Question

A patient uses nicotine products. What would be the nursing considerations for this patient?

Answer 1

Ans) Nurses play an important role in raising the issue of smoking cessation with patients and they can offer a balanced perspective on the challenges they might face. They can then sign-post patients to the most appropriate smoking cessation options.

- Nicotine is a powerful addictive substance that alters neurologic function. By stimulating dopamine release in the brain, its use leads to pleasurable feelings, mood modulation, and the desire for repeated administration. Tolerance develops, requiring more nicotine use over time until an ideal serum level is reached. Due to alveolar absorption of tobacco smoke, the cigarette is the most effective nicotine delivery device.

- The first step in helping patients stop smoking is to identify and document the smoking status of all patients. For those who smoke, the PHS guideline recommends a combination of pharmacotherapy and counseling for behavior modification as the most effective strategy to help smokers quit.

• Medications

Some of the approved agents for treating tobacco dependence are available over the counter; others require a prescription. The PHS guideline advises clinicians to urge all patients who are trying to quit to use these medications, except when medically contraindicated.

• Counseling: The 5As

The PHS guideline identifies two key components to counseling:

providing interpersonal support during a quit attempt
teaching the patient specific behavioral skills that address management of withdrawal effects, cravings, and urges.
The guideline proposes the “5As” framework to help smokers quit-Ask, Advise, Assess, Assist, and Arrange. Once this framework becomes part of your everyday practice, it can be completed in just a few moments.

Ask. Ask every patient at every encounter about tobacco use. For example, ask: “Do you, or does anyone in your household, smoke, or use any other type of tobacco?” For every patient chart at every clinical encounter, document the patient’s smoking status and the follow-up measures you took to address tobacco use.

Advise. Inform patients that quitting smoking or tobacco use is the most important thing they can do for their health. Discuss the medications and counseling services available to help them quit. Emphasize that counseling increases their chance of success.

Assess. Ask if the patient is ready and willing to make a quit attempt at this time. If so, provide resources and assistance to implement an effective cessation plan. If the patient is reluctant to try to quit, elicit his or her concerns and fears related to quitting. Even if the patient isn’t willing to try to quit at this time, provide information about available resources.

Assist. Help the patient create a cessation plan. An important first step is to set a quit date, ideally within the next 2 weeks. With a hospitalized patient, who has already been forced to quit by virtue of being in the hospital’s smoke-free environment, discuss strategies for staying abstinent after discharge.

For all tobacco users making a quit attempt, offer help in thinking through the challenges they’ll encounter when trying to quit, the times and situations when they have the most difficulty resisting the urge to smoke (for example, when drinking alcohol), and how to enlist support from family and friends. Remind them that withdrawal symptoms are common, and recommend a medication to lessen symptoms. Emphasize that abstinence (not even a single puff of a cigarette) is essential right from their quit date.

If they begin smoking again (relapse), advise them not to view this as a complete defeat. Relapse is common, particularly during the first week or two. Reassure them that relapse is often one step in the quitting process; it offers a learning opportunity and should be followed by another quit attempt. Inform patients that most smokers make multiple quit attempts before they can achieve long-term success.

You can also refer smokers to the national tobacco cessation telephone quitline at 1-800-QUIT-NOW. This free service, available everywhere to everyone, has been proven to increase the chance of quitting successfully. It offers trained counselors who can assist in the caller’s quit attempts. Depending on where your patient lives, other state and local resources might be available at the workplace and community or through health insurance providers. If smoking cessation specialists, hospital-based services, or community services are available, refer patients to these, too. (For details on strategies for helping patients quit, see Implementation strategies for smoking cessation by clicking on the PDF icon above.)

Arrange follow-up. Follow-up care is essential. After you spend a few minutes encouraging and supporting your patient in developing a quit plan, arrange for follow-up with a healthcare provider, a telephone quitline, or other resource. This important but often neglected step can help the patient avoid relapse. It also represents another opportunity for you to review the situations that put smokers at risk for relapse and help the patient develop strategies to cope if this occurs.