APNA Position: Psychiatric-Mental Health Nursing’s Role in Tobacco Treatment

Psychiatric-Mental Health Nurses are Champions in Translating Evidence into Effective Tobacco Treatment for Every Patient, at Every Visit, in Every Setting

Introduction

Since the American Psychiatric Nurses Association’s (APNA) 2008 call for changes in practice and education for nurses providing care to patients who smoke, many efforts have elevated the quality of nursing care for the treatment of tobacco dependence. For example, nurses now have more options to become informed and trained in evidence-based tobacco treatment interventions. A public resource page on the APNA website contains up-to-date tobacco treatment information and resources. Through participation in summits and conferences, members of the APNA Addictions Council Tobacco Dependence Branch (TDB) have ensured that nurses have representation at multidisciplinary, national-level activities.

From a public health perspective, some progress in addressing tobacco dependence has been realized. The rate of overall smoking has dropped below 14%. Tobacco product use widely recognized as an addiction, not merely a personal choice, and health care clinicians increasingly address this chronic, relapsing disease using recovery-oriented language. Terms such as “cessation” are being replaced with “treatment” and “smoker” replaced with person-first language such as “person who smokes.”

At the same time, new issues associated with novel tobacco and nicotine use devices have emerged. There is now a need to review, revise, and re-engage nursing-delivered, cost-effective interventions that are founded in objective evidence. Because psychiatric-mental health nurses are leaders in translating evidence into effective tobacco treatment, and because tobacco use disorders should receive care in every clinical setting, the APNA formed a task force to develop Nursing Competencies for Treating Tobacco Use and Dependence. APNA maintains that these competencies will enhance the practice of all nurses who provide care to persons impacted by tobacco use and dependence and that their dissemination will improve outcomes in the overall health of the population.

Discussion

The rate of cigarette smoking among U.S. adults continues to drop to historic levels (12.5%), yet the rate of deaths per year due to tobacco dependence continues to climb (Cornelius et al., 2022). The current rate of deaths due to tobacco dependence is approximately 480,000/year (U.S. Department of Health and Human Services, 2014). Additional data (Cornelius et al, 2022; SAMHSA, 2020; Cooper et al., 2022; Hu et al, 2022) provides a more nuanced picture of the problem:

• 47.1 million US adults (19.0%) currently use any tobacco product, 9.1 million (3.7%) use e-cigarettes
• 25.2% of Americans living in poverty use tobacco products (household income less than $35,000/year)
• Tobacco use among different ethno/racial groups is high: Non-Hispanic American Indian/Alaska native (34.9%); multiple race ethnicity (29.1%); non-Hispanic Black Americans (19.4%)
• 29.6% and 35.6% of persons reporting regular feelings of anxiety and depression use tobacco products respectively; 27.2% of U.S. adults with smoked cigarettes in the past month
• 14.1% (2.14 million) high school students currently use e-cigarettes
• More than half of adults who currently use e-cigarette users also use cigarettes

There is currently only a modest inclusion of efficacious tobacco treatment content in nursing curricula (AACN, 2013; NCSBN, 2019). What is offered in formal academic and continuing nursing education lacks standardization and consistency. In a cross-sectional web-based survey of nursing students (VanDevanter et al., 2017), most respondents (81%) felt that advising patients to quit tobacco use was an important part of their nursing practice and 72% indicated that counseling improves the odds that a patient will quit. However, only 17% of undergraduate and 29% of graduate nurses felt confident or very confident in their tobacco treatment interventions skills. In VanDevanter et al. (2017) there were nearly no respondents (3%) who indicated they received adequate education on interventions for the use of alternative tobacco products.

As efforts continue to treat the whole person, those who are addicted to nicotine and tobacco are increasingly seen in a wide variety of clinical and non-clinical settings. Nurses are the largest sector of the health care workforce and are seen as the most trusted profession. Psychiatric-mental health nurses are ideally positioned to be tobacco and nicotine addiction treatment leaders and champions in clinical practice, education, research, advocacy, policy and guideline development, and as innovators of new treatment methodologies.

Conclusion

The American Psychiatric Nurses Association understands that tobacco use and dependence is an addiction and patients with tobacco use disorders should receive care in every clinical setting. APNA also recognizes that many challenges remain in providing nursing education on effective nursing tobacco treatment and that the Nursing Competencies for Treating Tobacco Use and Dependence are a first step towards addressing that issue (Essenmacher et al., 2022). Therefore, the American Psychiatric Nurses Association takes the position that Psychiatric Mental Health Nurses are Champions in the Translation of Evidence into Effective Tobacco Treatment for Every Patient, at Every Visit, in Every Setting.

To support this position the American Psychiatric Nurses Association calls for:

• Action to highlight and help nurses resolve implicit and explicit bias in thoughts, beliefs, and actions.
• Creation of opportunities to increase the sense of urgency for care so that tobacco use is no longer seen as a secondary need.
• Translation of newly established nursing competencies for treating tobacco use and dependency into continuing education opportunities.
•  Positioning of psychiatric-mental health nurses as leaders, champions, and subject matter experts who disseminate efficacious tobacco treatment evidence.
• Dissemination of nursing-led tobacco treatment research and innovative treatment findings.
• Empowering nurses to advocate for patients and participate in the development and implementation of multidisciplinary local, state, and national tobacco treatment policy and guidelines.

Approved by the APNA Board of Directors October 2008
Revised and approved by the APNA Board of Directors July 2020; February 2023

References
American Association of Colleges of Nursing. (2013). Population-focused Nurse Practitioner competencies: Psychiatric-Mental health nurse Practitioner competencies. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Population-Focused-NP-Competencies-2013.pdf

American Psychiatric Nurses Association. (2008). APNA smoking cessation position statement: Psychiatric nurses as champions for smoking cessation

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Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep 2022;71:397–405. DOI: http://dx.doi.org/10.15585/mmwr.mm7111a1

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Hu SS, Wang TW, Homa DM, Tsai J, Neff L. Cigarettes, Smokeless Tobacco, and E-Cigarettes: State-Specific Use Patterns Among U.S. Adults, 2017-2018. Am J Prev Med. 2022 Jun;62(6):930-942. doi: 10.1016/j.amepre.2021.12.014. Epub 2022 Mar 28. PMID: 35393145.

National Council of State Boards or Nursing. (2019). NCLEX examinations webinar series: 2019 NCLEX-RN test plan overview. https://www.ncsbn.org/13397.htm

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2018 and 2019. Published: September 11, 2020. 2019 NSDUH Detailed Tables [accessed 2020, Nov 10].

Truth Initiative. (2019). E-cigarettes: Facts, stats and regulation. https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts-stats-and-regulations

U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. 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, 2014. Printed with corrections, January 2014.

VanDevanter, N., Katigback, C., Naegle, M., Zhou, S., Sherman, S., & Weitzman, M. (2017). Nursing education to reduce use of tobacco and alternative tobacco products: Change in imperative. Journal of the American Psychiatric Nurses Association, 23(6), 414-421. doi:10.1177/1078390317711252