Hospitalization: Nursing Role with In-Patients Who Smoke Created by the Registered Nurses’ Association of Ontario

Client/Patient Experience when 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 & Smoking 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 & 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… 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 & Smoking Chemicals 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 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: On Admission 1. 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: During Hospitalization for 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 Hospitalization for 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: On 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 Model: Best Practices 1. Document smoking status 2. 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 smoking 5. Track tobacco users for more than 30 days after discharge, provide counselling 6. Ensure training for health-care professionals 7. Provide self-help material 8. Establish referral links 9. Evaluate the provisions of tobacco dependence treatment 10. Provide feedback to health-care professionals

Hospital & Long-Term Care Facilities Smoking 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 Interventions Related to Discharge Planning It is important to provide support, information and follow-up Booklets Web resources Community counselling

Nurses Who Smoke Smoking 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: ◦

Motivational Interviewing Techniques 1. Express Empathy Helps identify and understand resistance and reasons for unhealthy behaviours 2. 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 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- hand smoke on the ability to quit smoking 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