Cessation of Smoking and Health Care Efforts

Health Care Efforts for Cessation of Smoking

 Smoking and Well known Affects,5 As Interventions,Nursing Role In Tobacco Cessation,Outcome of Interventions.

Smoking and Well known Affects

    Twenty three percent of all American adults continue to smoke, despite evidence that to- bacco is responsible for 430,000 deaths in the United States each year and remains the number one avoidable cause of death and disease in this country (Centers for Disease Control, 2003b) . 

    Direct medical costs associated with smoking or smoking attributable diseases have been estimated by the Centers for Disease Control (CDC) to exceed $50 billion annually. Of concern is the increase in smoking prevalence in adolescents since 1990, with 3,000 children and adolescents becoming regular users of tobacco every day. 

    Seventy percent of the approximately 50 million smokers in the United States have made at least one prior quit attempt, with about 46% percent trying each year (CDC). However, the annual quit rate in the US is only approximately 1.0%, with 4.7% having quit for between 3-12 months in the past year. 

    Smoking cessation, or smoking abstinence, differs from a quit episode, which is considered as 24 hours of continuous abstinence ( Ossip -Klein et al., 1986). Smoking cessation is defined as the discontinuation of a smoking behavior. The behavior is characterized as dynamic and is often accompanied by periods of slips and relapses. 

    Smoking cessation and tobacco use are important areas of research for nurses since, as clinicians, nurses represent key smoking cessation interventionists, capable of implementing effective cessation programs (Fiore et al., 2000).

    Sarna and Lillington (2002) conducted a review of databased articles that included the keywords “tobacco use” in Nursing Research during the years 1952-2000. Their findings indicated that 40 databased articles included this term in either the sample description or as an independent or mediating variable. 

    Fifty-three percent of these articles had been published since 1990, with 71% of the outcome studies being published within the past 5 years. While the authors recognized that nurses with a program of research in tobacco control have published in other interdisciplinary journals, they concluded that tobacco use and cessation are emerging topics for nursing research (Sarna & Lillington).

    According to the Treating Tobacco Use and Dependence Clinical Practice Guideline. published by the US Public Health Service Agency for Healthcare Research and Quality (AHRQ), a brief intervention should be provided to all tobacco users at each clinical visit (Fiore et al., 2000). 

5 As Interventions

    The intervention includes five major steps (the “5 As”) to managing tobacco dependence: ask the patient about tobacco use, advise tobacco cessation, assess willingness to quit, assist with the quit attempt, and arrange for follow-up to prevent relapse. 

    All tobacco users attempting to quit should receive one of the five AHRQ recommended first line pharmacotherapies for smoking cessation. Katz, DA, Muehlenbruch , Brown, Fiore, and Baker (2002) conducted a pre- and post-test design study of the AHRQ intervention utilizing usual care as the control group. Participants in the intervention group were willing to set a quit date within 30 days. 

    Those smoking at least 10 cigarettes a day were offered an 8-week supply of transdermal nicotine patches. Self-help material, as well as proactive telephone counseling by a trained cessation counselor, was also provided. The 6-month self-reported quit rate was 21% for the intervention group versus 13% in the control group. 

    Continuous abstinence was reported in 10% of the intervention participants versus 3% of the control participants.     

    It was also concluded that the implementation of a guideline driven smoking cessation intervention was associated with increased abstinence at two-month follow-up (p = 0.0004) among primary care patients interested in making a quit attempt as compared to abstinence rates at baseline ( 21% vs. 4%) (Katz et al., 2002).

Nursing Role In Tobacco Cessation

    PM Smith, Reilly, Miller, DeBusk , and Taylor (2002) examined the application of a nurse managed inpatient smoking cessation program. 

    The program included physician advice, bedside education including take home materials (videotape, workbook, and relaxation audiotape), counseling from a smoking cessation trained nurse, nicotine replacement therapy if requested, and four nurse-initiated post discharge telephone counseling calls. 

    Patients from Stanford University Hospital were recruited to participate in the program. Of 2,091 patients identified as smokers, 1,077 or 52% enrolled in the program, with only 720 patients eligible for 12-month follow up. 

    Seventy one percent (509) were reached for the 12-month follow-up and of these 509 participants, 49% reported that they were not smoking. However, a limitation noted by the authors included potential underreporting of smoking by the participant at the time of the 12-month follow-up. 

    The investigators acknowledged that misclassification of smoking status by self-report can be especially problematic in cessation studies of hospitalized patients, due to the “demand” characteristic of wanting to please the provider (Smith, PM, et al., 2002). 

    The lack of biochemical verification to confirm smoking status does represent a limitation in smoking cessation intervention research. Cotinine, the major metabolite of nicotine, can be measured in plasma, saliva, and urine, with excellent specificity for tobacco use except in persons utilizing nicotine replacement therapy. 

    Carbon monoxide (CO), a by-product of cigarette smoke, can be measured in expired air. Unfortunately, CO has a shorter half-life of 2-4 hours and is rapidly eliminated, whereas cotinine may be detected for several days after cessation. However, CO assessments are often used to confirm abstinence in studies where nicotine replacement therapy is ongoing. 

    It is recommended that biochemical verification be used in most or all studies of smoking cessation among special populations, including adolescents, pregnant women, and medical patients with smoking-related disease (SRNT, 2002).

Outcome of Interventions 

    Smoking is pronounced in the less educated and poor (CDC, 2003b). Efforts to promote cessation and abstinence in these individuals have, to date, been relatively unsuccessful. 

    Their lack of engagement in preventive health care services may, in part, be due to barriers to access and lack of information about prevention (US Department of Health and Human Services, 2000). 

    While the evidence based AHRQ clinical practice cessation guideline has been developed (Fiore et al., 2000), its testing among vulnerable populations is limited. 

    As an example, the guideline deserves examination among minority groups, pregnant and postpartum women, HIV+ persons, and smokers who are poor and often experiencing a comorbid condition, such as cancer or chronic obstructive pulmonary disease (COPD).