:for health care professionals

• Hypertension
• Smoking
• Diabetes
• Metabolic Syndrome

According to the Heart & Stroke Foundation in Canada, Cigarette smoking is the major cause of preventable death in Canada. Contrary to popular belief, smoking is responsible for more deaths due to heart disease and stroke than deaths due to cancer. Smoking increases the incidence of all major forms of heart disease and stroke. According to the latest results from the Canadian Tobacco Use Monitoring Survey (CTUMS), for data collected between February and December 2004, just over 5 million people, representing 20% of the population age 15 years and older, were current smokers, of which 15% reported smoking daily. Approximately 22% of men were current smokers, higher than the proportion of women (17%).

More than 45,000 people will die this year in Canada due to smoking. Of those, more than 300 non-smokers will die of lung cancer and at least 700 non-smokers will die of coronary heart disease caused by exposure to second-hand smoke. Exposure to smoking is a critical health issue for nonsmokers: Regular exposure to second-hand smoke increases the chances of contracting lung disease by 25% and heart disease by 10%

Health Risks Associated with Smoking
Smoking is associated with increased risk of the following:

• Hardening of the arteries leading to premature risk of heart disease and stroke
• Frequent colds, smoker's cough, chronic bronchitis
• Gastric ulcers
• Increase in heart rate and blood pressure
• Premature and more abundant face wrinkles
• Emphysema
• Cancers - mouth, larynx, pharynx, esophagus, lungs, pancreas, cervix, uterus and bladder
• Diminished or extinguished sense of smell and taste

The bottom line is that no cigarettes are safe. Low tar and low nicotine cigarettes may be even more harmful because smokers inhale more deeply and smoke more cigarettes to get the amount of nicotine they want. Smoking is the largest preventative cause of heart disease, stroke, lung cancer, chronic lung disease, chronic bronchitis, emphysema and a major cause of mouth and throat cancer. The evidence is clear: If you smoke the odds are higher that you will end up with heart disease or stroke.

Nicotine
The direct effects of nicotine in the body include:

• Increases myocardial work load
• Acts as a potent vasoconstrictor
• Increases blood pressure

The Registered Nurses Association of Ontario in 2003 published an excellent resource for nurses and other health care professionals on how to integrating smoking cessation counselling into daily nursing practice. (Registered Nurses Association of Ontario (2003). Integrating Smoking Cessation into Daily Nursing Practice. Toronto, Canada: Registered Nurses Association of Ontario).

This important resource is a key best practice guideline. The guiding principles/assumptions about smoking cessation include:

1. Regular tobacco use is an addiction that requires support and repeated interventions.
   
   
2. The offer of assistance to quit smoking will benefit every smoker.
   
   
3. The client has the right to accept or refuse smoking cessation intervention.
   
   
4. Individual smokers deserve to be treated with respect, dignity and sensitivity, while receiving smoking cessation intervention.
   
   
5. The public values and trusts specific advice provided by nurses in the practice of their profession.
   
   
6. Nurses are key members of the healthcare team, and have a unique, credible and powerful position within the team.
   
   
7. Nurses are involved with clients at multiple entry points to care. This provides many opportunities to identify smokers and implement smoking cessation interventions.
   
   
8. Actively implementing smoking cessation interventions in every care setting will increase successful quitting.
   
   
9. Nurses who are currently active smokers have a professional responsibility and can effectively provide smoking cessation intervention.
   
   
10. Nursing students have the right to education about evidence-based practice interventions and strategies for smoking cessation.
    
    
11. Nurses have the right to education to enable them to provide the best
    evidence-based standard of care.
    
    
12. Nurses are ideally positioned to provide a leadership role related to smoking cessation at the individual, program and/or policy level.
    
    

The information provided in this resource describes a brief (1-3 minute) smoking cessation intervention:

Smoking Cessation – The Stages of Change

The Stages of Change Model was developed by Dr, James Prochaska and focuses on individuals' readiness to change or attempt to change toward healthy behaviours. Readiness to change is a key factor in success. If an individual is not prepared to stop smoking, their quit attempt is more likely to be unsuccessful. Using interventions and therapeutic strategies targeted at the specific stage of change will increase the likelihood of success. The stages of change are:

1. Pre-contemplation. Smokers "in denial" may not see health advice even applying to them. The goal at this point is to get smokers to think about changing and personalizing their risk factors.

2. Contemplation. Smokers are thinking about the barriers to quitting, such as fear and not wanting to give up something they enjoy. But they also are thinking about the benefits of quitting.

3. Preparation. This is when smokers prepare to quit. They may switch to a different brand of cigarettes or try to cut back. Now is the time to develop a personalized quit plan, which involves setting a date to quit.

4. Action. This is the point where people work the hardest, Prochaska says. There is no one right way to quit. Although most smokers prefer to quit "cold turkey" – it is not always possible for many. Tapering and fading gradually reduces the number or cigarettes smoked each day and, thus, gradually reduces the amount of nicotine in the body. Some smokers need a nicotine substitute, such as the nicotine patch, gum, spray or inhaler, or other therapy, such as Zyban ® a prescription antidepressant designed to reduce symptoms of nicotine withdrawal. Prochaska says he believes it's much better to give people three good choices or options in quitting. "If they have only one choice, such as going cold turkey, then that can be a problem. They won't be as committed," he says.

5. Maintenance. At this point, people work to prevent relapse, which is extremely common. The maintenance phase can last months or years. Smokers need to keep reminding themselves why they quit.

6. Termination. People quit for good and don't have any temptations to smoke again. Prochaska says only about 20 percent of smokers who have quit in the past five years report no temptations.
   
   

How to Determine Stage of Change:

You can determine the person's stage of change for smoking cessation by asking the question:

Have you quit smoking cigarettes?

The answer that is provided will define the stage of change:

• Yes, I have, for more than 6 months. Defines maintenance.

• Yes, I have, but for less than 6 months. Defines action.

• No, but I intend to in the next 30 days. Defines preparation.

• No, but I intend to in the next 6 months. Defines contemplation.

• No, and I do not intend to in the next 6 months. Defines pre-contemplation.

Who benefits from Nicotine Replacement Therapy?
In addition to the social, emotional, and behavioural features of smoking behaviour, there is also the feature of nicotine dependence. Nicotine has been declared an addictive drug similar to heroin or cocaine. Users of nicotine-containing tobacco products experience an unpleasant withdrawal syndrome that may include such symptoms as depressed mood, disrupted sleep, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, and increased appetite or weight gain. The extremely unpleasant nature of withdrawal from tobacco helps explain why many people who make an effort to stop smoking start up again, often within a matter of hours or days. Nicotine replacement therapy can help nicotine-dependent individuals in their quit efforts.

The FAGERSTROM TOLERANCE SCALE is a tool used to assess nicotine dependence [1] .

FAGERSTROM TOLERANCE SCALE

Smoking Resources:

• Smoking Cessation Strategies for the 21st Century (PDF)

• Integrating Smoking Cessation into Daily Nursing Practice (PDF)

• Evaluation Tools (PDF)

[1] Heatherton, T. F., Kozlowski, L. T., Frecker, R. C., Fagerstrom, K. O. (1991). The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addictions, 86, 1119-1127.

Additional Resources:

Education for Health Care Professionals

Education for Patients

CLNN's Cholesterol Guide