| | Smoking cessation treatment by Dutch respiratory nurses: Reported practice, attitudes and perceived effectivenessReceived 3 May 2007; received in revised form 30 August 2007; accepted 1 September 2007. Abstract ObjectiveTo describe Dutch respiratory nurses’ current smoking cessation practices, attitudes and beliefs, and to compare these with a survey from the year 2000, before the national introduction of a protocol for the treatment of nicotine and tobacco addiction (the L-MIS protocol). MethodsQuestionnaire survey among all 413 registered respiratory nurses in the Netherlands in 2006. ResultsThe response rate was 62%. Seventy-seven percent of the respondents reported to have “fairly good” or “good” knowledge of all steps of the L-MIS protocol. Seven out of 10 behavioural techniques for smoking cessation from the protocol were used by more than 94% of the respondents. Seventy-four percent of the respiratory nurses recommended the use of either nicotine replacement therapy (70%) or bupropion (44%). Almost two-thirds (65% of 254) perceived lack of patient's motivation as the most important barrier for smoking cessation treatment; a four-fold increase compared to the year 2000. ConclusionWe conclude that respiratory nurses are compliant with the L-MIS protocol. They offer intensive support and use behavioural techniques for smoking cessation more frequently than evidence-based pharmacological aids for smoking cessation. Perceived lack of patient's motivation forms the most important threat to respiratory nurses’ future smoking cessation activities. Practice implicationsInternational guidelines acknowledge that respiratory patients have a more urgent need to stop smoking but have more difficulty doing so. They should be offered the most intensive smoking cessation counselling in combination with pharmacotherapy. This kind of counselling may be more feasible for respiratory nurses than for physicians who often lack time. Their efforts could be increased by reimbursing pharmacological aids for smoking cessation and by developing simple tools to systematically assess motivation to quit and psychiatric co-morbidity in smoking patients. 1. Introduction  According to national and international guidelines [2], [3], nurses can play an important role with regard to smoking cessation treatment. They are the largest group among health care providers and can treat patients for smoking cessation effectively [4]. In the Netherlands, as in a number of other countries, respiratory nurses are a relatively new discipline (starting in the 1990s). They are nurses with additional training in respiratory medicine. Supporting smoking cessation attempts is a vital part of respiratory nurses’ work as most of their clientele are patients with diseases which aetiology and prognosis are closely related to smoking. For example, smoking is the primary cause of chronic obstructive pulmonary disease (COPD), and smoking cessation is the single most effective way to reduce the risk of developing COPD and to affect the outcome in patients at all stages of the disease [5], [6]. There is only little empirical data available on Dutch respiratory nurses’ reported practice, attitudes and beliefs towards smoking and smoking cessation. The only study we could find is a report on a survey that was performed in 2000 by a research and consultancy agency on behalf of the Dutch foundation for a smoke free future (STIVORO) [7]. Since then, a protocol for the treatment of nicotine and tobacco addiction (the so-called “L-MIS”) [1] has been implemented nationally among all respiratory nurses and new evidence has become available on various smoking cessation strategies [8], [9], [10], [11]. The L-MIS protocol basically describes seven steps of smoking cessation treatment during several consultations. These steps are listed in the text box. We performed a questionnaire survey among all registered respiratory nurses in the Netherlands to assess and describe their current smoking cessation practices, attitudes and beliefs. Furthermore, we wanted to compare the results from the current survey with the STIVORO survey from the year 2000, before the introduction of the L-MIS protocol. By doing these analyses, we wanted to assess the feasibility of respiratory nurses for taking on greater responsibility for smoking cessation treatment, because primary care physicians can only deliver minimal care in this respect. Steps of the L-MIS protocol [1] Step 1:Quick smoking cessation advice by the lung physician. Step 2:Smoking characteristics. Ask about the patients’ smoking status, cigarettes smoked per day, and readiness to quit. Nicotine addiction is defined by smoking more than 15 cigarettes per day or smoking the first cigarette within 30 min after waking up in the morning. Step 3:Motivation for quitting. Ask readiness for quitting and reasons for smoking and quitting. Discuss health risks of smoking and the pros of quitting. Step 4:Barriers of quitting. Discuss barriers of quitting and problems with previous quit attempts. Increase self-efficacy. Step 5:Target quit date (TQD). Make arrangements for quitting and planning of a target quit date. Step 6:Discuss the use pharmacological aids. The protocol recommends to use NRT particularly in nicotine addicted smokers and bupropion in addicted smokers who had several previous quit attempts. Step 7:Follow-up. Evaluation of the quit attempt. Motivate quitters to refrain from smoking and relapsers to start a new quit attempt. Steps 2–6 occur during the first and second consultation (2 weeks later) with the respiratory nurse. The duration of both consultations is 30–45min. A telephonic consultation is planned on the TQD. Follow-up consultations are recommended 2 weeks after the TQD and after 3, 6, and 12 months (5–10min each). 2. Methods 2.1. Questionnaire development and content The questionnaire was developed by the author and the co-authors (a group of two epidemiologists, one lung physician, and two respiratory nurses). The relevance of the different aspects of the questionnaire (content validity) was assessed by reviewing the content of current evidence-based guidelines [2], [3] and earlier surveys among Dutch respiratory nurses [7] and physicians [12]. Furthermore, we asked experts in the field to judge the questionnaire (face validity). The questionnaire included questions about current practice, attitudes, knowledge, skills, perceived effectiveness and barriers with regard to the treatment of smoking. We asked two questions for defining the respondents’ own smoking status: (1) “Do you smoke now and again or daily?” and (2) “Did you smoke in the past now and again or daily?” A respondent who answered “yes” to question 1 was defined as “current smoker”, a respondent who answered “no” to question 1 but “yes” to question 2 was defined as “former smoker”, and a respondent who answered “no” to both questions was defined as “never smoker”. The questionnaire was pre-tested among four respiratory nurses from Maastricht University Hospital and subsequently adjusted. The final questionnaire comprised a booklet of 10 black and white pages (DIN A4) with orderly and well-structured text. The completion time was approximately 20min. 2.2. Questionnaire administration The survey was carried out in cooperation with The Dutch Society of Respiratory Nurses (NVL). New members of the NVL are routinely asked written consent to be approached by third parties. Approximately, 90% of new members usually give their consent. The NVL provided us with an electronic file with the names and postal addresses of these members (n=413). The survey was announced on the society's website and in their bulletin. We sent the first mailing in June 2006, and two reminders including new copies of the original questionnaire to all non-respondents in July and August 2006. We sent a reply card along with the last mailing on which persistent non-respondents could report reasons for not responding. Every mailing was introduced with a personalized letter stressing the importance of the topic and signed by the chair of the NVL (WL) and a lung physician (GW) who is well-known in the field. Also, we announced to give away 40 bottles of red wine (Château Moulin 2004) among a random sample of respondents. Respondents could use pre-paid return envelopes to return the questionnaire. 2.3. Data analysis The design of the study is cross-sectional. In order to assess developments during the past years, we compared our results where possible with the survey performed on behalf of STIVORO in the year 2000 [7]. That survey assessed the smoking cessation strategies among all members of the NVL at that time (n=288). One hundred forty-one (54%) filled out and returned the questionnaire. Unfortunately, results from this survey have not been published in an internationally accessible journal but in an internal report. We have approval from STIVORO to use these results. We used 4- or 5-point Likert scales for questions measuring the frequency of a behaviour or the degree of agreement with a certain statement. We dichotomized these questions afterwards. This is further explained for each question in the results section of this article. We did not calculate reliability scores because we did not construct sum scales for measuring specific concepts but rather used separate questions. We omitted missing values on variables when calculating percentages (indicated as “valid” percentages in the tables). The proportion of missing values was on average between 0 and 2% for each variable. All analyses were performed using the SPSS (version 13.0). 3. Results 3.1. Response Two hundred fifty-four of the 413 respiratory nurses filled out and returned the questionnaire (response rate 62%). Another 46 (11%) returned the reply card of the last mailing and stated reasons for not responding. The most frequently mentioned reasons were “I only work with children”, “I do not work as a respiratory nurse any more”, and “I do not have to do with smoking patients in my job”. 3.2. Characteristics of the study population Table 1 shows demographic, smoking and work-related characteristics of the respondents. Two hundred respiratory nurses were female (95% of 254), and the mean age was 44 years. Thirteen respiratory nurses were current smokers (5%); a lower proportion than among Dutch general practitioners (8%), and similar to Dutch cardiologists and lung physicians (both 4%) [12]. Most respondents were registered nurses with either higher (51%) or intermediate (19%) vocational education. This educational level is similar to that of a bachelor. Of the respondents who had additional training in respiratory nursing (93%), the majority had this training at the national training centre SSSV (Stichting Specifieke Scholing Verpleegkundigen). They offer a 6-month-training course and examination on nursing of patients with asthma and COPD. Respiratory nurses generally spend approximately 50% of their time on direct patient contact, 20% on education, and the remainder on innovation, research, and consultation. Most respiratory nurses from this survey worked either in a district hospital (53%) and/or in home care (34%). | a Multiple responses possible. |
The demographic characteristics of the respondents from the current survey were comparable with the respondents from the 2000 survey: 94% of the respondents from that survey were female, and the mean age was 41 years. Also the work setting was comparable: 50% of the respondents from the 2000 survey worked in a district hospital, and 37% in home care. The proportion of current smokers, however, was higher in the year 2000: 9%. Ninety-six percent of the respondents from the current survey were familiar with the L-MIS protocol for the treatment of smoking cessation in lung patients [1], which had been implemented nationally among all respiratory nurses between the years 2000 and 2006. Seventy-seven percent reported to have “fairly good” or “good” knowledge of all steps of the protocol. 3.4. Assessing and confronting the smoking patient Of the 205 respiratory nurses that reported to treat patients for smoking cessation, 166 (81% of 205) reported to systematically assess the motivation of the patient to quit smoking. Seventy-three (37%) used a validated questionnaire for this (which questionnaire was not stated). One hundred twenty-two respiratory nurses (60%) reported to systematically assess the degree of tobacco addiction of the patient, 30 (15%) by using the Fagerström Test for Nicotine Dependence [13]. Seventy-six respiratory nurses (37%) reported to systematically assess signs and symptoms of psychiatric co-morbidity such as depression or anxiety. Only one person used a validated questionnaire: the Beck Depression Inventory [14]. One hundred eighty-nine respiratory nurses (92% of 205) reported to use the “Fletcher curve” [15] and 143 (70%) to use results from spirometry for confronting the patient with the harmful effects of smoking during smoking cessation consultations. Within the latter group, 74 (52% of 143) believed that confrontation with spirometry for smoking cessation is more effective than health education without confrontation. 3.5. Use of behavioural techniques and recommendation of aids for smoking cessation Fig. 1, Fig. 2 show the use of various behavioural techniques and aids for smoking cessation. The black bars represent the proportion of respiratory nurses from this 2006 survey reporting to use the specific technique or aid “often” or “always” (versus “sometimes” or “never”). Responses are restricted to the sub-sample of 205 respiratory nurses who reported to treat patients for smoking cessation. The grey bars represent the response of respiratory nurses from the 2000 survey. Fig. 1 shows that, compared with the situation in 2000, all 10 behavioural techniques for smoking cessation were used by a higher proportion of respiratory nurses in 2006 (on average 93% compared to 72% in 2000). The largest increases were found in making arrangements for quitting (83% compared to 38%) and setting a target quit date (79% compared to 32%). Seven out of 10 techniques were used by more than 94% of the respondents. Seventy-four percent of the respiratory nurses recommended the use of the two most important evidence-based pharmacological aids for smoking cessation at that time; either nicotine replacement therapy (NRT, 70%) or bupropion (44%). Notriptyline, a tricyclic anti-depressant which has also been shown to be an effective aid for smoking cessation [8], was recommended by 19%. Fig. 2 shows that the proportion of respiratory nurses recommending NRT and bupropion was similar in 2006 compared with 2000. There was a sharp increase of nurses recommending individual counselling for smoking cessation. Furthermore, approximately 20% recommended acupuncture or laser therapy and 6% hypnosis—therapies not proven to be effective. 3.6. Perceived self-efficacy towards smoking cessation We asked the respiratory nurses about their perceived effectiveness towards strategies for smoking cessation. Seventy-two percent (n=184 of 254) of the respondents agreed that their behavioural counselling helps smokers to quit smoking. Seventy percent (n=178) agreed that NRT, such as nicotine gum or patch, helps smokers to quit smoking and 65% (n=164) agreed about anti-depressants, such as nortriptyline or bupropion. Forty-two percent (n=107) agreed that alternative treatments, such as acupuncture, help smokes to quit smoking. We also asked respiratory nurses to estimate what proportion of smokers that receive smoking cessation treatment remains abstinent for at least 1 year. The median percentage estimated was 30% (range 0–90%). One hundred and ten out of 254 respiratory nurses (44%) believed that a smoker with asthma or COPD has more difficulties to quit smoking than a “healthy” smoker. We asked an open-ended question to explain why. The most frequently given explanations were that smokers with asthma or COPD have a longer smoking history and a higher degree of nicotine addiction, more psycho-social co-morbidity, and that they perceive the cigarette as their last and only solace. Fig. 3 shows seven potential barriers for the treatment of smoking cessation. The bars represent the proportion of respiratory nurses who perceive to be hindered by the specific barrier “to a considerable” or “large extent” when treating a patient (versus “to a little extent”, “not at all”, or “indecisive”). Whereas six barriers were perceived by a minority of respiratory nurses (by less than a quarter), almost two-thirds (65% of 254) perceived lack of patient's motivation as a barrier for smoking cessation treatment. This is almost four times as much as in the 2000 survey where 17% reported lack of patient's motivation as a barrier. In that year, lack of time (31%), skills (29%), and knowledge (26%) where the most frequently reported barriers. 3.7. Perspectives towards a smoke-free future At the end of the questionnaire, we asked an open-ended question about the respiratory nurses’ personal view how smoking cessation should be further stimulated in the Netherlands. The three most frequently offered suggestions were: the introduction of a smoking ban in bars and restaurants, increased health education and promotion among the youth, and reimbursement of smoking cessation aids. 4. Discussion and conclusion 4.1. Discussion We conducted a questionnaire survey about smoking cessation treatment among all respiratory nurses registered at the Dutch Society of Respiratory Nurses (NVL). We compared our results where possible with the results from a survey conducted on behalf of the Dutch foundation for a smoke free future (STIVORO) in 2000, before the national introduction of a protocol for the treatment of nicotine and tobacco addiction (the so-called “L-MIS” protocol). Compared with the year 2000, respiratory nurses nowadays offer more intensive smoking cessation treatment to patients. A higher proportion uses various behavioural techniques which are important for smoking cessation whereas the use of pharmacological aids for smoking cessation has not increased (except for nortriptyline). A high proportion of respiratory nurses feels confident about the effectiveness of their behavioural counselling, NRT, and anti-depressants for smoking cessation. The most important barrier for smoking cessation treatment, currently perceived by two-thirds of the respondents, is lack of patient's motivation. Our findings are based on a repeated survey and not on a controlled trial, and therefore, no firm conclusions can be drawn about the effects of the implementation of the L-MIS protocol between 2000 and 2006. Despite this, we think that the results show that the majority of the respiratory nurses (77%) are familiar with all steps of the L-MIS protocol and suggest a very high compliance with the protocol. The recommendations from the protocol also seem to explain why bupropion is used less frequently than NRT and why both aids are used by not more than 44–70% of the respiratory nurses. Previous research has shown that the combination of counselling and pharmacotherapy is more effective than either alone [8], [9], [16], and international guidelines recommend the use of pharmacotherapy in all patients trying to make a quit attempt [3], [17]. Therefore, respiratory nurses should be encouraged to recommend more frequently evidence-based pharmacological aids for smoking cessation in combination with counselling. Today, smoking cessation aids are not reimbursed in the Netherlands, and the high costs of these aids, especially bupropion (Zyban™, EUR 70, per month of treatment [18]), restrain many smokers from their use. Nortriptyline, a generic non-patent medicine, reimbursed by all health-care insurance companies, has been shown to be a cheap and effective alternative [8], [19]. The patient's 12-month quit rate estimated by respiratory nurses from our survey (median 30%) seems to be low but is slightly optimistic compared to success rates reported from cotinine-validated explanatory randomized controlled trials (approximately 18–30% for a combination of pharmacotherapy with counselling) [3]. Half of the respiratory nurses believe that smokers with asthma or COPD have more difficulties quitting than a “healthy” smoker, an impression also shared by the European Respiratory Society's task force on smoking cessation in patients with respiratory diseases [17]. The nurses suspect addiction and psycho-social co-morbidity to be reasons for these difficulties. In fact, studies show that smokers with COPD tend to be more addicted to nicotine and tobacco [20] and are more likely to have depression [21] and anxiety [22]. As psycho-social co-morbidity is prevalent in smokers with COPD and associated with their smoking behaviour and attempts to quit smoking, systematic assessment of mental health and use of appropriate counselling techniques is important. Only a minority of respiratory nurses (37%) currently assesses psycho-social problems and most of them do not do this systematically or with the use of validated instruments. Respiratory nurses perceive lack of patient's motivation as their most important barrier for smoking cessation treatment. Motivation to quit is an important condition for successful smoking cessation, but there is no good, validated measure for assessing the degree of motivation to date [17]. However, is it really a lack of motivation or rather low perceived self-efficacy towards quitting and frustration about numerous relapses that discourage smokers to start a new quit attempt? Probably the majority of smokers would give up smoking if it was cheap and easy. An explanation for the four-fold increase in proportion of respiratory nurses who perceive this barrier in 2006 compared to 2000 might be that the patients they see nowadays who still smoke represent a group of “die-hards” who have enormous difficulties to give up smoking. Respiratory nurses’ perceptions of patients’ low motivation and high relapse rates (70% after 1 year) are likely to influence their attitudes towards smoking cessation. Twenty-two percent of respondents from the current survey stated: “I find it ridiculous that lung patients smoke despite their disease” (data not shown in the results section). As a dangerous consequence, negative attitudes might undermine respiratory nurses’ future smoking cessation activities. A different barrier for taking action against smoking may be personal smoking habits. The results from our survey show that the prevalence of smoking among respiratory nurses is only 5%, which is lower than in Dutch GPs (8%) [12] and much lower than in the general population in the Netherlands (30%) [23]. This indicates, that personal smoking may be a barrier only for a very small group of respiratory nurses. The most frequently offered suggestions to promote smoking cessation in the Netherlands were the introduction of a smoking ban in bars and restaurants, increased health education and promotion among the youth, and reimbursement of smoking cessation aids. The first two mentioned suggestions are well-known measures to prevent smoking, but are out of respiratory nurses’ influence. Reimbursement of smoking cessation aids, however, has been shown to be effective in promoting smoking cessation, both internationally [24] as in the Netherlands [25]. Reimbursement of evidence-based pharmacological aids has the potential to increase respiratory nurses’ efficacy in smoking cessation treatment. The findings from this questionnaire survey are limited by the moderate response rate of 62%. Such a response rate is not unusual for studies in this field. The response to our survey was higher than to the previous survey among respiratory nurses from the year 2000 (54%). Recent surveys about smoking cessation practices conducted among Dutch general practitioners, cardiologists and lung physicians in the years 2002 and 2003 yielded response rates of 42–69% [12]. Eleven percent of our population indicated by using a reply card that the content of the questionnaire was not applicable to them. We do not have information about the remaining 23%, but if selection bias has occurred, it is likely that the responders represent a group of respiratory nurses that is more active in smoking cessation treatment than the non-responders. In that case, the smoking cessation activities reported in this survey may be an overestimation of the actual situation. The comparison of the results from the current survey with data from the 2000 survey is limited by the fact that this is not a repeated survey among the same population. The characteristics of respondents from the two surveys were comparable, except for the proportion current smokers, which was lower in 2006 (5%) than in 2000 (9%). It cannot be ruled out that different selection of respondents has biased the comparison of results. 4.2. Conclusion Based on the results of our national survey, we conclude that respiratory nurses are compliant with the protocol for smoking cessation practices in lung patients which has been implemented nationally in previous years. They offer intensive support and use behavioural techniques for smoking cessation more frequently than evidence-based pharmacological aids for smoking cessation. By delivering such care for smoking cessation, respiratory nurses play a key role in the treatment of respiratory patients who smoke. Perceived lack of patient's motivation forms the most important threat to respiratory nurses’ future smoking cessation activities. 4.3. Practice implications International guidelines acknowledge that respiratory patients have a more urgent need to stop smoking but have more difficulty doing so than the average smoker [17]. Tobacco dependence is a chronic condition that often requires repeated intervention and the effectiveness of interventions increase with treatment intensity [3]. Respiratory patients should be offered the most intensive smoking cessation intervention [26], a combination of intensive smoking cessation counselling in combination with pharmacotherapy. Respiratory nurses are key to the delivery of smoking cessation treatment according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines [26]. The results from our survey show that respiratory nurses are able to deliver this treatment on the basis of the national protocol for smoking cessation. Intensive smoking cessation counselling may be more feasible for respiratory nurses than for physicians who often lack time. Their efforts could be increased by reimbursing pharmacological aids for smoking cessation and by developing simple tools to systematically assess motivation to quit and psychiatric co-morbidity in smoking patients. Acknowledgements We would like to thank Kitty van der Meer for her help with the administration of the survey. Competing interests: The authors have no competing interests. Funding: This study was supported by a grant from Pfizer. The funding source had no involvement in study design, collection, analysis, and interpretation of data, in writing of the report and in the decision to submit the paper for publication. Appendix A. References [1]. [1]STIVORO. De L-MIS: stoppen met roken voor longpatiënten. Handleiding voor longverpleegkundigen [The L-MIS: smoking cessation in lung patients. Strategy for respiratory nurses]. STIVORO: Den Haag; 2003. [2]. [2]Kwaliteitsinstituut voor de Gezondheidszorg CBO. 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[26]. [26]Global Initiative for Chronic Obstructive Lung Disease, Global strategy for the diagnosis, management, and prevention of chronic pulmonary disease. Executive summary; 2006 [NHLBI/WHO]. a Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands b Catharina Hospital Eindhoven, The Netherlands c Department of Respiratory Medicine, Maastricht University Hospital, The Netherlands d Dutch Society of Respiratory Nurses (NVL), Nijkerk, The Netherlands  Corresponding author at: Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands. Tel.: +31 43 3882893; fax: +31 43 3619344.
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