Tobacco use is responsible for more deaths in the United States than any other factor. In 1994, tobacco use was responsible for the deaths of 400,000 people in the United States alone (Campbell, 1995).
Nurses need te be prepared to meet the health challenges raised by tobacco use. Nurses are in a unique position to educate their thente and laypeople. A computerized review of the literature from 1966 to the present yielded no prior studies addressing the question of the amount or type of tobacco-related instruction in either nursing or medical education. Therefore, te evaluate the type and extent of tobacco-related background knowledge gained by nurses in the course of their education, the Nurses' Committee of the Illinois Division of the American Cancer Society (ACS) undertook a survey of schools of nursing in the state of Illinois.
A questionnaire was sent te the Director of each program of every school of nursing in the state of Illinois W = 1 10 programs, offered at 97 schools) during the summer of 1994. As an incentive to bolster response rate, a complementary copy of the ACS's (1993) tobacco-control film entitled, Take Time to Help- How Nurses Can Help Their Patients Step Smoking" was offered on long-term loan as a token of appreciation in exchange for each completed questionnaire. Completed questionnaires were returned from 70 programs (a response rate of 64%), with representation from all levels of undergraduate nursing education among respondents. Slightly more than half (n = 30) of the 54 responding schools of nursing provided a couree of study leading te an associate degree in nursing (ADN). Approximately one third (n = 19)prepared studente forthe role ofLPN; approximately one quarter (n. = 14) provided programs Ieaofng to the BSN degree for traditional undergraduates, with an additional 13% (n = 7) providing BSN completion programs for licensed RNs.
The total amount of time devoted to nursing instruction on the health risks of smoking ranged from 20 minutes to 12 hours. Seventeen programs indicated 1 hour or less was devoted to this topic within their program of nursing instruction. The LPN programs tended to allot the greatest amount of time to smoking instruction (mean = 3.26 hours) and traditional BSN programs the least (mean = 2.21 hours). However, because of the wide variability in hours of instruction within program types, this difference was not statistically significant (F^sub 2,80^ = .11).
Far fewer hours were devoted to instruction on the health risks of smokeless tobacco, with instruction time ranging from O minutes to 3 hours. Eighteen programs indicated 10 minutes or less were devoted to this topic within their program of instruction. The time allotment for the different types of programs followed a similar pattern, with LFN students receiving the most hours of instruction regarding smokeless tobacco (mean = 1.55) and traditional BSN students the least (mean = .87).
Given that baccalaureate nurses are perceived as having greater expertise in client counseling compared with the more technical orientation of LPN programs, it is surprising comparatively fewer hours were spent covering the health hazards of tobacco in BSN programs. The discrepancy is more evident when factoring in the greater duration of BSN programs. The BSN students' 2.05 average hours of instruction were stretched out over a minimum of four semesters of nursing courses, while the typical LPN program is 1 calendar year of general as well as nursing education. The shorter LPN program results in a more concentrated instructional experience. However, it should be noted some anti-tobacco instruction may have been included in the much greater general science education base of BSN students. Responses written in the margins of some the questionnaires suggested greater time was devoted to smoking in some of the LPN programs because this is an area of personal need for some of the students (e.g., "Since several of the students are smokers, we try to emphasize the risks of smoking and the importance of patient teaching"). Certainly, all nursing schools encourage student nurses to be role models of healthy lifestyles, and smoking habits are of central concern in such role modeling.
Textbook Coverage of Tobacco-Related Topics
When broken down by nursing course, the greatest amount of lecture time devoted to tobacco-related instruction across all types of programs was concentrated in the Adult Medical-Surgical Nursing courses. A mean of almost 1 hour was spent on smoking in the Adult Medical-Surgical Nursing courses. Trailing behind (with 15 to 30 minutes of instruction) were the Foundations, Obstetrics and Newborn, and Clinical courses. Far less urne (lese than 15 minutes) was spent on the adverse effects of smoking in the Pediatrics, Psychiatry, and Community Health courses. Adult Medical-Surgical Nursing was again the course where the bulk of instruction on smokeless tobacco (a mean of nearly 1 half hour) occurred. Other than a. mean of slightly more than 15 minutes in Community Health courses, negligible time (less than 10 minutes) was spent on smokeless tobacco in the other courses. Adult Medical-Surgical Nursing is generally among the first nursing courses taken by students, so it is not surprising tobacco-related content is concentrated in this core course. In a few programs, tobacco-related content was primarily covered in "other" courses. Some examples cited of other courses in which tobacco content was covered included: Pathophysiology, Health Assessment, Issues and Trends in Nursing, Gerontology, Medications, and Nutrition.
The majority of respondents (n = 45, 83%) relied heavily on nursing textbooks as a major source of information for instructing studente about smoking and smokeless tobacco risks and smoking cessation techniques. More than half of respondents (n = 33, 61%) supplemented textbook information with A Cancer Sourcebook for Nurses (Baird, Donehower, Stalsbroten, & Ades, 1991). A sizable minority (between 26% and 57%, depending on the publication) of respondents were aware of five tobacco control resources published by ACS which are available at no cost for distribution to student nurses (with the exception of one brochure which has been discontinued). Listed in descending order of awareness, these resources are:
* Caneer Prevention, Early Detection, and Screening (1990).
* Lung Cancer and Smoking Trends (1991).
* Health Effects of Involuntary Smofting (19891.
* Intervention Strategies for Smoking Cessation (1992).
* Health Effects of Smokeless Tobacco (1988, discontinued).
However, respondents were not questioned about whether these recently published ACS materials were distributed to nursing students, so it cannot be determined whether awareness translates into use.
Because the Adult Medical-Surgical Nursing course was identified by the majority of respondents ae the primary focus of tobacco-related instruction, the most recent editions of the seven medicalBurgical nursing textbooks identified by the respondents as being used in these courses were reviewed for tobacco-related content (Table).
The obvious caveat is that quantity (determined by a simple tally of the number of lines devoted to a particular topic) may not be a reliable indicator of the quality of information contained in those lines. Neither should the extent to which one single isolated topic (e.g., tobacco) is or is not covered in a general medical-surgical textbook be construed as an indicator of the extent to which other topics are discussed.
In all cases, the indexed entries (i.e., tobacco, nicotine, smoking, cigarette smoking, snuff, smokeless tobacco) were scattered throughout the books and were frequently repetitious. Nearly all of the textbooks at least mentioned the relationship of tobacco with: cancer, cardiovascular illness, peripheral vascular disease, respiratory illnesses, surgery and wound healing, smokeless tobacco, second-hand smoke, nurses' role in client education, and the pathophy siological basis for tobacco's health effects. Although the information presented was usually accurate, it generally was disappointingly superficial. A few textbooks offered noteworthy exceptions that were particularly useful. For example, an excellent discussion of nurses' role in tobacco-related client education is provided in three of the texts (Lewis & Collier, 1992; Ignatavicius, Workman, & Mishler, 1995; Phipps, Cassmeyer, Sands, & Lehman, 1995), specific and detailed information on the health effects of tobacco is provided in two of the texts (Lewis & Collier, 1992; Phipps et al., 1995), and the ethical issues surrounding second-hand smoke are discussed in one of the texte (Black & Matassarin-Jacobs, 1993). It is encouraging to note the more recently published texts provide considerably greater depth in the discussion of tobaccorelated concerns.
The results of this survey are specific to the state of Illinois and may not be representative of tobacco-related content taught in schools of nursing in other states. However, the survey could be easily replicated by ACS divisions in other states or by other organizations with an interest in tobacco-control issues e.g., cardiovascular and oncology nursing specialty groups).
Client and family education is one of the primary tobacco-related interventions offered by nurses. However, student nurses first must be taught the information themselves before they can teach others. Admittedly, it is not the purpose of comprehensive medical-surgical nursing texts to provide indepth discussion of any single individual issue, not even such a central issue as the pathophysiology of tobacco's effects on health. However, such information is a vital tool in nurses' educational reserve. Textbooks were a primary teaching source for most of the respondents. To ensure an adequate educational background, the cursory information supplied by general medical -surgical textbooks must be supplemented by materials drawn from other sources. Informative ACS materials which are appropriate for an audience of student nurses may be obtained on request without charge from any local chapter of the ACS.
The manner in which tobacco-related content is distributed among the various nursing courses suggests this information is not being approached in a coordinated manner. Rather, information is interspersed throughout the coursework. Such a scattered approach is not entirely negative. For example, it does make it likely the importance of tobacco's deleterious impact on health will be repeated again and again, permeating the entire course of study. Tobacco use is a multifaceted and complex issue. Tobacco-related content has a value and a place in every course in nursing programs. However, there is a danger that failure to identify one couree in which tobacco is covered as a central issue may allow essential indepth teaching to slip through the cracks. With so many pressing health issues requiring attention and only a limited time allotted for instruction, each instructor may teach about tobacco only on a superficial level, confident the content will be treated in greater detail in another course. As is the case with textbooks, it is not the quantity of lecture time devoted to tobacco that is important, so much as the quality of the content presented. The Nurses' Committee of the Illinois Division of the ACS recommends one course be identified as centrally responsible for relaying tobaccorelated content to nursing students in a coherent and concentrated format.
- American Cancer Society (ACS). (1988). Health effects of smokeless tobacco (Discontinued ACS Publication). [Brochure]. Atlanta, GA: Author.
- ACS. (1989). Health effects of involuntary smoking (ACS Order No. 3483.00). [Brochure]. Atlanta, OA: Author.
- ACS. (1990). Cancer prevention, early detection, and screening (ACS Order No. 4503.04). [Brochure]. Atlanta, GA: Author.
- ACS. (1991). Lung cancer ami smoking trends (ACS Order No. 3495.00). [Brochure], Atlanta, GA; Author.
- ACS. (1992). Intervention strategies for smoking cessation (ACS Order No. 3498.00). [Brochure]. Atlanta, GAj Author.
- ACS. (Producer). (1993>. Take time to help-How nurses can help their patients stop smoking (ACS Order No. 4504.05) [Film], (Available from ACS, 1599 Clifton Road NE, Atlanta, GA 30329-4251)
- Baird, S.B., Donehower, M.G., Stalabroten, V.L., & Adee, T.G. (Eds.). (1991). A cancer sourcebook /or nurses (6th ed., ACS Order No. 3010.00). Atlanta, GA: American Cancer Society.
- Black, J.M. , & Mataesarin-Jacoba, E. (Eds.). (1993). Luckmann & Sorensen's medical-surgicat nursing: A psychophyeialogie approach (4th ed.). Philadelphia: Saunders.
- Campbell, K. (1995). ANA receives funds for smoking cessation program. The American Nurse, 27(1), 32.
- Harkness, G., ft Dincher, J.R. (Eds.). 11996). Medical-surgical nursing: Tbtal patient care (9th ed.). St. Louis: Mosby.
- IgnataviciuB, D., Workman, L.M., & Mishler, M.A. (1995). Medical-surgical nursing: A nursing process approach (2nd ed.). Philadelphia: Saunders.
- Lewis, S.M., & Collier, l.C. (Eds.). (1992). Medical-surgical nursing: Assessment and management of clinical problems (3rd ed.). St. Louis: Mosby.
- Phipps, N.J., Cassmeyer, V.L., Sanda, J.K, & Lehman, M. K. (1995). Medical-surgical nursing: Concepts and ctinicai practice (5th ed.). St. Louis: Moeby.
- Scherer, J.C. (1991). Introductory medical-surgical nursing (5th ed.). Philadelphia: Lippinratt.
- Smeltzer, S.C., & Bare, B.G. (Eda.X (1992). Brunner and Suddarth's textbook of medicalsurgical nursing (7th ed.), Philadelphia: Lippincott.
Textbook Coverage of Tobacco-Related Topics