Extinguishing the American Smoking Habit

In Nursing@Simmons’s last map post, we took an in-depth look at obesity in America, and the role that Family Nurse Practitioners (FNPs) have in addressing one of the nation’s most significant health challenges. Next, we’re spotlighting smoking, the problem it poses for Americans’ health, and the interventions that FNPs are implementing.

In 1964, the U.S. Surgeon General released the office’s first report on the dangers of smoking. Now, just over 50 years after that first report was released, the prevalence of cigarette smoking has been cut by more than half. Additionally, smoking rates among users ages 11 to 17 (the age range at which 75 percent of adult smokers initiate their addiction) reached its lowest level in more than 20 years in 2013.

However, the decline of smoking rates does not mean the public health crisis has abated, or that it’s no longer a concern for primary care providers. An estimated 42.1 million adults still smoke, which is nearly 18 percent of the adult population. The rate is only slightly lower for the student population, which is reported at 15.7 percent. On a state-by-state basis, smoking rates vary significantly, as the map below indicates.

American Smoking Rates by State

The Surgeon General reports that more than 20 million premature deaths have occurred since 1964 as a result of smoking. Overall, smoking accounts for approximately one in five deaths in the United States today. Smoking can be linked to lung cancer, liver cancer, colorectal cancer, heart disease, diabetes, chronic obstructive pulmonary disease (COPD), and increased risk for a variety of other diseases. Given the leading causes of death discussed in our first map post, it’s easy to see how the effects of smoking can manifest in national mortality rates.

The 2010 paper, “Brief Evidence-Based Interventions for Nurse Practitioners to Aid Patients in Smoking Cessation,” identifies a framework for cessation interventions featuring the five “A’s” — ask, assess, advise, assist, and arrange — and the five “R’s” — relevance, risk, rewards, roadblocks, and repetition.
According to the U.S. Health and Human Services guidelines, appointments with smokers should always include the first three A’s: ask, assess, and advise. If the patient is ready to quit smoking, FNPs can initiate the final two A’s: assisting the patient with planning, counseling, referrals, and medication, and arranging for follow-ups.

If the patient is not yet ready to quit, FNPs can use the five “R’s” to increase the likelihood of quitting in the future. Discussing the personal relevance of quitting, the risks and rewards of quitting, and roadblocks to successful cessation are all effective intervention methods that can be used by primary care clinicians. Finally, repetition of these steps at every office visit is a critical part of eventual success in cessation.

FNPs have a unique opportunity to influence patient behavior and to encourage healthier lifestyle choices in their communities. Tobacco use is a significant cause of premature death in the United States, but primary care providers have the information and the responsibility to be a part of the solution.