The Unique Role of Nursing in Tobacco Harm Reduction:

I have always wanted to help people and the decision to become a nurse came easily to me. My nursing career began in labor and delivery, where I spent 8 years providing care to women in some of the happiest, and sometimes the most difficult, moments of their lives. Being a nurse is more than just administering medical care. Providing comprehensive care for a patient means developing a holistic understanding of an individual - not only as a patient but also as a person. Nursing means providing tools and resources that the patient can carry forward, improving their health and wellbeing. The best nurses are advocates for their patients, which means they take the time to understand those in their care and the context for their health conditions; they use that context to communicate a treatment plan.

As I advanced in the nursing profession, I discovered what I loved most about my job: the ability to both educate and treat the women under my care and provide resources to help and support them long after my shift was over. This passion led me into education, training nursing students in clinical settings and impressing upon my students the necessity of compassion and education in patient care.

After becoming a mother myself, I quickly learned that shift work was incompatible with my family life, and I made the decision to step back from a hospital setting in 2016. Today, I am the Lead Clinical Researcher for ARAC, a contract research organization that provides behavioral and social science research supporting regulatory studies. We specialize in reduced risk nicotine and tobacco products, providing the robust evidence necessary to gain marketing authorization from tobacco regulators, such as the FDA. While I have replaced healthcare for research, and patients for study participants, the work that I am doing today remains just as health-centered. I am proud to support research that seeks to end the smoking-related diseases that kill more than 480,000 Americans each year. The products in our studies deliver nicotine - the key constituent in cigarettes that drives smoking – but these reduced risk products (RRPs; e-cigarettes, heat-not-burn, and oral nicotine pouches), deliver none of the toxicants and carcinogens produced by combustion that are responsible for smoking-related morbidity and mortality. Few of these products will qualify as medicine, but these reduced risk products help more adult smokers quit and reduce cigarette consumption than any of the World Health Organization (WHO) approved Nicotine Replacement Therapies (NRTs). 

As a nurse, I advocated for my patients. As a nurse instructor, I advocated for my students. Today, I have the privilege of advocating for THR and the participants in our studies. People who smoke deserve access to products that will help them quit as surely and as quickly as possible. Every 2nd long term smoker will die prematurely as a result of smoking; those who quit before age 35 regain most of their projected life-years that would otherwise be lost to cigarettes. As the lead clinical researcher, I standardize and oversee on-site facility training, ensure compliance with study protocols and data collection, and verify that our research programs adhere to federal, state, and municipal laws. I also support study logistics and monitor, assess, and report adverse experiences. Unlike some of the tobacco and nicotine research conducted from the distant halls of academia, my colleagues and I stay closely connected to communities where smoking rates and related diseases are most prevalent.   This allows us to witness firsthand the benefits of smoking–cessation and reduction aided by reduced-risk nicotine products. 

The human stories coming out of our studies are truly inspirational. I have encountered thousands of participants since beginning my role with ARAC and their stories, which I am privileged to witness, deserve to be heard. I will never forget meeting an older gentleman who broke down at his initial visit, where I was collecting baseline clinical information and providing education on the study product. He informed me that he has been a smoker for at least 30 years. He expressed through tears that he had been trying to quit smoking for years and that nothing had helped him. His primary physician has told him countless times that he needed to quit but, like millions of other Americans told to ‘quit or die’, the all-important ‘how’ was never discussed. Like countless others, he did not need a doctor to tell him that he should quit; he had his own motivations. He told me how badly he wanted to be able to hold his grandchildren. This gentleman was randomly assigned to the product group. I later saw him at a follow-up visit where he told me, with the biggest smile on his face, that he had entirely stopped smoking thanks to the product in our study. I have dozens of similar stories, as do my colleagues. Stories of construction workers who have smoked since they were teens and didn’t think it was possible to quit, being able to stop smoking within months; young mothers with children who want to live a healthy life for themselves and their children, beaming with pride as they see their exhaled carbon monoxide decrease significantly as they reduce their cigarette use; couples who started smoking together, wanting to quit together, hugging at the end of the study because they were successful – all a testimony to the potential for tobacco harm reduction (THR).  

It strikes me that healthcare workers, and perhaps nurses especially, have a unique role to play in championing THR, and advocating for those in our community who need it most. Unlike physicians whose contact time with patients is necessarily restricted, nurses have more opportunity for facetime with those in their care. Nurses get to meet these people ‘where they are at’ in their health journey, talk to them, learn what motivates them, and understand their choices. How many of these conversations could serve as a catalyst for smoking cessation? How many more people would quit smoking if, rather than being coerced to do so via shame and stigma, they were provided legitimate alternatives by a compassionate voice? Some of those options are medically approved pharmacotherapies and nicotine replacement therapies. But, not for nothing, many who smoke do not consider themselves to be sick and for such people a ‘medicine’ often feels like an inappropriate solution. Behavioral therapy helps some people quit too, especially when combined with other cessation supports. But to engage in therapy requires an individual to make a commitment to cessation and to confront the possibility of failure – both are cessation impediments which many – too many – are unable or unwilling to overcome. Instead, commercial nicotine products simply provide an opportunity to replace a lethal commercial product with a significantly less dangerous alternative. RRPs outperform NRTs in clinical settings and are accelerating the decline of smoking cessation at a national level. We need more voices telling these stories and telling them to the disadvantaged segments of American society where smoking harms are greatest.  

The tragedy is that misinformation about the relative safety and efficacy of reduced risk products impedes uptake. It’s true that RRPs are not without risk, but statements to that effect often obscure the salient reality that these products - especially regulated ones that have been subject to stringent testing  - are much safer than combustible cigarettes. Access to the ‘highest attainable standard of health’ is a human right; one that people who smoke are denied when they are misadvised about the reality that different products present very different levels of risk. Nurses and other front-line healthcare workers could play a central role in educating patients about the benefits of cessation and the options available to them; correcting misinformation about reduced nicotine products; and informing those in their care about how to engage with RRPs including, for example, which products to use, where to find them, and how frequently to use them (frequency of use is a determining factor in smoking cessation outcomes). Not only is this information not widely available, but evidence suggest that false-beliefs about RRPs are concentrated among many of the same groups where smoking rates and related morbidity and mortality are highest. Unless that can be corrected, these communities will continue to be ‘left behind.’ There is a powerful opportunity for nurses, and perhaps other front-line service providers too (social workers, pharmacists, PAs and physicians) to foster health-positive consumer behavior via dialogue. Unfortunately, however, even medical professionals often mischaracterize the risks of THR products. No wonder. The American College of Physicians has spread misinformation about the risks of RRPs (see for example their discussion of the “major lung injuries from vaping, referring to EVALI – since linked with illicit THC products containing Vitamin E acetate – a thickening agent not found in nicotine e-cigarettes. ACP has also withheld scientifically sound information and evidence on the risk continuum surrounding the various types of nicotine and tobacco products If medical professionals do not understand the facts underpinning THR, they will not be able to communicate to them and countless opportunities to save lives will be squandered. Perhaps then, THR education should be targeted not only to the end-consumer, but also those in a position to advise them.  

Driven by my passion for education and tobacco harm reduction, I’m excited to use the scientific data our team is gathering to make a real difference. As a nurse, I’m committed to improving lives and advancing harm reduction through research, education, and advocacy. Beyond our module 6 studies and regulatory studies, my colleagues at ARAC and I are working to change the social norms regarding THR engaging with diverse stakeholders, including health-care providers, developing e-learning curriculums and professional development programs informed by our experience in the field and the human stories we have been privileged to be a part of.