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"Not Lighting Up":
A Case Study of a Woman Who Quit Smoking
Ellen Giarelli, RN, EdD, CRNP, Nancy Ledbetter, RN, MS,
Suzanne Mahon, RN, DNSc, AOCN, APNG, and Diane McElwain, RN, MEd, OCN
Key Points . . .
Purpose/Objectives: To review the prevalence, incidence, and risks of
smoking by American women; to outline services, treatments, and edu-
cational options for smoking prevention and cessation; and to present the
Cigarette smoking costs the United States $157.7 billion per
conceptual link between the epidemiologic and research literature and ex-
year in medical care and lost productivity and is a significant
periences of one individual in the target population--an adult female
cause of premature death.
former smoker with a 30-year habit who began smoking during her teen-
Tobacco use is declining overall, but cigarette use by women
age years.
Data Sources: Published literature, expert opinion, and an interview
continues to increase.
with a former smoker--a female healthcare professional who had a 30-
Several programs address specific issues associated with
year habit.
smoking prevention and cessation for women.
Data Synthesis: Literature was reviewed and the content was evalu-
ated for relevance, accuracy, and timeliness. The relevant content was
augmented with the author's practical experience and applied to the case
study to make recommendations.
From 19651990, tobacco use in the United States declined
Conclusions: Oncology nurses may use a number of strategies to
40% and consumption dropped from a 4,500 per capita cigarette
assist people to never start or to stop using tobacco products. The most
consumption in 1975 to approximately 2,200 per capita con-
effective strategy begins with collaboration between healthcare profes-
sumption in 1998 (American Cancer Society [ACS], 2002b,
sionals and patients and a combination of instruction, counseling, and
2003b). This change is attributed to different approaches taken
emotional support. Oncology nurses can participate in grassroots efforts
to prevent tobacco use, including public education initiatives,
to educate the public about addiction related to tobacco use, provide
counseling for patients who smoke, and become actively involved in leg-
high sales taxes, and antismoking campaigns. Eighty percent of
islative solutions to the problem of tobacco use.
adult smokers began smoking as minors. Although smoking is
Implications for Nursing: Oncology nurses may intervene to affect
declining among adults, first use of cigarettes rose 30% among
positive behavioral change and participate in grassroots efforts to edu-
teenagers from 19881996 (Centers for Disease Control and
cate the public. Substantial resources are available to professionals and
Prevention [CDC], 2002b). Nearly 22% of teenagers smoked a
patients who wish to quit smoking or prevent tobacco use by friends and
cigarette before age 13 and nearly 64% have tried cigarette
relatives. Nurses should take every opportunity to support smoking ces-
smoking (ACS, 2002d). Teenage girls who use oral contracep-
sation and tobacco use prevention.
Ellen Giarelli, RN, EdD, CRNP, is a research assistant professor in
ome women smoke over a lifetime. Some women start
S
the School of Nursing at the University of Pennsylvania in Philadel-
and quit. Others never try. What makes some women
phia; Nancy Ledbetter, RN, MS, is a cancer risk assessment and pre-
become tobacco users whereas others stay away? The
vention coordinator at Providence Health Systems in Portland, OR;
literature contains a litany of explanations, predictive factors,
Suzanne Mahon, RN, DNSc, AOCN, APNG, is an assistant clinical
and warnings. Yet, despite these warnings and evidence of
professor in the Division of Hematology and Oncology at St. Louis
harmful effects, people still use tobacco. Teenagers still think
University in Missouri; and Diane McElwain, RN, MEd, OCN, is a
that smoking is "cool." Nurses and other healthcare profes-
nurse manager and coordinator at the York Cancer Center in Penn-
sylvania. This article is the result of a special project designed at the
sionals know the risks, yet some still are seen "lighting up."
2002 networking meeting of the Oncology Nursing Society Preven-
Even though a substantial body of lay and scientific literature
tion and Early Detection Special Interest Group. (Submitted Octo-
describes the negative health effects of tobacco use, people
ber 2003. Accepted for publication December 5, 2003.)
deny the relevance and postpone quitting and young people
acquire new habits.
Digital Object Identifier: 10.1188/04.ONF.E54-E63
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E54
tives are at particular risk for acquiring a smoking habit (CDC,
digestive system or through mucous membranes. In 1994,
2002a). Evidence also exists that girls who start smoking dur-
about 7% of men in the United States reported using snuff and
ing their teenage years have an increased risk of developing
chewing tobacco (ACS, 2002c). In 1999, more than 14% of
breast cancer before they reach menopause (ACS, 2002d). Not
boys in their senior year of high school reported using smoke-
only is smoking hazardous, but the age at onset and duration of
less tobacco. Girls viewed smokeless tobacco users more fa-
use contribute to the health risks.
vorably than users of cigarettes (Kury, Rodrigue, & Perri,
The purpose of this article is twofold: first, to present a case
1998). Seven percent to 27% of regular smokeless tobacco
study of an American woman who began smoking at age 12
users have gingival recession, bone loss from the mandible,
and developed a habit that lasted 30 years; and second, to
and oral decay (ACS, 2002a). The most serious health effects
describe services, treatments, and educational options avail-
of smokeless tobacco are increased risk of cancer of the mouth
able to women who are at risk of smoking or who wish to stop.
and pharynx (Neville & Day, 2002).
An interview with "Laura" was conducted by one of authors
Demographic Variants
and condensed to a case study. The case illustrates the prob-
lems that are unique to female former smokers who struggle
Tobacco use is associated with access to products and po-
litical and economic benefits of production. When cigarettes
with lifelong addiction and obstacles to quitting. The authors,
who are experts in the field of cancer prevention and early de-
are easy to acquire, smoking prevalence is higher. Smoking
tection, critiqued the case. The critique summarizes problems
also is more prevalent among people who reside in tobacco-
raised by the case. Legislative approaches to controlling to-
producing states. In addition, a relationship appears to exist
bacco use are summarized along with comments on ways that
between level of education and tobacco use. The number of
nurses can advocate for preventing tobacco use among Ameri-
years of formal education is inversely correlated with tobacco
cans. This article is a project undertaken by members of the
use and smoking in particular. In 1999, smoking prevalence
Oncology Nursing Society Prevention and Early Detection
was more than four times higher among men and women who
Special Interest Group.
had 911 years of education versus those with 16 or more
years of education (CDC, 2001c).
Background
Smoking prevalence varies among U.S. states. In 2000,
Utah had the lowest adult smoking percentages for men and
women (14.6% and 12.1%, respectively) and Kentucky had
Tobacco use in the form of smoking costs money and lives.
the highest percentages for men and women (31.7% and
Each pack of cigarettes sold costs the United States more than
30.1%, respectively) (CDC, 2001c). Kentucky and other high-
$7 in medical care and lost productivity (CDC, 2002c). The
prevalence states usually are home to tobacco farms or to-
CDC set the nation's total cost of smoking at $3,391 a year for
bacco industries. Also, the risk of smoking is higher among
every smoker or $157.7 billion (Associated Press, 2002).
families involved in the production of tobacco products (Mur-
Smoking and Disease
phy & Price, 1988). Women smoke at rates (measured as
packs per day) comparable to men in most U.S. states, but
According to the U.S. Surgeon General, the American
25% of states reported higher use among women than men
Heart Association, the American Lung Association, and
(ACS, 2003b). The CDC publishes a state-by-state description
ACS, cigarette smoking is the most preventable cause of pre-
of tobacco use (CDC, 2001c).
mature death. ACS estimated that tobacco is responsible for
nearly one in five deaths in the United States. Approximately
Risks to Females
half of all continuing smokers die from diseases caused by
smoking, and half of these die in middle age, losing an aver-
More than 150,000 women die each year from smoking-re-
age of 2025 years of life (Jemal, Thomas, Murray, & Thun,
lated diseases, including heart disease, pulmonary disease, and
2002). Smoking is directly related to 30% of all cancer
lung cancer (Husten, 1998). Lung cancer surpassed breast
deaths and is a major cause of cardiovascular disease,
cancer in 1989 as the leading cause of cancer-related deaths
chronic bronchitis, and emphysema. Specifically, cigarette
and will be the cause of approximately one-quarter of the
smoking is responsible for 87% of diagnosed lung cancer
272,810 female cancer deaths in 2004 (Jemal et al., 2004). Pri-
cases and is implicated as contributing to the etiology of can-
marily as a result of smoking, lung cancer rates have increased
cers of the mouth, pharynx, larynx, esophagus, pancreas,
500% in women since the 1950s (Ernster, 1994).
Besides the general risks to health, women suffer gender-spe-
cervix, kidney, and bladder (ACS, 2002a). Persistent tobacco
use by adults and new use by minors have been obstacles to
cific liability because smoking adversely affects the female re-
public health efforts to decrease cancer mortality.
productive system, lung function (Gold et al., 1996), and high-
Smoke, whether firsthand or environmental, is the most
density lipoprotein cholesterol levels (Jacobson, Aldana,
dangerous component of cigarettes, cigars, and pipes (CDC,
Adams, & Quirk, 1995). Tobacco use has adverse effects dur-
2000a). Smoke contains nitrogen oxide and carbon monoxide.
ing pregnancy and health consequences for infants and young
Inhaling the smoke brings tar to the lung tissue. Tar contains
children of mothers who smoke. Maternal smoking is associated
approximately 4,000 chemicals. Some of these chemicals are
with tubal pregnancy, miscarriage, premature delivery, and in-
cyanide, benzene, formaldehyde, methanol, acetylene, and
creased risk of having a low birth-weight neonate (U.S. Depart-
ammonia (Battista, 1980). Secondhand smoke also is classi-
ment of Health and Human Services, 1990; Zahniser, Gupta,
fied as an environmental toxin equivalent to asbestos and
Kendrick, Lee, & Spirtas, 1994). Smoking prevalence among
other hazardous substances. Constant exposure to smoke in
pregnant women decreased from 19891998 but still ranges
the workplace or home nearly doubles the risk of heart attack.
from 12.9%22% (CDC, 2001d). Unfortunately, many women
Smokeless tobacco comes in two forms: snuff and chewing
who stop smoking during pregnancy resume smoking within
tobacco. Nicotine and other chemicals are absorbed by the
one year after delivery (Cataldo, Cooley, & Giarelli, 2002).
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E55
has been comparable (Johnston, O'Malley, & Bachman,
According to ACS and the CDC (ACS, 2003a; CDC,
2001a, 2001c, 2001d; Martin, Froelicher, & Miller, 2000), in
2001). According to a report by the Youth Risk Behavior Sur-
veillance System (CDC, 2001b), smoking among high school
1999 the prevalence of smoking among U.S. women (aged 18
students is a function of race, age, and gender (see Table 1).
and older) was 21.5%, compared to 25.7% in men. The high-
est smoking prevalence for women was found among Ameri-
In addition, the older the student is, the greater the likelihood
of tobacco use.
can Indians and Alaska Natives (40.8%), intermediate among
The persistently high use may be a result, in part, of easy
Caucasian and African Americans (23.1% and 20.8%, respec-
tively), and the lowest prevalence was among women of His-
access to cigarettes. More than 50% of the respondents aged
17 and younger who smoked reported that they personally
panic and Asian/Pacific Islander descent (12.3% and 7.1%,
bought cigarettes in the past month despite laws in all 50 states
respectively). Based on this information, smoking cessation
and prevention efforts can be targeted to populations based on
prohibiting tobacco sales to minors (CDC, 2000b). For a com-
plete description of the impact of smoking on the health of
selected demographic and health risk factors such as age, sex,
education, race and ethnicity, and state of residence.
children and adolescents, see Cataldo et al. (2002).
Beginning the Habit: Smoking by Young Women
A Smoker's Perspective
Most smokers start at a young age. Currently, all states pro-
hibit the sale of tobacco to minors, yet teenagers still buy and
Statistics reveal one dimension of the problem of tobacco use.
The personal experiences of smokers provide a deeper and
use cigarettes, snuff, and chewing tobacco (Glantz, 2002). Re-
search on buying patterns among young people shows that
richer understanding of habitual use. Therefore, one of the au-
adolescents and children purchase more than 256 million
thors of this article interviewed a woman who had the follow-
ing typical demographic characteristics: middle-age adult fe-
packs of cigarettes per year (Cummings, Pechacek, & Shop-
male, former smoker, employed part-time, married to a non-
land, 1994). Among high school seniors, smoking prevalence
smoker, and a parent of two minor children. The experiences of
peaked in the mid-1970s (39% in 1976), decreased to 29% by
this woman mirror the literature with regard to demographic
1981, and then remained at this level until 1992 (CDC,
characteristics of smokers, smoking habits prior to quitting, and
2000a). According to the CDC (2000b), in 1999, 70.4% of
high school students tried cigarettes and female students in
the addictive potential of cigarettes. The interview was semi-
structured, tape recorded, and transcribed. Responses were read
grades 1012 were more likely to use tobacco than younger
students. Smoking prevalence among high school seniors
by all of the investigators and condensed to form a biographic
peaked again in 1997 (37%), and declined in 2000 to 31%
sketch of the respondent's experiences from her earliest use of
tobacco to the present. The sketch was reviewed by the subject,
(CDC, 2000a). Unfortunately, even the lower figure equates
to more than 3,800 new teenage smokers each day. Since the
who verified the accuracy of the representation of her experi-
mid-1980s, smoking prevalence in 12th grade girls and boys
ences. The biographical sketch is presented as a case study.
Case Study
Laura is a 51-year-old healthy Caucasian mother of two adopted
Her smoking habit became more regular at age 18 when she started
boys and a former cigarette smoker. She is a physician's assistant
smoking up to a pack a week. She did not smoke every day. When she
for Planned Parenthood in the state of New York. Her patient popu-
attended college she believed that she had the freedom to smoke
lation is primarily young women, mostly in their mid-20s, who are
whenever and wherever she wanted. It became part of her identity; at
sexually active. Laura smoked for 30 years. During that time, she at-
first, having such an identity felt more addictive than the nicotine.
tempted to quit several times and succeeded once for two years.
While still in college, she advanced to smoking a pack a day. She
Presently, none of her friends smoke. Laura quit four years ago and
had a cigarette when she first got up in the morning, after meals, of-
since then has been using nicotine replacement gum or lozenges
ten when she was writing, and always when she was studying. She
continually. Even though she has been advised that nicotine substi-
claimed that it helped her to concentrate. When working as a wait-
tution should be limited to one year or less, she believes that if she
ress, she would have a cigarette in an ashtray ready to puff between
stops the nicotine replacement she will resume smoking.
orders. She would finish a good job and have a cigarette. It was a
Laura had her first cigarette in the early 1960s when she was
pleasurable activity. As stress increased, so did her smoking. She
about 12 years old. She admits that it was "cool" then and would
described it as energizing, satisfying, and relaxing. In part, she be-
sneak cigarettes from her parents' packs. Often her parents would
lieved the addiction was physical. A cigarette would wake her up. It
send her to the store to buy cigarettes for them. In the 1960s,
would help her to focus. It was easier to do mental work. It was
women smoked freely, even when pregnant. She recalled a scene
stimulating. She confessed that if the research revealed that ciga-
in which her mother, pregnant with her brother, would rest an ash-
rettes were safe she would return to smoking. One of the hardest
tray on her very large abdomen. Laura bought cigarettes for 25
things about stopping smoking was changing her self-image as a
cents in cigarette machines located in nearly every store (e.g., gro-
smoker. She saw herself as a smoker. Laura described smoking as
cery stores, delicatessens, candy stores, gas stations). Sometimes
enslavement and dependence. She would spend time thinking about
the machines were located at the entrance and boxes of matches
when she could have another cigarette. Limitations such as re-
were on top of the machine. There were no restrictions on selling
stricted access, prohibitions, and negative public attitudes were not
them to minors. Cigarettes were readily available. She said, "No one
deterrents. Her husband never smoked and actually disliked the
questioned a kid buying butts." At 12 years of age, she smoked oc-
smell, but she admitted that did not stop her.
casionally and considered it a "grown-up" thing to do, like a "rite of
(Continued on next page)
passage" to adulthood.
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E56
Case Study (continued)
Laura quit when she decided to become pregnant. After two years,
come a physician's assistant, she was uncomfortable providing health
when unable to conceive and in-vitro fertilization failed, she decided
care to patients while engaging in unhealthy behavior. After five at-
to resume smoking. Even though she said that it tasted bad and it
tempts over 15 years, she successfully quit and has not returned.
made her head cloudy, she ignored the negative sensation and con-
Now Laura actively rejects her former personae as a smoker. Instead,
tinued. Slowly she increased to a few cigarettes per day. It took one
she visualizes a middle-aged woman who smokes as unhealthy, un-
year for her habit to rise back to a pack a day. After adopting her first
attractive, wrinkled, and drawn. She believes that the years of smok-
child, she stopped smoking in the house to prevent him from being
ing accelerated her periodontal disease and dental problems and is
exposed to secondhand smoke. When she returned to school to be-
concerned about her increased risk of head, neck, and lung cancers.
Case Study Critique by Oncology Nurses
50 United States and the District of Columbia to evaluate their
effectiveness in reducing mortality, morbidity, and psychoso-
Several issues raised by the case are grouped into two main
cial problems associated with substance use and abuse. The
categories: (a) issues associated with prevention (e.g., availabil-
team found that certain retail environments frequented by
ity of tobacco products, peer pressure, developmental tasks) and
teenagers promote tobacco use (CDC, 2002c). Strategies used
(b) issues associated with cessation (e.g., linking smoking to
to promote tobacco use in these stores included (a) self-ser-
self-image, the addictive potential of tobacco products).
vice tobacco product placement, (b) advertising promotions
using multipack products with discounts or gift with purchase
Issues Associated With Prevention
offers, (c) tobacco-branded functional objects (e.g., counter
Laura's experiences match the literature on smoking predic-
change mats or shopping baskets with tobacco logos), and (d)
tion with regard to who is at risk for smoking. Several significant
tobacco advertising within the store. At least one of these
factors are the availability of tobacco products, advertising, im-
strategies to promote tobacco was observed in 92% of the
ages in mass media, and peer pressure and establishing identity.
stores surveyed; 65% had at least one tobacco-branded func-
Availability of tobacco products: Laura's parents smoked,
tional item, 36% of the stores offered multipack discounts or
and she grew up in a suburban community. Distefan, Gilpin,
gifts, and 23% had interior advertising.
Choie, and Pierce (1998) named parental smoking as a signifi-
Teenagers are receptive to tobacco company merchandise.
cant influence on smoking among children, and Farrow and
The CDC (2002f) reported that 45% of the teenagers surveyed
Schwartz (1992) reported that white suburban youth were
who used tobacco bought or received an item with a tobacco
heavier users of tobacco products than urban nonwhites and
name or logo (such as a cigarette lighter or t-shirt). Tobacco
they experienced more difficulties as a consequence. Selling
companies recognize the potential gains from reaching out to
tobacco products to minors is illegal, yet the accessibility of
school-aged children and have sought to sponsor public school-
vendors continues to aid young people in buying these products.
related sporting events and other activities such as fund-raisers
A study of product availability conducted by the CDC (1996)
that award bonus prizes that feature a brand logo. Advertise-
found that 89% of the young people surveyed purchased their
ments from three of the four major tobacco companies appear
own tobacco products and 45% were not asked for proof of age.
in magazines such as Rolling Stone, People, Entertainment
Small stores were the most common places that these products
Weekly, Sports Illustrated, and TV Guide (Kuczynski, 2001).
were purchased (89%), but products also were purchased in
Moreover, tobacco advertisers have focused on women for
larger stores (37%). The elimination of cigarette machines and
many years and target women's magazines. Products have
the implementation of age restrictions on those who purchase
been designed and marketed to this population using terms
cigarettes were designed to deter use. However, no data support
such as "attractive" or "feminine." A strong association con-
a direct link among purchase patterns and eliminating cigarette
tinues to exist between the emancipation and rights of women
machines and imposing age restrictions.
and smoking for many decades (Bell & Tingen, 2001).
One way to reduce availability is to provide individuals with
The financial impact of these sales and advertising is sig-
substitutes for cigarettes that meet their developmental needs
nificant. Illegal sales of tobacco products to underage buyers
and satisfy their desires. Researchers in the United Kingdom
amount to an estimated $1 billion per year (CDC, 2002c).
noted a drop in teenage smoking in Britain during the 1990s,
Laura's case illustrates the link between availability and pro-
hypothesizing the cause to be the corresponding increase in
gression of use, and the literature records the pervasiveness of
cellular phone use. Cellular phones provide something to do
the problem.
with the hands and mouth (Charlton & Bates, 2000).
Images in mass media: Young people spend an average of
Advertising: The ImpacTeen Research Team is identifying
16 hours weekly viewing television beginning as early as age
and tracking tobacco control policies at the state level for all
two (Strasburger & Donnerstein, 1999). Although cigarette
commercials are banned from network television, cigarettes
Table 1. Relationship Among Selected Race and Ethnicities,
appear in the mouths of actors, on situation comedies, and in
Gender, and Percent Smoking in High School Students
reruns of movies and shows produced prior to the ban. This
form of advertising is covert and subtle. A mixed message of
Gender
Caucasian (%)
Hispanic (%)
African American (%)
the dangers and appeal of smoking is found in images in the
mass media. An advertisement may place a visual cue that is
Female
39
34
18
linked to a product, such as a burning cigarette in an ashtray
Male
38
32
22
or an empty pack on or by a garbage can with the name of a
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E57
brand clearly visible. An American Lung Association study of
Addictive potential of tobacco products: Tobacco ces-
133 movies released from 19941995 found that 77% de-
sation literature describes the experiences of former smok-
picted tobacco use (Thomas, 1996). A survey by the CDC
ers who make multiple attempts to quit (Jorenby, 2001). The
(2002f) reported that 81% of students saw or heard an anti-
addiction is real. Tolerance quickly develops, which, in turn,
smoking commercial on television or radio during the prior 30
encourages an increase in smoking. As tobacco use in-
days. In the same sample, 88% of the subjects reported seeing
creases, smokers develop physical and psychological depen-
actors using tobacco on television or in movies in the prior 30
dence along with tolerance. Social and psychological factors
days and 32% reported seeing advertising for tobacco prod-
influence starting, but the physical effects of tobacco are cor-
ucts on the Internet.
related closely with habitual use (Botvin, Epstein, & Botvin,
Peer pressure and establishing identity: A developmental
1998).
task of adolescents is to separate from their parents and estab-
Nonsmokers may assume incorrectly that once smokers
lish their own identity. Sometimes this is accomplished through
quit, the influence of their smoking habit is eliminated.
rebellion, and smoking is rebellious. Lloyd, Lucas, and Fern-
Cravings may persist for years after quitting. Laura's continu-
bach (1997) reported that adolescent girls construct smoking
ing desire to smoke and her need for nicotine substitutes dem-
identities with an organized system of values, ideas, and peer
onstrate that, even after quitting, the addiction persists. She
practices. Smoking contributes to individuation. Paavola,
continued to use replacement gum and lozenges and believed
Vartiainen, and Puska (1996) reported that two-thirds of those
that she would smoke if these substitutes were not available.
who smoked in the ninth grade were still smoking at the age of
She was motivated to regain the pleasure that cigarettes pro-
28 and previous smoking status and use of tobacco by friends
vided even to the point of ignoring the acute displeasure (i.e.,
were the most important predictors of smoking.
"bad taste" and "cloudy head") that she initially experienced
when she resumed smoking.
Issues Associated With Smoking Cessation
Smoking prevention: Oncology nurses must think of to-
bacco use as a lifelong habit and prevention as a lifelong battle
Smoking is a complex behavior and no one remedy is effec-
to maintain abstinence. An effective smoking prevention pro-
tive for all smokers who attempt to quit many times before suc-
gram will consider developmental tasks and interpersonal
ceeding. Smoking cessation resources are aimed largely at
dynamics of the targeted population. Generally, stress man-
adults but may be modified for any target population by using
agement is a place to start. Some specific activities, such as
culturally and developmentally appropriate strategies. Pharma-
yoga, massage, meditation, and support groups, are techniques
cologic therapies, however, have been tested and approved for
that anyone can learn or use to reduce anxiety and redirect
use only by adults (Prokhorov, Hudmon, & Stancic, 2003).
energy to health-promoting behaviors. Consuming healthy
Factors that affect smoking cessation are the link to self-image,
foods enhances appearance, and socializing with nonsmoking
motivation to quit, and the addictive potential of nicotine.
friends reduces availability. All of these behaviors may de-
Link between smoking and self-image: The link of smok-
crease the likelihood of using tobacco. Former smokers can
ing with identity is a problem for all users at any age. The so-
talk to teenagers and young adults, and prevention efforts
cial pressures to start smoking may be internalized and trans-
should be organized to counter marketing strategies aimed at
formed to a self-image as "smoker" to perpetuate the habit.
this age group.
Laura, for example, identified smoking as a part of her person-
ality that she had difficulty giving up. She associated smoking
Smoking Cessation
with a feeling of "freedom" and believed that smoking in-
creased mental acuity. Research complements Laura's reality.
Strategies and Programs
The U.S. Department of Health and Human Services (2000)
reported that women may be more likely to face certain psycho-
Smoking cessation programs may be targeted to women
logical issues during smoking cessation therapy, including de-
based on the understanding of gender-specific physiology, so-
pression and weight control concerns. For Laura, quitting meant
cial roles, and patterns of stress. For women of reproductive
changing the way that she perceived herself. Although health-
age, the CDC (2002e) recommended relating the effects of
care professionals readily point out the health benefits of smok-
smoking directly to their reproductive goals and child-rearing
ing cessation during counseling, they also must acknowledge
responsibilities. Further research is needed to explore the
that smoking provides psychological benefits.
magnitude of the relationship between smoking and female
Motivation to quit: Laura's motivations for stopping smok-
health outcomes (e.g., fertility; psychosocial distress; breast,
ing were not linked directly to personal health. She identified
colorectal, and other cancers). Research is needed to identify
parenthood as a major motivator for stopping. She had difficulty
gender-specific differences in the success of smoking preven-
reconciling the conflicting images of "self-as-smoker" and
tion and to explain disparities in use among socioethnic-eco-
"self-as-healthcare provider." Her negative self-image as a
nomic groups. Because women access healthcare providers
smoker, especially after deciding to become a healthcare pro-
more frequently than men, especially during the reproductive
fessional, was the factor that prevented her from resuming the
years, these are junctures to initiate a discussion about the im-
habit. Oncology nurses who are trying to help people decide to
portance of tobacco avoidance and smoking cessation (Brit-
quit smoking must recall that health risks may not be sufficient
ton, 1998).
to motivate patients to quit. Associated benefits (e.g., enhanced
Smoking Cessation: What Works and What Does Not
reproductive ability, decreased risks to pregnancies, decreased
risk to the fetus and newborn) may be more influential for
Generally, the most effective way to help patients quit
women. A cessation program must be personal and individual-
smoking is by offering targeted smoking cessation therapy
ized and grow from an understanding of the manifest, latent,
combining pharmacologic therapy and counseling. Of the
and long- and short-term goals of women.
70% of smokers who report that they want to quit, less than
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E58
Table 2. The 5Rs Strategy for Smoking Cessation
8% are able to quit without assistance. Therapy that includes
nicotine replacement, antidepressants, and counseling has
Strategy
Reason
been shown to increase the quit rate to 35% (Mallin, 2002).
Research directly comparing one approach to another is lim-
Relevance
Help the person to identify reasons for quitting that are rel-
ited (Lancaster, Stead, Silagy, & Sowden, 2000). Therefore,
evant to them.
therapy is designed based on an individual's personality, de-
Risks
Help the person to identify short- and long-term negative con-
mographic, and healthcare profile as determined (often infor-
sequences of smoking.
mally) by healthcare professionals.
Rewards
Help the person to identify rewards or benefits to self and
Counseling and instruction: The first step toward increas-
loved ones from smoking cessation.
ing a person's likelihood of quitting is to point out the expe-
Roadblocks
Help the person to identify barriers to quitting.
riences of current tobacco users. Oncology clinic staff can
Repetition
Ensure that people who have quit previously know that it
adopt the 5As strategy used in primary care (see Figure 1).
usually takes more than one quit attempt to succeed.
The 5Rs is an intervention aimed at motivating smokers who
currently are unwilling to quit (see Table 2).
Note. Based on information from the U.S. Department of Health and Human
Brief advice from healthcare providers, in the form of sug-
Services, 2000.
gestions on where to find information about quitting, support
organizations, and the use of nicotine replacement therapy,
mended ways. Nicotine is addictive whether in natural to-
has been found to increase the quit rate in primary care, inpa-
bacco or in synthetic form; therefore, the patterns of use of
tient, outpatient, and occupational health settings (Lancaster
n i c o t i n e replacement products should be carefully re-
et al., 2000). Although not specifically studied in oncology
searched.
settings, nursing counseling regarding smoking cessation sig-
Antidepressants: Antidepressants have been used in com-
nificantly increased quit rates when compared to a control or
bination with psychosocial cessation programs. One agent is
usual care in 16 studies (Rice & Stead, 2001). The effective-
bupropion. The clinical effects of bupropion when used for
ness of individual and group counseling and self-help mate-
smoking cessation are not fully understood, but the antidepres-
rials has been studied. When compared to no intervention,
sant blocks uptake of noradrenaline and dopamine. Bupropion
self-help materials (e.g., pamphlets, manuals, audiotapes, vid-
has been found to improve tobacco quit rates when used with
eotapes, computer programs) improved quit rates somewhat
or without nicotine replacement therapy. Fewer studies report
but did not provide additional benefit when added to brief
evidence that nortriptyline is useful in smoking cessation
advice to quit (Lancaster et al.).
(Lancaster et al., 2000). Other medications and therapies that
Nicotine replacement therapy: Nicotine replacement
have been studied but have not been found to be effective aids
therapy increases the chances of quitting smoking by 1.52
for smoking cessation include anxiolytics, lobeline, acupunc-
times (Lancaster et al., 2000). The goal of nicotine replace-
ture, and hypnotherapy. Clonidine, an antihypertensive, has
ment is to reduce the symptoms of tobacco withdrawal. Nico-
been shown to improve quit rates, but its benefits must be
tine replacement therapy plus supportive interventions pro-
weighed against its troublesome side effects of sedation and
duces higher quit rates, but nicotine replacement therapy
postural hypotension (Lancaster et al.).
increases the likelihood of quitting regardless of the presence
Several private and public organizations provide informa-
of adjuvant support. Nicotine replacement comes in many
tion about the epidemiology and public health effects of to-
forms--chewing gum, transdermal patch, nasal spray, in-
bacco products, cessation and prevention programs, support
haler, sublingual tablet, or lozenge. Effectiveness varies little
services, and other resources. In addition, several Web sites
among the delivery systems (Lancaster et al.). Nicotine re-
provide smoking prevention and cessation resources that can
placement products usually are recommended for short-term
be accessed by patients, the public, and healthcare profession-
use. These products can be purchased without a prescription,
als (see Figures 2 and 3).
and patterns of use rarely are monitored by healthcare provid-
ers. Healthcare professionals do not know how many indi-
Social Advocacy and Antitobacco Legislation
viduals self-prescribe or use replacements in nonrecom-
Oncology nurses may become social advocates and join the
political debate on antismoking legislation. Local, state, and
Counseling Tools
federal legislative solutions (e.g., new laws, consistent en-
Offer brief advice to quit using the 5As: Ask patient whether he or she uses
forcement of regulations) are ways to limit the effect of to-
tobacco, advise patient to quit, assess patient's willingness to quit, assist if
bacco use on public health. More than 100 years ago, the Ten-
patient is willing to quit, and arrange for follow-up.
nessee Supreme Court upheld the conviction of a person for
If unwilling to quit now, use the 5Rs: relevance, risks, rewards, roadblocks,
selling cigarettes, saying that cigarettes were "wholly noxious
repetition.
and deleterious to health" (Glantz & Annas, 2000). By the
Group counseling
turn of the 20th century, 14 states had outlawed the sale,
Individual counseling
manufacture, or possession of cigarettes; 21 states had consid-
Self-help materials: weigh time and costs when developing if also providing
advice to quit
ered similar bans; and two states had passed laws that declared
cigarettes to be narcotics.
Pharmacotherapy
In 1994, attorneys general in several states filed lawsuits to
Nicotine replacement therapy: gum, patch, nasal spray, inhaler, sublingual
secure funds from the tobacco industry for reimbursement of
tablet, lozenge
healthcare expenditures arising from tobacco use. By the end
Antidepressants: bupropion, nortriptyline
of 1996, 18 other states had filed similar legal actions. In
Figure 1. Smoking Cessation Strategies
1997, a group of state attorneys general presented a tobacco
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E59
state budget shortfalls in lieu of layoffs or cuts in state aid to
Agency for Health Care Policy and Research--Publications Clearinghouse,
schools (McKinley, 2002). In another example, Governor
2101 East Jefferson Street, Suite 501, Rockville, MD 20852. Call 301-594-1364
Bob Holden of Missouri covered the state's budget shortfall
or visit www.ahcpr.gov. The site provides clinical, patient, and consumer infor-
by using $63.5 million that had been allocated to a tobacco-
mation about prevention services and links to sites that offer research about evi-
control program, a senior prescription drug program, an en-
dence-based practice, support groups, and other relevant Internet sites.
dowment fund, a state health laboratory, an early childhood
American Academy of Addiction Psychiatry--7301 Mission Road, Suite 252,
development, childhood lead screenings, and other health
Prairie Village, KS 66208. Call 913-262-6161 or visit www.aaap.org. Offers an
programs (Campaign for Tobacco-Free Kids, 2002). Some
Internet store with addiction resources and course material.
bills that have been proposed in the U.S. House of Represen-
American Cancer Society--1599 Clifton Road NE, Atlanta, GA 30329. Call 800-
tatives and the U.S. Senate that are directly related to the
ACS-2345 or 404-320-3333 or visit www.cancer.org or www.ca-jour nal.org.
control of the sale and use of tobacco products are listed in
Offers a good program that covers four one-hour sessions during a two-week
Figure 4.
period. They claim that 20%30% of people remain off cigarettes. Call to find
the nearest program for quitting smoking. The Web site includes the "Complete
Guide to Quitting," "Quitting Smokeless Tobacco," and "Help for Cravings and
www.cdc.gov/tobacco/how2quit.htm--Centers for Disease Control and Pre-
Tough Situations."
vention (CDC) references on how to quit
American Council on Science and Health--1995 Broadway, Second Floor,
New York, NY 10023-5860. Call 212-362-7044 or visit www.acsh.org. Offers
www.cdc.gov/tobacco/stat-nat-data.htm--online compilation of state-based
information on evidence-based practice and outcomes as well as a consumer
tobacco information that combines many different data sources and allows
quit-smoking program.
users to view comprehensive summary information on tobacco use in all 50
states and the District of Columbia. The state system contains up-to-date and
American Lung Association--1740 Broadway, New York, NY 10019-4374. Call
historical data on the prevalence of tobacco use, tobacco control laws, the
800-LUNG-USA or 212-315-8700 or visit www.lungusa.org. Offers a wide
health impact and costs associated with tobacco use, and tobacco agriculture
range of tobacco control fact sheets and online programs for cessation.
and manufacturing.
National Cancer Institute--31 Center Drive, MSC 2580, Building 31, Room
10A03, Bethesda, MD 20892-2580. Call 800-422-6237 or 301-435-3848 or
www.cdc.gov/tobacco/sports_initiatives_splash.htm--information about
visit www.nci.nih.gov. Offers free information on smoking cessation programs,
how the CDC encourages smoking cessation with sports activities
fact sheets, and links to related sites.
www.who.int/tobacco/wntd/2004/en--information on World No Tobacco Day
Nicotine Anonymous World Services--Call 866-536-4539 or visit www .nico-
www.cdc.gov/tobacco/data.htm--tobacco information and source tips for
tine-anonymous.org. Uses the same principles as Alcoholics Anonymous. Of-
health professionals from the CDC
fers a directory of meeting places and times in many locations as well as an
Internet store with helpful guides and aids.
www.cdc.gov/tobacco/bestprac.htm--The CDC's Best Practices for Compre-
hensive Tobacco Control Programs is an evidence-based guide to help states
Smokefree.gov--Visit http://smokefree.gov. Allows visitors to read, download,
plan and establish effective tobacco control programs to prevent and reduce to-
and print guides and tools for smoking cessation.
bacco use.
Sources of Alternative Methods
www.cdc.gov/tobacco/comguide.htm--The CDC's Guide to Community Pre-
American Academy of Medical Acupuncture--4929 Wilshire Boulevard, Suite
ventive Services addresses the effectiveness of community-based interventions
428, Los Angeles, CA 90010. Call 323-937-5514 or visit www.medical
for three strategies to promote tobacco use prevention and control: (a) prevent
acupuncture.org. To find an acupuncturist in a specific area, visit www.medical
tobacco product use initiation, (b) increase cessation, and (c) reduce exposure
acupuncture.org/refsearch.html.
to environmental tobacco smoke.
American Society of Clinical Hypnosis--130 East Elm Court, Suite 201,
www.naccho.org/GENERAL185.cfm--Guidelines can structure comprehensive
Roselle, IL 60172-2000. Call 630-980-4740 or visit www.asch.net. Reliable
local tobacco control efforts, offer tips on how to allocate local funds to help en-
hypnotherapists can be found by sending a self-addressed stamped envelope
sure effective programs, and provide a framework that local public health officials
to the society.
can use to discuss with local and state elected officials the allocation of funds
Figure 2. Resources for Smoking Cessation
from the Master Tobacco Settlement to local tobacco control programs.
www.cdc.gov/tobaccoevaluation_manual/contents.htm--This document is a
"how to" guide for planning and implementing evaluation activities. The manual
settlement proposal that would settle all pending class action
reflects the priorities of the CDC's Office on Smoking and Health for program
lawsuits against the tobacco industry and all pending actions
monitoring and evaluation.
against the industry brought by states and other governmen-
www.surgeongeneral.gov/tobacco--recommendations from the surgeon
tal entities (Campaign for Tobacco-Free Kids, 2004). These
general's office related to tobacco use cessation
actions resulted in the Master Tobacco Settlement (MTS), in
which the industry agreed to pay the 46 states $206 billion
www.cancer.org--American Cancer Society Web site that contains informa-
over a 25-year period, to respect certain limits on tobacco
tion for healthcare providers and the public
advertising, and to fund a nationwide campaign of public edu-
www.tobaccofreekids.org--up-to-date statistics and programs useful for the
cation (Kessler & Myers, 2001; Loveland, 2002).
public and healthcare professionals.
MTS can positively affect the health of young and adult
www.tobacco.org--news about tobacco and tobacco control; many links to
women if funding is used to augment educational programs
public press
and make instruction on prevention relevant to this subgroup
of tobacco users (Daynard, Parmet, Kelder, & Davidson,
www.lungusa.org/tobacco--information about the American Lung Association's
Freedom from Smoking Program
2001). State use of MTS funds, however, is at the discretion
of individual state legislatures. Tobacco suit settlements
www.quitnet.com--online smoking cessation program
have been used for smoking cessation programs, healthcare
Figure 3. Web Sites With Smoking Prevention and
expenses, or other expenses unrelated to health care. For ex-
Cessation Resources
ample, in New York the funds have been used to balance
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E60
children from beginning the habit and to help their loved ones
HR 1043, FDA Tobacco Jurisdiction Act of 2001--to amend the Federal Food,
quit. The second most apparent implication for oncology
Drug, and Cosmetic Act to provide the U.S. Food and Drug Administration juris-
nurses is that any efforts to modify the factors that promote
diction over tobacco. Sponsor: Rep. Henry A. Waxman
tobacco use will, in time, have a positive effect on the health
HR 1044, Child Tobacco Use Prevention Act of 2001--to prevent children
of the population. These effects, although slow and incremen-
from using tobacco products, to reduce the health costs attributable to tobacco
tal, are measurable and vital.
products, and for other purposes. Sponsor: Rep. Henry A. Waxman
The effectiveness of smoking cessation and prevention pro-
HR 1453, Smokeless Tobacco Warning Label Act--to strengthen warning la-
grams relies on the willingness of smokers to begin and their
bels on smokeless tobacco products. Sponsor: Rep. Elton Gallegly
commitment to complete them when completing means never
HR 1454, Bidi Cigarettes Import Prohibition--to prohibit the importation of
smoking again. Beginning the programs can be relatively
bidi cigarettes. Sponsor: Rep. Elton Gallegly
easy; the anecdotal evidence of the number of times smokers
HR 2180/S 190, National Youth Smoking Reduction Act--to amend the Fed-
attempt to quit supports this statement. Remaining a non-
eral Food, Drug, and Cosmetic Act to grant the secretary of Health and Human
smoker is more difficult.
Services the authority to regulate tobacco products, or for other purposes.
Another factor in the success of smoking prevention and ces-
Sponsors: Rep. Tom Davis and Sen. Bill Frist
sation efforts is the social environment and the community's
S 247, Kids Deserve Freedom From Tobacco Act of 2001 (Kids Act)--to pro-
beliefs about smoking. Tobacco use will be reduced in a social
vide for the protection of children from tobacco. Sponsor: Sen. Tom Hardin
environment that favors the nonsmoker, such as smoke-free
Visit www.tobaccoarchives.com for tobacco company documents that have
offices or restaurants. The CDC has developed a set of recom-
been produced from various lawsuits.
mendations for comprehensive tobacco control that include
personal, social, and legislative actions (see Table 3).
Figure 4. Bills Proposed in the U.S. Senate and House of
Oncology nurses are a credible source of information for
Representatives for Tobacco Control and Use Prevention
patients and the public, but they first must serve as role models
Note. Based on information from the Centers for Disease Control and Preven-
of health-promoting behavior. Oncology nurses may use a num-
tion, 2002d.
ber of strategies to assist people to never start or to stop using
tobacco products. Aspects of all of these programs can begin in
any practice setting. The most effective approach begins with
Conclusion and Implications for Nurses
the collaboration of healthcare professionals and patients to
identify a combination of instruction, counseling, and emotional
Tobacco use persists as a public health problem. The most
support. Oncology nurses should be involved in prevention
apparent implication for oncology nurses is that the health
activities and advocate for broader use and testing of the effec-
risks and diseases caused by tobacco use also will persist. On-
tiveness of cessation programs for high-risk populations, such
cology nurses must, therefore, remain actively engaged with
as women and young girls. Regardless of practice setting, on-
patients and their families in their struggle to prevent their
Table 3. Centers for Disease Control and Prevention Recommendations for Comprehensive Tobacco Control
Recommendation
Implementation Cost
Description
Community programs to reduce
$0.70$2 per capita for local governments; addi-
Implements tobacco control interventions and educational activities
tobacco use
tional costs for state personnel and resources
while partnering with local organizations
Chronic disease programs to re-
$2.8$4.1 million per year
Targets the areas of cardiovascular health, asthma prevention, oral
duce the burden of tobacco-re-
health, and cancer registries
lated diseases
School programs
$500,000$750,000 per year for personnel and re-
Implements tobacco-free policies, evidence-based curricula, teacher
sources; $4$6 per student in grades K12
training, and parent awareness
Enforcement
$150,000$300,000 for agency coordination;
Restricts minors' access to tobacco and reduces smoking in pub-
$0.43$0.80 per capita for year
lic places
`
Statewide programs
$0.40$1 per capita per year
State and regional support increases awareness of tobacco control
issues.
Counter-marketing
$1$3 per capita per year
Increases pro-health messages through a variety of media
Cessation programs
$1 per adult to identify and advise against tobacco;
Should consider the Agency for Health Care Policy and Research
$2 per smoker for brief counseling; $137.50 per
smoking cessation guidelines
smoker (if insured) or $275 (if publicly financed) for
other services (behavior modification, pharmaceuti-
cals, etc.)
Surveillance and evaluation
10% of annual program costs
Monitors tobacco-related behaviors, attitudes, and health outcomes
at regularly scheduled intervals
Administration
5% of annual program costs
Effective programs require strong management to facilitate coordi-
nation of program components and multiple agencies.
Note. Based on information from the Centers for Disease Control and Prevention, 1999.
ONCOLOGY NURSING FORUM VOL 31, NO 3, 2004
E61
cology nurses can participate in grassroots efforts to educate the
awareness of health risks, patient choices with regard to to-
public about addiction related to tobacco use, provide counsel-
bacco use, and patients' behavior changes based on oncology
ing for patients who smoke, and become actively involved in
nurse-initiated discussion or treatment. Research is needed to
legislative solutions to the problem of tobacco use.
demonstrate the force of oncology nursing against this public
Lastly, ample studies of the effect of tobacco on health and
health threat.
sufficient literature on cessation and prevention programs ex-
ist. Daily, oncology nurses discuss the issues with patients and
Author Contact: Ellen Giarelli, RN, EdD, CRNP, can be reached at
family members. However, no studies have determined the
giarelli@nursing.upenn.edu, with copy to editor at rose_mary@
impact that oncology nurses, in particular, have on public
earthlink.net.
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