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An NP & a PA Speak Out on Smoking Cessation

Clinicians give their two cents on why you should never quit trying to get your patients to quit.

This year, an estimated 158,040 Americans are expected to die from lung cancer, accounting for approximately 27% of all cancer deaths, according to American Cancer Society.1 Lung cancer causes more deaths than colorectal, breast and prostate cancers combined.

In addition, tobacco use is the leading preventable cause of illness in the United States, particularly with respect to cardiovascular disease, cancer, and lung diseases.2 Beside the lives lost (and the reduced quality of life for many), billions of dollars in medical expenses can be directly attributed to cigarette smoking each year.

Health care providers treat patients who smoke every day. The fact that smoking is an acquired behavior means that it's a preventable cause of death in our society. It is therefore crucial for providers to address the topic of quitting with our patients who admit to smoking.

Heath Promotion
According to World Health Organization, "health promotion" is the process of enabling people to increase control over their health and seek to improve it.3 Health promotion requires a commitment on the part of both patients and providers.

There are three levels of preventive efforts:

  Primary prevention involves trying to prevent the disease from occurring, via methods such as health education.

  Secondary prevention involves screening patients for early detection of disease.

  Tertiary prevention involves trying to restore the patient's health after an illness or disease.

While focusing preventive efforts on all three levels is crucial, primary prevention (through education of patients about the hazards of smoking) is the ultimate goal.

Patients often interact with a multidisciplinary team, which consists of physicians, PAs, NPs, nurses and therapists. Each member of the healthcare team can and should encourage patients in different ways to think about the hazards of smoking and nicotine dependence -- from a perspective that is unique to their specialty. Smoking cessation interventions should be brief (but also must be effective).  

An NP's Perspective: Smoking & Surgery

I practice as a nurse practitioner in an anesthesia department. I preform pre-operative assessments in an ambulatory care setting. In the event of a major adverse event during or the need for prolonged observation after a surgery, we have no choice in an ambulatory care setting but to contact emergency medical services to transport the patient to hospital. Obviously, this is something that we try to avoid. Therefore, we screen patients ahead of the time to see if they are appropriate candidates for surgery in our ambulatory care facility. Optimizing patients for surgery and reducing their risks is part of my teaching efforts with each patient.

The main focus when taking down a patient's history and physical information during an anesthesia assessment relates to the patient's cardiovascular and pulmonary function. Information regarding a past history of any respiratory diseases or symptoms, exercise intolerance, cough, prior hospital stays, sleep apnea, and the patient's smoking history is vital to uncovering any undiagnosed respiratory conditions.

If we discover that a patient has a compromised respiratory system due to congestion, fever or an active upper respiratory tract infection, or if they are exhibiting symptoms of wheezing, dyspnea, uncontrolled asthma or chronic obstructive pulmonary disease (COPD), their procedure will end up either being canceled and rescheduled for some time after the symptoms resolve, or the patient's procedure will be relocated to a nearby hospital if we feel that might be a safer setting based on their condition. Patient safety is always the main concern.

In pediatrics patients, I always look for the signs and symptoms of exposure to second-hand smoke. Studies show that children who are exposed to second-hand smoke are more prone to airway and pulmonary complications during surgery, such as laryngospasm, perioperative cough, hypoxemia and bronchospasm.4

In addition to considering the patient's readiness for surgery, we also ask questions about smoking history because multiple studies have demonstrated that the action of a number of drugs commonly used in anesthesia are modified in smokers, including neuromuscular-blocking drugs, opioids and sedatives.6 Smokers need increased levels of certain opioids, such as morphine, pentazocine, dextropropoxyphene and some of the newer synthetic drugs, during their post-op recovery.6 Another study shows that smoking decreases the potency of aminosteroids (muscle relaxants).7

Talking to patients about smoking cessation before surgery is something that I practice daily. It is never too late to quit. Patients who quit smoking six months before surgery have risk similar to those who never smoked. Some studies suggest that quitting smoking even four to eight weeks prior to surgery will significantly reduce smoking-related complications.8

A PA's Perspective: Chronic Pain and Smoking
In my practice as a physician assistant in the physical medicine and rehabilitation division of pain management, I believe that the single most important thing I can do for my patients is to help them quit smoking. Smoking cessation is something I am very passionate about.

Smoking has negative effects on both healing and recovery after injury, as well as being a risk factor for the development of chronic pain. Smokers not only have a higher incidence of chronic pain, but also rate their pain as more intense than non-smokers.

According to the researchers at Northwestern University in Evanston, IL, smokers are three times more likely to develop chronic back pain than non-smokers.5 This has been linked to increased brain activity between the nucleus accumbens and the medial pre-frontal cortex, both of which play a role in learning and addictive behavior. The study found that the stronger the connection is between the two areas the in the brain, the more vulnerable the individual is to the development of chronic pain. In the study, those who quit smoking had a notable decrease in the brain circuits' activity.

For many years, Americans have known about the multi-faceted dangers of smoking. Smoking is strongly linked to several types of cancer and can affect every organ system. Smoking causes poor blood supply and leads to vascular disease. It also interferes with healing and can cause peripheral neuropathy pain that can impact mobility and function. Smoking also leads to COPD and other breathing problems.

What can we do to help our patients to quit smoking? How do we convince them to stop? How do we get through to those who don't want to quit? If it was easy, we would all have practices full of healthy patients. It's not simple, but for what it's worth, here is my advice: never give up on your smoking patients, never stop talking about quitting, and never stop being their source of encouragement.

I offer smoking cessation counseling referrals to my patients and direct them to resources like such as "Tobacco Free Florida." Sometimes I even prescribe pharmacologic treatments to help curb cravings. I spend a great deal of time discussing smoking; every chief complaint is an opportunity to encourage my patients to quit. When a patient who smokes complains that their knee hurts from a meniscal tear, I will take that as an opportunity to remind them that smokers' red blood cells don't transport oxygen very well around the body, and inform them that a poor blood supply to the meniscus makes this injury particularly difficult to heal. When a patient complains about the financial strain and the cost of office visits or the medications I prescribe, we calculate the financial implications of smoking cigarettes. For a one-pack-a-day smoker, it adds up to approximately $2,000 a year spent on cigarettes alone.

My three-pronged approach to encourage smoking cessation includes the following points:

•  Know that quitting smoking is best accomplished as a team effort. If your spouse or your best friend smokes, they must be supportive of your efforts to quit; in fact, it is most ideal to quit smoking together. I encourage my patients to bring in their loved ones who smoke to discuss quitting as a family and to pick a quit date together. It is very difficult - though not impossible - to quit while you are surround by smokers.

•  Pick a quit date. I like to tell my patients to pick a date that has some significance to them: an anniversary, a birthday, a due date for a grandchild. Patients should pick a day that is important to them and worth remembering.

•  Create a "money jar" so you can display the money you're saving. Keep this jar somewhere visible and accessible. Watching that money grow can be a very empowering tool and a great source of additional income. I ask them to make a list of all the things they would like to do at the end of the year with the extra money they could save.

As a health care provider, the most important advice I can impart is to keep at it! I do have patients who would beg me not to talk about smoking cessation and swore they'd smoke until the day they died --- and they have managed to quit. One patient insisted he quit because he was sick of my lectures. Another patient quit after smoking for 40 years, and told me it was because she knew how much I worried about the negative effects it had on her health. Yet another patient, who smoked 5 packs a day, stopped about a year ago --- and I never thought I'd get through to him. The bottom line is, if you don't give up on your patients, you can help them give up this habit.

Snezana Radnovic
is a nurse practitioner in the anesthesia department at the Bascom Palmer Eye Institute of Anne Bates Leach Eye Hospital in Miami, FL. Jennifer B. Marjama is a physician assistant in the physical medicine and rehabilitation division of pain management at Southeastern Integrated Medical in Chiefland, FL.

1.  American Cancer Society. Cancer Facts and Figures 2015.

2.  Tobacco Use, Chapter 27 Health People 2010-Centers of Disease Control and Prevention. http://www.healthypeople.gove/Document/HTML/Volume2/27tobacco.htm.

3.  World Health Organization. Health Promotion.

4.  Lyson A. Pediatric respiratory complications after general anesthesia with exposure to environmental tobacco smoke in the home: a case report. AANA Journal. 2011;79(1):20-23.

5.  Whiteman, H. Smoking linked to increased risk of chronic back pain.

6.  Sweeney BP, Grayling M. Smoking and anesthesia: the pharmacological implications. Journal of the Association of Anesthesiologist of Great Britain and Ireland 2009;64: 179-186.

7.  Teiria H, Rautoma P, Yil-Hankala A. Effect of smoking on dose requirement for vecuronium.  British Journal of Anesthesia 1996;76:154-155.

8.  Khan M, Madhusudhan R, Syed A, Wasim S, Atif A, Jonathan J. Preoperative management of chronic respiratory disease. Journal of Preoperative Practice 2012;22:324-327.


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