Learning Outcome

• Analyze the dangers of tobacco abuse and it effect on the health of tobacco users.
• Demonstrate evidence-based practice assessment of tobacco use.
• Utilize multiple interventions to assist tobacco users to quit smoking.
• Analyze methods to prevent children and adolescents from becoming tobacco users.
• Practice advocacy to assist communities and populations to control tobacco use through political, social, and psychological methods. 
• Evaluate methods for individuals and communities to avoid exposure to second-hand smoke. 

Introduction

The leaves of the tobacco plant were originally harvested and smoked by Native Americans and were introduced to Europe by Christopher Columbus in the 15th century. The botanical name for tobacco, Nicotiana tabacum, is derived from the Jean Nicot, who sent the tobacco leaf to the Queen of France in the 16th century. During the late 18th century, packaged cigarettes and cigars rapidly gained popularity. Although it was suspected in the early 20th century that tobacco was linked to throat and mouth cancers, it was not until 1964 when the US government released the document titled Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. It has since been the prominent topic of most annual Surgeon Generals Reports.

The original report was an objective review of literature that pointed to tobacco use as being causal to a number of deleterious health conditions. There has since been much research conducted, and many new findings regarding the disease-causing aspects of tobacco smoking have been elucidated. Despite the widely published results of this research tobacco smoking-related illnesses remain the leading cause of preventable death in the United States.[1][2][3]

Nursing Diagnosis

There are several nursing diagnoses that can be used for tobacco cessation, such as: 

Ineffective Therapeutic Regimen Management: Pattern of regulating and integrating into daily living a program for the treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.  Tobacco use is an unsatisfactory daily activity that leads to negative health outcomes.

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response. Withdrawal from nicotine, an addictive substance, can lead to anxiety.

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.  Communities, families, and individuals require an understanding of the addictive nature of tobacco use and its accompanied negative health effects.

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Tobacco use damages lung tissue and influences the ability to exchange oxygen at the cellular level in both smokers and in individuals exposed to second-hand smoke.

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.  Nicotine initially provides a calming effect; thus is used as a stress reliever and taking a smoking break during activities can also be used as a coping mechanism; however, the long term use of a stress relief method such as tobacco leads to increased stressors associated with poor health.

Risk for Infection: At increased risk for being invaded by pathogen organisms. Exposure to tobacco products creates risk of respiratory infection for the smoker and those exposed to second-hand smoke; it is especially harmful to the immature respiratory systems in infants and children.

Short term outcomes should be for the individual to express a desire to quit using tobacco products; to refrain from smoking around others, especially infants and children; and to enroll in a cessation program.  Long term outcomes are to remain tobacco-free, thus eliminating exposure to the individual and others. 

Causes

Tobacco contains nicotine, which is an addictive substance.  Therefore smokers must contend with not only the habit of smoking but also a serious addiction to nicotine.  A habit develops as a smoker's routine when they use cigarettes or tobacco products for stress relief, relaxation, to decrease hunger, or many other reasons.  An addiction to nictoine can occur as soon as the first exposure to nicotine; therefore avoiding tobacco use altogether is important, making prevention a key intervention in tobacco control efforts.

Risk Factors

About 23% of the worldwide population smokes cigarettes. This includes 32% of all males and 7% of all women. Eastern and Southeast Asia have the highest prevalence of smokers in the world with about 45%, while the Caribbean and North American has the lowest prevalence at 20%.[4]

In 2017, the CDC estimates that 19.3% of the United States population over 18 years old uses some tobacco product. About 14% of the total population use cigarettes while the remaining 5% use cigars, electronic cigarettes, smokeless tobacco, or pipes. Furthermore, 24.8% of men smoke cigarettes, while 14.2% of women smoke cigarettes. By age group, smokers represent 18.3% of adults aged 18 to 24 years old, 22.5% of adults aged 25 to 44 years old, 21.3% of adults aged 45 to 64 years old and 11% of adults 65% and older.[5]

Tobacco use in any form—even occasional smoking—causes serious diseases and health problems, including:

• Several forms of cancer, including cancers of the lung, bladder, kidney, pancreas, mouth, and throat
• Heart disease and stroke
• Lung diseases, including emphysema, bronchitis, chronic obstructive pulmonary disease (COPD)
• Pregnancy complications, including preterm birth, low birth weight, and birth defects
• Gum disease
• Vision problems

Secondhand smoke from cigarettes and cigars also causes heart disease and lung cancer in adults and a number of health problems in infants and children, including:

• Asthma
• Respiratory infections and reactive airway
• Ear infections
• Sudden infant death syndrome (SIDS) 

Assessment

TS history should be routinely obtained from the patient during the admission assessment. Subjective and objective assessment of tobacco use should be included in every focused assessment. Pack-year history provides an estimate the amount cigarettes a patient has consumed over a lifetime and is calculated as packs smoked per day multiplied by the total number of years smoked. Obtaining a pack-year history has shown to be of some value when determining the presence and severity of smoking-related illnesses such as CAD and COPD, as smoking-related cancers have all been linked to increased pack-year history.[6][7][8]

Many assessment findings can be directly or indirectly related to tobacco smoking. Upon admission and with every aseesment be sure to assess the mouth, teeth, and mucous membranes. The scent of tobacco smoke often lingers on the patient's breath and clothing. Auscultation of the lungs may reveal decreased or asynchronous breath sounds. Cardiac exam often reveals an increased resting heart rate when compared to that of non-smokers. Tobacco stains may be present on the skin of the face and fingers. There may be decreased peripheral pulses due to smoking-related peripheral vascular disease.  Chronic smoking can cause voice changes, including a lower pitch and hoarseness.  Fine wrinkles in the face and around the mouth can also be noted in smokers.  [9][10][11]

Evaluation

Primary assessment of tobacco use is self-report during assesment of social history.  Family or significant others may also provide information regarding tobacco use and amount. Self-report may not be reliable; a patient may not understand the amount of tobacco products used; or may deny or minimize the amount when speaking to health care professionals for fear of being chastized for using tobacco. 

Medical Management

Management and control of tobacco use is four-fold:  1) cessation programs, 2) preventing children and adolescents from smoking, 3) preventing exposure to second-hand smoke, and 4) advocacy to change attitudes toward smoking.  Nurses in various roles, such as school nursing, occupational health, community health, obstetrics, medical-surgical, and research are responsible to assess and intervene to decrease the negative health impact of tobacco. 

Tobacco smoking is directly associated with multiple serious health problems that endanger and shorten the life of smokers and those subjected to cigarette smoke.  Special attention must be paid to pregnant tobacco users. Risks for both mom and baby include preterm labor, small for gestational age infants, and a risk for childhood cancers. For an active smoker, quitting smoking has proven to reduce the chances of developing a smoking-related illness.[12][13]

Daily cigarette smokers keep smoking because they are physically addicted to nicotine, a substance that is naturally found in tobacco leaves. Because nicotine is one of the most addictive substances known to man, TS is often very difficult to quit, often requiring repeated attempts at quitting involving various cessation methods. Five nicotine-based medications (gum, lozenges, inhaler, nasal spray, patch) and 2 non-nicotine-based medications (varenicline and bupropion SR) have been shown to aid in long-term smoking cessation. Recent evidence includes a potential role for cytisine and naltrexone. For patients willing to quit, a combination of counseling and one or more the medications has proven more effective than just counseling or medication alone.[14][15][16]

Nursing Management

Brief interventions on admission to the hospital include assessment of tobacco use; offering nicotine replacement while hospitalized, assessing if a patient is interested in cessation and referring them to counselling if needed.   Special attention must be paid to pregant women who use tobacco products. 

Smokers who are addicted to nicotine will have withdrawal symptoms if not allowed to use tobacco products while hospitalized, including anxiety, vertigo, mood swings, and a general feeling of uneasiness.  There may be standing orders for nicotine replacement therapy; or nurses should ask the provider for an order for nicotine replacement, such as a nicotine patch, gum, or lozenges. [17]

Formal cessation classes may be offered in the community.  Nurses who work in community health settings should conduct or arrange cessation classes that are low cost or free of charge to aid smokers to quit using tobacco. Quitlines, cessation aids that are available via phone, are readily accessible throughout the United States. New technology includes social media apps downloaded to electronic devices to provide cessation programs.   Apps and quitlines are convenient for a tobacco user because they can be used at any time and have been shown to be effective at assisting with cessation. _[18]

Nurses, especially nurses in Community Health should be involved in tobacco control, including prevention, second hand smoke avoidance, and advocacy.  Preventing children and adolescents from using tobacco is a primary duty of school nurses because most tobacco users begin smoking prior to the age of 18, leading to a lifetime of nicotine addiction. There are school based programs with various degress of success that have been used in school settings to help children decide not to use nicotine products.   Second hand smoke efforts to restrict public use of tobacco have been largely successful, smoking is no longer allowed in most public venues due to laws restricting exposure to second hand smoke.  On an individual level, parents who smoke must be made aware that they should not smoke in the presence of their children or in closed areas where children are present, such as in a house or motor vehicle.  Advocacy, including public awareness and advocating for anti-tobacco legislation, has been successful in changing attitudes toward tobacco use.  Social acceptance of tobacco use is decreasing through laws requiring a minimum age for purchase of tobacco products and by raising prices of tobacco products through taxation thus creating difficulty for adolescents to aquire tobacco.  Healthy People 2020 and 2030 have declared tobacco use one of the leading health indicators in the United States, with a goal of decreasing tobacco use in the next ten years. 

When To Seek Help

Nurses in various settings are in a unique position to discuss tobacco use with patients. Preventing children and adolescents from initial tobacco use is imperitive.  Admission assessments include assessment of tobacco use; and every smoker should be asked if they wish to quit, then referred to services to aid in cessation.  Apps and quitlines should be encouraged.   Nurses should practice health education with every encounter with each tobacco user, discussing health implications and aids to assist in cessation.

Outcome Identification

Healthy People 2020 has a goal to "Reduce illness, disability, and death related to tobacco use and secondhand smoke exposure."  Planning includes the use of various methods to promote cessation, prevention of tobacco use and second-hand smoke, and advocacy for legislation restricting access to tobacco products.  Nurses are in a unique position to influence tobacco use at the individual and community level; thereby decreasing the ill effects of tobacco use and healthcare costs.

Monitoring

Because tobacco use is determined by self-report, monitoring is also personal.  A nurse can encourage and refer or teach cessation classes; but ultimately the responsibility for cessation relies with the individual. Attitudes toward tobacco use are increasingly becoming negative as laws restricting public use of tobacco are enacted and advertising tobacco products has been restricted; however, tobacco use is still considered a personal choice, followed by an addiction to nicotine that is difficult to stop. 

Coordination of Care

TS is a life-threatening addiction that, if untreated, can cause damage to every organ system in the human body. The best way to avoid a TS related illness is never to start smoking, and the second best way is to stop smoking cigarettes as soon as possible. Helping a patient to stop smoking is one of the most beneficial preventive medicine interventions currently in existence. Nearly every member of the healthcare team may play an important role in the assistance of smoking cessation.

Nurses play a major role in tobacco cessation programs. In some hospitals, nurses are being trained to deliver behavioral and over the counter pharmaceutical interventions to inpatient smokers. These interventions have shown great promise in significantly reducing smoking in certain populations.[19]

Physicians are also at the front lines in the fight against TS. Unfortunately, several studies have shown that brief episodes of physician advice do very little to aid in smoking cessation.[20] It has been demonstrated that individually focused counseling can aid in the patient's cessation of smoking. There is also evidence that physician prescribed or health care team recommended over-the-counter medications can play an effective role in treating these patients.[21] 

Clinical scientists also play a very important role in the fight to end tobacco addiction and tobacco-related disease. They continue to investigate and discover the physiology of tobacco-related illnesses, the effectiveness of tobacco cessation medications and interventions, and study TS related conditions across a broad spectrum of populations. From the toils of scientific research, much about TS has been elucidated and yet society has much to learn.

Health Teaching and Health Promotion

Health promotion and health teaching is four-fold:  promoting cessation in nicotine-addicted individuals, prevention activities targeted toward children and adolescents, avoiding second-hand smoke in public and private venues, and advoacacy to restrict access to tobacco products and attitudes.  Nurses in various roles, including community and hospitals must assess and intervene for eduational needs of individuals and communities.  Individualize a plan for every tobacco user, including short-term and long-term plans for cessation and avoiding exposure to second hand smoke.  Evaluate frequently, reinforcing the need for cessation and promoting health.

Risk Management

All healthcare personnel should refrain from using tobacco products.  Aside from the personal risk to an individual's health; healthcare personnel are role models for healthy behaviors and using tobacco is not an example of good habits. 

Discharge Planning

Discharge planning for all tobacco users should include a patient-centered plan for cessation.  Medications are available to aid in cessation and should be prescribed by the provider.  Nicotine replacement products are available over the counter or through quit-lines.  Counselling is available through various community agencies or by quit lines or through social media apps.  Additionally smokers should have a plan for avoiding second hand smoke exposure to children and significant others. 

Evidence-Based Issues

Prevalence of tobacco use, negative health effects, and effectiveness of cessation methods can be monitored through evidence based practice.  Recent research on all facets of tobacco use should be utilized in the campaign to end suffering and high costs of tobacco use.  Analyze available research for application to populations, interventions, comparisons, outcomes, and time.

Pearls and Other issues

Tobacco use is a preventable cause of morbility and mortality and nurses are in a unique position to assist in the campaign to end suffering from tobacco use and nictoine addiction. Nurses and the entire healthcare team are expected to advocate cessation and prevention in individuals and communitiies through use of evidence based assessments, interventions, and evaluation of the impact of tobacco.