What is the best treatment modality for smoking cessation

1
Evidence-Based Practice

• What is the best treatment modality for smoking
  cessation?

By Brandi Fuselier, Courtney Garner, Rachael
Robison, Katy Stewart
2
Identification of Problem

• Smoking
• LEADING CAUSE OF PREVENATBLE DEATHS WORLDWIDE
• RELATED TO MANY HEALTH PROBLEMS
• Every 8 seconds one person dies from tobacco use
• Cigarettes cause 1 out of 5 American deaths
• Smoking-related diseases cost the united states
  more than 150 Billion a year

3
Identification Of Problem

• Healthy people 2010- Reduce tobacco consumption
  by 12
• Approximately 51 of smokers attempted cessation
  last year in the united states
• Unaided smoking cessation has been found to only
  have success rates of 2-4
• First-line therapy has traditionally been
  pharmacological agents
• Limited research on effectiveness of
  non-pharmacological treatments in sustaining
  abstinence

4
PICO

• PATIENT POPULATION OF INTEREST IS SMOKING ADULTS
  AGES 18 AND OVER
• INTERVENTION OF INTEREST IS THE USE OF
  NONPHARMACOLOGICAL AGENTS (SUCH AS GUIDED
  IMAGERY, QUITLINES, EXERCISE)
• Comparison of interest is pharmacological agents
• Outcome of interest is effectiveness in smoking
  cessation

5
EBP Question

• IN ADULTS AGES 18 YEARS AND OLDER IS THE USE OF
  NON-PHARMACOLOGICAL AGENTS (SUCH AS GUIDED
  IMAGERY, QUITLINES, AND EXCERISE) IN COMPARSION
  TO PHARMACOLOGICAL AGENTS MORE EFFECTIVE IN
  SMOKING CESSATION?

6
Review of Literature

• What is being done to study the problem?
• Medical research
• Randomized control trials
• Systematic Reviews
• Literature Reviews
• Clinical Guidelines
• Case studies
• Inadequate nursing research

7
Review of Literature

• pros of using Non-pharmacological agents
• Little to no adverse/ side effects
• No prescription needed
• May not require visit to PCP to initiate
  treatment
• Majority are cost effective
• Wide variety of options

8
Review of Literature

• Cons of using Non-pharmacological agents
• May not be as readily available to consumers
• May require more time and effort
• Lack of health care provider knowledge regarding
  options

9
Review of Literature

• Guided Imagery
• Involves using the imagination and mental images
  to promote relaxation, changes in attitude, or
  behavior, and encourages physical healing.
• Helps reduce stress
• Audio CDs available to guide clients through
  the process .
• Specially trained nurses on guided imagery.
• http//www.academyforguidedimagery.com

10
Review of Literature

• Non-pharmacological Studies - Guided Imagery
• Guided imagery was twice as effective as
  Bupropion (Zyban) (Grohs et al. 2008).
• Guided imagery was more effective than counseling
  alone (Wynd, 2005).

11
Review of Literature

• Exercise
• Individuals are often afraid to stop smoking for
  fear of weight gain.
• Types of exercise helpful to those attempting
  smoking cessation include weight-bearing,
  cardiovascular, and stretching.

12
Review of Literature

• Non-pharmacological Studies - Exercise
• Exercise was shown to aid in withdrawal symptoms
  associated with nicotine dependence (Usser,
  Taylor, Faulker, 2008).

13
Review of Literature

• Common Quitlines
• 1-800-QUITNOW
• 1-877-NOBUTTS

14
Review of Literature

• Non-pharmacological Studies Quitlines

• More effective than brief counseling from a
  healthcare provider or self-help materials alone
  (Stead, Perera, Lancaster, 2007).
• Effective in addressing the needs of large
  populations and enabled those in rural areas to
  obtain support with smoking cessation efforts
  (Lichtenstein, Glasgow, Ossip-Klein, Boles,
  1996).

15
Review of Literature

• Pros of using pharmacological agents
• Increased availability of OTCs
• Various forms of Nicotine Replacement Therapy
• Easy to use, time efficient
• More knowledge and research available

16
Review of Literature

• cons of using pharmacological agents
• May require prescription
• Adverse side effects
• Expensive

17
Review of Literature

• Pharmacological Studies
• Nicotine Replacement Therapy, Varencicline
  (Chantix), Bupropion (Zyban), were effective in
  sustaining both short-term and long-term
  abstinence from smoking(Wu, Wilson, Dimoulas,
  Mills, 2006).
• Varencicline (Chantix) superior to both NRT (in
  indirect study comparisons) and Bupropion (Zyban)
  (Wu, Wilson, Dimoulas, Mills, 2006).
• All of the available types of NRT increased
  abstinence rates 1.5 to 2-fold (Silagy,
  Lancaster, Mant, Fowler, 2004).

18
Review of Literature

• Pharmacological Agents Mechanisms of
  Action/Side Effects
• NRT
• Releases constant amounts of nicotine throughout
  the body using a tapering-off method.
• Available in several forms
• Side Effects skin irritation (patch),
  dizziness, racing heart rate, sleeping
  difficulties, headache, vomiting, muscle aches,
  and stiffness.

19
Review of Literature

• Pharmacological Agents Mechanisms of
  Action/Side Effects
• Varencicline (Chantix)
• Limits dopamine release and effectively blocks
  nicotine receptors in brain.
• Available in tablet form.
• Side Effects sleeping difficulties,
  constipation, vomiting, flatulence, gingivitis,
  chest pain, influenza-like symptoms, edema, and
  thirst.

20
Review of Literature

• Pharmacological Agents Mechanisms of
  Action/Side Effects
• Bupropion (Zyban)
• Atypical antidepressant norepinephrine
  dopamine reuptake inhibitor
• Available in extended-release tablets
• Side Effects anxiety, sleeping difficulties,
  seizures, dizziness, drowsiness, dry mouth, loss
  of appetite, abdominal pain, constipation, and
  diarrhea.

21
Recommendations

• 1. A comprehensive program that includes
  pharmacological agents as first-line therapies is
  supported.
• 2. Non-pharmacological interventions should serve
  as adjuvant therapies to medications to increase
  clients rates of sustained abstinence from
  smoking.
• 3. Treatment plans should be individualized and
  tailored specifically to each client in order to
  ensure positive outcomes

22
Literature Supporting Recommendations

• Both pharmacological and non-pharmacological
  treatment options address the various needs of
  the individual seeking smoking cessation.
• Combining non-pharmacological and
  pharmacological modalities and tailoring to the
  individual yields the best smoking cessation
  rates (Mundey, 2009).
• National Guideline Clearinghouse supports a
  multidimensional approach to smoking cessation.

23
Current Practice

• HOSPITAL A
• HOSPITAL B
• HOSPITAL C

24
Implementation Strategies

• Multidisciplinary Approach
• Awareness Campaign
• In-services (CEUs)
• Cafeteria posters/pamphlets
• Web-based materials
• PSAs (through television/radio)
• Admission assessment
• Designated smoking cessation experts on floors
• Recycling information (at specific time
  intervals)

25
Evaluation of Effectiveness

• Multidisciplinary Approach
• Client healthcare team satisfaction
• Awareness Campaign
• Short Term
• In-services evaluation forms
• Smoking history reassessment
• Follow-up phone calls questionnaires
• Development of focus groups
• Long-Term
• Assess the number of individuals enrolled in
  smoking cessation programs.
• Assess hospital readmission rates for
  smoking-related complications

26
Suggestions for Further Study

• What are other approaches to studying the
  identified problem?
• Long-term randomized control trial studies
• Specific studies comparing pharmacological and
  nonpharmacological interventions
• Studies on nursing related interventions
• Larger sample sizes
• Patient surveys

27
Suggestions for Further Study

• What new research questions have emerged as a
  result of the project?
• Why are long-term abstinent rates so low?
• What are ways to overcome barriers to successful
  smoking cessation?
• What is the most effective non-pharmacological
  treatment for smoking cessation?
• What types of physical activity including
  intensity levels are best for smoking
  cessation?

28
Future Therapies

• Nicotine Vaccine
• Rimonabant
• Pharmacogenetics

29
Questions
30
References
American Lung Association (2009). Quit smoking
benefits. Retrieved March 29, 2009 from
http//www.lungusa.org/site/c.dvLUK9O0E/b.33568/k
.CEBD/Benefits.htm. Grohs, U., Kemmler, G.,
Kriechbaum, N., Saria, A., Wallner, R., Zernig,
G. (2008). A randomized trial of short
psychotherapy versus sustained-release bupropion
for smoking cessation Electronic version.
Addiction, 103, 2024-2031. Institute for
Clinical Systems Improvement. (2004). Tobacco use
prevention and cessation for adults and mature
adolescents. National Guideline Clearinghouse,
1-25. Lichtenstein, E., Glasgow, R. E.,
Ossip-Klein, D. J., Boles, S. M. (1996).
Telephone counseling for smoking cessation
Rationales and meta-analytic review of evidence.
Health Education Research Theory Practice,
11(2), 243-257. Mundey, K. (2009). An appraisal
of smoking cessation aids. Current Opinion in
Pulmonary Medicine, 15, 105-112.
31
References
Silagy, C., Lancaster, T., Mant, D., Fowler, G.
(2004). Nicotine replacement therapy for smoking
cessation. Cochrane Database of Systematic
Reviews, 3, 1-8. Stead, L. F., Perera, R.,
Lancaster, T. (2007). A systematic review of
interventions for smokers who contact quitlines.
Tobacco Control, 16(1), 3-8. Ussher, M., Taylor,
A., Faulker, G. (2008). Exercise interventions
for smoking cessation. Cochrane Database of
Systematic Reviews, 4, 1-37. World Health
Organization (2009). Smoking statistics.
Retrieved March 29, 2009, from http//www.wpro.wh
o.int/media_centre/fact_sheets/fs_20020528.htm.
  Wu, P., Wilson, K., Dimoulas, P., Mills, E.
(2006). Effectiveness of smoking cessation
therapies A systematic review and
meta-anaylsis. Biomed Central Public Health, 6,
300-316. Wynd, C. (2005). Guided health imagery
for smoking cessation and long-term abstinence
Electronic version. Journal of Nursing
Scholarship, 37, 245-250.