Social Causes and Health Care Position Statements:
Tobacco Use Prevention, Cessation, and Exposure to Second-hand Smoke

Effective Date: April 20, 2005
Status: Revised Position Statement
Originated by: Congress on Nursing Practice and Economics
Adopted by: ANA Board of Directors

Related Past Actions:

1997 Prevention of Tobacco Use in Youth
1995 Cessation of Tobacco Use
1992 Discouragement of Economic Support for the Tobacco Industry
1986 Smoke-Free Society
1986 Smoking Policy for ANA Officials at ANA Headquarters
1986 Use of Smokeless Tobacco and Clove Cigarettes
1984 Action on Smoking Issues
1984 Amendments to Investment Guidelines for Investment Portfolios
1984 Guidelines for the Management of the Capital Improvements Fund
1974 Non-smokers Bill of Rights
1968 Smokers and Health

Summary

The American Nurses Association (ANA ) is dedicated to preventing and reducing tobacco-related morbidity and mortality, supporting efforts to prevent and reduce tobacco-related morbidity and mortality. Nurses must play a key role in reaching the nation’s Healthy People 2010 tobacco-related objectives. A healthy and safe environment, free of tobacco smoke, is a national public health priority. ANA believes that patient education and interventions to stop tobacco use should be central to good nursing practice. According to evidence-based guidelines of effective tobacco dependence treatment, all health professionals, including nurses must offer assistance to tobacco users at every point of contact. To that end, ANA believes that nursing involvement in assessing tobacco use, helping patients to stop using tobacco, taking action to prevent youth uptake of tobacco, educating the public about the dangers of second-hand smoke, and supporting the elimination of disparities among population groups should be an essential part of nursing practice at all levels.

Background

Tobacco use, the leading cause of death in the United States (Mokdad, 2004; U.S. Department of Health and Human Services, 2000; Centers for Disease Control and Prevention, 2000; Wong, 2002), is responsible for almost half a million deaths every year. In addition, tobacco use remains the leading preventable illness. It is estimated that 8.6 million Americans have serious smoking-related diseases. Tobacco use and exposure to second hand smoke, or environmental tobacco smoke, are causally related to cardiovascular diseases, respiratory diseases such as chronic obstructive pulmonary disease, a wide variety of cancers including cancers of the lung, oral pharynx and larynx, esophagus, bladder, kidney, pancreas, and cervix among others. Tobacco use has also been associated with a variety of other illnesses, such as osteoporosis, ulcers, low birth weight, etc. (HHS, 2000; Sarna, 2004) Furthermore, tobacco use has been found to increase suffering and diminish quality of life. (Schroeder, 2004)

Children also suffer from health problems related to smoking. When exposed to second hand smoke, children have a higher risk of asthma, ear infections, Sudden Infant Death Syndrome (SIDS), bronchitis, and pneumonia. (California Environmental Protection Agency, 1999) Children's exposure to secondhand smoke is responsible for respiratory tract infections resulting in 7,500 to 15,000 hospitalizations each year. (U.S. Environmental Protection Agency, 2004)

Historically, nurses have contributed to our knowledge of the morbidity and mortality caused by heart disease and lung cancer. The Nurses’ Health Study demonstrated the effects of tobacco use among women through nurses’ participation. (Brigham and Women’s Hospital, 1990)

ANA is committed to eliminating tobacco-induced diseases of our nation’s people and achieve the tobacco-related Healthy People (HP) 2010 objectives. (HHS, 2003) The nursing profession can collaborate with other healthcare providers to reduce and prevent tobacco-related disease, disability, and death.

Although smoking prevalence has declined since the first Surgeon General Report in 1964, more than 45 million Americans continue to smoke, (Schroeder, 2004) and an estimated 10 million use smokeless tobacco products (of which 3 million are under the age of 21). As smoking patterns have changed, tobacco-attributable diseases such as lung cancer and heart disease have increased in the impoverished, the poorly educated, and ethnic minority communities. (HHS, 1998; Wong 2002) Despite progresses, tobacco use prevalence is disproportionately high among some ethnic minorities, the prevalence among persons 18 to 24 years of age has increased from 1991 to 2000 (from 23% to 27%), and is also higher among people with mental illness. (Schroeder, 2004)

The health benefits of quitting are applicable to smokers at any age. For example, former smokers live longer than continuing smokers, and the benefits of quitting extend to those who quit at older ages. Persons who quit smoking before age 50 have only one-half the risk of dying in the next 15 years when compared to continuing smokers. Smoking cessation reduces the risk of a recurrent heart attack and cardiovascular death in patients with coronary heart disease (CHD). Studies show that cancer patients reduce their risk of a second primary cancer when they stop smoking. Patients with early chronic obstructive pulmonary disease (COPD) can slow lung-function decline with cessation of smoking and smokers with duodenal or gastric ulcers improve their healing process by quitting smoking. Women who stop smoking before becoming pregnant deliver infants whose birth weights are comparable to those whose mothers never smoked. (CDC, 2002; HHS 2000; HHS 2001)

Estimates show that smoking caused over $150 billion in annual health-related economic losses from 1995 to 1999 including $81.9 billion in mortality-related productivity losses (average for 1995–1999) and $75.5 billion in excess medical expenditures in 1998. (CDC, 2002) The health care costs of children exposed to parental smoking result in annual direct medical expenditures of $4.6 billion. (Aligne and Stoddard, 1997)

Although nearly 70% of all indoor workers in the US are protected by smoke free policies in the workplace, there is immense variance of protection among states and among the different levels of work. For example, just 43% of the country's 6.6 million food preparation and service occupations workers benefit from this level of health protection. (Shopland 2001, 2004)

Effective treatment options are available. The scientifically-based US Public Health Service’s Treating Tobacco Use and Dependence Clinical Practice Guideline (Fiore, 2000) recommends behavioral interventions (counseling and skills training) along with the use of pharmacotherapy to increase quit rates. Additional effective resources such as telephone quit lines and internet cessation resources also are available. (Lichtenstein, 2002; Zhu, 2002) Smoking-cessation interventions are among the most cost-effective uses of health care resources. (HHS, 2003)

In addition to comprehensive cessation programs for individuals, research has shown that comprehensive community-based policies have a positive impact in battling the tobacco epidemic (CDC, 1999) and supports an enhanced role for nurses in tobacco control. (Aguinaga Bialous, 2003) Such policies include the promotion of smoke-free workplaces and public places, including restaurants and bars; increase in cigarette taxes and the allocation of part of the tax revenue to fund tobacco control programs; restricting the marketing and advertising of tobacco products, stopping, for example, the sponsorship of music events targeting youth; development of counter-advertisement campaigns to educate the public about the tobacco industry strategies, the harms of tobacco and the benefits of quitting; restriction sales to minors; regulating the marketing and labeling of tobacco products, eliminating for example, misleading descriptors such as “mild” and “lights”; providing coverage of cessation treatment, and allocation of research funds to continue to advance knowledge about tobacco use initiation, continuation and cessation, as well as on effective tobacco control policies. (CDC, 1999)

Nurses are uniquely situated to assist in lowering the tobacco use prevalence in adults and youth across a variety of settings, ethnic groups, and socioeconomic strata. Nurses are in contact with the public in many settings where they could implement tobacco use prevention and cessation strategies, and are in key positions to advise and assist individuals and families in reducing their exposure to second-hand smoke. Nurses can educate all tobacco users about the major and immediate health benefits of cessation of tobacco use for men and women of all ages. Since these benefits apply to persons with and without symptoms of tobacco-related disease, nurses who advise and educate tobacco users to quit can have a significant effect in reducing the negative impact of tobacco use.

The National Quality Forum (NQF) Board of Directors noted the importance of reduction of smoking when it endorsed smoking cessation counseling measures as components of the “National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set.” The set presents 15 measures to promote public accountability and quality improvement, three of which are related to smoking cessation counseling in hospital inpatients diagnosed with acute myocardial infarction (AMI), heart failure or pneumonia. The measures evaluate the percentage of all inpatients with a diagnosis of AMI, heart failure or pneumonia and a history of smoking cigarettes anytime during the year prior to hospital arrival, who receive smoking cessation counseling. (National Quality Forum, 2004)

Nurses should also actively support legislation promoting a healthy and safe environment for the general public. Nurses, as nonsmoking role models, need to enhance public awareness and education about the hazards of environmental tobacco smoke within the work setting, and the benefits of smoking bans as mechanisms for enhancing the health of both smokers and nonsmokers. Nurses must also be prepared to deliver tobacco use prevention information to children and teens at risk. In order to prepare nurses to effectively intervene with patients, tobacco control content, especially effective tobacco cessation interventions must be included in basic nursing education and be a core competency of all graduates.

The American Nurses Association supports:

Nursing education related to tobacco use prevention, health effects, and cessation treatment options.

• Funding for nursing research related to best practices for smoking prevention and cessation strategies.
• Funding for research and support services to assist nurses and nursing students to become smoke-free role models.

• Nursing assessment and interventions across the lifespan according to USPHS guidelines- (5As—ask, advise, assess, assist, arrange).
• Reimbursement for all smoking cessation services, including pharmacotherapy, by private and government insurers.

• Preventing youth access to tobacco products through direct sales, vending machines, or other venues.
• Elimination of tobacco advertising and marketing to youth.
• Community and school-based health education and health promotion initiatives targeting tobacco use prevention and cessation.

• Health education and health promotion initiatives related to the hazards of second-hand smoke.
• Comprehensive legislation and regulatory measures to promote smoke-free policies in workplaces and public areas.
• Tobacco cessation assistance in combination with smoke-free environments.
• Implementing a smoke-free policy at all ANA meetings and functions.
• Encouraging affiliates to provide smoke free environments in all meetings and functions.

• Support for all nurses as role models promoting a tobacco-free culture.
• Collaboration with other stakeholders and professional groups to achieve Healthy People 2010 objectives related to tobacco.
• Effective policies restricting tobacco advertising, commercial support, and other vested interest in tobacco-related industries.
• Support for U.S. ratification and implementation of the WHO Framework Convention on Tobacco Control.

References

1. Aguinaga Bialous, S., N. Kaufman, and L. Sarna, Tobacco Control Policies. Seminars in Oncology Nursing, 2003. 19(4): p. 291-300.

2. Aligne, C. and J. Stoddard, Tobacco and children. An economic evaluation of the medical effects of parental smoking. Archives of Pediatric and Adolescent Medicine, 1997. 151(7): p. 648-53. Erratum in: Archives of Pediatric and Adolescent Medicine 1997 Oct; 151(10):988.

3. California Environmental Protection Agency, Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency . 1999, NIH: Bethesda , MD.

4. Centers for Disease Control and Prevention, Cigarette Smoking-Attributable Morbidity — United States , 2000. Morbidity and Mortality Weekly Report, 2003. 52(35).

5. Centers for Disease Control and Prevention, Smoking Cessation for Pregnant Women . 2002, Tobacco Information and Prevention Source. National Center For Chronic Disease Prevention and Health Promotion: Atlanta , GA.

6. Centers for Disease Control and Prevention, Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs — United States, 1995–1999. Morbidity and Mortality Weekly Report, 2002. 51(14): p. 953-56.

7. Centers for Disease Control and Prevention, Best Practices for Comprehensive Tobacco Control Programs. 1999, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA.

8. Fiore, M.C., et al., Treating tobacco use and dependence. Clinical Practice Guideline. 2000, U.S. Department of Health and Human Services, Public Health Service: Rockville , MD.

9. Lichtenstein, E., From rapid smoking to the Internet: five decades of cessation research. Nicotine and Tobacco Research, 2002. 4: p. 139-145.

10. Lichtenstein, E. An overview of quitlines. in North American Conference of Smoking Cessation Quitlines. 2002. Phoenix , AZ.

11. Mokdad, A., et al., Actual causes of death in the United States , 2000. Journal of the American Medical Association, 2004. 291(10): p. 1238-45. Nurses' Health Study, Brigham and Women's Hospital: Boston .

12. National Quality Forum. (2004). “National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set.” Washington , DC : National Quality Forum, pp. vi, A-4

13. Sarna, L. and S. Aguinaga Bialous, Why tobacco is a women's health issue. Nursing Clinics of North America , 2004. 39: p. 156-80.

14. Schroeder, S., Tobacco Control in the Wake of the 1998 Master Settlement Agreement. New England Journal of Medicine, 2004. 350(3): p. 293-301.

15. Shopland, D., et al., State-specific trends in smoke-free workplace policy coverage: the current population survey tobacco use supplement, 1993 to 1999. Journal of Occupational and Environmental Medicine, 2001. 43(8): p. 680-6.

16. Shopland, D., et al., Disparities in smoke-free workplace policies among food service workers Journal of Occupational and Environmental Medicine, 2004. 46(4): p. 347-56.

17. US Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health. 2003, U.S. Department of Health and Human Services: Washington , D.C.

18. US Department of Health and Human Services, Tobacco Use Among U.S. Racial/Ethnic Minority Groups – African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A report of the Surgeon General. 1998, U.S. Department of Health and Human Services, Centers for Disease Prevention and Control, National Center for Chronic Disease Prevention and Promotion, Office on Smoking and Health: Atlanta, GA.

19. US Department of Health and Human Services, Women and Smoking: A report of the Surgeon General. 2001, U.S. Department of Health and Human Services, Centers for Disease Prevention and Control, National Center for Chronic Disease Prevention and Promotion, Office on Smoking and Health: Washington, D.C.

20. US Department of Health and Human Services, Prevention Makes Common "Cents". 2003, USDHHS: Washington DC .

21. US Department of Health and Human Services, Reducing Tobacco Use: A Report of the Surgeon General. 2000, USDHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion: Atlanta , GA. p. 195.

22. US Environmental Protection Agency, Secondhand Smoke Can Make Children Suffer Serious Health Risks . 2004, US Environmental Protection Agency.

23. Wong, M., et al., Contribution of Major Diseases to Disparities in Mortality. New England Journal of Medicine, 2002. 347(20): p. 1585-92.

24. Zhu, S., et al., Evidence of real-world effectiveness of a telephone quitline for smokers. New England Journal of Medicine, 2002. 347(14): p. 1087-93.

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