The Centers for Disease Control and Prevention (CDC) estimates that 44.5 million adults in the U.S. smoke, of which 8.6 million have a serious illness attributed to their smoking habit. With 438,000 U.S. deaths yearly attributed to smoking, the CDC has identified smoking as the number one preventable cause of death.¹

Smoking cessation programs can help. However, they must target people from diverse backgrounds and health care needs. While every person who smokes would experience health-related benefits from quitting, not all understand the extent that smoking can damage the body and affect others. For example, women who smoke are at an increased risk for infertility and smoking during pregnancy increases the risk of complications, including premature delivery, low birth weight, stillbirth, and sudden infant death syndrome (SIDS).^2,3

Workable programs for seniors who smoke are in demand as the baby-boomer generation begins to experience the detrimental effects that smoking brings. Many programs are associated with cardiac or postoperative rehabilitation efforts. Beyond the widely known cardiopulmonary effects and cancer risks, many seniors are unaware that smoking reduces bone density among postmenopausal women and is related to an increased risk for hip fractures in both men and women. Smokers also have a two- to three-fold risk for developing cataracts when compared to nonsmokers.⁴

With recent litigation and subsequent media attention on cigarettes and smoking, nurses find themselves being called upon to offer support and counseling to smokers who are trying to quit. A good smoking cessation program combines proven readiness techniques with counseling and education guidelines.

Behavior modification programs abound. One, based on the theories set forth by psychologist James O. Prochaska, PhD, in his book, Changing for Good, assumes that the highest rate of success for change follows a predictable and similar path toward the goal, regardless of the specific behavior to overcome.⁵ In his view, moving toward change involves various stages, each of which requires specific action. These stages have been defined as precontemplation, contemplation, preparation, action, maintenance, and termination.⁵ The key to this process is to identify the patient’s present stage, develop appropriate coping skills for that stage, attain the stage-appropriate goals, and help the patient move forward.

First things first

Setting up a successful smoking cessation program involves two main components — education and counseling. These will be discussed as they apply specifically to each stage of readiness. Evidence-based practice guidelines related to the components of smoking cessation programs can be found at: www.cdc.gov/tobacco/research_data/stat_nat_data/bestprac-dwnld.htm.⁶

Before counseling, a patient’s medical and smoking history needs to be assessed. It’s critical that each health care setting establish a process whereby each patient encounter includes an assessment as well as documentation of tobacco use, and that a smoking cessation plan be included in the individual’s medical record.

Medical history is important in choosing a method of quitting and in preventing complications or new medical problems. For example, the use of nicotine gum or nicotine patches may be contraindicated in patients with a past medical history of allergic reactions, cardiovascular disease, peripheral vascular disease, hepatic insufficiency, hyperthyroidism, insulin-dependent diabetes, or peptic ulcer. The patient’s primary care provider should perform a thorough physical examination to evaluate the safety of using such smoking cessation aids.

A smoking history, including all attempts to quit, is also important. Assessment and evaluation of these areas will help determine the choice of educational material, community resources, support systems, degree of addiction to nicotine, and, ultimately, the best method of smoking cessation for each patient.

Precontemplation

At this point, people typically have no intention of changing their behavior and consider attempts to persuade them to be an intrusion. This stage is especially common in adolescence. The goal of precontemplation is to help the patient overcome denial. Education should focus on making patients aware that resources and materials are available, if and when they feel receptive to them. Personalizing reasons for quitting may get people thinking, so ask questions such as: Do you have children? Are you thinking of becoming pregnant? Issues of second-hand smoking exposure and synergistic risk factors should be mentioned, but patients should not be pressured or bombarded with information.

Counseling may be of little value and even be interpreted as “annoying.” Patients will benefit most by proper timing of educational efforts.

Contemplation

The short-term goals of the contemplation stage are to admit to a smoking problem and the need to do something about it (perhaps within three to six months) and to recognize roadblocks to quitting. These goals need to be fulfilled before the patient can move on successfully. Research findings indicate that many patients do desire to quit. Of the 44.5 million adults in the U.S. who smoke, an estimated 70% desire to quit.⁷

Patients in this stage think: “I need to consider quitting someday, but I’m not quite ready.” They know the destination, and even how to get there, but need more time to contemplate. They have real concerns, especially about roadblocks that may have hindered previous attempts to quit. Patients may be concerned about weight control, withdrawal symptoms, and fear of failure. Nurses can simply let them know that these concerns are understandable, yet surmountable.

Counseling encourages discussion of concerns and emphasizes the development of a good plan. It is important to emphasize the benefits of initiating new behavior patterns, such as diet and exercise, before quitting. If new behavioral patterns become part of a normal routine and lifestyle, it will be easier to fall back on them when roadblocks are encountered. Encouraging positive lifestyle changes in conjunction with smoking cessation can help to combat the average 10-pound weight gain that many smokers will experience when they quit.⁸

The nurse’s role at this phase is to serve as a source of encouragement and factual information. Fear of failure for contemplators is almost universal, especially if there have been repeated attempts at quitting. Offering some established facts — for example, 70% of people try at least twice to quit, multiple attempts are common, and 90% of quitters do so on their own — lets patients know that their experience is shared by others.⁷

Preparation

The emphasis here is on supplying information and resources about how to solve the problem. Most patients are planning to take action within the next month. They choose the most suitable action to accomplish the change and make a commitment to that action.

Self-Help Approaches: Many self-help booklets, videotapes, and quit-kits are available. Most are similar in their approach: understand smoking patterns, set a quit date, resist urges to smoke, think of alternatives to smoking, and handle slip-ups. These programs are attractive to self-motivators and those who work best with privacy and flexibility. Most smokers who quit will do so on their own, and there is little cost associated with self-help programs.

Group Approaches: These work best for people who need continuous support. Members of the group provide counseling and a supportive environment for one another. In addition to local hospital stop-smoking support groups, all local American Cancer Society (ACS) offices provide listings for groups in their areas. One-year quit rates are fairly high for those who participate; however, time and cost are considerations.

Nicotine Aids: These products are geared toward smokers who are concerned with withdrawal symptoms from addiction. Patients need to realize that nicotine products including patches, gum, nasal sprays, inhalers, and antidepressant or antianxiety drugs, are not cure-alls. These products are best used as part of a comprehensive behavioral smoking cessation program and in some cases should not be used at all.

Nicotine Patch: Some patches are now available for purchase over the counter (OTC). They contain medication, so directions must be followed exactly. The patch delivers a continuous flow of nicotine and can produce adverse effects, such as skin irritation and rash or elevations in heart rate and blood pressure. Encourage patients to be evaluated by a primary care provider beforehand, and instruct them about the risks of smoking while using the patch, such as nausea, vomiting, diarrhea, dizziness, or tachycardia.⁹

Nicotine Gum: This aid is available OTC, but it is best to advise potential users to consult a health care provider before using the gum because it, too, can produce adverse effects such as upset stomach, hiccups, or sore jaw (from chewing).

Nicotine Nasal Spray: This product is a liquid solution of nicotine that is sprayed into the nostrils and absorbed through the nasal membranes. It produces a relatively rapid rise in the blood nicotine concentration that closely mimics changes, which occur with smoking. Nasal irritation is common and other adverse effects include diarrhea and rapid heart rate. Compared to other nicotine aids, there is a greater risk for prolonging nicotine dependence when the spray is used.

Nicotine Inhaler: This product uses an inhaler device to deliver nicotine when the person inhales. The nicotine absorption is slow and its blood level is about a third of what is achieved with cigarette smoking. Irritation of the mouth and throat is common.

Bupropion: Bupropion hydrochloride is an antidepressant and its sustained release formulation, Zyban, is used as part of a smoking cessation program. Zyban is usually taken daily for three days, then the dose is increased to twice daily for the two weeks before the quit date and finally is continued for 7 to 12 weeks after smoking cessation. It may cause dry mouth and insomnia. Seizures are a rare adverse effect. It is not recommended for people with a history of a seizure disorder, head trauma, heavy alcohol ingestion, anorexia, or bulimia.

A new smoking cessation treatment option, varenicline tartrate (Chantix), acts on the nicotinic receptors in the brain to diminish the satisfaction associated with smoking. Available in 0.5 mg and 1.0 mg tablets, the initial dose of 0.5 mg is titrated up over the course of a week until a suggested dose of 1 mg twice daily. Therapy is recommended for 12 weeks and if the patient hasn’t stopped smoking by that time, they should be reevaluated for factors contributing to their desire to smoke before an additional course of therapy is prescribed. For those who completely stop smoking at the end of 12 weeks, an additional 12 week course may be prescribed to increase likelihood of long-term abstinence in the maintenance phase. Adverse reactions with varenicline are primarily GI, including nausea, vomiting, flatulence, and constipation. Some patients reported sleep disturbance associated with unusual dream activity. Patients with renal impairment require lower dosing at 0.5 mg twice daily and those on dialysis should only receive 0.5 mg once daily. Varenicline is removed by dialysis, so remind patients on dialysis to take their medication after their treatment.¹⁰

Even those people previously unsuccessful with other smoking cessation methods may be good candidates for therapy. In fact, varenicline has been found to be nearly twice as effective as buproprion (Zyban).¹⁰

Conditioning Methods: The most common techniques are rapid smoking (inhaling every few seconds until becoming ill) and satiation (smoking two to three times as many cigarettes as is usual in one day).¹¹ These methods have only limited success.

Hypnosis: This treatment works best when an understanding of smoking patterns and a change of belief systems would be helpful. Hypnosis is useful to break conditioned behavioral responses and instill new behaviors. Chances of success improve with repeated practice. Hypnosis can be expensive and requires commitment by the patient, but the costs may be covered by some health insurance plans.

Research reveals that certain factors including ethnicity, weight, and level of dependence on nicotine are important to consider and help predict which cessation method is more likely to result in abstinence maintenance. Smokers who are obese, highly dependent, or members of minority groups tend to achieve greater success with nasal sprays, whereas thinner, less dependent, Caucasian smokers achieve greater success with transdermal patches.¹²

Choosing a method also depends on motivation for quitting, past attempts at quitting, personality type, cost, and time commitment. During this phase, these interview questions can be helpful:

• “Why do you want to quit?” Highly motivated people are more successful. Coaching at this point might boost motivation.
• “Have you made previous attempts to quit?” Explore past quitting patterns and what triggered the resumption of smoking. Help the patient plan what to do differently in the same situation. Center on the aspects of quitting that were the most difficult during previous attempts, and how to best overcome those hurdles.
• “How much do you smoke?” Heavy smoking raises the difficulty level of quitting for most people. Degree of addiction should be established. Consider reducing smoking gradually as an initial step.
• “How much time and money are you willing to devote to quitting?” The chosen method should be realistic and conveniently fit the schedule and budget of the patient.
• “Do you have a support system — family, friends, or coworkers who can help you quit?” Encourage the potential quitter to ask another smoker to quit, too — someone who will be a supportive “buddy.” People without a strong support team may benefit from a support group.

After helping the patient choose the appropriate method of quitting, the nurse should focus on helping him or her make a firm commitment. Now is the time to encourage setting a specific quit date and letting other people know about the plan. To enhance commitment, suggest and explore the “SMART” Plan:¹³

• Specific — Set a concrete goal.
• Measurable — Be able to tell when you have accomplished your goal.
• Agreed Upon — What have you agreed to do to achieve your goal? The replacement behavior must be available and as convenient as reaching for a cigarette — for instance, taking a walk, chewing gum, or sucking sugar-free candy.
• Rewarding — How will you reward yourself for reaching your goal? Suggest some specific rewards.
• Trackable — How will you keep track of your progress?

During the preparation stage, it is important for the nurse to reinforce the concept of planning. Stress that the key to quitting is to plan ahead so that alternatives to smoking will be readily available when the time comes. Now is also a good time to discuss high-risk situations and other triggers the patients see as potential problems. Help them plan how they will counter urges to smoke.

To enhance patients’ commitment, explain that breaking small links in the chain of events that create a habit can break the entire habit. Use an example. “If you always smoke when you drink coffee, skip the coffee for a while. Plan for something in place of a coffee break, such as exercise or chatting with nonsmoking friends.”

If the preparation stage is done well, the patient should be ready to move to the action stage. Signs of readiness include mental commitment, identification of barriers to smoking cessation and methods to overcome them, choice of a method or program, and a specific quit date. Moving people ahead too soon will set them up for failure, but good planning encourages success.

Action phase

The patient now initiates the action to quit. This stage requires the greatest amount of time and energy from the patient and perhaps the most reassurance from the nurse. Even when all the necessary preparation has been done well, there is no guarantee that the action will be successful. The main problem areas are slip-ups or temporary lapses and relapses.

Counseling should center on countering unhealthy responses to quitting and the use of rewards. The planning of the preparation stage will be used to deal with urges and temptations. In addition, the nurse can suggest other reinforcing behaviors including getting rid of all cigarettes, especially spares that may have been stashed. Patients should discard ashtrays, lighters, and matches. Further, patients telling people they have quit, repeating the reasons for quitting out loud, and posting them in visible places normally used for smoking all can be helpful.

A review of nursing interventions should plan for dealing with weight control, urges, physical cravings, and remarks from smoking friends. To help ease the passage through this stage, the nurse will reinforce “countering,” offering healthy substitutes and responses for past unhealthy habits. These positive reinforcers need not be expensive, but rewards boost self-esteem. People who reward themselves are more likely to succeed, and a positive cycle can be created. Ask the patient to set up a plan of rewards for big milestones.

Often, the action stage is when patients become most frustrated. They slip and have a cigarette, or they may feel that they aren’t completely committed. The nurse can help patients decide whether they are ready to cope with a temporary setback and continue or to go back to the previous stage and feel more comfortable there before progressing. It is helpful to explain that many people move back and forth between stages at this point and it is quite normal to do so. Most smokers who quit will cycle between the stages several times in their attempts to be nonsmokers. In the action stage, the patient becomes smoke-free and develops new, healthy behavior patterns.

The action stage should be closely monitored or at the very least approved by the person’s primary health care professional, especially if he or she takes prescription or over-the-counter medications. Smoking cessation may require medication adjustment and additional therapeutic monitoring to maintain adequate blood levels of some medications and to avoid adverse events from others.¹⁰

Stopping smoking may increase the effects of aminophylline, insulin, labetalol (Trandate), prazosin (Minipress), propoxyphene (Darvon, Darvocet), propranolol (Inderal), and theophylline (Slo-Phyllin, Theo-Dur).¹⁰

Stopping smoking may decrease the effects of isoproterenol (Isuprel) or the over-the-counter medication phenylephrine (Neo-Synephrine).¹⁰

Maintenance

The maintenance stage begins when someone is smoke free for six months and lasts until the habit is completely broken.⁴ During this period, it is common to slide back and forth between previous stages, with relapses and repeated attempts to quit again. The focus of the work is usually the struggle to prevent these relapses. It is an active period that requires the patient to focus on new behavior patterns and to readjust some new coping strategies.

This is a time when the health and social benefits of quitting are discussed. It is also a time to deal with any social situations that may have been difficult and to help patients work through solutions. Help them by having them practice how to deal with people who do not understand what they are going through or who would like to see them fail. They need to find positive ways of handling negative situations and people.

All efforts must be made to help the patient remain smoke free. Counseling should reaffirm all efforts to deal with high-risk situations. It is important to prevent a momentary slip-up from becoming a relapse. Acknowledge that while there may be slips along the way, it does not mean the patient has failed. Let patients know that while it is difficult, if they can “forgive themselves” and get back to their plan, there is no need to relapse. They can continue to move toward their goal. The longer someone remains smoke-free, the easier it is to get back on track. Investigate together what may have gone wrong and what to do differently next time.

During maintenance, it is helpful to have patients make a log of the money they’ve saved while not smoking, so they can have a visual reminder of their success. This is also a time that weight issues may become troublesome. The focus on a healthy lifestyle offers the opportunity to review and teach diet and exercise strategies. The goals of maintenance are ongoing. The patient will have accomplished them when he or she learns to avoid high-risk situations and copes with and avoids relapses.

Termination

Termination is the ultimate goal for those pursuing change. It is marked by the absence of temptation to smoke and total confidence as a nonsmoker. For some smokers, it may take as long as five years for the urge to smoke to disappear, and some professionals believe that termination is really a lifetime of maintenance.¹¹

The role of the nurse is to serve as a patient guide through this process. Patients learn and use new skills effectively, enhance their self-esteem, and eventually become secure in their ability to remain smoke free.

The initial version of this self-study module was made possible through a grant from Robert Wood Johnson to the American Nurses Foundation, ID# 030254.