Turning smokers into quitters: Nurses prepare to help clients butt out: CrossCurrents Winter 2002/03
CrossCurrents
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.
Anita Dubey
Centre for Addiction
