Smoke-Free Zone
Nurses and patients tackle nicotine addiction
By Joanne Eglash
April 25, 2005
It’s one of today’s major paradoxes: Despite the health risks of tobacco, some people continue to smoke. As a result, nurses often face the challenge of helping patients — both psychologically and physically — stop smoking. Sometimes, a nurse must contend with an even more difficult obstacle: playing the role of both healer and patient. Sixteen percent of nurses in the U.S. still smoke.
Why is it so difficult to quit such a dangerous habit? Those who struggle to stop smoking say the habit relaxes them and reduces stress. And, they admit, they’re addicted to the “lift” from the tobacco. The good news, both for nurses guiding their patients and for nurses trying to end their own addictions, is this: ongoing research has resulted in new pharmacological and psychological techniques for would-be ex-smokers. In addition, there are new organizations designed specifically for nurses’ needs.
Tobacco-free nurses
The following quote on the Tobacco Free Nurses’ organization website sums up the challenge of trying to quit: “I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15 years. When I wanted to quit, I found out it takes the average person three to four attempts to quit because nicotine is so powerful. I learned that if you pick it up again, it’s part of a process. It’s not that you failed, that’s just how it works. When I finally quit, I had more weapons to help me — my pills, my support, and my nurse practitioner to talk to. Now we have Tobacco Free Nurses to help, too.”
Stella Aguinaga Bialous, RN, DrPH, is president of the San Francisco-based Tobacco Policy International and co-investigator of the Tobacco Free Nurses Initiative (www.tobaccofreenurses.org). A professor at the UCLA School of Nursing, Linda Sarna, RN, DNSc, is principal investigator of the Tobacco Free Nurses Initiative, funded by The Robert Wood Johnson Foundation. They describe the Tobacco Free Nurses initiative as “the first-ever national initiative to assist nurses to quit smoking.”
Through the organization, nurses can access Nurses QuitNet, an internet-based smoking cessation program. Nurses receive free consultations with experts and information about pharmacotherapy and cessation programs in their area. The website offers links to resources for nurses who are helping patients stop smoking, as well as information about research done by nurses.
According to Bialous and Sarna, research continues to show that tobacco usage should be regarded as an addiction, with a multi-disciplinary approach required to support those seeking to stop. One new resource is the launch of a national telephone number, 1-800-QUIT NOW, which will provide another resource for nurses helping patients stop smoking, as well as for those who want to stop themselves.
Patricia Bax, RN, MS, CASAC (certified alcohol and substance abuse counselor), is the marketing coordinator of the New York State Smokers’ Quitline. Bax worked for the American Cancer Society as a tobacco control specialist for two years. The latest research indicates that counseling sessions are more effective when they last longer and are more frequent, Bax says. Research also shows that smokers are more likely to use phone counseling than attend either individual or group counseling sessions.
But Bax encourages smokers not to overlook help from peers. In working with the Niagara Falls Memorial Medical Center, she coordinated a Quit and Win contest with hospital employees. She believes the financial incentives, coupled with peer and colleague pressure, motivated people to quit. “The power of support, such as a buddy system, can not be underestimated,” she says.
Among new medications now in the testing phases or soon to be available, Bax lists:
A new, better-tasting nicotine gum that delivers faster results. It’s supposed to be available in 2005.
Rimonabant (Acomplia), a new drug under development that may help battle smoking as well as obesity. Bax notes that the French pharmaceutical firm Sanofi-Aventis will seek federal approval for the drug next year, which means the drug “ is probably two years away from being available in the U.S.,” Bax says.
A nicotine vaccine in the testing phases by researchers at the University of Minnesota. The vaccine blocks nicotine uptake in the brain. Although human studies began just last year, Bax predicts the vaccine could dramatically change how we treat nicotine in the future.
Rx for Change
Cheryl Lang, RN, a member of the nursing faculty at Front Range Community College in northern Colorado, is working on her master’s degree in nursing education at the University of Northern Colorado. Lang was trained at Georgetown University’s Summer Institute for Tobacco Control Practice in Nursing Education.
“This initiative is providing nursing faculty from around the country with the needed skills to implement smoking cessation curricula in their programs,” says Lang. She describes the institute’s curriculum, “Rx for Change,” as a comprehensive tobacco-training program that equips nurses and other health care professionals with state-of-the-art knowledge and skills for helping patients quit. Lang notes that the college’s nursing department has teamed with Poudre Valley Health System and the Larimer County Department of Health and Environment to apply for funding. The funds will be used to integrate the skills needed to work with patients on smoking cessation into the nursing program curriculum.
Officials at the Colorado community college decided to implement the unique curriculum because they wanted to do more to help patients addicted to tobacco. Tobacco-related diseases, from cancers to heart disease, to emphysema and stroke, kill more than 440,000 Americans every year, Lang says. In addition, the college faculty and administration felt they could better prepare their nursing students for employment in areas that “support tobacco-free lifestyles.”
Lang is excited about the “Rx for Change”curriculum because it eliminates the need for teachers to prepare special smoking cessation materials. The “Rx for Change” program makes it easy for nurse educators to help students be experts, Lang says.
Among the teaching tools offered through the curriculum are videotapes, workshops for pharmaceutical aids, and role-play scenarios for practicing counseling strategies. Faculty members can choose which modules best suit their classes, as well as which research to emphasize. Some instructors stress studies that show the importance of personalizing the dangers of smoking based on each patient’s specific health concerns and risk factors. For instance, emphasizing the dangers to the unborn child, as well as the mother, would be critical information for a patient who is pregnant.
As a faculty member on a community college campus, Lang is aware of the importance of her role in helping nursing students stop smoking.
“As I’ve helped them to prepare to quit smoking, I’m struck by the conflict they feel about using smoking to handle their stress while knowing they should quit, especially as health care providers,” Lang says. The ambivalence felt by many smokers shows in their behavior and on-campus assessments, according to the Colorado nurse. Although these nursing students want to quit, they use smoking to relieve their stress. As a result, the students “feel caught and unable to move forward. I’ve really learned how important it is to have a nonjudgmental attitude and to help them to get ready to quit.”
Five stages
Whether they are nursing students or clinic patients, most individuals progress through five stages of smoking cessation, according to the Cancer Prevention Research Center at the University of Rhode Island:
Precontemplation — The smoker knows that quitting would be a wise health move but is not making any definite plans or setting any definitive dates.
Contemplation — The smoker has decided that the dangers of smoking outweigh the pleasures and is prepared to contemplate what it will take to quit.
Preparation — This midpoint is critical in smoking cessation. Smokers make up a battle plan for themselves, which may include asking for support from other individuals, from health care professionals to family members. At this time, they may also decide to use a medication.
Action — The smoker is ready to move forward and turn those plans into reality. Medications, counseling, and other forms of treatment may be used.
Maintenance — The now ex-smoker is in the successful stage of maintenance, where the goal is to maintain a new and healthy lifestyle without tobacco.
Although Lang has never smoked, she knows several students who continue to struggle with tobacco addiction. As an example, Lang describes a third-year student who succeeded in substituting physical activity and exercise for smoking. Toward the end of her third semester, though, the student nurse told Lang, “I had a lot of tests coming up and was feeling extremely stressed and did not have time to exercise. I started smoking again.” She believes nursing programs should offer more stress management techniques to their students. Lang says this student “believes she will stop smoking again and has set a short-term goal of quitting for herself, as she knows smoking is not consistent with who she wants to be.”
Other solutions
As for medications, Lang acknowledges there are many medications that can help people quit. She believes that using the correct dosage and timing are the most important factors in using pharmaceutical treatments. Depending on the patient and medication, pharmaceutical solutions may be delivered in various forms. “The selection of the form of administration is very individualized, sometimes based on convenience,” Lang says. “However, other factors, such as immediacy of nicotine availability or a steady blood level can make one form a much better choice for one patient over another.” Nicotine replacement products include a nasal spray and an inhaler available by prescription. Gum, patches, and lozenges are available over the counter. Bupropion (Zyban) (known as Wellbutrin when prescribed as an antidepressant) is available by prescription only.
In the same way, non-pharmaceutical solutions vary depending on the patient. Through her studies, Lang has learned strategies for each cessation stage, including how to prepare a “quit plan,” how to handle withdrawal symptoms and prevent relapse, and alternative methods such as acupuncture, massage, and hypnosis. For students who want to stop smoking, Lang has offered hypnosis groups, behavioral techniques for stress reduction, information on available medications, and information about other available resources in the community.
Lang’s message to nursing students and nurses who want to stop smoking is this: “It is OK to be wherever you are at with your smoking or your thoughts about wanting to quit or not. I want you to know there are no judgments and only help and resources to quit when you are ready to quit.”
In addition, Lang emphasizes, she asks nurses “to look inside and face your own feelings about your tobacco use. If you feel conflicted or embarrassed or concerned about talking with patients about their use because you smoke, pay attention to your feelings. Talk with people about it. Let your ambivalence be your guide. One day your desire to quit will be stronger than your desire to smoke. Every step between now and then is about getting ready to quit at the pace that is right for you.”
Joanne Eglash is a freelance writer for NurseWeek.