An examination of the smoking cessation management, and use of NRT in patients recovering from a recent symptomatic episode of coronary heart disease: a multi-method approach.

Abstract

Background: Smoking related coronary heart disease (CHD) is one of the greatest contributors to the occurrence of both primary and secondary cardiac events, and the subsequent premature death and disability of many Australians. Therefore, smoking cessation is an obvious way to reduce the risk of a repeat CHD event following an initial episode. Current evidence suggests that nicotine replacement therapy (NRT) can increase the odds of achieving cessation of smoking by as much as 50% when compared to placebo. However, despite the evidence which supports its effectiveness, NRT appears to be avoided and underutilised in the management of smokers recovering from a symptomatic episode of CHD. The literature indicates that much of this avoidance appears to be based upon unsubstantiated theory and concern regarding the safety and efficacy of NRT in this population. The three studies presented within this thesis were not designed to provide a definitive answer as to whether or not NRT is a safe and effective cessation of smoking treatment in those with symptomatic CHD but rather to examine the views, opinions and practice of healthcare professionals in both the inpatient and primary practice settings, along with the perspectives of patients admitted to hospital due to a symptomatic episode of CHD. It was hoped that this approach would help identify and explore the factors which contribute to, and direct the current practice, opinions and beliefs of both healthcare professionals and patients regarding the smoking cessation management and use of NRT in this population of smokers. For secondary prevention strategies such as smoking cessation to be successful in helping to curb the incidence of coronary events, current cessation management and interventions such as NRT need to be explored thoroughly. Method: A mixed method approach using both qualitative and quantitative methods provided the analytical foundations on which these studies were based. Both purposive and convenience samples of healthcare professionals practicing within the acute cardiac care inpatient setting, and the primary care setting, along with smokers admitted to the inpatient cardiac care environment were all utilised to inform the study. Results: From a patient perspective, admission to the cardiac inpatient environment appears to promote a self-assessment of current modifiable behaviours, which in turn can initiate a quit attempt and promote a patient’s willingness to be more receptive to cessation interventions and treatments such as NRT, and possibly increase the odds of achieving long-term cessation. However, several factors were identified which appear to influence a patients acceptance and adherence to interventions. Factors such as accessibility, knowledge, cost, family and environmental influences, and safety all have an influence on their odds of achieving success. Furthermore, from a clinical perspective, although healthcare professionals recognise the potential benefits of NRT, in most circumstances they are reluctant to use it due to safety concerns, inconsistent guidelines and policy, funding issues, accessibility issues, personal preference and possible legal implications. Conclusions: This research highlights that policy, guidelines and practice should change to reflect current best evidence and help patients with symptomatic CHD to stop smoking. Findings from this research suggest that there are several contributing factors that influence current practice, and the underutilisation of NRT in those recovering from a recent cardiac event. However, because much of the resistance to the use of this treatment is based upon unsubstantiated theory, concern resulting from inadequate knowledge, and conflicting guidelines, there is much that can be done to rectify the situation. Further research needs to be conducted that examines the safety and efficacy of NRT in this population of smokers, only then can evidence based knowledge be generated which will facilitate a change in current practice and improve the management of smokers recovering from an episode of acute or unstable CHD. Facilitating change should be considered paramount in order to pro-actively reduce the incidence of both smoking related primary and repeat cardiac events in this high risk population.