This article reviews the evidence for effective smoking cessation interventions in hospitalized cardiac and pulmonary patients. Research evidence from 1992 through June 2002 was located through searches of CINAHL (169 manuscripts), Medline (227 manuscripts), PsycINFO (123 manuscripts), the Cochrane Library, and AHCPR Clinical Practice Guidelines. Seventy-one studies were critiqued for this review. The results of the searches indicated that cigarette smoking and nicotine dependence exponentially increase risk factors for cardiac and pulmonary diseases. Stages of smoking behavior change and readiness to quit were identified as major components in the process of smoking cessation. Factors predicting success and change activities include: higher education, level of craving or nicotine dependence, and social support by work or family/friends. Risk factors for relapse include: work environment/stress and other smokers in the home or workplace. Hospitalized patients were shown to be in a "window of opportunity" for assisting the behavior change process of smoking cessation due to increased health motivation.
Key words: smoking cessation, tobacco, risk factors, addiction, hospitalized patient, and smoking behavior
PurposeThis State of the Evidence Review examines interventions to promote smoking cessation in hospitalized patients. The paper concludes with recommendations for best nursing practices based on the research.
Search StrategyResearch evidence from 1992 through June 2002, was located through searches of CINAHL (169 manuscripts), Medline (227 manuscripts), PsycINFO (123 manuscripts), the Cochrane Library, and AHCPR Clinical Practice Guidelines. Key search terms were smoking cessation, tobacco, risk factors, addiction, hospitalized patient, and smoking behavior. Seventy-one studies were critiqued for this review.
IntroductionSmoking-related diseases are responsible for almost half a million American deaths each year, and tobacco use is the chief cause of avoidable illness and death in this country. Smoking is a primary causative factor in heart disease, chronic obstructive pulmonary disease (COPD), cancer, and stroke (American Heart Association, n.d.; American Lung Association, 2000; U.S. Department of Health and Human Services, 2000). Smokers have a high prevalence of abnormal lung function, respiratory symptoms, and cardiac and pulmonary diseases (American Heart Association, n.d.; Centers for Disease Control and Prevention, 2000). Ischemic heart disease, diagnosed each year in over 30% of smokers in the United States, is the single largest killer of American men and women (Centers for Disease Control and Prevention, n.d.). COPD has a prevalence rate of 60.4 per 1000 persons, (American Lung Association, 2000) and lung cancer affects 70 per 100,000 men and 42.3 per 100,000 women (American Cancer Society, n.d.).
The younger people are when they begin smoking, the greater the risk of myocardial infarction (MI).
The younger people are when they begin smoking, the greater the risk of myocardial infarction.
Nicotine dependence has been defined as a "behavioral pattern of nicotine use involving highly controlled or compulsive use, psychoactive effects and drug-reinforced behavior"(Centers for Disease Control and Prevention, 2002). According to Pomerleau and colleagues, nicotine is desirable in part because it can temporarily improve functioning due to modifications at neuro-regulator sites (Pomerleau, Pomerleau, Morrell, & Lowenbergh, 1991). A study, designed to learn some of the causes of nicotine dependence among African American women, found that "smoking to cope, number of cigarettes per day, and positive outcome expectations about smoking" were significant contributors to nicotine dependence (Ahijevych & Wewers, 1994). The Surgeon General's 2000 report (Centers for Disease Control and Prevention, 2000) discussed the risks of smoking and methods for promoting smoking cessation. It also encouraged clinicians and the public to follow the recommendations of the Clinical Practice Guideline, which provided information for clinicians to assist patients with smoking cessation based on research and expert opinions (U.S. Department of Health and Human Services, 2000). Research identified in the Guideline has been incorporated into this evidence-based review of smoking cessation interventions.
Smoking cessation programs have been effective in producing short-and long-term cessation, though successful long-term cessation has often required multiple attempts (Sherman, Wang, & Nguyen, 1996). Stimulation, motivation, and education on how to stop smoking are all factors in smoking cessation. Sarna and colleagues identified barriers to smoking cessation in selected clinical practices (Sarna, Wewers, Brown, Lillinton, & Brecht, 2001). The Fagerstrom Tolerance Questionnaire (Fagerström, Tejding, Westin, & Lunell, 1997; Heatherton, Kozlowski, Frecker, & Fagerström, 1991) for assessing nicotine dependence has been useful in targeting smoking cessation interventions. Also, setting a date to begin a gradual decrease has been effective in initiating smoking behavior change when patients were not successful in entirely eliminating smoking (Crowley, Macdonald, & Walter, 1995).
Using cross-sectional comparisons, Prochaska and colleagues investigated change in 12 problem behaviors, including smoking cessation, and found evidence that smokers go through a series of five "stages of change" as they attempt to quit smoking:
- Pre-contemplation is a period in which smokers are not thinking about quitting smoking in the next six months.
- Contemplation is the period during which smokers are seriously thinking about quitting smoking in the next 6 months.
- Preparation is the time during which smokers who have tried to quit smoking in the past year seriously think about quitting in the next month.
- Action is a period ranging from 0 to 6 months after smokers have made an overt change, stopping smoking.
- Maintenance is the period beginning 6 months after action has started, and continuing until smoking is terminated as a problem (Prochaska et al., 1994, p. 40).
People who are ready to quit smoking are usually at least at the contemplation stage (Prochaska et al., 1994). Ahijevich, Wewers, and others tested the stages of change model with hospitalized patients and found that successful attempts at smoking cessation were preceded by the patient’s identification of an intention to quit smoking. They also found that motivational interviewing by a nurse while the patient felt susceptible was key in promoting intention to quit (Ahijevych & Wewers, 1992).
"Readiness to quit" is a major component of the stages of change model (Velicer, Hughes, Fava, Prochaska, & DiClemente, 1995).
At any specific time, in the U.S. population, 20% of smokers say they are ready to quit, and targeting interventions toward the patient’s "readiness to quit" has been effective in increasing smoking cessation rates.
DiClemente and colleagues further developed the stage of change model by identifying ten processes of change used during smoking cessation. The ten processes are:
- Consciousness-raising with recall of quitting information.
- Self-liberation in choosing not to smoke.
- Social liberation or recognizing social desirability of non-smoking.
- Self reevaluation or self perception relative to changing smoking habit.
- Environmental reevaluation" recognition of harmfulness of smoking for environment and others.
- Counterconditioning or substitution of other activities and thoughts for smoking behavior.
- Stimulus control to reduce reminders about smoking.
- Reinforcement management or rewards.
- Dramatic relief or emotional response to experience (positive and negative).
- Helping relationships (DiClemente et al., 1991).
Lending further research support to assessing the stage of change, Ahijevych and Wewers found significant differences in how frequently patients hospitalized with MI, in different stages of smoking cessation readiness, used the 10 processes (Ahijevych & Wewers, 1992). Seven of the ten processes, numbers one through seven, were found to be specifically related to different stages of change. Other researchers found stated intention to quit smoking was identified as necessary to promote actual smoking cessation at 3 weeks after MI and at 1 year, (Taylor, Houston-Miller, Killen, & DeBusk, 1990) as was motivation to quit smoking (Miller et al, 1997).
Interventions to Facilitate Smoking CessationFour out of five smokers state a desire to quit smoking, and each year 1.3 million smokers actually do quit. Smoking cessation ranges from 10 to 40% (Sherman et al., 1996). Interventions that have been shown to assist cessation include nicotine replacement therapy (NRT), non-nicotine replacement therapy, and combination therapies.
Nicotine Replacement Therapy
Nicotine replacement therapy (NRT) provides nicotine dosing that can be gradually decreased and is currently available in several forms including patch, gum, inhaler, lozenges and spray. Studies of NRT patches, both prescription and over-the-counter/non-prescription, have demonstrated effectiveness (Silagy et al., 2001). Studies also have shown varying effectiveness among the different forms of NRT. There is some evidence that combinations of NRT are more effective in relief of withdrawal symptoms and promoting cessation than non-NRT (Bohadana et al., 2000; Sweeney, Fant, Fagerström, McGovern, & Henningfield, 2001). Nicotine replacement patches were more effective than gum for older adults and those with severe COPD (Crowley et al., 1995). Among lung disease patients using NRT gums, healthier subjects were more likely to be successful in cessation efforts (Tonnesen et al., 1988). The smoking abstinence rate among lung disease patients using gum NRT was 45.6% at 3 months and 27% at 22 months (Garvey et al., 2002; Tonnesen et al.). Newer variations of NRT have become available, including the nicotine nasal spray (Blondal, 2002; Tonnesen et al., 1988), nicotine inhalers (Bohadana et al., 2000; Shiffman, Dresler, Hajek, Targett, & Strahs, 2002), nicotine sublingual tablets (Bolliger, 2000), and nicotine lozenges (Shiffman et al., 2002).
In a meta-analysis of NRT, Fiore and colleagues (Fiore, Smith, Jorenby, & Baker, 1994) noted that the combination of an active NRT patch and behavior therapy was most likely to produce significant increases in abstinence over the 6-month time frame studied. Patients with respiratory diseases were most likely to quit smoking when they were given advice in the hospital, and helped to use nicotine replacement patches (Lewis, Piasecki, Fiore, Anderson, & Baker, 1998).
The use of NRT was more effective than cessation efforts based on counseling alone among hospitalized patients (Pederson, Wanklin, & Lefcoe, 1991). Other researchers (Dornelas, Sampson, Gray, Waters, & Thompson, 2000; Miller, Smith, DeBusk, Sobel, & Taylor, 1997; Stevens, Glasgow, Hollis, & Mount, 2000) including those identified in the Clinical Practice Guideline (U.S. Department of Health and Human Services, 2000; Wewers, Bowen, Stanislaw, & Desimone, 1994), have demonstrated that hospitalization is a key time for nurse-delivered smoking cessation interventions. Discussion about risk factors associated with smoking can affect patients’ perceptions of smoking cessation as an attainable goal (Troisi et al., 1995).
A study by West compared four different NRTs for dependence and abuse including: patch, gum, spray and inhaler. The majority of patients were able to stop smoking and discontinue the NRT at the recommended time without discomfort (West, 2000). Etter (2001) examined attitudes about NRT and found that many smokers and non-smokers do not have enough information about NRT even with the publicity and availability of products to support smoking cessation.
Non-nicotine Replacement Therapy
Avoidance of depression has been considered a reason to continue smoking. Antidepressants are effective for short-term assistance with smoking cessation, but as with anxiolytics, benzodiazepines, and silver acetate, there is little data on the long-term effects of these treatments (U.S. Department of Health and Human Services, 2000). According to the Clinical Practice Guideline (U.S. Department of Health and Human Services, 2000), bupropion SR has been found effective for smoking cessation and is approved by the FDA for this use. Hurt and others compared bupropion to placebo and documented significant smoking cessation success (92%) at 6 weeks in those treated with sustained-release bupropion (Hurt et al., 1992; Hurt et al., 1997). However, at 3 months, 46% had relapsed, and at 1 year only 33% were still abstinent. There was less weight gain at 1 year with higher doses of bupropion. Shiffman and colleagues (2000) and Hilleman and colleagues (1992) also demonstrated that bupropion reduced depression and irritability with cessation, although it did not significantly decrease craving or restlessness.
Additionally, there is some evidence that clonidine is effective with helping women to stop smoking, but side effects, such as hypotension and sedation have limited its use (Glassman et al., 1993; Levine, Tonneson, Wennike, & Faries, 2000). Acupuncture and hypnosis may be helpful for some patients, but there has been little research on their effectiveness (U.S. Department of Health and Human Services, 2000).
Anxiety, weight gain, and depression have been identified as potential barriers to smoking cessation.
...anxiety should not be assumed to increase among those who stop smoking.
Social support is correlated with smoking cessation, and lack of social support is a risk factor for relapse (Murray et al., 1995). Thus, for hospitalized patients, nursing assessment should include the availability of interpersonal support, especially if smoking cessation is to be initiated in-hospital (Rodeman, Conn, & Rose, 1995). Spouses or significant others who have quit smoking themselves have been identified as significant supporters of cessation (Murray et al., 1995).
Interventions that are more intense, last longer, and include multiple components have been more successful than minimal programs (Blondal, 2002; U.S. Department of Health and Human Services, 2000). Miller and colleagues (1997) conducted a randomized trial of a nurse-mediated behaviorally focused counseling program for 2024 hospitalized patients. The in-hospital, intensive program was followed by multiple post-discharge contacts via telephone. After 1 year, 27% of the intensive intervention group remained abstinent from smoking, compared to 22% of the minimal intervention group, and 20% of the usual care group. Kanner and colleagues’ report of Lung Health Study patients with COPD (Kanner, Connett, Williams, & Buist, 1999), tested a smoking cessation intervention that included: (a) an individually delivered physician’s message, (b) group and individual meetings with a smoking cessation specialist, (c) a 10-week cessation group program, (d) eight 4-month clinic visits for 5 years, (e) a maintenance program to prevent relapse, and (f) a relapse intervention program. The intervention group had a 22% smoking cessation rate, compared to 5% in the control group (Kanner et al., 1999).
Diabetic smokers (17-84 yrs) were randomized into control (usual care, N=133) and intervention (N=147) smoking cessation groups (Canga et al., 2000). The intervention included a 40-minute nurse visit (counseling, education and contracting quit date) with follow-up phone calls, letters and visits. At 6-month follow-up, smoking incidence in the intervention group (17.0%) was significantly less than the control group. Among continuing smokers, a significantly greater reduction in mean cigarettes per day (from 20.0 at baseline to 15.5 at 6 months) was seen in the intervention group than in the control group (19.7 to 18.1 per day; p<0.01). Similar studies of interventions including NRT and support therapies, also were effective in promoting smoking cessation (Schaufller et al., 2001; Ward, 2001).
Risk Factors for RelapseAccording to the theory of "tobacco withdrawal syndrome" postulated by Shiffman and Jarvik (1976), a person experiences intolerable side effects due to withdrawal of nicotine and resumes smoking to counter those symptoms. Craving, or an intense desire for a cigarette, is one of the crucial withdrawal symptoms and an important factor in cessation relapse (Wewers, Rachfal, & Ahijevych, 1990). Although craving for cigarettes decreases over time, usually from 6 months to 2 years, Wewers and Gonyon found that craving was a major trigger for relapse in the immediate post-cessation period (Wewers & Gonyon, 1989). Other withdrawal symptoms include "insomnia, dizziness, loss of concentration, nervousness, tiredness, headaches, lightheadedness, and irritability" (Richmond, 1999). The pain of withdrawal symptoms occurs at different times during the process of quitting, but has been noted to be significantly greater between the 3rd and 6th days (Wewers & Gonyon, 1989). If these symptoms are not addressed, relapse can occur. Numerous researchers have documented the phenomenon of relapse (Eraker, Becker, Strecher, & Kirscht, 1985; O'Connell, Gerkovich, & Cook, 1995; Wewers & Gonyon, 1989). Relapse within 1 year after quitting occurs in more than 70% of smokers (Ahijevych & Wewers, 1992; Lando, Loken, Howard-Pitney, & Pechacek, 1990). The majority of those who relapse cite withdrawal symptoms as the causative trigger (Eraker et al., 1985; Lando et al., 1990; Perkins, Gerlach, Broge, & Sanders, 2002; West et al., 2001). Factors related to increased craving and relapse include job stress, actual or perceived increased workload, lack of control over job decisions, role uncertainty, and lack of social support (Wewers & Ahijevych, 1991).
Interventions to Prevent Recidivism in Hospitalized PatientsO’Connell and colleagues (1995) found that during smoking cessation attempts, personal mastery and the need for greater exertion to obtain cigarettes were related to success in resisting smoking urges. Also, temptation to smoke varied depending on the availability of cigarettes and motivation to continue abstinence (Cook, Gerkovich, O'Connell, & Potocky, 1995; Perkins et al., 2002).
Interventions for Hospitalized Patients
Hospitalization is an optimal time to explain the risk for developing progressive lung disease by identifying risk factors such as decreased expiratory flow (FEV1) (Stânescu et al., 1996). Evidence indicates that smoking cessation advice can be effective when provided at the time of an acute illness (Sarna, 1995). Many patients can advance in the stages of change readiness, from no interest in changing to total cessation of smoking. The impact of hospitalization for a life-threatening disorder can quickly move patients to Prochaska’s contemplation stage, and the traumatic hospital days immediately after admission can stimulate their decision to quit smoking.
Wewers and colleagues (1997) tested a smoking cessation intervention for hospitalized patients with lung cancer. At six weeks post intervention, 93% had attempted to quit smoking and 40% were abstinent as verified by cotinine levels. Ockene and colleagues (Ockene et al., 1992) conducted a randomized trial of a smoking intervention provided by multidisciplinary master’s-prepared health educators for 267 patients hospitalized with coronary artery disease (CAD). The intervention, consisting of one inpatient counseling session and four telephone calls after discharge, had the greatest effect on patients with the most severe CAD, who were admitted with an MI. At 6 months 45% of the treatment group patients were abstinent, compared to 34% of the usual care group. At 1 year, there was no significant difference between these groups of severe CAD patients with a 35% abstinence rate for the intervention group and 28% for the usual care group. The hospitalization period provided a "window of opportunity" for intervention, but most nurses did not discuss smoking cessation with their hospitalized patients and the treatment group had no follow-up counseling after the initial phone calls (Ockene et al., 1992). Post hospital discharge is a critical period related to smoking cessation as patients’ feelings of vulnerability decrease. Emmons and Goldstein (1992) also reported that limited smoking cessation interventions were provided for hospitalized smokers. However, nurses and physicians on specialized cardiac units were three times as likely to encourage smoking cessation as hospital staff on general medical units (52% vs. 16%) (Emmons & Goldstein, 1992).
Emmons et al. (2000) also examined NRT use during hospitalization of 580 smokers who participated in a motivational smoking cessation intervention. Only 7.1% overall used NRT: 6% used a trans-dermal nicotine patch, and 1.1% used nicotine gum. NRT use was significantly greater in those attempting to quit at time of admission, those seriously planning to quit within 30 days, those who were nicotine dependent, and those who had had previous NRT prescription.
The low rate of use of NRT suggests a need to further identify barriers to use and outcomes of use.
Smokers hospitalized in an urban, public hospital were assessed for addiction, stages of change, and self-efficacy (Vernon, Crane, Prochazka, Fairclough, & MacKenzie, 1999). One half (54.2%) were willing to try free NRT patches. The smokers (30.4%) who believed their admission was related to smoking had greater intentions (p<.001) and greater self-efficacy (p<.001) to quit. This study suggests that NRT could be more effectively used as an inpatient smoking intervention by targeting those who believe their admission is due to smoking.
A Cochrane review of interventions for smoking cessation in hospitalized patients found that an in-hospital intervention plus follow-up for one month was associated with a significantly higher quit rate compared to controls. There was insufficient evidence to evaluate the effectiveness of hospital-only interventions (Rigotti, Munafo, Murphy, & Stead, 2001). Interventions increased quit rates whether NRT was used or not, even though other data indicates that NRT increases quit rates. There was no strong evidence that clinical diagnosis affected the quit rate. The Cochrane group concluded that a behavioral cessation intervention begun in-hospital and with at least one month follow-up is effective in promoting smoking cessation (Rigotti et al.).
Motivation to quit smoking was assessed in a sample of hospitalized smokers using face-to-face counseling sessions. In examining the predictive validity of motivation to quit smoking, belief that one was "likely" to abstain from smoking was the best predictor of smoking cessation (Sciamanna, Hoch, Duke, Fogle, & Ford 2000).
Lancaster & Stead’s Cochrane Review (2001) of individual behavior counseling for smoking cessation identified 10 trials that compared counseling to minimal intervention.
There was no significant evidence that intensive counseling was more effective than brief counseling.
In a randomized trial the cessation rate of 324 (98% male, 25-82 years) current smokers admitted for non-cardiac surgery was examined (Simon, Solkowits, Carmody, & Browner, 1997). An intensive smoking cessation program for 168 participants included self-efficacy, coping skills, counseling sessions in the hospital, a smoking cessation video, self-help literature, NRT, and a 3-month phone follow-up. The control group of 156 received self-help literature and a brief 10-minute counseling while hospitalized. At 12-month follow-up, the self-reported cessation rate for the intervention group was 27%, compared to 13% among the self-help group. Biochemical confirmation of cessation was 15% for the intervention group compared to 8% in the control group.
Dornelas et al. (2000) reported on 100 smokers who had had a myocardial infarction and were assigned to a minimal care or a hospital-based smoking cessation intervention program that consisted of bedside counseling followed by seven phone calls over 6 months after discharge. Abstinence rates were 43% and 34% at 6 and 12 months among minimal care patients compared to 67% and 55% for intervention participants. In the minimal care group, low self-efficacy related to a 93% relapse rate at 1 year. In contrast, Griebel and associates found that there were no significant differences in smoking cessation among hospitalized patients who received the usual care and the intervention group who had scheduled counseling sessions (Griebel, Wewers, & Baker, 1998). However, there was a significant decrease (21% compared to 14%) in number of cigarettes smoked by the intervention group after discharge from the hospital. Taylor found a significant decrease in smoking in hospitalized patients who were involved in a nurse-managed smoking cessation program that included telephone follow-up. Greater success in quitting was associated with follow-up contact compared to no follow-up (Taylor et al., 1990).
A Cochrane Review of 16 studies (Rice & Stead, 2001) comparing nursing interventions to usual care found that nurses could significantly increase the odds of patients’ quitting smoking. Non-hospitalized patients also showed benefit, but five additional studies of nurse counseling during routine health checks showed less effectiveness for the nursing intervention.
In a quasi-experimental study, 146 hospitalized patients in a residential nicotine dependence program, were matched with 292 outpatients who received nicotine dependence consultation by a trained counselor (Hays et al., 2001). The 6- and 12-month abstinence rates for the residential group were 45%; the outpatient group had a 26% abstinence rate at 6 months and 23% at 12 months.
A study of self-reported smoking cessation was validated with biochemical markers of smoking activity in older hospitalized (>75 years) patients with ischemic heart disease(Attebring, Herlitz, Berndt, Arlsson, & Hjalmarson, 2001). Of the 260 "former smokers" who had participated in a nurse-monitored routine care program for secondary prevention, 6 had elevated carbon monoxide and 13 had elevated cotinine levels. This study suggests that chemical markers should be included in studies on smoking in order to validate results.
SummaryWhile hospitalized, patients with cardio-pulmonary disorders can be taught to recognize the serious consequences of smoking and to examine their choices in decreasing or stopping smoking.
Positive outcomes of smoking cessation can be especially significant for patients with cardiac and pulmonary disorders in terms of stabilization of lung and cardiac function and decreased mortality.
Assist Cessation Efforts
Georgia L. Narsavage, PhD, RN, CNS, ANP-BC
Georgia L. Narsavage, PhD, RN, CNS, ANP-BC, Associate Professor, Case Western Reserve University, Frances Payne Bolton School of Nursing, is Associate Dean for Academic Programs. Her research focus is chronic obstructive pulmonary disease, patient outcomes, and pulmonary rehabilitation; she is co-author of an internationally accepted pulmonary measure, the Pulmonary Functional Status Scale. She serves as reviewer for Applied Nursing Research and Heart and Lung nursing journals, and is listed as media expert for Sigma Theta Tau International Nursing Honor Society in home care and advanced practice nursing. She also has worked to develop international nursing education and management with the American International Health Alliance.
Bette K. Idemoto, MSN, RN, CCRN, CS
Bette K. Idemoto, MSN, RN, CCRN, CS, is a PhD student, Case Western Reserve University, Frances Payne Bolton School of Nursing. She is currently a Cardiothoracic Clinical Nurse Specialist (CNS), and was previously a Vascular CNS, both at University Hospitals of Cleveland. She has thirty years of Intensive and Cardiac Care nursing experience, 12 as a CNS in Cardiovascular nursing. Her patient focus is on health behaviors, specifically smoking and patient outcomes in all settings; and her doctoral research interest is smoking cessation and behavior change.
The Sarah Cole Hirsh Institute for Best Nursing Practices of the Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA
The Hirsh Institute's mission is to build a repository of best nursing practices based on research findings. Institute activities include: disseminating the most current scientific evidence on best nursing practices to clinicians, educators, administrators, and policy makers; guiding nursing research by identifying areas where scientific evidence is lacking; and conducting certificate programs for nursing staff to identify and implement evidence based practice.
Article published February 15, 2003
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