Tobacco: an emerging topic in nursing research

An international review of tobacco smoking research in the nursing profession, 1976-2006

Tobacco smoking represents a contentious issue in the nursing profession, and one that has now become an important topic in nursing research. Despite this fact, the epidemiological quality of research varies widely, and it has been difficult to accurately determine the true incidence of smoking among nurses. Given these inconsistencies, we conducted a state-of-the-art review to identify international trends in tobacco usage among nurses, to ascertain how the epidemiological quality of research has improved over the past 30 years, and also to elucidate the directions in which nursing research has evolved. A total of 73 English-language studies that met the inclusion criteria were located and analysed. Overall, our review suggests that, while tobacco smoking among nurses appears to be decreasing in many countries during recent years, the international trend is far from uniform, and some developed nations still report high smoking rates among their nursing staff. From a methodological perspective, the relative epidemiological quality of smoking research has also fluctuated over time, making it difficult to compare the results of one study to the next. Despite these caveats, tobacco smoking remains a key topic in nursing research, as well as a critically important occupational-health issue for the entire nursing profession. In order to make the next generation of tobacco research data as comparable as possible, future scholars should consider devising and implementing a standardised format for conducting international tobacco smoking research within the nursing profession.

Self-efficacy in providing smoking-cessation services among psychiatric nurses in central and southern Taiwan: an exploratory study

Smoking by psychiatric patients remains prevalent. The purpose of this cross-sectional study was to understand the influence of self-efficacy and its correlates among psychiatric nurses when providing smoking-cessation services (SCS). A convenience sample of 193 nurses from psychiatric institutions was obtained. Surveys were conducted using self-report measures regarding SCS provided by psychiatric nurses. The survey questions focused on self-efficacy, attitude, practical experience, and smoke-free policies, and their implementation in the workplace. The participants reported low self-efficacy for providing SCS in their self-assessment, as demonstrated by their scores of 55.3 ± 20.4, on a scale of 0 (low confidence) to 100 (high confidence). Using multiple linear regressions, statistically-significant, relevant factors included perceived provider-related barriers in providing SCS, environmental tobacco smoke exposure, the nurse's attitude towards a patient smoking, and the nurse's frequency and practical experience in providing SCS. The correlates of this self-efficacy can serve as a reference for in-service curriculum planning of SCS by psychiatric nurses. In addition, policies to limit exposure to second-hand tobacco smoke should be explored.

Historical Perspectives of the Causation of Lung Cancer: Nursing as a Bystander

Lung cancer is the leading cause of cancer deaths worldwide. Less-known forces are involved in the etiology of lung cancer and have relevant implications for providers in ameliorating care. The purpose of this article is to discuss theories of causation of lung cancer using historical analyses of the evolution of the disease and incorporating related explanations integrating the relationships of science, nursing, medicine, and society. Literature from 160 years was searched and Thagard's model of causation networks was used to exhibit how nursing and medicine were significant influences in lung cancer causation theory. Disease causation interfaces with sociological norms of behavior to form habits and rates of health behavior. Historically, nursing was detrimentally manipulated by the tobacco industry, engaging in harmful smoking behaviors, thus negatively affecting patient care. Understanding the underlying history behind lung cancer causation may empower nurses to play an active role in a patient's health.

Self-perceived factors associated with smoking cessation among primary health care nurses: a qualitative study

The aim of this work was to characterize the views of nurses about factors modulating smoking cessation. Results of this study will allow us to design helping interventions with the maximum specificity for nurses. A qualitative study through a semi-structured interview of 15 Primary Health Care nurses who were smokers was performed. In contrast with other studies in which nurses were not aware of any particular social pressure to give up smoking, 18 months after the application of the Anti-Smoking Spanish Law, this feeling was expressed. Therefore, the main reasons for giving up smoking include that smoking in public is every day worse seen, together with a sense of shame and guilt in front of their social and family environment, especially for being a professional group dedicated to health.

Promoting tobacco dependence treatment in nursing education

ISSUES

There are 17.3 million nurses worldwide, the largest group of health-care professionals, and they have great potential to address the epidemic of tobacco use and its related morbidity and mortality. However, the evidence indicates that the educational preparation of nurses for tobacco control remains inadequate.

APPROACH

This paper provides an overview of the efficacy of nurses in the delivery of smoking cessation interventions, existing tobacco control content in nursing educational programs, model curricula, teaching resources and strategies for reducing barriers to curricular change.

KEY FINDINGS

Despite the efficacy of nursing intervention for tobacco cessation, lack of appropriate knowledge and/or skill presents a major problem for implementation. An important factor fostering this lack of preparation is limited tobacco control content in current nursing educational programs. Barriers to enhancing and building this curricula include lack of preparation of educators, low priority for this content in an already overloaded curricula, negative attitudes, continued smoking by nursing students and/or faculty and lack of tested curricula. The availability of new tobacco control resources, including those specifically tailored for nurses can assist educators in teaching this content and nurses in implementing interventions.

IMPLICATIONS

Research and changes in policy are needed to ensure that nursing education includes essential content on tobacco control.

CONCLUSION

Nurses can be effective in delivering tobacco cessation interventions. Efforts are needed to promote curriculum that ensures that all nursing students and practicing nurses receive tobacco control content and are competent in the delivery of interventions; and to disseminate resources to nursing educators

Community mental healthcare providers' attitudes and practices related to smoking cessation interventions for people living with severe mental illness

OBJECTIVE

This study aimed to describe mental healthcare providers' attitudes about tobacco use, their personal smoking status, their confidence in offering smoking cessation support to clients living with severe mental illness, and the extent to which they incorporated smoking cessation interventions into their practice. The study also aimed to determine whether the providers' attitudes, smoking status, and confidence were associated with offering smoking cessation support to clients.

METHODS

Self-administered questionnaires were distributed within community-based mental health agencies to those who provide care and support to adults living with severe mental illness. Outcomes measured included respondents' smoking status, attitudes related to the provision of smoking cessation support, confidence in providing smoking cessation intervention, and smoking cessation practices. We conducted multivariate analyses using logistic regression analyses to examine the factors associated with the providers' tobacco-related practices.

RESULTS

In total 282 of 871 care providers responded to the survey, 22% of whom were current smokers. The providers who held sympathetic attitudes about their role and their clients' role in smoking cessation, who were never or former smokers, who were healthcare professionals rather than paraprofessionals, who had relatively more confidence, and who had more experience working in the mental health field were more likely to engage their clients in tobacco-related interventions.

CONCLUSIONS

In this study the healthcare providers working in community-based mental health have a smoking prevalence rate that exceeds that of the region's general population and did not provide optimal smoking cessation support to their clients.

PRACTICE IMPLICATIONS

Interventions that bolster the confidence of providers to engage is smoking cessation activities and that support a shift in attitudes about the role of tobacco use in mental health are required.

Smoking trends in the Nurses' Health Study (1976-2003)

BACKGROUND

Smoking trends among nurses are important to monitor as smoking negatively affects their health and decreases their likelihood of providing cessation interventions to patients.

OBJECTIVES

The objective of the study was to describe the changes in smoking trends in the participants in the Nurses' Health Study (NHS) cohorts over 27 years.

METHODS

An analysis of biennial changes in smoking status and cigarette consumption within nine 5-year birth cohorts (1920-1924 to 1960-1964) and age-specific mortality rates by smoking status were examined in 237,648 female registered nurses (RNs): NHS (ages of 30-55 years in 1976, followed through 2002) and NHS II (ages of 25-42 years in 1989, followed through 2003).

RESULTS

Current smokers constituted 33.2% of NHS in 1976 and 13.5% of NHS II in 1989. Smoking rates declined in all birth cohorts; 8.4% were smoking in 2002/2003. Seventy-nine percent of nurses who ever smoked had quit. The mean cigarettes per day declined over time but still exceeded half a pack per day (15.1 cigarettes) at the end of follow-up. The mortality rate among current smokers was higher than that of former smokers and was approximately twice that of never smokers in all age categories; those who smoked were more likely to have comorbid conditions.

DISCUSSION

This study provides the first report of smoking trends among RNs in the NHS. The decline in smoking rate among female nurses mirrors the decline in smoking rate among women in the United States over the past 25 years. Increased mortality and morbidity rates indicate the devastating cost of smoking to the profession and can provide support for the urgent need for further research to encourage continued smoking cessation efforts for nursing professionals.

Impact of smoking and smoking cessation on health-related quality of life in women in the Nurses' Health Study

PURPOSE

To examine the relationship between smoking and health-related quality of life (HRQOL) and the impact of quitting smoking on changes in HRQOL among women in the two Nurses' Health Study (NHS) cohorts (n = 158,736) who were 29 to 71 years of age in 1992/1993 when they reported data on smoking status and completed the Short Form-36 version 1 (SF-36).

METHODS

At baseline, the SF-36 physical component scores (SF-PCS) and mental component scores (SF-MCS) were examined by smoking status (never, 56%, former, 32%, and current, 13%) within 10-year age groups. Smoking characteristics were analyzed as correlates of SF-36. Changes in smoking status and SF-PCS and SF-MCS, adjusted for comorbid disease and other covariates, were reassessed at 4-year intervals among current smokers in 1992/1993 and those who either continued smoking after 4 and 8 years or reported not smoking at both intervals.

RESULTS

Smokers had lower HRQOL (SF-PCS and SF-MCS) as compared to never and former smokers. Current smoking, cigarettes per day and time since quitting were associated with significantly lower SF-PCS and SF-MCS. Continuing smokers and those who quit had significant declines in SF-PCS over time and significant improvements in SF-MCS at 8 years. There was minimal difference between groups, with some greater improvements in SF-MCS among those reporting non-smoking at 8 years. These findings support the lower ratings of HRQOL by smokers, but quitting alone, after an average of 21 years of smoking, did not improve HRQOL. Further study focused on the HRQOL impact of quitting smoking is needed.

Evidence-based approach to an inpatient tobacco cessation protocol

Tobacco use contributes to USD53 to USD73 billion per year in healthcare expenditures and causes nearly 440,000 deaths per year. Given the strong cause-effect relationship between smoking and poor health outcomes, it is critical that smokers are identified early and advised about smoking cessation. Furthermore, the Joint Commission now mandates that tobacco cessation advice be given to patients admitted with heart failure, pneumonia, and acute myocardial infarction. As such, an interdisciplinary group at an urban academic medical center developed and implemented a tobacco cessation protocol with the goal of identifying and targeting inpatient smokers through evidence-based education and counseling. The protocol focused on admission assessment, education, and provision of standing orders for medication treatment for nicotine withdrawal and/or tobacco cessation therapy during the inpatient encounter and referral for outpatient counseling at discharge.

Nursing's involvement in tobacco control: historical perspective and vision for the future

There is little evidence that nursing organizations have played a major leadership role in addressing tobacco control at the political level, and none have addressed collectively, in any sustained way, the role of the tobacco industry, the primary vector of the tobacco disease epidemic. The aims of this article are (a) to explore what accounts for organized nursing's relative quiescence about tobacco industry and (b) to elucidate why a nursing voice would be especially effective in addressing the industry as a vector of the tobacco disease epidemic. Drawing on the internal tobacco industry documents research, and incorporating a critical theoretical perspective on education, research, and practice, it is argued that tobacco cessation cannot be viewed solely as an individual problem but must be understood in a sociopolitical context and promoting a nursing agendum on cessation research and practice requires educating (and energizing) nurses on the sociopolitics of tobacco. Because of nurses' numbers, class status, political capital, and moral authority in society, they are the group of health professionals whose voices are needed urgently at this historical moment to help avert the global tobacco epidemic. The Nightingales is an example of a nursing group involved in activism against the tobacco industry, applying findings from research on the industry to engage nurses in tobacco control activism, research, and education. The cessation research agenda should include research on the tobacco industry and how its activities influence cessation, how political activism influences cessation, and how critical education may advance cessation research, policies, and practices.

Using evidence-based educational strategies to increase knowledge and skills in tobacco cessation

To meet the demand for improved patient outcomes and accountability for healthcare delivery, nurses must embrace a culture of evidence-based practice (EBP). Integrating EBP for tobacco cessation in nursing practice is particularly important for the 44.5 million smokers in the United States who contribute to 157 billion dollars of healthcare costs annually. Unfortunately, studies reveal that healthcare providers are not aware of what is considered the best evidence, the United States Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence, resulting in missed opportunities to promote optimal health outcomes for individuals wanting to quit smoking. Fortunately, leading healthcare authorities such as the Joint Commission of Accreditation for Healthcare Organizations and Centers for Medicare and Medicaid Services now require providers to offer tobacco cessation services. The challenges and opportunities to do this effectively are many and with limited resources it will be increasingly important to ensure that nurses have the necessary knowledge and skills to improve tobacco cessation outcomes. For tobacco cessation interventions to become a standard of nursing practice, strategic efforts must be directed at advancing nursing research that evaluates best educational strategies for promoting tobacco cessation interventions within nursing curricula. In this article, a framework to help address nursing strategies to bridge the gap between EBP and tobacco cessation will be described.

Strategic Directions for Nursing Research in Tobacco Dependence

Tobacco use continues to be the leading cause of preventable death in the United States, causing approximately 440,000 deaths a year. Even with significant progress in the last decades, there are over 45 million smokers in the United States. Despite the efficacy of nurses in providing tobacco cessation interventions, nursing research in this area has been minimal. The purpose of this presentation is to summarize the recommendations for focusing and fostering nursing research in tobacco cessation from 42 researchers, clinicians, educators, and representatives from the Agency for Healthcare Research and Quality (AHRQ), the National Cancer Institute (NCI), the Joint Commission on Accreditation of Healthcare Organizations, and from nursing organizations who attended a 1-day invitational conference. This conference evolved from the work of the Tobacco Free Nurses Initiative in promoting the role of nursing in tobacco control and in response to the recognition of potential contributions to the field from nursing research. Sponsored by AHRQ and the NCI, the conference included formal presentations, and small and large group discussions around tobacco cessation research, resulting in consensus statements about a research agenda. Participants recommended strategies for new approaches in nursing research on tobacco dependence and cessation; strategies for seizing opportunities and confronting challenges in building nursing research in the field; and enhancing utilization of research findings into clinical practice. This agenda provides direction for growing nursing research in tobacco cessation, breaking down barriers to research, and supporting efforts for increasing utilization of evidence-based findings in clinical practice.

Nursing Research and Treatment of Tobacco Dependence

Tobacco use is considered to be the single most preventable cause of premature morbidity and mortality among men and women. It is well documented that tobacco cessation reduces the burden of disease significantly and is cost effective. Efficacious therapy for tobacco dependence exists, and nurses have been shown to be effective tobacco cessation interventionists. Given the large number of nurses in the United States, nurses can influence national health objectives of reduced tobacco use significantly and help to decrease the number of adults at risk for tobacco-attributable disease and death. The objectives of this presentation are to (a) describe the scientific evidence for tobacco cessation interventions, based on the U.S. clinical practice guideline Treating Tobacco Use and Dependence; (b) present the meta-analytic findings of the efficacy of nursing interventions for smoking cessation; (c) discuss barriers to nursing research and tobacco interventions; and (d) provide future directions for nursing intervention research.

Strategies to implement tobacco control policy and advocacy initiatives

Critical care nursing organizations and individual critical care nurses can have an important impact on tobacco-related health policies. This article reviews the importance of critical care nursing involvement in policy efforts to achieve tobacco control goals, barriers to such involvement, and strategies to implement successful tobacco control policy initiatives. The involvement of the Association of Critical-Care Nurses and other nursing organizations in the Nursing Leadership in Tobacco Control Task Force is described.

Tobacco control in the 21st century: a critical issue for the nursing profession

Tobacco control is central to reducing death and disability and improving quality of life worldwide and nursing action is imperative. This article addresses tobacco as a global health issue with implications for nursing practice, education, research, and policy development. The lack of knowledge and skills, lack of expectation for clinical intervention, limited research, an absence of professional policies, and minimal nursing leadership have diminished the critical role that nurses can play in confronting this epidemic. Swift action is needed to ensure that all nurses are prepared to effectively engage in activities to prevent tobacco use, provide evidence-based cessation interventions, and support efforts to prevent exposure to secondhand smoke. Increased opportunities are needed to support creative nursing research efforts that test interventions and strategies to reduce barriers to tobacco control within different cultures, subcultures, and countries.

Multicomponent individualized smoking cessation intervention for patients with lung disease

AIMS

This paper reports a study examining the process and outcomes of a long-term, multicomponent smoking cessation intervention for patients with lung disease initiated while hospitalized and provided over 1-year postdischarge.

BACKGROUND

Successful smoking cessation interventions are of primary importance for people with lung disease. Initiation of such an intervention in hospital settings is particularly important as patients may be especially motivated to quit as a result of strong perceptions of vulnerability while hospitalized for a smoking-related disease. Tailoring the intervention to each person's needs is a promising approach to practice.

METHODS

All patients who smoked and were admitted to a pulmonary unit over 2 years were invited to participate in this quasi-experimental study (n = 85), and 69 continued beyond the first month. The intervention was shaped by the TransTheoretical Model and used nicotine replacement therapy, along with individual and group counselling and support grounded in the nurse-patient relationship. The intervention was provided during hospitalization and by telephone after discharge at 1 week, and 1, 3, 6 and 12 months.

RESULTS

At 12-months postdischarge, 39% of the patients reported continuous abstinence from smoking from the time they joined the programme and 52% were not smoking at that time. No relationship was found between abstinence and the number of quit attempts, readiness to quit, nicotine dependency and length of hospital stay. Readiness to quit had increased and nicotine dependency decreased significantly by the end of the programme. No gender differences were found for the main variables.

CONCLUSIONS

Comprehensive, individualized smoking cessation interventions for hospitalized patients having lung disease, with a 1-year follow-up, was successful. Abstinence was high in comparison with other studies. This may in part be explained by significantly enhanced motivation to quit during the smoking cessation programme.

Nurses' perspectives of smoking initiation, addiction, and cessation

BACKGROUND

It is estimated that 18% of registered nurses smoke. Although nurses can make an important contribution to national cessation efforts, continuing smoking among nurses has been cited as one of the barriers against higher nursing involvement.

OBJECTIVES

To develop a national program to assist nurses in smoking cessation through an in-depth understanding of issues related to nurses' attitudes toward smoking and quitting, and to explore nurses' preferences for smoking cessation interventions.

METHODS

Eight focus groups were conducted in four states with nurses who were current or former smokers. Content analysis was used to identify major themes.

RESULTS

Four themes were identified: initiation of smoking and addiction, myths and misconceptions about quitting, overcoming addictions, and strategies for enhancing successful cessation. Nurses described addiction and cessation efforts similar to those of the general population. However, nurses experienced guilt related to their smoking, and perceived a lack of understanding by nonsmoking colleagues and managers about their need of support for smoking cessation. Nurses who had successfully quit smoking were motivated by health concerns, pregnancy, and their children. Nurses suggested many interventions that would be supportive of their quit attempts, such as worksite services and Internet-based support groups.

CONCLUSIONS

Nurses expressed the need for smoking cessation interventions similar to that of the general population, and for additional support that recognizes two concerns: confidentiality about their smoking in terms of the general public, and support along with counseling with regard to their feelings of shame and guilt in relation to their public image as nurses.

Tobacco control policies of oncology nursing organizations

Nurses, the largest group of health care professionals, and the policies of nursing organizations, have tremendous potential to promote health and tobacco control. Policies addressing tobacco use have been implemented by a variety of national and international nursing organizations. This article reviews existing tobacco control policies in oncology nursing organizations.

Potential reduction exposure products and FDA tobacco and regulation: a CNS call to action

A new generation of tobacco harm reduction products is stirring controversy and confusion among healthcare providers. These products, known as "potential reduction exposure products" (PREPs), can be described in terms of reported scientific evidence, as "the good, the bad, and the ugly." On the good side, there is sufficient scientific evidence to support the use of Commit, a new over-the-counter nicotine lozenge PREP, approved for smoking cessation. On the bad side, there is no scientific evidence to support the use of Ariva, another over-the-counter nicotine lozenge PREP, marketed as an alternative to cigarettes when smoking is restricted. On the ugly side, both of these PREPs are nicotine delivery systems with "candy-like" appearances; however, one (Commit) has the Food and Drug Administration (FDA) approval and the other (Ariva) does not. This article provides an overview of PREPs and strategies to help clinical nurse specialists (CNSs) address tobacco harm reduction issues.

Women and the global tobacco epidemic: nurses call to action

BACKGROUND

Tobacco consumption is increasing among women across the globe at alarming rates. Without effective intervention, the smoking prevalence among women will nearly triple over the next generation. These trends are potentially more threatening when considering how tobacco intersects women's lives, regardless if they use tobacco products or not.

AIM

A review and analysis of the literature is conducted to examine the scope of tobacco's global effect on the multiple dimensions of women's health.

METHOD

Medline (1990-2003), Cumulative Index to Nursing and Allied Health Literature (1990-2003) and World Health Organization databases were searched for related topics. Keywords for searches included global health, tobacco, women and nursing.

FINDINGS

The epidemiology and prevalence of tobacco use among women are presented and its impact on women globally. Using an ecological perspective, the consequences of tobacco are analysed within the contexts of health, social, environment, economic and policy as it relates to women, their families and their communities.

IMPLICATIONS

Nurses are in prime positions to empower individuals, families, communities and nations in the prevention and treatment of tobacco use. Health for all women continues to be a call for equity and social justice. Recommendations are provided for nursing practice, education, theory, research and policy to address this global health concern.

Tobacco use and dependence

OBJECTIVES

To review tobacco use and dependence including nicotine pharmacology and addiction, and pharmacologic treatment.

DATA SOURCES

Professional journals, books, government publications.

CONCLUSION

Smoking is addictive and a major health problem. Habitual nicotine use is central to sustaining smoking dependence. This article provides the necessary basis for understanding nicotine addiction and pharmacologic therapies.

IMPLICATIONS FOR NURSING PRACTICE

Nurses' knowledge about nicotine addiction is important in helping patients to quit smoking.

Preventing exposure to second-hand smoke

OBJECTIVE

To report the effectiveness of a health education intervention provided by nurses to prevent second-hand smoke exposure in sick children in Hong Kong.

DATA SOURCES

A clinical trial, international and national government reports, and research studies.

CONCLUSION

Exposure to second-hand smoke is associated with significant morbidity and mortality. Nursing interventions to reduce exposure are critical and need further study.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are in a vital position to carry out health education about the health risks associated with second-hand smoke exposure and to protect the child from such exposure.

The global epidemic of tobacco and cancer

OBJECTIVES

To provide a global context for understanding the epidemic of tobacco-induced disease, and the need for nursing action.

DATA SOURCES

International cancer and tobacco statistics; published articles.

CONCLUSION

Tobacco use is a global problem and a significant issue for cancer control. The efforts of health professionals, especially those concerned about cancer, are needed to confront this epidemic.

IMPLICATIONS FOR NURSING PRACTICE

Worldwide action of nurses, the largest group of health professionals, is critical in preventing tobacco use, helping with tobacco cessation, and decreasing exposure to second-hand smoke.

Efficacy of a smoking-cessation intervention for elective-surgical patients

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.

Smoking and adolescence: narratives of identity

The purpose of this study was to understand the identities that youth hold in relation to smoking, as revealed in narrative accounts of their smoking experiences. The analysis was a narrative inquiry, a qualitative approach based on the propensity of people to narrate or tell stories about the experiences in their daily lives. A purposeful sample of 35 youths ages 14-18 years with a variety of smoking histories (all had tried smoking) participated in in-depth interviews. A detailed analysis of the transcripts revealed the key identities communicated by the youths including the confident nonsmoker, the vulnerable nonsmoker, the ardent nonsmoker, the accepting nonsmoker, the in-control smoker, the confirmed smoker, and the contrite smoker. Tobacco control interventions for youth must be designed to respond to and incorporate multiple smoking identities.

International efforts in tobacco control

OBJECTIVES

To review international nursing involvement in tobacco control and discuss opportunities and challenges to enhance nurses' participation in decreasing tobacco-related morbidity and mortality.

DATA SOURCES

Published literature and published and unpublished material developed by nurses in their tobacco control initiatives.

CONCLUSION

Worldwide, nurses have been involved in tobacco control. However, many opportunities remain for involvement in the areas of education, research, and practice.

IMPLICATIONS FOR NURSING PRACTICE

There are numerous opportunities for nurses throughout the world to enhance their involvement in tobacco control.