Smoking Cessation Education in the Elderly
Article written by Tammy L. Stuart MS, RN and Jennifer Gerhardt, Student Nurse at Massachusetts College of Pharmacy and Health Sciences.
Cigarette smoking rates continue to be on the rise despite the overwhelming health consequences. According to the U.S. Department of Health and Human Services “Smoking is the most preventable cause of death and disease in the United States” (Healthfinder.gov, 2009). Statistics indicate that approximately 500,000 people die each year from smoking cigarettes (CDC, 2007). Evidence shows that there are a little more than 45 million adults living in the U.S. and about 21% of them smoke cigarettes, and almost 10% are 65 years or older (CDC, 2007). The role of the professional nurse as direct care provider and educator is pivotal in providing clients with the information and support necessary to facilitate smoking cessation and improve client health outcomes.
Smoking cigarettes is a major health disparity in the United States. The CDC reports that smoking and it’s influence on disease has contributed to a rise in healthcare costs which totals a little over 90 million per year (CDC 2007). Smoking contributes too many chronic diseases such as emphysema and chronic bronchitis (COPD). Lung cancer is part of a group of smoking-related diseases that leads to “the largest number of smoking-related deaths” (CDC 2006). Smoking is a risk factor for many other chronic diseases such as coronary artery disease, atherosclerosis, stroke, heart disease, diabetes, hypertension and cancer. The elderly is the fastest growing population and about 75% of deaths in this population are caused by chronic illnesses such as cancer and heart disease which can be linked to cigarette smoking (CDC, 2006, 2007, 2008).
Smoking cessation has been proven to show immediate health benefits to the individual. In 2004 according to the Surgeon General about 20 minutes after the smoker quits their heart rate drops, 12 hours after quitting the levels of carbon monoxide decreases to normal levels and two weeks to three months after quitting the risk for a heart attack decreases and lung function improves (The 2004 Surgeon General's Report: The Health Consequences of Smoking, 2004) Professional nurses need to facilitate health promotion education specifically, smoking cessation with their elderly patients due to the direct link with improved health outcomes.
Nurses are among the largest population of healthcare workers with direct patient care responsibilities and as a result are on the front lines of the war on smoking. Nurses educate patients on a multitude of information which may include medications, invasive and interventional procedures, medical conditions, lifestyle changes, disease prevention and health promotion. Nurses’ have the ability; with their knowledge of disease and their role as direct care providers to provide education and interventions that facilitate smoking cessation (Cataldo, 2007; Roberts, 2002; Trossman, 2005, Healthfinder.gov, 2009).
There are many advances in medical and nursing research related to cigarette use and its impact on disease prevention and health promotion. Common interventions include pharmacological therapies such as nicotine replacement therapy (nicotine patches, gum, lozenges, sprays, and inhalers) and anti-depressant therapy, which if used correctly have been shown to have successful outcomes. Non-pharmacological therapies include practices such as hypnosis, acupuncture, herbal supplements, and support groups such as Nicotine Anonymous. There is little research on the best method for ensuring success with smoking cessation in the elderly, particularly with evidence-based nursing interventions (US Department of Health and Human Services; Public Health Services, 2008).
Elders are a population not usually considered for smoking cessation strategies. According to Nursing Standard (2004) there is evidence in the literature that suggests that health care professionals are not targeting elderly patients who smoke. In fact many elderly patients are being ignored when it comes to providing smoking cessation education. Many barriers have been evaluated within the literature that deters nurses from teaching smoking cessation to their elderly patients. Cataldo (2007) discusses the myths and realities of caring for elderly patients who smoke. She highlights several common myths which impede smoking cessation such as the damage of smoking is irreversible, therefore the healthcare professional should not bother with smoking cessation strategies. However smoking cessation practices even in elderly patients over 65 years old have proven significant health benefits as evidenced by the findings. The author continues with an United States study that states, “…men who quit smoking at age 65 years old gained 1.4 to 2.0 years of life and women gained 2.7 to 3.7 years of life” (Cataldo, 2007). These findings are extremely significant because it supports the idea of improving health outcomes for elders that are considering smoking cessation. Elderly patients will see significant benefits such as reduced mortality rates, increase activity tolerance, a decrease in respiratory symptoms such as shortness of breath, wheezing and coughing, overall quality of life improvement. Other challenges with the elderly population are the misconception that elders who smoke longer will have a harder time quitting. Conversely, the literature highlights that elderly populations are more likely to quit smoking than the younger population (Cataldo, 2007). The commitment rates for smoking cessation have also been studied and elderly patient over 65 years old are more likely to quit smoking and less likely too relapse as opposed to a younger group (Cataldo, 2007; US Department of Health and Human Services, 2008).
According to the Surgeon General’s report entitled, Health Consequences of Smoking: What they mean to you (2004), “more than 12 million deaths have been caused by smoking since the first published Surgeon General’s report on smoking in 1964” (Surgeon General's Report, 2004). It is the responsibility of the healthcare providers to promote and provide smoking cessation education and interventions to patients. (Surgeon General's Report, 2004).
In 2004 the Surgeon General reported, “quitting smoking has many benefits. It lowers your risk for diseases and death caused by smoking and improves your health.” The Surgeon General also states that “health goals for reducing smoking will prevent 7.1 million early deaths after 2010 (The Health Consequences of Smoking, 2004).
The Department of Health and Human Services Healthy People 2010 program provides a list of health promotion and disease prevention topics within the United States. “Leading health indicators” (Healthy People 2010, 2005) are used to measure the United States major health concerns. Healthy People 2010 states that these health indicators are chosen “on the basis of their ability to motivate action, the availability of data to measure progress, and their importance as public health issues” (Healthy People 2010, 2005). Healthy People 2010 initiatives indicate tobacco use as a “leading health indicator” (Healthy People 2010, 2005). This statement should stand out for the healthcare worker especially the nurse because they have the opportunity to impact indicators prioritized by Healthy People 2010.
Impact and implications on nursing practice
According to the U.S. Surgeon General’s document, The Health Consequences of Smoking (2004) patients who smoke increase demands on healthcare providers. Smokers have more respiratory complications, difficulty in wound healing and have a higher risk for hip fractures. These patients use more health resources, require more hospitalizations and are in need of more skilled nursing care. The U.S. Surgeon also reports that:
“The economic burden of cigarette use is enormous. From 1995 to 1999, smoking-related costs totaled $157.7 billion each year. This figure includes more than $75 billion in direct medical costs for adults (ambulatory care, hospital care, prescription drugs, nursing homes, and other care), about $82 billion in indirect costs from lost productivity, and $366 million for neonatal care. This equals an estimated $3,000 per smoker per year” (The 2004 Surgeon General's Report: The Health Consequences of Smoking, 2004).
In this 21st century nurses are alert to healthcare costs and how taxed the healthcare system becomes year after year. Providing smoking cessation education to patients especially the elderly is known to increase quitting rates which “decreases premature mortality and tobacco-related health care costs in the short term” (Department of Health and Human Services, Centers for Disease Control, 2007). Tobacco cessation interventions and treatments have been known to be more cost-effective than other secondary preventative services such as colon screenings, mammography, pap smear tests, some treatments for hypertension and high cholesterol (Department of Health and Human Services, Centers for Disease Control, 2007).
Nurse’s role in patient education
There is a gap in knowledge and practice related to the nurse’s role in educating elderly patients about smoking cessation. There is a lack of evidence-based nursing interventions for cessation practices specifically targeting the elderly. (Health & Jeannette, July/August 2006). Professional nurses need to integrate evidence-based recommendations for smoking cessation and incorporate them in practice in order to carry out successful interventions.
The Massachusetts Department of Public Health has created a program to identify and treat patients who smoke, both in the inpatient and outpatient settings called “QuitWorks” The goal of this program is to provide healthcare providers with cessation resources for their patients who want to quit smoking. This program offers providers with many different avenues that facilitate smoking cessation, such as tools to identify smokers, communication techniques to help intervene with smokers and treatment options, help lines that provide telephone counseling, and patient education materials. The QuitWorks program shows that participants are, “90% satisfied with the services and assistance received both from the Helpline and from the health care provider who enrolled them in the program” (QuitWorks, 2000-2007). As a result of the program, “86% said their health care provider increased their level of motivation to quit, thus reinforcing the significance of the provider-patient relationship in the successful quit smoking process” (QuitWorks, 2000-2007).
Research conducted by Roberts a nurse practictioner specializing in patients with COPD and other respiratory disorders discusses the role of nurses in smoking cessation and helped develop the concept of a “30 second approach” (Roberts, 2002). A group of nurses and primary care physicans collaborated to form a group promoting smoking cessation called, Smoking Cessation Action in Primary Care. This group created a tool that involves three smoking related questions. The questions are given to all patients as a screening tool. The purpose of the tool is to identify patients who may or may not be motivated to quit smoking. If they are found to have motivation to quit, the proper referrals can be made for smoking cessation. The goal is to identify and help treat patients who want to quit smoking in an effcient timely manner without wasting the time of the practitioner and patient (Roberts, 2002).
Professional nurses need to be knowledgeable about smoking cessation practices and integrate them into their care of the elderly. By the year 2030, “it is estimated that 20% of Americans will be 65 years of age or older” (Smeltzer et al. 2008), one of the fastest growing populations. Nurses are among the largest population of healthcare workers that provide direct patient care. Nurses should be aware of resources that can be used to teach elderly patients about disease prevention and health promotion. Elderly patients benefit from smoking cessation practices therefore the professional nurse should target this population in order to improve their health outcomes. Intergrating smoking cessation education in direct patient care within the elderly population will help to addess the growing health disparities effecting the elder population.
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