Supporting Smoking Cessation in the Wound Clinic

  Considering today’s more health-conscious society, it may be difficult to fathom that tobacco use and cigarette smoking were once considered to be socially acceptable, “normal” habits increasingly adopted by many Americans.¹ The US Surgeon General released its first report detailing the harmful effects associated with tobacco-related products in 1964, at a time when nearly half of the American adult population was a smoker. The rate of cigarette smoking has decreased dramatically over the years due in large part to ongoing education of its harmful and sometimes lifelong consequences.

  According to the 2011 National Health Interview Survey, only 19% of US adults smoked cigarettes in 2011. Still, tobacco is viewed as the most commonly used recreational drug in the US following alcohol consumption,¹ but it is only through active education by those in positions to curb habits that use will continue to decline.¹

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  With tobacco use still considered a national public health concern in 2014 and its negative health-associated risks tied to the leading cause of preventable mortality in America, not to mention an economic burden due to lost annual productivity and associated medical costs,² opportunities for healthcare providers to promote smoking cessation to their patients during regular office visits are justified.³ Any clinician should embrace the chance to advise patients of the benefits of quitting and how they can successfully quit given the many agents that are currently available on the market. This includes those providers in the outpatient wound clinic, where a lack of positive reinforcement of smoking cessation as well as infrequent reminders of the dangerous effects of nicotine, just as in any healthcare setting, could be a significant barrier toward better patient behavior. However, through appropriate education related to pharmacotherapeutic agents and collaboration with a pharmacist, wound care providers can be instrumental in maintaining ongoing efforts to achieve smoking cessation.⁴

  This article discusses cessation treatment strategies that should be considered for the wound care population.

Nonpharmacological Treatment Options

  In order to ensure the success of any attempt to quit smoking, whether it employs the use of pharmacological and/or nonpharmacological interventions, it is important for clinicians to provide multiple options to patients for counseling that can be provided in the form of individual, group, web-based, or telephone services in which the overall goal is to help promote smoking cessation. Studies have demonstrated the value of using both counseling and pharmacotherapy to improve patient outcomes.⁵

  To assess degree of nicotine dependence and begin the process of smoking cessation, clinicians are advised to follow the Five A’s: 1) ask, 2) advise, 3) assess, 4) assist, and 5) arrange.^5-7 This model is not intended to be strict, but it provides the key aspects of any smoking cessation program. Clinicians can play a vital role in assessing patients’ motivation to quit and their ability to follow through with a therapeutic regimen.⁷

  1) ASK about smoking or tobacco use: The clinician must place an emphasis on asking all patients about their smoking or tobacco use and record this information.⁷

  2) ADVISE the patient to quit: The clinician should speak in a clear, understandable, and concise manner.⁷

  3) ASSESS the patient’s ability and willingness to quit: If the patient indicates that he/she is not ready to quit, motivational interviewing can be used.⁷

  4) ASSIST patients in their attempt to fully quit: It is important for patients to express their own willingness to quit while the clinician works with them to develop a plan as well as advise the patient on the available treatment options for smoking cessation.⁷

  5) ARRANGE for follow-up visits with the patient that are periodic or ongoing, depending on patient availability until he/she is able to quit.⁷

Pharmacological Interventions

  There are many smoking cessation therapies and drugs available on today’s market. A decrease in smoking prevalence has become a priority for governments as well as healthcare systems due to the potential to lead to detrimental health outcomes.⁸ The existing US Food and Drug Administration (FDA)-approved nicotine replacement therapies (NRTs) as well as varenicline (Chantix®) and bupropion sustained-release (Zyban, Buproban) provide different agents with different mechanisms of action to promote cessation.⁹ The currently available agents (as of late 2014; labeled and unlabeled indications) that can be used for smoking cessation are listed in the Table beginning on page 27.¹⁰

  Wound care providers should be sure to note the special precautions listed as they relate to patients who live with diabetes and use insulin.

References

1. Wright J. A history of smoking: From cure to poison. Br J School Nurs. 2011;6(8):408-409.

2. US Department of Health and Human Services. The Health Consequences of Smoking — 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014.

3. Cokkinides V, Bandi P, McMahon C, et al. Tobacco control in the united states – recent progress and opportunities. CA Cancer J. Clin. 2009;59 352–365.

4. Chassin L, Presson C, Rose J, Sherman S. The natural history of cigarette smoking from adolescence to adulthood: Demographic predictors of continuity and change. Health Psych. 1996;15(6):478-484.

5. American Society of Health-System Pharmacists. ASHP therapeutic options on the cessation of tobacco use. Am J Health-Syst Pharm. 2008;65:2055-72.

6. Cigarette smoking prevalence among working adults - US, 2004-2010. MMWR: Morbidity & Mortality Weekly Report [serial online]. September 30, 2011;60:1305-1309.

7. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. May 2008.

8. Phillips A. Smoking cessation: Promoting the health of older people who smoke. Br J Comm Nurs [serial online]. December 2012;17(12):606-611.

9. Coleman T, Agboola, S, Bee JL, Taylor M, McEwen A, McNeil A. Relapse prevention in UK stop smoking services: Current practice, systematic reviews of effectiveness and cost-effectiveness analysis. Health Technol Access. 2010;14(49).

10. College of Psychiatric and Neurologic Pharmacists. 2010-2011 BCPP Examination Review and Recertification Course. Ortho-McNeil Jansseen Scientific Affairs, LLC, 2010.

Adapted from: College of Psychiatric and Neurologic Pharmacist 2010-11 BCPP Examination Review Certification Course & Substance Use Disorders: Pharmacotherapy Self-Assessment Program, 6th Edition.

Abimbola Farinde is on staff at Columbia Southern University, Orange Beach, AL.