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Article Excerpt
Nurses should encourage leaders in their health care systems to provide effective tobacco-use treatment and follow up. Nurses also need to support the policy and community interventions that motivate tobacco users to try to quit, create a supportive environment, and provide more intensive interventions for those needing them.
Tobacco use is the leading preventable cause of death in the United States, contributing to more than 1,200 deaths every day (Centers for Disease Control [CDC], 2005). The Institute of Medicine (2007) called for a concerted effort to end the epidemic of diseases caused by tobacco. Recommendations included giving the Food and Drug Administration (FDA) the authority to regulate tobacco products, and funding comprehensive tobacco control programs at the level recommended by the CDC. Such comprehensive tobacco control programs can reduce youth initiation (Tauras et al., 2005), adult prevalence (Farrelly, Pechacek, Thomas, & Nelson, 2008), and overall cigarette consumption (Farrelly, Pechacek, & Chaloupka, 2003). A comprehensive approach to tobacco control combines clinical interventions to help tobacco users quit with community interventions that create a supportive environment for those trying to quit, thus increasing the chances that they will be successful. Therefore, it is important for nurses to encourage leaders in their health care systems to screen and treat all tobacco users appropriately at every visit, as well as support the policy, community, and environmental changes that increase tobacco users' motivation to quit and makes it easier for them to succeed.
Clinical Interventions Proven to Increase Quitting
The Public Health Service (PHS) recently published the latest update of the tobacco-use treatment guideline, Treating Tobacco Use and Dependence (Fiore et al., 2008). Recommendations are based on meta-analyses of studies that met these criteria: (a) the study reported the results of a placebo/comparison controlled trial of a tobacco-use treatment randomized on the patient level (except for adolescents and system changes, where group randomization was allowed); (b) the study provided follow-up results at least 5 months after the quit date (except for pregnant smokers, where the follow up was end of pregnancy); (c) the study was published in a peer-reviewed journal; (d) the study was published between January 1975 and June 2007; (d) the study was published in English. The criteria for the strength of evidence recommendations were as follows:
* A Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.
* B Some evidence from randomized clinical trials supported the recommendations, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation.
* C Reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.
According to the Guideline recommendations (see Table 1), brief clinician advice to quit is effective (30% increase in cessation rates) but more intensive counseling doubles the cessation rate. Interventions can be delivered effectively by a variety of clinicians (physicians, nurses, psychologists, others). Counseling can be delivered via individual counseling, group programs, or telephone counseling. FDA-approved medications double or triple success rates. Patients not yet willing to quit smoking should receive a motivational intervention to promote later quit attempts. Changes were made in the recommendations from the 2000 edition to the 2008 publication (see Table 2), with some recommendations being strengthened and others being dropped.
Cessation counseling/coaching provides practical advice about how to quit, and how to deal with withdrawal and challenging situations when the tobacco user is offered tobacco or has a strong urge to smoke. It also provides social support to the tobacco user as he or she tries to quit. Using counseling and medication together or combining medications results in higher cessation rates. A major problem is that few tobacco users use treatments; evidence also suggests that tobacco users take fewer doses of medication than prescribed and for a shorter time period, which may contribute to lower success rates (Fiore et al., 2008). Because of the low unaided success rate, smokers make, on average 8-11 quit attempts before succeeding for good (Yankelovich, 1998).
The PHS clinical practice guideline (Fiore et al., 2008) concluded that effective tobacco use treatments should be offered to every patient who smokes. This assumes that office systems will be developed to ensure the routine assessment of tobacco use and appropriate treatment. The guideline also recommended a brief intervention (3 minutes) called the 5 As:
* Ask every patient at every visit if he or she uses tobacco and document the patient's status in the medical chart (e.g., as a vital sign).
* Advise all tobacco users to quit.
* Assess the patient's interest in quitting.
* Assist the smoker to quit by helping him or her set a quit date; recommending and/or prescribing FDA-approved medications unless contra-indicated; and providing or referring the patient to more intensive individual counseling, telephone counseling, or group programs in the community.
* Arrange for follow up (by telephone or by scheduling a return appointment) to assess progress and to encourage the relapsed smoker to try again.
Tobacco-use treatment for adults is extremely cost-effective, more so than other commonly covered preventive interventions, such as mammography, treatment for mild-to-moderate hypertension, and treatment for hypercholesterolemia (Fiore et al., 2008). An analysis of recommended clinical preventive services ranked the services based upon disease impact, treatment effectiveness, and cost-effectiveness; the conclusion was that treatment of tobacco use among adults ranked first (along with childhood immunizations and aspirin therapy to prevent cardiovascular events in high-risk adults) as an effective and cost-saving intervention. Tobacco use treatment also had one of the lowest...
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