Hospital nurses are ideally placed to advise those with long-term conditions on smoking cessation and the effects this can have on their condition and treatment
This article discusses how a stop smoking adviser role enhanced the smoking cessation service already offered at Lewisham University Hospital.
Citation: Peterken C (2013) Hospital nurses’ role in smoking cessation. Nursing Times; 109: 46, 16-19.
Author: Camilla Peterken is a freelance stop-smoking specialist for London and the South East.
- This article has been double-blind peer reviewed
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Smoking can have a negative impact on the recovery of hospital patients (Hughes et al, 2013) and many of the diseases treated in hospital are linked directly to smoking (Royal College of Physicians, 2000). In addition, continued smoking can lead to some long-term conditions developing more quickly than they might otherwise and reduce the efficacy of treatment. Some health professionals may feel when a patient has been diagnosed with cancer it is either too late or too sensitive a time to talk about smoking cessation, but continuing to smoke can reduce the efficacy of both chemotherapy and radiotherapy (Dresler, 2003; Matthews et al, 2001). Smoking cessation advice in hospitals is not just a prevention issue, it is an essential part of the treatment we provide.
For patients with chronic obstructive pulmonary disease (COPD), even temporarily stopping smoking can improve their quality of life and prevent future exacerbations and readmission (Garvey and Ortiz, 2012). It is important to communicate this message to patients, rather than a generic stop-smoking message, which they may feel is not relevant to them.
Most patients want to know what they can do to help themselves and what support is available to assist them. When they are in hospital, health professionals can take the opportunity to let patients try treatments such as nicotine replacement therapy (NRT), and experience the benefits first hand. During an unplanned admission, some patients may find being unable to smoke difficult - this presents an ideal opportunity for them to try NRT, experience how it works and appreciate the benefits. If this inpatient experience is followed up with specialist support once they return home, they are less likely to take up smoking again (West, 2012). Linking hospital and community stop smoking services can provide continued and integrated care.
The specialist stop smoking role
At University Hospital Lewisham, smoking cessation has been integrated into systems of care. Smoking prevalence in the local community is approximately 20% and it is likely to be as high as 31% for the hospital population (West, 2012).
In Spring 2011, Lewisham NHS Stop Smoking Service appointed a hospital specialist stop-smoking adviser to set up services for patients and staff. The adviser worked as part of the team providing stop-smoking services in the community, preventing continuity of care being lost when patients are discharged from hospital.
The key elements of the role are to:
- Develop referral systems within patient care pathways;
- Provide on-site staff and patient clinics;
- Develop policies and protocols for withdrawal management, such as NRT;
- Provide training for staff.
One of the main obstacles to achieving these aims is that smoking is often seen as a public health and prevention issue. During the first year, the priority was gaining commitment from senior management and clinicians. In this time, clinics were established, referral pathways set up and the adviser could treat inpatients, outpatients and staff on site. Referrals were channelled by phone and email, and staff were trained.
However, it was felt more could be achieved by embedding the systems and processes as part of a scheme involving the whole hospital, rather than just one specialist adviser or a few departments. The combination of smoking targets within a Commissioning for Quality and Innovation contract and an award from the London Health Improvement Board to introduce an integrated system, has meant the programme has developed quickly. Box 1 shows the key steps to be taken to establish an integrated smoking cessation service.
What does this mean for patients?
Hospitals are an ideal place to advise patients about stopping smoking; many will take this opportunity but some may find their motivation to stop is not straightforward. While they are in hospital and aware of their mortality and fragility they may feel motivated to do so, but when they get home and feel better they may be tempted to go back to smoking - particularly if they no longer have support to quit and the people around them smoke.
Anecdotal reports from stop-smoking services show the conversion rate of referral to treatment and quitting smoking for hospital patients can be much lower than among the general population. Patients’ fluctuating motivation and lack of continuity of care may be key reasons for this.
Nurses need to work with patients’ changing motivations and help them focus on the benefits that stopping smoking will have on their condition. For some patients, abstaining forever may not seem like an achievable goal, but stopping for a time may be possible. This gives them the opportunity to experience the benefits, build their confidence and work towards stopping permanently.
Research suggests there is an eight-week window when recurrence for patients with COPD after an initial exacerbation is most likely (Hurst et al, 2009). Smoking cessation is now recognised as a vital part of treatment for these patients, both in terms of risk reduction and day-to-day treatment (Garvey and Ortiz, 2012). Even a temporary abstinence may reduce the risk of a further exacerbation and admission but patient motivation may fluctuate and individuals need ongoing support.
COPD is just one disease where smoking cessation can make a difference. Nurses should have information about the impact of smoking cessation on the diseases they treat and overall patient wellbeing. This should be shared with patients to motivate them to quit or try a period of abstinence. They can be encouraged to use NRT and referred to a stop-smoking specialist who will provide continuity of care. NT
- Some long-term conditions can be improved by quitting smoking
- Often patients start smoking again when discharged from hospital because of lack of support
- Increasing smokers’ confidence in using treatments to quit smoking while in hospital may help them to quit
- Some patients may not see stopping permanently as an achievable aim, however short-term abstinence is still beneficial and should be encouraged
- Nurses should be aware of the effects of smoking on long-term conditions so they can educate and motivate their patients to quit
For further reading on the impact of smoking on specific disease areas go to: tinyurl.com/NCSCT-PractitionerResources
Dresler C (2003) Is it more important to quit smoking than which chemotherapy is used? Lung Cancer; 39, 119-124.
Garvey C, Ortiz G (2012) Exacerbations of chronic obstructive pulmonary disease. The Open Nursing Journal; 6: 13-19.
Hughes L et al (2013) How to advise and refer inpatients who smoke. Nursing Times; 109: 1/2, 14-18.
Hurst JR et al (2009) Temporal clustering of exacerbations in chronic obstructive pulmonary disease. American Journal of Respiratory Critical Care Medicine; 179: 369-374.
Matthews N et al (2001) Nitric oxide-mediated regulation of chemosensitivity in cancer cells. Journal of the National Cancer Institute; 93: 21, 1879-1885.
Royal College of Physicians (2000) Nicotine Addiction in Britain. London: RCP.
West R (2012) Stop Smoking Services: Increased Chance of Quitting. National Centre for Smoking Cessation and Training Briefing #8. London: NCSCT.