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Course Sample:
About the Authors
Robert W. Marder DMD
Dr. Marder is a general dentist with offices located in New York City and Rockland County, New York where he practices advanced restorative dentistry and oral diagnosis. His specialty is the treatment of medically compromised patients, including those with an allergy to latex. He is a lecturer at Columbia University School of Dental and Oral Surgery in New York City on the topics of Oral Medicine and Pathology.
Silvia Y. Beaupre, MS, RN, NPP, APRN, BC
Ms. Beaupre is an Associate Director, Nursing Education for the New York State Nurses Association and a board certified psychiatric nurse practitioner in private practice. Ms. Beaupre has worked in a variety of clinical settings, treating a range of psychiatric illness, from the chronically and persistently mentally ill in inpatient settings to treating adult patients in private out-patient settings. Her specialty area of focus is mood disorders in women. She has been an educator in the classroom and in the clinical setting for nursing students at associate degree, baccalaureate degree and masters degree levels. She also has extensive experience in staff development and clinical supervision.
Ms. Beaupre received a baccalaureate in nursing from DePaul University in Chicago, a master's degree in Psychiatric-Community Mental Health Nursing from the University of Illinois at Chicago and a Post Master's Certificate in Nursing, Psychiatric Nurse Practitioner from The Sage Colleges in Troy, NY. Ms. Beaupre has many years of clinical experience as a psychiatric clinical nurse specialist and psychiatric nurse practitioner, functioning as an educator, administrator, therapist, consultant and psychopharmacologist.
Updated 2005 By
Silvia Y. Beaupre, MS, RN, NPP, APRN, BC
Alysa G. Stringer, MBA
Ms. Stringer earned her MBA from St. John Fisher College in Rochester, NY. She is currently employed by the New York State Nurses Association as the Program Associate in the Nursing Advocacy and Information Program. Ms. Stringer has been with the online course team since its inception and routinely formats courses for posting on the NYSNA website.
Ms. Stringer earned a writing certificate from Long Ridge Writer?s Group in Connecticut where she wrote short stories and articles for publication. As part of the leadership team of the Southern Saratoga Chapter of Business Networking International, she writes press releases and works closely with their public relations consultant to ensure publication in area newspapers and other periodicals.
NYSNA Continuing Education
NYSNA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC) Commission on Accreditation.
All ANCC accredited organizations' contact hours are recognized by all other ANCC accredited organizations. Most states with mandatory continuing education requirements recognize the ANCC accreditation/approval system. Questions about the acceptance of ANCC contact hours to meet mandatory regulations should be directed to the Professional licensing board within that state.
NYSNA has been granted provider status by the Florida State Board of Nursing as a provider of continuing education in nursing (Provider number 50-1437).
Introduction
Tobacco use has been cited as the chief avoidable cause of illness and death in our society. In the US, tobacco use is responsible for nearly 1 in 5 deaths or an estimated 440,000 deaths per year during 1995-1999 (ACS, 2004). Smoking damages nearly every organ in the human body, is linked to at least 10 different cancers, and accounts for some 30% of all cancer deaths (ACS, 2005). Given the health dangers it presents and the public's awareness of those dangers, tobacco use remains surprisingly prevalent. According to the Centers for Disease Control and Prevention (CDC) (2005), 46.2 million US adults were current smokers in 2004, even though this single behavior will result in death or disability for half of all regular smokers. More than 8.6 million people in the United States have at least one serious illness caused by smoking. If current patterns of smoking persist, 6.4 million people currently younger than 18 will die prematurely from a tobacco-related disease.
When broken down by race/ethnicity, the numbers were as follows:
- Whites, 23.6%
- African Americans, 22.4%
- Hispanics, 16.7%
- American Indians/Alaska Natives, 40.8%
- Asian Americans, 13.3%
Alarmingly, the numbers were higher in younger age groups. Almost 29% of those 18 to 24 years old were current smokers. Nationwide, 21.9% of high school students were current smokers in 2003. White and Hispanic students were among the highest in terms of cigarette use (ACS, 2005).
Tobacco use is not only dangerous to the individual smoker and those who come into contact with second hand smoke (USEPA, 2002), it also results in staggering societal costs. The estimated smoking-attributable cost for medical care in 1993 was more than $50 billion (Miller, et al., 1998), and the cost of lost productivity and forfeited earnings due to smoking-related disability was estimated at $47 billion per year in 1994 (CDC, 1994). Much changes in over a decade: by 2004, more than $75 billion per year was spent in medical expenditures and another $80 billion per year resulted from lost productivity (CDC, 2005).
Nurses have long been aware of the relationship of cigarette smoking and lung cancer. Unfortunately, tobacco use can lead to many more health problems such as increased risk for cancer of the oral cavity, nasal cavities, larynx, pharynx, esophagus, stomach, liver, pancreas, kidney, bladder, uterine cervix, and myeloid leukemia (ACS, 2004).
In the United States, during the year 2002, approximately 7,400 persons died of oral and pharyngeal cancer. In the same year, 28,900 new cases will be diagnosed. About 90 percent of people with oral cavity cancers use tobacco; risk increases with the amount and duration of tobacco use. Alcohol use and exposure to sunlight also increase the risk of oral cavity cancer (www.inteliHealth.com).
Since the first Surgeon General?s report on smoking and health in 1964, 27 reports have concluded that tobacco use is the single most avoidable cause of disease, disability, and death in the United States. Over the past 4 decades, cigarette smoking has caused an estimated 12 million deaths, including 4.1 million deaths from cancer, 5.5 million deaths from cardiovascular diseases, 2.1 million deaths from respiratory diseases, and 94,000 infant deaths related to their mother?s smoking (CDC, 2005).
Over twenty-five years ago, in 1989, the U.S. Surgeon General issued a report that concluded that cigarettes and other forms of tobacco, such as cigars, pipe tobacco, and chewing tobacco, are addictive and that nicotine is the drug in tobacco that causes addiction. Nicotine is one of the most heavily used addictive drugs in the United States. Cigarette smoking has been the most popular method of taking nicotine since the beginning of the 20th century.
Despite the tragic health consequences of using tobacco, healthcare providers often fail to assess and treat tobacco use consistently and effectively. The purpose of this course is to assist nurses in providing the important functions of identification and treatment of tobacco use. It is incumbent upon nurses to routinely assess the oral cavity for lesions and to implement tobacco cessation programs into their nursing practices (ACS, 2002).
What is Harmful about Tobacco?
According to the American Cancer Society (ACS) (2001), when tobacco burns, it produces a complex mixture of organic and inorganic compounds. The smoke contains tar, which is made up of over 4,000 chemicals, including 43 known to cause cancer. Some of these chemicals cause heart and lung diseases, all of which can be deadly. Some of the chemicals found in cigarette smoke include:
- Cyanide
- Benzene
- Formaldehyde
- Methanol
- Acetylene
- Ammonia
Cigarette smoke also contains the poisonous gases nitrogen oxide and carbon monoxide. Its main active ingredient is nicotine. Nicotine is highly addictive. It is both a stimulant and a sedative to the central nervous system. The ingestion (both smoked and smokeless) of nicotine results in an almost immediate "kick" because it causes a discharge of epinephrine from the adrenal cortex. This stimulates the central nervous system, and other endocrine glands, which causes a sudden release of glucose. Stimulation is then followed by depression and fatigue, leading the abuser to seek more nicotine. Nicotine is absorbed readily from tobacco smoke in the lungs, and it does not matter whether the tobacco smoke is from cigarettes, cigars, or pipes (NIDA, 2003).
Nicotine also is absorbed readily when tobacco is chewed. With regular use of tobacco, levels of nicotine accumulate in the body during the day and persist overnight. Thus, daily smokers or chewers are exposed to the effects of nicotine for 24 hours each day. Nicotine taken in by cigarette or cigar smoking takes only seconds to reach the brain but has a direct effect on the body for up to 30 minutes (NIDA, 2003).
Research has shown that stress and anxiety affect nicotine tolerance and dependence. The stress hormone corticosterone reduces the effects of nicotine; therefore, more nicotine must be consumed to achieve the same effect. This increases tolerance to nicotine and leads to increased dependence. Studies in animals have also shown that stress can directly cause relapse to nicotine self-administration after a period of abstinence (NIDA, 2003).
Current tobacco product regulation requires cigarette manufacturers to disclose levels of tar and nicotine (USDHHS, 2000). However, smokers receive very little information regarding chemical constituents in tobacco smoke; the use of terms such as "light" and "ultra light" on packaging and in advertising may be misleading (USDHHS, 2000). More than 4,000 chemical compounds have been identified in tobacco smoke. Of these, at least 43 are known to cause cancer (USDHHS, 2000).
The chemical composition of tobacco is responsible for the increased risk of cancer and the problems associated with wound or surgical healing. Of the many substances found in tobacco, it is the tars in tobacco that have a significant role in producing cancer. Nicotine has been found to cause a release of adrenal catecholamines that results in vasoconstriction and decreased tissue blood perfusion. Nicotine also adversely affects fibroblasts and neutrophils by impairing their cellular functions in wound healing. The toxic product of acrolein and cyanide have also been shown to impair neutrophilic (leukocyte) function (Christen, 1995).
Hundreds of ingredients are used in the manufacture of tobacco products. Additives make cigarettes more acceptable to the consumer ? they make cigarettes milder and easier to inhale, improve taste, and prolong burning and shelf life. Federal law (the Comprehensive Smoking Education Act of 1984 and the Comprehensive Smokeless Tobacco Health Education Act of 1986) requires cigarette and smokeless tobacco manufacturers to submit a list of ingredients added to tobacco to the Secretary of Health and Human Services. In 1994 six major cigarette manufacturers reported 599 ingredients that were added to the tobacco of manufacture cigarettes. Although, these ingredients are regarded as safe when ingested in foods, some may form carcinogens when heated or burned (USDHHS, 2000).
Cigarettes with low tar and nicotine contents are not substantially less hazardous than higher?yield brands. Consumers may be misled by the implied promise of reduced toxicity underlying the marketing of such brands (USDHHS, 2000).
In order to intervene in the significant health problem of tobacco use, nurses need to be familiar with tobacco products, the problems that result from their use, and the treatments that can be utilized to intervene in these problems, as well as the available resources to assist the patient in breaking their tobacco habit.
Tobacco Products
Among the most common tobacco products are cigarettes, cigars, pipes, and smokeless tobacco. Other tobacco products include bidis, clove cigarettes and betel quid.
Cigarettes
The most commonly used form of tobacco in the United States is cigarettes; approximately 23% of the population smoke filtered or nonfiltered products (Casiglia and Woo, 2001). Cigarettes are highly engineered products, designed to deliver a steady dose of nicotine. Cigarettes have an average total nicotine content of about 8.4 milligrams (NIH, 2000).
Cigarette tobacco is blended from two main leaf varieties: yellowish ?bright?, also known as Virginia where it was originally grown, contains 2.5-3% nicotine; and ?burley? tobacco which has a higher nicotine content (3.5-4%). US blends also contain up to 10% of imported ?oriental? tobacco which is aromatic but relatively low (less than 2%) in nicotine (ASH, 2001).
Additive-free cigarettes have the perception of being less damaging than conventional cigarettes. However, researchers at the National Institute of Drug Abuse found that additive-free cigarettes produced the highest level of nicotine when compared to conventional cigarettes and bidis (described below) (O?Bryan, 2002).
Cigarettes that are low-tar may not necessarily be less harmful than high-tar cigarettes. Variables include the depth of the inhale, more frequent inhales, and smoking the cigarette to a shorter butt length. Smokers who switch to lower tar brands and who do not make these changes to compensate, still achieve little health benefit compared to the benefit of actually quitting for good (ACS, 2001).
Another variation on cigarette smoking is reverse smoking where the lighted end of the cigarette is placed in the mouth and secured by the lips. This is mainly practiced in India and Asian countries, but does occur in the United States.
Cigars
According to the American Cancer Society (ACS) ( 2001) rates of cigar-smoking are rising among both adults and teen-agers. Between 1993 and 1997, consumption of all types of cigars in the United States increased by 46.4 percent, reversing a steady decline amounting to 66 percent between 1964 and 1993. Once considered the choice of middle aged and elderly men, cigar smoking has enjoyed a recent change of image, now appealing to younger adults and adolescents.
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