Heart disease and stroke, both forms of cardiovascular disease (CVD), continue to be the first and third leading causes of death in the United States, respectively.1
Smoking is the most preventable risk factor that contributes to premature death of coronary heart disease (CHD). More than 4,000 known toxins and carcinogens are found in tobacco smoke, which contributes to smoking being the single, most preventable cause of disease and premature death,2
and also exposure to secondhand smoke also contributes to this risk.3
The U.S. adult smoking prevalence rate has decreased from 25% to 21% since the first publication of the guideline.4
The number of current smokers being advised to quit smoking5
in 2007 is twice the number it was in the 1990s6
with a greater number of smokers receiving more concentrated cessation interventions.7
While Chapter 32
describes smoking as a risk factor, we provide the assessment and management of smoking cessation in this chapter.
One of the major responsibilities of the nurse is health promotion; therefore, it is important that nurses be aware that they can play a major role in smoking cessation. There is a significant body of research that has documented the effectiveness of nursemanaged smoking cessation interventions, particularly in the hospitalized cardiovascular population.9
“If the 2.2 million working nurses in the U.S. each helped one person per year quit smoking, nurses would triple the U.S. quit rate.”20
Successful smoking cessation interventions usually have behavior modification as a core component. Behavioral modification skills include identifying areas of concern for patients, teaching patients strategies to cope with difficult situations, and role-playing strategies with patients to allow them to practice their new coping strategies. These behavioral modification skills usually are not part of most nursing school curricula.21
Even when they are taught, there is rarely an opportunity for practice, feedback, and development of confidence in performing these skills. This chapter focuses on the important steps in smoking cessation interventions that should be provided to patients with CVD, with an emphasis on behavioral and pharmacologic approaches. After reading this chapter, the nurse, no matter what setting he or she practices in—intensive care unit, cardiac care unit, medical-surgical, labor and delivery, outpatient care—will posses the necessary knowledge to provide a smoking cessation intervention to every patient who smokes, every time the patient is encountered.
Permanent smoking cessation should be the goal for every intervention and every person who smokes. Achievement of this goal is difficult, however, because the nicotine in tobacco products is an addictive substance.22
Smokers are physically and emotionally compelled to continue smoking even in the face of serious adverse health consequences. In addition, multiple quit attempts and failure to quit smoking despite high levels of motivation are common. The presence of withdrawal symptoms is another indicator of the addictive properties of nicotine. The criteria for diagnosis of nicotine withdrawal are met when any of the following symptoms commence within 24 hours of the abrupt cessation of nicotine use: dysphoric or depressed mood; insomnia; irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; or increased appetite or weight gain.23
Rapid identification of these withdrawal symptoms and prompt intervention are important skills for all nurses, particularly hospital-based nurses, because these withdrawal symptoms may be so intense for a given patient that he or she is unable to make rational health care decisions and may leave the hospital against medical advice to relieve them with a cigarette.
HARMFUL EFFECTS OF SMOKING
Cigarette smoking, hypercholesterolemia, hypertension, and physical inactivity are considered the four major risk factors for CVD. What makes cigarette smoking unique among these risk factors is that it interacts synergistically with hypercholesterolemia and hypertension to increase greatly the risk for CHD. For example, in people who smoke and have hypercholesterolemia or hypertension, the risk for CHD is doubled. For people who have all three risk factors, the risk for CHD is quadrupled.24
In general, cigarette smoking accelerates atherosclerosis throughout the body, but this effect is most important in the coronary arteries, the aorta, and the carotid and cerebral arteries. Several mechanisms have been described to explain how cigarette smoking leads to atherosclerosis. These include (1) adverse effects on lipid profiles; (2) endothelial damage or dysfunction; (3) hemodynamic stress; (4) oxidative injury; (5) neutrophil activation; (6) enhanced thrombosis; and (7) increased blood viscosity.25
Although the acceleration of atherosclerosis is a major contributor to cardiovascular morbidity (e.g., aggravation of stable angina pectoris, vasospastic angina, intermittent claudication), a major focus in the population of smokers with CVD is how smoking mediates acute cardiovascular events (e.g., myocardial infarction [MI], sudden death, stroke) that lead to hospitalization. The smoking-related mechanisms thought to contribute to these events are (1) induction of a hypercoagulable state; (2) increased myocardial workload; (3) reduced oxygen-carrying capacity of the blood; (4) coronary vasoconstriction; and (5) catecholamine release.25
Nicotine and carbon monoxide, although only two of the more than 4,000 chemicals in cigarette smoke, are generally considered to be the major contributors to atherosclerotic disease.26
Nicotine disrupts lipid metabolism, resulting in an increased level of low-density lipoprotein and a decreased level of high-density
lipoprotein. Nicotine is also responsible for the increased platelet aggregation and hypercoagulability found in smokers. In addition, it leads to increased production of catecholamines, which in turn increases blood pressure, heart rate and contractility, and systemic vascular resistance, all of which result in increased myocardial oxygen demand.25
Unfortunately, meeting this demand is difficult because cigarette smoking constricts large and small epicardial arteries and coronary resistance vessels, leading to a decrease in coronary blood flow.28
In fact, in a study of patients with established CHD, Barry et al.29
found that continued cigarette smoking was related to a 12-fold increase in the amount of total ischemia daily. Episodes of ischemic ST-segment depression occurred 3 times as often, and the duration was 12 times longer in smokers compared with nonsmokers (median duration of 24 min/24 h vs. 2 min/24 h). This increased ischemia may be related to the increased probability of recurrent coronary events in people who smoke. The increase in heart rate may also lead to endothelial injury, myocardial ischemia and MI, arrhythmias, and sudden death.25
Carbon monoxide interferes with oxygen transport, leading to a reduced supply of oxygen to the tissues, and, more important, to the myocardium at a time when the demand is high because of a higher heart rate.26
Carbon monoxide interferes with the oxygen-carrying capacity of red blood cells by binding to hemoglobin, thereby reducing the amount of hemoglobin available for binding with oxygen and by impeding oxygen release from hemoglobin.25
Carbon monoxide also increases the permeability of endothelial membranes, resulting in increased uptake of cholesterol that leads to atherogenesis.27
When the number of cigarettes smoked daily, the total number of years of smoking, the degree of inhalation, and the age of smoking initiation are considered, the risk for development of CHD is found to increase with increasing exposure to cigarette smoke. Overall, cigarette smokers have a two- to four-fold greater incidence of CHD than do nonsmokers, and cigarette smokers have a 70% greater death rate caused by CHD than do nonsmokers. Cigarette smokers also experience a two- to four-fold greater risk of sudden death than do nonsmokers.27
The damage caused by cigarette smoking is not restricted to the heart alone. Cigarette smokers have a higher incidence of arteriosclerotic peripheral arterial disease and more severe atherosclerosis of the aorta than do nonsmokers,26
as well as an increased rate of stroke and cerebrovascular disease.27
BENEFITS OF SMOKING CESSATION
The health benefits of smoking cessation on the cardiovascular system are well documented. The increased tendency to thrombus formation, coronary artery spasm, arrhythmias, and reduced oxygen supply are likely to reverse in a short time.30
For example, evidence suggests that quitting smoking after an initial MI decreases a person’s risk of death from CHD by at least 50% in the first year after quitting.31
This decline in risk appears to be independent of the severity of the MI.32
In addition, reports from the Coronary Artery Surgery Study (CASS) indicate that smoking cessation significantly improves survival for people of all ages, including those older than 70 years.33
In fact, after 1 year of abstinence from smoking, the excess risk of CHD related to smoking is cut in half and then gradually continues to decline over time. After 15 years of abstinence, the former smoker has achieved a risk level similar to that of a person who has never smoked. Smoking cessation also lowers the overall risk for stroke to that of a nonsmoker within 5 to 15 years of abstinence.26
Because the overall death rate and rate of reinfarction is higher in patients with established CHD, intensive smoking cessation intervention should be directed to this population. Nurses who provide care for patients with CVD in all practice settings must not miss the opportunity to encourage smokers to quit at every encounter. In addition to the smoking cessation efforts of public education, commercial programs, and worksite health promotion, efforts to assist patients who have manifestations of CHD in the primary care setting are worthwhile.
THEORETICAL FRAMEWORK FOR SMOKING CESSATION
The model we advocate for smoking cessation is the self-efficacy model based on social cognitive learning theory by Bandura.34
Self-efficacy, in the case of smoking cessation, is defined as the smoker’s level of confidence that he or she could refrain from smoking in various challenging or “risky” situations such as social situations (with friends in a cafe, when someone offers them a cigarette), emotional situations (when feeling tense or depressed), and habitual-addictive situations (when desiring a cigarette or when they are experiencing withdrawal symptoms).35
The belief is that as risky situations are identified, strategies can be developed by the patient in conjunction with his or her health care provider that will help the patient to either avoid or cope with a given situation. Low self-efficacy is a strong predictor of relapse to smoking16
; therefore, it behooves the health care provider to assess self-efficacy and provide coping skills and strategies to help the smoker successfully navigate those situations where they are most at risk to smoke.
Self-efficacy in various situations, however, is easily assessed in the clinical setting. It has recently been hypothesized, however, that self-efficacy is intertwined with the patient’s smoking behaviors and fluctuates over the course of the quit attempt. In other words, when the patient is initially attempting to quit, self-efficacy may be low to moderate; as the patient successfully abstains from smoking, self-efficacy increases; self-efficacy may then decrease with a relapse and increase with renewed cessation. This cycle would continue to fluctuate until permanent smoking cessation has been achieved which would lead, theoretically, to continuously high self-efficacy. Unfortunately, self-efficacy has rarely been measured more than once or twice in a clinical trial, so this hypothesis requires further testing.17
In the mean time, however, self-efficacy can be used clinically to help guide the intervention and is especially helpful in relapse prevention. The identification of risky situations, strategies to deal with risky situations, and relapse prevention are discussed in greater detail in the section titled “Relapse Prevention
SMOKING CESSATION INTERVENTIONS IN THE CHD POPULATION
The recent trials have had larger study populations, used more clearly defined definitions for abstinence, and saliva or serum cotinine levels or expired carbon monoxide levels have been used to biochemically verify nonsmoking status. Only recently have randomized clinical trials been conducted in women with
When the physician provides simple advice to the patient, the expected cessation rate in the general population is approximately 6% per year,39
whereas group programs that use behavioral methods may achieve yearly cessation rates as high as 26% to 40%.40
In the CHD population, in particular, the strong stimulus provided by a CHD event results in rates of smoking cessation that are higher than in most studies conducted in the general population.41
In particular, studies on those patients having coronary artery bypass graft surgery show smoking cessation rates of approximately 50%,44
whereas those undergoing coronary arteriography have smoking cessation rates of up to 62%.46
Finally, studies of patients with an MI or angina pectoris reported smoking cessation rates of between 20% and 70%.9
A significant body of research has also focused on nurse-managed smoking cessation interventions that begin in the hospital and then continue with telephone follow-up after discharge from the hospital. The effectiveness of this type of intervention has been demonstrated in patients after MI41
and cancer surgery49
and in patients admitted to the hospital.50
In general, research indicates that those patients with high motivation or strong intention to quit,45
more severe disease,46
who were given strong advice to quit by their physician,41
who have CVD50
have made fewer attempts to quit in the past, and who had no difficulty refraining from smoking while in the hospital45
achieved the highest smoking cessation rates. Patients with CHD who continue to smoke are in general younger,51
female, unmarried/not living with a partner,10
belong to a lower socioeconomic10
and educational level, have a less negative attitude about smoking, smoke a greater number of cigarettes, and are more likely to be anxious or depressed.52
Although effective interventions have been conducted to address some of these characteristics, interventions aimed at people of lower educational and socioeconomic status are still lacking.53
GENERAL TRENDS IN SMOKING CESSATION INTERVENTIONS
The public health approach to smoking cessation that has predominated in the smoking literature in the 1990s has primarily targeted populations or high-risk groups in their natural environments, such as worksites. Public health interventions are usually brief, low-cost, and are often provided by laypeople or through automated means (e.g., mail, contests).
Clinical approaches, however, are targeted to people who are self-referred or recruited, are most commonly applied in a medical or group setting, use trained professionals, and provide intensive multisession interventions. Because patients with CHD are at risk for recurrent cardiac events, such as another MI, a clinical approach is more cost-effective for this population—it is cheaper to help patients quit smoking than to hospitalize them for a repeat MI.54
Many intensive group smoking cessation programs are offered, but most smokers prefer to quit on their own or with individualized support.55
For example, in a study of cardiovascular patients admitted to the hospital who were smoking at the time of admission, 86% expressed an interest in quitting. However, of the 86% who were interested in quitting, 79% stated they were interested in quitting on their own, with 50% expressing interest in the use of self-help materials. Fewer than 10% of patients endorsed a formal treatment program.56
The international literature also supports these findings. One study of Korean men who were hospitalized with CVD found that 84% wanted to quit smoking, but 88% of them were interested in quitting on their own. However, surprisingly 51% were willing to participate in a formal, educational, smoking cessation program, if those programs were available during their hospitalization.57
The literature also supports the fact that 90% of all smokers eventually quit on their own, normally after three to four unsuccessful attempts.59
It therefore behooves nurses to consider methods that may be individualized to patient needs, combining a clinical approach with multicomponent strategies without requiring patients to attend a formal treatment program.
TREATING TOBACCO USE AND DEPENDENCE: CLINICAL PRACTICE GUIDELINE
As the body of knowledge about the health consequences of smoking and the health benefits of smoking cessation grow, smoking cessation interventions play an even greater role in decreasing smoking-related cardiovascular morbidity and mortality. The Treating Tobacco Use and Dependence Guideline Panel of 1996, 2000, and 2008 developed clinical practice guidelines for tobacco cessation.60
These guidelines provide an evidence-based recommendation for interventions for all smokers regardless of their intention to quit at the present time. The guidelines acknowledge that tobacco dependence is a chronic condition of dependence frequently requiring repeated interventions and that behavioral and pharmacologic interventions are cost-effective. The guidelines provide recommendations for primary care clinicians, smoking cessation specialists, and health care administrators, insurers, and purchasers. These recommendations are especially pertinent to the cardiovascular nurse because of the extensive contact nurses have with patients to initiate smoking cessation counseling.
So the guidelines60
have established five major intervention steps also known as the “5As.” These are (1) ask about tobacco use; (2) advise the patient to quit; (3) assess willingness to make a quit attempt; (4) assist in the quit attempt; and (5) arrange follow-up. Examples of how to implement a brief smoking cessation intervention outlined in the pocket guide, Helping Smokers Quit: A Guide for Clinicians63
consistent with the guidelines60
Step 1: Ask—Systematically Identify All Tobacco Users at Every Visit
To identify every smoker every time he or she is seen by a clinician, a system-wide structure must be put in place. It can be as simple as adding assessment of smoking status to the routine vital signs (heart rate, blood pressure, respiratory rate, temperature) at every visit. To ensure that the smoking status question is asked every time, preprinted progress notes can be used, vital sign stamps can be made, special stickers indicating smoking status can be placed on the outside of charts, and for those with computer charting, a query of smoking status can be inserted into the data collection tool. To obtain this information on patients who are hospitalized, smoking status must be asked as part of the routine
admission questionnaire or, as in the outpatient setting, assessed with initial vital signs. It is especially important to identify hospitalized smokers because hospital policies prohibit smoking. If not identified, these patients may go through severe nicotine withdrawal unnecessarily, which may lead to noncompliance with treatments and, in the extreme case, a patient leaving against medical advice.
The roles of the nurse and the physician need to be clearly identified in each setting. It is thus important that physicians and nurses, as well as all other health care professionals, assess their level of comfort in offering advice and, if necessary, receive training on how to counsel people. Simply bringing up the subject may seem overwhelming to health care professionals. Simple ways to introduce the subject are shown in Display 34-1
Step 2: Advise—Strongly Urge All Smokers to Quit
Smokers tend to deny anything but the most direct advice and clear-cut message about quitting. Therefore, the first step in the process of providing help to a smoker is to give him or her a clear, strong, and personalized message about quitting, such as “Your smoking is harming your health. As your nurse, I need to tell you that smoking is your major risk factor for cardiovascular disease. Continuing to smoke will lead to further cardiovascular disease and possibly death. Together, we must figure out how to help you become a nonsmoker.” Clear and strong, however, is not enough. The message must be personalized. Make your message relevant to the smoker’s current concerns about his or her health, disease status, family or social situation, age, sex, and past smoking behaviors. For example, if a patient is hospitalized for a coronary angioplasty, it is necessary for him or her to know that continued smoking is associated with an increased restenosis rate. Follow this with information about the health risks associated with continuing to smoke (see the section titled “Harmful Effects of Smoking
”) and the health and social benefits of smoking cessation (see the section titled “Benefits of Smoking Cessation
”). Display 34-2
illustrates how a smoker may interpret an inadequate message.
Step 3: Assess—Identify Smokers Willing to Make a Quit Attempt
After providing advice, it is important to determine if the patient is willing to quit smoking at this time. Willingness to quit can be measured through a simple yes/no question, such as “Are you willing to quit smoking now?” Another measure of a patient’s willingness to quit smoking can be assessed using an intention question, “Do you intend to stay off cigarettes or other tobacco products in the next month?” The patient can respond on a 7-point scale ranging from 1 (definitely no
) to 7 (definitely yes
). Patients who score a three or less usually are not interested or ready to quit.9
If the patient is willing to quit, provide a brief or more intensive intervention according to patient’s preference.
If patients are unwilling to quit, it is important to determine why. In some cases, patients may not have enough information about associated risks. Whatever the barrier, providing help or solutions to anticipated problems may encourage the patient to think further about quitting, helping the patients to identify the barriers to quitting now.
If the patient clearly states that he or she is not willing to quit at the present time, do not give up; instead, provide a motivational intervention. The guidelines60
recommends using the “5Rs”: (1) relevance, (2) risks, (3) rewards, (4) roadblocks, and (5) repetition. To ensure that the 5Rs are as individualized and personally motivational as possible, it is important to have the patient self-identify in conjunction with the provider their own relevance, risks, rewards, and roadblocks. To make an intervention relevant and meaningful to a patient, discuss smoking cessation in light of the patient’s disease status, family or social situation, age, sex, and other characteristics unique to the patient. Three types of risks should be addressed with the patient. Acute risks include shortness of breath and exacerbation of asthma. Long-term risks include heart attack, stroke, cancer, and chronic obstructive pulmonary disease. Environmental risks include risks that put the patient’s children and other family members at risk for lung cancer, sudden infant death syndrome, and asthma. The rewards of smoking cessation should also be discussed with the patient. These include improved health, energy level, sense of smell and taste, self-esteem, economic savings, reduced wrinkling/aging of skin, modeling nonsmoking for children, as well as freedom from worry about the effect the patient’s smoking has on his or her
children and other family members. Roadblocks or barriers to quitting that need to be identified with the patient include withdrawal symptoms, fear of failure, weight gain, lack of social support, living with a smoker, depression, and loss of tobacco. Finally, repetition is included because the relevance, risks, and rewards need to be reviewed with the patient every time he or she is seen because on any given visit, the patient may finally be receptive to a smoking cessation intervention.
Step 4: Assist—Aid the Patient in Quitting
Setting a Quit Date and Planning for an Intervention
The first step in assisting the patient ready to quit smoking involves establishing a quit plan. Components of a quit plan include (1) setting a quit date; (2) telling family, friends, and coworkers about quitting and the desire for support; (3) anticipating challenges to remaining smoke free; and (4) removing tobacco products from home and work settings. In regard to setting a quit date, if a patient is motivated, setting a quit date within 2 weeks of meeting with the health care provider is most appropriate. Some patients, however, prefer to quit suddenly, or “cold turkey.” If the smoker is identified in the hospital, setting a quit date is not necessary because the patient has become an ex-smoker because of the hospital smoking ban. Some programs have patients monitor the situations that cause them to smoke before they quit or reduce the number of cigarettes in the weeks before quitting. These techniques, however, although helpful to some, may simply prolong the process of quitting. Signing a contract at this point is a behavioral technique that has proved effective in helping patients to quit smoking. This process helps to formalize the smoker’s commitment to quitting and can serve as a method by which the nurse extends support to the patient in this process. Contracts must be simple and explicitly written so that both parties agree with the stated terms, and they should specify the consequences of not adhering to the expected behavior (see the section titled “Harmful Effects of Smoking
”) and the rewards of successful adherence (see the section titled “Benefits of Smoking Cessation
recommend that five major components be a part of a brief intervention. These include (1) provision of practical counseling such as problem solving, skills training, relapse prevention, and stress management; (2) provision of social support directly by the provider (intratreatment social support); (3) helping the patient obtain social support outside of the clinical setting (extratreatment social support); (4) recommending the use of approved pharmacotherapy, except in special circumstances; and (5) provision of supplementary materials. Practical counseling components include helping patients identify and anticipate “danger situations,” such as events, activities, and internal states that increase the risk for smoking relapse, for example, negative affect, being with or living with another smoker, drinking alcohol, and stress. Coping strategies to review with patients include anticipatory planning, avoidance, and stress reduction. When providing practical counseling, it is also imperative to advise patients that smoking, even one puff of a cigarette, increases the likelihood of a complete relapse to smoking. Other information that is useful to patients attempting to quit smoking includes the addictive nature of smoking,64
potential withdrawal symptoms, and that they can expect withdrawal symptoms to reach maximal intensity within 24 to 48 hours and then gradually subside over a 1- to 2-week period. The provision of intratreatment support is the simple act of providing the patient with encouragement, showing the patient that you care about them and their health, and giving the patient the opportunity to talk about their quit attempt (concerns, fears, successes). The provision of extratreatment social support includes encouraging family members and significant others to support the patient in the quit attempt and, if appropriate, providing a simultaneous smoking cessation intervention to household members who smoke. It is especially important to address this with women living with another smoker, because living with a smoker is a strong predictor of relapse in women.16
It may also include role-playing with the patient how he or she will ask for the support that is needed, identifying and referring patient to community resources such as hotlines, Web sites, or group meetings, and helping patients find “cessation buddies” with whom they can work. Provision of effective pharmacotherapies is strongly recommended and is discussed in greater detail later. Finally, as the patient leaves the health care setting, it is strongly advised that they take with them supplemental information in the form of pamphlets that are culturally, racially, educationally, and age appropriate for the patient. Patients then need follow-up in the form of face-to-face or telephone contacts.61
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