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American Journal of Critical Care. 2002;11: 27-33
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Tobacco Dependence Curricula in Acute Care Nurse Practitioner Education

By Janie Heath, RN, CS, MS, CCRN, ANP, ACNP, Jeannette Andrews, RN, CS, MSN, FNP, ACNP, Sue Ann Thomas, RN, PhD, Frances J. Kelley, RN, PhD, FNP and Erika Friedman, PhD. From Georgetown University, School of Nursing and Health Studies, Washington, DC (JH, SAT, FJK), Medical College of Georgia, School of Nursing, Augusta, Ga (JA), and Department of Health and Nutrition Sciences, Brooklyn College, City University of New York, Brooklyn, NY (EF).


   Abstract
Top
 Abstract
Literature Review
 Purpose of the Study
 Method
 Results
 Discussion
 Conclusions
 References
 
• Background Tobacco dependence is the leading preventable cause of death in the United States, yet healthcare professionals are not adequately educated on how to help patients break the deadly cycle of tobacco dependence.

• Objective To assess the content and extent of tobacco education in the curricula of acute care nurse practitioner programs in the United States.

• Methods A survey with 13 multiple-choice items was distributed to the coordinators of 72 acute care nurse practitioner programs. The survey was replicated and modified from previous research on tobacco dependence curricula in undergraduate medical education.

• Results Fifty programs (83%) responded to the survey. Overall, during an entire course of study, 70% of the respondents reported that only between 1 and 3 hours of content on tobacco dependence was covered. Seventy-eight percent reported that students were not required to teach smoking-cessation techniques to patients, and 94% did not provide opportunities for students to be certified as smoking-cessation counselors. Sixty percent reported that the national guidelines for smoking cessation were not used as a curriculum reference for tobacco content.

• Conclusions The majority of acute care nurse practitioner programs include brief tobacco education. More in-depth coverage is required to reduce tobacco dependence. Acute care nurse practitioners are in a prime position to intervene with tobacco dependence, especially when patients are recovering from life-threatening events. National recommendations for core tobacco curricula and inclusion of tobacco questions on board examinations should be developed and implemented.

Tobacco abuse remains the leading preventable cause of death in the United States, yet increasing evidence indicates that healthcare professionals are not adequately educated on how to help patients break the deadly cycle of tobacco dependence. An expert panel convened by the National Cancer Institute recommended that effective interventions to achieve smoking cessation and prevention should become a mandatory component of undergraduate medical education in all schools of medicine in the United States by 1995.1 In 1999, Ferry et al2 reported that almost 70% of medical schools in the United States did not require clinical training in smoking cessation techniques. Several years later, it is still questionable how well nursing schools are meeting this standard. This lack of clinical training is especially important for students in acute care nurse practitioner (ACNP) programs who are educated on how to reduce morbidity and mortality in hospitalized patients facing life-threatening conditions. Many of these patients are smokers, and ACNPs need an adequate knowledge base and skills to successfully affect this leading cause of preventable death. In this article, we address the important health effects of tobacco dependence and report findings on tobacco curriculum in ACNP programs. We also discuss implications for national recommendations on nursing practice and education for tobacco reduction to meet the Healthy People 2010 goals.


   Literature Review
Top
 Abstract
 Literature Review
Purpose of the Study
 Method
 Results
 Discussion
 Conclusions
 References
 
More than 46 million adults in the United States smoke tobacco products. Nicotine, the major component in tobacco, is an addictive drug that annually kills more than 430 000 persons and markedly contributes to cancer and cardiovascular and pulmonary disease. Tobacco dependence kills more persons in the United States than do acquired immunodeficiency syndrome, alcohol, motor vehicle accidents, suicides, homicides, fire-related incidents, and illicit drugs.3 The effects of smoking were largely known by the medical community and have been revealed to the public through access to the Internet,4 with the 1995 publication of the "Brown and Williamson tobacco documents." 5–9 It is now well known that regardless of the delivery of nicotine, more than 4000 chemical compounds are released. These chemicals include antigenic, cytotoxic, mutagenic, and carcinogenic agents5–9 and contribute to the diseases of a large population of patients that ACNPs manage.

The toxic effects associated with smoking are daily practice challenges in acute and primary care settings. Marked vascular responses to nicotine include increased heart rate, increased systolic and diastolic blood pressures, increased force of myocardial contraction, increased myocardial oxygen consumption, increased myocardial excitability, decreased coronary artery blood flow, and increased peripheral vasoconstriction.10,11 Pulmonary responses include decreased forced vital capacity, decreased forced expiratory volume in 1 second, and decreased peak expiratory flow rate.12 These damaging physiological responses are strongly linked not only to cardiovascular and pulmonary diseases but also to cancer. Smoking is responsible for nearly 30% of all deaths due to cancer; it accounts for 87% of lung cancers and is highly associated with cancers of the esophagus, kidney, bladder, pancreas, uterine, cervix, mouth, and larynx.13

The mortality and morbidity associated with tobacco dependence are staggering, not only to patients and their families but also to the economy. In 1993, the estimated direct healthcare costs related to smoking totaled $50 billion.14 Currently, each pack of cigarettes sold accounts for more than $3.90 in smoking-related health expenses.3 The estimated indirect healthcare costs in 1993 were $43 billion and included costs of illnesses related to the effects of passive smoking and costs of loss of work productivity due to absenteeism or smoking breaks.14

Because of the escalating illnesses and deaths related to smoking and the significant cost to society, healthcare providers need to take a more aggressive approach to prevent tobacco dependence. Seventy percent of persons in the United States who smoke say that they would like to quit, yet half of these tobacco-dependent persons report that they have never been advised to quit smoking or been provided specific strategies to be successful at quitting.15 Furthermore, previous research16,17 indicated that many healthcare providers do not educate their patients on how to stop smoking. Fortunately, through many initiatives such as the national guidelines from the Agency for Health Care Policy and Research, now known as the Agency for Healthcare Research and Quality (AHRQ), and the Health Plan Employer Data Information Set, opportunities are increasingly available for reporting outcomes of successful interventions in tobacco-dependent patients.18 In addition, evidence-based practice can be guided by the Healthy People 2010 goals,19 which include reduction of tobacco use.

Published articles20–26 strongly indicate that nurses have effective outcomes when they use tobacco-cessation interventions based on "best practice" standards in a variety of clinical settings. In addition, as Andrews et al20 reported, nurses and nurse practitioners consistently refer more tobacco-dependent patients for smoking-cessation interventions than does any other group of healthcare providers.20 Although not as extensive as the information on the outcomes of tobacco interventions provided in primary care settings, reports on the outcomes of interventions implemented in acute care settings are increasing. In particular, increased efficacy is reported for tobacco interventions for hospitalized patients with cardiovascular disease and cancer.27–30 In a recent study by Johnson et al31 of hospitalized patients (n = 102) with cardiac disease, the tobacco cessation rate at 6 months was 46% for patients who received smoking-cessation intervention from a nurse and 31% for patients in the control group.

According to the National Cancer Institute,15 if 100 000 healthcare providers were to help only 10% of their patients to stop smoking, the number of smokers would decrease by an additional 2 million per year. Sarna32 found that 87% of oncology nurses (n = 1561) encountered patients who used tobacco products on a weekly basis. Of these nurses, 64% did assess and document tobacco use in their patients. However, only 32% went beyond "just asking" about tobacco use and actually provided tobacco-cessation counseling. Interestingly, regardless of their education, fewer than 40% of the nurses were taught about tobacco cessation in their basic nursing program. Sarna concluded that if competency in tobacco prevention and cessation skills is not an expectation for licensure, then nurses and educators may not regard such skills as essential knowledge.

Core curriculum for advanced practice nurses continues to be debated by national nursing organizations and national organizations for nurse practitioner faculties. The American Association of Colleges of Nursing33 emphasizes a strong theoretical foundation in advanced practice nursing education that addresses health promotion, illness prevention, and maintenance of function across the health-illness continuum. Specifically for ACNPs, establishing core content, values, skills, and competencies to meet standards of practice has been a major thrust for the National Organization of Nurse Practitioner Faculties (NONPF). In 1995, the first national curriculum guidelines were developed by NONPF. In 2000, NONPF released revised curriculum guidelines to address the domains and competencies for entry into practice for all nurse practitioner specialties. One of the revisions pertains to genetic screening, counseling, prevention, and treatment of genetic disease.34 This revision is of great importance as the role of research on genetics and tobacco dependence increases. Recent findings35–37 indicate that genetic variations alter dopamine receptors involved in the metabolism of nicotine. Individuals have a greater resistance to nicotine addiction if they have a genetic variant on chromosome 19 that decreases the function of the enzyme CYP2A6.


   Purpose of the Study
Top
 Abstract
 Literature Review
 Purpose of the Study
Method
 Results
 Discussion
 Conclusions
 References
 
The purpose of our study was to identify each of the following:


   Method
Top
 Abstract
 Literature Review
 Purpose of the Study
 Method
Results
 Discussion
 Conclusions
 References
 
A survey with 13 multiple-choice items was mailed to 72 ACNP program coordinators in the United States. The survey was replicated from previous research by Ferry et al2 on tobacco dependence curricula in undergraduate medical education. We modified the survey to address specific hours of tobacco content taught; Ferry et al addressed the specific year in medical school that tobacco content was taught. To ensure an adequate response rate, ACNP programs that had not returned the survey within the allotted time received a reminder telephone call.

The survey included 6 basic science topics, defined by Ferry et al,2 that addressed the amount of content taught about cancer risks, health effects, passive effects, chemical content, withdrawal symptoms, and high-risk groups for tobacco dependence. Clinical topics, as defined by Ferry et al,2 included the amount of content about the 5 A’s (known as anticipate, ask, advise, assist, and arrange15 at the time of the survey; now known as ask, advise, assess, assist, arrange38) and the 5 R’s (relevance, risks, rewards, roadblocks, repetition15), pharmacological agents for smoking cessation, and behavior modification sessions. Overall content on the basic science and clinical topics was also addressed. Response options for each tobacco topic addressed included (1) not covered in entire ACNP program, (2) briefly covered (1-3 hours) in entire ACNP program, (3) moderately covered (3-5 hours) in entire ACNP program, and (4) covered in-depth (>5 hours) in entire ACNP program. Three additional questions addressed opportunities to teach smoking-cessation techniques to patients, certification opportunities, and references used about tobacco dependence.


   Results
Top
 Abstract
 Literature Review
 Purpose of the Study
 Method
 Results
Discussion
 Conclusions
 References
 
Fifty (83%) of the 60 then currently active ACNP programs responded to the survey. Twelve of the initial 72 programs no longer existed. Seventy percent of the participants reported that overall content on tobacco dependence was covered briefly during an entire ACNP course of study (Figure 1Go).



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  		Figure 1 Extent of overall tobacco content taught in acute care nurse practitioner programs.

 
The 6 basic science or core content on tobacco topics included in the ACNP programs were cancer risks, health effects, passive effects, chemical content, withdrawal symptoms, and high-risk groups for tobacco dependence. The amount of time spent on each of the topics ranged from 0 hours to more than 5 hours (Figure 2Go). Twenty-eight of the programs (56%) covered all 6 basic science tobacco topics. All ACNP programs addressed the cancer risks associated with tobacco dependence. The 2 tobacco topics most often omitted were related to chemical content (36% of the programs) and withdrawal symptoms (32% of the programs).



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  		Figure 2 Extent of basic science or core content on tobacco taught in acute care nurse practitioner programs.

 
The 3 clinical core tobacco topics included the technique of using the 5 A’s and the 5 R’s, pharmacological agents for smoking cessation, and behavior modification sessions. The amount of time devoted to each of these topics ranged from 0 hours to more than 5 hours (Figure 3Go). More than half of the programs covered the clinical topics briefly (1-3 hours). Twelve programs (24%) did not cover the 5 A’s and the 5 R’s, 3 (6%) did not cover pharmacological agents, and 8 (16%) did not cover behavioral modification for smoking cessation. Sixty-six percent of the programs included all of the topics, 20% included 2 of the topics, and 2 did not include any clinical topics in the ACNP curriculum. Two programs (6%) reported providing opportunities for certification in smoking-cessation counseling.



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  		Figure 3 Extent of clinical core content on tobacco taught in acute care nurse practitioner programs.

 
A comparison of our results with those of Ferry et al2 revealed that the mean number of basic science topics taught about tobacco in medical schools and ACNP programs is remarkably similar. The means were 5.2 (SD, 1.2) for medical schools and 5.14 (SD, 1.14) for ACNP programs. The means for clinical topics were 2.6 (SD, 1.5) for medical schools and 2.9 (SD, 1.4) for ACNP programs. The proportions of medical schools (83/122 or 68%) and ACNP programs (39/50 or 78%) that did not require any clinical experience in smoking cessation (P>.05) or those that required clinical experience with patients and a performance evaluation (6/122 or 5% of medical schools and 2/50 or 4% of ACNP program participants) did not differ significantly.

ACNP programs were similar to medical schools in the sources of materials used for teaching smoking-cessation content (Figure 4Go). The most common source for both programs was scientific literature. ACNP programs were more likely than medical programs to use peer-reviewed literature as a content source (P<.05). More ACNP programs than medical school programs used the US Preventive Services Task Force guidelines12 (P = .01). Of note, 40% of the ACNP programs but only 20.5% of medical schools used the AHRQ national guidelines for tobacco reduction. The 2 groups did not differ in the frequency of using materials from voluntary agencies and the National Cancer Institute references.



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  		Figure 4 Reference material on tobacco used in acute care nurse practitioner programs compared with material used in medical school programs AHRQ indicates Agency for Healthcare Research and Quality guidelines15; Lit, scientific literature; NCI, National Cancer Institute guidelines; USP, US Preventive Services guidelines12; Vol, material provided by voluntary agencies.

 

   Discussion
Top
 Abstract
 Literature Review
 Purpose of the Study
 Method
 Results
 Discussion
Conclusions
 References
 
When the majority of ACNP programs (70%) cover overall tobacco content "briefly" (1-3 hours for an entire ACNP program), the competency and knowledge base that graduates must have to meet the national challenges of tobacco control are a matter of concern. Students are continually reminded that a school’s responsibility is to provide a foundation of basic knowledge on which the students can build. We think that exposure to national guidelines and established tools to diagnose and treat tobacco dependency, regardless of setting, is part of the foundation of basic knowledge for ACNP education. This stance is supported by Pulcini and Marion,39 nursing leaders from NONPF, who stated that "health care practitioners will be subject to increasing scrutiny by government and health care consumers who will demand uniform national standards that cross state lines and reflect evidence-based practice guidelines."

Students look to nursing leaders and educators for guidance on successful course completion, certification, and standards for entry into practice. For example, if ACNPs are expected to be knowledgeable about such guidelines as Advanced Cardiac Life Support and Joint National Commission for Hypertension Revision VI, then ACNPs should be expected to be knowledgeable about the 5 A’s and the 5 R’s from the AHRQ guidelines. After all, tobacco is the leading cause of many of the conditions that require Advanced Cardiac Life Support or Joint National Commission for Hypertension Revision VI interventions, and more than half of the programs (60%) in our study did not use the AHRQ guidelines as a curriculum reference for tobacco content.

Future studies should evaluate how much tobacco content needs to be covered for ACNPs to be "adequately" prepared to implement tobacco reduction practices. For example, if an ACNP program included a course worth 40 semester credit hours, and the institution equated that to 200 classroom hours, how many of those hours should be devoted to tobacco? We define adequate as more than 5 hours of overall tobacco content in an entire ACNP program. Of the ACNP programs we surveyed, 14% are currently teaching tobacco content to this depth. Perhaps this amount of time is too much or perhaps not enough. Clearly, an evaluation of the knowledge base and tobacco reduction practices of recent ACNP graduates, experienced ACNPs, and faculty of ACNP programs would help answer this question. In addition, we think that all levels and specialties of nursing education probably do not include adequate coverage of tobacco topics.

Another limitation of our study is the lack of data on content devoted to other lifestyle behaviors in ACNP curricula, such as alcohol use, illicit drug use, and weight disorders. These topics are also major health concerns and have wide implications for ACNP practice. However, the question arises again about how much time needs to be devoted to these topics. It is unrealistic for ACNP educators to "teach everything," but we think that it is important to recognize deficiencies in curricula and to seek opportunities for improvement. Until further studies are done on the amount of time spent on topics on lifestyle behavior in ACNP programs, faculty can base curriculum decisions on national data such as the NONPF curriculum guidelines and the Healthy People 2010 goals of the Office of Disease Prevention and Health Promotion.

Developing and implementing curriculum changes can be challenging. A few of the ACNP programs we surveyed included creative tobacco control initiatives in the curricula. It would serve faculty well to collaborate with academic facilities and national organizations that have successful models in place and to collectively build more innovative and technology-driven learning strategies for tobacco control. Sarna32 identified several proven leaders in this area, but one relevant to this study is the Nursing Center for Tobacco Intervention at Ohio State University, College of Nursing (www.con.ohio-state.edu/tobacco). Although the university does not currently have an ACNP program, its mission "to increase nurse provider participation in the delivery of tobacco cessation interventions through multiple links and modules" is a model for many to facilitate learning about tobacco research, education, and policy.

We did not address global strategies for tobacco control policy in ACNP programs in this study. As legislation moves toward increased taxation on tobacco products and regulation by the Food and Drug Administration, educating nurses about tobacco control policy for domestic and international public health will be increasingly important. Montagna and Hupcey40 found that studies on the role of advanced practice nurses in bringing the AHRQ guidelines to the forefront of international borders are limited. Pulcini and Marion39 further emphasized that a successful transition to a global healthcare economy will require that education of nurse practitioners in the 21st century generate international standards for quality healthcare practice and education.

In closing, the implications for licensure that Sarna32 referred to are not as much of a concern for the outcome of our study. However, our results have tremendous implications for ACNP board certification. The American Nurses Credentialing Center’s blueprint for the ACNP examination does not specifically address tobacco content, and the center could not disclose the number of tobacco-related questions on the ACNP examination. However, ACNP graduates who took the examination during the past 5 years could not recall if it included specific questions about tobacco.


   Conclusions
Top
 Abstract
 Literature Review
 Purpose of the Study
 Method
 Results
 Discussion
 Conclusions
References
 
The effects of tobacco dependence are deadly. Until all healthcare providers and educators seriously assess how initiatives to reduce this dependence are implemented in their practice and/or curriculum, the mortality and morbidity due to tobacco dependence will continue in epidemic proportions. Critical care nurses and ACNPs are in a prime position to take a leadership role for national educational and practice standards that affect the deadly cycle of tobacco dependence.


   ACKNOWLEDGMENTS
 
This research was funded by a data-driven clinical practice grant from the American Association of Critical-Care Nurses. The study was done at Georgetown University, School of Nursing and Health Studies, Washington, DC.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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 Abstract
 Literature Review
 Purpose of the Study
 Method
 Results
 Discussion
 Conclusions
 References
 

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