraging her that quitting is also important for her, Provide problem solving/skills training to enhance his coping with stress. Emphasize that quitting at any age has positive benefits. Provide motivational information related to his current health status, and self-help literature.

Assist: Teach problem solving/skills training to enhance his coping with stress. Provide specific information related to diagnostic tests that may be ordered (e.g., an exercise stress test).

Arrange: Refer both patient and wife for group support. Follow-up telephone support. Reinforce his short term successes.

Case Presentation #3

Linda is a 51-year-old female who presents to her physician with complaints of a burning sensation in her chest. She has been experiencing intermittent burning for about one month, not consistent with the ingestion of a meal, but always after physical exertion. She tried a liquid antacid, thinking the burning was just heartburn, but received no relief. She has recently been promoted at work which resulted in an increased workload. She has been feeling stressed about managing her family, work and community responsibilities. She has smoked about ˝ - 1 pack of cigarettes per day since the age of 18. She has attempted smoking cessation about four times, but always became nervous and gained a few pounds, which led her to resume smoking. At age 48, she experienced menopause; however, she elected to delay hormone replacement therapy until she was older. Her last lipid profile revealed a high total cholesterol of 270mg/dl, an HDL of 30 mg/dl, and an LDL of 190 mg/dl. Her only exercise, consists of walking which she finds difficult to fit into her new schedule. She is approximately 20 pounds overweight, and struggles to lose the extra pounds. She takes no routine medications. She was surprised to have her doctor tell her that she may have coronary artery disease.

What are Linda's risk factors for coronary heart disease?

Overweight, smoker, high cholesterol and LDL, low HDL, postmenopausal without hormone replacement therapy, stress, and sedentary lifestyle are Linda's risk factors.

As Linda's nurse in the clinic, What strategies can be implemented to assist her make healthy lifestyle changes? What smoking cessation techniques may be helpful to her?

Ask: Support systems, readiness to make changes, previous quit attempts, specific triggers.

Advise:Provide motivational information related to her current health status, self-help literature,

information related to diagnostic tests that she may be ordered, such as an exercise stress test.

Assist: Teach her strategies to incorporate dietary and exercise lifestyle changes in the plan, teach problem solving/skills training to enhance coping with stress. Provide specific information related to diagnostic tests may be ordered (e.g., exercise stress test). Pharmacological Options: Nicotine gum may help offset further weight gain and be useful for cravings at work during stress. Bupropion HCL may be helpful if there are any signs of underlying depression.

Arrange:Refer her for group support if she desires. Schedule follow-up telephone support or face-to-face visits. Reinforce short term successes.

References