Nurses play an important role in tobacco use prevention, protection, and cessation. They are well-positioned to influence smokers due to being highly trusted healthcare providers. Smoking causes significant morbidity and mortality, with 18% of Canadians smoking cigarettes. It is responsible for 47,000 deaths per year and is the leading cause of preventable disease. Smoking is highly addictive due to nicotine and cessation is challenging, requiring a combination of counseling and pharmacotherapy for best results. Nurses can support prevention, protection from secondhand smoke, and smoking cessation through education, counseling, and promoting resources.

1. Introduction to
Tobacco Use Prevention,
Protection & Cessation
Created by the Registered Nurses’ Association of
Ontario

2. Nurses’ important role in smoking
cessation
 Largest health-care provider group in
Canadian health system (Canadian Institute for Health Information,
2008)
 Highly trusted by the public (Leger Marketing, 2004)
 Well-situated to influence and motivate
smokers to quit
 Nursing intervention increases likelihood
of abstinence from smoking (Rice & Stead, 2008)

3. Statistics on Tobacco Use
In Canada:
 18 % of people aged 15 years and older
smoke cigarettes (Health Canada, 2008)
- Almost 5 million people

4. Statistics on Morbidity and
Mortality
 Smoking related illnesses cause 47,000 deaths
per year in Canada (Health Canada, 2008)
• Single most preventable cause of morbidity and
death in the world today according to the World
Health Organization
• Significant costs to the health care system
 One in every two smokers will die earlier than
they otherwise would have, as a result of
smoking
 Contributes to chronic diseases
• Cardiovascular disease
• Chronic obstructive pulmonary disease(COPD)
(WHO, 2008)

5.  Primary cause of lung cancer (leading
cause of cancer related death for men and
women) (Canadian Cancer Society/National Cancer Institute of Canada, 2009)
 Contributes to many forms of cancer
 Pancreatic, stomach, kidney, cervical, esophageal,
laryngeal, oral and leukemia (U.S. Department of Health and Human
Services, 2004)
 1 in 5 deaths are due to smoking (5 times
those due to motor vehicle accidents,
suicides, other drug abuse, murder & HIV
combined!) (Health Canada, 2008; Ontario Ministry of Health Promotion, 2006)

6. Tobacco Products
 Cigarettes  dominant form of tobacco
used in North America
 Cigarette Alternatives:
◦ Chewing tobacco
◦ Snus
◦ Shisha
◦ Cigars & Cigarillos

7. What is a cigarette?
 Delivers nicotine to the lungs and brain
within 7 seconds each time a smoker inhales
 Frequent, small-dose stimulation makes
smoking highly addictive
 Most cigarettes contain ≥ 10 mg of nicotine
 Average smoker absorbs 1-2 mg of nicotine
per cigarette
 Cigarettes release carbon monoxide which
adheres to red blood cells faster than oxygen
• Reduced oxygen in the body causes increased
heart rate

8. What’s in a Cigarette?
 Tobacco
 Carbon monoxide
 Hydrogen cyanide
 Nitrogen oxide
 Ammonia (sub-micron sized particles)
 Nicotine, phenol, polyaromatic hydrocarbons, tobacco specific
nitrosamines.
 Tar total particulate matter (nicotine and water)
 Filter with titanium oxide accelerant
 Flavours
 Liquid vapour
 Benzene
 Formaldehyde
 Acrolein
 N-nitrosamines
 Non-particulate matter
There are approximately
50 known carcinogens
in cigarettes
(Canadian Cancer Society, 2007b)

9. Cigarette Alternatives
Chewing
Tobacco
• Frequently used by people in sports
• Various flavours
• Chewed in the mouth
• Nicotine absorbed through buccal mucosa
• Frequent users are subject to cancers of the mouth, gums and
face
Snus • New product to North America
• Similar to chew or spit tobacco (small pouch placed between
upper lip and gum)
• Purported by tobacco companies to be a milder alternative to
cigarette smoking
Shisha • AKA hookah, narg-eelay, hubble-bubble or gooza
• Water pipe with smoke from flavoured, burning tobacco
• Social activity, pipe passed from person to person
Cigars
and
Cigarillos
• Stronger than cigarettes, very addictive
• Not subject to the same commercial marketing regulations as
cigarettes

10. Prevention: Youth & Adolescents
 Most smokers began smoking before age
18
• Many people start smoking at an age when they
are easily influenced by peers and advertising
 Young adults (between the ages 20 – 24 years)
• Highest smoking rate (27%)
• Relatively brief smoking history
• Often identify themselves as “social smokers”
 Social smokers are at risk of becoming
regular smokers (Gilpin, White & Pierce, 2005)

11. On-campus Student Smoking
Cessation Programs
 Most campuses have smoking cessation
programs
◦ Student health services in campus clinics
◦ Peer-to-peer programs and activities
◦ Advocate for improved campus smoking
policies
Example: Leave the Pack Behind
(LTPB) in Ontario
http://www.leavethepackbehind.org/

12. Protection: Second-hand smoke
 Second-hand smoke:
◦ Also known as environmental tobacco smoke
 Combination of:
◦ Side stream smoke (smoke from the
end of a cigarette)
◦ Smoke exhaled by the smoker
 67% of smoke from a burning cigarette
is not inhaled by the smoker and ends
up in the surrounding environment (Health
Canada, 2007)

13. Second-hand smoke (cont.)
‣ 4000 chemicals have been identified in
second-hand smoke
◦ 50 of these are known carcinogens
(United States Environmental Protection Agency, 2000)
‣ Examples:
- Arsenic compounds - Benzene
- Chromium compounds - Ethylene oxide (chemical
to sterilize medical devices)
- Vinyl Chloride
(chemical used in
plastics manufacture)
- Polonium – 210
(radioactive species)

14. Second-hand smoke (cont.)
 Labeled as a known human carcinogen
 Labeled as a class A cancer-causing
substance (Class A = most dangerous)
 Causes at least 1000 deaths annually in
Canada

15. Cessation:
Smokers and Quitting Smoking
 Why do people continue to
smoke?
◦ Addiction to nicotine
◦ Perceived benefits (relaxation,
stress relief, weight loss)
◦ Social context
◦ Mental health issues

16. Smoke vs. Quit
Common Reasons not to
Quit
Common Reasons to Quit
• Family and friends smoke
• Withdrawal symptoms
• Inability to cope with
stress
• Connection with smoking
• Previous unsuccessful
attempts to quit
• Encouragement from
family and friends
• Health improvements
• To save money
• Pregnancy
• Smoke-free environment
policies
• Desire to be a role model
• Medical treatment that
requires abstinence

17. Nicotine
 Causes a release of adrenaline from the adrenal
glands providing a ‘hit’ or ‘kick’ from each puff of
a cigarette
 Adrenaline stimulates the body causing the
release of glucose, increased blood pressure,
respiration and heart rate
 Suppresses insulin output
 smokers are often in a hyperglycemic state
 Increases dopamine levels
 Creates a feeling of pleasure
(National Institute on Drug Abuse [NIDA], 2006)

18. Definition of Addiction
“Addiction is a primary, chronic disease characterized
by impaired control over the use of a psychoactive
substance and/or behaviour. Clinically, the
manifestations occur along biological, psychological,
social and spiritual dimensions. Common features of
addiction are: change in mood, relief from negative
emotions, provision of pleasure, preoccupation with
use of substance(s) or ritualistic behaviour(s); and
continued use of substance(s) and/or engagement in
behaviour(s) despite adverse physical,
psychological and/or social consequences.”
(The Canadian Society of Addiction Medicine, 1999)

19. General Characteristics of Nicotine
Addiction
 People who smoke more than 20 cigarettes/day and have their
first cigarette within 30 minutes of waking
◦ indicates high nicotine dependence
 Causes a release of adrenaline from the adrenal glands
providing a ‘hit’ or ‘kick’ from each puff of a cigarette
 Dependence develops fairly rapidly
◦ often within 60 days of regular use
 Withdrawal syndrome occurs when blood levels fall sharply
 Severity of dependence depends more on the difficulty the
person has in quitting smoking than on the amount and
pattern of smoking
 Chronic disease  it can be progressive, relapsing and fatal
(Fiore, Jaen, Baker, et al, 2008)

21. Withdrawal Symptoms
•Irritability •Anxiety
•Headache •Restlessness
•Coughing •Nausea
•Insomnia •Dizziness
•Depression •Difficulty
concentrating
• Physical and psychological
dependency

22. Treatment Options for
Nicotine Addiction
 Combination of counseling and
pharmacotherapy is more effective than
either option alone (Fiore, et al., 2008)
 The more intense the intervention, the
better the outcome of abstinence (Cairney & Lawrence,
2002)

23. Pharmacologic Options
 Clients/patients attempting to quit
smoking should always be encouraged to
use effective medications unless they are
contraindicated in specific populations
◦ eg. pregnant women, smokeless tobacco users,
light smokers, adolescents (Fiore, et al)
 Two categories of pharmaceutical options:
 Nicotine replacement therapy (NRT)
 Non-nicotine replacement therapy

24. Nicotine Replacement Therapy
(NRT)
 Nicotine Patch
 Nicotine Lozenges
 Nicotine Gum
 Nicotine Inhalers
 Provide nicotine to reduce withdrawal symptoms
 Take between 1-4 hours to reach maximum blood
levels (unlike cigarettes, 7 seconds)
 Do not cause sudden boost to nicotine blood levels
(prevents addiction to product)
 Dose depends on habits of the smoker but is reduced
over a 12 week period
Non-prescription 
available over-the-
counter

25. Non-nicotine Therapy
 Bupropion Hydrochloride (Zyban)
• Also marketed as the anti-depressant medication
Wellbutrin
• Presumed to alleviate cravings associated with nicotine
withdrawal affecting noradrenaline and dopamine
 Varenicline Tartrate (Champix)
• Targets nicotinic acetylcholine receptors to decrease
cravings and withdrawal
 Clonidine & Nortriptyline
• Second-line medications used in smoking cessation
All of these medications require a prescription

26. Counselling
 Intensive intervention that last a
minimum of 10 minutes
 Commonly conducted by nurses in various
health-care settings
 Motivational Interviewing
 Directive and client-centred standard counselling
techniques
 Stages of Change theory

27. Alternative Therapies
 No clinical evidence to verify results from
these treatments
 Some clients/patients report that they are
beneficial (Fiore, et al., 2008)
• Hypnosis • Herbal remedies
• Acupuncture • Laser treatment

28. Self-help
 Most smokers want to quit on their own
 Self-help material should be provided
 Based on the health behaviour change model
 Tailored to specific population
 Commonly used resources
 One Step at a Time smoking cessation guide
(Canadian Cancer Society)
 Smokers’ Helpline

29. 1. Phone
• Counselling
2. Online
• Self-help
• Tips, tools & support
3. Text messaging
• Supportive messages

30. Assessing Readiness to Quit
Question: Have you quit smoking cigarettes?
Answer:
Yes, I have, for more than 6
months.
Defines maintenance.
Yes, I have, but for less than 6
months.
Defines action.
No, but I intend to in the next 30
days and have tried for at least
24 hours in the past year.
Defines preparation.
No, but I intend to in the next 6
months.
Defines contemplation.
No, and I do not intend to in the
next 6 months.
Defines pre-contemplation.

31. Benefits of Quitting
 It’s never too late to quit smoking and
experience the benefits
 Immediate Rewards:
◦ Improved health
◦ Stop worrying about quitting
◦ Food will taste better
◦ Set a good example for children
◦ Improved sense of smell
◦ Have healthier babies and children
◦ Feel better about yourself
◦ Feel better physically
◦ Breath, home and car will smell better
◦ Reduce wrinkling/aging of skin

32. Immediate & Long-term Health
Benefits of Smoking Cessation
Timing Health Benefits
Within 20
minutes of last
cigarette
Blood pressure, pulse rate, and body temperature
reduce to within normal range
Within 8 hours Carbon monoxide levels in blood decrease and
oxygen levels increase
Within 24
hours
Risk of heart attack decreases
Within 48
hours
Food tastes and smells better
Within 2
weeks
Coughing, congestion, fatigue, shortness of breath
are reduced
Within 1 year Risk of heart disease decreases by 50 %
Within 10 – 15
years
Risk of dying prematurely approaches that of a
person who has never smoked

33. Key Points
 Smoking causes many chronic
illnesses and death
 Nurses play an important role in
helping patients/clients to quit
smoking
 There are effective treatment options
to help people quit smoking
 There are considerable immediate and
long-term benefits to smoking
cessation