Brenda Bowens was in rough shape when she arrived by ambulance to University of Colorado Hospital after complaining of dizziness last October. The news wasn’t good for the 71-year-old Aurora resident. Tests showed she had pneumonia. There was a noncancerous cyst on her kidney and her appendix was ready to burst.
Her physicians performed an appendectomy and treated her pneumonia with antibiotics. During her two-week hospital stint, Bowens, who is now back at home, decided to take on another tough challenge: kicking a pack-a-day smoking habit she started when she was 18.
Bowens isn’t going it alone. She is one of several hundred patients who have received help with quitting from a three-year pilot smoking cessation program funded by UCH, the University of Colorado Cancer Center and the University of Colorado School of Medicine.
The program, developed by Arnold Levinson, PhD, of CU Cancer Center and the Colorado School of Public Health, launched in July 2011. It offers counseling, educational materials and nicotine replacement therapy for patients who say they want the help. The goal: help patients quit a harmful addiction and improve their health and treatment outcomes.
Any inpatient or Cancer Center provider can order a smoking cessation consult, or patients can ask for one themselves, said Michele Kimminau, project manager with the Cancer Center’s Prevention & Control Division. The consultation documentation is integrated into the Epic electronic medical record on the inpatient side; work is underway to do so in the Cancer Center as well, she said.
Providers had ordered more than 700 consultations through mid- November, Kimminau said, and about 325 patients had agreed to go through the one-month program. The team is now working on developing a strategy for gathering reliable follow-up data, a difficult task.
“Most people average seven quit attempts before being successful,” Kimminau said. “Our job is to increase the number of quit attempts and support patients through the process.”
Finding the inner nonsmoker
The support comes from three tobacco treatment specialists who are trained in “Motivational Interviewing,” a technique that shuns condemnation and lectures about the evils of smoking in favor of helping patients find their own reasons for quitting.
If a provider orders a consultation, a treatment specialist goes to the bedside to meet the patient. “We ask, ‘How interested are you in quitting?’” says tobacco treatment specialist Kathleen Garrett. If the patient is not, Garrett asks if he or she wants more information, then leaves.
But if the patient expresses uncertainty (4 to 6 on a scale of 0 to 10), Garrett said, the specialist tries to pry open the readiness door just a bit more. “I try to evoke intrinsic motivation by exploring the patient’s ambivalence about quitting – in a non-judgmental way,” she explained.
“Most of us facing big changes in our behavior feel two ways about it,” she noted. Smokers, for example, may feel that quitting would be a good thing that would make them healthier. On the other hand, the habit may calm their nerves or give them something to do when they’re bored – among many other reasons to avoid quitting.
“It’s easy to do what you’re familiar with,” Garrett said. “I don’t take the side of change. If a person isn’t feeling totally confident about quitting, I ask them to tell me about the part that wants to do it. I want the person to tell me all the reasons and I ask them questions. The goal is for patients to talk themselves into it.”
Of those patients who have agreed to speak with her the past year, Garrett said, about two-thirds have accepted educational materials for help with quitting. The other third have agreed to accept the program, which includes about four telephone calls from Garrett in the month or so after discharge. Patients who can’t pay for nicotine replacement therapy, such as gum, lozenges or patches, get a free one-month supply from the program.
During the phone calls, Garrett asks patients to assess how the replacement therapy is working, encourages them to consult with their primary care provider about their medications and their health in general and tries to provide support if their motivation to quit wanes.
“I ask them to remember the reasons they cited were important for them to quit,” she said. “For a pregnant woman, that might be how important not smoking is to the baby.”
Fighting the battle
Bowens seemed to be at a crossroads as she sat at her kitchen table with her niece, Lorena (Rena) Hollinshed, who lives with her, on a November morning shortly before Thanksgiving. Bowens said she’d read the booklet on quitting Garrett left her and had cut down to two cigarettes a day. With the help of an inhaler, she no longer needs oxygen, she said, pointing to a tank in the corner of the living room. Showing the box of nicotine lozenges she recently received, Bowens said she wanted to check with her primary care physician before she began taking them, a decision Garrett said was a good one.
The reasons for Bowens to quit smoking are overwhelming. Before her recent serious health issues, she said she suffered a heart attack and a stroke. She is on medication to control her high blood pressure and uses the inhaler four times a day to manage chronic obstructive pulmonary disease. She admits that smoking causes her to cough and wheeze and makes it difficult to breathe.
But it’s not easy to quit, she said. She stopped after her heart attack but went back, she said, because of her nerves. She still wants to smoke after drinking coffee and eating. And it’s hard to avoid cigarettes altogether.
“I see somebody else smoke and I want a cigarette,” Bowens said. Rena, a smoker herself, said she won’t light up in the apartment and avoids having any cigarettes when she is around her aunt. “She asks for them from me,” Rena explained.
But Bowens also expressed a determination to stop smoking by her birthday the first week of January. “I’m going to quit on Jan. 7, period,” she said. “I’m going to hang that resolution on the Christmas tree.”
Reason for hope
As the program enters its second year, Kimminau believes there is reason to hope Bowens and others might get more help with nicotine addiction. For example, under the Affordable Care Act, Medicare will cover inpatient smoking cessation counseling.
In addition, Kimminau said, a preventive medicine resident is slated to start a rotation with the program next spring, providing much needed help with designing questions to ask patients, analyzing data and defining success.
For her part, Garrett sees firsthand the ravages of smoking, but said she chooses to focus on the individual courage of those who decide to change.
“It humbles me,” she said of her counseling work. “It renews my belief in people. I’m amazed by those who have courage in the face of great odds.”
This article was first published in the UCH Insider at the University of Colorado Hospital, the University of Colorado Cancer Center’s adult patient care partner. To subscribe to the UCH Insider, send an email to firstname.lastname@example.org.