Objective: To reflect on the nurse's professional role in supporting smoking management from an educational perspective and to understand its implications in educating people who use tobacco and the nursing staff.

Methods: a theoretical-reflexive study based on the historical-cultural approach of the Perceived Effects of Substance Use Theory of Smith.

Results: The harmful effects of cigarettes are well established in the world literature, and despite the harm that smoking causes, nicotine is considered one of the most consumed drugs in the world. Tobacco use is a chronic disease classified in the group of mental and behavioral disorders resulting from the use of psychoactive substances. For the past decade, nurses have been engaged in a wide range of interventions aimed at supporting smoking management. Nurse-led interventions usually aim to reduce control or achieve tobacco abstinence and involve methods such as manuals, pamphlets, brochures, training or printed educational materials, audio, and video files besides nursing consultations, as well as nicotine replacement methods.

Practice implications: Nurses have played an important role in smoking, promoting health education through individual and group guidance on smoking management. They have proven their competence and skill in these issues.

Keywords: nursing, tobacco use disorder, critical thinking, smoking management

Smoking can be defined as the consumption of any tobacco product, whether or not it produces smoke¹ constitutes a serious public health problem, with alarming data and damages for people who smoke and those who do not smoke but live with people who use tobacco.² We can name the individual as a person who uses tobacco if he smoked more than one hundred cigarettes in his life and at least one cigarette in the last thirty days.¹

Smoking has existed since ancient times but is still very current and has important long-term consequences. For a long time, it was considered a behavioral choice, and we saw the people who smoked as guilty for acting this way, someone who did something wrong and was not ashamed of such an act. As if managing smoking was quite simple and depended only on the individual's will. We know now that smoking is influenced by flashy advertisements marketing from big industries that want to sell their products without taking into account the harm it would bring to the population, thinking only of the profit it would bring. For women, developing such a habit was considered status elegance and would place them within the standards of a society that did not know where this behavior could lead them.^3,4

Today, we know that smoking is much more than a behavior. It is a disease with an International Classification, an addiction to a psychoactive substance known as nicotine, which causes people who use tobacco to lose control of the quantity, intensity, and cravings, making it difficult to quit or reduce tobacco use.⁵

In Brazil, the National Program for Smoking Cessation is a joint action of the Ministry of Health and the National Cancer Institute. Its purpose is to reduce the number of active smokers and, consequently, the mortality related to tobacco consumption and its derivatives.  Having the motivation to quit smoking is crucial to achieving success. Users who express this desire need family support, help from a trained professional, and a behavior change. This will make it easier for them to achieve their goal.⁶

Smith,⁷ in the Perceived Effects of Substance Use Theory, seeks to explain the reasons why individuals initiate and maintain the use of psychoactive substances, such as tobacco, alcohol, and other drugs. According to this theory, the consumption of these substances is directly related to the subjective perception of the effects they produce, whether positive, such as relaxation, anxiety relief, and a sense of pleasure, or negative, such as physical discomfort and dependence.

The author⁷ states that individuals continue using the substance if the perceived benefits outweigh the perceived costs. Additionally, biological, social, and psychological factors influence this perception, making substance use a complex behavior. This theory is widely used to understand patterns of dependence and to develop educational and therapeutic strategies that help in the prevention and treatment of substance use.

Nevertheless, having motivation is not always enough to change or achieve a desired behavior - there is a well-known gap between intention and behavior. These people are called "good intenders".⁸ In this perspective, educational, economic, and legislative actions may contribute to reducing the social acceptance of people who smoke and encouraging them to quit or control smoking.⁶

Nurses, then, can have a pivotal role in assisting these individuals in transforming their intentions into action by providing evidence-based interventions grounded in behavioral and psychological theories. Research indicates that nursing interventions, including motivational interviewing, cognitive-behavioral strategies, and structured counseling sessions, significantly enhance smoking cessation success rates.⁹ Nurses are well-positioned to deliver educational programs, offer pharmacological support, and facilitate relapse prevention strategies tailored to individual patient needs. Studies highlight that theory-based approaches, such as the Trans theoretical Model of Behavior Change and the Self-Efficacy Theory, can be integrated into nursing practice to strengthen patients' commitment to quitting smoking.¹⁰ Given their frequent patient interactions and trust-based relationships, nurses are crucial in bridging the gap between smoking cessation intentions and sustained behavioral change, ultimately contributing to improved public health outcomes.¹¹

The present study adopted the Perceived Effects of Substance Use Theory as its conceptual foundation to guide the reflection on the nurse's role in supporting smoking management from an educational perspective, analyzing its implications for the teaching process of tobacco users and the nursing staff.

The perceived effects of substance use: a general theory

This theory refers to the identification of the effects perceived by the use of a wide variety of substances besides cigarettes, such as alcohol, hallucinogens, marijuana, tranquilizers, stimulants, and cocaine, among other substances. Generally, the individual uses them for well-being, to minimize his traumas or psychic feelings, and many times cannot realize that this behavior is irrational and self-destructive. Even though they do not have this knowledge, they use these substances because this practice becomes satisfactory.¹²

The use of tobacco according to the perceived effects of substance use framework

The results obtained by substance use can be biased, misinterpreted, and even unrecognized. However, the user ends up having the perception of costs and benefits, and this is important for him to continue or stop using. Even if this perception is unconscious, his use will be prolonged as long as the advantage associated with the use is more estimated than the perceived aggregate costs. Tobacco is a powerful, legal, and widely available psychoactive substance. Involvement with such a substance can lead to a link with other types of drugs, such as marijuana, for example, where its use rarely occurs without prior enjoyment of alcoholic beverages, tobacco, or both.¹³

The addictive properties of a drug depend on the psychic and somatic effects it exerts. Some factors, such as age (puberty and adolescence) and psychiatric or physical illnesses, can be considered predisposing to the initiation of use. The young, for example, have no need for the use of nicotine but end up using it out of curiosity or to imitate an adult. A cigarette contains about 1.5 milligrams of nicotine, which is quite a lot for someone who is not used to smoking and is about half the weight of an adult. The first sensations are uncomfortable, such as coughing, dizziness, headache, nausea, and vomiting. The reason for continuing smoking may seem strange since the young person has not yet developed a nicotine dependency. Still, he may want to imitate his elders and even appear larger and more confident than his.¹²

In the voluntary phase of use, the smoker does not yet have an established craving for nicotine, so he has other goals when practicing the act of smoking. He may smoke a cigarette in place of a meal to decrease his calorie intake or to have something to do with his hands in places he does not feel comfortable and thus hide a shyness. The dependency phase begins when the individual has been inhaling and exhaling nicotine for some time. With this, the nervous system is stimulated and enjoys the pleasant stimulating effect generated. Without realizing it, a desire for the effects of nicotine begins to develop, and it leads to dependence on the drug. There is no information in the literature on how many cigarettes need to be consumed to install dependence.¹⁴

Harmful effects of smoking

Nicotine is the main addictive substance in cigarettes and has negative effects on the brain. Even though nicotine is the main chemical able to makes smoking addictive, the harmful health effects of tobacco are mainly attributed to carbon monoxide, tar, and other components present in the smoke generated by burning tobacco leaves.¹⁵ Nicotine dependence develops rapidly, especially in adolescents who smoke. Most of them started cigarette use before the age of 19, and therefore, smoking is considered a pediatric disease.¹⁶

Tobacco dependence is a multifaceted process. It involves a close temporal connection between the environment in which smoking occurs, the associated rituals, the sensory stimuli of touch, taste, and smell, and the rapid absorption of nicotine into the brain when smoking a cigarette. Studies suggest that psychosocial, biological, and genetic factors contribute to the development of nicotine dependence.¹⁷ The ways tobacco is used can also vary. Among those available, the most common are traditional cigarettes, electronic cigarettes, shisha, cigars, pipes, or smokeless tobacco (snuff or chewing). Adolescents and adults have used them, and the amount and form of use vary according to the sociodemographic data of the population.¹⁸ In addition to the person who uses tobacco being exposed to the harmful effects of smoking, this person can expose others to smoke and its toxins. We call passive smoking the exposure of a person who does not use tobacco to smoke from the burning of related tobacco products exhaled by the person who uses tobacco. There are no safe levels of such exposure, and it can cause serious health problems.¹⁹

Third-hand smoke exposure is contact with toxins that remain on surfaces after the cigarette is put out and is most commonly found on household surfaces such as sofas, chair upholstery, or carpets. It can also stay on the surfaces of seat upholstery or child seats inside cars, and its absorption is through skin contact, ingestion, or even inhalation. Children who are crawling or learning to walk may come into contact with the toxic, highly carcinogenic substance and ingest it by putting their fingers in their mouths.²⁰

Smoking during pregnancy can lead to serious health problems for mother and baby, such as fetal growth retardation, premature labor, and even abortion.²¹ In addition, exposure to smoking that occurs from prenatal care through adolescence can contribute to a multitude of harmful and adverse health effects in the pediatric population.¹⁸

Smoking is a significant risk factor for several types of cancer, including lung cancer, and is also linked to other serious health problems. Tobacco use, defined as the use of any tobacco product, with or without smoke production, is considered a chronic disease classified as a mental and behavioral disorder resulting from the use of psychoactive substances. Nicotine addiction is a complex process, with psychosocial, biological, and genetic factors playing a role.^22-24

Smoking is the primary risk factor for lung cancer, especially for non-small cell lung cancer (NSCLC), which accounts for over 85% of cases. Among the subtypes, adenocarcinoma stands out, which has been increasing, particularly among women and younger populations; squamous cell carcinoma, more associated with smoking, especially in men; and large cell carcinoma, less common but aggressive. Smokers also have a higher risk of other cancers, such as those of the mouth, esophagus, bladder, and pancreas, and of developing a second cancer over their lifetime. Smoking can also reduce the effectiveness of treatments. Adopting tobacco control policies and investing in research are essential to reducing its impact on public health.^22-24

Nursing professionals play a key role in tobacco management, acting as health educators, care team members, and care managers, with interventions aimed at reducing or stopping tobacco use through educational materials, consultations, and nicotine replacement methods. They are also essential in smoking prevention spreading information about the risks of tobacco, and for this, they need continuous education to plan effective interventions. Nurses need to have both theoretical and practical tools, recognizing that each patient with cigarette dependence has a unique history and needs, which requires an individualized approach, considering their context and priorities.²⁵

Strengths and frailties to manage smoking

Primary health care is considered the most favorable place to approach the person who uses tobacco, as well as other chronic problems, to the health of the population.²⁶

In addition, it is expected that the health teams can solve most of the health problems of the community to which they belong through quality care. As smoking is still one of the biggest health problems of the country's population, it is necessary to offer proper care for the person who smokes and guidance for the prevention of the beginning of this behavior.²⁷ Each individual dependent on cigarettes has their history, needs, values, and preferences. The health professional needs to know this individuality within the context of the patient's life. This is essential to manage smoking and understand if quitting is or is not a priority in the individual's life.²⁷

One may also opt to try to control smoking, reduce this behavior, or implement harm control strategies to deal with the symptoms tobacco may cause.²⁸

When we analyze the behavior of a person who smokes, we may hypothesize that he smokes to avoid withdrawal symptoms, such as anxiety, tachycardia, and headaches, among others. By doing so, he also feels pleasure improves his concentration and the performance of his daily activities, thus leaving his environment conditioned and related as a habit. So, if the person smokes after drinking coffee, the beverage becomes a "trigger" for smoking. We can classify this fact as a discriminative event because it generates a moment to smoke, besides developing the sensation of pleasure, becoming a conditioned stimulus.²⁹

The one who smokes often feels pleasure in the short term because nicotine stimulates the central nervous system, and the person feels more alert, with ease of concentration. However, smoking causes serious health problems in the long term. We must consider that nicotine causes dependence and tolerance, i.e., each time the individual seeks the same effect, its dose may be progressively and commonly increased.²⁹

Some people who smoke will be motivated to quit or reduce smoking by the guidance on the harmful effects of smoking, others by the illness of a close relative, and still others by their illness. Behind the habit, there is always an individual who may present other demands and needs.³⁰

Nursing interventions aimed at managing smoking

Training nurses today is a great challenge because these professionals must have various skills in several areas, critical thinking, and the ability to work in multiple contexts. The role of nurses in smoking control is essential, as they have continuous contact with patients and can implement effective strategies in the fight against tobacco. Various evidence-based interventions can be applied in clinical practice, as highlighted by Zampier²⁶ who also suggests screening patients to identify smokers and offer personalized interventions. Using tools such as the Fagerström Test is an effective approach.³¹

Brazilian guidelines for smoking cessation, approach, and treatment are established by the Unified Health System (SUS); it includes structured therapeutic counseling based on cognitive-behavioral and pharmacological treatment. The available pharmacological options are nicotine replacement therapy (patch, gum, and lozenge), either alone or in combination, and bupropion hydrochloride. The total suggested treatment duration is 12 months, involving the stages of assessment, intervention, and maintenance of abstinence.²⁷

Thus, it is within this system that nurses should guide their actions. Based on this information, it is important to provide the necessary tools for nurses to make adequate interventions for tobacco management. Therefore, these professionals must have theoretical and practical tools to improve these interventions.³²

The strengthening of innovative and current practices for nursing, the need for constant updating in the health area, and the difficulties that face-to-face teaching and care work require have driven the distance learning methodology. This modality and the development of courses in this format allow the worker to have the autonomy to schedule his studies, manage his time, get trained, and even supply the reality of the service to which he is inserted. Disseminating knowledge through work, teaching, and research is considered an important role in nursing practice and is in line with the essence of this profession. It can also contribute to public health issues, as in this case, smoking.³³

Nurses are considered health educators, assistive members, or care managers, playing a fundamental role due to their professional specificities. Therefore, they can use some interventions aimed at smoking case management, obtaining satisfactory results regarding smoking outcomes.²⁶

However, nurses also have this current mission of being pragmatic. The term applies primarily to doing human, purposeful activity, which is termed praxis; i.e., nursing knowledge and capacity of teaching and researching must be translated into practice to have actual value to society.³⁴

It is in this scenario that nurses act because, as observed, smoking is considered a public health problem. This professional acts mainly in what concerns smoking prevention and acts as an information disseminator because among the nurse's attributes is the participation in educational programs and activities aiming at improving the health of the individual, the family, and the population in general.  As a health professional, the nurse is a potential educator regardless of the context in which they are inserted.

However, there is moderate quality evidence that behavioral support to motivate improvements in smoking outcomes delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is still insufficient data to determine whether more intensive approaches, including additional follow-up or pathophysiological feedback, are more effective than single support. Moreover, no differences in the effects of support were observed across patient groups or healthcare settings.⁹ These data point to the pressing need for nurses to design and engage in theory-based tailored interventions aimed at assisting people in achieving their own planned goals regarding smoking behavior.

None.

The authors declare that they have no conflicts of interest.

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