LOS ANGELES-When nurses talk, smokers listen.
"We have just as much pull as physicians," said Virginia Hill Rice, PhD, RN, CNS, FAAN, Professor of Nursing at Wayne State University College of Nursing in Detroit and a smoke-free advocate.
When it comes to smoking, though, few nurses use their pull. That's the conclusion of Linda Sarna, DNSc, RN, AOCN, FAAN, Professor and the Lulu Wolf Hassenplug Endowed Chair in the School of Nursing at UCLA, who presented the results here at the ONS Conference on Cancer Nursing of Research of a study on nurses' attempts to help patients quit.
She found that few nurses referred smoking patients to toll-free quit lines. The National Cancer Institute operates a nationwide quit line, 1-800-QUITNOW, and many states also have toll-free help lines. Trained counselors advise callers over the phone and typically provide four to six follow-up calls. Counselors also can refer callers to local services including support groups.
"Over 70% of nurses rarely or never referred patients to this fine resource," Dr. Sarna said.
She conducted her survey of 1,790 nurses from 10 hospitals in each of three states-Indiana, West Virginia, and California. She said she chose hospital nurses because they have a captive audience.
Moreover, patients typically get a head start on permanently kicking the habit while having to refrain from smoking during their hospital stay. The Joint Commission requires hospitals to encourage smoking cessation with patients being treated for acute myocardial infarction, heart failure, or pneumonia, but makes no such requirements for cancer patients.
Yet, smoking not only causes several types of cancer, but the incidence of smoking is higher in cancer survivors than in the general population, particularly in those who are young and middle-aged. The National Center for Health Statistics reports that between 2000 and 2008, 24.4% of adults 18 to 44 smoked. The rate among cancer survivors of the same age was 40.4%.
"We really think tobacco cessation should be an essential part of oncology nursing," Dr. Sarna said.
Help Essential for Success
An estimated 70% of adult smokers want to quit, Dr. Rice noted, but without help fewer than 3% are able to. A review she published in the Cochrane Library in 2009 shows that when nurses give patients strategies to quit, the success rate climbs to 20%.
Dr. Rice, who was not at the ONS conference but was contacted afterwards for this article, said she believes that nurses avoid advising patients on giving up tobacco because they feel ill-prepared.
"Nurses don't know quit lines exist," she said. "Many nursing-school curricula don't have a module on tobacco use."
Nurses who already feel tentative about telling patients to quit may be discouraged when patients dismiss their advice, she noted.
"When they tell a patient to quit smoking, they say, 'Oh I was told that before,' so nurses feel that they aren't making a difference."
To help nurses give patients the best smoking-cessation advice, Dr. Rice recommends that hospitals provide in-service training. Nurses can also brush up on their own with the Agency for Healthcare Research and Quality AHRQ booklet Helping Smokers Quit: A Guide for Clinicians, which can be downloaded at http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm.
"Every nurse should be able to deliver a minimal smoking-cessation intervention," Dr. Sarna said.
Her study showed that nurses' own smoking practices influenced their willingness to intervene. In California, where only 6% of the nurses surveyed smoke, almost 30% referred patients to quit lines. In contrast, in Indiana, where 23% of respondents smoke, and West Virginia, where nearly 27% smoke, only 10% made the referrals.
"Never smokers and former smokers are more likely to make referrals," she said.
Dr. Sarna is one of the leaders of Tobacco Free Nurses (http://www.tobaccofreenurses.org), which provides information to help nurses kick their own habit as well as help their patients kick theirs.
Another nurse involved with that effort, Stella Anguinaga-Bialous, RN, MScN, DRPH, MPH, discussed the importance of hospitals being truly smoke-free.
She noted that although smoke-free medical campuses make it easier for nurses to quit and promote quitting to their patients, a survey she conducted of 30 hospitals showed that 76% allowed smoking-typically in outside, designated smoking areas, or in unofficial spots such as parking lots and garages. Nine of the hospitals surveyed allow patients to go outside to smoke.
"There has to be total enforcement of smoke-free campuses," Dr. Rice said. "The more that's enforced, the more likely nurses are to quit."
Advice Must be Specific
Nurses trying to persuade patients to quit will have more success if they give them specific information. She said she recommends, for example, that nurses tell patients when and where to join a support group-"the more specific the directions, the more likely it is that patients will follow them."
For some patients, she suggests nicotine-withdrawal products such as gum or patches, Dr. Rice noted. "If they can get a script, insurance often covers it."
She also urges follow-up, either from the hospital after discharge or by the patient's physician.
Dr. Sarna said that in spite of the low rate of quit-line referrals she found, she believes that nurses will increasingly persuade patients to quit. One item in favor of that is that the Joint Commission is considering expanding its requirement for smoking-cessation advice to all patients who smoke, not just those with three specific diagnoses.
"Nurses can make a difference," Dr. Sarna said. "One of the most important things a nurse can do is help patients quit smoking."