Smoking cessation programs for hospitalized women with heart disease may have lasting effects, according to a UCSF researcher. Not only is the medical event a stimulus to quit smoking, but patients are forced to comply with nonsmoking policies of hospitals. This creates a teachable moment that may lead to long term abstinence, according to Erika Froelicher, RN, PhD, UCSF professor of physiological nursing and epidemiology and biostatistics.
Froelicher's intervention which is described in the November/December issue of Heart and Lung, is one of the first to focus on smoking cessation in women recovering from heart disease. The Women's Initiative for Nonsmoking (WINS) is testing the short and long term effectiveness of nurse-managed relapse prevention programs for women who are forced to abstain from smoking for 48-72 hours during hospitalizations.
"The program has been successfully implemented in more than 140 women and has proven to be feasible and well accepted by women and their health care providers," said Froelicher.
The intervention begins when physicians come to the bedside to strongly urge patients to quit smoking. The next step includes a 45 minute one-to-one counseling session at bedside. Nurse managers offer relapse prevention training and information about weight gain, alcohol use, exercise, stress management, social support, and nicotine replacement therapy (NRT). Nurses monitor progress by telephoning patients at home 2, 7, 21, 28 and 90 days following the initial session. Because the average smoker attempts to quit three times before achieving success, nurses stress urge control methods and how to deal with "slips," or brief relapses.
"The program allows women to develop and practice tools that help them avoid smoking in risky situations," said Froelicher. Patients are taught to recognize situations in which they are at high risk to smoke. Risky situations include social situations (when drinking an alcoholic beverage with friends or when someone offers them a cigarette); emotional or negative mood situations (when feeling anxious, depressed or uncomfortable); crutch situations (when needing more energy or wanting to keep slim); self-image situations (when wanting to feel more mature or attractive); time-structuring situations (when feeling bored); and restless situations (when wanting to relax or when waiting for someone or something).
Next patients are taught ACE strategies. ACE is an acronym for Avoid, Cope, Escape. If a woman does not feel ready to handle a particular risky situation, she is instructed to avoid it, until her confidence to handle the situation improves, explained Froelicher. If she cannot avoid the risky circumstance, then coping is required. Possible coping strategies include distraction (any activity or thought process that gets her mind off smoking), incompatible behaviors (knitting or other tasks that use the hands, sucking on hard candy, or eating raw vegetables), and positive self-talk. Escape is the final option if neither of the others is feasible. In this case, women are coached to leave the situation without smoking.
Patients are encouraged to rehearse these coping strategies. This can be done with the intervention nurse, a friend or family member, or in front of a mirror, explained Froelicher. "Practice helps a woman be prepared for a situation whether it arises or not and can give her the confidence necessary to tackle the high-risk situation when it occurs," she said.
Tests for gender differences in smoking cessation have not been a major focus of research. Data for men and women has generally been pooled and sample sizes for women have been too small to draw conclusions, according to Froelicher. However, evidence from other studies has helped WINS researchers tailor the intervention for women.
Fear of weight gain is one of the most frequent excuses women use for not quitting, and weight gain is a key relapse trigger, said Froelicher. Up to 75 percent of women report an unwillingness to gain five or more pounds as a result of smoking cessation, and more than half of women younger than 25 and 39 percent of women over 40 state they are unwilling to gain any weight, according to previous research. Study participants are briefed about maintaining a diet low in fat and cholesterol and given lists of low fat snacks and sweets that can assist them through their early efforts. These lists, and other important smoking cessation information, are taken from the American Heart Association's Active Partnership for the Health of Your Heart workbook. The workbook is given to patients (along with an audio and video series) during the initial counseling session. Exercise is encouraged as an aid in coping with stress.
Study participants are also referred to the stress management section of the workbook and the relaxation audiotape. Women are encouraged to listen to the 15 minute tape daily for the first month after hospital discharge and then as needed. Because women have heart attacks at a later age, they are more likely to be widowed, single or living alone. Therefore, special emphasis is placed on social support provided by the nurse in the hospital and in follow up telephone calls, said Froelicher.
The menstrual cycle may also complicate smoking cessation. Irritability, depression, anxiety, tension, decreased concentration, sleep disturbance, and weight changes are common symptoms of menstrual distress and also of nicotine withdrawal, she said. Withdrawal may be less severe when the quit date is set in the first half of the menstrual cycle before ovulation. Though study participants are not always hospitalized at the most optimal time in their menstual cycle, interventions should take the menstrual cycle into account whenever possible, said Froelicher.
Nicotine replacement therapy (NRT) is not recommended for patients with serious arrythmias, angina, or those who have suffered a heart attack in the preceding four weeks. Consequently, NRT is only provided after the study nurse consults with the woman and her physician. The Therapy is limited to eight weeks without tapering (a gradual reduction of the dosage), unless otherwise requested by the physician.
The five year study is funded by the Behavior Medicine Section of the Heart, Lung and Blood Institute. Co-investigators include Dianne Christopherson, RN, PhD, UCSF assistant professor in the department of physiological nursing; Nancy Houston Miller, RN, BSN, UCSF assistant professor in the department of physiological nursing and associate director, cardiac rehabilitation, Stanford University School of Medicine; and Kirsten Martin, RN, MS, former UCSF research assistant in the department of physiological nursing now a staff nurse at Alta Bates Medical Center.
Journal
Heart & Lung