Tobacco cessation intervention in a nurse practitioner managed clinic

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

Transtheoretical Model-based Nursing Intervention on Lifestyle Change: A Review Focused on Intervention Delivery Methods

PURPOSE

The transtheoretical model (TTM) was used to provide tailored nursing for lifestyle management such as diet, physical activity, and smoking cessation. The present study aims to assess the provision of intervention delivery methods, intervention elements, and stage-matched interventions, in order to identify ways in which information technology is used in the TTM-based research.

METHODS

The relevant literature was selected by two researchers using inclusion criteria after searching for "TTM (transtheoretical or stage of change)" and "nursing" from the databases PubMed and CINAHL. The selected studies were categorized in terms of study characteristics, intervention delivery method, intervention element, and use and level of stage-matched intervention.

RESULTS

A total of 35 studies were selected including eight studies that used information communication technology (ICT). Nine different intervention delivery methods were used, of which "face-to-face" was the most common at 24 times. Of the 35 studies, 26 provided stage-matched interventions. Seven different intervention elements were used, of which "counseling" was the most common at 27 times. Of all the intervention elements, tailored feedback used ICT the most at seven instances out of nine, and there was a significant difference in the rate of ICT usage among intervention elements.

CONCLUSIONS

ICT is not yet actively used in the TTM-based nursing interventions. Stage-matched interventions and TTM concepts were shown to be in partial use also in the TTM-based interventions. Therefore, it is necessary to develop a variety of ways to use ICT in tailored nursing interventions and to use TTM frameworks and concepts.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Stage-based interventions for smoking cessation

BACKGROUND

The transtheoretical model is the most widely known of several stage-based theories of behaviour. It proposes that smokers move through a discrete series of motivational stages before they quit successfully. These are precontemplation (no thoughts of quitting), contemplation (thinking about quitting), preparation (planning to quit in the next 30 days), action (quitting successfully for up to six months), and maintenance (no smoking for more than six months). According to this influential model, interventions which help people to stop smoking should be tailored to their stage of readiness to quit, and are designed to move them forward through subsequent stages to eventual success. People in the preparation and action stages of quitting would require different types of support from those in precontemplation or contemplation.

OBJECTIVES

Our primary objective was to test the effectiveness of stage-based interventions in helping smokers to quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('stage* of change', 'transtheoretical model*', 'trans-theoretical model*, 'precaution adoption model*', 'health action model', 'processes of change questionnaire*', 'readiness to change', 'tailor*') and 'smoking' in the title or abstract, or as keywords. The latest search was in August 2010.

SELECTION CRITERIA

We included randomized controlled trials, which compared stage-based interventions with non-stage-based controls, with 'usual care' or with assessment only. We excluded trials which did not report a minimum follow-up period of six months from start of treatment, and those which measured stage of change but did not modify their intervention in the light of it.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the dose and duration of intervention, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up.The main outcome was abstinence from smoking for at least six months. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where reported. Where appropriate we performed meta-analysis to estimate a pooled risk ratio, using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We found 41 trials (>33,000 participants) which met our inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component. Stage-based versus standard self-help materials (two trials) gave a relative risk (RR) of 0.93 (95% CI 0.62 to 1.39). Stage-based versus standard counselling (two trials) gave a relative risk of 1.00 (95% CI 0.82 to 1.22). Six trials of stage-based self-help systems versus any standard self-help support demonstrated a benefit for the staged groups, with an RR of 1.27 (95% CI 1.01 to 1.59). Twelve trials comparing stage-based self help with 'usual care' or assessment-only gave an RR of 1.32 (95% CI 1.17 to 1.48). Thirteen trials of stage-based individual counselling versus any control condition gave an RR of 1.24 (95% CI 1.08 to 1.42). These findings are consistent with the proven effectiveness of these interventions in their non-stage-based versions. The evidence was unclear for telephone counselling, interactive computer programmes or training of doctors or lay supporters. This uncertainty may be due in part to smaller numbers of trials.

AUTHORS' CONCLUSIONS

Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in July 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed effect model and reported the outcome as a risk ratio (RR) with 95% confidence interval (CI).

MAIN RESULTS

Forty-two studies met the inclusion criteria. Thirty-one studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the likelihood of quitting (RR 1.28, 95% CI 1.18 to 1.38). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. In a subgroup analysis there was weaker evidence that lower intensity interventions were effective (RR 1.27, 95% CI 0.99 to 1.62). There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Nine studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow up.

Measuring quality in nurse-managed centers using HEDIS measures

Nurse-managed centers (NMCs) provide viable options for primary healthcare and contribute substantially to filling access gaps for vulnerable populations. The purposes of this paper are to (a) describe a pilot application and adaptation of eight Health Plan Employer Data and Information Set (HEDIS) measures to six NMCs, (b) report the findings from the quality assessments, and (c) compare findings to national HEDIS data. The eight quality assessment areas are asthma, cervical cancer screening, childhood immunizations, depression, diabetes, hypertension, mammography screening, and smoking cessation. The NMCs achieved or exceeded HEDIS 50th percentile levels in a number of important clinical areas, but did not attain the 50th percentile level in others. Thus, HEDIS measures are relevant for the assessment of care quality and provide useful data for quality improvement in NMCs.

Management of Tobacco Dependence in Older Adults: Using Evidence-Based Strategies

Reducing tobacco use is a leading goal of the nation's Healthy People 2010. To improve the health of all Americans during the first decade of the 21st century, tobacco control practices must be a top priority. Tobacco use is a chronic disease with multiple relapses, especially in older adults. Older adult smokers are often less educated, have a low socioeconomic status, are more likely to be female, and have reduced self-efficacy with the cessation process. Older adults suffer disproportionately from smoking-related diseases, yet experience physical, social, and psychological rewards from cessation. Older adults want to quit smoking and do so at similar rates of younger adults. Treating tobacco dependence in older adults should have the same consideration as treatment of other chronic diseases such as diabetes, hypertension, and hyperlipidemia. Clinicians managing the care of smokers can be effective in promoting smoking cessation, regardless of the smoker's age or duration of smoking history. The AHRQ guideline recommends clinicians ask, advise, assess, assist, and arrange follow-up for all smokers. Pharmacological and behavioral therapies are recommended to assist with the cessation process. Gerontological nurses can play a key role in optimizing health and successsful aging by reducing tobacco use in older adults.

Potential reduction exposure products and FDA tobacco and regulation: a CNS call to action

A new generation of tobacco harm reduction products is stirring controversy and confusion among healthcare providers. These products, known as "potential reduction exposure products" (PREPs), can be described in terms of reported scientific evidence, as "the good, the bad, and the ugly." On the good side, there is sufficient scientific evidence to support the use of Commit, a new over-the-counter nicotine lozenge PREP, approved for smoking cessation. On the bad side, there is no scientific evidence to support the use of Ariva, another over-the-counter nicotine lozenge PREP, marketed as an alternative to cigarettes when smoking is restricted. On the ugly side, both of these PREPs are nicotine delivery systems with "candy-like" appearances; however, one (Commit) has the Food and Drug Administration (FDA) approval and the other (Ariva) does not. This article provides an overview of PREPs and strategies to help clinical nurse specialists (CNSs) address tobacco harm reduction issues.

Women and the global tobacco epidemic: nurses call to action

BACKGROUND

Tobacco consumption is increasing among women across the globe at alarming rates. Without effective intervention, the smoking prevalence among women will nearly triple over the next generation. These trends are potentially more threatening when considering how tobacco intersects women's lives, regardless if they use tobacco products or not.

AIM

A review and analysis of the literature is conducted to examine the scope of tobacco's global effect on the multiple dimensions of women's health.

METHOD

Medline (1990-2003), Cumulative Index to Nursing and Allied Health Literature (1990-2003) and World Health Organization databases were searched for related topics. Keywords for searches included global health, tobacco, women and nursing.

FINDINGS

The epidemiology and prevalence of tobacco use among women are presented and its impact on women globally. Using an ecological perspective, the consequences of tobacco are analysed within the contexts of health, social, environment, economic and policy as it relates to women, their families and their communities.

IMPLICATIONS

Nurses are in prime positions to empower individuals, families, communities and nations in the prevention and treatment of tobacco use. Health for all women continues to be a call for equity and social justice. Recommendations are provided for nursing practice, education, theory, research and policy to address this global health concern.

Nursing interventions for smoking cessation

BACKGROUND

Health care professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in June 2003.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently.

MAIN RESULTS

Twenty-nine studies met the inclusion criteria. Twenty studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the odds of quitting (Peto Odds Ratio 1.47, 95% CI 1.29 to 1.68). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. There was limited evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Five studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found the nursing intervention to have less effect under these conditions.

REVIEWER'S CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that interventions can be effective. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

The Quality-Caring Model: blending dual paradigms

Evidence supports associations between professional nursing and quality health outcomes. Yet, what specifically accounts for those linkages remains buried in the daily practice of nursing. The Quality-Caring Model exposes and demonstrates the value of nursing within the evidence-based practice milieu of modern health care. It favors a process, or way of being, that challenges modernist conventions and highlights the power of relationships. By reaffirming the nature of nursing's work as relationship-centered, the blended model describes the 2 dominant relationships that comprise professional encounters. Relationships characterized by caring are theorized to influence positive outcomes for patients/families, health care providers, and health care systems. Model components are clarified, assumptions described, and propositions stated. Conceptual-theoretical linkages in the model are identified and ties to empirical indicators provide the logical consistency necessary for validation. Clinical practice and research applications of the model are offered. The Quality-Caring Model helps to translate the hidden work of nursing into objective terms that can be tested. Scientifically demonstrating its worth will advance professional nursing while simultaneously improving the quality of health care.

Promoting smoking cessation in adults

There is a wealth of opportunities for nurses to facilitate smoking cessation with their patients. Nurses have shown to have a modest but positive effect on cessation rates when they deliver brief or intensive counseling. Because nurses work in a multitude of clinical settings, they can impact both prevention and treatment of nicotine addiction associated with cigarette use. More nurses need to be educated about their role in reducing the morbidity and mortality of tobacco-related diseases.

The clinical leadership role of the CNS in the identification of nursing-sensitive and multidisciplinary quality indicator sets

Within a team-oriented approach to healthcare, the demonstration of quality is challenging. Multidisciplinary quality indicators ideally represent all pertinent stakeholders and are preferred when evaluating the quality of care for specific patient populations. Recently, however, nursing-sensitive indicators have been developed that reflect the unique contribution of nursing to patient outcomes. Because nursing-sensitive quality indicators reflect nursings' accountability for patient care, they must also be considered when identifying indicators sets. Controversy exists concerning the appropriate definition, number, and approach to indicator identification. Many organizations are attempting to measure everything to ensure that all appropriate indicators are represented. To incorporate both nursing-sensitive and multidisciplinary quality indicators, a phased organization-wide approach is advocated. Through clinical leadership skills combined with the advanced practice roles of consultant, educator, and researcher, the clinical nurse specialist can facilitate the inclusion of relevant indicators, preserve both multidisciplinary and nursing-sensitive approaches, and maintain efficiency during the process. The clinical nurse specialist, with clinical expertise and advanced education has a unique leadership role in the identification of the resultant critical indicator matrix.

Tobacco Dependence Curricula in Acute Care Nurse Practitioner Education

• Background Tobacco dependence is the leading preventable cause of death in the United States, yet healthcare professionals are not adequately educated on how to help patients break the deadly cycle of tobacco dependence.

• Objective To assess the content and extent of tobacco education in the curricula of acute care nurse practitioner programs in the United States.

• Methods A survey with 13 multiple-choice items was distributed to the coordinators of 72 acute care nurse practitioner programs. The survey was replicated and modified from previous research on tobacco dependence curricula in undergraduate medical education.

• Results Fifty programs (83%) responded to the survey. Overall, during an entire course of study, 70% of the respondents reported that only between 1 and 3 hours of content on tobacco dependence was covered. Seventy-eight percent reported that students were not required to teach smoking-cessation techniques to patients, and 94% did not provide opportunities for students to be certified as smoking-cessation counselors. Sixty percent reported that the national guidelines for smoking cessation were not used as a curriculum reference for tobacco content.

• Conclusions The majority of acute care nurse practitioner programs include brief tobacco education. More in-depth coverage is required to reduce tobacco dependence. Acute care nurse practitioners are in a prime position to intervene with tobacco dependence, especially when patients are recovering from life-threatening events. National recommendations for core tobacco curricula and inclusion of tobacco questions on board examinations should be developed and implemented.

Meeting national tobacco challenges: recommendations for smoking cessation groups

PURPOSE

To review the literature on model smoking cessation programs and provide an overview of the practice guidelines for intensive smoking cessation groups.

DATA SOURCES

Selected evidence-based literature and AHCPR/AHRQ clinical practice guidelines.

CONCLUSIONS

Smoking is the leading cause of preventable death in our global society and is expected to kill more people than any other disease within 20 years. Data support that most smokers want to quit and are more likely to succeed with a combination of behavioral and pharmacological support.

IMPLICATIONS FOR PRACTICE

Smoking cessation must be a priority in the delivery of patient care. Intensive interventions are more effective than brief interventions and should be available for all smokers.