- Email: [email protected]
Nursing strategies for smoking cessation
ISSUES IN RESPIRATORY CARE Official Section of the Respiratory Nursing Society
Nursing strategies for smoking cessation Kathleen Oare Lindell, MSN, RN,a and Lynn F. Reinke, MSN, RN-CS,b Philadelphia, Pa, and Milwaukee, Wis
The purpose of this article is to provide the staff nurse with an overview of the Agency for Health Care Policy and Research 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 and a comprehensive review of pharmacological therapy, are discussed. (Heart Lung® 1999;28:295-302)
Section Editor’s note: What follows is an article on smoking cessation written by two members of the Respiratory Nursing Society (RNS) and underwritten by the American Nurses Foundation. Smoking is a significant health risk and one that should be of concern to all nurses. The goal is to have all nurses, especially those caring for pulmonary patients, be aware of the research indicating the dangers of smoking, be able to assess patients regarding their smoking, and know the therapies available. Audrey G. Gift, PhD, RN, FAAN
S
moking 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- to 44-year-olds. Alarming statistics reveal that approximately 90% of new smokers are teenagers. More than 3000 adolescents younger than age 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 the following:
• 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
From the aUniversity of Pennsylvania Health System and bMilwaukee Veterans Affairs Medical Center. This article appeared as an independent study module in a supplement to the March/April issue of The American Nurse. The supplement was made possible through a grant by SmithKline Beecham Consumer Health. To complete this independent study for contact hours, visit the American Nurses Association (ANA) website atwww.nursingworld.org/ce or call 1-800-274-4262, ext. 7108. It is being reprinted here by permission of the American Nurses Association. Reprint requests: Kathleen Lindell, Penn Lung Center, 3400 Spruce St, Ravdin 3, Philadelphia, PA 19104. 0147-9563/99/$8.00 + 0 2/1/269
HEART & LUNG
VOL. 28, NO. 4
The economic impact of tobacco use is estimated at $50 billion annually for health care costs and another $47 billion for indirect expenses such as lost productivity (all those smoking breaks and sick days).1,5 Given these disheartening numbers, how can a staff nurse motivate patients to quit smoking and help to change these statistics? This article outlines the essentials of counseling for smoking cessation, whether it is in the inpatient acute care setting, the outpatient clinic, home care, or the ICU.
295
Nursing strategies for smoking cessation
Lindell and Reinke
ADVERSE OUTCOMES 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, discussing the shortterm symptoms of tobacco use that affect smokers may be useful. When a person smokes, the following physiological processes occur: 1. an increased heart rate of 15 to 25 bpm (can present with tachycardia and chest palpitations) 2. an increased blood pressure of 10 to 20 mm Hg 3. corrosion of the lip and palate mucous membranes 4. sensation of choking in the airways and shortness of breath 5. carbon monoxide enters the system, depriving tissues of oxygen (this may result in decreased energy level and exercise intolerance) 6. a morning cough 7. increased gastric acid flow that may lead to gastric ulcers 8. periodontal disease 9. increase in nervousness or anxiety levels 10. impotence and infertility 11. exacerbation of asthma 12. premature aging of skin Discussing these symptoms may help patients appreciate the daily impact of smoking that will eventually result in the debilitating and deadly diseases identified in the introduction.
ADVANTAGES OF SMOKING CESSATION Focusing on the short-term benefits of smoking cessation may be more motivating to a patient than emphasizing the long-term prevention of chronic illnesses, especially if the patient is of a younger age. Following are some positive short-term changes that occur when a patient stops smoking. The long-term risks of smoking are also listed for the nurse to reinforce. a. Within 2 hours after smoking cessation, the blood pressure and pulse start to normalize and the body temperature of extremities increases. b. Within 4 hours after the last cigarette is smoked, the carbon monoxide level returns
296
c.
d.
e.
f.
g.
h.
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 8 hours, indigestion and dyspepsia improve and the oxygen level in the blood increases. Within 24 hours, the chance of having a myocardial infarction decreases and returns to baseline as a nonsmoker at 1 year. Within 48 hours, the nerve endings in the oropharyngeal area are stimulated and the sense of taste and smell improve. (This means that the patient’s 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 1 to 9 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 that lung cancer and other cancer will develop decreases (but never reaches the level of a nonsmoker), and the chances of having myocardial infarction, stroke, and cancers of the larynx, oral cavity, pharynx, esophagus, bladder, or cervix are reduced.
The risk that smoking-related cancers will develop decreases more slowly after smoking cessation than the risk for coronary artery disease. Additional benefits of smoking cessation, which are 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 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 are known, how does the nurse assess a patient’s current tobacco use and level of nicotine dependence? Nurses represent the highest number of health
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
care providers in the United States, and although most nurses believe that instructing patients about smoking cessation is their responsibility, the percentage of nurses who counsel patients remains low.6 Taylor et al7 reported that a nurse-managed smoking cessation intervention can increase cessation rates for hospitalized smokers. In other studies, research conducted by Stillman8 at Johns Hopkins University described a model program for hospitalized cardiac patients. Wewers et al9 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. Finally, Utz et al10 at the University of Virginia reduced smoking behaviors in a community-based program. All these examples show nurses making the difference by counseling their patients on tobacco use and cessation. In the early 1990s, Fiore11 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. This approach provides an important opportunity to gain information about the patient’s tobacco status at each patient visit and to promote smoking cessation. The Agency for Health Care Policy and Research (AHCPR) incorporated this fifth vital sign into the Clinical Guideline on Smoking Cessation (see Fig 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. Once it is determined that the patient is a tobacco user, using the Fagerström Scale will help to estimate dependency on nicotine (see Fig 2).13 This tool serves to provide feedback to both the patient and the provider on the level of nicotine dependence. A score of 7 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 he or she quits. With this knowledge, the staff nurse can help the patient increase his or her 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, approximately 5000 other chemical compounds are found in tobacco smoke. These compounds include acetone, ammonia, arsenic, carbon monoxide, cyanide, formaldehyde, methane, tar, and toluene.15 The
HEART & LUNG
VOL. 28, NO. 4
Nursing strategies for smoking cessation
VITAL SIGNS Blood Pressure Pulse Weight Temperature Respiratory Rate Tobacco Use: Current Former Never (circle one)
Fig 1 Fifth vital sign. From Fiore, MC, et al (1995).11
burning of tobacco is a thermal reaction involving multiple chemical reactions, and many of the aforementioned chemicals and their byproducts are released into the air when a cigarette, cigar, or pipe is smoked. Many of these chemicals and their byproducts are known carcinogens; they are inhaled by the smoker and released to the air. This exposure to environmental tobacco smoke, often referred to as secondhand smoke, affects not only the smoker but all those exposed to the smoke, including children and pets.
TREATMENT OPTIONS People quit smoking every day. There are more former smokers than current smokers.16 Many smokers attempt to quit an average of 4 to 6 times before they quit for good, but it is important to recognize that each attempt builds on previous experience. An analogy can be made to learning to ride a bicycle: One may fall a few times before riding smoothly, but one or two falls does not mean that one will not learn to ride. In their attempts to quit, patients learn what does and does not work for them. The authors like to think of these attempts as practice for the final and permanent attempt to quit. It is important to advise patients to quit, and do so in a kind, caring, nonjudgmental manner. Quitting can be difficult for the smoker. The patient is likely to experience physical symptoms of nicotine withdrawal once he or she stops smoking. In addition, the patient associates many triggers or rituals with his or her smoking habit, and despite the cessation of cigarettes, those triggers will con-
297
Nursing strategies for smoking cessation
Lindell and Reinke
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? a. Within 5 minutes (3) b. 6-30 minutes (2) c. 31-60 minutes (1) d. After 60 minutes (0) ____ 2. Do you find it difficult to refrain from smoking in places where it is forbidden, eg, in church, at the library, in cinema, etc? a. Yes (1) b. No (0) ____ 3. Which cigarette would you hate most to give up? a. The first one in the morning (1) b. All others (0) ____ 4. How many cigarettes/day do you smoke? a. 10 or less (0) b. 11-20 (1) c. 21-30 (2) d. 31 or more (3) ____ 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? a. Yes (1) b. No (0) ____ 6. Do you smoke if you are so ill that you are in bed most of the day? a. Yes (1) b. 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.
Fig 2 Fagerström Scale.13 Reprinted with the kind permission of Dr. Karl-Olov Fagerström.
tinue to be present. Common triggers include coffee, alcohol, completion of a meal, work breaks, smoking “buddies,” 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, including going “cold turkey,” nicotine replacement therapy,17 or the use of a newly released non-nicotine medication, such as bupropion hydrochloride (Zyban).18 A patient’s desire to stop smoking is one of the most important indica-
298
tors for successful cessation. The following tips can assist the patient in the process of quitting: a. identify a support person b. advertise the quit attempt c. make the home smoke-free (this discourages a relapse) d. 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
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
Nursing strategies for smoking cessation
Table Pharmacological therapy Products
Dosage
Indications
Considerations
Nicotine polacrilex (nicotine gum); Nicorette
2 mg, 4 mg; 9-12 pieces/d; 2-3 mo duration
Faster delivery of nicotine than patches; useful during acute episodes of craving
Chew and park* method of administration essential; cannot eat or drink acidic beverages before, during, and after gum is being used
Nicotine patch
21 mg, 14 mg, 7 mg 15 mg, 10 mg, 5 mg (16 h/day; 6-8 wk duration) 21 mg, 14 mg, 7 mg 22 mg, 11 mg 24 h/d
Very effective primary base agent; must be smoke-free while using patch since smoking encourages relapse
Observe for mild rashes/ irritation; if abnormal dreams, remove qhs or use 16 h/d patch; use with caution in patients with MI within 4 wk; certain forms are OTC
Nicotine nasal spray; Nicotrol NS
0.5mg/inhalation/ nostril; 1-2 times/h or prn dosing
Fast delivery of nicotine, Must be taught to spray vs sniff; observe decreased craving for nose/eye/upper within minutes respiratory irritation
Nicotine oral inhaler; Nicotrol Inhaler
0.10 mg/cartridge; 80 puffs over 20-30 min; minimum of 6/d for 3-6 wk
May be used as adjunct therapy; mimics hand-to-mouth behavior
Bupropion hydrochlo ride; Wellbutrin SR, Zyban
150 mg qd ¥ 3 days, then 150 mg bid for 3 months
Very effective as primary Should initiate 1 wk prior to quit date; agent may be used with NRT; contraindicated in patients with history of seizures or eating disorders
NicoDerm CQ Nicotrol Habitrol ProStep
May cause mouth or throat irritation; deep inhalation is not indicated; nicotine delivery is difficult in cold, ambient conditions
bid, Twice a day; MI, myocardial infarction; OTC, over the counter; prn, as required; qd, every day; qhs, every hour of sleep. *Chew and park method: Instruct the patient to bite the gum slowly and deliberately. Somewhere around bite 15, the patient will start to notice a peppery taste and a slight tingling; that means the gum is beginning to release nicotine. Instruct the patient to then park the gum between their cheek and gum and leave it there. The peppery taste and the tingle will fade in about a minute, at which point the patient should give it a few more bites, until it starts working again, and then park it in another part of their mouth. The patient should go on this way for 30 minutes, biting and parking, until the taste and tingle stop coming back. Then instruct the patient to throw the used up gum away, in some place where children or pets cannot get at it.
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 2 weeks.19 The withdrawal symptoms are a response to nico-
HEART & LUNG
VOL. 28, NO. 4
tine 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.
299
Nursing strategies for smoking cessation
Lindell and Reinke
Nicotine replacement therapy
ders), and also for patients currently taking MAO inhibitors or one of the other bupropion hydrochloride preparations, such as Wellbutrin SR.
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 (see the Table for more information). Nicotine replacement therapy should be started on the selected quit date, and only after the 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 4 weeks of a myocardial infarction.12 The oral inhaler, the latest replacement product to be released, is meant to serve two purposes: provide nicotine replacement and provide a substitute for the handmouth routine so commonly experienced by smokers. Nasal spray has been found to provide the fastest delivery of nicotine due to rapid absorption through the nasal mucosa.
Bupropion hydrochloride (Zyban, Wellbutrin SR) Buproprion hydrochloride, a non-nicotine medication 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 Although the manner of its action is unknown, it is thought to work on certain pathways in the brain that are involved in nicotine addiction and withdrawal. Bupropion hydrochloride is available only by prescription and should be started approximately 1 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 3 days and then increased to twice a day dosing for the duration of therapy, which is usually 3 months. It is crucial for patient success that this medication not be discontinued if the patient is wavering about returning 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. Bupropion hydrochloride is contraindicated in patients with a history of seizures or disorders that may promote seizure activity (eg, alcoholism, unstable diabetes, or altered metabolic state, such as in eating disor-
300
Behavior modification The use of tobacco often becomes a learned behavior reinforced by the redundant triggers discussed earlier. Patients who are aware of their triggers and develop a personalized plan to quit 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 GUIDELINES12 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. The 4 A’s include asking the patient about his or her smoking habit, advising the patient that quitting is the most important health promotion activity for one’s health, providing the patient with information about available medical therapies and behavior modification tips, and arranging follow-up care either by telephone within 2 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 PRESENTATION NO. 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
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
who also smoked. At age 18, she now smokes one pack per day, and does not see why “everyone is concerned.” She does not notice any ill effects; in fact, smoking helps her calm herself when she is facing a big examination 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 versus stimulation, bad breath and other tobacco-related smells, and 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 attempts to quit. 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 problemsolving/skills training to enhance coping with stress. Nicotine replacement therapy, such as a patch, may be appropriate in weaning from the nicotine. Bupropion hydrochloride may be started, but realize that it takes approximately 8 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 NO. 2 Mr C is a 65-year-old man 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 made any attempts to quit 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.
HEART & LUNG
VOL. 28, NO. 4
Nursing strategies for smoking cessation
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. Bupropion hydrochloride may be started, but realize that it takes approximately 8 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 selfhelp literature. Assist: Teach problem-solving/skills training to enhance his ability to cope with stress. Provide specific information related to diagnostic tests that may be ordered (eg, an exercise stress test). Arrange: Refer both the patient and his wife for group support. Follow-up telephone support. Reinforce his short-term successes.
CASE PRESENTATION NO. 3 Linda is a 51-year-old woman who presents to her physician with complaints of a burning sensation in her chest. She has been experiencing intermittent burning for about 1 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 1/2 to 1 pack of cigarettes per day since the age of 18. She has attempted to stop smoking about 4 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 270 mg/dL, a high-density lipoprotein of 30 mg/dL, and a lowdensity lipoprotein 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
301
Nursing strategies for smoking cessation
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 lowdensity lipoprotein, low high-density lipoprotein, 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 attempts to quit, specific triggers. Advise: Provide motivational information related to her current health status, self-help literature, and information related to diagnostic tests that 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 that may be ordered (eg, exercise stress test). Pharmacological options: Nicotine gum may help offset further weight gain and be useful for cravings at work during stress. Bupropion hydrochloride 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. We thank Mary Ellen Wewers, PhD, RN, Audrey Gift, PhD, RN, Christine Wynd, PhD, RN, John HansenFlaschen, MD, and David Rosenthal, MD, for their valuable assistance in reviewing this program.
REFERENCES 1. U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. DHHS publication No. 89-8411. Atlanta, GA: Office of Smoking and Health, Centers for Disease Control & Prevention. 2. Centers for Disease Control and Prevention: National Centers for Health Statistics. (1998). Targeting tobacco use: The nation’s leading cause of death at-a-glance.
302
Lindell and Reinke 3. Wechsler H, Rigotti NA, Gledhill-Hoyt J, Lee H. (1998). Increase levels of cigarette use among college students: A cause for national concern. JAMA, 280(19), 1673-8. 4. Institute of Medicine. (1994). Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, DC: National Academy Press. 5. U.S. Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: DHHS publication No. 91-50212. 6. Wewers ME, Ahijevych KL, Sarna L. (1998). Smoking cessation interventions in nursing practice. Nursing Clinics of North America, 33, No. 1, pp 61-74. 7. Taylor CB, Miller NH, Herman S, Smith PM, Sobel D, Fisher L, DeBusk RF. (1996). A nurse-managed smoking cessation program for hospitalized smokers. American Journal of Public Health, 86(11), 1557-60. 8. Stillman FA. (1995). Smoking cessation for the hospitalized cardiac patient: rationale for and report of a model program. Journal of Cardiovascular Nursing. 9(2), 25-36. 9. Wewers ME, Jenkins L, Mignery T. 1997. A nurse-managed smoking cessation intervention during diagnostic testing for lung cancer. Oncology Nursing Forum, 24(8), 1419-22. 10. Utz SW, Shuster GF, III, Merwin E, Williams B. (1994). A community-based smoking cessation program: self-care behaviors and success. Public Health Nursing, 11(5), 291-9. 11. Fiore MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. (1995). Smoking status as the new vital sign: Effect on assessment and intervention in patients who smoke. Mayo Clinic Proceedings, 70, 209-213. 12. Smoking cessation: Implementing the AHCPR guidelines in clinical practice. Based on smoking cessation, clinical practice guideline No. 18, 1997. Agency for Health Care Policy and Research. 13. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. (1991). The Fagerström Test for nicotine dependence: a revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction, 86, 1119-1127. 14. Benowitz NL. (1991). Pharmacodynamics of nicotine: Implications for rational treatment of nicotine addiction. British Journal of Addiction, 86, 495-499. 15. US Environmental Protection Agency. (1986). Respiratory health effects of passive smoking: Lung Cancer and other disorders. Washington, DC: Office of Research and Development. 16. Centers for Disease Control and Prevention. (1994). CDC Surveillance Summaries, MMWR 43 (No. SS-3). 17. Fiore MC, Smith SS, Jorenby DE, Baker TB. (1994). The effectiveness of the nicotine patch for smoking cessation: A metaanalysis. JAMA, 271(24), 1940-7. 18. Hurt RD, Sachs DP, Glover ED, Offord KP, Johnston JA, Dale LC, Khayrallah MA, Schroeder MS, Glover PN, Sullivan CR, Croghan IT, Sullivan PM. (1997). A comparison of sustainedrelease Bupropion and placebo for smoking cessation. New England Journal of Medicine, 337(17), 1195-1202. 19. Shiffman SM, Jarvik ME. 1976. Smoking withdrawal symptoms in two weeks of abstinence. Psychopharmacology, 50, 35-9.
JULY/AUGUST 1999
HEART & LUNG
Nursing strategies for smoking cessation Kathleen Oare Lindell, MSN, RN,a and Lynn F. Reinke, MSN, RN-CS,b Philadelphia, Pa, and Milwaukee, Wis
The purpose of this article is to provide the staff nurse with an overview of the Agency for Health Care Policy and Research 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 and a comprehensive review of pharmacological therapy, are discussed. (Heart Lung® 1999;28:295-302)
Section Editor’s note: What follows is an article on smoking cessation written by two members of the Respiratory Nursing Society (RNS) and underwritten by the American Nurses Foundation. Smoking is a significant health risk and one that should be of concern to all nurses. The goal is to have all nurses, especially those caring for pulmonary patients, be aware of the research indicating the dangers of smoking, be able to assess patients regarding their smoking, and know the therapies available. Audrey G. Gift, PhD, RN, FAAN
S
moking 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- to 44-year-olds. Alarming statistics reveal that approximately 90% of new smokers are teenagers. More than 3000 adolescents younger than age 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 the following:
• 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
From the aUniversity of Pennsylvania Health System and bMilwaukee Veterans Affairs Medical Center. This article appeared as an independent study module in a supplement to the March/April issue of The American Nurse. The supplement was made possible through a grant by SmithKline Beecham Consumer Health. To complete this independent study for contact hours, visit the American Nurses Association (ANA) website atwww.nursingworld.org/ce or call 1-800-274-4262, ext. 7108. It is being reprinted here by permission of the American Nurses Association. Reprint requests: Kathleen Lindell, Penn Lung Center, 3400 Spruce St, Ravdin 3, Philadelphia, PA 19104. 0147-9563/99/$8.00 + 0 2/1/269
HEART & LUNG
VOL. 28, NO. 4
The economic impact of tobacco use is estimated at $50 billion annually for health care costs and another $47 billion for indirect expenses such as lost productivity (all those smoking breaks and sick days).1,5 Given these disheartening numbers, how can a staff nurse motivate patients to quit smoking and help to change these statistics? This article outlines the essentials of counseling for smoking cessation, whether it is in the inpatient acute care setting, the outpatient clinic, home care, or the ICU.
295
Nursing strategies for smoking cessation
Lindell and Reinke
ADVERSE OUTCOMES 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, discussing the shortterm symptoms of tobacco use that affect smokers may be useful. When a person smokes, the following physiological processes occur: 1. an increased heart rate of 15 to 25 bpm (can present with tachycardia and chest palpitations) 2. an increased blood pressure of 10 to 20 mm Hg 3. corrosion of the lip and palate mucous membranes 4. sensation of choking in the airways and shortness of breath 5. carbon monoxide enters the system, depriving tissues of oxygen (this may result in decreased energy level and exercise intolerance) 6. a morning cough 7. increased gastric acid flow that may lead to gastric ulcers 8. periodontal disease 9. increase in nervousness or anxiety levels 10. impotence and infertility 11. exacerbation of asthma 12. premature aging of skin Discussing these symptoms may help patients appreciate the daily impact of smoking that will eventually result in the debilitating and deadly diseases identified in the introduction.
ADVANTAGES OF SMOKING CESSATION Focusing on the short-term benefits of smoking cessation may be more motivating to a patient than emphasizing the long-term prevention of chronic illnesses, especially if the patient is of a younger age. Following are some positive short-term changes that occur when a patient stops smoking. The long-term risks of smoking are also listed for the nurse to reinforce. a. Within 2 hours after smoking cessation, the blood pressure and pulse start to normalize and the body temperature of extremities increases. b. Within 4 hours after the last cigarette is smoked, the carbon monoxide level returns
296
c.
d.
e.
f.
g.
h.
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 8 hours, indigestion and dyspepsia improve and the oxygen level in the blood increases. Within 24 hours, the chance of having a myocardial infarction decreases and returns to baseline as a nonsmoker at 1 year. Within 48 hours, the nerve endings in the oropharyngeal area are stimulated and the sense of taste and smell improve. (This means that the patient’s 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 1 to 9 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 that lung cancer and other cancer will develop decreases (but never reaches the level of a nonsmoker), and the chances of having myocardial infarction, stroke, and cancers of the larynx, oral cavity, pharynx, esophagus, bladder, or cervix are reduced.
The risk that smoking-related cancers will develop decreases more slowly after smoking cessation than the risk for coronary artery disease. Additional benefits of smoking cessation, which are 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 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 are known, how does the nurse assess a patient’s current tobacco use and level of nicotine dependence? Nurses represent the highest number of health
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
care providers in the United States, and although most nurses believe that instructing patients about smoking cessation is their responsibility, the percentage of nurses who counsel patients remains low.6 Taylor et al7 reported that a nurse-managed smoking cessation intervention can increase cessation rates for hospitalized smokers. In other studies, research conducted by Stillman8 at Johns Hopkins University described a model program for hospitalized cardiac patients. Wewers et al9 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. Finally, Utz et al10 at the University of Virginia reduced smoking behaviors in a community-based program. All these examples show nurses making the difference by counseling their patients on tobacco use and cessation. In the early 1990s, Fiore11 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. This approach provides an important opportunity to gain information about the patient’s tobacco status at each patient visit and to promote smoking cessation. The Agency for Health Care Policy and Research (AHCPR) incorporated this fifth vital sign into the Clinical Guideline on Smoking Cessation (see Fig 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. Once it is determined that the patient is a tobacco user, using the Fagerström Scale will help to estimate dependency on nicotine (see Fig 2).13 This tool serves to provide feedback to both the patient and the provider on the level of nicotine dependence. A score of 7 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 he or she quits. With this knowledge, the staff nurse can help the patient increase his or her 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, approximately 5000 other chemical compounds are found in tobacco smoke. These compounds include acetone, ammonia, arsenic, carbon monoxide, cyanide, formaldehyde, methane, tar, and toluene.15 The
HEART & LUNG
VOL. 28, NO. 4
Nursing strategies for smoking cessation
VITAL SIGNS Blood Pressure Pulse Weight Temperature Respiratory Rate Tobacco Use: Current Former Never (circle one)
Fig 1 Fifth vital sign. From Fiore, MC, et al (1995).11
burning of tobacco is a thermal reaction involving multiple chemical reactions, and many of the aforementioned chemicals and their byproducts are released into the air when a cigarette, cigar, or pipe is smoked. Many of these chemicals and their byproducts are known carcinogens; they are inhaled by the smoker and released to the air. This exposure to environmental tobacco smoke, often referred to as secondhand smoke, affects not only the smoker but all those exposed to the smoke, including children and pets.
TREATMENT OPTIONS People quit smoking every day. There are more former smokers than current smokers.16 Many smokers attempt to quit an average of 4 to 6 times before they quit for good, but it is important to recognize that each attempt builds on previous experience. An analogy can be made to learning to ride a bicycle: One may fall a few times before riding smoothly, but one or two falls does not mean that one will not learn to ride. In their attempts to quit, patients learn what does and does not work for them. The authors like to think of these attempts as practice for the final and permanent attempt to quit. It is important to advise patients to quit, and do so in a kind, caring, nonjudgmental manner. Quitting can be difficult for the smoker. The patient is likely to experience physical symptoms of nicotine withdrawal once he or she stops smoking. In addition, the patient associates many triggers or rituals with his or her smoking habit, and despite the cessation of cigarettes, those triggers will con-
297
Nursing strategies for smoking cessation
Lindell and Reinke
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? a. Within 5 minutes (3) b. 6-30 minutes (2) c. 31-60 minutes (1) d. After 60 minutes (0) ____ 2. Do you find it difficult to refrain from smoking in places where it is forbidden, eg, in church, at the library, in cinema, etc? a. Yes (1) b. No (0) ____ 3. Which cigarette would you hate most to give up? a. The first one in the morning (1) b. All others (0) ____ 4. How many cigarettes/day do you smoke? a. 10 or less (0) b. 11-20 (1) c. 21-30 (2) d. 31 or more (3) ____ 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? a. Yes (1) b. No (0) ____ 6. Do you smoke if you are so ill that you are in bed most of the day? a. Yes (1) b. 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.
Fig 2 Fagerström Scale.13 Reprinted with the kind permission of Dr. Karl-Olov Fagerström.
tinue to be present. Common triggers include coffee, alcohol, completion of a meal, work breaks, smoking “buddies,” 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, including going “cold turkey,” nicotine replacement therapy,17 or the use of a newly released non-nicotine medication, such as bupropion hydrochloride (Zyban).18 A patient’s desire to stop smoking is one of the most important indica-
298
tors for successful cessation. The following tips can assist the patient in the process of quitting: a. identify a support person b. advertise the quit attempt c. make the home smoke-free (this discourages a relapse) d. 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
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
Nursing strategies for smoking cessation
Table Pharmacological therapy Products
Dosage
Indications
Considerations
Nicotine polacrilex (nicotine gum); Nicorette
2 mg, 4 mg; 9-12 pieces/d; 2-3 mo duration
Faster delivery of nicotine than patches; useful during acute episodes of craving
Chew and park* method of administration essential; cannot eat or drink acidic beverages before, during, and after gum is being used
Nicotine patch
21 mg, 14 mg, 7 mg 15 mg, 10 mg, 5 mg (16 h/day; 6-8 wk duration) 21 mg, 14 mg, 7 mg 22 mg, 11 mg 24 h/d
Very effective primary base agent; must be smoke-free while using patch since smoking encourages relapse
Observe for mild rashes/ irritation; if abnormal dreams, remove qhs or use 16 h/d patch; use with caution in patients with MI within 4 wk; certain forms are OTC
Nicotine nasal spray; Nicotrol NS
0.5mg/inhalation/ nostril; 1-2 times/h or prn dosing
Fast delivery of nicotine, Must be taught to spray vs sniff; observe decreased craving for nose/eye/upper within minutes respiratory irritation
Nicotine oral inhaler; Nicotrol Inhaler
0.10 mg/cartridge; 80 puffs over 20-30 min; minimum of 6/d for 3-6 wk
May be used as adjunct therapy; mimics hand-to-mouth behavior
Bupropion hydrochlo ride; Wellbutrin SR, Zyban
150 mg qd ¥ 3 days, then 150 mg bid for 3 months
Very effective as primary Should initiate 1 wk prior to quit date; agent may be used with NRT; contraindicated in patients with history of seizures or eating disorders
NicoDerm CQ Nicotrol Habitrol ProStep
May cause mouth or throat irritation; deep inhalation is not indicated; nicotine delivery is difficult in cold, ambient conditions
bid, Twice a day; MI, myocardial infarction; OTC, over the counter; prn, as required; qd, every day; qhs, every hour of sleep. *Chew and park method: Instruct the patient to bite the gum slowly and deliberately. Somewhere around bite 15, the patient will start to notice a peppery taste and a slight tingling; that means the gum is beginning to release nicotine. Instruct the patient to then park the gum between their cheek and gum and leave it there. The peppery taste and the tingle will fade in about a minute, at which point the patient should give it a few more bites, until it starts working again, and then park it in another part of their mouth. The patient should go on this way for 30 minutes, biting and parking, until the taste and tingle stop coming back. Then instruct the patient to throw the used up gum away, in some place where children or pets cannot get at it.
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 2 weeks.19 The withdrawal symptoms are a response to nico-
HEART & LUNG
VOL. 28, NO. 4
tine 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.
299
Nursing strategies for smoking cessation
Lindell and Reinke
Nicotine replacement therapy
ders), and also for patients currently taking MAO inhibitors or one of the other bupropion hydrochloride preparations, such as Wellbutrin SR.
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 (see the Table for more information). Nicotine replacement therapy should be started on the selected quit date, and only after the 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 4 weeks of a myocardial infarction.12 The oral inhaler, the latest replacement product to be released, is meant to serve two purposes: provide nicotine replacement and provide a substitute for the handmouth routine so commonly experienced by smokers. Nasal spray has been found to provide the fastest delivery of nicotine due to rapid absorption through the nasal mucosa.
Bupropion hydrochloride (Zyban, Wellbutrin SR) Buproprion hydrochloride, a non-nicotine medication 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 Although the manner of its action is unknown, it is thought to work on certain pathways in the brain that are involved in nicotine addiction and withdrawal. Bupropion hydrochloride is available only by prescription and should be started approximately 1 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 3 days and then increased to twice a day dosing for the duration of therapy, which is usually 3 months. It is crucial for patient success that this medication not be discontinued if the patient is wavering about returning 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. Bupropion hydrochloride is contraindicated in patients with a history of seizures or disorders that may promote seizure activity (eg, alcoholism, unstable diabetes, or altered metabolic state, such as in eating disor-
300
Behavior modification The use of tobacco often becomes a learned behavior reinforced by the redundant triggers discussed earlier. Patients who are aware of their triggers and develop a personalized plan to quit 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 GUIDELINES12 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. The 4 A’s include asking the patient about his or her smoking habit, advising the patient that quitting is the most important health promotion activity for one’s health, providing the patient with information about available medical therapies and behavior modification tips, and arranging follow-up care either by telephone within 2 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 PRESENTATION NO. 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
JULY/AUGUST 1999
HEART & LUNG
Lindell and Reinke
who also smoked. At age 18, she now smokes one pack per day, and does not see why “everyone is concerned.” She does not notice any ill effects; in fact, smoking helps her calm herself when she is facing a big examination 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 versus stimulation, bad breath and other tobacco-related smells, and 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 attempts to quit. 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 problemsolving/skills training to enhance coping with stress. Nicotine replacement therapy, such as a patch, may be appropriate in weaning from the nicotine. Bupropion hydrochloride may be started, but realize that it takes approximately 8 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 NO. 2 Mr C is a 65-year-old man 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 made any attempts to quit 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.
HEART & LUNG
VOL. 28, NO. 4
Nursing strategies for smoking cessation
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. Bupropion hydrochloride may be started, but realize that it takes approximately 8 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 selfhelp literature. Assist: Teach problem-solving/skills training to enhance his ability to cope with stress. Provide specific information related to diagnostic tests that may be ordered (eg, an exercise stress test). Arrange: Refer both the patient and his wife for group support. Follow-up telephone support. Reinforce his short-term successes.
CASE PRESENTATION NO. 3 Linda is a 51-year-old woman who presents to her physician with complaints of a burning sensation in her chest. She has been experiencing intermittent burning for about 1 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 1/2 to 1 pack of cigarettes per day since the age of 18. She has attempted to stop smoking about 4 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 270 mg/dL, a high-density lipoprotein of 30 mg/dL, and a lowdensity lipoprotein 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
301
Nursing strategies for smoking cessation
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 lowdensity lipoprotein, low high-density lipoprotein, 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 attempts to quit, specific triggers. Advise: Provide motivational information related to her current health status, self-help literature, and information related to diagnostic tests that 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 that may be ordered (eg, exercise stress test). Pharmacological options: Nicotine gum may help offset further weight gain and be useful for cravings at work during stress. Bupropion hydrochloride 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. We thank Mary Ellen Wewers, PhD, RN, Audrey Gift, PhD, RN, Christine Wynd, PhD, RN, John HansenFlaschen, MD, and David Rosenthal, MD, for their valuable assistance in reviewing this program.
REFERENCES 1. U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General. DHHS publication No. 89-8411. Atlanta, GA: Office of Smoking and Health, Centers for Disease Control & Prevention. 2. Centers for Disease Control and Prevention: National Centers for Health Statistics. (1998). Targeting tobacco use: The nation’s leading cause of death at-a-glance.
302
Lindell and Reinke 3. Wechsler H, Rigotti NA, Gledhill-Hoyt J, Lee H. (1998). Increase levels of cigarette use among college students: A cause for national concern. JAMA, 280(19), 1673-8. 4. Institute of Medicine. (1994). Growing up tobacco free: Preventing nicotine addiction in children and youths. Washington, DC: National Academy Press. 5. U.S. Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: DHHS publication No. 91-50212. 6. Wewers ME, Ahijevych KL, Sarna L. (1998). Smoking cessation interventions in nursing practice. Nursing Clinics of North America, 33, No. 1, pp 61-74. 7. Taylor CB, Miller NH, Herman S, Smith PM, Sobel D, Fisher L, DeBusk RF. (1996). A nurse-managed smoking cessation program for hospitalized smokers. American Journal of Public Health, 86(11), 1557-60. 8. Stillman FA. (1995). Smoking cessation for the hospitalized cardiac patient: rationale for and report of a model program. Journal of Cardiovascular Nursing. 9(2), 25-36. 9. Wewers ME, Jenkins L, Mignery T. 1997. A nurse-managed smoking cessation intervention during diagnostic testing for lung cancer. Oncology Nursing Forum, 24(8), 1419-22. 10. Utz SW, Shuster GF, III, Merwin E, Williams B. (1994). A community-based smoking cessation program: self-care behaviors and success. Public Health Nursing, 11(5), 291-9. 11. Fiore MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. (1995). Smoking status as the new vital sign: Effect on assessment and intervention in patients who smoke. Mayo Clinic Proceedings, 70, 209-213. 12. Smoking cessation: Implementing the AHCPR guidelines in clinical practice. Based on smoking cessation, clinical practice guideline No. 18, 1997. Agency for Health Care Policy and Research. 13. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. (1991). The Fagerström Test for nicotine dependence: a revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction, 86, 1119-1127. 14. Benowitz NL. (1991). Pharmacodynamics of nicotine: Implications for rational treatment of nicotine addiction. British Journal of Addiction, 86, 495-499. 15. US Environmental Protection Agency. (1986). Respiratory health effects of passive smoking: Lung Cancer and other disorders. Washington, DC: Office of Research and Development. 16. Centers for Disease Control and Prevention. (1994). CDC Surveillance Summaries, MMWR 43 (No. SS-3). 17. Fiore MC, Smith SS, Jorenby DE, Baker TB. (1994). The effectiveness of the nicotine patch for smoking cessation: A metaanalysis. JAMA, 271(24), 1940-7. 18. Hurt RD, Sachs DP, Glover ED, Offord KP, Johnston JA, Dale LC, Khayrallah MA, Schroeder MS, Glover PN, Sullivan CR, Croghan IT, Sullivan PM. (1997). A comparison of sustainedrelease Bupropion and placebo for smoking cessation. New England Journal of Medicine, 337(17), 1195-1202. 19. Shiffman SM, Jarvik ME. 1976. Smoking withdrawal symptoms in two weeks of abstinence. Psychopharmacology, 50, 35-9.
JULY/AUGUST 1999
HEART & LUNG