Smoking Cessation a Prevention of Disease – Graduate Research Paper

Smoking Cessation a Prevention of Disease – Graduate Research Paper


This review of literature addresses the problem of smoking in America. The guidelines present comprehensive plans to help the clinician assist and direct their clients with this habitual problem. The review of literature reflects this monumental effect tobacco smoking has on everyone.

The cost of treating tobacco related illness is staggering. Prevention of tobacco consumption as shown in the literature starts with educating our children and providing programs that make our children aware of the risks at an early age.

Identification of the client with a smoking addiction is the first step the clinician must take. Counseling, providing educational materials, and offering pharmocotherapy are also necessary interventions on the practitioner’s level.
Community awareness and dedicated involvement is essential to be successful on a meaningful scale. Our community budgets need to include money to spend on prevention and treatment programs as well as managed care incentives and insurance reimbursement to hospitals and clinicians that practice smoking cessation and prevention.

Tobacco smoking is a huge problem and this paper identifies solutions and facts to support the need for cessation.

Tobacco is the single greatest cause of disease and premature death in America today and is responsible for more than 430,000 deaths each year. Americans spend an estimated $50 billion annually on direct medical care from smoking related disability and illness. Nearly 25 percent of adult Americans currently smoke, and 3,000 children and adolescents become regular users every day (U.S. Public Health, 2000). Because tobacco dependence is a chronic condition it often requires repeated intervention. Research shows that delivering treatment to tobacco users is cost effective. It is essential that clinicians and health care delivery systems offer treatments available and document their effect (American College, 2000). In 1998, The Office of Disease Prevention and Health Promotion set The Healthy People 2010 prevalence goal for a 13% reduction with a smoking prevalence at nearly 24% in 1997 the nation will likely fall short of this goal (Mendez & Warner, 2000). The authors go on to say “for adults older than 50 years, this would require that the annual cessation rate, currently 5.96%, increase to over 21%” (Mendez & Warner, 2000).

The purpose of this review of literature is to obtain the best practice for helping people stop smoking and to determine how serious the problem really is related to cost and determent to our nation’s health. As clinicians we will be attempting to determine our patient’s risk factors and giving them the opportunity and treatment to prevent illness. I would like to have the best understanding about what actually works according to research and the current guidelines available.

The evidenced based guidelines are very helpful and give very useful information to the clinician. The first guidelines I found are addressed not only to the practitioner but also to the health care administrator, insurers, managed care organizations and purchasers. The guidelines proposed by the U.S. Public Health Service call for a systems approach. Six strategies are recommended for treating tobacco use and dependence. They are as follows:
Every clinic should implement a tobacco-user identification system.
All health care systems should provide education, resources, and feedback to promote provider intervention.

Clinical sites should dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations.
Hospitals should promote policies that support and provide tobacco dependence services.
Insurers and managed care organizations should include tobacco dependence treatments (both counseling and pharmacotherapy) as paid or covered services for all subscribers or members of health insurance packages.

Insurers and managed care organizations should reimburse clinicians and specialists for delivery of effective tobacco dependence treatments and include these interventions among the defined duties of clinicians.

The guidelines take each strategy and give detailed explanations and examples of how to implement them. This guideline uses The Agency for Healthcare Research and Quality, The Centers for Disease Control and Prevention and The National Cancer Institute for their evidence base.

The next guideline is endorsed by the American College of Cardiology and is meant to be a clinical practice guideline for clinicians. These guidelines were developed by the committee of Tobacco Use and Dependence Guideline Panel and consists of 17 members fifteen MDs and two RNs. These guidelines have major recommendations which include screening for tobacco use, treatment structure and advice to quit smoking, treatment elements including counseling, behavioral therapies and pharmacotherapy, special populations which include gender, pregnancy, children and adolescents, and the last recommendation takes into account special topics such as weight gain and clinician training. Each recommendation is elaborated and detailed with specific examples of each.
Both of the guidelines are very helpful and give systematic approaches that will be very beneficial to the clinician and the patient.

Research article #1
Neil-Urban, S., Lasala, K., Todd, S. J. (2002). Community collaboration: using nursing students in a smoking cessation program for pregnant women. Journal of Nursing Education, 41, 76-79.
The authors identified the following problems.
Smoking results in the unnecessary premature deaths of more than 200,000 American women annually.

It has been established that approximately 25% of pregnant women smoke throughout their pregnancy.

Many studies demonstrate that smoking cessation during pregnancy or during the first trimester will result in improved pregnancy outcomes and statistically normal birth weights.

The purpose as stated is to provide community-based education, emphasizing health promotion and disease reduction, in which collaborative partnerships with agencies in the community are developed and maintained.

The hypotheses presented in this study focuses on the fact that less than 40% of clinicians routinely advise their patients to stop smoking. Citing lack of training, lack of time, sense of apathy and powerlessness to change client’s behavior, lack of funds for materials to offer clients and lack of awareness of the expert panel reports and recommendations for prenatal care. In addition reasons pregnant women offer for not participating in smoking cessation are inconvenience of group classes, lack of available child -care, lack of support, and too much going on in their lives. Most of these obstacles could potentially be solved, by using nursing students to implement such programs in the homes of the pregnant clients.

The literature review included 28 references. Some were older than 5 years especially related to birth weight in smoking mothers and counseling of pregnant mothers.
The theory used was the health belief model and personal health behavior presented by M.H. Becker originally in 1974 and is referenced. The authors also utilized the Agency of Health Care Policy and Research Guidelines for Smoking Cessation. The Pregnant Women’s guide to Quit Smoking handbook was utilized as a self -help program for the mothers.

This quantitative study is really a pilot study due to the size of the sample, with only 22 women participating in the study. This pilot study is descriptive and is the basis for further quantitative research.

Variables identified were social and environmental factors that mitigated against the success in quitting smoking, barriers produced by the community agency and the student collaboration, the lack of enthusiasm from the director and shyness on the part of the students. These variables are all conceptual demonstrated by the behavior of the students, clients and clinic.

The authors obtained permission to conduct this research project by the Human Subjects Review Committees at both the pregnancy clinic and the university. All clients reviewed and signed a consent form as stated in the study.

This study of 22 women although a small sample demonstrated an 18% quit rate at the 6 month follow-up and more than 40% reported a reduced amount they smoked, these rates compared favorably to other studies. This study is an important application to practice proving that elimination of some of the barriers to smoking cessation and providing a self -help program with follow-up and implementation from nursing students, can result in positive outcomes.

Research article #2
Secker-Walker, R. H., Flynn, B. S., & Solomon, L. (2000). Helping women quit smoking: results of a community intervention program. American Journal of Public Health 90, 940-946.

The problems as identified by the next research project are as follows:
In the mid-1980s, the decline in smoking prevalence among women was lagging behind men.

Lack of research on strategies to accomplish large-scale smoking cessation for women.
The need for social support while quitting.
The need for coping with negative affect in the absence of smoking.
Concerns about weight gain.

The purpose and goal of the project was to reduce the prevalence of smoking among women age 18 to 64 years, with special emphasis on the lower income women of childbearing age. Other objectives as stated:
Increase motivation and intention to quit smoking and confidence in staying quit despite weight gain and negative affect.
Increase awareness of, access to, and use of cessation activities or support for staying quit.

Strengthen perceived norms and available support to help women quit smoking.
The review of literature consisted of some 40 references. All of the
references except 2 were older than 5 years, however the baseline study was conducted from October 1989 to June 1990 and the 5 year follow-up survey was conducted in 1994. The researchers looked at many other smoking cessation programs including community intervention programs and analysis and assessment of outcome material.

As stated by the authors, the study used the social cognitive theory, the transtheoretical model of behavior change, diffusion of innovation theory and communications theory. They used the PRECEDE framework of predisposing factors, enabling factors, and reinforcing factors involved in behavior change to integrate the overall objectives of the intervention program.

The variables identified in this study were the nonrandomized design, the inclusion of only 2 counties in each condition, and the lack of prior measures of in these counties to assess earlier secular trends. The rural nature and lack of ethnic diversity in the population limit the generalizability of the results these were all conceptual definitions. The operational definitions related to the interventions used to increase awareness, the strategies used to increase motivation and the support provided to help the women quit smoking.

This quantitative study is a quasi-experimental design examining the effects of the interventions on the two rural counties with sample sizes of just over 6,000 each.

Because the study took place over 5 years, enthusiasm was the greatest in the first two years. Each annual plan included specific measurable objectives for each group to be accomplished during the next 12 months. The last 2 annual plans included strategies to institutionalize the Breath Easy programs. This plan even with change of personnel minimized the variables.

The project did not list any of the ethical issues related to consent or approval boards.

This study with a smoking prevalence reduction of 7.8% at five years in the county that received the treatment is a very positive outcome and is significant to the advanced practitioner. The problem of smoking cessation involves the entire community and this study tested a long- term plan that achieved a good effect.

Research article #3
Zhang, X., Miller, L., & Max, W. (1999). Cost of smoking to the Medicare program, 1993. Health Care Financing Review, 20, 179-196.
The problems tackled in this paper are related to the following issues:
Interest in smoking related costs has never been higher.
Other research has examined the cost borne by Medicaid only.
Medicare covers the medical expenses of 34 million Americans age 65 or over and 5.5 million persons with disabilities.

16 percent of Medicare enrollees in 1994 reported themselves as current smokers and 44 percent as former smokers.
The purpose and objective of this study is to present each state’s estimate of Medicare expenditures attributed to smoking for the Medicare population, including those with disabilities.

The review of literature consisted of 21 references half of which are older then 5 years. Many as you can imagine are related to the statistics and sample bias. The others are related to disability and the economic cost of smoking.
No theory was identified in this study.

The variables were many due to the huge sample. The authors have one large table identifying the many variables that come into play when attempting to do the statistics of this size population. Several variables identified included sample bias related to the likelihood that people who were more concerned about their health issues were more likely to participate in the supplemental survey and were likely to have a higher demand for medical services. Participants who were sicker and needed medical services were less likely to participate. Other variables listed were sociodemographic, economic and other risk factors. These are all considered operational definition and can be measured and manipulated.

This quantitative study is correlational and examines linear relationships between the different variables.

The study addresses the issue of sample bias and control of the variables by using the standard Heckman-Lee adjustments and the inverse Mill’s ratio.
There was no mention of consent or approval for this study.
This study is important to advanced practitioners especially related to our population being Medicare age here in Florida. If we can spend our health care monies on prevention rather than smoking related illness we will save as this study determined in 1993. The total Medicare smoking attributed expenditures in the United States amounted to $14.2 billion. Of this total $10.8 billion was for hospital care, $2.4 billion for ambulatory care, $488 million for nursing home care and $473 million on home health care services. As this study points out we are paying a lot for a habit that could be prevented.

Research article #4
Daughton, D., Fortmann, S. P., Golver, E. D., Hatsukami, D>, Heatley, S., Lichtenstein. E., Repsher, L., Millatmal, T., Killen, J.D., Nowak, R., Ullrich, F., Kashinath, P. D., & Rennard, S. I. (1998). The smoking cessation efficacy of varying doses of nicotine patch delivery systems 4 to 5 years post-quit day. Preventive Medicine, 28,113-118.
The research problems and issues addressed in this study are as follows:
Cigarette smoking is the major preventable risk factor for excess morbidity and mortality in the developed world.

While transdermal nicotine delivery has been found to aid in cessation efforts, the long term efficacy has been largely assessed at 6 months and 1 -year post quit.
Little is known about the long- term benefits of various doses of nicotine patch therapy over several years.

The purpose and objective of this study is to evaluate the long-term
smoking cessation efficacy of varying doses of the transdermal nicotine delivery system 4 to 5 years post -quit day.

There were 14 references used in this study. Most all of the sources are older then 5 years but the study was done in 1998 so the references were within the 5 year frame of the study. The literature involved previous studies of the nicotine patch and three related to weight gain.

No theory or framework was discussed.

The variables were described as demographic such as age and sex and smoking variables which were assessed by logistic regression . Self- rated motivation to quit was not related to long-term continuous abstinence.

This is a quantitative study is descriptive and quasi-experimental. The researchers examined the cause and effect of the nicotine patch 5 years out and explored a real life situation.

The study was first approved by the University of Nebraska Medical Center Institutional Review Board. The participants who were enrolled in this study were long-term abstinence patients from the transdermal nicotine study group investigation and all signed an informed consent.

This study concludes that the 21 mg. patch resulted in significantly higher long-term continuous abstinence rate compared to lower dose patches and placebo. This is an option the advanced practitioner has to offer her patients to help them with smoking cessation and the research shows it is an effective alternative.

Research article #5
Schonfeld, D.J., Bases, H., & Quakenbush, M. (2001). Pilot-testing a cancer education curriculum for grades K-6. The Journal of School Health, 71,61-65.

The problems researched in this study are as follows:
Nearly 1 in 3 Americans will develop cancer and is a leading cause of death in both adults and children.

Cigarette smoking alone causes more deaths in the U. S. than does AIDS, car accidents, alcohol, homicides, illegal drugs, suicides, and fires combined.
Risk factors learned and established in childhood and adolescence, such as tobacco use, eating habits, and sunning contribute to most cancers that appear later in adulthood.
Most smokers begin to experiment with tobacco between 10 and 14 years of age.
The purpose and hypotheses of this pilot study relates to the fact that to intervene with young children to help establish health-promoting behavior prior to adolescence will reduce the adult cancer risk. Cancer prevention education and the importance in elementary grades to discourage the adoption of tobacco use is an important link to adult cancer risk.

The review of literature involved the use of 18 references, half were older than 5 years. The literature relates to cancer prevention for children and adolescents.
The researchers used cognitive development, social cognitive and social influence theory to develop a seven-unit cancer prevention curriculum.

The variable was the children’s conceptual understanding about cancer. This is a conceptual definition and the authors used a two -tailed T test to control and measure the results of the conceptual understanding employing a pre test and a post-test after the 15 hours of instruction
In this quantitative study and due to the small sample size of 88 students, it was decided to apply the treatment to the entire group. The variable was then measured with a pre test and post-test. This would be considered a descriptive and correlational study that will generate new knowledge about smoking cessation and measures the conceptual variable before and after treatment.
The researchers minimized the threats to validity by utilizing the ASK interview which was individually administered, standardized, and semi structured and measured both factual and conceptual knowledge about cancer.There was a written informed parental consent and child’s assent used for interviewing the children.

This study is important for the clinician’s understanding that cancer prevention starts at the elementary school level. By increasing the children’s conceptual understanding and factual knowledge of cancer, America stands a chance in improving the strategic role in the prevention of smoking.

In conclusion, this review of literature presented facts and solutions to support the need for more definitive action toward the problem of smoking cessation.
Americans spend huge sums of money treating smoking related illness and not enough is done on prevention starting at the elementary school levels. Clinicians need to identify and address the problem with each of their patients that smoke and make available treatment options that are successful.

Lastly our communities, HMOs, and hospitals need to make a pro-active statement related to smoking cessation to support and develop programs that meet the goals of Healthy People 2010. Smoking is the most preventable deterrent to American’s health today and as presented in this review of litertature , we have ways to prevent it’s devastation.