A Global Health Issue
Prevention of tobacco-related disease is a major global health issue. More than 8 million tobacco-related deaths occur globally every year,1 the majority of these in low- and middle-income countries, where greater than 80% of the world’s 1.3 billion tobacco users live.1,2 Despite advances achieved through the World Health Organization (WHO) Framework Convention on Tobacco Control,3 tobacco and other nicotine products continue to be a major threat to global health and a leading cause of preventable death, disease, and suffering.1 In addition, the global financial cost is significant, and in 2019, the direct and indirect economic costs of tobacco use and exposure worldwide were estimated at US $1.85 trillion.4
Accelerating efforts to support tobacco users to quit and prevent youth from starting is a global imperative. Nine of 10 smokers start before the age of 25 years, and across the globe, approximately 155 million people are smokers.3 Entry into the global market of several novel tobacco and nicotine delivery products, also known as electronic nicotine delivery systems (ENDS), has created an additional need for vigilance to ensure that a new generation of young people does not become addicted to nicotine.5 Although in some controlled instances these products have been associated with cessation of cigarette use,6 their safety and toxicity are not yet well established, and their usefulness as a tobacco use cessation tool on a population level is yet to be demonstrated. The WHO has reported that ENDS are addictive and not without harm,7 advising consumers to not use these products until additional safety and toxicological data are available,5 noting that science-based evidence, not marketing, should guide actions.7
Promotion of tobacco control to prevent disease, disability, and death is a global public health priority. Tobacco use and exposure to tobacco smoke are known human carcinogens.6 More than a dozen different types of cancers are causally related to tobacco use, in addition to other chronic and acute illnesses.6,8 Furthermore, continued use of tobacco after a cancer diagnosis increases treatment toxicity, increases risk of secondary primary cancers, and negatively impacts quality of life and survival outcomes.9 Nurses have a critical role to play across all major tobacco control opportunities, including preventing uptake, helping smokers quit, preventing exposure to secondhand smoke, and contributing to local, national, and international advocacy and policy campaigns.10 Nurses worldwide have been integral to the implementation of these measures, but further efforts are needed.
Prevention and Education
More than a dozen different types of cancers are causally related to tobacco use.8,11 Nurses are ideally placed to deliver evidence-based interventions to prevent tobacco use and nicotine dependence among younger populations and to support quitting among existing tobacco- and nicotine-dependent adults.9 Despite claims that e-cigarettes are 95% less harmful than smoking, there is growing evidence that e-cigarettes can cause health harms, including increased risk of cardiovascular disease, respiratory disease, and cancer.5,7 The tobacco industry has marketed these products as being less harsh, with less irritating smoke,12 with the intent to attract new smokers.5,11 Nurses are ideally placed to educate the public about the harm of these products and the options for quitting and support their decision to quit.13
Intervention
Quitting smoking after a cancer diagnosis improves prognosis and treatment outcomes and decreases risk of a secondary cancer and death.9 Nurses have a responsibility to ensure that cessation is integral to cancer treatment. Nursing involvement in community action, helping patients quit, promoting an environment free of tobacco smoke, denormalizing tobacco and ENDS use, and supporting effective tobacco and nicotine control policies is essential to optimizing global public health.13,14
Nursing Research
In the area of tobacco control and tobacco dependence, treatment can contribute significantly to developing interventions for all persons who smoke,12,13 including people with a cancer diagnosis, but more efforts and support are needed to enhance the science in this area.15
As Cancer Nurses, We Must Take a Stand
The International Society of Nurses in Cancer Care (ISNCC) has updated its position statement on tobacco and recommends that prevention of tobacco and ENDS use, prevention of exposure to secondhand smoke, assessment of nicotine dependency, and support for smoking cessation are valuable approaches for nurses to decrease tobacco-related health problems. Furthermore, ISNCC is committed to mobilizing and maximizing the potential that nurses have in reducing adult and youth tobacco and ENDS use, promoting cessation, actively protecting all people against exposure to secondhand tobacco smoke, and helping to increase access to tobacco and nicotine 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 of adverse effects of treatment, a second tobacco-related cancer, increased morbidity, decreased survival, and diminished quality of life. Furthermore, nurses who support smoking cessation in patients thereby support patients’ families by potentially reducing the number of future familial smokers and potentially contribute to the reduction of financial toxicity caused by redirection of income to tobacco/ENDS.
Call to Action
ISNCC recommends that
- (1) Nurses must be recognized as and empowered to be critical enablers in the fight against the global tobacco epidemic.
- (2) Nursing curricula should include information about
- (a) Tobacco as a major contributor to social determinants of health,
- (b) Health effects of tobacco products,
- (c) Impact of tobacco use, and exposure to secondhand smoke,
- (d) 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 providing evidence-based cessation interventions, and
- (e) Emerging regulatory frameworks and information regarding the health impacts of ENDS.
- (3) Practicing nurses should be provided with educational opportunities and continuing professional education regarding tobacco control and ENDS.
- (4) Nurses should be informed about and supported to deliver evidence-based cessation interventions.
- (5) Tobacco control, to include ENDS, must be included in the agenda of scientific and educational nursing programs.
- (6) Benefits of cessation of tobacco and nicotine use in all clinical contexts (eg, sex, age, type of disease) must be recognized and articulated as part of a nursing plan of care.
- (7) Nurses, locally, nationally, regionally, and internationally, should work together to support the implementation of the WHO Framework Convention on Tobacco Control measures.
- (8) Nurses must be prepared to lead in tobacco control activities at local, national, regional, and international levels, including participation in the World No Tobacco Day celebrations (May 31 of every year).
- (9) Nurses must take an active role in initiating and supporting local, national, and international tobacco control policy and legislation.
- (10) Nurses must ensure that tobacco and ENDS use assessment, documentation, and dependence treatment is an expected part of care in all cancer inpatient and outpatient treatment programs and protocols, including addressing the stigma faced by many patients affected by a tobacco-related cancer and specifically highlighting the benefits of smoking cessation in the context of a cancer diagnosis.
- (11) Nurses must be prepared to discuss exposure to secondhand smoke at home and workplaces with patients and families, including strategies to create tobacco- and nicotine-free environments.
- (12) Nurses and those entering the profession should become nonsmoking role models for their own health and the health of their patients.
- (13) Nursing organizations should encourage and support cessation attempts by nurses and maintain or advocate for a tobacco-free workplace.
- (14) Nurses should collaborate with other healthcare organizations, public health, and tobacco-control groups to strengthen and fund tobacco control at all levels, including by increasing and supporting nursing research on tobacco use, prevention, cessation interventions, and reduction of exposure to secondhand smoke in people with and at risk of cancer.
- (15) That all activities or meetings and any public/community activity should be tobacco-free.
The ISNCC
- Declares that all society meetings, scientific, social, and any ISNCC public/community activity, be tobacco-free.
- Rejects direct or indirect sponsorship from the tobacco industry or any of its surrogates.
- Recommends to all organizations the endorsement of the no-tobacco policy at scientific meetings and other health-related events.
References
1. Institute for Health Metrics and Evaluation. The Lancet & The Lancet Public Health: latest global data finds nearly 8 million deaths from smoking in 2019, and 90% of new smokers addicted by age 25.
https://www.healthdata.org/news-release/lancet-lancet-public-health-latest-global-data-finds-nearly-8-million-deaths-smoking. Accessed November 21, 2022.
2. World Health Organization.
WHO Report on the Global Tobacco Epidemic, 2019. Geneva, Switzerland: World Health Organization; 2019.
3. World Health Organization.
2021 Global Progress Report on Implementation of the WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2022.
4. Economic Research Informing Tobacco Control Policy, Economic Costs of Tobacco Use 2019.
https://tobacconomics.org/files/research/523/UIC_Economic-Costs-of-Tobacco-Use-Policy-Brief_v1.3.pdf. Accessed November 21, 2022.
5. World Health Organization. Questions and answers: tobacco: e-cigarettes.
https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettes. Accessed May 25, 2022.
6. Hartmann-Boyce J, McRobbie H, Lindson N, et al. Electronic cigarettes for smoking cessation.
Cochrane Database Syst Rev. 2020;10(10):CD010216.
7. World Health Organization.
WHO Report on the Global Tobacco Epidemic, 2021: Addressing New and Emerging Products. Geneva, Switzerland: World Health Organization; 2021.
8. US Department of Health and Human Services.
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US 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; 2014.
9. Jassem J. Tobacco smoking after diagnosis of cancer: clinical aspects.
Transl Lung Cancer Res. 2019;8(suppl 1):S50–S58.
10. World Health Organization, International Council of Nurses and Nursing Now.
State of the World’s Nursing 2020; Investing in Education, Jobs and Leadership. Geneva, Switzerland: World Health Organization; 2020.
11. National Academies of Sciences, Engineering, and Medicine.
Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press; 2018.
12. Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: a review of tobacco industry documents.
Tob Control. 2011;20 suppl 2(suppl_2):ii20–ii28.
13. Sarna L, Bialous SA, Chan SS, Hollen P, O’Connell KA. Making a difference: nursing scholarship and leadership in tobacco control.
Nurs Outlook. 2013;61(1):31–42.
14. Rice VH, Heath L, Livingstone-Banks J, Hartmann-Boyce J. Nursing interventions for smoking cessation.
Cochrane Database Syst Rev. 2017;12(12):CD001188.
15. Hall S, Vogt F, Marteau TM. A short report: survey of practice nurses’ attitudes towards giving smoking cessation advice.
Fam Pract. 2005;22(6):614–616.
