This review article, published in the Online Journal of Issues in Nursing has been authored by two registered nurses at the Case Western Reserve University. One of them, Narsavage, is also the Associate Dean for Academic Programs at the School of Nursing and the other, Idemoto, isa PhD student at the same school. Both have extensive experience as healthcare providers and an interest in advanced nursing practices and their outcomes. This review was conducted at the Sarah Cole Hirsh Institute of Best Nursing Practices which has been very active in collecting evidence relating to the best practices in nursing and forwarding it to people who have a direct impact on the implementation of these practices such as clinicians, faculty and policy makers. This institute also carries out its own research in areas that are lacking and conducts training programs for people in the nursing profession.
The purpose of the review is to examine and evaluate the best intervention to reduce or quit smoking in patients hospitalized for cardiac and pulmonary conditions. Findings from seventy one studies are included in this review. Several studies evaluate the key role of the nurse in changing smoking behavior of the patient leading to cessation. These studies found that interviewing by nurses helped promote the willingness of the patient to quit. They also discovered that hospitalization is an ideal time for the nurses to intervene and deliver cessation related information, as at this point the patient would be highly concerned about his health and smoking related risks (window of opportunity). Counseling programs with multiple components (in-hospital and post-discharge) focus on nurses delivering the therapy (advice). Nurses also monitor routine care prevention programs for abstinence. All this highlights the importance of nurses being aware of intervention programs consisting of education and counseling as they can make a significant difference in smoking behavior and cessation when the patient wants to quit.
This review article examines a number of studies conducted over a ten year period that evaluate interventions used in smoking cessation programs and determine which ones are most effective. It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis. This systematic review considers Nicotine replacement therapy versus non-nicotine and behavior therapy as well as combines therapies and their short ad long term results. Overall combination therapies are the most successful, although such programs may need to be tailored according to each health center’s resources and thus made cost-effective and practical. Additionally, nurses may need to be trained to counsel patients regularly to maintain motivation and prevent relapse.
This review was conducted on studies done through a ten year period (1992-2002). Surveillance included retrieving studies from reliable and comprehensive databases such as CINAHL, MedLine, the Cochrane Library and AHCPR Clinical Practice Guidelines. Only those studies that focuses on smoking cessation in hospitalized patients was included. The mortality and morbidity associated with smoking was highlighted, especially the risk of myocardial infarction and chronic obstructive pulmonary disease. All study designs were included, such as randomized control trials, cross-sectional and meta-analysis.
Interventions included Nicotine replacement therapy (NRT), non-Nicotine replacement therapy and combination therapies. The incidence of smoking cessation is quite variable, ranging from 10-40%. This rate was high in patients with lung disease who were using nicotine replacement therapy in the form of gum. However in the long term, the best results came from combination therapy which included NRT and behavior modification through counseling.
Non-nicotine therapies include anti-depressants such as Bupropion which, when compared with placebo in a case-control trial showed significant success rates (>90%) but relapse rate was high. Side-effects limit the use of anti-depressants as long term therapy. Very little evidence is available on the role of acupuncture and hypnosis in cessation although they have been reported to be helpful by some patients.
Factors that negatively affect smoking cessation activities have been identified; anxiety, depression and weight gain. Withdrawal symptoms and craving are also risk factors for relapse. Strong social and interpersonal support is a predictor of a good prognosis. The highest rates of cessation are to be found in patients hospitalized with the most serious conditions, like lung cancer. Whatever the diagnosis, those convinced that their health problem was due to smoking were more willing to use NRT. Behavioral interventions in-patient and post-discharge were more effective whether NRT was used or not. When assessing motivation to quit, the predictive validity of strong motivation was high with regards to cessation. There may be an element of observer bias in the studies included in the review as it was conducted by nurses and is regarding their role in the intervention. No instance of blinding is mentioned, although two of the randomized control trials were double blind studies.
This paper is highly relevant to nursing practices as it reviews a wide variety of evidence based literature that proves the importance of interventions during the hospitalization time period for the cessation of smoking. The cost effectiveness and practicality of such interventions may vary between different centers and settings. For example, the preferred mode of NRT (gum, patch, inhaler) may not be available at all centers and may affect compliance. In certain areas, proper and complete information about NRTs may not be available, which may affect patient decisions and choices (Etter) compared to counseling and behavior modification, long term use of medicines such as anti-depressants and Bupropion is expensive and may affect the motivation of the patient specially when the medicines do not address the problem of craving and withdrawal symptoms.
Combination therapies, on the other hand, supplement NRT/non-NRT therapies with education and counseling. Such counseling is administered free, and in this paper, does not even require additional physician visits—it can be done during hospitalization and regular follow-ups. Although studies found that telephonic conversation encouraging abstinence post-discharge were effective in the cessation program as evidence by low relapse rates, it may not be practical in normal routine care as there are time constraints and healthcare providers may find it hard to accommodate regular telephone session for every patient in their schedule. It may also not be financially suitable for the heath care centre.
Recommendations include increasing awareness of the those involved in the intervention program to the different odes of smoking cessation and the limitations and drawback of each so that they are better able to answer the patient’s queries and clear any misconceptions which often hinder progress and lead to non-compliance and relapse. Promotion of smoking-alternatives should be done aggressively so that anyone considering quitting has hope and direction. Also, the ‘window of opportunity’ should be utilized as prime intervention time and counseling done on a regular basis whether the patients condition is a direct result of smoking or not, and whether the patient is at high risk for developing smoking related co-morbids or not, as it has been found that young people are more at risk of developing complications.
Motivation should be assessed at every opportunity, as it has been identified as the single most important prognostic factor. Motivated and ‘ready-to-quit’ people should be highly encouraged as they have the best quit rates. Anxiety and depression should be assessed at each visit as they can affect compliance. Withdrawal symptoms should also be monitored. History of compliance and abstinence should also be taken from a close friend or family member to gauge the real situation.