Indications and Diagnostic Considerations

10.2 Objective of Treatment

Treatment฀of฀the฀smoker฀should฀aim฀at฀complete฀cessation,฀and฀stopping฀smoking฀abruptly฀ is฀indicated.฀Only฀1–2฀of฀heavily฀dependent฀smokers฀achieve฀this฀goal฀without฀any฀ medical฀intervention฀and฀through฀willpower฀alone,฀and฀the฀number฀of฀cigarettes฀smoked day฀ need฀ not฀ be฀ a฀ decisive฀ factor.฀ This฀ abrupt฀ method฀ of฀ smoking฀ cessation฀ can฀ be฀ achieved฀with฀psychological฀support,฀but฀the฀outcome฀is฀more฀promising฀with฀pharmaco- logical฀support. It฀has฀subsequently฀become฀known฀that฀many฀smokers,฀because฀of฀their฀heavy฀depen- dence฀andor฀considerable฀habituation,฀are฀unable฀to฀give฀up฀smoking฀completely,฀with฀the฀ result฀that฀“harm฀reduction”฀or฀partial฀cessation฀is฀then฀a฀necessary฀option.฀The฀goal฀here฀ is฀for฀smokers฀simultaneously฀patients฀at฀risk฀to฀cut฀their฀consumption฀to฀10฀cigarettes day฀with฀pharmacological฀support.฀After฀a฀longer฀period฀of฀reduced฀cigarette฀consump- tion,฀some฀smokers฀may฀possibly฀themselves฀recognise฀the฀sense฀of฀stopping฀completely,฀ though฀this฀does฀not฀automatically฀imply฀any฀change฀in฀dependence.฀According฀to฀the฀ AHQR฀Agency฀for฀Healthcare฀Quality฀and฀Research฀guidelines,฀the฀following฀ive฀“A”s฀ should฀be฀used:฀Ask฀–฀Advice฀–฀Assess฀–฀Assist฀–฀Arrange฀fragen,฀raten,฀beurteilen,฀helfen,฀ arrangieren฀ [10] . Reducing฀tobacco฀use฀is฀a฀leading฀goal฀of฀the฀nation’s฀Healthy฀People฀2010.฀To฀improve฀ the฀health฀of฀all฀Americans฀during฀the฀irst฀decade฀of฀the฀twenty-irst฀century,฀tobacco฀con- trol฀practices฀must฀also฀be฀a฀top฀priority฀in฀older฀adults฀ [11] .฀Older฀adult฀smokers฀are฀often฀ less฀educated,฀have฀a฀low฀socio-economic฀status,฀are฀more฀likely฀to฀be฀female฀and฀have฀ reduced฀ self-eficacy฀ with฀ the฀ cessation฀ process.฀ Older฀ adults฀ suffer฀ disproportionately฀ Daily฀cigarette฀consumption฀regular฀or฀irregular฀consumption Cigarette฀brand฀subsequently฀classiied฀as฀light฀–฀medium฀–฀strong CO฀levels฀in฀expired฀air฀specifying฀time฀of฀measurement Fagerström฀test฀for฀nicotine฀dependence Interview฀to฀establish฀whether฀the฀smoker฀is฀dissonant฀loathes฀smoking,฀cannot฀quit฀without฀ medical฀assistance:฀nicotine฀pre-abstinence฀syndrome฀or฀consonant฀unwilling฀to฀quit Tar฀exposure฀level฀TEL:฀correlates฀with฀the฀risk฀of฀bronchial฀carcinoma;฀depends฀on฀the฀ number฀of฀years฀of฀smoking,฀daily฀cigarette฀consumption฀and฀the฀tar฀yield฀of฀the฀cigarette฀ brand฀15฀mg,฀15–24฀mg฀or฀24฀mg Carbohydrate฀dependence฀may฀be฀present฀additionally฀in฀dependent฀smokers Height฀and฀body฀weight฀calculate฀body฀mass฀index:฀subsequent฀weight฀gain Smoker’s฀past฀experience฀of฀attempted฀smoking฀cessation฀number฀of฀successes฀failures Occurrence฀of฀nocturnal฀sleep฀disturbances฀and฀smoking฀while฀sleep฀is฀interrupted฀nocturnal฀ sleep-disturbing฀nicotine฀craving:฀NSDNC Presence฀of฀additional฀cardiovascular฀or฀pulmonary฀disease฀previous฀angina฀attacks,฀myocar- dial฀infarction,฀hypertension,฀chronic฀obstructive฀pulmonary฀disease,฀bronchial฀carcinoma,฀ etc.,฀concurrent฀psychoses฀or฀depressive฀illness฀may฀complicate฀smoking฀cessation Concomitant฀medication฀neuroleptics,฀clozapine,฀antidepressants,฀antihypertensive฀agents,฀ lipid-lowering฀drugs,฀etc Table 10.1 ฀฀฀Diagnostic฀considerations฀in฀smoker฀counselling฀ [113] from฀smoking-related฀diseases,฀yet฀experience฀physical,฀social฀and฀psychological฀rewards฀ from฀cessation.฀Clinicians฀managing฀the฀care฀of฀smokers฀can฀be฀effective฀in฀promoting฀ smoking฀cessation,฀regardless฀of฀the฀smoker’s฀age฀or฀duration฀of฀smoking฀history.฀The฀ AHRQ฀guideline฀recommends฀clinicians฀to฀ask,฀advice,฀assess,฀assist฀and฀arrange฀follow- up฀for฀all฀smokers.฀Pharmacological฀and฀behavioural฀therapies฀are฀recommended฀to฀assist฀ with฀the฀cessation฀process.฀Gerontological฀nurses฀can฀play฀a฀key฀role฀in฀optimizing฀health฀ and฀successful฀aging฀by฀reducing฀tobacco฀use฀in฀older฀adults฀ [11] .

10.3 Self-Help Interventions by the Smoker

Undoubtedly,฀the฀ideal฀situation฀is฀for฀the฀smoker฀to฀decide฀one฀day,฀more฀or฀less฀sponta- neously,฀to฀give฀up฀smoking฀and฀from฀that฀time฀onwards฀never฀to฀smoke.฀This฀type฀of฀ decision฀is฀commonly฀taken฀on฀special฀days฀of฀the฀year฀e.g.฀as฀a฀New฀Year’s฀resolution฀ Odds฀ratio Assessment Reference Reduced฀smoking – ßß – Self-help฀interventions 1.23฀1.01–1.49 Û [25] Self-help฀intervention฀with฀ telephone฀counselling 1.62฀1.33–1.97 Ý [25] Training฀by฀health฀care฀ professionals 1.48฀1.20–1.83 Û [56] Nurse-managed฀counselling 1.43฀1.24–1.66 Ý [65] Physician฀counselling 1.69฀1.45–1.98 Ý [59] Individual฀counselling฀short฀ counselling฀session,฀ booklet,฀etc. 1.55฀1.27–1.90 Û [114] Group฀therapy฀behavioural฀ therapy 2.10฀1.64–2.70 ÝÝ [70,฀114] Hypnotherapy + Û [115] Aversion฀therapy฀aversive฀ stimulation 2.08฀1.39–3.12 Ý [77] Aversion฀therapy฀general 1.19฀0.77–1.83 Û [77] Acupuncture 1.22฀0.99–1.49 ßß [106] Table 10.2 ฀฀฀Assessment฀of฀non-drug฀treatment฀modalities฀to฀promote฀smoking฀cessation,฀compiled฀ from฀the฀Cochrane฀Database ÝÝ ฀Claim฀e.g.฀on฀eficacy฀supported฀by฀several฀suitable,฀valid฀clinical฀studies฀e.g.฀randomised฀ clinical฀trials฀or฀by฀one฀or฀more฀valid฀meta-analyses฀or฀systematic฀reviews.฀Positive฀claim฀clearly฀ conirmed Ý ฀Claim฀e.g.฀on฀eficacy฀supported฀by฀at฀least฀one฀suitable,฀valid฀clinical฀study฀e.g.฀randomised฀ clinical฀trial.฀Positive฀claim฀conirmed ßß ฀Negative฀claim฀e.g.฀on฀eficacy฀supported฀by฀one฀or฀more฀suitable,฀valid฀clinical฀studies฀e.g.฀ randomised฀clinical฀trials฀or฀by฀one฀or฀more฀valid฀meta-analyses฀or฀systematic฀reviews.฀Negative฀ claim฀clearly฀conirmed Û ฀No฀reliable฀study฀results฀available฀to฀conirm฀a฀positive฀or฀negative฀effect.฀This฀may฀be฀due฀to฀the฀ absence฀of฀suitable฀studies,฀but฀also฀to฀the฀availability฀of฀several฀studies฀with฀contradictory฀results +฀No฀usable฀studies