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Evidence-based strategies for tobacco cessation.

Acute and critical care nurses are well positioned to assist patients with tobacco cessation efforts. Their relationship with their patients and the patients' families equips them with many opportunities to intervene, identify tobacco use, and deliver interventions to assist with tobacco cessation. As trustworthy professionals, acute and critical care nurses are credible sources of health-related information and assistance. Since a healthcare provider's advice to stop smoking is a strong motivator for patients to make repeated attempts to quit, the influence that acute and critical care nurses have in motivating patients to quit cannot be overestimated.

It is well known that smoking is the leading preventable cause of morbidity and mortality and causes death, disability, and years lost each year. Tobacco costs the United States approximately $157 billion annually in medical care and losses of an economic nature. (3) Acute and critical care nurses are well versed in the health benefits of quitting, which include decreased risk of a heart attack, stroke, lung cancer, chronic lung disease, and other cancers related to smoking and/or second-hand smoke. (4) Despite the improvement in health that smoking cessation allows, adults in the United States continue to smoke. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has mandated implementation of hospital core measures. This implementation refers to the extent to which a measure addresses areas where performance improvement is likely to have a significant effect on the health of specified populations. As a result, tobacco cessation counseling is required for all patients admitted to the hospital who have a diagnosis of pneumonia, heart failure, and/or myocardial infarction.

A new Health Plan Employer Data and Information Set (HEDIS) measures medical assistance with smoking cessation. This tool is used to assess the proportion of tobacco users and recent quitters who were advised to quit and given information pertaining to strategies that aid with smoking cessation. (6) Thus healthcare plans and healthcare providers are more accountable for delivery of high-quality care as it relates to smoking cessation.

Released by the US Public Health Service in 2000, an evidence-based clinical guideline reviewed existing data to determine the best interventions for smoking cessation. Known as "Treating Tobacco Use and Dependence," this clinical practice guideline contains the strategies and recommendations designed to assist clinicians with effective smoking cessation techniques. (7) Brief counseling, defined as less than 3 minutes, was identified as an effective intervention for smoking cessation. Increased contact time improves the effectiveness of the counseling and the guideline further recommends a brief 5-step intervention known as the "5 A's."

* Ask about tobacco use: identify and document tobacco use status for every patient.

* Advise to quit: use a clear, strong, personalized message to urge tobacco users to quit.

* Assess willingness to attempt to quit: is the tobacco user willing to attempt to quit at this time?

* Assist in the quit attempt: use counseling and pharmacotherapy to ensure success with the quit attempt.

* Arrange follow-up: follow up to maximize success with the long-term quit attempt.

Strategies for implementing the 5 A's in acute and critical care nursing practice are illustrated further in Table 1.

Despite asking a smoker about an interest in quitting and advising the smoker to quit, the acute and/or critical care nurse must assess the person's motivation and readiness to quit. Success in smoking cessation is a long-term commitment. Nicotine dependence can require several attempts to quit before success is achieved and a long-term change is made. Stages of change that a smoker may pass through in making this change include the following: (8)

* Precontemplation: no consideration for quitting

* Contemplation: considering but uninterested in taking action

* Preparation: preparations are being made for an attempt to quit

* Action: making an attempt to quit

* Maintenance of tobacco abstinence

Most smokers (80%) fall into 1 of 2 of the change categories: precontemplation or contemplation. The 2 distinct groups of individuals need very different approaches to smoking cessation.

Patients who fall into the precontemplation stage are not convinced that the health hazards associated with smoking apply directly to them. They may not want to make a change in smoking as a health behavior, or they may express doubts about their ability to successfully make a change. The goals for these patients are to instill a sense of doubt about the desire to continue smoking, raise an awareness of the health hazards of smoking and their direct effect on the patient's health and well-being, and communicate the benefits of quitting. Exploring the positive perceptions the patient has about smoking may help overcome the resistance commonly seen in this stage of the change process.

Patients in the contemplation stage seek out information about the quit attempt but are unwilling to make a commitment to quit or express self-doubt about their ability to successfully quit. Identifying the positive and negative aspects of continuing to smoke and emphasizing the negative consequences of continuing to smoke will help the contemplator resolve ambivalence toward continuing to smoke.

The US Public Health Service's clinical practice guideline recommends a 5-step approach for both the precontemplators and the contemplators who are unwilling to quit, known as the "5 R's." They include the following:

* Relevance: encourage the individual to consider why quitting is important.

* Risk: ask the individual to identify the negative consequences of smoking.

* Rewards: ask the individual to identify positive aspects of quitting.

* Roadblocks: encourage the individual to identify barriers for success and those barriers that may have prevented success with previous quit attempts. Communicate with the individual about treatments that may improve success and reduce barriers.

* Repetition: Motivate the patient toward a successful quit attempt during each interaction. Assess the individual's interest in setting an intermediate goal, such as a reduction in the number of cigarettes consumed.

All smokers who are trying to quit should be encouraged to augment their cessation efforts with pharmacological cessation aids approved by the Food and Drug Administration. Individuals who have significant pre-existing medical conditions, smoke fewer than 10 cigarettes per day, or are in adolescence, pregnant, or breast-feeding require special consideration before these cessation aids are prescribed. (9) First-line agents include nicotine replacement therapy. These agents improve the chances for a successful attempt to quit by reducing the physical withdrawal symptoms associated with nicotine cessation and help patients focus on the behavioral changes necessary for successful cessation. Nicotine replacement therapy must be used with caution in patients with underlying cardiovascular disease, because it can increase myocardial workload. Table 2 depicts commonly prescribed agents for nicotine replacement therapy.

Acute and critical care nurses are able to communicate effectively with their patients. One area that is challenging for patients who are attempting to stop smoking is the withdrawal symptoms that some patients may experience after stopping smoking. These signs and symptoms may be wide and varied and include physiological changes, as the body adapts to the absence of nicotine, or could be the postcessation weight gain that is often experienced, especially by women.

Acute and/or critical care nurses can assist patients with these signs and symptoms. Strategies for reducing these signs and symptoms are listed in Table 3.

In summary, acute and critical care nurses are well positioned to assist patients and their families with tobacco cessation efforts to improve their health and well-being. Brief interventions, less than 5 minutes long, which can take place at the patient's bedside, are effective in motivating patients to attempt to quit smoking. Family members included in these interventions can assist the patient in the attempt to quit and be instrumental in reducing barriers to success. At the very least, busy acute and critical care nurses can do a 30-second intervention: ASK about tobacco use, ADVISE about the health effects, ASSESS readiness to quit and REFER to 1-800-QUIT-NOW.

Claudia P. Barone is a clinical associate professor in the College of Nursing and a tobacco cessation provider education coordinator in the College of Public Health at the University of Arkansas for Medical Sciences in Little Rock, Ark. Janie Heath is an assistant professor and director of the tobacco cessation program at Georgetown University School of Nursing and Health Studies in Washington, DC.


(1.) National Cancer Institute. Tobacco and the clinician: interventions for medical and dental practice. Monograph Natl Cancer Inst. 1994;5;1-22. NIH Publication No. 94-3693.

(2.) Owen N, Davies MJ. Smokers' preferences for assistance with cessation. Prev Med. 1990;19:424-431.

(3.) US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General-Executive Summary. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.

(4.) US Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health; 1990.

(5.) Performance measurement initiatives: core measure set information (pneumonia, heart failure, acute myocardial infarction). Available at: Accessed January 13, 2006.

(6.) Cressman T. Using category II codes for smoking cessation. Coding Edge. 2005;7(10):11-12, 33.

(7.) Fiore MC, Bailey WC, Chen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service; June 2000:25-35.

(8.) DiClementee CC, Prochaska JO, Fairhurst SK, et al. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991;59:295- 304.

(9.) Corelli RL, Hudmon KS. Tobacco use and dependence. In: Koda-Kimble MA, Young Ly, eds. Applied Therapeutics: The Clinical Use of Drugs. 8th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2004:85-1-85-29.

(10.) Rx for Change: Clinician Assisted Tobacco Cessation. San Francisco, Calif: The Regents of the University of California, University of Southern California, and Western University of Health Sciences, 1999-2003.
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Author:Barone, Claudia P.; Heath, Janie
Publication:AACN News
Geographic Code:1USA
Date:Apr 1, 2007
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