Tobacco dependence is a chronic condition that leads to significant morbidity and mortality. An estimated 500 million individuals now alive will be killed by tobacco products, and by 2020, tobacco is expected to kill more individuals than any single disease (World Health Organization, 1999). Although smoking in the United States declined moderately during the past decade, approximately one in four adults continues to smoke (American Cancer Society [ACS], 2004). Elderly smokers carry the greatest burden of smoking-related diseases and associated health care costs (U.S. Department of Health and Human Services [USDHHS], 2000).
Reducing tobacco use is a key component for Healthy People 2010, the national action plan for improving the health of all Americans during the first decade of the 21st century (Centers for Disease Control and Prevention [CDC], 2002). An estimated 70% of smokers want to quit, and 46% make an attempt each year (USDHHS, 2000). Older adults have the same quit rates as young adults, and even brief interventions are effective in smoking cessation (USDHHS, 2000).
It has been well documented that nurses are effective in delivering tobacco cessation interventions in a variety of care settings (Allen, 1996; Andrews, Tlngen, & Harper, 1999; DeBusk et al., 1994; Gebauer, Kwo, Haynes, & Wewers, 1998; GrahamGarcia & Heath, 2000; Hollis, Lichtenstein, Vogt, Stevens, & Biglan, 1993; Reeve, Calabro, & Adams-McNeill, 2000; Rice, 1999; Stanislaw & Wewers, 1994; Taylor, Houston-Miller, Killen, & DeBusk, 1990). Nurses in gerontological settings can make a significant impact on the nation's leading cause of preventable death with effective tobacco control practices.
This article examines tobacco dependence, specific health risks from chronic smoking, and benefits of smoking cessation for older adults. Evidence-based behavioral and pharmacological approaches to smoking cessation interventions are provided with implications for nurses in gerontological settings.
The chief physiological obstacle in quitting smoking at any age ís the addictive nature and chronic dependence of nicotine. Tobacco dependence has gripping effects and often is underestimated by its users. Eighty-one percent of current smokers express they would not initiate smoking again if they had the choice (Office on Smoking and Health, 1996).
In 1988, the U.S. Surgeon General issued a report that concluded cigarettes and other forms of tobacco are addictive and that nicotine is the drug in tobacco that causes the addiction and chronic dependence (USDHHS, 1988). Tobacco dependence is characterized by compulsive drug-seeking use, even in the face of psychological and physiological negative health consequences to the individual (USDHHS, 1988).
Most cigarettes in the U.S. market contain 2* 10 mg of nicotine. The average smoker inhales 1 to 2 mg of nicotine per cigarette. A one-packper-day smoker absorbs 20 to 40 mg of nicotine, achieving a plasma concentration of 25 to 35 mg/ml by midday (Henningfield, 1995). Nicotine is absorbed and distributed to most tissues of the body, where it binds with nicotine receptors and produces physiological effects on major organs and systems in the body.
Nicotine taken in by cigarette smoking reaches the brain in only 7 to 10 seconds and has a direct effect on the body for up to 30 minutes (Henningfield, 1985; National Institute on Drug Abuse, 1998). Smokers continue dosing frequently to maintain the drug's pleasurable effects and to prevent withdrawal. Individuals who smoke one pack per day selfadminister approximately "200 hits" of nicotine to the brain in a day (National Institute on Drug Abuse, 1998).
FACERSTROM test for nicotine dependence
The effects of nicotine that are related to dependence or addiction include activation of brain nicotinic receptors, changes in regional brain glucose metabolism, electroencephalographic changes, physiological dependence, and the release of catecholamines (e.g., dopamine, norepinephrine) and serotonin (Henningfield, 1995). The effects increase the desire to smoke through positive reinforcement (nicotine effects) and negative reinforcement (withdrawal symptoms).
Psychological factors also contribute to the difficulties smokers have when they try to quit. Tobacco use is a learned behavior and becomes integrated into an individual's daily routine. Smokers associate cigarettes with certain events, such as finishing a meal or having a cup of coffee.
Smoking often becomes a mechanism for coping with stressors (USDHHS, 2000). Women especially smoke in response to negative affect. Negative affect is a broad term referring to negative mood states. Negative affect can be characterized as either high arousal negative emotions of stress (e.g., anxiety, anger, fear), or low arousal negative emotions (e.g., sadness, depression, low energy, loneliness) (Solomon & Flynn, 1993). Women are characterized as negative effect smokers in response to emotional discomfort, stress, and tension, and as a measure to reduce stress (Pohl, 2000).
The components of tobacco dependence are in concordance with other drugs that cause dependence; the properties of nicotine serve as a reinforcement to repetitive seeking behaviors and elicit and abstinence syndrome when it is abruptly withdrawn. When tobacco is stopped, there is a withdrawal syndrome characterized by irritability, anger, impatience, restlessness, difficulty concentrating, insomnia, increased appetite, and depressed mood (American Psychiatric Association, 1994).
Symptoms of nicotine withdrawal vary widely in intensity and duration, and often are not correcdy identified by smokers. Symptoms begin a few hours after the last cigarette, peak 2 to 3 days later, and wane over a period of several weeks or months (American Psychiatric Association, 1994). The Sidebar summarizes the American Psychiatric Association's diagnostic criteria for nicotine dependence and withdrawal, and Table 1 outlines the Fagerstrom test, a common diagnostic tool used to assess tobacco dependence.
SMOKING HEALTH RISKS IN OLDER ADULTS
Considered to be the most preventable cause of death, smoking is associated with all three of the major causes of death among older adults: heart disease, cancer, and stroke (ACS, 2004). Smoking accounts for approximately 430,000 deaths per year in the United States (USDHHS, 2000). Approximately half of all continuing smokers die from diseases caused by smoking. Of these, approximately half die in middle age (age 35 to 69), losing an average of 20 to 25 years of life expectancy (ACS, 2004). In other words, smoking-related deaths have their most dramatic impact on the young-old, especially those in the age range of 50 to 70. These smokers are denied the opportunity of retirement, quality health, and successful aging.
Heart disease, cancer, and stroke are associated not only with death, but also with suffering, chronic illness, and debilitating lifestyles that erode the quality of the individual's existence and increase dependency on others. Smoking exacerbates other pre-existing illnesses and conditions that are more prevalent among older adults (e.g., circulatory and vascular conditions, diabetes, osteoporosis), leading to high health care use and poor quality of life.
Tobacco use is strongly linked to cardiovascular disease, the leading cause of death in men and women (USDHHS, 2004). Significant vascular responses to nicotine include increases in blood pressure, heart rate, force of myocardial contraction, myocardial oxygen consumption, coronary artery blood flow, myocardial excitability, and peripheral vasoconstriction (USDHHS, 1990, 2004). In the Systolic Hypertension in the Elderly Program study, both men and women older than age 60 who smoked had 73% more coronary artery disease related events (e.g., myocardial infarction, coronary artery bypass surgery, angioplasty) than did non-smokers (Frost et al., 1996).
More than 4,000 chemicals have been identified in cigarette smoke, including those with antigenic, cytotoxic, mutagenic, and carcinogenie properties (USDHHS, 1998). These chemicals act directly on the oral and respiratory mucosa, are absorbed into the blood, and are dissolved in the saliva and swallowed. Multiple adverse physiological effects occur as a result of ingestion of these chemicals, with an estimated 30% of all cancer deaths and 87% of lung cancers attributed to smoking (ACS, 2004).
Smoking also is strongly associated with cancers of the kidney, bladder, pancreas, uterine cervix, mouth, larynx, and esophagus (ACS, 2004). Individuals who smoke increase their risk of cancer 10-fold compared to non-smokers; those who smoke two packs per day may increase their risk more than 25-fold (USDHHS, 2004).
Smokers are more likely to develop chronic obstructive pulmonary disease, which results in prolonged respiratory disability (U.S. Preventive Services Task Force, 1996). Cigarette smoking is associated with an increased incidence of respiratory infections and deaths from pneumonia and influenza (U.S. Preventive Services Task Force, 1996). A chronic cough, sputum production, dyspnea, and changes in pulmonary function testing (i.e., decreased forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow rate) are common in older smokers (USDHHS, 1989).
Older adult smokers often demonstrate a lack of knowledge regarding smoking-related health risks, tend to minimize the negative impacts of smoking on their health, and are more apt to minimize potential health benefits of cessation (Wilcox & King, 1999). However, they may be responsive to the health risks of their family members and loved ones. Education on the health risks of secondary smoke exposure may be an effective tool in treating older adults with a spouse, children, and grandchildren. Each year, 3,000 non-smoking adults die from lung cancer, and an estimated 35,000 to 40,000 die from heart disease as a result of breathing environmental tobacco smoke or secondhand smoke (U.S. Environmental Protection Agency, 1992). Environmental tobacco smoke causes coughing, phlegm, chest discomfort, and reduced lung function in non-smokers (ACS, 2004). Infants and children exposed to environmental tobacco smoke suffer from lower respiratory infections (pneumonia and bronchitis), asthma, and middle ear infections (ACS, 2004).
PATIENT EDUCATION HANDOUT: IT'S NEVER TOO LATE TO QUIT
Besides the lethal health risks associated with smoking and environmental tobacco smoke, nicotine interacts with medications that are commonly used in older adults, thereby altering efficacy and therapeutic drug levels. Older adults and providers often are unaware of the effects of nicotine and its interaction with other drugs (Arcangelo & Peterson, 2001). This is especially concerning because older adults tend to have a higher use of overthe-counter medications. Nicotine alters the metabolism of many drugs, causes central nervous system effects, and interferes with platelet activity (Miller, 1995). Table 2 summarizes common nicotinemedication effects and interactions.
BENEFITS OF SMOKING CESSATION
The 1990 surgeon general's report on the health benefits of smoking cessation stated smoking cessation is beneficial at any age, and older adults have been identified as an important target for national smoking initiatives (USDHHS, 1990). Studies conducted during the past several decades clearly document smoking cessation leads to immediate and long-term health benefits among all age groups.
Smoking cessation reduces the risk of tobacco-related diseases, slows the progression of established tobacco-related diseases, and increases life expectancy, even when smokers stop smoking after the age of 65 or after the development of tobaccorelated disease (USDHHS, 1990). For example, those with a previous myocardial infarction have reduced risks of reinfarction, sudden cardiac death, and total mortality if they quit (Salonen, 1980; Sparrow, Dawber, & Colton, 1978; USDHHS, 1989, 2004). Besides cardiovascular, other benefits from cessation include a reduced risk of stroke, improvements in pulmonary function, and lessened risks of smoking-induced cancers (USDHHS, 2004). Patient education handouts (Table 3) illustrate the risks of smoking and rewards of smoking cessation in older adults.
SMOKING CESSATION OVERVIEW
Tobacco dependence is a chronic disease and should be treated as such. Many smokers continue tobacco use for a number of years and typically cycle through multiple periods of relapse and remission (USDHHS, 2000). A failure to appreciate the chronic nature of tobacco dependence may reduce clinicians' motivation to treat tobacco use consistently (USDHHS, 2000). As with other chronic diseases such as diabetes, hypertension, or hyperlipidemia, clinicians managing the care of tobacco-dependent individuals must provide these patients with simple counseling advice, support, and appropriate pharmacotherapy. It is important to recognize relapse is common and is reflective of the nature of the dependence and not failure of either the clinician or the patient (USDHHS, 2000).
To date, research examining age differences in smoking-related variables with cessation has been limited. Many studies that have included older adults have not presented their data in such a way that age differences could be examined. Studies that have examined variables of current tobacco use have revealed older smokers (older than age 50) tend to be less educated, have lower levels of income, and are more likely to be women than younger smokers (Wilcox & King, 1999).
With the exception of longer smoking habits in older smokers, smoking habits and quitting histories tend not to vary dramatically by age. Compared to younger smokers, older smokers tend to minimize both the negative impacts of smoking on their health and the health benefits of smoking cessation (Rimer, 1994; Rimer & Orleans, 1993). Older smokers have been shown to have less self-efficacy in their ability to quit smoking than younger smokers (Wilcox & King, 1999).
THEORETICAL MODEL FOR SMOKING CESSATION INTERVENTIONS
The most commonly used model to promote individual smoking cessation is Prochaska's transtheoretical model of change (Prochaska & DiClemente, 1983). This model proposes that individuals adopting or changing a behavior progress through five stages:
By understanding a smoker's stage of behavior and readiness to change, clinicians can better assist smokers to achieve successful cessation.
Smokers in this stage have no intention of changing their behavior in the foreseeable future. This generally represents 30% to 40% of smokers in a typical practitioner's practice (Prochaska & DiClemente, 1983). These individuals will benefit from motivational interventions that increase the awareness of the adverse effects of smoking and the risks of passive smoking for family and friends. Clinicians should elicit smokers' views of the pros and cons of smoking and cessation, and correct any misperceptions about the health risks of smoking and the process of quitting smoking (Rigotti, 2002).
Smokers who are giving serious thought to and are interested in quitting but are not yet ready to do so have moved into the contemplation stage. These smokers also will benefit from motivational counseling with an emphasis on the negative effects of smoking. Barriers to quitting should be addressed with smokers to include acknowledgement of nicotine dependence, fear of failure, lack of social support, concern of weight gain, and depression (Rigotti, 2002).
Smokers who are serious about quitting and have taken the initial steps toward cessation (e.g., informing their family members and friends of their plan, inquiring about nicotine replacement, attempting to abstain from tobacco) are in the preparation phase. Individuals in this stage benefit from interventions such as assisting to set a quit date, determining prior successes and barriers with the cessation process, and providing information about pharmacotherapies and behavior modification skills (Rigotti, 2002).
Smokers in the action stage quit smoking. The action stage lasts from several weeks to 6 months after cessation. Clinicians should provide assistance with behavioral modification and pharmacotherapies, and arrange a follow-up visit with smokers within 1 to 3 weeks of the initial quit date. Because of the likelihood of relapse during this stage, interventions should address relapse prevention, including congratulating successes and rewarding positive behavioral changes with more frequent contact by clinicians.
Smokers who have abstained from smoking for 6 months enter the maintenance stage. Most successful quitters relapse and recycle through these stages three or four times before attaining long-term abstinence; some may take several years to move through these stages until abstinence can be maintained (USDHHS, 2000). Assessment and recognition of these stages are key components in assisting older adult smokers to modify behavioral skills and successfully abstain from smoking.
EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE
In 1996, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) published a clinical guideline for smoking cessation based on a comprehensive review of the literature. In 2000, the AHRQ published an updated version of the guideline entitled, " Clinical Practice Guideline: Treating Tobacco Use and Dependence" (USDHHS, 2000). Approximately 6,000 research articles and abstracts, including 3,000 from the original guideline, were reviewed to identify studies appropriate for evaluation (U.S. Public Health Service, 2000).
The AHRQ guideline provides evidence-based strategies and recommendations designed to assist clinicians in delivering and supporting effective treatments for tobacco use and dependence. The AHRQ guideline advocates incorporating a set of brief interventions delivered by clinicians that can be summarized as the five As (Figure):
* Arrange follow up.
Providing a brief period of counseling (*s 3 minutes) is more effective than simply advising patients to quit and doubles the cessation rate compared with no intervention (U.S. Public Health Service, 2000).
The first step in treating tobacco use and dependence is to identify tobacco users. Approximately 70% of smokers visit a health provider each year, and effective identification of tobacco use status not only opens the door for successful interventions, but also guides clinicians to identify appropriate interventions based on patients' tobacco status and willingness to quit (U.S. Public Health Service, 2000).
Clinicians should record tobacco use as a vital sign, along with blood pressure and temperature. A sticker should be placed on smokers' charts to easily identify smokers, and tobacco dependence should be included on the problem list. Marking the chart with patients' tobacco status reminds clinicians about the need to counsel and involves the office staff in the smoking cessation process.
It is clinicians' responsibility to deliver clear advice to each smoker about the importance of stopping smoking. The stop smoking message should be clear, strong, personal, and straightforward. Commonly used in advising patients are the five R's:
* Risks of smoking.
* Relevance of smoking to presenting symptom/current illness.
* Roadblocks to quitting.
* Rewards of cessation.
* Repetition as needed.
The message should be personalized and related to the smoker's current health problem and its social and economic costs, the smoker's motivation level and readiness to quit, and the impact of tobacco use on others in the smoker's household (U.S. Public Health Service, 2000).
The third step for clinicians in the smoking cessation process is to assess smokers' willingness to make a quit attempt at this time (e.g., within the next 30 days). The interventions are then individualized based on the readiness of the smoker to quit (i.e., precontemplation, contemplation, preparation).
For older adult smokers who are willing to quit tobacco, negotiating a quit date is essential. The date should be within a short time of the initial counseling session, ideally within 1 to 2 weeks. Clinicians should assist smokers by determining prior successes with cessation and identifying activities that promote continued abstinence.
Behavioral methods should be used to discover high-risk relapse situations, create an aversion to smoking, develop self-monitoring of smoking behavior, and establish competing coping responses (U.S. Public Health Service, 2000). Clinicians also should assist patients in identifying events (e.g., being around other smokers) and internal states (e.g., negative affect, stress) that increase the risk of smoking and relapse. Identifying other cues to smoking may include behaviors such as drinking coffee, talking on the phone, driving a car, and consuming alcohol (USDHHS, 2000). Helping patients identify, anticipate, and avoid these cues or triggers are necessary for patients to remain abstinent.
Behavioral modification strategies applied on a personal level should be used to assist older adult smokers with cessation. Smokers must learn coping skills for both short-term and long-term prevention of relapse and how to apply those skills in crisis situations. Coping skills such as deep breathing, relaxation, exercise, yoga, and diversions may be helpful to manage situations such as negative moods, stress, poor quality of life, and smoking urges (USDHHS, 2000). Clinicians should assist patients to accomplish lifestyle changes that reduce stress, improve quality of life, or produce pleasure (U.S. Public Heath Service, 2000).
The AHRQ clinical practice guideline urges clinicians to provide both counseling and pharmacotherapy for all smokers making a quit attempt. The first-line pharmacotherapies recommended in the AHRQ guideline include sustained-release bupropion hydrochloride, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch. When considering among these five pharmacotherapies, clinicians should be guided by factors such as familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain).
Second-line pharmacotherapies that are recommended include Clonidine hydrochloride and nortriptyline hydrochloride. Another second-line approach may be to combine the nicotine patch with either nicotine gum, nicotine nasal spray, or bupropion hydrochloride (USDHHS, 2000). Table 4 summarize these pharmacotherapies and includes dosage and duration, costs, and other information. Patient education handouts (Table 5) can provide a helpful overview of the behavioral and pharmacological approaches for gerontological nurses to use in their setting.
Follow-up contact should be arranged soon after the quit date, preferably within 1 week. A second follow-up visit is recommended within the first month. Additional follow up should be scheduled (e.g., phone, appointment) as needed. During these follow-up sessions, clinicians should congratulate successes. If tobacco use has occurred, clinicians should review circumstances and elicit recommendations to total abstinence. Older adults can be reminded that a lapse can be used as a learning experience. Problems already encountered should be identified and challenges for the immediate future should be anticipated. The use of pharmacotherapies and potential problems also should be explored. Referral to more intensive treatment such as programs offered by local hospitals, Nicotine Anonymous, American Cancer Society, or the American Lung Association may be helpful.
Because an increasing number of patients receive their health care in managed care settings, system interventions can be useful in implementing effective smoking cessation rates for a population. Health system administrators, insurers, and health care purchasers serve an important role in the delivery of health care. Managed care organizations and other insurers influence health care through restrictive formularies, performance feedback to clinicians, and marketing approaches to prompt patient demand for certain services (USDHHS, 2000). These agents and organizations also can implement systems, policies, and prompts (e.g., chart stickers, posters, vital sign stamps) that promote tobacco use assessment and management as an integral part of patients' visits. Research has shown systems-level changes can increase utilization of tobacco dependence treatment and reduce smoking prevalence in managed health care plans (USDHHS, 2000).
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.
PHARMACOTHERAPIES TO AID SMOKING CESSATION
PATIENT EDUCATION HANDOUT: STRATEGIES TO HELP YOU QUIT SMOKING
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 successful aging by reducing tobacco use in older adults.
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FACERSTROM test for nicotine dependence
PATIENT EDUCATION HANDOUT: IT'S NEVER TOO LATE TO QUIT
PHARMACOTHERAPIES TO AID SMOKING CESSATION
PATIENT EDUCATION HANDOUT: STRATEGIES TO HELP YOU QUIT SMOKING