UCSF Trailblazers Redefine Nursing’s Role in Tobacco Control
Tobacco control may seem, at first glance, like a public health success story. In the United States, over the course of a generation, cigarette smoking has moved from a constant looming presence in restaurants, airplanes, and hospital corridors to the literal margins of public society — at least 25 feet away from businesses’ doors and windows.
But the bigger picture shows that the work is far from finished.
According to the World Health Organization (WHO), 1.2 billion people worldwide currently use tobacco. Smoking is the leading cause of preventable death in the U.S., and across the globe, tobacco use kills more people than AIDS, malaria, and tuberculosis combined.
For more than three decades, UCSF School of Nursing faculty have helped drive progress in tobacco control, shaping the global response to the tobacco epidemic with groundbreaking research and redefining the role nurses play in advancing public health policy worldwide.
Bringing an International Perspective
In her journey to becoming a globally recognized expert in tobacco control policy, professor Stella Bialous, DrPH, RN, FAAN, arrived at UC Berkeley from her native Brazil in the 1990s at the perfect moment. Internal documents detailing the tobacco industry’s marketing strategies had just been released, and they were housed nearby at UCSF — where they still reside.
As a doctoral student, Bialous became one of the first researchers to pore through the papers for international angles. “There was a lot,” she said. “These companies see the globe as their playground.”
Bialous landed a fellowship after graduation with the WHO, where she helped develop the WHO Framework Convention on Tobacco Control (FCTC). Adopted in 2003, it remains one of the most widely and quickly ratified treaties in United Nations history and offers a set of research-backed measures to help countries manage the tobacco epidemic.
One of the FCTC’s uniquely powerful elements is Article 5.3, which limits the role the tobacco industry can play in creating or altering policy.
“This is the only U.N. treaty that singles out an industry as being detrimental to the success of the treaty,” she said. “I’m really proud of the work I contributed to that.”
Harnessing the Power of Nurses
Alongside her policy efforts, Bialous supported tobacco users directly through innovative cessation programs. In 2003, Bialous and alum Linda Sarna, PhD ’89, RN, FAAN, launched Tobacco-Free Nurses (TFN).
TFN harnessed the considerable public health power of nurses — the largest population of health care workers — by first helping nurses stop using tobacco and then enlisting those nurses to help their patients quit.
During its most active span, TFN was recognized as an exemplar by both the WHO and the American Academy of Nursing, and its pocket clinician guide, Helping Smokers Quit, was among the U.S. Agency for Healthcare Research & Quality’s most requested documents.
Mobilizing ‘Formidable Opponents’
Around the same time, professor emeritus and UCSF alum Ruth Malone, PhD ’95, RN, also recognized the substantial potential of nurses to lead the change in tobacco control.
Malone’s groundbreaking research revealed that the tobacco industry itself was well aware of the profession’s power, noting in its internal documents that nurses, if mobilized, could become formidable opponents.
Also among those documents were hundreds of letters from sick and dying smokers and their grief-stricken families, calling the tobacco industry to task for its callousness. “These letters needed to be publicized,” said Malone, “and as a nurse, that was something I could do.”
She organized the Nightingales Nurses in 2004. For the better part of a decade, Malone and other members of the activist group purchased single shares of stock in tobacco companies, donned their white coats, and read those heartbreaking testimonials, as well as the latest health research, aloud at annual shareholders meetings.
Malone, who served as editor in chief of the internationally renowned journal Tobacco Control for 14 years, has more recently shifted her efforts toward a very specific goal: the end of commercial tobacco sales, often referred to as “the tobacco endgame.”
“This is an industrially produced epidemic of disease, but we can do something about that,” she said.
Resisting Complacence
Alum Anne Berit Petersen, PhD ’15, MPH, APRN-CNS, associate professor at Loma Linda University, was drawn into the international tobacco control effort by one of Malone’s own Nightingales Nurses presentations.
Moved by firsthand accounts of suffering from individuals and families affected by tobacco use, she first joined Malone in activism and then, as a graduate student, Bialous in research.
A maternal-child nursing specialist, Petersen has extensive global health experience and is invigorated by projects in Africa, where she spent her earliest years.
“I see that as the frontier where we can empower our colleagues to not have to do the damage control we’ve done in other countries with higher rates of smoking,” she said.
Back at the School of Nursing, professor Heather Leutwyler, PhD, NP, FAAN, addresses tobacco use in an often-overlooked segment of society: people with serious mental illness.
Before establishing her research career, Leutwyler worked as a family nurse practitioner in locked mental health facilities. “Major issues revolved around smoking and a lack of opportunities to be physically active,” she said.
Leutwyler recently wrapped up the successful PARQuit project, which paired outdoor games with nicotine replacement therapy and peer support groups to help participants with serious mental illness quit using tobacco.
She attributes her drive to pursue tobacco control in part to her fellow School of Nursing trailblazers. “I learned from Stella and Ruth to be very persistent about the importance of this issue,” she said.
Taking Steps Toward the Endgame
Despite measurable progress over the two decades since the FCTC was established, ample challenges remain in global tobacco control. Perhaps the greatest is the transnational, multibillion-dollar tobacco industry, which does not hesitate to use its political and financial might to try to undermine public health policy.
“There is a perception that they’re just like another business,” said Bialous. “But they sell a product that kills half of the users.”
To keep pace with the tobacco industry’s strategies, Bialous continues to probe the efficacy of the FCTC, illuminating the industry's attempts to circumvent it and advocating for new tactics to support its aims.
Both Bialous and Malone contributed to a recent report for the WHO FCTC Conference of the Parties on forward-looking measures to expand and intensify approaches to tobacco control worldwide.
Bialous also co-leads research to explore how the tobacco industry's strategies have introduced and reinforced disparities in the rates of tobacco use and tobacco-related deaths among racial and ethnic minorities and other vulnerable groups.
Finding Motivation in Collaboration
As she continues to seek new angles to combat the tobacco industry, Bialous finds inspiration in the ways that her international associates are fighting back.
Lessons learned abroad, she said, can be shared widely — and ultimately brought back home.
“We are getting there,” said Bialous. “Globally we are seeing decreases in tobacco use. Every year we see progress. It gives me hope.”
