This section addresses two other important psychosocial issues common to patients referred to pulmonary rehabilitation: inadequate social support and cigarette smoking. While cigarette smoking is a physical addiction with major systemic consequences, it has a very prominent psychosocial component as well, and will be discussed in this section.
The psychosocial intervention perhaps most fundamental to pulmonary rehabilitation is developing an adequate support system. (27) Staff support, consisting of caring professionals displaying counseling skills, is key to successful programs. Such services often entail active listening and crisis management skills as well as patient advocacy and facilitation of resource acquisition. Additional support may be derived from family members, friends, and other program participants. Generally speaking, patients with chronic respiratory disease who have positive social support have less depression and anxiety. (28) COPD patients living with a partner have a longer life expectancy.
Social support can be enhanced through educational presentations and patient involvement in support groups that encourage the sharing of personal experiences. The group environment is conducive to participant sharing of disease-related information and successful coping skills. It also provides an outlet for emotional release and elicitation of emotional support. Further opportunities for patient interaction can be developed in waiting areas and during social events. To enhance their sense of self-worth, some patients may also choose to serve as volunteers for the rehabilitation program or other community activities. It is important to note that some patients do not do well in a group setting; the pulmonary rehabilitation staff must respect each patient’s sense of privacy.
Social support can also be fostered through the involvement of the patient’s spouse or support person. Significant others should be encouraged to participate in support groups in which family dynamics and interpersonal skills can be observed, information can be shared, misperceptions can be clarified, and fears and concerns can be addressed. Rehabilitation staff should be sensitive to caregivers and spouses because they are often receiving little support themselves. Particularly important are discussions and skill development activities focusing on how family members can provide support to the patient without promoting dependency. Collaboration between the patient and support person is fostered when both parties can come to terms with the illness; commit to working together to manage the illness; be sensitive to cues signaling the needs, desires, and feelings of the other; compromise; and seek out choices and resources for managing their lives. (31) For the patient having significant interpersonal or family conflict, referral to a clinical social worker, psychologist, or other counselor for family or relationship counseling is recommended.
Tobacco use is the leading preventable cause of death and disease in the United States. Smoking results in more than 435,000 deaths annually (27-28) and is the major risk factor for COPD. Nicotine dependence interventions can rapidly reduce the risk of smoking-related diseases and their consequences. (29) Tobacco use and dependence are chronic disorders in which repeated cessation attempts and sporadic relapses are common. Successful long-term cessation without assistance is unlikely but improves with optimal clinical support. A chronic disease model emphasizes the importance of continued patient education, counseling, and advice over time. Clinicians in the pulmonary rehabilitation setting play a key role in motivating patients to quit and assisting them with proven methods to facilitate long-term successful cessation.
Nicotine dependence is often tied to the psychoactive impact of nicotine. Smoking stimulates neurochemical pathways associated with cognitive stimulation, memory, pleasure, mood control, anxiety reduction, relaxation, and appetite suppression. Smoking’s pleasurable effects are reinforced by the conditioned response associated with environmental triggers, including alcohol use. Conversely, nicotine withdrawal is associated with anxiety, restlessness, irritability, impaired concentration, depressed mood, insomnia, headache, increased appetite, and weight gain. Although nicotine has little danger beyond dependence, tobacco addiction is profoundly dangerous. The focus of pharmacological and behavioral management of nicotine dependence is to reduce withdrawal symptoms and promote behaviors linked with successful long-term cessation. Use of combined pharmacological and behavioral interventions improves the chances of successful long-term cessation. Persons who are pregnant should be encouraged to quit without medication.
A combination of behavioral and pharmacological treatments is recommended for optimal management of nicotine dependence and improved quit rates. Tools used to determine nicotine dependence include the Fagerstrom Tolerance Questionnaire and the Fagerstrom Test for Nicotine Dependence. Initial patient assessment should include the following:
- The patient’s desire to quit
- The number of cigarettes smoked daily
- Whether the patient smokes within 30 minutes of awakening
- Previous quit attempts including methods, effectiveness, and relapse triggers
Approved first-line pharmacological management for nicotine dependence includes nicotine replacement, bupropion (Zyban, Wellbutrin), and varenicline (Chantix). Nicotine replacement therapy (NRT) is available in patch, lozenge, and gum form without a prescription and as a nasal spray and oral inhaler with a prescription. NRT is normally begun on the identified quit date and usually continued for 2 to 3 months. NRT is considered generally safe in persons with known cardiovascular disease. Acidic beverages such as coffee, juices, and soft drinks reduce oral nicotine absorption and should be avoided for 15 minutes before and during use of nicotine gum, lozenges, and inhalers. Patient preference, affordability, and medical considerations should dictate pharmacological therapy.
Transdermal patches provide extended release of nicotine over 24 hours. Patches are applied daily to nonhairy skin, and the sites are rotated regularly to avoid irritation. Symptoms of insomnia and vivid dreams may be controlled by removal of the patch at bedtime. For persons smoking fewer than 10 cigarettes daily, 7 to 14 mg patches are recommended. For those smoking more than 10 cigarettes daily, 21 mg patches are recommended. Many people begin on a 21 mg patch and taper to a lower strength (14 and 7 mg) over 8 or more weeks. Brand name and generic patches offer identical nicotine delivery.
Nicotine gum provides rapid relief from craving, with peak serum nicotine levels achieved in 20 minutes. The gum is chewed until flavor is tasted and then is parked between the cheek and gums. The gum is chewed intermittently for up to 30 minutes. For people who smoke more than 25 cigarettes a day, 4 mg gum is recommended; 2 mg gum is appropriate for those who smoke less.
Nicotine lozenges offer an alternative to gum for those with dentures or poor dentition. The lozenge is dissolved in the mouth over 30 minutes by wetting and parking it between the cheek and gums. The 4 mg lozenge is recommended for those who smoke within 30 minutes of awakening. One or two lozenges are normally used per hour for 6 weeks (minimum of 9 per day), with a gradual dose reduction over 6 weeks.
Nicotine inhalers offer the advantage of addressing both physical and emotional nicotine dependence. The recommended dose is 6 to 16 cartridges a day for 6 to 12 weeks. Local mouth and throat irritation are common, and bronchospasm may occur.
Nicotine nasal spray provides a rapid rise in nicotine concentration, with a peak concentration 10 minutes after use. One spray in each nostril one or two times per hour as needed is recommended for approximately 3 months. The minimum recommended treatment is 8 doses per day, with a maximum of 40 doses per day or 5 doses per hour. Side effects include nasal and throat irritation, rhinitis, sneezing, and tearing.
Bupropion is thought to reduce craving by enhancing CNS noradrenergic and dopaminergic release. Bupropion is generally begun 1 week before the quit date, with a usual dose of 150 mg daily for three days followed by 150 mg twice daily for 7 to 12 weeks or longer. Bupropion may be a preferred choice for persons with depression or concerns about weight gain from cessation. Side effects include insomnia, agitation, dry mouth, and headache. Bupropion lowers the seizure threshold and is contraindicated in persons with a history of seizure disorder or eating disorder. See the box "Safety Warnings for Varenicline and Bupropion."
Varenicline is a partial nicotine receptor agonist that binds to and partially stimulates nicotine receptors. It acts to reduce both nicotine withdrawal symptoms and the rewarding sensations of cigarette smoking. Side effects include nausea and abnormal dreams. Nausea may be reduced by gradually titrating the dose upward over one week from 0.5 mg daily for 3 days to 0.5 mg twice daily for 3 days to 1 mg twice daily. See the box "Safety Warnings for Varenicline and Bupropion."
Nonpharmacological approaches include individual counseling and self-help materials. Effective counseling includes cognitive behavioral strategies such as self-monitoring, gradual reduction in smoking in anticipation of an established quit date, and relapse prevention strategies. Counseling helps patients problem-solve barriers to quitting and use social support for successful cessation. Motivational interviewing uses empathy, open discussions about positive and negative aspects of smoking, a menu of cessation techniques, and discussions of patient goals and how smoking is inconsistent with these goals. Offer patients alternatives and options for managing cravings such as distraction, deep breathing, postponing smoking and rethinking the need to smoke, and calling a supportive person. Toll-free numbers are available for counseling, including 1-800-QUIT-NOW in the United States. Encourage persons concerned about increased hunger to use oral substitutes for cigarettes such as gum, cinnamon sticks, sugar-free hard candy, toothpicks, water, and low-calorie drinks. Symptoms of irritability may improve with a walk, a bath, or a pleasurable activity. Patients should be encouraged to reward their successes with a healthy treat.
Critical factors for smoking cessation include a patient’s desire to quit as well as skills and assistance to quit. A framework for health care providers to help patients stop smoking is the five As:
1. Ask—Identify all tobacco users at every visit.
2. Advise—Deliver a clear, strong, and personalized message: "As your [respiratory therapist, nurse, physical therapist], I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. Smoking will make your lung disease worse. I will help you with quitting. It is important that you quit smoking now. Occasional or light smoking is still dangerous."
3. Assess—Determine the patient’s willingness to quit. "Are you willing to try to quit?"
4. Assist—Provide counseling and medication. Help the patient develop a quit plan and set a quit date, ideally within 2 weeks. The patient should discuss his plan with family and friends and ask for understanding and support. Challenges should be anticipated, particularly during the first 2 weeks of withdrawal symptoms. Instruct the patient to remove tobacco products from his environment. Recommend approved medication, except when contraindicated or when there is insufficient evidence of effectiveness, such as for pregnant women, smokeless tobacco users, light smokers, and adolescents. Evaluate what has helped and hindered past attempts at quitting, and build on past successes. Discuss challenges and triggers and how to successfully overcome them. Alcohol is associated with relapse, and the patient should consider not drinking or limiting alcohol while quitting. Quitting is more difficult when there is another smoker in the household. Other smokers at home should be encouraged to quit or advised to not smoke around the patient. Provide the patient with ongoing support, including written information from the national quitline network in the United States (1-800-QUIT-NOW) and other organizations. Materials should be appropriate for the patient’s culture, race, education, and age. Provide practical counseling including problem solving and skills training. Strive for total abstinence.
5. Arrange—Ensure follow-up contact. Follow-up contact should begin soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Identify concerns encountered, and anticipate future challenges. Assess medication use and problems. Congratulate nonsmokers on their success. If the patient is smoking, review the circumstances of relapse and work with the patient on complete cessation. Consider use of more intensive treatment.
If a patient has little or no interest in quitting, asking what the person likes and dislikes about smoking may help the clinician to understand the patient’s perspective and the patient to consider possible negative aspects of smoking.
Intensive behavioral interventions are the most effective. Adjunct strategies include recommending exercise, proper nutrition, and spiritual support for those who express interest. Those who struggle with persistent smoking despite use of guidelines strategies may benefit from referral to a nicotine dependence specialist.