CPEnhancing Patient Communication for the Psychiatric Nurse

July 2010 Volume 1, Number 1

Counseling Points™

Psychiatric Nurse

This activity is supported by an educational grant from Pfizer, Inc. A Publication of the

American Psychiatric Nurses Association

Breaking Barriers and

Implementing Changes

The Significance of Tobacco

Dependence in Persons

with Mental Illness

Part 1 in a 3-Part Series

Counseling Points™ 2

Chair:

Daryl Sharp, PhD, PMHCNS-BC, NPP

Director, Doctor of Nursing Practice Program

Associate Professor of Clinical Nursing and in the Center for Community Health

University of Rochester Medical Center

Rochester, New York

Faculty:

Susan W. Blaakman, MS, RN, NPP-BCResearch/Senior Associate and Doctoral

CandidateRuth L. Kirchstein NRSA Pre-doctoral FellowANF Presidential ScholarUniversity of RochesterRochester, New York

Steven A. Schroeder, MDDepartment of Medicine and Smoking

Cessation Leadership CenterUniversity of California, San FranciscoSan Francisco, California

Daryl Sharp, PhD, PMHCNS-BC, NPPDirector, Doctor of Nursing Practice ProgramAssociate Professor of Clinical Nursing and in

the Center for Community HealthUniversity of Rochester Medical CenterRochester, New York

Faculty Disclosure Statements:

Susan Blaakman, Steven Schroeder, and Daryl Sharp have no conflicts to disclose. Susan Blaakman’s work is partially supported by a Ruth L. Kirschstein National Research Service Award (F31NR011266, Susan W. Blaakman, Principal Investigator) from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

Publishing Information:

PublishersJoseph J. D’OnofrioFrank M. MarinoDelaware Media Group66 South Maple AvenueRidgewood, NJ 07450Tel: 201-612-7676Fax: 201-612-8282Websites: www.delmedgroup.com www.counselingpoints.com

Editorial DirectorNancy Monson

Art Director

James Ticchio

Cover photo credit: © Blend Images / Veer

©2010 Delaware Media Group, Inc. All rights reserved. None of the contents may be reproduced in any form without prior written permission from the publisher. The opinions expressed in this publication are those of the faculty and do not necessarily reflect the opinions or recommendations of their affiliated institutions, the publisher, APNA, or Pfizer, Inc.

Counseling Points™ Breaking Barriers and Implementing ChangesThe Significance of Tobacco Dependence in Persons with Mental Illness

Continuing Education Information

Target AudienceThis educational activity is designed to meet the needs of psychiatric nurses with an interest

in providing quality care to patients with mental illness who smoke.

Learning ObjectivesUpon completion of this educational activity, the participant should be able to:

• Understand that tobacco dependence is a significant problem in persons with mental illness

• Describe the factors that are believed to be responsible for increased tobacco use in persons

with mental illness

• Understand that tobacco dependence can be successfully reduced or eliminated in persons

with mental illness

Continuing Education CreditThe American Psychiatric Nurses Association is accredited as a provider of continu-

ing nursing education by the American Nurses Credentialing Center’s Commission on

Accreditation.

1.0 CNE contact hours may be earned for successful completion of this activity.

This program expires: July 15, 2012.

Disclosure of Unlabeled UseThis educational activity may contain discussion of published and/or investigational uses of

agents that are not indicated by the FDA. The American Psychiatric Nurses Association,

Delaware Media Group, and Pfizer, Inc. do not recommend the use of any agent outside of

the labeled indications. The opinions expressed in this educational activity are those of the

faculty and do not necessarily represent the views of the American Psychiatric Nurses Asso-

ciation, Delaware Media Group, or Pfizer, Inc.

DisclaimerParticipants have an implied responsibility to use the newly acquired information to enhance

patient outcomes and their own professional development. The information presented in

this activity is not meant to serve as a guideline for patient management. Any medications,

diagnostic procedures, or treatments discussed in this publication should not be used by clini-

cians or other healthcare professionals without first evaluating their patients’ conditions, con-

sidering possible contraindications or risks, reviewing any applicable manufacturer’s product

information, and comparing any therapeutic approach with the recommendations of other

authorities.

July 20103

Dear Colleague,

Welcome to this new series of Psychiatric Nurse Counseling Points™, an official publica-tion of the American Psychiatric Nurses Association (APNA), on tobacco cessation for persons with mental illnesses and/or substance abuse addictions. We would like to thank Pfizer, Inc. for providing an educational grant for the series of three issues.

Tobacco use has often been ignored, or even tolerated or encouraged, in patients with mental illness. Given what we now know about the toll that smoking takes on the overall health and lifespan of patients and the fact that available interventions can successfully help these patients to quit, tobacco cessation is an issue whose time has come for psychiatric nurses.

APNA has formed a Tobacco Dependence Council and partnered with the Smoking Cessation Leadership Center at UCSF, led by Dr. Steven Schroeder, to educate our membership about smoking interventions and strategies. Currently, survey data sug-gest that 61% of psychiatric nurses refer or assist smokers with quitting interventions and 29% provide intensive reduction interventions. The Council has set a goal of increasing the percentage of psychiatric nurses intervening by 5% each year—which is where you, the reader, come in.

We have been lucky enough to benefit from the efforts of several energized leaders in this field in meeting this goal, most notably the chair for this series, Daryl Sharp, PHD,

PMHCNS-BC, NPP, of the University of Rochester School of Nursing. Along with fac-ulty member Susan Blaakman, MS, RN, NPP-BC, Daryl is co-author of Intensive Tobacco Dependence Intervention with Persons Challenged by Mental Illness: Manual for Nurses, which is available on the Tobacco Dependence Information Center section of the APNA website at www.apna.org/TDInfoCenter. We encourage you to take advan-tage of the many resources available on the website, as well as in this issue and the two to come over the next few months. The time to act is now!

Best regards,

Mary D. Moller, DNP, APRN, PMHCNS-BC, CPRP, FAAN

President, APNA

welcome

Counseling Points™ 4

Introduction

It is well established that people with mental illnesses

and/or addictive disorders are dying, on average, at

significantly younger ages than found in the general

population.1 In large part, the 25-year shorter life expectan-

cy of the psychiatrically ill can be explained by their excep-

tionally high rates of tobacco dependence. It is estimated

that those with mental illnesses and/or addictive disorders

account for approximately 200,000 of the 443,000 annual

deaths from tobacco-related illnesses in the United States,

with another 8.6 million suffering from tobacco-related

disabilities.2-4 Sadly, many smokers with mental illness do

not reach their 50th birthday.5 Furthermore, living with the

co-morbid illnesses caused by tobacco use (including car-

diovascular disease, cancer, and respiratory illnesses) nega-

tively impacts quality of life and prevents many people from

working toward their recovery goals.6,7

Given the widespread incidence of smoking in this

population, a significant disease burden is also borne by oth-

ers due to exposure to the negative health effects of second-

hand smoke, which contains at least 250 chemicals known

to be toxins.8

Despite the scope of this epidemic, nurses and other cli-

nicians have typically failed to intervene with their patients

who smoke even though efficacious interventions exist to

treat tobacco dependence.9,10 In light of the increasingly

stigmatizing nature of tobacco dependence, it is particularly

disconcerting that treatment is withheld from a vulnerable

population that is often already stigmatized by the nature of

their diseases and by the educational, social, and economic

disadvantages that may accompany them.11

General Factors Linked with High Smoking RatesAlthough smoking in the general population has significant-

ly declined over the past several decades, tobacco use preva-

lence rates among those with psychiatric and/or addictive

disorders (other than tobacco dependence) remain more

than twice that of the general population (Table 1).12,13

Tobacco dependence experts agree that nicotine addiction

results from a complex interplay of genetic, neurobiological,

psychological, social, economic, and cultural factors.14 There

is strong genetic evidence linking smoking and depression,

as well as smoking and alcohol use.15 Nicotine binds to sev-

eral neurotransmitters that underlie mental illness, including

dopamine, norepinephrine, acetylcholine, glutamate, sero-

tonin, β-endorphin, and GABA.1 Some have postulated that

nicotine is used as a form of self-medication among those

with mental illnesses because it tends to help people calm

down and concentrate better, thereby ameliorating some

psychiatric symptoms and improving cognition (Table 2).1

Nicotine also elicits a pleasure response, which may be dif-

ficult for some with mental illnesses to experience via other

routes, such as typically experienced through relationships,

work, and play.16 Boredom is a widely reported problem in

this population, and many report reliance on smoking as a

key coping strategy for combating monotony in their daily

lives.17 Furthermore, nicotine’s dopaminergic effects may

improve some of the negative symptoms associated with

psychotic disorders as well as some medication side effects

from the use of traditional antipsychotic agents.18

Given the psychoneurobiological underpinnings of psy-

chiatric illnesses, patients with serious mental illness (SMI)

may be particularly sensitive to withdrawal effects, which

only heighten the challenges posed by reducing or stop-

ping smoking.19 Beyond these genetic, neurobiological, and

psychological factors, social support is often lacking among

clients with SMI; they frequently live in community resi-

dences where smoking is not only permitted but is part of

The Significance of Tobacco Dependence in Persons with Mental Illness

Table 1. Smoking Prevalence Rates Among Persons with Mental Illness12,13,18,22,30,44,52,53

Schizophrenia 75%-85%

Major depression 30%

Anxiety disorder 19%-66%

Bipolar disorder 69%

Substance abuse disorders 75%-90%

July 20105

the normative culture. Although researchers have demon-

strated through social network analyses that smoking in the

general population has become progressively marginalized,

high smoking rates among those with mental illnesses and/

or substance use disorders have persisted, thereby reinforc-

ing smoking in these subpopulations.11,20 Added to these

factors, high unemployment rates, poverty, and relatively

low education levels among the psychiatrically ill increase

the likelihood of tobacco dependence and contribute to the

smoking epidemic in this population.7,17,21

Nicotine Dependence and Specific Psychiatric DisordersNicotine Dependence and SchizophreniaSmoking rates among people with schizophrenia are esti-

mated to be 75%-85%, with higher rates among males than

females.22 Approximately half of smokers with schizophrenia

consume more than 25 cigarettes daily.1,13,23 Researchers

conducting smoking topography studies have found that

people with schizophrenia puff their cigarettes more fre-

quently, extract more nicotine from them, and experience

a greater carbon monoxide boost than those without the

disease.24-26 Although researchers agree that a complex inter-

play of genetic, biological, psychological, and social factors

underlie schizophrenia and nicotine dependence, studies

regarding causal mechanisms are limited. Nicotine improves

sensory gating (a largely automatic process by which the

brain is able to adaptively adjust so it can attend to stimuli)

and may improve visuospacial working memory, both of

which are negatively affected by schizophrenia.27

Smoking may be a form of self-medication, but Ziedonis

and colleagues emphasize that it is important for both clini-

cians and researchers to stay open to other explanations such

as addiction, dependence, tolerance, or nicotine withdrawal

effects as reasons for why patients continue to use tobacco

products.1

Smoking outcomes also may be affected by psychiatric

treatment medications.18,28,29 For instance, people taking atypi-

cal antipsychotic medications have demonstrated better smok-

ing outcomes (number of cigarettes smoked daily and/or quit

rates) than those taking typical antipsychotic medications.18,29

Nicotine Dependence and Depression

People who smoke have significantly higher rates of life-

time depression in comparison to nonsmokers.1,30,31 Recent

estimates from cross-sectional surveys indicate that approxi-

mately 30% of those with depression smoke.12,32 Consis-

tent evidence also exists supporting the strong relationship

between smoking and bipolar disorder with reported preva-

lence rates as high as 68.8% 13,18 The Substance Abuse and

Mental Health Services Administration (SAMHSA) report-

ed findings from the 2006 National Survey on Drug Use

and Health (NSDUH) in which those aged 18 or older who

were nicotine dependent in the past month were more than

twice as likely as those who were not dependent on nico-

tine to have experienced serious psychological distress in the

past year.33 The survey also revealed that youths aged 12-17

who were nicotine dependent in the past month were over

twice as likely to have met the criteria for major depressive

disorder; a similar pattern was noted among adults aged 18

or older.

Such findings have led clinicians and researchers to

hypothesize that depression may cause smoking. Youths or

young adults may start smoking because they experience

relief from depressive symptoms when they do so.1 Indeed

nicotine may ameliorate depressive symptoms, which per-

petuates smoking.34 Researchers also hypothesize that the

strong relationship between depression and nicotine depen-

dence may be due to genetic vulnerability to both illness-

es.35,36 There also is some evidence that smoking may cause

depression due to compensatory neurophysiological changes

catalyzed by prolonged smoking. Ziedonis and colleagues

conclude that the causal relationship between depression

and smoking is likely to be bidirectional.1 Although there

is debate about whether a history of major depression is an

independent risk factor for cessation failure, smokers with

Table 2. Factors Linked to High Smoking Rates in the Psychiatrically Ill Population

• Genetic predisposition• Effects of nicotine (calming, pleasurable, and improves

concentration) • Boredom• Smoking is part of the culture and used as a reward or

behavioral tool in some psychiatric settings• May negate some antipsychotic agents’ side effects • Increased sensitivity to nicotine withdrawal• Lack of social support• High unemployment rates and poverty• Relatively low education levels

Counseling Points™ 6

a past history of major depressive disorder are more likely

than those without such a history to experience the disorder

after they stop smoking.24,34,37-39 This has led to the develop-

ment and testing of interventions in which both depressive

symptoms and nicotine withdrawal are treated concurrently.

Investigators have concluded that adding cognitive-behav-

ioral treatments (CBT) targeting depression to tobacco

dependence interventions yields better quit rates than

standard cessation interventions for those with a history of

recurrent depression (two or more episodes).1,40,41 Bupro-

pion SR and nortriptyline are the most effective pharma-

cotherapy options to aid cessation in this population, yet

their mechanism of action does not appear to be a decrease

in depressive symptoms.1,42,43 In general, selective serotonin

reuptake inhibitors (SSRIs), which are widely used to treat

depression, have not been demonstrated to be effective ces-

sation medications.21

Nicotine Dependence and Anxiety

Anxiety disorders comprise the largest single group of psy-

chiatric disorders in the United States and commonly occur

with other mental and physical disorders.1,44 Although esti-

mates vary by anxiety disorder diagnosis and the selected

sample population, prevalence estimates of smoking among

those with anxiety disorders is significantly greater in com-

parison to those in the general population.45 Highest preva-

lence estimates across studies are reported for those with

panic disorder (with or without agoraphobia, 19%-47%)

and those with posttraumatic stress disorder (44-66%).45

Similar to the research regarding the association between

smoking and depression, the underlying causal relationships

have not been clearly established with respect to anxiety

disorders and smoking. Researchers hypothesize that while

the presence of an anxiety disorder may increase one’s risk

for nicotine dependence, the reverse process may be true

for some anxiety disorders (i.e., smoking may cause the dis-

order).1 For example, nicotine-dependent young adults are

at higher risk for developing anxiety disorders.31,45

Evidence suggests that nicotine may be anxiolytic, yet

such anxiety relief is likely to be quite variable depending

on administration route (i.e., inhaled versus transdermal),

as well as administration timing and severity of anxiety.45

It also is possible that for some anxiety disorders, nicotine

could be anxiogenic, although current research in this area

is limited to animal models.45

The relationship between smoking and anxiety is par-

ticularly important because smokers often report stress as a

cue for smoking, and those who are trying to quit typically

report negative affect as a primary reason for relapsing.46,47

Poor tolerance of the distressing symptoms associated

with withdrawal from nicotine may also impede cessation

efforts.1 Additionally, “anxiety sensitivity” (fear of the sensa-

tions accompanying fear, dread, or panic) predisposes peo-

ple to developing some anxiety disorders (e.g., panic and

posttraumatic stress disorder), and has been associated with

more intense nicotine withdrawal symptoms, more per-

ceived difficulty quitting, and early relapse.48-50 Although

effect sizes were small and primarily linked to panic dis-

order, Morissette and colleagues found that smokers with

anxiety disorders experienced greater anxiety sensitivity,

anxiety symptoms, agoraphobic avoidance, depressed mood,

negative affect, stress, and life interference in comparison

with nonsmokers.51 Further research exploring media-

tors and moderators of the relationship between anxiety

and nicotine dependence are needed so that more tar-

geted interventions can be developed to aid cessation efforts

among those with anxiety disorders.

Nicotine Dependence and Substance Use Disorders

Epidemiological evidence indicates that the prevalence of

smoking among those who are alcohol dependent is as high

as 75%.52 Smoking rates among those using cocaine are

estimated to be approximately 80%, with prevalence esti-

mates of 90% among those who are opioid-dependent.18,53,54

Findings from the 2006 NSDUH survey revealed that

those aged 12 or older who were nicotine dependent in

the past month were more likely to have engaged in alco-

hol use, binge alcohol abuse, and heavy alcohol abuse in

the past month.33 They also were over 3 times more likely

to have engaged in illicit drug use within the past month.

Although the findings from one study support delaying

smoking cessation until after alcohol treatment to maximize

the effectiveness of anti-drinking interventions, researchers

have generally concluded that stopping smoking does not

interfere with recovery from other drug use.21,55 Smok-

ing abstinence also has been correlated with reductions in

July 20107

illicit substance use, which underscores the importance of

integrated treatment approaches that target all substances of

abuse, including tobacco.56

How Providers Contribute to the EpidemicUnfortunately, provider reticence to intervene contributes to continued high smoking prevalence rates among the mentally ill and those with addictive disorders. Despite the fact that tobacco dependence has strong neurobiological and psychological underpinnings, and the high likelihood that there cannot be recovery from mental illness or substance use disorders without physical wellness, many psychiat-ric clinicians express disinterest and discomfort in treating tobacco dependence, some even claiming that such treat-ment exceeds the limits of their practice responsibilities.7,57

Prochaska and colleagues found that only 1% of psychiatric inpatients were assessed for smoking status during hospital-ization, with smoking status largely absent from treatment planning.58 Thorndike and colleagues reported only 38% of outpatients with psychiatric illnesses received tobacco dependence counseling from their primary care physicians and only 12% from their psychiatrists.59

The current literature shows that persons

with mental illness often wish to quit,

look for resources to assist their efforts,

and can be successful at decreasing and/or

quitting smoking.

Lack of provider intervention is likely a function of

the decades-long practice of using cigarettes as behavioral

reinforcement and even viewing smoking with patients as

therapeutic.60 Despite providing care in “smoke-free” treat-

ment facilities, staff members (who frequently are smokers)

may still escort patients for smoking breaks (i.e., “privi-

leges”) outdoors.61 Clinicians, erroneously, have described

smoking as the “least of their patients’ problems” and may

try to preserve one of the few “pleasures” enjoyed by these

already burdened individuals.62 Clinicians have also reported

concern that psychiatric symptoms will worsen when smok-

ing is discontinued, that quitting or decreasing smoking is

not realistic for those with mental illness, and/or that per-

sons with mental illness/addictive disorders are not invested

in smoking cessation.10,17,63 Research, however, does not

support any of these conclusions.

The current literature shows that persons with mental

illness often wish to quit, look for resources to assist their

efforts, and can be successful at decreasing and/or quitting

smoking.7,64,65 Research regarding smoke-free policies in

psychiatric hospitals has revealed that persons with mental

illness are able to quit smoking and that cessation may be

linked to decreases in violence and the need for disciplinary

action in addition to increases in staff satisfaction and time

spent with patients.64,66,67

Especially as smoking prevalence decreases in the gen-

eral population, continued high rates of smoking contribute

to the stigma of mental illness and the marginalization of

this vulnerable population, and interfere with the ability

of many with mental illnesses to lead healthy, productive

lives.6 For these reasons, researchers, clinical leaders, and

policy experts are urging psychiatric clinicians to over-

come their reluctance to intervene with their patients who

smoke.21,68

Tobacco Dependence Treatment EfficacyIndividual Level Interventions

Across psychiatric and substance use disorders, persuasive

evidence exists that smokers can be helped to stop smoking

with intensive interventions.1,20,69 The expert panel behind

the Clinical Practice Guideline for Treating Tobacco Use and

Dependence identifies several interventions that are effective in

the general population—and that can also be used effectively

for those with psychiatric and/or substance use disorders.21

Although smokers with these disorders are at higher risk for

relapse than those without mental illness and/or addictive dis-

orders, convincing evidence exists to support the efficacy and

effectiveness of pharmacotherapy and psychosocial tobacco

dependence counseling in predicting cessation outcomes

among the mentally ill.1,21,70

A critical review of the literature comprised of 24 studies

with samples that included persons with a variety of psychi-

atric disorders and a meta-analysis of 15 studies focused on

participants with depressive disorders found comparable quit

rates to those in the general population.24,64 Most interven-

tions in these studies combined medications and tobacco

dependence counseling.

Counseling Points™ 8

Although both individual and group formats have been

found to be effective, brief interventions and self-help

approaches are not likely to provide sufficient interven-

tion doses to help patients with psychiatric illnesses and/

or substance use disorders to stop smoking. Thus, intensive

integrated interventions (7 to 10 sessions) are recommended

in this population.21,55,69 Investigators in clinical settings

have reported results similar to those obtained in efficacy

trials.67,71 Cessation outcomes among 79 subjects with men-

tal illnesses receiving group-based cessation treatment in

a community mental health clinic in Canada were com-

parable to those reported following group-based cessation

treatment for those without mental illnesses.72 Foulds and

colleagues concluded from a large cohort study (N=1021)

in a free tobacco clinic in New Jersey that smokers who

were highly nicotine-dependent and of lower socioeco-

nomic status (as are many smokers with mental illness and/

or substance use disorders) required more support to main-

tain treatment adherence, which predicted greater success in

stopping smoking.73

Systems Level InterventionsIn addition to providing access to evidence-based individ-

ual treatments, the Practice Guideline expert panel recom-

mends systems intervention strategies, including:

• establishing a tobacco user identification system to ensure

comprehensive screening;

• providing adequate training, resources, and feedback to

all clinicians;

• dedicating staff to provide tobacco dependence treat-

ments (and evaluating their performance in this role);

• promoting hospital policies (e.g., tobacco-free campuses)

that support and provide tobacco dependence services; and

• expanding clinic formularies to include FDA-approved

pharmacotherapies to aid in cessation efforts.21

Creating treatment settings that honor the central mis-

sion of health care (to heal and comfort) begins with not

permitting smoking on clinic grounds while providing

evidence-based cessation treatments for patients and staff.

One of the effective strategies for reducing tobacco use in the

general population has been the “person-to-person spread

of smoking cessation,” which has resulted in the progressive

denormalization of tobacco use and the marginalization of

those who smoke.11,19 This process has not been realized to

the same extent within the subculture of those with mental

illnesses and/or other addictive disorders. When clinicians

advocate for smoke-free health care facilities and provide cli-

ents with evidence-based treatments, smoking cessation can

potentially spread person-to-person, which can denormalize

tobacco use, and by extension, reduce stigma for those with

mental illnesses and/or substance use disorders who are able

to quit smoking when these supports are in place.62

Given that tobacco dependence is the most common

co-occurring disorder for the SMI population, some men-

tal health leaders have advocated the use of a co-occurring

mental illness and addiction paradigm in conceptualizing

tobacco dependence treatment.17 Integrated treatment

requires that the mental health system eliminate any practic-

es that support tobacco use (e.g., smoking breaks with staff).

Although considerable concern has been raised regard-

ing the potential negative impact of smoke-free treatment

setting policies on patients with psychiatric illnesses who are

heavily addicted to nicotine, achieving such policies has not

resulted in negative outcomes and, in fact, has had benefi-

cial effects.64,74,75 The positive impact of these policies, how-

ever, can be undermined by a lack of sustained investment

in staff training, as well as a lack of available comprehensive

cessation treatments.66

Treatment Cost ConsiderationsThe CDC estimates that tobacco dependence costs the

United States nearly $96 billion per year in direct medi-

cal costs and more than $97 billion in lost productivity.21,76

The health benefits and cost savings of quitting smoking are

substantive: Those who quit by age 30 eliminate nearly all

excess risk associated with smoking.77 Even when people

quit later in life, they experience considerable health gains.

Those quitting by age 50 cut their risk of dying in half

within the next 15 years.78 Tobacco dependence interven-

tions are highly cost-effective in relation to other reim-

bursed interventions such as mammography, hypertension

screening for men ages 45-54, and high cholesterol treat-

ment.21,79 Health care costs also are realized when chronic

diseases such as heart and pulmonary diseases as well as can-

cer are prevented by smoking cessation.21

Tobacco dependence interventions have actually been

referred to as the “gold standard” of health care cost-

effectiveness.80 Because the economic burden caused by the

morbidities associated with continued smoking is so great,

July 20109

tobacco dependence interventions are cost-effective even

when a single application of an effective treatment results in

modest quit rates or sustained abstinence in only a minority

of smokers.21

A Challenge to NursesNurses possess a long track record of advocating for patients

and of creating health care and social reform in the most

challenging of circumstances. From our earliest history,

Dorothea Dix (1802-1887) spoke out for prisoners and per-

sons with mental illness who were inhumanely treated and

otherwise did not have a voice.81 Florence Nightingale

(1820-1910) fought fiercely to develop nursing into a science

through which holistic care could be delivered and evaluat-

ed.82 Her perseverance decreased patient mortality, improved

quality of life, and led to policy changes that have shaped

nursing and environmental practices both then and now.82,83

Additional nurse activists have included Lillian D. Wald

(1867-1940) who changed the health and functioning of

entire communities; Margaret Sanger (1879-1966) who

gave marginalized women access to reproductive health

options; Florence Wald (1917-2008) who prioritized care

at the end of life; and, among contemporary nurse lead-

ers, Margo McCaffery, who has altered how patient pain is

assessed and managed.84-88

For these nurses, a keen moral obligation accompanied

their professional drive to help those in need. Nurses,

including psychiatric-mental health and addiction special-

ists, are guided in practice by standards for ethical and qual-

ity care. It is the responsibility of nurses to promote, and

not compromise, patients’ health and well-being.89-91 Sally

Gadow describes the ideal philosophical foundation of nurs-

ing in terms of “existential advocacy” or the moral commit-

ment of nurses to authentically understand the experiences

of patients, as well as their own, through the caring rela-

tionship.92 From this perspective, nurses cannot undervalue

the needs and desires of their patients.74 Coupled with the

view that nursing involves “the protection, promotion, and

optimization of health and abilities, prevention of illness and

injury, alleviation of suffering through the diagnosis and

treatment of human response, and advocacy in the care of

individuals, families, communities, and populations,” it is

unimaginable that nurses can wait any longer to fully inter-

vene on behalf of those who disproportionately bear the

burdens of tobacco dependence.90,91

Smoking Cessation Resources

Agency for Healthcare Research and QualityTreating Tobacco Use and Dependence: 2008 Updatewww.ahrq.gov/path/tobacco.htm

American Psychiatric AssociationTreatment of Patients with Substance Use Disorders, Second Editionwww.psych.org/MainMenu/PsychiatricPractice/Addiction Psychiatry/ClinicalPracticeGuidelinesandOther.aspx

American Psychiatric Nurses AssociationTobacco Dependence Information Centerwww.apna.org/TDInfoCenter.

American Psychiatric Nurses AssociationSharp DL, Bellush NK, Evinger JS, et al.Intensive Tobacco Dependence Intervention with Persons Challenged by Mental Illness: Manual for Nurseswww.apna.org/i4a/pages/index.cfm?pageid=3643.

Centers for Disease Control and PreventionOffice on Smoking and Healthwww.cdc.gov/tobacco/

Mayo Clinic Nicotine Dependence Centerwww.mayoclinic.org/ndc-rst/

New York State Tobacco Control Programwww.nysmokefree.com/newweb/pageview.aspx?p=55

Rx for ChangeClinician-assisted Tobacco Cessationwww.rxforchange.ucsf.edu

Smoking Cessation Leadership Centerhttp://smokingcessationleadership.ucsf.edu/

Society for Research on Nicotine and Tobaccowww.srnt.org/

Tobacco Disparities Initiatives of the State Tobacco Education and Prevention Partnership Colorado Department of Public Health and EnvironmentMorris C, Waxmonsky J, Giese A, et al. Smoking Cessation for Persons with Mental Illnesses: A Toolkit for Mental Health Providers.http://smokingcessationleadership.ucsf.edu/Resources.htm #Toolkits

Tobacco Free Nurseswww.tobaccofreenurses.org

University of Medicine and Dentistry of New JerseyTobacco Dependence Programwww.tobaccoprogram.org/index.htm

University of Wisconsin Center for Tobacco Research and Interventionwww.ctri.wisc.edu/About.CTRI/About.CTRI

Counseling Points™ 10

What prompted your interest in tobacco dependence?

One reason is my history as a clinician. I am a general inter-nist and I’ve seen a number of patients who became ill from smoking, including some who really wanted to quit, and couldn’t. Another reason was that I became knowledgeable about the public health toll of smoking. The third was that I found that tobacco cessation efforts were largely ignored: Here was this huge problem causing so much misery, yet very few people seemed interested in trying to combat it.

Why have you focused most recently on helping people with psychiatric and addictive disorders to stop smoking?

I became interested in psychiatric populations just as a func-tion of the greater number of patients with mental illness who smoke—the rates are much higher than in the general popu-lation—and how much damage it causes.

Tell us about the Smoking Cessation Leadership Center—when was it established and what is its mission?

The Center was established by the Robert Wood Johnson Foundation in the beginning of 2003, with subsequent support from the Veterans Health Administration and the American Legacy Foundation. It is currently supported by the Foundation at the University of California at San Francisco, and its intent is to help health professionals and other groups do a better job of helping smokers quit.

How do you think the Smoking Cessation Leadership Cen-ter can be helpful in supporting psychiatric nurses’ efforts to provide cessation interventions for those with mental illnesses?

As we’ve done with other health professionals, we’d like to help psychiatric nurses give voice to the importance of this issue within their specialty. We also want to help them iden-tify champions within their midst—for example, Daryl Sharp, the chair for this APNA series of publications. Our goal is to educate these thought leaders so they, in turn, can educate their colleagues.

How do you envision psychiatric nurses interfacing with nurses from other specialties to help more people (with and without mental or addictive illnesses) to stop smoking?

There are a couple of interesting things about nursing in general: One is that it is the largest health profession. Two, for the longest time, nurses smoked more than other health professionals. Smoking among nurses is down to 13%, and

the rate in the general population is 20%, but contrast that to what it is for doctors (1%) or pharmacists, dental hygienists or dentists, who have much lower rates.93

Any conjecture as to why that is—for instance, are nurses more stressed out due to the intense work pressures they face?

It’s part of the culture in many hospitals. Nurses take smoking breaks, and in mental health fields, many of them smoke at higher rates than the general population. I’m not sure I fully understand why.

Nurses, like most health professionals, have underper-formed as smoking cessation champions. But psychiatric nurses have taken a leadership role in this area and there is an opportunity for them to help their colleagues in other nursing specialties to do this, leading by example. Nurses as individuals can also stimulate their colleagues to get inter-ested in smoking cessation efforts.

Why do some mental health providers believe that smok-ing cessation is an unrealistic goal for their clients?

They think (A) patients are not interested in stopping smok-ing, (B) even if they are, they’re not able to stop smoking, and (C) their clinical conditions might get worse if they stop. It turns out all three are misconceptions. A fourth reason is they say, “We’re dealing with very disruptive patterns of per-sonal behavior—suicidal tendencies, maybe psychosis—and cigarette smoking is pretty trivial in comparison to these other issues.” One of the things that’s helped to dissuade that viewpoint is the recent knowledge that people with chronic mental illness die so much earlier, 25 years earlier than the general population, and a large part of that is due to smoking.

How can mental health professionals become more pro-active in promoting smoking cessation and counseling among those with mental illnesses?

First of all they can say “It is part of my job to find out which of my patients smoke. It’s also part of my job to keep them healthy—and the most important thing I can do to keep them healthy is to get them to stop smoking.” Clinicians need to engage the patient in a discussion about stopping smoking and figure out how best to do that—either counseling the patient herself or referring her elsewhere.

But it has to be part of every initial encounter with a client?

Yes, it has to be part of every encounter period. You can’t have healthy patients if they keep smoking.

An Interview with Steven A. Schroeder, MDDirector

Smoking Cessation Leadership CenterUniversity of California, San Francisco

San Francisco, Californiahttp://smokingcessationleadership.ucsf.edu/

July 201011

This educational series is designed to better equip psy-

chiatric-mental health nurses to grapple with the challenges

of tobacco dependence among persons with mental illness

and/or addictive disorders. Informed, skilled, and motivated

nurses can facilitate transformation in tobacco dependence

treatment at all levels of practice, education, research,

administration, and policy implementation. The American

Psychiatric Nurses Association (APNA) has issued a policy

statement asserting that now is the time to act on tobacco

dependence and failure to do so is harmful.7 The call to

action is for each of us: How will you choose to answer?

References 1. Ziedonis DM, Hobbs M, Beckham JC, et al. Tobacco use and cessation in

psychiatric disorders: National Institute of Mental Health report. Nicotine Tob Res. 2008;10:1691-1715.

2. Centers for Disease Control and Prevention. Smoking-attributable mor-tality, years of potential life lost, and productivity losses—United States, 2000-2004. MMWR.2008;45:1226-1228.

3. Centers for Disease Control and Prevention. Smoking-attributable mor-tality, years of potential life lost, and productivity losses—United States, 2000-2004. MMWR. 2008;57:1221-1226.

4. Schroeder S, Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illness and substance abuse problems. Annu Rev Public Health. 2010;31;16.1-16.18.

5. Rosenberg L. National council’s Linda Rosenberg testifies before Con-gress about funding. Behav Healthc. Accessed June 16, 2009 at http://www.behavioral.net.

6. National Association of State Mental Health Program Directors. Tobacco-free living in psychiatric settings: A best-practices toolkit promoting well-

ness and recovery. 2007. Accessed October 24, 2007 at www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated 90708.pdf.

7. Sharp DL, Blaakman SW. A review of research by nurses regarding tobac-co dependence and mental health. In: Sarna L, Bialous S, eds. Annu Rev Nurs Res. 2009;27:297-318.

8. United States Department of Health & Human Services. The health con-sequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. 2007. Accessed May 12, 2010 at: www.surgeongeneral.gov/library/secondhandsmoke/factsheets/factsheet1.html

9. Gollust SE, Schroeder SA, Warner KE. Helping smokers quit: Understand-ing the barriers to utilization of smoking cessation services. Milbank Quart. 2008;86;601-627.

10. Williams JM, Zeidonis DM. Snuffing out tobacco dependence: Ten rea-sons behavioral health providers need to be involved. Behav Healthc. 2006;26:27-31.

11. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New Engl J Med. 2008;358:2249-2258.

12. Grant BF, Hasin DS, Chou SP, et al. Nicotine dependence and psychiatric disorders in the United States. Arch Gen Psychiatry. 2004;61:1107-1115.

13. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA. 2000;284:2606-2610.

14. Warner KE. Tobacco Control Policy. San Francisco, Ca: Jossey-Bass. 2006.15. Benowitz NL. Neurobiology of nicotine addiction: Implications for smok-

ing cessation treatment. Am J Med. 2008;121(Suppl 4A):S3-S10.16. Sederer LI, Miller GA, Armon TC. How to quit smoking for good! 2010.

Accessed May 12, 2010 at www.huffingtonpost.com/lloyd-i-sederer-md/quitting-smoking-how-to-s_b_507177.html.

17. Ziedonis D, Williams JM, Smelson D. Serious mental illness and tobacco addiction: A model program to address this common but neglected issue. Am J Med Sci. 2003;326:223-230.

18. Allen TM, Sacco KA, Weinberger AH, et al. Medication treatments for nic-otine dependence in psychiatric and substance use disorders. In: George TP, ed. Medication Treatments for Nicotine Dependence. Boca Raton, Fl: CRC Press. 2007, pp 245-262.

19. Goff DC, Cather C, Evins E, et al. Medical morbidity and mortality in schizophrenia: Guidelines for psychiatrists. J Clin Psychiatry. 2005;66:183-193.

Networking and Information Accessibility 24/7• Stay informed with a free subscription to the print and

online versions of our Journal of the American Psychiatric Nurses Association (JAPNA)

• Stay connected with the organization through our monthly newsletter, APNA News: The Psychiatric Nursing Voice

• Communicate and network with members using a members-only social networking tool called Member Bridge

• Find position papers, publications, and videos in our online Resource Center

• Locate jobs specifically for psychiatric-mental health nurses through APNA CareerLine

• Understand important issues related to psychiatric nursing with free issues of Counseling Points™

Professional Growth• Overcome budgetary restrictions with online continuing

education opportunities• Enhance your nursing knowledge with continuing education

contact hours for psychiatric-mental health nursing

• Have an impact in your field by participating in volunteer committees, institutes, councils, and task forces

• Achieve recognition through APNA Annual Awards

• Learn from nationally recognized speakers and attend state-of-the-art workshops during the Annual APNA and Clinical Psychopharmacology Institute Conferences

• Enhance your member experience by participating in local education and networking opportunities

• Apply for grants and scholarships from the American Psychiatric Nursing Foundation

Discounts

• Save $200 on general registration fees for APNA and other conferences

• Download full-text articles of JAPNA at no cost

• Get substantial savings on certification, exams, and review materials from the American Nurses Credentialing Center

• Get discounts on long-term care coverage

• Receive a 10% discount on publications offered by American Psychiatric Publishing, Inc.

Join APNA today…Your resource for psychiatric-mental health nursing

The American Psychiatric Nurses Association (APNA) provides over 6,500 members with exceptional benefits to further their leadership potential and training opportunities.

Go to www.apna.org for a membership application.

Counseling Points™ 12

20. Schroeder S. Stranded in the periphery—the increasing marginalization of smokers. N Engl J Med. 2008;358:2284-2286.

21. Fiore MC, Jaen CR, Baker TB, et al.. Treating Tobacco Use and Depen-dence: 2008 Update. Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services. Public Health Service. May 2008.

22. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res. 2005;76:135-157.

23. Ziedonis DM, Kosten TR, Glazer WM, et al. Nicotine dependence and schizophrenia. Hosp Community Psychiatry. 1994;45:204-206.

24. Hitsman B, Borrelli B, McChargue DE, et al. History of depression and smoking cessation outcome: A meta-analysis. J Consult Clin Psychol. 2003;71: 657-663.

25. Tidey JW, Rohsenow DJ, Kaplan GB, et al. Subjective and physiological responses to smoking cues in smokers with schizophrenia. Nicotine Tob Res. 2005;7: 421-429.

26. Williams JM , Gandhi KK, Karavidas M, et al. More puffs and shorter inter-puff interval in smokers with schizophrenia using CReSSmicro® Topogra-phy Device. Paper presented at the 12th annual meeting of the Society for Research on Nicotine and Tobacco, Orlando, Fl. 2006.

27. George TP, Termine A, Sacco KA, et al. A preliminary study of the effects of cigarette smoking on prepulse inhibition in schizophrenia: Involvement of nicotinic receptor mechanisms. Schizophr Res. 2006;87:307-315.

28. George TP, Vessicchio JC, Termine A, et al. A placebo controlled trial of bupropion for smoking cessation in schizophrenia. Biol Psychiatry. 2002;52:53-61.

29. Procyshyn RM, Ihsan N, Thompson D. A comparison of smoking behav-iours between patients treated with clozapine and depot neuroleptics. Int Clin Psychopharmacol. 2001;16:291-294.

30. Sharp DL, Bellush NK, Evinger JS, et al. Intensive Tobacco Depen-dence Intervention with Persons Challenged by Mental Illness: Manual for Nurses. Rochester, NY: University of Rochester School of Nursing. 2009. Accessed April 14, 2010 at www.apna.org/i4a/pages/index.cfm?pageID=3839 .

31. Breslau N, Kilbey MM, Andreski P. DSM-III-R nicotine dependence in young adults: Prevalence, correlates and associated psychiatric disorders. Addiction. 1994;89:743-754.

32. Waxmonsky JA, Thomas MR, Miklowitz DJ, et al Prevalence and cor-relates of tobacco use in bipolar disorder: Data from the first 2000 par-ticipants in the Systematic Treatment Enhancement Program. Gen Hosp Psychiatry. 2005;27:321-328.

33. Substance Abuse and Mental Health Services Administration (SAMHSA). The NSDUH Report: Nicotine Dependence: 2006. Rockville, Md: Office of Applied Studies. 2008.

34. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Update of the Cochrane Database systematic review 2004. Cochrane Database Sys Rev. 2007:CD000031.

35. Lyons MJ, Hitsman B, Xian H, et al. A twin study of smoking, nico-tine dependence, and major depression in men. Nicotine Tob Res. 2008;10:97-108.

36. Kendler KS, Neale MC, MacLean CJ, et al. Smoking and major depres-sion. A causal analysis. Arch Gen Psychiatry. 1993;50:36-43.

37. Covey LS. Comments on “History of depression and smoking cessation outcome: A meta-analysis.” Nicotine Tob Res. 2004;6:743-745; author reply 747-749; discussion 751-752.

38. Hall SM, Humfleet GL, Reus VI, et al. Extended nortriptyline and psy-chological treatment for cigarette smoking. Am J Psychiatry. 2004;161:2100-2107.

39. Hughes JR. Depression during tobacco abstinence. Nicotine Tob Res. 2007;9:443-446.

40. Brown RA, Kahler CW, Niaura R, et al. Cognitive-behavioral treatment for depression in smoking cessation. J Consult Clin Psychology. 2001;69:471-480.

41. Haas AL, Munoz RF, Humfleet GL, et al. Influences of mood, depression history, and treatment modality on outcomes in smoking cessation. J Consult Clin Psychol. 2004;72:563-570.

42. Lerman C, Niaura R, Collins BN, et al. Effect of bupropion on depression symptoms in a smoking cessation clinical trial. Psychol Addict Behav. 2004;18:362-366.

43. Hall SM, Reus VI, Munoz RF, et al. Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry. 1998;55:683-690.

44. Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005;14:106-123.

45. Morissette SB, Tull MT, Gulliver SB, et al. Anxiety, anxiety disorders, tobacco use, and nicotine: A critical review of interrelationships. Psychol Bull. 2007;133:245-272.

46. Baer JS, Kamarck T, Lichtenstein E, et al. Prediction of smoking relapse: Analyses of temptations and transgressions after initial cessation. J Con-sult Clin Psychol. 1989;57:623-627.

47. Baer JS, Lichtenstein E. Classification and prediction of smoking relapse episodes: An exploration of individual differences. J Consult Clin Psychol. 1988;56:104-110.

48. Reiss S, McNally RJ. Expectancy model of fear. In: Reiss S, Bootzin RR, eds. Theoretical Issues in Behavior Therapy. New York, NY: Academic Press. 1985, pp 107-121.

49. McNally RJ. Anxiety sensitivity and panic disorder. Biol Psychiatry. 2002;52: 938-946.

50. Zvolensky MJ, Vujanovic AA, Miller MO, et al. Incremental validity of anxi-ety sensitivity in terms of motivation to quit, reasons for quitting, and bar-riers to quitting among community-recruited daily smokers. Nicotine Tob Res. 2007;9:965-975.

51. Morissette SB, Brown TA, Kamholz BW, et al. Differences between smokers and nonsmokers with anxiety disorders. J Anxiety Disord. 2006;20:597-613.

52. Hughes JR. Clinical implications of the association between smoking and alcoholism. In: Fertig J, Fuller R, eds. Alcohol and Tobacco: From Basic Science to Policy. Washington, DC: National Institute on Alcohol Abuse and Alcoholism. 1995; pp 171-181.

53. Patkar AA, Vergare MJ, Thornton CC, et al. Nicotine dependence and treatment outcome among african american cocaine-dependent patients. Nicotine Tob Res. 2003;5:411-418.

54. Clemmey P, Brooner R, Chutuape MA, et al. Smoking habits and atti-Smoking habits and atti-tudes in a methadone maintenance treatment population. Drug Alcohol Depend. 1997;44:123-132.

55. Joseph AM, Willenbring ML, Nugent SM, et al. A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. J Stud Alcohol. 2004;65:681-691.

56. Shoptaw S, Rotheram-Fuller E, Yang X, et al. Smoking cessation in metha-done maintenance. Addiction. 2002;97:1317-1328.

57. Hogan MF. The president’s new freedom commission: Recommenda-tions to transform mental health care in America. Psychiatr Serv. 2003;54:1467-1474.

58. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol. 2004;72:1144-1156.

59. Thorndike AN, Stafford RS, Rigotti NA. US physicians’ treatment of smoking in outpatients with psychiatric diagnoses. Nicotine Tob Res. 2001;3:85-91.

60. Dickens GL, Stubbs JH, Haw CM. Smoking and mental health nurses: A survey of clinical staff in a psychiatric hospital. J Psychiatr Ment Health Nurs. 2004;11:445-451.

61. Williams JM. Eliminating tobacco use in mental health facilities: Patients’ rights, public health and policy issues. JAMA. 2008;299:571-573.

62. Sharp D, Blaakman S, Cole R, et al. Report from a national tobacco dependence survey of psychiatric nurses. J Am Psychiatr Nurses Assoc. 2009;15:172-181.

63. Strasser KM. Smoking Reduction and Cessation for People with Schizo-phrenia: Guidelines for General Practitioners. South Melborne, SANE Aus-tralia. Accessed June 11, 2010 at www.health.vic.gov.au/mentalhealth/smoke/index.htm (click on “guidelines”). 2001.

64. el-Guebaly N, Cathcart J, Currie S, et al. Smoking cessation approaches for persons with mental illness or addictive disorders. Psychiatr Serv. 2002;53: 1166-1170.

65. Hall SM, Tsoh JY, Prochaska JJ, et al. Treatment for cigarette smoking among depressed mental health outpatients: A randomized clinical trial. Am J Public Health. 2006;96:1808-1814.

66. Ratschen E, Britton J, Doody GA, et al. Smoke-free policy in acute men-tal health wards: Avoiding the pitfalls. Gen Hosp Psychiatry. 2009;31:131-136.

67. Ferguson J, Bauld L, Chesterman J, et al. The English smoking treatment services: One-year outcomes. Addiction. 2005;100( Suppl 2):59-69.

68. Naegle M, Baird C, Stein KF. (2009). Psychiatric nurses as champions for smoking cessation. J Am Psychiatr Nurses Assoc. 2009;15:21-23.

69. Morris C, Waxmonsky J, Giese A, et al. Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Tobacco Disparities Initiatives of the State Tobacco Education and Prevention

July 201013

• People with mental illnesses and/or addictive disorders die at significantly younger ages than people in the general population, largely due to use of tobacco.

• Approximately 200,000 of the 443,000 annual deaths from tobacco-related illnesses in the United States occur among people who are mentally ill or who have addictive disorders.

• Co-morbid illnesses caused by tobacco use (including cardiovascular disease, cancer, and respiratory illnesses) negatively impact quality of life and prevent people from working toward their recovery goals.

• Tobacco dependence experts agree that nicotine addiction results from a complex interplay of genetic, neurobiological, psychological, social, economic, and cultural factors.

• According to Dr. Steven Schroeder, mental health clinicians may not encourage smoking cessation for patients with mental illnesses and addiction disorders because they mistakenly believe these patients are not interested in stopping smoking, are not able to stop smoking, and that their clinical condition might worsen if they stop smoking.

• Intensive integrated interventions are likely to be most effective in this population compared to brief and self-help interventions.

• Psychiatric nurses can impact smoking rates in their patients by intervening both on the individual level, and on a system-wide level.

The Significance of Tobacco Dependence in Persons with Mental Illness

CPCounseling Points™

Partnership. Denver, Co: Colorado Department of Public Health and Environment. Updated January 2009. Accessed June 11, 2010 at http://smokingcessationleadership.ucsf.edu/Resources.htm#Toolkits.

70. Schroeder SA. A 51-year-old woman with bipolar disorder who wants to quit smoking. JAMA. 2009;301:522-531.

71. Judge K, Bauld L, Chesterman J, et al. The English smoking treatment services: Short-term outcomes. Addiction. 2005;100(Suppl 2):46-58.

72. Currie SR, Karltyn J, Lussier D, et al. Outcome from a community-based smoking cessation program for persons with serious mental illness. Com-munity Ment Health J. 2008;44:187-194.

73. Foulds J. The neurobiological basis for partial agonist treatment of nico-tine dependence: Varenicline. Int J Clin Pract. 2006;60:571-576.

74. Lawn SJ, Pols RG, Barger JG. Smoking and quitting: A qualitative study with community-living psychiatric clients. Social Sci Med. 2002;54: 93-104.

75. Willemsen MC, Gorts CA, Van Soelen P, et al. Exposure to environmental tobacco smoke (ETS) and determinants of support for complete smoking bans in psychiatric settings. Tob Control. 2004;13:180-185.

76. Centers For Disease Control And Prevention. Best Practices For Compre-hensive Tobacco Control Programs—2007. Atlanta Ga: Department of Health And Human Services, Centers For Disease Control And Preven-tion, National Center For Chronic Disease Prevention And Health Promo-tion, Office On Smoking And Health, 2007.

77. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007;97:1503-1509.

78. Doll R, Peto R, Boreham I, et al. Mortality in relation to smoking: 50 years’ observation on male British doctors. Br Med J. 2004;328: 1519 - 1528

79. Curry SJ, Grothaus LC, McAfee T, et al. Use and cost effectiveness of smoking-cessation:Services under four insurance plans in a health mainte-nance organization. N Engl J Med.. 1998;339:673-679.

80. Eddy DM. David Eddy ranks the tests. Harv Health Lett. 1992;special suppl:10-11

81. Reddi V. Biography of Dorothea Lynde Dix. 2005. Accessed May 17, 2010 at www.nursingadvocacy.org/press/pioneers/dix.html.

82. Nightingale F. Notes on Nursing: What It Is and What It Is Not. New York, NY: Dover Publications, Inc. 1969 (originally published 1859).

83. Reed PG, Zurakowski TL. Nightingale revisted: A visionary model for nursing. In: Fitzpatrick JJ, Whall AL, eds. Conceptual Models of Nursing: Analysis and Application, 2nd ed. Norwalk, Ct: Appleton & Lange. 1989, pp 33-47.

84. Adams C. Florence Wald (1917-2008): Pioneer in hospice care. 2008. Accessed May 17, 2010 at www.nursingadvocacy.org/press/pioneers/flor-ence_wald.html.

85. Centers for Disease Control and Prevention. Margaret Sanger. MMWR. 1999;48:1075.

86. Nurses. Inspirational personalities: Lillian D. Wald. 2010. Accessed May 17, 2010 at www.nurses.info/personalities_lillian_wald.htm.

87. Wald FS, Foster Z, Wald HJ. The hospice movement as a health care reform. Nurs Outlook. 1980;28:173-178.

88. McCaffery, M., & Robinson, E.S. (2002). Your patient is in pain: Here’s how you respond. Nursing, 32, 36-47.

89. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Washington, DC: American Nurses Publishing. 2001.

90. American Nurses Association. Nursing’s Social Policy Statement, 2nd ed. Washington, DC: Nursesbooks.org. 2003.

91. American Nurses Association. Psychiatric-Mental Health Nursing: Scope and Standards of Practice. Silver Spring, Md: Nursesbooks.org. 2007.

92. Gadow S. Existential advocacy: Philosophical foundations of nursing. In Spickeer SF, Gadow S, eds. Nursing: Images and Ideals, Opening Dia-logue with the Humanities. New York, NY: Springer. 1980, pp 79-101.

93. Tong EK, Strouse R, Hall T, et al. National survey of US health profession-als’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010;epub doi:10.1093/ntr/ntq071.

Post test, Evaluation, & CE Certificate

1. To obtain your certificate, please go to the following URL: http://eo2.commpartners.com/users/apnaweb/evaluation/index.php?id=4844

2. You may need a password to access the post test and evaluation. If so,

use the password from your registration confirmation email. If not go directly to step 3.

3. Enter the following (case sensitive) certificate code: qu4Up

4. Complete the questions, click submit and then print your certificate.