Page 817 - Cardiac Nursing

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C HAPTER 3 4 / Smoking Cessation and Relapse Prevention 793
used in the clinical setting to help guide plans for a smoking cessa-
SPECIAL AREAS ON WHICH tion intervention. The two questions are (1) during the past
TO FOCUS month, have you often been bothered by feeling down, depressed,
or hopeless? and (2) during the past month, have you often been
Stress bothered by having little interest or pleasure in doing things? If the
patient answers “no” to both questions, the patient is unlikely to
Patients may often relapse to smoking during stressful times, es- have major depression. If the patient answers “yes” to either ques-
pecially those involving emotional circumstances, such as argu- tion, a follow-up clinical interview by a mental health professional
ments or a crisis situation with a spouse, family members, or is recommended; alternatively, a referral to either the primary care
coworkers. 75 The frequency and severity ofdistressingdemands provider or a psychiatrist is indicated. Bupropion SR should be
during everyday life have also been shown to be predictors oflater considered the first-line pharmacotherapeutic agent used in pa-
relapse to smoking in both men and women. 106,107 Although tients with current or past depression because it has been proven
some patients may need in-depth counseling to help them with effective for both smoking cessation and depression therapy. 61
such problems, simple relaxation training may produce a sense of
increased control, which may in turn affect the patient’s confi- Alcohol Use
dence to withstand the urge to smoke. Many patients can benefit
from the use of inexpensive relaxation audiotapes that use simple Social situations that involve alcohol use are another predictor of
instructions on how to use muscle tension anddeep breathing ex- relapse to smoking. 75 For this reason, nurses need to determine
ercises to achieve relaxation. whether the smoker attempting to quit consumes excessive alco-
hol regularly. This information can be ascertained while taking a
Depression smoking history by using the simple four-item CAGE question-
naire (Fig. 34-3), 113 which is a screening tool for alcohol abuse. If
Current smokers have been found to have higher mean depression a diagnosis of alcoholism is made, patients should be encouraged
scores than never smokers in both men and women. 108 Smokers, to seek treatment for alcoholism and smoking cessation simulta-
in general, have had a significantly greater number of past episodes neously. Patients who are heavy social drinkers should also be en-
of major depression than average, and smokers with a history of couraged to avoid alcohol or decrease their consumption substan-
major depression who quit smoking are seven times more likely to tially until they feel successful in their smoking cessation efforts.
have a recurrence of major depression than do individuals who
continue to smoke. 109 Depressive episodes occurring before smok- Loss
ing cessation have an inverse relationship with 6-month absti-
nence. 110 In other words, patients who have had a previous history For many patients, giving up smoking is like “losing a best
ofdepression but are not depressed at the time smoking cessation friend.” Nurses must help patients to recognize and understand
is initiatedhave less success at quitting than do smokers who have the magnitude of this loss. Helping patients acknowledge how
never experienceddepression. Higher depression scores are also re- they feel about their loss and working with them to select new ac-
lated to lower self-efficacy for quitting, especially among men, 108 tivities that provide immediate gratification is important. For ex-
anddecreases in self-efficacy, if they are going to occur, will most ample, patients should be encouraged to focus on old hobbies or
likely happen in the first 2 weeks after cessation. 110 Women expe- select new hobbies. They can also develop reward systems for their
riencing depression were found to have more difficulty initiating a daily success in remaining nonsmokers. Nurses should also en-
smoking cessation attempt, maintaining abstinence, and were courage patients to build new activities into their daily schedules
likely to relapse to smoking significantly earlier than were nonde- that also increase confidence as their focus shifts to new behaviors.
pressed women. 111 Therefore, clinicians working with depressed
smokers making a quit attempt may need to focus on enhancing Weight Gain
self-efficacy and providing additional support in the first few weeks
after cessation to prevent negative affect from significantly decreas- The average weight gain after smoking cessation is approximately
ing self-efficacy and increasing the likelihood of relapse. One thing 6 to 10 lb, much of which is caused by metabolic changes that oc-
that does bode well for smoking cessation is the finding that higher cur with cessation. 114 It appears weight gain is more often associ-
depression scores are related to a greater motivation to quit in ated with those who smoke more cigarettes or have a history of
women, a factor that clinicians must use in their favor. 108 Al- weight problems. 115 In addition, those who quit smoking often
though there are multiple depression screening tools available in crave sweet foods. 116
the literature, Whooley and Simon 112 have developed a very brief Encouraging patients to be more active through daily exercise
two-question case finding instrument that is quickly and easily and helping them to identify low-calorie snacks and sweets can help
YES NO
1. Have you ever felt you ought to CUT DOWN on your drinking? ❑ ❑
2. Have people ANNOYED you by criticizing your drinking? ❑ ❑
3. Have you ever felt GUILTY about your drinking? ❑ ❑
4. Have you ever had a drink first thing in the morning (EYE OPENER) to steady your
nerves or get rid of a hangover? ❑ ❑
■ Figure 34-3 The CAGE questionnaire. (Reprinted with permission from Ewing, J. A. [1984]. Detecting
2
alcoholism: The CAGE questionnaire. JAMA, 252, 1905–1907.)2