Art & science | health promotion

How smoking can hinder fracture healing Sallyann Miller emphasises the importance of promoting smoking cessation among patients to ensure that their injuries can repair in a timely manner Correspondence [email protected] Sallyann Miller is sister and emergency nurse practitioner in the emergency department at Bristol Royal Infirmary Date submitted July 19 2013 Date accepted June 6 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com

Abstract Patients commonly present to the emergency department (ED) with fractures. Since it is known that smoking is a contributory factor to delayed bone union, emergency nurses should deliver smoking cessation advice to those patients with fractures who smoke. This article briefly examines the literature on cigarette smoking and its effects on bone healing and suggests that emergency nurse practitioners can use brief interventions in the ED to encourage patients with fractures to stop smoking. Keywords Smoking, fracture, cessation, bone healing OFFICE FOR National Statistics (ONS) figures for 2009 suggest that 21% of adults in the UK aged 16 and over were smokers (ONS 2011). More than one million people a year in the UK sustain a fracture, and 5-10% of these individuals will develop complications with healing, which places a considerable burden on themselves and healthcare providers (Battersby et al 2011). The cost to the NHS of commonly sustained non-union fractures in long bones is £15,566 for humeral, £17,200 for femoral and £16,300 for tibial (Tosounidis et al 2009). This cost to the NHS does not take into account the indirect costs that are harder to quantify such as quality of life and psychosocial effects. As a result, delayed fracture healing can have a significant effect on patients’ wellbeing and an economic impact that has yet to be fully assessed. It is therefore important to heal patients as quickly as possible, and any potential delays to recovery – including smoking – should be identified and addressed by emergency nurse practitioners (ENPs).

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Fractures result in injury to local soft tissues, periosteum and the bone itself, while bone healing involves regeneration of bone and restoration of skeletal integrity (Haverstock and Mandracchia 1998). Bone is healed when there is no motion present at the site of a fracture, the area is free of pain, swelling, or other inflammatory changes, and patients can ambulate without external support (Adams et al 2001). There are several risk factors for non-union of a fracture that relate to the fracture itself and to the patient. Fracture-related factors include the particular bone that is affected, the specific part of the affected bone, bone loss, surrounding soft injury or whether the injury is open or closed (Pugh and Rozbruch 2005). Patient-related factors include age, general health including comorbidities, if they are immunocompromised, smoking and medication (Pugh and Rozbruch 2005). Battersby et al (2011) state: ‘Although the physiological processes underlying delayed union and non-union associated with tobacco smoking are yet to be fully elucidated, there is increasing acceptance that smoking cessation should be incorporated into fracture management.’ Cigarette smoke is a complex mixture of gaseous and particulate matter within which more than 4,700 chemical compounds, including 43 cancercausing substances, have been isolated; individually, and in combination, these compounds inhibit the conditions required for timely wound repair (Sloan et al 2010). Nicotine, carbon monoxide and hydrogen cyanide – all elements of cigarette smoke – are associated with impairment of the healing process (Haverstock and Mandracchia 1998), while nicotine is recognised as a risk factor for reduced bone density (Ward and Klesges 2001). EMERGENCY NURSE

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Nicotine also decreases blood flow to the extremities, essential for fracture healing, due to increased peripheral vasoconstriction. According to one study, smoking only two cigarettes a day can decrease blood flow to the hand by 29% (Sloan et al 2010). Clinical observations have linked cigarette smoking to impaired bone healing. For example, in a study that compared the rate of pseudarthrosis in patients who had a two-level laminectomy and fusion, Adams et al (2001) found a surgical nonunion rate of 40% in the smoking group compared to 4% in the non-smoking group. The researchers conclude that habitual smokers generally have lower oxygen blood gas levels because of increased carbon monoxide and smoking-induced arterial constriction, that their fractures healed more slowly and their rate of non-union was higher than those of non-smokers. In a discussion of smoking cessation advice in hospital trauma units, Battersby et al (2011) noted that cigarette smoking is recognised increasingly as an inhibiting factor in fracture healing and a risk factor for non-union. The authors undertook a study to determine whether adequate smoking cessation advice and support was being given to patients who smoke and who were undergoing fracture management. They concluded that smoking cessation advice given to trauma patients was suboptimal and that although staff members were good at taking a ‘smoking history’ from patients, this was not followed up in any way in most cases. Various studies of smoking cessation advice provided to patients suggest that it is more likely to take place in the context of conditions in which smoking is a well-recognised risk factor, such as cardiac and respiratory disease (Freund et al 2008). However, West et al (2000) claim there is evidence that brief interventions from healthcare professionals can increase the likelihood of smoking cessation. Malone (2005) suggests that emergency nurses might think that time pressures prevent them from offering smoking cessation counselling, but suggests that even being asked about tobacco use by healthcare providers can help people stop or move towards making an attempt. Malone (2005) also proposes that, at minimum, all patients’ tobacco use status should be assessed as a basic ‘vital sign’ and those identified as smokers should be advised that stopping is the most important thing they can do to protect their health. The researcher also suggests that if patients are ready to quit then emergency nurses should be able and prepared to provide referral resources. EMERGENCY NURSE

Smoking cessation has been high on the public health agenda in recent years, partly influenced by government policies to ban smoking in public spaces and workplaces across the UK (Bishop and Redman 2008). ENPs are in an ideal situation to promote health and provide smoking cessation advice (West et al 2000). However, there are many pressures on their time so using a simple tool designed to support clinicians in discussing smoking cessation with patients could be incorporated into daily practice. This could also be included in ENP education programmes.

Education One such tool is the US Public Health Service’s 5As of smoking (Battersby et al 2011), which is endorsed by the British Heart Foundation, British Thoracic Society and Royal College of Physicians and Surgeons (Battersby et al 2011). These are: ■■ Ask all patients about their histories. ■■ Advise all patients to quit using personalised but non-judgemental language. ■■ Assess motivation to quit: ‘How do you feel about your smoking?’ ‘Are you ready to give up?’ ■■ Assist by assessing readiness to quit and providing resources and referrals. ■■ Arrange support follow up with the local smoking cessation service. It was developed by nurses who recognised that in a busy environment a simple tool would be more effective than long questionnaires and detailed instructions (Malone 2005). The 5As tool can be adapted easily to individual clinical settings and provides nurses with a framework that might increase their confidence in trying to address related issues with patients. If it were used as standard practice for all patients, it could become a routine part of nurses’ history taking. This is just one example and trusts often have their own smoking cessation programmes. However, this is an easy tool to remember, which makes it user-friendly for busy ENPs. Berkelmans et al (2011) note that various guidelines on health promotion recommend that all health professionals give opportunistic smoking cessation advice as part of routine patient care, and add that ‘a meta-analysis of nurses’ effectiveness in smoking cessation demonstrated a significant increase in the likelihood of people quitting, however incorporating smoking cessation care into routine practice has been difficult to achieve’. Battersby et al (2011) recommend that, to optimise fracture management, smoking cessation advice should be incorporated into the management plan of all smokers who present to orthopaedic and July 2014 | Volume 22 | Number 4 29

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Art & science | health promotion trauma departments, and should ideally occur as soon as possible after admission to hospital. After examining the literature, the author’s recommendations for helping patients minimise the risk of delay to bone healing caused by smoking are: ■■ Increase awareness among ENPs that smoking should be recognised as a risk factor for impaired fracture healing. This could be achieved through teaching sessions or individual feedback or discussions with colleagues. ■■ Introduce a tool, such as the ‘5As’, which can act as a prompt for ENPs when taking patients’ histories, and consider what further resources might be appropriate for that individual. ■■ Undertake an audit of ENPs’ notes, which would identify if there has been any change in practice following teaching sessions. ■■ Ensure the department’s ENPs are aware of the smoking cessation programme the trust provides and are proactive in accessing it for patients. Having posters and literature in the waiting area is a simple way to promote smoking cessation. ■■ Adapt/improve documentation so that it includes not only patients’ smoking history but also identifies any further action taken by ENPs towards supporting them to stop smoking. Having a ‘champion’ to help promote, encourage, teach and maintain an emphasis on smoking

cessation advice would be valuable in any emergency department. Emergency care environments are dynamic and pressured, but it is important that ENPs consider this form of health promotion as another important part of their role.

Conclusion Cigarette smoking is increasingly recognised as an inhibiting factor in fracture healing and a risk factor for non-union. Studies suggest that impaired bone healing results in prolonged time out of work for patients and potentially reduced functional outcome of the affected limb (Moghaddam et al 2011). There is also an economic factor to consider when patients are out of work for longer periods due to delayed healing. It is important that this is widely recognised and not regarded as specific to trauma and orthopaedic surgeons; education should be spread among all healthcare professionals (Battersby et al 2011). The NHS has placed an increasing emphasis on smoking cessation strategies and since ENPs are at the ‘front door’ they are in the ideal position to promote them. Questioning patients about their smoking habits should be part of any routine history taking, but using tools such as the 5As can take this to the next stage by providing clinicians with a framework on which to base their health promotion advice.

Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared

References Adams A, Keating J, Court-Brown C (2001) Cigarette smoking and open tibial fractures. Injury. 32, 1, 61-65.

Bishop R, Redman S (2008) Improving smoking cessation services for patients. Nurse Prescribing. 6, 2, 53-58.

Battersby, C, Jermin P, Haigh GA et al (2011) Clinical experience of smoking cessation advice in hospital trauma units. European Journal of Orthopaedic Surgery and Trauma. 21, 10, 453-457.

Freund M, Campbell E, McElduff P et al (2008) Smoking care provision in hospitals: a review of prevalence. Nicotine and Tobacco Research. 10, 5, 757-774.

Berkelmans A, Burton D, Page K et al (2011) Registered nurses’ smoking behaviours and their attitudes to personal cessation. Journal of Advanced Nursing. 67, 7, 1580-1590.

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Haverstock B, Mandracchia V (1998) Cigarette smoking and bone healing; implications in foot and ankle surgery. Journal of Foot and Ankle Surgery. 37, 1, 69-74. Malone R (2005) New practical book helps nurses to help patients stop smoking using the five A’s: ask, advise, assess,

assist, arrange. Journal of Emergency Nursing. 31, 5, 497-499. Moghaddam A, Zimmermann G, Hammer K et al (2011) Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury. 42, 12, 1435-1442. Office for National Statistics (2011) Smoking and Drinking Among Adults, 2009: A Report on the 2009 General Lifestyle Survey. ONS, London. Pugh K, Rozbruch S (2005) Non-unions and malunions. In Baumgaertner MR, Tornetta III P (Eds) Orthopaedic Knowledge Update: Trauma 3. American Academy of Orthopaedic Surgeons, Rosemont IL.

Sloan A, Hussain I, Maqsood M et al (2010) The effects of smoking on fracture healing. Surgeon. 8, 2, 111-116. Tosounidis T, Kontakis G, Nikolaou V et al (2009) Fracture healing and bone repair: an update. Trauma. 11, 145-146. Ward K, Klesges R (2001) A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcified Tissue International. 68, 5, 259-270. West R, McNeill A, Raw M (2000) Smoking cessation guidelines for health professionals: an update. Thorax. 55, 987-999.

EMERGENCY NURSE

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How smoking can hinder fracture healing.

Patients commonly present to the emergency department (ED) with fractures. Since it is known that smoking is a contributory factor to delayed bone uni...
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