Smoking is both a physical addiction and a physiological habit that can become deeply ingrained in an individual’s daily routine. As of 2013, 19% of the adult population (43.8 million adults) smoke, and The Centers for Disease Control and Prevention identified smoking as the number one preventable cause of death in the United States⁷. Among current U.S. adult smokers, 68.8% report that they want to quit completely, and millions have attempted to quit smoking⁷.

Approximately 70% of current smokers visit their primary-care physician each year, thus there exists an opportunity for effective smoking cessation interventions⁹. This, combined with the reported level of interest in quitting is positive news for health care provider teams across the nation. It is up to health care providers to implement internal smoking cessation processes so that at the absolute minimum each patient encounter includes an assessment of the patient’s medical and smoking (including past quitting attempts) history. With that information the patient can then fall into the correct step of a provider directed smoking cessation plan.

Health care teams across the nation have built upon the research done by James O. Prochaska, Ph.D., John Norcross Ph.D., and Carlo DiClemente Ph.D. in regards to their trans-theoretical model of behavior change¹¹. This model is commonly referred to as the six stage model of behavioral change. It consists of:
● Pre-contemplation
● Contemplation
● Preparation
● Action
● Maintenance
● Termination
This model is useful for planning teams because it establishes the different stages that a health care provider may find a patient undertaking the goal of quitting smoking. Each stage of behavioral change involves different levels of patient readiness (readiness to change) ¹¹. The goals for health care providers using this model will be to identify the patient’s current stage, create a plan to move on to the next stage, implement the patient’s plan in order to reach the pre-defined goals, and help the patient move forward onto the next stage of change.

The interactions and interventions that occur in each stage can vary tremendously on a case by case basis. Listed below are rough guidelines to potential questions, issues, and intervention solutions per stage.

• At this stage patients may have little to no interest in changing their behavior, and may even be defensive¹².
• Timing of educational efforts is crucial, and patients should not be pressured or “hard-sold” to change.
• In order for the patient to move to the following step, they will need to overcome any denial (“I don’t have a smoking issue”) and acknowledge smoking as a problem¹². Educating the patient about available resources can be valuable at this stage.
• The patient may be defensive towards any health benefit claims. If so, try to connect on a personal note by asking questions that may get them thinking about the possibility of quitting smoking.

● This stage differs from the Pre-Contemplation stage in that the patient has acknowledged the smoking problem and the need to make some sort of change¹².
● Statements such as, “I really should quit, but I don’t think I can right now” are common at this stage.
● Patients acknowledge that it will be a long road ahead and that there will be roadblocks. The patient may be scared of failing.
● The objectives for health care providers at this stage of behavioral change are to reassure the patient that potential roadblocks can be overcome and that they are not alone in their struggle. Over 23.7 million people are working to quit each year_⁷.

● The patient has now decided that they will make a change and are now planning on taking immediate action (within the next 30 days). The patient is now looking for the best way to get started.
● Successful transition from the preparation stage to the Action stage and beyond relies on planning. Ask the patient about potential roadblocks or issue. Help them come up with potential solutions or answers.
● The patient may ask for a recommendation in regards to “The best way to quit”. There is no singular “silver-bullet” approach, and it is crucial that health care providers take into account the patient’s medical history, smoking history, social support system, and budget (both time and monetary) before making any recommendations¹.

● There are a variety of options that have been successful in other cases. In most cases a combination of approaches will be necessary¹². Some options are:

o Personal (Self-Help) Approaches – The American Lung Association has excellent online and print options. These options have minimal cost and can be started immediately. They are often most appealing to a highly motivated individual.
o Group Counseling (Support Groups) – Fresh Start (American Cancer Society’s Program), Nicotine Anonymous, or even online options such as quitnet.com are examples of different types of support groups. These can work great in tandem with other methods such as self-help, medication or nicotine patches. Remember, not everyone is comfortable sharing in a group session and some people find group sessions to be an incredibly stressful and uncomfortable social situation.
o Nicotine Replacement Aids (Gum, Patch, and Lozenges) – The majority of options are available over the counter nationwide. Each option does have medication and adverse potential side effects and it is highly recommend that patients are evaluated by their primary care provider before using any of these products¹⁵. The ecommended timeline of use for these products are at least 12 weeks, so cost may be factor.
o Prescription Only Nicotine Replacement Products (Nasal Spray and Inhalers) – These have a variety of medication and potential side effects, and talking with a primary care provider is necessary¹⁵. Nasal Spray and Inhalers have varying timelines of use. Both products can be extremely effective in controlling sudden urges since they provide concentrated doses (bursts) of nicotine.

● Prescription Only Medication (Chantix (Varenicline tartrate) and Zyban (Buproprion)) – Both options are available in tablet form and do not contain nicotine. Prescription Only Medication is a good option for patients who have been unsuccessful with other smoking cessation methods¹⁵. In July 2009, The United States Food and Drug Association (FDA) required both products to carry new safety information on their labeling for health care professionals citing serious risks for users taking these drugs. These risks include changes in behavior, depressed mood, hostility, and suicidal thoughts or actions¹⁵.

o Chantix (Varenicline Tartrate) acts at sites in the brain affected by nicotine. It provides some nicotine effects to ease withdrawal symptoms and blocks the effects of nicotine from cigarettes if users resume smoking⁴. It is not recommended for people under 18 years of age.
o Zyban (Buproprion) contains the same active ingredient as the antidepressant Wellbutrin¹⁵. The FDA reports that, “Zyban helps users abstain from smoking; however, the precise means by which it accomplishes this is unknown¹⁵”. It is highly recommended that patients talk to their health care professional about the risks and benefits of smoking cessation treatment with antidepressant medicines⁴. This product is not recommended for people under 18 years of age.

● Alternative Smoking Cessation Methods (Acupuncture, Laser Acupuncture, Hypnosis, and Herbal Remedies) – A patient may inquire about alternative methods of smoking cessation. Hypnosis is the most popularly used, of the four options listed above, however in all four cases availability and cost may be issues. It is recommended that health care providers become aware of local alternative method providers in the event that a patient should inquire.

● The patient has acknowledged the problem, planned a course of action, and is now on their way towards quitting. This can be an extremely difficult time for the patient, relapses may occur and frustration may set in. It is crucial for health care providers to help provide positive reinforcement throughout this stage.
● The American Cancer Society estimates that only about 4% to 7% of people are able to quit smoking on any given attempt without medicines or other help. The rates for people using medication and a combination of methods can increase to 20%³. It is crucial that health care providers reassure the patient by mentioning that they are by no means alone.
● The action stage may feature multiple relapses into previous stages. This is completely normal and to be expected¹². Positive reinforcement is necessary in order to help the patient move into the following stage.
● At minimum, it is recommended that the patient’s primary health care provider be notified of the patients plan to quit smoking¹. Encouraging the primary health care provider to aid in positive reinforcement can be extremely beneficial.
● It is also crucial to find ways to document any nurse interventions (counseling) in the patient’s medical history for future reference⁸.

● If the patient has been discharged, arrange for counseling and follow-up. The American Cancer Society and American Lung Association have references to
organizations who can call to follow up with patients about their smoking cessation program¹. Depending on the patient’s background, help arrange for language-specific or ethnicity-specific programs. For example, a Hispanic male with limited English will be better suited by a follow up program conducted in Spanish.

● The patient has now been smoke-free for at least six months and is working to become completely (life-time) smoke-free.
● Depending on the patient’s status within your organization, arranging appropriate outpatient counseling or follow-up programs may be necessary. Remember, the patient is making a significant life change that will have positive effects on their overall health. The health care provider’s role is to support this decision as thoroughly as possible.
● Relapses may occur. Positive reinforcement is crucial in order to help the patient get back on track towards quitting completely¹². The patient has not failed; remind them that the journey is not over.

● The final step in the process, this is a complete absence of smoking urges and complete self-assurance as a non-smoking individual. It is important to remember that the patient has successfully battled an addiction. This is not easy and is a case worth celebrating⁸.

● Help the patient think of how they are going to celebrate certain milestones (How are they going to celebrate year 2, 5, 10?).
● If the patient is interested, ask them if they would like to get involved with support groups or find a way to share their story with others. In order for an organizational smoking cessation program to be successful it must be able to successfully move patients through the 6 stages of behavioral change¹.

In order to facilitate this movement, patient education and counseling is necessary. Although the Surgeon General recommends that health care providers routinely counsel patients to quit smoking and arrange for outpatient follow-up services, many hospitals fail to provide counseling or to arrange for such follow-up¹.

Health care providers around the nation are finding creative ways to implement smoking cessation programs. Some key parts of different successful smoking cessation programs include:
● A trained unit based nurse leader – Successful programs often identified one nurse leader per unit who could identify smokers, provide them with a self-help quit smoking guide or pamphlets, and can train additional nurses how to provide counseling⁸.

o Successful organization also created quick informational packets or folders filled with self-help quit smoking information. This folder included local support information, and supplemental health benefit information that the patient could then review at their convenience¹. Often times this was given to the patient during admission after the patient was identified as a smoker.

o Clinical staff should be consistently trained on the 5A model for tobacco cessation treatment:

▪ Ask about tobacco use at every visit.
▪ Advise patients to quit.
▪ Assess readiness to quit.
▪ Assist with quitting through counseling and medication.
▪ Arrange follow-up care.

● Consistent bedside counseling – Building on the Surgeon General’s clinical practice guidelines, a trained staff nurse visits the patient at the bedside in order to assess their initial level of readiness to quit and then advise and assist in quitting. All patients who smoke receive an informational packet at the time of admission to the unit. Future counseling depends on the patient’s current level of readiness to change (6 Stage Model).

● Documenting the counseling – Find ways to include any smoking cessation counseling as “patient education” and include it in their medical record². This is extremely helpful for following up with a patient after 1 year, 2 years, etc.

● Involving the Primary Care Provider – With successful documentation the patient’s primary care provider can be informed of what went on during each nurse intervention and can play a valuable support role in helping the patient through the different steps of change⁸.

● Referral upon discharge to an outpatient counseling program – There are many free support organizations that can help health care providers by providing the absolutely crucial follow-up necessary to help a patient make a change in their smoking behavior. Successful programs found ways to refer patients to the group that was most likely to help.

The above listed items are not all-inclusive and are not the only ideas possible. They represent ideas that have been pulled from successful smoking cessation programs across the United States. In most cases, the programs were started in a single unit or department, tested and tweaked, and then expanded within the organization.

As the single largest preventable cause of death within the United States, smoking cessation programs are absolutely crucial to improving the level of patient care. Battling
an addiction is difficult, but through smoking cessation programs health care providers have the opportunity to help patients improve their lives and the lives of the loved ones that surround them.

1. Agency for Health Care Research and Quality. (2012 Update). Nurse-Led Program Increases Provision of Cessation Counseling to Inpatients Who Smoke.
http://www.innovations.ahrq.gov/content.aspx?id=2325#1
2. Agency for Health Care Research and Quality. (2008). Treating Tobacco Use and Dependence http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf
3. American Cancer Society. (2012). A Word about Quitting Success Rates. http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-q
uitting-smoking-success-rates
4. American Cancer Society. (2012). Guide to Quitting Smoking – Prescription Drugs. http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-help-phys-rx-drugs
5. Campaign for Tobacco-Free Kids. (2010). Toll of tobacco in the United States of America. http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf.
6. Centers for Disease Control and Prevention. (2013). Implementing Tobacco-Use Cessation Programs. http://www.cdc.gov/workplacehealthpromotion/implementation/topics/tobacco-use.html
7. Centers for Disease Control and Prevention. (2013). Smoking Cessation Fact Sheet. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/#use
8. Center for Tobacco Research and Intervention at The University of Wisconsin School of Medicine and Public Health. (2011). Developing a Successful Hospital-wide Tobacco Cessation Program to meet The Joint Commission Tobacco Measure Set. http://www.ctri.wisc.edu/HC.Providers/h0spit8ls/PagesfromSect2pgs912117112.pdf 9. Fiore, Michael C. M.D., M.P.H., M.B.A., and Baker, Timothy B. Ph.D. (2011). Treating Smokers in the Health Care Setting. New England Journal of Medicine.
365:1222-1231. DOI: 10.1056/NEJMcp1101512
10. Joint Commission. (2012). Tobacco Treatment Measurement Set. http://www.jointcommission.org/assets/1/6/Tobacco_Treatment_Measures_List.doc.pdf
11. Prochaska, J.O. and DiClemente, C.C. (1984). The Transtheoretical approach: Crossing the Traditional Boundaries of Therapy. Melbourne, Florida: Krieger Publishing
Company.
12. Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for Good. New York: Morrow
13. Smith SS, McCarthy DE, Japuntich SJ, et al. Comparative Effectiveness of 5 Smoking Cessation Pharmacotherapies in Primary Care Clinics. Arch Intern Med
2009;169:2148-2155
14. Surgeon General.gov. (2010). A Report of the Surgeon General: How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable
Disease ; http://www.surgeongeneral.gov/library/reports/tobaccosmoke/index.html
15. United States Food and Drug Administration. (2012). FDA 101: Smoking Cessation Products. http://www.fda.gov/forconsumers/consumerupdates/ucm198176.htm