Cessation of Smoking Smoking and Well-known Effects
Smoking remains a significant public health challenge in the United States. Despite a wealth of evidence illustrating the detrimental health effects of smoking, approximately 23% of all American adults continue to smoke. Tobacco use is responsible for an estimated 430,000 deaths annually in the United States, maintaining its position as the leading preventable cause of death and disease (Centers for Disease Control, 2003b). Smoking is not only a significant health hazard but also a substantial economic burden. The Centers for Disease Control and Prevention (CDC) estimates direct medical costs associated with smoking or smoking-attributable diseases to exceed $50 billion each year. These staggering costs underline the urgent need for effective smoking cessation efforts.
A concerning trend is the increase in smoking prevalence among adolescents since 1990, with approximately 3,000 children and adolescents becoming regular tobacco users daily. This trend threatens to perpetuate the cycle of tobacco addiction and its associated health risks into future generations. Although many smokers express a desire to quit, with 70% of the approximately 50 million smokers in the U.S. having made at least one prior quit attempt and 46% trying each year (CDC), the success rate remains disappointingly low. The annual quit rate in the U.S. is only about 1.0%, with just 4.7% managing to abstain from smoking for between 3 to 12 months in the past year.
Smoking cessation, or the discontinuation of smoking behavior, differs from a “quit episode,” defined as 24 hours of continuous abstinence (Ossip-Klein et al., 1986). Smoking cessation is a dynamic process often accompanied by slips and relapses, requiring ongoing support and intervention. Smoking cessation is particularly relevant to nursing research and practice since nurses, as frontline healthcare providers, are ideally positioned to implement effective cessation programs. Research by Sarna and Lillington (2002) demonstrated that tobacco use and cessation are emerging topics in nursing research. Their review of databased articles published in Nursing Research from 1952 to 2000 revealed that tobacco use was mentioned in 40 articles, with 53% of these published since 1990. This trend indicates increasing recognition of the importance of smoking cessation in nursing practice.
According to the “Treating Tobacco Use and Dependence Clinical Practice Guideline” published by the U.S. Public Health Service Agency for Healthcare Research and Quality (AHRQ), all tobacco users should receive a brief intervention at each clinical visit (Fiore et al., 2000). This guideline underscores the need for consistent and proactive efforts to promote smoking cessation at every opportunity.
5 As Interventions
The AHRQ guideline emphasizes a structured approach to managing tobacco dependence, known as the “5 As”:
- Ask about tobacco use.
- Advise tobacco cessation.
- Assess willingness to quit.
- Assist with the quit attempt.
- Arrange follow-up to prevent relapse.
These steps provide a comprehensive framework for healthcare providers to support patients in their journey toward smoking cessation.
All tobacco users attempting to quit should receive one of the five AHRQ-recommended first-line pharmacotherapies for smoking cessation. Katz et al. (2002) conducted a study using a pre- and post-test design to evaluate the effectiveness of the AHRQ intervention, comparing it to usual care. Participants in the intervention group were encouraged to set a quit date within 30 days and were offered an 8-week supply of transdermal nicotine patches if they smoked at least ten cigarettes daily. Additionally, they received self-help materials and proactive telephone counseling from a trained cessation counselor. The study found that the 6-month self-reported quit rate was 21% in the intervention group compared to 13% in the control group. Continuous abstinence was reported in 10% of the intervention participants versus 3% of the control participants.
These results suggest that implementing a guideline-driven smoking cessation intervention is associated with increased abstinence rates among primary care patients willing to quit. At the two-month follow-up, abstinence rates in the intervention group were significantly higher (21% vs. 4%) than baseline rates (Katz et al., 2002). This finding supports the efficacy of the 5 As approach in clinical practice.
Nursing Role in Tobacco Cessation
Nurses play a critical role in smoking cessation efforts due to their frequent patient interactions and unique position to provide ongoing support. Smith et al. (2002) examined the impact of a nurse-managed inpatient smoking cessation program. The program included physician advice, bedside education with take-home materials (such as a videotape, workbook, and relaxation audiotape), counseling from a nurse trained in smoking cessation, nicotine replacement therapy if requested, and four nurse-initiated post-discharge telephone counseling calls.
The study involved patients from Stanford University Hospital, where 2,091 patients were identified as smokers, and 1,077 (52%) enrolled in the program. Of these, 720 patients were eligible for 12-month follow-up. Seventy-one percent (509) were reached for the follow-up, and of these, 49% reported they were not smoking. However, a limitation noted by the authors was the potential underreporting of smoking at the 12-month follow-up. The study acknowledged that self-reported smoking status could be problematic in cessation studies, particularly among hospitalized patients who may feel compelled to provide socially desirable responses (Smith et al., 2002).
The lack of biochemical verification to confirm smoking status represents a limitation in smoking cessation intervention research. Cotinine, a major metabolite of nicotine, can be measured in plasma, saliva, and urine with excellent specificity for tobacco use, except in individuals using nicotine replacement therapy. Carbon monoxide (CO), a by-product of cigarette smoke, can be measured in expired air. However, CO has a shorter half-life (2-4 hours) and is rapidly eliminated, whereas cotinine may be detected for several days after cessation. CO assessments are often used to confirm abstinence in studies where nicotine replacement therapy is ongoing. The Society for Research on Nicotine and Tobacco (SRNT, 2002) recommends biochemical verification in most or all studies of smoking cessation among special populations, including adolescents, pregnant women, and medical patients with smoking-related diseases.
Outcome of Interventions
Smoking cessation efforts have yielded varying results across different populations. Notably, smoking is more prevalent among individuals with lower education levels and those living in poverty (CDC, 2003b). Efforts to promote cessation and abstinence in these populations have generally been less successful, highlighting the need for tailored interventions that address the unique barriers these individuals face. These barriers may include limited access to healthcare services, lack of information about prevention, and socioeconomic challenges (U.S. Department of Health and Human Services, 2000).
While the AHRQ clinical practice guideline for smoking cessation is evidence-based, its testing among vulnerable populations is limited. For example, the guideline deserves further examination among minority groups, pregnant and postpartum women, HIV-positive individuals, and smokers who are poor and often dealing with comorbid conditions such as cancer or chronic obstructive pulmonary disease (COPD).
To improve outcomes, healthcare providers must consider the social determinants of health that contribute to tobacco use and its cessation. Targeted interventions that address the specific needs of high-risk populations are essential. For example, culturally appropriate educational materials, enhanced access to cessation resources, and tailored support services may be more effective in promoting smoking cessation among these groups.
Conclusion
Smoking cessation remains a critical public health priority, given the significant health and economic impacts of tobacco use. The 5 As intervention framework provides a structured approach for healthcare providers to support patients in quitting smoking. Nurses, as frontline healthcare providers, have a unique role in promoting smoking cessation through patient education, counseling, and follow-up. Research supports the effectiveness of nurse-managed cessation programs, highlighting the importance of ongoing support and tailored interventions.
However, challenges remain in promoting smoking cessation among high-risk populations, particularly those with socioeconomic disadvantages or comorbid health conditions. To address these challenges, healthcare efforts must focus on developing and testing targeted interventions that consider the social determinants of health and the unique needs of vulnerable populations. By enhancing access to cessation resources and providing culturally appropriate support, healthcare providers can improve outcomes and reduce the burden of smoking-related disease.