Page 811 - Cardiac Nursing

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C HAPTER 3 4 / Smoking Cessation and Relapse Prevention 787
children and other family members. Roadblocks or barriers to 1- to 2-week period. The provision of intratreatment support is
quitting that need to be identified with the patient include with- the simple act of providing the patient with encouragement,
drawal symptoms, fear of failure, weight gain, lack of social sup- showing the patient that you care about them and their health,
port, living with a smoker, depression, and loss of tobacco. Fi- and giving the patient the opportunity to talk about their quit at-
nally, repetition is included because the relevance, risks, and tempt (concerns, fears, successes). The provision of extratreatment
rewards need to be reviewed with the patient every time he or she social support includes encouraging family members and signifi-
is seen because on any given visit, the patient may finally be re- cant others to support the patient in the quit attempt and, if ap-
ceptive to a smoking cessation intervention. propriate, providing a simultaneous smoking cessation interven-
tion to household members who smoke. It is especially important
Step 4: Assist—Aid the Patient to address this with women living with another smoker, because
in Quitting living with a smoker is a strong predictor of relapse in women. 16
It may also include role-playing with the patient how he or she
Setting a Quit Date and Planning will ask for the support that is needed, identifying and referring
for an Intervention patient to community resources such as hotlines, Web sites, or
The first step in assisting the patient ready to quit smoking in- group meetings, and helping patients find “cessation buddies”
volves establishing a quit plan. Components of a quit plan include with whom they can work. Provision of effective pharmacothera-
(1) setting a quit date; (2) telling family, friends, and coworkers pies is strongly recommended and is discussed in greater detail
about quitting and the desire for support; (3) anticipating chal- later. Finally, as the patient leaves the health care setting, it is
lenges to remaining smoke free; and (4) removing tobacco prod- strongly advised that they take with them supplemental informa-
ucts from home and work settings. In regard to setting a quit date, tion in the form of pamphlets that are culturally, racially, educa-
if a patient is motivated, setting a quit date within 2 weeks of tionally, and age appropriate for the patient. Patients then need
meeting with the health care provider is most appropriate. Some follow-up in the form of face-to-face or telephone contacts. 61,62
patients, however, prefer to quit suddenly, or “cold turkey.” If the When planning a smoking cessation intervention, the nurse
smoker is identified in the hospital, setting a quit date is not nec- should take into account the patient’s desire for formal help. Lit-
essary because the patient has become an ex-smoker because of erature on compliance suggests that when the patient partici-
the hospital smoking ban. Some programs have patients monitor pates in developing a personalized plan of action, greater follow-
the situations that cause them to smoke before they quit or re- through is achieved (Chapter 40). Because most people choose
duce the number of cigarettes in the weeks before quitting. These individual methods for cessation, providing self-help materials is
techniques, however, although helpful to some, may simply pro- a low-cost method of intervention. When combined with strong
long the process of quitting. Signing a contract at this point is a advice by the nurse, these materials often double success rates.
behavioral technique that has proved effective in helping patients For the cardiac patient, the American Heart Association’s An Ac-
to quit smoking. This process helps to formalize the smoker’s tive Partnership for the Health of Your Heart offers effective mul-
commitment to quitting and can serve as a method by which the timedia materials, including a videotape, audiotape, and work-
nurse extends support to the patient in this process. Contracts book. 65 Other self-help materials, like those from the U.S.
must be simple and explicitly written so that both parties agree Department of Health and Human Services, 66 Tobacco Free
with the stated terms, and they should specify the consequences of Nurses, 63 the American Cancer Society, and the American Lung
not adhering to the expected behavior (see the section titled Association, along with information for the nurse, are listed at
“Harmful Effects of Smoking”) and the rewards of successful ad- the end of this chapter.
herence (see the section titled “Benefits of Smoking Cessation”). Although most patients choose to quit on their own with min-
The guidelines 60–62 recommend that five major components imal help, some patients prefer, and may benefit from, a group
be a part of a brief intervention. These include (1) provision of program that provides 8 to 10 weeks of behavior modification.
practical counseling such as problem solving, skills training, re- Knowing available community resources and making them avail-
lapse prevention, and stress management; (2) provision of social able to patients by providing them with a list of programs to
support directly by the provider (intratreatment social support); choose from, including the intervention methods, costs, and a
(3) helping the patient obtain social support outside of the clini- contact person, ensures that patients are adequately informed.
cal setting (extratreatment social support); (4) recommending the The patient may also be encouraged to address the issue with his
use of approved pharmacotherapy, except in special circum- or her employer, because many larger employers offer smoking
stances; and (5) provision of supplementary materials. Practical cessation programs as an employee benefit.
counseling components include helping patients identify and an- Occasionally, patients may decide that acupuncture or hypno-
ticipate “danger situations,” such as events, activities, and internal sis is a viable alternative. The success rates of these types of smok-
states that increase the risk for smoking relapse, for example, neg- ing cessation interventions, however, have been shown to be no
ative affect, being with or living with another smoker, drinking al- better than placebo. 61 Some patients, however, anecdotally report
cohol, and stress. Coping strategies to review with patients include these methods to be helpful. If a patient chooses a group cessation
anticipatory planning, avoidance, and stress reduction. When program or an alternative intervention, referral should be made
providing practical counseling, it is also imperative to advise pa- and follow-up scheduled to determine the success of the chosen
tients that smoking, even one puff of a cigarette, increases the like- intervention. It is important to note that although the majority of
lihood of a complete relapse to smoking. Other information that smokers will express the desire to quit on their own, this strategy
is useful to patients attempting to quit smoking includes the ad- has proven to be of limited success; therefore, it behooves the
dictive nature of smoking, 64 potential withdrawal symptoms, and health care provider to encourage a combination of self-help
that they can expect withdrawal symptoms to reach maximal and more intensive strategies including pharmacological therapy
intensity within 24 to 48 hours and then gradually subside over a (Tables 34-1 and 34-2).