Nurse-Led Smoking Cessation: Methods and Outcomes

Introduction: The Scope of the Smoking Problem

According to the American Cancer Society (2010), smoking causes 419,000 deaths annually. It is the single most preventable factor resulting in deaths and disability from cancers of the lung, mouth, pharynx, esophagus, and bladder. In addition, it contributes to stroke and heart attacks and is instrumental in respiratory diseases such as chronic obstructive pulmonary disease and bronchitis. Smoking may also cause a decrease in physical fitness and elevated serum cholesterol levels.

According to the CDC (2007), smoking affects 19.1% of the population — a decrease of approximately 1% from previous data collected by the CDC (2004). The prevalence is moving in the right direction, primarily because of increased public awareness of the dangers of smoking, the rising cost of cigarettes, laws governing smoke-free areas (airlines, restaurants, and other public venues), and intervention by healthcare professionals who are taking a more proactive stance on cigarette cessation.

In addition to being a habit, smoking is also an addiction because of the nicotine found in cigarettes. Nicotine is considered as addictive as heroin or cocaine. What causes the medical symptoms is the tar in cigarettes, which causes cancer, and the ash, which causes pulmonary and cardiovascular symptoms. It can be fairly stated that nicotine addicts the individual while the tar and ash ultimately kill the smoker. If it were not for the body's ability to partially cleanse the lungs, pharynx, and sinus passages through cilia and mucus, one could not survive or tolerate smoking at all. Because of this cleansing ability, cigarette smoking becomes a long-term chronic condition with severe consequences late in a smoker's life — a life that may be prematurely shortened by 10 to 15 years (Andrews & Heath, 2003).

Beyond the primary smoker, there are serious consequences of second-hand smoke for non-smokers. Children exposed to second-hand smoke may develop respiratory diseases and experience stunted lung development. They may also face a greater risk of developing lung cancer as adults, as well as moderate to severe asthma. It is therefore important to start smoking cessation programs as early as possible, as children are among the most receptive groups that nurses can educate.

The national goal is to reduce cigarette smoking to a prevalence rate of 12% or below. There are currently groups that meet or exceed these national expectations, and studies confirm the effectiveness of both minimal and intensive nursing intervention in achieving cessation outcomes.

Literature Review

Fritz, Wider, Hardin, & Horrocks (2008) found that school nurses who work with adolescents are in an ideal position to guide students toward early non-smoking behaviors. Students who begin smoking tend to continue as adults. Without nursing instruction, these students often fail to recognize the harmful nature of cigarette smoking and show little concern for their future health. With a nurse educator involved, students can be informed about the harmful nature of smoking and its long-term effects. The nurse is also positioned to recruit faculty to help guide students toward better behavior patterns, and by partnering with faculty to establish a non-smoking school environment, further student compliance can be achieved.

Scanlon, Clark, & McGuiness (2008) are Australian investigators who determined that using the evidence-based Australian 5A's smoking cessation program is the most successful approach to encouraging cessation, yet it was not being widely used by nurses because they were unaware of how to properly implement it. While 87% of nurses in the study agreed on the importance of a strong smoking cessation program, few knew how to carry one out. This disparity was attributed to poor dissemination of clinical information about smoking during nursing school. Of the nurses surveyed, only 22% had the necessary information to provide useful direction to smokers.

The 5A's of the Australian system are:

1. Ask about current and past tobacco use;
2. Assess a smoker's desire to quit;
3. Advise a smoker to quit;
4. Assist through education about the dangers and harms of smoking to encourage quitting;
5. Arrange follow-up visits to continue counseling and direction, either through nursing or other support services (Zewar et al.).

An information-gathering questionnaire was administered to 162 nurses to determine how much they knew about cigarettes and smoking. The nurses scored a mean of 54.93 — below the passing threshold of 65 — with a score range of 14 to 87.12. The data confirmed that nurses' reluctance to address smoking stemmed from a lack of factual knowledge needed to instruct patients effectively. At the same time, the study showed that nurses were willing to learn, as 87% considered smoking cessation an important public health issue.

Scanlon noted that acute-care nurses are in a unique position to educate patients about smoking. These nurses are present with patients 24 hours a day and constitute the largest group of healthcare providers with continuous patient contact during a hospital stay. While hospitalized, patients are often motivated to improve their health, making the acute-care nurse an ideal resource for cessation information (Conroy et al., 2005).

Smith & Burgess (2009) examined the Canadian smoking cessation program for patients admitted to a cardiac unit following acute myocardial infarction or coronary bypass procedures. They reviewed 276 sequentially admitted patients and compared those who received minimal instruction — brief advice from a nurse or physician along with two pamphlets — against those who received an intensive intervention program. The intensive program consisted of the minimal intervention plus 60 minutes of bedside counseling, additional educational materials, and seven nursing follow-up calls over the two months following discharge.

The results showed that 12-month self-reported abstinence was significantly higher in the intensively treated group (60%) versus the minimally treated group (46%). When confirmed by cotinine assays, the actual abstinence rates were 57% in the intensive group versus 39% in the minimal group. The conclusion was clear: intensive intervention is beneficial for smokers at risk of cardiac complications.

Ritchie, Evans, & Matthews (2010) examined nursing students' and clinical instructors' perceptions during the implementation of best-practice guidelines. They identified four categories of bias and barriers:

1. Personal and professional self — how past smokers, non-smokers, and current smokers related to patients who smoked;
2. Health preaching — concern among nurses that they would appear judgmental, causing patients to lose confidence in them;
3. Developmental perspective — nursing students who were typically younger than their patients felt uncomfortable questioning a lifestyle the patient had maintained for many years;
4. Environmental constraints — time pressures from other clinical duties and documentation requirements left little opportunity to introduce best-practice guidelines.

During their third year of training, nursing students were introduced to a comprehensive program on cigarettes and cessation, alongside more efficient time-management skills. With these new tools, they felt more comfortable and competent teaching patients the best-practice guidelines. Education and professional maturation proved essential to building confidence in delivering cessation instruction.

Sanders, Fowler, Mant, Fuller, Jones, & Marzillier (1989) originally found that a group of patients given a single informational session by nurses — advising them not to smoke — achieved a significantly higher cessation rate than a control group receiving the same advice from non-nursing personnel. At the one-year mark, the nurse-counseled group had a 3.6% cessation rate compared to 0.9% in the control group, making nurses approximately three times more successful with minimal intervention alone.

The CDC (2010) identifies the following reasons why tobacco use must be identified and discouraged in youth:

1. Each day, 4,000 American youth (ages 12–17) try their first cigarette;
2. 25% become daily smokers;
3. Youth do not understand that nicotine is as addictive as heroin or cocaine;
4. Young people are generally unaware of the long-term health consequences;
5. School programs can have a major impact on smoking cessation and long-term health.

The CDC (2010) also recognizes the health consequences of tobacco use, including premature death; heart disease, stroke, and chronic obstructive pulmonary disease; elevated blood cholesterol, bronchitis, and bronchiectasis; oral cancers from smokeless tobacco and cigars; and the effects of second-hand smoke on children, including hindered lung development, new cases of asthma, and worsened existing asthma.

The CDC (2010) further notes that well-designed school programs have proven effective in reducing tobacco use, establishing non-use as a social norm, and preventing the use of other drugs. Effective school programs typically prohibit tobacco use at all school functions, encourage administrators and staff to quit smoking, provide developmentally appropriate curricula for K–12, ensure a consistent anti-tobacco message from nurses, teachers, administrators, families, and community leaders, and promote uniform anti-tobacco messages at the community level.

References

American Cancer Society. (2010). Incidence of cancer, United States.

American Lung Association. (2010). Incidence of respiratory diseases caused by smoking.

Andrews, J. O., & Heath, J. (2003). Women and the global tobacco epidemic: Nurses' call to action. International Nursing Review, 50, 215–228.

CDC, MMWR. (2008). Cigarette smoking among adults — United States, 2007. 57(45), 1221–1226.

CDC. (2010). Healthy Youth! Health topics: Tobacco use — school health guidelines.

Fritz, D. J., Wider, L. C., Hardin, S. B., & Horrocks, M. (2008). Program strategies for adolescent smoking cessation. The Journal of School Nursing, 24(1).

Ritchie, L., Evans, M. K., & Matthews, J. (2010). Nursing students' and clinical instructors' perceptions on the implementation of best practice guidelines. Journal of Nursing Education, 49(4).

Sanders, D., Fowler, G., Mant, D., Fuller, A., Jones, L., & Marzillier, J. (1989). Randomized controlled trial of anti-smoking advice by nurses in general practice. Journal of the Royal College of General Practitioners, 39, 273–276.

Scanlon, A., Clark, E., & McGuiness, W. (2008). Acute (adult clinical inpatient) care nurses' attitudes toward and knowledge of nationally endorsed smoking cessation guidelines. Collegian: Journal of the Royal College of Nursing Australia, 29(1).

Smith, P. M., & Burgess, E. (2009). Smoking cessation initiated during hospital stay for patients with coronary artery disease: A randomized controlled trial. CMAJ, 180(13).