Recently, novelist and essayist Barbara King-solver wrote of the events of September 11, 2001: “It is desperately painful to see people die without having done anything to deserve it, and yet this is how lives end nearly always.”11 What made this particular set of events so shocking, I think, was so much death and suffering all at once in one place, a circumstance that created widespread public anguish and generated policy changes aimed at prevention, preparations for comprehensive responses on many levels, and unprecedented political unanimity. Such situations suddenly disrupt our ability to cope with the sheer, irrevocable power of death to stop us—every one of us—in our tracks. If we could watch all this from afar, as one watches ants when their numbers are decimated suddenly by the swipe of a sponge or a heavy footfall across their trail, we might better understand an enduring mystery: why our society’s response to death—and to its proximate causes—is so different when it is slow and widely distributed rather than fast and localized.
Every week, 52 weeks a year, some 8000 people in this country die from tobacco-related diseases, their lives ended prematurely by an aggressive tobacco industry and the addictive properties of nicotine. They, too, have done nothing to “deserve” death—nothing except to succumb, typically as adolescents or very young adults, to sophisticated marketing and promotion that falsely equate smoking with adult privilege, glamour, independence, emancipation, toughness, naturalness, authenticity, social success, and other desirable attributes, in messages selectively delivered for maximum impact. The total: more than 400 000 premature deaths yearly in the United States and 3 million worldwide. Among the dead will be many nurses, providing evidence that mere knowledge—even firsthand knowledge—about tobacco’s harmful effects on health is not enough to prevent them.
Although most nurses are nonsmokers and there is evidence that many nurses have quit during the past 2 decades, smoking rates among nurses (18.3% for registered nurses, 27.2% for licensed practical nurses) are still far higher than those for physicians (3.3%), and nurses’ rates of quitting are lower than physicians’ rates.22 Some evidence indicates that smoking may be more common among nurses in critical care specialty areas and psychiatry than among nurses in women’s health, pediatric, and general practice areas.33 Many reasons have been advanced for the continuing use of tobacco among the largest group of healthcare professionals, including stress, personal characteristics, professional role conflicts, and lack of knowledge, but the evidence for many of these is mixed.44 However, it seems clear that aggressive industry promotion of tobacco products, especially to women, and the highly addictive nature of the products are primary causes.
In 1999, according to figures from the Federal Trade Commission, the 3 largest cigarette manufacturers reported having spent $8.24 billion on advertising and promotion. This means that the industry spends almost $1 million an hour, 24 hours a day, 365 days a year in its efforts to attract new smokers and keep people smoking. By comparison, the entire proposed budget for 2002 for the United States Centers for Disease Control and Prevention is $4.1 billion, of which only $575 million is proposed for chronic disease prevention and health promotion (a decrease of 23% from last year).55
There is nothing about nursing, medicine, or any other health profession that intrinsically renders its practitioners immune from this barrage of social messages, crafted by the best marketing minds money can buy and insinuating themselves into so many aspects of our social fabric. Combine that with the industry’s decades-long efforts to conceal and counter the solid scientific evidence showing the deadly effects of their products,66 and one begins to see that all of these local, private deaths have their origins in public, intentional actions. The tobacco industry, as one public health expert put it, is “the vector of the tobacco epidemic.”77
It is important to understand that the large numbers of tobacco-related deaths that clinicians see in critical care units and other healthcare settings are really a phenomenon only of the past century, almost entirely created through the industrial production and marketing of cigarettes by companies that have now become powerful multinational corporations. Before 1900, cigarettes were not a major industry, and very few people smoked them. In 1914, for example, adult per capita consumption of tobacco was less than 1 pound (0.45 kg) per year, mostly as cigars or spit tobacco, and the death rate from lung cancer was 0.6 per 100 000 persons. A total of 371 cases of lung cancer were reported that year in the United States. The disease was reportedly so rare that medical students might never see a case during their careers.88
By the 1950s, adult per capita consumption was more than 10 pounds (4.5 kg) yearly. Even today, when the health dangers of tobacco use are widely known, consumption is still approximately 4 times what it was in 1914, and U.S. lung cancer death rates in 1986 ranged from 24.3 to more than 70 per 100 000 persons—as high as 116 times the rate in 1914.99,1010 In 2001, according to the American Cancer Society, lung cancer will be the number-one cause of cancer deaths, with an estimated 157 400 people succumbing to this once-rare, highly preventable disease alone. Hundreds of thousands of other tobacco-related deaths from other cancers, emphysema, heart disease, and other illnesses will also occur.
The tobacco industry f irst began targeting women during the 1920s and 1930s. From the 1940s through the 1970s, this effort increased dramatically, and women (including nurses) took up smoking in greater numbers than ever before. In fact, nurses and physicians were important figures in tobacco marketing from the 1930s through the 1950s, an era in which the industry sold cigarettes by making health claims about their products: that they were “less irritating to the throat,” that “more doctors” smoked them; and that they were “fresh,” suggesting wholesomeness and “hygiene” (see FigureF1). Advertisements during this period featured clinicians in medical or nursing dress and settings, and the ads themselves appeared regularly in professional publications, including the American Journal of Nursing, suggesting links between smoking and good health, despite the fact that the first studies linking smoking with lung cancer had appeared at least a decade before.
During the 1960s and 1970s, the industry became even more aggressive in targeting women, introducing the hugely successful Virginia Slims “Baby, you’ve come a long way” campaign, which piggybacked on the emergence of the women’s rights movement and sold tobacco addiction as a “liberating” choice. Lung cancer, of course, typically is diagnosed 20 to 30 or more years after smoking initiation. Between 1960 and 1990, deaths from lung cancer among women subsequently increased by more than 400%—exceeding breast cancer deaths by the mid-1980s,1111 a trend that has increased in succeeding years.
At the patient care level, nurses who smoke have been shown to be less effective in cessation/prevention counseling and may be less effective as role models for their patients.44 In the larger public policy arena, the absence of a major nursing presence among those advocating for strong tobacco-control measures and attention to the role of the tobacco industry is regrettable, particularly considering the trust in which the public holds nurses as a group. For example, a recent study of people’s reactions to viewing The Insider, a film about the deceptive activities of the tobacco industry, asked subjects to rate people in a list of professions on “ethics and honesty” and on “power.” The list included politician, movie director, nurse, tobacco industry executive, scientist, TV reporter, and multinational food company executive. Nurses received the highest mean rating, and tobacco industry executives received the lowest mean rating for “ethics and honesty.” Disconcertingly, however, “nurse” was ranked lowest on “power,” while tobacco industry executive was second in power only to “politician.”1212
Regarding this perception, one issue warranting further thought within the profession is that nurses have invested considerable political capital in getting access to “inside” political channels through professional organizations and political action committees. However, nurses have not, as a group, developed major “outsider” advocacy in terms of tobacco or, arguably, in terms of public health issues more generally—strategies that would increase nursing’s public visibility and power. In the area of tobacco-control policy, “insider” strategies have been shown to be considerably less effective than “outsider” advocacy strategies that draw public and media attention to the issues.1313 It is intriguing to imagine what attention even small groups of highly committed nurses might bring to tobacco issues—and to nursing—if they began showing up at tobacco company stockholders’ meetings, challenging industry-backed legislation through well-placed editorials, or demonstrating at tobacco-sponsored events.
Today, though many policy statements have been issued and nurses are well aware of the harmful effects associated with tobacco use (including not only lung cancer but also heart disease, hypertension, stroke, emphysema and other respiratory illnesses, other cancers, impaired healing, and numerous other health problems), nurses are not, as a group, especially vocal in advocating for tobacco-control measures or challenging the industry’s tactics, nor are they active in conducting tobacco-control research—with a few stellar exceptions. Yet, if mobilized, nurses “could easily become formidable opponents for the tobacco industry,” in the words of one tobacco industry executive.1414 Nursing’s strategic advantage lies in the trust the public places in the profession. Publicly confronting the tobacco industry and working on multiple fronts to end the tobacco epidemic could bring nursing back in touch with its public health origins and the grassroots sources of nursing’s true power.
What would it take to mobilize nurses? First, a comprehensive effort is needed to help all nurses quit smoking. This means not merely offering cessation programs tailored to the needs of health professionals, but broader measures in schools of nursing, professional organizations, and across public spheres (including strong clean indoor air policies) so that smoking becomes socially undesired.
Second, support for organizing locally based, grassroots campaigns that call attention to the ways in which the tobacco industry continues to market disease and death in attractive disguises could stimulate nurses to direct action. Such support could come from professional organizations, health foundations, or other advocacy groups. Initially, what would be most needed is communications support: hosting a list serve, for example, could help nurses share creative ideas and extend their networks rapidly.
Finally, nursing must develop its vision and extend its concerns beyond helping patients cope with tobacco-related suffering, important though this is and will continue to be. This means recognizing that caring is always a political act and understanding that nursing’s untapped political strength lies in advocacy. But doing this will mean imagining a world where 8000 undeserved, preventable deaths in 1 week will shock us.
Financial support was provided by Grant No. 9RT-0095 from the California Tobacco-Related Disease Research Program and Grant Nos. 1 R01 CA87472-01 and 1 R01 CA90789-01 from the National Cancer Institute.
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