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Integrating tobacco interventions into daily practice.

Registered Nurses Association of Ontario (RNAO). Integrating tobacco interventions into daily practice. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Jun. 84 p.

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline updates a previous version: Registered Nurses Association of Ontario (RNAO). Integrating smoking cessation into daily nursing practice. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Mar. 87 p. [87 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

National Guideline Clearinghouse (NGC) has assessed this guideline's adherence to standards of trustworthiness, derived from the Institute of Medicine's report Clinical Practice Guidelines We Can Trust External Web Site Policy.

NEATS Assessment More about NGC's appraisal Standard of Trustworthiness
Yes Disclosure of Guideline Funding Source
Very Good Disclosure and Management of Financial Conflict of Interests
Guideline Development Group Composition
Yes Multidisciplinary Group
Unknown Methodologist Involvement
Poor Patient and Public Perspectives
Use of a Systematic Review of Evidence
Very Good Search Strategy
Excellent Study Selection
Excellent Synthesis of Evidence
Evidence Foundations for and Rating Strength of Recommendations
Good Grading the Quality or Strength of Evidence
Very Good Benefits and Harms of Recommendations
Excellent Evidence Summary Supporting Recommendations
Poor Rating the Strength of Recommendations
Excellent Specific and Unambiguous Articulation of Recommendations
Excellent External Review
Excellent Updating

Major Recommendations

Definitions for the levels of evidence (Ia, Ib, IIa, IIb, III, IV, V) are provided at the end of the "Major Recommendations" field.

Practice Recommendations

Assessment

Recommendation 1.1

Use brief interventions to screen all clients for all forms of tobacco use and initiate intervention as appropriate.

(Levels of Evidence = Ia & Ib)

Planning

Recommendation 2.1

Develop a person-centred tobacco intervention plan with the client.

(Level of Evidence = V)

Implementation

Recommendation 3.1

Provide clients with, or refer them to, intensive interventions and counselling on the use of pharmacotherapy, if they use tobacco and express an interest in reducing or quitting their tobacco use.

(Levels of Evidence Ia & V)

Recommendation 3.2

Treat or refer all pregnant or postpartum women at every encounter for intensive behavioural counselling for tobacco harm reduction, cessation, and relapse prevention, in conjunction with nicotine replacement therapy, on a case by case basis.

(Levels of Evidence = Ia, Ib, & V)

Evaluation

Recommendation 4.1

Evaluate the effectiveness of the intervention plan until the client's goals are met.

(Level of Evidence = V)

Education Recommendations

Education

Recommendation 5.1

Incorporate evidence-based content on tobacco interventions in health-care professional education programs.

(Levels of Evidence = Ib, IIb, IV, & V)

Recommendation 5.2

Ensure delivery of the tobacco intervention curriculum is facilitated by educators who are trained and skilled in the field of tobacco use interventions.

(Level of Evidence = IV)

System, Organization, and Policy Recommendations

System, Organization, and Policy

Recommendation 6.1

Advocate with policy-makers at all levels of government for comprehensive smoke- and vape-free legislation and enforcement in the community.

(Levels of Evidence = Ia, IIb, & IV)

Recommendation 6.2

Implement and enforce comprehensive tobacco-free policies in all health-care delivery settings and with all clients, including in-patients and out-patients, as well as with permanent and contract staff.

(Levels of Evidence = Ia & IV)

Recommendation 6.3

Embed tobacco use prompts in health records/documentation to facilitate addressing tobacco interventions during health-care visits.

(Level of Evidence = Ib)

Recommendation 6.4

Evaluate tobacco intervention programs and services.

(Level of Evidence = V)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III Evidence obtained from the synthesis of multiple studies primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities.

Clinical Algorithm(s)

An algorithm titled "Brief Intervention Flow Chart" is provided in the original guideline document.

Disease/Condition(s)

  • Tobacco use/dependence
  • Exposure to tobacco smoke

Note: In this guideline, "tobacco" refers to all smoking and smokeless forms of commercial tobacco products, including but not limited to cigarettes, cigars, cigarillos, chewing tobacco, dissolvables, hookah/water pipe/shisha, snuff, roll-your-own cigarettes, and pipes, as well as other products that may contain nicotine, such as electronic cigarettes (e-cigarettes). It does not include therapeutic uses of tobacco and nicotine, such as traditional ceremonial use and nicotine replacement therapy.

Guideline Category

Counseling

Prevention

Screening

Treatment

Clinical Specialty

Family Practice

Nursing

Obstetrics and Gynecology

Preventive Medicine

Intended Users

Advanced Practice Nurses

Health Care Providers

Nurses

Guideline Objective(s)

To provide tobacco interventions best practices for nurses and other health-care providers across all care settings, with evidence-based recommendations related to assessment and interventions for adults who use tobacco

Target Population

Adults who use tobacco

Interventions and Practices Considered

  1. Use of brief interventions to screen for tobacco use
  2. Development and evaluation of person-centered tobacco intervention plan
  3. Referral to or provision of intensive behavioural or pharmacological interventions
  4. Treatment/referral of pregnant or postpartum women for intensive behavioral counseling, in conjunction with NRT
  5. Incorporation of evidence-based tobacco intervention curriculum by trained educators
  6. Advocating for comprehensive smoke- and vape-free legislation and enforcement in the community
  7. Implementation of comprehensive tobacco-free policies in all health-care settings, embed tobacco use prompts in health records, and evaluate intervention programs/services

Major Outcomes Considered

  • Incidence of tobacco use
  • Smoking cessation
  • Relapse rate
  • Tobacco-related disease rates
  • Adverse effects of pharmacotherapy
  • Health-care costs
  • Quality of life

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Review

The Registered Nurses' Association of Ontario (RNAO) guideline development team's project coordinator searched an established list of Web sites for guidelines and other relevant content published between 2006 and 2015. This list was compiled based on knowledge of evidence-based practice Web sites and recommendations from the literature, and included key Web sites related to tobacco addiction and treatment interventions. Detailed information about the search strategy for existing guidelines, including the list of websites searched and inclusion criteria, is available at www.rnao.ca External Web Site Policy. Guidelines were also identified by members of the RNAO expert panel.

Systematic Review

The RNAO research team and a health sciences librarian developed a comprehensive search strategy based on inclusion and exclusion criteria created with the RNAO expert panel. The team searched the following databases for relevant articles published in English between 2006 and 2015: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), EMBASE, MEDLINE, and PsycINFO. In addition to this systematic search, expert panel members were asked to review their personal libraries for key articles not found in these databases.

Detailed information about the search strategy for the systematic review, including the inclusion and exclusion criteria and search terms, is available in the guideline search strategy document (see the "Availability of Companion Documents" field).

Retrieved articles were divided equally between two nursing research associates (NRA), who are nurses holding master's degrees. Each NRA independently assessed the eligibility of the studies according to established inclusion/exclusion criteria. The RNAO's Best Practice Guideline program manager, involved in supporting the RNAO expert panel, resolved disagreements between NRAs.

Number of Source Documents

Six guidelines and 53 studies were selected to inform the recommendations and discussions of evidence. See the flow diagrams in Appendix C in the original guideline document for more information on the review process and the bibliography of all included studies (see the "Availability of Companion Documents" field).

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III Evidence obtained from the synthesis of multiple studies primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Guideline Review

Members of the Registered Nurses' Association of Ontario (RNAO) guideline development team critically appraised six international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II. Refer to the original guideline document for a list of the selected guidelines.

Systematic Review

Quality appraisal scores for 26 articles (a random sample of 10 percent of articles eligible for data extraction and quality appraisal) were independently assessed by each Nursing Research Associate (NRA). Acceptable inter-rater agreement (kappa statistic K=0.88) justified proceeding with quality appraisal and data extraction, and the remaining studies were again divided equally between the NRAs (Fleiss, Levin, & Paik, 2003). The NRAs also completed a final summary of literature findings. The comprehensive data tables and summary were provided to all RNAO expert panel members for review and discussion.

A complete bibliography of all full-text articles screened for inclusion is available (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Guideline Development Process

For this guideline, the Registered Nurses' Association of Ontario (RNAO) assembled a panel of experts who represent a range of sectors and practice areas. A systematic review of the evidence was based on the purpose and scope, and was supported by the four research questions listed below. The systematic review captured relevant peer-reviewed literature and guidelines published between 2006 and 2015. The following research questions were established to guide the systematic review:

  1. In patients who use tobacco, which screening and assessment methods used by health-care professionals are most effective in promoting harm reduction, quit attempts, smoking cessation and preventing relapse?
  2. In patients who use tobacco, which treatment and management interventions/strategies used by health-care professionals are most effective in treating tobacco dependence, nicotine withdrawal and promoting harm reduction, smoking cessation and preventing relapse?
  3. For health-care professionals, what education is required to deliver effective care for patients regarding tobacco dependency treatment?
  4. In healthcare organizations, what systematic approaches and mechanisms support effective uptake of tobacco use and nicotine dependence interventions by health-care professionals?

The RNAO expert panel's mandate was to develop an evidence-based best practice guideline that will provide nurses and other health-care providers with current best practices for engaging clients who use tobacco. The recommendations in this guideline aim to bridge the identified gap between current practice and evidence-based practice.

This edition (2017) is the result of the expert panel's work to integrate the most current and best evidence into the recommendations and provide supporting evidence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Stakeholder reviewers for Registered Nurses' Association of Ontario (RNAO) guidelines are identified in two ways. First, stakeholders are recruited through a public call issued on the RNAO Web site External Web Site Policy. Second, key individuals and organizations with expertise in the guideline topic area are identified by the RNAO guideline development team and expert panel and directly invited to participate in the review.

Reviewers are asked to read a full draft of the guideline and participate in the review prior to its publication. Stakeholders submit their feedback by completing an online questionnaire. Stakeholders are asked the following questions about each recommendation:

  • Is this recommendation clear?
  • Do you agree with this recommendation?
  • Does the evidence support this recommendation?
  • Does this recommendation apply to all roles, regions, and practice settings?

The online questionnaire also gives stakeholders an opportunity to include comments and feedback for each section of the guideline.

The RNAO guideline development team compiles the submissions and prepares a summary of the feedback. The RNAO expert panel reviews and considers all feedback and, if necessary, modifies the content and recommendations in the guideline prior to publication to address the feedback. Stakeholder reviewers consent to the publication of their names and contact details in the guideline.

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

  • There is strong evidence suggesting that tobacco interventions contribute to reduced health-care costs and increased quality of life for those who quit or reduce their use (refer to Appendix E: The Benefits of Quitting Smoking in the original guideline document). For example, brief interventions with clients can lead to greater cessation and reduction rates and contribute to preventing illness and premature death. Therefore, interventions with clients who use tobacco have the potential to reduce morbidity and mortality associated with tobacco use.
  • Through implementation of tobacco interventions, health-care providers can contribute to reducing tobacco use, which is the single greatest preventable cause of death in the world today.
  • Exposure to training makes educators more likely to develop and integrate tobacco-related content and competencies into their teaching.
  • Evidence from a systematic review and other studies from Europe suggest that smoke-free legislation benefits entire populations by promoting the downward trend in tobacco use prevalence and by influencing positive behaviour change outcomes with regard to an increase in the number of quit attempts.
  • Implementing comprehensive tobacco-free policies in all health-care settings provides a supportive environment for both clients and health-care staff to reduce or quit their tobacco use.

Potential Harms

  • Withdrawal symptoms from nicotine may include strong cravings; mood changes, such as anxiety and depression; restlessness; insomnia; increased appetite; and lack of mental focus.
  • Problems with pharmacotherapy, such as under-dosing, side effects, compliance challenges, or premature discontinuation.

Contraindications

At this time, the use of varenicline should be avoided during pregnancy and breastfeeding due to insufficient evidence regarding its safety and efficacy as a tobacco cessation intervention in pregnant women.

Qualifying Statements

  • These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
  • This nursing Best Practice Guideline (BPG) is a comprehensive document that provides resources for evidence-based nursing practice. It is not intended to be a manual or "how to" guide, but rather a tool to guide best practices and enhance decision-making for nurses and other health-care providers working with older adults who have delirium, dementia, and/or depression. The guideline should be reviewed and applied in accordance with both the needs of individual organizations or practice settings and the needs and preferences of persons and their families accessing the health system for care and services. In addition, the guideline offers an overview of appropriate structures and supports for providing the best possible evidence-based care.

Description of Implementation Strategy

Guideline implementation at the point of care is multi-faceted and challenging; it takes more than awareness and distribution of guidelines to get people to change how they practice. Guidelines must be adapted for each practice setting in a systematic and participatory way, to ensure recommendations fit the local context. The Registered Nurses' Association of Ontario's (RNAO's) Toolkit: Implementation of Best Practice Guidelines provides an evidence-informed process based on implementation science for successful uptake of the guidelines (see Appendix K: Description of the Toolkit in the original guideline document).

The critical success factors identified in the Toolkit include:

  • Leaders at all levels are committed to supporting guideline implementation.
  • Guidelines are selected for implementation through a systematic, participatory process.
  • Stakeholders for whom the guidelines are relevant are identified and engaged in the implementation.
  • A comprehensive readiness assessment is required prior to guideline implementation.
  • Guidelines are customized to the local context.
  • Barriers and facilitators to guideline implementation are identified, monitored and where possible, mitigation strategies are implemented.
  • Interventions to promote uptake of the guidelines are selected.
  • Guideline implementation is systematically monitored and sustained.
  • Evaluation of the guidelines' impact is embedded in the process.
  • There are adequate resources to complete all aspects of the implementation.

The Toolkit uses the "Knowledge-to-Action" framework to demonstrate the process steps required for knowledge inquiry and synthesis. It also guides the adaptation of the new knowledge, such as guidelines, to the local context. This framework suggests identifying and using knowledge tools to identify gaps and to begin the process of tailoring the new knowledge to local settings.

RNAO is committed to widespread dissemination and implementation of its BPGs. RNAO uses a coordinated approach for dissemination, incorporating a variety of strategies, including:

  • The Nursing Best Practice Champions Network®, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs;
  • Nursing Order Sets, which provide clear, concise, actionable intervention statements derived from the BPGs' practice recommendations that can be readily embedded within electronic health records, but may also be used in paper-based or hybrid environments; and
  • The Best Practice Spotlight Organization® (BPSO®) designation, which supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate, and sustain multiple RNAO BPGs.

In addition, RNAO offers capacity-building learning institutes on specific BPGs and their implementation annually. Information about the full range of RNAO implementation strategies can be found at:

Implementation Tools

Audit Criteria/Indicators

Clinical Algorithm

Foreign Language Translations

Patient Resources

Resources

Tool Kits

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Registered Nurses Association of Ontario (RNAO). Integrating tobacco interventions into daily practice. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Jun. 84 p.

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2017 Jun

Guideline Developer(s)

Registered Nurses' Association of Ontario - Professional Association

Source(s) of Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by the Registered Nurses' Association of Ontario (RNAO) is editorially independent from its funding source.

Guideline Committee

Registered Nurses' Association of Ontario Expert Panel

Composition of Group That Authored the Guideline

Expert Panel Members

Peter Selby, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM
Expert Panel Co-chair
Professor, Departments of Family & Community Medicine and Psychiatry, and Dalla Lana School of Public Health, University of Toronto
Full Member, Institute of Medical Sciences, School of Graduate Studies, University of Toronto
Director, Medical Education and Clinician Scientist Addictions Division, Centre for Addiction and Mental Health (CAMH)
Toronto, Ontario

Shelley Walkerley, NP-PHC, Ph
Expert Panel Co-chair
Assistant Professor, Nurse Practitioner Program and Coordinator
School of Nursing, York University
Toronto, Ontario

Annette Schultz, RN, PhD
Associate Professor
University of Manitoba Rady Faculty of Health Sciences, College of Nursing
Winnipeg, Manitoba

Debbie Aitken, RN, BScN, APN
Program Manager, Smoking Cessation Program
University of Ottawa Heart Institute
Ottawa, Ontario

Jennifer Bouwmeester, RN, BScN, CCHN(C), CTE
Public Health Nurse
Simcoe Muskoka District Health Unit
Barrie, Ontario

Claire Gignac, RN, M-TTS
Former Tobacco Treatment Specialist, Master Registered Nurse, Counsellor and Educator
Health Sciences North
Sudbury, Ontario

Catherine Goldie, RN, PhD
Assistant Professor, Faculty of Health Sciences
Queen's University School of Nursing
Kingston, Ontario

Jan Johnston, RN, BScN, MEd, CCHN(C)
Public Health Nurse
Hamilton Public Health Services
Hamilton, Ontario

Gail Luciano, BSc, MEd
Manager, Smoking Cessation, Smokers' Helpline
Canadian Cancer Society, Ontario Division
Hamilton, Ontario

Tanya Magee, RN, BN
Faculty Registered Nurses Professional
Development Centre
Halifax, Nova Scotia

Patricia Smith, PhD
Associate Professor
Northern Ontario School of Medicine
Lakehead University Faculty of Medicine
Thunder Bay, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the Registered Nurses' Association of Ontario (RNAO) expert panel, and members were asked to update their disclosures regularly throughout the guideline development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference.

No limiting conflicts were identified. Further details are available from the RNAO.

Guideline Endorser(s)

Canadian Cancer Society - Medical Specialty Society

Centre for Addiction and Mental Health - Hospital/Medical Center

University of Ottawa Heart Institute - Academic Affiliated Research Institute

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Registered Nurses Association of Ontario (RNAO). Integrating smoking cessation into daily nursing practice. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2007 Mar. 87 p. [87 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Availability of Companion Documents

The following are available:

  • Registered Nurses' Association of Ontario – Clinical Best Practice Guidelines Program: integrating tobacco interventions into daily practice third edition. Systematic review search strategy. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017. 10 p. Available from the Registered Nurses' Association of Ontario (RNAO) Web site External Web Site Policy.
  • Registered Nurses' Association of Ontario – Clinical Best Practice Guidelines Program: integrating tobacco interventions into daily practice third edition. Bibliography. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017. 16 p. Available from the RNAO Web site External Web Site Policy.
  • Declarations of interests. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017. 2 p. Available from the RNAO Web site External Web Site Policy.
  • Toolkit: implementation of best practice guidelines, second edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2012 Sept. 154 p. Available in English and French from the RNAO Web site External Web Site Policy.

Various tools, including harms from tobacco, the benefits of quitting smoking, strategies to avoid relapse, the Fagerström Test for Nicotine Dependence (Revised), and the STOP Program: Sample Nicotine Replacement Therapy (NRT) Algorithm, are available in the appendices of the original guideline document.

Structure, process and outcome indicators for monitoring and evaluating the guideline are available in Table 6 in the original guideline document.

Mobile versions of RNAO guidelines are available from the RNAO Web site External Web Site Policy.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on September 20, 2004. The information was verified by the guideline developer on October 14, 2004. This NGC summary was updated by ECRI Institute on December 28, 2007. The updated information was verified by the guideline developer on March 4, 2008. This NGC summary was updated by ECRI Institute on September 12, 2017. The updated information was verified by the guideline developer on November 23, 2017.

This NEATS assessment was completed by ECRI Institute on August 17, 2017. The information was verified by the guideline developer on November 23, 2017.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario (2017). Integrating tobacco interventions into daily practice (3rd ed). Toronto (ON): Registered Nurses' Association of Ontario.

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