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%. Smoking and tobacco use are 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 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 smoking continues to drop to historic levels (13.7%), yet the rate of deaths per year due to tobacco dependence continues to climb. The current rate deaths due to tobacco dependence is approximately 480,000/year (CDC, 2019 a). Additional data (CDC, 2019 a,b,c) provides a more nuanced picture of the problem:

• 34 million US adults continue to smoke
• 16 million more Americans are living with a serious medical illness due to smoking
• 21.3% of Americans living in poverty smoke (household income less than $35,000/year)
• Minority tobacco use is high: Non-Hispanic American Indian/Alaska native (22.6%); multiple race ethnicity (19.1%); Black Americans (14.65%)
• 31.6% of American adults living with any mental illness smoke and they consume 40% of all cigarettes smoked
• Youth e-cigarette use led to a 38% increase in tobacco product use among high school students and a 29% increase of tobacco use among middle school students from 2017-2018
• 54.6% of adults who use e-cigarettes also smoke combustible cigarettes (Truth Initiative, 2019)

There is currently only a modest inclusion of efficacious tobacco treatment content in nursing curricula (AACN, 2019; 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, Katigbak, Naegle, Zhou, Sherman, & Weitzman, 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. 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 14, 2008
Revised and approved by the APNA Board of Directors July 14, 2020

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

Centers for Disease Control and Prevention. (2019). Smoking & tobacco use: Current cigarette smoking among adults in the United States. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

Centers for Disease Control and Prevention. (2019). Smoking & tobacco use: Fast facts. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm

Centers for Disease Control and Prevention, Smoking and Tobacco Use. (2019). Tobacco use among adults with mental illness and substance use disorders.
https://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm

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

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

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