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Using evidence-based guidelines to help patients stop smoking


No matter where you work, you’re likely to encounter many patients with tobacco-related illnesses, which kill at least 440,000 Americans annually. Treating tobacco use and dependence is no longer optional. Helping smokers quit is now an expected part of good nursing care.

The American Nurses Association urges all nurses to provide tobacco-dependence treatment and to engage in other aspects of tobacco use prevention and control. Even if you didn’t learn about smoking cessation during your nursing education, new science-based guidance is available to help you intervene. The U.S. Public Health Service (PHS) guideline, Treating Tobacco Use and Dependence: 2008 Update (available at www.surgeongeneral.gov/tobacco) is an evidence-based clinical practice guideline you can readily adopt to your daily practice. The key is to offer every patient evidence-based therapy to quit.

Two parts of the problem

Tobacco dependence is a two-part problemóa physiologic component caused by nicotine addiction and a behavioral component arising from repeated tobacco use in certain situations (for example, when getting into a car, when under stress, or when socializing or drinking alcohol). Treating tobacco dependence is most successful when it addresses both components.

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.

Nicotine withdrawal

Nicotine deprivation creates cravings and withdrawal symptoms. The most common signs and symptoms of nicotine withdrawal are depression, insomnia, irritability, frustration, anger, anxiety, poor concentration, restlessness, increased appetite, weight gain, decreased heart rate, and cravings.

Smokers may complain that stress leads them to abandon their cessation attempt, when actually they may be having nicotine withdrawal symptoms that they feel as stress. Most withdrawal symptoms diminish a few weeks after a quit attempt, but some may continue for months. Cigarette cravings, on the other hand, can persist for years.

If you care for hospitalized patients who smoke, you may observe nicotine withdrawal symptoms. If you’re able to distinguish these from symptoms related to the underlying cause of hospitalization, you can develop a care plan that addresses the patient’s smoking-related needs.

Cessation strategies

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.


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. (See Drugs used to treat tobacco dependence by clicking on the PDF icon above.)

Approved agents fall into two main groups:

  • nicotine replacement therapies (NRTs), which contain nicotine and minimize withdrawal symptoms
  • drugs that act at various neurotransmitter levels to minimize nicotine cravings.

Patients in withdrawal commonly benefit from NRTs. Although currently available products deliver nicotine to the brain and minimize withdrawal symptoms, none acts as quickly as tobacco-smoke delivered nicotine. Thus, you’ll need to work with your patient and the physician to ensure selection of the appropriate drug and dosage to minimize withdrawal symptoms.

For pregnant women, adolescents, noncigarette tobacco users, and light tobacco users, the PHS guideline makes no recommendation for medication useóeither because of safety concerns, lack of evidence that the drugs are effective, or inconclusive research results in these populations.

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 (see “Assist” below). 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 (see “Advise” above).

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.

A simple way to arrange for follow-up is to make a referral to the telephone quitline, which can conduct the follow-up and ensure the patient continues to receive support long after he or she leaves your direct care. In some settings, a fax referral or phone call to the quitline while the patient is still hospitalized can help ensure in advance that the patient gets follow-up treatment.

Condensing the 5As. If time is especially short, you might want to condense the 5As into “AAR”:

  • Ask patients about tobacco use.
  • Advise tobacco users that quitting is the best thing they can do for their health.
  • Refer tobacco users to the telephone quitline or other cessation service available in your facility or community.

Motivating smokers to quit

Some smokers are reluctant to consider quitting because they’ve made unsuccessful attempts in the past. The PHS guideline recommends using motivational strategies that help them understand the pros and cons of continued smoking and of quitting. You may want to discuss the patient’s concerns and fears as well as the health benefits of quitting. And rememberóeven patients who say they’re not ready to quit should receive information about available resources.

Fewer than 5% of smokers who try to quit without clinical assistance will still be nonsmokers 12 months later. Any help you provide to encourage quitting increases the chance of success. Let smokers know it’s never too late to quit. Research shows that quitting has both immediate and long-term benefits. Regardless of age or how long a person has been a smoker, quitting is always beneficial. (If you’re a smoker yourself and want to quit, or seek additional resources to help patients quit, visit www.tobaccofreenurses.org.)

Helping patients quit smoking is one of the most important things you can do to protect a patient’s health. If each of the 2.9 million nurses in the United States could help four smokers quit smoking, we could reach 11.6 million smokersóapproximately 25% of U.S. smokers.

For a summary of the 5As framework for helping patients quit visit www.AmericanNurseToday.com.

Selected references

Centers for Disease Control and Prevention. Cigarette smoking among adultsóUnited States, 2007. MMWR. 2008;57(45);1221-1226. www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a2.htm. Accessed November 25, 2009.

Clinical Practice Guideline: Treating Tobacco Use and Dependence. 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf. Accessed November 13, 2009.

Office of Public Health and Science, U.S. Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General, 2004.www.surgeongeneral.gov/library/smoking
consequences. Accessed November 25, 2009.

Linda Sarna is a professor in the School of Nursing at the University of California, Los Angeles. Stella Aguinaga Bialous is the president of Tobacco Policy International in San Francisco, California.

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