About Smoking Cessation

1

Question:

How can I find the time to add smoking cessation to my daily duties?

Answer:

Nurses can always find time to provide interventions that may save a life!  With the assistance of some of the tools provided through the HSQ, nurses can find ways to incorporate the steps included in the pocket guide during their routine patient assessment.  The U.S. Public Health Services’ Tobacco Cessation Guideline, Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline estimates that a brief intervention takes approximately 10 minutes.  For nurses who find it difficult to dedicate 10 minutes to the brief intervention, the Guideline recommends the minimal intervention, which takes less than 3 minutes. A comprehensive assessment and intervention can take time and will vary from patient to patient and the longer the intervention, the higher the odds of the patient quitting.  However, even minimal intervention help patients quit. It only takes a few minutes ask a patient about their tobacco use, provide them a brief advice to quit (for example, say “Quitting smoking is the best thing you could do for your health” and assessing if the patient is willing to make a quit attempt and refer them to a telephone quitline, which will take over from there (see your state fact sheet). Be sure to follow-up to see if your patient has any questions or concerns.  You may want to find out if your hospital has a team of tobacco experts or individuals who can help provide more intensive support, education and follow up. In addition to the telephone quitline, there are other resources in your state that can support patients in their quit attempts. Please find these materials on the HSQ tab for your state.  Remember that just asking about a patient tobacco use and suggesting that they quit could make a difference.

2

Question:

Can nurses really make a difference? Isn’t this something that the doctor should do?

Answer:

Yes, the research is mounting that nurses are effective in providing smoking cessation interventions. Additionally, the evidence suggests that when multiple health care providers (nurses, pharmacists, physicians, etc.) are involved in providing patients advice to quit, it can increase the patient's success of quitting smoking. The HSQ project and materials will help you become equipped with the knowledge and skills to effectively help patients quit and make a difference.

3

Question:

What if I don’t know how to answer a question about smoking cessation?

Answer:

We expect that you will not know all of the answers For this project; we have tried to provide you with many resources that can help you help patients quit smoking addressing the questions that are most frequently asked by patients. The materials in the Toolkit you received and the Helping smokers quit pocket guide will have answers to many of your questions, especially about cessation methods and the use of medication; your state’s HSQ tab and the Tobacco Free Nurses website are other good resources. When in doubt, you can see if there is a physician/nurse/pharmacist or other expert in tobacco cessation at your hospital that can help you with a specific question about an individual patient. Many hospitals do have them. Quitlines (West Virginia, Indiana, California) can often serve as an additional resource for health providers that have questions related to cessation and to referring patients. The more often you include helping patients quit as part of your everyday nursing care, the more confident you will become. You can also contact us directly or by phone at 1-877-203-4144.

4

Question:

Do these interventions really work?

Answer:

Yes! Providing patients with support during their quit attempts, especially if combined with the use of medications more than doubles their chance of being smoke-free one year later. Remember, it is not uncommon for smokers to return to smoking (relapse) several times before they are able to quit for good. It is hard, but people can quit smoking, and they have better chances of success when they receive support from a health care provider. There are now more former (ex-)smokers in the U.S. than current smokers.

5

Question:

What if the patient quits smoking but gets addicted to the patch/ gum/ lozenge/ spray? (i.e., Isn’t the nicotine in cigarettes is the same as the nicotine found in Nicotine Replacement Therapy (NRT) products, so I’m just trading one addiction for another?)

Answer:

The likelihood of long-term addiction to nicotine replacement products (NRT) is very low -- about 1 in 20 people who stop smoking with the help of NRT will continue to use NRT in the longer term. NRT products have a much lower risk of addiction than cigarettes. Unlike cigarettes, the nicotine found in NRT is regulated by the Federal Drug Administration (FDA). Apart from causing addiction, nicotine is not thought to cause disease. The health problems from tobacco use, such as lung and heart diseases, are due to the tar and other chemicals in cigarettes and in smokeless tobacco. So, taking NRT instead of smoking is one step towards a healthier life. The amount of nicotine in NRT is less than in cigarettes and it is delivered to the body more slowly so NRT is not a perfect replacement. Withdrawal symptoms are reduced with NRT, but may not go away completely. Please see NCI NTTC. Dispelling Myths about Nicotine Replacement Therapy. DHHS (or this link from the UK).

6

Question:

Should we first suggest to the patients that they try cutting down on the amount they smoke?

Answer:

No.  While the patient is at the hospital they can’t smoke and it is a perfect opportunity to use evidence-based cessation interventions to help them to quit.  Although there might be programs that promote cutting down as you get closer to a pre-set quitting date, this requires close follow-up (and requires that a quit date and a quit plan be in place). While hospitalized, the patient will have already reduced or stopped smoking, thus it is more appropriate to follow the steps outlined in the 5 A’s and make arrangements for follow-up and additional cessation intervention post-discharge. Without the close follow up found in a cessation program, a pre-set quit date and a quit plan, “cutting down” is not an effective method to quit since people tend to return to baseline smoking levels.  Additionally, it may give them the misperception that by smoking fewer cigarettes a day, they are addressing the health risks associated with smoking. Quitting is the only way to eliminate the health risks associated with cigarette smoking.  It is important to remember that there are no safe levels of smoking, every cigarette is harmful.

7

Question:

Wouldn’t it be adding stress to a patient’s life to suggest they quit smoking while they are dealing with a hospitalization?

Answer:

Not necessarily.  In fact, if you don’t address smoking, it may increase their stress. Although some nurses may have this misconception, research has demonstrated that patients welcome, and in fact many expect to receive, cessation interventions provided by nurses and other health care professionals while hospitalized.  Additionally, behaviors sometimes interpreted as “stress” are nicotine withdrawal symptoms from not smoking while hospitalized and may signal the need for medication to help with withdrawal symptoms.  When nurses provide patients with evidence-based cessation interventions (as included in the pocket guide) including discussion with the health care team about pharmacotherapy support (such as nicotine replacement therapy), they assist in minimizing withdrawal symptoms associated with abstinence/quitting and they provide patients with high level quality of care.

If the patient who smokes does not have his or her nurse and other health professionals discuss cessation while hospitalized, the message being delivered is that it may not be an important health risk.  Patients may think “if it was important, someone would have talked to me about it [my smoking].” In the same way that nurses would not ignore a patient’s high glucose or high blood pressure levels (despite stress that could be caused by suggesting a change in diet, for example), nurses should not ignore patients’ smoking and should go further and provide evidence-based cessation interventions.

Smoking is more common among people with mental illness, but even they can quit smoking successfully.

Some patients may experience serious psychological symptoms when trying to quit and need additional assistance with support and medications. If your patients experience depression or other psychological symptoms be sure to let the patient’s physician know.

8

Question:

What if the patient tells me he/she doesn’t want to quit?

Answer:

You may encounter more than one patient who may be unsure about quitting, or who states that he or she is not interested in quitting. However, this is not a reason not to provide a brief intervention and, at a minimum, a referral to a telephone quitline and or other resources available on your hospital or community.  One appropriate response for patients who tell you that they do not want to quit is to say “I understand, but please note that quitting is the most important thing you can do for your health and if you want to hear more about it, I’d be happy to discuss it with you.”  It is important to let the patient know that quitting is very important and that whenever he or she is ready to talk about it, you will be there to provide him with assistance.  The 2008 USPHS Treating Tobacco Use and Dependence clinical practice guideline [hyperlink] has additional detailed suggestions on providing brief cessation interventions to patients who are not interested in quitting.

9

Question:

What if the patients asked me for additional help and support in quitting?

Answer:

We understand that there is just so much you can do during your shift.  If after you implemented all the steps of the evidence-based intervention (as per the pocket guide), including making arrangements to follow-up after discharge, you can provide the patient with the toll-free telephone quitline number and any other additional support available in your community listed on your state's HSQ tab, or on the additional resources. In some cases the arrangement for additional treatment and follow up could also be a referral to a cessation service or cessation specialist in your hospital, in other cases it could be referral to a community support group.  However, even if you need some time to investigate these additional resources (included in the Toolkit you received as part of the HSQ project, you can always give the patient the quitline number (1-800-Quit Now) and or make the call from his bedside number with the patient.

10

Question:

Are the medications to quit smoking dangerous?

Answer:

No.  Every medication has to be prescribed and recommended with care.  While some of the cessation drugs have some side effects (as listed on the last page of your pocket guide), these medications have been approved by the Federal Drug Administration (FDA) for use as cessation aids and a few are available over the counter (no prescription required). It is important for you to ask the patient’s physician if you have any questions or concerns. The important thing to remember is that despite any risks of side effects, which are minimized by adequate prescribing, continued smoking poses a far greater health hazard and the benefits of quitting have been demonstrated to far outweigh any perceived risks of cessation medication that are properly prescribed.

For any doubts regarding the risk of becoming addicted to nicotine replace therapy, please see  #5.

11

Question:

Can I still help patients quit even if I am a smoker?

Answer:

Even nurses and health care providers who smoke can identify patients who smoke, encourage them to quit, and provide them with access to resources. A number of studies have reported that health care providers who smoke may be less likely to provide patients with the type of support that they need. This is a great opportunity for nurses to quit too. Many of the resources that are provided in the tool kit and are on the Tobacco Free Nurses website will work for nurses who are trying to quit.

About HSQ Procedures

1

Question:

What is the purpose of this project?

1

Answer:

Helping Smokers Quit (HSQ) is a research project that will test to see if providing nurses training and resources to help patients with smoking cessation will make a difference in the frequency of their delivery of interventions to help patients quit smoking. The purpose of the Web-based HSQ survey is to assess tobacco cessation interventions used by nurses like you.

2

Question:

Who is going to answer questions I may have during the project?

Answer:

Please direct questions or concerns to Dr. Marjorie Wells, Project Director, UCLA School of Nursing at (310) 825-9802 or (310) 206-2824 or e-mail: mjwells@sonnet.ucla.edu, or to Dr. Linda Sarna, Principal Investigator, UCLA School of Nursing, at (310) 825-8690.

3

Question:

A colleague missed the Web conference but was interested in learning more – can she get information?

Answer:

All nurses from your hospital, including your colleague, will be able to access the information from the Web conference on the HSQ web pages for your state and should also have received the Toolkit.

4

Question:

Is my supervisor going to check if I am participating in the HSQ project?

Answer:

Participation in this study is voluntary so no one will be checking to see whether you do or do not participate.

5

Question:

What happens if I don’t answer the follow-up web survey?

Answer:

All nurses from participating hospitals are invited to participate in this survey. However, it is very important that as many nurses as possible at your institution complete the follow-up survey so that we will be able to evaluate whether or not nurses like yourself who participate in the HSQ were helped are now more likely to provide tobacco cessation interventions to patients.

6

Question:

How can I be eligible for the survey raffle?

Answer:

After you have completed the third and final survey, 12 months after taking the first of the 3 surveys, you will be given the opportunity to enter a drawing to win $150.00 for nurses at your hospital.  You will enter by sending an email message with your name and contact information (email address and telephone number) so that we can contact you if you win the drawing. The drawing will take place about 3 weeks after the 12-month survey begins at you hospital.  You will be contacted only if you are the winner.

About the Implementation in the Hospital

1

Question:

The campus is going smoke-free, what should we do about patients who want to go outside to smoke?

Answer:

If patients are able to go outside, you may not be able to prevent them from smoking.  One thing to consider is that when a patient inquires about going off campus for a cigarette it may mean that he/she is having withdrawal symptoms from nicotine and need medications to help minimize these symptoms. It also presents yet another good opportunity to offer cessation support.  Even if you have already offered an intervention, this would be another opportunity to ask the patient about his or her desire to quit and to let them know that help is available.

Remember that if patients have a nicotine patch or are using other Nicotine Replacement medication, they should not smoke as it can cause increased risk of side effects from the added dose of nicotine.

2

Question:

Is this intervention what the Joint Commission requires for compliance with smoking cessation interventions?

Answer:

Yes. The Joint Commission has a broad set of measures that meet its requirements and in fact, this intervention goes beyond the minimum requirements of the JC.

3

Question:

Do we need to intervene with patients that have diagnoses that are different form the ones established by the Joint Commission?

Answer:

Yes.  While the Joint Commission may review the list of diagnosis for which it requires cessation intervention, it is in fact the duty of every health care provider to intervene with patients who smoke.  This is similar to the situation of a patient with high blood pressure. Regardless of regulatory requirements, you would intervene. The same needs to be done with patients with smoke.  This is good quality patient care and needs to be incorporated into practice.  For time available for intervention and other such questions, please see the FAQ above about Smoking Cessation.

About Smokeless Tobacco

1

Question:

What if the patient quits smoking but gets addicted to smokeless tobacco?

Answer:

Smokeless tobacco products are still harmful. All forms of oral tobacco contain known carcinogens (cancer-causing agents) and are addictive and are not a safe substitute for tobacco smoking. Harmful health effects include: oral (mouth) cancer, pancreatic cancer, leukoplakia (white sores in the mouth that can lead to cancer), receding gums (gums slowly shrink away from around the teeth), bone loss around the roots of the teeth, abrasion (scratching and wearing down) of teeth, staining of teeth, bad breath and addiction to nicotine. The snuff and chewing tobacco products most widely used in the United States contain very high levels of tobacco-specific nitrosamines, which are carcinogenic. These carcinogens (cancer-causing agents) cause lung cancer in animals, even when injected.  These products have not been proven to be effective in helping smokers quit. Smokers who delay quitting by using smokeless products between cigarettes greatly increase their risk of lung cancer. They also set themselves up for new health problems caused by smokeless tobacco.

2

Question:

What is smokeless tobacco?

Answer:

The two main types of smokeless tobacco in the United States are chewing tobacco and snuff. Chewing tobacco comes in the form of loose leaf, plug, or twist. Snuff is finely ground tobacco that can be dry, moist, or in sachets (tea bag-like pouches). Although some forms of snuff can be used by sniffing or inhaling into the nose, most smokeless tobacco users place the product in their cheek or between their gum and cheek. Users then suck on the tobacco and spit out the tobacco juices, which is why smokeless tobacco is often referred to as spit or spitting tobacco. Smokeless tobacco is a significant health risk and is not a safe substitute for smoking cigarettes.

Tobacco companies have responded to the popular laws that ban smoking in public places by promoting smokeless products as an alternative to use tobacco in no-smoking settings. They also promote the idea that switching to smokeless products is an effective way to quit smoking. There are two serious problems with this marketing of smokeless tobacco. The first is that their ads encourage smokers to use these products to meet their nicotine cravings in settings where they cannot smoke, encouraging dual use (cigarettes and smokeless). This wipes out one of the benefits of smoke-free laws which is the decrease in consumption and prevalence of tobacco use. Smokers who delay quitting by using smokeless products while continuing to smoke increase their risk of lung cancer. The second problem from uncontrolled marketing of these products is that it may worsen the problem of tobacco use among teenagers, who may perceive smokeless as a safe alternative to smoking, leading people who might not otherwise