Effective treatment for tobacco intervention include nicotine and non-nicotine replacement therapies and follow-up within 1 week after the quit date.

Why do people use tobacco? Many use it to manage stress, pain, or weight; control anger or frustration; and regulate moods. Tobacco-related death and diseases cost approximately $100 billion each year. The cost of lost productivity and forfeited earnings due to smoking-related disability has been estimated at $47 billion per year. Tobacco dependence is a chronic condition that often requires repeated interventions. Effective treatments are available for long-term or permanent abstinence. RCPs must take the initiative to identify and document all tobacco-using patients.

These patients fall into three groups: those willing to make a quit attempt; those unwilling to make a quit attempt; and former tobacco users. Patients willing to make a quit attempt must be provided with effective treatment strategies. It is essential for RCPs to consistently identify, document, and treat each tobacco user. Patients unwilling to make a quit attempt and former tobacco users should be provided with a brief intervention and motivational information.

Tobacco-using patients willing to make a quit attempt should be offered a smoking cessation intervention. The RCP should be aware of the 5 As, which include asking, advising, assessing, assisting, and arranging. It is important for all RCPs to systematically identify all tobacco users within their facility. This system must ensure every patient is asked about tobacco use and the information is documented on the patient chart.

RCPs should strongly advise all tobacco users to quit. This advice must be clear, strong, and personal. For example, an RCP could say, “I believe as a respiratory therapist, it is important for you to quit smoking. It is the most important thing you can do for your health. The smoking is aggravating your asthma” (or other disease process patients may have). The information must be personal to patients in order to motivate their readiness to quit. This is the most important and least time-consuming of all the intervention steps. The American Association for Respiratory Care endorses all RTs to spend 3-5 minutes advising all patients who use tobacco to stop.

RTs must assess their patients’ willingness to make a quit attempt by asking each tobacco user if they are willing to make a quit attempt. Once they know the patient’s intent, they can provide the necessary assistance for those willing to make a quit attempt or the 5 Rs, which include relevance, risk, rewards, roadblocks, and repetition, and a motivational intervention for those unwilling to make a quit attempt.

STAR
Assisting the patient with the quit attempt (STAR) includes helping the patient set a quit date; talk with family, friends, and coworkers about the patient’s desire to quit; anticipate and plan for difficulties; and have the family members remove all tobacco products from the patient’s home and work environment. The RT may provide the patient with practical counseling and problem-solving training tips. The patient must be educated with coping strategies for relapse intervention. Examples of coping strategies include a stop and think response (stop and ask yourself why you feel the urge to smoke and think of the reasons you are quitting and act by getting away from your desk, telephone, going to get a drink of water, or talking to a friend), visualization, meditation, positive reinforcement, beginning an exercise program, or starting a new hobby. Inform the patient of nicotine withdrawal syndrome and symptoms. These symptoms may include craving nicotine, frustration and anger, anxiety, difficulty concentrating, headaches, and sleep disturbances. Also encourage the patient to adhere to a low fat diet.

Treatment
As with other chronic diseases, the most effective treatment for tobacco dependence requires the use of approved pharmacotherapies (medications). All patients except those who have medical contraindications, smoke less than 10 cigarettes per day, are pregnant or breast-feeding, or are adolescent smokers should be offered an approved pharmacotherapy. Both non-nicotine and nicotine replacement therapy options increase smoking cessation success and reduce withdrawal symptoms. There are five first-line medications. One is a non-nicotine replacement therapy, bupropion, and there are several nicotine replacement therapy (NRT) options. Patients must not use any type of tobacco when taking any form of nicotine replacement therapy. Patients who have cheated have experienced a severe sudden rise of their blood pressure and heart attacks.

Nicotine Replacement Therapies
The nicotine replacement therapies include the nicotine patch, gum, nasal spray, and inhaler.

The nicotine patch contains a nicotine compound that is absorbed through the skin. The patch may be worn for a 24-hour period, although some patients have complained of vivid dreams while wearing the patch at night and, therefore, it has been recommended to remove the patch before going to bed. Patients with sensitive skin or reactions to adhesive tape may want to use a different method of nicotine replacement, as the patch may cause skin irritations.

Nicotine gum is available over the counter. The nicotine compound is absorbed by the membrane linings of the mouth. The gum is initially chewed gently until the patient senses a peppery taste at which time it is “parked” between the teeth and the side of the cheek. The sequence of gently chewing and parking is alternated approximately every half hour to achieve the full effect. Different strengths are available. Acid-type drinks like coffee or orange juice will inactivate the nicotine compound and the patient should rinse the mouth after such drinks. It is important to note that nicotine gum is not to be swallowed. It is poorly absorbed through the stomach, and if it is swallowed, the patient may experience light-headedness, abdominal discomfort, or heartburn.

Nicotine nasal spray is available over the counter. The nicotine compound is transferred into the bloodstream through the membranes of the nares. The starting dose is one spray into each nostril one or twice each hour. The most common side effect is nasal irritation.

Nicotine inhalers are available by prescription. The nicotine compound is in a small capsule that is punctured and placed in a plastic mouthpiece. The patient inhales through the holder, which causes the aerosolized nicotine to come in contact with the oropharynx where it is absorbed into the bloodstream.

Non-Nicotine Replacement Therapy
Non-nicotine replacement therapy includes bupropion, which is an antidepressant and must be prescribed by a physician. This medication is a slow-release formulation intended for smoking cessation. It is not a nicotine replacement therapy. The patient must start taking bupropion 2 weeks before the actual quit date. And on the quit date, the patient may add one of the nicotine replacement therapies. Bupropion should not be prescribed for patients with seizure disorders, anorexia nervosa, or bulimia.

There are also two second-line medications in the event that patients are unable to use any of the first-line agents or if the first-line agents are unsuccessful—clonidine and nortriptylline. Both of these must be prescribed and followed by a physician.

The NRTs may be used in combination or with the non-nicotine replacement therapy. The pharmacotherapies may be used long term.

Follow-up
Once the assistance intervention has been completed, arrange to schedule follow-up contact with the patient. Ideally, follow up within 1 week after the quit date. The follow-up may be in person, by telephone, or by electronic mail. It is essential to follow up during the first week and first month of the quit date. The follow-up allows the therapist to assess each patient for abstinence during and at the completion of the treatment.

The tobacco user unwilling to make a quit attempt may lack information about the harmful effects of tobacco, lack financial resources, have few cares or concerns about quitting, or may have failed at a previous attempt. These patients may respond to a motivational intervention that provides the RT with an opportunity to educate, reassure, and motivate them. This is most successful when RTs are empathetic, promote patient autonomy, avoid arguments, and support the patient’s self-efficacy. Patients should be introduced to the 5 Rs and remember that relevance is key to encouraging the unwilling patient to be a willing patient. Encourage the patient to state a reason for quitting. This makes quitting personally relevant (possibly the disease status or risk, family, health concerns, age, or gender).

Inform patients of the acute and long-term risks at hand. Acute risks include shortness of breath, exacerbation of asthma, harm to the fetus during pregnancy, impotency, and infertility. Long-term risks include heart attacks and strokes, lung and other cancers, and chronic obstructive pulmonary disease. Inform the patient of environmental risks such as increased risk of lung cancer and heart disease in spouses, higher rates of smoking in children of tobacco users, increased risk for low birth weight infants, sudden infant death syndrome, and asthma, middle ear diseases, and respiratory infections in children.

RTs should inform patients of the wonderful rewards they will reap after quitting. One year after quitting, the risk for coronary heart disease is cut in half. Five years after quitting, the risk of having a stroke is reduced to that of a nonsmoker. Ten years after quitting, the risk of lung cancer is cut in half, and 15 years after quitting, the risk for coronary heart disease returns to that of a nonsmoker. The health of patients will improve, food will taste better, and their sense of smell will improve. Patients will save money and feel better about themselves and their children will be healthier as well.

Patients may identify various barriers such as withdrawal symptoms, fear of failing, weight gain, and depression. These roadblocks must be addressed.

Repeat the information. Repetition is often necessary for many patients. Encourage them to make a quit attempt and remind patients that any previous attempts to quit are considered successes.

Conclusion
Tobacco dependence is a chronic condition that must be treated. Tobacco interventions are both clinically and cost effective relative to other medical and disease prevention interventions. Effective treatments are available, and all tobacco users should be offered an intervention. Do not be the weakest link between smoking cessation information and a tobacco-using patient. No one says it better than Robert C. Cohn, MD, MetroHealth Medical Center, Cleveland, who states, “There is no other clinical intervention that can reduce illness, prevent death, and increase the quality of life more than effective tobacco treatment interventions.”

Donna D. Gardner, RRT, is an instructor in the Department of Respiratory Care, University of Texas Health Science Center at San Antonio.

References
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2. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking cessation: information for specialists. Clinical Practice Guidelines. Quick Reference Guide for Smoking Cessation Specialists. No. 18. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and Centers for Disease Control and Prevention. April 1996. AHCPR Publication No. 96-0694.

3. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.

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