Unique program addresses patients' psychological as well as physiological addictions to tobacco use.
David Nelson's Smoking Cessation Program
Clarify the patient's motivation.
Have the patient pick a quit date.
Have the patient prepare his environment to quit.
Address the patient's physical and psychological addictions.
Arrange for ongoing support systems.
Manage the patient's expectations.
As the medical director for Barlow Respiratory Hospital in Los Angeles, pulmonologist David Nelson, MD, has seen the effects of smoking firsthand, but he also knows that there is something he—and RTs—can do about it.
Among the respiratory effects of smoking cigarettes are chronic obstructive pulmonary disease (COPD), emphysema, and, of course, lung cancer. According to the Centers for Disease Control and Prevention (CDC), cigarette smoking causes the death of more than 400,000 people a year in the United States alone, including those affected by secondhand smoke.1 In addition, the CDC estimates that 8.6 million Americans have at least one serious illness due to smoking.2
Nelson has been the medical director of Barlow for the past 16 years and often sees the patients who are part of the CDC's smoking statistics. Numerous COPD patients he treats are on mechanical ventilators. Personally, he has seen an aunt die of lung cancer because of smoking.
"Obviously, there are many medical issues that we deal with every day that we can't do anything about, that we can't anticipate, and that we can't prevent," said Nelson. "But if we do recognize a disease like COPD, where we can significantly impact its development, it's a great place to put your energy. Too often, we end up putting all of our energy in medicine into diseases at the end stage."
As a result, Nelson has placed a great deal of energy behind creating a smoking cessation program at Barlow.
Recent local government legislation barring cigarette smoking in public places, higher smoking taxes, and public awareness campaigns have all contributed to more smokers wanting to quit. But because cigarettes are both physically and psychologically addictive, smokers need to realize that it will probably take more than just willpower to become a nonsmoker.
Nelson says, "It's the unusual person who is successful at quitting right out of the starting block. Generally, it takes several attempts." But Nelson believes that a good smoking cessation program can manage patient expectations and provide a structured method that can ultimately lead to permanently kicking the habit.
Nelson breaks down Barlow's smoking cessation program into six steps:
"The first thing you want to do before you start is to sit down with the patient or the person who wants to quit and clarify what motivates that person to quit," says Nelson. He sees patients who are motivated by their own health concerns, although sometimes it may be for the health concerns of a child who might be exposed to secondhand smoke. Some motivations may be as simple as the rising cost of cigarettes or the social stigma attached to smoking.
Nelson says that having this information gives physicians, RTs, or other health care professionals the ammunition to help support the person in their ongoing efforts to stay off cigarettes. The information can also be used by patients, who can remind and remotivate themselves about their goals when tempted to light up.
Nelson says, "[Having the patient pick a quit date] sounds simple, but it's probably not as simple as it would appear. It's important to try to come up with a time—as much as possible—that's going to be a less stressful period. For instance, you wouldn't want to do it the week before your wedding or if you're anticipating starting a new job. You have to be realistic in what is going to be a reasonable day to quit."
Once a quit date is decided, patients need to begin to prepare the environment of their homes, offices, and anywhere else they spend a lot of time. Transforming a smoking environment into a nonsmoking environment can mean removing ashtrays, stashes of cigarettes, matches, favorite lighters, or any other familiar cigarette paraphernalia.
"You don't want to be running into dirty ashtrays when you are an ex-smoker, especially an immediate ex-smoker," says Nelson. "[Getting rid of anything that's going to remind you of smoking] would be really helpful, even getting the place cleaned to get rid of the smell of smoke."
Nelson advises that these preparations be done as close to the quit date as possible.
Because cigarettes are both physically and psychologically addictive, Nelson recommends that health practitioners try to address both components.
To address the physical component, patients can be prescribed a nicotine replacement therapy (NRT). For the psychological component, practitioners can help in a number of ways, from reminding patients about their motivations for quitting to prescribing antidepressants, or perhaps helping patients cope with roommates who are still smoking. It is also important to address a patient's everyday smoking behaviors, such as lighting up first thing in the morning, after meals, or at break times at work. These behaviors must be replaced by new, more healthful habits, such as taking a walk after meals.
Nelson explains, "Ideally, it's nice to have a quit buddy. The best kind of quit buddy would be somebody such as an ex-smoker, who can be completely sympathetic and empathetic with the person who's trying to quit."
While an ex-smoker may be helpful as a quit buddy, Nelson does not recommend choosing a fellow smoker who is trying to quit at the same time. One smoker's weakness may enable the other's, causing both to fail.
In the absence of a successful quitter, patients may turn to a spouse, family member, or just a friend for support. The main idea is to find a person who can listen and perhaps distract the patient by doing something productive, such as taking a walk or going to a movie.
"Support can come in a variety of different ways," Nelson adds. "It doesn't have to be a single individual. There are also commercially available support systems, like Smoke Enders, and there are also those you don't have to pay."
In addition to traditional smoking cessation programs, Nelson points out that the American Lung Association has a free online program (www.ffsonine.org) that incorporates many of the same strategies as Barlow's. For those who do not personally know a quit buddy, the Lung Association has a system that can pair a person who is quitting with another person in the same geographical area.
"Clearly, people are not all successful," says Nelson. "In fact, the majority of people are not successful the first time out, so work with the person and say, ‘It's OK, you'll try again,' and then do some Monday morning quarterbacking. You can ask, ‘What do you think we did wrong? What could we have done better? Was it a support system issue? Was it being around smoking friends? What was the issue?' "
Nelson generally does not tell his patients that they are unlikely to succeed the first time because he does not want to give them an easy out. He says, "There are those people who can successfully quit the first time, so you don't necessarily want to say, ‘Don't worry if you can't do it this time.' "
"Obviously, RTs have a lot of experience in dealing with people with specific and advanced respiratory disease, many of whom had been smokers before," says Nelson. Because RTs often may see patients more than physicians do, Nelson says that RTs are in a good position to bring their expertise to patients and be a very educated quit buddy.
"RTs not only have the empathy and their experience to share, they also have their expertise to share. Knowing about how lungs work, they can reinforce all the good health aspects of quitting smoking," he says.
RTs can also participate in many of Nelson's six steps, clarifying and reinforcing the quitter motivations, helping to manage expectations, and perhaps helping to pick a convenient quit date. Of course, RTs can always provide ongoing support for quitting during normal patient visits.
In the end, however, Nelson says that no matter how much expertise, time, or concern health professionals have, quitting smoking is ultimately up to the patient. Nelson mentions his aunt, a lifelong smoker who had attempted to quit for many years; she always failed because she was afraid of gaining weight. Ultimately, she died of lung cancer.
"You just can't live a person's life for them," says Nelson. "As practitioners, all we can do is educate people about the benefits of stopping smoking, teach them what we have to offer to help them; and then they've got to make up their own mind. They have to be motivated to do it."
To address the physical component of cigarette addiction, nicotine replacement therapy (NRT) has been proven to be very effective. NRTs come in a variety of forms these days, including gums, nicotine patches, nasal sprays, and oral inhalers.
David Nelson, MD, Barlow Respiratory Hospital, Los Angeles, believes that the oral inhaler is very effective for those trying to satisfy the oral phase of gratification that smokers feel when first trying to quit.
He says, "If there isn't a strong reason to choose any of the other ones, oral inhalers might be a good choice for people who are really into the physical, hand-to-mouth kind of gratification that some smokers are reliant on, what they get their buzz from."
Nelson also cautions that NRTs be used temporarily, usually over the course of 10 weeks, depending on how much a person has been smoking. He says, "If they smoked a pack a day or more, then they probably need the full dose and then gradually cut down. On the patch, it's easy to cut down, because they come in three different strengths; so you do 6 weeks at the strongest strength, then 2 weeks on the medium, and then 2 weeks on the weakest."
Nelson has observed that side effects for NRTs are most prominent in people who were light smokers, smoking a half pack a day or less. "Sometimes, what you're giving them as nicotine replacement could actually be more nicotine than they're used to, and then they can potentially get nervousness, shakiness, twitchiness, etc."
For these individuals, Nelson recommends starting on a lower dose of NRT; for example, the medium-strength patches. Nelson also has had a patient who had an allergic reaction to the adhesive on the patch, so health professionals should be sure to ask patients if their skin is sensitive or have any known allergies to adhesives before prescribing the patch.
In addition to NRTs, an antidepressant called Zyban (buproprion, also marketed under the name Wellbutrin for depression) has been shown to improve the chances of smoking cessation, and is typically used together with the nicotine replacement. Nelson generally prescribes Zyban to people who have not been successful quitting after trying two or three times.
Tor Valenza is a staff writer for RT. For further information, contact [email protected].