CPD
CONTINUING PROFESSIONAL DEVELOPMENT
Chronic obstructive pulmonary disease part 1: smoking cessation NS789 Jones D (2015) Chronic obstructive pulmonary disease part 1: smoking cessation. Nursing Standard. 29, 33, 52-57. Date of submission: October 11 2014; date of acceptance: January 23 2015.
Aims and intended learning outcomes
Abstract Chronic obstructive pulmonary disease (COPD) is common in the UK and causes a significant burden to patients and the NHS. Healthcare provision for COPD is largely focused on biomedical treatment, yet research suggests the complexity of factors contributing to this disease requires a deeper understanding of the patient experience and a more holistic approach to the provision of care. Smoking cessation is the single most cost-effective and significant way to slow the disease progress and improve outcomes for patients. However, barriers to smoking cessation are higher in patients with COPD than in other groups, requiring different approaches. This is part one of a two-part article, which focuses on patients with COPD caused by smoking. The second part will focus on non-pharmacological therapy.
Author Donna Jones District nurse sister, Shropshire Community Health NHS Trust, Shrewsbury, England. Correspondence to: [email protected]
Keywords Behaviour change, chronic obstructive pulmonary disease, COPD, health promotion, lung disease, smoking, smoking cessation
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
The aim of this article is to increase knowledge and encourage critical thinking and reflection when managing the treatment of patients with chronic obstructive pulmonary disease (COPD). This first article refers in particular to tackling the barriers to smoking cessation. After reading this article and completing the time out activities, you should be able to: Explain and provide insights into the importance of effective health promotion and symptom management, within socioeconomic influences, for high quality care and efficient use of resources. Develop a holistic approach to care for patients with COPD with extensive and complex health problems, social circumstances, attitudes and preferences. Analyse the barriers and challenges of smoking cessation for patients with COPD and how these may be addressed to influence health behaviour positively. Understand the physical and psychological consequences of breathlessness and its effects on quality of life and the NHS.
Background COPD is common in the UK, with an estimated three million people living with the disease (Healthcare Commission 2006, National Institute for Health and Care Excellence (NICE) 2010). It is the fifth highest cause of death in the UK, causing around 25,000 deaths each year (Department of Health (DH) 2011), and the incidence of deaths is increasing (NICE 2010). COPD is characterised by lung airflow obstruction with the presence of breathlessness or cough (NICE 2010). Airflow obstruction occurs as a result of chronic inflammation and damage to the airway and parenchyma, most often caused by tobacco smoke. COPD is an irreversible,
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progressive disease resulting in subsequent disability, impaired quality of life (NICE 2010) and ultimately death (DH 2011). COPD costs the NHS more than £800 million each year and represents one of the most frequent causes of emergency hospital admission (DH 2010a). The DH strategy for COPD services highlights the potential for community care to engage with patients with COPD, promote health (DH 2010b) and address the cost of avoidable COPD-related hospital admissions as outlined in the document Delivering Care Closer to Home: Meeting the Challenge (DH 2008). In relation to COPD, it is suggested that healthcare providers often focus on biomedical treatment of the disease (Arnold et al 2005, Bausewein et al 2007). The King’s Fund, however, reviewed research investigating the effectiveness of interventions for reducing avoidable hospital admissions of patients with COPD and found that the complexity of patients’ chronic health problems, home situation, attitudes and preferences rendered a single model of care insufficient (Purdy 2010). To improve service quality and economic accountability, the evidence base for COPD should incorporate both quantitative and qualitative evidence that captures biological, psychological and social influences on health. A deeper understanding of the attitudes, values and beliefs of patients with COPD is also required (Green and Tones 2010, Kumar 2011). Complete time out activity 1
Smoking and COPD: extent of the problem Although not all patients with COPD smoke or have a history of smoking, smoking cessation has been identified as the single most cost-effective and significant way to slow the disease progress (Hersh et al 2004, Willemse et al 2004) and improve outcomes for patients in all stages of COPD (Coakley and Ruston 2001). Barnett (2008) suggests that exacerbations can be reduced by smoking cessation. However, nicotine is highly addictive and people with COPD have been shown to be heavier smokers and more addicted to nicotine than those without COPD (Shahab 2006). Approximately 19.5% of the UK population smokes, but 53.3% of older people in poor health are smokers (Office for National Statistics 2012). Smoking cessation rates are
lower in people with COPD than without (Schiller and Ni 2006, Lundh et al 2012). However, 78% of smokers with COPD had made at least one attempt to quit over their lifetime and 79% had reduced the number of cigarettes smoked (Schofield et al 2007). Schofield et al (2007) suggest that this indicates a major desire to quit. COPD and smoking rates are much higher in deprived socioeconomic groups (Acheson 1998). The predictive factors associated with unsuccessful smoking cessation attempts are poverty and feelings of hopelessness (Schiller and Ni 2006), which suggests that these patients require more help to stop smoking (Wagena et al 2004, Lundh et al 2012). Complete time out activity 2
Patients’ perceptions of smoking cessation Hilbernick et al (2006) suggest that most smokers understand the harmfulness of smoking. However, one study of 22 participants with COPD found that only one participant made reference to the benefits of smoking cessation (Schofield et al 2007). Other participants remarked that smoking improved their breathing and was helpful when they were upset because it reduced anxiety. Further, smoking cessation appeared ‘pointless’ for these participants because damage to their bodies had already been done. Despite this, most participants wanted to quit, and Hilbernick et al (2006) estimated that 50% of smokers with COPD are amenable to smoking cessation support. Wilson et al (2011) suggest that people with COPD are ambivalent about the advantages and disadvantages of smoking cessation. Becker’s (1974) health belief model requires an individual to identify first that they are susceptible to harm, with subsequent behaviour change depending on how the individual weighs up the benefits and costs. Since smokers with COPD appear to place little emphasis on the benefits of smoking cessation, behaviour change is unlikely, particularly when cigarettes are perceived to provide comfort. The focus of smoking cessation with patients with COPD should therefore emphasise the benefits of reduced exacerbations and improved lung function, rather than the harms of smoking. Complete time out activity 3
1 Reflect on any encounter you have had with a patient with COPD. What was the focus of the encounter? Did you explore the attitudes, values, beliefs and preferences of the patient? What areas might you improve on? 2 Return to the patient with COPD you identified in time out activity 1. What socioeconomic factors influenced the patient? Discuss with your colleagues how any socioeconomic deficits may be addressed. 3 Review the following websites to determine how you might improve smoking cessation advice: tinyurl.com/ q8vvcph, http://smoke free.gov. Make a list of your three most favoured strategies.
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CPD respiratory disease Changing health behaviour
4 Return to your patient with COPD (time out activities 1 and 2). Research the transtheoretical model of change, and identify what stage the patient is in, or was in according to this model and how this might be addressed.
Smoking can provide structure, routine and company throughout the day (Wilson et al 2011). People with COPD may experience greater levels of psychological distress and low self-esteem (Nicolson and Anderson 2003). During smoking cessation, times of grief are often the trigger for relapse (Schofield et al 2007). The self-inflicted nature of COPD may cause embarrassment and shame for individuals continuing to smoke and they may adapt their behaviour to avoid confrontation and upsetting their family. This can create a cycle of guilt, low self-esteem and low self-worth that compounds the inability to achieve smoking cessation (Wilson et al 2011). Lundh et al (2012) suggest that this can have either a positive or negative effect. In other words, pressure to stop smoking can result in either smoking cessation (or continuation of attempts to stop), or loss of motivation and hope of quitting. Lundh et al (2012) discuss the transtheoretical model of change and its stages: Pre-contemplation – the individual may not be aware of any issues with their health behaviour and does not intend to make changes in the foreseeable future. Contemplation – the individual starts to realise that their behaviour is an issue and assesses the benefits of and barriers to behaviour change. Preparation – there is intention to change the behaviour in the immediate future and the individual prepares for this. Action – the individual makes specific modifications and changes to their health behaviour. Maintenance – the individual works to prevent relapse and the new health behaviour is sustained. Since the role of the community practitioner involves assisting the individual through the pre-contemplation and contemplation stages, motivational interviewing can be used to help patients who are not ready to change behaviour and to identify reasons for behaviour change. This is especially important when the rationale for smoking cessation requires an emphasis on improved lung function rather than on prevention of ill health. Complete time out activity 4
Impact of the family
Luker et al (2007) suggest that being married or single has a positive effect on smoking cessation in men, compared with men who are
divorced or separated. Further, men whose spouse did not smoke were more likely to quit than those with a spouse who smoked. Those who were successful in quitting reported that their close family was the most important factor in quitting. Women, however, often cited pressures at home and family members who smoked as reasons for not succeeding in their smoking cessation efforts. These findings may reflect limited self-efficacy and external locus of control (where the individual believes the factors influencing their behaviour are uncontrollable) and highlight the need for empowerment techniques and support. Health practitioners should consider the effect of the patient’s family and encourage inclusion of any close family members in the smoking cessation intervention (Luker et al 2007, Schofield et al 2007). This would also promote ethical practice in which the health needs of family members are included (NMC 2015).
Raising self-efficacy
Counselling and learning coping mechanisms such as stress management, relaxation and exercise can raise self-efficacy (Petty 2000, Schofield et al 2007). These empowerment techniques aim to increase people’s control over their lives, raise self-esteem and change their ‘social reality’ to achieve the skills and confidence necessary to stop smoking (Naidoo and Wills 2009). However, Sarafino (2002) argues that empowering older people may be particularly difficult as a result of their socialisation at a time when attitudes were more paternalistic than today. Loft et al (2003) suggest that the ways older people are regarded also create a barrier for empowerment, because issues associated with old age, such as living alone, deteriorating health and lower income, make them vulnerable and create an assumption that they are less able to care for themselves.
Impact of health professionals
Each smoker, regardless of their age, should be offered smoking cessation advice and support at every clinical opportunity (NICE 2010, 2013). However, evidence suggests that health professionals are less likely to engage in smoking cessation advice with older people as they consider success less likely (Maguire et al 2000). Schiller and Ni (2006) found that 22.9% of respondents had not received smoking cessation advice from a health professional in the previous year.
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Rice et al’s (2013) systematic review of 35 trials, published between 1987 and 2012 with a total of more than 17,000 participants, revealed that smoking cessation interventions by nurses increase the likelihood of quitting. A high-intensity smoking cessation intervention produced a quit rate of 172 per 1,000, compared with a rate in the control group of 137 per 1,000. A low-intensity smoking cessation intervention produced a quit rate of 64 per 1,000, compared with 51 per 1,000 in the control group. These interventions produced a combined quit rate of 144 per 1,000 for a smoking cessation intervention as opposed to a rate of 115 per 1,000 in the control group. Schorr et al (2008) found tailored smoking cessation interventions to be more effective than standardised interventions. Stead et al’s (2013) literature review of advice interventions on smoking cessation revealed that even brief advice can raise smoking cessation rates by 1-3%. Schofield et al (2007) reported that smoking cessation attempts are inspired by external sources rather than by increasing disease severity. Participants in another study spoke about previous failed attempts to quit with regret (Wilson et al 2011). However, Petty (2000) acknowledged that smokers may relapse six or seven times before abstinence from smoking is achieved. Therefore, previous quit attempts should be reframed as positive in order to motivate the patient for a further attempt (Wilson et al 2011). Assessment, advice and support for smoking cessation in patients with COPD may be time consuming; however, the potential patient benefits are well documented. Community practitioners already support, monitor and treat patients with COPD at home, and this presents an efficient opportunity to explore smoking cessation with patients to maximise health outcomes (NICE 2013). It has been suggested that the cost benefits of investing time in effective smoking cessation interventions are favourable, compared with simply treating smoking-related diseases (Parrott et al 1998). Complete time out activity 5
Assisting with health behaviour change An initial interview may assess patients for baseline health beliefs, attitudes, values, knowledge, skills, health status, functional ability, confidence and self-efficacy (Corcoran 2013). The health professional may use motivational interviewing as a brief intervention, where the patient’s motivational readiness for
behaviour change is identified as deficient; this is well supported in behaviour change management (Miller and Rollnick 1991, National Institute on Drug Abuse 1999) and has been successfully applied to smoking cessation (Taylor et al 1996, Wakefield et al 2004). Interviewing enhances the patient’s internal motivation to increase the success of the change and involves the regular assessment of motivation, assisting the health professional to tailor the approach, duration and resources used with and for the patient. Motivational interviewing can be used with the stages of the transtheoretical model of change, where the goal is to encourage the patient to move through the stages of change rather than to cease smoking. Therefore motivation to change is determined by the patient, rather than externally imposed by the health professional, and the patient has the responsibility of resolving their ambivalence (Lai et al 2010). Motivational interviewing is based on four guiding principles (Miller and Rollnick 2002): Expressing empathy. Developing discrepancy. Rolling with resistance. Supporting self-efficacy. The health professional-patient relationship is regarded as one of collaboration and partnership, rather than one of expert and recipient. A patient’s resistance and denial are viewed as reactions to the behaviour of the health professional rather than an expression of their personality, and should be addressed through a change of strategy; this can reframe the patient’s thinking and encourage examination of different perspectives. The health professional should be non-judgemental, and adopt a sensitive and empathetic approach to understanding the patient’s experience. Suggesting externally derived methods or techniques is ineffective; instead, the nurse should be led by the patient’s own means of change. Patients should be encouraged to perceive the difference between their present behaviour and the desired change in lifestyle, as this increases their motivation to change when they realise that their current behaviour will not achieve a future goal. Self-efficacy should be supported and hope fostered through the celebration of previous efforts. A patient’s motivation may be assessed using a motivation or readiness ruler (Figure 1) (Centre for Evidence-Based Practice 2011). Motivation rulers are popular in clinical practice (Kahler et al 2009), are quick to use and can rapidly assess three dimensions of motivation:
5 With your patient and with COPD in mind, formulate a plan for providing effective advice on smoking cessation support. Write down the key steps in your plan.
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CPD respiratory disease FIGURE 1 Example of a motivation or ‘readiness’ ruler Not ready
0
1
Unsure
2
3
4
importance, readiness and confidence. Subsequent interviews and motivation ruler assessments can assist with evaluating the effect of motivational interviewing on the patient’s cognitive processes as well as on smoking cessation outcomes in terms of physical health and ability (Corcoran 2013).
Conclusion 6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 61.
COPD is a major health burden to both the NHS and the individual, causing poor quality of life. Although smoking cessation slows the disease progression (Hersh et al 2004, Willemse et al 2004) and improves patient outcomes (Coakley and Ruston 2001), many people with COPD are unsuccessful at quitting
5
Ready
6
7
8
9
10
and require more help (Lundh et al 2012). Smoking cessation is identified as an important health promotion intervention because of its beneficial impact on physical health, functional ability and mental health (Coakley and Ruston 2001, DH 2010b). However, the issues affecting the ability of the individual to give up are complex and require a sensitive and empathetic approach. Motivational interviewing and assessment using a motivational ruler are useful tools for supporting patients to achieve successful health behaviour change. The second part of this article, to be published next week, focuses on non-pharmacological therapy in patients with COPD NS Complete time out activity 6
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Corcoran N (2013) Communicating Health: Strategies for Health Promotion. Second edition. Sage Publications, London.
Healthcare Commission (2006) Clearing the Air: A National Study of Chronic Obstructive Pulmonary Disease. Healthcare Commission, London.
Department of Health (2008) Delivering Care Closer to Home: Meeting the Challenge. tiny.cc/jgfntx (Last accessed: March 19 2015.) Department of Health (2010a) Facts about COPD. tinyurl. com/qasg4s6 (Last accessed: March 19 2015.) Department of Health (2010b) Consultation on a Strategy for Services for Chronic Obstructive Pulmonary Disease (COPD) in England. tiny.cc/cbfntx (Last accessed: March 19 2015.) Department of Health (2011) An Outcomes Strategy for People with Chronic Obstructive Pulmonary Disease (COPD) and Asthma in
Hersh CP, DeMeo DL, Al-Ansari E et al (2004) Predictors of survival in severe, early onset COPD. Chest. 126, 5, 1443-1451. Hilbernick S, Jacobs J, Schlösser M, Grol R, de Vries H (2006) Characteristics of participants with COPD in three motivational stages related to smoking cessation. Patient Education and Counselling. 61, 3, 449-457. Kahler CW, Leventhal AM, Brown RA (2009) Behavioral interventions in smoking cessation. In Ries RK, Fiellin DA, Miller SC, Saitz R (Eds) Principles of Addiction Medicine. Fourth edition. Lippincott
Lai DT, Cahill K, Qin Y, Tang JL (2010) Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews. Issue 1, CD006936. Loft M, McWilliam C, Ward-Griffin C (2003) Patient empowerment after total hip and knee replacement. Orthopaedic Nursing. 22, 1, 42-47. Luker KA, Chalmers KI, Caress AL, Salmon MP (2007) Smoking cessation interventions in chronic obstructive pulmonary disease and the role of the family: a systematic literature review. Journal of Advanced Nursing. 59, 6, 559-568. Lundh L, Hylander I, Tömkvist L (2012) The process of trying to quit smoking from the perspective of patients with chronic obstructive pulmonary disease. Scandinavian Journal of Caring Sciences. 26, 3, 485-493.
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Maguire CP, Ryan J, Kelly A, O’Neill D, Coakley D, Walsh JB (2000) Do patient age and medical condition influence medical advice to stop smoking? Age and Ageing. 29, 3, 264-266. Miller WR, Rollnick S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford Press, New York NY. Miller WR, Rollnick S (2002) Motivational Interviewing: Preparing People for Change. Second edition. Guilford Press, New York NY. Naidoo J, Wills J (2009) Foundations for Health Promotion. Third edition. Ballière Tindall Elsevier, London. National Institute for Health and Care Excellence (2010) Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care (Partial Update). Clinical guideline No. 101. www.nice.org.uk/guidance/cg101 (Last accessed: March 19 2015.) National Institute for Health and Care Excellence (2013) NICE Local Government Briefings: Behaviour Change. www.nice.org.uk/advice/ lgb7/resources/non-guidance-beh aviour-change-pdf (Last accessed: March 19 2015.) National Institute on Drug Abuse (1999) Principles of Drug Abuse Treatment: A Research-based Guide. Third edition. www. drugabuse.gov/sites/default/
files/podat_1.pdf (Last accessed: March 19 2015.)
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Nicolson P, Anderson P (2003) Quality of life, distress and self-esteem: a focus group study of people with chronic bronchitis. British Journal of Health Psychology. 8, Part 3, 251-270.
Sarafino E (2002) Health Psychology: Biopsychosocial Interactions. Fourth edition. Wiley, New York NY.
Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, London. Office for National Statistics (2012) Integrated Household Survey: April 2011 to March 2012: Experimental Statistics. www.ons.gov.uk/ons/ dcp171778_280451.pdf (Last accessed: March 19 2015.) Parrott S, Godfrey C, Raw M, West R, McNeill A (1998) Guidance for commissioners on the cost effectiveness of smoking cessation interventions. Health Educational Authority. Thorax. Suppl 5, Part 2, S1-S38. Petty T (2000) COPD. Interventions for smoking cessation and improved ventilatory function. Geriatrics. 55, 12, 30-32, 35-39. Purdy S (2010) Avoiding Hospital Admissions: What Does the Research Evidence Say? The Kings Fund, London. Rice VH, Hartmann-Boyce J, Stead LF (2013) Nursing interventions for smoking cessation. Cochrane
Schiller JS, Ni H (2006) Cigarette smoking and smoking cessation among persons with chronic obstructive pulmonary disease. American Journal of Health Promotion. 20, 5, 319-323. Schofield I, Kerr S, Tolson D (2007) An exploration of the smoking-related health beliefs of older people with chronic obstructive pulmonary disease. Journal of Clinical Nursing. 16, 9, 1726-1735. Schorr G, Ulbricht S, Schmidt CO et al (2008) Does precontemplation represent a homogenous stage category? A latent class analysis on German smokers. Journal of Consulting and Clinical Psychology. 76, 5, 840-851. Shahab L, Jarvis MJ, Britton J, West R (2006) Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample. Thorax. 61, 12, 1043-1047. Sossai K, Gray M, Tanner B (2013) Living with chronic obstructive pulmonary disease: experiences in northern regional Australia. International Journal of Therapy and Rehabilitation. 18, 11, 631-642.
Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T (2013) Physician advice for smoking cessation. Cochrane Database of Systematic Reviews. Issue 5, CD000165. Taylor CB, Miller NH, Herman S et al (1996) A nurse-managed smoking cessation program for hospitalized smokers. American Journal of Public Health. 86, 11, 1557-1560. Wagena EJ, van der Meer R, Ostelo RJWG, Jacobs JE, van Schayck CP (2004) The efficacy of smoking cessation strategies in people with chronic obstructive pulmonary disease: results from a systematic review. Respiratory Medicine. 98, 9, 805-815. Wakefield M, Olver I, Whitford H, Rosenfeld E (2004) Motivational interviewing as a smoking cessation intervention for patients with cancer: randomized controlled trial. Nurse Researcher. 53, 6, 396-405. Willemse BW, Postma DS, Timens W, ten Hacken NH (2004) The impact of smoking cessation on respiratory symptoms, lung function, hyperresponsiveness and inflammation. European Respiratory Journal. 23, 3, 464-476. Wilson JS, Elborn JS, Fitzsimons D (2011) ‘It’s not worth stopping now’: why do smokers with chronic obstructive pulmonary disease continue to smoke? A qualitative study. Journal of Clinical Nursing. 20, 5-6, 819-827.
Call for papers Nursing Standard is welcoming submissions from experienced or new authors on a variety of subjects. Contact the Art & Science editor Gwen Clarke at [email protected]
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CONTINUING PROFESSIONAL DEVELOPMENT
Chronic obstructive pulmonary disease part 1: smoking cessation NS789 Jones D (2015) Chronic obstructive pulmonary disease part 1: smoking cessation. Nursing Standard. 29, 33, 52-57. Date of submission: October 11 2014; date of acceptance: January 23 2015.
Aims and intended learning outcomes
Abstract Chronic obstructive pulmonary disease (COPD) is common in the UK and causes a significant burden to patients and the NHS. Healthcare provision for COPD is largely focused on biomedical treatment, yet research suggests the complexity of factors contributing to this disease requires a deeper understanding of the patient experience and a more holistic approach to the provision of care. Smoking cessation is the single most cost-effective and significant way to slow the disease progress and improve outcomes for patients. However, barriers to smoking cessation are higher in patients with COPD than in other groups, requiring different approaches. This is part one of a two-part article, which focuses on patients with COPD caused by smoking. The second part will focus on non-pharmacological therapy.
Author Donna Jones District nurse sister, Shropshire Community Health NHS Trust, Shrewsbury, England. Correspondence to: [email protected]
Keywords Behaviour change, chronic obstructive pulmonary disease, COPD, health promotion, lung disease, smoking, smoking cessation
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
The aim of this article is to increase knowledge and encourage critical thinking and reflection when managing the treatment of patients with chronic obstructive pulmonary disease (COPD). This first article refers in particular to tackling the barriers to smoking cessation. After reading this article and completing the time out activities, you should be able to: Explain and provide insights into the importance of effective health promotion and symptom management, within socioeconomic influences, for high quality care and efficient use of resources. Develop a holistic approach to care for patients with COPD with extensive and complex health problems, social circumstances, attitudes and preferences. Analyse the barriers and challenges of smoking cessation for patients with COPD and how these may be addressed to influence health behaviour positively. Understand the physical and psychological consequences of breathlessness and its effects on quality of life and the NHS.
Background COPD is common in the UK, with an estimated three million people living with the disease (Healthcare Commission 2006, National Institute for Health and Care Excellence (NICE) 2010). It is the fifth highest cause of death in the UK, causing around 25,000 deaths each year (Department of Health (DH) 2011), and the incidence of deaths is increasing (NICE 2010). COPD is characterised by lung airflow obstruction with the presence of breathlessness or cough (NICE 2010). Airflow obstruction occurs as a result of chronic inflammation and damage to the airway and parenchyma, most often caused by tobacco smoke. COPD is an irreversible,
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progressive disease resulting in subsequent disability, impaired quality of life (NICE 2010) and ultimately death (DH 2011). COPD costs the NHS more than £800 million each year and represents one of the most frequent causes of emergency hospital admission (DH 2010a). The DH strategy for COPD services highlights the potential for community care to engage with patients with COPD, promote health (DH 2010b) and address the cost of avoidable COPD-related hospital admissions as outlined in the document Delivering Care Closer to Home: Meeting the Challenge (DH 2008). In relation to COPD, it is suggested that healthcare providers often focus on biomedical treatment of the disease (Arnold et al 2005, Bausewein et al 2007). The King’s Fund, however, reviewed research investigating the effectiveness of interventions for reducing avoidable hospital admissions of patients with COPD and found that the complexity of patients’ chronic health problems, home situation, attitudes and preferences rendered a single model of care insufficient (Purdy 2010). To improve service quality and economic accountability, the evidence base for COPD should incorporate both quantitative and qualitative evidence that captures biological, psychological and social influences on health. A deeper understanding of the attitudes, values and beliefs of patients with COPD is also required (Green and Tones 2010, Kumar 2011). Complete time out activity 1
Smoking and COPD: extent of the problem Although not all patients with COPD smoke or have a history of smoking, smoking cessation has been identified as the single most cost-effective and significant way to slow the disease progress (Hersh et al 2004, Willemse et al 2004) and improve outcomes for patients in all stages of COPD (Coakley and Ruston 2001). Barnett (2008) suggests that exacerbations can be reduced by smoking cessation. However, nicotine is highly addictive and people with COPD have been shown to be heavier smokers and more addicted to nicotine than those without COPD (Shahab 2006). Approximately 19.5% of the UK population smokes, but 53.3% of older people in poor health are smokers (Office for National Statistics 2012). Smoking cessation rates are
lower in people with COPD than without (Schiller and Ni 2006, Lundh et al 2012). However, 78% of smokers with COPD had made at least one attempt to quit over their lifetime and 79% had reduced the number of cigarettes smoked (Schofield et al 2007). Schofield et al (2007) suggest that this indicates a major desire to quit. COPD and smoking rates are much higher in deprived socioeconomic groups (Acheson 1998). The predictive factors associated with unsuccessful smoking cessation attempts are poverty and feelings of hopelessness (Schiller and Ni 2006), which suggests that these patients require more help to stop smoking (Wagena et al 2004, Lundh et al 2012). Complete time out activity 2
Patients’ perceptions of smoking cessation Hilbernick et al (2006) suggest that most smokers understand the harmfulness of smoking. However, one study of 22 participants with COPD found that only one participant made reference to the benefits of smoking cessation (Schofield et al 2007). Other participants remarked that smoking improved their breathing and was helpful when they were upset because it reduced anxiety. Further, smoking cessation appeared ‘pointless’ for these participants because damage to their bodies had already been done. Despite this, most participants wanted to quit, and Hilbernick et al (2006) estimated that 50% of smokers with COPD are amenable to smoking cessation support. Wilson et al (2011) suggest that people with COPD are ambivalent about the advantages and disadvantages of smoking cessation. Becker’s (1974) health belief model requires an individual to identify first that they are susceptible to harm, with subsequent behaviour change depending on how the individual weighs up the benefits and costs. Since smokers with COPD appear to place little emphasis on the benefits of smoking cessation, behaviour change is unlikely, particularly when cigarettes are perceived to provide comfort. The focus of smoking cessation with patients with COPD should therefore emphasise the benefits of reduced exacerbations and improved lung function, rather than the harms of smoking. Complete time out activity 3
1 Reflect on any encounter you have had with a patient with COPD. What was the focus of the encounter? Did you explore the attitudes, values, beliefs and preferences of the patient? What areas might you improve on? 2 Return to the patient with COPD you identified in time out activity 1. What socioeconomic factors influenced the patient? Discuss with your colleagues how any socioeconomic deficits may be addressed. 3 Review the following websites to determine how you might improve smoking cessation advice: tinyurl.com/ q8vvcph, http://smoke free.gov. Make a list of your three most favoured strategies.
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CPD respiratory disease Changing health behaviour
4 Return to your patient with COPD (time out activities 1 and 2). Research the transtheoretical model of change, and identify what stage the patient is in, or was in according to this model and how this might be addressed.
Smoking can provide structure, routine and company throughout the day (Wilson et al 2011). People with COPD may experience greater levels of psychological distress and low self-esteem (Nicolson and Anderson 2003). During smoking cessation, times of grief are often the trigger for relapse (Schofield et al 2007). The self-inflicted nature of COPD may cause embarrassment and shame for individuals continuing to smoke and they may adapt their behaviour to avoid confrontation and upsetting their family. This can create a cycle of guilt, low self-esteem and low self-worth that compounds the inability to achieve smoking cessation (Wilson et al 2011). Lundh et al (2012) suggest that this can have either a positive or negative effect. In other words, pressure to stop smoking can result in either smoking cessation (or continuation of attempts to stop), or loss of motivation and hope of quitting. Lundh et al (2012) discuss the transtheoretical model of change and its stages: Pre-contemplation – the individual may not be aware of any issues with their health behaviour and does not intend to make changes in the foreseeable future. Contemplation – the individual starts to realise that their behaviour is an issue and assesses the benefits of and barriers to behaviour change. Preparation – there is intention to change the behaviour in the immediate future and the individual prepares for this. Action – the individual makes specific modifications and changes to their health behaviour. Maintenance – the individual works to prevent relapse and the new health behaviour is sustained. Since the role of the community practitioner involves assisting the individual through the pre-contemplation and contemplation stages, motivational interviewing can be used to help patients who are not ready to change behaviour and to identify reasons for behaviour change. This is especially important when the rationale for smoking cessation requires an emphasis on improved lung function rather than on prevention of ill health. Complete time out activity 4
Impact of the family
Luker et al (2007) suggest that being married or single has a positive effect on smoking cessation in men, compared with men who are
divorced or separated. Further, men whose spouse did not smoke were more likely to quit than those with a spouse who smoked. Those who were successful in quitting reported that their close family was the most important factor in quitting. Women, however, often cited pressures at home and family members who smoked as reasons for not succeeding in their smoking cessation efforts. These findings may reflect limited self-efficacy and external locus of control (where the individual believes the factors influencing their behaviour are uncontrollable) and highlight the need for empowerment techniques and support. Health practitioners should consider the effect of the patient’s family and encourage inclusion of any close family members in the smoking cessation intervention (Luker et al 2007, Schofield et al 2007). This would also promote ethical practice in which the health needs of family members are included (NMC 2015).
Raising self-efficacy
Counselling and learning coping mechanisms such as stress management, relaxation and exercise can raise self-efficacy (Petty 2000, Schofield et al 2007). These empowerment techniques aim to increase people’s control over their lives, raise self-esteem and change their ‘social reality’ to achieve the skills and confidence necessary to stop smoking (Naidoo and Wills 2009). However, Sarafino (2002) argues that empowering older people may be particularly difficult as a result of their socialisation at a time when attitudes were more paternalistic than today. Loft et al (2003) suggest that the ways older people are regarded also create a barrier for empowerment, because issues associated with old age, such as living alone, deteriorating health and lower income, make them vulnerable and create an assumption that they are less able to care for themselves.
Impact of health professionals
Each smoker, regardless of their age, should be offered smoking cessation advice and support at every clinical opportunity (NICE 2010, 2013). However, evidence suggests that health professionals are less likely to engage in smoking cessation advice with older people as they consider success less likely (Maguire et al 2000). Schiller and Ni (2006) found that 22.9% of respondents had not received smoking cessation advice from a health professional in the previous year.
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Rice et al’s (2013) systematic review of 35 trials, published between 1987 and 2012 with a total of more than 17,000 participants, revealed that smoking cessation interventions by nurses increase the likelihood of quitting. A high-intensity smoking cessation intervention produced a quit rate of 172 per 1,000, compared with a rate in the control group of 137 per 1,000. A low-intensity smoking cessation intervention produced a quit rate of 64 per 1,000, compared with 51 per 1,000 in the control group. These interventions produced a combined quit rate of 144 per 1,000 for a smoking cessation intervention as opposed to a rate of 115 per 1,000 in the control group. Schorr et al (2008) found tailored smoking cessation interventions to be more effective than standardised interventions. Stead et al’s (2013) literature review of advice interventions on smoking cessation revealed that even brief advice can raise smoking cessation rates by 1-3%. Schofield et al (2007) reported that smoking cessation attempts are inspired by external sources rather than by increasing disease severity. Participants in another study spoke about previous failed attempts to quit with regret (Wilson et al 2011). However, Petty (2000) acknowledged that smokers may relapse six or seven times before abstinence from smoking is achieved. Therefore, previous quit attempts should be reframed as positive in order to motivate the patient for a further attempt (Wilson et al 2011). Assessment, advice and support for smoking cessation in patients with COPD may be time consuming; however, the potential patient benefits are well documented. Community practitioners already support, monitor and treat patients with COPD at home, and this presents an efficient opportunity to explore smoking cessation with patients to maximise health outcomes (NICE 2013). It has been suggested that the cost benefits of investing time in effective smoking cessation interventions are favourable, compared with simply treating smoking-related diseases (Parrott et al 1998). Complete time out activity 5
Assisting with health behaviour change An initial interview may assess patients for baseline health beliefs, attitudes, values, knowledge, skills, health status, functional ability, confidence and self-efficacy (Corcoran 2013). The health professional may use motivational interviewing as a brief intervention, where the patient’s motivational readiness for
behaviour change is identified as deficient; this is well supported in behaviour change management (Miller and Rollnick 1991, National Institute on Drug Abuse 1999) and has been successfully applied to smoking cessation (Taylor et al 1996, Wakefield et al 2004). Interviewing enhances the patient’s internal motivation to increase the success of the change and involves the regular assessment of motivation, assisting the health professional to tailor the approach, duration and resources used with and for the patient. Motivational interviewing can be used with the stages of the transtheoretical model of change, where the goal is to encourage the patient to move through the stages of change rather than to cease smoking. Therefore motivation to change is determined by the patient, rather than externally imposed by the health professional, and the patient has the responsibility of resolving their ambivalence (Lai et al 2010). Motivational interviewing is based on four guiding principles (Miller and Rollnick 2002): Expressing empathy. Developing discrepancy. Rolling with resistance. Supporting self-efficacy. The health professional-patient relationship is regarded as one of collaboration and partnership, rather than one of expert and recipient. A patient’s resistance and denial are viewed as reactions to the behaviour of the health professional rather than an expression of their personality, and should be addressed through a change of strategy; this can reframe the patient’s thinking and encourage examination of different perspectives. The health professional should be non-judgemental, and adopt a sensitive and empathetic approach to understanding the patient’s experience. Suggesting externally derived methods or techniques is ineffective; instead, the nurse should be led by the patient’s own means of change. Patients should be encouraged to perceive the difference between their present behaviour and the desired change in lifestyle, as this increases their motivation to change when they realise that their current behaviour will not achieve a future goal. Self-efficacy should be supported and hope fostered through the celebration of previous efforts. A patient’s motivation may be assessed using a motivation or readiness ruler (Figure 1) (Centre for Evidence-Based Practice 2011). Motivation rulers are popular in clinical practice (Kahler et al 2009), are quick to use and can rapidly assess three dimensions of motivation:
5 With your patient and with COPD in mind, formulate a plan for providing effective advice on smoking cessation support. Write down the key steps in your plan.
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CPD respiratory disease FIGURE 1 Example of a motivation or ‘readiness’ ruler Not ready
0
1
Unsure
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importance, readiness and confidence. Subsequent interviews and motivation ruler assessments can assist with evaluating the effect of motivational interviewing on the patient’s cognitive processes as well as on smoking cessation outcomes in terms of physical health and ability (Corcoran 2013).
Conclusion 6 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 61.
COPD is a major health burden to both the NHS and the individual, causing poor quality of life. Although smoking cessation slows the disease progression (Hersh et al 2004, Willemse et al 2004) and improves patient outcomes (Coakley and Ruston 2001), many people with COPD are unsuccessful at quitting
5
Ready
6
7
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and require more help (Lundh et al 2012). Smoking cessation is identified as an important health promotion intervention because of its beneficial impact on physical health, functional ability and mental health (Coakley and Ruston 2001, DH 2010b). However, the issues affecting the ability of the individual to give up are complex and require a sensitive and empathetic approach. Motivational interviewing and assessment using a motivational ruler are useful tools for supporting patients to achieve successful health behaviour change. The second part of this article, to be published next week, focuses on non-pharmacological therapy in patients with COPD NS Complete time out activity 6
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