Implementation, Maintenance, and Outcomes of an Electronic Referral to a Tobacco Quitline Across Five Health Systems

INTRODUCTION

Electronic referral (e-referral) to quitlines helps connect tobacco-using patients to free, evidence-based cessation counseling. Little has been published about the real-world implementation of e-referrals across U.S. health systems, their maintenance over time, and the outcomes of e-referred patients.

AIMS AND METHODS

Beginning in 2014, the University of California (UC)-wide project called UC Quits scaled up quitline e-referrals and related modifications to clinical workflows from one to five UC health systems. Implementation strategies were used to increase site readiness. Maintenance was supported through ongoing monitoring and quality improvement programs. Data on e-referred patients (n = 20 709) and quitline callers (n = 197 377) were collected from April 2014 to March 2021. Analyses of referral trends and cessation outcomes were conducted in 2021-2022.

RESULTS

Of 20 709 patients referred, the quitline contacted 47.1%, 20.6% completed intake, 15.2% requested counseling, and 10.9% received it. In the 1.5-year implementation phase, 1813 patients were referred. In the 5.5-year maintenance phase, volume was sustained, with 3436 referrals annually on average. Among referred patients completing intake (n = 4264), 46.2% were nonwhite, 58.8% had Medicaid, 58.7% had a chronic disease, and 48.8% had a behavioral health condition. In a sample randomly selected for follow-up, e-referred patients were as likely as general quitline callers to attempt quitting (68.5% vs. 71.4%; p = .23), quit for 30 days (28.3% vs. 26.9%; p = .52), and quit for 6 months (13.6% vs. 13.9%; p = .88).

CONCLUSIONS

With a whole-systems approach, quitline e-referrals can be established and sustained across inpatient and outpatient settings with diverse patient populations. Cessation outcomes were similar to those of general quitline callers.

IMPLICATIONS

This study supports the broad implementation of tobacco quitline e-referrals in health care. To the best of our knowledge, no other paper has described the implementation of e-referrals across multiple U.S. health systems or how they were sustained over time. Modifying electronic health records systems and clinical workflows to enable and encourage e-referrals, if implemented and maintained appropriately, can be expected to improve patient care, make it easier for clinicians to support patients in quitting, increase the proportion of patients using evidence-based treatment, provide data to assess progress on quality goals, and help meet reporting requirements for tobacco screening and prevention.

Impact of a web-based educational program on Japanese nurses tobacco cessation practice and attitudes in oncology settings

PURPOSE

To evaluate the effects of a short web-based educational program on Japanese nurses' self-reported attitudes toward tobacco cessation and their use of interventions to help smokers to quit.

DESIGN

Prospective, single-group design with a pre-educational survey, a short web-based educational program, and a follow-up survey at 3 months.

METHODS

Clinical nurses were asked to view two prerecorded webcasts about helping smokers quit. They completed two online surveys, one at baseline and one at a 3-month follow-up. Generalized linear models were used to determine changes in nurses' self-reported routine practice after the study intervention.

FINDINGS

A total of 1401 nurses responded to the baseline survey, 678 of whom completed the follow-up survey. Compared with baseline, nurses at follow-up were more likely to advise smokers to quit (odds ratio [OR] = 1.45, 95% confidence interval [CI: 1.15, 1.82]), assess patients' interest in quitting (OR = 1.46, 95% CI [1.01, 1.04]), and assist patients with smoking cessation (OR = 1.34, 95% CI [1.04, 1.72]). However, the proportion of nurses who consistently recommended resources for tobacco cessation did not significantly improve at follow-up.

CONCLUSIONS

This study provides preliminary evidence that a web-based educational program can increase nurses' implementation of tobacco dependence interventions in cancer care practice. Sustaining these educational efforts could increase nurses' involvement in providing these interventions, encourage nurses to refer patients to cessation resources, and support nurses' attitudes towards their role in smoking cessation.

CLINICAL RELEVANCE

Our short web-based educational program can increase nurses' use of tobacco-dependence interventions in cancer care practice. This role can be enhanced with additional information about existing cessation resources that nurses could use to refer patients for support post-discharge. Japanese nurses, when properly educated, are willing and significant contributors to promote tobacco use cessation for cancer patients. The contribution can be facilitated through nursing care protocol that integrate tobacco use cessation interventions within evidence-based cancer care approaches.

Interpersonal Trauma in the Lives of Nurses and Perceptions of Nursing Work

The purpose of this study was to explore associations between trauma experiences among nurses and nursing perceptions of risk for involuntary job loss and standing in society. This observational study used 2001 data from the Nurses' Health Study II (N = 53,323 female nurses). The outcome variables were nurses' perceptions of their risk for involuntary job loss and their social standing in the United States and within their own community. The exposure variables were childhood and adulthood interpersonal trauma. Nurses reported high levels of emotional (60% childhood; 44% adulthood), physical (45% childhood, 23% adulthood), and sexual trauma (15% childhood, 11% adulthood). Emotional trauma was associated with perception of higher risk for involuntary job loss, but also higher perception of nurse societal standing. Nurses experience high rates of interpersonal trauma, which may influence how they perceive their profession.

Transitions in hookah (Waterpipe) smoking by U.S. sexual minority adults between 2013 and 2015: the population assessment of tobacco and health study wave 1 and wave 2

BACKGROUND

Tobacco smoking using a hookah (i.e., waterpipe) is a global epidemic. While evidence suggests that sexual minorities (SM) have higher odds of hookah use compared to heterosexuals, little is known about their hookah use patterns and transitions. We sought to examine transitions between hookah smoking and use of other tobacco and electronic (e-) products among SM adults aged 18 years of age and older versus their heterosexual counterparts.

METHODS

We analyzed nationally representative data of ever and current hookah smokers from Wave 1 (2013-2014; ever use n = 1014 SM and n = 9462 heterosexuals; current use n = 144 SM and n = 910 heterosexuals) and Wave 2 (2014-2015; ever use n = 901 SM and n = 8049 heterosexuals; current use n = 117 SM and n = 602 heterosexuals) of the Population Assessment of Tobacco and Health Study. Comparisons between groups and gender subgroups within SM identity groups were determined with Rao-Scott chi-square tests and multivariable survey-weighted multinomial logistic regression models were estimated for transition patterns and initiation of electronic product use in Wave 2.

RESULTS

Ever and current hookah smoking among SM adults (ever use Wave 1: 29% and Wave 2: 31%; current use Wave 1: 4% and Wave 2: 3%) was higher than heterosexuals (ever use Wave 1: 16% and Wave 2: 16%; current use Wave 1: 1% and Wave 2: 1%; both p < 0.0001). Among SM adults who reported hookah use at Wave 1, 46% quit hookah use at Wave 2; 39% continued hookah use and did not transition to other products while 36% of heterosexual adults quit hookah use at Wave 2 and 36% continued hookah use and did not transition to other products. Compared with heterosexuals, SM adults reported higher use of hookah plus e-products (Wave 2 usage increased by 65 and 83%, respectively).

CONCLUSIONS

Compared to heterosexuals, in addition to higher rates of hookah smoking, higher percentages of SM adults transitioned to hookah plus e-product use between 2013 and 2015. Results have implications for stronger efforts to increase awareness of the harmful effects of hookah as well as vaping, specifically tailored among SM communities.

Building capacity in tobacco control by establishing the Eastern Europe Nurses' Center of Excellence for Tobacco Control

INTRODUCTION

Properly educated nurses delivering evidence-based tobacco dependence treatment could contribute to improving health and reducing regional disparities in tobacco-related disease and death in Central and Eastern Europe. The aims of this study are to describe development of the Eastern European Nurses’ Centre of Excellence for Tobacco Control (COE) and evaluate its online educational program on tobacco dependence treatment using the 5As framework.

METHODS

The online education evaluation followed a prospective, single group, pre- and post-assessment of changes in nurses’ self-reported tobacco cessation interventions. Leaders from five Eastern European countries (Hungary, Czech Republic, Romania, Slovakia, Slovenia) developed protocols for in-country tobacco control education. Nurses responded to a baseline survey, accessed an online nursing educational program, and completed a follow-up survey at 3 months, in the period December 2015 to June 2016. A total of 695 nurses from five countries answered questions on cessation interventions at baseline and of these 507 (73%) completed a follow-up survey at 3 months.

RESULTS

At the follow-up at 3 months, the 507 nurses self-reported a significant increase in providing all 5A components, i.e. nurses were significantly (p<0.0001) more likely to always /usually advise a patient to quit, assess interest in quitting (p=0.002), assist with a quit plan, review barriers to quitting and recommend a smoke-free home post-discharge (all p<0.0001). They were also significantly more likely (p=0.01) to agree or strongly agree that nurses have an obligation to advise patients on the risks of smoking. There was a significant increase (p<0.0001) in nurses’ estimate of the number of patients they provided a cessation intervention the previous week. Nurses who smoked were 60% more likely to assist and arrange compared to nurses who never smoked.

CONCLUSIONS

Coordinating multi-country activities through a COE was successful in engaging a network of nurses to use an online educational program and participate in other tobacco control activities.

High Carbon Monoxide Levels from Charcoal Combustion Mask Acute Endothelial Dysfunction Induced by Hookah (Waterpipe) Smoking in Young Adults

BACKGROUND

Hookah smoking is marketed to youth as a harmless alternative to cigarettes. Although cigarette smoking acutely impairs endothelial function, the effect of smoking fruit-flavored hookah tobacco is unknown. Because charcoal traditionally is used to heat the hookah tobacco in the waterpipe, hookah smoke delivers tobacco toxicants and nicotine plus charcoal combustion products: not only carbon-rich nanoparticles, oxidants that may destroy nitric oxide and impair endothelial function, but also large amounts of carbon monoxide (CO), a putative vasodilator molecule.

METHODS

To test the acute effect of hookah smoking on endothelial function, in young adult hookah smokers (n=30, age 26±1 years, mean±SE), we measured plasma nicotine, exhaled CO, and brachial artery flow-mediated dilation (FMD) before and after charcoal-heated hookah smoking. To remove the effect of charcoal combustion, the same measurements were performed when the same flavored hookah tobacco product was heated electrically (n=20). As a positive internal control, we studied age-matched cigarette smokers (n=15) who smoked 1 cigarette. To isolate the effect of the CO boost on FMD, hookah smokers (n=8) inhaled a 0.1% CO gas mixture to approximate their CO boost achieved with charcoal-heated hookah smoking.

RESULTS

Nicotine levels increased similarly with all types of smoking, whereas exhaled CO increased 9- to 10-fold more after charcoal-heated hookah than after either electrically heated hookah or cigarette smoking. FMD did not decrease after smoking charcoal-heated hookah but instead increased by +43±7% ( P<0.001). In contrast, FMD decreased by -27±4% ( P<0.001) after smoking electrically heated hookah, comparable to the decrease after cigarette smoking. FMD increased markedly by 138±71% ( P<0.001) after breathing CO gas, 2.8 times more than the increase induced in the same subjects after smoking charcoal-heated hookah ( P<0.001), despite comparable increases in exhaled CO (24±1 versus 28±3 ppm, hookah versus CO).

CONCLUSIONS

Smoking hookah tobacco, similar to cigarette tobacco, acutely impairs endothelial function. With traditional charcoal-heated hookah smoking, the acute endothelial dysfunction is masked by high levels of carbon monoxide, a potent vasodilator molecule generated by charcoal combustion. With respect to large-artery endothelial function, smoking hookah is not harmless.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifiers: NCT03616002 and NCT03067701.

Increased adoption of smoke-free policies on campuses with schools of nursing

BACKGROUND

In 2015, the majority of U.S. American Association of Colleges of Nursing (AACN)-accredited schools of nursing resided on campuses without smoke-free policies.

PURPOSE

To determine the presence of smoke-free policies at AACN-accredited after resolutions from AACN and the American Academy of Nursing, and the creation of online resources.

METHODS

Smoke-free policies (2015-2017) were determined through listings on the ANRF College Campus Policy Database© and survey responses from nursing deans.

RESULTS

Smoke-free policies for 689 schools of nursing increased from 36% in 2015 to 91% in 2017. There were no significant differences by nursing program types or geographic area. Twenty percent of deans reported using the resources, with over 1700-page views.

CONCLUSION

Smoke-free policies increased after support from two national nursing organizations. Learning in a smoke-free environment should be an expectation for nursing students to protect their own health, and to support their future critical role in tobacco control.

Attitudes, barriers and facilitators to smoking cessation among Central and Eastern European nurses: A focus group study

PURPOSE

Smoking among nurses is a barrier to providing smoking cessation interventions to patients. In Central and Eastern Europe-where tobacco use is the leading cause of preventable death and disease-there is limited knowledge about nurses' attitudes toward cessation interventions. Our aim was to describe the attitudes of nurses who are former and current smokers toward providing cessation interventions to patients as well as explore barriers and facilitators to their own quit efforts.

METHODS

Nine focus groups with 81 nurses (94% females) in five Central and Eastern European countries. Content analysis was used to identify major themes.

RESULTS

Nurses agreed that they should set a good example by not smoking; should be involved in helping patients stop smoking; and needed additional training in tobacco control. Five common themes were identified as barriers to quitting: smoking cues in the environment; presence of smokers in the environment; relapse postpartum; stress and nicotine addiction; and misperceptions about the dangers of smoking. Former smokers reported facilitators to quitting including: seeing the health consequences of smoking among their patients; personal and family health concerns; receiving support from family; and pregnancy.

CONCLUSION

There is a need to build upon nurses' positive attitudes about engaging in smoking cessation interventions with patients to ensure that cessation interventions are standard nursing practice. Future studies should focus on programs that support nurses' quit efforts by addressing barriers to smoking cessation, which will improve their health and patient care.

Acute Effect of Hookah Smoking on Arterial Stiffness and Wave Reflections in Adults Aged 18 to 34 Years of Age

Hookah (waterpipe) smoking is rapidly increasing in popularity worldwide. Despite being heavily advertised in the media as a healthier alternative to cigarettes, the toxicology of hookah smoke suggest otherwise. Cigarette smoking unequivocally causes an acute increase in arterial stiffness, but whether hookah does the same is unknown. In 48 young healthy habitual hookah but not cigarette smokers, we measured heart rate, peripheral and central blood pressure, carotid-femoral pulse wave velocity (measure of arterial stiffness), aortic augmentation index (measure of wave reflection), plasma nicotine, and exhaled carbon monoxide before and after ad lib hookah smoking. Hookah smoking increased heart rate by +16 ± 1 beats/min and mean brachial arterial pressure by +6 ± 1 mm Hg (both p <0.05, mean ± SE). Most importantly, it increased carotid-femoral pulse wave velocity and aortic augmentation index by +0.66 ± 0.09 m/s^-1 and +8.76 ± 3.99%, respectively (p <0.05, mean ± SE), denoting increased acute arterial stiffness. These vascular effects were accompanied by increases in plasma nicotine concentration (+5.8 ± 1.2 ng/ml, p <0.05) and expired carbon monoxide (+25.44 ± 1.68 ppm, p <0.05). All these parameters were unchanged during time-control studies (n = 14). Thus, in contrast to effective media marketing of hookah as a safer alternative to cigarettes, the present study shows for the first time that in young adult hookah smokers, a single hookah smoking session causes an acute increase in arterial stiffness of comparable magnitude to what has been previously reported for cigarettes. Further research is warranted to determine whether habitual hookah smoking accelerates the age-dependent development of hypertension and its cardiovascular complications.

Impact of a webcast on nurses' delivery of tobacco dependence treatment

AIMS AND OBJECTIVES

To evaluate an educational programme about nurses' role in tobacco dependence treatment, and its webcast component, on the long-term impact of increasing the frequency of nurses' self-reported changes in practice related to delivery of smoking cessation interventions.

BACKGROUND

Healthcare professionals' knowledge about evidence-based tobacco dependence treatment using the 5As framework (Ask about tobacco use, Advise users to quit, Assess willingness to quit, Assist in making a quit plan and Arrange for follow-up, including referral to a quitline) is essential to increase smoking cessation rates in the United States.

DESIGN

A 6-month pre-post design.

METHODS

A convenience sample of nurses (N = 283) from Kentucky and Louisiana was provided access to the webcast and printed toolkit. Responses from those who completed an online survey at baseline, and at 3 or 6 months postimplementation of the educational programme were included in an analysis of changes in the consistent (always/usually) delivery of the 5As plus referral to the quitline.

RESULTS

After 3 months, the intervention had a significant impact on increasing nurses' reports of consistently providing the 5As to patients who smoked, which was largely sustained at 6 months. Nurses who viewed the webcast were three times more likely to refer smokers to a quitline at 3 months; and four times more likely at 6 months than those who did not.

CONCLUSIONS

An online educational programme, plus printed toolkit about tobacco dependence treatment increased nurses' delivery of smoking cessation interventions over time. This study provided preliminary evidence that including a webcast in a nurse-targeted educational programme could significantly increase the proportion of nurses who referred smokers to a quitline beyond the benefit of access to printed materials and web-based resources.

RELEVANCE TO CLINICAL PRACTICE

Distance learning is a feasible mechanism for enhancing nurses' involvement in tobacco dependence treatment and promoting evidence-based clinical practice.

Nurses' Attitudes toward Intervening with Smokers: Their Knowledge, Opinion and E-Learning Impact

BACKGROUND

Numbering about 90,000, nurses represent the largest group of health care providers in the Czech Republic. Therefore, nurses can make a significant impact in the treatment of tobacco dependence, particularly in applying brief interventions to smokers.

METHODS

During 2014, 279 nurses from the Czech Republic participated in an e-learning education programme consisting of two Webcasts with additional web-based resources about smoking cessation in relation to health and treatment options in daily clinical practice, particularly regarding brief intervention methods. Before viewing the e-learning programme, and three months after viewing it, the nurses completed a questionnaire documenting their interventions with smokers and their knowledge, attitudes and opinions regarding nurses' roles in smoking cessation.

RESULTS

The responses in all of the following categories significantly improved: usually/always asking patients about smoking from 58% to 69% (OR 1.62, CI=1.14-2.29, p=0.007); recommendations to stop smoking from 56% to 66% (OR 1.46, CI=1.03-2.06, p=0.03); assessing willingness to quit from 49% to 63% (OR 1.72, CI=1.23-2.42, p=0.002); assisting with cessation from 21% to 33% (OR 1.85, CI=1.26-2.71, p=0.002); and recommending a smoke-free home from 39% to 58% (OR 2.16, CI=1.54-3.04, p<0.001). The increase in arranging follow-up from 7% to 10% did not constitute a statistically significant improvement, however, this finding is understandable in relation to the status of nurses in the Czech Republic. However, nurses' confidence in helping smokers to quit smoking, their senses of responsibility and determining the appropriateness of these interventions remains inadequate.

CONCLUSION

The nurses' brief intervention skills improved significantly after the completion of the e-learning programme, even though reservations remain among this group. The systematic education of nurses aimed at smoking cessation intervention and analyzing their motivation for treatment may contribute to improved nursing care, and thus lead to a reduction of smoking prevalence in the general population.

Impact of Online Education on Nurses' Delivery of Smoking Cessation Interventions With Implications for Evidence-Based Practice

BACKGROUND

Tobacco use is the leading cause of preventable disease and death in Europe and worldwide. Nurses, if properly educated, can contribute to decreasing the burden of tobacco use in the region by helping smokers quit smoking.

AIMS

To assess: (a) the feasibility of an online program to educate nurses in Czech Republic and Poland on evidence-based smoking cessation interventions for patients and (b) self-reported changes in practices related to consistently (usually or always) providing smoking cessation interventions to smokers, before and 3 months after participation in the program.

METHODS

A prospective single-group pre-post design.

RESULTS

A total of 280 nurses from Czech Republic and 156 from Poland completed baseline and follow-up surveys. At 3 months, nurses were significantly more likely to provide smoking cessation interventions to patients who smoke and refer patients for cessation services (p < .01). Nurses significantly improved their views about the importance of nursing involvement in tobacco control.

IMPLICATIONS FOR PRACTICE

Education about tobacco control can make a difference in clinical practice, but ongoing support is needed to maintain these changes. Health system changes can also facilitate the expectation that delivering evidence-based smoking cessation interventions should be routine nursing care.

LINKING EVIDENCE TO ACTION

Educating nurses on cessation interventions and tobacco control is pivotal to decrease tobacco-related disparities, disease, and death. Online methods provide an accessible way to reach a large number of nurses.

Evaluation of a web-based educational programme on changes in frequency of nurses' interventions to help smokers quit and reduce second-hand smoke exposure in China

AIMS

To evaluate a web-based educational smoking cessation programme on changes in the frequency of hospital-based nurses' self-reported interventions to help smokers quit using the 5 As (i.e. Ask, Advise, Assess, Assist, Arrange), to reduce exposure to second-hand smoke and to change attitudes about nurses' involvement in tobacco control.

BACKGROUND

Few nurses in China support smokers' quit attempts using evidence-based smoking cessation interventions based on the 5 As. Limited knowledge is a barrier to intervention. Web-based tobacco cessation programs have the potential to reach a large population of nurses.

DESIGN

A prospective single-group design with pre-, 3- and 6-month follow-up after the educational programme evaluated the feasibility of conducting web-based educational programs in two cities in China in 2012-2013.

METHODS

Frequency of interventions was assessed using a valid and reliable web-based survey with a convenience sample of nurses from eight hospitals in Beijing and Hefei, China. Generalized linear models, adjusting for age, clinical setting, education and site were used to determine changes in the consistent (usually/always) use of the 5 As from baseline to 3 and to 6 months.

RESULTS

Nurses (N = 1386) had baseline and/or 3- and 6-month data. At 6 months, nurses were significantly more likely to Assess, Assist and Arrange for smoking cessation and recommend smoke-free home environments. There was significant improvement in attitudes about tobacco control.

CONCLUSIONS

Nurses receiving web-based smoking cessation education significantly increased self-reports of frequency of providing interventions to patients who smoke, including recommending smoke-free home environments to support quit attempts.

Helping smokers quit: behaviours and attitudes of Chinese Registered Nurses

AIMS

To describe the self-reported frequency of Chinese nurses' interventions to help smokers quit, using the 5 As (i.e. Ask, Advise, Assess, Assist, Arrange), attitudes towards tobacco control and differences in consistency interventions by demographic and professional characteristics prior to an educational intervention to increase nurses' support for quit efforts.

BACKGROUND

Tobacco use is the leading cause of preventable death in China; quitting smoking reduces health risks and premature death. The China Tobacco Cessation Treatment Guideline supports the 5 As model for intervention, but nurses' frequency of delivering smoking cessation interventions is unknown.

DESIGN

Descriptive survey using a convenience sample.

METHODS

Nurses from eight hospitals in Beijing and Hefei, China completed a web-based survey in 2012. Differences in consistency of the 5 As by nurse characteristics were determined using multivariate logistic regression. Overall importance of nurses in tobacco control was evaluated on a 1-5 scale (5 = most important).

RESULTS

Nurses (N = 2440; 1404 Beijing, 1036 Hefei) participated. 64% consistently asked about smoking status, 85% advised patients to quit, 52% assessed readiness to quit and assisted with smoking cessation and 17% arranged for follow-up. Interventions varied by nurses' education and clinical setting. Nurses positively viewed involvement in tobacco control (4·3/5) and thought nurses should be smoke-free role models (4·8/5·0).

CONCLUSIONS

This study demonstrates that the majority of nurses asked about smoking status, but few assisted patients with quitting. Further efforts are needed to help nurses actively promote smoking cessation interventions.

National cancer institute conference on treating tobacco dependence at cancer centers

The National Cancer Institute cancer centers possess the credibility to help smokers quit. With the greater life expectancies forecast for patients with cancer, addressing smoking at cancer centers has taken on greater importance.

A review of images of nurses and smoking on the World Wide Web

With the advent of the World Wide Web, historic images previously having limited distributions are now widely available. As tobacco use has evolved, so have images of nurses related to smoking. Using a systematic search, the purpose of this article is to describe types of images of nurses and smoking available on the World Wide Web. Approximately 10,000 images of nurses and smoking published over the past century were identified through search engines and digital archives. Seven major themes were identified: nurses smoking, cigarette advertisements, helping patients smoke, "naughty" nurse, teaching women to smoke, smoking in and outside of health care facilities, and antitobacco images. The use of nursing images to market cigarettes was known but the extent of the use of these images has not been reported previously. Digital archives can be used to explore the past, provide a perspective for understanding the present, and suggest directions for the future in confronting negative images of nursing.

Are quit attempts among U.S. female nurses who smoke different from female smokers in the general population? An analysis of the 2006/2007 tobacco use supplement to the current population survey

Background

Smoking is a significant women's health issue. Examining smoking behaviors among occupational groups with a high prevalence of women may reveal the culture of smoking behavior and quit efforts of female smokers. The purpose of this study was to examine how smoking and quitting characteristics (i.e., ever and recent quit attempts) among females in the occupation of nursing are similar or different to those of women in the general population.

Methods

Cross-sectional data from the Tobacco Use Supplement of the Current Population Survey 2006/2007 were used to compare smoking behaviors of nurses (n = 2, 566) to those of non-healthcare professional women (n = 93, 717). Smoking characteristics included years of smoking, number of cigarettes, and time to first cigarette with smoking within the first 30 minutes as an indicator of nicotine dependence. Logistic regression models using replicate weights were used to determine correlates of ever and previous 12 months quit attempts.

Results

Nurses had a lower smoking prevalence than other women (12.1% vs 16.6%, p < 0.0001); were more likely to have ever made a quit attempt (77% vs 68%, p = 0.0002); but not in the previous 12 months (42% vs 43%, p = 0.77). Among those who ever made a quit attempt, nurses who smoked within 30 minutes of waking, were more likely to have made a quit attempt compared to other women (OR = 3.1, 95% CI: 1.9, 5.1). When considering quit attempts within the last 12 months, nurses whose first cigarette was after 30 minutes of waking were less likely to have made a quit attempt compared to other females (OR = 0.69, 95% CI: 0.49, 0.98). There were no other significant differences in ever/recent quitting.

Conclusions

Smoking prevalence among female nurses was lower than among women who were not in healthcare occupations, as expected. The lack of difference in recent quit efforts among female nurses as compared to other female smokers has not been previously reported. The link between lower level of nicotine dependence, as reflected by the longer time to first cigarette, and lower quit attempts among nurses needs further exploration.

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

Why nursing research in tobacco control?

Tobacco use is an epidemic of overwhelming proportions affecting survival, causing millions of deaths every year, causing untold human suffering worldwide, and contributing to escalating health care costs. Nursing research is vital to advancing knowledge in the field and to the translation of science to evidence-based practice. As the largest group of health care professionals (17 million worldwide), nurses have the capacity for an enormous impact on this leading cause of preventable death. This chapter thus provides a historical overview of the tobacco epidemic, health risks of smoking and benefits of quitting, nicotine addiction, and recommendations of evidence-based tobacco dependence treatment as a backdrop for understanding the importance and need for nursing scholarship. Also examined are nursing science efforts and leadership in removing two barriers to mounting programs of nursing research in tobacco control: (1) lack of nursing education and training in tobacco control, and (2) limited research funding and mentorship. The chapter also addresses the issue of smoking in the profession as it impacts nurses' health, clinical practice, and, potentially, scholarship efforts.

Nurses trying to quit smoking using the Internet

Nurses QuitNet, an Internet-based smoking cessation program, was created to support nurses' quit attempts. The purposes of this study were to evaluate quit attempts at 3, 6, and 12 months after the use of the program and to determine differences in demographic, professional, and smoking characteristics by smoking status. Differences in the use of quit methods, barriers, and facilitators to quitting also were assessed. Data among 246 smokers who responded to at least 1 follow-up email at 3, 6, or 12 months after registration were analyzed. Quit rates among respondents were 43% (3 months), 45% (6 months), and 53% (12 months). Total time on the website was significantly higher for those who quit. Barriers to quitting included lack of support from colleagues, stress, lack of cessation services, and fear of not getting a work-break. Facilitators included working in a smoke-free facility, support from colleagues, and workplace cessation services. The use of Nurses QuitNet demonstrated promise in supporting quit attempts. Quitting was influenced by workplace factors.

Quality of life supersedes the classic prognosticators for long-term survival in locally advanced non-small-cell lung cancer: an analysis of RTOG 9801

PURPOSE

To determine the added value of quality of life (QOL) as a prognostic factor for overall survival (OS) in patients with locally advanced non-small-cell lung cancer (NSCLC) treated on Radiation Therapy Oncology Group RTOG-9801.

PATIENTS AND METHODS

Two hundred forty-three patients with stage II/IIIAB NSCLC received induction paclitaxel and carboplatin (PC) and then concurrent weekly PC and hyperfractionated radiation (to 69.6 Gy). Patients were randomly assigned to amifostine (AM) or no AM during chemoradiotherapy. The following pretreatment factors were analyzed as prognostic factors for OS: Karnofsky performance status, stage, sex, age, race, marital status, histology, tumor location, hemoglobin, tobacco use, treatment arm (AM v no AM) and QOL scores (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 [QLQ-C30] and Lung Cancer 13 [LC-13]). A multivariate (MVA) Cox proportional hazards model was performed using a backwards selection process.

RESULTS

Of the 239 analyzable patients, 91% had a baseline global QOL score. Median follow-up time was 59 months for patients still alive and 17 months for all patients. Median baseline QLQ-C30 global QOL score was 66.7 on both treatment arms. Whether the global QOL score was treated as a dichotomized variable (based on the median score) or a continuous variable, all other variables fell out of the MVA for OS. Patients with a global QOL score less than 66.7 had an approximately 70% higher rate of death than patients with scores > or = 66.7 (P = .004). A 10-point higher baseline global QOL score corresponded to a decrease in the hazard of death by approximately 10% (P = .004). The other independent QOL predictors for OS were the QLQ-C30 physical functioning (P = .011) and LC-13 dyspnea scores (P = .012).

CONCLUSION

In this analysis, baseline global QOL score replaced known prognostic factors as the sole predictor of long-term OS for patients with locally advanced NSCLC.

Frequency of nurses' smoking cessation interventions: report from a national survey

AIMS AND OBJECTIVES

To describe the frequency of nurses' delivery of tobacco cessation interventions ('Five A's': Ask, Advise, Assess, Assist, Arrange) and to determine the relationship of interventions to nurses' awareness of the Tobacco Free Nurses initiative.

BACKGROUND

Tobacco cessation interventions can be effectively provided by nurses. The delivery of smoking cessation interventions by healthcare providers is mandated by several organisations in the USA and around the world. Lack of education and resources about tobacco cessation may contribute to the minimal level of interventions. The Tobacco Free Nurses initiative was developed to provide nurses with easy access to web-based resources about tobacco control.

DESIGN

Cross-sectional survey of nurses (n = 3482) working in 35 Magnet-designated hospitals in the USA (21% response rate).

METHOD

A valid and reliable questionnaire used in previous studies to assess the frequency of the nurse's delivery of smoking cessation interventions ('Five A's') was adapted for use on the web.

RESULTS

The majority of nurses asked (73%) and assisted (73%) with cessation. However, only 24% recommended pharmacotherapy. Only 22% referred to community resources and only 10% recommended use of the quitline. Nurses familiar with TFN (15%) were significantly more likely to report delivery of all aspects of interventions, including assisting with cessation (OR = 1.55, 95% CI 1.27, 1.90) and recommending medications (OR = 1.81, 95% CI 1.45, 2.24).

CONCLUSIONS

Nurses' delivery of comprehensive smoking cessation interventions was suboptimal. Awareness of Tobacco Free Nurses was associated with increased interventions. Relevance to clinical practice. Further efforts are needed to ensure that nurses incorporate evidence-based interventions into clinical practice to help smokers quit. These findings support the value of Tobacco Free Nurses in providing nurses with information to support patients' quit attempts.

Women's perceptions of the personal and family impact of genetic cancer risk assessment: focus group findings

Women with a personal or family history of breast or ovarian cancer are increasingly presenting for genetic cancer risk assessment (GCRA). To explore the personal and family impact of GCRA, four focus groups were conducted of women seen for risk assessment. Participants were 22 primarily non-Latina White women with a personal or family history of breast or ovarian cancer. Analysis of the data identified new themes related to balancing time to assimilate risk information with the need to make timely healthcare decisions, physicians' lack of sufficient genetic knowledge, and concern for daughters regardless of the daughters' age. Other themes related to protecting others, knowledge as empowerment, reassessing personal attribution of cancer risk, managing uncertainty, reappraising body image, and experiencing divergent family responses to communication of cancer risk and healthcare decisions. Understanding the personal and family impact of GCRA may enable genetics professionals to tailor their counseling efforts to better meet the needs of these women. Additional research is needed to extend these findings and identify interventions to support positive outcomes of GCRA.

Characteristics of nurses who used the Internet-based nurses QuitNet for smoking cessation

BACKGROUND

Smoking among nurses is higher than other health care professionals but nurse-specific cessation programs are limited. Nurses QuitNet, launched in January 2004, provided an evidence-based online smoking cessation program for nurses and nursing students.

OBJECTIVES

To describe Nurses QuitNet registrants and relationships among the demographic and smoking characteristics, program dissemination strategies, and site utilization patterns.

DESIGN

Cross-sectional study.

SAMPLE

1,790 Nurses QuitNets registrants.

MEASUREMENTS

Demographics and smoking characteristics on the Nurses QuitNet intake questionnaire.

RESULTS

Most registrants were female (92.5%), 45-54 years old (34.3%), Caucasian (84.5%), and college graduates (57.5%). Over 68% smoked 10-20 cigarettes/day; 66.4% smoked within 30 min of waking. Half of those with previous quit attempts did not use evidence-based methods; 30% had not made a quit attempt in the past year. "Read-only" social support was the most frequently used Nurses Quitnet feature.

CONCLUSIONS

The Internet can be a viable option to support nurses' cessation and is available to accommodate their work schedules. The sample is similar to the general nursing population, except for higher levels of education. Efforts are needed to assist nurses struggling with nicotine addiction and disseminate cessation resources, particularly targeting nurses with the highest prevalence of current smoking, for example licensed practical nurses.

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

Do you need to smoke to get a break?: smoking status and missed work breaks among staff nurses

INTRODUCTION

The prevalence of missed work breaks by smoking status in healthcare settings is unknown. The work routines of nurses (Registered Nurses [RNs] and Licensed Practical Nurses [LPNs]), who smoke at higher rates than other health professionals, may be influenced by smokers who use breaks to avoid nicotine withdrawal. The purpose of this study was to examine the relationship between nurses' smoking status and work breaks and to explore the relationships among personal, professional, and workplace variables associated with missed work breaks.

METHODS

A web-based survey of 2589 staff nurses from 34 hospitals was conducted in 2006. Each hospital had been designated as a Magnet hospital by the American Nurses Credentialing Center. Data analysis included descriptive statistics, chi-square tests, and multivariate logistic regression.

RESULTS

The majority (90%) were nonsmokers; 97% were RNs. Missed breaks were common (70%) and differed by smoking status: 59% of smokers and 72% of nonsmokers frequently missed work breaks. Multivariate logistic regression determined that nonsmokers (OR=1.81, 95% CI=1.36, 2.42), LPNs (OR=2.37, 95% CI=1.16, 4.84), older nurses (OR 1.02, 95% CI=1.01, 1.03), those in emergency rooms (OR=1.75, 95% CI=1.25, 2.47), and in intensive care units (OR=1.60, 95% CI=1.22, 2.09) were more likely to miss breaks.

CONCLUSIONS

Missed work breaks were common among nurses. Those who did not smoke were almost twice as likely to miss their work breaks as compared to smokers. Inequities in breaks, especially by smoking status, may cause dissension in the workplace and negatively affect patient care. Policies that support work breaks for all nurses are needed.

Smoking among psychiatric nurses: does it hinder tobacco dependence treatment?

BACKGROUND

Data on tobacco dependence treatment for patients with mental illness are limited.

OBJECTIVE

Describe factors associated with psychiatric nurses' tobacco interventions.

STUDY DESIGN

Survey of 100 psychiatric nurses.

RESULTS

The majority "always/usually" asked (87%), advised (70%), and assessed (74%) tobacco use. A minority (49%) assisted with quit attempts, and arranged (21%) for follow-up. Former (56%, odds ratio [OR] = 0.13, 95% confidence interval [CI] = 0.02, 0.88) and current smokers (20%, OR = .08, 95% CI = 0.01, 0.72) were less likely to ask about tobacco use than never smokers.

CONCLUSIONS

Efforts are needed to promote tobacco cessation and to support nurses who smoke to quit.

Opportunities for nursing research in tobacco control

Nurse scientists have made important contributions to evidence-based practice in tobacco control. This chapter will discuss recent tobacco control developments in the United States and globally, such as legislation giving the U.S. Food and Drug Administration regulatory authority over tobacco products manufacturing, marketing and sales, the World Health Organization Framework Convention on Tobacco Control, and a brief review of research that has guided policy advances and nursing research in tobacco control. Suggestions for future research based on the update of the U.S. Public Health Services Treating Tobacco Use and Dependence clinical practice guideline will be explored. These developments offer nursing researchers a wealth of opportunities and challenges to advance nursing and tobacco control knowledge, address research gaps, and bring a unique nursing perspective to tobacco use prevention, reduction of exposure to secondhand smoke, tobacco dependence treatment, and tobacco control policies. Additionally, we will address how nursing scholarship can and should be supported by academic and organizational leadership to support nurses in realizing their full potential in mitigating the global epidemic of tobacco-caused death and disease.