APNA Smoking Cessation Position Statement
Psychiatric Nurses as Champions for Smoking Cessation
Approved by APNA Board of Directors October 14, 2008
This paper provides the rationale for the American Psychiatric Nurses Association position that Failure to Act on Tobacco Dependence Equals Harm. Partnering with the International Nurses Society on Addiction and the International Society for Psychiatric Nursing, this position advocates and provides direction for, changes in practice and education for nurses caring for patients who smoke, in both specialty and general care settings. The organization recognizes the devastating effects of smoking, especially among the patients/clients served by nurses employed in mental health settings, and seeks to motivate psychiatric nurses to increase their individual provider knowledge and skills, educate students and fellow practitioners, and implement change in employing institutions. A comprehensive plan for action to addresses gaps in motivation and clinical skills will prepare the next generation of psychiatric nurses to significantly deter the prevalence and negative health outcomes of tobacco use.
Tobacco use continues as the cause of 438,000 U.S. deaths annually (CDC, 2003, 2006). Despite this, approximately 20.9% of adults smoke, risking cancer and associated cardiovascular and respiratory complications. Among persons diagnosed with mental disorders including substance use disorders, the prevalence of smoking is much higher, increasing the morbidity and mortality and shortening life expectancy by 20% of that of the general population (Colton & Mandersheid, 2006; Hennekens, Hennekens Hollar & Casey, 2005). Tobacco use rates are highest among those with psychotic disorders (ranging from 54.0-67% [Leon & Diaz, 2005; Newcomer, 2006]), but smoking rates of persons with other DSM-IV-TR Axis I disorders, including substance use, anxiety, mood and Axis II personality disorders exceed those of the general population as well (Grant, Hasin, Chou, Stinson & Dawson, 2004). Study findings suggest that smokers with co-existing psychiatric or substance use disorders account for 44% of all cigarettes smoked in the U.S. (Lasser, Boyd,Woolhandler, Himmelstein, McCormack & Bor, 2000).
Additional research findings suggest that people with psychiatric diagnoses respond to the same smoking cessation interventions with success rates just slightly below those of the general population (El Guebaly, Cathcart, Currie, Brown & Gloster, 2002; Ranney, Melvin,Lux,McClain & Lohr,2006) and that significant reductions in smoking occur without changes in psychiatric symptoms (Baker, Richmond, Haile, Lewin, Hons, Vaughan, 2006). While there is the need for replication of this research, there is sufficient support to warrant action by nurses.
APNA has an established history in advocating for smoking cessation. As a collaborating partner, APNA has supported ANA resolutions dating from 1968 (Smokers and Health), Non-smokers Bill of Rights 1974, Guidelines for the Management of the Capital Improvements Fund Amendments to Investment Guidelines for Investment Portfolios and Action on Smoking Issues1984 , Use of Smokeless Tobacco and Clove Cigarettes, Smoke-Free Society and Smoking Policy for ANA Officials at ANA Headquarters1986, Action on Smoking Issues1984 , Discouragement of Economic Support for the Tobacco Industry1992, Cessation of Tobacco Use 1995, Prevention of Tobacco Use in Youth 1997, the most recent being Tobacco Use Prevention, Cessation, and Exposure to Second-hand Smoke – (2005).
In 2008 APNA collaborated with the Smoking Cessation Leadership Center to establish the APNA Tobacco Dependence Task Force, making APNA one of more than 18 national professional and mental health advocacy organizations to officially endorse anti-smoking policies and initiatives. These timely steps and the publication of revised, evidence based USPHS Guidelines for Smoking Cessation, position the organization well to seek support and a plan for action from its membership. A 2008 survey of 1,288 members of the American Psychiatric Nurses Association, revealed that only 30% of respondents provide tobacco dependence treatment in line with national “best practice” guidelines and another 33% rated tobacco dependence as a low priority in their work (Tobacco Dependence Survey 2008).In addition, few (12.3%) rated their ability to help clients stop smoking very highly, and reported that 70% of their organizations do not provide intensive tobacco dependence treatment (Tobacco Dependence Survey 2008). At the same time, 75% of the responding members believe that APNA should support nurses' roles in assessment and intervention with tobacco dependence. While the low survey response rate limits the strength of these findings, they provide a bellwether for future directions.
A lack of formal and continuing nursing education about tobacco dependence and its treatment remains a barrier to action. Of 48 responding graduate psychiatric/mental health nursing programs in a recent survey, 1/3 included no content on the physiology of tobacco dependence or appropriate interventions (Price, Jordan, Jeffrey, Stanley & Price, 2008). Undergraduate programs, as well, are deficient in the number of hours and extent of content offered on this nicotine dependence and addiction generally (Naegle, 2002). Similarly, advanced practice programs lack both content and clinical experiences in caring for persons with substance use disorders, including nicotine dependence ( Vasquez & O'Nieal, 2002).
The American Psychiatric Nurses Association advocates that all nurses working with individuals with mental health or substance use disorders:
- Demonstrate competencies at respective education levels, for smoking cessation,
- Implement intervention with all tobacco dependent persons in respective practice settings,
- Take action to change attitudinal, institutional and organizational barriers to improve patient access to smoking cessation interventions by:
- Engaging in state-focused efforts by APNA leaders and members, including APNA chapter activities and
- Disseminating APNA's position through media, professional and lay literature, and partnering with other professional organizations.
- Advocate for policy and system wide changes,
- Promote education through the inclusion of didactic and experiential content nursing education and continuing nursing education programs,
- Support the proposal of the APNA Smoking Cessation Task Force for actions to increase each year by 5%, the number of psychiatric nurses who report referring smokers to treatment,
- Support the proposal of the APNA Smoking Cessation Task Force for actions to increase each year by 5%, the number of psychiatric nurses who provide best clinical practice in tobacco cessation interventions.
Baker, A. Richmond, R., Haile, M., Lewin, T.J., Hons, B. ,Vaughan, J.C. ( 2006). A randomized controlled trial of smoking cessation intervention among people with a psychotic disorder. American Journal of Psychiatry, 163, 1934-1942.
Center for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses-United States, 1997–2001. Morbidity and Mortality Weekly Report [serial online]. 2002;51(14):300–303 [cited 2006 Dec 5]. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5114a2.htm.
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Colton, C. & Mandersheid, R. (2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease: Public Health Research, Practice and Policy, 3. Retrieved September 9, 2008, from http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
de Leon, J. & Diaz, F. (2005). A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophrenia Research, 76,135-137.
El Guebaly, N., Cathcart, J., Currie, S.,Brown, D. & Gloster, S.(2002). Smoking cessation approaches for persons with mental illness or addictive disorders. Psychiatric Services, 53,1166-1170.
Grant, B.F. , Hasin, D.S., Chou, S.P., Stinson, F.S.& Dawson, D.A. (2004). Nicotine dependence and psychiatric disorders in the United States: Results from a national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry,61,1107-1115.
Hennekens, C.H., Hennekens, A.R., Hollar, D. & Casey, C.E.(2005). Schizophrenia and increased risk of cardiovascular disease. American Heart Journal,150,1115-1121.
Lasser, K., Boyd, J.W.,Woolhandler, S., Himmelstein, D.U., McCormack, D., & Bor, D.H. 2000). Smoking and mental illness: A population based prevalence study. Journal of the American Medical Association, 284, 2606-10.
Naegle, M.A.(2002). Nursing education in the prevention and treatment of SUD (Substance Use Disorders) in Haack, M. & Adger, H. (eds.) (2002). Strategic plan of interdisciplinary faculty development : Arming the nation`s health professional workforce for a new approach to substance use disorders. Substance Use, 23(3), 347-261.
Newcomer, J.W (.2006). Medical risk in patients with bipolar disorder and schizophrenia. Journal of Clinical Psychology,67 (Suppl 9), 25-30.
Tobacco Dependence Survey.(2008). Retrieved September 6, 2008, from http://www.apna.org/i4a/pages/index.cfm?pageid=3654.
Price, J.H. Jordan, T.R., Jeffrey, J.D. Stanley, M.S. & Price, J.A.(2008). Tobacco intervention training in graduate psychiatric nursing education programs. Journal of the American Psychiatric Nurses Association. 14 , 117-124.
Ranney, L., Melvin, C.,Lux, L., McClain, E., & Lohr, K.N. (2006). Systematic review: Smoking cessation intervention strategies for adults and adults in special populations. Annals of Internal Medicine,145,845-856.
Vasquez, E, & O`Nieal, M.E.(2002). Substance abuse education for nurse practitioners in primary care. in Haack, M. & Adger, H. (eds.) (2002). Strategic plan of interdisciplinary faculty development: Arming the nation's health professional workforce for a new approach to substance use disorders. Substance Use, 23(3) 235-246.
Approved by APNA Board of Directors October 14, 2008.