Climate Change, Public Health, Health Policy, and Nurses Training.

There are few educational programs in the United States that have a primary focus on preparing nurses to engage in all levels of public health, health policy, and climate change. The United Nations sustainability development goals (SDG) and the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021) report underscored the importance of key stakeholders, including nurses, engaging in advocacy and policy to promote health equity. We discuss the role of nursing at the intersection of public health, policy, climate change, and the SDG. We also discuss the history and merger of the University of California San Francisco (UCSF) School of Nursing public health and health policy specialties, a significant innovation in our effort to promote health equity. We provide a brief overview of the redesigning of our curriculum that meets the needs of today's learners by including content on climate change, data analytics, and racial, social, and environmental justice. Finally, we emphasize the need to train the next cadre of nurses interested in careers in public health and health policy for us to meet the challenges facing our communities. (Am J Public Health. 2022;112(S3):S321-S327. https://doi.org/10.2105/AJPH.2022.306826).

The taste of smoke: tobacco industry strategies to prevent the prohibition of additives in tobacco products in Brazil.

BACKGROUND: The tobacco industry (TI) uses several strategies to attract new consumers, including using additives in tobacco products, which makes tobacco especially attractive to youth. Based on scientific evidence and the principles of the WHO Framework Convention on Tobacco Control, the Brazilian Health Regulatory Agency (ANVISA, for the name in Portuguese), published the Collegiate Board Resolution (RDC, for the name in Portuguese) 14/2012 in 2012, prohibiting the addition of substances that enhance the flavour and taste of tobacco products in order to make them more attractive. In response, the TI used various strategies to prevent RDC 14/2012 from entering into force. At the time, the Brazilian additive ban was the most comprehensive in the world as it included a ban on menthol. OBJECTIVES: This paper analyses the arguments and strategies used by the TI to prevent the implementation of the additives ban. METHODS: Review of published articles, reports, legislation and legislative activity, internal TI documents, media stories and other documents to describe TI's reaction to the ban. RESULTS: The results show that the TI used some well-known strategies to delay or cancel the entering into force of the resolution. For example, the TI attempted political interference, used litigation and commissioned studies with findings that questioned the resolution's rationale. The TI strategies used in Brazil are similar to those used at the global level to oppose other tobacco control measures. CONCLUSIONS: TI successfully delayed the most comprehensive additive ban in the world using its usual tactics, despite the fact that none of the arguments presented by the TI had an acceptable scientific basis or evidence.

Increased adoption of smoke-free policies on campuses with schools of nursing.

BACKGROUND: In 2015, the majority of U.S. American Association of Colleges of Nursing (AACN)-accredited schools of nursing resided on campuses without smoke-free policies. PURPOSE: To determine the presence of smoke-free policies at AACN-accredited after resolutions from AACN and the American Academy of Nursing, and the creation of online resources. METHODS: Smoke-free policies (2015-2017) were determined through listings on the ANRF College Campus Policy Database© and survey responses from nursing deans. RESULTS: Smoke-free policies for 689 schools of nursing increased from 36% in 2015 to 91% in 2017. There were no significant differences by nursing program types or geographic area. Twenty percent of deans reported using the resources, with over 1700-page views. CONCLUSION: Smoke-free policies increased after support from two national nursing organizations. Learning in a smoke-free environment should be an expectation for nursing students to protect their own health, and to support their future critical role in tobacco control.

Tobacco growing and the sustainable development goals, Malawi.

Negative impacts of tobacco result from human consumption and from tobacco-growing activities, most of which now occur in low- and middle-income countries. Malawi is the world's largest producer of burley tobacco and its population is affected by the negative consequences of both tobacco consumption and production. In countries like Malawi, tobacco control refers to control of the tobacco supply chain, rather than control of consumption. We review the impact of tobacco cultivation, using Malawi as an example, to illustrate the economic, environmental, health and social issues faced by low- and middle-income countries that still produce significant tobacco crops. We place these issues in the context of the sustainable development goals (SDGs), particularly 3a which calls on all governments to strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control. Other goals address the negative effects that tobacco cultivation has on development. The SDGs offer an opportunity for low- and middle-income countries that are dependent on tobacco production and that are not yet parties to the Convention, to reconsider joining the FCTC.

Les impacts négatifs du tabac résultent de la consommation humaine et des activités de culture du tabac, qui sont aujourd'hui exercées pour la plupart dans les pays à revenu faible et intermédiaire. Le Malawi est le plus grand producteur mondial de tabac Burley et sa population subit les effets négatifs de la consommation et de la production de tabac. Dans des pays comme le Malawi, le contrôle du tabac porte davantage sur le contrôle de la chaîne d'approvisionnement que sur le contrôle de la consommation de tabac. Nous examinons ici l'impact de la culture du tabac, en prenant le Malawi comme exemple pour illustrer les problèmes économiques, environnementaux, sanitaires et sociaux que rencontrent les pays à revenu faible et intermédiaire qui continuent de produire d'importantes récoltes de tabac. Nous plaçons ces problèmes dans le cadre des objectifs de développement durable (ODD), en particulier du 3.a, qui appelle tous les gouvernements à renforcer l'application de la Convention-cadre de l'Organisation mondiale de la Santé pour la lutte antitabac (CCLAT). D'autres objectifs s'intéressent aux effets négatifs de la culture du tabac sur le développement. Les ODD offrent l'opportunité aux pays à revenu faible et intermédiaire qui dépendent de la production de tabac et qui ne sont pas encore parties à la Convention de réenvisager de la signer.

Los impactos negativos del tabaco se derivan del consumo humano y las actividades de cultivo de tabaco, la mayoría de las cuales suelen realizarse actualmente en países con ingresos bajos y medios. Malawi es el mayor productor de tabaco burley del mundo y su población se ha visto afectada por las consecuencias negativas del consumo y la producción de tabaco. En países como Malawi, el control del tabaco hace referencia al control de la cadena de suministro de tabaco, en lugar del control del consumo. Se revisó el impacto del cultivo de tabaco, utilizando Malawi como ejemplo, para ilustrar los problemas económicos, medioambientales, sanitarios y sociales a los que se enfrentan los países de ingresos bajos y medios que siguen produciendo grandes cosechas de tabaco. Se situaron estos problemas en el contexto de los objetivos de desarrollo sostenible, principalmente el 3.a, que hace un llamamiento a todos los gobiernos para que fortalezcan la implementación del Convenio Marco de la OMS para el Control del Tabaco (CMCT). Otros objetivos abordan los efectos negativos del cultivo de tabaco en el desarrollo. Los ODS ofrecen una oportunidad para que los países con ingresos bajos y medios que dependen de la producción del tabaco y que aún no forman parte del convenio reconsideren incorporarse al CMCT.

Exposing and addressing tobacco industry conduct in low-income and middle-income countries.

The tobacco industry's future depends on increasing tobacco use in low-income and middle-income countries (LMICs), which face a growing burden of tobacco-related disease, yet have potential to prevent full-scale escalation of this epidemic. To drive up sales the industry markets its products heavily, deliberately targeting non-smokers and keeps prices low until smoking and local economies are sufficiently established to drive prices and profits up. The industry systematically flaunts existing tobacco control legislation and works aggressively to prevent future policies using its resource advantage to present highly misleading economic arguments, rebrand political activities as corporate social responsibility, and establish and use third parties to make its arguments more palatable. Increasingly it is using domestic litigation and international arbitration to bully LMICs from implementing effective policies and hijacking the problem of tobacco smuggling for policy gain, attempting to put itself in control of an illegal trade in which there is overwhelming historical evidence of its complicity. Progress will not be realised until tobacco industry interference is actively addressed as outlined in Article 5.3 of the Framework Convention on Tobacco Control. Exemplar LMICs show this action can be achieved and indicate that exposing tobacco industry misconduct is an essential first step.

Evaluation of a web-based educational programme on changes in frequency of nurses' interventions to help smokers quit and reduce second-hand smoke exposure in China.

AIMS: To evaluate a web-based educational smoking cessation programme on changes in the frequency of hospital-based nurses' self-reported interventions to help smokers quit using the 5 As (i.e. Ask, Advise, Assess, Assist, Arrange), to reduce exposure to second-hand smoke and to change attitudes about nurses' involvement in tobacco control. BACKGROUND: Few nurses in China support smokers' quit attempts using evidence-based smoking cessation interventions based on the 5 As. Limited knowledge is a barrier to intervention. Web-based tobacco cessation programs have the potential to reach a large population of nurses. DESIGN: A prospective single-group design with pre-, 3- and 6-month follow-up after the educational programme evaluated the feasibility of conducting web-based educational programs in two cities in China in 2012-2013. METHODS: Frequency of interventions was assessed using a valid and reliable web-based survey with a convenience sample of nurses from eight hospitals in Beijing and Hefei, China. Generalized linear models, adjusting for age, clinical setting, education and site were used to determine changes in the consistent (usually/always) use of the 5 As from baseline to 3 and to 6 months. RESULTS: Nurses (N = 1386) had baseline and/or 3- and 6-month data. At 6 months, nurses were significantly more likely to Assess, Assist and Arrange for smoking cessation and recommend smoke-free home environments. There was significant improvement in attitudes about tobacco control. CONCLUSIONS: Nurses receiving web-based smoking cessation education significantly increased self-reports of frequency of providing interventions to patients who smoke, including recommending smoke-free home environments to support quit attempts.

Helping smokers quit: behaviours and attitudes of Chinese Registered Nurses.

AIMS: To describe the self-reported frequency of Chinese nurses' interventions to help smokers quit, using the 5 As (i.e. Ask, Advise, Assess, Assist, Arrange), attitudes towards tobacco control and differences in consistency interventions by demographic and professional characteristics prior to an educational intervention to increase nurses' support for quit efforts. BACKGROUND: Tobacco use is the leading cause of preventable death in China; quitting smoking reduces health risks and premature death. The China Tobacco Cessation Treatment Guideline supports the 5 As model for intervention, but nurses' frequency of delivering smoking cessation interventions is unknown. DESIGN: Descriptive survey using a convenience sample. METHODS: Nurses from eight hospitals in Beijing and Hefei, China completed a web-based survey in 2012. Differences in consistency of the 5 As by nurse characteristics were determined using multivariate logistic regression. Overall importance of nurses in tobacco control was evaluated on a 1-5 scale (5 = most important). RESULTS: Nurses (N = 2440; 1404 Beijing, 1036 Hefei) participated. 64% consistently asked about smoking status, 85% advised patients to quit, 52% assessed readiness to quit and assisted with smoking cessation and 17% arranged for follow-up. Interventions varied by nurses' education and clinical setting. Nurses positively viewed involvement in tobacco control (4·3/5) and thought nurses should be smoke-free role models (4·8/5·0). CONCLUSIONS: This study demonstrates that the majority of nurses asked about smoking status, but few assisted patients with quitting. Further efforts are needed to help nurses actively promote smoking cessation interventions.

Few U.S. schools of nursing on campuses with smoke-free policies: A Call for Action.

INTRODUCTION: Tobacco remains the leading cause of preventable death in the United States. Recognizing that smoke-free policies can significantly reduce tobacco-related morbidity and mortality by preventing exposure to second-hand smoke and increasing quit rates, members of the Tobacco Control Subgroup of the American Academy of Nursing's (AAN) Health Behavior Expert Panel launched a health policy initiative entitled the Smoke-Free Campus Policy for Schools of Nursing Campaign. Designed as a two-phased initiative, the Campaign is a Call to Action to increase smoke-free policies on campuses with Schools of Nursing across the United States by 2020. METHODS: Phase I of the AAN Campaign included a cross-sectional study using secondary data analysis to describe the presence of smoke-free policies on campuses of Schools of Nursing across the United States. A list of colleges and universities with smoke-free policies maintained by the Americans for Nonsmokers Rights Foundation in January 2015 was accessed to conduct the analysis. Schools of Nursing granting baccalaureate and graduate nursing degrees were included. Descriptive statistics were obtained for Schools of Nursing by region of the country and by highest level of nursing degree program of study at each institution. RESULTS: Smoke-free policies of 689 Schools of Nursing were examined. Of these, 442 (64%) did not have 100% smoke-free policies on their campuses. A greater percentage of nursing schools without a smoke-free policy were located in the Northeast (114, 79%) and West (70, 73%). Nearly half (57, 46%) of the Schools of Nursing with a PhD/DNS program had a smoke-free policy in place compared with all other degree program levels (BS/BSN: 69, 35%; MS/MSN: 83, 35%; DNP: 38, 30%). CONCLUSIONS: With only 247 (36%) of Schools of Nursing on campuses with comprehensive smoke-free policies, more must be performed to promote healthy learning and working environments for nursing students, staff, and faculty. As public health advocates, nursing leaders in Schools of Nursing have a moral and ethical imperative to advance tobacco control on college campuses to meet the American College Health Association goals for smoke-free/tobacco-free environments.

The environmental and health impacts of tobacco agriculture, cigarette manufacture and consumption.

The health consequences of tobacco use are well known, but less recognized are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organization's Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. We detail the environmental impacts of the tobacco life-cycle and suggest policy responses.

Les conséquences du tabagisme sur la santé sont notoires. En revanche, les impacts environnementaux considérables de la production et de la consommation de tabac sont moins connus. Ces impacts environnementaux sont liés à la culture et au séchage du tabac, à la fabrication des produits du tabac et à leur distribution, au tabagisme et aux déchets générés après consommation. La Convention-cadre de l'OMS pour la lutte antitabac évoque ces problèmes environnementaux dans ses Articles 17 et 18, qui s'appliquent avant tout à la culture du tabac. L'Article 5.3 préconise de ne pas laisser l'industrie du tabac influencer les mesures politiques en ce qui concerne les effets négatifs de la production et de la consommation du tabac sur l'environnement. Nous détaillons dans ce dossier les impacts environnementaux sur tout le cycle de vie du tabac et formulons plusieurs suggestions en termes de réponse politique.

Las consecuencias sanitarias del consumo de tabaco son bien conocidas, pero no tanto los significativos efectos que el cultivo y consumo de tabaco tienen en el medio ambiente. Los efectos medioambientales del tabaco incluyen el crecimiento y la cura del tabaco, la producción y distribución del producto, el consumo del producto y los residuos resultantes de su consumo. El Convenio Marco de la OMS para el Control del Tabaco aborda las preocupaciones medioambientales en los Artículos 17 y 18, los cuales se aplican principalmente en el cultivo del tabaco. El Artículo 5.3 exige medidas cautelares respecto a las políticas de interferencia de la industria del tabaco en lo que se refiere a los daños medioambientales del cultivo y el consumo de tabaco. Se enumeran los efectos medioambientales del ciclo de vida del tabaco y se sugieren respuestas políticas.

Impact of a smoking cessation educational program on nurses' interventions.

PURPOSE: To evaluate a brief educational program about smoking cessation on the frequency of nurses' interventions with smokers, and impact of nurses' smoking status on outcomes. DESIGN: Prospective, single group design with prestudy and 3 months post-study data. METHODS: Nurses in the Czech Republic attended hospital-based 1-hr educational programs about helping smokers quit. They completed surveys about the frequency (i.e., always, usually, sometimes, rarely, never) of their smoking cessation interventions with patients using the five A's framework (i.e., ask, advise, assess, assist, arrange), and their attitudes prior to and 3 months after the course. Demographic data included smoking status. FINDINGS: Among the 98 nurses with prestudy and post-study data, all were female, mean age was 43 years, 33% were current smokers, and 64% worked in a medical or surgical or oncology settings. At 3 months, compared to baseline, significantly (p < .05) more nurses assessed patients' interest in quitting, assisted with quit attempts, and recommended the use of the quitline for cessation. At 3 months after the program, nurses who smoked were less likely to ask about smoking status (odds ratio [OR] = 4.24, 95% confidence interval [CI; 1.71, 10.53]), advise smokers to quit (OR = 3.03, 95% CI [1.24,7.45]), and refer patients to a quitline (OR = 2.92, 95% CI [0.99, 8.63]) compared to nonsmokers, despite no differences in delivery of interventions at baseline. CONCLUSIONS: Three months after attendance at an educational program focused on the nurses' role in supporting smoking cessation efforts, more nurses engaged in interventions to help smokers quit. However, the program was less effective for nurses who smoked. CLINICAL RELEVANCE: This program demonstrated promise in building capacity among Czech nurses to assist with smoking cessation, but nurses' smoking poses a challenge.

Tobacco policy (in)coherence in Mozambique: an examination of national and subnational stakeholder perspectives.

Mozambique ranks fifth on the list of tobacco producing countries in Africa, while also being a Party to the WHO Framework Convention on Tobacco Control (FCTC). Tobacco farming is regarded by some governments as a strategic economic commodity for export and remains deeply entrenched within Mozambique's political and economic landscape. This study uses a qualitative description methodology to identify tensions, conflicts and alignment or misalignment in policy on tobacco across government sectors and levels in Mozambique. We conducted semi-structured qualitative interviews with 33 key informants from sectors across national and subnational levels including health, agriculture, economic and commercial sectors, as well as non-state actors from civil society organizations, the tobacco industry, farmers unions and associations and individual farmers. Incoherence was present across sectoral mandates, perspectives on industry's presence in the country and regions and between FCTC provisions and informant perceptions of tobacco production as a development strategy. Despite tobacco being viewed as an important economic commodity by many informants, there was also widespread dissatisfaction with tobacco from both farmers and some government officials. There were indications of an openness to shifting to a policy that emphasizes alternatives to tobacco growing. The findings also illustrate where points of convergence exist across sectors and where opportunities for aligning tobacco policy with the provisions of the FCTC can occur.

Making a difference: nursing scholarship and leadership in tobacco control.

This report from members of the Health Behavior Expert Panel of the American Academy of Nursing (AAN) provides an overview of nurse-led scholarship in tobacco control. We reviewed published reviews of nurse-led studies in the field. The synthesis includes theory development, methodological approaches, studies focused on prevention of tobacco use, nursing interventions for tobacco dependence including studies with selected populations, investigations to reduce secondhand smoke, and studies of health care systems and policy. Gaps in the literature provided direction for stimulating nursing science, accelerating adoption of evidence-based recommendations in practice, expanding nursing education, and increasing nursing visibility and influence in health care policy efforts. The AAN is positioned to maximize nursing leadership in this effort.

Are quit attempts among U.S. female nurses who smoke different from female smokers in the general population? An analysis of the 2006/2007 tobacco use supplement to the current population survey.

BACKGROUND: Smoking is a significant women's health issue. Examining smoking behaviors among occupational groups with a high prevalence of women may reveal the culture of smoking behavior and quit efforts of female smokers. The purpose of this study was to examine how smoking and quitting characteristics (i.e., ever and recent quit attempts) among females in the occupation of nursing are similar or different to those of women in the general population. METHODS: Cross-sectional data from the Tobacco Use Supplement of the Current Population Survey 2006/2007 were used to compare smoking behaviors of nurses (n = 2, 566) to those of non-healthcare professional women (n = 93, 717). Smoking characteristics included years of smoking, number of cigarettes, and time to first cigarette with smoking within the first 30 minutes as an indicator of nicotine dependence. Logistic regression models using replicate weights were used to determine correlates of ever and previous 12 months quit attempts. RESULTS: Nurses had a lower smoking prevalence than other women (12.1% vs 16.6%, p < 0.0001); were more likely to have ever made a quit attempt (77% vs 68%, p = 0.0002); but not in the previous 12 months (42% vs 43%, p = 0.77). Among those who ever made a quit attempt, nurses who smoked within 30 minutes of waking, were more likely to have made a quit attempt compared to other women (OR = 3.1, 95% CI: 1.9, 5.1). When considering quit attempts within the last 12 months, nurses whose first cigarette was after 30 minutes of waking were less likely to have made a quit attempt compared to other females (OR = 0.69, 95% CI: 0.49, 0.98). There were no other significant differences in ever/recent quitting. CONCLUSIONS: Smoking prevalence among female nurses was lower than among women who were not in healthcare occupations, as expected. The lack of difference in recent quit efforts among female nurses as compared to other female smokers has not been previously reported. The link between lower level of nicotine dependence, as reflected by the longer time to first cigarette, and lower quit attempts among nurses needs further exploration.

Feasibility study of a smoking cessation intervention in Directly Observed Therapy Short-Course tuberculosis treatment clinics in Rio de Janeiro, Brazil.

A pilot feasibility study was conducted to determine whether Directly Observed Therapy Short-Course (DOTS) workers could be trained to deliver smoking cessation counseling and referral interventions, identify potential barriers to a full-scale randomized controlled trial on the effectiveness of integrated smoking cessation in DOTS, and determine whether tuberculosis (TB) patients who smoke would agree to participate in such a program. DOTS providers in two Rio de Janeiro primary health clinics received 1-day training in cessation counseling. They completed pre- and post-training surveys and participated in post-program focus groups. Patients were surveyed 3 months after program completion, and semiquantitative urine assays for cotinine were used to confirm cessation. Providers' mean self-efficacy scores for cessation counseling improved significantly (advise to quit, assess readiness, assist with quitting, and arrange follow-up) from scores (on a scale of 1-5) of 2-3 pre-training to 3-4 post-training (P < 0.05), with only ability to change motivation not significant. Providers' knowledge about cessation (withdrawal, nicotine replacement therapy, precontemplation) was low before training and did not improve after training (P > 0.1 for all comparisons). Implementation of a smoking cessation intervention by DOTS providers in TB clinics in Brazil is feasible. Randomized controlled trials to test intervention effectiveness in reducing TB-related morbidity must include cross-training for tobacco control and TB providers. Smoking cessation in DOTS programs may be important in reducing the global burden of TB, improving the health of TB patients, and reducing TB transmission in households.

A review of images of nurses and smoking on the World Wide Web.

With the advent of the World Wide Web, historic images previously having limited distributions are now widely available. As tobacco use has evolved, so have images of nurses related to smoking. Using a systematic search, the purpose of this article is to describe types of images of nurses and smoking available on the World Wide Web. Approximately 10,000 images of nurses and smoking published over the past century were identified through search engines and digital archives. Seven major themes were identified: nurses smoking, cigarette advertisements, helping patients smoke, "naughty" nurse, teaching women to smoke, smoking in and outside of health care facilities, and antitobacco images. The use of nursing images to market cigarettes was known but the extent of the use of these images has not been reported previously. Digital archives can be used to explore the past, provide a perspective for understanding the present, and suggest directions for the future in confronting negative images of nursing.

Is It Possible to Solve the Conflicts Over Conflict of Interest? Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool".

Addressing conflicts of interest (COIs) when developing and implementing policies to address commercial determinants of health is pivotal to ensure that these policies are free from commercial and other vested interests of unhealthy commodities industry. As a concept, this is well accepted within the tobacco control community, and supported by the existence of an international treaty, the WHO Framework Convention on Tobacco Control (FCTC). But in nutrition policy the engagement of the food industry appears to remain controversial, as efforts to create partnerships are still underway. There is a need to undertake evaluation of existing COI policies to assess their implementation and outcomes, creating best practice models that can be replicated, and understanding how to change norms within governments. Additionally, a review of existing norms, codes of conduct, and ethics to determine their impact on preventing COI would guide future implementation of these measures. Finally, governments, academics, and advocates should consider how existing tools, guidelines or other instruments could help frame the COI discussion to ensure its political feasibility. There is a need for a discussion on whether the current approach of separate policies for distinct industries is preferable than a broader COI policy that would be applicable to a wide range of unhealthy commodities and across governmental sectors.