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Nursing Best Practice GuidelineShaping the future of Nursing

Integrating Smoking Cessationinto Daily Nursing Practice

Revised March 2007

Greetings from Doris Grinspun

Executive Director

Registered Nurses’ Association of Ontario

It is with great excitement that the Registered Nurses’ Association of Ontario (RNAO)

disseminates this revised nursing best practice guideline to you. Evidence-based practice

supports the excellence in service that nurses are committed to deliver in our day-to-day

practice. The RNAO is committed to ensuring that the evidence supporting guideline

recommendations is the best available, and this guideline has been recently reviewed and

revised to reflect the current state of knowledge.

We offer our endless thanks to the many institutions and individuals that are making RNAO’s vision for

Nursing Best Practice Guidelines (NBPGs) a reality. The Government of Ontario recognized RNAO’s ability

to lead this program and is providing multi-year funding. Tazim Virani – NBPG program director – with her

fearless determination and skills, is moving the program forward faster and stronger than ever imagined.

The nursing community, with its commitment and passion for excellence in nursing care, is providing the

knowledge and countless hours essential to the creation, evaluation and revision of each guideline.

Employers have responded enthusiastically to the request for proposals (RFP), and are opening their

organizations to pilot test the NBPGs.

Now comes the true test in this phenomenal journey: Will nurses utilize the guidelines in their day-to-day practice?

Successful uptake of these NBPGs requires a concerted effort of four groups: nurses themselves, other

healthcare colleagues, nurse educators in academic and practice settings, and employers. After lodging

these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need

healthy and supportive work environments to help bring these guidelines to life.

We ask that you share this NBPG, and others, with members of the interdisciplinary team. There is much to

learn from one another. Together, we can ensure that Ontarians receive the best possible care every time

they come in contact with us. Let’s make them the real winners of this important effort!

RNAO will continue to work hard at developing and evaluating future guidelines. We wish you the best for a

successful implementation!

Doris Grinspun, RN, MSN, PhD (cand), OOnt

Executive Director


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Nursing Best Practice Guideline

Project Team:

Tazim Virani, RN, MScN, PhD(cand)Program Director

Heather McConnell, RN, BScN, MA(Ed)Program Manager

Samantha Mayo, RN, BScN, MNProgram Coordinator

Janet Chee, RN, BScN, MNProgram Coordinator

Julie BurrisProgram Assistant

Jill-Marie Burke, BAPublic Relations/Communications

Elizabeth Chiu, HBSc, MPCProgram Assistant

Meagan Cleary, BAProgram Assistant

Carrie ScottProgram Assistant

Citlali Villa SinghProgram Assistant

Keith Powell, BA, AITWeb Editor

Integrating Smoking Cessation intoDaily Nursing Practice


Nursing Best Practice Guidelines Program

158 Pearl St.

Toronto, Ontario M5H 1L3

Website: www.rnao.org/bestpractices

Janet Nevala, RN, BScN Team Leader

Consultant, The Program Training and

Consultation Centre

Ottawa, Ontario

Carol Bossenberry, RN, BN, TTSTobacco Use Prevention Coordinator

Oxford County Public Health &

Emergency Services

Woodstock, Ontario

Jennifer Hart, MPADirector, Clinical Tobacco Intervention Program

Ontario Medical Association

Toronto, Ontario

Sherrie Hertz, BScPhm., R.PhDirector, Pharmacy Programs

Ontario Pharmacists’ Association

Don Mills, Ontario

Sharon Lawler, RN, BA, MEdCo-Director and Manager,

Leave the Pack Behind Program

Community Health Science Dept.

Brock University

St. Catharines, Ontario

Joan Mitchell, RN(EC),Primary Health Care Nurse Practitioner

Byron Family Medical Centre

London, Ontario

Annette Railton, RN, BScNOperating Room (CPT)

Welland Hospital Site Niagara Health System

Welland, Ontario

Annette Schultz, RN, PhDAssistant Professor, Cancer Prevention

Cancer Nursing Research

Faculty of Nursing, University of Manitoba

Winnipeg, Manitoba

Declarations of interest and confidentiality were

made by members of the guideline revision panel.

Further details are available from the Registered

Nurses’ Association of Ontario.

The RNAO also wishes to acknowledge Dawn

Kingston, RN, BSc, MSc, PhD (student) for her

work in conducting the quality appraisal of the

literature and preparation of evidence tables.

The RNAO would also like to acknowledge Bonnie

Quinlan, RN for her contribution to this guideline

revision as a reviewer.

Integrating Smoking Cessation into Daily Nursing Practice

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Revision Panel Members (2006/2007)

Declarations of interest and confidentiality were made by all members of the guideline development panel.

Further details are available from the Registered Nurses’ Association of Ontario

7


Janet Nevala, RN, BScNTeam Leader

Coordinator, Program Training and

Consultation Centre

Ontario Tobacco Strategy

City of Ottawa

Ottawa, Ontario

Carol Bossenberry, RN, BNTobacco Use Prevention Coordinator

County of Oxford, Department of Public

Health & Emergency Services

Woodstock, Ontario

Debbie Cooke, RN, BACardiac Prevention and Rehabilitation Nurse

Smoking Cessation Counsellor

University of Ottawa Heart Institute

Cardiac Prevention and Rehabilitation

Ottawa, Ontario

Nancy Edwards, RN, PhDProfessor, School of Nursing

Director, Community Health Research Unit

University of Ottawa

Ottawa, Ontario

Sharon Lawler, RN, BA, MEdManager, Leave The Pack Behind

Community Health Sciences Department

Brock University


Heather Logan*, RN, BScN, MHSc(c)Manager, Cancer Control Policy

Canadian Cancer Society

National Cancer Institute of Canada

Toronto, Ontario

Joan Mitchell, RN(EC)Primary Healthcare Nurse Practitioner

Community Care Access Centre

London Middlesex

London, Ontario

Shirley Saasto-Stopyra*, RN, PHNONA Representative (Local 014)

Public Health Nurse

Family Health Program

Thunder Bay District Health Unit

Thunder Bay, Ontario

Josephine Santos, RN, MNFacilitator, Project Coordinator

Nursing Best Practice Guideline Project


Toronto, Ontario

Louise Walker*, BA, BScProvincial Coordinator, Smokers’ Helpline

Canadian Cancer Society

Ontario Division

Hamilton, Ontario

*Contributed to the initial development

of the guideline

Original Contributors

Development Panel Members (2003)


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Stakeholder Acknowledgment

The Registered Nurses’ Association of Ontario wishes to acknowledge the following individuals and/or groups for their

contribution in reviewing this nursing best practice guideline and providing valuable feedback during the initial

development of this document (2001–2003):

Monique Bouvier Centre for Addiction and Mental Health, Hammond, Ontario

Wendy Burgoyne Algoma Best Start, Wawa, Ontario

Ruth Busija-Lowe Registered Nurse (retired), Woodstock, Ontario

Donald Déry Tobacco Project Officer, City of Ottawa, Agent de projet sur letabagisme, Ottawa, Ontario

Dr. Roberta Ferrence Director, Centre for Addiction and Mental Health,Ontario Tobacco Research Unit, Toronto, Ontario

Sherrie Hertz Program Manager, Clinical Tobacco Intervention Drug Information Pharmacist,Ontario Pharmacists’ Association, North York, Ontario

Simon Hoad Health Promotion Planner, Thunder Bay District Health Unit,Thunder Bay, Ontario

Colleen Kearns Public Health Nurse, Prenatal Tobacco Use Prevention, City of Ottawa,Ottawa, Ontario

Cheryl Kee Acute Care Nurse Practitioner-Cardiology, London Health Sciences Centre,London, Ontario

Dana Martin Registered Nurse, Gane Yohs Health Centre, Ohsweken Ontario

Elizabeth Martin Manager of Operations, Woodingford Lodge, Woodstock, Ontario

Dr. Paul W. McDonald Director, Centre for Applied Health Research, University of Waterloo,Waterloo, Ontario

Dr. William McLeish Oxford Interagency Council on Smoking and Health, Woodstock, Ontario

Phil Onafrychuk Occupational Health Nurse, Timberjack Inc., Woodstock, Ontario OntarioPhysical and Health Education Association, Toronto, Ontario

Dr. Andrew Pipe Director, Smoking Cessation Program, University of Ottawa Heart Institute,Ottawa, Ontario

Nancy Pogson Public Health Nurse, Kitchener, Ontario

Lorraine Repo Coordinator, Healthy Babies/Healthy Children, Thunder Bay District Health Unit,Thunder Bay, Ontario

Linda Ritchie Chair, Department of Nursing, Brock University, St. Catharines, Ontario

Sherryl Smith Health Promotion Coordinator, Somerset West Community Health Centre,Ottawa, Ontario

Tracey E. Taylor Program Manager, Healthy Lifestyles and Disease Prevention Branch, Social andPublic Health Services Department, City of Hamilton, Hamilton, Ontario

9


A special acknowledgment also goes to:

Barbara Willson, RN, MSc, and Anne Tait, RN, BScN, who served as Project Coordinators at the onset of the

guideline development.

RNAO also wishes to acknowledge the Centre for Addiction and Mental Health in Toronto, Ontario for their role in pilot

testing this guideline.

As well, RNAO sincerely acknowledges the leadership and dedication of the researchers who have directed the

evaluation phase of the Nursing Best Practice Guidelines Project, in 2002–2003. The Evaluation Team was comprised of:

Principal Investigators: Nancy Edwards, RN, PhD; Barbara Davies, RN, PhD – University of Ottawa

Evaluation Team: Maureen Dobbins, RN, PhD; Jenny Ploeg, RN, PhD; Jennifer Skelly, RN, PhD – McMaster University

Patricia Griffin, RN, PhD – University of Ottawa

Project Staff: Barbara Helliwell, BA(Hons); Marilynn Kuhn, MHA; Diana Ehlers, MA(SW), MA(Dem);

Christy-Ann Drouin, BBA; Sabrina Farmer, BA; Mandy Fisher, BN, MSc(cand); Lian Kitts, RN;

Elana Ptack, BA – University of Ottawa


Nursing Best Practice Guidelines Program

158 Pearl St.

Toronto, Ontario M5H 1L3

Website: www.rnao.org/bestpractices

Integrating Smoking Cessation intoDaily Nursing Practice

Disclaimer

These best practice guidelines are related only to nursing practice and not intended to take into account

fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to

accommodate client/family wishes and local circumstances. They neither constitute a liability or discharge

from liability. While every effort has been made to ensure the accuracy of the contents at the time of

publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any

guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to

loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any

reference throughout the document to specific pharmaceutical products as examples does not imply

endorsement of any of these products.

Copyright

First published in 2003 by the Registered Nurses’ Association of Ontario. This document was revised in

March 2007.

With the exception of those portions of this document for which a specific prohibition or limitation against

copying appears, the balance of this document may be produced, reproduced and published in its entirety

only, in any form, including in electronic form, for educational or non-commercial purposes, without

requiring the consent or permission of the Registered Nurses’ Association of Ontario, provided that an

appropriate credit or citation appears in the copied work as follows:

Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing

Practice. Revised. Toronto, Canada: Registered Nurses’ Association of Ontario.


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How to Use this Document

This nursing best practice guideline is a comprehensive document providing resources necessaryfor the support of evidence-based nursing practice. The document should be reviewed and applied,based on the specific needs of the organization or practice setting/environment, as well as the needs andwishes of the client. Guidelines should not be applied in a “cookbook” fashion but used as a tool to assist indecision making for individualized client care, as well as ensuring that appropriate structures andsupports are in place to provide the best possible care.

Nurses, other healthcare professionals and administrators who are leading and facilitating practice changeswill find this document valuable for the development of policies, procedures, protocols, educationalprograms, assessments and documentation tools. It is recommended that the nursing best practiceguidelines be used as a resource tool. Nurses providing direct client care will benefit from reviewing therecommendations, the evidence in support of the recommendations and the process that was used todevelop the guidelines. However, it is highly recommended that practice settings/environments adaptthese guidelines in formats that would be user-friendly for daily use. This guideline has some suggestedformats for such local adaptation and tailoring.

Organizations wishing to use the guideline may decide to do so in a number of ways:■ Assess current nursing and healthcare practices using the recommendations in the guideline.■ Identify recommendations that will address identified needs or gaps in services.■ Systematically develop a plan to implement the recommendations using associated tools and resources.

RNAO is interested in hearing how you have implemented this guideline. Please contact us toshare your story. Implementation resources will be made available through the RNAO website atwww.rnao.org/bestpractices to assist individuals and organizations to implement best practice guidelines.


Table of Contents

Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Interpretation of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Responsibility for Guideline Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Purpose & Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Original Development Process – 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Revision Process 2006/2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Definition of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Background Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Practice Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Education Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Organization & Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Evaluation & Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Implementation Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Research Gaps & Future Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Process for Update/Review of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47


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Appendix A – Search Strategy for Existing Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Appendix B – Glossary of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Appendix C – The Health Risks of Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Appendix D – The Benefits of Quitting Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Appendix E – Stages of Change Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Appendix F – Identifying Your Client’s Readiness to Quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Appendix G – Motivational Interviewing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Appendix H – Ask, Advise, Assist, Arrange Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Appendix I – The WHY Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Appendix J – Fagerstrom Test for Nicotine Dependence (Revised Version). . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Appendix K – Intensive Nursing Intervention: Tips for the Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Appendix L – Quit Smoking First-Line Medications Compared . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Appendix M – Strategies to Avoid Relapse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Appendix N – List of Resources Available for Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Appendix O – Description of the Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87



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Summary of RecommendationsRECOMMENDATION *STRENGTH OF EVIDENCE

Practice 1.0 Nurses implement minimal tobacco use intervention using theRecommendations "Ask, Advise, Assist, Arrange" protocol with all clients. A

2.0 Nurses introduce intensive smoking cessation intervention (more than10 minutes duration) when their knowledge and time enables them to Aengage in more intensive counselling.

3.0 Nurses recognize that tobacco users may relapse several times before achievingabstinence and need to re-engage clients in the smoking cessation process. B

4.0 Nurses should be knowledgeable about community smoking cessationresources, for referral and follow-up. C

5.0 Nurses implement smoking cessation interventions, paying particular attentionto gender, ethnicity and age-related issues, and tailor strategies to the diverse Cneeds of populations.

6.0 Nurses implement, wherever possible, intensive intervention with womenwho are pregnant and postpartum. A

7.0 Nurses encourage persons who smoke, as well as those who do not, tomake their homes smoke-free, to protect children, families and themselves Afrom exposure to second-hand smoke.

Education 8.0 All nursing programs should include content about tobacco use, associatedRecommendations health risks and smoking cessation interventions as core concepts in C

nursing curricula.

Organization & Policy 9.0 Organizations and Regional Health Authorities should consider smokingRecommendations cessation as integral to nursing practice, and thereby integrate a variety of

professional development opportunities to support nurses in effectivelydeveloping skills in smoking cessation intervention and counselling. B

All corporate hospital orientation programs should include training touse brief smoking cessation interventions as well as information onpharmacotherapy to support hospitalized persons who smoke.

10.0 Nurses seek opportunities to be actively involved in advocating for effectivesmoking cessation services, including "stop smoking medications”. C

11.0 Nurses seek opportunities to be actively involved in advocating for smoke-freespaces and protection against second-hand smoke. C

12.0 Nursing best practice guidelines can be successfully implemented only wherethere are adequate planning, resources, organizational and administrativesupport, as well as appropriate facilitation. Organizations may wish todevelop a plan for implementation that includes:

■ An assessment of organizational readiness and barriers to education. C■ Involvement of all members (whether in a direct or indirect supportive

function) who will contribute to the implementation process.

*See page 16 for details regarding “Interpretation of Evidence”

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Summary of RecommendationsRECOMMENDATION *STRENGTH OF EVIDENCE

■ Dedication of a qualified individual to provide the support needed for theeducation and implementation process.

■ Ongoing opportunities for discussion and education to reinforce theimportance of best practices.

■ Opportunities for reflection on personal and organizational experiencein implementing guidelines. C

In this regard, RNAO (through a panel of nurses, researchers andadministrators) has developed the Toolkit: Implementation of clinical practiceguidelines, based on available evidence, theoretical perspectives andconsensus. The Toolkit is recommended for guiding the implementation ofthe RNAO guideline Integrating Smoking Cessation into Daily Nursing Practice.


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Interpretation of EvidenceWhen this RNAO guideline was originally published, the material was a synthesis of a number of

source guidelines. At that time, in order to fully inform the reader, every effort was made to maintain

the original level of evidence cited in the source document. No alterations were made to the wording of

the source documents involving recommendations based on randomized controlled trials or research

studies. Where a source document demonstrated an "expert opinion" level of evidence, wording may

have been altered and the notation of RNAO Consensus Panel 2003 added. In the guidelines reviewed,

the panel assigned each recommendation a rating of A, B or C to indicate the strength of the evidence

supporting the recommendation.

Through the revision process, additional literature was reviewed and used to update the

recommendations and discussion of evidence. As these materials were considered, the strength of

evidence were updated to reflect the state of the knowledge in that area. It is important to clarify that

these ratings represent the strength of the supporting evidence to date.

Strength of Evidence

A Requires at least two randomized controlled trials as part of the body of literature of overall quality

and consistency addressing the specific recommendations.

B Requires availability of well conducted clinical studies, but no randomized controlled trials on the

topic of recommendations.

C Requires evidence from expert committee reports or opinions and/or clinical experience of

respected authorities. Indicates absence of directly applicable studies of good quality.

Responsibility for DevelopmentThe Registered Nurses’ Association of Ontario (RNAO), with funding from the Government

of Ontario, has embarked on a multi-year program of nursing best practice guideline development, pilot

implementation, evaluation, dissemination and support of uptake. This guideline was originally developed,

and subsequently revised, by a panel of nurses and researchers convened by the RNAO and conducting its

work independent of any bias or influence from the Government of Ontario.

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Purpose and ScopeThis best practice guideline is intended to provide direction to nurses during daily practice in all care

settings, both institutional and community. This guideline does not describe in-depth interventions for

special populations such as youths, although the recommendations may also be applied to this group.

This guideline contains recommendations for all Registered Nurses (RNs) and Registered Practical Nurses

(RPNs). It is acknowledged that the individual competency of nurses varies between individuals and across

categories of nursing professionals, and is based on knowledge, skills, attitudes and judgment, enhanced

over time by experience and education.

Best practice guidelines are systematically developed statements to assist nurses and clients in decision making

about appropriate healthcare (Field & Lohr, 1990). This guideline focuses on four areas of smoking cessation:

1. Practice recommendations, directed at the nurse and nursing practice.

2. Education recommendations, directed at competencies required for practice.

3. Organization and policy recommendations, directed at the organizational setting and the environment

to facilitate nursing practice.

4. Evaluation and monitoring criteria.

Although this best practice guideline contains recommendations for Registered Nurses (RNs) and

Registered Practical Nurses (RPNs), it is acknowledged by the development panel that promotion of

smoking cessation is enhanced by the involvement of healthcare providers from a range of disciplines.

Thus, other healthcare providers may also find this guideline useful in their practice.

Rationale for a Smoking Cessation GuidelineGlobally, efforts to reduce tobacco use and exposure to second-hand smoke are gaining momentum. Both

the federal and provincial governments’ efforts to regulate advertising, packaging, restricting minor’s

access by increasing cost of cigarettes through taxation and imposing restrictions on public exposure to

second-hand smoke are good examples. The movement to reduce tobacco use has been furthered by

knowledge of the health effects that tobacco use poses and the recognition that tobacco use is an addiction.

There is also heightened public awareness about the dangers of second-hand smoke through media

campaigns. In Ontario, the Smoke-Free Ontario strategy introduced in May 2006, will improve the health

of Ontarians by preventing children and youth from starting to smoke, helping Ontarians quit smoking and

protecting Ontarians from involuntary exposure to second-hand smoke (Ontario Ministry of Health Promotion,

2006). See Appendix N for further information regarding resources to support smoking cessation.

The most important outcome of this guideline is to motivate and support all nurses to identify the tobacco

use status of their clients and encourage them to intervene with those identified as individuals who smoke

in a sensitive, non-judgmental manner about the importance of cessation.

It is suggested that if a substantial number of healthcare providers implement minimal smoking cessation

interventions, there will be a significant reduction in the number of tobacco users, a decrease in related

tobacco diseases and a lowering of healthcare costs. Tobacco-related diseases cost the Ontario economy at

least $1.7 billion in healthcare annually, result in more than $2.6 billion in productivity losses and account

for at least 500,000 hospital days each year (Ontario Ministry of Health Promotion, 2006).


Guiding Principles/Assumptions about Smoking CessationThe guiding principles and assumptions that underlie this nursing best practice guideline related to

smoking cessation are as follows:

1. Regular tobacco use is an addiction that requires support and repeated interventions.

2. The offer of assistance to quit smoking will benefit every person who smokes.

3. The client has the right to accept or refuse smoking cessation intervention.

4. Individuals who smoke deserve to be treated with respect, dignity and sensitivity, while receiving

smoking cessation intervention.

5. The public values and trusts specific advice provided by nurses in the practice of their profession.

6. Nurses are key members of the healthcare team and have a unique, credible and powerful

position within the team.

7. Nurses are involved with clients at multiple entry points to care. This provides many

opportunities to identify persons who smoke and implement smoking cessation interventions.

8. Actively implementing smoking cessation interventions in every care setting will increase

successful quitting.

9. Nurses who currently smoke have a professional responsibility and can effectively provide

smoking cessation intervention.

10. Nursing students have the right to education about evidence-based practice interventions and

strategies for smoking cessation.

11. Nurses have the right to education to enable them to provide the best evidence-based

standard of care.

12. Nurses are ideally positioned to provide a leadership role related to smoking cessation at the

individual, program and/or policy level.


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Original Development Process – 2001/2003In February of 2001, a panel of nurses and researchers with expertise in practice and research related

to smoking cessation, from community and academic settings, was convened under the auspices of the

RNAO. At the onset the panel discussed and came to consensus on the scope of the best practice guideline.

A search of the literature for systematic reviews, clinical practice guidelines, relevant articles and websites

was conducted.

The panel identified a total of 14 clinical practice guidelines related to smoking cessation. An initial

screening was conducted using the following inclusion criteria:

■ Guideline was in English.■ Guideline was dated no earlier than 1996.■ Guideline was strictly about the topic area.■ Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence).■ Guideline was available and accessible for retrieval.

Eight guidelines were short-listed for critical appraisal using the Appraisal Instrument for Clinical Practice

Guidelines (Cluzeau et al., 1997). This appraisal tool allows for evaluation in three key dimensions.

The panel, following the appraisal process, identified the following guidelines, and related updates, to

adapt and modify in the development of recommendations:

■ Canadian Nurses Association. (1997). Guidelines for registered nurses working with Canadians affected

by tobacco. Ottawa, Ontario: Canadian Nurses Association.

■ Institute for Clinical Systems Improvement. (2000a). Tobacco use prevention and cessation for adults

and mature adolescents. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI)

[On-line]. Available: http://www/icsi.org/guidelst.htm#guidelines*

■ Institute for Clinical Systems Improvement. (2000b). Tobacco use prevention and cessation for infants,

children and adolescents. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI)

[On-line]. Available: http://www/icsi.org/guidelst.htm#guidelines*

■ National Health Committee. (1999a). Guidelines for smoking cessation: Literature review and

background information. New Zealand Guidelines Group [On-line]. Available:

http://www.nzgg.org.nz/library.cfm*

■ National Health Committee. (1999b). Guidelines for smoking cessation: Quit Now. New Zealand

Guidelines Group [On-line]. Available: http://www.nzgg.org.nz/library.cfm*

■ Royal College of Nursing. (1999). Clearing the air: A nurses guide to smoking and tobacco control.

London, England: The Royal College of Nursing.


■ University of Toronto Department of Family & Community Medicine. (2000). Smoking cessation

guidelines: How to treat your patient’s tobacco addiction. Toronto, Ontario: Pegasus Healthcare

International.

■ U.S. Department of Health and Human Services, Public Health Service. (2000). Clinical practice

guideline: Treating tobacco use and dependence. Office of the Surgeon General [On-line]. Available:

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf*

A critique of systematic review articles and pertinent literature was conducted to update the existing

guidelines. Through a process of evidence gathering, synthesis and consensus, a draft set of

recommendations was established. This draft document was submitted to a set of external stakeholders for

review and feedback – an acknowledgment of these reviewers is provided at the front of this document.

Stakeholders represented various healthcare professional groups, clients and families, as well as

professional associations. External stakeholders were provided with specific questions for comment, as

well as the opportunity to give overall feedback and general impressions. The results were compiled and

reviewed by the development panel – discussion and consensus resulted in revisions to the draft document

prior to pilot testing.

A pilot implementation practice setting was identified through a "Request for Proposal" (RFP) process.

Practice settings in Ontario were asked to submit a proposal if they were interested in pilot testing the

recommendations of the guideline. These proposals were then subjected to a review process, from which a

successful practice setting was identified. A nine month pilot implementation was undertaken to test and

evaluate the recommendations. The evaluation took place in a recently amalgamated organization

comprised of four different sites and serving clients with addictions and mental health. An

acknowledgment of this organization is included at the front of this document. The development panel

reconvened after the pilot implementation in order to review the experiences of the pilot site, consider the

evaluation results and review any new literature published since the initial development phase. All these

sources of information were used to update/revise the document prior to publication.

* During the original guideline development process between 2001-2003, these materials were retrieved online at the indicated

web addresses and were current at that time, however, these links may no longer be active.

Revision Process – 2006/2007The Registered Nurses’ Association of Ontario (RNAO) has made a commitment to ensure

that this best practice guideline is based on the best available evidence. In order to meet this commitment,

a monitoring and revision process has been established for each published guideline.

A “current awareness” review has been completed twice each year since the nursing best practice guideline

Integrating Smoking Cessation into Daily Nursing Practice (2003) was originally published. Guideline

development staff reviewed abstracts published in key databases on the topic of smoking cessation,

focusing on systematic reviews, randomized controlled trials and recently published clinical practice

guidelines. The purpose of this review was to identify evidence that would impact on the

recommendations, either further supporting the published recommendations, or indicating that a


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recommendation was no longer appropriate. In the latter case, an “action alert” would be issued, or a full

review would be conducted prior to the three-year schedule. No evidence of this nature was identified

during the ongoing monitoring phase, and this guideline moved into the revision phase as originally scheduled.

In June of 2006, a panel of nurses with expertise in smoking cessation from a range of practice settings

(including institutional, community and academic sectors) was convened by the RNAO. This group was

invited to participate as a review panel to revise the Integrating Smoking Cessation into Daily Nursing

Practice guideline that was originally published in October 2003. This panel was comprised of members of

the original development panel, as well as other recommended specialists.

The panel members were given the mandate to review the guideline, focusing on the currency of the

recommendations and evidence, keeping to the original scope of the document. This work was conducted

as follows:

Planning:■ Clinical questions were identified to structure the literature search.■ Search terms were generated with input from the panel team leader for each recommendation in

the guideline.■ Literature search was conducted by a health sciences librarian. ■ Structured website search was conducted by program staff, focusing on recently published

clinical guidelines.

Critical Appraisal:■ Search results were reviewed by a Research Assistant assigned to the panel. This review included

assessing for inclusion/exclusion related to the clinical questions. See Appendix A for a detailed

description of the search strategy. ■ Studies that met the inclusion/exclusion criteria were retrieved. Quality appraisal and data extraction

was conducted by the Research Assistant. These results were summarized and circulated to the panel.■ Panel members reviewed identified guidelines with the AGREE Instrument (AGREE Collaboration, 2001). See

Appendix A for details of this review.

Panel Review:■ Panel members reviewed the data extraction tables, systematic reviews, and where appropriate,

original studies and clinical guidelines. ■ Recommendations for additional search strategies were identified, if required. ■ Through a process of consensus, recommendations for revision to the guideline were identified.



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Definition of TermsAn additional Glossary of Terms related to clinical aspects of the document is located in Appendix B.

Clinical Practice Guidelines or Best Practice Guidelines: Systematically developed

statements (based on best available evidence) to assist practitioner and client decisions about

appropriate healthcare for specific clinical (practice) circumstances (Field & Lohr, 1990).

Consensus: A process for making policy decisions, not a scientific method for creating new

knowledge. At its best, consensus development merely makes the best use of available information,

be that of scientific data or the collective wisdom of the participants (Black et al., 1999).

Education Recommendations: Statements of educational requirements and educational

approaches/strategies for the introduction, implementation and sustainability of the best

practice guideline.

Evidence: Evidence is information that comes closest to the facts of a matter. The form it takes

depends on context. The findings of high-quality, methodologically appropriate research are the most

accurate evidence. Because research is often incomplete and sometimes contradictory or

unavailable, other kinds of information are necessary supplements to or stand-ins for research. The

evidence base for a decision is the multiple forms of evidence combined to balance rigour with

expedience – while privileging the former over the latter. (Canadian Health Services Research Foundation, 2006).

Meta-Analysis: The use of statistical methods to summarize the results of independent studies,

thus providing more precise estimates of the effects of healthcare than those derived from the

individual studies included in a review (Clarke & Oxman, 1999).

Organization & Policy Recommendations: Statements of conditions required for a

practice setting that enables the successful implementation of the best practice guideline. The

conditions for success are largely the responsibility of the organization, although they may have

implications for policy at a broader government or societal level.

Practice Recommendations: Statements of best practice directed at the practice of

healthcare professionals that are ideally evidence-based.

Randomized Controlled Trial: For the purposes of this guideline, a study in which subjects

are assigned to conditions on the basis of chance, and where at least one of the conditions is a control

or comparison condition.

Stakeholder: A stakeholder is an individual, group or organization with a vested interest in the

decisions and actions of organizations who may attempt to influence decisions and actions (Baker et

al., 1999). Stakeholders include all individuals or groups who will be directly or indirectly affected by

the change or solution to the problem. Stakeholders can be of various types, and can be divided into

opponents, supporters and neutrals (Ontario Public Health Association, 1996).

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Systematic Review: Application of a rigorous scientific approach to the preparation of a review

article (National Health and Medical Research Council, 1998). Systematic reviews establish where

the effects of healthcare are consistent and research results can be applied across populations, settings,

and differences in treatment (e.g., dose); and where effects may vary significantly. The use of explicit,

systematic methods in reviews limits bias (systematic errors) and reduces chance effects, thus providing

more reliable results upon which to draw conclusions and make decisions (Clarke & Oxman, 1999).

Background ContextFacts on Tobacco Use (adapted from several sources; see Appendix C for references)■ Tobacco use is the leading preventable cause of premature death, disease and disability.■ Tobacco use increases the risk of cardiovascular disease, cancers, respiratory diseases, adverse effects

in pregnancy, gastrointestinal problems and tooth and gum problems.■ In 2005, 16 percent of Ontario adults aged 18 years and older were current smokers of cigarettes

(i.e., smoked daily or occasionally in the past month and smoked at least 100 cigarettes in their

lifetime) which is lower than the current national rate of 20% (Ontario Tobacco Research Unit, 2006).

■ More than 47,000 Canadians, aged 35 or older, are estimated to die annually as a direct result of smoking.■ Tobacco kills over 16,000 Ontario residents each year (Ontario Ministry of Health Promotion, 2006).

■ In 2002, the total economic cost of tobacco use in Ontario was almost $6.1 billion (Ontario Tobacco

Research Unit, 2006).

■ Smoking is responsible for about one-third of potential years of life lost due to cancer, about one-quarter

of potential years of life lost due to diseases of the heart and about one-half of potential years of life

lost due to respiratory disease.■ 80 percent of persons who smoke, who have been identified and advised to stop smoking, report that

they want to stop smoking (Brodish, 1998).

■ Cigarettes and other forms of tobacco are addictive. Smoking is both a psychological and a physical

addiction. Nicotine is one of the most highly addictive substances known.■ Second-hand smoke or environmental tobacco smoke is a toxic mixture of chemicals produced during

the burning and smoking of tobacco products.■ There are approximately 4,000 chemical compounds in second-hand smoke. More than 40 of them are

known to cause cancer.■ The average additional annual cost to an employer of employing a person who smokes has been

estimated by the Conference Board of Canada to be $3,396.00 (Conference Board of Canada, 2006).

Benefits of Quitting SmokingQuitting smoking is the single most effective thing that a person who smokes can do to enhance the quality

and length of their life. For some conditions, such as ischemic heart disease, the benefits of quitting

smoking are substantial, both immediately and in the long term. The risks of dying from tobacco-related

diseases are reduced over time, in comparison with those who continue to smoke (Health Canada, 2001). The

risk of smoking related disease continues to decrease as the duration of abstinence increases. (See

Appendix D for a list of health benefits.)

Understanding Tobacco Addiction■ Tobacco contains nicotine, which is a powerful and highly addictive substance. Smoking delivers

nicotine to the brain very rapidly and effectively, bringing on the rapid onset and maintenance of

addiction. The resulting physiological need for tobacco, as well as the accompanying psychological

need, explains the continuing use of tobacco products in spite of all the known health risks.

■ Nicotine dependence consists of both physical and behavioural components. Tobacco use triggers the

release of dopamine – a chemical in the brain that is associated with feelings of pleasure (relief of

withdrawal symptoms). Persons who smoke need greater and greater amounts of nicotine to achieve the

same levels of satisfaction. Further smoking alleviates the withdrawal symptoms that set in as soon as

the effects of nicotine wear off.

■ Smoking cessation is not a single event but a process that involves a change in lifestyle, values, social

circles, thinking and feeling patterns, and coping skills.

■ Most researchers agree that individual users of tobacco differ to the degree to which they are dependent

(Heatherton, Koslowski, Frecker & Fagerstrom, 1991).

■ Historically, addiction to nicotine is one of the hardest substance use dependencies to break.

Pharmacologic and behavioural characteristics that determine tobacco addiction are similar to those that

determine addiction to drugs such as heroin and cocaine (Surgeon General of the United States, 2000).


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How to Help People Stop Smoking■ The most important step in addressing tobacco use and dependence is screening for tobacco use and

offering minimal smoking cessation intervention messages to all persons who smoke, at every

opportunity. When surveyed, over half of Ontarians who currently smoke expressed an intention to

quit smoking within six months of their interview; one quarter indicated a serious intention to quit

within 30 days (Ontario Tobacco Research Unit, 2006).

■ Organization of the clinical environment indicates to the client that the healthcare team will provide

cessation assistance. A powerful message can be delivered to clients, families, the public and staff by

prominently displaying "quit smoking" posters and ensuring cessation materials are visible, accessible

and available.

■ A cueing system for the chart (e.g., labeling each client’s smoking status clearly and visibly with stickers,

stamps or on a flow sheet) prompts healthcare providers to consistently and effectively integrate

smoking cessation into their care.

■ Prochaska and DiClemente’s Stages of Change Model (see Appendix E), recognizes that individuals who

smoke are at different stages of readiness to quit smoking. The use of the model can assist nurses in

smoking cessation intervention by understanding the various stages of willingness to change. Progress

is accomplished when a person who smokes moves onto the next stage or closer to the stage of quitting.

Appendix F shows an example of how to assess and identify a client’s readiness to quit.

■ Provide information and support for the use of pharmacological and non-pharmacological aids for

persons who smoke, who want to quit. The risks of short term nicotine replacement therapy as an aid to

smoking cessation in healthy people are acceptable and substantially outweighed by the risks of

cigarette smoking (Surgeon General of the United States, 2000).



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Practice Recommendations

Recommendation 1.0Nurses implement minimal tobacco use intervention using the “Ask, Advise, Assist, Arrange”

protocol with all clients. (Strength of Evidence =A)

Minimal Smoking Cessation Intervention (Lasting 1 to 3 minutes)Every nurse will:

ASK: About tobacco use with all clients (e.g., “have you used any form of tobacco in the

past six months?”) and assess readiness to quit. If time allows, assess the person’s

level of motivation to change behavior, using motivational interviewing

techniques (see Appendix G).■ Document tobacco use status (e.g. non-smoker, smoker, ex-smoker).

ADVISE: Every tobacco user of the importance of quitting in a non-judgmental and

unambiguous manner.

ASSIST: By providing minimal intervention:■ Refer to the Canadian Cancer Society’s Smokers’ Helpline 1-877-513-5333 or

www.smokershelpline.ca.■ Offer support and self-help resources, such as booklets (See Appendix N for a

listof resources).■ Inform about, or refer to a community stop smoking clinic or service. ■ Refer to other healthcare provider.

ARRANGE: Follow-up or referral.

For a flow chart of the Ask, Advise, Assist and Arrange protocol for minimal intervention, see Appendix H.

Discussion of EvidenceIt is essential to provide at least a minimal intervention (1 – 3 minute duration) to all tobacco users at every

appropriate occasion. There is good evidence that even brief advice from health professionals has a

significant effect on smoking cessation rates (National Health Committee, 2002). Brief advice from a health

professional decreases the proportion of people smoking by about 2 percent per year (NHS Centre for Reviews

and Dissemination – The University of York, 1998). The literature suggests that minimal intervention may encourage

a committed person who smokes to think about their smoking and to start to look at the disadvantages as

well as the benefits. It has also been stated that for clients not ready to quit at this time, providing self-help

material will increase their awareness and motivation to quit (U.S. Dept. of Health and Human Services, 2000).

All nurses have opportunities to assist clients to stop smoking through brief counselling and minimal

interventions. The results indicate, with reasonable evidence, that minimal interventions can be effective

as the nurses provide clients with information about the potential benefits of smoking cessation and

counselling (Rice & Stead, 2003).

A study conducted by the University of Ulster (2001), showed that nurses constitute 65 percent of the

healthcare workforce and are well placed to share the health promotion message with a large proportion of

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the population. Healthcare personnel should treat inquiries about tobacco use and smoking cessation as a

standard assessment question at every visit, recording current use, history and amount (Fiore et al., 2000; Fiore,

Jorenby, & Baker, 1997).

Recommendation 2.0Nurses introduce intensive smoking cessation intervention (more than 10 minutes duration) when

their knowledge and time enables them to engage in more intensive counselling.

(Strength of Evidence =A)

Intensive Smoking Cessation Intervention (Lasting more than 10 minutes)Every nurse will:

ASK: About tobacco use with all clients (e.g., “have you used any form of tobacco in the

past six months?”) and assess readiness to quit. If time allows, assess person’s level

of motivation to change behaviour, using motivational interviewing techniques

(see Appendix G).■ Document tobacco use status (e.g. non-smoker, smoker, ex-smoker).

ADVISE: Every tobacco user of the importance of quitting in a non-judgmental and

unambiguous manner.

ASSIST: By providing intensive intervention:■ Determine and discuss the stage of change (Appendix E);■ Reasons for smoking (WHY Test) (Appendix I);■ Nicotine Dependence (Fagerstrom Test) (Appendix J);■ Discuss strategies to quit and treatment options■ Offer information re: pharmacotherapy options (see Discussion of Evidence);■ Set a quit date;■ Review quitting history, past quit attempts and discuss these experiences; ■ Review potential challenges and triggers (Appendix M); and■ Encourage support of family and friends.

ARRANGE: Follow-up or referral.■ Schedule follow-up or refer to a community stop smoking clinic or service

For a flow chart of the Ask, Advise, Assist and Arrange protocol for intensive intervention, see Appendix H.

Discussion of EvidenceMotivation is the key to giving up smoking (Royal College of Nursing, 1999). It was found that increasing the

intensity of advice (time spent giving advice and duration of follow up) improves effectiveness, decreasing

the proportion of persons who smoke by approximately 3 to 5 percent (U.S. Dept. of Health and Human Services,

2000). Counselling interventions could include areas such as smoking history, motivation to quit,

identification of high risk situations and help with problem solving strategies to deal with high risk

situations (Lancaster & Stead, 2003a). The more components added to the intervention, the more intensive the

intervention (Rice, 1999). Individual counselling increases the likelihood of cessation compared to less

intensive support (Lancaster & Stead, 2003b).

Intensive intervention is appropriate for all persons who smoke and are willing to participate and is

especially recommended to be offered to “special populations” (pregnant women, cardiovascular clients,

clients with other chemical dependencies or psychiatric disorders and various health issues) of persons

who smoke.

Proactive telephone counselling, group counselling and individual counselling formats are effective and

should be used in smoking cessation interventions (U.S. Dept. of Health and Human Services, 2000). Research

shows that telephone counselling can significantly improve quit rates in young adults and older adults

wanting to quit (Rabius et al, 2004). All Canadian provinces have telephone quitlines for persons who smoke.

For a list of telephone resources, see Appendix N.

Proactive counselling helps persons who smoke to quit. In a review conducted by Stead, Lancaster and Perera

(2003), it was found that a call from a counsellor is likely to increase the chances of quitting by approximately

50 percent and certainly by 2 to 4 percentage points, compared to a minimal intervention such as providing

standard self-help materials. Smoking cessation interventions that are delivered in multiple formats increase

abstinence rates and should be encouraged (U.S. Dept. of Health and Human Services, 2000).

In a systematic review conducted by Rigotti, Munafo, Murphy and Stead (2003), it was found that smoking

cessation interventions delivered during a period of hospitalization, with follow-up support after

discharge, increased smoking cessation. However, there was no clear evidence that clients with different

clinical diagnoses responded in different ways.

Pharmacotherapy OptionsBefore recommending over-the-counter (OTC) drugs, nurses must have knowledge, skill and judgment

about the client’s situation, their condition and medication profile and the medication (College of Nurses of

Ontario, 2003). Pharmacological therapy should be recommended to all clients except in the presence of

special circumstances or in cases of contraindications (Orsetti, Dwyer, Sheldon, Thomas & Harrison, 2001). In

special circumstances or in cases of contraindications, nurses must work in collaboration with the client’s

physician to determine the appropriate treatment for the client.

It is found that pharmacological options approximately double the long term abstinence rates over those

produced by placebo interventions (U.S. Dept. of Health and Human Services, 2000; University of Toronto, 2000). As part

of tobacco-dependence treatment, nicotine replacement therapy (NRT) and bupropion hydrochloride

should be considered first as they have been proven to significantly improve cessation rates. Nicotine is

highly addictive and by using NRT or Zyban® instead of smoking, thousands of other chemicals associated

with tobacco smoke are no longer being inhaled (University of Toronto, 2000). The therapy used must depend

on such factors as ease of administration, cost, compliance and particular vulnerabilities to side effects

(National Health Committee, 1999a). Client preference, previous experience and contraindications should also

be considered in recommending which pharmacological option to pursue.

The following first-line medications have been documented to significantly increase the rate of long-term

smoking abstinence, and each has been approved as safe and efficacious by the U.S. Food and Drug

Administration (Anderson, Jorenby, Scott & Fiore, 2002).


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A) Nicotine Replacement Therapy (NRT) NRT is the most commonly used pharmacological treatment for smoking cessation, which provides a

“clean” alternative source of nicotine that the person who smokes would have otherwise received from

tobacco. The aim of NRT is to partially replace the nicotine otherwise obtained from cigarettes. This may

reduce the incidence and intensity of withdrawal symptoms induced by nicotine abstinence during the

first few weeks of smoking cessation (Ontario Tobacco Research Unit, 2000b). It should be noted that oral nicotine

replacement products reduce the effects of irritability, anxiety and overall withdrawal discomfort (West &

Shiffman, 2001). The advantage of using NRT is that it supplies nicotine in a safe manner without the harmful

constituents contained in tobacco smoke (National Health Committee, 1999a). Systematic reviews show that all

forms of NRT increase quit rates at 12 months, approximately 1.5 to 2 fold compared with placebo,

regardless of the setting (National Health Committee, 2002).

Perhaps the most useful approach to pharmacotherapies is to recognize that non-pharmacological

interventions (counselling and other supports) remain vital contributors to successful smoking cessation;

they should not be considered inferior to drug treatment. In fact, a robust evidence base exists supporting

the combination of non-pharmacological and pharmacological interventions to aid in smoking cessation

(Coleman, 2004).

Types of NRT:1. Nicotine patch (e.g., Habitrol®, Nicoderm®)■ Can be purchased over the counter (no prescription needed).■ Is available in three strengths (7 mg, 14 mg, and 21 mg,).■ Provides a rate-controlled delivery of nicotine that is absorbed through the skin.■ Is applied to non-hairy, clean, dry site above waist and held in place for 10 seconds to secure. The

placement site must be changed with each application.■ Usual schedule –21 mg x 4 wks, 14 mg x 4 wk, 7 mg x 2 wks (start with strength matching to

nicotine dependence).■ Has a slow onset and contains lower levels of nicotine than cigarettes and higher levels than gum.■ May cause sleep disturbance (if these become serious, patch should be removed once in bed and

immediately reapplied in the morning).

2. Nicotine gum (e.g., Nicorette®, Nicorette® Plus)■ Can be purchased over the counter (no prescription needed).■ Substitutes a piece of gum for the craving for a cigarette, providing gratification for oral needs and

nicotine cravings. ■ Is absorbed by buccal mucosa.■ Is not chewed continuously, rather, chewed 2-3 times, then parked between the cheek and the gum.

“Bite, bite and park” between cheek and gums – wait a minute then repeat over 30 mins or less.■ 1 - 2 pieces per hour, or with urge, up to 20 pieces day, gradually reduced over 4-12 weeks. ■ 25 cigs or more/day = 4 mg gum. (Nicorette® Plus) <25 cigs/day = 2 mg gum (Nicorette®). ■ Absorption diminished by concomitant use with coffee, tea, alcohol, juice and soft drinks.


There is evidence that combining the nicotine patch with nicotine gum increases long-term abstinence

rates over those produced by a single form of NRT (Centres for Disease Control and Prevention, 1999). Bupropion

hydrochloride can be used in combination with nicotine replacement therapies (U.S. Department of Health and

Human Services, Public Health Service, 2000).

3. Nicotine inhaler (e.g. Nicorette® inhaler)■ Can be purchased over the counter (no prescription needed). ■ Is a mouthpiece with a nicotine cartridge insert. A 10 mg inhaler cartridge delivers 4 mg nicotine vapor

with 2 mg absorbed. One puff delivers less nicotine than one puff from a cigarette. ■ Addresses both the physical and behavioural dependency of smoking as it mimics the hand-to-mouth

ritual of smoking. ■ ‘Puff (into mouth) and hold’. Nicotine is absorbed by blood vessels in the buccal cavity. The number of

puffs taken depends on the amount of nicotine required to meet individual’s cravings and dependence

(most users require > 2 puffs at a time). The same cartridge may be used to address the next craving.

Once opened, each cartridge should be changed every 2-4 hours, as the unused nicotine will evaporate. ■ Manufacturer recommends starting dose of 6 - 12 cartridges per day but many need significantly less.

Taper amount over 3 months (max. 6 months).■ Acidic foods or drinks interfere with absorption. Do not eat or drink (except water) for 15 minutes prior.

4. Options such as nicotine nasal spray, sublingual tablets and lozenges are not currently available in

Canada, but have been tested in placebo controlled trials, demonstrated to be effective and recommended

as first-line pharmacotherapies in the United States (University of Toronto, 2000).

B) Bupropion Hydrochloride (Zyban®)Bupropion hydrochloride is also marketed as the anti-depressant medication Wellbutrin®. It is a non-

nicotine medication and requires a prescription. The exact mechanism by which bupropion hydrochloride

works is unknown, but it is presumed to alleviate cravings associated with nicotine withdrawal affecting

noradrenaline and dopamine, two chemicals in the brain that may be key components of the nicotine

addiction pathway (National Health Committee, 1999a).

C) Other Options:Varenicline tartate will be available in Canada in 2007, and was approved by the U.S. Food and Drug

Administration in May 2006. Studies have shown Varenicline to increase the odds of quitting by four times

compared to placebo, and double compared to Zyban® at 12 weeks and at 1 year. Varenicline targets nicotinic

acetylcholine receptors to decrease craving, withdrawal and the reinforcement associated with smoking

cigarettes. Studies have found varenicline to be safe and well tolerated, with the most common adverse

effects reported being nausea and sleep disturbances (Gonzales et al., 2006; Jorenby et al., 2006; Tonstad et al., 2006).

Clonidine and Nortriptyline are second-line prescription medications used in smoking cessation. These

are pharmacotherapies for which there is evidence of efficacy for treating tobacco dependence, but which

have a more limited role than first-line medications.

For a comparison and explanation of the medications used in smoking cessation treatment, see Appendix L.


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Non-Pharmacological InterventionsThere are numerous options to assist a person who smokes, who is planning to stop smoking:

■ Self-help books and materials;■ Individual counselling (e.g., physicians, nurses/nurse practitioners, pharmacists, dentists);■ Group programs; and■ Mutual aid and self-help group support.

While acupuncture and hypnotherapy are popular, there is insufficient evidence to support their

effectiveness (Joanna Briggs Institute, 2001). However, if the individual has faith in acupuncture or

hypnotherapy, they may benefit from the counselling that these approaches offer (U.S. Dept. of Health and

Human Services, 2000; University of Toronto, 2000). Other potential quit methods that haven’t been clinically

proven include herbal supplements, herbal patches and laser therapy.

Recommendation 3.0Nurses recognize that tobacco users may relapse several times before achieving abstinence and

need to re-engage clients in the smoking cessation process.

(Strength of Evidence = B)

Discussion of EvidenceNicotine dependence is increasingly being recognized as a chronic, relapsing condition similar to that of

other addictive substances.

Most relapse occurs within the first three months after quitting. Because of the chronic, relapsing nature of

tobacco dependence, relapse prevention is especially important during this period. Strategies designed to

prevent relapse should be included in the initial preparation for a quit attempt. It is important to encourage

clients to report difficulties (lapses, depression, side effects) promptly while continuing their efforts to quit

(U.S. Dept. of Health and Human Services, 2000). A variety of interventions targeting relapse prevention exist. In one

significant review, researchers conclude that there is insufficient evidence to recommend particular

interventions for relapse prevention; rather, they recommend continued focus on primary cessation

attempts as well as the identification and resolution of tempting or high-risk situations (Hajek et al., 2006).

Relapse is perfectly normal and does not mean that a person who smokes has failed. Researchers have

found that the more past attempts to stop smoking a person has made, the more likely they will be to

successfully stop in the future. All experiences learned in previous attempts are useful and can be built on

for a future successful attempt (Royal College of Nurses, 1999). Even after withdrawal symptoms pass, the risk

of relapse continues to be high, largely due to exposure to temptations, social situations and other

smoking triggers. All attempts to quit should be congratulated. Never condemn the person who smokes

for lapsing. Encourage the person who smokes to take time to plan for their next stop smoke attempt and

to use the information learned from the last one (University of Toronto, 2000). For Strategies to Avoid Relapse,

see Appendix M.



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Recommendation 4.0Nurses should be knowledgeable about community smoking cessation resources, for referral and

follow-up. (Strength of Evidence = C – RNAO Consensus Panel, 2003/2007)

Discussion of EvidenceThere is evidence that self-help materials alone are of some benefit. A Cochrane review by Lancaster and

Stead (2003b) did not find evidence that self-help materials produce incremental benefits over other

minimal interventions, such as advice from a healthcare professional or nicotine replacement therapy.

However, they found there is increasing evidence that materials that are individually tailored to the person

who smokes have an effect. Tailoring materials to the characteristics of an individual who smokes and

adding follow-up telephone calls improves effectiveness (National Health Committee, 1999a).

The following are examples of community resources (for a complete listing, see Appendix N):■ The Canadian Cancer Society Smokers’ Helpline number is 1-877-513-5333.■ Local smoking cessation programs (inquire via local Public Health Unit).■ Employee Assistance Programs, accessible through an individual’s employer.■ Physicians and other healthcare providers.

Recommendation 5.0Nurses implement smoking cessation interventions, paying particular attention to gender,

ethnicity and age-related issues, and tailor strategies to the diverse needs of populations.

(Strength of Evidence = C – RNAO Consensus Panel, 2003/2007)

Discussion of EvidenceThere is substantial evidence in the literature citing the long-term benefits of “targeting” smoking cessation

interventions at different populations (e.g., youth, women, older adults, ethnic groups). The Royal College

of Nursing (1999), states that nurses are in a unique position, and have access to the population at all levels,

citing several examples of successful implementation of smoking cessation programs with different target

groups. The RNAO guideline development panel supports this concept of tailoring strategies where

possible, during the implementation of minimal intervention.

In 2005, males aged 25-29 had the highest prevalence of current smoking at 39 percent, almost double that

of their female counterpart (21 percent) (Ontario Tobacco Research Unit, 2006). More research is needed to

determine the most effective quit methods as many young adults do not consider themselves ‘smokers’

because they don’t smoke every day or they only smoke in certain situations. Please see Appendix N for

resources which may be of use to nurses working with this population.

Additional research is also needed in the area of co-morbidity and smoking. Eighty percent of alcohol dependent

people currently smoke and concurrent cannabis use is becoming increasingly relevant to smoking cessation as

it has been linked to depression, suicidal ideation and difficulty of tobacco cessation (Wilhelm, et al. 2006). These

populations require the nurse’s special attention and consultation with other mental health practitioners to

establish a smoking cessation care plan, especially with the use of nicotine replacement therapies.

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Recommendation 6.0Nurses implement, wherever possible, intensive intervention with women who are pregnant

and postpartum. (Strength of Evidence = A)

Discussion of EvidenceIn 2005, 10 percent of mothers in Ontario (aged 20-44) who gave birth in the past five years had smoked

during their most recent pregnancy, with 5 percent having smoked daily and 5 percent having smoked

occasionally (Ontario Tobacco Research Unit, 2006).

Pregnancy, and the period preceding and following, provides a unique opportunity to help women stop

smoking. Many women are motivated to quit smoking during pregnancy and healthcare professionals can

take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the

fetus and that there are postpartum benefits to both the mother and the child. Women who stop smoking

before or during the first trimester of pregnancy reduce risks to their baby to a level comparable to that of

women who have never smoked (National Health Committee, 2002). Self-help manuals, particularly material

specifically directed to pregnancy, are more effective in this population than in other groups (National Health

Committee, 1999a).

Smoking during pregnancy has harmful effects for both the woman and the fetus. Approaches to smoking

cessation for pregnant women often focus on the health of the fetus and give less attention to the woman’s own

health. Greaves et al., (2003) emphasize a woman-centred approach, focusing on the health of the woman in

addition to the health of the fetus, thus encouraging a sustained abstinence in the postpartum period.

Stopping smoking during pregnancy may be treated as a suspension of the habit and is not always a change

that is intentional or permanent or made for personal benefit. The research on process of change for

smoking cessation suggests that pregnant women may experience the stages of quitting in a unique way,

moving through the pre-contemplation and contemplation stages into preparation and action stages very

quickly (Prochaska et al. 1983; 2001) which may be detrimental to smoking cessation and maintenance,

resulting in postpartum relapse. Another study found that some women reported that they had never really

quit because they quit for the fetus/baby and not for themselves (Bottoroff et al., 2000).

There are many helpful resource agencies, websites and help lines that the consumer can access to increase

their knowledge base about smoking cessation. Information for accessing these resources, like the Ontario

program PREGNETS which provides information for pregnant women who intend to quit smoking, are

listed in Appendix N. However, programs are still needed to raise awareness and motivate behavioural

change among pregnant women and their partners, to reduce the harmful effects of prenatal and postnatal

exposure to tobacco smoke (Ontario Tobacco Research Unit, 2000b).

According to the National Health Committee (2002), “NRT should be considered when a pregnant/lactating

woman is unable to quit, and when the likelihood of quitting, with its potential benefits, outweighs the risks

of NRT and potential continued smoking” (p. 22). A nurse can then recommend NRT to the client and suggest

that the pregnant woman discuss this option with the healthcare provider who is monitoring her pregnancy.



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Recommendation 7.0Nurses encourage persons who smoke, as well as those who do not, to make their homes smoke-free,

to protect children, families and themselves from exposure to second-hand smoke.

(Strength of Evidence = A)

Discussion of EvidenceAll involuntary exposure to tobacco smoke is harmful and should be eliminated (Ontario Tobacco Research Unit,

2000a). The scientific evidence indicates that there is no risk-free level of exposure to second-hand smoke.

Second-hand smoke causes premature death and disease in children and in adults who do not smoke.

Children who are exposed to second-hand smoke are at an increased risk for Sudden Infant Death

Syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents

causes respiratory symptoms and slows lung growth in their children. Exposure of non-smoking women to

environmental tobacco smoke during pregnancy also causes reductions in fetal growth (Ontario Tobacco

Research Unit, 2000a). Children do not choose this exposure. Their right to grow up in an environment free

from tobacco smoke must be safeguarded through actions by national and local governments, voluntary

bodies, community leaders, health workers, educators and parents (Ontario Tobacco Research Unit, 2000a).

Exposure of adults to second-hand smoke has immediate adverse effects on the cardiovascular system and

causes coronary heart disease and lung cancer (U.S. Department of Health and Human Services, 2006). In 2005,

more than 600,000 Ontarians (7.3 percent) 12 years and older were exposed every day or almost every day

to second-hand smoke at home (Ontario Tobacco Research Unit, 2006). A short-term objective of the Smoke-free

Ontario Strategy is to increase the adoption of voluntary policies to make homes smoke-free (Ontario Tobacco

Research Unit, 2006).

Education RecommendationsEducation is the foundation of the success of all activities in smoking cessation. Education must be

continually reinforced, and the best methods for educating must be chosen, in order to ensure practice

change in the adoption of the best practice guidelines. The literature demonstrates that initiating and

maintaining behavioural change is a complex process that requires the implementation of intensive and

sustained efforts using strategies that influence a number of factors.

Recommendation 8.0All nursing programs should include content about tobacco use, associated health risks and

smoking cessation interventions as core concepts in nursing curricula.


Discussion of EvidenceSeveral sources, including the U.S. Department of Health and Human Services (2000), widely support the

inclusion of education and training in tobacco dependence treatments in the required curricula of all

clinical disciplines. The RNAO guideline development panel also supports this need for educational

programs at all levels of nursing.

35

Nurses require education and guidance so they can develop their understanding and a positive view as to

the effectiveness of smoking cessation programs (Lawvere, 2003). Nurses described concern about their

ability to motivate their clients. Education about the health risks of tobacco, assessing clients’ nicotine

dependency and motivation to cease smoking is necessary to include in nursing curricula (Pelkonen, 2001).

Organization & Policy RecommendationsRecommendation 9.0Organizations and Regional Health Authorities should consider smoking cessation as integral to

nursing practice, and thereby integrate a variety of professional development opportunities to

support nurses in effectively developing skills in smoking cessation intervention and counselling.

All corporate hospital orientation programs should include training to use brief smoking cessation

interventions as well as information on pharmacotherapy to support hospitalized persons who smoke.

(Strength of Evidence =B)

Discussion of EvidenceEducational development in the area of smoking cessation, for nurses in all specializations and practice

settings, is needed to provide additional background knowledge and expertise in the practice of smoking

cessation interventions. In particular, there is a need to educate nurses concerning the mechanisms

underlying the additive nature of tobacco use (Schultz, Bottorff & Johnson, 2005); tobacco use is not a habit or

choice. Increased awareness and knowledge would assist nurses in adequately treating withdrawal

symptoms, which is necessary to support abstinence from tobacco use and eventual successful cessation.

As well, organizations must provide professional development opportunities for nurses that are tailored to

individual and group learning styles. Health professionals who receive training are much more likely to

intervene with people who smoke than those who are not trained (University of Toronto, 2000).

To promote providers addressing tobacco cessation, organizations need to systemically approach tobacco

cessation through education, resources, cues embedded in patient care documents, and feedback to providers.

The healthcare system should ensure the following:

1. Nurses have sufficient training to treat tobacco dependence. For example, in Ontario, the Centre for

Addiction and Mental Health launched a workshop Training Enhancement in Applied Cessation

Counselling and Health (TEACH) that trains practitioners in the area of tobacco cessation.

2. Healthcare providers and clients have cessation resources; for example, access to patient resources that

address stopping smoking (which includes addressing relapse and community supports available to

address the process of stopping); protecting their environment from tobacco smoke exposure; options

to refer for future cessation support.

3. Environmental prompts promote the integration of cessation support being offered by health providers

(U.S. Dept. of Health and Human Services, 2000). For example, patient history forms, patient care forms, referral

forms, and discharge forms should include cues regarding tobacco use status and cessation support.

Currently, many of these components of health records document tobacco use while indications of

cessation support are absent (Schultz et al., 2006).


4. Healthcare providers are given feedback about their tobacco dependence treatment practices (U.S.

Dept. of Health and Human Services, 2000) and are referred to self-help resources specifically tailored

for nurses and students who wish to stop smoking (i.e. Nurses Quit Net available on-line at

www.tobaccofreenurses.org).

For a list of training and self help resources available to nurses, please see Appendix N.

Recommendation 10.0Nurses seek opportunities to be actively involved in advocating for effective smoking cessation

services, including “stop smoking medications”.


Discussion of EvidenceSuggested advocacy roles for nurses can include:■ Lobbying governments and third-party payers for funding to support the provision of smoking cessation

services by health professionals.

■ Advocating for the provincial government to have the Ontario Drug Benefit Plan (ODB) cover the cost of

all nicotine replacement products and other smoking cessation related pharmaceuticals. At present,

nicotine replacement products are not covered by most insurance plans.

■ Advocating for employer sponsors, (for example, health insurance companies) to cover the cost of all

nicotine replacement products and other smoking cessation related pharmaceuticals. In the longer

term, the health consequences of tobacco use may prove more costly to the insurance industry than

covering the cost of NRT products and other pharmaceuticals.

Recommendation 11.0Nurses seek opportunities to be actively involved in advocating for smoke-free spaces and protection

against second-hand smoke. (Strength of Evidence = C – RNAO Consensus Panel, 2003/2007)

Discussion of EvidenceSmoke-free workplaces are associated with a decrease in prevalence of tobacco consumption of nearly four

percent (Fichtenberg & Glantz, 2002; Moher et al., 2003; Smedlsund et al., 2004). Smoke-free workplaces also make it easier

for persons who smoke to reduce or stop smoking, and substantially reduce tobacco industry sales (Fichtenberg &

Glantz, 2002). Most adults spend about a third of their day in a workplace environment, therefore the workplace

is a setting through which large groups of people who smoke can potentially be reached by smoking cessation

messages. The workplace has the potential for a higher participation than non-workplace environments and

may encourage sustained peer group support and positive peer pressure (Moher, 2004).

On June 27, 2006 the U.S. Surgeon General released a report on involuntary exposure to second-hand

smoke, concluding that secondhand smoke causes disease and death in children and non-smoking adults.

The report finds a causal relationship between second-hand smoke exposure and Sudden Infant Death

Syndrome (SIDS), and declares that the home is becoming the predominant location for exposure of

children and adults to second-hand smoke.


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Eliminating smoking in indoor spaces fully protects those who do not smoke from exposure to second-hand

smoke. Separating persons who smoke from those who do not, cleaning the air, and ventilating buildings

alone cannot eliminate exposures of nonsmokers to second-hand smoke (U.S. Department of Health and Human

Services, 2006).

Nurses can help by:■ Promoting smoke-free environments, such as smoke-free initiatives on hospital grounds. Nurses can

provide smoke-free task force leaders with valuable information and strategies to support patients,

families, public and staff during implementation.

■ Advocating for smoke-free outdoor recreation areas, and encouraging nurses to set an example by being

smoke-free.

■ Supporting and educating the public regarding the Ontario legislation that shields workers and the public

from the harmful effects of tobacco by banning smoking in enclosed public places and enclosed workplaces.

Recommendation 12.0Nursing best practice guidelines can be successfully implemented only when there is adequate

planning, resources, organizational and administrative support, as well as appropriate facilitation.

Organizations may wish to develop a plan for implementation that includes:■ An assessment of organizational readiness and barriers to education.■ Involvement of all members (whether in a direct or indirect supportive function) who will

contribute to the implementation process.■ Dedication of a qualified individual to provide the support needed for the education and

implementation process.■ Ongoing opportunities for discussion and education to reinforce the importance of best practices.■ Opportunities for reflection on personal and organizational experience in implementing guidelines.

In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the

“Toolkit: Implementation of clinical practice guidelines” based on available evidence, theoretical

perspectives and consensus. The Toolkit is recommended for guiding the implementation of the

RNAO guideline Integrating Smoking Cessation into Daily Nursing Practice.

Strength of Evidence = C

A critical step in the implementation of guidelines must be the formal adoption of the guidelines.

Organizations need to consider how to formally incorporate the recommendations to be adopted into their

policy and procedure structure (Graham et al., 2002). This initial step paves the way for general acceptance

and integration of the guideline into such systems as the quality management process.

New initiatives such as the implementation of a best practice guideline require strong leadership from

nurses who are able to transform the evidence-based recommendations into useful tools that will assist in

directing practice. Refer to Appendix O for a description of the Toolkit.



38

Evaluation & MonitoringResearch on smoking and tobacco use has begun to focus not just on outcomes, e.g., quitting, reduction,

and cessation, but on stages of smoking behaviour, based on stages of change. Understanding the cycle is important

for developing and implementing interventions directed specifically to the individual’s current stage of change.

Minimal intervention has been shown to decrease the proportion of persons who smoke by around 2 percent.

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how

the implementation and its impact will be monitored and evaluated. The following table, based on the framework

outlined in the RNAO Toolkit: Implementation of clinical practice guidelines (2002), illustrates some suggested

indicators for monitoring and evaluation.

Objectives

Organization/Unit

Provider

■ To evaluate the supportsavailable in theorganization that allow fornurses to implementminimal and intensivesmoking cessationinterventions.

■ Review of best practicerecommendations byorganizational committee(s)responsible for policies orprocedures, e.g., list ofreferral sources for smokingcessation.

■ Availability of clienteducation resources that areconsistent with the guidelinerecommendations.

■ Organizational missionstatement that supports asmoke-free environment.

■ Percentage of nurses andother healthcareprofessionals attendingeducation sessions onsmoking cessation.

■ To evaluate changes inpractice that lead towardsintegration of minimal andintensive smokingcessation interventionsinto daily nursing practice.

■ Documentation systemsavailable for recordingsmoking status and relatedstrategies.

■ Nurses’ self-assessedknowledge of theimportance of:■ Assessing and

implementing minimalor intensive smokingcessation interventionsusing the Ask, Advise,Assist and Arrangeprotocol.

■ Documenting thesmoking cessationinterventions providedto clients.

■ Understanding thevarious stages ofreadiness to quitsmoking.

■ To evaluate the impactof implementing therecommendations.

■ Smoke-free environment.■ Incorporation of smoking

cessation intervention educationin staff orientation program.

■ Incorporation of smokingcessation intervention in clientinformation material.

■ Organizational policy reflectingcommitment for a smoke-freeenvironment and support forsmoking cessation.

■ Number of institutions wheresmoking cessation is measured asa quality indicator.

■ Percentage of persons who smokeindicating they were advised toquit smoking by one or morenurses and/or other healthcareprofessionals during their mostrecent contact as indicated inchart audits.

■ Percentage of nurses and/or otherhealthcare professionals referringclients for follow-up to communitysmoking cessation programs.

■ Percentage of clients admittedto unit/facility with theirsmoking status and smokinghistory recorded.

■ Percentage of clients withdocumented interventionscharted.

Indicator Structure Process Outcome

39


Client

FinancialCosts

■ Total percentage of personswho smoke.

■ Provision of adequatefinancial resources for thelevel of staffing necessary toimplement minimal andintensive smoking cessationinterventions. Provision ofdesignated individual tocoordinate and supportsmoking cessation programinitiatives throughouthealthcare organization.

■ Percent of nursesself-reporting:

■ Adequate assessment ofa client’s desire to be anactive partner in thesmoking cessationprocess.

■ Adequate knowledge ofcommunity referralsources for smokingcessation.

■ Percentage of persons whosmoke who receivedcessation advice from anurse and/or healthcareprofessionals at each clinicencounter and on eachadmission to hospital.

■ Percentage of clientsaccessing referral sourcesin the community.

■ Client confidence to quitsmoking and maintainsmoking cessation.

■ Cost for education, otherinterventions and supports.

■ Cost related toimplementing theguideline.

■ Education and access toon-the-job supports.

■ New documentationsystems.

■ Support systems.

■ Percentage of clients who setquit date.

■ Percentage of clients who madequit attempts 2 weeks post-cessation counselling.

■ Percentage of clients whosuccessfully quit smoking 8weeks or 2 months post-cessationcounselling.

■ Overall resource utilization(identify organizational specifics,new staff hires, medications, etc.).

Indicator Structure Process Outcome

Examples of evaluation tools that were used to collect data during the pilot implementation can be found

at the RNAO website (www.rnao.org/bestpractices).

Implementation StrategiesThe Registered Nurses’ Association of Ontario and the guideline development panel have

compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines

who are interested in implementing this guideline. At the time of its original publication, this best practice

guideline was pilot tested in four clinical settings within one organization, and many of these strategies

were found to be helpful during the implementation. A summary of these strategies follows:

■ Have a dedicated person such as a clinical resource nurse who will provide support, clinical expertise

and leadership. The individual should also have good interpersonal, facilitation and project

management skills.

■ Establish a steering committee comprised of key stakeholders and members committed

to leading the initiative. A work plan can assist as a means of keeping track of activities, responsibilities

and timelines.

■ Provide educational sessions and ongoing support for implementation. At the pilot site, a core

education session of approximately two hours was developed by a steering committee. The education

session consisted of a Powerpoint presentation, discussion of case scenarios and was designed to be

informal and interactive. The content drew on the recommendations contained in this guideline.

Reminders, such as buttons, posters, laminated cards summarizing the steps in the Ask, Advise, Assist

and Arrange strategy, were also used as education strategies.

■ Attitudes on smoking are shaped by a number of factors including an individual's personal value system.

Early attention to attitudes and values is needed by providing staff the opportunity to talk and problem

solve on the job. This can be achieved using case scenarios to reflect the situations each group of

participants faced with their clients.

■ Organizational support, such as having the structures in place to facilitate the implementation.

Examples include: hiring of replacement staff so participants would not be distracted by concerns about

work and having an organizational philosophy that reflects the value of best practices through policies

and procedures and documentation tools.

■ Teamwork and collaboration through interdisciplinary work is beneficial in helping clients quit

smoking. It is essential to be cognizant of smoking cessation programs and to tap the resources that are

available in the community. An example would be linking and developing partnerships with nicotine

addiction clinics for referral process. The RNAO’s Advanced Clinical/Practice Fellowship (ACPF) Project

is a resource for registered nurses. They apply for a fellowship and have an opportunity to work with a

mentor who has expertise in smoking cessation programs. With the ACPF, the nurse fellow will also have

the opportunity to learn more about new resources.

In addition to the tips mentioned above, the RNAO has developed resources that are available on the

website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description of

the Toolkit can be found in Appendix O. A full version of the document in .pdf format is also available at the

RNAO website, www.rnao.org/bestpractices.


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An e-learning module on smoking cessation has also been developed by the RNAO. The e-learning module

can be used in conjunction with other teaching/learning modalities and it is available at

www.rnao.org/smokingcessation.

The Program Training and Consultation Centre’s website also provides resources that might be helpful

as teaching tools. These teaching tools are available at www.ptcc.on.ca. (See Appendix N for listing of

other resources.)

It is most important to emphasize the minimal intervention aspect of this best practice guideline.

This takes less than three minutes. Nurses and others need to know that minimal intervention can

be easily integrated in their daily practice. The minimal intervention is crucial for implementation.

It can be implemented not only by nurses, but by all healthcare providers in any clinical setting.

Research Gaps & Future ImplicationsIn reviewing the evidence for the revision of this guideline, it is clear that future research opportunities involve:

■ Interventions to prevent relapse in individuals who have recently quit smoking.■ Attitudes of nurses towards smoking cessation counselling, and the impact on practice.■ The needs of special populations as they are reflected in program development and delivery.■ The benefits of NRT, to persons of various levels of nicotine dependency.■ The impact of the cost of accessing NRT on smoking cessationoutcomes.



42

Process for Update/Review of GuidelineThe Registered Nurses’ Association of Ontario proposes to update the Best Practice

Guidelines as follows:

1. Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the

topic area every three years following the last set of revisions.

2. During the three-year period between development and revision, RNAO Nursing Best Practice

Guidelines program staff will regularly monitor relevant literature in the field.

3. Based on the results of this monitoring, program staff will recommend an earlier revision period.

Appropriate consultation with a team of members comprised of original panel members and other

specialists in the field will help inform the decision to review and revise the guideline earlier than

the three-year milestone.

4. Three months prior to the three-year review milestone, the program staff will commence the

planning of the review process by:

a. Inviting specialists in the field to participate in the Review team. The Review Team will be

comprised of members from the original panel as well as other recommended specialists.

b. Compiling feedback received, questions encountered during the dissemination phase as well as

other comments and experiences of implementation sites.

c. Compiling new clinical practice guidelines in the field, systematic reviews, meta-analysis papers,

technical reviews and randomized controlled trial research, and other relevant literature.

d. Developing a detailed work plan with target dates and deliverables.

The revised guideline will undergo dissemination based on established structures and processes.

43

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Appendix A: Search Strategyfor Existing EvidenceThe search strategy utilized during the revision of this guideline focused on two key areas. One was the

identification of new guidelines published on the topic smoking cessation since the original guideline was

published in 2003, and the second was to identify systematic reviews and primary studies published in this

area from 2003 to 2006.

STEP 1 – DATABASE SearchA database search for existing evidence related to smoking cessation was conducted by a university health

sciences library. An initial search of the Medline, Embase and CINAHL databases for guidelines and studies

published from 2003 to 2006 was conducted in March 2006, using the following search terms and key

words: “smoking cessation”, “smoking addiction(s)”, “relapse”, “practice guidelines”, “practice guideline”,

“clinical practice guideline”, “clinical practice guidelines”, “standards”, “consensus statement(s)”,

“consensus”, “evidence based guidelines” and “best practice guidelines”. In addition, a search of the

Cochrane Library database for systematic reviews was conducted using the above search terms.

STEP 2 – Structured Website SearchOne individual searched an established list of websites for guidelines related to the topic area in April 2006.

This list of sites, reviewed and updated in April 2006, was compiled based on existing knowledge of

evidence-based practice websites, known guideline developers, and recommendations from the literature.

Presence or absence of guidelines was noted for each site searched as well as date searched. The websites

at times did not house a guideline but directed to another website or source for guideline retrieval.

Guidelines were either downloaded if full versions were available or were ordered by phone/email.

■ Agency for Healthcare Research and Quality: http://www.ahrq.gov

■ Alberta Heritage Foundation for Medical Research - Health Technology Assessment: http://www.ahfmr.ab.ca//hta

■ Alberta Medical Association - Clinical Practice Guidelines: http://www.albertadoctors.org

■ Bandolier Journal: http://www.jr2.ox.ac.uk/bandolier

■ British Columbia Council on Clinical Practice Guidelines: http://www.hlth.gov.bc.ca/msp/protoguides/index.html

■ Canadian Coordinating Office for Health Technology Assessment: http://www.ccohta.ca

■ Canadian Institute of Health Information: http://www.cihi.ca

■ Canadian Health Network: www.canadian-health-network.ca

■ Centers for Disease Control and Prevention: http://www.cdc.gov

■ Clinical Evidence: www.clinicalevidence.com

■ CMA Infobase: Clinical Practice Guidelines: http://mdm.ca/cpgsnew/cpgs/index.asp

■ Cochrane Database of Systematic Reviews: www.thecochranelibrary.com

■ Database of Abstracts of Reviews of Effectiveness (DARE): http://www.update-software.com/cochrane

■ European Observatory on health Care for Chronic Conditions, World Health Organization:

http://www.euro.who.int/observatory/About/london/20041215_3

■ Evidence-based On-Call: http://www.eboncall.org

■ Guidelines Advisory Committee: http://gacguidelines.ca

■ Guidelines International Network: www.g-i-n.net


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■ Institute for Clinical Systems Improvement: http://www.icsi.org/index.asp

■ Institute for Clinical Evaluative Sciences: www.ices.on.ca

■ Joanna Briggs Institute: http://www.joannabriggs.edu.au

■ Medic8.com: http://www.medic8.com/ClinicalGuidelines.htm

■ Monash University Centre for Clinical Effectiveness: http://www.mihsr.monash.org/cce

■ National Electronic Library for Health: http://www.nelh.nhs.uk

■ National Guideline Clearinghouse: http://www.guidelines.gov

■ National Institute for Clinical Excellence (NICE): http://www.nice.org.uk

■ New Zealand Guidelines Group: http://www.nzgg.org.nz

■ NHS Centre for Reviews and Dissemination: http://www.york.ac.uk/inst/crd

■ NHS R & D Health Technology Assessment Programme: http://www.hta.nhsweb.nhs.uk/htapubs.htm

■ NIH Consensus Development Program: http://consensus.nih.gov/about/about.htm

■ PEDro: The Physiotherapy Evidence Database: http://www.pedro.fhs.usyd.edu.au/index.html

■ Periodic Task Force on Preventive Health Care: http://www.ctfphc.org

■ Queen’s University at Kingston: http://post.queensu.ca/~bhc/gim/cpgs.html

■ Royal College of General Practitioners: http://www.rcgp.org.uk

■ Royal College of Nursing: http://www.rcn.org.uk/index.php

■ Royal College of Physicians: http://www.rcplondon.ac.uk

■ Sarah Cole Hirsh Institute – Online Journal of Issues in Nursing: http://fpb.cwru.edu/HirshInstitute

■ Scottish Intercollegiate Guidelines Network: http://www.sign.ac.uk

■ SUMSearch: http://sumsearch.uthscsa.edu

■ The Qualitative Report: http://www.nova.edu/ssss/QR

■ TRIP Database: http://www.tripdatabase.com

■ U.S. Preventive Service Task Force: http://www.ahrq.gov/clinic/uspstfix.htm

■ University of California, San Francisco: http://medicine.ucsf.edu/resources/guidelines/index.html

■ University of Laval – Directory of Clinical Information Websites: http://132.203.128.28/medecine

■ Virginia Henderson International Nursing Library: www.nursinglibrary.org

STEP 3 – Search Engine Web SearchA website search for existing practice guidelines on smoking cessation was conducted via the search engine

“Google”, using key search terms. One individual conducted this search, noting the results of the search, the

websites reviewed, date and a summary of the results. The search results were further reviewed by a second

individual who identified guidelines and literature not previously retrieved.

STEP 4 – Hand Search/Panel Contributions Additionally, panel members were asked to review personal archives to identify guidelines not previously found

through the above search strategy. Results of this strategy revealed no additional clinical practice guidelines.

SEARCH RESULTS:The search strategy described above resulted in the retrieval of 362 abstracts on the topic of smoking

cessation. These abstracts were then screened by a research assistant related to duplications and

inclusion/exclusion criteria. A total of 83 abstracts were identified for article retrieval and critical appraisal.


In addition, four recently published clinical practice guidelines were identified for review and critical

appraisal by the panel, using the “Appraisal of Guidelines for Research and Evaluation” (AGREE

Collaboration, 2001) instrument. These guidelines included:

■ Institute for Clinical Systems Improvement. (2004). Tobacco use prevention and cessation for adults and

mature adolescents. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI).■ National Advisory Committee on Health and Disability. (2002) Guidelines for smoking cessation: (Revised

2002.) Wellington, NZ: National Advisory Committee on Health and Disability (National Health Committee).■ Singapore Ministry of Health. (2002). Smoking cessation. Singapore: Singapore Ministry of Health.■ National Institute for Health and Clinical Excellence. (2006) Brief interventions and referral for smoking

cessation in primary care and other settings. National Institute for Health and Clinical Excellence.


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Appendix B: Glossary of TermsAcupuncture: A treatment involving the placement of needles in specific areas of the body, in this

instance with the intent to promote abstinence from tobacco use.

Bupropion HCI (bupropion sustained-release) (Zyban®): A non-nicotine

aid to smoking cessation originally developed and marketed as an antidepressant. It is chemically

unrelated to tricyclics, tetracyclics, selective serotonin re-uptake inhibitors and other known

antidepressant medications. Its mechanism of action is presumed to be mediated through its

capacity to block the re-uptake of dopamine and norepinephrine centrally.

Clonidine: An alpha-2-adrenergic agonist typically used as an anti-hypertensive medication, but

also documented in this guideline as an effective medication for smoking cessation. The U.S. Food

and Drug Administration (FDA) has not approved clonidine as a smoking cessation aid.

Continuous abstinence: A measure of tobacco abstinence based on whether subjects are

continuously abstinent from smoking/tobacco use from their quit day to a designated outcome point

(e.g., end of treatment, 6 months after the quit day).

Cotinine: Cotinine is nicotine’s major metabolite, which has a significantly longer half-life than

nicotine. This is often used to estimate a client’s tobacco/nicotine self-administration prior to

quitting, and to confirm abstinence self-reports during follow up. Cotinine can be measured in urine,

saliva or blood.

Dependence: Is defined by the DSM IV (American Psychiatric Association, 2000) as: tolerance to a

substance; withdrawal from a substance; taking a substance for a longer period and in larger amounts

than intended; having a persistent desire or unsuccessful efforts to cut down or control substance

use; spending a great deal of time obtaining, using or recovering from the effects of the substance,

giving up important social, occupational, or recreational activities because of substance use;

substance use continues despite knowledge of having a persistent or recurrent physical or

psychological problem that is likely to have been caused or exacerbated by the substance.

Diazepam: A benzodiazepine anxiolytic medication intended to reduce anxiety.

Environmental tobacco smoke (ETS): Also known as “second-hand smoke.” The

smoke inhaled by an individual not actively engaged in smoking, but due to exposure to ambient

tobacco smoke.

First-line pharmacotherapy for tobacco dependence: First-line pharmacotherapies

have been found to be safe and effective for tobacco dependence treatment and have been approved

by the FDA for this use. First-line medications have an established empirical record of efficacy,

and should be considered first as part of tobacco dependence treatment, except in cases

of contraindications.

Hotline/help-line: See telephone hotline/help-line.

Hypnosis (hypnotherapy): A treatment by which a healthcare provider attempts to induce an

altered attention state and heightened suggestibility in a tobacco user for the purpose of promoting

abstinence from tobacco use.

Informal support: Support and resources provided by persons associated with the individual

receiving care. Persons providing informal support can include: family, friends, members of a

religious group, and neighbours.

Intensive intervention: Refers to interventions that involve extended contact between

healthcare provider and client (greater than 10 minutes of time spent in intervention).

Interdisciplinary: A process where healthcare professionals representing expertise from various

healthcare disciplines participate in the support of clients/families in the care process.

Minimal intervention: Refers to interventions in which there is brief contact between

healthcare provider and client (1 to 3 minutes of time spent in intervention).

Motivational Interviewing: Is a directive, client-centred counselling style for eliciting

behaviour change by helping clients to explore and resolve ambivalence. Compared with

nondirective counselling, it is more focused and goal directed. Motivation to change is elicited from

the client not imposed from without by healthcare providers, peers, or others.

Nicotine: This is often used to assess a client’s tobacco/nicotine self-administration prior to quitting, and

to confirm abstinence self-reports during follow up. Nicotine can be measured in urine, blood and saliva.

Nicotine replacement therapy (NRT): Refers to a medication containing nicotine that is

intended to promote smoking cessation. The nicotine chewing gum, nicotine inhaler and nicotine

patch are currently approved for use in Canada.

Person-to-person intervention: In-person or face-to-face contact between a healthcare

provider and a client, for the purpose of tobacco use assessment or intervention.

Point prevalence: A measure of tobacco abstinence based on smoking/tobacco use occurrence

within a set time period (usually 7 days) prior to a follow-up assessment.

Practical counselling (problem solving/skills training): Refers to a tobacco use

treatment, in which tobacco users are trained to identify and cope with events or problems that increase

the likelihood of their tobacco use. For example, quitters might be trained to anticipate stressful events

and to use coping skills such as distraction or deep breathing to cope with an urge to smoke. Related and

similar interventions are coping skills training, relapse prevention and stress management.

Proactive telephone counselling: Treatment initiated by a healthcare provider who

telephones and counsels the client over the telephone.


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Psychosocial interventions: Refers to intervention strategies that are designed to increase

tobacco abstinence rates due to psychological or social support mechanisms. These interventions

comprise such treatment strategies as counselling, self-help and behavioural treatment and

contingency contracting.

Quit day: The day of a given cessation attempt during which a client tries to abstain totally from

tobacco use. Also refers to a motivational intervention, whereby a client commits to quit tobacco use

on a specified day.

Relaxation/breathing: An intervention strategy in which clients are trained in relaxation

techniques. Interventions using meditation and breathing exercises fit this category. This category

should be distinguished from the category of problem solving, which includes a much wider range of

stress-reduction/management strategies.

Second-hand smoke: See “environmental tobacco smoke”.

Second-line pharmacotherapy for tobacco dependence: Second-line medications

are pharmacotherapies for which there is evidence of efficacy for treating tobacco dependence, but

they have a more limited role than first-line medications. Second-line treatments should be

considered for use on a case-by-case basis, after first-line treatments have been used or considered.

Self-help: An intervention strategy in which the client uses a non-pharmacologic, physical aid to

achieve abstinence from tobacco. Self-help strategies typically involve little contact with a healthcare

provider, although some strategies (e.g., hotline/help-line) involve client-initiated contact. Examples

of types of self-help materials include: pamphlets, booklets, mailings, manuals, videos, audio tapes,

referrals to 12-step programs, mass media community-level interventions, list of community

programs, reactive telephone hotlines/help-lines and computer programs/internet resources.

Smokeless tobacco: Any used form of unburned tobacco, including chewing tobacco and snuff.

Smoking cessation: Smoking cessation is a process whereby a person who uses tobacco

products quits smoking and stops using tobacco products for a minimum of 24 hours.

Smoking cessation intervention: Smoking cessation intervention is formally identifying,

assisting, motivating and advising the person who smokes to become, and remain, smoke-free.

Telephone hotline/help-line: A reactive telephone line dedicated to over-the-phone smoking

intervention. A hotline/help-line treatment occurs when a hotline/help-line number is provided to a

client, or a referral to a hotline/help-line is made. The key distinction between hotline/help-line and

proactive telephone counselling is that in the former the client must initiate clinical contact.

Transdermal nicotine: Refers to delivery of nicotine by diffusion through the skin. Often used

as a synonym for a “nicotine patch.”


Appendix C: The Health Risks of SmokingToxic Components of cigarettesExposure to these chemicals occurs whenever a tobacco product is burned:

■ Tar■ Nicotine■ Carbon monoxide■ Formaldehyde■ Hydrogen cyanide■ Benzene

For further details on the toxic components of cigarettes, visit Health Canada’s Toxic Emissions Statement,

webpage at: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/legislation/label-etiquette/tox/index_e.html

■ More than 47,000 people die prematurely each year in Canada due to tobacco use.■ The average person who smokes will die about eight years earlier than a similar non-smoker.

Tobacco use increases the risk of:

1. Cardiovascular disease 7. Rheumatologic conditions

2. Cancers 8. Kidney damage

3. Respiratory diseases 9. Type 2 Diabetes

4. Adverse effects in pregnancy 10. Skin conditions

and early childhood 11. Cataracts

5. Gastrointestinal problems 12. Tooth and gum problems

6. Orthopedic conditions

1. Cardiovascular Disease■ About 30 percent of all heart disease deaths are due to smoking. ■ Smoking accounts for about three quarters of all cases of peripheral vascular disease. The risk of peripheral

vascular disease may be as much as 16 times higher in persons who smoke than in those who do not.■ Smoking is a dominant cause of heart disease, stroke and diseases of the blood vessels.■ Each year in Canada, more than 17,600 cardiovascular deaths result from smoking.■ Each year in Canada, more than 2,000 deaths from stroke result from smoking.■ Many of these deaths occur prematurely, before the age of 70.■ The incidence of coronary heart disease (CHD) is 2 to 4 times greater in smokers. ■ Health Canada estimates that at least 700 non-smokers will die each year of coronary heart disease

caused by exposure to second-hand smoke.■ Smoking is a major risk factor for heart attacks and sudden cardiac death.■ Smoking acts synergistically with other risk factors (high cholesterol and blood pressure) to increase

the risk of CHD.■ Smoking increases the risk of recurrence in persons who have survived a heart attack.■ Smoking increases the risk of stroke in women more so than men.■ Quitting smoking substantially reduces the risk of CHD and stroke.


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2. Cancers■ Smoking is responsible for more than 21,000 deaths (Canadian Cancer Society et al., 2000) from cancer

each year, almost 30 percent of all cancer deaths. The risk of developing cancer increases with duration

of smoking, number of cigarettes smoked per day and degree of inhalation. The risk of lung cancer is

significantly reduced with smoking cessation in comparison to those individuals who continue to smoke.■ Smoking causes cancer of the lung, oral cavity, larynx, esophagus, pancreas, kidney and urinary bladder.■ Recent evidence links smoking with cancer of the large intestine and some forms of leukemia. Tobacco

causes 80 to 85 percent of all lung cancers and 30 percent of the total cancer burden.■ Smokeless tobacco is a major cause of cancer of the mouth.■ Cigarette smoking is estimated to account for about 30 to 40 percent of bladder cancers.■ Since 1993, lung cancer exceeded breast cancer as the leading cause of cancer deaths in Canadian women.

3. Respiratory Diseases■ Each year smoking is responsible for more than 8,000 deaths in Canada from respiratory diseases.

Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, chronic airway

obstruction, emphysema and related disorders. Persons with these conditions often suffer long periods

of disability marked by progressive shortness of breath and limitations in daily activities.■ Smoking accounts for 80 to 90 percent of all COPD deaths.■ Smoking far outweighs all other factors, including air pollution and occupational exposures, in causing

these conditions.■ Smoking depresses the body’s immune system and other defense mechanisms.■ Smokers are at increased risk of respiratory infections compared to non-smokers.■ Smoking may increase susceptibility to the common cold.

4. Adverse Effects in Pregnancy and Early Childhood■ Bleeding during pregnancy.■ Ectopic pregnancy.■ Miscarriage.■ Premature delivery.■ Stillbirth.■ Abnormalities of the placenta.

■ An increased risk of childhood allergies.■ Higher blood pressure in childhood. ■ A greater likelihood of obesity. ■ Being shorter in childhood. ■ Poorer lung function. ■ A greater likelihood that the child will have asthma.■ Women who smoke during pregnancy risk complications including.■ Low birth-weight newborn (less than 2500 grams).■ Babies receive nicotine and carbon monoxide from their mother’s blood.■ Smoking may contribute to Sudden Infant Death Syndrome (SIDS).■ Nicotine and other chemical components of cigarette smoke are found in the breast milk of nursing

mothers who smoke or are exposed to environmental tobacco smoke (ETS).■ Smoking appears to decrease the quantity of breast milk which, combined with the effects on the

quality of breast milk, may lead to early weaning.


5. Gastrointestinal Problems■ Peptic ulcer disease is more likely to occur in smokers than non-smokers.■ When ulcers are present, they heal less readily in smokers and are likely to recur.■ Smoking increases the risk of death from ulcers.■ Smoking is a risk factor for Chronic Bowel Disease and Crohn’s Disease.

6. Orthopedic Conditions■ Osteoporosis

■ Smoking increases the chances of developing osteoporosis and of breaking bones. Smoking

decreases the amount of calcium absorbed from food.

7. Rheumatologic Conditions■ Rheumatoid arthritis.

8. Kidney Damage■ Smoking worsens kidney damage in people who have medical problems that affect the kidneys, such

as diabetes or high blood pressure.

9. Type 2 Diabetes ■ Persons who smoke are at least 50 percent more likely than nonsmokers to get Type 2 diabetes.■ Among people who have diabetes, those who smoke are more likely to develop diabetes-related kidney

damage, nerve damage, eye problems and heart disease.

10. Skin Conditions■ Contact allergies occur more often in persons who smoke than in those who do not.

11. Cataracts

12. Tooth and Gum Problems■ Smoking causes oral cancer.■ Smokers are more likely than non-smokers to lose their natural teeth, for their remaining teeth to be

decayed, and to have significant gum loss (periodontal disease).

Additional Hazards for Males■ Erectile dysfunction.

■ Men who smoke are about twice as likely as men who don’t smoke to suffer from erectile

dysfunction and impotence. ■ Fertility may be impaired in men who smoke.

Additional Hazards for Women■ Smoking is a risk for cancer of the cervix.■ Natural menopause occurs earlier.■ Smoking increases the risk of menstrual disorders.■ Fertility may be impaired in women who smoke.■ Smoking, and the use of oral contraceptives, greatly increases the risk of strokes, heart attacks and

other vascular complications.


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Health Risks of Second-hand SmokeExposure to second-hand smoke causes the following diseases and conditions:

In adults:■ Heart disease.■ Lung cancer.■ Nasal sinus cancer.

In children:■ Sudden Infant Death Syndrome.■ Fetal growth impairment including low birth-weight and measuring small for gestational age.■ Bronchitis, pneumonia and other lower respiratory tract infections.■ Asthma exacerbation.■ Middle ear disease.■ Respiratory symptoms.

Exposure to second-hand smoke has also been linked to other adverse health effects, although the

relationships may be causal. These include:

In adults:■ Stroke.■ Breast cancer.■ Cervical cancer.■ Miscarriages.

In children:■ Adverse impact on cognition and behaviour.■ Decreased lung function.■ Asthma induction.■ Exacerbation of cystic fibrosis.

Exposure to second-hand smoke causes between 1,100 and 7,800 deaths per year in Canada, at least

one-third of them in Ontario.

Second-hand smoke is more dangerous than directly inhaled smoke. It is harmful even when you cannot

see or smell it. Second-hand smoke releases the same chemicals as smoke that is directly inhaled, but in

even greater quantity.


References:1. Anda RF, Williamson D.F., Escobedo L.G., Remington .PL. (1990). Smoking and the risk of peptic ulcer disease among

women in the United States. Archives of Internal Medicine, 1990, 150, 1437-1441.

2. Ayanian J.Z., Cleary P.D. Perceived risks of heart disease and cancer among cigarette smokers. Journal of the AmericanMedical Association, 1999, 281, 1019-1021.

3. Barry J., Mead K., Nabel E.G., Rocco M.B., Campbell S., Fenton T., Mudge G.H. Jr. Effect of smoking on the activity ofischemic heart disease. Journal of the American Medical Association, 1989, 261, 398-402.

4. Brodish, P.H. (1998). The irreversible health effects of cigarette smoking. American Council on Science and Health [On-line].Available: http://www.acsh.org/publications/booklets/iesmoke.pdf*

5. Burke K.E. (1990). Facial wrinkles: Prevention and nonsurgical correction. Postgraduate Medicine, 88, 207-228.

6. Canadian Cancer Society. (2003). Canadian cancer statistics. Canadian Cancer Society [On-line]. Available: www.cancer.ca

7. Cole C.W., Hill G.B., Farzad E., Bouchard A., Moher D., Rody K., Shea B. (1993). Cigarette smoking and peripheral arterialocclusive disease. Surgery, 114, 753-757.

8. Health Canada. (2003). Facts about tobacco. Health Canada [On-line].Available: www.hc.-sc.ca/hecs-sesc/tobacco/facts/index.html*

9. Koh J.S., Kang H., Choi S.W., Kim H.O. (2002). Cigarette smoking associated with premature facial wrinkling: imageanalysis of facial skin replicas. International Journal of Dermatology, 41, 21-27.

10. McVary M.T., Carrier S., Wessels H.; Subcommittee on Smoking and Erectile Dysfunction Socioeconomic Committee, SexualMedicine Society of North America. (2001) Smoking and erectile dysfunction: evidence based analysis. Journal of Urology,166, 1624-1632.

11. Ontario Tobacco Research Unit – University of Toronto. (2001). Protection from second-hand tobacco smoke in Ontario – Areview of the evidence regarding best practices. National Clearinghouse on Tobacco and Health Programs [On-line].Available: http://www.ncth.ca*

12. Ontario Tobacco Research Unit. (1995). Facts on Tobacco: Prevention, protection and cessation. Toronto, Ontario: AddictionResearch Foundation of Ontario.

13. Salminen E., Pukkala E., Teppo L. (1994). Bladder cancer and the risk of smoking-related cancers during followup. Journalof Urology, 152, 1420-1423.

14. Saraiya M., Berg C.J., Kendrick J.S., Strauss L.T., Atrash H.K., Ahn Y.W. Cigarette smoking as a risk factor for ectopicpregnancy. American Journal of Obstetrics and Gynecology, 1998, 178, 493-498.

15. Schabas, R.E. (1996). Tobacco: Sounding the alarm: Report of the Chief Medical Officer of Health, Ottawa: Queen’s Printerof Ontario.

16. Schmitz M.A., Finnegan M., Natarajan R., Champine J. (1999) Effect of smoking on tibial shaft fracture healing. ClinicalOrthopedics, 365, 184-200.

17. World Health Organization. (1995). Tobacco costs more than you think. World no-tobacco day. World Health Organization.

* At the time of the original publication, these resources were retrieved at the web addresses above. These links mayno longer be active.


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Within 20 minutes of last cigarette:■ Blood pressure may drop to

normal level.■ Pulse rate drops to normal rate.■ Body temperature of hands, feet

increases to normal.

Within 8 Hours:■ Carbon monoxide level in blood drops.■ Oxygen level in blood increases.

Within 24 Hours:■ May reduce chance of heart attack.

Within 48 Hours:■ Nerve endings may regrow.■ Ability to smell and taste enhanced.

Within 72 Hours:■ Bronchial tubes relax; if undamaged,

will make breathing easier.■ Lung capacity increases.

2 Weeks to 3 Months:■ Circulation improves.■ Walking becomes easier.■ Lung function may increase

up to 20 percent.

1 Month to 9 Months:■ Coughing, sinus congestion, fatigue,

shortness of breath may decrease markedly

over a number of weeks.■ Potential for cilia to regrow in lungs,

increasing ability to handle mucous, clean

the lungs, and reduce infection.

1 Year:■ The risk of heart disease is reduced by half.

After 15 years, the risk is similar to that of

persons who have never smoked.

2 Years:■ Cervical cancer risk reduced compared to

continuing smokers.■ Bladder cancer risk halved compared to

continuing smokers.

5 Years:■ Lung cancer death rate for average smoker

(one pack a day) decreases from

137 per 100,000 to 72 per 100,000.■ 5 to 15 years after quitting, stroke risk is

reduced to that of someone who has

never smoked.

10 Years and Longer:■ Precancerous cells are replaced.■ Risk of other cancers – such as those

of the mouth, larynx, esophagus,

bladder, kidney and pancreas decrease.■ After long-term quitting the risk of death

from Chronic Obstructive Pulmonary

Disease is reduced compared to someone

who continues to smoke.

Appendix D: The Benefits of Quitting Smoking

Time periods mentioned are to be taken as a general measure only and will naturally vary from individual

to individual and are dependent upon length of habit and amount of cigarettes smoked.

Reprinted with permission. Public Health and Long-Term Care Branch – City of Ottawa (2006). Health Benefits of QuittingSmoking. Ottawa, Ontario: Public Health and Long-Term Care Branch – City of Ottawa.

Originally adapted from:

1. Summary of the Health Benefits of Smoking cessation: A report of the Surgeon General, (1990). CDC, U.S. PublicHealth Services.

2. American Cancer Society, New York Times.

3. Metropolitan Toronto Interagency Council on Smoking and Health.


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Appendix E: Stages of Change ModelPre-contemplation■ Unaware or unwilling to change.■ Not thinking of quitting in the next 6 months.

Goal:■ To help the client begin to think seriously about quitting .

What to do■ ASK regarding feelings about smoking.■ ASK about the pros and possible cons of smoking.■ ADVISE by offering quitting information and assistance at any time.

Contemplation■ Ambivalent, but thinking about quitting within 6 months.

Goal:■ To help smoker move towards a decision to stop smoking.■ To help the client feel more confident.

What to do■ ASK about the pros and cons of both continuing to smoke and quitting■ (decision balance).■ Acknowledge ambivalent feelings.■ ASSIST by reinforcing their reasons for change, and exploring new ones.■ Suggest they cut back or stop for a day.■ ASSIST by offering a future visit and information.

Preparation■ Getting ready to stop within the next 30 days.■ Have set stop smoking date.■ Have made a 24 hour quit attempt in the last 12 months.

Goal:■ To help smoker prepare for and anticipate positively a quit date.

What to do■ ASK about concerns, preparations and lessons learned from previous attempts.■ ADVISE by identifying barriers to stopping and elicit solutions.■ ASSIST by Booklet, Action Plan, Nicotine Replacement, Date for quitting (BAND).


Action■ Have quit smoking within past 6 months and are actively applying cessation skills.

Goal:■ To help client stay off tobacco products and recover from relapses.

What To Do■ ASK how the client is doing: relapses, temptations, successes, NRT use.■ ADVISE re: relapse prevention, weight gain, triggers.■ ASSIST by focusing on successes, encourage self rewards and increase support, elicit solutions for problems.

Maintenance■ Quit for more than 6 months.■ Integrating smoke-free living into their routine.

Goal:■ To help client remain smoke-free for a life time.

What To Do■ ASK how the client is doing: risk situations, relapses.■ ASSIST by offering suggestions for difficult times, support, encouragement.■ Congratulate!

The Cycle of Change■ Most smokers will cycle through the stages 3 to 4 times before quitting for life.■ Each attempt offers new opportunities to learn new skills and new techniques that will help them

in their next attempt.

Relapse: a normal event in the process of making behavioural change

Reference:Canadian Council on Smoking and Health. (2003). Guide your patients to a smoke-free future: A program of the CanadianCouncil on Smoking and Health. Ottawa, Ontario: Canadian Council on Smoking and Health.

Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self-change of smoking. Toward an integrative modelof change. Journal of Counselling and Clinical Psychology, 51(3), 390-395.

University of Toronto Department of Family & Community Medicine. (1998). Project CREATE: Smoking cessation module.(Vols. 3) Toronto, Ontario: Project CREATE.


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Appendix F: Identifying Your Client’sReadiness to Quit

Question: Have you quit smoking cigarettes? Check one:

Answer Stage❏ Yes, I have, for more than 6 months. ❏ Defines maintenance.

❏ Yes, I have, but for less than 6 months ❏ Defines action.

❏ No, but I intend to in the next 30 days ❏ Defines preparation.

and have tried for at least 24 hours in

the past year.

❏ No, but I intend to in the next 6 months ❏ Defines contemplation.

❏ No, and I do not intend to in the ❏ Defines pre-contemplation.

next 6 months.

Reprinted with permission. Program Training and Consultation Centre (1995). Info Pack: Understanding and using the stages ofchange. Ottawa, ON: Ontario Tobacco Strategy.


Appendix G: Motivational InterviewingAdapted from the Heart and Stroke Foundation of Ontario and RNAO’s Nursing Management of

Hypertension (2005) guideline.

Motivational Interviewing is a focused, goal directed client-centred counselling style for eliciting

behaviour change by helping clients explore and resolve ambivalence (Miller & Rollnick, 1991; Rollnick & Miller,

1995). To enhance motivation and change, motivational interviewing, through an assessment of the change

process, systematically directs the client toward motivation for change; offers advice and feedback where

appropriate, selectively uses empathic reflection to reinforce certain processes, and seeks to elicit and

amplify the client’s discrepancies about their unhealthy behaviour(s). Motivational interviewing is

facilitative rather than coercive and tentatively challenging rather than directly confrontational. The

strategies support the client through the change process by fostering self-reflection rather than arguments

between practitioner and client (Botelho & Skinner, 1995).

Searching for a method to facilitate behaviour change in clients with substance abuse, psychologists

William Miller and Stephen Rollnick developed motivational interviewing. Behaviour change should be

negotiated, not dictated. Healthcare practitioners do not motivate clients, but assess motivation and apply

the appropriate skills and strategies to address readiness to change. This point is critical. Clients vary in

their readiness to change a behaviour (e.g., take medications, make lifestyle changes) and must be assessed

to determine how prepared they are to do what is needed to integrate change into their lives. How

important do they think the changes are? Are they confident they can do so? Will they need help? Do they

understand the benefits? What barriers do they perceive? How will they reduce them? By assessing the

degree of readiness, nurses can choose specific communication skills and appropriate strategies to

facilitate change. This is the heart of motivational interviewing (Berger, 2004a,b). The role of the nurse is to

understand and accept, in a non-judgmental way, clients’ needs and concerns and not be coercive by

trying to talk them in or out of these behaviours. This will create a favourable and supportive climate for

change – problems are attacked, not people.

Motivational interviewing, designed to take 3-5 minutes per session, is a psychosocial or socio-behavioural

approach to client care that contrasts with the traditional biomedical approach. The psychosocial model is

client-centred and stresses that the client’s needs and concerns must be appropriately addressed;

otherwise, non-adherence may occur. Asking if there are questions or concerns the client may have about

the illness or treatments is a positive way of assessing this possibility. The psychosocial model also views

the encounter between client and healthcare provider as a meeting of experts. The nurse or other

healthcare providers may be an expert on disease management, but clients are experts on themselves and

how they will be affected by the proposed changes in their lives. It is the client’s decision (with input from

healthcare providers) to choose healthy or unhealthy behaviours. Clients manage their illness, not nurses.

However, nurses can create an environment through caring, sufficient information, and understanding to

improve the chance that the client will manage their illness effectively (Berger, 2004a,b).

Change and resistance are opposite sides of the same coin. Change often evokes resistance because change

inherently questions one’s motivation and ability to do what is needed. If the pros of the change outweigh the

cons, clients will make the change. Alternatively, ambivalence kills change. When people are ambivalent, they

do nothing. The pros and cons of the change seem the same. Some examples of ambiguity are: client doubts


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that the medication will actually work; they are unclear about what to do; or if they doubt they have the

necessary skills. Resistance is information and provides insight into what the person is thinking and feeling: “I

need to explore this and see if it works for me.” Exploring and understanding what has been said with the client,

not persuasion or criticism, are the keys to managing resistance. If nurses try to move people too quickly

toward a behaviour change, they will dig in and resist. An appropriate response to a client who indicates that

he/she does not want to take a medication would be: “What bothers you the most about taking this medicine?”

This way the client can explain their reasoning, and the nurse can specifically address his/her concern.

Motivational interviewing creates dissonance in a person. Dissonance, or an inconsistency between two

behaviours (attitudes, values, etc.), creates a discomfort that, in itself, can be motivating. For example, if a

person’s attitudes are inconsistent with their behaviours, dissonance occurs. Dissonance is uncomfortable

and the person may be motivated to explore ways to reduce this uncomfortable feeling. The spirit of

motivational interviewing is collaboration, evocation and autonomy. Healthcare professionals using this

approach desire a relationship with the client in which they can collaborate on mutually agreed upon goals.

Questions are asked to determine and understand the client’s resistance or ambivalence – the client knows

the answers, not the healthcare provider. Additionally, clients must make informed choices. It is not

enough to simply provide information. One needs to evaluate that the client has understood the

information, knows how to use it, and has a feeling of self-efficacy or confidence in their ability to do what

is needed. This includes assessing the client’s understanding of the illness and its treatment.

How does motivational interviewing work?Motivational interviewing uses the general process of elicit-provide-elicit. The nurse elicits information

from clients to better understand who they are and what they already know about the illness and its

management interventions. This is done to facilitate clients’ movement forward with the treatment plan.

Then, nurses elicit information again to check for concerns or questions resulting from the new information.

Motivational interviewing uses five principles or counselling techniques to assess and create motivation

within the client (Berger, 2004a,b; Miller & Rollnick, 1991; Smith, Heckemeyer, Kraft & Mason, 1997).

1. Express empathy – Empathy is defined as the “ability of the provider to accurately reflect what the

client is saying” (Moyers, 2000; p.155). Empathy is an objective identification with the affective state of

another (not his or her experience) – nurses identify with the client’s affect (emotions), not with the

experience. Empathetic responding, through active listening, helps identify and understand resistance and

reasons for unhealthy behaviours (or non-adherence). For example, your client smokes and you are

advising him to quit. You ask him what he likes about smoking, and he says it relaxes him. Instead of

creating defensiveness by asking, “Can’t you think of something else to relax you?” you state empathetically,

“It would be difficult to give up something that was relaxing.” As a result, the client sees you as an advocate,

and is in a better position to hear what you have to say.

2. Avoid arguments – By avoiding arguments, the client is more likely to see the healthcare provider

as being on his/her side. It is important to note that motivational interviewing is confrontational; however,

it should not be argumentative or judgmental. For example, “Mrs. Jones, I see that you have been getting

your medication refilled about every 40 days or so, but you receive only a 30-day supply. Can you tell me

what happened?” Also, it should be noted that feelings a client may express (e.g., fear or concern) are not

arguable but real for the client.


3. Develop discrepancy (dissonance) – Creating dissonance can be achieved in two major ways.

The goal is to elicit from the client those aspects of his or her life that are important but may be

compromised because of the behaviour. For example, the client may say that he or she enjoys going to the

bar and drinking with his or her friends for most of the weekend, and how he or she hates taking

medication especially those that do not make him or her feel well. In the next sentence, he or she may add

that since he or she was diagnosed as having high blood pressure, he or she is very worried about having a

stroke. The healthcare provider needs to understand what is important to the client in terms of short- and

long-term goals. Ask the client about the pros and cons of the changes that are needed and then listen

carefully for discrepancies that allow for the creation of dissonance. Remember, dissonance is motivating.

We develop discrepancies by repeating back the pros and cons as stated by the client. Then, ask the client

to discuss his or her goals relative to the treatment.

4. Roll with resistance – Ignore antagonistic elements in the client’s comments in order to focus on

the important underlying issues. For example, the client says, “Look, I haven’t had any real problems with

my smoking so far, so don’t worry about it.” Instead of rejecting this comment by saying, “If you continue

smoking, I can assure you that you will suffer some major consequences,” the healthcare provider can roll

with the expressed resistance by saying, “I hope your health continues to stay that way. I would like you to

consider getting your lungs checked because early stages of cancer and lung disease may not have

symptoms. That way, you can make a better decision about whether you want to keep smoking. I am

worried that your smoking is going to make your heart disease much worse in the future. However, the

decision to smoke or quit smoking is yours.” Do not meet resistance with confrontation but instead utilize

reflection to create dissonance. This allows the client to hear information without being chastised. In the

end, the decision belongs to the client.

5. Support self-efficacy – A person’s belief in the possibility of change (Bandura, 1977; 1982) is an

important motivator. Clients, based on their abilities and the resources and strengths they possess, need to

be encouraged by the healthcare provider. Questions such as: “What worked before?” or “What do you

think helped you to be successful last time?” provide valuable information about the client’s strengths.

Examine past successes (or failures) and offer genuine support for the successes. It is important to notice

not only actual changes in behaviour, but also contemplated changes, expressed in a positive manner. The

client must be able to imagine that success is a possibility before actually trying to change.

When using Motivational Interviewing,there are six general skills that should be utilized.

1. Asking open-ended questions: Asking questions in such a way that it is the client who is

encouraged to do most of the talking. Some examples: “What concerns you about your health?” or ”What

is it that you like about smoking” or “What reasons might you have for not quitting smoking?” or “Tell me

about the difficulties you encounter when trying to refill your prescriptions.” Miller and Rollnick (1991)

recommend not asking more than three questions in a row. Asking open-ended questions sets the stage for

reflective listening, affirmations and summation.

2. Reflective listening: As a foundational skill in motivational interviewing, reflective listening is

useful to address resistance. Reflections can be simple “you’re feeling sad” to more complex, “It sounds like

you are concerned what smoking all these years may have done to your overall health.” Reflective


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statements, whether simple, amplified or double sided, tells the client that you have heard what he or she

is saying and encourages them to explore their feelings. Simple reflection acknowledges the client’s

thoughts, feelings and positions in a neutral manner.

3. Affirmations: Support for what the client is saying should occur frequently throughout the

conversation. Praising or complimenting and exploring past successes help to build a therapeutic relationship.

4. Summarizing or reframing: Reframing pulls the information together so that the client can reflect upon

it. By reframing, you tell the client that you have been listening and are open to exploring the situation further.

The summary links together the main points of the interview, both past and present. The ambivalence is

clear and the reflection in the end encourages the client to address the ambivalence (whether to continue

to struggle to get her prescriptions filled or ask someone to help).

5. Self-motivational statements: Clients must be responsible for change and motivated to

acknowledge ambivalence when change is being considered and set the stage for dialogue to occur. The

client argues the pros and cons of changing the behavour and the healthcare provider gets insight into the

client’s feelings and values as he listens to the argument.

6. Personalized feedback: This can be done on a one-to-one basis or through the use of standardized

tools; for example, a chart showing the change of blood pressure toward the target levels as the client

adheres to the goals set at a previous visit. The feedback must not be confrontational to the client. Instead,

the data will do the confronting if the client has not been adherent.

References:Bandura, A. (1977). Social learning theory. New York: General Learning Press.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Berger, B.A. (2004a). Assessing and interviewing patients for meaningful behavior change. Part 1. The Case Manager, 15(5), 46-50.

Berger, B.A. (2004b). Assessing and interviewing patients for meaningful behavior change. Part 2. The Case Manager, 15(5), 58-62.

Botelho, R.J. & Skinner, H. (1995). Motivating change in health behavior. Implications for health promotion and dieseaseprevention. Primary Care, 22(4), 565-589.

Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario. (2005). Nursing Management ofHypertension. Toronto, Canada: Heart and Stroke Foundation and Registered Nurses’ Association of Ontario.

Miller, W. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York:The Guilford Press.

Rollnick, S. & Miller, W. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334.

Smith, D., Heckemeyer, C., Kratt, P., & Mason, D. (1997). Motivational interviewing to improve adherence to a behaviouralweight control program for older obese women with NIDDM: A pilot study. Diabetes Care, 20, 52-54.


ARRANGEFollow-up

or refer client to smoking cessation program.

Support use of telephone counselling or community/public health programs.


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Minimal Intervention 1 – 3 minutes

Provide basic information about smoking

and successful stopping■ Referral to community resource.■ Pharmacotherapy, i.e. NRT

(for hospitalized patients this should

be a standard of care)■ Self-help material.■ Referral to other healthcare provider.■ Smokers’ Helpline (1-877-513-5333).

Intensive InterventionPersonalize tobacco use to current health OR illness,

readiness to stop and the impact of tobacco use on

others in the household (social and economic costs).

Discuss strategies to quit and treatment options –

check client preferences■ Determine & discuss the stage of change.■ Reasons for smoking (WHY Test).■ Nicotine Dependence (Fagerstrom Test).■ Offer information re:

pharmacotherapy options.■ Set a quit date.■ Review quitting history.■ Review potential challenges and triggers.■ Encourage support of family and friends

Appendix H:Ask, Advise, Assist, Arrange Protocol

ASK“Have you used any form of tobacco in the past 6 months?”

Do you smoke (even a puff now and again) or use tobacco products of any kind?

(cigarettes, pipe, cigars, chew, spit, bidis)

Yes ❏ No ❏

Non-Smoker ❏ Smoker ❏ Ex-Smoker (greater than 6 months) ❏ Quit Date ___________

Have you ever considered stopping?

ADVISE“As your nurse, the most important advice I can give you is to quit smoking.”

ASSISTOffer help for a stop smoking attempt

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References:Fiore, M. C. (1997). AHCPR smoking cessation guideline: A fundamental review. Tobacco Control, 6 (Suppl. 1), S4-S8.

National Health Committee. (1999a). Guidelines for smoking cessation: Literature review and background information. NewZealand Guidelines Group [On-line]. Available: http://www.nzgg.org.nz/library.cfm*

National Health Committee. (1999b). Guidelines for smoking cessation: Quit Now. New Zealand Guidelines Group [On-line].Available: http://www.nzgg.org.nz/library.cfm*

U.S. Department of Health and Human Services, Public Health Service. (2000). Clinical practice guideline: Treating tobacco useand dependence. Office of the Surgeon General [On-line].Available: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf*

* At the time of the original publication, these resources were retrieved at the web addresses above. These links may nolonger be active.


Appendix I: The WHY TestNext to the following statements, mark the number that best describes your own experience.

1 = Never 2 = Rarely 3 = Once in a while 4 = Most of the time 5 = Always

❏ A. I smoke to keep myself from slowing down.

❏ B. Handling a cigarette is part of the enjoyment of smoking it.

❏ C. Smoking is pleasant and relaxing.

❏ D. I light up a cigarette when I feel angry about something.

❏ E. When I’m out of cigarettes, it’s near-torture until I can get them.

❏ F. I smoke automatically, without even being aware of it.

❏ G. I smoke when other people around me are smoking.

❏ H. I smoke to perk myself up.

❏ I. Part of enjoying smoking is preparing to light up.

❏ J. I get pleasure from smoking.

❏ K. When I feel uncomfortable or upset, I light up a cigarette.

❏ L. I’m very much aware of it when I‘m not smoking a cigarette.

❏ M. I often light up a cigarette while one is still burning in the ashtray.

❏ N. I smoke cigarettes with friends when I’m having a good time.

❏ O. When I smoke, part of my enjoyment is watching the smoke as I exhale it.

❏ P. I want a cigarette most often when I am comfortable and relaxed.

❏ Q. I smoke when I’m “blue” and want to take my mind off what’s bothering me.

❏ R. I get a real craving for a cigarette when I haven’t had one in a while.

❏ S. I’ve found a cigarette in my mouth and haven’t remembered that it was there.

❏ T. I always smoke when I’m out with friends at a party, bar, etc.

❏ U. I smoke cigarettes to get a lift.


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SCORECARDWrite the number you put beside each letter in The WHY Test beside the same letter on the scorecard. For

example, if you marked a “3” beside question “C” on the test, put a “3” beside the letter “C” on the

scorecard. Then, add up the numbers to get the totals for each category.

A ___ H ___ U ___ “IT STIMULATES ME”

With a high score here, you feel that smoking gives you energy, keeps you

Stimulation Total ___ going. So, think about alternatives that give you energy, such as washing

your face, brisk walking and jogging.

B ___ I ___ O ___ “I WANT SOMETHING IN MY HAND”

There are a lot of things you can do with your hands without lighting up.

Handling Total ___ Try doodling with a pencil, knitting or get a “dummy” cigarette you can

play with.

C ___ J ___ P ___ “IT FEELS GOOD”

A high score means that you get a lot of physical pleasure out of smoking.

Pleasure/Relaxation Total ___ Various forms of exercise can be effective alternatives. People in this

category may be helped by the use of nicotine chewing pieces or a

nicotine transdermal patch if medically indicated.

D ___ K ___ Q ___ “IT’S A CRUTCH”

Finding cigarettes to be comforting in moments of stress can make

Crutch/Tension Total ___ stopping tough, but there are many better ways to deal with stress. Learn

to use relaxation breathing or another technique for deep relaxation

instead. People in this category may be helped by the use of nicotine

chewing pieces or a nicotine transdermal patch if medically indicated.

E ___ L ___ R ___ “I’M HOOKED”

In addition to having a psychological dependency to smoking, you may

Craving Addiction Total ___ also be physically addicted to nicotine. It’s a hard addiction to break, but it

can be done. People in this category are the ones most likely to benefit

from the use of nicotine chewing pieces or a nicotine transdermal patch if

medically indicated.

F ___ M ___ S ___ “IT’S PART OF MY ROUTINE”

If cigarettes are merely part of your routine, one key to success is being

Habit Total ___ aware of every cigarette you smoke. Keeping a diary or writing down

every cigarette on the inside of your cigarette pack is a good way to do it.

G ___ N ___ T ___ “I’M A SOCIAL SMOKER”

You smoke in social situations, when people around you are smoking and

Social Smoker Total ___ when you are offered cigarettes. It is important for you to remind others

that you are a non-smoker. You may want to change your social habits to

avoid the “triggers” which may lead to smoking again.

Source: Health Canada. (1997). Helping pregnant and postpartum women and their families to quit or reduce

smoking. Reproduced with permission of the Ministry of Public Works and Government Services Canada.


Appendix J: Fagerstrom Test for NicotineDependence (Revised Version)

The following test is designed to help you determine the strength of your nicotine addiction. Circle the appropriate

score for each question. Total the number of points to arrive at your score. The highest possible score is 10.

How soon after you wake up Within 5 min............................3 points

do you smoke your first cigarette? 5-30 min..................................2 points

31-60 min................................1 point

after 60 min.............................0 points

Do you find it hard not to smoke in places that Yes...........................................1 point

you shouldn’t smoke such as in church, in school, No ...........................................0 points

in a movie, on the bus, in court or in a hospital?

Which cigarette would you hate The first one in the morning ....1 point

most to have to give up? Any other one..........................0 points

How many cigarettes do you smoke each day? 10-fewer..................................0 points

11-20.......................................1 point

21-30.......................................2 points

31 or more...............................3 points

Do you smoke more in the first few hours after waking Yes...........................................1 point

than you do during the rest of the day? No ...........................................0 points

Do you still smoke, even if you are so sick that you are in Yes...........................................1 point

bed most of the day, or if you have the flu or a severe cough? No ...........................................0 points

Total ........................................................................................................................................___points

Interpretation of Scoring

7 to 10: You are highly dependent on nicotine and may benefit from a smoking cessation

program based on treatment for nicotine addiction. Start with 21 mg patch or 4 mg gum.

4 to 6: You have a low to moderate dependence on nicotine, however this does not rule out a smoking

cessation program based on treatment for nicotine addiction. Start with 14 mg patch or 2 mg gum.

< 4: You have a low to moderate addiction, but are not likely to need Nicotine Replacement Therapy.

Reprinted with permission of Dr. Karl Fagerstrom.

BPG Head to come

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Appendix K: Intensive Nursing InterventionTips for the Client■ Make a plan ahead of time for coping with stressful situations.■ Pick a day for stopping that will be relatively stress-free and stick to this date.■ Think positively – you can do it – and concentrate on the benefits of not smoking.■ Take it one day at a time.■ Congratulate yourself frequently.■ Ask a friend to stop with you and support each other.■ Remember that using NRT doubles the chances of quitting and lessens withdrawal symptoms.■ Avoid visiting places where you usually smoke (when you first stop smoking).■ Keep yourself busy and try to increase your level of physical activity.■ Count or save the money you would have spent on cigarettes and treat yourself to something special.■ Don’t try “just one” cigarette – it will take you back to the beginning.

Reprinted with permission.



Appendix L: Quit SmokingFirst-Line Medications Compared

Quit Smoking Aid How to use How long to take it Possible side effects


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-Nicotine gum(Nicorette®)

Available over thecounter

• “bite & park” gum

• 1 piece of gum every1-2 hours

• 2 mg if you’re alight smoker(20 cigarettes per day)

• 4 mg if you’re aheavy smoker(> 20 cigarettes per day)

• stop smoking beforestarting

• several weeks to severalmonths or longer ifnecessary

• burning in throat

• hiccups if chewedtoo quickly

• dental problems

Nicotine patch(Habitrol®, Nicoderm®)

Available over thecounter

• if you’re a light smoker(>20 cigarettes per day),start 14 or 7 mg

• if you’re a heavysmoker (> 20 cigarettesper day) start 21 mg for4-8 weeks. Discusstapering to lower doseswith your doctor.

• 8-12 weeks or longer ifnecessary

• local skin reaction

• disturbed sleep,nightmares

Nicotine Inhaler Consists of amouthpiece anda cartridge containingnicotine. Inhaledinto the mouth andheld so nicotine isabsorbed into buccalmucosa. Mostusers require 2-10 puffsper craving.

6-12 cartridges a day forapproximately 3 months isrecommended by themanufacturer, althoughmany may needsignificantly less.

• burning throat, cough,sneezing and hiccups.

Bupropion(Zyban®)

Available only byprescription

• 150 mg once a day (inthe morning) for 3days, then twice a day(morning and evening,with at least 8 hoursbetween doses)

• start 7-14 days beforequit date

• 7-12 weeks or longer ifnecessary

• dry mouth

• insomnia

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Cautions When not to take it Advantages• pregnant and

breastfeeding*• check with doctor if pregnant and

breastfeeding* or if have had unstablemedical conditions (e.g., unstable heartcondition in the past 2 weeks)

• you can control when to take nicotine andhow much

• satisfies oral cravings

• delays weight gain while you use it

• pregnant andbreastfeeding*

• check with doctor if pregnant andbreastfeeding* or if have had unstablemedical conditions (e.g., unstable heartcondition in the past 2 weeks)

• you need only apply it once a day

• can control your craving for 24 hours

• delays weight gain while you use it

• remove patch at night if sleep disturbances occur

Avoid acidic drinkslike coffee, soda popor juices for 15minutes before andafter using the inhalerbecause the nicotinewill be absorbedin the stomachinstead of the mouthand throat

Satisfies need for hand-to-mouth action,addressing the behavioural dependency ofsmoking, as well as the physical.

If you:• drink > 4 drinks

containing alcohola day

• take St. John’s wort

• take drugs thatreduce seizurethreshold

• are pregnant and/orbreastfeeding*

If you:• are pregnant or breastfeeding*

• have a seizure disorder

• have an eating disorder

• take monoamine oxidase inhibitors

• inexpensive

• improves depression

• minimal weight gain while you use it


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Nicorette® (nicotine polacrilex); registered trademark of Aventis Pharma Inc. Habitrol® (nicotine): registered trademark of Novartis Consumer Health Canada Inc.Nicoderm® (nicotine): registered trademark of Aventis Pharma Inc. Zyban® (bupropion HCL): registered trademark of Glaxo Wellcome Inc.

*Many doctors believe that using nicotine gum or the patch is better than smoking during pregnancy because, bystopping smoking, you are not inhaling thousands of toxic chemicals from cigarette smoke. However, there is notenough evidence to show that using nicotine gum or the patch is safer than smoking during pregnancy.

If you are pregnant or breastfeeding, always check with your doctor before using nicotine gum or the patch.

NB: Additional products may be available

Reprinted with permission:University of Toronto Department of Family & Community Medicine. (2000). Smoking cessation guidelines: How to treatyour patient’s tobacco addiction. Toronto, Ontario: Pegasus Healthcare International.

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Appendix M: Strategies to Avoid Relapse■ Encourage client to identify tempting situations and develop a specific plan to handle them (e.g., write

down three strategies and carry this list at all times).■ Reframe a lapse (slip) as a learning opportunity, not a failure.■ Recommend that the client:

■ learn stress management and relaxation techniques;■ learn to balance lifestyle so that pressures and triggers are not overwhelming.

Common Factors Associated with Relapse:■ Alcohol use■ Negative mood or depression■ Negative self-talk■ Other smokers in household■ Prolonged withdrawal symptoms■ Exposure to high-risk situations, such as social situations, arguments, and other sources of stress■ Dietary restriction■ Lack of cessation support■ Problems with pharmacotherapy, such as under-dosing, side effects, compliance or premature

discontinuation■ Recreational drug abuse

Reprinted with permission:

University of Toronto Department of Family & Community Medicine. (2000). Smoking cessation guidelines: How to treat yourpatient’s tobacco addiction. Toronto, Ontario: Pegasus Healthcare International.


Appendix N: List of Resources Available forSmoking Cessation


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■ Canadian Cancer SocietyNational Office, Suite 200

10 Alcorn Avenue

Toronto, Ontario M4V 3B1

www.cancer.ca

E-mail: [email protected]

Toll Free: 1-888-939-3333

Offers booklets and self-help resources for

smokers, such as “For Smokers who want to

Quit”, and “For Smokers who don’t want to

Quit”, available in English, French and Chinese.

Ontario Smoker’s Helpline:

1-877-513-5333 www.smokershelpline.ca

Offers a free self-help smoking cessation

program called One Step at a Time.

■ Canadian Council of TobaccoControl (CCTC)170 Laurier Avenue West, Suite 100

Ottawa, Ontario K1P 5V5

Tel: 613-567-3050

www.cctc.ca


This is a national, non-profit organization

specializing in tobacco and health issues.

■ Canadian Health Network (CHN)www.canadian-health-network.ca

CHN is a national, non-profit, bilingual

web-based health information service,

sponsored by Health Canada.

■ Centre for Addiction andMental Health33 Russell Street

Toronto, Ontario M5S 2S1

416-535-8501 ext 1600

Operates a Smoking Cessation Clinic and

has launched a workshop, TEACH The Training

Enhancement in Applied Cessation Counselling

and Health for health practitioners

■ TEACH(Training Enhancement in AppliedCessation Counselling and Health)33 Russell Street, Room 1081

Toronto, Ontario M5S 2S1

Tel: 416-535-8501 ext.1600

Fax: 416-260-418


www.teachproject.ca

Trains practitioners in tobacco cessation

interventions.

■ Health CanadaTobacco Control Programme P.L. 3507C

Ottawa, Ontario K1A 0K9

Tel: 1-866-318-1116

(Monday-Friday, 8 a.m. to 4 p.m. ET;

voice-mail available at all other times)

Fax: 613-954-2284

www.gosmokefree.ca


This website contains a variety of new tools to

help Canadians quit smoking. Persons who

smoke can sign up with the e-Quit program for

a 30-day series of free e-mail messages to help

them through the cessation process.

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■ Heart & Stroke Foundation of Canada222 Queen Street, Suite 1402

Ottawa, Ontario K1P 5V9

Tel: 613-569-4361

www.heartandstroke.ca


■ Leave the Pack BehindBrock University

500 Glenridge Avenue,


Tel: 905-688-5550 ext. 4992

www.LeaveThePackBehind.org

■ Physicians for aSmoke-free Canada (PSC)1226 A Wellington Street

Ottawa, Ontario K1Y 3A1

Tel: 613-233-4878

Fax: 613-233-7797

www.smoke-free.ca

PSC is a national health organization, founded

in 1985 as a registered charity. It is a unique

organization of Canadian physicians who

share one goal: the reduction of tobacco-caused

illness through reduced smoking and reduced

exposure to second-hand smoke. It also provides

information on a variety of tobacco issues.

■ Pregnetswww.pregnets.org

Up-to-date information on smoking cessation

practices for pregnant and postpartum women

can be found here.


■ Program Trainingand Consultation CentreToll free: 1-800-363-7822

www.ptcc-cfc.on.ca

Provides training and consultation services

in Ontario to implement effective community-

based tobacco use reduction strategies.

■ The Lung Association National Office1900 City Park Drive, Suite 508

Blair Business Park

Gloucester, Ontario K1J 1A3

Tel: 613-747-6776

www.lung.ca


■ Ontario Lung AssociationTel: (416)-864-9911

Toll Free: 1-800-972-2636

www.on.lung.ca

Nurses Quit Net available on-line for nurses

and nursing students who want to quit

smoking; www.tobaccofreenurses.org

■ Registered Nurses Association ofOntario (RNAO)www.rnao.org/smokingcessation

RNAO offers an e-learning course to help

educate health professionals on smoking

cessation interventions.

Additional Online Support Help to Quit Smoking

■ American Cancer SocietyGreat American Smoke Out

www.cancer.org/docroot/PED/ped_10_4.asp?sitearea=PED

■ Centers for Disease Control and Prevention (CDC)Quit Tips: Don’t let another year go up in smoke

http://www.cdc.gov/tobacco/quit/quittip.htm

■ Nicotine Anonymoushttp://www.nicotine-anonymous.org

Nicotine Anonymous is a non-profit 12 Step help program for those who would like to cease using

tobacco and nicotine products. Group support and recovery using the 12 Steps, as adapted from

Alcoholics Anonymous, help to achieve abstinence from nicotine.

■ Smokefree.govwww.smokefree.gov

■ The Foundation for a Smoke Free Americawww.tobaccofree.org


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Appendix O: Description of the ToolkitThe Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating,

and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in

implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline

2. Identification, assessment and engagement of stakeholders

3. Assessment of environmental readiness for guideline implementation

4. Identifying and planning evidence-based implementation strategies

5. Planning and implementing evaluation

6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact

is a complex undertaking. The Toolkit is one key resource for managing this process.

The Toolkit is available through the Registered Nurses’ Association of Ontario.

The document is available in a bound format for a nominal fee, and is also

available free of charge from the RNAO website. For more information, an

order form or to download the Toolkit, please visit the RNAO website at

www.rnao.org/bestpractices.


Integrating Smoking Cessationinto Daily Nursing Practice

This program is funded by the Government of Ontario

Revised March 2007

0-920166-83-0

Integrating Smoking Cessation into Daily Nursing Practice Guidelines... · Integrating Smoking Cessation into Daily Nursing Practice ... Project Team: Tazim Virani, RN ... Integrating

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