Psychosocial and Pharmacological Interventions on Smoking
Of the many causes of death in the world, coronary heart disease (CHD) remains one of the top global killers with an estimated 7.2 million people dying each year (Howell, 2011). The United States comprises a great majority of this mortality rate, which is approximately 450, 000 deaths in the United States alone (Capewell, et.al, 2010). Fortunately, since the 1970s CHD mortality rates in most industrialized nations have been reduced, especially in the younger populations (Capwell, et.al, 2010). A large majority of the American population, however, remains at heightened risk for developing cardiovascular disease, largely due to elevated cholesterol levels, even after smoking cessation. (Capwell, et.al, 2010). These increased cholesterol levels can result in hypertension, hypertriglyceridemia, and eventual development of atherosclerosis (Bass, 1991).
CHD is even more problematical in individuals that smoke. Over time smoking causes diseased arterial smooth muscle and, thus, is a clear risk factor for coronary heart disease (Bass, 1991). A clear solution, which is not so simple in practice, is that stopping smoking lowers risk. Mortality risk can be reduced by as much as 36% when smokers with CHD decide to quit smoking compared to those who continue to smoke (Critchley, 2003). In fact, drastic decreases in myocardial infarctions have been demonstrated when smokers stop smoking for as little as one year (Quist-Paulsen, & Gallefoss, 2003). Unfortunately, as most doctors and nurses can attest, many patients diagnosed with CHD continue to smoke despite the availability of smoking cessation interventions, medications, and programs.
In my own practice I have observed patients come into the hospital repeatedly, continuing to smoke, despite their diagnosis of coronary heart disease. This has spurred my interest I in finding successful measures to encourage smoking cessation in patients who have coronary heart disease. The purpose of this synthesis of the literature is to answer my PICO question: In patients with CHD who smoke how do psychosocial interventions compare to pharmacological interventions as related to smoking cessation?
The nurse can play a very important role in promoting smoking cessation. After reviewing much of this research I believe the information will be useful for communicating the importance of smoking cessation to my patients. Prior to starting my research I would merely give my patients the usual and basic information regarding the health effect of smoking. It did not seem, however, that I was effectively communicating the gravity of the health effects. As a result, I've found the topic of smoking cessation very interesting, and I am committed to learning new and effective ways of communicating the importance of smoking cessation to my patients. I enjoy talking with patients about the supportive resources at their disposal and, as a nurse practitioner; I can eventually help with pharmacologic interventions by prescribing nicotine replacement therapy.
Identification of Data Sources
I searched Maryville library databases including CINAHL, ERIC, Historical Abstracts, Library, Information Science & Technology Abstract, Literary Reference Center, Master FILE Premier, MEDLINE, MLA International Bibliography, PsycARTICLES, PsycINFO, Newspaper Source, SocINDEX, and Academic Search Premier. All of these databases where searched through the EBSCOHOST framework. The search had no restrictions and the key words used were: smoking cessation, nicotine replacement therapy, pharmacological interventions for smoking, and psychosocial interventions for smoking, Smoking, CHD, myocardial ischemia, and coronary heart disease. I also checked reference lists from pertinent articles.
One of the most promising approaches to smoking cessation is a multidisciplinary focus on the social context of smoking (Poland, et al., 2006). The Poland, et al. (2006) study examines the influence of power relations in a society on the incidences of smoking across social classes and strata. The dimensions of smoking are primarily physiological, psychological, and sociological. Taking a multidisciplinary approach to the study of smoking, Poland, et al. (2006) consider the collective patterns of tobacco consumption and the manner in which smoking is "a social activity that is rooted in place" (p. 59). Further, they examine the sociology and physical desires related to the pleasure of smoking, and the manner in which smoking contributes to or detracts from "the construction and maintenance of social identity" (Poland, et al., 2006, p. 59).
The work of Prilleltensky and Nelson (2000) is a natural extension of the literature concerning social influences and smoking behavior. The authors call for focused efforts on prevention in wellness settings through greater consideration of social interventions. Prilleltensky and Nelson (2000) argue that a medical paradigm on individual responsibility results in wellness programs that are only for at-risk families. The economic and social determinants of wellness -- or their opposite-are not properly addressed through an individual responsibility paradigm. In fact, the authors argue, such programs ask people to adjust to "unjust social conditions" (Prilleltensky & Nelson, 2000, p. 99). On the other hand, social responsibility models foster social policy that supports all families, not just those at-risk. Pointing to the social responsibility programs in some European countries, they note the relationships between these programs and extant economic and social determinants of maltreatment vs. determinants of health and well-being. In order to avoid the tendency to patholgize patients, systems of healthcare and government support should focus on counseling and education (Prilleltensky & Nelson, 2000, p. 99). Further, patients who smoke and experience health problems should be encouraged, through smoking cessation programs, to take a broader view of how their smoking behavior affects themselves and others in their lives.
Pharmacological intervention and psychosocial intervention research allows nurses to provide accurate and compelling information regarding smoking cessation. Nurses play a dominant role in the frontline of patient education by counseling patients, making telephone calls, and conducting interviews to track and help patients progress in successful smoking cessation (Huttunen-Lenz, Song, & Poland, 2010). Since smoking is an addiction and many patients experience extreme difficulty stopping the habit, many physicians find anti-smoking counsel unrewarding and fall short in making it a major element of patient care (Burt, et.al.1974). As a result, nurses naturally tend to take on advocacy roles in which they emphasize anti-smoking interventions and encourage patients or engage in and respond to psychosocial interventions. In addition, as a nurse practitioner, I find myself providing options for pharmacological interventions.
A combination of techniques seems to be the most efficacious in helping individuals to quit smoking (Barth, et.al, 2008). In the 1970s, medical personnel took an extremely paternal and strong point-of-view, particularly after any coronary surgery or procedure. This approach to intervention resulted in about two-thirds of patients giving up smoking completely. Over 50% of the remaining individuals cut back considerably. This was achieved primarily with doctor-patient or nurse-patient communication and regular reminders to patients (Burt, et.al., 1974). With the nursing staff taking an aggressive, post-procedure role, fear arousal caused approximately 60% of a study group to stop smoking for at least 12 months after the procedure (Quist-Paulsen & Gallefos, 2003). The cooperative efforts of nurses and doctors to implement psychosocial interventions are critical to effective cessation, but this approach is often most effective when combined with a wider array of tools.
It is important to include a broad spectrum of smoking cessation interventions in healthcare efforts because cessation creates marked risk reduction for many diseases including CHD. Smoking is the single most preventable cause of disease in the world, so it is critical to focus on the role of the healthcare industry in targeting and eradicating this epidemic. Capewell et al. (2008) reported that smoking cessation and improved cardiovascular function could account for 51,000 less CHD related deaths by 2010. They also reported that if the United States Healthy People 2010 risk targets can be met a total of approximately 188,000 CHD related deaths would be avoided each year. Additionally, Critchley and Capewell (2003) conducted a literature review to determine the reduction that smoking cessation affects patients with CHD, and they found that cessation resulted in a 36% relative risk reduction. A study by Greenwood et al. (1995) found that heart patients who stopped smoking after suffering myocardial infarction showed significantly reduced mortality rates compared to those who did not.
There is strong statistical evidence that pharmacological management of smoking cessation, along with a robust psychosocial support system, is a very cost-effective and efficacious way to intervene and aid in smoking cessation. In particular, patients have a higher success rate for quitting and continuing to maintain a non-smoking status when nurses or doctors help monitor nicotine replacement (Percival and Milner, 2002). That said, there are a variety of pharmacological interventions for treating tobacco dependence and patients must work with doctors and nurse practitioners to select to most viable choice for the individual. Typically, these may be grouped into four generalized subgroups: 1) nicotine replacement therapies (patches, gum, lozenges); 2) anxiolytic medications to reduce anxiety during withdrawal; 3) antidepressants (bupropion, etc.); and 4) clonidine, nortriptyline, mecamylamine, naltrexone and silver acetate. All of these methods, of course, require a physician's regular monitoring, particularly during the first few weeks of therapy (Al-Doghether, 2004). Use of one of more of these pharmacological interventions should be…
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