Response to Underwood S & Ryan T (2010) Commentary on Sarna L, Bialous SA, Wells M, Kotlerman J, Wewers ME & Froelicher ES (2009) Frequency of nurses’ smoking cessation interventions: report from a national survey. Journal of Clinical Nursing19, 294–296


  • Linda Sarna,

  • Stella Aguinaga Bialous

The Global Health Professions Students Survey (GHPSS) conducted by Warren et al. (2009) demonstrates that the concerns expressed by Underwood and Ryan (2010) in their commentary on our article (Sarna et al. 2009) affect nursing education and nurses’ ability to intervene with patients all over the world. The findings from the GHPSS indicate that smoking among nurses and nursing students remains high in many countries, and the lack of formal education on tobacco dependence treatment is a common trait of nursing programmes. Fortunately, the GHPSS demonstrated that the majority (89%) of nursing students believe they have a role in offering smoking cessation interventions, and 91% believed that they should receive formal training to perform this role. Our experience in conducting surveys and workshops for nurses in the United States, India (Sarna & Bialous 2009b) and China (Chan et al. 2008, 2009) confirms the findings of the GHPSS; nurses are eager and willing to learn more about tobacco dependence treatment and want to offer evidence-based intervention to their patients in hospitals and primary care settings. Nurses also welcome the opportunity to network and learn from each others’ experience in practice and research.

As Underwood and Ryan (2010) observe, the Internet offers intriguing opportunities to develop continuing education and long-distance learning on smoking cessation. The increasing accessibility of information through the Internet now provides unparalleled opportunities to enhance communications, as we experienced through our own website (; retrieved 7 November 2010). We recently concluded the implementation of a web-based education study targeting nurses in 30 hospitals in three states, the Helping Smokers Quit (; accessed 7 November 2010). Analyses are underway to assess the impact of this web-based education and resources on nurses’ interventions with patients.

However, there is an urgent need to accelerate the development and implementation of nurse-focused capacity building in tobacco control. A formal mechanism to foster such communications and exchange would be an important initial step in addressing the gaps between nurses’ knowledge and skills and take advantage of the potential for an increased nursing role in tobacco control. Publications documenting nurses’ contributions to research (Bialous & Sarna 2009, Sarna & Bialous 2009a,b) and practice, such as Underwood and Ryan’s (2010) efforts, are all too rare. As tobacco-related problems grow, nurses, particularly those in low-resource countries, could greatly benefit from learning from each other and from their colleagues in high-resource countries. The International Society of Nurses in Cancer Care is one organisation that is pursuing outreach efforts, most recently to nurses in the Czech Republic where over one-third of adolescents smoke (World Health Organization 2009).

The changing expectations that nurses deliver these interventions in an acute care environment, and not just primary care settings, are a consequence of the increased awareness of the importance of continued smoking in negatively affecting recovery and quality of life after discharge (Gritz et al. 2007). Furthermore, hospitalisation provides a ‘window of opportunity’ for smokers to quit and for nurses to intervene. With the worldwide movement towards smoke-free hospitals, many smokers, when hospitalised, must quit. Cessation intervention during hospitalisation not only serves as an impetus to achieve long-term abstinence after discharge but is also essential in alleviating the suffering from nicotine withdrawal symptoms that many smokers experience when they quit ‘cold turkey’. Research supports the effectiveness of nurses delivering smoking cessation interventions (Rice & Stead 2008). Three quarters of the studies in a meta-analysis of 33 cessation intervention trials for hospitalised patients demonstrating successful smoking cessation interventions initiated during hospitalisation involved nurses either exclusively or as part of the healthcare team (Rigotti et al. 2008).

Policy changes also will influence expectations for nursing action in tobacco control. Countries that are party to the WHO Framework Convention on Tobacco Control are required to implement Article 14, which states ‘Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence’ (WHO 2009). Guidelines to assist counties in implementing Article 14 mandate are expected to be approved in November 2010 at the 4th Conference of the Parties, and all healthcare professionals will be pivotal in making implementation a success. In many situations, these will be nurses.

The need to assist health professionals themselves to quit also continues, as tobacco use among health professionals is a barrier to providing cessation interventions to patients (Sarna & Bialous 2009a,b). Our recent analysis of changes in smoking prevalence using data from the 2003 and 2006/2007 US Current Population Survey – Tobacco Use Supplement (Sarna et al. 2010) indicates that while registered nurses had a current smoking prevalence of 10·7%, the rate of quitting had not experienced a significant decline since 2003. Licensed registered nurses’ current smoking was 20·55% in 2006/2007, also unchanged since 2003. More needs to be done to assist nurses’ quitting efforts.

The results from the Sheffield experience (Underwood & Ryan 2010), combining a training programme for practising nurses as well as the possibility of including cessation-related topics in the preregistration curriculum, could shed light on the best ways to provide nurses and nursing students with the proper tools to offer tobacco dependence treatment to all patients who need it, regardless of setting or diagnoses. It also exemplifies partnerships between schools of nursing and community health settings that should be encouraged. We urge nursing organisations, countries and funding agencies to ensure that nursing involvement in tobacco control becomes an integral part of national and regional tobacco control planning and funding. The 17 million nurses worldwide have an opportunity, and a challenge, to claim their rightful place in the global efforts to combat the tobacco epidemic.