The document discusses applying Pender's Health Promotion Model to assist with smoking cessation in a primary care setting. The HPM provides a framework to understand factors influencing health behaviors. It was developed to promote healthy lifestyles through counseling. The HPM identifies individual characteristics, experiences, and cognitive/affective factors that influence behaviors and can be addressed to support behavioral change. The document proposes using the HPM to guide assessment of factors impacting a patient's smoking and ability to quit, such as perceived benefits/barriers, self-efficacy, social influences and developing a personalized plan to address these. Barriers to smoking cessation efforts are also discussed.

1. Health Promotion
Model
& Smoking
BY: Group 7- FABIANA SAAD, THAO NGUYEN, DILYS FAN, JESSICA FANT, and AMAN
SAHOTA

2. Theory: Health Promotion Model
Pender’s Health Promotion Model (HPM) offers a framework for understanding the
determinants of health behaviors. Based from a nursing perspective of holistic human
functioning, the HPM is an integrative middle range theory that incorporates the concept
of multidimensional people interacting with their physical and social environments as
they pursue health (Butts & Rich, 2015). The HPM was developed in 1982 by Dr. Nola
Pender, a nurse who sought to promote healthy lifestyles through behavioral counseling.
Health care providers were encouraged to use this model to help their patients identify
factors that influence health behaviors in order to achieve the highest levels of well-being
(Pender, 2011).

3. Setting/Problem
Smoking Cessation in Primary Care setting

4. Introduction
1. This video provides a good overview
of Pender’s HPM
https://www.youtube.com/watch?v=o6zdblvVz2A
1. This youtube video illustrates the
effects of smoking and how the HPM
can be applied in the clinical setting:
https://www.youtube.com/watch?v=KkKk5eVDoIw
● The Health Promotion Model is being applied in the primary care
setting to assist providers in helping their patients with smoking
cessation.
● Research indicates that PCP have a strong influence on smoking
cessation, and with the right tools can intervene successfully. In fact,
70% smokers visit PCP, making primary care setting ideal to
intervene for counseling (Kruger et al., 2015)
● The International Agency for Research on Cancer, for example,
concluded that brief advice from physicians to smokers have been
more effective than other individually focused interventions (Kruger,
O’Halloran, & Rosenthal, 2015).
Learning Activities

5. This is a more visual step-by-step approach to aid providers in the primary care setting

6. Objectives
A. Understand the epidemiology and significance of smoking tobacco and why it is relevant to
nursing (prevalence, morbidity/mortality, as well as the consequences associated with it).
B. Describe and evaluate Pender’s Health Promotion Model.
C. Discuss why and how the Health Promotion Model can be utilized to quit smoking.
D. Identify problems that arise when applying the Health Promotion Model to smoking cessation
in the primary care setting, and how they can be solved.

7. Magnitude of the Problem & Consequences
Smoking increases risk for cancer
Risk of developing lung cancer is
about 23 times higher among
men who smoke cigarettes and
about 13 times higher among
women who smoke cigarettes
compared with never smokers
Smoking compromises overall health
and financial well being
(CDC, 2014)

8. Smoking’s Relevance to Nursing
Smoking is the leading preventable cause of death in the United States
(CDC, 2014a). Smoking cessation decreases further damage to the body.
Nurses are frequently at the “front line” and in contact with the public,
and thus can play an important role in the primary prevention of cancer
(McIlfatrick, Keeney, McKenna, McCarley, & McIlwee, 2014).
Nurses and nurse practitioners are trained in health promotion and
prevention, and thus are the ideal group to empower individuals to take
responsibility for their own health and make more informed lifestyle
choices (McIlfatrick et al., 2014).

9. How do we Approach this Problem?
Pender’s Health Promotion Model
Pender’s Health Promotion Model (HPM) helps nurses understand major determinants of
health behaviors, which support behavioral counseling to promote healthier lifestyles (Pender,
2011). The overall goal is to increase the well-being and self-actualization of individuals,
families, communities and society (Raingruber, 2014).
According to Pender’s HPM, one’s individual characteristics, including biological,
psychological, sociocultural, and prior health-related behavior, help to determine individual
perceptions (Raingruber, 2014).
The model’s 8 beliefs: perceived benefits of action, perceived barriers to action, perceived
self-efficacy, activity-related affect, interpersonal influences, situational influences, commitment
to a plan of action, and immediate competing demands and preferences (Pender, 2011).

10. How can HPM Affect Smoking Cessation?
Perceived benefits
● Health benefits to quitting at any age
● Decreased risk of cancer, heart disease (within 2yrs of
quitting), stroke and peripheral vascular disease;
● Decreased respiratory symptoms and lung diseases
● Increased fertility and birth weight (if smoking during
pregnancy) (CDC, 2015).
Activity Related Affect
● How one feels prior to, during and following smoking
(Pender, 2011). A provider can use this knowledge to
help motivate the patient towards the action of
smoking cessation.
Perceived barriers (blocks, hurdles, personal costs)
● Stress management
● Lack of support from providers
● High prevalence and acceptability of smoking
● Maintenance of mental health
● Cultural and historical norms, living conditions,
● Competing priorities
● High accessibility of tobacco (Twyman, Bonevski, Paul, & Bryant,
2014).
● Enjoyment of smoking
● Craving
● Withdrawal symptoms
● Weight gain
● Fear of failure
● Cost of medications
● Disruption of social relations, and discouragement
(Theobald, Smith & Fiore, 2005).

11. How can HPM Affect Smoking Cessation?
Perceived Efficacy
● Defined as one’s confidence in abstaining from
smoking.
○ If a person believes they can quit smoking,
then they are more likely to commit to it
and succeed at smoking cessation (Pender, 2011).
● People tend to have greater self-efficacy when
they have fewer perceived barriers to stop
smoking and a positive attitude towards
smoking cessation (Pender, 2011).
How to improve self-efficacy
● Successful experiences lead to greater self
efficacy
● Vicarious experience through social modeling
increases self-efficacy.
○ Observing someone else successfully
quitting smoking increases one’s belief
that they, too, can succeed.
● Verbal or social persuasion increases self-
efficacy through encouragement from others
○ Helps one to overcome self doubt.
● Improving physical and emotional states can
increase confidence about their personal ability
(Bandura, 1977).

12. How can HPM Affect Smoking Cessation?
Identify Interpersonal Influences
● Norms, social support, and role models (family,
peers, providers), and their perceptions of behaviors,
beliefs, or attitudes towards smoking (Pender,
2011).
○ Who in the patient’s life will support their smoking
cessation and encourage them to quit?
Situational influences
● What in the environment encourages a person to
smoke? How can the external environment be
changed to decrease smoking behavior?
○ For example, removing ashtrays may help. Or if a
person smokes on the way to work, what is the cue
that encourages this behavior? Perhaps driving a
different route would help. Or replacing smoking
with chewing gum.
Commitment to a plan of action.
● The greater one’s intention to stop smoking is, the more
likely one will be successful and maintain it over time
(Pender, 2011).
● Identifying specific strategies for a person.
Immediate competing demands and
preferences
● Reduce demands that require immediate attention so more
attention can be devoted to smoking cessation (Pender, 2011).
● By reducing stresses or aspects of one’s life that encourage
smoking, it becomes easier to quit. A strong support
system could be helpful with this.

13. Health Promotion Model Evaluation
● The HPM is commonly used as it demonstrates clarity,
consistency, and congruency in its philosophical and
theoretical bases and conceptual components.
○ Philosophically, the model draws from the reciprocal
interaction worldview. The mutual interaction between
humans and their environment, help people to meet their
needs and goals (Pender, 2011).
○ Theoretically, the HPM is derived expectancy value
theory and social cognitive theory.
● The health promotion model is consistent with other related
theories and disciplines, as well as drawing influence from
them.
○ Health belief model: disease prevention behavior, but
without fear or threat as motivating factors (Alligood,
& Tomey, 2013).
○ Theory of reasoned action: attitudes and social norms
affect behavior (Butts & Rich, 2015).
○ Social learning theory: learning is a cognitive process
occurring through observation in a social setting (Butts
& Rich, 2015). This cognitive process includes self-
attribution, self-evaluation, and self-efficacy as
important constructs for behavior change.

14. Health Promotion Model Evaluation
● Pender (2011) clearly defines behavior specific cognitions and affects.
○ These are in alignment with the model’s contextual and conceptual basis.
● Congruent assumptions and theoretical propositions reflect nursing and behavioral science perspectives
while highlighting the multifaceted processes involved in motivation for action.
● Research and inductive reasoning built HPM, forming a consistent pattern about health behavior (Butts &
Rich, 2015).
● HPM is parsimonious and easy to understand, as clearly displayed by a diagram (Alligood & Tomey, 2013).
● Empirically adequate: used compatibly in multiple settings.
○ The theoretical assertions have been proven successful and verifiable in many studies.
● Pragmatically adequate: requires collaboration to create a personalized plan that is relevant, practical, and
applicable (Alligood & Tomey, 2013).
○ The model can be applied it to any patient demographic, across the lifespan and is culturally
sensitive.
○ Instruments have been designed to help patients achieve their individual goals, making it feasible to
apply to practice (Pender, 2011).
● HPM is feasible because it aligns NPs with core competencies
○ providing health promotion and prevention services via the application of principles for behavioral
change during counseling and patient coaching
○ formulating and implementing an evidence-based action plan that includes promoting a healthy
environment and incorporating community needs, strengths, and resources into practice (American
Academy of Nurse Practitioners, 2013).

15. Rationale for Using HPM for Smoking Cessation
❖ HPM guides the problem solving process
❖ Behavior specific cognitions and affects, alter a person’s
ability to plan for and commit to a health promoting action.
❖ Proven treatments for smokers who want help quitting:
➢ brief help by a provider
➢ individual, group, or telephone counseling
➢ behavioral therapies
➢ more person-to-person counseling sessions
➢ mobile phone treatment delivery (CDC, 2015).
❖ HPM guides all of these treatments, so they are thorough
and effective.
❖ Studies support the use of HPM for disease avoidance.
➢ Perceived susceptibility is a strong predictor for
preventive health behaviors, while perceived
benefits are a strong predictor for sick-role behavior.
(Galloway, 2003).
➢ Interpersonal influence is related to social support
and expectations of others. Using this factor, a
primary care provider can help provide motivation
to quit smoking (Kelley, Sherrod, & Smyth, 2009).
❖ By addressing perceived benefits, barriers, self-efficacy,
feelings about cessation, interpersonal and situational
influences, a provider is more likely to be successful in
bringing about change. The idea is to be as comprehensive
as possible to understand what influences a person to
smoke and how a provider can go about changing those
influences.

16. Solution:
Smoking Questionnaire
❏ 11 questions addressing major components of HPM such as
perceived threat, benefit, barriers self-efficacy to stop smoking.
❏ Questionnaire has mix questions of yes/now & Likert Scale type
questions
❏ Result < 65 indicates may not be ready to stop smoking
❏ Result > 65 indicates may be ready to stop smoking
❏ Quick, short, easy to understand, time friendly
❏ Can be administered in outpatient setting as both providers and
nurses are busy

17. Solution
Th RN can
● Interview the patient to assess purpose of visit
and smoking exposure
● Explain the purpose of the screening tool
questionnaire for smoking
● Document results in the chart
● Inform the Advanced Practicing Nurse (APN)
or Physician of the results
● Provide patient with resources and education as
necessary
The APN can
● Interview the patient to assess smoking behavior
● Discuss the results of the smoking questionnaire
● Provide the patient with resources and education
as necessary
● Maintain follow up visits with patient to guide
and maintain smoking cessation

18. Solution: additional resource for APN or physician to use when counseling for smoking cessation
5A’s for smoking cessation from American Academy of Family Practice
Ask Ask about tobacco use at every clinical encounter. “Have you ever been a smoker/used
tobacco products? If so, how much?”
Advise Emphasize the rewards and relevance of quitting, as well as the risks of smoking and
anticipated barriers to abstinence (see part 3A and 3B for risks and benefits to share
with the patient).
Assess Assessed for motivation to quit at every clinical encounter. “Are you ready to quit?
What would need to happen for you to quit?” Consider using stages of behavior change
Assist Set a quit date and provide resources: pharmacologic assistance in quitting (i.e. NRT,
Bupropion, and Varenicline), counselor/classes/support groups, hotline (American
Cancer Society at 1-800-227-2345 OR 1-800-QUIT-NOW), self-help resources such as
http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/index
Arrange Arrange for follow-up around their quit date to reinforce cessation messages.
NRT: Nicotine replacement therapy
The APN can use the 5 A’s algorithm in combination with the smoking
cessation questionnaire that our group developed.
❏ 1st: Ask: Individual's attitudes, beliefs, and behaviors towards smoking.
For example, asking use of tobacco, frequency, products use, degree of
dependence, history of previous quit attempts, and readiness to quit are
all relevant questions to smoking cessation
❏ 2nd: Advice: Understand patients perceived threats, susceptibility to
suffer ill-effects of tobacco use
❏ 3rd: Assess: perceived benefits and barriers to smoking (i.e. costs each
month to buying cigarettes)
Assess readiness to quit smoking
❏ 4th: Advice & Assist: Cue to action:set quit date, provide educational
materials, hotline, online modules. (i.e. removing cigarettes in
accessible areas)
❏ 5th: Arrange: Maintain Follow up
(Rigotti, Rennard, & Daughton, 2015).

19. Barriers to Implementation
Despite efforts at intervention, barriers to smoking cessation are common and expected. The Health Promotion
Model guides the provider in anticipating potential barriers by identifying components specific to the behavior from
which problems may arise. According to the model, individual characteristics and experiences influence behavior-
specific cognitions and affect, and all of these influence the behavioral outcome (Pender, 2011). Problems may occur
within any of these components.
➢ For example, an individual’s prior smoking-related behavior may have ingrained smoking into their daily routine,
making it a hard habit to break due to psychological and physical dependence.
➢ They may have tried to quit before, unsuccessfully, and subsequently perceive lower self-efficacy to quit.
➢ They may perceive the barriers to quitting to be too great to overcome, or they may fail to see enough benefits
from quitting to motivate them to try.
The HPM identifies these potentially problematic factors under individual characteristics and experiences and
behavior-specific cognitions and affect.

20. Barriers to Implementation
The HPM also points to personal, interpersonal, and situational factors that may impair cessation attempts.
➢ Family members or peers who normalize smoking, or they may have picked up smoking as a social activity. It
would be difficult to quit if surrounded by people who continued to smoke, if tobacco products continued to be
highly visible and accessible.
➢ Mental health issues (i.e. anxiety or depression) may have turned to smoking as a maladaptive coping mechanism;
if they are currently experiencing many life stressors, it may be hard to quit if smoking is how they cope with
stress.
These barriers may reduce their commitment to a smoking cessation action plan.
➢ Even after commitment to a plan, immediate competing demands outside of one’s control may impede successful
cessation or maintenance of abstinence.
Pender (2011) highlights these variables as essential influences on health behaviors. Using the HPM to guide
assessment of these factors, a provider can anticipate the potential barriers to intervention and thus identify ways to
circumvent problems.

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