Nicotine addiction is a preventable illness, and, with training, RTs can help their patients kick the habit.

By Roberta B. Hollander, PhD, MPH, and Donna Oliver-Freeman, MS , RRT

In 1979, the Surgeon General declared cigarette smoking the nation’s key cause of preventable illness and premature death.1 It is a leading risk factor for cardiovascular disease; chronic obstructive pulmonary disease; lung, throat, mouth, kidney, pancreatic, bladder, and stomach cancers; and a growing list of other serious health problems. It accounts for 90% of all lung cancer deaths. Pregnant women who smoke raise their risk of low birth weight babies, preterm deliveries, and infant deaths.5

In addition, secondhand smoke exposure has been linked to sudden infant death syndrome, asthma and other respiratory and ear infections in children, and cardiovascular disease and cancers in family members, leading the Environmental Protection Agency to label it a Group A carcinogen.3,5,6

Overall, smoking rates for US adults are gradually trending downward, but smoking and its adverse health effects continue to impact some racial/ethnic, income, educational, and age groups disproportionately. Women now pay the price of lung cancer cases and deaths from decades of increased smoking. Also, because 28% of high school students use tobacco (22.3% use cigarettes), 90% of smokers start before age 21, and smokers who begin early are less likely to quit, tobacco companies aggressively target youth (and other special populations) in advertising, sponsorship of events, and product offers.5,7,8

As well, the decline in smoking is not occurring quickly enough. The Centers for Disease Control and Prevention warn that at the present pace, the national health objective to reduce adult cigarette smoking prevalence to 12% by 2010 will not be achieved. Accordingly, we need more and better tailored programs to help people quit or keep them from starting altogether. These should include evidence-based strategies such as waging new antismoking media campaigns, raising the price of tobacco products, and reducing the ability of minors to access products.9,10

Benefits of Quitting

Smokers who quit reap immediate health benefits. In the long term, risks of heart disease, lung and other cancers, and stroke are lowered.3 For some conditions, such as peripheral artery occlusive disease, stroke, and duodenal and gastric ulcers, ex-smokers reduce their risks to those of nonsmokers; for others, the risks are cut substantially. The bottom line is that quitting increases the potential for longer and healthier lives.7 (See Table 1).

Table 1. Health benefits of quitting.
• Blood pressure and circulation improve.
• Carbon monoxide levels drop.
• Coronary heart disease risk begins to decrease.
• Lung function begins to improve.
• Senses of smell and taste begin to improve.
• Heart disease risk is reduced by half after 1 year of abstinence.
• The risk of stroke is decreased.
• Lung cancer risk is decreased by 30%–50% after 10 years.
• After 5 years, risk of oral, esophageal, bladder, and cervical cancer is half that of smokers.
• Respiratory problems decrease.
• There is overall improvement in health and quality of life; less shortness of breath, fatigue, etc; and if the individual quits before age 50, the risk of dying in the subsequent 15 years is half that of smokers.
Special Benefits for Pregnant Women:
• Risk of low birth weight baby is decreased.
• Risk of miscarriage is decreased.
• Risk of stillbirth is decreased. [3,7,11]

Why Is It So Difficult to Quit?

Given these significant health benefits, why don’t more smokers quit? Nicotine addiction is the key. Terms like habituating, substance abuse, dependency, and powerfully addictive have been used by the US Surgeon General since the 1960s to describe how nicotine affects smokers. In 1988, nicotine was recognized as the principal pharmacological agent in tobacco, and nicotine dependence and nicotine addiction became scientifically equivalent.7 Just 10 to 20 seconds after inhaling a puff, nicotine reaches the brain; binds with the nicotinic receptor, autonomic ganglia, medulla, and neuromuscular junctions7,12; and increases nicotine receptor sites twofold to threefold. Receptor activation facilitates release of neurotransmitters. Acute nicotine administration results in increased dopamine and norepinephrine release from the central nervous system, producing the pleasurable effects that make nicotine so addictive and quitting so hard.12

Guideline for Treating Tobacco Dependence

Faced with the enormous public health burden of smoking, in 2000 the US Public Health Service, in partnership with nonprofit organizations, developed the Clinical Practice Guideline for Treating Tobacco Use and Dependence.13 The expert panel used published evidence-based research as the basis for their recommendations.

Since the clinical practice guideline was issued, researchers have examined various behavioral, pharmacologic, and alternative smoking-cessation interventions; and have assessed the level of research evidence for their effectiveness (see Table 2 and Smoking Cessation Resources sidebar for other evidence-based programs and materials). Many authors14,15 have observed that tailoring cessation interventions by combining types (such as behavioral interventions of counseling or self-help with pharmacological interventions like nicotine-replacement therapy) yields higher quit rates.

Table 2 Behavioral, pharmacologic, and alternative interventions.14-16
brief and low-intensity
intervention lasting 3-5 minutes
A group counseling/individual
counseling/intensive sessions
two or more sessions lasting longer than 10 minutes
A telephone counseling proactive telephone calls
A self-help written materials, audio or video tapes, computer programs
A nicotine replacement therapy (NRT) available as gum, transdermal patches, intranasal spray, inhaler devices, sublingual tablets
A bupropion anxiolytic and antidepressant
B** clonidine antihypertensive, may reduce withdrawal symptoms (has significant side effects)
B mecamylamine nicotine antagonist, may reduce desire to smoke
B nortriptyline tricyclic antidepressant
B fluoxetine, sertraline, paroxetine, naltrexone selective serotonin reuptake inhibitors
C*** alternative interventions aversion therapy, hypnotherapy, acupuncture, acupressure, electroacupressure, exercise
A*—Multiple, well-designed randomized clinical trials, directly relevant to the recommendation, that yield a consistent pattern of findings.

B**—Some evidence from randomized clinical trials supports the recommendation, but scientific support is not optimal (such as too few trials, inconsistent trials, trials not directly relevant).

C***—Studies have mixed results; some show significant improvement in cessation rates, and others show no evidence of improvement.14-16

Other Factors in Smoking and Quitting

A majority of smokers want to quit, but few plan to do so within the following 6 months; and only 20% to 25% of smokers who attempt to quit remain smoke-free at the end of 1 year.17 Thompson et al18 conducted interviews with heavy smokers (smoked 25 or more cigarettes daily) to understand the psychosocial issues related to smoking and quitting. They found that heavy smokers were least likely to stop and more likely to seek smoking-cessation assistance. They also discovered factors that influenced or promoted smoking, factors that influenced quitting, perceptions of quitting, and explanations of failure (see Table 3).

Smokers were highly addicted to nicotine; were physically, emotionally, and socially dependent on cigarettes; and used smoking to cope and comfort themselves because they felt their lives were conflicted and they had few personal resources to deal with their conflicts. The few successful quitters said that there was no single factor that accounted for their success; rather, they just knew “it was time to quit.” The researchers felt that the significant difference between being a smoker and an ex-smoker was a change in self-perception from being a smoker to being a former smoker. Quitting occurred when all internal and external influences merged with the desire, motivation, and commitment to quit smoking.18

Table 3 Factors that promote smoking and influence quitting.
Factors that promote smoking:
• physical addiction
• smell and taste of tobacco
• psychological habit
• drinking and stress relief
• social pressure from tobacco companies
• family members and smoking buddies
Factors that influence quitting:
• encouraging environment that included family and friends and a work site that supported cessation
• fear of weight gain
• loss of smoking friends
• felt it was impossible to quit
• fear of failure
• too many triggers for cessation to be easily achieved12,18


Clearly, for many smokers and some clinicians, changing smoking behavior seems like a daunting, even impossible task. Over the past two decades, Prochaska and colleagues have developed their Transtheoretical Model (TTM) to explain how people change smoking and other health behaviors.19-21 TTM has been applied to numerous smoking interventions and has resulted in cessation rates double those of standard efforts.12 TTM conceptualizes an individual’s change process using stages of change:

  • Precontemplation: Smoker does not intend to take action in the foreseeable future.
  • Contemplation: Smoker intends to change in the next 6 months.
  • Preparation: Smoker intends to take action soon, usually within the next month.
  • Action: Smoker made changes in lifestyle within the past 6 months.
  • Maintenance: Smoker has engaged in new behavior for 6 months or more without relapse.
  • Termination: Smoker does not give in to temptation and has complete self-efficacy.22

TTM also includes the measurable concepts of decisional balance and self-efficacy. For smoking cessation, self-efficacy is the belief in one’s capability to organize and execute specific actions necessary for successful quitting. Individuals with greater self-confidence in their ability to avoid smoking in high-risk situations are more likely to be successful in quitting.12,23 In 1997, Prochaska et al20 reported that approximately 40% of smokers are in the Precontemplation and Contemplation stages, respectively, and another 20% are in the Preparation stage. Someone who moves to the Action stage has decided that the pros or benefits outweigh the costs or barriers.

Smoking cessation, then, is seen as a process by which people move from stage to stage, sometimes regressing to an earlier stage, until they finally quit. Prochaska et al21 suggest that even brief interventions can help smokers progress one stage and result in high abstinence levels. Theoretical models like TTM and evidence-based interventions can help respiratory therapists understand the factors and processes inherent in smoking, quitting, and maintaining behavioral changes, and assist them in creating activities, messages, and referrals to fit the needs of individual smokers.

The Role of RTs in Smoking Cessation

Most smokers who present in the primary care setting and physician offices are not offered effective assistance in quitting.13,24 In fact, merely 15% to 21% are provided with help in quitting,13,15 and only 3% are given follow-up appointments to address the topic.13 A recent survey of physicians showed that 21% believed they were adequately prepared in their training to help smokers quit.12 Specific barriers to offering a smoking-cessation intervention include limited counseling skills and knowledge of interventions, lack of perceived effectiveness, inability to be reimbursed, and limited resources and organizational support.26,27

RTs are strongly committed to activities and programs that support smoking cessation. The American Association for Respiratory Care (AARC) has long been active in direct care, cessation programs, and advocacy.28-30 Yet there is much more to be done. Exactly how can RTs help smokers quit? First, as Goldberg et al12 note, we must have empathy for patients who smoke: “Without empathy, our ability to help our patients who smoke may be limited.”

Next, RTs must be aware of the smoker’s stage of change, and how we can facilitate a change. This requires understanding decisional balance: smokers must perceive reasons to stop as outweighing reasons to continue. This is where RTs can gain insight into the best way to approach the smoker. Smokers often move from one stage to another in a spiral-like pattern, rather than linearly, and must master each stage. If smokers are offered interventions when they are not ready, it could lead to resistance (and frustration for clinicians). For example, smokers in the Precontemplation stage are uninformed or uninterested in changing; in the Contemplation stage, they are informed and considering making a change; and in the Preparation stage, they are ready to try out different behaviors. Low self-efficacy may account for a relapse to an earlier stage.12

In their efforts to help smokers quit, RTs might also follow the advice of the World Health Organization and suggest a combination of behavioral and pharmacological interventions.7 As Cofta-Gunn and colleagues15 state, even “Brief interventions lasting less than 3 minutes are effective and can be delivered to all smokers in any clinical setting.” To this end, RTs can utilize the National Cancer Institute’s 5-A Model of Ask, Advise, Assess, Assist, and Arrange a follow-up (see Table 4).

Table 4 The 5-A Model.
Ask about and record smoking status Advise smokers of benefits of stopping in a personalized and appropriate manner (this may include linking advice to their clinical condition) Assess readiness to quit Assist smokers in their quit attempt (this might include the offer of support or referral to a specialist cessation service if necessary)

What’s Next?

Although many smoking-cessation services and products are available, there remains a large population of smokers who are unable or unwilling to quit. Research is under way to develop methods to help this group reduce their exposure to tobacco and thereby reduce their health risks17,29, and preliminary findings from studies examining nicotine-replacement therapy to maintain nicotine levels in conjunction with a reduction of cigarettes are promising.29 For smokers for whom these methods just don’t seem to work, a vaccine to encourage the immune system to attack nicotine and induce a high antibody response is under investigation.30


In your efforts to help smokers quit, the following takeaway points may prove helpful:

  • Quitting smoking has benefits for everyone.
  • Effective smoking-cessation interventions are built on theoretical models, address the influence of culture on smoking behavior, and are tailored for individuals.
  • Because smoking is highly addictive physically and psychologically, quitting often takes several tries, most people require assistance, and many relapse to an earlier stage before finally achieving their goals.
  • Multiple smoking-cessation techniques are more effective than a single technique, and incentives and follow-up activities can help sustain behavior change.
  • Finally, quitting is voluntary. No matter how well you convey the adverse health effects of smoking and the benefits of quitting, ultimately the decision to quit is up to the individual.


Roberta B. Hollander, PhD, MPH, is professor of health education, Howard University, Washington, DC. Donna Oliver-Freeman, MS , RRT, is adjunct faculty member, Northern Virginia Community College, Springfield, Va.


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