Question

Harriet And Smoking Cessation

This chapter’s case study demonstrates the usefulness of the Ecological Model and its interaction with individual-focused interventions, and it also draws together information from other models discussed in the chapter. The case study is presented in segments of a life course as well as an episodic perspective of factors involved in the case. It provides a perspective of the social changes that allow individual behavior changes to succeed, while also examining some of the processes involved in individual change. For these reasons, this case study is longer than others in this book.

            Smoking is one of the most harmful behaviors in which a person can engage. It affects every major organ system, and second-hand smoke harms those around the smoker (U.S. Department of Health and Human Services, 2004). Smoking is also one of the most difficult behaviors to change because of the addictive nature of nicotine and because of the social cues that support smoking behavior. It usually takes several attempts before a smoker can become smoke-free (U.S. Department of Health and Human Services, 1998). Smoking is a social phenomenon that is linked to other behaviors, like eating and drinking. The decision to smoke is influenced by depictions of smoking and tobacco products in movies, on television, and in advertisements.

Brief Health and Social History

Harriet is a 78-year-old white woman who worked most of her life in a factory in a northeastern “rust-belt” city. Because she was a line worker assembling parts that went into small appliances, she had no pension benefits or retirement plan contributions. She earned just enough to pay for her monthly living expenses, with a small amount left over for small luxuries. As a result, she now lives in senior housing, which means that her rent is subsidized by state and federal funds because her income is low and she has no other financial assets to draw upon. She lives on a fixed income of $620 monthly from Social Security and receives Medicare/Medicaid combined benefits to partly cover her health care costs. Her ever-increasing health care copayments are a concern to her because she is on a fixed income. She has little money in her budget to pay for extras, so cigarettes are for her a substitute for entertainment, cable television, and dinners out. She has smoked for more than 50 years, starting in high school and continuing through her working years. All of her friends and coworkers smoked as well. For much of Harriett’s adult life, people smoked wherever she went. Her motivation to quit smoking now comes from the recent deaths of close friends from smoking-related causes and the need to conserve her money. Cigarettes cost her about $40/week or $160/month—one-quarter of her monthly income.

Clinical Management

Harriet went to the local Community Health Center to see her nurse practitioner. During that visit, Harriet asked about ways to stop smoking. Her practitioner used the five As (Ask, Advise, Assess, Assist, Arrange) approach to cessation counseling and found Harriet receptive to quitting (Helping Smokers Quit, 2009). The nurse practitioner provided assistance and information on various methods of smoking cessation. She also explained that this behavior change could take several attempts to be successful.

            After further assessment of her current health, choice of cessation methods, and ability to adhere to the plan, Harriet left the Community Health Center with a plan for support, a follow-up appointment, and enough resources at her disposal to “kick the habit.” She selected nicotine patches in a decreasing dosage so she could control the expected withdrawal symptoms. She also had nicotine gum to supplement the patches, if needed. Harriet joined a telephone support group, run by a registered nurse and open to others trying to quit smoking, so she had someone to call if she felt unable to manage on her own. She could also call the nurse practitioner if these approaches did not seem to be helping.

Societal Change to Support Cessation

There were other changes, however, that contributed to both Harriet’s decision to quit smoking and to her provider’s ability to help her quit smoking. When Harriet was younger, almost all of her family, friends, and coworkers smoked. Everywhere she went people smoked, including hotels, movie theaters, restaurants, bars, and stores. Her doctor even smoked during her periodic visits! The tobacco industry had incredible influence within state and federal government, lobbying for farm subsidies for growing tobacco, tax credits for manufacturing facilities, and contracts to distribute tobacco products on government sites. The tobacco industry also hired psychologists to better understand consumer behavior and to develop marketing methods to reach people who were less likely to smoke. They provided free tobacco products to the armed forces during World War II, gave away free samples on street corners and in restaurants, and created new products that appealed to women and African-Americans (Glantz et al., 1998). By 1964, the Advisory Committee to the Surgeon General issued its landmark report titled Smoking and Health (U.S. Department of Health, Education, and Welfare, 1964). In response to the many people who stopped smoking as a result of this report, the tobacco industry increased sales and marketing efforts.

As Harriet got older, she had friends who became ill with respiratory diseases, friends who died because of smoking-related illnesses such as heart disease and hypertension, and friends who quit smoking. As her age cohort shrank in size due to death, Harriet became more aware of the decrease in smoking around her.

            From the 1980s until more recently, laws were enacted to establish smoke-free worksites, buses, public spaces, and restaurants. She now had to leave the building in most places if she needed to smoke. Taxes on cigarette purchases continued to rise on a regular basis making them an increasing percentage of her monthly expenditures. And her nurse practitioner constantly provided her with new information on the harmful effects that smoking could have on her health. At first Harriet just ignored the information. After all, she was well over 65 years old! Surely quitting smoking would not benefit her at this point.

Harriet noticed that she became short of breath walking up the stairs in her apartment building. She also had a persistent cough that got worse if she had the slightest cold. Once, she developed pneumonia that required hospitalization in part because of the damage that smoking caused in her lungs. While in the hospital, she was not allowed to smoke due to the oxygen therapy she received and the risk of fire and explosion the oxygen presented. Several of the registered nurses talked with her about quitting smoking and described the damage to her lungs from this behavior. That hospitalization was the only other time that she had stopped smoking. As soon as she returned home from the hospital, the cigarettes were there and, with little else to keep her occupied during the day, she was soon smoking just as much as before her pneumonia episode and hospitalization.

            Now, however, she was ready to quit smoking. In addition to the mutually developed treatment plan, she also agreed to two positive incentives. First, she was placing $50 dollars each month into a savings account to be used for entertainment. Going out with other older adults was her personal reward for stopping smoking. Second, the Medicare Health Maintenance Organization (HMO) she belonged to reduced her copayments if she successfully stopped smoking. This change made even more of her monthly income available to pay bills. This HMO also provided a telephone resource nurse whom she could call with any questions. All of these changes she believed would motivate her to quit and stay smoke-free.

Bumpy Road to Recovery

Harriet found that all the motivation and supports were not enough, at first. Within days, she was smoking again. She had not used the telephone support group or the HMO resource nurse, because she felt as though she had let everyone down. A follow-up telephone call from her nurse practitioner, however, was just what she needed. After a good cry and chat about what went wrong, Harriet was willing to try again. Her nurse practitioner had suggested that Harriet try hypnosis as an adjunct to her other methods, and recommended a nontraditional health specialist near her apartment building. Although the hypnosis session cost her some money out-of-pocket, she found the she was now able to get through breakfast and the mid-afternoon without needing to smoke. At her next scheduled visit with the nurse practitioner a month later, Harriet was smoke-free for 2 weeks.

            At this point, her nurse practitioner suggested that Harriet begin walking after breakfast and in the mid-afternoon. Her thinking was that, because these seemed to be the most difficult periods of Harriet’s day, supplanting a positive behavior for the negative one might help Harriet. In addition, the walking should help increase Harriet’s endurance and decrease her shortness of breath. After some additional discussion, Harriet agreed to try this plan. Again, Harriet had some difficulty implementing this additional change. First it rained. Then a friend stopped by just as she was getting ready to go out, so she stayed in and talked instead. But 2 weeks later she went out for a walk. She started slowly, as her nurse practitioner suggested, but soon was walking over 1 mile every day. Two weeks after that, she had increased her pace and distance. She did call the HMO resource nurse for suggestions on better shoes for walking and on nutritional changes she could make to keep from gaining weight. Harriet was now smoke-free for 2 months and was actually feeling better physically. She noticed that she only felt short of breath when climbing more than one flight of stairs and seldom when just walking. She also noticed that she felt stronger, more able to do things like cleaning her apartment, than she had in the months prior to these behavior changes. As a treat, she took the bus to the mall, bought herself lunch at a restaurant, and purchased some walking shoes to replace the older shoes she had been wearing. All of these changes reinforced that it had been a good decision to stop smoking.

Unexpected Benefits

The next visit Harriet made to the nurse practitioner was for her yearly visit. She was surprised to find that she had lost 20 pounds! Part of her weight loss was clearly due to the amount of walking she was doing—almost 2 miles each day. Her second surprise was that her blood pressure, which had always been higher than normal, was now below normal. Her weight loss and increased exercise combined to lower her blood pressure, and the nurse practitioner took her off her antihypertensive medication. The nurse practitioner also suggested some higher protein foods that Harriet might try to further build up her muscle mass. Plus, she added some exercises to strengthen muscles not affected by walking. These additional exercises would address upper body strength and balance. The nurse practitioner praised Harriet for her success at making such difficult life changes and reminded her how far she had come is a relatively short time. The nurse practitioner also suggested that Harriet explore an indoor walking group that met at the local mall because colder weather was coming and she wanted Harriet to continue these activities.

Critical Thinking Questions

1.      What parts of the models of individual behavior change would explain why people do not change behavior when presented with information alone?

2.      Using the Ecological Model of Health, which factors in her life course fit into the living and working conditions and encouraged her smoking behavior?

3.      What social and environmental factors made it easier for Harriet to quit smoking at this point in her life?

4.      At what points did various nurses interact with Harriet? Why might have some nurses been more effective than others?

Answer 1

Answer:The model of individual behavior change describes about how people get into delimma or convince themselves to bring any kind of change in their behavior. The Precontemplation stage involves the ignorance of the problem as well as denial of the person to accept change.

The interpersonal that is the social environment has encouraged her smoking behavior as when Harriet was younger, almost all of her family, friends, and coworkers smoked. Everywhere she went people smoked, including hotels, movie theaters, restaurants, bars, and stores. Her doctor even smoked during her periodic visits. This Encourages her to smoke.

The social and environmental factors made it easier for Harriet to quit smoking as Harriet got older, she had friends who became ill with respiratory diseases, friends who died because of smoking-related illnesses such as heart disease and hypertension, and friends who quit smoking.

Nurses interact and told the Harriet about the damage of lungs the smoke causes as well as they even explained her about the ways how to quit smoking. Nurses can provide counseling to her.