Hospitalization: Hospitalization: Nursing Role with Nursing Role with

In-Patients Who SmokeIn-Patients Who SmokeCreated by the Registered Nurses’

Association of Ontario

Client/Patient ExperienceClient/Patient Experiencewhen they become ill or hospitalizedwhen they become ill or hospitalized

Client/patient motivation◦Approx. 70% more smokers than non-smokers

access the health-care system• Exposure to healthcare professionals who can assist

them with cessation• Health issues could act as motivation to quit

Teachable moments• Opportunity to link smoking with illness

Discussion: Palliative Care & Discussion: Palliative Care & Smoking CessationSmoking Cessation

Should smoking be addressed with palliative patients?

What approach would you take when addressing smoking with this patient population?

Consider challenges you would have as a nurse discussing smoking cessation with this patient population.

Mental Health & SmokingMental Health & Smoking• Individuals who suffer from mental illness are

about twice as likely to smoke cigarettes as the general population

• Up to 90% of individuals with schizophrenia are smokers

• Almost half of all cigarettes smoked in North America are consumed by people who suffer from mental illness

• Research: Lower quit rates in mentally ill people who smoke

• Mental health clients who smoke have a life expectancy of nearly 20% less than other Canadians (even after suicides are discounted)

(Els & Kunyk 2008)

Consider…Consider…• Clients are smoking as a form of self-medication• Fear that quitting may cause mental instability• Cost of cigarettes is a significant portion of

income• Smoking is a form of socialization• Smoking to ease boredom, loneliness, and/or

anxiety• Access to cigarettes at treatment facilities is

often high• Smoke-free supportive housing is rare(Selby & Herie 2009)

Medications & SmokingMedications & SmokingChemicals in tobacco can interact with

medications:• Examples:

Important to keep this in mind when encouraging clients/patients to quit• Requires monitoring of drug levels & referral to physician

who prescribed medication

Drug/Class Mechanism of Interaction and Effects

Caffeine Increased metabolism

Alprazolam (Xanax) Decreased half-life

Warfarin Increased metabolism

Ottawa ModelOttawa Model• A systematic approach to tobacco

dependence treatment for hospitalized smokers

• Designed and implemented at the University of Ottawa Heart Institute• Adopted by a number of hospitals in Ontario &

across Canada• Uses 5As Protocol • (Ask, Advise, Assess, Assist & Arrange)

• Smokers are more likely to be hospitalized than non-smokers• Opportunity to help smokers quit smoking

Ottawa Model:Ottawa Model: On Admission On Admission1. Ask

• Ask about client/patient tobacco use in the past 6 months

• Document smoking status & quitting history

2. Advise• Advise client/patient to quit

3. Assess• Assess the smoker’s interest in quitting (during

hospital stay, within 30 days, within 6 months?)

4. Assist• Brief counseling (includes pharmacotherapy

options)

Ottawa Model: Ottawa Model: During During HospitalizationHospitalizationfor people who want to quit smokingfor people who want to quit smoking

• Counselling focuses on: • Managing withdrawal symptoms• Planning how to remain smoke-free following

discharge• Pharmacotherapy • Offered during the hospital stay• Prescribed for 10 – 12 weeks after discharge

• Self-help materials for smokers wanting to quit are provided

Ottawa Model: During Ottawa Model: During HospitalizationHospitalizationfor people who DO NOT want to quit smokingfor people who DO NOT want to quit smoking

• Counselling focuses on: • Pros and cons of smoking• ie. ‘what do you see as some of the advantages and

disadvantages of smoking?’• Pharmacotherapy is offered during the

hospital stay to help patients remain comfortable in the smoke-free environment

• Self-help materials tailored to smokers who do not want to quit are provided

• Information about community cessation services is provided

Ottawa Model: Ottawa Model: On DischargeOn Discharge

5. Arrange Offer follow up to all smokers

Interactive, voice response (IVR) – mediated telephony system & database

Automated calls inquiring about smoking status

Results can be scanned by a nurse Clients/patients receive a telephone call from

a nurse if they appear to need more support

Ottawa ModelOttawa Model: Best Practices: Best Practices1. Document smoking status2. Designate staff to provide treatment 3. Include tobacco dependence treatment in

clinical pathways, care maps, or Kardex systems used for quality management

4. Ensure pharmacotherapy for smoking5. Track tobacco users for more than 30 days

after discharge, provide counselling6. Ensure training for health-care professionals7. Provide self-help material8. Establish referral links9. Evaluate the provisions of tobacco dependence

treatment10. Provide feedback to health-care professionals

Hospital & Long-Term Care Hospital & Long-Term Care Facilities Facilities Smoking PoliciesSmoking Policies

Provincial/Territorial• Varies slightly between provinces/territories• Examples:

In Newfoundland and Labrador ventilated smoking rooms are permitted

In B.C. and P.E.I ventilated smoking rooms are permitted in long-term care facilities

Local • Facilities decide on their own individual policies

Tobacco InterventionsTobacco InterventionsRelated to Discharge PlanningRelated to Discharge Planning

It is important to provide support, information and follow-up• Booklets• Web resources• Community counselling

Nurses Who SmokeNurses Who SmokeSmoking prevalence among nurses is

similar to the general population Approximately 16%–18 %

Nurses who smoke may feel uncertain or conflicted about conducting smoking cessation interventions

Support for nurses who smoke:◦http://www.TobaccoFreeNurses.org/

Motivational Interviewing Motivational Interviewing TechniquesTechniques

1. Express Empathy• Helps identify and understand resistance

and reasons for unhealthy behaviours2. Avoid Arguments

• Client is more likely to see the healthcare provider as being on his/her side

3. Develop Discrepancy (Dissonance)• Ask about pros and cons of smoking• Listen for discrepancies that allow for the

creation of dissonance

Motivational Interviewing Motivational Interviewing Techniques (cont.)Techniques (cont.)

4. Roll with Resistance• Do not meet resistance with

confrontation, instead utilize reflection to create dissonance

5. Support Self-efficacy• Clients/patients need to be encouraged • Examine client/patient strengths • Help client/patient imagine success

Effects of exposure to second-Effects of exposure to second-hand smoke on the ability to quit hand smoke on the ability to quit smokingsmoking• It can be more difficult for a client/patient to

remain smoke-free upon discharge if they have family & friends who smoke

• Living with a smoker is the primary cause of relapse during a quit attempt

• Assisting clients/patients regarding how to negotiate clean air policies in their home and workplace should be part of discharge planning• Web-based resources available