Smoking and Withdrawal:

How to be your patient’s advocate

Megan M. Martin

DeSales University

Nicotine

Used as an insecticide and plant spray when in liquid form

Considered a very poisonous alkaloid: colorless, oily liquid in its pure state

Amount used in cigarettes is not enough to cause (immediate, direct) death.

Nicotine in tobacco can cause indigestion, increase blood pressure, and dull appetite.

Action of Nicotine

Nicotine is absorbed through the skin, GI tract, and respiratory mucous membrane

Action of drug is dose-related Temporarily stimulates both sympathetic and

parasympathetic ganglia; also stimulates skeletal muscle

Following stimulant phase, nicotine causes a depressant phase; relaxes skeletal muscle

Nicotine in cigarettes: A powerful addiction

Cigarettes are the primary vector of nicotine ingestion.– Others are chew, cigars, and pipe smoking – Cigarettes become addicting after approximately

two weeks of smoking ten cigarettes per day– Initial rush of nicotine initiates a temporary feeling

of well-being by increasing activity of dopamine in the brain

– Considered as addictive as heroine; same action

Addiction

The DSM-IV criteria for substance dependence are shown below:– Maladaptive pattern of substance use leading to

clinically significant impairment or distress, manifested by three or more of the following within a 12-month period:

– Presence of tolerance to the drug; presence of withdrawal symptom

– Substance taken in larger amounts/longer period of time than intended

– Unsuccessful or persistent desire to cut down or control use…• Varcarolis, 1998

Withdrawal

Occurs after a period of continued use Stopping or reducing use results in specific

physical and psychological signs and symptoms

Occurs approximately four hours after last cigarette, peaks in 3-5 days, lasts at least two weeks

Physical and Mental Side Effects of Nicotine Withdrawal:

PHYSICAL Tingling in hands and feet Sweating Intestinal disorders,

primarily constipation and/or upset stomach

Headache S/S of colds and respiratory

problems initially Weight gain

MENTAL Insomnia Mental confusion Vagueness Irritability Tension, perceived

unbearable Depression, mimics grief Anxiety

First two weeks of withdrawal

Critical in determining failure rate– If smoker cheats in this period, highly likely to

return to habit within six months– After five days, the smoker is undergoing the

most severe physical effects of withdrawal– Emotional effects are carried for approximately

1-3 months after quitting

Success Rates of Quitting

47 million people in U.S. smoke; 28% of males, 23% of females

3,000 young people start smoking every day Although about 25% of adults smoke, 70% of

them want to quit– 1/3 will try seriously to quit– Only 6% will be successful within one year– Those who continue to try have 50% success rate

Reasons smokers relapse; fail to quit permanently Depression: Cigarettes relieve minor depression,

fits of anger, enhance sense of well being, enhance concentration

Physical effects over long-term seem abstract; “won’t happen to me; I’ll quit”

Weight gain: quitting smoking/withdrawal causes body’s basal metabolic rate to drop for 3-6 months before return to normal.– Average weight gain: 10-25 lbs.

Nursing’s relation to the smoking patient Patients are ill to begin with; withdrawal

symptoms can exacerbate their sense of illness Be your patient’s advocate!! If you know

you’re patient is a smoker, call the physician: Request some form of nicotine replacement unless

contraindicated Request an oral replacement/antidepressant, e.g. Zyban®

Nicotine Replacements

Nicotine Patch: Available in several dosages: 21mg-7mg Dosages should gradually be decreased over min. of 6 wks.

Absorbed transdermally Should be worn 24hrs/day Adverse SE: pruritus/erythema under patch, nausea,

dizziness, myalgias, coughing, difficulty sleeping, nightmares

Recommend that patient change sites daily

Nicotine Gum

Absorbed through buccal mucosa Dosage: 2mg, repeated prn up to 30 pieces of

gum/day. Gum not chewed, rather bitten into and held

in the cheek Adverse SE: injury to mouth, teeth, dental

work. Rare: irregular heartbeat Largest complaint: Gum has peppery taste

Nicotine Nasal Spray

Administers 1 mg/2 sprays to the nasal membrane

Faster onset of action than patch or gum Should be used for at least three months, no

longer than six months Adverse SE: belching, tachycardia, mild

H/A, increased appetite, increased watering of mouth, sore mouth or throat

Nursing Considerations

Instruct client to take exactly as directed Instruct the client of the importance of NOT

smoking at all while using nicotine replacement therapy; could lead to nicotine toxicity

Give client information of smoking cessation support groups relative to their area

Instruct family if possible of patient needs and support

Nursing Diagnoses

Anxiety-Nurses teach deep breathing Self-esteem disturbance-Nurses teach coping

mechanisms Noncompliance-Nurses support patient throughout

withdrawal process Sleep-pattern disturbance (r/t withdrawal and Zyban/

nicotine replacement)-Nurses teach it is temporary effect; recommend decrease in caffeine, increase in exercise

Constipation-Nurses teach patient about better diet, high in fiber, increase in exercise will decrease occurrence

Oral agents; Zyban®

Zyban, also Wellbutrin (bupropion HCl) is an oral agent used to curb the most severe side effects of nicotine withdrawal

Only available through prescription Actually an antidepressant, Zyban acts as a

weak serotonin reuptake inhibitor, also acts on dopamine and norepinephrine centers of the brain

Zyban...

When used on people not previously depressed, has no effect on mood

Instruct patient that its primary function is to prevent depression, not an upper

Dosages for smoking cessation differ from dosage used for depressive disorders

Patient usually starts with 150 mg QD X 3days, then 150 mg BID X 7-12 wks.

Zyban...

Contraindicated in patients with seizure disorders, MAOI’s, eating disorders

Adverse SE: Weight loss/weight gain, agitation, dry mouth, blurred vision, headache, dizziness, tremor, nausea, vomiting, constipation, insomnia, vivid dreams– SEIZURES with overdose (>450mg/day)

Zyban...

Instruct patient that the full antidepressant effect of drug may not be realized for up to 4 wks

Patient is to pick a target date for cessation, stick to it.

Patient may continue smoking while taking Zyban for up to two weeks

It is recommended that the patient consider nicotine replacement in conjunction

Nursing Teaching Points...

It is important that the patient be READY to quit, otherwise will be unsuccessful

NEVER push a patient to quit. This will only hurt your relationship with that patient.

Respect the patient’s wishes. Only instruct about the effects of smoking, the values of quitting. Be a support system to your patient.

Remember the effects of Nicotine withdrawal. Be empathetic with the patient’s needs. Be an advocate!

Stage-of-Readiness Model for Smoking CessationStage-of-Readiness Model for Smoking CessationStage Description of Stage Nursing Strategies

PRECONTEMPLATION Client has no desire toquit smoking

Teach negative effects ofsmoking, reassure clientthat feelings are part ofaddiction process

CONTEMPLATION Client has thought aboutsmoking cessation buthave taken no action

Provide specific examplesof how smoking isaffecting client; stresshealth benefits of quitting

PREPARATION Client has taken somesteps to quit smoking

Provide behavioralreinforcement; help the clientidentify cues that lead tosmoking; help identify copingstategies

ACTION Client quits smoking Provide positivereinforcement to preventrelapse

MAINTENANCE Client has not smoked for6 months

Continue positivereinforcement

Physical Response to Quitting

Time after last cigarette Physical Response

20 Minutes BP and pulse return to normal

8 hours CO and O2 levels in bloodnormalize

24 hours Chance of heart attack decreases

48 hours Nerve ending start to regrow; abilityto taste and smell increase; after 72hrs lung capacity increases

2 wks. -3 mos. Improved circulation; lungfunction increases up to 30%

1-9 months Decreased incidence ofcoughing, sinus infx, fatigue, andSOB; regrowth of cilia in lungs,increasing ability to handlemucus, clean the lungs, reducechance of infx, overall energylevel increases.

Nursing Teaching: Diet

Encourage your patient to increase the amount of fruits, vegetables, whole grains, and fiber-rich foods.

Encourage the patient to drink large amounts of water

Teach the patient about oral cravings; encourage healthy snacks such as carrots, apples, celery. Also recommend sugar-free gum.

Exercise

Quitting may be harder for women than men due to body image perceptions

Encourage patient to increase levels of activity; recommend taking walks during times of craving

Remind patient that if weight is gained, it will most likely come off in time

Teach deep breathing exercises. This helps to mimic feeling of smoking; induces relaxation

Conclusion

Smoking is a common addiction Nurses must be aware of the effects of nicotine both

physically and mentally on their patients Nurses MUST be patient advocates.

– Encourage patient to quit– Never push– Speak to the physician about possibility of smoking

cessation aide– Continue to have a positive, supportive relationship

with patient. Nothing helps more than understanding

References

Guthrie, C. (2001). Kick butts now! Online. Available: http://my.webmd.com/content/article/1689.50430

Ignatavicius, D.D., Workman, M.L., & Mischler, M.A. (1999). Medical-Surgical nursing across the health care continuum (3rd ed.). Philadelphia: W.B. Saunders Company.

McKenry, L.M. & Salerno, E. (1998). Pharmacology in nursing. (20th ed.). St. Louis: Mosby.

Miller, B.F & Keane, C.B. (1997). Encyclopedia & dictionary of medicine, nursing, and allied health. (6th ed.). Philadelphia: W.B. Saunders Company.

References (con’t)

Varcarolis, E.M. (1998). Foundations of psychiatric mental health nursing. (3rd Ed). Philadelphia: W.B. Saunders Company

WebMDHealth. (2001). Smoking. Online. Available: http://my.webmd.com/content/article/1680.51953.

Wilson, B.A., Shannon, M.T. & Stang, C.L. (2001). Nursing drug guide 2001. New Jersey: Prentice-Hall, Inc.