Nurse S sat in her backyard smoking a cigarette. She would be facing some hard choices soon and she wasn't sure how to handle it. Three years ago, the hospital where she works became a smoke-free campus. The smokers' lounge disappeared and no one was allowed to light up on the premises anymore, not even visitors. Some workers were fired for sitting in their cars to smoke during their breaks.
Employees were given warnings that more antismoking changes were on the way, including firing employees who continued to smoke—even at home. The facility wasn't hiring any new employees who were smokers either. For the past 3 years, Nurse S had the opportunity to quit smoking. She tried, but it was hard and she was unsuccessful after a few weeks. She hoped that someone would step forward to challenge the hospital's policy on forcing nurses to quit smoking permanently if they wanted to keep their jobs.
“Isn't that illegal?” she wondered. “What about my rights as a smoker?” Although smokers were fighting the new policies at work, nothing was resolved and the deadline loomed nearer. Now she would have to quit smoking or lose her job. Nurse S decided it was time to quit. But how?
Breaking up is hard to do
According to the U.S. Bureau of Labor Statistics, 18% of the 3.1 million nurses in the nation are smokers. Many nurses who smoke are hesitant to educate their patients on the hazards of smoking because they believe they aren't good role models or they may feel hypocritical. However, smoking cessation is an important part of patient education.
Smoking is linked with deadly comorbidities, lost work productivity, and negative perceptions. So, why do people continue to smoke? Because they're addicted to nicotine. Stedman's Medical Dictionary states that addiction is “a habitual psychological and physiological dependence on a substance or practice which is beyond voluntary control.” There's a link between smoking, the nicotine receptors in the brain, and addiction.
Why's it so hard to quit? Nicotine is as addictive as many illegal drugs. Reaching the brain within a few seconds, nicotine starts a series of biochemical reactions that releases a cascade of dopamine and immediately causes feelings of pleasure and calmness to occur. Between cigarettes, as the dopamine levels in the brain begin to fall, the smoker experiences unpleasant symptoms of withdrawal, such as irritability and stress. The brain receptors crave the nicotine, thus the smoker picks up another cigarette and a cycle is set up that's difficult to break.
Nicotine addiction is a physical and psychological condition. Although withdrawal symptoms usually resolve in 3 to 4 weeks, the craving can persist for months to years. It's the craving and withdrawal symptoms that are major hurdles to overcome for a smoker to achieve success in quitting. Environmental triggers can lead to a relapse, and just one cigarette will rekindle the same level of addiction that existed before cessation. Relapses are likely to occur, but they shouldn't be considered a sign of failure on the part of the smoker.
Because quitting is so difficult, smokers need information on and assistance with cessation treatment, including education about what to expect during withdrawal, behavioral and environmental modifications, and pharmacologic support for withdrawal. The treatment needed to quit requires counseling, pharmacotherapy, and ongoing support and care.
The smoking cessation journey
Let's get back to Nurse S's decision. There are different motivators for smokers to quit, but not all smokers are at the same level of action:
- precontemplation—the smoker isn't even considering quitting
- contemplation—the smoker is actively thinking about quitting, but isn't yet ready to take that step
- preparation—the smoker seriously intends to quit and is ready to make a plan, or may even have a plan
- action—the smoker has quit and is in the first 6 months of the quit phase
- maintenance—the new nonsmoker actively takes steps to avoid relapse and adopts healthy behaviors.
There are steps that Nurse S can take to get on the road to success. She should begin by setting a quit day within the next week or so. If the quit day is too far into the future, she may talk herself out of it. She can prepare for her quit day by telling family and friends, and by visiting her healthcare provider to discuss nicotine replacement therapies (NRTs), such as patches, gum, lozenges, sprays, and inhalers, or other smoking cessation medications, such as bupropion or varenicline.
Nurse S should find a coach or a smoking cessation group to support her during the journey. Many states have quit lines (1–800-QUIT-NOW), which offer free counseling and NRTs, and there are several smoking cessation websites, such as BecomeAnEx.org, which has an app for the quit plan on the go, and TobaccoFreeU.org.
In continuing to prepare for her quit day, Nurse S should buy a new toothbrush for her first day as a nonsmoker because the old one is full of smoke and nicotine. She may also want to consider cleaning the house. She should have plenty of water on hand to help flush the nicotine out of her system. Cigarettes and smoking paraphernalia must be thrown away; if necessary, she can give them to someone to destroy so she isn't tempted to dig through the trash for them.
Triggers need to be identified before the quit day. For example, if Nurse S smokes in the car, she should clean out her car, put the cigarettes in the trunk, and if she must smoke while driving, then she can pull over to a safe area and smoke outside the car. She may find that by the time she finds a place to park, the urge to smoke has disappeared. If she smokes with her morning cup of coffee outside on the patio, then she should drink her coffee inside the house where she doesn't allow herself to smoke, and then smoke outside on the patio when she's finished with the coffee. Many smokers find the craving passes by the time they're finished with their coffee.
Nurse S can keep a diary of what she's doing when she lights up and make plans to replace the cigarettes with something else while performing that activity. Many people light a cigarette and aren't even aware of it. She may benefit from learning stress management techniques, such as meditation, deep breathing, and aromatherapy. She should plan in advance for how she'll deal with the irritability that accompanies withdrawal. The goal is not to allow herself to get hungry, angry, lonely, or tired. Practicing healthy behaviors, such as a proper diet with six small meals per day, drinking plenty of water, exercising, and getting plenty of sleep, can help.
Some people are concerned about weight gain when they quit, and Nurse S is no exception. However, the average weight gain shouldn't be more than 7 lb (3.18 kg). Many people substitute the cigarette-to-mouth activity with food. Nurse S may find that chewing gum, sucking mints, or snacking on healthy foods such as carrots may ease the transition.
Nurse S may need to temporarily separate from friends who smoke or from some social situations and certain settings in which she's tempted to smoke. She should let her family and friends know that she's quitting and ask for their support.
Get by with a little help
Nurse S thinks she'll have a better chance of permanently quitting if she uses an NRT. These therapies offer a low dose of nicotine to help minimize the cravings experienced when quitting. There are several NRTs available. Let's take a closer look.
Nicotine gum and lozenges help soon-to-be ex-smokers get through cravings during the day. Both the gum and lozenges are to be chewed or sucked until a peppery taste occurs, which means the nicotine is activated, and then placed between the gum and the cheek so the nicotine can be absorbed into the bloodstream. After the nicotine is absorbed, the same piece of gum or lozenge can be activated again by chewing or sucking and parked in the cheek yet again, until it's no longer needed or the nicotine has been completely released.
If nicotine patches are used, they're replaced each morning with a new one. Patches offer a low, continuous dose of nicotine throughout the day. The nicotine is slowly absorbed into the bloodstream via the skin at a rate of just under 1 mg/hour. One cigarette itself can release 1 to 3 mg of tobacco, so the amount of nicotine in the patch is extremely low when compared with smoking a cigarette. Research has also shown that patches can be used concomitantly with gum or lozenges for even greater success in quitting, especially at the beginning of the cessation period. Assessment of the cardiovascular system is important; NRTs shouldn't be used within 2 weeks of a cardiac event.
Nicotine inhalers, nasal sprays, bupropion, and varenicline require a prescription for use. Although it has received some negative publicity, varenicline has been used successfully in most smokers when used properly. People who suffer from depression, psychological disorders, or liver disease shouldn't take varenicline.
Breaking an addiction is tough. Quitting smoking isn't easy, but it's possible. Being ready to quit means being committed to it and having a plan. There's a wealth of smoking cessation help available today for those who want to take that step. But it's Nurse S's reasons for quitting that will help her take those steps to success.
Nurse S decided to quit smoking and, after setting up a plan, began to take action. Her first step was to set a quit day, and she prepared for that day by sharing her decision with family and friends. Not all were receptive, but she was determined to make the change.
Before her quit day, Nurse S did her research on smoking cessation. She visited the TobaccoFreeU.org website and took the Fagerstrom test for nicotine dependence to determine her degree of dependency on nicotine. By knowing how much she was addicted to nicotine, she would be able to set up strategies for handling her cravings. The BecomeAnEx.org website provided Nurse S with many helpful hints on how to quit and what to do to get through the tough days ahead.
Nurse S also investigated the various NRTs that were available, and decided to speak to her physician about using varenicline. Her physician informed her that he would also need to adjust some of her medication dosages after she became nicotine-free because nicotine can decrease the absorption of some drugs.
Nurse S found that her community had free smoking cessation groups that she could attend for additional support. She was surprised that these groups existed and didn't know about the quit line phone resource either. Quitting smoking was going to help her in more ways than one; she would become an ex-smoker and also be knowledgeable in smoking cessation so she could help her patients quit, too.
It has been a year since Nurse S quit. It hasn't been easy, and there are times when she still craves a cigarette. However, she finds that she feels much healthier and her level of activity has increased. She's also able to share her success with her smoking patients and offer them words of encouragement and hope.
The hospital rules for smoking haven't changed despite the attempts by smokers to uphold their rights. But, in a way, Nurse S is happy that the hospital instituted those regulations because it has made a difference in her personal and professional life—for the better.