Where There’s Smoke
As health care providers, nurses are charged not only with healing, but also with preventing. Yet each day, too many nurses ignore opportunities to help prevent some of the top killers of minority Americans: cancer, heart disease and lung disorders, such as emphysema. How? By failing to counsel patients on the dangers of tobacco use and the best ways to quit.
Today, however, this situation is beginning to change, as a growing number of nurses are taking action, both individually and collectively, to fight tobacco use in minority communities.
“For too long, nurses have viewed tobacco use as a personal issue instead of a health care concern,” believes Doris Greggs-McQuilkin, RN, MA, BSN, president of the Academy of Medical-Surgical Nurses (AMSN). For Greggs-McQuilkin, who is African American, the war against tobacco is personal. She lost her father to lung cancer.
“It’s a very sad death. People suffer,” she says. “As nurses, we are on the front lines of health care every day. We deal with patients and their families, and it’s important for us to be involved in efforts to cut tobacco usage.”
In minority communities, the fight against tobacco is especially challenging, because it is not waged on a level playing field. According to the Centers for Disease Control and Prevention (CDC), billboards advertising cigarettes appear in minority communities four to five times more often than in white communities. Advertising targeting minority smokers usually promotes stronger, mentholated brands. In recent years, tobacco companies’ efforts to lure more minority youths into smoking have expanded to include sponsorship of family-oriented cultural events–such as music festivals and powwows in Native American communities–and even funding of educational events.
“There’s isn’t an organized way to respond to [tobacco] industry targeting. That’s where we hope to make a difference,” says Helen Lettlow, director of the Priority Populations Initiative of the American Legacy Foundation, a national, independent public health foundation dedicated to decreasing tobacco consumption in the United States.
Lettlow, who is African American, overseas a grant program that will fund $21 million in projects aimed at reducing smoking among minorities and women. “[Event] sponsorships and money flow freely from tobacco companies into minority and low-income communities,” she explains. “Those marketing efforts have to be counteracted.”
The health risks of tobacco use in minority populations are further exacerbated by the overall problem of racial and ethnic disparities in accessibility and quality of treatment throughout the health care system. Lettlow points out that reduced access to health care can prolong the damage caused by smoking and makes it more difficult to fight heart disease, lung cancer, emphysema or the dozens of other health problems complicated by tobacco use. “Once [minority patients] are in the system, they don’t receive the same level of advice or aggressive treatment that others receive,” she maintains.
The American Legacy Foundation hopes the funding it provides will support a nationwide grassroots movement to promote a tobacco-free lifestyle among people of color and women across America. Grant recipients have ranged from small community-based groups targeting minority high school students to large organizations developing national efforts, such as the National Alaska Native American Indian Nurses Association.
“Basically, we’re looking for people to take ownership of this issue,” says Lettlow. “We look for organizations that have some grassroots communication with members of the community. We look for cultural appropriateness and we know that means different things for different communities. It may mean linking up with a faith-based component or partnering with other organizations that may have a different focus, such as housing, but are established in the community.”
Another important criteria, she adds, is sustainability, so that the organization can continue the work after the Foundation’s funding has ended.
Taking a Stand
The AMSN recently demonstrated its willingness to take the ownership Lettlow is advocating by adopting a position statement on tobacco use. The statement encourages the association’s members to focus more aggressively on anti-tobacco activities:
“AMSN believes that education, preventive health policies and intervention to assist with tobacco cessation, nicotine dependence treatment and relapse prevention are standard nursing practices.”
The policy statement goes on to offer the motivation–a long list of health ailments blamed on tobacco use. It challenges nurses to alert the public, identify at-risk individuals, refer patients to proper anti-smoking resources and shape patients’ beliefs and attitudes toward the positive effects of smoking cessation. The statement also calls on nurses to get involved in legislative and policy matters–such as advocating that smoking cessation treatments be covered by health insurance–and encourages nurses who smoke to give up the habit and become better role models.
The position statement is posted on the association’s Web site (see “Internet Resources”) and has been published in its quarterly magazine, Med Surge Matters. So far, the group hasn’t received any negative feedback–even from its smoking members.
“We have a smoke-free environment during our annual convention,” says Greggs-McQuilkin. “We know some [member] nurses still smoke, but they haven’t said anything. They know our mission is adult health.”
Putting It into Practice
Nurses are in a unique position to take the anti-tobacco message from theory to practice. After all, over 70% of all smokers will seek health care treatment at least once each year. Nurses are not only well respected by the public but are likely to spend more time with a patient than any other health care provider.
“The most important thing is to not be judgmental,” says AMSN treasurer Kathleen Reeves, RN, C, MSN, an associate professor at the University of Texas Health Sciences Center and a clinical nurse at Methodist Healthcare System in San Antonio. Reeves, who is of Japanese, Czech and Italian ancestry, suggests using a non-threatening, informational approach to address tobacco use as part of the patient assessment.
“I just ask, ‘do you smoke or have you ever smoked?’” she explains. “That leads to a discussion about how much they smoke and the health risks.” Of course, Reeves is sensitive to each patient’s individual needs. “If a patient is critically ill, that’s not the time to tell them they need to quit smoking.”
Reeves has also found that talking about the risks of second-hand smoke can sometimes get a smoker’s attention. “They may not want to [stop smoking] for themselves, but they’ll do it for their children.” According to the Environmental Protection Agency, second-hand smoke is responsible for an estimated 3,000 lung cancer deaths in nonsmokers each year.
In addition, Reeves is actively involved in Smoke Free San Antonio, an advocacy group that works to eliminate smoking in the city. Among other activities, Smoke Free San Antonio works on lobbying city government leaders to enact anti-smoking legislation.
Lettlow, who is currently pursuing a doctorate in public health, recommends that nurses consider using the “5A” approach to tobacco counseling, developed by the National Cancer Institute and the Agency for Healthcare Research and Quality. Although this method was originally designed for use by physicians, its elements can, with administrative approval, easily fit into nursing assessment plans:
• Ask about smoking status.
• Assess attitude toward quitting.
• Advise patients about health risks and effective cessation methods.
• Assist patient in developing a plan to quit.
• Arrange for follow-up care.
Lettlow reminds nurses that providing patients with information about the risks of smoking is only the first step. The other four steps are even more crucial, yet they are the ones many nurses may fail to mention.
“It’s more than just giving advice,” she emphasizes. “It’s actually linking the patient to health care resources that could help them take the next step in quitting. A patient may not be thinking so much about quitting until a nurse talks to them about the hazards and then tells them about available resources.”
One such resource is Freedom From Smoking, a new online support group available on the American Lung Association’s Web site, www.lungusa.org. The program offers five different stages of support, including stress management, substitute behaviors and long-term strategies for staying tobacco-free. Other helpful resources include local chapters of groups like the American Cancer Society.
Furthermore, Lettlow believes nurses also have a responsibility to help smokers take advantage of nicotine replacement therapies–the patches and gum that help them back off cigarettes by suppressing nicotine cravings. Many insurance companies do not pay for these aids and the costs can be prohibitive for a low-income family. Nurses may want to form partnerships with health care social workers to find alternative funding, such as grant money, that will assist low-income or underinsured patients in purchasing these products.
“The most successful smoking cessation programs use some kind of aid to help people quit, but many patients don’t know that,” Lettlow says. “They think going it alone is the best way.”
Nurses who work in hospitals or other clinical settings should consider enlisting the support of colleagues, supervisors and management to enhance their efforts to incorporate anti-smoking counseling into their practice. While obtaining the support of your hospital administration may not be absolutely vital, programs become much more effective when the entire organization buys into making smoking cessation a priority.
“Encourage your hospital to use annual training and continuing education as a chance to provide tobacco education and teach nurses how to best get out the message,” Greggs-McQuilkin advises. She adds that AMSN is currently exploring the possibility of having a “train the trainer” session on tobacco cessation at its next national convention. “Even if just 30 people came to the session and then took that back to their hospital, it would make a big impact.”
Making Community Connections
Because of their unique status in the community, the influence of minority nurses extends far beyond the hospital or clinic. Nurses are usually among the most trusted members of minority communities, and they can leverage that standing to get out the anti-smoking message even when they’re not at work.
“Many nurses are highly regarded as leaders in their communities and their expertise is very valued,” Lettlow says. “One way to help in this fight is to become more informed about the health impact of tobacco and translate that into layman’s terms.” She encourages nurses to seek out formal training as smoking cessation counselors and then put those skills to use both on and off the job. “Incorporate those skills into your own practice and offer it to patients as a volunteer service,” she suggests.
Greggs-McQuilkin encourages nurses of color to get involved in educating community members about tobacco risks and cessation resources where they live, work, shop and worship. “Just put the facts and figures together and have that information available for people in your church and in your community.”
An anti-tobacco booth equipped with informational brochures and practical tips for those interested in quitting should be standard at health fairs and community festivals. For example, Greggs-McQuilkin participates in her neighborhood’s Lake Harbor Days, a fun, family-oriented event that draws a large crowd each year. At gatherings like this, you have the opportunity to catch those 30% of smokers who don’t visit a doctor each year, and you may also have more time for conversation than you would have during an admission or a discharge.
Native Americans and Smoking
In Native American communities throughout the country, tobacco use presents a unique set of cultural concerns. Tobacco is considered sacred in Native American culture and has a very prominent place in tribal ceremonies and traditions. In addition, many Indian reservations generate income for the tribes by operating smoke shops, small stores that sell tax-free tobacco products. These factors can create a very real set of conflicts for nurses working in Indian communities who wish to encourage patients to give up smoking or chewing tobacco.
The National Alaska Native American Indian Nurses Association (NANAINA) is aggressively addressing these issues through its Project on Tobacco Interventions and American Indian Nurses, funded by the American Legacy Foundation. NANAINA member Jacque Dolberry, RN, MS, director of the RN/BSN program at Salish Kootenai College, a tribal college in Pablo, Mont., near the Flathead Indian reservation, participated in one of the project’s outreach programs last year.
Nursing students in Salish Kootenai’s associate’s degree program received special NANAINA-led training on tobacco interventions, Dolberry reports. A pre-test and post-test proved that the training did elevate the students’ awareness of tobacco issues and proven nursing intervention methods.
This year, the student group shared that information with other students and community members by manning an anti-tobacco booth at a local health fair. Some of them are also doing community outreach to prevent younger tribal members from starting to use tobacco. The nursing students are mentors at an alternative middle school near the campus.
Dolberry recalls how tobacco-related cultural conflicts became an issue at Salish Kootenai 10 years ago when the college made the decision to make its campus a smoke-free zone. “That was kind of controversial,” she says, “because it was thought that it might impact our student enrollment. It did not.”
Although creating effective interventions within the context of Native Americans’ traditional beliefs about tobacco is extremely challenging and requires great cultural sensitivity, Dolberry believes Indian nurses shouldn’t shy away from the tobacco issue. She stresses, however, that nurses have to treat each case differently, and try to educate patients about the difference between ceremonial tobacco use vs. tobacco abuse.
“There’s no reason why nurses should not address tobacco use among Native Americans, especially as it is related so closely to so many health risks,” she explains.
“The first step all nurses are supposed to do is assess the patient. Find out if the person uses tobacco and for what purposes. Does he or she use it for ceremonial purposes or for personal use? Does the patient understand the risk related to smoking? Find out what the meaning of smoking is to that person. Is it done only for ceremonial reasons or when a prayer is sent up? From there, develop a plan.”
Simple words of encouragement combined with practical smoking cessation aids can be very effective in helping a patient along the path to tobacco-free living, Dolberry believes. She also feels that nurses can gently encourage their colleagues who smoke to give up the habit. She saw this happen recently when a nursing class at Salish Kootenai decided as a whole to kick the tobacco habit as part of a personal change course. Every member of the class was successful and they celebrated their smoke-free status along with their pinning when they graduated.
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