Tobacco use is the most preventable cause of death and disease in the United States. Annually, it results in 440,000 deaths at a cost of $157 billion and an estimated 5.6 million years of life lost. Tobacco use not only increases the risk of lung and other cancers and cardiovascular and respiratory diseases for smokers. It raises these risks for nonsmokers as well through exposure to secondhand smoke. Because of nurses’ important role in smoking-cessation counseling, the U.S. Department of Health and Human Services (HHS) published specific guidelines for nurses in 2005.
Much is known about effective strategies to promote successful smoking cessation. Smoking-cessation counseling is a core measure of quality for acute-care hospitals for various diagnoses, including heart failure, myocardial infarction, and pneumonia. Healthcare providers can increase the chance that patients will quit smoking.
Use of evidence-based strategies is an expectation of good nursing care. To promote successful cessation attempts for patients who smoke, clinicians should follow the 5 A’s:
Ask about tobacco use at every visit.
Advise tobacco users to quit.
Assess readiness to quit.
Assist tobacco users with a quit plan.
Arrange follow up visits.
The purpose of this study was to describe the smoking-cessation counseling practices of nurses in acute-care rural hospitals and examine whether nurses’ personal characteristics affected smoking-cessation counseling activities.
After approval from the University of Maryland Institutional Review Board, 23 rural hospitals in the eastern United States were enrolled in a heart-failure quality collaborative. Baseline de-identified survey data were collected from nurses using the Smoking Cessation Counseling Scale (SCC).
The SCC was developed based on HHS guidelines for nurses. The 26-item survey includes 24 items with a four-level response format that indicates the extent to which the nurse implemented each item (not at all, less than half the time, more than half the time, or all the time). Twenty-four items were assigned values ranging from 1 to 4, with 1 indicating “not at all” and 4 denoting “all the time.” The results were summed, producing an overall score. Two additional items assessing comfort in smoking-cessation counseling skill and comfort in referral to resources included a 10-point response format, with 1 indicating “not at all confident” and 10 denoting “very confident.” The SCC was piloted in a study of 103 nurses who attended the 2006 Maryland Nurses Association Annual Conference. The survey was reliable, with a Cronbach’s alpha of 0.91.
The SCC was administered to RNs via a TeleForm survey. De-identified surveys were sent back to the study team in sealed envelopes. Surveys were scanned into an SPSS database. (SPSS is software used for statistical analysis.) Respondents could provide their names and contact numbers in a separate envelope if they wished to be included in a drawing for a $100 gift card for each participating hospital at the end of the study. Data from the 2006 American Hospital Association Annual Survey were used to describe hospital characteristics (average daily census and number of full-time equivalents (FTEs).
Analysis was performed using SPSS version 17.0. Univariate, descriptive statistical analyses were conducted and summary statistics were calculated for nurse characteristics (age, gender, work status, education, and ethnicity). Frequency statistics were calculated for 24 survey items that described the smoking-cessation counseling practices of nurses in acute-care rural hospitals. General linear regression models with stepwise selection were conducted to examine the nurse characteristics that may affect the summary scale score of the 24 items on the SCC survey.
An overall response rate of 37% (683/1852) was attained from 23 hospitals (591 RNs, 90 licensed practical nurses, and 2 nurses who did not designate their RN or LPN status). Only the RN respondents were included in this study. Their characteristics appear in the box below.
Most nurses were female (94%), Caucasian (88%), and aged 36 to 50 (41%). A majority of RNs were educated at the associate-degree level (57%). Nurses provided direct patient care 76% (SD=26) of the time. Respondents worked in rural hospitals with an average daily census of 102 (range of 7 to 290). Hospitals had an average of 153 RN FTEs (range of 14 to 524 FTEs).
Table 2 (below) shows item frequencies on the SCC. Aspects of smoking-cessation counseling that were reported to occur all the time by the greatest proportion of nurses were:
- providing resources and assistance (68%)
- assessing tobacco use (66%)
- documenting tobacco use (61%)
- advising tobacco users to quit (62%)
- asking tobacco users if they are willing to quit (52%).
Nurses reported a mean of 6.3 (SD=2.5) for comfort in conducting smoking cessation and 6.9 (SD=2.3) for comfort in referring patients for smoking-cessation counseling on 10-point scales.
Frequencies of smoking-cessation counseling activities by RNs (n=591)
Recommended practices most frequently reported as never completed were:
- three types of patient referrals for more information—tobacco-free nurses (51%), healthcare research (43%), and free telephone “quitline” tool (35%)
- three items that helped patients create a quit plan—drinking alcohol may result in a relapse of smoking (28%); if relapse, occurs pharmacotherapy should be reassessed (27%); and the patient should set a quit date (24%).
Estimates of internal consistency for the SCC were adequate using Cronbach’s alpha (a = .955).
Next, total SCC was regressed on education, gender, age, ethnicity, and comfort in smoking-cessation counseling skills. Total SCC correlated positively with comfort in smoking-cessation counseling (r=.602, p<.000). When controlling for age, gender, work status, education, and ethnicity, comfort with smoking-cessation counseling was the only significant predictor of higher total SCC scores with positive effect, which explained 36% of variance in SCC performance (adjusted R-square=0.36). This indicates that more counseling activities occur as the RN’s comfort with counseling skills increases, regardless of RN characteristics.
This study yielded three major results:
- Nurses more comfortable with smoking-cessation counseling skills used more evidence-based nursing interventions regardless of age, education, work status, gender, or ethnicity.
- Items reported by nurses as less likely to occur were those requiring the greatest degree of comfort with evidence-based practice.
- Nurses in this sample of rural hospitals reported a moderate level of smoking-cessation counseling.
These results are important because the ability to deliver evidence-based interventions is a hallmark of nursing science and is expected of healthcare professionals. Smoking-cessation counseling will remain an important quality metric.
Despite decreased smoking by U.S. adults from 25% in 1997 to 20% in 2007, the goal for Healthy People 2010 (a government-sponsored health promotion and disease-prevention initiative) wasn’t met. Healthy People 2020 maintains the goal of reducing smoking by adults to 12%. The most recent progress report suggests expanded strategies are needed to increase both demand and use for smoking-cessation services and treatments. Clinicians and healthcare systems are called on to promote and provide telephone quitline access for patients.
The Joint Commission (JC) requires accredited hospitals to report quality performance measures. New JC directions will classify performance measures into accountability measures and nonaccountability measures to help hospitals prepare for higher performance levels as pressure for pay-for-performance and public reporting escalates. Smoking cessation will become a nonaccountability measure, as the smoking-cessation core measure doesn’t accurately represent the quality of smoking-cessation processes. Nursing must continue to infuse effective interventions into smoking-cessation counseling to enhance the quality of care.
Results of this study indicate that hospitals can improve healthcare processes and the extent to which patients receive smoking-cessation activities by increasing nurses’ comfort with smoking-cessation counseling skills. This positive effect occurs when controlling for gender, ethnicity, education levels, age, and employment status (full or part-time). A majority of our sample held associate degrees; the academic curriculum of associate-degree programs usually doesn’t cover basic research and evidence-based practice content. However, our results show that the type of nursing degree doesn’t predict higher use of evidence-based practices. Other studies have found similar results, with nurses reporting low confidence and training as reasons for not providing smoking-cessation services.
Cessation interventions reported as less likely to occur were the items that require higher engagement in evidence-based practice. For example, nurses scored well on the assessment and documentation efforts, which are integrated into standard hospital processes. Lower scores occurred in areas that require more detailed knowledge of evidence, such as referrals to external resources, relapse plans, and specific quit strategies.
Activities that nurses implement least often require a focused effort to integrate them within systems of care, as nursing interventions are known to positively affect smoking cessation. In a systematic review of 31 studies that compared nursing interventions to a control group, the interventions had a significant effect on patients’ successful quit attempts (RR 1.28, 95% CI 1.18 to 1.38). Implementation of evidence-based multidisciplinary and multifaceted standard interventions has been effective in significantly improving cessation services (57% to 86%). Without a dedicated smoking-cessation program, training of nurses about this program, and time allocated to smoking-cessation counseling, nurses will lack the knowledge and time for smoking-cessation activities.
This study has a number of implications.
- It highlights the important role of nurse educators both in rural community hospital and academic settings in ensuring high quality of care, if nurses’ comfort in skills can be increased by incorporating smoking-cessation training in coursework and continung education. Educational interventions will reinforce knowledge, skills, and attitudes to promote smoking-cessation efforts. Training should include behavioral counseling with specific interventions that work (setting a quit date, disposing of cigarettes, handling relapses, and referring to state-supported 1-800-QUIT NOW telephone support lines). Pharmacologic interventions should be incorporated—for instance, nicotine replacement therapy, bupropion, verenicline, and combination therapies. Although most nurses don’t order medications for patients, they can prompt physicians or nurse practitioners to order these medications for patients. Without a comprehensive infusion of smoking-cessation training, improved service provision is unlikely.
- Researchers and guideline developers need to package smoking-cessation interventions to make them easy and feasible to implement. These guidelines must indicate which features always should be implemented and which strategies lack effectiveness. Focusing on a small number of essential smoking-cessation activities may be an alternative to refine the interventions to an implementable effective bundle. This would allow nurses to use their available time to focus on smoking-cessation counseling activities known to work. Interventions should be assessed for cost-effectiveness from both the hospital’s and society’s perspectives.
- Rural hospitals will need to find creative solutions, such as collaboratives or networks, to educate nurses in cessation counseling. Small hospitals have fewer resources and therefore are less likely to have dedicated cessation counselors than larger hospitals or academic settings.
- The SCC scale can be used to identify nurses who are least comfortable with their smoking-cessation counseling skills. This will allow education to be targeted to those with a self-identified need to benefit from the additional support.
- If nurses themselves are smokers, they also may be in need of interventions. Those who smoke are unlikely to be comfortable providing cessation counseling and referral for services. Other arrangements should be made to provide smoking-cessation activities for their patients if needed.
Limitations of this study should be considered when interpreting the results. First, the sample was drawn from a heterogeneous sample of rural hospitals in the eastern United States and may not be representative of all rural hospitals. Response rates were low and varied, so they may not represent rural hospital nurses in general.
Second, the SCC used in this study is a new instrument. It demonstrates adequate internal consistency and was derived from evidence-based guidelines specific for nurses.
In addition, the nurse usually isn’t the only provider responsible for smoking-cessation counseling. Each organization assigns responsibility for smoking-cessation assessment, planning, implementation, and evaluation. For example, the nurse may assess and refer the patient to a dedicated counselor, or a respiratory therapist may be charged with counseling activities.
Finally, we did not evaluate efforts made by hospitals to train nurses (which probably varied widely among hospitals) or whether patients quit smoking as a result of nurses’ efforts.
Despite these limitations, we believe the study highlights the imporance of nurse self-efficacy in smoking-cessation counseling and the importance of training nurses in evidence-based interventions.
This study describes the smoking-cessation practices of nurses in acute-care rural hospitals. The nurse’s comfort in smoking-cessation counseling skills—not his or her personal characteristics—is the only variable that predicts more smoking cessation-counseling activities. Smoking-cessation counseling varies by activity, with lowest performance in areas that require knowledge of evidence-based practices. These areas of low performance are an opportunity for nurses to implement interventions known to work, as well as to improve the potential success of the patient’s quit attempt.
Hospitalization is an opportune time to target smoking-cessation efforts because the patient has quit temporarily due to hospital smoking bans. Also, hospitalization usually results in a “teachable moment” as the diagnosis or disease exacerbation commonly makes patients more receptive (especially if their disease is smoking related).
Researchers and clinicians should prioritize the smoking-cessation interventions that are most effective, create guidelines, and train nurses in their use. Such guidelines must find a balance between scientific soundness and feasibility. With such an approach, hospitals will be more likely to contribute to national efforts to improve population health by reducing patients’ smoking rates.
The authors work in Baltimore. Robin Newhouse is assistant dean of the Doctor of Nursing Practice Program and an associate professor of Organizational Systems and Adult Health at the University of Maryland School of Nursing. Cheryl R. Dennison is an associate professor in the Department of Health Systems and Outcomes at Johns Hopkins University School of Nursing. Yulan Liang is an associate professor in the department of Family and Community Health and a biostatistician for the Office of Research of the University of Maryland School of Nursing. Laura Morlock and Kevin D. Frick are professors in the department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. Peter Pronovost is a professor in the departments of Anesthesiology and Critical Care Medicine and Surgery at the Johns Hopkins University School of Medicine, a professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, medical director for the Center for Innovation in Quality Patient Care, and director of the Quality and Safety Research Group.
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This study was funded by a grant from the Robert Wood Johnson Foundation through the Interdisciplinary Nursing Quality Research Initiative. Development of the Smoking Cessation Counseling Scale was funded through a grant from the Maryland Cigarette Restitution Funds at Johns Hopkins University. The authors wish to acknowledge Janine Michaelson, MS, RN, Julie Twigg, BSN, RN, and Clola Robertson, MS, RN, for research assistance study and an anonymous reviewer for helpful comments.