Now that the effects of tobacco use on patients is known, how does the nurse assess current tobacco use and nicotine dependence? Nurses represent the highest number of health care providers in the United States, and most nurses believe it is their responsibility to instruct patients about smoking cessation, but the percentage of nurses who counsel patients remains low. (6) Taylor et al. reported a nurse-managed smoking cessation intervention can increase cessation rates for hospitalized smokers. (7) In other studies, research conducted by Stillman at Johns Hopkins University described a model program for the hospitalized cardiac patient. (8) Wewers et al. at Ohio State University indicated that a nurse-managed smoking cessation intervention during diagnostic testing for lung cancer was successful in achieving short-term cessation. (9) Finally, Utz et al. at University of Virginia reduced smoking behaviors in a community-based program. (10) These are all examples of nurses making the difference in counseling their patients on tobacco use and cessation.

In the early 1990s, Fiore introduced the concept of the fifth vital sign; that is, considering a patient's smoking status along with blood pressure, pulse, temperature and respiratory rate. (11) This approach provides an important opportunity to gain information at each patient visit about the patient's tobacco status and an opportunity to promote smoking cessation. The AHCPR incorporated this 5th vital sign into the Clinical Guideline on Smoking Cessation (See Table 1) as a means to identify tobacco use at every patient visit. (12) Tobacco use is routinely assessed upon inpatient admission, but may only be assessed with initial ambulatory or home visits.

Table 1: Fifth Vital Sign

Fiore (1991). (11)

Once it is determined that the patient is a tobacco user, utilizing the Fagerstrom Scale will help to estimate dependency on nicotine (See Table 2). (13) This tool serves to provide feedback to both the patient and the provider on the level of nicotine dependence. A score of seven or greater is considered high. A higher score means that the patient who continues smoking is highly dependent on nicotine and more likely to experience withdrawal symptoms when they quit. By knowing this, the staff nurse can assist the patient to increase their awareness of possible effects that may be experienced, and how to plan his or her attempt to quit. A simple question to assess the patient's readiness to quit smoking is, "Can you see yourself smoke-free?"

Nicotine, a major ingredient in tobacco smoke, is addictive. (14) In addition to nicotine, there are approximately 5,000 other chemical compounds in tobacco smoke. These include acetone, ammonia, arsenic, carbon monoxide, cyanide, formaldehyde, methane, tar, and toluene. (15) The burning of tobacco is a thermal reaction involving multiple chemical reactions, releasing many of the above chemicals and their byproducts into the air when a cigarette, cigar or pipe is smoked. Many of these are known carcinogens. These are inhaled by the smoker and released to the air. This exposure to environmental tobacco smoke (ETS), often referred to as secondhand smoke, affects not only the smoker, but all those exposed to the smoke, including children and pets.