MT20 • Montana Nurses 2019-2020

Table of Contents

MT20 • Montana Nurses 2019-2020

How to Receive Credit

NetCE 10 Hour Course #91783 • Smoking and Secondhand Smoke

91783 • Smoking and Secondhand Smoke

1. INTRODUCTION

2. DEFINITIONS

3. HISTORY OF TOBACCO USE AND RESTRICTION

4. PREVALENCE AND ECONOMIC IMPACT OF SMOKING

5. TOBACCO AND NICOTINE PRODUCTS

6. TOBACCO-RELATED CONCEPTS

7. CIGARETTE SMOKE

8. ANATOMY AND PHYSIOLOGY OF SMOKE INHALATION

9. LEARNING OF BEHAVIOR

10. SMOKING DEPENDENCE

11. HEALTH COMPLICATIONS RELATED TO SMOKING

12. COMORBID CONDITIONS

13. FETAL EXPOSURE

14. PASSIVE SMOKING EFFECTS ON CHILDREN

15. PASSIVE SMOKING EFFECTS ON ADULTS

16. MEASURING SECONDHAND SMOKE EXPOSURE

17. THIRDHAND SMOKE

18. INTERVENTIONS FOR SMOKING CESSATION

19. REDUCING TOBACCO SMOKE EXPOSURE

20. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 15 Hour Course #31960 • Rural Public Health and Nursing Care

31960 • Rural Public Health and Nursing Care

1. INTRODUCTION

2. DEFINITIONS

3. CHARACTERISTICS OF RURAL POPULATIONS

4. RURAL POPULATION HEALTH

5. CHARACTERISTICS OF THE RURAL HEALTHCARE SYSTEM

6. IMPROVING THE RURAL PUBLIC HEALTHCARE SYSTEM

7. CONSIDERATIONS FOR NON-ENGLISH-PROFICIENT PATIENTS

8. CONCLUSION

9. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

MT20 • Montana Nurses 2019-2020

Mark S. Gold, MD, DFASAM, DLFAPA

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

MT20 • Montana Nurses 2019-2020

Expiration Date: 04/30/2020

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

91783 • Smoking and Secondhand Smoke

Mark S. Gold, MD, DFASAM, DLFAPA

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

This course provides comprehensive clinical education on tobacco smoke in primary care and public health. It addresses core competencies as well as knowledge, assessment, and treatment-based competencies of healthcare providers. It covers the history of tobacco, epidemiology of tobacco use, tobacco smoke metabolism, dependence, treatment and relapse. It also addresses complications associated with direct and indirect exposure to tobacco smoke, effects of prenatal exposure, methods of screening for exposure, and brief intervention training. This course includes a review of available screening tools, predisposing genetic factors, associated risk and protective factors, withdrawal symptoms and treatment, lab testing procedures, diagnostic tools, and age and gender issues.

Table of Contents

91783 • Smoking and Secondhand Smoke

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. DEFINITIONS

3. HISTORY OF TOBACCO USE AND RESTRICTION

4. PREVALENCE AND ECONOMIC IMPACT OF SMOKING

5. TOBACCO AND NICOTINE PRODUCTS

6. TOBACCO-RELATED CONCEPTS

7. CIGARETTE SMOKE

POTENTIALLY THERAPEUTIC COMPONENTS OF TOBACCO

8. ANATOMY AND PHYSIOLOGY OF SMOKE INHALATION

9. LEARNING OF BEHAVIOR

RITUALISM

MEDIA INFLUENCE

GENETICS

10. SMOKING DEPENDENCE

PSYCHOLOGIC DEPENDENCE

11. HEALTH COMPLICATIONS RELATED TO SMOKING

PULMONARY COMPLICATIONS

CARDIOVASCULAR COMPLICATIONS

NEUROLOGIC COMPLICATIONS

CANCER

OSTEOPOROSIS

PROBLEMS WITH CONCEPTION AND EMBRYONIC HEALTH

12. COMORBID CONDITIONS

ALCOHOL ABUSE

DRUG ABUSE

PSYCHIATRIC DISORDERS

13. FETAL EXPOSURE

PHARMACOKINETICS AND DYNAMICS

NEUROLOGIC COMPLICATIONS

PULMONARY COMPLICATIONS

CARDIOVASCULAR COMPLICATIONS

LOW BIRTH WEIGHT AND SMALL FOR GESTATIONAL AGE

MIDDLE EAR DISEASE

CANCER

OSTEOPOROSIS

PSYCHIATRIC DISORDERS

14. PASSIVE SMOKING EFFECTS ON CHILDREN

NEUROLOGIC EFFECTS

CARDIAC COMPLICATIONS

SIDS

PULMONARY COMPLICATIONS

DENTAL CARIES

VITAMIN DEFICIENCY

RESULTANT SYMPTOMS IN ADULTHOOD

15. PASSIVE SMOKING EFFECTS ON ADULTS

OCCUPATIONAL EXPOSURE

HEART DISEASE

STROKE

LUNG DISEASE

CANCER

GLUCOSE INTOLERANCE/DIABETES

SKIN DISORDERS

WOUND REPAIR

AGE-RELATED MACULAR DEGENERATION

CERVICAL INTRAEPITHELIAL NEOPLASM (CIN)

NONALCOHOLIC FATTY LIVER DISEASE

16. MEASURING SECONDHAND SMOKE EXPOSURE

17. THIRDHAND SMOKE

18. INTERVENTIONS FOR SMOKING CESSATION

PRIMARY CARE INTERVENTION

BRIEF INTERVENTION

MOTIVATIONAL INTERVIEWING

INTERVENTIONS FOR NON-ENGLISH-PROFICIENT INDIVIDUALS

TREATING NICOTINE DEPENDENCE

19. REDUCING TOBACCO SMOKE EXPOSURE

20. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

91783 • Smoking and Secondhand Smoke

Education Category. Community Health

Release Date. 06/01/2019

Expiration Date. 05/31/2022

Course Overview

This course provides comprehensive clinical education on tobacco smoke in primary care and public health. It addresses core competencies as well as knowledge, assessment, and treatment-based competencies of healthcare providers. It covers the history of tobacco, epidemiology of tobacco use, tobacco smoke metabolism, dependence, treatment and relapse. It also addresses complications associated with direct and indirect exposure to tobacco smoke, effects of prenatal exposure, methods of screening for exposure, and brief intervention training. This course includes a review of available screening tools, predisposing genetic factors, associated risk and protective factors, withdrawal symptoms and treatment, lab testing procedures, diagnostic tools, and age and gender issues.

Audience

This course is designed for physicians, nurses, and other healthcare professionals who may intervene to stop patients from smoking.

Course Objective

The purpose of this course is to provide physicians, nurses, behavioral health professionals, and other members of the interdisciplinary team with a formal educational opportunity that will address the impact of tobacco smoking and secondhand exposure in public health and disease as well as interventions to promote smoking cessation among their patients.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the history of tobacco and its impact on society.

2. Define the prevalence and economic impact of tobacco smoke exposure on public health.

3. Differentiate between available tobacco products.

4. Describe the neurophysiologic effects and addictive components of tobacco smoke.

5. Describe the anatomy and physiology of smoke inhalation, and outline key points in learning of behavior.

6. Define the psychologic and physiologic aspects of smoking dependence.

7. List the common health complications related to smoke exposure.

8. Identify the common comorbid conditions of tobacco users.

9. Describe the developmental complications related to prenatal exposure to smoke.

10. Define the effects of exposure to secondhand smoke for children and adults.

11. Identify the methods of detecting and measuring tobacco smoke exposure.

12. Define thirdhand smoke.

13. Outline the methods of tobacco cessation interventions, including necessary considerations for non-English-proficient patients.

14. Define the treatment modalities for tobacco addiction, including pharmacologic options.

15. Identify strategies to reduce exposure to tobacco smoke.

Faculty

Mark S. Gold, MD, DFASAM, DLFAPA, is a teacher of the year, translational researcher, author, mentor, and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine, and food. Dr. Gold was a Professor, Eminent Scholar, Distinguished Professor, Distinguished Alumni Professor, Chairman, and Emeritus Eminent Scholar during his 25 years at the University of Florida. He was a Founding Director of the McKnight Brain Institute and a pioneering neuroscience-addiction researcher funded by the NIH-NIDA-Pharma, whose work helped to de-stigmatize addictions and mainstream addiction education and treatment. He also developed and taught courses and training programs at the University of Florida for undergraduates and medical students.

He is an author and inventor who has published more than 1,000 peer-reviewed scientific articles, 20 text books, popular-general audience books, and physician practice guidelines. Dr. Gold was co-inventor of the use of clonidine in opioid withdrawal and the dopamine hypothesis for cocaine addiction and anhedonia. Both revolutionized how neuroscientists and physicians thought about drugs of abuse, addiction, and the brain. He pioneered the use of clonidine and lofexidine, which became the first non-opioid medication-assisted therapies. His first academic appointment was at Yale University School of Medicine in 1978. Working with Dr. Herb Kleber, he advanced his noradrenergic hyperactivity theory of opioid withdrawal and the use of clonidine and lofexidine to ameliorate these signs and symptoms. During this time, Dr. Gold and Dr. Kleber also worked on rapid detoxification with naloxone and induction on to naltrexone.

Dr. Gold has been awarded many state and national awards for research and service over his long career. He has been awarded major national awards for his neuroscience research including the annual Foundations Fund Prize for the most important research in Psychiatry, the DEA 30 Years of Service Pin (2014), the American Foundation for Addiction Research’s Lifetime Achievement Award (2014), the McGovern Award for Lifetime Achievement (2015) for the most important contributions to the understanding and treatment of addiction, the National Leadership Award (NAATP) from addiction treatment providers for helping understand that addiction is a disease of the brain, the DARE Lifetime Achievement Award for volunteer and prevention efforts, the Silver Anvil from the PR Society of America for anti-drug prevention ads, the PRIDE and DARE awards for his career in research and prevention (2015), and the PATH Foundation’s Lifetime Achievement Award (2016) as one of the “fathers” of addiction medicine and MAT presented to him by President Obama’s White House Drug Czar Michael Botticelli. He was awarded Distinguished Alumni Awards at Yale University, the University of Florida, and Washington University and the Wall of Fame at the University of Florida College of Medicine. Gold was appointed by the University President to two terms as the University’s overall Distinguished Professor, allowing him to mentor students and faculty from every college and institute. The University of Florida College of Medicine’s White Coat Ceremony for new medical students is named in his honor.

Since his retirement as a full-time academic in 2014, Dr. Gold has continued his teaching, mentoring, research, and writing as an Adjunct Professor in the Department of Psychiatry at Washington University and an active member of the Clinical Council at the Washington University School of Medicine’s Public Health Institute. He regularly lectures at medical schools and grand rounds around the country and at international and national scientific meetings on his career and on bench-to-bedside science in eating disorders, psychiatry, obesity, and addictions. He continues on the Faculty at the University of Florida College of Medicine, Department of Psychiatry as an Emeritus Distinguished Professor. He has traveled extensively to help many states develop prevention, education, and treatment approaches to the opioid crisis.

Faculty Disclosure

Contributing faculty, Mark S. Gold, MD, DFASAM, DLFAPA, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Jane C. Norman, RN, MSN, CNE, PhD

Alice Yick Flanagan, PhD, MSW

Abimbola Farinde, PharmD, PhD

James Trent, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

1. INTRODUCTION

Tobacco smoke exposure is a major cause of the nation's most serious and preventable health problems. This course provides comprehensive clinical education on tobacco smoke in primary care and public health. It addresses core competencies as well as knowledge, assessment, and treatment-based competencies of healthcare providers. It covers the history of tobacco, epidemiology of tobacco use, tobacco smoke metabolism, dependence, treatment, and relapse. It also addresses complications associated with direct and indirect exposure to tobacco smoke, effects of prenatal exposure, methods of screening for exposure, and brief intervention training. This course includes a review of available screening tools, predisposing genetic factors, associated risk and protective factors, withdrawal symptoms and treatment, lab testing procedures, diagnostic tools, and age and gender issues.

2. DEFINITIONS

A clear understanding of tobacco use and smoking is dependent on a knowledge of the basic underlying concepts associated with addiction [1].

Tolerance: The need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance.

Withdrawal: Maladaptive behavioral change, with physiologic and cognitive concomitants, that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing unpleasant withdrawal symptoms, the person is likely to take the substance to relieve or to avoid those symptoms, typically using the substance throughout the day, beginning soon after awakening.

Substance use disorder: A cluster of cognitive, behavioral, and physiologic symptoms indicating that the individual continues using the substance despite significant substance-related problems. There is also an underlying change in brain circuits that may persist beyond detoxification.

3. HISTORY OF TOBACCO USE AND RESTRICTION

Tobacco was the first export of the New World and was marketed in Europe as a remedy for stress, ulcers, headaches, asthma, and even rheumatism. Tobacco's botanical name, Nicotiana tabacum, is derived from Jean Nicot, a French ambassador to Portugal who, convinced of tobacco's medicinal value, sent the plant's seeds to the royal family in France [2].

Tobacco product use has been discouraged in the United States and abroad for centuries. In 1586 the first recorded tobacco prohibition was issued by Pope Sixtus V, who declared it a sin "for any priest to use tobacco before celebrating or administering communion." In 1604, King James I published A Counterblaste to Tobacco, describing smoking tobacco as, "a custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, [and] dangerous to the Lungs" [3]. Tobacco use and distribution saw further restrictions across the globe in the early 1600s. King James I levied heavy taxes on tobacco, the czar of Russia exiled tobacco users, and the Chinese executed persons caught selling tobacco [4].

However, in contrast to strict regulations found elsewhere in the world, tobacco was brought to the United States as a cash crop. The 1880s saw the invention of an automated cigarette-making machine, which paved the way for cigarettes to become the predominant form of tobacco with the start of World War I. The twentieth century also experienced the first major outcry against tobacco in the United States. Though medical concerns were suggested, the first tobacco prohibition movements in the United States were primarily driven by religious and moral motivations. Groups including religious leaders, the Women's Christian Temperance Union, and the Non-smokers Protective supported efforts for prohibition of tobacco. However, strong public resistance against alcohol prohibition also led to the repeal of tobacco restrictions, and by the 1930s these restrictions had all but vanished [5].

One of the lesser known consequences of World War II was that German smoking research and corresponding social change were not acknowledged by the rest of the world. In the 1930s and early 1940s, Germany conducted an aggressive anti-smoking campaign based on medical research from the 1920s and 1930s, which elucidated the carcinogenic effects of smoking. As part of the German movement aimed to preserve a racial "utopia" of pure, healthy Germans, they banned smoking in the workplace, imposed cigarette taxes, restricted advertising and farming, and implemented programs to eliminate smoking [6,7].

Associations between smoking and cancer were not published in the United States until the 1950s and 1960s. The 1964 publication Smoking and Health: Report of the Advisory Committee to the Surgeon General led to immediate political notice of the tobacco issue and the advent of programs and policies to reduce smoking [8]. Anti-tobacco policies have included taxation on tobacco products, increased insurance premiums, warning labels, public health campaigns, and restrictions on tobacco sales to minors, smoking in public areas, and tobacco marketing. Prior to 1964 there were few if any laws regulating involuntary secondhand smoke (SHS) exposure. Studies revealing the detrimental effects of SHS to nonsmokers led to new anti-smoking legislation. As of June 2009, the General Services Administration (GSA) has established smoke-free environments for federal facilities. Interior areas previously designated for smoking have been closed and smoking is prohibited in courtyards and within 25 feet of doorways and air intake ducts in outdoor spaces [9]. Further, nearly all 50 states have laws restricting smoking in places such as schools, public transportation, government buildings, elevators, and restaurants. In accordance with federal law, smoking is prohibited on buses, trains, and domestic airline flights. Such laws have decreased cigarette consumption by making smoking less socially acceptable and more inconvenient [5].

On June 22, 2009, President Barack Obama signed HR1256: The Family Smoking Prevention and Tobacco Control Act. This was enacted as a result of several findings made by Congress, specifically that almost all new users of tobacco products are younger than the minimum legal age to purchase such products. Under this law, the U.S. Food and Drug Administration (FDA) now has the authority to regulate tobacco products [10]. The FDA had previously attempted to assert jurisdiction under the Food, Drug, and Cosmetic Act in 1996 to regulate tobacco advertising, labeling, and purchasing restrictions (e.g., federal minimum age of 18 years and requiring retailers to check identification). However, the tobacco industry retaliated by suing the federal government, as there was no set legislation to give the FDA this authority. As a result, all FDA regulations were dropped [11]. Due to the 2009 law, the FDA can now establish a minimum age of sale of tobacco products, test and report on tobacco product ingredients/additives, prohibit cigarettes from containing any flavors other than tobacco or menthol, and apply the same restrictions on labeling and advertising of cigarettes to smokeless tobacco products. Of note, this law states that the FDA cannot ban existing products or require nicotine be eliminated from any product.

In 2017, the FDA unveiled a comprehensive plan on tobacco and nicotine regulation to reduce the number of preventable deaths caused by smoking and tobacco use. The two key areas of focus of this plan are reducing the nicotine levels in combustible cigarettes to render them minimally or nonaddictive and harnessing new forms of nicotine delivery that could allow currently addicted adult smokers to get access to nicotine without many of the risks associated with using combustible tobacco products. Similar to the 2009 policy, this plan will also explore the extent of tobacco flavoring in attracting youth and new smokers; menthol flavoring will be included in this plan. Of note, this policy only affects newly regulated tobacco products and will not affect any current requirements for cigarettes and smokeless tobacco. As of 2019, the plan was still in development and the FDA was continuing to seek public comment and expert opinion [472,474].

4. PREVALENCE AND ECONOMIC IMPACT OF SMOKING

Approximately 480,000 Americans die each year as a result of active and/or passive smoking-related health consequences [12]. Despite the seemingly well-known and highly publicized health consequences of smoking, 13.9% of the U.S. population 18 years of age or older are current cigarette smokers [460]. Former U.S. Assistant Secretary for Health Howard Koh asserted that although evidence-based tools were successful in substantially reducing smoking prevalence between 1997 and 2004, efforts were not applied to their full potential nationwide, limiting the efficacy of anti-smoking campaigns [14]. Other experts have attributed declines in cigarette smoking to anti-smoking advertisements, stigma, smoking bans, and increased taxation [460]. Evidence-based tools remain valuable, indicated by slow, steady downward prevalence trends since 1997. However, they are only useful if they reach an audience. These tools seem not to be preventing the initiation of new smokers, despite the overall reductions in use [14,15].

Nearly 1.8 million Americans initiated cigarette smoking in 2016, continuing a downward trend noted between 2002 and 2013 (ranging from 1.9 to 2.2 million); 40.6% of these were younger than 18 years of age [13]. About one-third of new smokers will ultimately die from a smoking-related illness [16]. Higher levels of education are correlated with a lower likelihood of having smoked cigarettes in the past month [13]. The number of first-time cigar users is slowly declining, from 2.8 million in 2011 to 2.4 million in 2016 [13]. In 2016, current use of any tobacco product was highest among American Indians/Alaska Natives (42.6%) followed by persons of two or more races (40.2%), whites (31.3%), blacks (27.8%), Hispanics (22%), and Asians (11.9%) [13].

Approximately 41,000 adult nonsmokers die each year from exposure to SHS, and this continues to be a significant environmental risk in the United States [19]. According to a 2009 study by Ellis and colleagues, the prevalence of smoking in New York City was lower than the national average (23.3% vs. 29.7%), but the proportion of nonsmoking adults with elevated cotinine levels was higher (56.7% vs. 44.9%), especially among Asians, even after close to two years after implementation of smoke-free workplace legislation [20]. They attribute this finding to the large amounts of people in such small proximity (26,000 people and 10,000 housing units per square mile vs. the national average of 80 people and 33 housing units per square mile) [20]. In a 2017 study, Perlman and colleagues reviewed cotinine levels in New York City nonsmokers, and found that 37.1% had elevated levels [17]. It is thought that this reduction is a result of smoke-free air policies enforced within the previous 10 to 15 years. The researchers also agreed that greater population density and pedestrian exposure continued to contribute to the high number of nonsmokers with elevated cotinine levels [17].

Tobacco use is one of the most expensive addictive behaviors in the United States. In 2015, an estimated 299.9 billion cigarette stick equivalents (based on the weight of 0.0325 ounces of tobacco per cigarette) were consumed in the United States, of which 262.7 billion were cigarettes; the rest were other combustible tobacco products [21]. This accounted for $93.9 billion in national expenditures on cigarettes alone in the 2017 fiscal year [23].

Smoking-related costs in the United States are staggering. The total annual public and private healthcare expenditures caused by smoking are estimated to be greater than $300 billion, including nearly $170 billion in direct medical costs and more than $156 billion in lost productivity related to premature death and exposure to SHS [12].

5. TOBACCO AND NICOTINE PRODUCTS

Cigarette smoking is on the decline in the United States, but use of other tobacco products is not [21]. In addition to a rise in use of smokeless tobacco, people across the United States (especially youth) are using e-cigarettes, cigars, cigarillos (small cigars), hookahs, kreteks, pipes, and bidis (or beedis) [18,25]. Unfortunately, each of these products is just as dangerous (if not more so) as use of cigarettes. Cigarettes are defined by the U.S. Department of the Treasury as "any roll of tobacco wrapped in paper or in any substance not containing tobacco," while cigars are defined as "any roll of tobacco wrapped in leaf tobacco or in any substance containing tobacco" [26]. Cigars also differ from cigarettes in processing; they consist of filler, a binder, and a wrapper, all made of air-cured and fermented tobaccos [27]. Cigars show significant variability in physical and chemical characteristics, with total nicotine content ranging from 10.1 mg to 444 mg per cigar, length ranging from 68.0 mm to 213.5 mm, and diameter ranging from 8.0 mm to 20.5 mm [28]. Due to their size and makeup, smokers can spend up to an hour smoking a single cigar; therefore, its ensuing effects (e.g., rates of cancer, chronic obstructive pulmonary disease [COPD]) are more pronounced. Cigarillos, or "little cigars," are generally about half the size of a normal cigar, weighing 1.5 to 3 g on average [29]. Many types are made to look like cigarettes and are sold in packs of 20 with filter tips. Cigarillos are perceived as a less addictive, less harmful, and less expensive alternative to cigarette use [30; 31].

Due to increased federal taxation on cigarettes, cigarette tobacco, and small cigars, many consumers apparently switched to smoking products virtually identical to cigarettes or small cigars, but classified as large cigars, or from smoking roll-your-own tobacco to smoking pipe tobacco [22]. Subsequent to the 2009 tax increase and intensified FDA regulation, many companies simply relabeled cigarette rolling tobaccos as pipe tobaccos (not subject to increased taxation) [21]. Sales of "pipe tobacco" increased from 5.2 million pounds in 2009 to 43.7 million pounds in 2013 (a 740% change) while roll-your-own tobacco sales dropped from 21.3 million pounds to 3.8 million pounds [22]. Following a similar relabeling and marketing effort for small cigars, sales of large cigars jumped from 5.8 billion sticks in 2009 to more than 12.4 billion sticks in 2013, while small cigars decreased from 5.7 billion sticks to 0.7 billion sticks in the same years. In 2016, the FDA extended its limitations for tobacco products to include e-cigarettes, vaporizers, and other electronic nicotine delivery systems [458]. As a result, these products must include warnings and manufacturers must submit documentation to the FDA for review and limit sales to persons 18 years of age or older. The goals of these regulations are to increase public health awareness and, especially, reduce marketing and sales to adolescents, who are commonly targeted by providing tobacco flavors including apple, cherry, cream, grape, "jazz," strawberry, and wine. Before this ruling, there were no federal laws restricting sales of these types of products, but an alarming increase in unregulated tobacco products, especially among high school students, prompted the FDA to enforce regulations.

The rise of e-cigarettes in the past decade has introduced new variables in the prevention and treatment of nicotine addiction. Originally marketed as a smoking cessation tool, e-cigarettes are electronic products that typically deliver nicotine in the form of an aerosol [456]. Most e-cigarettes consist of a cartridge (which holds a liquid solution containing varying amounts of nicotine, flavorings, and other chemicals), a heating device (vaporizer), and a power source (usually a battery) [457]. In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called "vaping") [457]. It is unclear if this delivery method decreases the risks seen with conventional tobacco smoking; however, it does introduce the risks of toxicity associated with consumption of the potent e-liquid.

In 2017, 2.8% of adults were current e-cigarette users. Adults 25 to 44 years of age have the highest rate of e-cigarette use (22.5%), followed by those 45 to 64 years of age (21.3%), 18 to 24 years of age (18.3%), and older than 65 (11%) [456]. Use is much higher among men (24.8%) than women (14.2%).

Adolescent use of e-cigarettes has skyrocketed from 1.5% in 2011 to 20.8% in 2018, making it the number one form of tobacco used among youth [459,465]. In 2018, the FDA issued more than 1,300 warnings and fines to retailers who illegally sold e-cigarette products to minors [464].

According to the Centers for Disease Control and Prevention (CDC), large cigar consumption increased 116% from 2000 to 2017, with cigar smoking being the third most common form of tobacco use among youth [32,33]. However, it has been shown that adolescent (and likely adult) cigar use is significantly underestimated due to systematic misreporting on statewide surveys, which is mainly attributed to the language and definitions used in questions that assume knowledge of all types of cigars [34]. For example, it was found that more than half of Black & Mild (brand of cigars and cigarillos) users did not report any cigar/cigarillo use on a 2009 Virginia survey, largely because the usage of the terms "cigar" or "cigarillo" for this (and other similar products) is not common in the youth- or culture-specific lexicon.

Bidis consist of sun-dried tobacco, finely ground and rolled into a leaf of the Diospyros melanoxylon plant native to India. They contain concentrated tobacco, with an average 21.2 mg/g of nicotine compared with 16.3 mg/g of nicotine in filtered and 13.5 mg/g in unfiltered cigarettes, but have less total nicotine because they are shorter [35]. Nonetheless, an unfiltered bidi can release three to five times more tar and nicotine and contain more ammonia and carbon monoxide (CO) than a regular cigarette. Bidis look similar to small cigars or marijuana cigarettes and are available filtered or unfiltered in many flavors, including vanilla, chocolate, strawberry, cherry, and menthol [36]. Bidis are not commonly used in the United States, and sale and distribution is banned in some states (e.g., Illinois, Vermont, West Virginia). However, these products are available on the Internet [37].

Kreteks, or clove cigarettes, are composed of a mixture of tobacco (60% to 80%) and ground clove buds (20% to 40%), available with or without filters [38]. A popular, representative kretek brand contains less nicotine than popular cigarettes (7.39 mg), but smokers extract equal amounts of nicotine by altering smoking behavior [39]. For example, clove cigarettes can be smoked slower, using more puffs. Overall, smokers will do whatever is necessary to achieve plasma levels of nicotine comparable to their usual brand of cigarette.

A hookah is a type of waterpipe comprised of a head or bowl, plate, body, jar, hose, and mouthpiece (Figure 1). The body of the hookah fits down into the jar, which is partially filled with water, although any liquid (e.g., alcohol, juice) can be used. Tobacco is placed in the bowl at the head of the body and covered with a filter, such as perforated tin foil, and then burning embers or charcoal is placed above it (and sometimes covered by a cap). The hot air from the charcoal roasts the tobacco and the ensuing smoke is passed down into the liquid in the jar where it is partially filtered, diluted, and cooled. The smoke then bubbles up and passes through the hose and mouthpiece for inhalation. Repeated inhalation is required to keep the tobacco burning. The plate stores dead coals/embers. The types of tobacco used for hookah are ajami or tumbak, which is a pure, dark tobacco paste; "honeyed" or tobamel or maassel, containing 70% honey or molasses and featuring flavors (e.g., apple, mango, banana); or jurak, which may be sweetened or contain fruits or oils. It is commonplace to use 10–20 g at a time, and these tobaccos may be mixed with other drugs [40]. Smoking sessions last up to an hour or longer, and it has been reported that the nicotine content of the tobacco used for hookah is higher than that in cigarettes [41]. Thus, the smoker is exposed to a higher volume of smoke for longer periods (not to mention those in the vicinity). A report from the World Health Organization states that a hookah user may inhale as much smoke in one session as a cigarette smoker would after consuming at least 100 cigarettes [42]. Contrary to popular belief, waterpipe smoking is not safer or less addictive than cigarette smoking [43]. The FDA began regulating the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of tobacco mixtures used for hookah in 2016 [24]. Hookah smoke contains higher concentrations of CO, nicotine, tar, heavy metals, and carcinogens, likely because of its method of use (i.e., tobacco mixtures heated by quick-burning charcoal or wood embers and inhalation through use of a plastic hose for an hour or longer) [44,45]. It is also common to share a hookah, so users are also at risk of exposure to infections (e.g., herpes due to sharing of the mouthpiece) [46]. Hookah pipe smoking may be a gateway to cigarette smoking and other drug use. Although policies are in place to ban smoking in many public places, many times, hookah use is exempt because it is done in places which identify themselves as "tobacco bars," waterpipe smoking areas are set up outside, or the smoking is done in places where tobacco is sold.

Figure 1: SCHEMATIC OF A WATERPIPE

Source: [46]

6. TOBACCO-RELATED CONCEPTS

For many years, efforts to make cigarettes "safer" have been pursued as a compromise solution [48]. Filtering devices have been used to selectively reduce cigarette smoke constituents for almost 60 years [49]. Studies from the 1970s concluded that charcoal filters can remove up to 66% of ciliotoxic agents from mainstream smoke, and cellulose acetate filter tips can eliminate up to 75% of N-nitrosamines, which are known volatile carcinogenic compounds [50,51]. However more recent studies have shown that neither type of filter is effective for reducing the free radical and reactive oxygen species content in the particulate or gas phase of cigarette smoke [52]. Additionally, remnant (i.e., post-filter) aqueous tar can cause the formation of DNA adducts, particularly the mutagenic 8-Oxo-2'-deoxyguanosine (8-oxo-dG).

The FTC performs tar, nicotine, and CO content measurements in all domestic cigarette varieties sold in the United States, which numbered almost 1,300 in 1998, the last year the report was conducted. The FTC defines tar as the particulates of cigarette smoke minus water and alkaloids, such as nicotine, detected using a method developed in 1966 [53]. In 2016, 99.7% of cigarettes sold in the United States had filters, and the FTC reported that 87.9% of the market share of cigarettes had less than 15 mg of tar, compared with only 2% in 1967 [53,54]. Nevertheless, epidemiologic evidence does not indicate that modern cigarettes are any safer. Smokers participating in the Cancer Prevention Study II (CPS-II) from 1982 to 1988 manifested an almost sixfold increase in lung cancer death compared to Cancer Prevention Study I (CPS-I) participants during 1959 to 1965, even though filter tips were introduced in the 1950s and only the latter group benefited from their implementation [55]. Smoking pattern compensation and use of stronger tobacco strains may be at least partially responsible for this paradoxical trend.

Filter vents, usually shaped in rings of small perforations along the filter, allow air to mix with smoke, diluting the amount of tar, nicotine, and CO detected by the FTC method [53]. Interestingly, as many as 58% of smokers of cigarettes with tar less than approximately 7% (formerly labeled "ultralight") and 53% of smokers of cigarettes with tar levels of 8–14 mg of tar (formerly labeled "light") cover these vents to some extent [56,57]. Blocking half of the vents of a 4.4 mg tar cigarette, as is done when smokers pinch the cigarette with their fingers or hold the cigarette in their lips, increases yields of tar by 60%, nicotine by 62%, and CO by 73% [58]. Poor reliability of the FTC method is further made evident in the work of Byrd and Robinson, who concluded that the "FTC yield cannot precisely predict nicotine uptake for an individual smoker" and "nicotine uptake by smokers is influenced by…many possible smoker-controlled parameters" [59]. Interestingly, this publication originates from the R.J. Reynolds Tobacco Company. Another contributing factor to the increase in mortality related to smoking may be the concentration of nitrate in tobacco leaves, one of the most important precursors for the endogenous formation of N-nitrosamines during smoke inhalation [60]. Cigarette nitrate content has increased from 0.5% in the 1950s to 1.2% to 1.5% in the late 1980s, possibly due to the increased use of chemical fertilizers and the introduction of plant ribs and stems into U.S. tobacco blends [61]. The carcinogenic potential of nitrosamines has been well documented.

All in all, efforts to reduce the health hazards of smoking leave much to desire, and in spite of filter tip implementation and reportedly lower tar values, cigarettes remain a serious health hazard, affecting smokers and those around them.

7. CIGARETTE SMOKE

Cigarette smoke is a complex mixture of more than 7,000 components, including nicotine, aromatic hydrocarbons, sterols and oxygenated isoprenoid compounds, aldehydes, nitriles, cyclic ethers, and sulfur compounds [62,63,134]. At least 70 of these components are known to cause cancer [134]. Firsthand smoke is defined as the smoke that the smoker inhales. Smoking tobacco products also generates environmental tobacco smoke, also known as SHS and passive smoke, which consists of both exhaled mainstream and sidestream smoke. These two forms of smoke differ in chemical composition and have different temperatures and oxygen levels during generation. The burning end of a cigarette produces sidestream smoke, which in turn is the main component of SHS. Some known toxins of the thousands of chemical constituents in tobacco smoke are also present in SHS, including benzene, cadmium, ethylbenzene, formaldehyde, hydrazine, lead, limonene, methylamine, methylene chloride, nicotine, pyridine, toluene, and radioactive polonium-210 [64,65,66]. One study identified indoor air pollution from SHS as 10 times greater than diesel car exhaust [67].

Many of the diseases once thought only to be caused by active smoking have now been authoritatively linked to environmental tobacco smoke [62,68]. This finding is not surprising considering that many of the harmful components found in both firsthand smoke and SHS are more concentrated in SHS. Nicotine, tar, nitric oxide, and CO levels have been shown to be nearly twice as concentrated in SHS. Other harmful chemicals preferentially formed in SHS include carcinogenic aromatic amines (e.g., o-toluidine, 2-naphthylamine, and 4-aminobiphenyl) [62,65,69].

POTENTIALLY THERAPEUTIC COMPONENTS OF TOBACCO

According to Lans et al., the crushed leaves of Nicotiana tabacum are applied to wounds in Guatemala, and tobacco steam vapor is considered a cure-all in Latin America and the Caribbean. In addition to its most addictive component, nicotine, the tobacco plant contains many enzymes, flavonoids, and coumarins and malic, citric, and phenolic acids [70]. In a case-control study by Sandler et al., tobacco use and secondhand exposure (e.g., parents had smoked) reduced the risk of developing ulcerative colitis [71]. Plants of the genus Nicotiana have been manipulated in various experiments to express proteins that may be used medicinally. Indeed, transgenic tobacco plants have been used in the development of vaccines for measles, lymphoma, and diabetes [72,73,74].

8. ANATOMY AND PHYSIOLOGY OF SMOKE INHALATION

Administration of any drug via smoking is a highly efficient route, allowing rapid delivery to the brain. This act involves inhalation of a small volume of smoke (an average of about 35 ml for cigarettes) into the mouth from which it is drawn into the lungs [75]. The breathing pattern employed is different from normal tidal breathing in that a smoker's inhalation is deeper and more rapid, drawing the smoke in as a bolus at the beginning of inhalation [76]. However, this pattern varies greatly between smokers and during the course of consuming a single cigarette [77]. Uptake of smoke ingredients is determined by many factors, including chemical composition, smoker's inhalation behavior, lung morphology, and physiologic parameters such as tidal volume, vital capacity, rate of breathing, and rate of lung clearance [78]. Individual differences in size, metabolism, and genetics may also play a role. One hypothesis suggests that stimulation of nicotine-sensitive receptors in the upper airway by various elements of smoke governs the amount inhaled. Indeed, application of a topical anesthetic to the upper airway reduces the quantity of smoke inhaled [79].

Tobacco smoke consists of gaseous and particulate phases, with the particulate phase comprising about 8% of the total volume [76]. Particulate deposition depends on the size, shape, and hygroscopicity (ability to absorb water vapor) of the particles as well as the duration and depth of inhalation [77]. Smoke particles range from 0.1–1.0 mm in diameter as they exit a cigarette, doubling in size within half a second due to aggregation, cooling, and condensation [80]. Larger particles (1–5 mm) are likely to deposit in the trachea and bronchi, whereas smaller particles (0.01–1 mm) reach bronchioles, alveolar ducts, and alveoli. Irregularly shaped or fibrous particles tend to get trapped at branching points, although some of these particles can travel on to the alveoli [81]. Interestingly, smoking seems to result in a greater apical and central distribution of particles than normal tidal breathing. This finding may help to explain the pathogenesis of centrilobular emphysema [76].

Cigarettes deliver nicotine in a pulsatile manner, with plasma concentrations reaching their peak within 1.5 to 3 minutes of the commencement of smoking and gradually returning toward baseline within two to three hours [82]. Thus, nicotine levels rise and fall throughout the day with each cigarette smoked, declining to minimum amounts found in nonsmokers in the morning after the extended abstinence period of sleep. Such continuous flux in blood nicotine levels locks the user into an endless cycle of ups and downs and is thought to lead to the commonly held notion that smoking has a positive effect on mood. Considering smokers begin to experience withdrawal symptoms within hours of their last cigarette, and because these unpleasant effects are almost completely alleviated by smoking, this perception is hardly surprising. Daily repetition of this process links these perceived positive health benefits to the act of smoking in the smoker's mind and often results in the false identification of cigarettes as an effective form of self-medication [83].

9. LEARNING OF BEHAVIOR

What is it about smoking that makes it so addictive? On one hand, this form of drug delivery is very efficient; inhaled nicotine is absorbed through pulmonary rather than systemic circulation and can reach the brain within 10 to 20 seconds [84]. Once inside the central nervous system (CNS), nicotine stimulates release of dopamine from the nucleus accumbens, much like the use of cocaine and amphetamines, leading to the feeling of satisfaction and well-being. Given such rapid central reinforcement, it is not surprising that tobacco can become highly addictive. On the other hand, familial and social influences often play a crucial role in determining who might start smoking, quit, or become dependent [83]. For example, one study managed to train a small percentage of rhesus monkeys to smoke, but with such difficulty that it concluded that "environmental factors play the primary role in developing smoking behavior" [85].

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

http://annals.org/aim/fullarticle/1748857

Last Accessed: May 13, 2019

Level of Evidence: B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.)

Experimenting with smoking usually occurs in the early teen years and is predominantly driven by psychosocial motives [83]. For a first-time user, lighting a cigarette is a symbolic expression of autonomy and independence; acquisition of the desired image is often a sufficient incentive for a novice smoker to tolerate the body's rejection of the first few cigarettes. Despite an admitted awareness of at least some of the deleterious effects of smoking, in 2018, 1 in 4 high school students and 1 in 14 middle school students admitted to using a tobacco product in the past 30 days [135]. Almost all people (90%) who will smoke as adults have started doing so by 18 years of age, and the earlier a person begins, the more likely they are to continue [135]. Within a year, adolescents inhale the same amount of nicotine per cigarette as adults, and they too experience the craving and withdrawal symptoms associated with nicotine addiction [83]. By 20 years of age, 80% of smokers regret ever having started.

Much research has been dedicated to uncovering reasons for the development of a smoking habit. Risk factors include [86]:

- Presence of a smoker in the household

- Single parent home and/or strained relationship with parent

- Comorbid psychiatric disorders

- Low level of expressed self-esteem and self-worth

- Poor academic performance

- In boys, high levels of aggression and rebelliousness

- In girls, preoccupation with weight and body image

- Increased adolescent perception of parental approval of smoking

- Affiliation with smoking peers

- Availability of cigarettes

In addition, twin studies revealed a significant genetic contribution to both smoking initiation and dependence [87,88].

RITUALISM

In practice, many find the very act of smoking a cigarette ritualistic and calming. The process of "packing" cigarettes by tapping the box on the palm of a hand, removing a cigarette, lighting it, inhaling, and watching the smoke as it is exhaled all contribute to the perceived need to smoke. Some go so far as to claim that they "would not know what to do with their hands" if they were to stop smoking [83]. An investigation using denicotinized cigarettes illustrated that the sensorimotor experience of smoking makes a significant contribution to the perceived satisfaction [89].

MEDIA INFLUENCE

Mass media is another factor that contributes to the learning of smoking behavior. Historically, the tobacco industry recruited new smokers by associating its products with fun, excitement, sex, wealth, power, and a means of expressing rebellion and independence [90]. Such promotional efforts have proven to be especially effective on teenagers, a particularly lucrative market with a lifetime of cigarette consumption ahead of them [91]. Although at present tobacco companies can no longer directly advertise to teenagers, they retain the most potent form of marketing: movies. Smoking in film is a "more powerful force than overt advertising," perhaps because the audience is generally unaware of any sponsor involvement [92]. Philip Morris, one of the world's leading tobacco companies, stated in their 1989 marketing plan, "We believe that most of the strong, positive images for cigarettes and smoking are created by cinema and television" [90]. Although television is taking a more socially responsible stance on the subject of on-air tobacco use, movies continue to model smoking as a socially acceptable behavior, portraying it as a social behavior or a way to relieve tension [93,94]. A study exploring the connection between a child's professed favorite movie star and that actor's on-screen smoking history revealed "a clear relation between on-screen use and the initiation of smoking in the adolescents who admire them" [95]. Tobacco use in movies, albeit falling through the 1970s and 1980s, increased significantly after 1990 [90]. Furthermore, despite declining tobacco use and increasing public understanding of the dangers of nicotine, smoking in movies returned to the levels observed in the 1950s, when it was nearly twice as prevalent in society as in 2002 [96]. A study analyzing the content of the top 25 grossing films each year from 1988 to 1997 found that 87% of movies depicted tobacco use, with an average of 5 occurrences per film. The vast majority of tobacco use was portrayed as experienced use (91.5%) and rarely did it represent a character's first use (0.3%) or a relapse from a previous quit attempt (0.5%). Despite the fact that R-rated movies contained most tobacco exposure and were more likely to feature a major character using tobacco, about 60% of the total coverage of smoking occurred in youth-rated films (G, PG, and PG-13). Negative reactions to tobacco use, including comments about health effects or gestures such as coughing, were depicted in only 5.9% of the occurrences. Unrealistic portrayal of cigarette smoking on the big screen may help to explain the somewhat surprising finding that children of nonsmoking parents are especially susceptible to the effects of movie smoking exposure [93]. Between 2002 and 2017, 6 out of every 10 movies rated PG-13 contained smoking or tobacco use, with historically high average of occurrences per film in 2016 (34 per film) and 2017 (29 per film), prompting many health groups to advocate for the requirement of an R rating (i.e., younger than 17 years of age require accompanying adult) for any films containing tobacco use. Researchers estimate that requiring a R rating would reduce the number of teen smokers by 18%, preventing up to 1 million deaths from smoking in the future [184]. Since May 2007, the Motion Picture Association of America (MPAA) has made smoking a factor in assigning ratings to films. The pervasiveness of tobacco use, context in which smoking appears, and whether or not the act is glamorized are all taken into account by film raters [97].

GENETICS

It has been suggested that high genetic vulnerability to cigarette smoking may explain why some people begin and continue to smoke despite associated risks [98]. Twin studies found significant heritability for persistence of smoking versus quitting. Heritability estimates for smoking persistence ranged from 27% to 70% and were greater for older than younger cohorts [99,100,101]. Madden et al. examined cross-cultural differences in the genetic risk of becoming a regular smoker and of persistence in smoking in men and women. They found strong genetic influences on smoking behavior, 46% for women and 57% for men, consistent across country and age group [102]. In a U.S. study, estimates of the genetic contribution to risk of becoming a smoker were 60% in men and 51% in women [103].

10. SMOKING DEPENDENCE

Of the numerous ingredients in tobacco smoke, nicotine is believed to be the primary cause of cigarette addiction [104]. Commercially available forms of nicotine-replacement therapy (NRT) increase cessation rates approximately 1.5- to 2-fold [105,106,107]. Yet, the fact that only a fraction of those who use such products succeed suggests that cigarette addiction depends on specific characteristics of cigarette smoking. It appears that the rapid delivery of nicotine via inhalation is a primary contributor to cigarette dependence [108]. Indeed, a district court judge found that major U.S. cigarette companies have designed their cigarettes to precisely control nicotine delivery levels and provide doses of nicotine sufficient to create and sustain addiction [109].

Active components of cigarette smoke affect many organ systems, but the effects on the CNS may be of most clinical importance due to its mediating role in dependence. Central effects of nicotine include electroencephalogram (EEG) desynchronization, with a shift toward higher frequency [110]. Studies have demonstrated that nicotine from cigarette smoke reduces global cerebral blood flow (gCBF), most markedly in the right hemisphere, and increases regional cerebral blood flow (rCBF) by more than 10% in the cerebellum, occipital cortex, and insula. Decreases in rCBF have been observed in such subcortical structures as the hippocampus, anterior cingulate, amygdala, and nucleus accumbens [111]. Positron emission tomography (PET) studies show that nasal nicotine administration increases cerebral glucose metabolism in the left inferior frontal gyrus, left posterior cingulate gyrus, left lateral occipitotemporal gyrus, left and right cuneus, and right thalamus, while it decreases glucose metabolism in the left insula and the right inferior occipital gyrus [112].

Further, the physiology of nicotine dependence has been characterized as biphasic; it stimulates the pleasure response in the brain and creates a relaxed state. As with cocaine, amphetamines, and morphine, addiction to nicotine is believed to result from increased release of dopamine in the nucleus accumbens. Nicotinic acetylcholine receptors are located throughout the CNS. Neurons located in the ventral tegmental area become more active with nicotine administration, leading to an increase in dopamine release into the nucleus accumbens [113]. Indeed, lesions to these pathways reduce rates of self-administered nicotine [114].

PSYCHOLOGIC DEPENDENCE

Many smokers believe that smoking increases concentration, treats stress, and gives pleasure. These beliefs are false. The light-headed feeling that may accompany the act of smoking gives the smoker a false sense of pleasure or release. However, smoking actually causes a decline in physical and cognitive functioning. Additionally, a study by Ota et al. showed that nurses in Japan indulged in smoking as a result of the psychologic demands of their jobs, and this psychologic job demand was positively correlated with their Tobacco Dependence Screener score. The nurses associated stressful tasks with dysphoria, insomnia, anxiety, and other symptoms similar to that of nicotine withdrawal. To alleviate these symptoms, the nurses would smoke and become increasingly psychologically dependent on nicotine with each demanding occupational event [115].

11. HEALTH COMPLICATIONS RELATED TO SMOKING

PULMONARY COMPLICATIONS

Smoking severely compromises pulmonary function in a variety of ways, including causing infiltration of the airways with leukocytes. An imbalance among proteases, their endogenous inhibitors, and local cytokine secretion in the lung leads to airway inflammation and alveolar destruction. Smokers also experience more acute lower respiratory illnesses. Smoking has been implicated in the development of malignant and nonmalignant lung disease, including COPD, bronchitis, influenza, emphysema, pneumonia, and lung cancer. Smokers are also shown to be at increased risk of intraoperative pulmonary complications and a wide range of postoperative complications. For example, a study of postoperative care revealed smoking, being older than 65 years of age, and a history of chronic lung disease increased the risk of unplanned intensive care admittance [116].

Chronic Obstructive Pulmonary Disease

Smoking is the main cause of COPD, which encompasses both chronic bronchitis and emphysema. Between 20% and 30% of smokers (or about 1 in 4) will develop COPD, and risk is determined largely based on genetic susceptibility coupled with age at smoking initiation [117,118]. It is very rare in nonsmokers; at least 80% of deaths from this disease can be attributed to cigarette smoking. The risk of death from COPD rises concurrently with the number of cigarettes smoked. If smokers with COPD quit smoking while they are still young, an improvement in lung function can be expected. However, such improvement is not possible in older people, although after cessation further deterioration will run parallel to that of nonsmokers.

The age at which one begins smoking is important. Wiencke and colleagues discovered that smoking as an adolescent causes permanent genetic changes in the lungs and forever increases the risk of lung cancer, even if the smoker subsequently stops [119]. A Canadian community health survey conducted between 2000 and 2001 found that the risks for heart disease, COPD, and rheumatoid arthritis were far higher among people who began smoking as teenagers than among their nonsmoking peers. For COPD alone, teen smokers were three times more likely to develop the condition later in life than nonsmokers. Similarly, a retrospective cohort study of adult smokers suggests that women are particularly at risk of COPD if they start to smoke before 16 years of age [120].

Influenza

Upper respiratory tract infections are common, and tobacco smoke is a proven risk factor for bacterial infection. The link between influenza and smoking has been demonstrated both for adult smokers and children exposed to smoke-filled environments. According to Arcavi and Benowitz, influenza risk is higher and infections are more severe (e.g., more cough, phlegm production, breathlessness, and wheezing) in smokers versus nonsmokers. Apparently, the antibody response is depressed in cigarette smokers. Nonsmokers should also avoid SHS exposure to decrease the risk of contracting influenza [121]. In a study of Israeli military men, presence and severity of influenza was stronger in smokers than in nonsmokers. Of all smokers, 68.5% contracted influenza compared with 47.2% of nonsmokers, and 50.6% of smokers required bed rest or lost workdays compared with 30.1% of nonsmokers [122]. A 2018 study of patients older than 65 years of age showed that smokers had a higher rate of hospitalization due to influenza (47.4%) compared with nonsmokers (42.1%). In addition, the effectiveness of the influenza vaccine in preventing hospitalization was 21% among current and ex-smokers and 39% in nonsmokers [376].

Pneumonia

Smoking is associated with a significant increase in the relative risk of pneumonia and pneumonia-related hospitalization [123,124]. Pneumonia is not only more common among smokers, it is much more likely to be fatal. Longitudinal studies have identified an increase in the mortality rate from pneumonia in smokers associated with dose-response [125]. In general, cessation of smoking is not associated with a decrease in hospitalization for pneumonia; however, patients without COPD and a greater than 10-year history of not smoking are at a decreased risk [124]. A 2013 study found that children exposed to SHS were four times more likely to develop lower respiratory illnesses, including pneumonia [126]. Proposed explanations of the increased risk for infection in active, passive, and former smokers include increased bacterial adherence, decrease of lung and nasal clearance, and changes in the immune response.

CARDIOVASCULAR COMPLICATIONS

Cardiovascular disease, defined as acute myocardial infarction (MI) and stroke, is strongly related to smoking and comprises 34% of smoking-related mortality; conversely, smoking yields 16% of cardiovascular-related mortality [62]. The relative risk of MI for smokers has been estimated at 2.88 for men and 3.85 for women, and the relative risk of stroke for smokers is estimated at 2.80. These estimates do not include the effects of passive smoking. Low-tar cigarettes and smokeless tobacco have similarly been shown to increase the risk of cardiovascular events among users in comparison to nonsmokers [127]. Cigarette smoking impacts all phases of atherosclerosis, from endothelial dysfunction to acute clinical events. Both active and passive cigarette smoke exposure predispose to cardiovascular events. The exact toxic components of cigarette smoke and the mechanisms involved in smoking that are related to cardiovascular dysfunction are largely unknown, but smoking increases inflammation, thrombosis, and oxidation of low-density lipoprotein cholesterol (LDL-C). Experimental and clinical data support the hypothesis that increased oxidative exposure may be a potential mechanism for initiating cardiovascular dysfunction. Research also suggests that small doses of toxic materials from tobacco smoke cause a nonlinear dose-response effect on cardiovascular function [128]. The risk for cardiovascular disease declines rapidly after smoking is ceased [129].

NEUROLOGIC COMPLICATIONS

Tobacco smoking is strongly related to atherosclerosis and chronic vascular disease. Atherothrombotic ischemic stroke, transient ischemic attack, and atherothrombotic origin symptomatic or asymptomatic peripheral arterial disease are all associated with a high risk of vascular death, MI, and stroke. Exposure to tobacco smoke is a noted risk factor of all these events. A positive association was found between cigarette smoking and subarachnoid hemorrhage (SAH), especially for aneurysmal SAH in women [130].

Evidence is emerging that suggests an association between the development of other neurologic diseases and smoking. A study by Riise et al. identified the risk of multiple sclerosis as higher among smokers than among those who never smoked [131].

Studies have shown that the amount of monoamine oxidase (MAO) is reduced by 30% to 40% in the brains of smokers, compared to nonsmokers or former smokers [132]. This reduction in brain MAO levels may result in an increase in levels of dopamine. It has been suggested that nicotine may have short-term protective actions against mechanisms that cause Alzheimer disease; however, the numerous toxins in cigarette smoke negate any benefit [133]. Though the risk for dementia is slightly higher in smokers, the relative risk for Alzheimer disease is unclear. A 2013 Alzheimer study using a mouse model found that smoking hastens disease onset, exacerbates amyloid pathology, and increases neuroinflammation and tau phosphorylation [133]. Further research is needed in order to better elucidate the risk.

CANCER

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography in adults 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

http://annals.org/aim/fullarticle/1809422

Last Accessed: May 13, 2019

Level of Evidence: B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.)

In the United States beginning in the early 1950s, a series of epidemiologic, biochemical, pathologic, and animal studies demonstrated a link between cigarette smoking and lung cancer. Tobacco smoking increases the risk of all histologic types of lung cancer. More than 80% to 90% of people who develop lung cancer are current or past smokers. However, not all smokers will develop lung cancer [134]. Cited reasons include the modification of lung cancer risk by previous respiratory disease. In comparison to nonsmokers, smokers are 23 times more likely to develop lung cancer if male and 13 times more likely if female. The risk of lung cancer increases directly with the number of cigarettes smoked and decreases when smoking is ceased. The most important parameter of smoking that affects lung cancer risk is the duration of smoking. Smoking low-tar cigarettes does not substantially reduce the risk of lung cancer [14].

Tobacco smoking is also causally linked to other types of cancer, including oral, oropharyngeal and nasal cavity, urinary tract, larynx, pancreas, esophageal, stomach, liver, cervix, colon, breast, endometrial, prostate, and leukemia. In most cases, the risk increases substantially with duration of smoking and amount of cigarettes/tobacco consumed. Similarly, alcohol in combination with tobacco greatly elevates the risk of many forms of cancer [14].

OSTEOPOROSIS

Smoking can lead to adverse long-term effects on bone health, rendering smokers prone to falls and fractures. Many smokers begin smoking during adolescence—a point in which bone mass is still being constructed; thus, smoking may hinder a person from reaching their maximum bone mass, leaving them fragile and prone to fractures with longer recuperation time [136]. Further, cigarette smoking has been shown to be a key risk factor for osteoporosis and unfortunately, menopausal women are at increased risk due to a loss of estrogen during this period of life. Giampietro and colleagues suggest that a genetic variation in interleukin 6 (IL6) and lipoprotein receptor-related protein 5 (LRP5) observed in smoking white women may confer risk for osteoporosis among smokers [137]. In a study of human-derived osteoblast-like cells and trabecular bone organ culture, Walker et al. demonstrated the presence of the α4 neuronal nicotinic acetylcholine receptor (nAChR) and found that nicotine modulates proliferation in a dose-dependent manner, upregulates c-fos transcription factor, and affects synthesis of osteopontin, a bone matrix protein [138].

PROBLEMS WITH CONCEPTION AND EMBRYONIC HEALTH

Women who smoke prior to pregnancy are more likely to experience a delay in conception and have about 30% higher odds of infertility [139]. Further, men who smoke are at increased risk of erectile dysfunction due to decreased bioavailability of nitric oxide and damage to peripheral nerves, the vascular epithelium, and structure of corporal tissue. Smoking may also affect the quality and mobility of spermatozoa [140,141]. Ramlau-Hansen et al. report a dose-dependent relationship between smoking and sperm concentration, testosterone, luteinizing hormone (LH), and the LH/free testosterone ratio [142].

Success of assisted reproduction therapy (ART) is reduced among smoking couples. In a meta-analysis, Waylen and colleagues found that smokers undergoing ART (e.g., in-vitro fertilization, intracytoplasmic sperm injection, gamete intrafallopian transfer, zygote intrafallopian transfer) had lower odds of live birth per cycle (i.e., birth of one or more infants that show signs of life). They also observed lower odds of clinical pregnancy per cycle (i.e., a sonographically visible gestational sac in the uterus) and higher odds of spontaneous miscarriage and ectopic pregnancy when compared to nonsmokers undergoing the same treatments [143]. A retrospective study published in 2018 found that smoking has a negative effect on endometrial thickness on the day of the embryo transfer, resulting in lower rates of implantation and pregnancy [466].

If conception is achieved (with or without ART), maternal smoking during pregnancy increases the risk for adverse conditions including low birth weight, spontaneous abortion, placenta previa, abruptio placentae, preterm premature rupture of the membrane (PPROM), and overall poor outcomes [144,145].

The miscarriage rate among mothers who smoke may be as high as 33% [146,147]. This may be due to an increased syncytial necrosis and increased thickness of syncytio/cytotrophoblast membrane, as smoking appears to induce dysfunction of villous and invasive trophoblasts early in pregnancy. Additionally, maternal levels of estriol, estradiol, human chorionic gonadotropin, and human placental lactogen are lower in smokers than in nonsmokers [148]. All of these are markers of prenatal health and well-being.

12. COMORBID CONDITIONS

ALCOHOL ABUSE

There is a strong comorbidity between alcohol consumption and tobacco use. Drinkers are more likely to smoke than nondrinkers, and smokers are more likely to drink than nonsmokers [149]. In fact, smokers are 30% more likely to consume alcohol and 10 times more likely to develop alcoholism than nonsmokers. Between 80% and 95% of all alcoholics also smoke cigarettes, and 70% are heavy smokers who consume more than one pack per day [150]. A study examining an association between alcohol and tobacco, using a combination of short-term (1-year) and long-term (15-year) follow-up intervals, found that past-year alcohol and tobacco use disorders were associated not only cross-sectionally, but also prospectively. These associations were present even after controlling for age, gender, and race. Year 1 tobacco dependence prospectively predicted diagnosis with an alcohol use disorder (AUD) at year 2, and a baseline diagnosis of AUD increased the likelihood of diagnosis with tobacco dependence 15 years later. Having been diagnosed with tobacco dependence at year 1 predicted AUD persistence, and vice versa. These findings demonstrate the complex association between tobacco dependence and AUDs [151]. Similarly, a study examining the natural course of AUDs from adolescence to early adulthood found that daily smoking predicted future AUD when adolescent AUD and other disorders were controlled. It is possible that chronic smoking may contribute to alcohol tolerance, increasing alcohol consumption and metabolism [152].

In the instance of nonsmokers, data from a study by Romberger and Grant suggests that patterns of alcohol abuse would be similar in workers exposed to SHS; however, the severity of the alcohol abuse may be less pronounced [153].

DRUG ABUSE

Smoking usually precedes illicit drug use. Among those who used both cigarettes and marijuana by the 12th grade, 65% smoked cigarettes before marijuana, and 98% of those who used both cigarettes and cocaine smoked cigarettes first. Apparently, the earlier a person uses tobacco, the more likely he or she will be to experiment with cocaine, heroin, and other drugs. More than half of those who start smoking before 15 years of age use an illegal drug in their lifetime, compared to only a quarter of those who do not start smoking until 17 years of age or later. Moreover, those who start smoking before 15 years of age are seven times more likely to use cocaine than those who never smoke. Also, heavy smokers are more likely to use marijuana or harder drugs. For example, young people who smoke more than 15 cigarettes a day are twice as likely to use an illicit drug and 16 times more likely to use cocaine than those who smoke less frequently. They are also 10 times more likely to use an illicit drug and 100 times more likely to use cocaine than those who never smoked. Even heavy users of smokeless tobacco are more likely to experiment with drugs. High school students who used smokeless tobacco 20 to 30 days per month were four times more likely to concomitantly use marijuana than nonusers, and almost three times more likely to ever use cocaine [150].

PSYCHIATRIC DISORDERS

Many smokers report a link between smoking and anxiety. Researchers at the National Institute on Drug Abuse hypothesized that impaired respiration and the detrimental effects of nicotine on blood vessels to the brain elucidate why those exposed to smoking are at an increased risk of developing anxiety disorders [154,467].

Smoking is shown to be highly comorbid with such psychiatric disorders as major depression, panic disorder, and schizophrenia. Cigarette smoke has other psychoactive properties apart from nicotinic receptor stimulation. For example, it inhibits MAO, which is the enzyme responsible for breaking down the biogenic amine neurotransmitters norepinephrine, serotonin, and dopamine in the brain [155,156]. Not surprisingly, the association between smoking and major depression is well established [157,158,159]. Reports of severe major depressive episodes after smoking cessation are also common, with the onset of depressive symptoms ranging from two days to six weeks after the initial abstinence from smoking [160,161]. In some cases, depression was alleviated with the use of NRT or antidepressants; in others, depressive symptoms went away after a relapse to smoking [160,162]. In a trial of smoking cessation using fluoxetine (30 mg), 7% of participants with a previous history of major depressive disorder (MDD) were diagnosed with major depressive episodes after a 10-week treatment, suggesting that a subset of smokers may be particularly at risk for developing MDD after smoking cessation [163].

In addition to relieving depressive symptoms or major depressive episodes associated with nicotine withdrawal, antidepressants may aid in long-term smoking cessation by substituting for the antidepressant effects of nicotine that help maintain smoking. They may also have a specific effect on neural pathways (e.g., MAO inhibition) or receptors (e.g., nicotinic-cholinergic receptor blockade) that underlie nicotine addiction. A 2013 Cochrane review assessed the efficacy of antidepressant medications to aid long-term smoking cessation. The majority (75) of the 90 randomized trials included in the review were of bupropion and nortriptyline. The reviewers found high-quality evidence that bupropion significantly increased long-term smoking cessation when used as the sole pharmacotherapy, and moderate-quality evidence (limited by the small number of trials and participants) that nortriptyline also significantly increased long-term cessation. The drugs' effectiveness for long-term smoking cessation was independent of their antidepressant effects, with efficacy similar to NRT [156].

Smoking could also be a risk factor for panic disorder [164,467]. A disproportionate number of persons with panic disorder smoke cigarettes compared to the general population [165]. Mild-to-moderate nicotine dependence was associated with an 11% lifetime prevalence of panic disorder, a rate approximately 2.5 times greater than in persons with no nicotine dependence. Pohl et al. found that female patients with panic disorder had significantly higher smoking prevalence at the onset of their illness than did control subjects (54% versus 35%) and that smoking prevalence for the female patients was also significantly higher than for the control subjects (40% versus 25%) [166]. Male smoking rates did not differ between patients and control subjects.

Although the cause of this comorbidity remains controversial, several explanations have been offered: smoking promotes panic by inducing respiratory abnormalities/lung disease; nicotine produces the physiologic effects characteristic of panic by releasing norepinephrine; cigarette smoking is a form of self-medication for panic disorder; and/or a shared vulnerability promotes both conditions [167]. One study examined the effect of smoking cessation on the reduction of panic symptoms by monitoring the post-cessation abstinence status of 185 smokers. Abstinence was biochemically verified at weeks 1 and 2 and month 1. The severity of panic-relevant symptoms was self-reported by the participants at month 1 and month 3, post-cessation. The 80 participants (43.2%) who remained abstinent for one month, relative to the 105 (56.8%) who did not, demonstrated significant reductions in self-reported panic symptoms [168].

Smoking is also more prevalent in persons with schizophrenia, although reasons for its pervasiveness remain debatable [169,170,171]. Investigators have suggested that nicotine might temper positive or negative symptoms, and cigarette smoking is used as self-medication (e.g., to treat cognitive impairment and anhedonia) [171,172,173,174]. Nicotine may also attenuate the adverse effects of neuroleptics, perhaps by reducing elevated blood levels after use of antipsychotic medications [128,175,176]. Weiser et al. examined the prevalence of cigarette smoking in apparently healthy adolescents later hospitalized for schizophrenia. The number of cigarettes smoked was significantly associated with the risk for schizophrenia. Compared to nonsmokers, adolescents who smoked 1 to 9 cigarettes per day were 1.38 times as likely to be hospitalized later for schizophrenia, and adolescents who smoked 10 cigarettes per day or more were 2.28 times as likely; the latter difference was statistically significant. The authors concluded that the higher prevalence of smoking in future schizophrenia patients might indicate that impaired nicotinic neurotransmission is involved in the pathophysiology of schizophrenia [177]. Bupropion has been found to increase smoking abstinence rates in smokers with schizophrenia [178]. Additionally, a number of medications that target nicotinic acetylcholine receptors have been tested or are in development, but further research is necessary to determine their clinical utility in the treatment of schizophrenia [174].

13. FETAL EXPOSURE

Maternal cigarette smoking before and during pregnancy adversely affects the health of both mother and fetus. However, analysis of data from the 2016 National Vital Statistics Systems (NVSS) indicated that 7.2% of pregnant women in the United States reported smoking during pregnancy [179]. In addition to the effects on fertility and embryonic health discussed, maternal smoking before conception increases the risk of sudden infant death syndrome (SIDS), and smoking at the time of conception increases the risk of infants being born with cleft lip, with or without cleft palate [14,179,180]. A 2010 study showed that as many as 8% of preterm deliveries, 7% of preterm-related deaths, 19% of term low-birth-weight deliveries, and 34% of SIDS cases in the United States were attributable to prenatal smoking [181]. Further, several studies indicate that the offspring of mothers who smoked during pregnancy are at elevated risk of developing nicotine dependence as adults [182,183].

According to 2016 NVSS data, the prevalence of smoking during pregnancy was highest among women who were between 20 and 24 years of age (10.7%), followed by women 15 to 19 years of age (8.5%) and 25 to 29 years of age (8.2%). Among racial groups, the highest rates were found in non-Hispanic American Indian/Alaska Native women (16.7%%), followed by white (10.5%), black (6.0%), Native Hawaiian/Pacific Islander (4.5%), Hispanic (1.8%), and Asian (0.6%) women. Smoking rates were highest among those with a high school diploma or equivalent (12.2%), followed by those with less than 12 years of school completed (11.7%), and women with some college or an associate's degree (7.9%). Less than 1% of women with a bachelor's degree or higher reported smoking during pregnancy [179]. Rates of maternal smoking during pregnancy differ greatly between individual states, with West Virginia (25.1%) and Kentucky (18.4%) reporting the highest percentages, and the District of Columbia (2.6%) and California (1.6%) reporting the lowest. SHS exposure in infancy greatly increases the odds of respiratory tract infections, ear infections, and death from SIDS [14].

Ohida and colleagues performed cross-sectional surveys in Japanese obstetric clinics to investigate the effects of passive smoking on sleep disturbance during pregnancy [185]. Pregnant women exposed to passive smoking were likely to have insufficient sleep, difficulty initiating sleep, short sleep duration, loud snoring, or uncomfortable breathing. These experiences also occurred in pregnant women who were smokers.

Nicotine has a low molecular weight and high lipid solubility, allowing it to cross the placenta freely and accumulate in amniotic fluid. In animal models, nicotine could be identified in fetal tissues as early as five minutes following maternal injection [186,187]. Because less than 5% of nicotine binds to human plasma proteins, the majority of the administered dose is available to equilibrate with fetal circulation [188]. Studies in humans showed that nicotine is readily transferred to the fetal compartment throughout pregnancy, with accumulation in placental tissue and amniotic fluid [189]. Apparently, a significant amount of nicotine is retained by the placenta and may later transfer to fetal and maternal circulation, thus prolonging the effect of nicotine on the fetus [188].

Acetylcholine causes dilation of blood vessels and maintains placental blood flow by the activation of endothelial muscarinic receptors. Nicotine blocks acetylcholine-facilitated amino-acid transport, depressing diffusion of amino acids and other nutrients from the trophoblast into placental circulation. Maternal smoking actually leads to trophoblast apoptosis and thickening of the trophoblast basement membrane [190,191]. Further, CO from tobacco smoke crosses the placenta by passive diffusion, leading to increased carboxyhemoglobin in umbilical cord blood and placental hypoxia. The resultant hypoxia causes fetal growth retardation and alteration in the physiologic development of organs and tissues [192].

PHARMACOKINETICS AND DYNAMICS

Among pregnant smokers, maternal levels of cotinine correlate better with outcome measures such as birth weight than the number of cigarettes smoked per day [193]. Cotinine can accumulate in fetal compartments as early as 7 weeks' gestation in both active and passive smokers [194]. Of note, the half-life of nicotine is three to four times longer in newborns than in adults, whereas the half-life of cotinine is similar in newborns and adults. The prolonged elimination of nicotine, but not of cotinine, in the newborn compared with that in the adult may be a result of different newborn cytochrome P450 2A6 (CYP2A6) enzymatic substrate specificity, low CYP2A6 activity with another enzyme that is primarily responsible for cotinine metabolism, or differences in tissue distribution [195]. Also, pregnancy is well known for affecting metabolism of some drugs and may contribute to higher or lower clearances compared with the nonpregnant state [196]. Indeed, metabolic clearance of both nicotine and cotinine are substantially increased during pregnancy, resulting in a marked decrease in the half-life of cotinine. The mechanism for such increase in metabolic clearance is not known. It is possible that nicotine and cotinine clearances are accelerated by faster oxidation via CYP2A6 and faster glucuronide formation. Although nicotine and cotinine share the same metabolizing enzymes, their increased clearances may occur by different physiologic mechanisms. Nicotine is a rapidly cleared drug with a high affinity for CYP2A6, and the rate of clearance is primarily controlled by liver blood flow. Cotinine is a slowly metabolized chemical, with a low affinity for CYP2A6 relative to nicotine. The level of CYP2A6 in the liver, which is markedly elevated during pregnancy, primarily determines the rate of cotinine metabolism. A substantial increase in the percentage of nicotine and cotinine excreted as their glucuronide conjugates is also observed in pregnancy, but there is no increase in the percentage of 3'-hydroxycotinine excreted as a glucuronide. This suggests an acceleration of nicotine and cotinine metabolism via the N-glucuronidation pathway, but no effect on hydroxycotinine metabolism by the O-glucuronidation pathway. Also, the profile of nicotine and its metabolites in urine is altered during pregnancy. The excretion of nicotine is substantially decreased, and despite large differences in plasma cotinine concentration during smoking, there is no difference between the daily dose of nicotine absorbed from cigarette smoking during and after pregnancy [197].

NEUROLOGIC COMPLICATIONS

Fetal nicotine exposure can result in permanent abnormalities of the dopaminergic regulation of the brain [198]. These effects can occur even at low nicotine doses and lead to a greater nicotine dependence [182]. Unlike in mature organisms, where stimulation of a target cell elicits only a short-term response, receptor stimulation in the developing systems interacts with the genes controlling cell differentiation, permanently altering the cells' responsiveness. Nicotine exposure to the prenatal brain may also prematurely stimulate the shift from proliferation to differentiation; thus, nicotine may act as a cholinergic signal, mimicking trophic effects of acetylcholine. Because of the close regulatory association of cholinergic and catecholaminergic systems, adverse effects of nicotine involve multiple transmitter pathways and influence not only the immediate developmental events in the fetal brain but also the eventual programming of synaptic competence. Therefore, defects may appear after a prolonged period of apparent normality, leading to cognitive and learning defects that appear in childhood or adolescence. Similar modifications occur in peripheral autonomic pathways, leading to increased susceptibility to hypoxia-induced brain damage and perinatal mortality [199]. These changes are especially prominent in tissues rich in nicotinic cholinergic receptors, such as the brainstem [200].

Prenatal exposure to nicotine produces alterations in tegmental nuclei related to the following [201]:

- Cardiopulmonary integration (nucleus tractus solitarii, parabrachial complex)

- Regulation of arousal, attention, and rapid eye movement (REM) sleep (mesencephalic and pontine reticular formation)

- Somatic motor control (paramedian pontine and medullary reticular formation)

- Tongue and upper airway regulation (hypoglossal nucleus)

Autonomic deregulation could explain the inhibition of some homeostatic reflexes seen in infants exposed to tobacco smoke, including a deficiency in arousal responsiveness to hypoxia or hypercapnia [202]. Roy et al. evaluated cellular morphology and regional architecture in the juvenile and adolescent hippocampus and the somatosensory cortex in rats prenatally exposed to nicotine. They found a substantial decrease in cell size in the hippocampal CA3 region and dentate gyrus, with corresponding decrements in cell layer thickness and increments in cell packing density. Smaller, transient changes were seen in CA1. There was a reduction in the proportion of medium-sized pyramidal neurons in layer five of the somatosensory cortex and an increase in the proportion of smaller, nonpyramidal cells. All regions showed elevated numbers of glia. These data demonstrate that prenatal nicotine exposure compromises neuronal maturation, leading to long-lasting alterations in the structure of key brain regions involved in cognition, learning, and memory [203].

PULMONARY COMPLICATIONS

Fetal growth and duration of gestation are the major factors affecting lung development [204]. Intrauterine influences that retard fetal weight gain may irrecoverably restrict the growth of the airways, with consequences persisting throughout the individual's life span. Fetal exposure to nicotine is associated with several abnormalities in lung growth. In animal studies, nicotine has been shown to directly interact with nicotinic acetylcholine receptors in pulmonary vessels, altering connective tissue expression and producing vascular structural alterations [205]. Furthermore, maternal nicotine exposure results in larger alveolar volumes and suppresses alveolarization in the lungs of the offspring of rats, reducing the surface potentially available for gas exchange [206,207]. Human smokers have a high rate of poor perfusion patterns, suggesting that smoking during pregnancy may compromise uteroplacental blood flow and contribute to poor fetal development [208,209].

CARDIOVASCULAR COMPLICATIONS

Maternal smoking during pregnancy poses severe risks to the developing fetal heart. Nicotine alters cardiac cell differentiation to increase the cellular injury caused by hypoxia [210]. Prenatal nicotine exposure interferes with the ability of neonatal adrenal glands to secrete catecholamines in response to hypoxia [200]. Given that the neonatal heart lacks functional sympathetic innervation, there is virtually a complete dependence on circulating catecholamines secreted by the adrenal medulla to maintain heart rate response to hypoxia. Nicotine exposure reduces the number of cardiac ß-adrenergic receptors, magnifying functional consequences of impaired catecholamine release [211]. The resultant impaired cardiac function can lead to cardiovascular collapse, subsequent brain damage, and/or death during delivery [212,213].

Adenosine diphosphate (ADP) is a major factor in determining electrical stability of myocytes, because the longer the action potential, the higher the likelihood of abnormal cardiac activity [214]. It is possible that a component in smoke temporarily disables electrical properties of ventricular myocytes, rendering the ventricular muscle more susceptible to developing arrhythmias [215].

Fetuses exposed to smoke also manifest an increase in cardiac volume growth between 23 and 27 weeks' gestation [216,217]. This could be attributed to either an exaggeration of normal cardiac growth patterns or a compensatory response to an increase in upper body growth at the time.

LOW BIRTH WEIGHT AND SMALL FOR GESTATIONAL AGE

Infants born to mothers who smoke weigh less than other infants (independent of maternal body mass index), and low birth weight (<2,500 grams) is a key predictor for infant mortality. Effects of maternal smoking during pregnancy on infant birth weight have been recognized since 1957; nevertheless, smoking remains the most hazardous factor affecting a newborn's weight, even at present [218,219,220]. Similar to earlier studies, Bernstein and colleagues report that maternal third-trimester cigarette smoking is one of the strongest predictors of low birth weight. This study is thought to be the first to accurately assess maternal smoking levels, and startlingly, they purport that there is an estimated 27 g reduction in birth weight per cigarette consumed each day during the third trimester, or roughly twice the amount previously shown [220]. Another study found that 11.5% of infants born to women smoking less than six cigarettes daily had low birth weight [221]. Taken together, these studies demonstrate that there is not a safe level of smoking during pregnancy [221,222]. Additionally, Aagaard-Tillery et al. reported that tobacco-exposed infants were small for gestational age regardless of maternal body mass index or pregnancies complicated by diabetes or hypertension [223].

A study examining the effect of prenatal smoke on a fetus in midgestation identified greater early gestational upper-body growth with preferential growth of head dimensions, upper limb length, and abdominal circumference with smoke exposure. This was followed by decreases in biparietal dimensions of the head, abdominal diameter, and distal limb length. Data from the late gestation period revealed cranial dolichocephaly, proportionally longer upper limbs, and legs with relatively reduced tibias, indicating that smoke exposure altered the growth rate of individual body segments [216]. It is possible that during hypoxia, blood supply to the lower limbs and internal organs is reduced in order to preserve brain metabolism [224]. Retardation of limb growth by 32 weeks could be due to diminished oxygen availability for distribution to distal tissues. The tibia, being one of the last consumers in the fetal nutrient distribution food chain, is therefore regarded as a good marker of available oxygen resources [216].

MIDDLE EAR DISEASE

Passive smoke exposure is independently associated with an increased risk of otitis media [222,225,226]. Though the immediate complications of otitis media are significant, one must also consider the lasting complications including an increased prevalence of speech and language difficulties, attention disorders, and learning difficulty [226]. The mechanism by which cigarette smoke causes otitis media is currently unknown. Histologic changes in fetal alveolar and bronchial epithelium lend support to a contemporary theory that purports that fetal cigarette smoke exposure may interfere with the development of the middle ear and eustachian tube epithelium. An alternative theory proposes that passive smoke-related immune system depression allows for opportunistic middle ear infections [226].

CANCER

One of the potentially negative effects of smoking during pregnancy is exposure of the fetus to carcinogens [227,228]. The potent tobacco-related carcinogen 4-aminobiphenyl has been shown to cross the human placenta and bind to fetal hemoglobin [229]. Two metabolites of the tobacco-specific transplacental carcinogen NNK, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronide (NNAL-Gluc), were detected in the urine from newborns of mothers who smoked cigarettes during pregnancy [144]. Studies relating childhood and in utero cigarette exposure to brain tumors and leukemia have been inconsistent in their findings [230]. A meta-analysis of the association between exposure to maternal tobacco smoke during pregnancy and cancer in childhood found a small increase in risk of all neoplasms (based on 12 studies) but not of specific neoplasms such as leukemia (based on 8 studies) and CNS tumors (based on 12 studies) [231].

OSTEOPOROSIS

Maternal smoking has been shown to modulate bone mineral acquisition for the fetus, which may lead to increased risk of osteoporosis later in life [232].

PSYCHIATRIC DISORDERS

Previous studies have reported an association between maternal smoking during pregnancy and behavioral problems such as hyperactivity and decreased attention span. The association with behavioral problems has been shown in investigations of hyperactive children and controls, sibling studies in which the mother smoked in one pregnancy but not in the other, and in neuropsychologic evaluations of children of smokers and nonsmokers using tests of sustained vigilance and attention [233,234,235,236]. Naeye and Peters found that hemoglobin levels in neonates increased with the number of cigarettes smoked by the mother during pregnancy and that children who were more active or had shorter attention spans had significantly higher hemoglobin levels [235]. Further, early secondhand exposure to nicotine as a child via maternal smoking during pregnancy shows an association with offspring attention deficit hyperactivity disorder (ADHD) symptoms [237,238]. Evidence also supports a statistical association between prenatal smoking and increased risk for antisocial outcomes in offspring. Maternal smoking during pregnancy has been shown to be associated with a significant increase in externalizing behavior (tendency to seek controversy, aggressive, hyperactive) but not internalizing behavior (withdrawn, depressed, anxious) problems [239]. Similarly, maternal smoking during pregnancy has been shown to have an adverse effect on the child's negativity [240]. In a sample of 99 children 2 years of age, maternal smoking was identified as a significant predictor of childhood negativity, independent of demographic factors, perinatal factors, maternal personality attributes, and the mother-child relationship. Behavior problems associated with in utero exposure to SHS seem to continue into childhood and young adolescence, demonstrated by increased risk for ADHD, conduct disorders, criminality, and substance abuse [241]. An 18-year epidemiologic study of 1,265 New Zealand children identified that maternal smoking during pregnancy contributed to risk of higher psychiatric symptom rates for conduct disorder(s), alcohol abuse, substance abuse, and depression [242,243].

14. PASSIVE SMOKING EFFECTS ON CHILDREN

It is possible that SHS exposure during childhood may be potentially more hazardous to neurodevelopment than in utero exposure to maternal smoking. Young children have higher ventilation rates, meaning they receive higher levels of SHS for the same duration and level of external exposure [244]. Passive smoking is believed to increase the prevalence of sudden infant death syndrome (SIDS); exacerbate asthma symptoms; interfere with cognition and behavior; increase cancer risk; and cause respiratory tract illness [226,245,246]. Breastfed infants with a smoking or snuff-taking mother are exposed to nicotine in breast milk, with a mean intake of nicotine of 7 mcg/kg per day [247]. Older children experience decreased physical fitness and are susceptible to tobacco-related illnesses just as adult smokers are.

Evidence Based Practice Recommendation

The National Heart, Lung, and Blood Institute recommends promoting a smoke-free home environment for all children and reinforcing this message at every encounter, including urgent visits for respiratory problems.

https://www.nhlbi.nih.gov/node/80308

Last Accessed: May 13, 2019

Level of Evidence: A (Well-designed randomized controlled trials or diagnostic studies performed on a population similar to the Guidelines' target population)

Aside from adverse health effects due to SHS exposure, parental smoking is also positively correlated to their offspring's smoking as adolescents and adults. Counseling parents on the adverse health effects of SHS on children has been shown to dramatically reduce their children's subsequent cigarette smoke exposure [6,246]. Smokers should be encouraged to smoke outside their homes and minimize SHS exposure to their children [248]. However, studies have shown that, though smoking outdoors decreases SHS exposure, children of parents who smoke outdoors still have higher prevalence of ear infections and respiratory symptoms than children of nonsmokers [249].

NEUROLOGIC EFFECTS

Prenatal and perinatal exposure to SHS adversely affects neurobehavioral development. Evidence now supports the notion that tobacco-exposed infants are more excitable and hypertonic, require more handling, and show more stress and abstinence signs than infants not exposed to tobacco. Symptoms are particularly noteworthy in the CNS, gastrointestinal system, and visual areas [250]. The presumed neurobiologic effect of SHS is altered brain development resulting from fetal hypoxia, due to either nicotine acting to reduce blood flow to the fetus, or possibly CO, which produces higher levels of carboxyhemoglobin. Nicotine may also target specific neurotransmitter receptors in the fetal brain to discoordinate the events of cell replication, differentiation, and synaptic development in the brain. Nicotine is thought to disrupt brain development via cholinergic mechanisms. In rats, exposure to nicotine alone has been shown to result in a significant increase in acetylcholinesterase (AChE) activity in the brainstem and midbrain. A significant increase in ligand binding to nAChR has been observed in the brainstem and cortex following exposure to nicotine. This suggests that exposure to nicotine may impair neurobehavioral performance and affect the cholinergic pathways [251].

In another study, postnatal SHS reduced hindbrain (comprising the pons and medulla oblongata) DNA concentration, increased the protein-to-DNA ratio, and reduced the body weight of exposed rats. These data suggest that postnatal exposure to SHS affects the hindbrain, a region that undergoes significant postnatal growth, by reducing the total number of cells and by increasing cell size. The authors concluded that, despite preserved hindbrain weight, the effects of postnatal exposure to SHS might result in neurologic dysfunction [252]. This study provided clear biologic evidence for an alteration of brain development due to postnatal, but not prenatal, SHS exposure. Interestingly, although gross dysmorphology is demonstrable in the animal brain by SHS exposure to nicotine, brain structures are not grossly abnormal when examined later in adolescence or adulthood [203]. However, longer-lasting changes in morphology are noted in the hippocampus and somatosensory cortex in the form of decreased cell size and elevated numbers of glia. In considering synaptic function, several neurochemical studies have identified multiple biochemical markers of cell injury that indicate prenatal nicotine exposure damages the developing brain [253,254].

CARDIAC COMPLICATIONS

Nicotine exposure causes myocyte cell damage in newborns, reduced platelet activation, increased resting sympathetic nerve activity, and hypertension. In rats, exposure to SHS during the neonatal period resulted in abnormal vasoconstrictor and vasodilator responses and smooth muscle dysfunction [255]. Abnormalities of endothelial cell function were found in rabbits exposed to SHS for 3 to 10 weeks [256]. Exposure to SHS also appears to directly affect endothelial function in children by means of a dose-dependent decrease in the bioavailability of nitric oxide [257]. Exposure to SHS also caused left ventricular hypertrophy in rabbits [258]. SHS exposure in childhood reduces high-density lipoprotein levels [259]. In addition, adolescents exposed to their parents' smoke show depressed levels of high-density lipoprotein cholesterol (HDL-C), suggesting that SHS exposure may accelerate atherosclerotic change and place children at increased risk for the premature development of coronary artery disease [260,261].

SIDS

SIDS occurs within the first year of life and is a significant cause of infant mortality, with an estimated 1,400 deaths in the United States annually [262]. SIDS is a diagnosis of exclusion, and etiology is presently unclear. Various risk factors have been suggested including prone sleeping position, sex, age, birth weight, parental cigarette smoking, maternal substance abuse, bed sharing, soft bedding, and overheating [262,263]. Matturi et al. found evidence supporting an association between maternal smoking and SIDS. Specifically, CO from cigarette smoke forms carboxyhemoglobin, leading to brain hypoxia. This lack of oxygen inhibits normal brain development of the arcuate nucleus and normal brain function in the locus coeruleus and arcuate nucleus. These abnormalities could potentially affect control of the respiratory and cardiovascular systems, resulting in sudden unexplained infant death. Matturi et al. concluded that the most preventable risk factor for SIDS is maternal smoking during pregnancy [264]. Zhang et al. concluded that the association between maternal smoking and elevated SIDS risk is dose-dependent and significantly increased in infants who co-sleep with smoking mothers [265]. Another study that sampled pericardial fluid in SIDS cases found that 70% had elevated levels of cotinine [266].

PULMONARY COMPLICATIONS

Children with smoking parents demonstrate higher frequencies of common respiratory symptoms including cough, phlegm, asthma, breathlessness, and wheeze. Parental smoking inhibits lung growth and function during childhood [267,268,269,270]. One study assessed the pulmonary function of 80 healthy infants soon after birth and found significantly reduced pulmonary function in infants whose mothers had higher urine cotinine concentrations [271]. Another study demonstrated an association between in utero nicotine exposure and variable DNA methylation in fetal lung and placental tissues, suggesting that this variation may have a role in the fetal origins of chronic diseases [272].

Cough/Wheeze

Both past and current SHS exposure has been shown by multiple studies to cause cough and wheeze in children. Joad et al. worked with guinea pigs to establish the mechanism by which air pollutants, particularly SHS, causes cough. Secondhand smoke modifies afferent sensory fibers (specifically C-fibers and rapidly activating receptors) in the lungs and airways, thereby activating a neurally controlled cough mechanism. The vagus nerve receives input from the afferent sensory fibers, which is modified by interneurons in the nucleus tractus solitarius (NTS). A few additional modifications of the efferent activity occur in the brain stem. Cough occurs when the efferent signal modifies input to the respiratory muscles involved in inspiration and expiration. Wheeze occurs with bronchoconstriction and mucus secretion, which can be caused by locally released neurokinins or parasympathetic fibers synapsing on airway ganglia [64].

Asthma

Asthma is a chronic inflammatory disease, often with an initial onset in childhood. An association has been established between exposure to passive tobacco smoke and pediatric asthma development, while a causal relationship has been shown between exacerbated pediatric asthma and environmental tobacco exposure [273,274]. Cigarette smoke causes an "exaggerated bronchoconstrictor response" in asthmatics, leading to an increase in severity and frequency of acute asthma attacks as well as asthma-related hospitalizations [275]. Studies have shown a decreased respiratory drive and hypoxic ventilatory response in infants of smoking mothers [247]. Exposure to nicotine for the full gestation produced an increased risk of depressed hypoxic ventilatory response in rats [18]. Parents of asthmatic children should be strongly cautioned that smoke exposure is likely to dramatically worsen their child's asthma [276,277].

DENTAL CARIES

Each year, several billion dollars are spent treating pediatric dental caries in the United States. Dental caries are an oral infectious disease caused by Streptococcus mutans colonization and subsequent lactic acid production leading to dental decay. In addition to poverty, passive smoking is a substantial risk factor for developing dental caries. The reason for an increased prevalence of dental caries in children of low socioeconomic status is unclear. However, as poor children are more likely to be exposed to SHS, it has been suggested that environmental tobacco smoke exposure may help explain the increased dental decay in this particular population. Environmental tobacco smoke is considered a causal factor for dental caries in primary but not in permanent teeth. Mechanisms for the role of cigarette smoke in the development of pediatric dental decay include nicotine promotion of bacterial growth; immunosuppression from environmental tobacco smoke; decreased levels of vitamin C leading to increased bacterial growth; passive smoking-related saliva reduction, which impairs the natural defense against bacteria-related acid production; and a general increase in inflammation [278].

VITAMIN DEFICIENCY

Vitamin C (ascorbic acid) deficiency is common among active smokers due to both increased metabolism and decreased dietary consumption [68]. Cigarette smoking-induced oxidant damage is caused by both the immune system's inflammatory response and free radicals in cigarette smoke. Vitamin C and other antioxidants play an important role in preventing oxidant-induced damage.

Studies have supported a dose-dependent inverse relationship between environmental tobacco smoke exposure and ascorbic acid and beta carotene concentrations [68,279]. A 2011 study found that children with no SHS exposure had higher levels of vitamin A, C, and E, beta carotene, and folate (controlling for dietary and supplement intake) than children with either moderate or high SHS exposure [279]. A lower concentration of these key nutrients was associated with higher cotinine levels. Vitamin B6, B12, and D levels were not found to be significantly affected.

RESULTANT SYMPTOMS IN ADULTHOOD

The relationship between childhood passive smoke exposure and resultant health consequences in childhood has been firmly established. There is less known about the long-term respiratory effects of childhood passive smoke exposure. David et al. studied Chinese adults from the Singapore Chinese Health study who were exposed to cigarette smoke as children but never actively smoked, thereby eliminating active smoking as confounding bias often found in similar studies. They found an association, independent of adult SHS exposure, between childhood environmental tobacco smoke exposure and chronic dry cough and phlegm production. Other findings included a lack of an association between childhood SHS exposure and asthma or chronic bronchitis. Also, they found low-fiber predisposed patients to respiratory maladies [280]. One study found a 50% increase in adult-onset cancer for children whose fathers smoked, and the risk of hematopoietic cancer increased when both parents smoked [281].

Peppone et al. reported that never-smoking women who grew up with a smoking parent may have more difficulty becoming pregnant. Those exposed to SHS regularly in childhood and adulthood were 39% more likely to have suffered a miscarriage or stillbirth and 68% more likely to have trouble conceiving when trying for more than one year [282]. Further, among women exposed to environmental tobacco smoke in youth undergoing ART between 1994 and 1998, there was decrease in implantation rate and increased odds of spontaneous abortion [65].

In a study by Strohsnitter et al., early menopause was more likely to occur in never-smoking women exposed to maternal cigarette smoke. They attribute this association to smoke's effects on follicle production in utero [283].

15. PASSIVE SMOKING EFFECTS ON ADULTS

The International Agency for Research on Cancer (IARC) Working Group concluded that secondhand tobacco smoke is carcinogenic to humans [284]. Complications of exposure to SHS include adverse effects on the pulmonary, cardiovascular, and neurologic systems as well as increased risk for cancer and fibroblast changes.

OCCUPATIONAL EXPOSURE

Occupational exposure to SHS affects the health of countless employees worldwide. Workplace exposure is highly influenced by the type of smoking policy in the workplace. Airborne nicotine is present, often in excessive concentrations, in various job settings due to variable public smoking laws [285,286]. Local and state regulation of smoking in public places was instituted in response to data published by the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE). These standards assert that satisfactory indoor air quality cannot be maintained if smoking is allowed indoors, even with additional ventilation and air-cleaning devices [287]. Several studies have shown that smoke-free workplace policies decrease exposure of nonsmoking employees to SHS at work, while increasing rates of smoking cessation and decreasing the number of employees who smoke [14,288,289,290,291]. Policies that are less restrictive are associated with higher levels of sustained tobacco use among employees [290]. Policies that make indoor workplaces smoke-free result in improved worker health [290,292]. For example, smoke-free polices in the hospitality industry have been shown to improve health among bar workers, who are often heavily exposed to SHS in the absence of such policies [184,290,293].

Studies have shown that segregating smokers and nonsmokers within the same airspace reduces SHS exposure to nonsmokers but does not eradicate it. One such study, in smoking-segregated restaurants in Albuquerque, New Mexico, showed levels of nicotine in nonsmoking sections approximately equal to those found in smoking sections [294].

SHS remains an issue for those employed in some casinos, bowling alleys, restaurants, lounges, and bars [295]. These work environments can contain high concentrations of airborne nicotine in the air if there is a lenient smoking policy. One study found that male blue-collar workers are exposed to significantly more SHS than their counterparts in management/professional occupations [296]. Also, on average, blue-collar smokers smoke more heavily than white-collar smokers [296]. Interestingly, female blue-collar workers are far less likely to smoke than women in management/professional occupations [296]. However, women's SHS exposure is approximately equal regardless of occupation, and SHS exposure is lowest for female service industry workers.

In 1986, the National Academy of Sciences warned, "SHS (also called environmental tobacco smoke) is a hazardous substance and is the most frequent source of complaint about aircraft air quality. Because of the high concentration of SHS generated in the smoking zone, it cannot be compensated for by increased ventilation in that zone" [297]. The area, volume, and ventilation rate per smoker on an aircraft is the smallest of any workplace setting. However, essentially all airlines now prohibit smoking on their planes.

Overall, exposure to SHS in different microenvironments is based on the strength of the active source, the ventilation system, and the presence and effectiveness of air-cleaning devices. Personal SHS exposure is also affected by age, gender, and race. Constant exposure to SHS at workplaces leads to various complications to the exposed workers.

HEART DISEASE

SHS is estimated to cause 5% to 30% of premature deaths from heart disease each year in the United States among nonsmokers [14,298]. A key difference between the effects of smoking on the risk of cancer compared with the risk of heart disease is that the effects on cancer develop slowly, whereas the effects of smoking on the cardiovascular system occur rapidly. Passive smoking has been shown to cause atherosclerosis in both animal and human models, increase platelet aggregation, and increase myocardial oxygen demand. Multiple epidemiologic studies have consistently found an increased relative risk of cardiac events in nonsmokers with regular SHS exposure [299,300]. Investigators demonstrated through experimentation that 30 minutes of exposure to SHS compromised the endothelial function in coronary arteries of nonsmokers so that the endothelial response of nonsmokers was identical to that of routine smokers [301].

The CDC asserts that people at risk for heart disease should avoid SHS because it can increase one's risk of acute MI. A study was conducted to verify this assertion and concluded that smoking bans at public working places correlate with a reduced morbidity from heart disease [302]. Researchers have suggested that platelet activation, endothelial dysfunction, and broad inflammation may have some relevance [303]. Another theory states that even light exposure to smoke concomitantly restricts blood vessels and allows for blood clotting. This combination raises the risk for MI.

Atherosclerosis

Atherosclerosis, a chronic inflammatory atheromatous disease characterized by focal, noncircumferential, and (most often) proximal plaques, is a major underlying cause of cardiovascular disease, which continues to be the leading cause of death, accounting for 840,678 deaths in the United States in 2016 [304]. Monocytes play a key role in the pathogenesis of atherosclerosis. Monocytes migrate from the blood to the subendothelial space beneath injured endothelial cells, where they differentiate into macrophages. These subendothelial macrophages readily take up oxidized LDL, becoming "foam cells." Collections of "foam cells" are dubbed "fatty streaks" and may first appear in the aorta at 10 years of age. Fatty streaks are precursors to atherosclerotic plaques. Such plaques are advanced lesions characterized by the accumulation of lipid-rich necrotic debris and smooth muscle cells [63,305]. Triggers of endothelial cell injury include hyperlipidemia; bacterial or viral infection; oxidative stress through abnormal regulation of reactive oxygen species, hypoxia, turbulent blood flow, and shear stress; and environmental irritants, such as tobacco smoke [306].

Yuan et al. exposed transgenic human apoB-100 mice to sidestream whole smoke (SSW) (a major component of SHS) in order to study the effects of SHS on atherosclerosis. The transgenic mice received SHS exposure comparable to SHS exposure a nonsmoker would receive from a typical smoking housemate. They found a decrease in plasma HDL-C levels; a decrease in the ratio between HDL-C and triglyceride; and a decrease in ratio between HDL-C and total cholesterol. Yuan et al. noted increased lipid accretion in the aorta, heart vessels, and hepatocytes corresponding to the noted blood lipid profile alterations. Furthermore, they found increased levels of monocyte chemoattractant protein-1 (MCP-1) in blood, heart tissue, and aortic tissue. Increased numbers of macrophages were noted in arterial walls. This finding was significant as MCP-1 is a chemokine that attracts monocytes to the damaged subendothelial cells in the process of plaque formation. Decreased adiponectin monomer levels were noted in the smoke-exposed mice [63]. Adiponectin is an adipocyte-specific plasma protein with potential anti-atherogenic properties. In vitro, adiponectin suppresses the endothelial inflammatory response, the proliferation of vascular smooth muscle cells, and the transition of macrophages to foam cells [307]. Finally, based on examination of the cytokine profile, Yuan et al. determined that cigarette exposure caused a permanent pro-inflammatory state; the normal adaptive response (i.e., initial pro-inflammatory Th1 type cell-mediated response to a Th2 mediated immune response) did not occur [63].

Coronary Heart Disease

A strong association between active smoking and coronary heart disease has been well established, and one study found a 50% to 60% increase in risk for coronary heart disease development in passive smokers [308,309]. Active and passive smoking are known to [310]:

- Increase the incidence and frequency to cardiac arrhythmias

- Decrease the oxygen-carrying capacity of blood

- Increase the incidence of coronary artery spasm

- Promote atherosclerosis, thereby increasing the risk of cardiovascular disease

- Increase the incidence and tendency for thrombosis

The relationship between SHS and coronary heart disease is supported by a study that shows exposure to SHS is associated with increased inflammatory markers, including higher white blood cell counts and levels of C-reactive protein, homocysteine, fibrinogen, and oxidized LDL-C [311]. The intensity of inflammation markers was proportional to the number of years of reported exposure to SHS. Furthermore, subjects with only occasional SHS exposure also experienced increased levels of inflammatory markers, showing that even low SHS exposure is a significant concern. Increased coronary risk is mechanistically mediated by increased platelet aggregation, reduced oxygen uptake and exercise capacity, accelerated lipid peroxidation, and endothelial damage by SHS [312,313,314]. Passive smoke causes arteriosclerosis by altering cholesterol concentrations or by accelerating lipid peroxidation via reductions in serum antioxidant defense [315].

Many elements of tobacco smoke, including CO, nicotine, and polycyclic aromatic hydrocarbons, contribute to the damaging effects on the cardiovascular system. Studies of the effects of tobacco smoke on platelet sensitivity suggest that nicotine is not the sole cause of increased aggregation. Burghuber et al. compared the sensitivity of platelets to the antiaggregatory action of exogenous prostacyclin (PGI2) in nonsmokers and smokers exposed to SHS for 20 minutes. No change was observed in the smoking subjects' platelet sensitivity to PGI2 after SHS exposure, but the smokers' platelets were significantly lower than that of the nonsmoking subjects' before SHS exposure. The nonsmoking subjects experienced significant changes in sensitivity to PGI2 with reported platelet sensitivities matching those of smokers after SHS exposure [316]. However, another study by Benowitz et al. showed that smokers and abstinent smokers with nicotine patches differed significantly in platelet activity despite similar nicotine levels [317]. Thus, nicotine is not the only component of tobacco smoke that mediates increased platelet aggregation.

A British regional heart study examined 4,729 men 40 to 59 years of age and found a 50% to 60% increase in coronary heart disease caused by exposure to SHS [309]. This study is significant because most studies on the relationship between SHS and coronary heart disease either show significant risk increases or only show modest risk increases. Whincup et al. used cotinine measurements to determine passive exposure to smoking. This study noted that although high cotinine levels were associated with an excessive risk of coronary heart disease, they showed little association with the risk of stroke. Whincup et al. offered an explanation for the underestimated association between serum cotinine and coronary heart disease, in that the association tends to decrease over long follow-up periods since assessment of exposure. Finally, this study suggested that risks associated with passive smoking are widespread among nonsmokers.

The American Heart Association's Council on Cardiopulmonary and Critical Care, the Scientific Committee on Tobacco and Health in the United Kingdom, and the California Environmental Protection Agency have all concluded that SHS increases the risk of heart disease [318,319,320].

STROKE

According to findings of the Health and Retirement Study, a national longitudinal study of U.S. adults 50 years of age and older and their spouses, never-smokers with spouses who were current smokers had a 42% increased risk of first stroke. Former smokers married to current smokers had a stroke risk similar to respondents who were current smokers [321].

LUNG DISEASE

Environmental tobacco smoke exposure is associated with respiratory symptoms, asthma, a slight impairment of lung function, and increased bronchial responsiveness [322]. A Swiss study on air pollution and lung diseases with a sample of 4,197 nonsmoking adults, showed that SHS was associated with increased risk of asthma, wheezing, bronchitis, and dyspnea [323]. Greater levels of cumulative exposure to tobacco smoke in the home and workplace are also associated with an increased risk of COPD [324]. It is estimated that a (hypothetical) elimination of SHS in home and work environments would decrease COPD diagnoses in the United States by 18% (or 11% and 7%, respectively).

In a report by Schick and Glantz of unpublished in vivo research done by Philip Morris during the 1980s, inhaled sidestream smoke was found to be four times more toxic per gram of total particulate matter than mainstream smoke. They report that the gas/vapor phase of sidestream smoke is responsible for most of the sensory irritation and respiratory tract epithelium damage that occurs [325].

Asthma

SHS is an established trigger for the onset of asthma in children, and there is growing evidence that it is also a causal factor for asthma in adult nonsmokers [326]. Finland researchers found that subjects exposed to tobacco smoke in the workplace were twice as likely to develop asthma as those who were not exposed. Health effects for adult asthmatics include asthma attacks; increased sensitivity and reduced lung function; and irritation of the eyes, nose, and throat. Exposure to cigarette smoke for just one hour can cause 20% deterioration in short-term lung function of adults with asthma [327].

CANCER

Lung cancer holds the distinction as "the first disease linked definitively" to both active and passive smoking [299,328,329]. Zhong et al., based on epidemiologic studies, estimate a 30% risk of lung cancer in nonsmokers exposed to environmental tobacco smoke. Chinese women have one of the highest incidences of lung cancer in the world, yet active smoking does not appear to be a major risk factor for lung cancer in this population [328]. Smoking among Chinese women is relatively rare, and among those who do smoke, cigarette consumption is limited. However, smoking among Chinese men is especially common, so their spouses are exposed to considerable quantities of environmental tobacco smoke. Thus, nonsmoking Chinese women were an ideal population for a case-control study considering the effects of environmental tobacco smoke on lung cancer. Certain histologic types of lung cancer are more commonly associated with active smoking. The risk of developing squamous cell and small cell cancer is much higher than the risk of developing adenocarcinoma and large cell carcinoma [330,331]. The study by Zhong et al. showed that passive smoking also favors the development of squamous cell and small cell lung cancers over adenocarcinoma and large cell carcinoma [328].

Zhong et al. conducted a meta-analysis study on the relationship between lung cancer and environmental tobacco smoke. They found a 48% increased risk of lung cancer in nonsmoking males exposed to environmental tobacco smoke in their homes, while nonsmoking males had a 29% increased risk of lung cancer if exposed to smoke at work. A 20% increased risk of lung cancer was noted in nonsmoking females exposed to smoke in their homes, while nonsmoking females had a 15% increased risk of lung cancer if exposed to smoke at work. Furthermore, environmental tobacco smoke-exposed nonsmoking women "showed statistically significant monotonic exposure-response relationships." Finally, Zhong et al. found that childhood environmental tobacco smoke exposure did not correspond to an increased risk of lung cancer in adulthood [66].

Genetics may play an influential role in the risk of developing lung cancer from SHS exposure. Polymorphisms in the gene glutathione S-transferase (GST) M1 show a greatly increased risk of developing lung cancer with SHS exposure. GSTM1 is believed to prevent tumorigenesis by detoxifying carcinogens in tobacco smoke. Lung cancer susceptibility has been associated with anomalies in several cytochrome P450 pathways and several GST enzymes that detoxify chemical carcinogens [332,333,334,335,336]. GST enzymes are considered phase II detoxification enzymes, which conjugate glutathione to carcinogens and reactive oxygen species to detoxify them. Two of the four polymorphic gene classes of GSTs, mu (µ) and theta (θ), have been linked to tobacco-associated cancers. The GSTM1 is a variant of the mu class, which contains a null allele that may be inactivated by a deletion of DNA coding sequences [336,337]. Approximately 50% of the white populations of Europe and North America have homozygous null genotypes for the GSTM1 enzymatic activity [338]. Loss of GSTM1 enzymatic activity has been associated with increased risks of various cancers, including tobacco-associated lung cancer, head and neck cancer, larynx cancer, and bladder cancers. Bennett et al. found that SHS-exposed nonsmoking women with the null polymorphism represented 42% to 49% of the lung cancer cases [337]. Women with the homozygous null genotype have a greater risk of tobacco-associated cancer relative to men [339].

GSTTI is an isoenzyme of the theta class of GSTs, which is deactivated by a homozygous deletion in 11% to 18% of whites [338]. United deficiency of GSTT1 and GSTM1 produces a dramatically increased risk for lung cancer in U.S. populations [340]. Kawajri et al. found that a mutant variation in exon 7 of the cytochrome P450 1A1 (CYP1A1) enzyme was associated with higher rates of lung cancer in the Japanese subjects studied [341]. CYP1A1 is known to activate carcinogenic polycyclic aromatic hydrocarbons including the benzo(a)pyrene component of tobacco smoking [342]. Rebbeck et al. found a synergistic increase in lung cancer risk with both homozygous deletions of GSTM1 and the valine allele variant of exon 7 in CYP1A1 [338].

Large-scale genome-wide association studies have identified several novel lung cancer susceptibility genes, including those on chromosomes 5p15.33, 15q24-25.1, and 6p21 [343]. The 5p15.33 region is associated with risks specific to adenocarcinoma of the lung. The 15q25 region contains three nicotine acetylcholine receptor subunit genes. Their polymorphisms have been associated with nicotine dependence [343]. Associations of the 6p21 region have not been consistently replicated among studies [343,344]. Other regions (e.g., 6q23-25, 13q31.3) have also been identified by genome-wide studies as being associated with risk of lung cancer, including some studies specific to African Americans and to those who have never smoked. Further studies are necessary to assess individual susceptibility based on the combination of polymorphisms in multiple genes [343,344,345].

GLUCOSE INTOLERANCE/DIABETES

Houston and colleagues questioned whether active and passive smokers are more likely than nonsmokers to develop clinically-relevant glucose intolerance or diabetes. Of 4657 participants in the Coronary Artery Risk Development In Young Adults (CARDIA) study, 16.7% developed glucose intolerance at 15-year follow-up. Incidence of glucose intolerance was highest among smokers (21.8%), followed by never-smokers with passive smoke exposure (17.2%), then previous smokers (14.4%), and was lowest for never smokers with no passive smoke exposure (11.5%). The risk among current and never smokers remained after adjustment for sociodemographic, biologic, and behavioral factors, but risk in previous smokers was similar to that in never smokers without passive smoke exposure [346]. A meta-analysis conducted by Pan et al. found that both active and passive smoking are associated with significantly increased risks of type 2 diabetes. The risk was increased in individuals who had recently quit smoking, but decreased substantially as time from quitting increased. They also identified a dose-response relation for current smoking and risk of diabetes [347].

SKIN DISORDERS

Setty, Curhan, and Choi prospectively examined over a 14-year period (1991–2005) the relation between smoking status, duration, intensity, cessation, and exposure to SHS and incident psoriasis in 78,532 women from the Nurses' Health Study II. Prenatal and childhood exposure to passive smoke as well as current and past smoking and cumulative measures of smoking were associated with an increased risk of psoriasis. The risk of incident psoriasis among former smokers decreases nearly to that of never smokers 20 years after cessation [348].

WOUND REPAIR

Passive smoking is known to interfere with normal tissue repair and remodeling, though the underlying pathology is not well understood. Passive smoking has been shown to obstruct wound healing by decreasing blood flow to the damaged tissue and hindering granulation tissue formation and function. Tissue repair and remodeling is heavily reliant upon fibroblasts, which migrate to the site of damage, proliferate, and secrete cytokines, growth factors, and extracellular matrix molecules. Wong et al. found that SSW smoke causes cytoskeletal changes in fibroblasts, which may account for decreased fibroblast migration. Furthermore, excess scarring in SHS-exposed individuals is likely due to a combination of prolonged cell survival (due to a cellular stress response invoked by SHS) and the aforementioned decreased cell migration [62].

AGE-RELATED MACULAR DEGENERATION

Khan and colleagues designed a case-control study to investigate a possible relation between smoking and risk of development of age-related macular degeneration (AMD) among whites. Although many risk factors are related to AMD (e.g., aging, hypertension, family history, obesity), they found a strong association between AMD and pack years of cigarette smoking, and the odds ratio increased with the amount smoked. Smoking impairs the functioning of the retinal pigment epithelium, causing buildup on the retina and subsequent damage to Bruch's membrane. Stopping smoking was associated with reduced odds of AMD and the risk in those who had not smoked for over 20 years was comparable to nonsmokers [349].

CERVICAL INTRAEPITHELIAL NEOPLASM (CIN)

Cervical intraepithelial neoplasm (CIN) is a precursor to cervical cancer, which is the fourth most common cause of cancer-related death in women worldwide [350]. Firmly established major risk factors for CIN include active smoking and human papillomavirus (HPV) infection. A 2006 case-control study of Taiwanese women established SHS as a major risk factor for CIN in addition to active smoking and HPV. The authors presented an indirect and a direct potential mechanism for the development of CIN following SHS exposure. CIN could be caused indirectly by immune suppression or directly by a polycyclic aromatic hydrocarbon-DNA adduct [69]. More recent studies continue to suggest an association between SHS and CIN, and while these studies continue to be conducted, few have provided conclusive results [468,469].

NONALCOHOLIC FATTY LIVER DISEASE

Nonalcoholic fatty liver disease is one of the most common liver diseases in the United States. Nonalcoholic fatty liver disease covers a broad range of diseases from steatosis to nonalcoholic steatohepatitis (NASH) and can have dramatically varied underlying pathology. NASH is a significant clinical concern due to potential disease progression resulting in cirrhosis and end-stage liver disease [351]. Yuan et al. employed a mouse model transgenic for human apoB100 to consider the effect of passive smoke on cholesterol and triglyceride levels. They found no significant change in cholesterol levels with passive smoke exposure but a marked increase in triglycerides in the liver. The increased lipid accretion in hepatocytes is consistent with lipid changes seen in nonalcoholic fatty liver disease [63].

16. MEASURING SECONDHAND SMOKE EXPOSURE

Seventy percent to 80% of nicotine is initially metabolized to cotinine, primarily by CYP2A6 [195]. Cotinine is, for the most part, metabolized to 3'-trans-hydroxycotinine, mainly by the same CYP2A6 enzyme [352]. Both nicotine and cotinine undergo N-glucuronidation; however, 3'-hydroxycotinine undergoes O-glucuronidation [353]. Cotinine is also partly metabolized to 3'-trans-hydroxycotinine by CYP2A6 [352]. Cotinine has a half-life of 15 to 20 hours, and its serum concentrations are tenfold higher than nicotine; thus, cotinine is generally used as an index of nicotine exposure [354].

Cotinine can be measured in hair, nails, blood, saliva, or urine samples. Although other biomarkers for environmental tobacco smoke exposure exist, cotinine is currently the most sensitive and specific. Such objective quantification is especially important in studies concerning passive smoke exposure in children, as parental assessment of smoke exposure is frequently unreliable [65,69,277,355,356]. SHS exposure can also be assessed through CO breath analysis, measurement of certain carcinogens (e.g., NNAL can be found in urine, blood, and nails) or benzene, or measurement of respirable suspended particulates in the air [355].

Breath analysis has improved as an assessment tool. It utilizes the monitoring of volatile organic compounds, which are predominantly bloodborne and therefore enable monitoring of different processes in the body. One study utilizing a real-time breath analyzer identified the presence of volatile organic compounds (1,3-butadiene) after SHS exposure in the breath of nonsmokers [357]. While this method of smoking analysis is improving, studies using this tool still suffer issues of sampling and lack of normalization data. Results could be skewed by participants' varying degrees of exposure to other common sources of volatile organic compounds, for example, wood smoke and automobile exhaust [358].

Studies of genetic polymorphisms of genes that modulate cell growth and proliferation provide potentially helpful biomarkers associated with long-term exposure to carcinogens and eventual tumor formation. One such biomarker used to study lung cancer in SHS-exposed patients is the tumor suppressor gene p53. The p53 gene encodes a multifactorial transcription factor that controls cellular response to DNA damage [359]. Husgafvel-Pursiainen et al. found a three- to fourfold increase in the risk of p53 mutation in SHS-exposed patients who develop lung cancer, while in long-term heavy smokers, p53 mutations are found in 50% of patients with lung tumors [360]. Furthermore, Husgafvel-Pursiainen et al. demonstrated that the majority of the p53 mutations were G:C to A:T transitions. The CpG dinucleotide sites were mutational hotspots, accounting for 50% of the reported G:C to A:T substitutions within the p53 gene. Endogenous deaminations of methylated cysteine residues or preferential carcinogen binding are proposed explanations for G:C to A:T substitutions within CpG islands. This evidence supports the role of p53 as a biomarker for both passive and active tobacco-related carcinogenesis [360].

A combination of the measurement of body fluids for cotinine and hair for nicotine, with the questionnaire and interview-derived information, seems to be the optimal method for assessing SHS exposure. Empirical studies show general concordance of reported environmental or biologic measures of SHS exposure [361]. In addition, urinary cotinine is often used for evaluation of smoking-cessation program efficacy, monitoring of pregnancy/other at-risk groups, and assessment of occupational exposure [362].

17. THIRDHAND SMOKE

The term "thirdhand smoke," or "environmental tobacco smoke," has been and is often used synonymously with SHS, but it can be more accurately described as any airborne particulate matter originating from burning tobacco. It is comprised of both active mainstream smoke (tobacco smoke exhaled by active smokers) and sidestream smoke (smoke from the burning end of a cigarette) that is inhaled by nonsmokers, and evidence shows the possibility of harm for a significant period of time after the cigarette/tobacco product has been extinguished.

In a 2009 study by Winickoff et al., more than 80% of national survey respondents (regardless of smoking status) agreed that SHS was harmful to children, but only 43% of smokers and 65% of nonsmokers thought the same of thirdhand smoke (defined as "breathing air in a room today where people smoked yesterday") [363]. Thirdhand smoke, or any exposure to residual tobacco smoke contamination on surfaces or breathing air in a room where smoking previously occurred, can be dangerous. Unfortunately, not all smokers are cognizant of these harms. Many believe that confining smoking to one room in the home or smoking in the absence of children or even smoking outside with all household windows and doors closed is enough to protect their children. Tobacco smoke does not simply disappear after cigarettes are extinguished, and it (and other toxins) may linger even with what is perceived as adequate ventilation.

Hein and colleagues were likely the first to measure nicotine content of household dust. Nicotine has a high affinity for dust particles, and the amount of tobacco smoking that occurs in the home is highly correlated with concentration of nicotine in household dust [364]. According to a 2004 study by Matt et al., vapor components of tobacco smoke "are absorbed onto walls, furniture, clothes, toys, and other objects within 10 minutes to hours after tobacco smoke has been emitted. From there, they are re-emitted into the air over the course of hours to months" [365]. Similar to findings of a 2001 study of hair nicotine levels among children in New Zealand, whether household smokers smoked indoors in the presence of their child or attempted to limit their children's smoke exposure by smoking outside or in the children's absence, the children were not protected from exposure to nicotine in the indoor air [366]. Further, skin-to-skin contact poses additional risk as nicotine was found on the index fingers of 92% of mothers in the sample [365].

Part of the reason behind the danger of thirdhand smoke may be the lead content of tobacco smoke. According to the Environmental Protection Agency, the tobacco leaves used to make cigarettes contain radioactive lead-210. Indeed, increased blood lead levels among youth is directly associated with household smoking and house dust [367]. Mainstream smoke contains at least 58 percutaneous penetration enhancers, which are used to enhance transdermal delivery of drugs. Of these, 69% are hydrophobic or strongly hydrophobic and can therefore readily permeate the skin and likely settle in percutaneous fat for continued exposure long after the cigarette has been extinguished [368]. Further, unpublished research from Philip Morris Co. shows that 4-(methylnitrosamino)-I-(3-pyridyl)-1-butanone (NNK) forms in sidestream smoke and increases up to 200% per hour during the first six hours after cigarettes are extinguished [369]. NNK has been shown to cause an exaggerated response in microglia (causing them to attack healthy brain cells) and overall neuroinflammation, which can lead to disorders such as multiple sclerosis [370].

Oie and colleagues report that low ventilation in homes can strengthen the effects of indoor pollutants. They found that odds of bronchial obstruction among children was higher in homes where they were exposed to environmental tobacco smoke as well as dampness, textile wallpaper, and plasticizer-containing surfaces [371].

The problem is not confined to homes. In a 2008 study by Matt and colleagues, it was found that cars of people who smoked in their vehicles contained elevated levels of nicotine in dust on surfaces and in the air when compared with cars of nonsmokers [372].

Haussmann et al. performed a study of fresh versus room-aged sidestream smoke to ascertain how the different types of smoke would affect rats. Their study revealed that the room-aged smoke had decreased concentrations of smoke components such as nicotine and total particulate matter. However, levels of CO remained equal to that of the fresh smoke. The rats manifested reserve cell hyperplasia in the nose and hyperplastic and metaplastic epithelial changes in the larynx; these effects were not as profound in those exposed to the room-aged smoke [373]. Rao and colleagues found that lung tissue from mice exposed to aged and diluted sidestream smoke exhibits increased angiogenesis associated with leukocyte rolling and adhesion. This phenomenon may lead to recruitment of inflammatory cells as observed in bronchitis or asthma [374]. These research studies confirm the unpublished research of Philip Morris Co. in the early 1990s, which revealed that aged sidestream smoke is more toxic to lab animals than fresh sidestream smoke [375].

18. INTERVENTIONS FOR SMOKING CESSATION

PRIMARY CARE INTERVENTION

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco.

http://annals.org/aim/fullarticle/2443060

Last Accessed: May 13, 2019

Level of Evidence: A (There is high certainty that the net benefit is substantial.)

Smoking cessation may be helpful in reducing firsthand and secondhand tobacco smoke exposure by eliminating the source: the smoker(s). Parents and caregivers of young children should receive cessation counseling and/or pharmacotherapy to quit smoking and eliminate the exposure of children to SHS. Parents should also be informed of the importance of a smoke-free environment for children and that it should be instituted before pregnancy. Pregnant women must learn that smoking will likely produce lasting adverse effects on their offspring. Furthermore, smoking parents should be aware that smoking is known to cause and exacerbate asthma, chronic serous otitis, otitis media, respiratory illness, and possibly childhood cancers. A healthcare provider is required to intervene if a child is suffering from one of these disorders. Healthcare providers are responsible for advising smoking parents about the harms of passive smoke as well as how to provide a smoke-free environment for their children [249]. There are many smoking cessation resources that may be provided to patients, including several "quitlines." These hotlines provide free telephone access to a smoking cessation counselor. The National Cancer Institute's quitline is 1-877-44U-QUIT (1-877-448-7848), and both English- and Spanish-speaking assistance is available. The website https://smokefree.gov also offers support, tools, and expert advice through their app, text messaging, and social media networks. Assistance for issues unique to different subgroups, such as veterans, women, adolescents, adults older than 60 years of age, and those who speak Spanish, are also available.

Although nearly 70% of patients who smoke say they would like to quit, only 7.4% are able to do so without help [376,377]. The advice of a physician alone can increase the smoking cessation rate to 10.2% [378]. It is important for physicians to add an inquiry about smoking to the questions routinely asked while a patient's vital signs are being taken (Figure 2). Further assessment using an abbreviated form of the Fagerström Test for Nicotine Dependence can provide information about whether a patient is addicted to or physically dependent on nicotine. The Fagerström test is a question and answer test that rates an individual's nicotine dependence on a scale of 0 to 10 [379].

Figure 2: PATHWAY FOR TOBACCO CESSATION TREATMENT

Source: Modified with permission from Barua RS, Rigotti NA, Benowitz NL, et al. ACC expert consensus decision pathway on tobacco cessation treatment: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2018;72(25):3332-3365.

After the diagnosis of nicotine dependence is made, the next step is to assess the patient's readiness to change. The five-stage model for readiness to change can be applied to addictive behaviors such as smoking. The stages are precontemplation, contemplation, preparation, action, and maintenance. In the precontemplation stage, a patient does not believe that smoking is a problem or refuses to consider smoking cessation. In the contemplation stage, the patient recognizes that smoking is a problem and is thinking about quitting. During the preparation stage, the patient makes specific plans to stop smoking, such as setting a quit date and determining how smoking cessation will be accomplished. In the action stage, the patient stops smoking. Finally, the maintenance stage is marked by the patient's continued abstinence from smoking. Relapse to smoking behavior is common. Patients often cycle through the stages of change several times before reaching stable abstinence [380].

Interventions can be classified into behavioral, pharmacologic, and alternative methods. Behavioral interventions include physician advice and individual, group, and telephone- or Internet-based counseling. Pharmacologic interventions include NRT and sustained-release bupropion. Alternative interventions include hypnosis, acupuncture, exercise, lobeline, anxiolytics, mecamylamine, and opioid agonists [381].

BRIEF INTERVENTION

Evidence Based Practice Recommendation

According to the University of Michigan Health System, healthcare professionals should advise all tobacco users to seriously consider making a quit attempt using a clear and personalized message. Advice as brief as three minutes is effective.

https://www.med.umich.edu/1info/FHP/practiceguides/smoking/smoking.pdf

Last Accessed: May 13, 2019

Strength of Recommendation/Level of Evidence: IA (Generally should be performed based on randomized controlled trials)

Brief intervention training allows healthcare professionals to offer basic support, ensuring that all smokers who come into contact with these health professionals are able to receive help as appropriate. Brief intervention offers short-term professional input, self-help leaflets and videos, and complementary therapies. This type of information can be applicable for smokers at any level. Milch et al. compared the effects of two brief interventions against treatment as usual. The minimal intervention consisted of a smoking status vital sign stamp, which documents the patient's smoking status. The enhanced intervention consisted of a five-question form that assessed the patient's level of cessation readiness and provided cessation counseling prompts for clinicians. Medical record documentation of screening for smoking and cessation advice and self-reported patient smoking cessation rates were collected 8 to 10 months after implementation. Self-reported patient smoking cessation was higher in the enhanced intervention group (12%) compared with the minimal intervention (2%) and control (4%) groups. This demonstrated that even a short questionnaire that assessed readiness to quit and provided documentation of cessation advice improved rates of clinician cessation advice and patient smoking cessation compared with no intervention [382]. In a study by Smith and Burgess of patients admitted to the hospital with diagnoses of coronary artery disease, a minimal intervention (i.e., advice from physicians and nurses and two pamphlets) resulted in 35% of the group confirmed abstinent at 12 months [383].

5 A's

The U.S. Public Health Service Clinical Practice Guideline was updated in 2018, but continues to recommend the 5 A's approach for intervening with the patient who smokes [384,470]:

- Ask about smoking status

- Advise to quit

- Assess willingness to quit

- Assist by suggesting and encouraging the use of problem-solving methods for cessation

- Arrange for follow-up contacts and relapse prevention

Mullen et al. found that simple changes in question format, such as moving away from requiring "yes" or "no" answers and allowing responses such as "I used to smoke" or "I have cut down," increased smoking disclosure by 40% [385]. Every clinician should ask patients about tobacco use and advise them to quit. Abrupt smoking cessation with medical and psychologic assistance is more successful than tapering or "smoking less" [461].

Given the magnitude of tobacco use as a health risk, tobacco use status should be considered a vital sign requiring regular assessment [384,386]. Nevertheless, studies continue to find that clinicians inconsistently practice assessment of tobacco use and advice to quit smoking [387]. The third step of the Five A's approach, after asking and advising, is to assess the patient's willingness to quit. For the patient who is unwilling to quit at this time, the clinician should help increase motivation by discussing the immediate and long-term risks of continued smoking, benefits of quitting, and the patient's perceived barriers to quitting. The clinician should try to make the discussion personally relevant to the patient and include risks and benefits in addition to those related to health [384]. For the patient willing to quit, the clinician should provide assistance, such as helping the patient choose a target quit date in the near future, suggesting appropriate pharmacotherapy, providing social support, advising the patient about the nature and time course of nicotine withdrawal, recommending behavioral and cognitive coping responses to use when the patient experiences urges to smoke, and perhaps making a referral to an intensive behavioral counseling program [384]. The last of the Five A's involves arranging follow-up contact. This strategy is also based on evidence that total contact time predicts treatment outcome [384]. Follow-up contact can take the form of additional office visits, telephone calls, text messages, or even written materials sent through the mail [462]. Such contact communicates the importance of the cessation attempt, provides social support, and offers the opportunity to intercede if problems have developed. Because the risk of relapse is greatest immediately after quitting, follow-up contact ideally should begin close to the target quit date [388].

MOTIVATIONAL INTERVIEWING

Introduced by Miller in 1983, motivational interviewing is a method of counseling designed to enhance patients' motivation to change by helping them explore and resolve their ambivalence about making the change [389]. It is a collaborative, non-confrontational, "guiding" approach. Motivational interviewing for tobacco cessation utilizes active listening to understand how the patient feels about his or her tobacco use in an effort to uncover any ambivalence [384]. The healthcare provider elicits the patient's own views regarding consequences of continuing to use tobacco and benefits of quitting and asks permission to share additional information on risks when necessary. Goals are developed collaboratively, based on the patient's current readiness to change. Originally developed as an intervention for alcohol abuse, it has shown promise as a successful strategy for smoking cessation. Lai et al. reviewed 28 studies and found that motivational interviewing yields a significant increase in quit rate, especially when conducted by primary care physicians or counselors for sessions lasting more than 20 minutes [390,391]. Further, in a randomized, controlled trial, Ruger and colleagues reported that motivational interviewing for smoking cessation actually saves money, and prevents relapse, among low-income pregnant women with $628/quality-adjusted life-year saved versus usual care [392].

INTERVENTIONS FOR NON-ENGLISH-PROFICIENT INDIVIDUALS

Because communication with patients regarding cessation of smoking is a vital aspect of patient care, it is important that discussions and printed materials are provided in the language with which the individual is most comfortable. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required. In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners.

Interpreters are more than passive agents who translate and transmit information back and forth from party to party [393]. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. When providing care for patients for whom English is a second language, the consideration of the use of an interpreter and/or patient education materials in their native language may improve patient understanding and outcomes. The American Heart Association, the American Medical Association, and the American Academy of Family Physicians produce patient education references in several languages. Primary care providers may utilize these in their interactions with patients for whom English is a second language.

TREATING NICOTINE DEPENDENCE

Behavioral Modifications

Behavioral interventions are nonpharmacologic treatments delivered directly to individual smokers [388]. The main disadvantage of this approach is that relatively few smokers (about 5%) are interested in attending specific classes at any given time [394,395]. Therefore, group sessions appear to be the most cost-effective approach to delivering smoking cessation interventions [396]. Although relatively few patients want to go to classes, physicians should still have a list of referral smoking cessation clinics in their area for those smokers who express an interest in attending them and for those who have failed to respond to other approaches. Simple text, app, and web-tailored cessation messages may also be an effective alternative for behavioral support, doubling the cessation rates. This concept has been incorporated into patient support programs provided by several manufacturers of smoking cessation products [394].

There are several behavioral interventions that have empirical support, such as multicomponent coping skills training (e.g., coping response therapy, problem-focused treatment, relapse prevention training, and cognitive-behavioral therapy). This training includes social support and didactic information about nicotine dependence, withdrawal symptoms, and situations that are risks for relapse (e.g., alcohol use, negative moods, or presence of other smokers) as well as training in the use of cognitive and behavioral responses to cope with urges to smoke that reduce the risk of relapse [397,398]. Aversive therapy for smoking cessation, known as rapid smoking, involves smokers in a controlled clinical setting who deeply inhale on cigarettes at six-second intervals. Up to nine cigarettes would be smoked per treatment session to produce strong aversive reactions to cigarettes [399]. Aversive cigarette use greatly declined after the introduction of NRTs, and reviews have concluded that there is insufficient evidence to determine the efficacy of this method for smoking cessation [400,401]. Another behavioral treatment, scheduled reduced smoking, involves three weeks of gradually reduced nicotine intake. In contrast with other smoking cessation strategies involving reduction of smoking, the patient does not control when and where smoking will occur. Rather, an algorithm is used to determine when each cigarette is to be smoked based on the passage of time [402].

Pharmacotherapy

The first-line pharmacologic interventions for smoking cessation are NRT and bupropion [381,403]. However, no pharmacotherapy has been approved for use among pregnant or nursing women. The five forms of NRT available are the patch, gum, lozenge, nasal spray, and inhaler. A Cochrane review found that all commercially available forms of NRT increased the quit rate by 50% to 70%, independent of the intensity of additional support provided to the individual. Although support is beneficial, it does not appear to be essential to the success of NRT [404].

All available pharmacotherapies are safe for non-pregnant or nursing adults. In a 2016 analysis, varenicline outcomes are found to be equal to NRT plus counseling, and varenicline is also associated with a reduced risk of relapse [463]. Bupropion has the added advantage of reducing smoking cessation-related hyperphagia and weight gain. It is also an antidepressant and can ameliorate withdrawal-associated anhedonia and depression.

The nicotine transdermal system, otherwise known as the patch, releases nicotine steadily during an extended period, with blood levels rising within the first 2 to 4 hours and then remaining relatively constant between 8 and 24 hours after application, depending on the product used [405]. A number of transdermal nicotine-replacement systems are available over the counter. Prescribing information inserts for all transdermal nicotine products indicate that they should be used as part of a cessation program; yet, many patients receive the patch without any physician advice or behavioral support [406]. Adverse reactions to transdermal nicotine-replacement systems seldom cause discontinuation of therapy. Thirty percent to 50% of patients experience mild skin irritation with the patch. In most patients, rotating patch application sites can alleviate this problem. Sleep disruption is usually resolved by removing the patch at bedtime [407]. Unfortunately, use of the patch without any behavioral support is not likely to be successful.

The U.S. Food and Drug Administration adopted labeling for the patch, allowing use beyond the standard duration of eight weeks. This decision was based in part on data showing that extended-duration (24-week) transdermal nicotine therapy reduced the risk for smoking lapses and increased the likelihood of recovery to abstinence compared to the standard 8-week duration of therapy [408,409].

Nicotine chewing gum is a type of NRT that may aid in smoking cessation and/or quitting smokeless tobacco. Chewing allows nicotine to be delivered quickly into the bloodstream. Typically available in either 2- or 4-mg doses, nicotine chewing gum is expected to last one to two hours. Release of nicotine from the gum is proportional to the rate of chewing, a feature that allows for self-titration [410]. However, like the patch, nicotine gum is most successful as an adjunct to behavioral interventions. Indeed, Schneider et al. showed that merely dispensing nicotine gum resulted in a lower quit rate with active gum than with placebo treatment (8% nicotine gum, 13% placebo gum) [411].

The nicotine lozenge is similar to a hard candy. It slowly dissolves in the mouth (for 20 minutes or so) to release nicotine to the brain more quickly than the patch. Shiffman, Di Marino, and Pilliteri analyzed two trials of a 21-mg nicotine patch and 4-mg lozenge to assess the efficacy of each in heavy and dependent smokers. Both therapies were found to significantly increase six-month, continuous abstinence in heavy smokers (≥40 cigarettes per day) and the highly dependent (Fagerström score >7) [412].

A 2-mg sublingual nicotine tablet has shown efficacy in several studies and has been approved in Europe to manage nicotine withdrawal [413,414,415]. Interestingly, one study found that being married was strongly associated with smoking cessation while on this medication [416]. Sublingual tablets (2 mg) have similar pharmacokinetics to that of the 2-mg nicotine chewing gum [417]. One study of high-dependence smokers (those who smoked their first cigarette of the day within 30 minutes of waking) found that a 4-mg nicotine lozenge significantly reduced withdrawal symptoms and cravings over six weeks of treatment [418].

Nasal nicotine spray (NNS) was approved by the FDA in 1997. Available by prescription, each spray contains 0.5 mg of nicotine, and a dose is defined as one spray in each nostril. In clinical trials, subjects were allowed to take up to 5 doses/hour, with a maximum of 40 doses/day (40 mg of nicotine). The cessation rates in trials with NNS at 1 year ranged from 15% to 25% [419,420,421]. A meta-analysis of nicotine replacement suggested that NNS and the inhaler might have higher quit rates than the patch or gum [422]. Indeed, nicotine administered via nasal spray is considered to be the next fastest acting delivery method after smoking and requires 11 to 13 minutes for nicotine levels to reach peak plasma concentration [423].

The FDA also approved a nicotine inhalation system consisting of a mouthpiece and a nicotine-containing cartridge. Available with a prescription, each inhaler contains 10 mg of nicotine and 1 mg of menthol, of which 4 mg of nicotine can be extracted and 2 mg are systemically available. Shallow or deep puffing results in similar nicotine absorption. Nicotine is delivered mainly to the oral cavity, throat, and upper respiratory tract, with a minor fraction reaching the lungs. A single inhaler can be used for one 20-minute period of continuous puffing or periodic use of as many as 400 puffs per inhaler. With controlled puffing in laboratory testing, venous plasma nicotine concentrations from a single inhaler puffed 80 times for 20 minutes, averaged 8.1 mcg/L at 30 minutes. Lower concentrations of 6.4 to 6.9 mcg/L have been reported for self-administration under clinical conditions. The time to reach peak plasma concentrations varies but is always significantly longer than with cigarette delivery [424].

Quitting smoking can be a difficult process, even with use of NRT. When subjects were given denicotinized cigarettes along with IV saline or nicotine, the variable most responsible for craving satisfaction, psychologic reward, and craving reduction was the denicotinized cigarette [425]. When ad libitum smoking of preferred brands was also allowed, the combination of nicotine-less cigarette and bolus IV nicotine were the most effective in lowering craving, negative affect, and total amount smoked [89]. Sensations in the tongue, nose, back of mouth, throat, windpipe, and chest showed strong correlation between nicotine-less cigarettes and the usual brand smoked by the subjects, perhaps explaining the strong effects on smoking suppression observed [425]. Therefore, it is important to recognize that while NRT is a key part of cessation therapy, it does not address all aspects of smoking behavior. In addition, certain smoking cessation strategies, such as NRT, have been found to be less effective among women than men. Given that researchers have found that women are 31% less likely to quit smoking successfully, further studies on gender-specific smoking cessation strategies are warranted [471].

Bupropion is an atypical antidepressant that has both dopaminergic and adrenergic actions [426]. In 1998, the slow-release preparation of bupropion became available as a prescription item specifically for smoking cessation, with the trade name Zyban. This treatment could be appropriate for smokers who do not wish to use an NRT or for those whose treatment with NRT has failed. Unlike NRT, smokers begin bupropion treatment one week prior to cessation. The suggested dosage is 300 mg/day, and the duration of treatment is 7 to 12 weeks [427]. A double-blind, placebo-controlled trial randomized patients to placebo or sustained-released bupropion (50 mg twice a day, 150 mg once a day, or 150 mg twice a day) and treated them for six weeks. Smokers with active depression were excluded, though smokers with a history of depression were not. The cessation rates at the end of therapy were 10.5%, 13.7%, 18.3%, and 24.4%, respectively. Follow-up at one year suggested a continued benefit of bupropion therapy [428]. Data from a study of bupropion combined with transdermal nicotine showed high long-term quit rates with the combination therapy [429]. Discontinuation of treatment may be appropriate for individuals unable to achieve significant progress after seven weeks, as success after this point is unlikely [430].

Another effective non-nicotine therapy for smoking cessation is varenicline tartrate (Chantix), a partial agonist selective for nicotine acetylcholine receptor subtypes. Released in 2006, varenicline is available in monthly dose packs (0.5 mg and 1 mg tablets) and is approved for a 12-week course of treatment [403]. Patients able to quit smoking may continue the therapy for an additional 12 weeks for increased likelihood of long-term cessation; however, medication should be stopped and patients should be reassessed if the intervention has not led to smoking cessation [430,431]. Clinical trials reveal that varenicline may be favorable to bupropion for abstinence (44% versus 30%); the medication has also been shown to help at least 20% of patients remain smoke-free for up to one year [432,433]. Recognizing that cessation success rates increase when pharmacologic and behavioral therapies are combined, the manufacturer urges patients to combine use of varenicline with a behavioral support plan. Co-administration of varenicline and transdermal nicotine may exacerbate incidence of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue. One study found varenicline alone to be more effective than other treatment options, while a meta-analysis study found that combination therapy (varenicline and NRT) was more effective than varenicline alone [434,435]. In 2021, the manufacturer halted production of varenicline due to unacceptable levels of nitrosamines [475]. In addition, all lots of 0.5-mg and 1-mg tablets of varenicline have been subject to a voluntary recall.

The two second-line drugs for smoking cessation are clonidine and nortriptyline [381]. Clonidine is an antihypertensive medication that is administered orally or transdermally. It appears to increase the smoking cessation rate by approximately 11%; however, clonidine is known to produce such side effects as dry mouth, dizziness, sedation, and orthostatic hypotension [430,436]. Clonidine has not been approved by the FDA for smoking cessation but has been used with individuals who have failed NRT or bupropion [430]. Nortriptyline is a tricyclic antidepressant that has been used to assist smoking cessation, although this is an unlabeled use [430]. A 12% improvement in cessation over controls has been reported, but the limited number of trials, combined with the adverse side effects (e.g., dry mouth, weight gain, constipation, drowsiness, sexual problems), makes nortriptyline a second-line intervention [381].

Other drugs have also been used in smoking cessation. Silver acetate, which causes cigarettes to have a bad taste, has been used as a smoking cessation aid for many years. But, there appears to be little evidence for a specific effect of silver acetate in promoting quitting [437,438]. The addition of mecamylamine, a ganglionic blocker classified as an antihypertensive agent, to transdermal nicotine replacement has been shown to improve the abstinence rate in smokers compared with use of the patch alone [439,440].

Additional pharmacotherapy options are in the development phase. A nicotine vaccine and other partial agonists for the nicotine receptors are being evaluated [441]. Interference with the liver enzymes that metabolize nicotine is another approach being tested [442].

In addition, it was found that methoxsalen, a compound used to treat skin disorders, reduces the activity of CYP2A6, the enzyme that metabolizes nicotine. This allows for more nicotine, whether from a cigarette or nicotine replacement, to be present in the blood and to remain there longer, which should minimize smokers' craving to smoke. However, methoxsalen has not been proven safe for use in humans and must undergo more trials before it can be used in a smoking cessation program [443]. Tranylcypromine (a monoamine oxidase inhibitor used to treat depression) and tryptamine (substrate of MAO) are also being investigated for this purpose [444].

Withdrawal

Similar to all addictions, nicotine withdrawal elicits a number of clinical consequences. Desire to avoid withdrawal symptoms promotes smoking. Nicotine withdrawal may last for several weeks and include such symptoms as irritability, anxiety, depression, difficulty concentrating, weight gain, restlessness, and impatience [445]. Withdrawal effects can be elicited and observed in those exposed to secondhand smoke as well as in smokers. Intensity of these withdrawal symptoms may be related to the level of nicotine dependence. In 2017, there were an estimated 34 million adults that smoked cigarettes. Although the prevalence of cigarette smoking continues to decline, there is some evidence that this decline is a reflection of a migration to non-cigarette products, especially e-cigarettes [446,456]

19. REDUCING TOBACCO SMOKE EXPOSURE

A dramatic increase in public awareness concerning the dangers of SHS has corresponded to social demand for smoking restrictions. Beginning in the 1990s, McMillen et al. found broad public support in the United States for smoking restrictions in many public places, including child care centers, hospitals, shopping malls, convenience stores, fast-food restaurants, and indoor sporting events [6]. An Irish study by Mulcahy et al. demonstrated dramatic reductions in SHS exposure following a national workplace smoking ban in Ireland. Thus, this study justified such bans given the known adverse effects of SHS, which include lung disease, heart disease, and asthma [356].

Workers suffering the detrimental effects of secondhand tobacco smoke have taken legal actions. For example, a group of 60,000 flight attendants filed a suit alleging that they had endured smoking-related illnesses from being exposed to high concentrations of environmental smoke in airplane cabins when smoking was still allowed on board [447]. Although the tobacco industry (Philip Morris, R.J. Reynolds, Brown and Williamson, the Ligett Group, and the Lorillard Group) made no admission of guilt, it established the Flight Attendant Medical Research Institute (FAMRI), a $300 million not-for-profit research institute, as a part of the settlement for flight attendants who suffered and died due to SHS exposure in air cabins. FAMRI's mission is "to sponsor scientific and medical research for the early detection and cure of diseases and medical conditions caused from exposure to tobacco smoke" [448].

Efforts to regulate tobacco products include the World Health Organization's Framework Convention on Tobacco Control (FCTC). Additionally, legislation has been passed to give the FDA regulatory authority over tobacco. The main reason for these proposals is to minimize death and disease caused by tobacco smoke by reducing the prevalence of its use and the toxicity of its products. Based on scientific studies and tobacco industry documents, it is believed that tobacco products could be made less toxic if their design, content, emissions, and manufacturing were better controlled [449].

Nationwide polls reveal broad public support for increased taxing of tobacco [450]. Since 2002, the average state cigarette tax has increased from 43.4 cents to $1.79 per pack [451,453,473]. In February 2009, President Obama signed a 61.66-cent federal cigarette tax increase into law, bringing the federal cigarette tax to $1.01. This increase resulted in an 8.3% decline in cigarette sales, one of the largest declines in years, and a continuing downward trend of cigarette sales [452,453]. As of 2016, the CDC reported an average national retail price of $6.43 per pack of cigarettes [453]. Increasing the cost of tobacco not only decreases tobacco use by creating a larger economic barrier to smoking, it also motivates people to try to quit.

Effective behavioral and pharmacologic treatments exist and can work if they are affordable, widely available, and used properly in clinics and communities. Smoking cessation group programs have been found to be more effective than minimal treatment programs, although less intensive treatment approaches, when combined with high participation rates, can still influence larger groups. Tobacco policies have reduced cigarette consumption at work and worksite tobacco smoke exposure [454]. Innovative partnerships with public- and population-based organizations to reach smokers and reduce exposure to tobacco have been initiated. There is a high level of support for smoking restrictions in public places to protect nonsmokers from tobacco smoke [455,473]. Due to the 2009 federal tax increase, several health benefits and cost savings are projected, including an increase in the number of children alive today who will not become smokers (1.2 million) and $51.9 billion in long-term healthcare savings from fewer adult and youth smokers over the lifetimes of the adults who quit and kids who never start [452,473].

Though the state and local governments and employers provide protection from tobacco smoke at work, private homes are not subject to such regulation. Educational strategies are needed to increase awareness of personal and childhood tobacco exposure both in and out of the home. As with the business microenvironment, air quality cannot be maintained if smoking is allowed indoors, even with additional ventilation and air-cleaning devices.

20. CONCLUSION

The purpose of this course was to increase awareness of the various implications of tobacco use and exposure and to provide examples of healthcare assessment and treatment. It should be noted that the health complications incorporated here are only part of an exhaustive list of issues linked to tobacco smoke—more findings are uncovered each day. Changes in policy (e.g., taxation, bans in federal and other public establishments, regulation by the FDA) may spur the public to take a second look before using tobacco products or exposing themselves and friends/family to its smoke. However, it is important to continue to combat tobacco use and exposure at the primary care level at every possible opportunity. Brief intervention methods are more helpful than many realize. Further, although cigarettes have historically been implicated for the majority of health problems, it is important to be cognizant of other tobacco products' health effects and the evolving trends of tobacco use.

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31960 • Rural Public Health and Nursing Care

Mary Schmeida, RN, PhD

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

The rural public health system is working to prevent disease and promote the highest level of well-being and quality of life for rural populations/communities in the United States. The role of the rural public health nurse is ever-evolving, as new public health infrastructures are being considered and implemented and as evidence-based ideas are being applied. Progress has been made in transforming the rural healthcare system and meeting the needs of every public community. This course will outline public health initiatives affecting rural populations as well as unique health and mental health considerations for these populations.

Table of Contents

31960 • Rural Public Health and Nursing Care

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

1. INTRODUCTION

2. DEFINITIONS

THE PUBLIC HEALTH NURSE

PUBLIC HEALTH VITAL FUNCTIONS

RURAL AND URBAN DEFINITIONS

3. CHARACTERISTICS OF RURAL POPULATIONS

DEATHS AND BIRTHS

MIGRATION, EMPLOYMENT, AND ECONOMIC OPPORTUNITIES

AGE AND RELATIONSHIP STATUS

POVERTY

EDUCATION

INSURANCE COVERAGE

INTERNET ACCESS

4. RURAL POPULATION HEALTH

CHRONIC ILLNESS

TOBACCO USE

OBESITY

CANCER

MENTAL HEALTH

DOMESTIC AND SEXUAL VIOLENCE

MOTOR VEHICLE ACCIDENTS

FIREARM INJURIES AND DEATHS

VETERAN HEALTH ISSUES

DENTAL HEALTH

ACCESS TO CARE

5. CHARACTERISTICS OF THE RURAL HEALTHCARE SYSTEM

THE PUBLIC HEALTH WORKFORCE

PUBLIC HEALTH AGENCIES, HOSPITALS, AND COMMUNITY HEALTH CENTERS

INDIAN HEALTH SERVICE

SERVICES FOR ELDERLY PATIENTS

6. IMPROVING THE RURAL PUBLIC HEALTHCARE SYSTEM

HEALTH PROMOTION AND DISEASE PREVENTION

IMPROVING ACCESS TO COMMUNITY SERVICES

BUILDING WORKFORCE CAPACITY

THE ROLE OF SCHOOLS

7. CONSIDERATIONS FOR NON-ENGLISH-PROFICIENT PATIENTS

8. CONCLUSION

9. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

31960 • Rural Public Health and Nursing Care

Education Category. Community Health

Release Date. 08/01/2019

Expiration Date. 07/31/2022

Course Overview

The rural public health system is working to prevent disease and promote the highest level of well-being and quality of life for rural populations/communities in the United States. The role of the rural public health nurse is ever-evolving, as new public health infrastructures are being considered and implemented and as evidence-based ideas are being applied. Progress has been made in transforming the rural healthcare system and meeting the needs of every public community. This course will outline public health initiatives affecting rural populations as well as unique health and mental health considerations for these populations.

Audience

This course is designed for nurses in all practice settings with patients from rural communities.

Course Objective

The purpose of this course is to provide nurses with the knowledge and skills necessary to provide optimum care to rural residents and to advocate for the needs of this population.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the role of the public health nurse.

2. Discuss the vital functions of public health.

3. Operationally define rural and urban.

4. Identify varying determinants characterizing rural populations.

5. Describe the chronic illness, tobacco use, and cancer issues of rural populations.

6. Outline the injuries and mental and dental health issues of the rural population.

7. Analyze the access to care service issue for rural areas.

8. Discuss the characteristics and issues of the rural public health workforce.

9. Evaluate the responsiveness of emergency medical services (EMS) in rural regions.

10. Discuss the public health agency, hospital, and the community health center.

11. Describe the health issues of American Indian/Alaska Native (AI/AN) populations and the Indian Health Service (IHS).

12. Identify issues of the aged and U.S. services for the aged.

13. Outline health promotion and disease prevention for the rural population.

14. Discuss how advanced communication technology can improve care access.

15. Discuss initiatives to building nursing workforce capacity.

16. Discuss schools and nurses as community health educators.

Faculty

Mary Schmeida, RN, PhD, completed her Master of Science in Nursing degree from Kent State University in 1984. Her PhD in Political Science with a specialty tract of Public Policy Analysis and Design was completed in 2005. She has more than 40 years' experience within the U.S. healthcare service delivery system. As a clinical nurse specialist in psychiatric-mental health nursing, she has held faculty positions at the university level and several research positions. Dr. Schmeida has presented numerous research papers in public health policy and healthcare at many conferences across the country. Her research is published in peer-reviewed journals, books, and international government reports.

Faculty Disclosure

Contributing faculty, Mary Schmeida, RN, PhD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Jane C. Norman, RN, MSN, CNE, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

1. INTRODUCTION

The U.S. rural population differs from the urban sector on many demographic levels, including age, employment, and access to care services. The cultural context of these communities also differs from nonrural communities and can vary across rural counties. Rural residents rank higher on measures of many chronic illnesses, obesity, and unintentional injuries than urban counterparts. In this context, public health nurses are responsive to the unique and diverse needs of the rural setting, assuming a culturally competent practice to promote health, well-being, and a better quality of life for the rural community. In strengthening the rural health system, a collaborative, multi-method approach that involves public and non-public entities is being taken in many states. As new public health infrastructures are being considered and implemented to strengthen the U.S. healthcare system, the role of the public health nurse is evolving.

2. DEFINITIONS

This section outlines both the role of the public health nurse and the vital services of public health to create a conceptual definition of the public health nurse. Different operational definitions of rural are given to illustrate that the "rural" in rural public health is not the same for all public health stakeholders and/or their work cultures. The definition of the term rural provided by the U.S. Census Bureau is a foundation.

THE PUBLIC HEALTH NURSE

Public health nurses are an essential part of a changing care system. Newer roles are evolving as the system evolves. Advancing technology, for example, has largely already been adopted by the system, enabling rural public health nurses working in remote areas to connect electronically with other providers from across miles and to more efficiently do surveillance on public health crises, such as the opioid drug crisis. Technology competence is important, as technology changes are dramatic and rapid. The National Rural Health Association states, "Given the broad and demanding scope of practice and the high level of autonomy that characterizes rural public health nursing, it is essential that these nurses have the strongest backgrounds and highest levels of competency" [1].

Abbreviated, the duties performed by public health nurses include investigating, surveillance/monitoring, diagnosing, and evaluating community health issues (e.g., environmental health hazards); mobilizing partnerships to resolve issues; promoting a competent workforce; promoting quality services and safety ideals; advocating for population health; enforcing policy and program goals; creating policy; and implementing and evaluating health and social policies related to population health needs [2,3]. The assessment skills of the public health nurse, in addition to their primary prevention focus and system-level perspectives, can "assure that local and state needs are met, services and programs are coordinated, and communities are engaged" [4].

Differing from acute care practice, the public health nurse aims to improve population health through prevention efforts and by attending to multiple determinants of health [4]. With a multi-level view of health, public health nursing action occurs through community applications of theory, evidence, and a commitment to health equity [4]. The Health Resources and Services Administration defines population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group. In this concept, the population as a whole is viewed as the patient" [3].

According to the Association of Public Health Nurses, public health nursing is defined as "the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences," with a focus on "population health, with the goal of promoting health and preventing disease and disability" [5]. These nurses practice in public health departments, schools, homes, community-based health centers, clinics, correctional facilities, and other settings [5]. In some practices, the term public health nursing is interchanged with community health nursing.

PUBLIC HEALTH VITAL FUNCTIONS

Public health in the United States has many functions. According to the Centers for Disease Control and Prevention (CDC), public health prevents epidemics and the spread of disease, protects against environmental hazards, prevents injuries, promotes and encourages healthy behaviors, responds to disasters and assists communities in recovery, and assures the quality and accessibility of health services [6]. It aims to promote physical and mental health, prevent disease, injury, and disability. The CDC has identified the following 10 vital services applied to all entities of public health—national, state, local, and tribes and territories [6]:

- Monitor the environmental health status in order to identify and resolve environmental health problems (e.g., community health assessment and registries).

- Diagnose and investigate environmental community health hazards, such as infectious water-, food-, and vector-borne disease outbreaks.

- Provide health education and health promotion, and empower people on environmental health issues.

- Mobilize community partnerships and actions with the private sector, civic groups, non-governmental organizations, faith communities, and other stakeholders toward resolving environmental health issues.

- Develop policies and conduct strategic and community health improvement planning that supports environmental health.

- Enforce laws and regulations, and review laws that protect environmental health and ensure community safety.

- Link people to needed health services and ensure the access to care when it is not available.

- Assure a competent public health workforce and leadership.

- Evaluate the effectiveness, accessibility, and quality of both personal- and population-based health services, and provide continuous quality improvement.

- Research new insights and innovative solutions to public health problems, and identify and share best practices.

The CDC has provided this guide of vital functions to aid public health workers in their practice, planning, implementation of initiatives, and evaluation of actions. It provides practical direction that can be used across all public health entities in their aim to develop healthy and safe community environments [6,7].

RURAL AND URBAN DEFINITIONS

The definitions of rural and urban are not the same for all public health stakeholders, as definitions vary among researchers, policy decision-makers, program rule-makers, and practitioners. Rural and urban are multi-dimensional concepts, making clear-cut distinctions between the two difficult. Some prefer the definition to be based on population density, while others rely on geographic isolation [8]. Regardless, the choice of a rural definition should be based on the purpose of the application. This variation in definitions can lead to some level of unnecessary confusion and unwanted mismatches in program eligibility. As such, it is important to familiarize oneself with the definition used at one's public health workplace so as to prevent this confusion [9].

The U.S. Census Bureau has historically taken the lead in defining rural and urban. It uses statistical data to analyze population characteristics and changes in population distribution in the development of their definition. For more than 100 years, since 1910, the Bureau has provided an official definition of urban territory, population, and housing, but over time, they have changed the concept behind their definitions or the methods or classification schema. The U.S. Census Bureau first defines urban areas and defines rural areas as those that are not urban. Urban areas may be further classified as urbanized areas or urban clusters. Rural areas are further divided into three categories: completely rural, mostly rural, and mostly urban [10]. For the most part, the definition of urban is based on residential population density and a few other land-use characteristics (e.g., land cover, airports) used to identify densely developed territory [10]. Rural areas encompass a wide variety of settlements, from densely settled small towns and "large-lot" housing subdivisions on the fringes of urban areas, to more sparsely populated and remote areas [10]. Although some sources interchange the entities nonmetropolitan and rural, the U.S. Census Bureau states that these geographic entities are not identical and should not be used interchangeably [10]. Professionals working with public reports and agency data should familiarize themselves with the particular definition of rural and urban used in the report or data.

The U.S. Census Bureau's urban-rural classification, however, provides a common reference for federal government agencies and departments. For example, it provides public health planning with a base to determine eligibility for participation and level of funding [11]. Still, some U.S. agencies have their own method of defining what is considered urban and rural. In fact, U.S. federal agencies apply more than two dozen rural definitions [8]. One reason for the different definitions is that multi-dimensional concepts and elements are involved, making it difficult to make clear-cut distinctions between the areas. Some people reside in areas that are not clearly distinguished as falling within either urban or rural designations [9].

Some may wonder why clearly identifying rural areas is important, but small changes in how rural areas are defined can have large impacts on public planning and implementation, program budgeting, and candidates for program participation. Specific definitions of rural and urban can be attached to a public program for administrative boundaries and to help guide program rule-making. For healthcare practitioners, specific definitions help guide the delivery of everyday services.

Although the U.S. Census Bureau states that the terms "nonmetropolitan" and "rural" should not be used interchangeably, the U.S. Department of Agriculture (USDA) does interchange the terms [10]. In the creation of its definitions, the USDA analyzes conditions in nonmetropolitan areas, such as trends in population, the economy, and social diversity. The USDA considers counties to be the basic unit of analysis or "standard building block" for their research, but the U.S. Census Bureau uses much smaller geographic building blocks to define rural areas as open country and settlements with fewer than 2,500 residents [12]. As of 2017, the total population in nonmetro counties stood at 46.1 million [9]. According to the U.S. Census Bureau definitions, most counties have both rural and urban populations.

Other federal offices use still different methodology to define rural/urban. One example is the Office of Management and Budget within the executive branch of the federal government. Much like the USDA, the Office of Management and Budget uses the terminology "nonmetropolitan," but they rely on a regional-economic concept (e.g., labor markets) to delineate the metropolitan-nonmetropolitan classification [9]. The U.S. Department of Health and Human Services uses an urban-rural county-based classification. This method is preferred by this department for many reasons, not least because health data are more readily available at the county level [13].

So, while the U.S. Census Bureau provides a base for a rural and urban definition, definitions vary across agencies and public departments to best fulfill their own purposes. The National Rural Health Association supports the right of "state and federal programs to select the most appropriate methodology to achieve their program goals rather than being constrained to any single methodology" [14].

The term frontier, much like the terms rural, suburban, and urban, is intended to categorize a portion of the population along a continuum. Defining "frontier" is also an important step for program development and implementation, particularly for program funding. Frontier has been defined many ways, including at the county level, by census tract, by ZIP code, and by government criteria. Having many ways to define frontier helps the decision-maker to align the definition to his or her purpose [14]. Examples of criteria that may be used in defining frontier include the travel time for a resident to reach a population center or the weather changes that occur with different seasons that inhibit a resident's travel to reach needed service. These areas generally have unique health and economic goals and challenges and therefore require special recognition [14].

Frontier health professional shortage areas are also important to conceptualize. According to the U.S. Census Bureau, counties classified as frontier have a population density of fewer than seven people per square mile [15]. The 2010 Patient Protection and Affordable Care Act defines frontier health professional shortage area to mean an area "with a population density less than six persons per square mile within the service area; and with respect to which the distance or time for the population to access care is excessive" [16]. The health professional shortages of primary care, mental health, or dental health professionals, regardless of classification—frontier, rural, suburban, urban, or mixed—can limit service availability for a population. The designation of health professional shortage area may be based on a health professional shortage for a particular population group and/or a shortage for an entire population within a defined geographic area. In some cases, it may be facility-based, such as a Centers for Medicare and Medicaid Services-certified rural health clinic [17].

According to the National Rural Health Association, frontier areas are different from rural areas in that they lack sufficient population numbers to support a range of healthcare services (including primary care services), have less health insurance as compared to rural residents, have less income and more poverty than rural areas, have older populations in demand of health services, and generally lack the capacity to develop and sustain a comprehensive system of care [18]. Historically, public health nurses were the primary support system for frontier health, often providing care via home visits. In 1925, Mary Breckinridge, a public health nurse and midwife, founded the Frontier Nursing Service, which provided nursing care to Appalachian Kentuckians and other underserved and poor regions. The common public health equipment carried by the nurse-midwife on a health visit in the frontier area was two saddlebags; one was for "general health care" and another for newborn deliveries [19].

3. CHARACTERISTICS OF RURAL POPULATIONS

According to the U.S. Census Bureau, and based on the 2011–2015 American Community Survey, there are differences between rural and urban America in terms of demographic, social, and economic determinants (e.g., age, education, income, health insurance) [20]. Rural residents are more likely to be older, married, and not living alone. They tend to have completed less education and have lower civilian employment, lower health insurance coverage, and less Internet access compared with urban residents [20]. The CDC reports that rural Americans tend to show higher rates of cigarette smoking, higher rates of hypertension and obesity, and less access to healthcare services [21]. Negative determinants (e.g., lower employment) place residents at a higher risk for certain public health conditions, such as chronic disease. All these factors can lead to poor health outcomes [21].

It is important to note that rural areas are not homogenous, and determinants (or factors) can vary across rural counties. Understanding the socioeconomic, demographic, environmental, and health conditions that exist for rural and urban populations gives public health stakeholders insight on the disparities and inequalities of groups and largely influences policy and public programs designed to help the public.

DEATHS AND BIRTHS

Rural counties are facing a demographic change, as many have a greater number of deaths than births. Between 2010 and 2017, 995 nonmetro counties recorded more deaths than births, resulting in a population loss of 284,000 from natural decease in those counties [22]. A county population change is reported to include two parts—a natural change (i.e., births minus deaths) and a net migration change (i.e., people moving in minus people moving out). According to the USDA Economic Research Service, since 2010, the increase in rural population from natural change has not matched the decrease in population from net migration [23]. As a result, there is little or no population growth, with significant declines in some rural areas. This population loss is most widespread in the eastern portion of the United States [24]. The reasons for this rural population loss include mortality of the aged, the opioid epidemic, fewer births, reclassification of counties, and urban employment incentives.

MIGRATION, EMPLOYMENT, AND ECONOMIC OPPORTUNITIES

Outmigration of young adults of childbearing age from rural areas has left an older population behind. In addition to deaths of the older population, younger adults who remain in rural areas have been significantly impacted by the opioid epidemic, with an increase in rural working-age adult mortality related to prescription opioid- and heroin-overdose deaths. Another reason for rural population loss is women having fewer children and couples postponing having children amid economic uncertainty. Urbanization and the reclassification of counties from nonmetro to metro results in smaller rural areas that are characterized as slow-growing with more limited economic potential [24]. Limited economic opportunities for working-age adults can be an incentive to migrate out of rural areas to urban employment areas [24].

Economic recessions have been an incentive for some working-age rural residents to relocate to urban areas in search of employment, and not all relocated residents return to their rural life post-recession. Compared with the economic recovery periods from past U.S. recessions, the recovery in rural growth after the 2008–2009 recession has been more gradual [22].

Rural civilian employment among persons 18 to 64 years of age is lower (67.6%) than that reported for urban residents (70%) [20]. Three major service industries together with manufacturing provide more than 70% of rural employment: education and health (25%); trade, transportation, and utilities (20%); and leisure and hospitality (11%). Manufacturing, farming, and mining have historically been the goods production focus for rural areas [24]. In 2009, rural employment was growing, although it has not yet fully recovered from the recession. According to the USDA, half of the observed decline in the unemployment rate since 2010 is due to a reduction in the size of the labor force, not an increase in employment, which is partly the result of little or no population growth in rural America [25]. Regardless, employment for rural America still lags below the pre-recession figures.

AGE AND RELATIONSHIP STATUS

Age is another determinant characterizing the rural population. As noted, the rural population is considered an older population than urban. Among adults, the median age for the rural person is 51 years, compared with 45 years in urban settings [20]. The marriage rate is significantly higher among rural residents (61.9%) than among urban residents (50.8%). Fewer rural people report living alone (11.6%) than urban people (14.3%) [20].

POVERTY

Although some claim that rural America has a higher poverty rate compared with urban areas, U.S. Census Bureau data show that the urban poverty rate is higher than the rural rate [26]. Poverty is defined as "any individual with income less than that deemed sufficient to purchase basic needs of food, shelter, clothing, and other essential goods and services" [27]. Based on the 2011–2015 American Community Survey, all four regions of the United States (Western, Midwestern, Southern, and Northeastern) showed consistently lower poverty rates in rural areas compared with urban areas [26]. The poverty rate for rural adults is 11.7%, compared with 14% for urban adults. The poverty rate for rural children (younger than 18 years of age) is 18.9%, compared with 22.3% for urban children [20]. In total, 42 states report lower poverty rates for their rural areas than for their urban areas [26].

The median household income for rural areas is $52,386, while the median household income for urban areas is $54,296 [20]. Rural household income is led by younger householders (44 years of age and younger) whereas urban median household income is greater for households led by an older householder (45 years of age and older). There are 32 states with greater median household incomes for rural households than for urban households [26]. Between 2007 and 2014, rural incomes were highest in rural recreation counties, and incomes were also high in the farming and mining counties [28]. Incomes were lowest in the government-dependent and non-specialized job category for rural counties; these counties have the highest rural poverty rates [28].

EDUCATION

The chance of a rural person reporting a bachelor's degree or higher (19.5%) is less than that for urban residents (29%) [20]. Between 2003 and 2014, rural household heads with a college degree showed an increase from 15.8% to 19.5%. This increase is reported as attributing to a lowering of poverty by 0.9% over the same period [29].

INSURANCE COVERAGE

More adults in rural America have health insurance than urban adults, but the opposite is true for children in rural America. The uninsured rate for rural adults is 13.6%, compared with 15.3% for urban adults. For rural children, the uninsured rate is 7.3%, compared with 6.3% for urban children [20]. Improvements in adult coverage are largely attributed to expanded Medicaid enrollment following passage of the 2010 Affordable Care Act [20].

INTERNET ACCESS

Internet access is important for rural persons, because it can be a tool to overcome the geographic distance to many services, such as prevention screening. Currently, U.S. Internet access is greater for urban areas than for rural. Based on 2015 survey data, 23.8% of rural residents have no Internet access in their homes, compared with 17.3% of urban residents [20].

4. RURAL POPULATION HEALTH

Many health characteristics of the rural population differ from urban areas, including chronic illness, tobacco use, obesity, mental health, dental health, and disadvantaged access to the healthcare system. Although these characteristics are important, the population characteristics (e.g., age, employment, Internet access) are the underlying conditions predisposing the group to chronic illness, obesity, and other poor health outcomes. For example, rural populations without Internet access are less likely to attend online prevention teaching on nutrition, and in turn have a greater chance of obesity than those with access to Internet nutrition programs [30].

CHRONIC ILLNESS

Chronic illness is associated with significant morbidity and mortality in rural America. Chronic disease is defined broadly as a condition that lasts one year or longer and requires ongoing medical attention or limits activities of daily living or both. Most chronic disease is found to be related to risky behaviors such as tobacco use, poor diet, lack of exercise, and high alcohol use, and to inaccessible health care [30]. In addition to physical medical conditions, chronic conditions also include problems such as substance use and addiction disorders, mental illnesses, dementia and other cognitive impairment disorders, and developmental disabilities [31]. In rural America, there is a high incidence of comorbidity (i.e., having two or more illnesses at the same time), and comorbid conditions are often chronic or long-term. Compared with urban residents, rural communities have less access to primary care services and prevention programs that are important to mitigating chronic illness [32,33].

The CDC reports that the leading cause of rural deaths in 2014 was heart disease, followed by cancer, unintentional injury (e.g., motor vehicle accidents), chronic lower respiratory disease, and cerebrovascular accident [34]. The percentages of deaths that were potentially preventable are higher in rural areas than in urban areas [34]. A considerable number of cases of premature heart and cerebrovascular disease in rural areas are preventable; potentially preventable rural deaths from stroke and heart disease were higher than for urban areas [34]. Risk factors for heart disease include hypertension, elevated low-density lipoprotein cholesterol, smoking, diabetes, obesity, and lifestyles characterized as sedentary with poor nutritional intake and high alcohol intake.

Type 2 diabetes is a chronic illness associated with a variety of long-term complications. Diabetes prevalence is estimated to be 17% higher in rural areas than urban areas [36]. Further, diabetes-related mortality is higher in rural areas, particularly among black and Hispanic residents [37]. Public health nurses can act to mitigate these conditions with screening, healthy lifestyle teaching, community education on risk factors, and teaching of self-management principles [38].

Chronic lower respiratory disease is a risk factor for long-term disability and a leading cause of rural mortality, with 11,000 deaths reported in 2014 [34]. Rural populations have a higher incidence than urban areas. Chronic lower respiratory disease encompasses a group of respiratory disorders, including asthma, pulmonary hypertension, occupational lung disease, and, perhaps most significantly, chronic obstructive pulmonary disease [39]. Rural economic sectors have specific work-related lung problems. Agricultural workers may develop hypersensitivity pneumonitis and/or idiopathic pulmonary fibrosis after repeated exposures to mold/fungi, animal feed, dust, and pesticides [40]. Exposure to chemicals in manufacturing work can lead to bronchiolitis obliterans (also known as obliterative bronchiolitis or "popcorn lung"), and rural construction and mining industries are at increased risk for pneumoconiosis from inhalation of dust (e.g., silica, coal). Major risk factors for the development of chronic lower respiratory disease include tobacco exposure, occupational and environmental toxin exposures, respiratory infections, and genetic predisposition. Among youth, asthma is one of the most prevalent chronic health conditions [41,42]. Exposing youth and parents early to prevention programs on respiratory disease can help offset disease.

Arthritis is another prevalent chronic disease in rural America. Arthritis includes more than 100 conditions that affect the joints, tissues around the joint, and other connective tissues [43]. It has significant negative effects for patients, including incurred healthcare treatment costs, the loss of earnings due to limited work ability, impaired activities of daily living, reduced quality of life, and chronic pain. In 2013, U.S. adults with arthritis comprised more than half (53%) of all US adults taking a prescribed opioid [44]. The CDC estimates that up to one-third of rural residents have arthritis. Prevalence of the condition increases with age, a considerable consideration given the older median age in rural areas and aging of the U.S. population in general [45].

Interventions for Families

Because chronic illness can vary over time, the medical regimen prescribed to the patient, the prognosis, and the functional capability of the patient will inevitably vary as well. This unpredictability undoubtedly causes stress for every member of the family system. Chronic illness involves a life-long commitment from all parties—patients, their caregiver(s), and their family members. Consequently, it is imperative that public health nurses and all professionals involved in the care of rural persons have an understanding of the various types of interventions that can help families and caregivers mitigate the stress brought on by chronic illness, with particular focus on resources for persons who are geographically isolated and/or lack reliable transportation. This section is meant to provide some general guidelines for those who work with families with a chronically ill member.

Providing Information

Families who have members with chronic illness require information. This sounds simple, but it is crucial for nurses to realize that chronic illness is a new and unanticipated event to the family. Therefore, families need concrete information. At the initial diagnosis, the family may be overwhelmed and struggling to come to terms with the illness. They may also be grappling to understand new medical jargon and trying to assimilate a tremendous amount of information in order to make decisions about medical care plans. Over time, some family members may be required to take on more responsibilities related to the medical care, particularly if they live remote to care centers. This requires practitioners to teach family members necessary skills and to provide support when they feel uncertain about these new responsibilities [46]. At this juncture, the nurse should assist in enhancing communication between the primary physician and the family [47]. Technical information about the illness, prognosis, and care regimen should be conveyed. Healthcare professionals should be sensitive to the fact that this information may need to be relayed on several occasions. During this time, the helping professional may want to begin to coordinate a list of resources and referrals [47].

Over the course of the illness, caregivers and family members continue to need information about how to efficiently care for the patient. The types of information may range widely. Lubkin and Larsen, for example, note that healthcare professionals can provide general information about human development to family members. It is beneficial for caregivers and family members to understand normal changes that are part of human development and the life cycle, changes that are specifically related to the illness, or possibly, an interaction of both [48]. Egocentrism, for example, is a part of adolescence. Chronic illness can magnify this as the adolescent receives a great deal of medical and parental attention, and the adolescent can become overbearing [49]. Yet, simultaneously, an adolescent may believe that he/she is the only one with these problems and feel that no one can empathize [49]. Social isolation may occur or be compounded. Therefore, it becomes a complicated issue to determine whether a particular behavioral change is the result of normal human development or illness-related.

Technical information related to the daily care of the patient should also be relayed. Family members may have to be taught how to lift and move patients around without hurting themselves or the patient and how to administer medications [48]. Family members should be reminded and educated about the physical consequences of the illness. Patients, for example, may experience fatigue as a result of the medications and/or the illness; however, some family members may become frustrated with the patient and interpret the patient as being lazy and taking advantage of the sick role [48]. Healthcare professionals should be fully knowledgeable about resources on both the local and national level to assist families in coordinating care for both the patient and themselves. Resources and services include places to access special equipment, legal and financial information, respite care, counseling, and support groups [48].

Exploring the Meaning of Chronic Illness and Ambiguous Loss

The emphasis is to provide an opportunity for family members to explore their feelings of loss, sorrow, mourning, and grief. Interventions also focus on helping families to accept the ill family member's lost physical functioning and capabilities [50].

Boss and Couden argue for the importance of helping families deal with ambiguous loss [51]. The goal is not necessarily to eliminate this sense of loss, but rather, to increase family tolerance and coping. Interventions are both structural/short-term and solutions-focused as well as psychodynamic [51]. After identifying the loss, the family would work collaboratively to make decisions regarding day-to-day care and activities. Operating from this lens, depression, which is commonly experienced among caregivers, may also be viewed as symptomatic of ambiguous loss. Therefore, practitioners can help encourage caregivers to not assume all the burden of responsibility, but rather to delegate and distribute the work. This may mean obtaining respite assistance [51].

One of the more difficult tasks is for family members to understand and make sense of the ambiguous loss [51]. They can begin by looking at their own family's socialization, spiritual and religious values, and mentality of thinking and viewing the world optimistically, and by evaluating the family's beliefs about mastery [51].

Self-Care for Family Members

In order to prevent burnout, family members and caregivers should learn to take care of themselves. Caregivers often experience a host of conflicting emotions, including guilt, sadness, anxiety, and exhaustion. They often feel that they should not express negative feelings, believing that it will adversely affect the patient [48]. Healthcare professionals should routinely ask caregivers how they are feeling and coping, and then validate their experiences and feelings.

Caregivers should also be encouraged to obtain respite care. Respite refers to any type of service, either informal or formal, that offers relief and assistance for family members to cope with the challenges of chronic illness [52]. Informal respite assistance may include extended family members, neighbors, and friends who might periodically help with meal preparations, transportation, or housekeeping. Formal respite consists of in-home respite or out-of-home respite. In-home respite care involves a paid companion who spends time with the patient and helps with the patient's care, while out-of-home respite care includes adult day-care centers and community recreational services [52].

Unfortunately, access to respite care is difficult in rural areas. Caregiver support programs in rural areas often aim to facilitate the development of caregiver support networks, which can provide support and even respite care. The Rural Caregivers Website contains links to many of these support communities and collections of resources to support family caregivers in rural areas (Resources).

Adult day care programs are another good option for respite care, but these are rarely a feasible option in rural communities. To overcome this barrier, mobile programs have been developed, with some success. For example, the Georgia Mobile Adult Day Care Program provides adult social day care and respite services to rural Georgia by sharing staff, who travel between locations [35]. Program staff travels up to 50 miles one way each day to deliver services, generally at a senior center in the community. Staffing varies but typically includes a registered nurse (RN), an activity director, an aide, and community volunteers. Caregivers have reported that the mobile adult day care program helped them keep their family member with dementia at home longer, reduced caregiver burden, and provided them with relief and peace of mind [35].

Caregiver support programs in rural areas often aim to teach hands-on caregiver skills, stress management, care management skills (i.e., ability to identify and coordinate care with outside support services), and self-care skills to elders and people with disabilities [35]. Training within these systems can be conducted using videoconferencing, conference calls, in-person meetings, or web-based trainings.

Mindfulness interventions may also be beneficial for caregivers. These approaches teach caregivers to be aware of what is occurring at the moment without any judgement and to focus on regulating emotions. In a study to evaluate the effectiveness of an online mindfulness intervention, the level of caregiver burden was decreased after eight weeks of weekly, one-hour mindfulness practice and self-compassion training [53].

In collectivist cultures, one's identity is intertwined with the ill family member, and how the ill family member fares also affects the caregiver [54]. As such, interventions may target the patient and caregiver simultaneously [54].

Family Therapy

Based on family systems theory, family therapy can be a useful intervention to assist families in acknowledging and accepting the patient's illness as well as the treatment plan and prognosis [47]. It can help families develop coping skills to manage the challenges of the continual stressors related to chronic illness and identify maladaptive family patterns, such as enmeshment, triangulation, overprotectiveness, and rigidity [47]. Role expectations can be clarified among family members, and lines of communication can be opened, and at times, restored, if certain family members feel overloaded with caregiving responsibilities [82]. Furthermore, assuming a caregiving role for an elderly parent may resurrect previous developmental issues [55].

Again, rural families may struggle to identify therapists or to travel to areas offering these types of services. In these cases, Internet or other technologies may be helpful.

Psychoeducational Groups

Psychoeducational groups were first used in families with members who had schizophrenia; however, they have been adapted for use with other clinical populations. Psychoeducational groups typically involve a didactic and support component, whereby family members (i.e., caregivers) convene (in-person or remotely) for 10 to 12 structured sessions, on a biweekly basis [56]. It assumes that the caregivers are experts and each member can help each other [57]. The didactic component focuses on both cognitive information and behavioral change. Caregivers, for example, listen to a series of mini-lectures that focus on disease etiology, treatment, and management [56]. Problem-solving skills and coping strategies are often discussed. Caregivers are encouraged to use these newly learned skills and apply them at home. The support component of the psychoeducational groups provides a forum for family members to talk about various issues that may come up in the caregiving situation. Facilitators and other family members provide validation and recognition of feelings. Ultimately, when family members feel confident about providing care, their quality of life improves [46]. In terms of the research evaluating the effectiveness of psychoeducational groups for caregivers, the findings are mixed. In one study, nurse-facilitated psychoeducational groups for caregivers resulted in no improvements in perceived caregiver burden [58]. But a separate study found participation in distance or in-person psychoeducational groups was associated with improved caregiver distress and burden [59].

Self-Help Groups

Support and self-help groups focus on a specific client population (e.g., patients diagnosed with cancer) and related caregiver needs. These groups are facilitated either by volunteers or healthcare professionals. They may vary, but will provide information regarding the illness and disease process and symptom management, normalize members' experiences, provide emotional support around caregiving, encourage advocacy, or a combination of these services [48,60]. Trust is a key element for these types of groups [61].

Macro-Oriented Interventions

Findley argues that part of their social justice advocacy role for social workers and other service providers is to challenge issues of marginalization when working with families and family members who have been diagnosed with a chronic illness [62]. It is important to advocate reducing or eliminating barriers that prevent families and patients from receiving the care and support that they need. Practitioners can also work to promote evidence-based interventions and guidelines to ensure greater collaboration between patients and their family members at the various levels of care [62].

TOBACCO USE

Since the 1960s, tobacco use has been recognized as the single most avoidable cause of disease, disability, and death in the United States, and tobacco use is considered a prevalent public health concern for both rural and urban America [38]. The CDC reports the prevalence of adult cigarette smoking is higher among those living in rural areas (28.5%) than among those living in urban areas (25.1%) [63]. Smokers in rural areas are more likely to smoke 15 or more cigarettes daily and have a greater chance of developing heart disease, stroke, and lung disease from smoking [63].

The use of smokeless tobacco is also a greater issue for rural adolescents and adults than for their urban counterparts. Smokeless tobacco is defined as tobacco products that are sucked or chewed (not burned) and includes chewing tobacco, snuff, and dissolvables. An estimated 8.6% of rural adults use smokeless tobacco, compared with 6% of urban adults [63]. Rates of smokeless tobacco use are greatest in states with large rural areas: Wyoming, West Virginia, Arkansas, and Montana [64]. Results of studies suggest that factors other than age, gender, poverty level, and region are driving urban-rural differences in tobacco use. In one study, the most likely reasons given for smokeless tobacco use were affordability, choice of flavors, ability to use in public places (as opposed to smoking), and safety to persons around the user (i.e., no secondhand smoke) [65]. While there may be a perception that these products are safer than smoked tobacco, they contain nicotine, are highly addictive, and have been linked to oral, esophageal, and pancreatic cancers [66].

Nurses and other healthcare providers are responsible for advising smoking parents about the harms of passive smoke as well as how to provide a smoke-free environment for their children [67]. There are many smoking cessation resources that may be provided to patients, including several "quitlines." These hotlines provide free telephone access to a smoking cessation counselor. The National Cancer Institute's quitline is 1-877-44U-QUIT (1-877-448-7848), and both English- and Spanish-speaking assistance is available. The website https://smokefree.gov also offers support, tools, and expert advice through their app, text messaging, and social media networks. Assistance for issues unique to different subgroups, such as veterans, women, adolescents, adults older than 60 years of age, and those who speak Spanish, are also available. To help address the growing issue of smokeless tobacco use in rural adolescents, the U.S. Food and Drug Administration (FDA) started the Real Cost Campaign, an initiative to educate adolescents (12 to 17 years of age) on the risks of smokeless tobacco [68].

OBESITY

Obesity is a priority in chronic disease prevention and has been linked to increased risk for heart disease, hypertension, type 2 diabetes, arthritis-related disability, and some cancers [38]. The 2016 Behavioral Risk Factor Surveillance System found adult obesity is higher in rural areas, with a rate of 34.2% in nonmetropolitan counties and 28.7% in metropolitan counties [69]. In 24 of the 47 states included in the study, obesity prevalence was higher in nonmetropolitan than metropolitan counties. In only one state (Wyoming) was the prevalence of obesity higher for metropolitan than nonmetropolitan residents [69].

The National Health and Nutrition Examination Survey found an association between lower formal education of head of households and an increased chance of obesity in the youth living in the same household [70]. Between 1999–2002 and 2011–2014, obesity increased among both female and male children and adolescents in households that were headed by someone with high school education or less; obesity was also increased among female children and adolescents in households headed by persons with some college education [70].

As of 2017, the seven states with the highest percentage of adult obesity were Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia (Table 1). These states have significant rural populations [71]. Because of its impact on public health, obesity has received attention and funding from the government for public programs designed to mitigate the impacts of overweight and obesity. Rural school programs, for example, receive guidance and funding on obesity initiatives, as schools provide an early opportunity to teach youth and families about healthy eating habits and physical activity.

Table 1: SCOPE OF OBESITY AMONG ADULTS ACROSS THE UNITED STATES, 2017

Percentage of Adult Population with Obesity

Corresponding States

20% to <25%

2 states and the District of Columbia

25% to <30%

19 states

30% to <35%

22 states plus Guam and Puerto Rico

≥35%

7 states (Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia)

Source: [71]

Ample scientific evidence exists that demonstrates an increasing body mass index (BMI) corresponds to increasing morbidity and mortality. Numerous treatments for obesity are available, but the cornerstone of any treatment regimen is behavioral modification, focusing on diet changes and exercise regimens. Additional therapies include drugs and surgery. To improve care for overweight and obese patients, nurses should have a thorough understanding of obesity and its treatment and to understand the importance of addressing the topic with patients. In addition, they must recognize that recidivism and failure are quite high and that successful treatment requires a concerted and sustained effort.

CANCER

Although cancer rates are lower in rural areas than urban areas, cancer-related mortality is greater [34,72]. In particular, higher death rates have been reported for lung, colorectal, cervical, and prostate cancers in rural areas. The highest mortality rates are typically in the rural South. Geography alone cannot predict cancer risk, but it can have an impact on prevention measures, diagnosis, and the treatment opportunities. As such, some cancer cases can potentially be mitigated with public health intervention [72]. Certainly mortality rates could be improved by ensuring adherence to screening guidelines and access to optimal care.

Despite decreases in cancer death rates nationwide, a 2017 report shows slower reduction in cancer death rates in rural America (a decrease of 1.0% per year) compared with urban America (a decrease of 1.6% per year) [73]. Many cancer cases and deaths could be prevented, and public health programs can use evidence-based strategies from the U.S. Preventive Services Task Force and Advisory Committee for Immunization Practices to support cancer prevention and control. The U.S. Preventive Services Task Force recommends population-based screening for colorectal, female breast, and cervical cancers among adults at average risk for these cancers and for lung cancer among adults at high risk; screening adults for tobacco use and excessive alcohol use, offering counseling and interventions as needed; and using low-dose aspirin to prevent colorectal cancer among adults considered to be at high risk based on specific criteria. The Advisory Committee for Immunization Practices recommends vaccination against cancer-related infectious diseases including human papillomavirus and hepatitis B virus. The Guide to Community Preventive Services describes program and policy interventions proven to increase cancer screening and vaccination rates and to prevent tobacco use, excessive alcohol use, obesity, and physical inactivity [73].

MENTAL HEALTH

Substance Use Disorders

Substance abuse refers to a set of related conditions associated with the consumption of mind- and behavior-altering substances that have negative behavioral and health outcomes [74]. Rural areas can vary on type of substance(s) abused. Residents of rural areas are more likely to experience self-inflicted injuries and unintentional opioid overdose deaths than those in urban areas [74].

The rate of opioid misuse and related fatalities are considered public health emergencies in the United States. Although the general rate of drug use in rural areas (14.2%) is lower than urban (19.4%), the rate of opioid misuse is roughly the same among the two groups [75]. Furthermore, the rate of drug overdose deaths is greater in rural areas, with the rural overdose rate (unintentional injury) 50% higher than the urban rate [76]. Between 1999 and 2015, the rural opioid death rate quadrupled among those 18 to 25 years of age and tripled for women [76]. Socioeconomic factors, behavioral factors, and access to services contribute to these rural-urban differences. An understanding of how rural areas are different when it comes to drug use and drug overdose deaths, including opioids, can help public health professionals identify, monitor, and prioritize their response to the opioid epidemic [76]. To develop this understanding, ongoing data collection, analysis of data, and reporting of findings are critical to staying ahead of the drug crisis in public health.

In the past few decades, the manufacture and abuse of methamphetamine in the United States has gained increased attention. The admissions rates for treatment of methamphetamine-related disorders have ballooned alarmingly in some areas, particularly in rural or frontier areas, causing public health concerns. While national trends are showing declines, regional use of methamphetamine continues to vary widely, with the strongest effects felt in Alaska, the West, the Southwest, and parts of the Midwest (particularly Iowa, Oklahoma, Missouri, and Nebraska), with rural areas being the most severely impacted [77,78,79]. During the first half of 2012, treatment admissions for methamphetamine use were highest in Hawaii and San Diego, second highest in San Francisco, and third highest in Denver and Phoenix [80]. The higher use of methamphetamine in Western states is also reflected by the number of persons under its influence who come into contact with law enforcement. According to the 2016 National Drug Threat Assessment compiled by the U.S. Drug Enforcement Administration, methamphetamine was reported as the greatest drug threat in the Southwest region (71%), followed by West Central (56%), Pacific (50%), and Southeast (43%). The percentages declined in areas further east [78].

Methamphetamine users in rural areas, especially areas designated as frontier regions, are likely to experience great difficulty in accessing medical, psychiatric, or substance abuse services. Even self-help groups are likely to be nonexistent in these areas, and when they are available, the degree of anonymity in a 12-step group in a small town may be compromised. The nearest available small city often serves as the population center for the region. Social services in these cities may be overwhelmed by numbers of transient persons from the surrounding rural areas needing services in addition to the inhabitants of the city [81].

Substance abuse treatment approaches should be tailored to meet the needs of the rural population. One such approach, Structured Behavioral Outpatient Rural Therapy, is designed around the use of storytelling activities, a more culturally acceptable form of therapy than the traditional role-playing techniques [82]. Case management and behavioral contracting have also been identified as useful approaches to engage and maintain rural residents in therapy [83]. It is also important that healthcare professionals in rural settings receive the training necessary to effectively diagnose and treat drug-dependent patients. Kentucky and North Carolina have implemented a system by which specialists in substance abuse are available at welfare or social services offices [83]. Other possible approaches in the treatment of rural substance use disorder include treatment of jail and prison inmates and the use of drug courts [83].

To overcome the geographic barriers to accessing mental health prevention and treatment services, federal policies have authorized funding/grants for rural telehealth programs. For example, the USDA has expanded telehealth in addiction prevention and treatment by awarding monies to rural areas for programs and projects combating the opioid issue. They are giving five distance learning and telemedicine grants for treatment in rural central Appalachia, with about $1.4 million in grants distributed in Kentucky, Tennessee, and Virginia [84]. The U.S. Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration are leading a five-strategy evidence-based response to the opioid crisis, which includes approaches to improve patient access to services (e.g., using advanced technology and telehealth) [85].

Suicide

Suicide is part of a broader class of self-directed violence and is defined as death caused by self-directed injurious behavior with any intent to die as a result of the behavior [86]. The means or method used for self-directed violence varies across geographic areas and across age groups [87,88]. Suicide has no one underlying cause. It occurs in response to multiple biologic, psychologic, interpersonal, environmental, and societal factors that interact with one another, often over time [86,87]. However, mental illness, particularly major depression, can be a risk factor [86].

Suicide rates have been increasing across the United States, led by areas considered less urban, with the gap in rates between less urban and urban areas widening between 1999 and 2016 [87,269]. While white men are at highest risk for suicide nationally, in rural areas American Indians/Alaska Natives (AI/ANs) are the most affected [87]. Geographic disparities in suicide rates might reflect risk factors known to be prevalent in less urban areas, such as limited access to mental health care, social isolation, and opioid misuse [89]. Addressing the opioid crisis in rural areas is one way of reducing suicide rates.

Many organizations have issued consensus statements regarding screening for suicide risk in the primary care setting. The U.S. Preventive Services Task Force states that although suicide screening is of high national importance, it is very difficult to predict who will die from suicide and has therefore found insufficient evidence for routine screening by primary care clinicians to detect suicide risk and limited evidence of the accuracy of screening tools to identify suicide risk in the primary care setting [90]. The Canadian Task Force on Preventive Health Care found insufficient evidence for routine screening by primary care clinicians to detect depression and suicide risk [91].

However, the American Academy of Pediatrics recommends asking about depression, substance abuse, suicidal thoughts, sexual abuse, and other suicide risk factors during the routine history in all ages throughout adolescence [92]. The American Academy of Child and Adolescent Psychiatry recommends clinician awareness of patients at high risk for suicide (i.e., older male adolescents and all adolescents with current psychiatric illness or disordered mental state), especially when complicated by comorbid substance abuse, irritability, agitation, or psychosis [93]. Finally, the American Medical Association recommends that all adolescents be asked annually about behaviors or emotions that indicate risk for suicide [94].

The opportunity for an emotionally disturbed patient with vague suicidal ideation to vent his or her thoughts and feelings to an understanding health or mental health provider may bring a degree of relief such that no further intervention is needed. However, in all cases the encouragement of further contact and follow-up should be conveyed to the patient, especially when inadequate social support is present. Independent of the actual catalyst, most suicidal persons possess feelings of helplessness, hopelessness, and despair and a triad of three cognitive/emotional conditions [95,96]:

- Ambivalence: Most suicidal patients are ambivalent, with alternating wishes to die and to live. The healthcare provider can use patient ambivalence to increase the wish to live, thus reducing suicide risk.

- Impulsivity: Suicide is usually an impulsive act, and impulse, by its nature, is transient. A suicide crisis can be defused if support is provided at the moment of impulse.

- Rigidity: Suicidal people experience constricted thinking, mood, and action and dichotomized black-and-white reasoning to their problems. The provider can help the patient understand alternative options to death through gentle reasoning.

Healthcare professionals should assess the strength and availability of emotional support to the patient, help the patient identify a relative, friend, acquaintance, or other person who can provide emotional support, and solicit the person's help [95,96]. The engagement of supportive third parties in the patient's life can be a useful tool in preventing suicide completion.

Family members and friends affected by the death of a loved one through suicide are referred to as "suicide survivors." Conservative estimates suggesting a ratio of six survivors for every completed suicide indicate that an estimated 6 million Americans became suicide survivors in the past 25 years [97].

The death of a loved one by suicide can be shocking, painful, and unexpected for survivors. The ensuing grief can be intense, complex, chronic, and nonlinear. Working through grief is a highly individual and unique process that survivors experience in their own way and at their own pace. Grief does not always move in a forward direction, and there is no timeframe for grief. Survivors should not expect their lives to return to their previous state and should strive to adjust to life without their loved one. The initial emotional response may be overwhelming, and crying is a natural reaction and an expression of sadness following the loss of a loved one [98].

Survivors often struggle with trying to comprehend why the suicide occurred and how they could have intervened. Feelings of guilt are likely when the survivor believes he or she could have prevented the suicide. The survivor may even experience relief at times, especially if the loved one had a psychiatric illness. The stigma and shame that surround suicide may cause difficulty among the family members and friends of survivors in knowing what to say and how to support the survivor and might prevent the survivor from reaching out for help. Ongoing support remains important to maintain family and other relationships during the grieving process [98].

Many survivors find that the best help comes from attending a support group for survivors of suicide in which they can openly share their own story and their feelings with fellow survivors without pressure or fear of judgment and shame. Support groups can be a helpful source of guidance, understanding, and support through the healing process [98]. The American Foundation for Suicide Prevention maintains an international directory of suicide bereavement support groups on their website, https://afsp.org.

DOMESTIC AND SEXUAL VIOLENCE

A large national study found that lifetime intimate partner violence victimization rates in rural areas (26.7% in women, 15.5% in men) are similar to the prevalence found among men and women in nonrural areas [99]. There is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [100].

Substance use disorders and unemployment are more common among perpetrators of intimate partner violence in rural areas [100]. It has been suggested that intimate partner violence in rural areas may be more chronic and severe and may result in worse psychosocial and physical health outcomes. Poverty in rural areas is also associated with an increased risk for intimate partner violence victimization and perpetration for both men and women [101]. Residents of rural areas are less likely to support government involvement in intimate partner violence prevention and intervention than urban residents [100].

Although the rates are similar, the risk factors, effects, and needs of rural victims are unique. For example, research indicates that rural women live three times further from their nearest intimate partner violence resource than urban women. In addition, domestic violence programs serving rural communities offer fewer services for a greater geographic area than urban programs [102].

It is important to assess victims' proximity to available resources and to help in times of crisis. Rural victims may benefit from improved access to services, including technology-based outreach (e.g., videoconferencing, telehealth programs) [103].

MOTOR VEHICLE ACCIDENTS

Motor vehicle crash-related injuries are the leading cause of death among people 5 to 34 years of age [104]. Motor vehicle crash fatality rates are especially high in rural areas and for residents of tribal lands, in part because of poor road maintenance, higher rates of alcohol-impaired driving, lower rates of seat belt and child safety seat use, and less access to emergency response and trauma care [104]. The federal government has committed to supporting state, tribal, local, and territorial agencies in implementing, strengthening, and enforcing transportation safety policies and programs.

Deaths from motor vehicle crashes for drivers or passengers are 3 to 10 times higher in rural America than in urban America, depending on the region [105]. In one study, physical inactivity and lack of insurance were associated with higher rates of motor vehicle fatalities, as was having a more racially or ethnically concentrated population and larger percentages of younger or older adults [106]. Seat belt use has been found to be lower in rural areas, and 61% of drivers and passengers in fatal crashes in the most rural counties in America did not have their seat belts on at the time of the crash [105].

The CDC has developed several resources and tools that states and communities can use to identify effective interventions that might help to address rural-urban disparities in seat belt use and passenger-vehicle-occupant death rates. These include the Motor Vehicle Prioritizing Interventions and Cost Calculator for States, which calculates the expected number and monetized value of injuries prevented and lives saved at the state level after implementation of up to 14 proven strategies (https://www.cdc.gov/motorvehiclesafety/calculator), and the Guide to Community Preventive Services, a collection of systematic reviews of evidence-based findings of the Community Preventive Services Task Force that includes motor-vehicle injury prevention reviews (https://www.thecommunityguide.org).

However, experts have argued that policy interventions to address the rate of motor vehicle fatalities in rural communities should go beyond state laws about seat belts, texting, and similar safety issues, which are important but ultimately will not reverse the urban-rural disparity or eliminate all fatalities [106]. Instead, they recommend a multifaceted approach, including addressing rural transportation infrastructure, access to health care, and emergency response capability.

FIREARM INJURIES AND DEATHS

In the United States, those who live in rural areas are more likely to reporting owning a gun (46%) than those who live in the suburbs (28%) or urban areas (19%) [107]. Gun owners in rural areas are less likely to cite protection as a motivator of gun ownership (62%), compared with suburban and urban residents (both 71%), though it is the most cited reason. They are more likely to report having a gun for hunting or collecting purposes. Regardless of the reasons for owning a gun, the presence of a firearm in the home increases the risk of fatality from suicide, domestic violence, and homicide [108,109]. For providers devoted to preserving life and promoting health, this can make advising patients in risk situations to remove guns from their home seem ethically self-evident [109,110].

However, a cultural divide can exist between gun-owning patients and clinicians. For many patients who own guns, gun ownership is a core element of a deeply rooted system of beliefs and values referred to as gun culture. Clinicians who are not part of this culture benefit from an understanding of the perceptions, beliefs, and values of gun culture members before initiating gun safety conversations with their patients. Although difficult for some clinicians, this reflects cross-cultural competence, a core element of patient-centered care. Understanding gun culture can make the difference between reaching versus alienating a patient.

VETERAN HEALTH ISSUES

Nearly 4 million veterans reside in rural (nonmetropolitan) America [111]. They are a rapidly aging and increasingly diverse group of men and women who still comprise more than 10% of rural adults, despite consistently declining numbers. A disproportionate share of men and women serving in the military grew up in rural counties and most return home after completing tours of duty [111]. Thus, rural Americans are disproportionately represented in the veteran population, comprising 19% of all U.S. veterans, compared with 16% of the general population [111].

Despite being more likely to report physical and mental illness, rural veterans are less likely to use the U.S. Department of Veterans Affairs (VA) or public health care [112]. Only 38% of rural veterans live within a 30-minute drive of a VA facility, and only 49% of highly rural veterans live within 60 minutes. As such, the VA may partner with federally qualified health centers to provide care to veterans who live outside of a designated care area [112].

As the number of military conflicts and deployments has increased since 2001, the need to identify and provide better treatment to veterans and their families has become a greater priority. The first step in providing optimal care is the identification of veterans and veteran families during initial assessments, with an acknowledgement that veterans may be any sex/gender and are present in all adult age groups [113]. Unfortunately, veterans and military families often do not voluntarily report their military service in healthcare appointments. In 2015, the American Medical Association updated its recommendations for social history taking to include military history and veteran status [114]. In addition, the American Academy of Nursing has designed the Have You Ever Served? Initiative to encourage health and mental health professionals to ask their patients about military service and related areas of concern [115]. This program provides pocket cards, posters, and resource links for professionals working with veterans and their families.

Several mental health issues are common to veterans of wars, including post-traumatic stress disorder (PTSD), depression/suicide, substance misuse, sexual assault, domestic violence, and intermittent explosive disorder. Military personnel may confront numerous potentially traumatizing experiences, including military-specific events and those experienced by civilians. Research suggests the most common traumatic events experienced during active duty are witnessing someone badly injured or killed or unexpectedly seeing a dead body. Events most likely to result in the development of PTSD include witnessing atrocities, accidentally injuring or killing another person, and other interpersonal traumas, such as rape, domestic violence, and being stalked, kidnapped, or held captive [116,117].

Exposure to multiple traumatic events is not uncommon during deployment, and exposure to real or threatened death and serious physical injury that can lead to PTSD is likely. Fundamental beliefs about self, the world, and humanity can become severely challenged by the nature of wartime traumatic events, such as exposure to the death of civilians and destruction of communities on an unimaginable scale with little preparation. Veterans may themselves have committed acts of violence they deem with hindsight as atrocities, shattering previously held beliefs about the self [116].

Although the true incidence of suicide among military war veterans is difficult to estimate due to the lack of national suicide surveillance data, the VA estimates that 22% of all deaths from suicide in the United States are in military war veterans [118]. In addition, 12% of all U.S. Army suicides occur within 12 months of hospital discharge [119]. Despite preventive measures taken by the military, the number of suicides in this population continues to increase [120,121,122,123,124]. Although the majority of military suicides occur among young men shortly after their discharge from military service, military women 18 to 35 years of age commit suicide nearly three times more frequently than nonveteran women of the same age group [125,126].

The VA defines military sexual trauma as "sexual assault or repeated, threatening sexual harassment that occurred while the veteran was in the military" [127]. This can include rape (nonconsenting, forced, or coerced sexual activity); unwanted sexual touching or grabbing; threatening, offensive remarks about a person's body or sexual activities; and/or threatening or unwelcome sexual advances [127]. In 2015, the Department of Defense received 6,083 reports of sexual assault involving service members [128]. In a survey of 60,000 veterans who served during the Operations Enduring Freedom and Iraqi Freedom eras, approximately 41% of women and 4% of men reported experiencing military sexual trauma [129].

Intermittent explosive disorder is included under the general category of disruptive, impulse-control, and conduct disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [130]. Approximately 2.7% of the general public meets the diagnostic criteria for this disorder, but it is much more common among military veterans. In one study of nondeployed U.S. Army personnel, 11.2% of participants met the criteria for intermittent explosive disorder in the past 30 days; it was the most prevalent mental disorder, surpassing PTSD and attention deficit hyperactivity disorder [131].

DENTAL HEALTH

Mouth and throat diseases, including tooth decay, periodontal disease, and oral cancers, cause pain and disability for millions of Americans each year [38]. Poor dental health is associated with impaired intake and systemic disease. As compared to decades ago, dental health has improved across the United States, which is primarily attributed to fluoridation of water and toothpaste and greater awareness of optimal oral hygiene. However, rural areas have a variety of factors that contribute to poor oral health [132]:

- Geographic isolation

- Lack of adequate transportation

- Higher rate of poverty compared to metro areas

- Large elderly population (with limited insurance coverage of oral health services)

- Acute provider shortages

- State-by-state variability in scope of practice

- Difficulty finding providers willing to treat Medicaid patients

- Lack of fluoridated community water

- Poor oral health education

The shortage of dental professionals has resulted in some rural residents seeking dental care at the local emergency department [15]. To address this problem, areas with fewer dental professionals may qualify for a federal dental health professional shortage area designation. Having this designation can qualify the area to receive financial aid or recruitment aid from the government [38,133].

Although the link between oral health and general health is well-established, the divide between the two fields is great. Many healthcare professionals have not received formal training in oral health. Collaborative care with dental professionals is an essential aspect of improving dental care in rural areas.

ACCESS TO CARE

Access to health care involves many components, including health insurance coverage, having a usual source of care, encountering difficulties when seeking care, and receiving care when wanted [134]. According to the National Prevention Strategy, residents of rural areas are more likely to have a number of chronic conditions and less likely to receive recommended preventive services because of the lack of healthcare professionals and patient care sites in rural areas [104]. Inaccessible service is faced by low-income and disabled populations both urban and rural alike. Despite geographic location and socioeconomic context, preventive health care should be accessible to all people [104].

Disparity is a historic issue for rural counties. As discussed, rural demographic groups have higher disease rates and higher death rates for many conditions than urban groups, and one reason for these disparities is lack of quality care [34]. Differences in health status or treatment outcomes that result in a certain demographic or cultural group experiencing negative health status at a greater rate than another group can be the result of a combination of factors such as age, income, primary language, geographic locale (e.g., rural), gender/sex, or race/ethnicity [134]. The presence of rural health disparities has spurred local and state governments to take steps to ensure that all patients have access to culturally appropriate and evidence-based care; one such approach is improving the diversity and cultural competence of the rural workforce [134].

Evidence Based Practice Recommendation

According to the World Health Organization, telemedicine is an alternative to direct healthcare provision. It reduces the difficulties of access to health services by providing links between patients at the contact point and the medical expertise, wherever it may be.

https://apps.who.int/iris/bitstream/handle/10665/44589/9789241501514_eng.pdf

Last Accessed: July 29, 2019

Level of Evidence: Expert Opinion/Consensus Statement

A more recent disparity is rural access to technology, particularly the Internet. This is important because the Internet is a medium that could be used to deliver public programs to isolated rural regions. Telehealth is greatly dependent on the Internet, promising to improve care access for rural communities by linking services to residents in distant places. Yet, studies show poorer populations (both rural and nonrural) are less likely to have any Internet access than wealthier cohorts. According to the U.S. Department of Health and Human Services, broadband infrastructure is not accessible in all regions and can be as much as three times more costly in rural areas [135,136]. Broadband deployment in rural areas is catching up, but may not keep pace with increasing bandwidth demands of high-quality video, graphics, and data offerings [135,136].

Prevention programs are key to public health, but rural residents have less access to these programs [33,137]. The National Rural Health Association states, "despite the initiation of effective health programs by rural health departments to improve community-level health behaviors, many more rural areas lack the public health agencies, personnel, and financial resources required to implement these interventions" [2]. Although professional maldistribution, geographic isolation, and physical immobility are being addressed as barriers to accessing care, other barriers exist—for example, insufficient health insurance. The insurance marketplace under the 2010 Affordable Care Act and its expansion of Medicaid eligibility is an example of federal policy to increase access to sufficient health insurance.

Access to public health services is critical to rural population health, but it is incumbent on rural population health providers expand beyond the traditional healthcare delivery system to address the social and economic conditions of rural communities associated with poor health and poor patient outcomes throughout the lifespan [138]. There is a growing momentum to move beyond disease management and toward disease prevention and population health in rural communities [138].

Transport of Critically Ill Patients

Airplanes, helicopters, and ambulances are often necessary to transport very ill or severely injured patients from rural community hospitals to higher levels of care or specialty service available at larger hospitals. As such, the mode of transportation available can impact rural patient health.

Ground transport is the cornerstone of the emergency response system in the United States. Ground ambulances are accessed by the public through the 911 system and provide rapid stabilization of ill or injured patients. In large urban areas with well-developed prehospital care systems, the time-to-patient is less than 10 minutes. However, as the population base expands into rural areas, the time-to-patient tends to lengthen, delaying access to medical care. To reduce the patient's out-of-hospital time, air ambulances have been developed to augment ground transport programs, providing rapid transfer.

Ground ambulance transport is an efficient and appropriate method of transport for most ill and injured patients in this country. The number of ground transports increases annually and the appropriateness of these transports is unquestioned. However, there are instances in which ground transport is at a disadvantage. Adverse weather conditions can impact the vehicle's ability to traverse certain terrain. At the same time, this adverse weather can prevent air ambulances from flying, leaving ground transport as the only viable option. Time-in-transit is another drawback of ground transport. Some critically ill or injured patients cannot withstand the stressors of transport and the shorter the out-of-hospital time, the better that patient's chance for survival. Finally, when choosing to utilize a ground ambulance, the needs of the community should be examined. Some isolated rural areas have only a single ground ambulance to service a largely scattered population base. If this vehicle is taken out of service for an interfacility transport, the people of the community are temporarily left without the medical coverage they have come to expect.

Air transport should be considered an adjunct to, not a replacement for, ground transport. There are inherent dangers in transporting by air, and it is an expensive alternative. Many third-party providers are withholding reimbursement for flights, which are considered nonemergent. The advantage of fixed-wing transport is the ability to travel long distances at speeds between 250 and 570 miles per hour. Care is usually provided in a pressurized cabin with sophisticated on-board medical equipment. Many aircraft utilized for air transport of patients have the capability of transporting multiple patients, and in some instances, family members are allowed to accompany the patient. All-weather navigational equipment allows for the transfer of patients during inclement weather. Many of the dedicated aircraft utilized in air transports have been referred to as "flying ICUs."

Fixed-wing transport requires suitable airfields to ensure the safety of the crew and patient. Accessibility to such fields may be a problem in isolated areas. Optimally, a 5,000-foot paved runway located near the site of the patient would erase the disadvantages of air transport. However, because hospitals are located a considerable distance from most airfields, ground transport is utilized at the beginning and the end of the air transport. (Note: A unique situation exists in Anchorage, Alaska, where a regional referral medical center is located on the edge of an appropriate airfield and the patient can be off-loaded from the plane and wheeled directly into the hospital. This is far from the norm.) The patient should be moved in and out of the aircraft to a waiting ground ambulance and then transported from the referring hospital or to the receiving hospital. This increases the likelihood of the dislodgement of tubes, lines, etc. There is an additional cost associated with this supplemental ground transport.

Rotor-wing vehicles provide rapid point-to-point transfers. Helicopters are capable of reaching most areas and can bypass difficult terrain. Landing zones can be made at or near the site of the patient to prevent lengthy ground transport times. Most helicopters operate within a 150-mile radius of their base station to allow for routine flights without refueling. The type of helicopter utilized by a transport program is determined by a number of factors. Most programs now rely on twin-engine helicopters for their enhanced performance and safety records. Certain helicopters perform better at altitude; they are utilized in areas of high terrain, such as in the Rocky Mountains or in the Swiss Alps. The highest helicopter rescue was performed in 2010 at 23,240 feet (density altitude) for injured climbers on the Kamet glacier in the Himalayas. In 2013, a simulated rescue was performed at 25,590 feet on Mt. Everest; however, the practical limit for safe rescue operations is generally agreed to be 23,000 feet [261].

The single largest disadvantage of helicopters is their dependence upon certain minimum weather conditions; if these conditions are not met, the weather can cause delay or cancellation of the flight. Helicopter cabin size often restricts access to the patient once the patient has been loaded into the helicopter. This limited access reduces the number of in-flight interventions possible. Weight limitations restrict the number of passengers and the amount of equipment on board. When transferring a patient by rotor-wing vehicle, comprehensive stabilization of the patient is required prior to departure.

As healthcare dollars become tighter and legislation mandates transport of patients to better-equipped facilities, those caring for patients who need transport should be cognizant of the advantages and disadvantages of the modes of transport. As air ambulance programs continue to proliferate in this country (although the number of programs has leveled off in the last few years), the preparation to choose between ground, helicopter, or fixed-wing transport will be important.

5. CHARACTERISTICS OF THE RURAL HEALTHCARE SYSTEM

THE PUBLIC HEALTH WORKFORCE

One characteristic of the rural healthcare system is the public health workforce, which encompasses all persons involved in the public health system, including local boards of health, other governance bodies, and non-governmental organizations. Many healthcare professionals contribute to the public health workforce, including nurses, physicians, social workers, pharmacists, and psychologists [2].

A chief characteristic of the rural health workforce is one of maldistribution (Table 2). In most of the country, health professionals concentrate in urban areas, creating an insufficient supply and unequal distribution of primary healthcare providers [139,140]. This disparity is expected to grow as a result of demographic changes, insurance coverage expansions, and a decline in the primary care physician workforce [141]. Specialists and subspecialists are particularly limited in rural areas, as they tend to concentrate in areas with larger population bases where they have enough demand for their services to be economically viable [142,143].

Table 2: HEALTHCARE WORKFORCE IN RURAL VS. URBAN AREAS, 2017

Profession

Rate in Urban Areas (Per 100,000 Population)

Rate in Rural Areas (Per 100,000 Population)

Primary care physicians

53

40

Nurse practitioners

36

28

Dentists

30

22

Source: [141]

Evidence Based Practice Recommendation

The World Health Organization recommends that health professionals practicing in well-served areas in secondary-level or tertiary-level facilities can support their colleagues working in rural areas, but also serve the population directly. Physical outreach strategies can include remote day consultations, rotation in health structures, and mobile clinics.

https://apps.who.int/iris/bitstream/handle/10665/44589/9789241501514_eng.pdf

Last Accessed: July 29, 2019

Level of Evidence: Expert Opinion/Consensus Statement

Rural counties are also historically disadvantaged in terms of mental health services [136]. According to the CDC, more than 85 million Americans live in areas with an insufficient number of mental health providers; this shortage is particularly severe among low-income rural communities [86]. Rural Americans with mental health needs typically enter care later, have more serious symptoms, and require more costly and intensive treatment [141]. Patients in rural care settings are also more likely to be given pharmacotherapy for psychiatric illness due to a shortage of professionals qualified to provide psychotherapy.

As noted, rural areas lacking health professionals may meet the criteria to be federally designated health professional shortage areas. The U.S. Department of Health and Human Services defines a health professional shortage area as having shortage of primary care, mental health, and/or dental providers [144]. These shortage areas may be designated based on geographic characteristics, population characteristics (e.g., low income), or service availability (e.g., a specific type of facility not having the professional workforce to meet needs) [144]. About 6,700 primary care health professional shortage areas exist in the United States, with 59% located in rural areas [145]. These medically underserved areas are more likely to see unfavorable clinical outcomes.

Nurse Workforce

Nurses comprise the largest sector of the rural health workforce. According to the U.S. Census Bureau, the greatest portion of the civilian workforce in rural counties (22.3%) is employed in education and health services, which includes physicians, nurses, social workers, home healthcare providers, and school teachers [2,146]. Studies show that by 2030, some states will have a workforce shortage in RNs and licensed practical or vocational nurses (LPNs/LVNs).

The U.S. Department of Health and Human Services projects a national RN excess of about 8% of the projected need and a national LPN deficit (shortage) of 13% of the projected need by 2030 [147]. However, these projections are national and do not necessarily reflect the projected supply or demand for rural areas. In predicting change between 2014 and 2030, California ranked high on an expected future shortage of full-time equivalent RNs. Alternatively, a high "excess" of RNs is expected in Florida, Ohio, Virginia, and New York. Historically, the U.S. supply and shortage for nurses has been cyclical, with periodic shortages of nurses followed by periods of overproduction leading to nursing surpluses [147]. For LPNs/LVNs, 17 states are projected to have an excess in 2030, led by Ohio and California [147]. In total, 33 states are projected to have a shortage of full-time equivalent LPNs/LVNs by 2030, with Texas expected to have the largest shortage followed by Pennsylvania [147]. Of these 33 states, 14 are Southern states, 7 are Midwestern states, 6 are Northeastern states, and 6 are Western states [147]. The growing demand for LPNs/LVNs by 2030 is driven by many determinants, perhaps most importantly a growing and aging population, resulting in increased health service needs in nursing homes, residential care, and hospital settings [147]. Emerging healthcare delivery models are expected to contribute to a new growth in demand for nurses (e.g., with nurses taking on new and increased roles in prevention and care coordination) [148]. Evaluation of these new delivery models and their impact on nurse supply will be needed in the future.

Frontier and rural communities have a greater likelihood of experiencing a nurse shortage than urban areas for multiple reasons. Most rural areas cannot compete economically with the urban areas for nurses, and urban nurses may not have the training preparation to cross over into rural health care [147,148]. Policy solutions aimed at reducing nursing shortages in frontier and rural communities should consider that it is a different nursing context than an urban environment. Solutions that emphasize improving competitiveness may be short-lived and draw nurses away from and exacerbate the shortage elsewhere—possibly other rural and frontier areas [147,148]. To improve the healthcare workforce capacity in rural communities, stakeholders should focus on community-based development approaches. Approaches failing to address the well-being of the community in a holistic sense will not improve nursing shortages over the long term [149]. Building the capacity of the public health workforce is a priority policy solution [136]. An adequate rural workforce supply is expected to offset the shortage of preventive services and to prevent hospitalizations [145].

Emergency Medical Services

Emergency medical services (EMS) are defined as the practice of medicine involving the evaluation and management of patients with acute traumatic and medical conditions in an environment outside the hospital (prehospital). It combines the disciplines of public safety, acute patient care, and public health [150]. In rural trauma care, rural hospitals are integrated with the local rural public health system, working as part of the state and local trauma care system to provide a collaborative approach to care.

Emergency response services are a vital part of the rural healthcare system. The goal of the EMS system is to provide a coordinated, timely, and effective response to medical emergencies. As discussed, the distances between population centers and the need to transport patients from hospitals and nursing homes in small communities to larger facilities make these services essential in rural areas [151]. Advanced life support units respond to life-threatening events requiring immediate attention (e.g., stroke) and aim for an immediate response time. Rural factors such as difficult geographic terrain, a longer travel time to patient and/or facility, and weather-related factors can be potential barriers for an optimal response time. For prehospital EMS, travel time and distance to the patient location alone can far exceed an eight-minute threshold [152].

Persons living in rural areas have an increased need for prehospital care and emergency transport. Rural residents tend to be older, poorer, and sicker than those living in urban areas [32]. The death rates for rural unintentional injuries (e.g., motor vehicle crashes, drug overdose) are about double that of urban areas [151]. Residents not able to access emergency or prehospital services (e.g., for an acute cardiac event or stroke) are more likely to experience an unfavorable clinical outcome. Furthermore, patients with restricted access to medications, equipment, or special care they need (more common among rural patients) are at increased risk of complications and death during an emergency [151].

The EMS workforce is fewer in number in isolated rural areas as compared to the workforce in larger rural or urban areas. Mostly volunteers, rural prehospital EMS providers often struggle with recruitment, training, and retention of a sufficient workforce to meet the needs of the local population [153]. Medically underserved areas such as isolated rural areas have a greater chance to see negative clinical outcomes because of barriers to timely care as compared with urban areas with fewer barriers. The EMS rural staffing concern is not limited to EMS but is part of the larger picture of a rural-urban disparity in all healthcare staffing.

This unequal distribution of medical specialists, hospitals, and care resources (including EMS) has been defined as a policy problem by the U.S. government, which has passed legislation to advance communications technology as part of the solution. Telemedicine promises to overcome the rural unevenness of professionals and to be a less-costly alternative than recruiting a larger rural workforce. In fact, the original goal for telemedicine was to improve the consumer access to care professionals for those living in federally designated professional shortage areas and other underserved areas [136]. In the context of emergency services, technology can connect the EMS workforce to emergency medicine at a distant site. Device technology can capture various physiologic data, including image, sound, or video, for transmission to emergency centers for immediate interpretation, diagnosis, and instruction to field personnel. Technology enables e-consultation in the field when needed, making it more feasible to treat the geographically isolated patient before arriving at the hospital and ultimately improving outcomes [150].

Dental Workforce

There are fewer rural dentists (per capita) available to address oral disease than in urban settings, and the majority of dental health professional shortage areas lacking access to dental services are rural [154]. An estimated 8,600 additional dentists will be required nationally to meet care needs by 2025 [154].

PUBLIC HEALTH AGENCIES, HOSPITALS, AND COMMUNITY HEALTH CENTERS

Public health agencies, rural hospitals, and community health centers are key players in the rural health infrastructure. Although many rural hospitals have closed, other entities and solutions are being established to meet the needs of the rural population. Ideally, these entities work collaboratively in the rural community toward promoting public health, well-being, and quality of life.

Public Health Agencies

The U.S. public health system broadly consists of the public, private, and voluntary bodies contributing to the delivery of health services within a jurisdiction. Providing optimum care requires a collaborative and well-coordinated effort among the multiple stakeholders involved in the system. The U.S. government agencies and departments at all levels guide and oversee public health. Federal agencies work in alliance with state and local agencies to provide guidance and support on issues such as workforce recruitment and retention, infrastructure, funding of public services, and information technology use [155].

Of the many federal agencies involved in public health, the CDC guides health promotion, prevention, and preparedness actions. The Partners in Information Access for the Public Health Workforce (often referred to as Partners) is a collaboration of public health-related stakeholders (organizations, agencies, and health sciences libraries) providing public health resources for the nation's public health workforce, such as historical literature, reports, guidelines, and global and local health data for research, legislation, and policy [156].

The USDA also provides financial support and guidance for rural communities through its Rural Development program. This program supports loans to businesses, technical aid to agriculture producers, affordable housing, home safety and health repairs, public safety services, first responder equipment, and a spectrum of infrastructure assistance that addresses the social determinants of rural health [157].

The U.S. Environmental Protection Agency (EPA) is also an important part of the federal infrastructure to improve the health of rural communities. It protects the health and environment with guidance, oversight, and programs that ensure clean air, land, and water, making community life safer and healthier [155].

In all, the federal government has assumed many responsibilities to improving national public health. These agencies ensure all levels of government have the capability to provide essential public health services and respond to emergencies, and are supportive to all government levels with scientific research [6].

Although all levels of government work together to support the mission of promoting public health, the state or local health department retains the primary responsibility. State governments vary in the extent of their authority over local health agencies and the types of partnerships and collaborations they engage in with other government and non-government entities [6]. In 2016, the 50 state public health agencies included 2,795 local health departments and 312 regional or district offices, with 58% being freestanding and/or independent agencies and 42% having a unit of a larger combined health and human services organization or umbrella organization [6,159].

Each state health agency is led by an appointed state health official. State agencies collaborate with a variety of local stakeholders (e.g., local public health departments, hospitals, provider practices/medical groups, community health centers). Today, more states are sharing resources (e.g., surveillance data) across state lines and are collaborating with each other to form multi-state response teams for hazards and health emergencies [160]. States and their territorial agencies engage in a variety of actions to promote resident health—disease screening, primary prevention initiatives, providing treatment for disease, state laboratory testing, technical assistance and training to the workforce, epidemiology and surveillance, and vaccine management and inventory distribution [6,160].

Local public health infrastructure can vary. Within a state, local health departments can take on a variety of structural arrangements. For example, some local health departments have more decision-making authority and are locally led by their government for funding; other local departments are parts of the greater state health department (referred to as centralization). Theoretically, with centralization, funding and decision-making is centralized at the state level. Still other local departments fall under a mixed or shared structural decision-making arrangement in their state [6]. Local public health agencies receive oversight from the local board of health. As a legal oversight authority, the roles of the local board of health are many and include recommending public health regulations and policy; collaborating with health departments on strategic planning; and recommending and approving the health department budget [6]. The National Association of Local Boards of Health is considered the grassroots of public health and is the national voice for effective and competent public health governance [161]. A functional public health system is expected to have a strong working relationship with the other bodies. Communications channels and the communication feedback loop ideally involve the many public health players and allows for a sharing of objectives and a pooling and sharing of resources [6].

Rural Hospitals

Rural hospitals are a source of primary care for rural populations; in some areas, they are the only source of care. However, rural hospitals have faced many challenges, mostly due to financial pressure. According to the National Conference of State Legislatures, 673 rural hospitals were vulnerable to closing as of 2016; of these hospitals, 355 are identified as being in markets with significant health disparities [141]. In other words, many of the rural hospitals vulnerable to closing are in communities already facing care access issues. This number of vulnerable closings translates to about 700,000 rural residents facing closure of their nearest hospital emergency room, often used for many medical reasons (even dental care). Without an alternative, many residents will have no source of care. In response, the health system is searching for the best alternative(s) to the financially unsustainable rural hospital, such as converting hospitals to emergency or urgent care stand-alone centers, telehealth services, outpatient centers, and skilled nursing facilities [141]. These models may offset the rural community losing their care and are generally more cost-effective. As discussed, telehealth as an alternative model of care (or medium to deliver care) has the potential to offset a number of rural hospital closure issues. It can make healthcare delivery less costly and more efficient, reach more people, and bring better quality of care into the home. Telehealth as a quality improvement component can bring system-wide, sustainable improvements in access to care [136].

Community Health Centers

As part of his war on poverty, former President Lyndon B. Johnson signed into effect the Economic Opportunity Act of 1964, which was the conception of the community health center. Soon after, the first center opened. Aimed to reduce disparities to care across all geographic areas in the United States, community health centers deliver primary care and prevention services to the most vulnerable populations [162]. Community health centers are defined as community-owned, locally administered medical clinics where people can receive preventive care, free vaccine clinics, health alerts, disease screening, and counseling [163]. In 2017, more than 1,400 community health centers serviced nearly 28 million people across the United States and its territories [164]. Federally qualified health centers are community-based, nonprofit or public organizations located in areas where private health providers lack financial incentives to operate, including sparsely populated rural locations with fewer patients or areas where there are high rates of publicly insured or uninsured patients [165]. To assure that these centers are bridging gaps in care provided by the private market, they are required to serve federally designated medically underserved areas or populations [165]. Health centers can help narrow disparities and rural hospital closings, hospitalizations, and emergency department visits for conditions that can be managed by preventive or primary care [140]. The center is an example of a well-coordinated, comprehensive care model that integrates services from various disciplines such as primary care providers, behavioral health practitioners, and dental professionals [166].

The role of these community-based and patient-directed organizations is to provide comprehensive, culturally competent, high-quality services, many times integrating access to pharmacy, mental health, substance use disorder, and oral/dental health services in areas where economic, geographic, or cultural barriers limit access to affordable healthcare services [162]. Compared with other primary care facilities, community health centers provide more screening for diabetes, hypertension, and breast and cervical cancer, and 80% of centers outperform benchmarks on diabetes control [163]. Even while serving more complex patients and more chronic illness than other primary care providers, community health center patient outcomes are reported to be the same or better than the outcome levels of outside providers [163]. One in seven people served by a community health center are rural residents, and because these community health centers are locally governed, the services they provide are more likely to be tailored to meet the needs of the local population. A common element across rural hospitals, clinics, and community health centers is their focus on the local community [138].

The community health center can also be an important economic force in a community, offering employment and training opportunities and purchasing local services [165]. Building the economic force of a rural community is as important as obtaining access to care, particularly because community health is a multi-dimensional concept taking into account socioeconomic determinants [141]. In all, these centers advance a coordinated, comprehensive, patient-centered care model [166]. Although rural community health centers may provide primary care in rural settings, it is important to remember that a responsive rural health delivery system requires collaborative efforts of clinical and behavioral health providers, public health, education, local businesses, and community-based organizations [167].

Other health centers are rural health clinics and school-based health centers, which consist of clinics in schools working to provide primary care and preventive services for youth. Services provided in school settings are broad and not limited to school health education; primary medical care for conditions such as asthma, substance use disorders, and dental care may be provided [141,165].

Aside from community health centers, schools, and rural hospitals, other creative solutions are being explored to promote the health and well-being of rural communities. Regardless of the mode of care delivery, these efforts are characterized by collaboration and a flexible infrastructure.

INDIAN HEALTH SERVICE

Compared with other Americans, AI/AN populations have long experienced lesser health and quality of life, having a greater proportion of disease burden and a lower life expectancy [168]. For example, AI/AN individuals are more likely than other Americans to die from chronic liver disease and cirrhosis, diabetes, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases [168]. Across all racial/ethnic groups in the United States, AI/ANs have the highest percentage of type 2 diabetes, which can lead to many complications and exacerbation of other chronic illnesses. As compared with the general population and other racial/ethnic groups, AI/AN children are disproportionately affected by dental disease, and oral health for school-aged children 6 to 9 years of age did not change significantly between 2012 and 2017 [169]. The compromised health of this population is believed to be rooted in historic economic adversity and poor social conditions [168].

The federal health program for AI/AN patients is the Indian Health Service (IHS). An agency within the U.S. Department of Health and Human Services, the IHS assumes the large share of responsibility for the well-being of AI/AN populations (rural and urban) by providing a comprehensive health service delivery system for approximately 2.6 million members of the 573 federally recognized tribes in 37 states [170]. The provision of health services to members of federally recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes, which has its foundation in the U.S. Constitution [170].

There is an infrastructure of entities within the IHS, including tribal health organizations, IHS units, Indian health boards, and the Tribal Health Department, which operates under the jurisdiction of a federally recognized tribe or an association of these tribes and receives funding to operate from the IHS [6]. In all, many partnerships have been created to meet the needs of AI/AN citizens, but the IHS is considered the primary program for this population.

A person may be regarded as eligible and within the scope of the IHS health care program if he or she is of AI/AN descent and belongs to the Indian community served by the IHS program, as evidenced by such factors as [158]:

- Membership, enrolled or otherwise, in an AI/AN federally recognized tribe or group under federal supervision

- Resides on tax-exempt land or owns restricted property

- Actively participates in tribal affairs

- Any other reasonable factor indicative of American Indian descent

In addition, care and treatment of non-Indians shall be provided for children, spouses, and pregnant women meeting certain requirements. This includes any individual who is 18 years of age of younger; is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and is not otherwise eligible for health services provided by the IHS [158]. Any spouse, including a same-sex spouse, of an eligible Indian who is not an Indian, or who is of Indian descent but is not otherwise eligible for the health services provided by the IHS, is eligible for such health services if the governing body of the Indian tribe or tribal organization providing such services deem them eligible by an appropriate resolution as a class. In addition, a non-Indian woman pregnant with an eligible Indian's child may receive IHS services for the duration of her pregnancy and through the postpartum period (usually six weeks after delivery) [158].

Programs and Initiatives

The services provided by the IHS for the AI/AN community are diverse. Diabetes prevention and the treatment of diabetes-associated complications are among the high priorities for the IHS [171]. They have developed diabetes surveillance systems to track diabetes prevalence and complications and an extensive network of professionals (including nurses) who are conducting diabetes treatment and prevention programs [171]. For the IHS, diabetes management and prevention are most critical because unmanaged diabetes can lead to increased morbidity and mortality.

The IHS has received special federal support to prevent and mitigate the diabetes epidemic in the AI/AN population. Following creation of the Special Diabetes Program for Indians in 1997, 301 communities in 35 states have implemented evidence-based best practices diabetes treatment and prevention programs [171]. The IHS has reported a significant improvement for AI/AN program participants, perhaps most importantly an 8% reduction in the average blood glucose levels for those with diagnosed diabetes between 1997 and 2015 [171].

The IHS Early Childhood Caries Initiative provides AI/AN children with oral assessments and interventions to mitigate early childhood dental disease, giving public health nurses the opportunity to be part of a collaborative team effort improving oral health. Similar to the collaborative approach used by public health programs outside the IHS, the IHS Early Childhood Caries initiative involves multiple stakeholders, including dental and medical staff and other programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC is a social program for low-income women, infants, and children up to 5 years of age to provide healthy foods and referrals [172]. In order to promote dental health, the nurse assesses the oral health status of children during visits for childhood immunizations and screenings (e.g., vision, hearing, weight). According to the IHS, nurses can do oral health assessments on young children to look for chalky spots, black spots in grooves, and caries and provide positive oral health messages and education to parents on early childhood caries; they may also refer children to dental clinics [172].

The IHS also administers the Alcohol and Substance Abuse Program to decrease the incidence and prevalence of alcohol and substance abuse in AI/AN populations to a level that is at or below the general U.S. population [173]. This program provides access to behavioral health professionals through telemedicine (telebehavioral health), which acts to expand the reach of preventive, educational, and treatment services [173].

Another holistic model initiative is the Methamphetamine and Suicide Prevention Initiative, a national, community-driven program that uses evidence-based practice and culturally appropriate prevention and treatment approaches [174]. From 2009 to 2015, the Methamphetamine and Suicide Prevention Initiative resulted in more than 12,200 individuals entering treatment for methamphetamine abuse; more than 16,560 substance use and mental health disorder encounters via telehealth; more than 16,250 professionals and community members trained in suicide crisis response; and more than 690,590 encounters with youth provided as part of evidence-based and practice-based prevention activities.

The IHS also funds 12 Youth Regional Treatment Centers, which provide culturally sensitive education and prevention to youth experiencing substance abuse and co-existing disorders. The professional services are holistic, collaborative, and evidence-based [175]. These services include clinical evaluation; substance abuse education; group, individual, and family psychotherapy; art therapy; adventure-based counseling; life skills; medication management or monitoring; evidence-based/practice-based treatment; aftercare relapse prevention; and post-treatment follow-up services.

Because compromised AI/AN health is believed to be rooted in economic adversity and poor social conditions, having IHS and other players open access to care is not enough to improve the quality of life and promote public health for the AI/AN [168]. Access to services only accounts for part of the overall determinants of population health [138]. Population health is also affected by healthy lifestyle behaviors (e.g., nutrition, exercise), social conditions, economic factors, the physical environment (e.g., water and air quality), safe housing, law enforcement, and violence [138]. The belief that improvements in health services alone will mean improvements in overall health status is not reasonable. Improvements must take place in all areas that can contribute to a better quality of life, including educational achievement, employment opportunities, and economic development [176]. The federal government, state and local health departments, and tribal health are an integrated system working together to protect the AI/AN population and promote initiatives to improve their well-being [6]. Each brings expertise for developing innovative strategies to benefit the AI/AN population. The idea of integrating systems together to service populations is of interest to others, and the IHS shares its public health approaches and best practices with other countries and their respective indigenous populations, including Canada, Mexico, Australia, and New Zealand [176]. Mutual partnerships may also include non-government stakeholders, such as the business community.

Public Health Nursing and the Indian Health Service

Evidence Based Practice Recommendation

In a consensus Canadian guideline, experts recommend that health professionals inquire about their native patients' use of traditional medicines and practices as part of routine health care, including prenatal care.

https://www.jogc.com/article/S1701-2163

Last Accessed: July 29, 2019

Strength of Recommendation/Level of Evidence: III-A (There is good evidence based on expert opinion to recommend the clinical preventive action.)

Nurses working in or with the IHS play a vital role in improving the health and well-being of AI/AN populations. The IHS conceptualizes its public health nursing program as autonomous—flexible and individualized. For those in the IHS, the primary focuses of the public health nurse are on prevention of illness; promotion and maintenance of health through the provision of therapeutic services, counseling, and education; and advocacy [158]. This is accomplished through assessment and identification of individual, family, and community needs; consumer participation; and the planning and coordination of community health programs and services. In this environment, the public health nurse takes into account the prevailing economic, cultural, social, and geographic characteristics of his or her patients. Nursing actions are considered dependent, interdependent, and intradependent with other disciplines, and nurses are part of an interprofessional team of providers [158]. Many of the IHS sites throughout 35 states are in rural remote areas, and IHS nurses have connections with patients, the greater community, clinics, and hospitals.

Other Services for AI/AN Populations

The USDA is another public health resource supporting AI/AN populations. As discussed, the USDA's Rural Development program improves the quality of life of rural communities through community development and safety [177]. Through this program, Indian tribes are eligible for a variety of grants, direct loans, loan guarantees, and legal guidance pertaining to rural infrastructure issues, including rural rental housing, community facilities, business development, water and waste disposal, and broadband access. The targeting of these determinants in AI/AN communities is important, as economic adversity and impaired social conditions can compromise health.

Adequate sanitation facilities are lacking in approximately 68,000 AI/AN homes (or 17%). Of these homes, approximately 7,600 (or 1.9%) lack access to a safe water supply and/or waste disposal facilities, compared with less than 1% of homes for the U.S. general population [179]. Unregulated and unsafe water sources and poor waste disposal practices increase individuals' risk for infectious diseases (particularly waterborne disease). Lack of potable drinking water may also result in individuals relying on high-calorie drinks for hydration, which has been linked to overweight/obesity and diabetes.

The IHS Sanitation Facilities Construction Program is a preventative health program that yields positive benefits. A cost-benefit analysis indicated that for every dollar IHS spends on sanitation facilities to serve eligible existing homes, at least a 20-fold return in health benefits is achieved [179]. The IHS Sanitation Facilities Construction Program has been the primary provider of these services since 1960.

Telecommunication is a concern for AI/AN populations, and as noted, USDA assistance includes a broadband program and a community connect grant program. Communities in southwestern Alaska, for example, had no access to broadband services due to frontier factors—specifically remoteness, extreme weather, and terrain. The USDA Rural Development program enabled 65 communities through a project spanning 75,000 square miles to receive connectivity, giving the communities access to services through advanced technology and resulting in better connectivity for native communities [177]. Today, more than 9,000 rural Alaskans and 750 businesses and organizations, such as regional healthcare providers, school districts, and Alaska Native organizations, have broadband access, bringing new commerce, social, and educational opportunities to area residents [177]. Technology is also essential for public health personnel to link with each other into a network, working toward mutual goals. Because cultural issues are unique for each tribal nation, the assistance given by the USDA Rural Development program is diverse [177].

States are also involved in advocacy for tribal health. Nebraska, for example, has passed laws to improve the quality of life of native populations in their state. The state established a contractual relationship between the Nebraska Department of Health and Human Services and public health organizations and/or other health clinics having AI/AN clientele for the provision of education and public health services [179].

Case Example: Improving Tribal Dietary Health

The Navajo Nation in New Mexico is improving their dietary intake with help from partnerships. Healthy eating is a critical element to reducing disease risks, such as diabetes and cardiovascular disease, in all population groups. According to minority health experts, as compared with non-Hispanic white Americans, AI/AN adults and adolescents are reported to be twice as likely to have diabetes and twice as likely to be obese [180]. Because obesity is a predisposing condition for diabetes and other chronic diseases, a healthy dietary intake is important. According to the CDC, of the AI/AN population, only 24% to 33% had a daily nutritional intake of five or more servings of fruits and vegetables, with many not having the access to required daily nutrition due to a lack of grocery stores and/or a low income (as some healthier foods are more costly than less expensive alternatives) [181].

In partnership with a charity organization, a community outreach and empowerment project was carried out in the Navajo Nation in New Mexico. The Navajo Nation is considered the largest Indian reservation in the United States, geographically covering about 27,000 square miles and home to about 300,000 residents [182]. A variety of factors contribute to an increased risk for obesity among AI/AN populations, including:

- Replacement of the traditional diet (historically high in complex carbohydrates/high-fiber foods) with foods high in refined carbohydrates (e.g. refined sugars), fat, and sodium, and low in fruits and vegetables

- Unemployment and poverty

- Historical trauma and grief

- Differences in weight attitudes and ideas surrounding a healthy or attractive physique

- Depression

- Genetic predisposition

- Sedentary lifestyle

Through outreach, empowerment, and partnerships, fruits and vegetables were made more accessible to help Navajo families living in a food desert (defined as areas lacking food retailers and access to fresh and affordable foods) and needing dietary changes. As part of the outreach and empowerment program, free vouchers are given for produce and nutrition teaching. In response to the outreach empowerment program and increased demand for fruits and vegetables, local food markets expanded their produce selection. The project has brought favorable results. As of 2015, more than 9,050 members of New Mexico's Navajo Nation have increased access to healthy produce and are better educated on nutrition. Reports show, over a five-month period, 26 families in five Navajo communities participated in the project and increased their fruit and vegetable intake by 48%. Also, outcomes show an improvement in the BMI of adults and children participating in the initiative, with a decrease of 41% in BMI measured for participating youth. Due to the favorable outcomes and response from communities, the project continues to evolve. Local stores plan to host cooking demonstrations and support groups and expand the education part of the project to include healthy food preparation. There is also a plan for community health teams consisting of clinics, clinicians, and community health workers to expand the healthy eating initiative across the Navajo Nation [183]. Navajo youth are also taking ownership to better nutrition across the reservation. Trained students from five high schools are teaching across the reservation about nutrition-related illnesses [184].

SERVICES FOR ELDERLY PATIENTS

The U.S. population is aging at an unprecedented rate. Two factors—longer life spans and aging "baby boomers"—will combine in the next 20 years to double the population of Americans 65 years of age or older to about 72 million [185]. By 2030, older adults will account for roughly 20% of the U.S. population [185]. The public health workforce will be increasingly interfacing with the aging population in their daily work, influencing the health and well-being of U.S. seniors.

Historically, responsibility for caring for the elderly largely fell to family, friends, neighbors, and churches (the "informal sector"). Government and private intervention were considered a secondary source of service when the primary option—the informal sector—was insufficient or fragmented. Before the 20th century, poor houses for those without any provision of help grew in number, attempting to service the vulnerable, but access was not equitable. In response, the Social Security Act of 1935 was passed and prompted the development of a more structured safety net for housing to replace the poor house. Incrementally, the social service system for the elderly developed. In 1952, for example, Congress funded social service programs for seniors. Later, the Older Americans Act of 1965 was enacted, assigning responsibility for elder care to all levels of government and aiming to preserve the dignity of elderly Americans with more comprehensive services, including community services [187]. The Act developed the national aging network, made up of many units that are partnered in an effort to service seniors. This network includes the Administration on Aging, state units on aging, and local agencies on aging. The "aging network" is also a resource to meals for older adults in need, and when the network provides meals, it can be an opportunity to provide other services, including falls prevention programs, chronic disease self-management programs, and transportation [187].

The Administration on Aging is considered a major venue for senior services, although other federal programs are also important. In fact, Medicare, VA, and IHS provide much of the financing for health care for elderly in this country [188]. The Administration on Aging authorizes an array of programs through a national network of 56 state agencies on aging, 629 area agencies on aging, nearly 20,000 service providers, 244 tribal organizations, and 2 native Hawaiian organizations representing 400 tribes [188]. Community services supported by the Administration on Aging include programs related to elder abuse, nutrition, health promotion, transportation to care, information assistance, and caregiver support [189]. The local area agencies on aging provide social services for elders and are generally administered through state offices of elder services. Low-income seniors requiring assistance with activities of living (e.g., feeding, bathing, grocery shopping, bill paying) greatly rely on state programs [190].

Medicaid is a federal-state joint public program providing health services to children, pregnant women, parents, seniors, and disabled persons, and it is considered the largest U.S. healthcare insurance provider [191]. It is administered by the states, and states have a good amount of discretion on the Medicaid program they provide, resulting in interstate variation in programs. Skilled long-term care that is largely used by disabled seniors is covered under Medicaid, and this coverage was expanded by the 2010 Affordable Care Act, giving consumers the choice of traditional care at a long-term care facility or receiving services in a community-based setting, including home. Although the federal law has authorized community-based services, not all states and their locales offer this option, instead limiting covered care to state-run nursing homes for long-term care [191]. According to the National Conference of State Legislatures, "rural seniors with unmet personal and healthcare needs may be prematurely forced into assisted living or nursing homes because they are unable to live independently in their own home or community. The shift to institutionalization not only restricts consumer choice and satisfaction, but it is a major cost driver for state Medicaid programs" [141]. In rural communities, there are fewer support services for elderly patients and fewer options for long-term care services. Rural health clinics certified to give home health services are an option when there is no home health agency in the area. These clinics can supply visiting nurse services to home-bound patients in areas with shortages of certified home health agencies [192].

Promoting Health in Old Age Through Public Health Services

Public health services, particularly preventive health services (e.g., screenings for chronic disease, immunization programs, health counseling services) are important for maintaining the quality of life and wellness of older adults [193]. However, rural seniors are often disadvantaged in regard to social services and health care due to lack of financial resources in rural areas [190]. Rural residents may find it difficult to access healthy food, with some rural households or residents considered "food insecure," which is defined as having limited access to nutritious and affordable foods. Food insecurity has been associated with chronic disease and poor health, and in the long term, it can affect learning, development, productivity, physical and mental health, and family life [194]. The USDA reports food insecurity rates for rural areas to be 13.3% in 2017 [194]. The factors underlying community-level food security issues are complex and include social, economic, and institutional factors. Households with limited resources use a variety of methods to help meet their food needs. Some participate in federal food and nutrition assistance programs or obtain food from emergency providers in their communities to supplement the food they purchase [195]. There are food assistance programs specifically available for elderly persons living in rural areas. Nutrition services made available by the Older Americans Act include the Congregate Nutrition Program and the Home-Delivered Nutrition Program, which provide healthy meals in group settings, such as senior centers and faith-based locations, as well as in the homes of older adults who live alone [195]. The USDA administers the Senior Farmers' Market Nutrition Program, which awards grants to states, territories, and federally recognized Indian tribal governments to provide low-income seniors with coupons that can be exchanged for eligible foods (i.e., fruits, vegetables, honey, and fresh-cut herbs) at farmers' markets, roadside stands, and community supported agriculture programs. The goal of this program is to provide better access to fresh foods to older adults with poor access to a healthy diet. More information on government nutrition programs for older individuals is available online at https://www.nutrition.gov.

According to the CDC, there are many benefits to physical activity for the older adult, such as decreasing the risk of falls, fractures, coronary artery disease, diabetes, hypertension, stroke, and colon cancer and improving mental and emotional health, skeletomuscular health, and some symptoms of arthritis (e.g., joint swelling). Even a moderate amount of daily physical activity can lead to significant health benefits. It is recommended that older adults first have a consultation with their physician or primary care provider before starting a new physical activity program. Higher levels of physical activity can carry a greater risk for injury, and therefore caution should be taken not to engage in excessive amounts of activity. Communities can offer programs for aerobic, strengthening, and flexibility components specifically designed for older adults [196]. Walking is often a preferred approach, but rural communities tend to lack sidewalks, trails, and parks. Schools and community centers may provide a venue for exercise programs, but not all older adults can reach these locations due to geographic isolation and lack of transportation.

Alzheimer Disease: A Public Health Concern

According to the CDC, Alzheimer disease and other dementias are public health concerns, compromising the health and quality of life for U.S. adults. Projections show the number of people with Alzheimer disease and other dementias is growing. As of 2018, nearly 6 million Americans were living with Alzheimer disease. More than 95% of people with dementia have one or more other chronic conditions and are expected to have a functional decline in the future. In 2015, there were 1,471 emergency department visits for every 1,000 Medicare beneficiaries with dementia [198]. About 200,000 persons younger than 65 years of age are reported as having early-onset Alzheimer disease [199].

Alzheimer disease slowly destroys brain function, leading to cognitive decline (e.g., memory loss, language difficulty, poor executive function), behavioral and psychiatric disorders (e.g., depression, delusions, agitation), and declines in functional status (e.g., ability to engage in activities of daily living and self-care). Alzheimer disease not only impacts the quality of life of the individual with the diagnosis but may impact the health of caregivers who assume responsibility to provide care [197].

In an effort to measure the scope of the caregiver role in caring for those with dementia across the United States, data from the 2015–2016 Behavioral Risk Factor Surveillance System (BRFSS) was analyzed [198,200,201]. Based on this data, one in five adults are caregivers, providing regular care or assistance to a friend or family member with a health problem or disability, typically a parent or parent-in-law. About 10% of caregivers are caring for someone with dementia. Based on the BRFSS, nearly one in three home caregivers with duties related to Alzheimer disease report a decline in self-health [198,200,201].

The Role of Nurses

Nurses comprise the largest proportion of the rural healthcare workforce and are most likely to participate in senior programs and groups. Because public health nurses in rural areas often have a broad scope of practice and a high level of autonomy, it is essential that they are fully prepared to provide care to elderly patients and are familiar with the aging population [1]. In order to improve health and quality of life for persons and communities at every stage of life, nurses should engage in activities to promote health, prevent injury, manage chronic conditions, facilitate social engagement, and optimize physical, cognitive, and mental health [189]. The National Prevention Strategy recommends educating professionals to assess, identify, and address disparities that could be exacerbated with age [189]. Factors that have potential to exacerbate health disparities experienced by older adults in rural areas include physical disability, isolated living with few contacts, and limited or insufficient retirement income. The National Prevention Council suggests shifting from the traditional, reactive personal health and wellness approach to a more modern, proactive approach that emphasizes prevention [189]. To support healthy aging, the Council encourages a collaborative effort across the disciplines and professions to work together on this approach [189].

6. IMPROVING THE RURAL PUBLIC HEALTHCARE SYSTEM

HEALTH PROMOTION AND DISEASE PREVENTION

Health promotion and disease prevention are important objectives for the U.S. public health system. As discussed, there are many key players working in partnership to improve the system. Among them is the CDC, which maintains several campaigns for healthier lives, including those focused on smoke-free environments, healthy daily nutrition, physical activity, and health-friendly communities [202]. The CDC promotes a cross-cutting intervention and multi-stakeholder collaboration approach that can be used to mitigate chronic conditions and related risk factors. The CDC offers four areas of intervention for offsetting chronic disease and promoting population health [203]:

- Epidemiology and surveillance

- Environmental and policy interventions

- Health system enhancements

- Linking community-level programs to clinical services

Epidemiology and Surveillance

Epidemiology and surveillance are key in promoting population health [203]. Epidemiology is the basic science of public health, defined as the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems [203]. These health-related states or events can be anything that affects the well-being of a population. Determinants are the factors influencing (or associated with) disease occurrence and health-related events [204].

The CDC defines surveillance as the process of continuously monitoring attitudes, behaviors, and health outcomes over time [205]. The health promotion and disease prevention activities of public health agencies rely on data collected through public health screening and treatment services, as well as from laboratories, pharmacies, environmental health monitors, EMS, local public health agencies, and clinical care providers. There are many types of data registries, including ones related to cancer, childhood immunizations, birth defects, autism, asthma, diabetes, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), blood lead levels, sexually transmitted infections, chronic disease, and traumatic injuries. There are also case reporting systems for monitoring disease outbreaks and trends. There is variation across public health agencies' information systems [206].

Data are systematically gathered, and the CDC has developed data indicators of chronic disease and associated risk factors that impact public health. These indicators enable public health professionals and policymakers to retrieve uniformly defined state-level and selected metropolitan-level data for chronic diseases and risk factors that have a substantial impact on public health. These data are essential for surveillance, setting policy priorities, and analysis of public policy programs [207].

Public programs educate and guide communities toward healthy behaviors, and providing these programs requires accountability. Some of this accountability is represented through evaluation of data during and following program implementation to determine impact and social value and to show the community that providers are accountable for their public health actions. Surveillance data are also used for public agency budget-setting and strategic planning for the future [74]. Some public health nurses routinely conduct surveillance as part of their practice.

One example of a public health surveillance system is the Foodborne Disease Outbreak Surveillance System, which collects data related to foodborne disease outbreaks [208]. In this registry, data are collected to give insight into the cause, the context, and the underlying conditions of the outbreak. Tracking and analysis are ongoing objective efforts intended to inform targeted prevention efforts. This system guides state and local health departments to investigate and report outbreaks through the identification of foods, etiologies, outbreak settings, and specific points of contamination [208]. Analyzed surveillance data are disseminated through different means to stakeholders.

Another example of a public health surveillance system is the BRFSS, a telephone survey of adults 18 years and older conducted by the CDC and state and local public health departments. The BRFSS is considered as the largest continuous telephone health surveillance system in the world, with more than 450,000 adults 18 years of age and older interviewed annually [201]. The system collects data about health risk behaviors, chronic health conditions, and the use of preventive services among U.S. residents. In turn, it provides information to the federal government, states, and local communities for planning, implementing, and evaluating public health programs and actions [201]. States have used BRFSS surveillance data to monitor trends in physical activity, prevalence of obesity, risk factors related to chronic disease, vaccination rates, and prevalence of arthritis. They then prepare grant applications and public health reports, create plans, and evaluate program interventions. For information on how BRFSS data are used in your state, visit https://www.cdc.gov/brfss/state_info.

The CDC disseminates surveillance summaries and interpretation of public health trends and patterns in the Morbidity and Mortality Weekly Report (MMWR), available to read online at https://www.cdc.gov/mmwr/publications.

Environmental and Policy Interventions

Policy and environmental actions are considered to be more effective than other types of population health interventions, partially because policies tend to have broader implications than other interventions. The stakeholders—policy leaders, private-sector employers, community planning committees, economic development agencies, and grassroots organizations—are involved in developing and implementing these actions [203]. Government leadership is largely involved in the creation and funding of policy/environmental interventions. Funding is critical to public health policy and programs, and historically, wealthier states and locales have been more likely to legislatively adopt innovative policies.

Community interventions based on policy/environment actions can positively impact population health. Several case examples demonstrate the effectiveness of environmental initiatives against obesity. The South Dakota Department of Health, for example, partnered with a coalition of statewide organizations to provide wellness programs at different South Dakota workplaces/employers [209]. Employers establish wellness programs and other incentives to encourage employees to get physically active, such as setting up bike racks to encourage employees to bike to and from work and making work schedule changes that would permit physical activity during paid time. These employer interventions have received positive feedback from the community [209]. Worksite evaluation studies have showed that these types of interventions resulted in an increase in the amount of time spent engaged in moderate aerobic physical activity among workers [209].

In Wisconsin, the state has authorized grants to businesses for the development of worksite wellness programs to include health risk assessments [210]. In Montana, the Department of Public Health and Human Services is teaching community stakeholders to build a healthier environment for residents through designing streets, sidewalks, bike lanes, parks, and trails that help people be more physically active [211]. Participating counties have received awards for their "Complete Streets Policy."

Utah is also involved in policy/environment actions to fight chronic illness and risk factors. Here, multiple stakeholders (including the Utah Department of Transportation, the Utah Department of Health, local health departments, and city planners) have collaboratively formulated transportation policies for Utah residents that provide more physical activity options in the community, such as safe and sustainable walking trails and bike lanes [212]. This is important because residents in rural and low-income areas typically do not have walking trails or bike lanes that support safe, interconnected spaces for people to be physically active [212].

State and local communities have also developed policy/environment actions targeting the need for a healthy daily diet. Healthy nutrition is important for mitigating disease, and the literature overwhelmingly supports the increased intake of fruits and vegetables. Despite health benefits, research shows that far less than the recommended number of fruits and vegetables are being consumed as part of the typical American diet [213]. One reason is inaccessibility and the high cost of fresh, nutritious food, an even greater issue for low-income communities or families. Although the government is already implementing policies to facilitate better access to healthy foods (e.g., through the WIC federal assistance program), states and communities can do more to improve accessibility [213]. For example, policy actions can strengthen the regional food systems for both consumers and producers. According to the CDC, 32 states have an active state food policy council, and there are 234 local food policy councils in the United States. Ten states have adopted a policy on food service guidelines that ensures healthy food options be sold or served in government-owned or -controlled facilities [213]. In addition, about 42% of school districts participate in farm-to-food programs and provide salad bars. Outside schools and government workplaces, farmers' markets have begun to accept WIC and vouchers from the Farmers' Market Nutrition Program [213]. Typically, a combination of policies and environmental interventions is used in order to meet the needs of rural residents.

Enhancing the Healthcare System

Enhancing the healthcare system is necessary in order to more effectively deliver clinical and other services to prevent, detect early, and mitigate diseases in all populations, including those in rural communities [203]. System enhancements can have effect on the organization, the people engaged in the healthcare system, the population being served, and other parties (e.g., insurance carriers). Telehealth and electronic health records are examples of initiatives aimed at enhancing the health system. Federal laws have been enacted largely supporting health technology and more are being passed on the state level, laying a legal foundation to make technology in healthcare work better.

Electronic medical records are real-time, patient-centered records that make information available instantly and securely to authorized users, allowing patient records to be electronically coordinated among various providers [214]. A coordinated system is critical, because coordinated actions by public health and healthcare professionals, communities, and healthcare systems can and will keep people healthy, optimize care, and improve outcomes within priority populations [202]. This healthcare system enhancement is still evolving. Although many care systems report enhanced operations by way of electronic medical records, some sources acknowledge that organizational preparation is critical before implementing a new system. Lack of facility preparation or personnel training on electronic medical records may lead to issues. This technology allows providers to share patient data in a centralized location readily accessible to the entire interprofessional care team. A single electronic record can bring together information from current and past providers, emergency facilities, school and workplace clinics, pharmacies, laboratories, and medical imaging facilities [215]. Some states (e.g., Nebraska, New Mexico) have established statewide telehealth and health information technology systems to better meet the needs of rural and medically underserved areas, promoting efficient and effective care, better quality, and increased access to services [179,216].

Another example of the use of technology to support the interprofessional healthcare team is the growing use of prescription drug monitoring databases. Prescription drug monitoring programs are one of the most effective measures for reducing opioid analgesic diversion and abuse and are a cornerstone of state efforts to address the opioid crisis. Almost all states have enacted these programs to facilitate the collection, analysis, and reporting of information on controlled substances prescribing and dispensing.

Technology can also enhance surveillance operations, making them more efficient and potentially keeping data safer and enabling efficient data sharing. Health information technology has the potential to link activities between information/data "trading partners," such as health insurance providers, inpatient and outpatient providers, state and local governments, and federal organizations. Technology brings together partners for many reasons, including program planning, direct care, administration, and surveillance sharing. There has been federal support for health information exchange organizations, which are believed to have the potential to enhance the healthcare system by promoting efficiency in connections across jurisdictions. Although federal funding is available, there are factors that may limit (or temporarily limit) public health's use of these initiatives, including lack of trained public health informatics resources; the complexity of local, state, and federal laws; a dearth of leadership and champions to advance integration; and competing priorities [206]. In all, technology is improving connectivity within, among, and across rural public and non-public health systems.

Linking Community Programs and Clinical Services

Linking together community programs and clinical services promises to improve and sustain management of chronic conditions, as it can open up a pool of resources among providers and broaden the scope of community care. When these two entities work closely together, integrated approaches that bundle strategies and interventions may be effectively deployed [203].

Some areas or groups use community outreach programs to bring together prevention programs and clinical services. For example, health and wellness fairs have been used to introduce the public to prevention principles and to clinicians under the same tent; this may involve hosting on-site screening services (e.g., hypertension and/or lipid screening, bone density tests, hearing and vision screenings, nutrition assessments), physical fitness programs, and/or farmers' markets for healthy eating habits. These community health fairs integrate public health principles of prevention and screening with local primary care clinical services. The theory is that population health (not just individual outcomes) may be improved through the use of community partnerships and collaboration with stakeholders [217].

Citizen engagement can also be used to bring together community programs and clinical services. In Oregon, community residents who have experienced colon cancer screening engage in outreach to other residents to encourage participation in similar screening services using multiple communication channels, including radio advertising, social media, websites, billboards, health plans, and local news outlets. The overall campaign resulted in an increase in the rate of screenings among residents across the communities—from 59% in 2010 to 69% in 2015 for those 50 to 75 years of age. Also, late-stage colorectal cancer diagnoses were reported to have decreased by 12% for the years 2009 to 2013 for those who did participate in the screening [218].

A Multi-Intervention Approach: The Healthy Brain Initiative

It is common for decision-makers to employ a multi-intervention approach in rural public health, given the unique rural context and many disparities of rural populations (e.g., economically disadvantaged, insufficient food sources, barriers to broadband connectivity). One example illustrating a multi-intervention and proactive approach to a public health issue is the CDC's initiative addressing the challenge of dementia.

As discussed, dementias are a serious public health concern, affecting nearly 6 million Americans and resulting in $277 billion in annual costs [198]. By 2050, these numbers are expected to increase significantly, to 14 million Americans and $1.1 trillion annually. To promote brain health, improve servicing to populations with cognitive decline, and provide support to dementia caregivers, the CDC developed the Healthy Brain Initiative. The Healthy Brain Initiative aims to stimulate changes in policies, systems, and environments and consists of a roadmap of 25 actions for years 2018–2023 to be accomplished by state and local public health agencies and partners [198].

The Healthy Brain Initiative supports informed decision-making by educating policy-makers on the basics of cognitive health and impairment, the impact of dementia on caregivers and communities, and the role of public health in addressing this priority problem. The Healthy Brain Initiative is informed by four essential services of public health [198]:

- Assure a competent workforce

- Educate and empower the nation

- Monitor and evaluate

- Develop policies and mobilize partnerships

Unfortunately, the healthcare workforce appears under-equipped to meet the growing demand for high-quality dementia care in the coming years. As of 2015, only two states required training in dementia for RNs and/or LPNs/LVNs, and only 23 states required dementia training for staff of nursing homes. The majority of states with a mandate only require training for personnel in Alzheimer disease special care units. Less than 3% of medical students choose geriatric electives during their training, which means that most will enter the workforce with little exposure to the needs of older adults [198].

The Healthy Brain Initiative encourages training the healthcare workforce so it is intellectually prepared to provide cognitive impairment and dementia care [198]. To be professionally prepared for dementia care, healthcare professionals should have education on the importance of treating comorbidities, addressing injury risks, and attending to behavioral health needs of patients at all stages of dementia. Caregivers should be given referrals to supportive programs and services and encouraged to make use of available resources. Public health professionals are to have reliable sources of information on brain health and evidence-based dementia education [198].

Educating the community is another key aspect of the Healthy Brain Initiative. Public information campaigns focus on brain health and cognitive decline. Informal caregivers should be given appropriate tools and support for aiding those with dementia. When required, professionals should offer counseling and referrals to dementia caregivers and assist them in gaining access to evidence-based interventions and services. The Initiative encourages environmental policies that engage the workplace and community to support the needs of the aging population. For example, emergency response/preparedness planning should be aligned with dementia care needs and home caregivers needs (e.g., the caregiver having immediate access to critical public health information) [198].

Monitoring and evaluating the growing dementia care issue is aligned with the chronic disease epidemiology and surveillance intervention [203]. The Healthy Brain Initiative emphasizes national monitoring and evaluation of training programs, caregiver support programs, and brain health policy initiative outcomes. To implement dementia surveillance, the BRFSS includes modules measuring level of cognitive capacity for those with dementia and caregiving [198]. More information on the conceptual framework for the Healthy Brain Initiative and its 25 action items for public health professionals can be found online at https://www.cdc.gov/aging/pdf/2018-2023-Road-Map-508.pdf.

IMPROVING ACCESS TO COMMUNITY SERVICES

Rural access to public programs and other services is lacking. Many states have initiatives in place to improve access, including programs to improve the healthcare infrastructure, decrease provider shortages, build up professional workforce competencies, and take advantage of technology (e.g., the Internet). The solution to the problem of access in rural communities requires a comprehensive and collaborative approach with many stakeholders. Despite efforts to date, rural populations still lag behind urban populations in access to needed healthcare and social services. According to the National Prevention Strategy, residents of rural areas are more likely to have a number of chronic conditions and less likely to receive recommended preventive services because of the lack of access to care providers and patient care sites [104].

In order to promote wellness and prevent disease in rural communities, the National Prevention Strategy established the following priorities [104]:

- Support initiatives to increase the availability of healthy and affordable foods in underserved rural and frontier communities.

- Pilot and evaluate models of integrated mental and physical health in primary care, with particular attention to underserved populations and areas, such as rural communities.

- Support local efforts that promote active living by supporting efficient transportation networks that connect people in rural communities to parks and other outdoor recreation venues.

- Improve access to high-quality mental health services and facilitate integration of mental health services into a range of clinical and community settings.

A key government agency working toward eliminating disparities and improving access to care is the Health Resources and Services Administration. This is the primary federal agency responsible for improving health care for people who are geographically isolated and/or economically or medically vulnerable [219]. In an effort to strengthen the healthcare workforce, the Health Resources and Services Administration is aiming to advance professional competencies of health workers and to improve the diversity of the workforce, which will improve the ability of providers to meet the needs of underserved populations and correct the maldistribution of the workforce [220].

Evidence Based Practice Recommendation

The World Health Organization recommends using targeted admission policies to enroll students with a rural background in education programs for various health disciplines, in order to increase the likelihood of graduates choosing to practice in rural areas.

https://apps.who.int/iris/bitstream/handle/10665/44369/9789241564014_eng.pdf

Last Accessed: July 29, 2019

Strength of Recommendation/Level of Evidence: Strong/Moderate

In addition to the National Prevention Strategy, the Health Resources and Services Administration, and the 2010 Affordable Care Act, states are also taking action to reduce disparities in care access in rural communities. Some states have passed legislation aimed to eliminate disparities in healthcare access in rural communities, though they have taken different approaches to address this problem [134,216]. As nurses are a backbone to rural health care, some states have passed laws or enacted campaigns to increase the density of nurses practicing in underserved areas. For example, Arkansas law permits public higher education institutions to give special consideration to recruit students from medically underserved areas interested in nursing or another health-related career [179,216]. Kansas established the Advanced Registered Nurse Practitioner Service Scholarship Program for students who agree to practice nursing in a medically underserved or rural area in their state upon finishing a program of study as an advanced registered nurse practitioner [179,216].

Loan forgiveness and loan repayment programs have also been instituted by states in an effort to improve the distribution of nurses in rural areas. In Alabama, the Advanced Practice Loan Repayment program awards loans to RNs who are pursuing an advanced practice degree. This program provides students with $12,000 toward their education in exchange for an 18-month commitment to work in a geographical area of critical need (defined as at least 5 miles outside of an "urbanized area") following graduation [221]. The West Virginia State Loan Repayment Program awards nurse practitioners and nurse midwives up to $90,000 in loan forgiveness for four years' commitment working in a health professional shortage area [222]. Such state initiatives promise to increase the density of nurses in rural areas. These same approaches have been applied to other professions, including physicians, dental professionals, and mental health providers, in order to improve access to care in underserved areas.

Use of Technology in Public Health

The possibility for advanced technology to improve population health is growing. As discussed, advanced technology (e.g., Internet, satellite, mobile technology) may be used in rural communities to improve access to and quality of care, to improve health outcomes, and to minimize costs. Despite its promise in meeting healthcare needs in underserved rural areas, research on the topic is mixed. Upon systematic review of a large body of research literature, the Agency for Healthcare Research and Quality concluded there is sufficient evidence to support the effectiveness of telehealth for specific uses with some types of patients, including remote patient monitoring for patients with chronic conditions; communication and counseling for patients with chronic conditions; and psychotherapy as part of behavioral health [223]. Other evaluative studies, including one conducted by the VA on their rural telehealth initiatives, report numerous favorable outcomes associated with telehealth actions [135]. However, some still express doubt as to the real value of telehealth's ability to replace traditional care services [135].

Telehealth approaches can create a network linking rural providers to nonrural providers and agencies and the rural population to online providers and programs, ultimately improving access for populations who are living in rural areas who tend to have higher chronic disease and mortality rates [135]. Federal telehealth pioneers include the U.S. Department of Defense, the VA, National Air and Space Administration, and Medicare.

Telehealth innovation requires a positive legal environment, advocacy, and funding. Federal agencies such as the FDA play a large role in the regulation of safe technology use in health, and the federal government has been a primary funding source for agencies interested in piloting telehealth programs for rural residents [224]. Aside from funding, the federal government has enacted legislation making the Internet and broadband more accessible to rural areas. Many states have passed laws enabling care providers to participate in telehealth and regulating the practice. In particular, Texas and California have been historical innovators in telehealth, using telephone and video technologies to improve access to care for prison inmates in remote correctional facilities [136]. Telehealth practitioner reimbursement and tele-licensure laws have been critical in allowing telehealth to progress. Health interest groups also play a significant role in influencing the adoption and implementation of telehealth practices, as does nurse advocacy. In one study of telehealth implementation, nurse and physician policy networks were found to influence the extent of telehealth program implementation across the entire nation [136].

Collaborative telehealth programs involving public agencies, medical centers, rural and/or urban clinics, universities, and professionals were developed in response to early telehealth projects that required additional funding and stakeholder buy-in in order to continue after federal funding ended. One example of this approach is the South Carolina Department of Mental Health, which partnered with the University of South Carolina School of Medicine and about 18 predominantly rural hospitals to develop a statewide telepsychiatry initiative [225].

Telehealth

There have been a number of definitions for telehealth, varying across organizations and healthcare work cultures. The American Telemedicine Association defines telehealth as [226]:

…technology-enabled health and care management and delivery systems that extend capacity and access…What was, until recently, referred to as telemedicine now encompasses a much broader array of services and technologies—artificial intelligence, virtual reality, and behavioral economics are a few examples that come to mind—that are transforming the way health and care are delivered.

U.S. Congress defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration [227]. Internet-based health care is a form of telehealth, also referred to as "e-health." E-health may also be used to describe any health-related online activity (e.g., searching for wellness information online) or, in some contexts, to cover other technology use in health care.

Evidence Based Practice Recommendation

The World Health Organization recommends that appropriate outreach activities should be implemented to facilitate cooperation between health workers from better-served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas.

https://apps.who.int/iris/bitstream/handle/10665/44369/9789241564014_eng.pdf

Last Accessed: July 29, 2019

Strength of Recommendation/Level of Evidence: Strong/Low

The original goal for telehealth was to improve consumer access to healthcare professionals for persons living in federally designated professional shortage areas and the other underserved areas [136]. Most rural states have historically used telehealth for this purpose.

An early form of Internet use in public health was information sharing, or using technology to disseminate health information to the general public. Agencies place information on their websites to educate the public on outbreaks, preventive medicine recommendations, health plans, providers, and health insurance [228]. The CDC uses their website, social media accounts, and listservs to disseminate information to providers and the public, including information on disease outbreaks and pandemics, food recalls, travel health, and health statistics. The Internet can make tracking disease, gathering data, and administrative decisions on population health issues more efficient and reliable. It has the potential to enhance the detection of disease outbreaks by enabling the efficient sharing of surveillance data. In a public emergency, effectively sharing data may influence a better response for outbreak coordination and management [229].

Educating communities is an important component of public health nursing, and the Internet is a health-education medium that can be used to empower patients with knowledge, expose them to information covering a spectrum of health and wellness programs, and link them with providers and services [231]. The Southern Nevada Health District created an Internet and social media educational campaign regarding the health risks of cigarette smoking and e-cigarette use in teens. This online nicotine prevention campaign is reported to have reached at least 2,400 people on social media, 27,130 people via online campaign videos, and 287,000 via online messaging; a reported 1,113 teens took the educational campaign's online training to learn how they can help promote nicotine-free living among their peers using social media [231].

Rural school nurses are in a pivotal position to link health care and education, and Internet technologies can help link nurses with nonrural resources, network with other agencies, make point-of-care decisions, attend distant meetings, enter surveillance data, and access public reports [232]. Technology can also aid in student health and wellness screenings, providing behavioral health services, assessing injuries and illnesses, and communicating with parents/guardian. The role of school nurses in providing rural health care will be discussed in detail later in this course.

Barriers to Internet Use in Rural Areas

Because the Internet has become so important for connecting professionals and transmitting health information, broadband access has become vital [233]. Broadband is particularly important for rural healthcare providers interested in meaningfully using electronic health records, as many of the capabilities of health information technology, such as telehealth and electronic exchange of healthcare information, require broadband capability [233]. Broadband connectivity has made great strides in recent years, and county-level data indicate that rural household connectivity continues to improve and expand geographically [135]. The number of rural counties in which the proportion of households with fixed broadband subscriptions was higher than the rural average of 60% of households increased from 281 in 2010 to nearly 1,200 in 2016 [24]. Rural counties with higher-than-average connectivity are primarily located in the Northeast, upper Midwest, and Intermountain West; extensive parts of rural Appalachia also saw improvements [24]. Although more rural households are getting connected with broadband, other barriers still exist, including not having the skills to navigate the Internet. Public libraries often have programs to teach computer skills to residents or to help residents access Internet technology. However, public libraries are not as accessible in geographically remote areas. Rural schools may be an alternative option for computer skills training in rural communities, if funded.

BUILDING WORKFORCE CAPACITY

As stated, the U.S. rural health professional workforce is characterized by maldistribution and shortages, particularly in areas of primary care, mental health, and dental services and in specific health subspecialties [136]. The Health Resources and Services Administration has predicted a nurse shortage by 2030, with the largest shortages noted in states with significant rural populations (e.g., Alaska, South Carolina, South Dakota) [147]. Shortages are not new, and building the capacity of the health workforce is part of the national movement to strengthen and transform the healthcare system.

The Role of the Government

In response to need, U.S. Congress has historically passed laws to build the capacity of the nursing workforce. A cornerstone federal legislation to build this workforce is the Public Health Service Act, enacted in 1944 and originally aimed at infection control and the consolidation of the numerous other public health service laws. The succeeding amendments to this 1944 Public Health Service Act expanded nursing training actions and funding.

The Nurse Training Act of 1964 (amendment to the 1944 Public Health Services Act) created the widely cited Title VIII Nurse Training that provides many educational incentives for nursing today [234]. Collectively, Title VIII and its amendments provide a broad spectrum of awards for building the nursing workforce capacity, including for basic nursing practice, RN traineeships to advanced practice, diversity grants for persons with a disadvantaged background, nurse retention grants (e.g., for comprehensive geriatric training, career ladders), and a nurse faculty loan program [235,236]. These awards have been used to recruit or retain those already in the nursing workforce and/or to expand the possibilities of nurses' careers into rural settings.

Funding is important for program viability. Some funding has been extended over time (often through amendments), and the funding for other programs has been allowed to expire. Title VIII and the Public Health Service Act of 1944 are not the only opportunities to improve nursing. Title III funds a loan repayment incentive for health professionals to work in selected health professional shortage areas, and Title IV supports nurses interested in clinical research [237].

Passage of the Affordable Care Act in 2010 expanded Medicaid eligibility, and rural Medicaid enrollment increased in the following years [16]. As many rural populations now have greater insurance access, a greater demand has been placed on healthcare professionals to implement public health services. National Health Service Corps programs provide scholarships and repay educational loans for primary care, dental, and mental and behavioral health clinicians who agree to two, three, or four years of service in designated high-need areas [17].

In addition to federal government initiatives for building the rural workforce, states have initiatives to address rural shortages, as discussed (e.g., school loan forgiveness, scholarship programs) [134,216]. These programs often seek students from backgrounds historically under-represented in health care, such as racial and ethnic minorities, with the aim of improving workforce diversity [134,145].

Workforce Cultural Competency

A culturally competent rural workforce can help improve the care of unique populations. Professionals should be prepared to care for diverse populations with different behaviors, resources, perceptions of health and health care, and outcomes of care, particularly when working with groups whose culture, language, economic status, age, and/or education result in health disparities and poor health outcomes [238].

Workforce policies should also consider cultural differences. Culturally competent healthcare providers and systems provide care in ways that are appropriate and aligned with patients' social, cultural, and linguistic needs, which in turn affects how patients receive and perceive information and the degree to which they adhere to recommendations. In acknowledgment of the importance of a culturally competent rural workforce, states have begun to invest in public health educational programs to build upon the competency of the existing rural workforce [134]. As of 2013, more than 20 states had enacted legislation to improve cultural competency in their healthcare workforces [134]. In a 2015 bill, Maryland legislators required the Office of Minority Health and Health Disparities to provide certain health occupations boards with a list of recommended courses. Courses include cultural and linguistic competency, health disparities, and health literacy [134].

Incentive Laws in Underserved Areas

Federal and state governments have passed incentive-type laws to improve the workforce capacity in health professional shortage areas. As discussed, an example of these incentives is loan repayment programs for practitioners who work in shortage areas [239]. The Nurse Corps Loan Repayment Program helps with nursing education debts in return for the registered or advance practice nurse working in an eligible critical shortage facility in a high-need area [240]. A critical shortage facility is defined as a public or private nonprofit healthcare facility located in, designated as, or serving a health professional shortage area having shortages in the primary care or mental-health workforce [240]. As of 2018, 36 states and the District of Columbia have implemented state loan repayment programs and receive grants from the National Health Service Corps to help fund these programs. Some states have expanded the program to other regions. Nevada and New Hampshire, for instance, expanded the criteria for health workers receiving financial support or loan forgiveness to include those who provide services to medically underserved populations and in other needy locations [134]. In all, the majority of states have passed laws providing an incentive for practitioners to seek work in professional shortage areas and other underserved needy areas.

Primary Care Professionals

Rural areas have an unmet need for primary care providers. These unmet needs are expected to intensify as a result of demographic changes, coverage expansions resulting from the 2010 Affordable Care Act, and a decline in the rural primary care workforce [141]. Many solutions are at work to offset the expected increased demand for primary care and preventive services. One strategy is to promote the role of non-physician primary care practitioners, such as advanced practice nurses and physician assistants, and to expand the scope of practice for these providers to practice more independently [140]. The role of the paramedic is also being expanded. In Minnesota, for example, as part of a statewide innovation grant, community paramedics are providing a broader range of services, including primary care (e.g., health assessments, chronic disease monitoring, collecting laboratory specimens). In a study evaluating this program and care provided by paramedics, patients with paramedic contact were more likely to have a future primary care visit, to keep post-discharge mental-health visits, and to safely manage medication [241].

Dental Workforce

Dental care is a rural problem largely because of a lack of practicing dentists and insufficient dental insurance. A shortage of dental practitioners in rural and micropolitan areas has resulted in emergency departments becoming the alternative for evaluation and treatment of dental conditions [15]. To address this problem, states have passed laws intended to expand the dental care workforce. In Minnesota, for example, additional license types (dental therapists and advanced dental therapists) have been added to help meet the need for dental professionals qualified to provide preventive and restorative dental care, in some cases with less direct supervision [145,241]. In this case, at least half of a dental therapist's patients must be considered underserved—that is, on public assistance, uninsured, or living in an area with a shortage of dentists [242]. Several states permit new dental profession types to provide dental care under varying levels of supervision by dentists, allowing these providers to meet dental care needs in nontraditional, tribal, school-based, and community settings [145]. In Alaska, where the majority of land is classified as rural, some clinics have sent out dental health aide therapists to distant rural sites to deliver routine restorative care. As a result of this initiative, many recipients were able to have regular access to dental care for the first time [242].

Aside from government actions to increase workforce numbers and to expand the scope of practice, dental care workforce capacity can be built using teledentistry. In California, dental hygienists use teledentistry to improve dental care access for the young and disabled. Dental hygienists go to community settings such as schools, Head Start public programs, and nursing homes, where patients are screened and data are transmitted digitally back to the dentist, who creates a treatment plan for the hygienist to implement [242]. These solutions have potential to mitigate dental disease in rural underserved communities.

Community Health Workers

Another initiative to build workforce capacity is the community health worker. Community health workers have a strong understanding of their communities and serve as a liaison between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery [243]. Providing invaluable support to public health and private care, they are found in public health departments, community locations, primary care settings, and hospitals, and are generally well-positioned to reach patients in rural settings [244]. The role of the community health worker is broad and includes conducting outreach for community health promotion programs, providing community education, and collecting assessment data on community health needs [245]. Community health workers have a long history of service in the United States and are known by many titles, such as community health advisors, lay health advocates, outreach educators, community health representatives, peer health promoters, and peer health educators [244]. Some states have passed laws defining the role of the community health worker, developing standards or credentials, defining their training and certification needs, and collecting community health worker workforce data [141].

To intensify the impact on the public health workforce as a whole and to benefit all public health disciplines, integrating the workforce and sharing priorities are vital [246]. This idea of integrating and sharing of aims is well aligned with the trend of using more collaborative networks and partnerships (public and non-public) in delivering health care in the United States.

THE ROLE OF SCHOOLS

Education is an important element to promoting health and well-being in rural populations. Education combined with community-based action promises to increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and injury, improve health, and enhance quality of life in rural communities [247]. Public health education on physical activity and exercise, nutrition, safe food handling, immunizations, and smoking cessation is vital in rural areas, and this education may be delivered in many settings—home health visits, online educational forums, early care and child education settings, secondary schools, and healthcare visits. Historically, the county public health nurse was active in the school community, working alongside and with school personnel, families, and associations.

As a community resource, rural schools are engaging in health-related activities and promoting a better learning experience for youth. Although the primary focus is on education, in many rural counties, schools serve as a health center or a hub for community health education—these schools may be the only centralized place to meet. The extent that schools are a health gathering place to learn and receive service varies, as each county is unique in its needs, leadership, socioeconomic profile, and demographics.

In schools, children can learn the basics of health and wellness, such as principles of physical activity and nutrition, while also having a place to apply the learned principles [248]. Each day, 132,000 public schools provide a setting for 55 million students to learn about health and healthy behaviors [249]. There are many benefits of teaching and applying healthy lifestyle choices to youth at school. Physical activity at school is reported to result in reduced risk for childhood obesity, mitigation of disease risk factors, and better mental health [249]. Physical activity may be integrated into classroom lessons, through intramural or sports programs, at lunchtime, or during recess [250].

Involving schools and school nurses in public health partnerships can help bridge accessibility and outreach gaps. In Iowa, for example, the departments of public health and education have partnered to improve policy and practices for physical education/activity and nutrition [251]. As part of this initiative, additional funding was provided to improve on-grounds access to water for school children and to increase physical education instructional time [251]. In South Dakota, the departments of health and education in collaboration with a state university provided training to personnel on healthy school meals and physical activity [252]. In addition to learning about health, schools can be a venue for youth to receive clinical health services and counseling. As schools play a role for a healthy lifestyle for youth, they may also be a venue for clinical services, when feasible.

Historically, rural public health nurses worked with schools to promote the health and well-being of youth and families. Much like today, health agencies played a vital role in giving adequate health services, in identifying health issues (i.e., surveillance), providing training or in-servicing of teachers on community health services, and training families and teachers in promoting student growth and well-being. Cooperatively, the county public health nurse promoted good nutrition and food safety, helped with safe storage for school lunches, and provided community education on planting vegetables [253]. Many of these principles and practices are still in place today.

Learning programs that engage the rural nurse vary across school districts depending on the need, policy, and support of funding. According to the National Association of School Nurses, school nurses bring together health care and education and collaboratively develop healthy communities [232]. They apply evidence-based concepts in their practice, promoting both the individual and population-based health of students, providing the coordination of care, serving as advocates for quality student-centered care, and acting to advance academic success [232].

CDC Initiatives

Educating children early regarding healthy lifestyle habits (e.g., good nutrition, physical activity) can promote school performance and help mitigate unhealthy living and disease later in life. In 2012, the CDC introduced the early care and education concept to promote healthy practices early in life, bringing "good habits" into early care facilities and schools. This idea of teaching healthy habits early is based on the belief that it is easier to influence children's food and physical activity choices when they are young, before habits are formed. Developing healthy habits for physical activity and diet early in life can influence daily practices as individuals grow and can favorably influence a child's cognitive development [254]. Early care and education programs promote social, emotional, cognitive, and motor skill development for the very young (up to 3 to 4 years of age). In addition to healthy physical activity, some programs include nutritious meals, support for parents, health screening, and social services. Early care and education programs may be delivered in a variety of ways and settings, including state and district programs (available to all children), federal Head Start programs for low-income children and families, and other programs targeting low-income children at risk. These early childhood education programs are reported to lessen the chance for obesity, improve child cognitive development, reduce the incidence of child abuse and neglect, lessen youth violence, and limit use of emergency department services [255].

The CDC has advocated for the early care and education setting as one of the best settings to implement an obesity prevention program, providing early education to prevent childhood obesity and to promote readiness to learn in childcare centers, family childcare, Head Start, and pre-kindergarten programs across the country [256]. The number of states implementing early care and education programs is growing. As an example, in 2016, New Mexico reported that more than 160 early care and education centers had put wellness policies in place to increase physical activity, good nutrition and breastfeeding practices, and family engagement [257]. The CDC initiative on early care and education has been applied in many states, involving many public and private partners and tailored to meet the needs of youth in different locales and cultures [258].

School health services are not limited to learning healthy habits and accessing preventive services; many schools have been hubs for primary care clinical services for conditions such as asthma, substance abuse, and dental care for both youth and parents [141]. Individuals facing the disparities inherent to rural America (e.g., geographic isolation, poverty, lack of health insurance) may not have another "concrete" place to receive care. School-based health centers often operate as a partnership between the school and a community health center, hospital, or local health department to improve the health of students and the community as a whole [248]. School health services staff can help all students with preventive care (e.g., immunizations, vision and hearing screenings) as well as acute and emergency care.

The school nurse and other care providers can play a critical role in the daily management of chronic health issues, such as asthma and allergies, among school-aged children [259]. Many public health nurses monitor at-risk students and engage them in prevention strategies; closely treating and managing chronic conditions can help offset many of the consequences. For example, asthma education programs in school districts can promote improved symptom management and fewer school absences [42]. Ideally, school education can set the foundation for a healthy lifestyle in later years, but some counties/districts may not have the funding to expand the role of the school beyond health education to also include other community health activities.

The Whole School, Whole Community, Whole Child Model

The CDC framework for promoting classroom health is called the Whole School, Whole Community, Whole Child (WSCC) model. It is a student-centered model that emphasizes the role of the community in supporting the school, the connections between health and academic achievement, and the importance of evidence-based school policies and practices [260]. The WSCC model aligns the goals of education, public health, and school health. Because school education and public health give service to the same population and in the same setting, the WSCC model depends on collaboration between the sectors interested in promoting youth cognitive, emotional, physical, and social development. The elements of WSCC create a model for promoting a whole-child approach to education and include [260]:

- Nutrition environment and services

- Employee wellness

- Social and emotional school climate

- Physical environment

- Health services

- Counseling, psychologic, and social services

- Community involvement

- Family engagement

- Physical education and physical activity

This model emphasizes the sharing of the school facility as a community health and fitness center for families and youth. Health services, including clinical services, are important to the holistic well-being of rural youth. These services may be provided at schools by school nurses, nurse practitioners, physicians, dental professionals, and allied health and other disciplines in order to mitigate health risks and to manage chronic conditions, with medical care referrals made when needed.

7. CONSIDERATIONS FOR NON-ENGLISH-PROFICIENT PATIENTS

Language and cultural barriers have the potential for far-reaching effect, given the growing percentages of racial/ethnic populations. The rural community is diversifying, and nurses working in these areas would benefit from an understanding of cultural competence and collaborating with interpreters. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required.

According to U.S. Census Bureau data from 2017, 21% of households speak a language other than English at home [262]. Clinicians should ask their patients what language they prefer for their medical care information, as some individuals prefer their native language even though they have said they can understand and discuss symptoms in English [263]. Translation services should be provided for patients who do not understand the clinician's language. "Ad hoc" interpreters (family members, friends, bilingual staff members,) are often used instead of professional interpreters for a variety of reasons, including convenience and cost. However, clinicians should check with their state's health officials about the use of ad hoc interpreters, as several states have laws about who can interpret medical information for a patient [264]. Even when allowed by law, the use of a patient's family member or friend as an interpreter should be avoided, as the patient may not be as forthcoming with information and the family member or friend may not remain objective [264]. Children should especially be avoided as interpreters, as their understanding of medical language is limited and they may filter information to protect their parents or other adult family members [264]. Individuals with limited English language skills have actually indicated a preference for professional interpreters rather than family members [265].

Most important, perhaps, is the fact that clinical consequences are more likely with ad hoc interpreters than with professional interpreters [266]. A systematic review of the literature showed that the use of professional interpreters facilitates a broader understanding and leads to better clinical care than the use of ad hoc interpreters, and many studies have demonstrated that the lack of an interpreter for patients with limited English proficiency compromises the quality of care and that the use of professional interpreters improves communication (errors and comprehension), utilization, clinical outcomes, and patient satisfaction with care [267,268].

Clinicians should use plain language in their discussions with their patients who have low literacy or limited English proficiency. They should ask them to repeat pertinent information in their own words to confirm understanding, and reinforcement with the use of low-literacy or translated educational materials may be helpful.

8. CONCLUSION

The rural public health system is working to prevent disease and promote the highest level of well-being and quality of life for rural populations/communities in the United States. The role of the rural public health nurse is ever-evolving, as new public health infrastructures are being considered and implemented and as evidence-based ideas are being applied. Progress has been made in transforming the rural healthcare system and meeting the needs of every public community. However, more work is required, and the public health nurse is in the unique position to help improve rural health care and the health of rural communities.

The need to reach geographically isolated patients in need of care has been a driving goal behind telehealth evolution, and Internet technologies have the potential to bring care and health-promoting programs to remote populations. In the future, advanced communication technology will likely play an even bigger role in improving access to services and broadening the scope of prevention initiatives. With time, technology can improve the coordination of care and decrease fragmentation of services. Currently, more funding and technology infrastructure is required, as not all rural areas have the resources to benefit from these technologies.

Rural health is strengthened from the maturing of partnerships and collaborative efforts of public health stakeholders (e.g., public health agencies, private organizations, community residents) working together and sharing resources. These types of efforts have the potential to improve the rural healthcare system. Although strides have been made, more work is necessary to ensure that all rural populations are functioning at their best level.

9. RESOURCES

Partners in Information Access for the Public Health Workforce

https://www.phpartners.org

USDA Rural Development Program

https://www.rd.usda.gov

CDC Rural Health

https://www.cdc.gov/ruralhealth

National Rural Health Association

https://www.ruralhealthweb.org

Rural Nurse Organization

http://www.rno.org

Federal Office of Rural Health Policy

https://www.hrsa.gov/rural-health

Rural Caregivers Website

https://engineering.purdue.edu/~bng/Caregiving

National Rural Health Resource Center

https://www.ruralcenter.org

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Evidence-Based Practice Recommendations Citations

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