Improving Concordance to Smoking Cessation Treatment

National Institute of Clinical Excellence (2009) identified that medicine taking is a complex human behaviour that lies ultimately, in the hands of the patient. NICE (2009) estimates that between a third and a half of all medicines prescribed are not taken as recommended and Dunbar-Jacob et al (1995) evaluates that up to 80 per cent of patients can be expected not to comply with their treatment at some time.

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Shuttleworth (2006) noticed that health professionals use two terms to describe the medicine taking behaviour of patients: ‘compliance’ and respectively ‘adherence’. Compliance represents the extent to which a person’s behaviour coincides with the medical advice, for example patients to do as they are told (Haynes et al, 1979) while adherence is the capacity of the patient to self-regulate his or her treatment, for example his or her ability to re-fill prescriptions (Brock, 2000).

Medicines Partnership (2003) argue that in both compliance and adherence patients have a passive role, with no implication in their care and therefore concordance is needed to correct issues of non-compliance and non-adherence. Concordance advocates the idea of shared decision-making between health professionals and patients and it requires health professionals to engage with patients as partners, taking into account their beliefs and concerns (Medicines Partnership, 2003).

NICE (2009) insists that the biggest challenge of the research of concordance is how to influence and change behaviour and this is where health psychology comes in. According to Marks and Evans (2005) health psychology attempts to move away from a linear model of health that treats only the physical, to a model that treats the whole person including his or her behaviour.

In this essay the author will critically discuss how knowledge of health psychology can help nurses improve concordance with treatment in smoking cessation treatment. The idea promoted is that smoking is a behaviour influenced by the patient’s beliefs; the nurse will explore the patient’s beliefs on smoking and will help the patient to make an informed decision regarding her treatment. Patient X will be used as an example to observe behaviour change. The Stages of Change Model and other theories from health psychology will also be discussed.


Health Development Agency (2004) estimates that smoking is the greatest single cause of preventable illness and premature death in the UK, being responsible for more than 106,500 deaths each year.

Approximately 4000 chemical compounds have been identified in the cigarette smoke, of which 40 are known to cause cancer (McEwen et al, 2006). Among these compounds “tar” was linked to cancer, lung disease and heart disease; carbon monoxide (CO) was also identified as an inevitable consequence of the combustion that takes place while smoking (Tyler, 1995); furthermore, nicotine was found in cigarettes, however nicotine is not connected to cancer but with the addiction process. According to the RCP [1] (2000) nicotine meets all criteria used to define a drug of dependence and Wilkinson et al (2004) reasons that this makes smoking not a habit but an addiction.

In the light of these, nurses face a real challenge when trying to improve patient’s concordance with smoking cessation treatment. However, NIH [2] (2008) urges that most patients are ready to hear and receive help from nurses as the patient’s willpower alone has been shown to succeed in only 3 per cent cases of smoking cessation (McNeill et al, 2001).

The following scenario will be used to exemplify a nurse’s action and use of health psychology knowledge in helping improve a patient’s concordance with smoking cessation treatment: “Patient X is a bank manager. She has been a smoker for ten years. She is married and has one child age 5. She doesn’t want to stop smoking because smoking ‘calms her nerves’, because ‘it is not a good time’ and because she is afraid of withdrawal symptoms and gaining weight.”

The nurse will use the Transtheoretical Stages of Change Model to assess patient’s X motivation. The model was developed by Prochaska and DiClemente in 1982 to examine the five stages of change in addictive behaviours. According to Odgen (2009) the model is dynamic, not linear, with individuals moving backwards and forwards across the stages.

The first stage of the model is Pre-contemplation. Patient X was identified as being in this stage because she is not interested in quitting. McGough (2004) points out that sometimes beliefs are used to sustain unhealthy behaviours, for example ‘cigarettes calm my nerves’, as patient X claims. To address such health beliefs and her resistance to change, the nurse will use a consciousness raising exercise, respectively she will address patient X reasons for not quitting and give counterpoints to refute these reasons (Perkins, Conklin and Levine, 2007; Kaufman and Birks, 2009). For example, patient X states that ‘it is not the right time’; the nurse can address this by saying, ‘I’m concerned about your health and I would like you to consider quitting. I know it’s going to be difficult because it will interfere with life responsibilities however, the perfect time to quit may never come therefore this moment is as good to quit as any’ (Perkins, Conklin and Levine, 2007; Hollis et al, 2003; Rana and Upton, 2009). TMA [3] (2008) suggests that such message can prove more effective than a lecture about the lung cancer however the nurse can have a stop smoking handout to give to the patient as well.

This interaction with the patient must be kept as patient-centred as possible to improve concordance with treatment (Walker, J et al, 2007). Balint et al (1970) as cited in Rena and Upton (2009) suggest that “being patient-centred” should involve the asking and receiving of questions and information which result in patient’s understanding of the health information and the treatment proposed.

An accurate assessment of patient X within this stage will generate a strong treatment plan, therefore improved concordance (Straub, 2006; Brock, 2000). Furthermore, the nurse will convey warmth, understanding, acceptance and respect for the patient; this will help develop a fundamental nurse-patient relationship that is seen as a contributing factor to the patient’s concordance with the treatment regimen (Rana and Upton, 2006; Donohue and Levensky, 2006).

By learning that smoking is not good for her health patient X will move to the second stage of the Stages of Change Model called Contemplation. The patient is now aware of the health risks that smoking entails and ‘contemplates’ the idea of quitting (Perkins, Conklin and Levine, 2007). At this stage motivational interviewing can be used by the nurse to allow the patient to discover her own internal motivating factors in the favour of quitting; examples of factors can be: ‘my five year old child will grow in a smoke free environment’ or ‘I will have less changes of getting cancer’ (Ogden, 2009; NIH [4] , 2009). Furthermore, the nurse can suggest that patient X writes down as a reminder ‘I lose these benefits every day that I do not quit smoking’ (Connors, Donovan and DiClemente, 2004).

Moreover, the nurse can help patient X identify the pros and cons of smoking cessation treatment (Hollis et al, 2003). According to the Health Belief Model (HBM) (Rosentock, 1974 as cited in Rana and Upton, 2009) by weighing the pros and cons of treatment, people arrive at a decision of whether the perceived benefits (e.g. NRT [5] ) outweighs the perceived barriers (e.g. being afraid of the side effects of NRT).

Moreover, patient X is concerned that she may gain weight upon quitting. By still using the HBM the nurse can help the patient decide whether the perceived benefits of quitting (e.g. improved health) outweighs the perceived barriers (e.g. gaining weight) (Perkins, Conklin and Levine 2007).

The HBM is a social cognition model that has been applied to understand adherence behaviour in patients. This model suggests that the likelihood that someone will engage in a given health behaviour (e.g. adherence) is a result of four functions: perceived susceptibility, perceived severity, perceived benefits and cues to action (Rena and Upton, 2009).

In an argument against HBM’s application to smoking cessation, Robinson and Beridge (2003) state that weighing pros and cons of smoking cessation treatment is not a reliable approach because the smoking behaviour is underlined by addiction, so that it operates outside conscious awareness and it does not follow decision-making rules.

Perkins, Conklin and Levine (2007) agree that the motivational intervention used in the contemplation stage may push the person into the third stage of the Stages of Change model, called Preparation. The patient is now determined to make a change.

Both the nurse and patient X will share a decision making over preparation strategies; the outcome of this partnership will be a patient-centred, tailored plan that will improve adherence. For example, a nicotine patch may indeed help patient X to quit smoking, but a patient Z who not only has nicotine patches but also told his family and colleagues (especially those who smoke) about his quit attempt and ask for their support, is likely to be more successful than someone who relies on nicotine patches and willpower alone because social support enhances the likelihood of adherence (TMA, 2009; McEwen et al, 2006; Medicines Partnership, 2003).

Furthermore, patient X will be encouraged to set a quit date. The chosen date should be of significance for the patient so she can feel motivated to adhere to the treatment (Gross and Kinnision, 2007).

Moreover, the nurse may suggest behavioural changes such as clearing the house of all cigarettes and lighters (Marinker and Shaw, 2003).

Patient X will also be educated to recognize withdrawal symptoms and will be given tips on how to resist cravings (e.g. keep busy, eat fruits, sip water, call a helping friend); patient X will be re-assured that withdrawal symptoms last 2-4 weeks and reduce gradually; also, the nurse must introduce patient X to medication that can help reduce the severity of the withdrawal discomfort, such as NRT and Bupropion (McEwen et al, 2000). According to NICE (2009) the information about medication should be written to serve as a reminder at any stage of the treatment. Moreover, the patient will be shown how to use nicotine patches and gums because in this stage specific skills rather than motivation alone are needed to facilitate concordance with treatment (Gross and Kinnison, 2007; Thomason, Parahoo and Blair, 2007).

Furthermore, the nurse will answer any questions that the patient may have regarding medication. The Royal Pharmaceutical Society (1997) as cited in Rana and Upton (2009) suggests that how individuals perceive and think about medication (medication belief) is important when considering treatment adherence, therefore the nurse should be aware of patient’s X medication beliefs if she wants to break the barrier of non-adherence to treatment.

Patient X is now considered ready to move into the penultimate stage of the Stages of Change Model called Action.

At this stage, the nurse must provide on-going support to prevent the patient’s relapse. The nurse is encouraged to be honest with patient X about the likelihood of reverting to the old behaviour once the change process has started, not because the nurse expects patient X to fail, but because it normalizes the experience and takes away some of sense of failure and shame (Singer, 2009).

The nurse will also monitor patient X’s CO and saliva cotinine to confirm abstinence and boost motivation (Haskard-Zolnierek and DiMatteo, 2010). According to the Foundation for Blood research (2010) many patients may not be truthful when answering questions about their smoking behaviour, therefore tests such as measuring the amount of nicotine in saliva and the amount of carbon monoxide levels in the patient’s expired air can be useful to compare self-reported smoking behaviour against real measurements.

In an argument against this, Riemsma et al (2003) state that there is no evidence that moving an individual closer to the action stage actually results in a sustained change of behaviour at a later date.

After approximately six months in the action stage patient X will move to the last stage of the Stages of change model, the maintenance stage.

The nurse will praise the patient for the efforts made to change the unhealthy behaviour into a healthy one. This will make the patient feel self-efficient and have confidence to maintain the behavioural changes done in the quitting process (Odgen, 2009; NIH 2009). ‘Self-efficacy’ is a term introduced by Bandura (1997) as a cognitive mechanism underlying behavioural change. According to this theory, efficacy determines whether coping behaviour is initiated and maintained when faced with obstacles (e.g. nicotine cravings) (DiClemente, 1981).

Furthermore, the nurse can also write down essential tips to help patient X maintain concordance with treatment, such as ‘do something else instead of smoking, keep yourself busy’, ‘avoid tempting situations’ and ‘stick with your effort to quit, you can do it’ (Johnson et al, 1999; NIH, 2009).


To review, within this essay the author highlighted the ideas that knowledge of health psychology can be used to understand the patient’s smoking related health beliefs and also, improved concordance with smoking cessation treatment can be achieved by involving the patient as partner in care.