The ideal Smoking Cessation Program

Another responsibility laid upon us respiratory therapists is educating our patients who smoke on the importance of quitting. Most smoking cessation programs are fully reimbursed by most insurance companies, Medicaid and Medicare.

I always felt I was overstepping my bounds telling my patients they ought to quit. That was until I saw the latest statistics. The fact is, 70% of smokers say a health care professional has never told them to quit, and yet 70% of smokers say they want to quit.

Likewise, with the help of a clinical professional, the odds of a person quitting doubles. On top of that, the chances are that smoking is probably what caused and exacerbated the illness that caused the patient to be in the hospital in the first place. Smoking is also known to slow the immune process which delays healing. Quitting smoking, therefore, can prevent such an occurrence from re-occurring in the future.

Also, According to the CDC, " Constituents in tobacco smoke (e.g., polycyclic aromatic hydrocarbons) may enhance the metabolism of drugs, resulting in a reduced pharmacologic response. Smoking might adversely affect the clinical response to the treatment of a wide variety of conditions."

The job of the RT is not to finish the program, just start it. All we have to do is remind the patient of the importance of quitting, and what are the latest recommendations or products to help them quit, and then show them what steps they need to get started. Ultimately, our job is to nudge the patient.

The following is what the Michigan Department of Community Health recommends we do:

1. Ask about tobacco use at every visit:

• Advise patients to quit: "I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future."
• Link current illness and tobacco use (Condition x is caused or worsened by smoking)
• Counsel on proper use of cessation medications
• Review the benefits of behavioral counseling

2. Assess readiness to quit: The Average person takes 9-11 attempts

3. Refer patient to tobacco quit line, or provide patient with tobacco quit kit

• refer to the Michigan Tobacco Quitline (1-800-480-QUIT)
• Refer patient to a self help quit book like this one.

4. Encourage the patient by emphasizing that quitting is possible.

5. Address ambivalence by reminding patient that it is normal to be scared about quitting smoking, and "getting stuck there is not!" Try to get them to look at the advantages of quitting smoking; of how they will be healthier; "Is there any way at all in which you’d be better off if you quit? That might be something to think about."

Types of ambivalence include:

• The products don’t work: The truth is, medications significantly improve quit rates, and all smokers should be encouraged to use them. If they didn't work in the past, it's because they weren't used properly, or the wrong dose was prescribed. Make sure the patient understand how to take medicine properly, and that they never quit. Encourage patient to use on a steady basis, and not as needed.
• I’m trading one addiction for another: Nicotine is absorbed from the lungs and reaches the brain in 11 seconds. That's what makes smoking so addictive. Cessation meds provide nicotine very slow, and therefore it's harder to get addicted. Also, it's easier to wean off the meds than cigarettes.
• I can quit on my own:
  Fewer than 5% of people who quit without assistance are successful in quitting for more than a year. Most people do not succeed on their own, and medications double your chances of quitting.
• NRT is harmful: NRT is the nicotine used in medications. Nicotine, however, is not the harmful component of tobacco. Harm comes from the 4,800 hazardous chemicals in cigarette smoke (see below). NRT is safe and when you are getting NRT you are not getting the 4,800 hazardous chemicals that come with smoking cigarettes. Likewise, people don't die from using nicotine meds, they do die of smoking cigarettes.

6. Address withdrawal concerns:

Nicotine withdrawal effects include:

• Depression
• Insomnia
• Irritability/frustration/anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite/weight gain
• Decreased heart rate
• Cravings

It must be noted here that most symptoms peak 24–48 hours after quitting and subside within 2–4 weeks.

7. There are many products available for you and your doctor to choose from:

• Nicotine gum
• nicotine lozenge
• Nicotine transdermal patch
• Nicotine nasal spray
• Nicotine inhaler
• Zyban
• Chantix

8. The advantages of nicotine replacement:

• Reduces physical withdrawal from nicotine
• Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
• Allows patient to focus on behavioral and psychological aspects of tobacco cessation

9. Encourage Behavioral change:

• Fewer than 5% of people who quit without assistance are successful in quitting for more than a year
• Few patients adequately plan and prepare for quitting on their own
• Many patients do not understand the need to change behavior.
• Often, patients think they can just "make themselves quit."
• Patients who get help are more likely to be able to quit for good."

Triggers for tobacco use: What situations lead to temptations to use tobacco?

Routines/situations associated with tobacco use:

• When drinking coffee
• While driving in the car
• When bored or stressed
• While watching television
• While at a bar with friends
• After meals
• During breaks at work
• While on the telephone
• While with specific friends or family

Control your environment:

• Create a tobacco-free home and workplace: Don't let other smoke around you
• Actively avoid trigger situations as listed above
• Modify behaviors that you associate with tobacco
• Create substitutes for smoking: nicotine gum, etc.

10. Note facts: It is not nicotine that causes health problems, it is the 4,800 chemicals in cigarettes. Nicotine replacement therapy is not addicting because you receive smaller doses that can be controlled. You cannot control the amount of nicotine in a cigarette.

Some chemicals in cigarettes besides nicotine include:

• Arsenic
• Acetic Acid
• Acitone
• Ammonia
• Benzene
• Butane
• Cadmium
• Carbon Monoxide
• Ethanol
• Formaldehyde
• Hydrazine
• Hexamine
• Hydrogen Cyanide
• Lead
• Methane
• Methanol
• Naphthalene
• Nickel
• Phenol
• Polonium
• Steric Acid
• Styrene
• Tar
• Toluene

Consider the following facts about quitting smoking:

• Within hours after you stop your carbon monoxide level falls to normal and the oxygen in your blood increases
• One day after you stop your risk for heart attack starts to go down
• Two days after you stop your nerve endings start to repair themselves so your senses of taste and smell start to return to normal
• Two weeks after you quit your lungs are working 30% better than before you quit
• Within 1-9 months lung function continues to improve, cough, sinus congestion, fatigue and shortness of breath all decrease as your lungs regain normal function
• Within one year your risk of heart disease is cut in half.
• Within 15 years risk of stroke, lung cancer and heart disease are that of a person who never smoked, and you can consider yourself fully healed.

10. Allay the fallacies:

• "Smoking gets rid of all my stress." Truth: There will always be stress in one’s life.
• "I can’t relax without a cigarette." Truth: There are many ways to relax without a cigarette.
• Smokers confuse the relief of withdrawal with the feeling of relaxation.
• Second hand smoke is safe. Truth: Studies show even short term exposure to 2nd hand smoke can increase the risk of heart attacks and cancer. It also increases childhood risk of respiratory tract infections like RSV and bronchiolitis, which can lead to hospitalization and even death. It's also linked to increased risk for sudden infant death syndrome (SIDS). It also causes asthma attacks and is even linked to causing asthma.
• Third hand smoke is safe. Truth: The smell of smoke in your house and on your clothing has also been linked to disease.

The following are the five R's to motivate a patient to quit smoking as per the Certified Respiratory Therapy Review Guide (2010, page 273):

1. Relevance: Use facts to encourage patient to indicate why smoking is relevent (risk to my own health, risk to my family and friend's health, etc.)
2. Risks: Ask patient to identify the negative consequences of tobacco use. Highlight those that are most relevent to patient: shortness of breath, exacerbation of asthma, harm to pregrancy, impotence, risk of heart attack, cancer and stroke. Also, increased risk of health complications for others.
3. Rewards: Ask the patient to identify potential benefits of quitting. Examples: Smoking will improve your health, smell, taste, length of life, improve self esteem, good example for kids, have healthier babies and children, stop forcing others to breath in your smoke, feel better, perform better physically, reduced wrinkles, etc.
4. Roadblocks: Ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address these parriers. Typical bariers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, and enjoyment of tobacco.
5. Repeat: Repeat all the above motivational interventions as needed.

This post based on this power point presentation by the Michigan Department of Community Health. I also used some information from this power point presentation MSFH.