Evidence-Based Nursing Interventions for Smoking Cessation
Evidence-Based Nursing Interventions for Smoking CessationMegan Clinard, Carola Schlatter, Judith Spoor, Daana VanDellenFerris State UniversityResearch in NursingNURS 350Omar G. BakerApril 30, 2010Abstract“Although the United States has made great strides toward reducing the prevalence of smoking, approximately 46 million adults (20.6% of the population) still smoke, and every day, another 1,000 young persons become new smokers” (CDC, 2009). As members of the multidisciplinary team, nurses spend the most time with their clients, and they play a key role to influence them in smoking cessation. Current nursing research articles are explored for evidence-based practices related to smoking cessation. Recommendations are to utilize the transtheoretical model for health promotion and disease prevention. A Quick Reference Guide for Clinicians Treating Tobacco Use and Dependence is provided as a tool to aide nurses in teaching smoking cessation.Evidence-Based Nursing Interventions for Smoking CessationThis research study defines smoking within the context of cigarette smoking. “Nicotine, a component of tobacco, is the primary reason that tobacco is addictive, although cigarette smoke contains many other dangerous chemicals, including tar, carbon monoxide, acetaldehyde, nitrosamines, and more” (Volkow, 2009). “Nicotine is a potent psychoactive drug that induces euphoria, serves as a reinforcer of its use, and leads to nicotine withdrawal syndrome when it is absent. As an addictive drug, nicotine has 2 very potent issues: it is a stimulant and it is also a depressant” (Lande, n.d.). Withdrawal symptoms include “irritability, insomnia, moodiness, headache,” and “difficulty concentrating” (Bennet et al., 2007, p.38). Wewers, Sarna & Rice (2006) defines nursing intervention as advice, counseling, or a combination. It is important to recognize the impact of nursing interventions on patient success with smoking cessation. Nurses can play an extremely important role in smoking cessation by stimulating awareness in the patient and making referrals to services for assisting patients with smoking cessation (Joanna Briggs Institute, 2008, p. 1). There are clinical practice guidelines with specific recommendations to follow when working with patients who smoke. Problem IdentifiedTobacco use in the United States is considered to be a “key preventable cause of death” (Holtrop, et al, 2009, p. 243). It has been known for decades that smoking causes lung cancer, heart disease, and respiratory illnesses. U.S. Surgeon General Richard H. Carmona reported other diseases that were also linked to cigarette smoking. These include “leukemia, cataracts, pneumonia and cancers of the cervix, kidney, pancreas and stomach” (HHS, 2004). Second hand smoke causes allergies and respiratory diseases in children and adults. Children may also experience negative side effects from smoking such as ear infections, more severe asthma, and sudden infant death syndrome (Bennet, Andrews, & Heath, 2007). Michigan has passed several laws to help reduce the number of smokers and the amount of second hand smoke. There are restrictions to prevent people from smoking in public places and government buildings. In 2004, the state increased taxes on a carton of cigarettes from $1.25 to $2.00. Legislation restricts advertising to youth, and imposes fines for selling cigarettes to minors. Michigan has restricted cigarette vending machines to special licensure. Starting May 1st, 2010, Michigan will implement a new law which prohibits smoking in all workplaces, restaurants and bars. (ALA, n.d.) With all limits in place, the American Lung Association’s report card grade for Michigan in the performance of “Tobacco Prevention and Control Spending” is an F. Michigan also received an F for cessation coverage, and a C for cigarette tax. (“Report Card”, 2009). Organizations have also made attempts to reduce cigarette smoking. The objective of Healthy People 2010 is to reduce cigarette smoking prevalence among adults to less than 12%. (CDC, 2009) The Great American Smokeout, sponsored by the American Cancer Society, challenges smoking cessation for a day, and provides resources to help people stop smoking permanently. (CDC, 2009) World No Tobacco Day is held annually on May 31st. “The goals of World No tobacco Day are to raise awareness about the dangers of tobacco use, encourage people not to use tobacco, motivate users to quit and encourage countries to implement comprehensive tobacco control programs” (HHS, 2004). Despite these efforts cigarette smoking continues to be a huge health problem.Many smokers pass through to health care professionals, including nurses, and they receive no advice about smoking cessation (Joanna Briggs Institute, 2001, p. 1). Wewers (2006) identified 3 major barriers to effective teaching on smoking cessation. Smoking cessation is not considered central to nursing practice. As a result, it is not a priority for nursing research. Secondly, smoking cessation interventions are not part of the nursing school curriculum. Finally, many nurses in clinical practice continue to smoke and are less likely to intervene with smokers. Summary of the Evidence Wewers, Sarna and Rice (2006) found that smoking cessation programs can significantly reduce disease burden and are cost effective. “According to estimates from the Tobacco Free Nurses National Initiative (Tobacco Free Nurses, 2005), if each of the 2.2 million practicing nurses offered cessation treatment to only one of their smoking patients, the annual quit rate would triple” (Wewers, Sarna, and Rice, 2006, p.S11). The Agency for Health Care Policy and Research guideline for clinicians was reviewed. This guideline recommends that clinicians use the five A’s (ask, advise, assess, assist, and arrange) to treat tobacco dependence. Dependence on tobacco should be treated as a chronic condition with repeated interventions, individual counseling and pharmacotherapy. According to Malucky (2010), tobacco dependence should be treated as a chronic disease that requires multiple interventions and follow-up. Intensive intervention is the most effective, but even brief interventions of 3 minutes at each visit can make a difference. The five A’s (ask, advise, assess, assist and arrange) model should be used systematically for all patient with tobacco dependence. It may be determined during an assessment that the timing is not right for a client to quit smoking. Clinicians can use the 5 R’s (relevance, risks, rewards, roadblocks, and repetition) to uncover ambivalence and increase motivation for smoking cessation.An article published in The Western Journal of Nursing Research entitled “Effect of an Inpatient Nurse-Directed Smoking Cessation Program”, described a research study. The purpose of the study was to determine which was more effective; standard nursing intervention of printed literature, or standard intervention with follow-up phone calls. On admission to this institution, all patients who reported being a smoker were given a pamphlet about smoking cessation. Patients who only received the standard pamphlet were in the control group. The study groups were also given the pamphlet, and additionally, received a 30 minute counseling session and 1 or 4 follow up phone calls within a 3 month post-discharge period. The study group was subdivided into 1 follow up phone call or 4 phone calls. There was no significant difference in smoking abstinence within these subgroups. However, the study revealed that the control group had a 5.21% abstinence rate, whereas the study group had a 17.55% abstinence rate after 3 months. The researchers concluded that it was more effective for nurses to give out a pamphlet and follow up with phone calls than to just give a pamphlet. (Buchman et al., 2008) Holtrop, et al, (2009) performed a study by using nurses as consultants for primary care practices. The purpose of the study was to help clinicians identify and establish interventions to assist adult patients to improve health behaviors, including the use of tobacco (Holtrop, et al, 2009, p. 243). Barriers to providing effective interventions for smoking cessation include lack of reimbursement, lack of knowledge, and a lack of time (Holtrop, et al, 2009, p. 243). The authors used a consultation model of support. Past studies have shown this conceptual model to help overcome barriers and improve the care process (Holtrop, et al, 2009, p. 244). A sample size of 20 primary care practices was used for the study. The study used the intervention of nurse consultation based on the 5 A’s model. The 5 A’s model includes: Assisting clinicians to identify at risk patients, asking patients about health behaviors, advising patients to modify their efforts to change, assessing the patient interest to make the health behavior change, and arranging follow up that is appropriate to the patient (Holtrop, et al, 2009, p. 244). The study revealed an 85% increase in documentation of healthy behavior interventions (Holtrop, et al, 2009, p. 243). The authors concluded that “nurse consultation has the potential to improve preventive health care provided to primary care physicians” (Holtrop, et al, 2009, p. 249). In a review of literature and recommendations for Best Practice guidelines, Rice and Stead found advice given by nurses to be highly effective with smoking cessation. “Nurse initiated advice should be considered a front line therapy” (Joanna Briggs Institute, 2001, p. 2). Recommendations were made that all clients should be screened for use of tobacco (Joanna Briggs Institute, 2001, p.2). Motivational strategies should also be implemented to assist the patient with smoking cessation (Joanna Briggs Institute, 2001, p. 3). Motivational strategies include relevance, risks, rewards and repetition. Patient information should be relevant. Acute and long term risks should be reviewed, along with the rewards of saving money, feeling better, and the potential for improved health of the client’s family. Freedom from addiction should be emphasized, and strategies should be reviewed with each patient visit (Joanna Briggs Institute, 2001, p. 5). A Search of the Cochrane Library revealed a review of nursing interventions for smoking cessation. The review was done to determine the effectiveness of smoking cessation interventions delivered by nurses. The review included 42 studies, of which 31 were comparing a nursing intervention to a control or to usual care that has been provided regarding smoking cessation. Nursing intervention significantly increased the likelihood of quitting (Rice & Stead, 2009, p. 1). Using a confidence level of 95%, the risk ratio was 1.28. This resulted in a confidence interval of 1.18 to 1.38 (Rice & Stead, 2009, p. 1). The authors concluded that there are potential benefits of smoking cessation when advice/counseling is offered by nurses (Rice & Stead, 2009, p. 1). When nursing interventions for smoking cessation are brief and are not offered by health promotion nurses, the effect of smoking cessation is weaker (Rice & Stead, 2009, p. 2). The author suggests that there is a challenge for nurses to incorporate both smoking behavior monitoring and smoking cessation interventions as part of standard practice by nurses (Rice & Stead, 2009, p. 2). “The decline in smoking has been seen mostly in affluent groups and is unequal across socioeconomic and ethnic groups. Cigarette smoking rates are higher in lower socioeconomic groups and among those with a high school education or less” (Bennett et al., 2007, p. 37). Bennett et al. (2007) provided awareness of differences in culture and ethnicity relating to tobacco effects. Cigarette smoking among American Indians occurs at a higher rate and consumption than among whites. African-Americans are inclined to prefer cigarette brands higher in nicotine, inhale deeper, and “have a slower rate of cotinine clearance than other ethnic groups. These differences may partially explain why African-Americans suffer increased morbidity and mortality from smoking-related diseases and report difficulties with cessation” (Bennett et al., 2007, p. 37). Experience Affects Decisions to Use Evidence in PracticeNurses’ own perceptions of smoking can influence their health promoting behaviors. A descriptive quantitative study was conducted at The Ohio State University College of Nursing. The study evaluated nursing students’ attitudes about smoking, their smoking-related behaviors, and their knowledge of treatment and interventions for smoking cessation. Questionnaires were distributed in 424 mailboxes of the undergraduate sophomore, junior, and senior nursing students. A convenience sample of 200 participants consented to the study by returning their questionnaires. Of the nursing students surveyed, 6% were smokers, 12% were ex-smokers, and 82% never smoked. Ages of the nursing students ranged from 19 to 51, and 91% were women. (Jenkins & Ahijevych, 2003)Not surprisingly, 98% of the nursing students agreed to the harmful effects of cigarette smoking. However, results from the study revealed that smoking cessation counseling was not given as frequently by nursing students who smoked (8%) as by the nursing students who did not smoke (26%). Also, there were differences in perception in nursing students’ confidence levels related to educating and counseling clients about smoking cessation. The average confidence level for sophomores was 51.5, juniors at 67.7, and seniors at 69.5. (Jenkins & Ahijevych, 2003)Analysis of the Evidence The articles reviewed strongly supported nursing interventions as a front line approach to reduce the number of patients who smoke. Rice and Stead (2003) found that the effect of brief interventions was weaker, but Malucky (2010), suggested that interactions as short as 3 minutes were effective in decreasing the number of patients with nicotine dependence. Wewers et al, (2006) and Malucky (2010) are both in agreement that tobacco dependence is a chronic condition, and recommended repeated or multiple interventions with follow-up. Buchman et al., (2008) provided the most significant support for nursing intervention. Their study concluded that a control group of clients receiving only a pamphlet had 5.21% abstinence rate after 3 months, whereas the study group receiving a pamphlet as well as at least one follow-up call had an abstinence rate of 17.55%. People in lower socioeconomic classes are more likely to use tobacco (Wewers et al., 2006). This population is also less likely to get routine medical care, so it is essential for nurses to provide education and intervention at every visit to reinforce health promotion and disease prevention. Socioeconomic, educational, cultural, and ethnic considerations should be made for clients who smoke to individualize nursing interventions. (Bennett et al., 2007)Nurses are not routinely educated on smoking cessation interventions. Wewers et al. (2006) found that teaching about smoking cessation within nursing curriculums was found in only one third of the nursing programs studied. Jenkins & Ahijevych (2003) found that nurses’ own smoking behaviors directly influence the frequency of their smoking cessation counseling. They also suggested that advanced courses and more clinical experience can develop nursing students’ confidence levels. Barriers to nurses providing health interventions include lack of reimbursement, knowledge, and time (Holtrop et al., 2009, p. 243). Recommendations to Utilize the EvidenceSeventy percent of the 45.3 million smokers want to quit (Malucky, 2010). Nursing intervention has proven effective. Smokers who received nursing interventions were 50% more likely to quit than smokers without nursing intervention (Wewers, 2006). Literature reviews overwhelmingly support the 5 A’s (ask, advise, assess, assist, and arrange), as well as the 5 R’s (relevant, risks, rewards, roadblocks, and repeat) to motivate clients in smoking cessation. Motivation is necessary to provide encouragement for clients, and to prevent relapse. Appendix A outlines the Quick reference Guide for Clinicians Treating Tobacco Use and Dependence, a tool that nurses can utilize for smoking cessation teaching. “The purpose of tobacco treatment is to help individuals quit using tobacco products for good if they are ready, and to help them progress to the next level in their readiness to quit” (Bennet et al., 2007, p. 39). The transtheoretical model developed by Prochaska and DiClemente (1984) is an existing nursing theory that provides a conceptual framework for health promotion and disease prevention. This model can assist nurses not only with evaluating clients in the assessment phase, but can also help in awareness of nurses’ own health behaviors.The transtheoretical model outlines 5 stages for quitting or adopting a health behavior. Smoking cessation is the perfect example to incorporate into this model. The first stage is “pre-contemplation” in which a client makes no attempt to change their current smoking behavior. The second stage is “contemplation” in which a client is considering smoking cessation. “Planning or preparation” is the third stage in which a client has made some small changes as evidence of smoking cessation such as cutting back in the number of cigarettes smoked or setting a quit date. The fourth stage is “action” in which the client has, over the past 6 months, actively changed their smoking behavior. “Maintenance” is the fifth and final stage in which the client has surpassed a 6 month time frame towards smoking cessation indefinitely.When individualizing care plans, nurses should pay particular attention to clients related to ethnicity, socioeconomic, and age-related issues. Nurses should also be knowledgeable about helpful organizations within the community when making referrals related to smoking cessation. Clients can be encouraged to keep their homes smoke-free to prevent exposure to second hand smoke. (RNAO, 2007)ConclusionNurses are at the frontlines of patient care, and can therefore play an extremely important role by providing advice to patients about improving their health through smoking cessation (Rice & Stead, 2009, p. 1). Nursing intervention has proven effective. Smokers who received nursing interventions were 50% more likely to quit than smokers without nursing intervention (Wewers, 2006). By understanding that evidence-based nursing interventions achieve success in smoking cessation, nurses can be assured that they are making an impact within their respective practices. Professional nursing goes beyond the scope of practice. The Registered Nurses’ Associate of Ontario (RNAO) highly recommends that nursing schools incorporate smoking cessation into their curriculum. According to the RNAO best practice guideline, “Organizations and Regional Health Authorities should consider smoking cessation as integral to nursing practice, and thereby integrate a variety of professional development opportunities to support nurses in effectively developing skills in smoking cessation intervention and counseling” (RNAO, 2007, p. 14).DOCVARIABLE SH5SectionTitleReferencesAmerican Lung Association [ALA]. (n.d.). State Legislated Action on Tobacco Issues. Retrieved from Public Health Association. (2009). AHRQ Healthcare Cost and Utilization Project. Retrieved from Bennett, S.M., Andrews, J.O., Janie, H. (2007). Breaking the ties of nicotine dependence. The Nurse Practitioner, 32(11), 36-45. ISSN: 0361-1817Centers for Disease Control and Prevention [CDC]. (2009). Cigarette smoking among adults and trends in smoking cessation-United States, 2008. MMWR 2009;58: 1227-1232Centers for Disease Control and Prevention [CDC]. (n.d.). Cessation Fact sheet. Retrieved from , C., Buchman, D., Robinson, J., & Smolen, D. (2008). Effect of an inpatient nurse-directed smoking cessation program. Western Journal of Nursing Research, 30(1), 6-19. doi:10.1177/0193945907302729Holtrop, J.S., Dosh, S.A., Torres, T., Arnold, A.K., Baumann, J., White, L., & Pathak, P.K. (2009). Nurse consultation support to primary care practices to increase delivery of health behavior services. Applied Nursing Research, 22(4), 243-249. Jenkins, K., Ahijevych, K. (2003). Nursing students’ beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention. Applied Nursing Research, 16(3), 164-172.Joanna Briggs Institute for Evidence Based Nursing and Midwifery. (2001). Evidence based practice information sheets for health professionals: Smoking cessation interventions and strategies, 5(3), 1-5Joanna Briggs Institute. Evidence based practice sheet for health professionals: Smoking cessation interventions and strategies, 12(8), p. 1-4. Lande, R. G. (n.d.). Nicotine Addiction. Retrieved from , A., (2010). Brief evidence-based interventions for nurse practitioners to aid patients in smoking cessation. The Journal for Nurse Practioners, 6(2), 126-131. Nieswiadomy, R. M. (2008). Foundations of Nursing Research (5th ed.). Upper Saddle River, New Jersey: Prentice Hall Pender, N.J., Murdaugh, C.L., Parsons, M.A., (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.Registered Nurses’ Associate of Ontario [RNAO]. (2007). Nursing best practice Guideline: Integrating smoking cessation into daily nursing practice, p. 14Report Card. (2009). Retrieved from , V., & Stead, L. (2009). Nursing interventions for smoking cessation. Cochrane Library, Issue 1.U.S. Department of Health & Human Services [HHS]. (2004). New Surgeon General’s report expands list of diseases caused by smoking. Retrieved March 4, 2010, from , N. D. (2009). Tobacco addiction. The Science of Drug Abuse and Addiction. Retrieved from , M., Sarna, L., & Rice, V., (2006). Nursing research and treatment of tobacco dependence. Nursing Research, 55(4). 11-15. ................
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