© Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, e-mail pubpermissions@ons.org. To purchase high-quality reprints, email reprints@ons.org.


April 2014, Volume 18, Number 2



Guest Editorial

Deborah K. Mayer, PhD, RN, AOCN®, FAAN—Editor


Enough Is Enough

Linda Sarna, PhD, RN, FAAN, AOCN®


Coinciding with the 50th anniversary of the first Surgeon General report on smoking and health (U.S. Department of Health, Education and Welfare, 1964) was the release of the 2014 Surgeon General report The Health Consequences of Smoking—50 Years of Progress (U.S. Department of Health and Human Services, 2014). During a press conference announcing the report in January 2014, Acting Surgeon General Rear Admiral Boris Lushniak, MD, MPH, repeated the refrain “Enough is enough” in frustration with the continuing burden of death and misery caused by tobacco use as he urged action to be taken. That challenge gives us an opportunity to ask ourselves whether, as nurses (particularly as oncology nurses), we have done enough to help patients who are still struggling with nicotine addiction.


The latest surgeon general report has new and important information that will affect oncology nursing practice. The link between smoking and certain cancers has been well established, but, for the first time, an entire section in the report is devoted to adverse health outcomes in patients with cancer and survivors. That information is relevant not only for patients with cancers caused by tobacco (e.g., lung cancer, the leading cause of cancer death), but for patients with other types of cancers as well. For patients with cancer, the evidence is considered sufficient to support the link between smoking and negative health outcomes as well as the benefits of quitting; the relationship between smoking and increased mortality from cancer and other diseases; and the increased risk of second cancers. Emerging evidence suggests that continued smoking after diagnosis results in poorer response to treatment. In the current issue of the Clinical Journal of Oncology Nursing, a timely article explores the negative impact of smoking on the quality of life of patients with cancer and the importance of integrating smoking cessation programs as essential care for patients with cancer and their family members (McDonnell, Bullock, Hollen, Heath, & Kozower, 2014).


Although we can celebrate the dramatic decline in smoking among adults in the United States, from 42% in 1965 to less than 20% in 2012, 42 million Americans continue to smoke (U.S. Department of Health and Human Services, 2014). Included among those statistics are nurses. Nurses were not immune to the lure of tobacco advertisements and the power of the highly addictive properties of nicotine. In the mid-1970s, female nurses had a higher smoking prevalence than American women in general. In 2003, in response to higher levels of smoking among nurses compared to physicians, the Tobacco Free Nurses initiative (www.tobaccofreenurses.org) was launched to support nurses in their own cessation efforts and reduce other barriers to nursing involvement in tobacco control (Sarna, Bialous, Barbeau, & McClellan, 2006).


As a result, I was thrilled to see that recent data (2003 to 2010–2011) from the Tobacco Use Supplement to the Current Population Survey described a 36% decline in smoking among RNs, from about 11% to 7%, twice that of the decline in the general population (Sarna, Bialous, Nandy, Antonio, & Yang, 2014). The proportion of RNs with a history of smoking and who quit (70%) was higher than the general population (54%). Although that was good news, that rate still is much higher than the 2% rate of smoking among physicians, and almost a quarter of licensed practice nurses surveyed were current smokers (Sarna et al., 2014).


Smoking among healthcare professionals is important not just because it affects their personal health, but because studies have suggested that smoking negatively affects interventions with patients and attitudes about tobacco control. Less than 20 years ago, the inclusion of the expectation that oncology nurses be smoke-free role models in an Oncology Nursing Society (ONS) tobacco control policy was debated at the 1995 ONS Annual Congress before its final inclusion (Sarna & Brown, 1995).


The delivery of a tobacco cessation intervention still is not a routine part of cancer nursing care, even in designated cancer centers (Hanna, Mulshine, Wollins, Tyne, & Dresler, 2013). Given the evidence that continued smoking will cause serious harm to patients, it would be unacceptable to not address smoking after a cancer diagnosis and help patients quit. In the past, some nurses were reluctant to broach the issue of smoking and cessation with their patients because they did not want them to feel stigmatized or guilty. The American Society of Clinical Oncology (2012) adapted the U.S. Department of Health and Human Services’s (2008) Treating Tobacco Use and Dependence: 2008 Update to assist oncology clinicians, including nurses, to sensitively support cessation attempts among their patients. Oncology nurses need to support all smokers who are trying to quit using evidence-based methods, including their own colleagues. Enough is enough!




American Society of Clinical Oncology. (2012). Tobacco cessation guide for oncology providers. Retrieved from https://www.asco.org/sites/default/files/tobacco_cessation_guide.pdf


Hanna, N., Mulshine, J., Wollins, D.S., Tyne, C., & Dresler, C. (2013). Tobacco cessation and control a decade later: American Society of Clinical Oncology policy statement update. Journal of Clinical Oncology, 31, 3147–3157. http://dx.doi.org/10.1200/JCO.2013.48.8932


McDonnell, K.K., Bullock, L.F.C., Hollen, P.J., Heath, J., & Kozower, B.D. (2014). Emerging issues on the impact of smoking on health-related quality of life in patients with lung cancer and their families. Clinical Journal of Oncology Nursing, 18, 171–181. http://dx.doi.org/10.1188/14.CJON.18-02AP


Sarna, L., Bialous, S., Barbeau, E., & McClellan, D. (2006). Strategies to implement tobacco control policy and advocacy initiatives. Critical Care Nursing Clinics of North America, 18(1), 113–122, xiii. http://dx.doi.org/10.1016/j.ccell.2005.11.002


Sarna, L., Bialous, S.A., Nandy, K., Antonio, A.L., & Yang, Q. (2014). Changes in smoking prevalences among health care professionals from 2003 to 2010–2011. JAMA, 311, 197–199.


Sarna, L., & Brown, J. (1995). Tobacco prevention and cessation in oncology nursing practice, education, and research. Oncology Nursing Forum, 22, 256–257.


U.S. Department of Health, Education and Welfare. (1964). Smoking and health: Report of the Advisory Committee to the Surgeon General of the Public Health Service (Publication No. 1103). Washington, DC: Author.


U.S. Department of Health and Human Services. (2008). Treating tobacco use and dependence: 2008 update. Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf


U.S. Department of Health and Human Services. (2014). The health consequences of smoking—50 years of progress. A report of the Surgeon General: Executive summary. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/exec-summary.pdf


Linda Sarna, PhD, RN, FAAN, AOCN®, is a professor and the Lulu Wolf Hassenplug Endowed Chair in the School of Nursing at the University of California, Los Angeles. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Sarna can be reached at lsarna@sonnet.ucla.edu, with copy to editor at CJONEditor@ons.org.