September 2008, Volume 35, Number 5



Oncology Nursing Society Position: Nursing Leadership in Global and Domestic Tobacco Control



Tobacco use and exposure to tobacco smoke are known human carcinogens and have contributed to a global epidemic and public health emergency. Tobacco continues to be the leading cause of preventable death and illness in the United States and the second-leading cause in the world (U.S. Department of Health and Human Services, 2004; World Health Organization [WHO], 2008b). Tobacco is responsible for one in three cancer deaths in the United States. Prevention of tobacco-related disease, disability, and death could be achieved through the promoting of tobacco control: preventing uptake, helping smokers quit, and preventing exposure to secondhand smoke. Nurses can effectively deliver evidence-based interventions for tobacco dependence that significantly reduce tobacco use (Rice & Stead, 2008). Nursing involvement in community action, helping patients quit, promoting an environment free of tobacco smoke, and supporting effective tobacco control policies is essential to solve this problem (Sarna, Bialous, Barbeau, & McLellan, 2006). Nurses must provide leadership in these efforts (Malone, 2006; Sarna & Bialous, 2005), along with other healthcare professionals.


Worldwide, more than 1 billion people smoke (WHO, 2008a), 1 of 10 youths smoke, and 50% of youths are exposed to tobacco smoke in public places (Warren, Jones, Eriksen, & Asma, 2006). Five million tobacco-related deaths occur every year. If trends continue, by 2030 more than 8 million people will die annually because of tobacco use; 80% in developing countries (WHO, 2008b). To address this epidemic, WHO initiated the first international, legally binding treaty focusing on a public health problem: the WHO Framework Convention on Tobacco Control (FCTC). More than 150 countries have ratified the WHO (2008a) FCTC. The treaty calls for restrictions on tobacco advertising, promotion, and sponsorship; tobacco smuggling control; a ban on misleading tobacco descriptors such as “low tar,” “light,” and “mild”; protection from secondhand smoke; cessation treatment for tobacco users, and prominent pictorial health warnings on tobacco products. Recently, WHO launched policy recommendations that will facilitate the implementation of the WHO (2008b) FCTC. It provides guidance to countries on increasing tobacco product taxes, preventing exposure to tobacco smoke and providing cessation services, among other policy recommendations. Nurses worldwide have been involved in efforts to ensure that these policies are adopted, but further efforts are needed.


Global action is essential because tobacco-induced death and disability is predicted to increase in countries with limited healthcare resources. Efforts in the United States also are central to reducing the risk to Americans, especially youth and underserved populations. Health disparities exist in tobacco-related conditions, such as increased risk for cancer among certain ethnic minorities and those with lower socioeconomic status and decreased access to health services (U.S. Department of Health and Human Services, 2004).


Patients who smoke often are blamed unfairly or blame themselves for causing a tobacco-related cancer. In fact, many became addicted to nicotine in their adolescence or youth by an industry that spends billions of dollars to promote a product that, if used as directed, kills up to 50% of its users. Nurses must actively engage in efforts to diminish this stigma. Tobacco dependence is a chronic condition that  requires ongoing treatment (Steinberg, Schmelzer, Richardson & Foulds, 2008). The tobacco industry has been found guilty of hiding evidence from the public and obfuscating science and scientists (U.S. District Court for the District of Columbia, 2006), and calls have been made for professional organizations and academic centers to refuse to accept tobacco industry funding for research or services.


Given the enormous public health cost of tobacco use—more than $100 billion per year—federal spending on efforts to reduce tobacco use and address tobacco-related diseases is severely underfunded (Gritz, Sarna, Dresler, & Healton, 2007). Nursing research in the area of tobacco control and tobacco dependence treatment can contribute significantly to developing interventions for all persons who smoke, including people with a cancer diagnosis (Cooley, Sipples, Murphy, & Sarna, 2008; Sarna & Bialous, 2006), but more efforts and support are needed to enhance the science in this area.


The Oncology Nursing Society (ONS) acknowledges and is committed to maximizing the potential that nurses, the largest group of healthcare professionals, have in reducing adult and youth tobacco use, promoting cessation, actively protecting all people against secondhand tobacco smoke, and helping to increase access to tobacco use prevention and cessation services. In addition to the prevention of tobacco use to reduce cancer risk, intervention is needed to support the cessation efforts of patients with cancer and cancer survivors who are at increased risk for side effects of treatment, cancer recurrence, a second tobacco-related cancer, increased morbidity, decreased survival, and diminished quality of life.


It Is the Position of ONS That


•       Tobacco is a worldwide epidemic that requires the leadership and active involvement of nurses.

•       The U.S. government ratify and implement the WHO FCTC.




All nurses and nursing organizations are actively involved in developing and supporting local, state, and national legislative and regulatory efforts that

•       Restrict the direct and indirect marketing of tobacco products, including those products that might be launched in the future, and those making unproven health claims.

•       Strengthen warning labels on all tobacco products and require pictorial warnings, as recommended by WHO.

•       Increase the price of tobacco products through taxation and allocate part of the revenue to tobacco-control programs and tobacco-related research.

•       Prohibit the sale and distribution of tobacco products, including those available via mail order, the Internet, and vending machines, to anyone younger than age 18.

•       Eliminate sponsorship of sports and cultural events by tobacco companies.

•       Develop and enforce 100% smoke-free public spaces.

•       Promote prevention of tobacco for any use.

•       Promote collaboration with other healthcare organizations, public health, and tobacco-control groups to strengthen tobacco control at all levels.

•       Support efforts to increase funding for tobacco control and for tobacco-related research; this includes funding tobacco control programs at the levels recommended by the Centers for Disease Control and Prevention and use of a significant percentage of the funds from the states’ Master Settlement Agreement to meeting programmatic funding needs.

•       Include participation in World No Tobacco Day (May 31 of every year) in advocacy activities.

•       Support efforts for communities to become 100% smoke-free.




•       All people have the right to obtain effective tobacco dependence treatment services according to the 2008 U.S. Department of Health and Human Services guideline, Treating Tobacco Use and Dependence (e.g., pharmacotherapy and behavioral therapies; counseling that is accessible, effective, and sustained).

•       Greater investments be made in federal, state, and local tobacco-control programs to reach the Healthy People 2010 tobacco-related objectives (U.S. Department of Health and Human Services, 2000), including addressing the needs of low-income, ethnic minority communities targeted by the tobacco industry.

•       Interventions for individuals addicted to tobacco be promoted, facilitated, and covered by public and private health plans and insurers.

•       The evidence-based 2008 PHS guideline, Treating Tobacco Use and Dependence be implemented in all clinical settings. At a minimum, all nurses should assess tobacco use and willingness to quit, provide advice to quit, and refer tobacco users to existing resources, including telephone quitlines.

•       Ensure that tobacco assessment and dependence treatment is an expected part of care in all cancer treatment programs, including addressing the stigma faced by many patients affected by a tobacco-related cancer


Public Education


•       There is ongoing federal support of a sustained mass media public education campaign about tobacco prevention and treatment.

•       Support is needed for the development and use of culture-, gender-, age-, and literacy-appropriate educational materials and skills, including those appropriate for people with cancer and their families, to address the benefits of cessation and the risks of tobacco use and exposure to secondhand smoke.


Professional Education


•       Nursing curricula include information about the health effects of tobacco use, exposure to secondhand smoke, prevention of tobacco use, and science-based strategies for tobacco dependence treatment, as well as clinical practice opportunities, to ensure that all nurses are competent in tobacco control and cessation interventions.

•       Practicing nurses are  provided with educational workshops and professional education regarding tobacco control.

•       Essential competencies related to tobacco control are included as part of basic licensure for nursing practice and as part of oncology nursing certification.

•       Tobacco control is included in the agenda of scientific and educational nursing programs.




•       Nursing research on tobacco use, prevention, cessation interventions, and reduction of exposure to secondhand smoke in people with and at risk for cancer is supported.

•       Efforts are needed to increase federal dollars for research funding and be dedicated to tobacco-related cancers and their treatment.

•       All nursing organizations, professional and educational, implement clear policies that refuse to accept tobacco industry funding, direct or indirect, for research and other activities. 


Furthermore, ONS Recommends That


•       Nurses worldwide serve as tobacco-free role models. Employers of nurses provide cessation resources and services for all nurses who use tobacco,

including those in training.

•       Healthcare professionals hold all meetings in smoke-free environments.

•       Nurses collaborate with interdisciplinary healthcare policy organizations that have a shared commitment to oncology and tobacco control.

•       Public health organizations  recognize nursing leadership in tobacco control.




Cooley, M.E., Sipples, R.L, Murphy, M., & Sarna, L. (2008). Smoking cessation and lung cancer: Oncology nurses can make a difference.  Seminars in Oncology Nursing, 24(1), 6–26. [CrossRef]


Gritz, E.R., Sarna, L., Dresler, C., & Healton, C.G. (2007). Building a united front: Aligning the agendas for tobacco control, lung cancer research, and policy. Cancer Epidemiology, Biomarkers, and  Prevention, 16(5), 859–863.  [CrossRef]


Malone, R.E. (2006). Nursing’s involvement in tobacco control: Historical perspective and vision for the future. Nursing Research, 55(4, Suppl), S51–S57.  [CrossRef]


Rice, V.H., Stead, L.F. (2008). Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews, 1, CD001188.


Sarna, L., & Bialous, S. (2005). Tobacco control in the 21st century: A critical issue for the nursing profession. Research in Theory and Nursing  Practice, 19(1), 15–24.  [CrossRef]


Sarna, L., Bialous, S., Barbeau, E., & McLellan, D. (2006). Strategies to implement tobacco control policy and advocacy initiatives. Critical Care Nursing Clinics of North America, 18(1), 113–122.  [CrossRef]


Sarna, L., & Bialous, S.A. (2006). Strategic directions for nursing research in tobacco dependence. Nursing Research, 55(4, Suppl.), S1–S9. [CrossRef]


Steinberg, M.B., Schmeizer, A.C., Richardson, D.L., & Foulds, J. (2008). The case for treating tobacco dependence as a chronic disease. Annals of Internal Medicine, 148(7), 554–556.


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U.S. Department of Health and Human Services. (2004). The health consequences of smoking: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.


U.S. Department of Health and Human Services. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: Author.


U.S. District Court for the District of Columbia. (2006). United States of America v. Philip Morris U.S.A., Inc. Retrieved August 12, 2008, from


Warren, C.W., Jones, N.R., Eriksen, M.P., & Asma, S. (2006). Patterns of global tobacco use in young people and implications for future chronic disease burdgen in adults. Lancet, 367(9512), 749–753. [CrossRef]


World Health Organization. (2008a). The WHO framework convention on tobacco control. Retrieved April 17, 2008, from  


World Health Organization. (2008b). WHO report on the global tobacco epidemic, 2008: The MPOWER package. Geneva, Switzerland: Author.


Approved by the ONS Board of Directors 3/99; revised 5/00, 10/02, 4/05, 7/08