HELPING HOSPITAL PATIENTS STOP SMOKING JENNIFER PERCIVAL RGN. RM.RHV. FETC Counselling Dip RCN TOBACCO POLICY ADVISOR
So. what s the problem? Research has shown: WORLD HEALTH ORGANIZATION Epidemiologist Sir Richard Peto stated: Tobacco use is increasing. Over 100 million deaths from tobacco will occur during the next 20 years. and if nothing changes there will be a billion deaths this century. Half of all regular smokers die prematurely: ¼ in middle age (35-69) ¼ in old age Stopping before 35 avoids most of the risks of premature death. Stopping smoking works.
What is smoking? Chronic relapsing dependence syndrome Smoking is use of the addictive drug nicotine Delivered to the brain by tobacco smoke via lungs and blood Reinforced by sensory, behavioural and social conditioning Entrenched by powerful withdrawal syndrome Great harm caused by toxins in the smoke Promoted commercially, exempt from consumer protection legislation
Effectiveness of various smoking cessation interventions for those making an attempt to stop Quit approach used Unaided using willpower alone Willpower plus use of self help materials (e.g. audiotapes, videos, booklets) Using NRT supplied by a pharmacy Support and counselling from a smokers clinic but without using NRT/Zyban Support and counselling from a smokers clinic with a pharmacotherapy product Chance of being a non-smoker 12 months after giving up 3% 4% 6% 10% 20%
Recommendations for Clinical Practice Ask Advise Assess Assist Arrange about smoking at every opportunity and update records all smokers to stop in a personalised and appropriate manner motivation to stop the smoker to stop follow up if possible Recommend smokers to use NRT/Zyban and provide accurate information and on treatment options
A hospital stay should be treated as an opportunity to help smokers stop smoking Provide advice on appropriate TREATMENT OPTIONS eg NRT Recommend follow-up services Give encouragement and support Supply information leaflets
That s all well in theory but!!! How do you engage the reluctant smoker???
CL1 GOOD ADVICE
Slide 10 CL1 Jennifer - you mentioned that you might be able to provide some alternative cartoons which are more relevant to the renal setting? I wondered whether you are still planning to do this? Charlotte Lewis; 6.8.2003
Have you already observed that direct persuasion is not effective for resolving peoples ambivalence to change? Miller WR et al. J Consult Clin Psychol 1993;61:455 61 Rollnick S and Miller WR. Behavioural and Cognitive Psychotherapy 1995;23 :325 34
CL2
Slide 12 CL2 Jennifer - you mentioned that you might be able to provide some alternative cartoons which are more relevant to the renal setting? I wondered if you were still planning to do this? Charlotte Lewis; 6.8.2003
Smokers attitudes Reluctant and disillusioned 83% say they would not smoke if they had their time again 71% want to quit Reasons 61% Health 43% Expense 20% Addiction 17% Disgust 5% Social stigma
SMOKERS GIVE MANY REASONS FOR CONTINUNING Enjoyment Habit Social norm Ritual Routine Few mention addiction.
It s tempting to try to be helpful by persuading people of the urgency of the problem and the benefits of change Butthese tactics frequently increase peoples resistance and lessen the probability of change Miller WR et al. J Consult Clin Psychol 1993;61:455 61; Miller and Rollnick, 1991
Nurses Attitudes to the Topic of Smoking Myth No.1 If I ask about my patient s smoking habits they: Will not like me or let me care for them Will think I don t understand Will not return for their care Will not let me into their home again
Instead of listening to your advice they can often spend quite a bit of time justifying their smoking habit!! Which leads you to the Tennis match conversation
NURSES AND THE CHANGE PROCESS No-one changes their behaviour without first changing their attitudes and beliefs. When a patient argues with you it means you have made a wrong assumption. Long term behaviour change takes time If you lose the sense of urgency you will find opportunistic interventions much easier
RELAPSE Why do smokers fail to quit? Stopping under pressure from someone else Lack of personal motivation Attaching insufficient importance to stopping Withdrawal symptoms Poor timing A question of self-image I thought `just one wouldn t hurt
People succeed when they: Invest time and thought in quitting Want to stop and know what to expect when they do Have enough information and have developed coping strategies Can plan ahead for difficult or unexpected situations Have encouragement from others Can see themselves as non-smokers
Do you follow all the good advice you are given?
Giving Advice to Stop Smoking? Most smokers know its bad for them. Most can give you good reasons why they do not want to stop right now. When you discuss this it often polarises them into taking a defensive position
Instead help smokers weight up the pros and cons
Current Behaviour
What works? Elicit what the smoker already knows and their interest in receiving information Provide information neutrally Elicit the smoker s interpretation
QUESTIONS SMOKERS NEED TO CONSIDER Why do I want to stop smoking? What is the major benefit to me? When will I stop? Living without my cigarettes What will I do when I want a cigarette? What happened last time I failed to stop smoking? How will I avoid this happening this time? The day I stop smoking What will I do to prepare? Am I prepared to STOP, not cut down? After I stop smoking What will I spend the money on? What will be better about my life without cigarettes?
Stopping Smoking - Not ready! Respect this decision Ask: What would need to be different for you to consider change? Explain your own concern Leave the door open for future discussions
Unsure about change? Examine the pros and cons Understand ambivalence Explore concerns
Assessing motivation to change Importance: What is their expectation of the costs and benefits Confidence: What is their anticipated ability to achieve change?
Building confidence Ask: What did you learn from previous stop smoking attempts? What works and what doesn t work? Ask: What Do you know of anything that has worked for other people? Theses question can help the smoker develop a plan of action
Basic principles of motivational interviewing: Show empathy: even if you do not share a person s views, find ways to show that you understand and respect theirs Identify discrepancies: there are often differences between how a person behaves and how they see themselves Name these in a neutral way
Basic principles of motivational interviewing Avoid making pressure to change: this will create resistance. You can never win and, in the process, may lose the chance to help Roll with any resistance: do not argue with the patient if they say their action is not harmful. Instead, respectfully clarify their own thoughts or views Support the patient s self-confidence: look for the positive aspects and build on them
In summary changing the conversation helps From A tennis match Telling them why they should change Counter arguments / Justification The patient thinks You don t understand Collusion / Resistance to change Denial To Self re-evaluation Giving personally relevant facts Time to analyse their own motivation and confidence I can see the effect on me. `Believing I have the power to change. Movement through the cycle of change
Nicotine Replacement Therapy (NRT) NRT doubles the chance of success of smokers wishing to stop. NRT does not provide a complete replacement for cigarettes, it helps reduce cravings and withdrawal symptoms. NRT usually provides nicotine in a way which is slower and less satisfying, but safer than cigarettes. NRT does not contain tar and carbon monoxide as tobacco smoke does. There is no evidence that nicotine causes cancer. Addiction to NRT is not a problem. NRT should be used in sufficient quantities and for long enough. NRT is not a magic cure but it works when a smoker is determined to stop.
Withdrawal effects: duration and frequency Light-headedness Sleep disturbance Poor concentration Craving Irritability/aggression Depression Restlessness Increased appetite <48 hrs 10% < 1 wk 25% <2 wks 60% > 2 wks 70% < 4 wks 50% < 4 wks 60% < 4 wks 60% > 10 wks 70%
Nicotine delivery Royal College of Physicians, Nicotine Addiction in Britain, 2000
CHANGES IN NRT LICENCING Dec 2005 The UK Committee on Safety of Medicines stated All forms of NRT can be used by patients with heart and circulatory disease All forms of NRT can be used by regular smokers over 12 NRT can be used by pregnant smokers More than one form of NRT can be used together. NRT can be prescribed for up to 9 months if there is evidence of a continued need for treatment beyond the initial 8 to 12 week treatment period. NRT can be used while still smoking, to help a smoker reduce the amount smoked, before a planned quit date.
People succeed when they: Invest time and thought in quitting Want to stop and know what to expect when they do Have enough information and have developed coping strategies Can plan ahead for difficult or unexpected situations Have encouragement from others Can see themselves as non-smokers
GOOD LUCK YOU CAN MAKE A BIG DIFFERENCE!! and in the process PREVENT RE ADMISSIONS for SMOKING RELATED PROBLEMS REDUCE POST-OP RECOVERY TIME IMPROVE WOUND HEALING SAVE THE HOSPITAL MONEY