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Seminars in Oncology Nursing, Vol 19, No 4 (November), 2003: pp 291-300

OBJECTIVES: To review and summarize tobacco control policies, their impact in curbing the tobacco epidemic, and to describe a role for nursing advocacy.

DATA SOURCES:

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Published articles and research studies.

STELLA AGUINAGA BIALOUS, NANCY KAUFMAN, AND LINDA SARNA

CONCLUSION: Comprehensive tobacco control policy is one of the most effective mechanisms to prevent tobaccorelated cancers and other illnesses. The World Health Organization’s Framework Convention on Tobacco Control, and the Master Settlement Agreement in the United States have provided new opportunities for tobacco control. Nursing participation in the policy process can expand and strengthen these policies’ activities.

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Involvement in tobacco control should be integral to oncology nursing efforts to prevent cancer, promote health, and quality of life.

From Tobacco Policy International, San Francisco, CA; Strategic Vision Group, Princeton Junction, NJ; and the UCLA School of Nursing, Los Angeles, CA. Stella Aguinaga Bialous, RN, DrPH: President, Tobacco Policy International, San Francisco, CA. Nancy Kaufman, RN, MS: President, Strategic Vision Group, Princeton Junction, NJ. Linda Sarna, RN, DNSc, FAAN: Professor, School of Nursing, University of California, Los Angeles. Address reprint requests to Stella Aguinaga Bialous, RN, DrPH, 676 Funston Ave, San Francisco, CA 94118.

© 2003 Elsevier Inc. All rights reserved. 0749-2081/03/1904-0009$30.00/0 doi:10.1053/S0749-2081(03)00105-0

“Nurses and the ANA have a history of anti-smoking activity, primarily in the area of cessation. They must be considered increasingly strong opponents not because of this history but because of their increasing involvement in the political process. . . . Nurses, as a group, feel strongly negative about tobacco use. . . . As they become more active in politics . . . at all levels, they could easily be formidable opponents of the tobacco industry.” Philip Morris, 1988 Bates# 2026168786A

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HE WORLD Health Organization (WHO) declared cancer prevention and control as one of the most important scientific and public health challenges of our time.1 Cancer is one of the leading causes of death in Europe and several other developed and developing countries,2 and its incidence is increasing with the increase in life expectancy of the world’s population and changes in lifestyle factors, especially increasing tobacco use worldwide. In the past five decades, thousands of studies have shown that tobacco use and exposure to second-hand smoke cause a variety of cardiovascular, respiratory and other illnesses, as well as several types of cancer.3-8 Given the lag time between smoking and the development of cancer, it is estimated that the cancer toll in developing countries will increase in the next few decades. The purpose of this article is to (1) discuss the critical link between tobacco control and cancer, (2) describe recent advances in tobacco control, including the WHO Framework Convention on Tobacco Control, and the Master Settlement Agreement (MSA), and (3) propose opportunities for enhanced oncology nursing involvement in tobacco control policies.

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he present and future burden of tobacco-related cancers makes tobacco control a high priority for all nurses, especially oncology nurses, and a key component of nursing practice. Tobacco control is a cost-effective measure that alleviates the burden of tobacco-related diseases.9 The essential elements of a comprehensive tobacco control program are: taxation, regulation of prod-

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ucts, restrictions on advertisement/promotions and sponsorships, bans on smoking in workplaces and public spaces, protection of nonsmokers, support for cessation, youth access restriction, and firm action against cigarette smuggling.9-11 In addition to being declared the single-most important preventable cause of death and disease by many health authorities,9,12 the cancer statistics alone should place tobacco control at the highest level of importance on political, health care, and cancer control agendas. Unfortunately, health professionals, including nurses, have not given tobacco control its due priority. Parsons and Mayer13 have reviewed the history of nursing involvement in tobacco control. Some of the barriers to involvement in tobacco control are: lack of understanding about the extent of the harmful health effects of tobacco use and the addictive nature of nicotine; lack of skills to help with cessation and prevention efforts, lack of experience with political involvement, and ultimately, a lack in political will. The tobacco industry, by contrast, wields powerful influence in the political process and is a significant barrier to tobacco control. There is growing evidence that the tobacco industry has targeted youth, women, and minorities, and has used predatory marketing practices in promoting its products in developing countries.14-19 Tobacco control policies vary widely from country to country and within countries.20,21 Moreover, access to tobacco use prevention and cessation services is unevenly distributed among the population within a country. Even in developed countries with resources and programs in place, access to these services do not reach equally all segments of the population, with ethnic minorities and the poor having less access to services.22-25 The lack of action in addressing tobacco-related health disparities by health care providers, professional organizations, and health systems is caused by a variety of factors, including lack of cultural sensitivity, lack of outreach efforts, and low priority given to prevention practices and health education.24,25 Nurses may be best suited to provide these essential services in underserved communities. Thus, in addition to the creation and implementation of specific policies to address the tobacco epidemic, other health care policy changes are necessary to address these barriers, to increase access to services, and to increase nursing involvement in tobacco prevention and cessation for those at highest risk.

THE TOBACCO INDUSTRY

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he WHO describes tobacco use as a communicable disease whose vector is the tobacco industry.19 For decades, the tobacco industry had known about the carcinogenic effects of cigarette smoking but had not disclosed the relevant data or publicly admitted that tobacco causes cancer.26,27 Although some tobacco companies now admit the link between smoking and cancer, in general the tobacco industry continues to deny both the harmful effects of second-hand smoke and the addictive properties of tobacco.28-30 The actual exposure to tobacco carcinogens will vary depending on the amount, intensity, and method of individual smoking or tobacco use, as well as length of exposure in terms of years of current smoking and exposure to second-hand tobacco smoke. Contents of cigarettes sold abroad also vary widely. Tests by the Center for Disease Control showed that Marlboro cigarettes, one of the best-selling international brands worldwide, has one of the highest levels of cancer-causing tobacco-specific nitrosamines.31 Additionally, stated cigarette package tar and nicotine yields bear no relationship to actual intake. These values are assessed through a machine smoking test method that does not accurately mimic human smoking and, despite claims by the tobacco industry, there are no benefits in using “lights” or “mild” products. All currently available tobacco products deliver carcinogenic substances when consumed as intended.32,33 Because of these issues, many public health advocates have called for the regulation of the contents of cigarettes. The tobacco industry has waged massive public and political campaigns to influence the development of tobacco control policies, including attempts to influence the work of the WHO and its cancer research arm, the International Agency on Cancer Research. Among several of the strategies used by the tobacco industry was infiltration of these agencies at the central and national levels with secretly paid consultants, and attempts to divert attention from tobacco control in developing countries to other health care issues, such as immunization.19,34-36 In addition, the tobacco industry has manipulated the media to confuse the public’s understanding of the health effects of tobacco. Worldwide, governmental spending on tobacco control is dwarfed by the tobacco industry’s spending on marketing and political strate-

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THE FRAMEWORK CONVENTION CONTROL

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FIGURE 1.

Per capita tobacco industry and tobacco control expenditures in California, 1990 to 2001. Note: The California tobacco industry tures calculated as a proportion of US expenditures based on the California population as reported by the US Census Bureau. Both tobacco control and tobacco industry expenditures have been standardized to the US 2001 dollar, based on the Consumer Price Index. Tobacco control expenditures are based on expenditures from the Proposition 99 cigarette Tax to several programs. Tobacco industry expenditures taken from the Federal Trade Commission Cigarette Report for 2001, issued 2003. (Sources: California Department of Health Services Tobacco Control Section and the Federal Trade Commission Cigarette Report for 2001.) Dark grey, tobacco control; light grey, tobacco industry.

gies. In the United States, where these data are readily available, the industry spends more than $11 billion a year on marketing and lobbying, while only $1 billion is spent on tobacco control. Figure 1 shows the difference in expenditures in California, which is still one of the highest funded tobacco control programs in the world, despite recent drastic cuts.37 The industry sponsors civic and professional organizations, including women’s groups, arts programming, and minority organizations. This philanthropy comes with a high price. These efforts make the industry appear caring and noble; however 50% of those using its products will die from a tobacco-related disease. In 2000, Philip Morris spent $150 million in a media campaign to inform the American public about its donations to a variety of causes, from domestic violence to aid of victims of natural disasters. This amount was higher than the actual amount donated.38 Two recent events, the WHO Framework Convention on Tobacco Control, and the Master Settlement Agreement (MSA) in the United States, have changed the landscape of tobacco control, and have created new opportunities for nursing advocacy.

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n May of 1999, the World Health Assembly, the governing body of the WHO, voted in favor of the development of an international treaty to address the global epidemic of tobacco-related diseases and deaths. This was to be a comprehensive treaty, addressing all of the main components of tobacco policy making.39-41 After 4 years of intense negotiations by diplomats from around the world, and with the participation of several nongovernmental organizations, a final text of the treaty was unanimously approved by all United Nations members on May 21, 2003 at the World Health Assembly in Geneva. The overall text recognizes the devastating health impact that both tobacco use and exposure to tobacco smoke has on the health of people and on the welfare and economy of countries. It also recognizes the need for collaborative, international measures to address the problem and calls for political commitment to achieve the goals of the treaty. Several nursing organizations, such as the American Nurses Association, Oncology Nursing Society (ONS), the International Council of Nurses, the International Society of Nurses in Cancer Care, as well as national nursing organizations worldwide, submitted formal written comments in support of the Framework Convention on Tobacco Control (FCTC).42 The main points of the treaty are summarized in Table 1 and described below: Price and taxation measures. Increase taxation and prices of tobacco products have been proven as an effective mechanism to reduce consumption and has been recommended by the World Bank. The FCTC calls participating countries to establish taxation and in some cases, price policies that are compatible with the goals of tobacco control. The FCTC is not specific about percentages and amounts, and in the case of taxation, as in the case of many other articles of the treaty, language was crafted with diplomatic concerns about sovereignty in mind. Additional pricerelated measures include a suggested restriction on duty-free tobacco products availability. Protection from exposure to tobacco smoke. The FCTC included protection against secondhand smoke throughout the text. The final recommendation is of adoption of protective measures in “indoor workplaces, public transport, indoor

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TABLE 1. Key Aspects of the WHO’s Framework Convention on Tobacco Control Advertising: Comprehensive ban, or a restriction as extensive as constitutionally allowed, on direct and indirect tobacco advertising, promotion, and sponsorship within 5 years of ratifying the treaty. It includes cross-border advertising. Packaging: Large health warning labels are required. Health warning labels with rotating messages should cover preferably 50% or more, and at a minimum 30%, of the principle display areas of each cigarette packet within 3 year after ratifying the treaty. Labeling: Ban misleading or deceptive descriptors and the examples provided include “light” and “low tar” within 3 years of ratifying the treaty. Second Hand Smoke: Nonsmokers must be protected from exposure to tobacco smoke in workplaces, public transport, and indoor public places. Smuggling: Requires collaborative measures to eliminate cigarette smuggling. Pricing: Encourages price increases through taxation or other means as per the country’s policies. Product Regulation & Ingredient Disclosure: Countries that signed the treaty agreed to establish guidelines to regulate the content of tobacco products and requires manufacturers to disclose product ingredients to the government of each country.

public places and, as appropriate, other public places.” However, the FCTC did not define exposure. There is no scientifically based ventilation technology that can effectively and feasibly address the health effects of second-hand smoke. Ventilation is not an effective solution in preventing the public from the health risks of secondhand smoke. Packaging and labeling of tobacco products. To eliminate any false impressions the industry might convey through labeling of tobacco products, as had been the case with “light” cigarettes, the FCTC urges participating countries to adopt measures to eliminate misleading claims by tobacco companies through descriptors such as “lights” and “mild,” as well as to institute larger warning labels in the packaging. The FCTC recommends a minimum of 30% size warning on the package label. It did not require the effective pictorial warnings of devastating health effects, as have been used in Canada and Brazil. One of Brazil’s nine warnings shows the photo of a conscious, entubated woman with the

text “Smoking causes lung cancer” (http://www.smokefreeair. org/Canada_Brazil_Warnings.jpg). Tobacco advertising, promotion and sponsorship. It is widely accepted that a complete ban on tobacco product marketing, advertising, and sponsorship of events is a very important step in the reduction of tobacco consumption, mainly among young people. This was one of the most controversial measures of the FCTC and one which the US opposed. The final text 43 recognizes that a comprehensive ban is an effective way to reduce consumption, but it makes exceptions for countries with constitutional impediments to implement total bans. However, it still recommends that to the extent possible, all countries should restrict “advertising, promotion, and sponsorship” and when possible, also ban cross-border advertising. At a minimum, the FCTC bans misleading and deceptive advertising and restricts marketing and promotion on “radio, television, print media and, as appropriate, other media, such as the internet.” The FCTC requires reporting by the tobacco industry of advertising and promotion expenditures. Smuggling or illicit trade in tobacco products. The importance of cigarette contraband in consumption and the economic and social issues associated with this problem have been amply described. Also previously described has been the tobacco companies’ involvement and profit from the contraband of cigarettes. The FCTC recognizes the need to eliminate cigarette smuggling as well as counterfeiting as essential for tobacco control, and to achieve that, the need for the “development and implementation of related national law, in addition to subregional, regional and global agreements...” The FCTC suggests many ways in which participating countries will contribute to curbing smuggling, such as special pack marking, tracking, and monitoring systems for tobacco trade, as well as the adoption of enforcement measures. Youth access. The tobacco industry has been, for years, developing and promoting ineffective youth smoking prevention programs worldwide, in an attempt to avoid legislative and regulatory measures. As with the industry’s voluntary marketing restriction codes, these programs have not had an impact on tobacco consumption. The FCTC requires participating countries to enact measures to limit access to tobacco products, making them available only to

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those who are 18 years old or older, if national law goes beyond 18. Among other access measures, the FCTC also requires sellers to make tobacco products less available to minors, and bans the distribution of free samples to the public. Additionally, the FCTC calls each country to establish regulatory measures for the contents of tobacco products, for the establishment of measures to promote and support cessation, to consider taking legislative action to “deal with criminal and civil liability” of tobacco companies, and it calls for the participation of civil society as “essential in achieving the objective of the Convention and its protocols.” Throughout the negotiations, the actions of the US delegation were criticized by the world health community, including tobacco control and health leaders in the US, such as the American Cancer Society, the Campaign for Tobacco Free Kids, and the ONS. The US delegation position in the FCTC negotiations was seen as one that appeared to favor the tobacco industry and failed to protect the health of people. However, the FCTC was unanimously approved at the World Health Assembly in Geneva, Switzerland, on May 21, 2003. It remains to be seen if the US government will ratify the treaty provisions, and whether resources will be provided for effective domestic implementation.

THE MASTER SETTLEMENT AGREEMENT

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n the mid 1990s several states sued the tobacco industry to recover the costs to the state of treating tobacco-related illnesses. After the settlement of the first four initial cases the tobacco industry settled out of court with 46 state attorneys-general in November of 1998,13, 44 in what became known as the MSA. Among other clauses of the MSA, the tobacco industry agreed to voluntary curb marketing to youth and agreed to pay over $260 billion over the next 25 years to these states. In addition, the MSA created the American Legacy Foundation, which receives funding from the industry but works independently to prevent smoking initiation and promote cessation. There has been much debate within the health community about the utilization of the MSA funds by the states, and the assumption that at least part of this pay out would be used for comprehensive tobacco control measures to prevent tobacco use, help to

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support cessation services, and support care for the millions affected by tobacco-induced disease. Unfortunately, that has not been the case. Five years later, most states have been using the funds from the MSA to cover budget deficits with a very small percentage (4%) going to tobacco-related programs.45 There is disturbing evidence that the tobacco industry has been finding ways to circumvent some of the restrictions imposed by the MSA. In the year after the MSA was implemented, marketing expenditures rose 22% and advertising in youth-read magazines rose 33%. Discounts on brands youth favor and in-store promotions rose 65%.46-48 Several states produced dramatic reductions in smoking. California, with one of the most aggressive tobacco-control programs in the nation, has reduced adult prevalence three times faster than the nation (33% since 1988). Between 1995 and 1999, youth use of cigarettes dropped 44%, compared with no change nationally. Minnesota, after a 36% increase in teen smoking over 6 years, cut its teen prevalence in 2000 by 25%. New York’s 55-cent/pack cigarette tax increase in 2000 dropped sales 20% in 1 year. Florida launched a youth-focused campaign, the TRUTH campaign (http://www.thetruth.com/), which was so successful in reducing smoking among youth that it is now a national campaign supported by the American Legacy Foundation. Unfortunately, with the widespread state budget deficits, states have reduced their tobacco control budgets so dramatically that, in cases such as Minnesota, Massachusetts and Oregon, the statewide program became nonexistent for all practical purposes. The longterm public health impact of such measures is not yet known, but it is predicted to be very negative. Another outcome of the lawsuits against the tobacco industry was that as part of both individual states settlements and the MSA, the industry has to maintain and update a large Internet-based depository of internal documents. These documents continue to be produced and made public as a result of legal proceedings, in what is called the discovery process. Research based on information from these documents, including those conducted by nurses, have provided tobacco control professionals throughout the world with a better understanding of the workings, and deceptions, of the industry, and in many cases, has assisted in moving the tobacco control agenda forward.

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TOBACCO CONTROL AND ONCOLOGY HEALTH PROFESSIONALS

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n light of the well-known link to cancer deaths, oncology health professional organizations are increasing policy efforts to prevent and reduce tobacco use, and reduce exposure to second-hand smoke. Oncology organizations such as the ONS, the American Society of Clinical Oncology, the International Society for Nurses in Cancer Care, and the International Union Against Cancer, which are dedicated to preventing cancer, have strong statements about the role of oncology health professionals in tobacco control. The ONS has been increasingly involved in tobacco control policies, including providing testimony in 2003 for revisions in Healthy People 2010 and to the Health and Human Services’ Interagency Committee on Smoking and Health’s Subcommittee on Cessation to support increasing the nurses’ role in tobacco prevention, cessation, and reducing exposure to second-hand smoke. The American Society of Clinical Oncology released a new policy statement in 2003 that calls for increased efforts for science-based tobacco control policies with a special focus on US trade policy in promoting tobacco use abroad, where smoking has increased exponentially.49 The American Society of Clinical Oncology is partnering with other organizations in the development of a core curriculum for use in medical schools, recommending the inclusion of tobacco cessation questions on board examinations, and endorsing the integration of tobacco cessation as part of cancer care. A tobacco control policy approved by the ONS in 1995 made similar recommendations for nursing education, certification, and clinical practice.50

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nvolvement in the political process by health professionals, including nurses, can greatly assist in the implementation of tobacco control measures, and the subsequent prevention of tobaccorelated cancers. In fact, since 1988, the Institute of Medicine51 has identified policy development as one of public health’s core functions. Policy interventions have been at the center of several large scale tobacco control programs in the United States.13,52-57 Politics are an integral part of public health and health care13,58 and political ideology will deter-

TABLE 2. Opportunities for Nursing Involvement in Tobacco Control Write letters to the editor or Op-Eds on tobacco control policy proposals at the local, state, or federal level Write/call/e-mail legislators and policy makers at all levels to express support for tobacco control proposals Get involved with a local tobacco control group or organization, such as a local branch of the American Cancer Society Create a committee at your workplace to enhance nurses’ awareness about tobacco control issues, such as integrating smoking cessation in nursing practice Advocate for access to and reimbursement for tobacco cessation treatment (behavioral and pharmaceutical) Adoption of smoking status as a vital sign on all patient records Improve the quality of tobacco cessation treatment through adoption of the clinical practice guideline for tobacco use cessation Push for government regulation of nicotine as a drug Advocate for tobacco tax increases and dedication of funds for tobacco control programs and research Advocate for bans on smoking in workplaces and public spaces Support and participate in lawsuits against the industry

mine the financial support, availability, type, and scope of services, as well as dissemination of scientific research findings. For example, a policy commitment with tobacco control facilitated the development of the Treating tobacco use and dependence Clinical Practice Guideline,59 and continued commitment is needed for implementation and dissemination of the guideline recommendations. Sarna72 suggested many ways in which nurses could be involved in tobacco control at the local, national, and international level. Table 2 provides some additional examples. A description of the growing number of agencies involved in tobacco control that can partner with nursing organizations in policy development and implementation are listed in the Appendix. Brendtro61 describes how breast cancer gained its prominence in the formal agenda in the United States, and the potential role for nurses in the political process. Unfortunately, such level of awareness-raising, advocacy, and political involvement has not yet been reached with lung cancer, a cancer almost entirely caused by smoking. Lung cancer is less “visible” than breast cancer, partly because societal misunderstanding of lung cancer. Lung cancer is still largely perceived

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as self-inflicted by an individual’s smoking, rather than the power of addiction and the practices of the tobacco industry. Nurses could play a major role in reframing the perception of lung cancer in society and in moving tobacco control into the formal and public agendas. Research has shown that oncology nurses are open to implement smoking cessation interventions and be involved in tobacco control advocacy. However, despite this willingness, barriers, such as lack of adequate knowledge and skills, remain and need to be addressed at the organizational level before these tobacco control policies can be fully implemented.62-64

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he culture of acceptability of tobacco use in the US, pervasive in the 1960s, has changed in the beginning of the 21st century. Individually directed behavior modification, interventions traditionally used in nursing practice, presents many challenges. These interventions are more likely to be successful when changes in individual behaviors are in concert with broader social and political interventions that promote healthy behavior as the social norm. For example, smoke-free environments, increasingly adopted in many states, promote nonsmoking as the social norm and empower nonsmokers to claim their right to breathe clean air. Comprehensive, population-based tobacco control strategies, such as increasing cigarette taxes and banning smoking in public places, reach more people and are more effective than programs aimed at changing personal behaviors. However, these strategies are most effective when combined with individual interventions, such as smoking cessation services. Oncology nurses, with their perspective of car-

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ing for individuals suffering the devastation of tobacco-induced cancer, can play an important role in reducing the devastation caused by tobacco use and addiction.60,62,63,65 Policy approaches such as taxation, bans on smoking in public spaces, and bans or restrictions on advertising and promotion decrease tobacco consumption. Nurses, the largest segment of the health professions, have many opportunities to lead and to partner in tobacco control efforts. For example, advocating for access to and reimbursement for tobacco cessation treatment (behavioral and pharmaceutical), adoption of smoking status as a vital sign on all patient records, improving the quality of cessation treatment through adoption of the clinical practice guideline, pushing for government regulation of nicotine as a drug, advocating for tax increases and bans on smoking in work and public spaces, and providing testimony to policy making organizations. Nurses can support and link with other health professionals through participation in lawsuits against the tobacco industry; these lawsuits raise the visibility of the tobacco addiction problem and educate the general public about tobacco and the industry. In conclusion, recent changes in tobacco control policies on international and national fronts provide new opportunities and challenges. Tobacco control is central to reducing the projected death toll of cancer in the 21st century. The involvement and leadership of oncology health professionals is essential. Oncology nurses and oncology nursing organizations can help to shape and implement policies that prevent tobacco use, increase tobacco cessation, and decrease exposure to second-hand smoke. These actions will ultimately result in the reduction of the risk of tobacco-induced cancers; and the promotion of health, and quality of life for generations.

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tobacco control: A global “good” for public health. Bull World Health Organ 78:920-929, 2000 41. LeGrand C: Framework Convention Alliance: Building support for global tobacco control. Can J Cardiol 17:647-648, 2001 42. Public Hearings on the Framework Convention on Tobacco Control. October 12-13, 2000. Available at: http:// www5.who.int/tobacco/page.cfm?sid⫽90 (accessed May 27, 2003) 43. World Health Organization: Framework Convention on Tobacco Control. Geneva, WHO, 2003. Available at: http:// www5.who.int/tobacco/page.cfm?sid⫽96 (accessed May 27, 2003) 44. Fisher L: Update: Master Settlement Agreement between the states and the tobacco industry (United States). Cancer Causes Control 11:285-287, 2000 45. Campaign for Tobacco Free Kids: Show Us the Money: A Report On The States’ Allocation Of The Tobacco Settlement Dollars. Washington, DC, CTFK, January 22, 2003. Available at: http://www.tobaccofreekids.org/reports/settlements/2003/ fullreport.pdf (accessed May 27, 2003) 46. Hamilton W, Turner-Bowker D, Celebucki C, et al: Cigarette advertising in magazines: The tobacco industry response to the Master Settlement Agreement and to public pressure. Tob Control 11:ii54-58, 2002 (suppl 2) 47. Chung P, Garfield C, Rathouz P, et al: Youth targeting by tobacco manufacturers since the Master Settlement Agreement: The first study to document violations of the youthtargeting ban in magazine ads by the three top US tobacco companies. Health Aff (Millwood) 21:254-263, 2002 48. King CR, Siegel M: The Master Settlement Agreement with the tobacco industry and cigarette advertising in magazines. N Engl J Med 345:504-511, 2001 49. American Society of Clinical Oncology: Policy Statement Update: Tobacco Control-Reducing Cancer Incidence and Saving Lives. Adopted on May 23, 2003. J Clin Oncol 21:2777-2786, 2003 50. Sarna L, Brown J: Tobacco prevention and cessation in oncology nursing practice, education, and research. Oncol Nurs Forum 22:256-277, 1995 51. Institute of Medicine: The Future of Public Health. Washington, DC, National Academy Press, 1988

52. American Medical Association: SmokeLess States: National Tobacco Policy Initiative; 2003. Available at: http:// www.ama-assn.org/ama/pub/category/3229.html (accessed May 27, 2003) 53. Manley M, Pierce J, Gilpin E, et al: Impact of the American stop smoking intervention study on cigarette consumption. Tob Control 6:S12-S16, 1997 (suppl 2) 54. Pierce J, Gilpin E, Farkas A: Can strategies used by statewide tobacco control programs help smokers make progress in quitting? Cancer Epidemiol Biomarkers Prev 7:459-464, 1998 55. Pierce J, Gilpin E, Emery S, et al: Has the California tobacco control program reduced smoking? JAMA 280:893899, 1998 56. Burns D: Reducing tobacco use: What works in the population? J Dent Educ 66:1051-1060, 2002 57. Siegel M: The effectiveness of state-level tobacco control interventions: A review of program implementation and behavioral outcomes. Annu Rev Public Health 23:45-71, 2002 58. McKinlay J, Marceau L: Upstream healthy public policy: lessons from the battle of tobacco. Int J Health Serv 30:49-69, 2000 59. Fiore MC, Bailey WC, Cohen SJ, et al: Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD, US Department of Health and Human Services, Public Health Service, June 2000 60. Sarna L: Hope and vision. Prevention: Tobacco control and cancer nursing: Cancer Nurs 22:21-28, 1999 61. Brendtro M: Breast cancer: Agenda setting through activism. Adv Pract Nurs Q 4:54-63, 1998 62. Sarna L, Brown J, Lillington L, et al: Tobacco interventions by oncology nurses in clinical practice: Report from a national survey. Cancer 89:881-889, 2000 63. Sarna L, Brown J, Lillington L, et al: Tobacco-control attitudes, advocacy, and smoking behaviors of oncology nurses. Oncol Nurs Forum 27:1519-1528, 2000 64. Sarna L, Wewers M, Brown J, et al: Barriers to tobacco cessation in clinical practice: Report from a national survey of oncology nurses. Nurs Outlook 49:166-172, 2000 65. Wewers M, Ahijevych K, Sarna L: Smoking cessation interventions in nursing practice. Nurs Clin North Am 33:6174, 1998

APPENDIX: TOBACCO CONTROL RESOURCES FOR NURSES

key tobacco efforts such as SmokeLess States coalitions, Smoke-Free Families program, Substance Abuse Policy Research Program, Addressing Tobacco in Managed Care. The American Legacy Foundationwww.americanlegacy.org The American Legacy Foundation is dedicated to building a world where young people reject tobacco and anyone can quit. The foundation is a 501(c)(3) organization that was established in March 1999 as a result of the Master Settlement Agreement (MSA) between a coalition of attorneys general in 46 states and five US territories and the tobacco industry, and is funded primarily by payments designated by the settlement. As a national, independent public health foundation located in Washington, DC, the foundation develops national programs that address the health effects of tobacco use through grants, technical training and assistance, youth activism, strategic

Campaign for Tobacco Free Kids- www.tobaccofreekids.org The Campaign for Tobacco-Free Kids is fighting to free America’s youth from tobacco and to create a healthier environment. The Campaign is one of the nation’s largest non-governmental initiatives ever launched to protect children from tobacco addiction and exposure to second-hand smoke. The Robert Wood Johnson Foundation- www.rwjf.org Established in 1972, The Robert Wood Johnson Foundation, based in Princeton, NJ is the largest philanthropy devoted exclusively to health and health care in the United States. It has played a leadership role in tobacco policy and treatment in the United States. Its website includes information and links to

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partnerships, counter-marketing and grass roots marketing campaigns, public relations, and community outreach to populations disproportionately affected by the toll of tobacco. See the website for information on TRUTH, Great Start, and Circle of Friends initiatives. Americans for Nonsmokers’ Rights- www.no-smoke.org Americans for Nonsmokers’ Rights (ANR) is the only national lobbying organization dedicated to nonsmokers’ rights, taking on the tobacco industry at all levels of government to protect nonsmokers from second-hand smoke and youth from tobacco addiction. ANR pursues an action-oriented program of policy and legislation. ANR has promoted clean indoor air ordinances in over 1,500 communities across the United States since the early 1980s. Centers for Disease Control & Prevention, Office and Smoking or Health- www.cdc.gov/tobacco The Office on Smoking and Health (OSH) is a division within the National Center for Chronic Disease Prevention and Health Promotion, which is one of the centers within the Centers for Disease Control and Prevention (CDC). OSH is responsible for leading and coordinating strategic efforts aimed at preventing tobacco use among youth, promoting smoking cessation among youth and adults, protecting nonsmokers from environmental tobacco smoke (ETS), and eliminating tobacco-related health disparities. See their Tobacco Information and Prevention Source (TIPS) website for research, programs, and contacts. World Health Organization, Tobacco Free Initiativehttp://tobacco.who.int/ The Tobacco Free Initiative (TFI) is a WHO cabinet project created to focus international attention, resources, and action on the global tobacco pandemic that kills 4.9 million people a year today. “World No Tobacco Day” is celebrated around the world every year on May 31. The Member States of the World Health Organization created “World No Tobacco Day” in 1987 to draw global attention to the tobacco epidemic and the preventable death and disease it causes. American Cancer Society (ACS)- www.cancer.org Provides smoking education, prevention, and cessation programs and distributes pamphlets, posters, and exhibits on smoking. Refer to your phone book for the ACS chapter in your area or contact the national office. Action on Smoking and Health (ASH)- http://ash.org ASH is the nation’s oldest and largest antismoking organization. They provide nonsmokers with valuable information to help them protect their rights, and to learn more about the problems and costs of smoking to nonsmokers. ASH’s actions have helped prohibit cigarette commercials; ban smoking on planes, buses, and many public places; lower insurance premiums for nonsmokers, etc.

The Advocacy Institute (AI)- www.advocacy.org Founded in 1985, the Advocacy Institute works to achieve a just society, in the United States and outside of it, grounded in the following core values: justice for those denied justice; economic equality for those denied sustenance and opportunity; public health and security for those at preventable risk; and access to political power for those who have been denied an equal voice in the policy-making process. The Advocacy Institute facilitates capacity building workshops and seminars that aim to strengthen social movements, including tobacco control. American Heart Association (AHA)- www.americanheart.org Promotes smoking intervention programs at schools, workplaces, and health care sites. Refer to the AHA chapter in your area or contact the national office. American Lung Association- www.lungusa.org Conducts programs addressing smoking cessation, prevention, and the protection of nonsmokers’ health and provides a variety of educational materials for the public and health professionals. Refer to the ALA chapter in your area or contact the national office. International Network of Women Against Tobacco (INWAT)- http://www.inwat.org/ INWAT was founded in 1990 by women tobacco control leaders to address the complex issues of tobacco use among women of all ages. National Cancer Institute- www.nci.nih.gov Develops and implements smoking intervention programs and produces publications on smoking. NCI also provides telephone counseling services for smoking cessation. Programs and materials are available to health professionals and the public. National Institute on Drug Abuse (NIDA)www.nida.nih.gov NIDA’s mission is to lead the Nation in bringing the power of science to bear on drug abuse and addiction. NIDA supports over 85% of the world’s research on the health aspects of drug abuse and addiction, including tobacco addiction. Oncology Nursing Society (ONS) Legislative Action Center- http://www.ons.org/xp6/ONS/News.xml/LAC.xml ONS health policy and advocacy resources include opportunities to join legislative alerts and calls for action, as well as tools on advocacy, political speaking, and a “Health Policy Tool Kit.” Tobaco Free Nurse- www.tobaccofreenurse.org A new initiative to help nurses stop smoking and build nursing leadership in tobacco control. Agency for Healthcare Research and Quality (AHRQ)www.ahcpr.gov Provides access to the “Treating Tobacco Use and Guideline” and continuing education course and consumer information.