“The latest news from me is that I died May 9, 1990, of lung cancer. Maybe my widower would like your free trip. Although I doubt it … You see, he has been mourning my death for 4 years. I was all he had left—me and my Benson & Hedges. Wish you were here” (Halpin, 1994). An elderly widower, perhaps sitting alone under the lamp at the kitchen table where he and his wife had eaten many meals together, wrote these words to the Philip Morris tobacco company in a trembling hand—on the back of a glossy Benson & Hedges cigarette brand mailer.

I found his letter online, one of perhaps thousands, written to tobacco companies by suffering customers and their families. Something about it caught me and wouldn’t let me rest. In many ways, he and the many others whose letters I found were the founders of the Nightingales Nurses.

I smoked for years. I’d smoke feeling guilty as I cared for patients who were suffering from emphysema or lung cancer or heart disease. I tried to quit so many times, but I would slip back. I felt so alone. That was more than 20 years ago, but I vividly remember reading about new studies showing that smoking was not really so bad, comparing it with eating chocolate or having a glass of wine. I never dreamed, then, that the tobacco industry was behind those phony “studies” (Smith, 2007).

What I didn’t know then would fill a book. Mainly, I didn’t realize that the tobacco industry (TI) had set up front groups, hired scientists, and organized massive campaigns to promote bogus ideas, had sponsored “distracting” scientific studies selected by industry lawyers to be sure they would result in findings favorable to the industry, and had promoted their intentionally deceptive ideas through an astonishingly large and varied assortment of paid “consultants” and front groups (Bero, 2003, 2005; Glantz, Slade, Bero, Hanauer, & Barnes, 1996). I had no idea that the tobacco companies had special marketing plans developed to reassure those, like me, who worried even as we lit up another cigarette (Brown and Williamson Tobacco Company, 1971; Cataldo & Malone, 2008) and that they were working on a global scale to fight tobacco control policies and ensure that smoking remained socially acceptable (Zeltner, Kessler, Martiny, & Randera, 2000; McDaniel, Intinarelli, & Malone, 2008).

I learned that until the advent of the machine-rolled cigarette in the late 1800s, almost nobody ever died from lung cancer. It was once such a rare disease that most physicians never saw a case in their lifetimes. Those same entrepreneurs who introduced machine-rolled cigarettes also introduced aggressive, innovative advertising techniques that linked cigarettes with glamour, freedom, sexuality, and status (Kluger, 1997). I realized that we were facing an industrially produced disease epidemic from tobacco.

More than 10 million internal tobacco company documents became publicly available as the result of multiple state attorney general lawsuits in the late 1990s and are accessible online (http://legacy.library.ucsf.edu). They offer an amazing window into this incredibly destructive industry, including its business plans, budgets, scientific research, public relations and marketing plans, memos, letters, and much more. I developed a program of research drawing on them, and while doing this research, I stumbled on the letters.

As a nurse I could easily fill in the terrible subtext accompanying every anguished word. Behind each letter were family members who had used every economic and emotional resource they had trying to cope with the suffering and loss of a loved one; orphaned children who would never have the guidance of a father or mother; and aging parents who helplessly watched their children die before them. I knew that the suffering from tobacco-related illnesses was often terrible to witness, much less to experience. And these stories were repeated more than 400,000 times every year, year after year, in the United States alone (Centers for Disease Control and Prevention [CDC], 2008).

I also knew that the products that had killed all these people had been engineered for addictiveness (Kessler, 2001). I knew that companies had targeted their aggressive marketing and outreach efforts to the most vulnerable groups: the poor, less educated, and minority groups (Apollonio & Malone, 2005; Balbach, Gasior, & Barbeau, 2003; Cook, Wayne, Keithly, & Connolly, 2004; Hackbarth, Silvestri, & Cosper, 1995; Landrine et al., 2005; Muggli, Pollay, Lew, & Joseph, 2002; Smith & Malone, 2003; Yerger & Malone, 2002).

I knew that tobacco companies had conspired to create “doubts” about the scientific evidence that cigarettes caused disease, and later, that secondhand smoke caused disease (U.S. Tobacco Companies, 1954), and that they had tried to undermine the work of the World Health Organization (WHO) and other public health bodies (Zeltner et al., 2000) and interfere with tobacco-control efforts (WHO, 2009a). I knew that the industry’s political and philanthropic contributions bought silence from policymakers and groups that should have been protecting the public (Tesler & Malone, 2008; Yerger & Malone, 2002). But somehow, I had never once considered that these companies had been getting letters like these for decades and filing them away, year after deadly year. Although I tried to continue with my research projects, the letters would not let me rest. It simply wasn’t right for them to remain forever hidden in the tobacco industry’s files.

Inspired by youth activists who had attended the Altria/Philip Morris shareholders’ meeting to speak out about the industry’s targeting of youth, I decided to buy one share of stock and go to the shareholders’ meeting as a nurse, taking some of the letters with me to read aloud in protest (Figures 98-1 and 98-2). Through networking, I recruited 11 other nurses from around the country who agreed to buy one share of Altria stock (only shareholders or their representatives could attend the meeting) and travel with me to the meeting in New Jersey. Other nurses paid for airfares for those who attended. We picked the Altria/Philip Morris meeting because Philip Morris is the largest U.S. tobacco company.

Our theme was “nurses bearing witness.” We sought to point out the contradictions inherent in the company’s claims to be “changed” and “socially responsible” while continuing the aggressive promotion of the most deadly consumer products ever made. Our key message: “A socially responsible company would not continue to promote products that it admits addict and kill.” Initially, we focused on getting coverage in nursing media to help us spread the word about our group—the first nursing group to confront Big Tobacco on its own turf (Schwarz, 2004, 2005).

A nurse in New Jersey who had been active with the American Lung Association scoped out the site for us. Other activists working with youth invited us to be part of a postmeeting press conference. We assembled a selection of the letters into a 30-foot banner and made handouts about our efforts, including some of the letters and a press release (Box 98-1). We learned from other activists about the meeting format and how long we might have to speak. We would wear white lab coats and black armbands, indicating solidarity with those who suffered from tobacco. The next morning, and every year since, the Nightingales Nurses have borne witness at tobacco company shareholder meetings.

Teaching smoking cessation classes in the late 1980s was moving, frustrating, and unsettling. Unfortunately, at the time, tobacco was considered a “habit”; nicotine was not declared an addiction by the U.S. Surgeon General until 1988 (U.S. Department of Health and Human Services, 1988). Midway through the program was quit day, but often less than a quarter of the participants would remain quit for 48 hours; the disappointment and frustration showed clearly on their faces—if they came back to class at all. Seeing firsthand the power of addiction in people who strove so hard to quit was disturbing. Now, with advances in cessation practices, smoking cessation success rates have improved (Agency for Healthcare Research and Quality, 2008).

In 1992, I led a local public health tobacco prevention program in Minot, North Dakota. After developing a broad-based coalition, we successfully advocated for five local youth access laws. The policy and advocacy lessons learned through these efforts were invaluable for our later work on smoke-free environments that resulted in Minot being the first community in the state to pass a local smoke-free ordinance (Welle, Ibrahim, & Glantz, 2004; Buettner-Schmidt, Muhlbradt, & Brierley, 2003).

Our smoke-free environment efforts included public education events and billboard contests; collaborating with the American Cancer Society to encourage restaurants to be smoke-free the day of the Great American Smoke Out; and publicly recognizing restaurants that met public health standards and were smoke-free. In 2000, a new father and Minot city council member called me, asking if the coalition would assist him in having restaurants become smoke-free. With a newborn, he was concerned about the exposure of his child and others to secondhand smoke. A partnership began, and approximately 1 year later, after much political and media maneuvering, the city council passed the smoke-free ordinance. As we basked in our victory, however, opponents gathered enough signatures to put the new ordinance to a public vote. The battle-weary coalition began to meet weekly again to strategize how to defeat this referendum. Strategy for influencing city council members is vastly different from strategy to educate and influence an entire community. Thankfully, we did not have to fight alone. In conjunction with the Campaign for Tobacco Free Kids, Americans for Nonsmokers’ Rights, the Robert Wood Johnson Foundation’s Smokeless States grant program, the North Dakota Nurses Association, the North Dakota Medical Association, the American Lung Association, the American Cancer Society, the American Heart Association, and others, we defeated the referendum 55% to 45% on July 10, 2001. The new ordinance became effective January 1, 2002.

I later took a consulting position assisting other communities working on tobacco policy, helping pass several local ordinances and facilitating a statewide coalition that passed a bill banning tobacco use in public places and workplaces. I was involved in evaluating the effects of the local ordinance and the state law (Harstad Strategic Research Inc., 2003; Buettner-Schmidt, 2003, 2007; Buettner-Schmidt, Mangskau, & Boots, 2007; Buettner-Schmidt & Moseley, 2003). In a university faculty role, I developed a project within my Community Health Nursing course wherein senior nursing students conducted an assessment of college-age smoking and smoking policies on university campuses. The students developed a smoke-free campus recommendation and presented it to the university president. After going through many committees, our campus became smoke-free in June 2006. After all this, when I heard about the Nightingales’ call for more nurse volunteers to speak out at the shareholder meeting, I could not resist. I had seen the industry in action before. Locally, lobbyists of organizations who collaborated with the tobacco industry attempted to derail our city-level policy efforts. Statewide, the tobacco industry lobbyists themselves would roam the halls of the legislature, something I never would have believed in my pre-tobacco activist years.

Now I was on my way into the belly of the beast. After a long flight and a meeting with other nurse activists the night before, feeling the solidarity among colleagues working on tobacco control in many different roles, I was excited as we drove through luxurious acreage leading to the corporate offices. As we parked and entered the building, there were “Men in Black” everywhere speaking into hidden microphones, and we could hear whispers: “The nurses are here…,” “the nurses are coming…” It felt very James Bond–like, almost surreal.

Envision a cold-sounding CEO, a transfixing video presentation about cigarettes and other products, an opulent environment—these are my memories of the shareholder meeting. After the video, CEO Louis Camilleri highlighted how successful the company had been in increasing cigarette sales worldwide and how profitable an investment the stock was. Then it was time for the shareholder “question-and-answer” period. I told my family story and the stories of others who I knew. Other nurses spoke about the suffering they had witnessed: A nurse practitioner spoke about the harm tobacco does to pregnant women and children, and a burn nurse spoke about caring for burn victims from cigarette-caused fires. Each time, the room fell silent as we spoke; I felt the symbolic power of our white lab coats and our nursing presence. Some of the protesting youth stood boldly to interrupt the meeting; the CEO repeatedly told them to sit down. Then the Men in Black forced the youth to the back of the room and out the door. I remember wondering if we had made an impact.

In our debriefing later and in self-reflection, I realized that although we cannot know whether our words on that one day will create change, it is essential for nurses to continue to speak out because we are nurses. People who profit from selling death should not be able to do so without, at the very least, hearing about the suffering and devastation that their product causes. As nurses, we have a responsibility to “speak truth to power.”

According to the WHO (2009b), tobacco caused 100 million deaths in the twentieth century and kills about 5.4 million people worldwide annually. Describing this in understandable numbers for laypeople should be among nurses’ roles. This translates into 1 out of every 10 adult deaths or one person every 6 seconds. Meanwhile, in the U.S. alone, the tobacco industry spends more than $1 million an hour promoting its products (Federal Trade Commission, 2007). Globally, tobacco companies are now aggressively targeting low- and middle-income countries, seeking new generations of young people and women who will develop tobacco addiction.

Currently, we have Nightingales in more than half the states and in Canada. We annually attend both the Altria and Reynolds American tobacco company shareholders’ meetings. We’ve challenged the company’s claims of “responsibility” at Philip Morris public relations events. Our website (www.nightingalesnurses.org) is a source for information about the industry. Our work has all been done with volunteer effort.

Of course, tobacco companies are still promoting tobacco products. We have a long way to go, and we will need to develop new and innovative strategies to get there. But our efforts have borne fruit in several respects. First, we have sent a strong message to the tobacco industry that nurses are their opponents. Nurses are trusted and respected by the public, and we owe it to our patients to speak out and tell the whole truth about Big Tobacco. Nurses need to promote public dialogue on an endgame for this industrially-produced tobacco disease epidemic—perhaps, as a recent article suggests, by phasing out cigarettes (Daynard, 2009) or by converting the tobacco market to a nonprofit entity with a public health mandate (Callard, Thompson, & Collishaw, 2005).

Whether our clients are starting to smoke or trying to quit, they receive constant messages from tobacco companies, straight into their homes, and increasingly through more subtle marketing methods, such as experiential programs, viral marketing, and music events. Philip Morris has a database of more than 20 million smokers, which it uses to establish personalized relationships and targeted communications (Philip Morris USA, 2003). We need to help clients understand how the industry has studied their every psychological weakness, segmenting the market to reach everyone from starter “replacement smokers,” as the industry called youth, to worried older smokers whom they seek to reassure. We would not treat malaria victims without ever mentioning the mosquito that transmits the disease. As patient advocates, we must likewise name, discuss, and find ways to combat the industry vector of the tobacco disease epidemic.

Second, our efforts have inspired others. The youths we joined are still talking at meetings about “the nurses” and how we helped them feel part of something larger. Perhaps some of them will become nurses. We need their passion and political awareness in nursing. Finally, speaking out empowers us as nurses, as past shareholder meeting attendees have said: “This experience has changed the whole way I feel about being a nurse” and “Now I feel that I can say anything to anyone with confidence.”

The tobacco industry has worried that nurses might take them on. Among the industry documents is a report on organizations the industry viewed as its opponents, with each one’s strengths appraised, including the American Nurses Association, the American Public Health Association, the American Medical Association, and others. “Nurses, as a group, feel strongly and negatively about tobacco use,” the report reads. “As they become more active in politics…at all levels, they could easily become formidable opponents for the tobacco industry” (Osmon, 1990). Formidable opponents. We aren’t used to thinking of nurses in those terms. But when it comes to the tobacco industry, we need to be its “formidable opponents” in every possible way.

The Nightingales build on the great work of many nurses all over the country. Here are some other examples: Nightingale Jill A. Jarvie, RN, MSN, represented the San Francisco Department of Public Health on a workgroup that resulted in stronger restrictions on smoking in and around city-funded shelters for the homeless. Minnesota Nightingale Cheryl Bisping chairs two coalitions working on secondhand smoke, smoke-free restaurants, and tobacco-free youth recreation policies. Drs. Linda Sarna, Stella Bialous, and Erika Froelicher are continuing the Tobacco Free Nurses project (www.tobaccofreenurses.org), which is aimed at helping nurses quit smoking. At UCLA, Professor Sarna helped pass a policy against accepting tobacco industry research funding.

In Kentucky, Nightingale Lisa Greathouse organized a World No-Tobacco Day display of our Nightingales banner showing the letters at the University of Kentucky (UK). Ellen J. Hahn, DNS, RN, and Carol A. Riker, MSN, RN, at the UK Tobacco Policy Research Program are actively involved in community engagement, smoke-free policy development, and research, helping 12 communities in Kentucky pass smoke-free policies since 2007.

Internationally, Nightingale and nursing professor Dr. Sophia Chan conducted the first Asia Pacific Workshop on Tobacco Control and Nurses inclusive of policy implications; developed the first smoking cessation counseling training program in Hong Kong; initiated a task force to help women smokers quit; launched the first youth quitline; and also influenced the government to fund 10 smoking cessation clinics.

Nightingales founding member Dr. Diana Hackbarth chairs the Illinois Coalition Against Tobacco, the oldest anti-tobacco coalition in the U.S., and for decades has worked on legislation, including clean indoor air legislation, outlawing bidis, banning tobacco billboards, and raising tobacco taxes. Nightingale Colleen Hughes of Nevada served as president of the Nevada Tobacco Prevention Coalition, working toward a smoke-free public places ballot initiative. Nightingale founding member Carol Southard, RN, MSN, was responsible for founding Chicago Second Wind, whose mission is to reduce tobacco use and increase quit attempts. In California, Gina Intinarelli worked to secure smoke-free campus policies for UCSF’s medical center and to ensure that tobacco content (including content about the role of the tobacco industry) is incorporated into the curriculum of all health professions programs. In 2008, Nightingale Kelly Buettner-Schmidt worked on a statewide effort to mandate that certain tobacco settlement dollars be allocated to a fully funded, CDC Best Practices–based tobacco prevention program. North Dakota is the first tobacco prevention program in the country to be fully funded at the CDC recommended level.

Other nurses are organizing letter-writing campaigns, developing cessation services for special populations, conducting tobacco-related research, and working on a wide range of policy efforts to reduce tobacco’s deadly toll. The Nightingales are always looking for more nurses to help—even writing a letter to the editor once a year can make a difference if enough letters appear at the right time.

As early as 1916, writings of Florence Nightingale referred to her knowledge of politics (Gourlay, 2004; Kopf, 1916; McDonald, 2006a, 2006b; Pfettscher, 2006). Nightingale emphasized having political will, using the media, and seeking the support of professionals and leaders (McDonald, 2006b). She encouraged others to lobby: “Agitate, agitate, agitate …” (McDonald, 2006b). Ms. Nightingale would surely support the Nightingales’ tobacco-control policy efforts (Nightingale, 1946).

For a list of related websites, please refer to your Evolve Resources at http://evolve.elsevier.com/Mason/policypolitics/