Whereas rates of smoking in the United States declined by 3.5% between 2001 and 2008, rates have remained unchanged in recent years, and smoking continues to be a major health hazard as well as the chief cause of preventable morbidity and mortality today.¹ With an estimated 44.5 million smokers in the United States, it is thought that 430,000 premature deaths are caused annually because of smoking.² One out of every five adults is a smoker, and there is a disproportionately higher prevalence of smoking among adults with lower educational attainment. 1 Less than half of smokers ever achieve long-term abstinence even though approximately 75% want to quit, and at least a third have made serious attempts to quit.³ These statistics are sobering and underscore the need to focus on smoking prevention.

Currently, there are about 1.3 billion smokers in the world, 84% of whom live in developing countries.⁴ Tobacco use is responsible for an estimated 5 million deaths worldwide each year and is projected to cause 10 million deaths per year by 2030.⁵ Between direct healthcare costs and loss of productivity from smoking-related illness around the world, tobacco use is projected to cost governments more than $200 billion per year.⁴

Cigarette smoking (and secondhand smoke) contributes to four of the five leading causes of death per year in the United States, including lung cancer, coronary heart disease, chronic lung disease, and stroke. In May 2007, the state of Arizona put into effect a comprehensive statewide smoking ban. Research into the impact of this ban reveals significant reductions in hospital admissions for smoking-linked diagnoses including acute myocardial infarction, angina, stroke, and asthma.⁶ The American Heart Association -American Stroke Association (AHA-ASA) strongly recommends smoking cessation because of the direct correlation between smoking and both coronary artery disease and ischemic stroke.⁷ It is estimated that tobacco is responsible for 85% of deaths caused by lung cancer.

Smokers constitute 20.9% of the U.S. population. Twenty-three percent of men and 18.3% of women smoke cigarettes, and 22% of white adults and 21.3% of black adults use tobacco.¹ Rates of smoking prevalence continue to be high among certain population groups, especially American Indians and Alaska Natives (32.4%) and are highest among those with low educational attainment (grades 9-11) and those with a General Educational Development certificate (GED) (41.3%). Conversely, rates of smoking are lowest among adults with graduate degrees. Adults who live below poverty levels also experience a high prevalence of tobacco use (31.5%).¹

Though the use of tobacco by women in the United States was 6% in 1924, peaked at 33% in 1965, and is now at 18.5% (including 18% of pregnant women), it is estimated that 250 million women throughout the world smoke, and most of these are in developed countries. In Europe, South Africa, and Australia, 20-45% of pregnant women smoke.⁸ Smoking during pregnancy harms both mother and baby and is a leading cause of morbidity and mortality during the intrauterine and early childhood stages of life. These preventable problems include premature birth and miscarriages; implantation, placental, and membrane issues; and infant respiratory, cognitive, and behavioral issues.⁸

Marketing campaigns over the years have used glamorous imagery to promote cigarettes and
offer “light” or low-tar alternatives that falsely claim safety advantages. Chronic obstructive pulmonary disease (COPD), once thought of as a predominately male disease, now kills more women than breast cancer, and the number of new cases of COPD in women is increasing three times faster than in men.⁹ Growth and development of lung and airway tissue are different in males and females, and the airways of females are vulnerable to hormonal effects. Estrogen affects the metabolism of nicotine, and this also affects addiction and cessation in women smokers. Healthcare providers tend to diagnose COPD more readily in men than in women, offering spirometry evaluation more often to men than to women, even in women with more severe dyspnea and cough.⁹

Smoking is a problem among nurses. The prevalence of smoking is higher in licensed practical nurses (LPNs; 28%) than in registered nurses (RNs; 15%). The rate among RNs is lower than the 18% average for females in general, and LPNs have higher smoking rates than women in general and other health professionals. These findings are significant because those who smoke are less likely to encourage cessation in others.¹⁰

Smoking cessation should be a priority in women’s health, and it should be geared toward the unique needs of females. For example, one study reported increased smoking relapse rates among women during the premenstrual (luteal, progesterone predominant) phase of the cycle. Another found no difference in relapse rates according to stage of menstrual cycle, but did find the withdrawal symptoms of craving and anger to be the most frequently associated with relapse, but only in women who quit during the follicular phase of the cycle.⁹

Although some research shows increased difficulty for women to quit, other studies show women to have greater receptivity to smoking cessation. Women tend to be more afraid of weight gain as a result of cessation than male smokers do. Smoking cessation has been associated with increased body fat in several studies; however, one study also found an increase in functional muscle mass.¹¹ This potential for increased functional capacity in women who quit could be used as a motivator, especially when designing holistic approaches to cessation that include exercise and other lifestyle changes. In a study of female prisoners who participated in a group smoking cessation intervention with nicotine replacement, significant weight gain (net difference of 10 pounds) was experienced by abstainers when compared to continuing smokers. This effect did slow down at 1 year post intervention, however.¹² The fear of weight gain should be taken into account when designing cessation programs for women.

Various mood states such as depression and anxiety have been correlated with higher rates of exacerbation and hospitalization in patients with COPD and are more frequently seen in women. Among COPD patients with psychiatric comorbidity, 60% of women had psychiatric disorders as compared to 38% of men.⁹ So, though research on women and smoking is often contradictory, there is evidence that hormone fluctuation, physiology, mood, and differences in motivation play roles in smoking and cessation that make women different from men.

In addition to smoking cigarettes and inhaling smoke directly, there is also the problem of passive smoking (sometimes referred to as “second-hand smoke”), better known as environmental tobacco smoke (ETS). ETS is a combination of smoke from the burning end of a cigarette, cigar, or pipe and the smoke exhaled from a smoker’s lungs. This environmental perspective on exposure has now been expanded to include “thirdhand smoke,” or the residual chemical contamination that remains in an environment (clinging to furniture, carpets, walls, and the like) even 24 hours after a cigarette has been extinguished.¹³ ETS contains more than 4,000 highly toxic chemicals, such as formaldehyde, nitrogen oxide, acrolein, Group A carcinogens (asbestos), cadmium, nickel, and carbon monoxide. In addition, ETS contains a radioactive substance from tobacco leaves that have been subjected to high-phosphate fertilizers.¹⁴

Children and adults exposed to ETS have a greater risk for respiratory illness, including lung cancer; higher rates of respiratory tract infections; exacerbation of asthma; otitis media; and sudden infant death syndrome (SIDS).¹⁴,¹⁵,¹⁶ One study found higher rates of mental health
disorders among adolescents and children exposed to ETS.¹⁷ Increased exposure to ETS nearly doubles a woman’s risk of heart attack.¹⁵ Measures of cotinine, a metabolite of nicotine in the bloodstream, demonstrate that 37% of adult nonsmokers and 43% of U.S. children, aged 2 months through 11 years, are exposed to ETS in their homes or workplaces.¹⁶

A study of nonsmoking bar workers in Scotland revealed a remarkable (89%) and lasting reduction in salivary cotinine levels after smoke-free legislation (public smoking ban) was put into place.¹⁷

In the United States, approximately 59% of children aged 4-11 years are exposed to second-hand smoke in their homes. Young children are especially vulnerable to the damaging effects of ETS, including risk for asthma, bronchitis, pneumonia, and SIDS. Because mothers usually spend more time in the home and more time with their children than do fathers, maternal smoking has been linked with childhood respiratory problems and some facial deformities.¹⁸ Children of mothers who smoke more than 10 cigarettes per day are twice as likely to develop asthma as are children of nonsmokers. These same youngsters are 2.5 times more likely to develop asthma in their first year of life and 4.5 times more likely to need medicine to control asthma attacks.¹⁹ Maternal smoking remains an indicator of childhood asthma even after variables such as gender, race, presence of both biologic parents in the household, and number of rooms in the house are taken into account.

Smoking and tobacco contribute directly to death. Yet, deaths from smoking do not receive the same amount of attention from the news media as do airplane crashes, violence, and disease epidemics, situations resulting in far fewer deaths. Smoking causes more deaths, but these deaths take a very long time to develop; therefore, the significance of the problem is often minimized.

Over time, smoking strips the lungs of their normal defenses and completely paralyzes the natural cleansing processes. The early morning cough associated with smoking results from attempts by the bronchial cilia to clear the thick, yellow or yellow-green mucus that accumulates in the air passage to an abnormal amount because toxic cigarette smoke interferes with the cilia’s normal function. This cleansing action triggers the cough reflex. As exposure continues, the bronchi begin to thicken, which predisposes the person to bacterial and viral infections, asthma, emphysema, and cancer.²⁰

The smoker’s heart rate speeds up an extra 10 to 25 beats per minute, with a predisposition to dysrhythmias. The blood pressure increases by 10-15%, thus exposing the person to risks of myocardial infarction, stroke, and vascular disease.¹⁹

Within seconds after the smoke is inhaled, irritating gases (e.g., formaldehyde, hydrogen sulfide, ammonia) begin to affect the eyes, nose, and throat. With each inhaled breath of smoke, carbon monoxide enters the bloodstream, and its concentration eventually rises to a level 4 to 15 times as high as that of a nonsmoker. The carbon monoxide passes immediately to the bloodstream, binding to the oxygen receptor sites and, thus, depleting the cells of oxygen. Hemoglobin, which normally carries oxygen throughout the body, becomes bound to the carbon monoxide and is converted to carboxyhemoglobin, which is unable to deliver oxygen to the cells. In addition, smoking increases platelet aggregation, allowing the blood to clot more easily.⁹,¹⁹

The constriction of tiny blood vessels decreases the delivery of oxygen to the skin and contributes to “smoker’s face,” where deep lines appear around the mouth, eyes, and center of the brow. The muscular puffing action also contributes to lines around the mouth. There is an established link between nicotine and erection problems in male smokers, and smoking is believed to be the leading cause of impotence in the United States today. Smoking also adversely affects fertility by decreasing sperm count and sperm motility. Female smokers are significantly more likely than nonsmoking females to be infertile, and heavy smoking amplifies this decline in fertility.

Recent research demonstrates a clear correlation between smoking and gene expression (individual genes as well as entire networks of gene interaction) that corresponds to smoking-related pathologies including cancer, cell death, and immune response.²¹

Nicotine is the drug inhaled from cigarettes that quickly reaches the smoker’s brain. As the average smoker takes an estimated 10 puffs per
cigarette, a pack-a-day smoker gets about 200 puffs per day. Each nicotine “hit” goes directly to the lungs, and the nicotine-rich blood travels to the brain in approximately 7 seconds. This time is twice as fast as that of an intravenous injection of heroin, which must pass through the body’s systemic circulatory system before reaching the brain.¹⁹,²²

As nicotine enters the brain, it acts as a “mood thermostat” and can help users to maintain a steady and pleasant sensation of psychological neutrality. Nicotine stimulates people when they are drowsy and calms them when they are tense; it affects cognitive processes of concentration and emotional states. Unlike other powerful street drugs, nicotine does not interfere with the capacity to work and create, and it may actually enhance individuals’ capabilities.

The action of nicotine causes the brain to release norepinephrine, endorphins, corticosteroids, and dopamine.⁴ The brain then adapts to accept these chemicals by increasing the number of nicotine receptors and becomes physically dependent on nicotine. Thus, the general level of arousal is adjusted up or down by introducing nicotine levels that allow the smoker to feel stimulated or relaxed. The effects of nicotine are reached in a matter of seconds; the smoker experiences drug-induced contentedness, all in a legally sanctioned manner.

Norepinephrine controls arousal and alertness. Beta-endorphin, referred to as the brain’s natural analgesic, can decrease pain and anxiety. Dopamine is part of the brain’s pleasure center and also can decrease pain and anxiety. Smoking’s “attention thermostat” effect is mediated through the brain’s limbic system, where the major neurotransmitters are adrenaline and dopamine, both of which are influenced by nicotine. It appears that nicotine helps the smoker concentrate by promoting selective attention to important tasks, which increases learning and memory. So, nicotine can enhance cognitive processes and reduce fatigue. In addition, nicotine can exert a sedating effect, reducing anxiety and inducing euphoria.⁴ Continued smoking also prevents the unpleasant side effects of nicotine withdrawal, such as irritability, irrational mood changes, low energy levels, inability to feel stimulated, and increased sensitivity to light, touch, and sound.

The overall effect of smoking is a shift in brain chemistry that creates the mood needed for the situation at hand, that is, increased relaxation, alertness, or pleasure and decreased pain or anxiety. But, even though nicotine is a powerful and effective drug, concerned smokers can create and sustain new behaviors to achieve the same positive effects without the health risk to themselves or those around them. The physiologic dependency declines sharply in the first week of cessation; however, the behavioral or habitual pattern triggering the desire to smoke is more difficult to modify. Success in smoking cessation requires a plan of action and a great deal of body-mind-spirit self-care. A growing body of research underscores the fact that successful cessation plans must address any issues pertaining to mood disorders and focus on underlying or withdrawalrelated depression. Although some smokers go it alone and quit “cold turkey,” for many, smoking cessation is a process that can take time and a great deal of emotional and physical support. The hopeful reality is that cessation can be achieved by anyone who is motivated, open to addressing concomitant depression, and willing to try a variety of strategies to find what works.

Research supports the effectiveness of smoking cessation counseling and programming for people from all cultural backgrounds.²³,²⁴ Resources must be linguistically appropriate, and accessible, including for those with sensory impairments such as deafness or blindness. The Internet is a valuable resource for those with special needs of any kind and can link almost anyone to resources tailored to help with cessation. Those with mental illness (including psychosis) can benefit from cessation counseling and resources, but again, the mode of delivery must be accessible and tailored to accommodate special needs.²⁵ Smoking cessation in those with mental illness is also more complex because smoking is a pervasive behavior in most mental health environments, so triggers are difficult, if not impossible, to avoid. In addition, nicotine often calms and enhances well-being in a way that the other drugs persons with mental illness take do not. So, motivation to quit among this population of clients is often a problem.

Native American tobacco users often have difficulty with smoking cessation because for them tobacco use is part of sacred ceremony. The deep cultural, spiritual, and social ties to smoking and tobacco can make addressing the addiction component more complex. Careful exploration of perceived benefits, motivation, and supportive resources is necessary to assist in quitting.

Because smoking cessation is not an easy task, success is often measured in small increments. Smoking quit rates vary with the different approaches to cessation. Over the years, research has evaluated a variety of public and private multicomponent cessation programs, healthcare provider-directed counseling, and community-based programs. Researchers have compared types of programs, for example, one such study looked at group interventions compared to individual interventions offered in pharmacies in Scotland. It was found that the group interventions were significantly more successful.²⁶ Measures of success also vary, and smoking cessation may be defined as point prevalence (a measure taken at one point in time) at the end of a cessation program or long-term abstinence lasting for 1 year or more.²⁷ Fourteen meta-analyses of 17 different treatments for cessation demonstrated efficacy with 100% agreement, and the researchers conclude that clinicians should offer a variety of treatments and be reimbursed on par with other medical and behavioral disorders.²⁸ Smoking cessation treatments can be extremely powerful in aiding those who want to quit.

There are conflicting data as to the best way to quit smoking. Research reports estimate 90% of successful quitters kick the habit on their own each year , and quit rates are twice as high for those who quit on their own as for those who participated in a cessation program.²² Other studies demonstrate that smokers who quit cold turkey were more likely to remain abstinent than were those who gradually decreased their daily consumption of cigarettes, switched to cigarettes with lower tar or nicotine, or used special filters or holders. Yet other researchers claim that those who use medications to support cessation efforts are more likely to be successful. All agree that the quitter must be motivated and must be ready to quit. Careful exploration of these factors with the client, and strategic support to bolster strengths and minimize challenges, can amplify chances of quitting.

Smokers who received nonsmoking advice from their healthcare providers were nearly twice as likely to quit smoking. Heavy smokers (25 cigarettes a day) and more addicted smokers were much more likely to participate in an organized cessation program than were people who smoked less. A recent Cochrane review looked at 14 studies involving more than 10,000 smokers that used motivational interviewing as an intervention. (See Chapter 10.) This focused, goal-directed interview lasts between 20 and 45 minutes and explores the smoking behavior from the client’s perspective in a nonjudgmental manner, aiming to help them gain insight and formulate a quit plan. Most of the studies also involved provision of self-help materials and telephone follow-up. Participants receiving motivational interviewing had 23% improved success rates for quitting, with better results if they were offered by primary care providers or counselors and the interviews lasted longer than 20 minutes. In fact, for those who were offered motivational interviewing by their primary care providers, the success rate was three times higher than in those who received “usual care.”²⁹ Details regarding specific content of the counseling were lacking in the study reports, making application difficult. One could extrapolate these findings to suggest that nurses could have a significant impact on smoking cessation using motivational interviewing and could hone the skills needed to amplify this effect. (Chapter 10 can assist in developing skills for motivational interviewing.)

Healthcare providers and nurses have considerable opportunity to reach all demographic subgroups of the population.²⁷ Seventy percent of smokers see a healthcare provider at least once per year. Nurses working in hospitals regularly encounter patients who are smokers. These represent ideal opportunities for motivational interviewing whereby the smoker is asked about
the behavior, encouraged to quit, and given the opportunity to explore cessation strategies.

The Tobacco Free Nurses (TFN) initiative was launched in 2003 as an effort to reduce smoking among nurses as well as to encourage nurses to become more involved in tobacco control efforts. The “5 As” behavioral approach has been adopted by TFN and can be readily used by nurses and other healthcare providers during encounters with patients in any setting.³⁰ Key elements of this approach include the following:

A survey of 3,482 nurses working in Magnetdesignated hospitals in the United States were found to be deficient in addressing smoking cessation among their patients. Although 73% of nurses asked and assisted with cessation, only 24% recommended pharmacotherapy, 22% referred to community resources, and only 10% recommended use of the Quit Line. Nurses who were familiar with the TFN were significantly more likely to deliver all aspects of the 5 As, including assisting with cessation and recommending medications.³¹

Although the impact of healthcare provider advice varies, many smokers say that they would quit if urged to do so by a healthcare provider. For smoking interventions to become a routine part of healthcare practice, however, medical and nursing education must integrate smoking cessation strategies into the curriculum. Research findings support the value and effectiveness of treatment and follow-up by nurses and other healthcare providers.

Initially developed with input from psychologists and available 7 days a week and (most often) 24 hours a day, telephone quit lines offer personal, convenient, accessible, and comprehensive support for those endeavoring to quit tobacco use.³² Trained counselors are available to talk with callers about their readiness and motivation to quit, their smoking triggers, their support system, local referral resources, and more. These counselors can customize a quit plan with the client and are also available during a craving or to answer questions like “I have redness under my nicotine patch, is that normal?” Most states have quit lines, and most state departments of health can connect callers with a quit line. Most services are free of charge, including free medications such as nicotine replacement patches. When medication support is determined to be appropriate, a brief medical interview is conducted, and medications are sent through the mail. In some cases, a caller’s healthcare provider must sign for the medications, as in the case of someone with a cardiac history or a pregnant caller. The quit line counselors also link individuals with local resources (such as smoking cessation support groups or local chapters of the 12-step program Nicotine Anonymous) and assist them in maximizing relevant benefits available through their health insurance. The American Cancer Society (1-866-784-8454) and American Lung Association (1-800-586-4872) have quit lines, and Great Start has a quit line for pregnant women (1-866-667-8278). All of these resources are easily explored on the Internet.

Seven medications have been shown to support long-term smoking cessation, including five forms of nicotine replacement therapy (NRT). NRT decreases intensity of withdrawal symptoms and the urge to smoke. Nicotine gum, lozenges, and the transdermal patch are available over the counter, and nicotine cartridge inhalers, nasal spray, and higher-dose patches are available by prescription.³³ By using NRT, maintaining nicotine levels is divorced from cigarettes, helping the smoker to break the emotional ties with smoking. Nicotine replacement therapy does not release the client from the bad effects of nicotine including nausea, dyspepsia, altered cardiac rhythms, dizziness, headache, and local irritations of the nose, mouth, and skin that vary with
mode of delivery.³⁴ Approximately 25% of those using NRT experience adverse effects in the first 2 weeks of use, and 40% experience adverse effects within 2 to 3 months of use; however, these effects are usually described as mild. Still, NRT should be discontinued as soon as possible.

There are four major controversies regarding the use of NRT: (1) the use of NRT while a person continues to smoke; (2) how long to use NRT before weaning from the drug; (3) the recommended dose of the NRT product; and (4) misusing and abusing NRT, especially becoming addicted to over-the-counter gum.

Because of nicotine’s potentially dangerous side effects, NRT must be used with caution in cardiac patients and should not be used within 4 weeks of myocardial infarction.³³ Although NRT is a means for achieving short-term smoking cessation for nicotine-addicted individuals, it does not seem to reduce relapse rates and is not a substitute for learning new and healthier coping behaviors. NRT should always be used in tandem with a smoking cessation program that addresses behavior and lifestyle changes.

Many tobacco cessation experts believe that sufficient doses of NRT are needed for sufficient lengths of time to support cessation, and that the risks of smoking far outweigh the risks of NRT. And, although NRT is expensive and carries with it the potential for adverse effects, many believe the benefit is estimated to outweigh the risks. A simulation model using a large body of survey data estimated the number of premature deaths (caused by smoking) avoided because of NRT use to be 40,000 over a 20-year period. After factoring out the potential risks from long-term NRT use, a net projection of 32,000 premature deaths because of smoking would still be avoided.³⁵ Although significant, this is a small portion of smoking-related deaths over a 20-year period of time.