Page 809 - Cardiac Nursing

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C HAPTER 3 4 / Smoking Cessation and Relapse Prevention 785
CHD. 13–18,36–38 When the physician provides simple advice to in the use of self-help materials. Fewer than 10% of patients en-
the patient, the expected cessation rate in the general population dorsed a formal treatment program. 56 The international litera-
is approximately 6% per year, 39 whereas group programs that use ture also supports these findings. One study of Korean men who
behavioral methods may achieve yearly cessation rates as high as were hospitalized with CVD found that 84% wanted to quit
26% to 40%. 40 In the CHD population, in particular, the strong smoking, but 88% of them were interested in quitting on their
stimulus provided by a CHD event results in rates of smoking ces- own. However, surprisingly 51% were willing to participate in a
sation that are higher than in most studies conducted in the gen- formal, educational, smoking cessation program, if those pro-
eral population. 41–43 In particular, studies on those patients hav- grams were available during their hospitalization. 57,58
ing coronary artery bypass graft surgery show smoking cessation The literature also supports the fact that 90% of all smokers
rates of approximately 50%, 44,45 whereas those undergoing coro- eventually quit on their own, normally after three to four unsuc-
nary arteriography have smoking cessation rates of up to 62%. 46 cessful attempts. 59 It therefore behooves nurses to consider meth-
Finally, studies of patients with an MI or angina pectoris reported ods that may be individualized to patient needs, combining a clin-
smoking cessation rates of between 20% and 70%. 9,41,43,47,48 ical approach with multicomponent strategies without requiring
A significant body of research has also focused on nurse-man- patients to attend a formal treatment program.
aged smoking cessation interventions that begin in the hospital
and then continue with telephone follow-up after discharge from
the hospital. The effectiveness of this type of intervention has TREATING TOBACCO
been demonstrated in patients after MI 41 and cancer surgery 49 USE AND DEPENDENCE:
and in patients admitted to the hospital. 50 CLINICAL PRACTICE GUIDELINE
In general, research indicates that those patients with high mo-
46
tivation or strong intention to quit, 45,46 more severe disease, who
were given strong advice to quit by their physician, 41,50 who have As the body of knowledge about the health consequences of
CVD 50 are male, 10 have made fewer attempts to quit in the past, smoking and the health benefits of smoking cessation grow, smok-
and who had no difficulty refraining from smoking while in the ing cessation interventions play an even greater role in decreasing
hospital 45 achieved the highest smoking cessation rates. Patients smoking-related cardiovascular morbidity and mortality. The
with CHD who continue to smoke are in general younger, 51 fe- Treating Tobacco Use and Dependence Guideline Panel of 1996,
male, unmarried/not living with a partner, 10,51 belong to a lower 2000, and 2008 developed clinical practice guidelines for tobacco
60–62
socioeconomic 10,52 and educational level, have a less negative atti- cessation. These guidelines provide an evidence-based rec-
tude about smoking, smoke a greater number of cigarettes, and ommendation for interventions for all smokers regardless of their
are more likely to be anxious or depressed. 52 Although effective intention to quit at the present time. The guidelines acknowledge
interventions have been conducted to address some of these char- that tobacco dependence is a chronic condition of dependence
acteristics, interventions aimed at people of lower educational and frequently requiring repeated interventions and that behavioral
socioeconomic status are still lacking. 53 and pharmacologic interventions are cost-effective. The guidelines
provide recommendations for primary care clinicians, smoking
cessation specialists, and health care administrators, insurers, and
purchasers. These recommendations are especially pertinent to the
GENERAL TRENDS IN cardiovascular nurse because of the extensive contact nurses have
SMOKING CESSATION with patients to initiate smoking cessation counseling.
INTERVENTIONS So the guidelines 60–62 have established five major interven-
tion steps also known as the “5As.” These are (1) ask about tobacco
use; (2) advise the patient to quit; (3) assess willingness to make a
The public health approach to smoking cessation that has pre-
dominated in the smoking literature in the 1990s has primarily quit attempt; (4) assist in the quit attempt; and (5) arrange follow-
targeted populations or high-risk groups in their natural environ- up. Examples of how to implement a brief smoking cessation
ments, such as worksites. Public health interventions are usually intervention outlined in the pocket guide, Helping Smokers
60–62
63
brief, low-cost, and are often provided by laypeople or through Quit: A Guide for Clinicianss consistent with the guidelines
automated means (e.g., mail, contests). follow.
Clinical approaches, however, are targeted to people who are
self-referred or recruited, are most commonly applied in a med- Step 1: Ask—Systematically Identify
ical or group setting, use trained professionals, and provide in- All Tobacco Users at Every Visit
tensive multisession interventions. Because patients with CHD
are at risk for recurrent cardiac events, such as another MI, a clin- To identify every smoker every time he or she is seen by a clini-
ical approach is more cost-effective for this population—it is cian, a system-wide structure must be put in place. It can be as
cheaper to help patients quit smoking than to hospitalize them simple as adding assessment of smoking status to the routine vital
for a repeat MI. 54 signs (heart rate, blood pressure, respiratory rate, temperature) at
Many intensive group smoking cessation programs are of- every visit. To ensure that the smoking status question is asked
fered, but most smokers prefer to quit on their own or with in- every time, preprinted progress notes can be used, vital sign
dividualized support. 55 For example, in a study of cardiovascular stamps can be made, special stickers indicating smoking status can
patients admitted to the hospital who were smoking at the time be placed on the outside of charts, and for those with computer
of admission, 86% expressed an interest in quitting. However, of charting, a query of smoking status can be inserted into the data
the 86% who were interested in quitting, 79% stated they were collection tool. To obtain this information on patients who are
interested in quitting on their own, with 50% expressing interest hospitalized, smoking status must be asked as part of the routine