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Csaeec Nutaag' 1M5) 2_5--3 1991. C 1991 Raven ?ress. Ltd.. rew t ork ' I I I I I I I I I I I I I I I I Intervention strategies for smoking cessation The role of oncology nursing Marilee A. Rose, R.N., M.S. The role of oncology nurses concerned with the health effects of cigarette smoking may often be defined as dealing with the morbidity and mortality associated with tobacco use-caring for individuals diagnosed with tobacco-related malignancies. As current treat- ment methods of many of these malignancies offer little hope of cure, oncology nurses need to diverge from these traditional roles and include a focus on primary prevention activities. An essential component of these activities is a knowledge of smoking cessation education strategies and an understanding of the methods that motivate and arsist individuals to quit smoking. Key Words: Smoking cessation interventions-,Role of oncology nursing--"Patient education. There are numerous ways of explicitly stating the health hazards tdateci to smoking. Smoking is responsible for more than one of every six deaths in Marike Rox nuar of Oncolop Ctinial Research, Methodist Hospll~Centa. Minneapolis. Minnesota. Address correspondafce and ceprint rqquats to NuiJee A. Rose, Coadinator Oncoiop Resarch: MethodisyHc~it~! Cattoer, Center.!5Q0, Facalsio~ F~~ard, p O. $bc 650:!Minnapolisl MN 3544ok Acoepted for pubiiation May 2Z. 199t. the United States (1). Cigarette smoking is the single greatest cause of preventable death and disability in the nation (2). Cigarette smoking is responsible for, 83% of lung cancer cases and acx~unts for about 30% of all cancer deaths (3). The economic implications of smoking are overwhelming. The U.S. Congress, Office of Technology Assessment has estimated the total of smoking-related health care costs and lost productivity costs at approximately $65 billion dollars each year (4). There is growing recognition of the health risks associated with passive smoking or the inhalation of smoke from the tobacco products of others (5). Scientific evidence has established the involuntary inhalation of tobacco smoke as a causative factor in diseases and death among nonsmokers. According to the National Research Cauncil, every year, 2,500-8,400 of the > 12,000 lung cancer deaths in the United States not due to smoking may be attributable to environmental tobacco smoke (6). Scientific and public knowledge of the health consequences of smoking, and programs and pQlicies that encourage nonsmoking behavior have iri~ significantly since 1964 (1). Approximatel}c three- quarters of a million smoking-related deat#,s' were avoided or postponed between 1964 and 198~ as a result of decisions to quit smoking or not to 'atart. These decisions will also result in the postponement or avoidance of an estimated 2.1 million smoking- 225

I I I I I I I I I I I I I I I I I I 226 M. A. ROSE related deaths between 1986 and the year 2000. Although >50 million Americans continue to smoke, >90 million would be smoking in the absence of the changes in the smoking and health environment that have occurred since 1964. Understanding the methods for motivating and assisting individuals to quit smoking is essential for all health professionals (7). It is imperative that oncology nurses become familiar with smoking ces- sation education and adept in the methods to assist individuals with quitting in order to effectively influ- ence the morbidity and mortality associated with smoking. Oncology nurses can influence smoking behaviors in a variety of settings and populations. The opportunity exists in outpatient treatment or screening clinics, hospital patient care areas, support groups, family education, and interactions with co- workers and friends. The intent of this article is to increase the awareness of the need and purpose for smoking cessation education within oncology patient care settings and to provide an overview of current smoking cessation education strategies. SMOKING CESSATION ASSISTANCE AFTER A CANCER DIAGNOSIS Knowledge of effective smoking cessation inter- ventions for patients with cancer is limited. Many false assumptions and attitudes exist regarding the necessity and importance of addressing smoking ces- sation among cancer patients such as, "all people who are diagnosed with cancer automatically quit smoking" or "what is the benefit of quitting for someone diagnosed with cancer?" A recent survey of >2,500 cancer patients ad- mitted to M. D. Anderson Hospital showed a current smoking rate of 34.6% for men and 31.8% for women (8). The preliminary results of a National Cancer Institute Cooperative study designed to evaluate smoking patterns and cessation interventions in early stage cancer patients within 1 year of the initial diagnosis found a smoking rate of 17% (9). Oncology nurses may often see patients who make an attempt to quit smoking at the time of diagnosis, but relapse rates are high. Davison (10) studied the smoking habits of long-term lung cancer survivors and reported that 56% of the patients who smoked had stopped prior to their surgery, but the majority resumed smoking within 1 year of diagnosis. Although smoking cessation after the diagnosis of inetastatic or advanced cancer may have limited benefits and may create an unnecessary burden for Canoer KwtrRr. Vol. 1!. No. 3.1991 patients with a poor prognosis. there are multiple reasons to advocate smoking cessation among patienu who have the potential for cure (11-15). 1. Reduced risk of disease recurrence 2. Reduced risk of heart and lung disease and second malignancies 3. Improvements in therapy tolerance 4. Decreased risk of pulmonary infections 5. Improvement of lung and cardiac function 6. Improved quality of life There is a reduced risk for future malignancies. Tobacco use is strongly implicated in the development of subsequent malignancies and increases the risk of disease recurrence in persons with cancers of the head and neck (12,13). Moore (12) followed 203 patients who had been cured of cancer of the oral cavity, pharynx, or larynx, and reported that 40% of patients who continued to smoke developed second cancers, compared to a 6% rate of recurrence among patients who had stopped smoking. Smoking has been asso- ciated with more rapid development of metastasis in women over 50 years of age with breast cance: ( I4). Because cigarette smoking affects multiple organs, smoking cessation will decrease the risk of respiratory and cardiovascular disease among long-term survivors and also may reduce the risk of developing second malignancies. Patients will experience improvements in therapy tolerance such as improved sleep, appetite, sense of taste and smell, and energy level. In a survey of patients with lung cancer, those who stopped smoking felt that the benefits of quitting contributed to an improved quality of life (15). Cigarette smoking causes excessive secretions and a predisposition to pulmonary infections. Cancer patients who smoke will continue to compromise their fespiratory and cardiac function. This is critical for patients whose lung or cardiac function may already be compromised by resectional thoracic surgeries, infections, chemo- therapy agents with pulmonary or cardiac toxicities, or chest irradiation. There are several factors potentially complicating smoking cessation for patients with cancer (8). The lack of perceived health benefits once a cancer is diagnosed may be experienced. Many patients are extremely nicotine dependent and often have impair- ments that make chewing nicotine gum difficult or impossible. Patients often have strong defensein{ech- anisms such as denial to justify their conti4ued smoking. The stress of the diagnosis and treatment make trying to quit smoking very difficult. Wle are dealing with a life-threatening illness; thercfore. ~ C'? O ~ ~ ©

INTERVENTION STRATEGIES FOR SMOKING CESSATIOh' I I I I I smoking cessation may not be a high priority for many individuals. The preliminary results of a National Cancer Institute (NCI) cooperative study in early stage cancer patients are very positive and speak to the need to address smoking cessation in this population (9). Approximately 1,300 patients in outpatient oncology settings were asked to complete a smoking question- naire. Of the 625 eligible participants, 66% expressed a strong belief in the personal benefits of quitting, over two-thirds expressed a strong desire to quit or were seriously considering stopping smoking in the next 6 months, and over three-fourths were interested in materials to help them quit. INTERVENTION STRATEGIES Ninety-five peteent of American ex-smokers have quit on their own (16). What does "quitting on your own" really mean? It is usually not just a one-time thought with immediate success. These words can be misleading, sending the message that stopping smoking is a simple and easy thing to do without any assistance. People who "quit on their own" are motivated by mass media antismoking messages, policies that re- strict smoking, and taxation that increases the price of cigarettes. People who "quit on their own" get assistance and support from friends, family, coworkers, medical personnel, and self-help materials. Self-help manuals provide step-by-step instruc- tions for the preparations and planning necessary to make quit attempts more tolerable and successful. They are available from many organizations either free or for a minimal charge, including Freedom From Smoking For You and Your Family from the American Lung Association, Clearing the Air from the NCI, and the Patieru Stop Smoking Guide from the American Academy of Family Physicians (17-19). Physicians and other health care professionals have the opportunity to deliver widespread smoking cescation interventions. In the U.S., approximately 75% of adults visit a physician at least once annually; the average number of physician-patient contacts per year is five (20). There is convincing evidence that physicians can influence their patients to stop smok- ing. A study by Russell in England demonstrated that 5 min of physician advice about the importance of stopping smoking accompanied by educational ma- terials and a warning about follow-up produced 1- year quit rates of -5% (21). There is an increased adherence to advice to quit smoking during a serious or life-threatening illness, particularly if the symptonis are smoking-related (7,20). Nurses can also effectively influence patients to quit smoking by providing similar motivational advice or reinforcing physician advice and providing formal education and smoking cessation counseling. A study by Taylor et al. (22) concludt.t that a nurse-managed, hospital-based smoking cessa- tion intervention program significantly reduced smoking rates in patients who had had a myocardial infarction. Several factors act as barriers to physician in- volvement with smoking cessation (16,23,24). 1. Pessimism about the ability of patients' to quit smoking or influence a change in behav- ior 2. Counseling is an unfamiliar role 3. Lack of training and knowledge of resources 4. Infringement on personal freedom 5. Lack of time 6. Lack of reimbursement In my experience, similar barriers are also strongly evident among nurses. The first barrier is a pessimistic attitude of patients' ability to quit smoking or the ability to influence a change in smoking behavior. The evidence shows that health care professionals can influence patients to stop smoking even with very brief and concise interventions. In order to keep a positive outlook, reasonable goals for success should be established (7,23). It would be unrealistic to expect that any intervention will result in 100% quit rates. A second barrier is the belief that counseling is not part of the physician or nurse role. Complex coun- seling is not necessary for most smokers; direct advice and motivation are more helpful. Third is the lack of training and knowledge of resources. Yet simple protocols can be designed and incorporated into office routines. Infringement on personal freedom is another barrier. Physicians and nucses may feel that they do not want to embarrass their patients or discourage them from returning. The failure to ask about smoking can be interpreted by the patient as a sign that quitting smoking is not important or may send a pessimistic message about the belief in the patient's ability to quit. Lack of time can be a barr}et. even though smoking status can be determined ~ith a single question, "Do you use tobacco?." and it only takes a few minutes to deliver a quit smoking"F"SageA final barrier is the lack of reimbursement. Although the lack of-third party reimbursement for preventive health is often a reality, creative ways must be found to provide smoking cessation education to patients. I I I I I I 1 I I I I I Caacrr NwstRC. I iW !4. No. S. 1991 I

??8 M. A. ROSE I I I I I I I I I I I I I I I I PROVIDING EFFECTIVE EDUCATION How can we motivate and assist persons to quit smoking? The message to quit smoking must be personalized, firm, and straightforward. This message is most effective if delivered in a positive manner, offering resources, encouragement, understanding, and support; criticisms, judgments, or personal attitudes about smoking should be avoided. The role of public health interventions is to provide information that maximizes healthy choices and to assist persons who are in the process of quitting. We need to be careful not to imply moral condemnation or penalty, or stigma in our educational efforts to help people stop smoking. Our interventions may be most effective when w,! try to understand the perspective of individuals «no smoke and are trying to quit. Ninety percent of the people who smoke would like to quit, and 60% have tried (23). Smoking is a strongly reinforced habit! If an individual averages 10 puffs per cigarette and has smoked 1 pack per day for 10 years, they have had 730,000 hits of nicotine, and a person who has smoked 2 packs per day for 20 years has puffed on a cigarette nearly 3,000,000 times (19). In 1988, Surgeon General Koop issued the warning that nic- otine is as addictive as heroin and cocaine (25). Follow-up support is an important component of any smoking cessation program (7,23,24,26). Many methods can be utilized, including a scheduled follow- up visit, a personalized letter, or a phone call. All of these methods offer support that indicate a continued interest in the individual and emphasize the impor- tance of stopping smoking. STAGES OF QUITTING The process of becoming an ex-smoker has been described in terms of movement through a series of stages (27). First is the motivational stage or initial decision, second is the stage of behavioral changes, and third is•the maintenance stage. Modratioml Stsp The key motivational factor associated with suc- crssful smoking cessation is the desire to protect future health and overcome minor smoking-related symptoms (23). This is the single most important reason people have for quitting. Other factors include a sense of personal vulnerability to smoking-related health risks, a desire for greater self-control, self- esteem, confidence in their ability to quit, and the expectation of benefits from quitting such as improved health or the elimination of social pressures. There are many fears that people who smoke anticipate when they are contemplating quitting (23,24,26.28) 1. Fear of failing 2. Fear of withdrawal symptoms and unbearable cravings 3. Fear of weight gain 4. Fear of ridicule 5. Fear of inability to relax or sleep 6. Fear of emotional changes It is important to recognize and respond to these fears on an individual basis. One is the fear of failing. Fewer than 25% of smokers quit the first time they try, most take three or four attempts (24). A second is the fear of withdrawal symptoms and unbearable cravings. These symptoms are transient and, more importantly, temporary. Most urges last only 3-5 min and become less frequent over the first 7-10 days after quitting. Third, is the fear of weight gain. Only one-third of ex-smokers gain weight and gen- erally <10 pounds (23,24). The other two-thirds either lose weight or maintain their weight. Weight gain is not automatic and can be controlled by dietary restrictions and increasing physical activity. Fourth ii the fear of ridicule from smoking friends. This can be countered by enlisting support from nonsmoking friends or from others who have also quit smoking. There is also the fear of the inability to relax or sleep without smoking. The feeling of relaxation from smoking is only temporary and is related to the relief of withdrawal symptoms. Nicotine is actually a stim- ulant. Healthier alternatives to help with relaxatior include exercise, avoiding naps, and limiting the amount of caffeine ingested. The fear of emotional changes such as irritability is experienced by some. This can be dealt with by temporarily decreasing personal demands and learning stress reduction meth- ods such as relaxation techniques. Once the decision is made to stop smoking, what are the next steps? Most important is the identification of personal reasons for quitting. There are many different reasons for wanting to stoQ qrnok• ing; the stronger the reasons, the better the thance: for success. A list of personal reasons caft ~be 2 powerful reminder of the commitment to sto6 s}nok• ing later when urges to smoke are experienced. Rkea the reasons for starting smoking. Point out that wher people first begin smoking, it is awkward and probSN3 makes them feel sick. Becoming a smoker reQMrc. I I Cairrr Nwstn". Vo(. 11, No. S. 1991

I I I I I I I I I I I I I I I I 1 INTERVEA710N STRATEGIES FOR SMOKING CESSATION practice. It is important to understand that smoking is not a natural act. It is a learned behavior, therefore, people must learn new behaviors in order to quit. Identify the reasons for smoking now. Smoking is a very complex behavior, people smoke at different times for different reasons. These reasons include psychological issues, habits, social pressures, and physical dependence. They may vary from day to day depending on the situation. It is important to raise a person's awareness of what triggers their smoking patterns. Many of the self-help manuals available include written exercises to help individuals identify and personalize these issues. Behavioral Changes There are many methods that have been used to facilitate smoking cessation. Aversive strategies are designed to reduce the reinforcing value of smoking by pairing it with an aversive stimulus (28). Rapid smoking is the method of inhaling every 6 s, whereas the average smoker puffs at the rate of one puff per minut.e. Satiation is the method of doubling or tripling the normal amount of smoking. Th: possibility of physical side effects with these me- ss limits their application to individuals with hea,. .-;roblems or to pregnant women. Gradual re3uction and nicotine fading are meth- ods that decrease the physiological addiction to nic- otine and decrease withdrawal symptoms (23,28). With gradual reduction, persons gradually reduce the number of cigarettes they smoke until a predetermined quit date. A potential problem with this method is that initially it is easiest to eliminate cigarettes that are the least rewarding and enjoyable, and as the tapering occurs, persons are left with the cigarettes they enjoy the most. These last few cigarettes can become very powerful reinforcers and can be very difficult to give up. Nicotine fading is the process of switching brands gradually to lower levels of tar and nicotine. The rationale for this method is that smokers will gradually reduce their physical dependence to nicotine and the actual quitting will be easier. Nicotine fading by itself actually has little impact on cessation if the psychological component of the addiction is not addressed, but it can be effective when combined with other behavioral techniques (28). Cue extinction is another method of preparing for stopping smoking (29). The purpose and rationale are to identify the cues associated with smoking, and alter the social and psychological reinforcers that trigger smoking behaviors. The actual quitting method is cold turkey. Persons identify their favorite ritual 229 cigarettes or the cigarettes that are going to be the hardest to give up, and eliminate them before they quit. The rationale is that when a person quits, the strongest urges have already been experienced and will not be as difficult to overcome. This method also allows for the identification of cues or trigger situations that are strongly associated with smoking so that alternative behaviors or ways to avoid these situations can be planned before they quit. The purpose of nicotine gum is to help decrease the urge to smoke and minimize the withdrawal symptoms while dealing with the psychological and behavioral components of smoking. Studies indicate that the long-term effectiveness of nicotine gum is improved when it is used in combination with be- havioral counseling (30). Instructions for proper use are important (31,32). Nicotine gum should be thought of as medication, and not gum. Nicotine gum should be chewed very slowly. The gum should be used on a regular schedule rather than waiting for the urge to smoke. Nicotine gum is intended solely for use while stopping smoking. It is not to be used to cut down on cigarettes. The recommended length of use is 3-6 months. Then a method of reduction should be planned--either by decreasing the daily amount by one piece of gum every week, cutting the gum in half and using only half pieces, or alternating nicotine gum with regular chewing gum. Nicotine gum is contraindicated for pregnant women, patients with oral or pharyngeal in8ammation, temporoman- dibular joint disease, a history of esophagitis, peptic ulcer, coronary heart disea.se, cardiac arrythmias, or hypertension. Nicotine gum is considered to be more useful for smokers who have a high physiological dependence to nicotine-generally those who smoke 25 or more cigarettes a day and -those who have experienced severe withdrawal symptoms in previous quit attempts (23). Before prescribing nicotine gum, it is important to assess individual physical addiction to nicotine. The Fagerstrom nicotine tolerance scale is a useful tool to determine the degree of nicotine dependence (33). It includes questions that examine smoking habits such as the number of cigarettes that are smoked daily, the tar/nicotine rating of the brand of cigarettes, when the first cigarette of the day is smoked, and patterns of inhaling. The highest pbssible score is l1; a score of Z7 indicates that a petson is highly nicotine dependent. Whatever method is utilized to quit smoking, a critical factor for succest is selecting a quie date. Setting the target date for quitting confirms the cr,mmitment and is the most universally agreed upon CeMa. NWsuW. t -rd. 1 t. No. S. 1991 I

230 at. A. ROSE I I I I I I I I I I I I I I I I I I component of physician-delivered advice (7). It is essential to prepare for the quit date by throwing away cigarettes and smoking paraphernalia, and plan- ning activities during the first few days with non- smoking friends. Maintenance The third stage of becoming an ex-smoker is maintenance. A period of 6 months must elapse before a person is at relatively low risk of relapse (7). There are several situations known to pose high risk for the relapse of smoking (34). Social situations tend to be particularly difficult times due to social drinking and exposure to smoking. Times of relaxation such as following a meal are strongly reinforced situations for many people. Work can create smssful and anxiety-producing situations, where in the past smok- ing provided a tension release. Unusual life events, such as vacations and holidays, can be difficult ex- periences when faced for the first time as a nonsmoker. Stressful life events such as a change of job, divorce, death, or illness are high relapse situations. How can these critical relapse situations be effectively handled? Self-management techniques are reinforcement systems that should be put in place before quitting (17,18). Contracts can be written with a friend - or family member to help get through difficult times. A system of rewards, proportional to the achievement, should be developed and utilized for both short-term and long-term goals. It is impor- tant that plans are made for immediate rewards that can be personally reinforcing. Encourage individuals to develop a buddy system or means of social support with nonsmokers or friends who have quit. Provide information on stress management techniques such as deep breathing and relaxation exercises. Help individuals to develop an appropriate physical exercise or a weight gain management program. It is important to discuss realistic exercise tolerance expectations and avoid severe dietary re.sirictions; otherwise, adopting all of these citanges at once can become overwhelming and unsueaessful. Most important is the need for individuals to identify and anticipate stressful situa- tions and prepare for them in advance. A slip should be thought of as a small setback and not a total failure. Slips should be viewed as an opportunity to learn what triggered the urge to smoke and to plan for future similar situations. SUMMARY Oncology nurses can only be effective role models and educators if we understand the methods that can Caro NunirtC. Vol. 14, No. S. 1991 best assist individuals to stop smoking and if we provide this assistance in a compassionate, but firm approach. The vast majority of individuals who smoke would like to quit; therefore, it is easy to identify those who may require our assistance. We need to continue to identify and develop effective interven- tions, and determine what we can do to encourage and assist persons who are at the "trying to quit" stage. D REFERENCES 1. The surgeon general's 1989 report on reducing the fieatth consequences of smoldttg 25 years of progtesi VMti'R 1989;38 (Suppl S2). 2. U.SD.H.H.S., Office on Smoking and Health. The health carts[quences of smoking: cancer. A reporr of tRe swgeoie generaL Washington, DC DHHS (PHS) 82-50179. 1982. 3. American Cancer Society. Caruer,facts and frgures-1990. New Yor(<: American Caneer Society, 1990. 4. U.S. Cot>aresa Office of Tecttnolop Assessment. Smoking- re/ate,d deaths and financial costs. OTA Staff Memorandum. Setnember 1985. 5. Fielding IE. Phenow KJ. Health effects of invoiuatuy smoking. N Ertg/ J Med 1988:319:1452-60. 6. National Research Council. Committee on Psmive Smoicine. Ertrhorvxerual tobacco s•nioke: measuring expo.tuns and as- senirtg healgh effects. Wnhington. 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I I I I I I I I 1 I I I I I I I I INTERVEh77ON STR4TEGIES FOR SMOKING CESS4TION 231 20. Ockene JK Sachs DP. Solberg L. Sure-fire smoking cessation. Pattent Care 1988L2-1:83-116. 21. Russell M.A. Wilson C, Taylor C. Baker CD. Effect of general practttioners' advice against smoking. Br Med J 1979:2:231-5. 22. Taylor CB. Houston-Mi11-r N, Killen JD. DeBusk R.F. Smoking cessation after acute myocardial infarction: effects of a nurse- managed intervention. Ann lnternMed 1990:113:1 18-23. 23. Orleans CT. Smoking cessation in primary rare setting. NJ Med 1988:85:116-26. 24. Hughes JR. Kottke T. Doctors helping smokers. Real world tactics. Minn Med 1986:69Z93-5. 25. U.S.D.H.H.S., Office on Smoking and Health. The health consequences of smolcing.• ntcottne addiction. A report of the surgeon general. Rockville. MD: DHHS (CDC) 88-8406, 1988. 26. Orieans CT. Undttstanding and promonn` smoking cessation: overview and Euideiina for physician intervention. Annu Rev Med 1985:36:51-61. 27. Ivetson DC. Smoking oontrol pnograms: premises and prontises Am J Xealth Prom 1987;1:16-30. 28. Alexander L. Patient smoking cessation: treatment strategles. Nurse Pract 1988:13:27-37. 29. Bishop D. French R. Rose MA. Smoking cessatton protocol for pnmary care phvstcran's offices. NCI Concept xCCC-88- 008. July, 1988. 30. Kamarack TW. Lichtenstein E. Current trends in clinic-ba_sed smoking control. Ann Behav Med 1985:7:19-23. 31. Schneider N. How to use nicotine gum and other strategies to qutt smoking. New York: Simon and Schuster, 1988. 32. Oregon Health Sciences Unive:sity. A patient guide to nicotine reduction therapy: how to use nicorette medicine. Portland, OR: Oregon Health Sciences Univasity, 1989. 33. Fagerurom KO. Measuring degree of physial dependence to tobacco smoking with ttference to individualiutton of treat- ment. Addtct Behav 1978:3:235-41. 34. Schiffman S. A duster-analytic ciasrifiation of smoking telapse epssodes. Addict Behav 1986;11:295-307. Co+tte- NiasrW. tbl. 14. No. S. 1991 I