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Smoking cessation: the case for hospital-based interventions

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Mark Wallace-Bell, PhD, RGN, Cert Psychol

Lecturer in Tobacco Addiction, Centre for Addiction Studies, St George's Hospital Medical School, University of London

Smoking cessation in the UK has progressed extensively since the publication of the Government White Paper Smoking Kills (DoH, 1998). Over the past decade we have witnessed the establishment of national smoking-cessation services. A robust body of evidence supports the argument that these services are both effective and cost-effective in reducing mortality and morbidity from smoking (Raw et al, 1998, 2000; Lancaster et al, 2000; RCP, 2000).

Smoking cessation in the UK has progressed extensively since the publication of the Government White Paper Smoking Kills (DoH, 1998). Over the past decade we have witnessed the establishment of national smoking-cessation services. A robust body of evidence supports the argument that these services are both effective and cost-effective in reducing mortality and morbidity from smoking (Raw et al, 1998, 2000; Lancaster et al, 2000; RCP, 2000).

This paper aims briefly to review the evidence for providing smoking-cessation advice and support to smokers in hospital and to suggest a practical approach to assist hospital nurses.

The evidence base for smoking cessation delivered by nurses
Nurses' roles and wide availability puts them in a prime position both to encourage smokers to think about giving up, and to provide them with appropriate information and help to quit.

Interventions to help people stop smoking are beneficial, not just to the individual smoker but also to society at large. Smoking places a great burden on any health service. Health-care costs for smokers at any given age are higher than for non-smokers. Half of all those people who continue to smoke for most of their lives will die of the habit, half of these before the age of 69 (Royal College of Physicians, 2000). Many smokers say they would like to give up but find the process too hard.

Smokers often turn to nurses and other health professionals for help to stop, so nurses are well positioned to promote a tobacco-free lifestyle. With more facts, information and specialist training nurses can provide information to the public on the harmful effects of tobacco use and become key players in the prevention and treatment of tobacco dependence.

Stevens et al (1993) evaluated a brief smoking-cessation and relapse-prevention programme with a follow-up telephone call against usual care in 1119 hospitalised patients. They found that, of those who received smoking cessation and relapse- prevention advice, the proportion of patients who quit smoking was increased by half, demonstrating that relapse-prevention efforts are required to convert temporary cessation during hospitalisation into long-term abstinence. Similarly, Simon et al (1997) found that surgical patients who received a multicomponent intervention had higher abstinence rates than a comparison group who received self-help materials, suggesting that surgical hospitalisations provide an opportunity to reach smokers who want to quit smoking. There is also evidence that smoking cessation is possible and efficacious in accident and emergency (A&E) departments (Lowenstein et al, 1995) general medical units (Emmons and Goldstein, 1992) and general hospital patients (Miller et al, 1997).

Systematic reviews of interventions for smoking cessation in hospitalised patients analysed the effectiveness of 15 hospital-based studies and evaluated their efficacy (Rigotti, et al, 2001; Munafo et al, 2001). They found that hospitalised smokers who receive inpatient advice and follow-up for one month are more likely not to be smoking after six months than patients who receive standard care.

The effects of less intensive interventions are unclear. However, one large-scale UK-based study does suggest that brief interventions delivered by nurses in busy clinical settings may not be so effective. Hajek et al (2002) conducted a randomised controlled trial evaluating a brief hospital-based intervention for myocardial infarction (MI) and coronary artery bypass graft (CABG) patients.

They found that 60% of the patients in the intervention group were abstinent at six weeks, with the control group achieving 59% abstinence. At 12 months' follow-up abstinence rates had dropped in both groups to 37% and 41% respectively.

The main conclusion was that brief interventions delivered within routine care may not be easy to deliver, because nurses are too busy and cannot deliver the intervention consistently, and may lack the power required to achieve long-term abstinence, as other have noted (West, 2002). Furthermore, any treatment package that is delivered to patients needs to match the degree of nicotine dependence the patient presents with, as the study also found that dependence on nicotine and motivation to quit were the two best predictors of positive outcome.

In summary, it would appear that there is good evidence that smoking-cessation advice delivered to smokers who are in hospital is appropriate and effective.

Nevertheless several factors need to be kept in mind. It is clear that nurses are well placed to provide advice but may not be effective in providing more intensive support. This may be because they need to be more skilled in the provision of intensive support to provide appropriate and consistent care to smokers. In addition many nurses may be too busy to deliver anything other than a basic intervention as well as their usual care.

Nurses' attitudes toward smoking cessation
Although most nurses agree that hospitalised smokers should be given advice about smoking cessation, pressure on time and circumstantial factors may prevent them from doing so (McCarty, et al, 2000).

Furthermore those nurses who smoke may be inhibited from offering smoking-cessation advice, and could think that they are not the best people to offer advice. For an interesting review of the reasons why nurses smoke see Rowe and Macleod-Clark (2000).

Nevertheless, most nurses have a positive attitude toward helping their patients give up smoking and believe they have an obligation to advise patients to quit smoking. From the patient's perspective studies have shown that smokers hospitalised for smoking-related diseases are most susceptible to disease-specific smoking cessation advice (Bursey and Craig, 2000). Furthermore, for those patients who are ready to quit post-discharge, follow-up maximises abstinence rates and may reduce recidivism (Munafo et al, 2001).

In relation to the stages of change model and self-efficacy Vernon et al (1999) have found that patients who believe their hospitalisation was due to smoking have greater intentions to quit and higher levels of self-efficacy.

The extent to which smokers believe they can give up smoking is a key factor in becoming a non-smoker. This evidence suggests that hospitalised smokers should be thoroughly assessed on admission and that this assessment should include smoking status, stage of change and readiness to quit. It is also important to keep in mind that smokers suffering from a smoking-related condition would be more responsive to specific advice and support.

The benefits of stopping smoking
The health of people who have already developed smoking-related diseases will improve after giving up tobacco. Although damage to the lungs caused by years of smoking is permanent, stopping smoking will prevent further deterioration.

Giving up hastens a person's recovery, reduces the chance of serious complications and extends life expectancy. For those who have had a heart attack, stopping smoking reduces the chance of a second cardiac event. Box 1 outlines the short- and long-term benefits of stopping smoking. It is worth reminding patients of these as part of a brief intervention.

Recommendations for smoking cessation advice
The evidence base for the treatment of tobacco dependence is well established (Raw et al, 1998, 2000). The recommendations cover the roles of individual health professionals working to help and treat smokers and can be applied to any health-care context.

Essentially, the features of a brief intervention to help a smoker consider stopping the habit are the five 'A's:

- Ask about smoking at every opportunity

- Advise all smokers to stop in a personalised and appropriate manner

- Assess motivation to change

- Assist the smoker to stop

- Arrange follow-up if possible.

Recommendations for brief interventions
As part of their normal clinical work, health professionals should provide brief interventions including the following essential features:

Ask about and record smoking status - All clients should have their smoking (or other tobacco use) status established and checked. A system should be devised to record smoking status in the notes.

Nursing notes should at least describe clients as a smoker, non-smoker or recent ex-smoker and note any current interest in stopping.

This record should be kept as up to date as possible. Interest in stopping can be assessed with an open-ended question such as 'Have you ever tried to stop?' which can be followed by 'Are you interested at all in stopping now?'

For strategies for helping patients to help themselves see Box 2.

Advise smokers of the benefit of stopping - All smokers should be advised of the value of stopping and the risks to health of continuing. The advice should be given in a personalised and appropriate manner. The advice should be clear and firm, linking smoking to their current health status.

Assess willingness to stop - All smokers should have been asked about their willingness to stop. This can be done with a simple assessment. Ask smokers to rate the importance of quitting on a scale of one to ten, with one being not important at all and ten being very important. Then ask them to rate their confidence in their ability to quit on the same scale.

The feedback you get will give you a good idea about how ready the patient is to stop smoking. It may be that they think it is important to quit but have little self-confidence, perhaps because of past failures. Or they may be confident about their ability to quit but don't think it is very important to do so. Please refer to activity 2 and consider your approach to assessing readiness to quit in your patients.

Assist smokers in their stop attempt - This might include the offer of support, a recommendation to use nicotine replacement therapy (NRT) or bupropion where available and the provision of accurate information and advice about both.

If the smoker would like to stop, cover the following key points in a few minutes:

- Review past experience: what helped, what hindered?

- Plan ahead: identify likely problem areas, make plans to deal with them

- Tell family and friends and enlist their support

- Set a date to stop; advise them to stop completely on that day

- Plan what they are going to do about situations in which they will be tempted to smoke, such as when drinking alcohol, social occasions, and so on

- Encourage the use of NRT or bupropion as a cessation aid. Offer accurate information.

Arrange follow-up to monitor progress - Smokers who need additional help should be referred to a specialist support service if possible. If the hospital has a smoking-cessation service then seek consent to refer the patient to the service for prompt follow-up. They should be able to offer a follow-up appointment and further support sessions after that if possible.

Most smokers make several attempts to stop before finally succeeding - the average is around five to six attempts. Thus relapse is a normal part of the process. If a smoker has made repeated attempts to stop and failed, and/or experienced severe withdrawal and/or requested more intensive help, consider referral to a specialist cessation service where available.

Hospital staff should ask about smoking status before or on admission, and offer brief advice and assistance to those interested in stopping. Smokers should be advised of the hospital's smoke-free status before admission. Hospitalised patients who need it should also be offered NRT or bupropion. Health-care premises and their immediate surroundings should be smoke free.

Conclusion
This paper has briefly reviewed the evidence supporting the provision of smoking-cessation interventions in secondary care settings. There is clearly a need to capitalise on the opportunity being in hospital presents to smokers to give up as it has been demonstrated that advice in the hospital setting is effective.

There is good evidence that brief advice from nurses can prompt some smokers to make a quit attempt and, with follow-up support, this may translate into long-term abstinence and reduced morbidity and mortality. Nurses need to consider ways in which they can be effective smoking-cessation advisers and deliver consistent advice to their smoking patients.

This may require reflection and revision of current smoking-cessation practice. To support them in this work health professionals should be trained to advise and help smokers stop smoking, and the budget holder should ensure the provision of adequate training budgets and programmes. Education and training for the different types of interventions should be provided not only at the postgraduate and clinical level, but should start at undergraduate and basic level, in medical and nursing schools and other relevant training institutions.

ACTIVITY 1
Reflect on your own smoking status and your attitudes toward smoking cessation.

- Do you give the topic priority?

- When did you last give smoking cessation advice to a patient who was a smoker?

- List the reasons why you do or do not give smoking-cessation advice.

ACTIVITY 2
Review your ward/hospital system for assessing and recording smoking status.

- Do you assess motivation and readiness to quit?

- Do you assess nicotine replacement therapy (NRT) needs?

Bursey, M., Craig, D. (2000) Attitudes, subjective norm, perceived behavioural control, and intentions related to adult smoking cessation after coronary artery bypass graft surgery. Public Health Nursing 17: 6, 460-467.

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