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2. METHODS

Chapter 8

Support For Smoking Cessation

Jeannette Larsen

8.1 Introduction

Smoking cessation is considered an important element in both primary and secondary prevention of cardiovascular disease.The Cardiac Rehabilitation Unit supports smoking cessation through individual counselling with a nurse, smoking cessation counselling in groups and individual cessation programmes.


8.2 Evidence On The Effects Of Smoking Cessation

Tobacco smoking is the most important modifiable risk factor for ischaemic heart disease (1–3). Several studies (4–6) have calculated that smoking causes at least 25–30% of cases of acute myocardial infarction in Denmark, and 80% among young people

Support for smoking cessation

Illustration af Støtte til rygestop

Among people who have had an acute myocardial infarction, smokers have higher mortality than nonsmokers. A meta-analysis (7) estimated a 20% mortality rate among patients who have an acute myocardial infarction and continue to smoke.

These findings have never been confirmed in randomized clinical trials. The evidence is so convincing, however, that guidelines in Denmark recommend that patients with heart disease (8–10) and patients at high risk of heart disease stop smoking (11).

Many smokers who have had an acute myocardial infarction stop smoking spontaneously, but most start to smoke again shortly after admission (12;13).

Strong evidence shows that structured counselling by physicians (14), smoking cessation counsellors (15) and nurses (16) influences the rate of cessation. Support and counselling begun during admission and followed up at least one month after admission produces significantly higher cessation rates (17). Intensive counselling during admission without follow-up after admission did not seem to have any additional effect, however (18). Both individual counselling (15) and group education (19) increase the potential for sustaining cessation (20). Clear evidence indicates that nicotine replacement therapy combined with structured counselling is effective for heavy smokers, independent of the intensity of the counselling and the external setting (21). Evidence (22) also shows that bupropion, an antidepressant, has a positive effect. Nevertheless, experience is lacking in the use of bupropion among patients with heart disease, and it is therefore not routinely recommended for them.


8.3 Purpose

The purpose of smoking cessation services in the comprehensive cardiac rehabilitation programme is to support patients in quitting smoking and maintaining this.


8.4 Methods

8.4.1 Principles

Smoking cessation services are composed based on existing knowledge about activities that positively influence the cessation rate and based on a scheme developed by the Danish Council on Tobacco and the Danish Cancer Society that targets the general population. This scheme has been adapted and developed further to tackle the complex situation of the patients admitted to a hospital (23).


8.4.2 Individual smoking cessation counselling

The nurse records a smoking assessment for all patients who smoke or quit within the past 6 months at the individual consultation. The smoking assessment includes the smoking history and an assessment of the patients’ motivation for smoking cessation. The smoking assessment is recorded on a form for registering current data (available in Danish at www.CardiacRehabilitation.dk).

Patients’ smoking history
The consultation clarifies the patient’s previous experience with smoking cessation, smoking experience and present smoking profile and consumption. Patients are tested using the Fagerström Test for Nicotine Dependence (available in Danish at www.CardiacRehabilitation.dk and in English from many sources) to determine dependence and the dosage of nicotine required.

Assessment of motivation
Based on the cycle of motivation (described in Chapter 3), the nurse tries to determine patients’ motivation to quit smoking to initiate further activities if indicated. Patients are asked to state whether they have plans to quit smoking or have quit recently, and they are placed in one of the six stages in the cycle of motivation. The steps to be taken are arranged based on this placement. This section describes only the patients who are considering quitting or have begun to quit.

Patients who want to attend the group smoking cessation counselling during the intensive part of the comprehensive cardiac rehabilitation programme can agree with the nurse at the initial consultation about reducing smoking and start immediately. Patients who start to reduce smoking after the initial consultation can reduce consumption during the 10 days that elapse before the actual smoking cessation is planned.

Patients considering quitting (contemplation): The nurse’s tasks include supporting patients in overcoming their ambivalent attitudes towards quitting; informing patients about the effects of smoking and the significance of quitting on their disease and treatment; and determining whether patients want to reduce their consumption before quitting. The nurse explains nicotine replacement therapy to patients who want to cut down and supplies products.

Patients with plans to quit (preparation): The nurse’s tasks include helping patients in planning quitting; assessing whether patients should have individual support in quitting or participate in group cessation counselling; supporting patients in setting a date for quitting; and determining whether patients want to reduce smoking before quitting.

Patients in a cessation programme (action and maintenance): The nurse’s tasks include allowing patients to describe their progress in quitting; supporting patients with information on the health advantages of quitting, especially in relation to cardiovascular disease; continuing to inform about and offer nicotine replacement therapy; assessing whether patients have abstinence, including measuring the carbon monoxide concentration in expired air; and assessing the need for further follow-up.

Patients who have resumed smoking (relapse): Not all patients can quit permanently. Patients who have failed in quitting need acceptance and understanding and are therefore offered individual consultation to liberate them from guilt and help them to focus on the experience they have acquired in attempting to quit, since patients need to draw on their experience in new attempts to quit. Patients are informed to expect relapse in quitting smoking.

Nicotine replacement therapy
In the individual consultation, the nurse reviews the various forms of nicotine replacement therapy with patients. The nurse gives them two or three products, depending on their needs, a supply lasting 6 weeks. Spouses who want to quit smoking can receive nicotine replacement products for 1 week. Patients are instructed thoroughly in using nicotine replacement therapy so they do not increase the daily intake of nicotine. Patients and the professional agree on how much nicotine (lozenges, sublingual tablets, inhalers, chewing gum and patches) the patient may consume, and this is recorded in the smoking cessation form (available in Danish at www.CardiacRehabilitation.dk).The nurse monitors the patient at the next consultation, either at the first group counselling session or at the next individual smoking counselling. Symptoms of abstinence and overdose are corrected.

Carbon monoxide measurement
All patients have their concentration of carbon monoxide in expired air measured in accordance with current instructions (available in Danish at www.CardiacRehabilitation.dk). The carbon monoxide concentration is measured regularly among patients who are quitting to allow the patient to see that this parameter declines as a result of quitting.


8.4.3 Smoking cessation counselling in groups

The nurse informs patients about the group smoking cessation counselling during the initial consultation and at the first heart-health meeting and emphasizes that patients’ motivation is decisive to the success of this counselling. The group counselling is also open to the patient’s spouse or cohabitant.

The counselling is arranged as a programme of five sessions of 1.0–1.5 hours depending on the number of participants. Group counselling programmes start regularly so that patients can start as soon as they are motivated to quit. The sessions have the following themes: the patients’ smoking history, the motivation to quit, information on addiction and maintaining cessation. Nurses who are qualified smoking cessation counsellors conduct the sessions, which are structured around the following topics and relevant slides that are viewed at each session:

Group smoking cessation programme
Session Topic
1 Smoking history and ambivalence towards quitting
2 Nicotine addiction, abstinence and nicotine replacement therapy
3 High-risk situations, relaxation and distraction
4 Health benefits of quitting and the problems of weight gain
5 Maintenance and evaluation


Session 1
Smoking history and ambivalence towards quitting

The patients and smoking cessation counsellor introduce themselves and review the patients’ smoking history. Based on the cycle of motivation, the participants discuss ambivalence towards quitting, focusing on why each patient wishes to quit now. Experience from any previous attempts to quit is discussed. The counsellor reviews the relationship between smoking and heart disease and other tobacco-related disease as well as the short-term health benefits. The participants discuss why quitting is so difficult, including both physical and mental addiction. Patients’ carbon monoxide concentrations in expired air are measured at the end of the session, and the group may decide to agree on a common quitting date while considering individual needs.


Session 2
Nicotine addiction, abstinence and nicotine replacement therapy

The participants say whether they have succeeded in reducing tobacco consumption. Nicotine addiction, abstinence and nicotine replacement therapy are discussed. The results of the Fagerström Test for Nicotine Dependence are used to determine the dosage of nicotine replacement therapy. The counsellor demonstrates the various nicotine replacement products and gives the participants samples. Patients’ carbon monoxide concentrations in expired air are measured and the group agrees on a common quitting date.


Session 3
High-risk situations, relaxation and distraction

The participants evaluate their attempt to quit and are encouraged to maintain cessation. The participants who have not quit are supported in their decision to quit, and a new date for quitting is set. The participants discuss situations with a high risk of resuming smoking, such as parties and after meals and learn distraction techniques and relaxation exercises. The counsellor emphasizes the health benefits again, and nicotine replacement therapy is evaluated for each participant. Patients’ carbon monoxide concentrations in expired air are measured.


Session 4
Health benefits of quitting and the problems of weight gain

The participants discuss the health benefits after about 12 days of nonsmoking. They discuss individual weight gain and change in dietary habits, and some participants may plan a meeting with the dietitian. Patients’ carbon monoxide concentrations in expired air are measured, and the counsellor gives patients more nicotine replacement products.


Session 5
Maintenance and evaluation

The participants evaluate the cessation efforts and discuss ways of maintaining cessation. The counsellor informs about the necessity of gradually reducing nicotine replacement.The counsellor hands out certificates of participation (available in Danish at www.cardiacrehabilitation.dk) and commemorative pins.


8.4.4 Individual support for smoking cessation

Patients who do not want to participate in the group smoking cessation are offered individual support for smoking cessation with a nurse and attend the same programme as group participants but with reduced time. After the 6-week intensive programme, the physician asks patients about their current smoking habits at the planned followup consultations and offers patients a counselling session with the nurse.


References

(1) Schnohr P, Jensen JS, Scharling H, Nordestgaard BG. Coronary heart disease risk factors ranked by importance for the individual and community.A 21 year follow-up of 12 000 men and women from The Copenhagen City Heart Study. Eur Heart J 2002; 23(8): 620–626.

(2) Shaper AG, Pocock SJ, Walker M, Phillips AN, Whitehead TP, Macfarlane PW. Risk factors for ischaemic heart disease: the prospective phase of the British Regional Heart Study. J Epidemiol Community Health 1985; 39(3): 197–209.

(3) Kawachi I, Colditz GA, Stampfer MJ,Willett WC, Manson JE, Rosner B et al. Smoking cessation in relation to total mortality rates in women. A prospective cohort study. Ann Intern Med 1993; 119(10): 992–1000.

(4) Kirchhoff M, Schroll M, Hagerup L, Larsen S. [Smoking habits and risk of coronary heart disease, especially risk associated with low daily tobacco consumption.] Ugeskr Laeger 1993; 155(10): 718–721.

(5) Hein HO, Suadicani P, Gyntelberg F. Ischaemic heart disease incidence by social class and form of smoking: the Copenhagen Male Study – 17 years’ follow-up. J Intern Med 1992; 231(5): 477–483.

(6) Nyboe J, Jensen G, Appleyard M, Schnohr P. Smoking and the risk of first acute myocardial infarction. Am Heart J 1991; 122(2): 438–447.

(7) Wilson K, Gibson N,Willan A, Cook D. Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med 2000; 160(7): 939–944.

(8) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(9) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(10) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(11) Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR et al. Type 2-diabetes og det metaboliske syndrom – diagnostik og behandling [Type 2 diabetes and the metabolic syndrome – diagnosis and treatment]. Ugeskr Laeger 2000; 162(suppl 6): 1–36.

(12) The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 1996; 275(16): 1270–1280.

(13) Miller NH, Smith PM, DeBusk RF, Sobel DS, Taylor CB. Smoking cessation in hospitalized patients. Results of a randomized trial. Arch Intern Med 1997; 157(4): 409–415.

(14) Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995; 155(18): 1933–1941.

(15) Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 2002; (3): CD001292.

(16) Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2001; (3): CD001188.

(17) Rigotti NA, Munafo MR, Murphy MF, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2003; (1): CD001837.

(18) Hajek P, Taylor TZ, Mills P. Brief intervention during hospital admission to help patients to give up smoking after myocardial infarction and by-pass surgery: randomised controlled trial. BMJ 2002; 324(7329): 87–89.

(19) Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev 2002; (3):CD001007.

(20) Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000; 321(7257): 355–358.

(21) Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2002; (4): CD000146.

(22) Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2003; (2): CD000031.

(23) Mundt K, Fugleholm AM, Hedegaard AM, Jepsen JM. Rygeophør på sygehus. Fakta, metoder og anbefalinger [Hospital-based smoking cessation. Facts, methods and recommendations]. Copenhagen, Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital and National Network of Health Promoting Hospitals in Denmark, 2001.


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