Comfort first step in smoking cessation

Replacement therapy provides opportunity to quit

Smokers admitted to Mid Coast Hospital in Brunswick, ME, are offered nicotine-replacement therapy to help them manage their habit in a smoke-free environment.

While it is often the first step in permanently giving up cigarettes, it is not the main reason for the intervention.

"When many people come to the hospital it is an unplanned-for event, and if they are dependent on nicotine coming to a smoke-free environment can be very uncomfortable. Our first concern is to help patients maintain their comfort," says Marla Davis, MSN, RN, manager of community health education and a tobacco treatment specialist at Mid Coast Hospital.

A patient who is comfortable and not struggling with nicotine withdrawal can focus on the treatment of his or her illness. However nicotine-replacement therapy also provides experience with positive steps for smoking cessation and improves the smoker's confidence in his or her ability to quit for good.

To implement this plan of care, a smoking cessation protocol called the Tobacco CareMap was put in place at Mid Coast Hospital in 2001 when a new facility was built and the decision was made to make it a smoke-free environment. At that time Davis and other members of the multidisciplinary team created the Tobacco CareMap by reviewing best practices in smoking cessation. Davis says the committee relied heavily on the clinical practice guidelines from the U.S. Department of Health and Human Services titled, "Treating Tobacco Use and Dependence."

Once completed, other groups within the hospital that were not involved in the development of the protocol but that would have an interest in it, such as pharmacy, reviewed the plan. It also went through a full medical review before it was implemented.

The protocol, which is initiated by a physician's order, provides strategies for working with a hospitalized smoker that include discussions about the patient's need for comfort, says Davis.

"Our first strategy is to discuss the use of nicotine-replacement therapy and to encourage them to use it. Once you have established a comfort level you can talk about cessation. It is taking advantage of a teachable moment," says Davis.

Quitting smoker's choice

Nurses implement the Tobacco CareMap, working directly with the patients to determine the amount of nicotine-replacement therapy that is appropriate. A bedside consultation on strategies for quitting is conducted with anyone who is willing to consider cessation. Included in the discussion are the rewards of quitting, barriers to quitting, and some strategies for overcoming the urge to smoke a cigarette such as deep breathing.

Patients are given resources to aid their efforts once they leave the hospital. For example, they receive the number for the Maine Tobacco Helpline, which provides free counseling over the telephone, and they also receive written handouts on strategies for quitting.

Davis provides patients with free nicotine-replacement therapy at discharge, such as a couple of nicotine patches, and makes arrangements for further assistance with replacement therapy through state resources.

She says she is very concerned about patients' transition from hospital to home because patients who want to quit smoking are very vulnerable at that time.

"They are going back to what they know and nicotine dependency is a form of relaxation. It has a habit component and there are a lot of triggers. Once patients step outside of the smoke-free zone they become vulnerable to the lure of what they know will be a satisfying experience," explains Davis.

Yet policy does make a difference. Having policy in place that prohibits smoking within a medical environment sends a clear message to people that the practice is unhealthy. Davis says it also sends a message of hope because people find out they can quit, even if for a short period of time.

"Those of us who have been in tobacco control for a long time have finally grasped that policy is what really brings cultural and environmental changes. If you make policy that de-normalizes an activity then people start seeing things differently," says Davis.

Although not every smoker is ready to quit during his or her hospitalization, having a health problem that may be impacted by a smoking habit is often a catalyst to stop. Davis is currently gathering data to determine what percentage of smokers agree to a smoking cessation consultation once the Tobacco CareMap is initiated.

Also a team is putting together a packet of information all patients will receive whether they are interested in smoking cessation or not, to empower them to make healthy choices in the future.

"We can provide them with information and coaching on ways of quitting that others have taught us have been successful, but we try very hard not to be the experts in this situation. We want the patient to be the expert about their lives and that is so empowering," says Davis.


For more information about the Tobacco CareMap used at Mid Coast Hospital in smoking cessation, contact:

  • Marla Davis, MSN, RN, manager, community health education, tobacco treatment specialist, Mid Coast Hospital, 123 Medical Center Drive, Brunswick, ME 04011. Phone: (207) 373-6586. E-mail: