Page 807 - Cardiac Nursing

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CHAPTER
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S S S S Smoking Cessation and Relapse Prevention
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Min Sohn / Mark Hawk / Kirsten Martin /
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Erika S. Sivarajan Froelicher
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Heart disease and stroke, both forms of cardiovascular disease common. The presencce off withdrawal symptomss is annother indi-
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(CCVD)), con inue to be thhe fifirst a d thi d leading causes fof dea h cattor of thhe adddiic ive properties of nicotine. The criteria for diag-
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in in the United States, resppectively. Smoking is the most preventa- no si of n ic ot in wi f
nosis of nicotinee withdrawal are met whhenn any fof the following
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ble risk factor that contributes to premature death of coronary symptoms commence within 24 hours of the abrupt cessation of
heart disease (CHD). More than 4,000 known toxins and car- nicotine use: dysphoric or depressed mood; insomnia; irritability,
cinogens are found in tobacco smoke, which contributes to smok- frustration, or anger; anxiety; difficulty concentrating; restless-
ing being the single, most preventable cause of disease and pre- ness; decreased heart rate; or increased appetite or weight gain. 23
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mature death, and also exposure to secondhand smoke also Rapid identification of these withdrawal symptoms and prompt
contributes to this risk. 3 intervention are important skills for all nurses, particularly hospi-
The U.S. adult smoking prevalence rate has decreased from tal-based nurses, because these withdrawal symptoms may be so
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25% to 21% since the first publication of the guideline. The intense for a given patient that he or she is unable to make rational
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number of current smokers being advised to quit smoking in health care decisions and may leave the hospital against medical
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2007 is twice the number it was in the 1990s with a greater num- advice to relieve them with a cigarette.
ber of smokers receiving more concentrated cessation interven-
tions. 7,8 While Chapter 32 describes smoking as a risk factor, we
provide the assessment and management of smoking cessation in HARMFUL EFFECTS OF
this chapter. SMOKING
One of the major responsibilities of the nurse is health pro-
motion; therefore, it is important that nurses be aware that they Cigarette smoking, hypercholesterolemia, hypertension, and
can play a major role in smoking cessation. There is a significant physical inactivity are considered the four major risk factors for
body of research that has documented the effectiveness of nurse- CVD. What makes cigarette smoking unique among these risk
managed smoking cessation interventions, particularly in the hos- factors is that it interacts synergistically with hypercholesterolemia
pitalized cardiovascular population. 9–19 “If the 2.2 million work- and hypertension to increase greatly the risk for CHD. For exam-
ing nurses in the U.S. each helped one person per year quit ple, in people who smoke and have hypercholesterolemia or hy-
smoking, nurses would triple the U.S. quit rate.” 20 pertension, the risk for CHD is doubled. For people who have all
Successful smoking cessation interventions usually have behav- three risk factors, the risk for CHD is quadrupled. 24
ior modification as a core component. Behavioral modification In general, cigarette smoking accelerates atherosclerosis
skills include identifying areas of concern for patients, teaching throughout the body, but this effect is most important in the
patients strategies to cope with difficult situations, and role-play- coronary arteries, the aorta, and the carotid and cerebral arteries.
ing strategies with patients to allow them to practice their new Several mechanisms have been described to explain how cigarette
coping strategies. These behavioral modification skills usually are smoking leads to atherosclerosis. These include (1) adverse effects
not part of most nursing school curricula. 21 Even when they are on lipid profiles; (2) endothelial damage or dysfunction; (3) he-
taught, there is rarely an opportunity for practice, feedback, and modynamic stress; (4) oxidative injury; (5) neutrophil activation;
development of confidence in performing these skills. This chap- (6) enhanced thrombosis; and (7) increased blood viscosity. 25
ter focuses on the important steps in smoking cessation interven- Although the acceleration of atherosclerosis is a major contribu-
tions that should be provided to patients with CVD, with an em- tor to cardiovascular morbidity (e.g., aggravation of stable angina
phasis on behavioral and pharmacologic approaches. After reading pectoris, vasospastic angina, intermittent claudication), a major fo-
this chapter, the nurse, no matter what setting he or she practices cus in the population of smokers with CVD is how smoking medi-
in—intensive care unit, cardiac care unit, medical–surgical, labor ates acute cardiovascular events (e.g., myocardial infarction [MI],
and delivery, outpatient care—will posses the necessary knowl- sudden death, stroke) that lead to hospitalization. The smoking-
edge to provide a smoking cessation intervention to every patient related mechanisms thought to contribute to these events are (1) in-
who smokes, every time the patient is encountered. duction of a hypercoagulable state; (2) increased myocardial
Permanent smoking cessation should be the goal for every in- workload; (3) reduced oxygen-carrying capacity of the blood;
tervention and every person who smokes. Achievement of this (4) coronary vasoconstriction; and (5) catecholamine release. 25
goal is difficult, however, because the nicotine in tobacco products Nicotine and carbon monoxide, although only two of the
is an addictive substance. 22 Smokers are physically and emotion- more than 4,000 chemicals in cigarette smoke, are generally con-
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ally compelled to continue smoking even in the face of serious ad-ll mp ll d t ntin m kin n in th f f ri d sidered to be the major contributors to atherosclerotic disease.id r d t b th m j r ntrib t r t th r l r ti di 26
verse health consequences. In addition, multiple quit attempts Nicotine disrupts lipid metabolism, resulting in an increased level
and failure to quit smoking despite high levels of motivation are of low-density lipoprotein and a decreased level of high-density
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