Turning smokers into quitters
Nurses prepare to help
clients butt out
Nurses are integrating smoking cessation into their daily practice in
a new pilot project at the Centre for Addiction and Mental Health (CAMH).
The Best Practice Guidelines for Smoking Cessation is one of several such
guidelines being piloted by the Registered Nurses Association of Ontario
(RNAO). The guidelines offer a simple but effective approach for nurses
to integrate this additional role into their daily care of clients.
"We think that nurses have a responsibility to promote smoking cessation
among clients and the general public," says Janet Nevala, team leader
of the committee that wrote the guidelines and provincial co-ordinator
of the Program Training and Consultation Centre with the Ontario Tobacco
Strategy in Ottawa.
As the American Nurses Association notes, 90 per cent of smokers who
want to quit will not attend the usual smoking cessation classes, which
is why nurses should make efforts to help at each opportunity.
"Nurses are in a position to address a variety of issues with clients,"
says Marisa Tacconelli Termine, project leader of the pilot and manager
of two outpatient sites at CAMH. "They play a holistic role, co-ordinating
the many aspects of client care."
The pilot is running at eight inpatient and outpatient sites with different
client populations, including units for people with schizophrenia, with
addictions and for women with mood disorders who have had previous trauma.
A work group of nine staff are implementing the project, which launched
in the spring. Non-nursing clinicians are also participating. Researchers
from the University of Ottawa are studying the pilot's impact.
"We know that most of our clients smoke," says Tacconelli Termine.
"Rates are higher than in the general population." While there
is a nicotine dependence clinic at CAMH, she says it is not always feasible
for clients to attend appointments.
Part of the pilot was determining at the outset whether clients had been
asked about smoking practices and cessation. Similarly, before the guidelines
were introduced, 88 staff members completed a survey to assess their understanding
of smoking.
In the summer, the guidelines were taught in two-hour sessions and during
nursing rounds. They provide background explanations of such issues as
the health risks of smoking and the reasons why people smoke. The actual
intervention, which is summarized on a pocket-sized card, uses the "Ask,
Advise, Assist and Arrange" program, an approach based on the U.S.
Department of Public Health and Human Services guidelines, says Nevala.
After asking clients about their smoking, nurses can assess clients'
readiness to quit. Based on a model called the "Stages of Change,"
this approach offers clinical direction depending on clients' attitudes.
For example, for clients who haven't yet thought of quitting, the intervention
may involve asking them how they feel about smoking and offering quitting
information, while those in the process of quitting would need advice
on relapse prevention, weight gain and smoking triggers.
Several approaches are being used to assess how the guidelines are being
put into practice. In the fall, following staff training, a different
set of clients were interviewed to see whether clinicians addressed smoking
practices and cessation with them. In addition, chart audits were done
and staff were surveyed again.
One issue in the mental health area was to get staff to see smoking as
an addiction problem, says work group member Wendy Fenomeno. "There
was lots of discussion around how we could reframe smoking as an addiction.
We thought there would be a lot of resistance, but there wasn't."
Even if smoking is recognized as an addiction, sympathy toward those
with serious mental health problems -- who may be living in poverty and
have lost significant relationships and jobs -- may lead to the attitude:
"Allow the client this pleasure," says Tacconelli Termine.
Taking a harm reduction approach allows "baby steps" that don't
place unrealistic demands on clients, says Fenomeno, who is the manager
of two inpatient areas at CAMH. "For some of our clients, the idea
of stopping smoking might not be a feasible goal," she says. Their
goals might be to avoid smoking in inappropriate areas or around other
people, and to decrease the amount they smoke. "Lots of nurses could
see this as being feasible."
"We're fortunate in addictions because staff are more familiar with
this model and with smoking cessation," says Carol Edwards, a nurse
practitioner at CAMH. About 90 per cent of people with a substance use
problem smoke, she says.
"The biggest challenge will be the uptake of the guidelines,"
says Nevala. "Anything that takes an extra 30 seconds takes valuable
time."
But there is evidence that nurses can make a difference, says Nevala.
A 1999 Cochrane review found reasonable evidence that nurses can be effective
in getting clients to quit smoking. The review looked at 15 randomized
studies with at least a six-month follow-up that compared a nursing intervention
with a control group or usual care group.
The CAMH pilot is being funded by the RNAO, and all smoking cessation
products for inpatients are provided, while outpatients pay a small fee.
Once the results are assessed, the Best Practices Guidelines will be
published and disseminated across Ontario. The RNAO is also piloting a
"toolkit" that offers advice on how to implement a project.
By Anita Dubey
Smoking and mental illness
According to the World Health Report 2001, people with psychiatric illnesses
are about twice as likely to smoke as others; those with schizophrenia
and alcohol dependence are particularly likely to be heavy smokers, with
rates as high as 86%. A 2000 study published in the Journal of the American
Medical Association found that individuals with psychiatric illnesses
had a smoking rate of 41% compared with 22.5% in the general population,
and estimated that 44% of all cigarettes smoked in the United States are
consumed by people with psychiatric illnesses.
|
(416) 595-6714 
