Counseling Chinese patientsabout cigarette smoking: the role

of nursesHan Zao Li

University of Northern British Columbia, Prince George, Canada

Yu ZhangBaoding First Hospital, Baoding, People’s Republic of China

Karen MacDonellWayne State University School of Medicine, Wayne State University, Detroit,

Michigan, USA

Xiao Ping LiXiantao Vocational College, Xiantao, People’s Republic of China, and

Xinguang ChenWayne State University School of Medicine, Wayne State University, Detroit,

Michigan, USA

Abstract

Purpose – The main purpose of this study is to determine the cigarette smoking rate and smokingcessation counseling frequency in a sample of Chinese nurses.

Design/methodology/approach – At the time of data collection, the hospital had 260 nurses, 255females and five males. The 200 nurses working on the two daytime shifts were given thequestionnaires; none refused to participate, reaching a response rate of 100 percent. All theparticipants were females as the five male nurses were working in the operation rooms at the time ofdata collection, are were thus not accessible.

Findings – Some key findings include: only two nurses, out of 200, identified themselves as currentcigarette smokers; all provided anti-smoking counseling to patients, the majority of them did not thinktheir efforts were successful; cigarette smoking is a problem in China: the nurses estimated that 80percent of male and 10 percent of female patients were current smokers; in the opinions of the nurses,Chinese smokers used smoking as a stress reliever and a social lubricant; two methods may helpsmokers to quit or reduce smoking: using aids such as patches, acupuncture and nicotine gum, andcounseling by health professionals; the nurses think that cigarette smoking is well accepted in theChinese culture.

Practical implications – Findings of this research suggest that the Chinese Ministry of Healthshould take measures to change the cultural norms and values regarding cigarette smoking includingstrict rules be imposed on not passing/sharing cigarettes in the workplace.

Originality/value – In a collectivistic culture such as China where opinions of authorities arerespected, the part of nurses, who represent health authority to their patients, in assisting patients toquit or reduce smoking cannot be overemphasized. This study adds to the scarce research on Chinesenurses’ role in helping patients’ smoking cessation efforts.

Keywords Cigarettes, Smoking, China, Nurses, Health professionals, Counseling, Patients,Personal health

Paper type Research paper

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0965-4283.htm

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Received 13 October 2010Revised 6 December 201012 January 201127 January 2011Accepted 28 January 2011

Health EducationVol. 112 No. 4, 2012pp. 350-364q Emerald Group Publishing Limited0965-4283DOI 10.1108/09654281211237171

Cigarette smoking is known to be associated with a number of serious health problemsincluding cancer, cardiovascular and respiratory diseases (Centers for Disease Controland Prevention (CDC), 2004), as well as impaired cognitive functioning (Swan andLessov-Schlaggar, 2007). China is currently the world’s largest consumer of tobacco,accounting for approximately 40 percent of total global consumption (United NationsFood and Agriculture Organization (UNFAO), 2003). Systematic research on Chinesesmoking practices was not conducted until 1984, when a national survey found that 61percent of males and 7 percent of females were current tobacco smokers (Chen, 1985). Inthe 1990s, several large-scale studies in China revealed that an overwhelming majority ofadult males (70-87 percent) were regular tobacco smokers (Gao et al., 1991; Lubin et al.,1992; Yang et al., 1999). Moreover, more recent data suggest that the incidence of smokingin China continues to increase among both men and women (Gu et al., 2004; Pan, 2004),though rates remain substantially higher among males than females (Yang et al., 2005).Furthermore, the frequency of cigarette smoking (i.e. number of cigarettes smoked) varieslittle among Chinese males according to socio-economic indicators, including level ofeducation and literacy (Pan, 2004). Several surveys revealed high smoking rates amonghighly educated and respected social groups such as physicians (Li et al., 1999, 2007, 2008;Jiang et al., 2007; Yu et al., 2009). These studies found smoking rates ranged from 41 to61.3 percent of male and 1 to 12.2 percent among female physicians. The smoking rateamong nurses in China has also been examined. Although less than 3 percent of nurses inChina report smoking cigarettes, the gender disparity seen across Chinese culture is alsofound in the nursing profession. When stratified by gender, over 50 percent of malenurses in China report smoking cigarettes regularly (Smith et al., 2005).

An important reason for the continued high prevalence of cigarette smoking relatesto the special function cigarettes serve in Chinese society. For example, it is commonfor smokers to offer cigarettes to one another as a signal of respect and hospitality(Pan, 2004). To fit into a special social group or to ask a favor of another person, it isadvantageous to be a smoker. On the other hand, it is awkward for nonsmokers to usea cigarette to help with social relationships. It follows that some people may choose toand/or continue smoking because of the social advantages smoking provides in dailyinteractions with coworkers, friends, and authority figures.

Efforts to reduce smoking in China have largely been ineffective, perhaps becausesmoking is so well accepted in Chinese culture. For example, months before the BeijingOlympics in the summer of 2008, Beijing city government announced that restaurantswould be required to have designated nonsmoking sections by May 1. After fierceresistance from restaurant owners, Beijing yielded and gave up the plan in mid-April2008. Canada’s Globe and Mail’s correspondent Geoffrey York interviewed arestaurant owner in Beijing in April 2008 regarding the smoking ban. The managersaid that of the 200 tables in his restaurant, only six were reserved for nonsmokers,mostly for pregnant women and small children; moreover, very few customers hadrequested nonsmoking tables (York, 2008).

Research suggests that most Chinese are aware that smoking is harmful to health(e.g. 88.4 percent), yet cessation and intent-to-quit rates have remained low (Gong et al.,1995). Yang et al. (2001) found the majority (72 percent) of adult Chinese smokers hadno intention of quitting smoking. Among those who reported having quit smoking, themost common reason cited was illness. Thus, it follows that Chinese healthprofessionals could have an important role in promoting smoking cessation among

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their patients. The role of Chinese physicians in promoting smoking cessation has beenexplored in several studies ( Jiang et al., 2007; Li et al., 1999, 2007, 2008), which foundthat over half of the male physicians and two-thirds of female physicians often oralways counsel patients about smoking, but less than 10 percent thought that theirefforts were very successful. In comparison with male physicians, more femalephysicians often or always counseled patients about smoking. This gender differenceis compounded by the smoking status of the physicians as significantly more malephysicians are smokers. When smoking status is controlled for, however, genderdifference disappeared. These results indicate that health professionals who are alsononsmokers provided more anti-smoking counseling than otherwise.

Although the role of Chinese physicians has been examined extensively, the role ofChinese nurses has not yet been examined systematically. In one of the few studiesspecifically focused on Chinese nurses’ smoking cessation efforts, Chan et al. (2007) foundthat most nurses reported some knowledge of the detrimental effects of smoking, but fewactually practiced smoking-cessation interventions. Likewise, Chan et al. (2008) found thatmost undergraduate nursing education programs in China included the health hazards oftobacco use in standard curriculum. However, few programs covered behavioral orpharmacological smoking cessation interventions in the curriculum. In China the vastmajority of nurses are females and as Chinese females tend to smoke less, the role ofnurses in smoking cessation could be significant. As well, nurses carry out physicians’instructions, so they have the opportunity to directly supervise patients’ efforts to reduceor quit smoking. Nurses may be in a crucial position in smoking cessation efforts becausethey are the largest group in the worldwide health labor force, may have multipleopportunities to intervene with patients, and are a respected and trusted group overall(Smith, 2010). Overall, nurses tend to spend more time with each patient than a physicianand may have a better understanding of the patient’s thoughts regarding smoking as wellas other needs (Aiken et al., 2002). Importantly, China is a collectivistic culture and anessential characteristic of such a culture is the high respect placed upon the opinions ofauthorities (Li, 2003; Li et al., 2006; Markus and Kitayama, 1991; Triandis, 1995). In theeyes of the Chinese, nurses are health authorities and their opinions regarding health andhealth-related behaviors, including smoking, carry great power.

The role of nurses to help patients quit or reduce smoking has been widely studied inwestern countries. Rice and Stead (2009) and the Cochrane Collaboration AddictionGroup conducted a systematic review of 42 studies of smoking cessation programsdelivered by nurses with at least six months of follow-up data. The authors foundevidence that smoking interventions delivered by nurses are largely effective inpromoting smoking cessation, particularly when interventions are longer and moreintensive and delivered by a nurse whose main role is health promotion or smokingcessation. Highly encouraging results have been reported in several representativestudies. For example, in two nurse-delivered inpatient smoking cessation programs,adult patients hospitalized for a variety of conditions have reported high smokingabstinence rates up to 12 months after the program was delivered (Chouinard andRobichaud-Ekstrand, 2005; Taylor et al., 1996). Researchers have also tested the efficacyof home-based, nurse-delivered smoking relapse prevention programs (Groner et al.,2005). Groner et al. (2005) reported that the smoking relapse prevention program for newmothers was both feasible and acceptable for the population of interest. Finally,nurse-delivered programs have been found to be effective in adolescent populations viaschool-based smoking cessation interventions (Pbert et al., 2006). Pbert et al. (2006) tested

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a four-session, one-on-one intervention with a school nurse and found significantlygreater smoking abstinence rates after six weeks in the intervention than the controlgroup (24 vs 5 percent, respectively). Taken together, results of these studies suggest thatnurse-delivered smoking cessation counseling programs are highly effective and feasiblein promoting smoking abstinence in the west.

What is the role of Chinese nurses in helping patients reduce or quit smoking? Anextensive search in both Chinese and English languages yielded little information. Thepresent study intends to fill a gap in the literature by exploring smoking behaviors,attitudes, and counseling practices among Chinese nurses. Specifically, the followingresearch questions are examined:

RQ1. What percentage of nurses are current cigarette smokers?

RQ2. In the opinions of the nurses, what percentage of male and female patientsare current cigarette smokers?

RQ3. How often do nurses counsel their patients about cigarette smoking?

RQ4. What measures do nurses believe are most effective in helping patients quitor reduce cigarette smoking?

RQ5. What variables are associated with the frequency of anti-smoking counselingamong nurses?

MethodParticipantsA convenience sample of 200 nurses was drawn from a city hospital in Baoding, capitalof Hebei Province, the People’s Republic of China. Baoding, with a population of600,000, is located in northeast China, 85 miles north of Beijing. Prior to data collection,the permission of the President’s council of the hospital was sought and granted.

The second author of this study (hereafter referred to as the researcher) collected thedata in the first two weeks of April 2010. The researcher was a physician in thehospital where the sample was drawn. At the time of data collection, the hospital had260 nurses, 255 females and 5 males. The nurses worked on a three-shift schedule. The200 nurses working on the two daytime shifts were given the questionnaires. Nonerefused to participate, reaching a response rate of 100 percent. When distributing thequestionnaires, the researcher instructed the nurses to answer the questionsindependently. They were also told that their names would not appear on thequestionnaire, therefore their identity would be anonymous. While the nurses werefilling out the questionnaires, the researcher was nearby to answer any questions.Completed questionnaires were returned to the researcher.

All the participants were females as the five male nurses were working in the operationrooms at the time of data collection, thus not accessible. All the nurses in the present studywork in a state-owned hospital either in in-patient or out-patient departments.

Questionnaire and coding. The questionnaire used in this study was identical,except the word “physician” was changed into “nurse”, to the one employed in earlierstudies (Li et al., 2007, 2008), and was mainly a derivation of previous empirical studies(Kenney et al., 1988; Strecher et al., 1991). In the present study, only the Chinese versionof the questionnaire was utilized.

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All the scales and coding systems employed in the present study were identical tothose in previous studies (Li et al., 2007, 2008). A nurse was defined as a smoker if shereported that she “occasionally”, “sometimes”, or “often” smoked. Non-smoking statuswas decided when a nurse reported that she “never” smoked. Besides asking abouttheir own cigarette smoking status, information regarding the following dimensionswas also sought: nurses’ perception of the cigarette smoking rates of male and femalepatients, patients’ knowledge of the health hazards related to smoking, the frequency ofnurses’ anti-smoking counseling, the method used, and nurses’ perceived success of thecounseling.

Data processing and statistical analysisData were manually entered into a MS Excel spreadsheet by the researcher. Dataquality was checked and errors corrected against the originally completedquestionnaire. The proportion (%) was used to describe sample characteristics,cigarette smoking (including smoking among spouse and parents), perceivedknowledge of cigarette smoking to health among patients, attitudes towardsmoking, and patient counseling, including frequency, method and perceivedsuccess. The median (inter-quarter range IQR) was used to estimate the perceivedtobacco smoking among patients (percentage of patients who smoke and number ofcigarettes smoked per day by most patients). A Chi-square test was conducted to testwhether frequency of smoking cessation counseling was influenced by demographics(i.e. age, years of working as a nurse and specialty), and attitudinal factors with type Ierror set at p , 0.05 (two-sided). Statistical analysis was conducted using SAS 9.23(SAS Institute Inc, Cary, NC).

ResultsAs shown in Table I, among the 200 nurses participating in the survey, all were female,most (89.5 percent) were 30-39 years old, more than half (55.5 percent) were married,and more than 60 percent had worked as a nurse for 21 years or longer.

RQ1. What percentage of nurses are current cigarette smokers?Only two nurses, out of 200, were current cigarette smokers. Two-thirds of the nursesidentified their spouses as current cigarette smokers; approximately 25 percent of thenurses stated that both father and mother smoked cigarettes, 60.8 percent reportedonly father smoked and 14.6 percent reported only mother smoked.

RQ2. In the opinions of the nurses, what percentage of male and female patients arecurrent cigarette smokers?According to the nurses in this study, approximately 80 percent of male patients and10 percent of female patients are current cigarette smokers. More than 60 percent of thenurses believed that smoking among Chinese patients had either increased or notchanged and 38.5 percent believed that smoking among patients declined in the pastyear (Table II).

Table III presents nurses’ attitudes toward smoking, knowledge of possible healthhazards related to smoking, and reasons for smoking and quitting in the generalpopulation. As shown in Table III, 85 percent of the nurses agreed or somewhat agreedthat smoking is accepted in the Chinese culture. According to these nurses, the two

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major roles of cigarette smoking were stress removal (58.5 percent) and as a sociallubricant (26.0 percent); the two major reasons for people to quit smoking werefinancial considerations (41.5 percent) and health considerations (39.5 percent). Abouttwo-thirds of the nurses believed that every Chinese knew about the health hazards ofsmoking (Table III).

RQ3. How often do nurses counsel their patients about cigarette smoking?Approximately nine out of ten nurses reported counseling patients about cigarettesmoking either often (63.0 percent) or always (26.5 percent), with a quarter reportingsuccess or somewhat success in advising patients not to smoke.

RQ4. What measures do nurses believe are most effective in helping patients quit orreduce cigarette smoking?When asked what method they had used helping patients to quit or reduce smoking,54.5 percent of the nurses said that they related smoking to patients’ illness and 44percent of the nurses warned patients of the harm smoking does to their health.However, when asked, in their opinion, what methods would be most effective inassisting smokers to quit, 54 percent of the nurses thought using aids such as patch,hypnosis, acupuncture, nicotine gum could be helpful, while 32.5 percent thought thatcounseling by health professionals such as physicians and nurses could be helpful.

Variables Proportion (%) Frequency n

Total 100 200 200

GenderMale 0.0 0 200Female 10 200 200

Age group,30 7.0 14 20030-39 89.5 179 20040 þ 3.5 7 200

Marital statusMarried 55.5 111 200Other 45.5 89 200

SpecialtySurgical 10.7 21 199Internal 8.0 16 199Traditional Chinese medicine 5.5 11 199Others 75.8 151 199

Years working as a nurse#5 8.0 16 2006-10 6.5 13 20011-15 4.0 8 20016-20 19.5 39 20021 þ 62.0 124 200

Note: One nurse did not report her specialtyTable I.

Demographics

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Questions Percentage (%) Frequency n

Self smokingCurrent smoking 1.0 2 200Nonsmoking 99.0 198 200

Spouse smoking statusFrequent 37.5 42 112Occasional 29.5 33 112No 33.0 37 112

Parent smoking statusBoth 24.6 49 199Father 60.8 121 199Mother 14.6 29 199

Patient smoking status% smoking, median (IQR)Male patients 80 (70-90) 200Female patients 10 (5-15) 200No. cigarettes smoked per day by most patients, median (IQR) 20 (15-20) 200

Changes in smoking rates among patients in the past yearIncreased 45.5 91 200No change 16.0 32 200Declined 38.5 77 200

Notes: IQR: inter-quarter range (range from 25th percentile to 75th percentile); The median is thesame as the upper limit of IQR for the number of cigarettes smoked per day by patients because most(87) of the patents reported smoking 20 cigarettes per day

Table II.Self smoking status andperceived others’smoking behaviors

Variable Proportion (%) Frequency n

Smoking is accepted in the cultureAgree 30.5 61 200Somewhat agree 49.5 99 200Somewhat disagree 17.4 35 200Disagree 2.5 5 200

How many people know the health hazards of smokingEveryone 66.5 133 200Most 28.0 56 200About a half or fewer 5.5 11 200

Reasons people smokeShow social status 0.5 1 200Serve as social lubricant 26.0 52 200Dealing with stress 58.5 117 200Habit 15.0 30 200

Reasons for smokers to quitHealth 39.5 79 200Financial 41.5 83 200Family pressure 11.0 22 200Social pressure 8.0 16 200

Table III.Perceptions of cigarettesmoking behaviors inChina

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Interestingly, more than 70 percent (141/200) of the nurses reported that they shouldset examples for patients by not smoking and 65.5 percent believed that the finaldecision lay with smokers themselves (Table IV).

RQ5. What variables are associated with the frequency of anti-smoking counseling?Table V indicates that both age and years of working as a nurse were associated withfrequencies of patient counseling concerning cigarette smoking ( p , 0.01, Chi-squaretest). For example, for nurses 40 years of age and older, everyone reported provision ofcounseling, while for nurses younger than 30 years of age, only 61.4 percent providedcounseling. With regard to specialty, nurses worked in the internal medicinedepartment were the least likely to provide counseling. None of the three attitudinalvariables was significantly associated with the frequency of patient counseling.

DiscussionThe data uncovered in this research present the following picture. Few Chinese femalenurses were cigarette smokers and all reported providing anti-smoking counseling topatients. However, the majority of them did not think their efforts were successful.

VariablesProportion

(%) Frequency n

Should nurse set examples by not smoking 70.5 141 200

Who has influence on smokers to quitSmokers themselves 65.5 131 200Doctors/nurses 26.0 52 200Family members 7.5 15 200Do you agree that nurses have the responsibility to advise patientsnot to smoke 52.5 105 200

In your opinion, what is the most effective method for smokers to quitCold turkey 1.5 3 200Bio- and pharmacologic aid 54.0 108 200Counseling 32.5 65 200Others 12.0 24 200

What method do you most frequently use in advising patients not to smokeRelated smoking to their health and illnesses 54.5 109 200Warn patients about the harm from smoking 44.0 88 200Ask patients not to smoke 1.5 3 200

Frequency of advising patients not to smokeAlways 26.5 53 200Often 63.0 126 200Sometimes 10.5 21 200Occasionally or none 0.0 0 200

Perceived success in advising patients not to smokeSuccessful 4.5 9 200Somewhat successful 20.5 41 200Somewhat unsuccessful 68.5 137 200Unsuccessful 6.5 13 200

Table IV.Attitudes towards,knowledge of and

frequency to conductcounseling

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Cigarette smoking is a public health problem in China, with an estimated 80 percent ofmale and 10 percent of female patients being current smokers. In terms of the number ofthe daily cigarette consumption, the nurses estimated that the majority of the smokersconsumed 15-20 cigarettes daily. Furthermore, patients are either smoking more or thesame, with no signs of decrease. Do Chinese smokers know about the health hazards? Theanswer is yes, but smoking is perceived to serve important personal and social functionsand also to act as a stress reliever and a social lubricant. The two main factors influencingpeople’s decision to quit may be financial considerations (if they cannot afford it) andillness (e.g. a lung cancer patient may be motivated to quit). Two methods may help: aidssuch as patches, acupuncture and nicotine gum, and counseling by health professionals.

Perhaps the most significant finding is that 85 percent of the nurses think that cigarettesmoking is well accepted in the Chinese culture. This view is mirrored by otherresearchers. For example, in offices and households, smokers do not bother to ask whether

Counseling provided

Subtotal Often AlwaysCounseling

not providedInfluential factors n n % n % n % n %

Age * *

,30 14 10 71.4 3 21.4 7 50.0 4 28.630-39 179 162 90.5 121 67.6 41 22.9 17 9.540 þ 7 7 100.0 2 28.6 5 71.4 0 0.0

Years of being a nurse * *

#10 29 23 79.3 11 37.9 12 41.4 6 20.711-20 47 42 89.4 24 51.1 18 38.3 5 10.621 þ 124 114 91.9 91 73.4 23 18.5 10 8.1

Specialty * *

Surgical 21 19 90.5 5 23.8 14 66.7 2 9.5Internal 16 13 81.3 7 43.8 6 37.5 3 18.7Traditional Chinese Medicine 11 10 90.9 8 72.7 2 18.2 1 9.1Others 151 136 90.0 106 70.2 30 19.9 15 9.9

AttitudinalSmoking is accepted in the Chinese cultureDisagree 5 5 100.0 1 20 4 80.0 0 0.0Somewhat disagree 35 29 82.9 18 51.4 11 13.4 6 17.1Somewhat agree 99 88 90.9 65 65.7 23 23.2 11 11.1Agree 61 57 93.4 42 68.9 15 24.6 4 6.6

Nurses should set examples by not smokingAgree 141 125 88.7 87 61.7 38 27.0 16 11.4Disagree 59 54 91.5 39 66.1 15 25.4 5 8.5

Nurses responsible to advise patients not to smokeAgree 105 90 85.7 60 57.1 30 28.6 15 14.3Disagree 95 89 93.7 66 69.5 23 24.2 6 6.3

Notes: The number of subjects did not add up to the total 200 for two variables (age and specialty) dueto missing; one subject with missing data on specialty was not included for the analysis by specialty; *

p , 0.05; * *p , 0.01 by Chi-square test

Table V.Variables associated withfrequency of smokingcounseling

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it is okay for them to smoke in front of non-smokers (Ma et al., 2007). Non-smokers do notwant to be socially inappropriate by raising any concerns (Ma et al., 2007). Instead, theyaccept smoking as a cultural norm. What if the majority of nonsmokers would not acceptsmoking in offices, their homes and public places? This would be a revolutionary step ashas been demonstrated in the West. The nurses in this study believe that social pressurefor smokers to reduce or quit is small. What if more awareness was cultivated amongnonsmokers, who in turn put pressure on smokers to reduce or quit smoking? There is arealistic difficulty in this effort as China is a chauvinistic society where males havedominated females for thousands of years with endorsement from the most reveredspiritual leader Confucius, who specified that females should unconditionally obey males(Lau, 1979). The fact that the majority of Chinese males are smokers and the majority offemales are nonsmokers makes it very difficult for nonsmokers to stand up for their rights.Females (with the exception of females in authority such as nurses) would be scorned ifthey attempted to interfere with the enjoyment and freedom of smoking in males (Li, 2004).

Over half of the nurses in this study said that smokers use cigarettes as a stressreliever, implying that many Chinese experience stress with no other means to relieveit. The authors argue that the high level of stress could be related to the rapid economicdevelopment in recent years requiring adaptation, where many Chinese may or maynot be ready. It is interesting that about one-third of the nurses think that cigarettesserve as a social lubricant. It is a universal truth that the Chinese culture emphasizesinterpersonal connections, without which, few goals can be accomplished (Ni and Chen,2006; Li et al., 2008; Pan, 2004; Unger et al., 2002). A well-known saying in China statesthat cigarettes are for sharing among co-workers, neighbors, and friends, influencingpeople to believe that accepting a carton of cigarettes from a favor-asking inferior is nota bribe. This cultural belief opens a door for cigarettes to play a unique role in buildinginterpersonal channels among cigarette smokers. Making good use of this tokenbribing method may enable one to achieve important personal goals. Reducingcigarette smoking in China involves changing this cultural norm, which may prove tobe very complex. Some Western societies have had great success in removing smokingfrom work places and public areas, and could prove to be a positive influence onChinese smoking behavior in the future.

According to the nurses in this study, the majority of Chinese people know aboutthe health hazards of cigarette smoking, but they continue to smoke. Apparently healthmay not be the priority for many smokers; rather, getting other goals fulfilled may beperceived as more important. In the Chinese society it seems that social and businessinterests, for example, have a higher priority than health concerns.

One advantage of a socialist society, where power is centralized, is thatgovernment’s measures to reduce smoking may be highly possible. To make it work,the Ministry of Health would need to mobilize nationwide anti-smoking campaignsendorsed by China’s highest administration without its support, little can beaccomplished. According to a recent report by the Chinese News Agency, Xinhua, aspecial team of lawyers, designated by the Chinese government, have starteddiscussions on enacting tobacco control law in China by 2012, banning smoking inoffices and certain parts of restaurants (Zhou, 2012). Although past efforts to bancigarette smoking in certain parts of restaurants by local Chinese city governmentshave largely failed due to the strong resistance from smokers and restaurant owners(York, 2008), a nationwide campaign authorized by the government could work better.

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The findings of this survey do indicate that nurses can be used to help smokers toreduce or quit as all the nurses counseled their patients about smoking, over half feel it istheir responsibility to help patients, and over two-thirds agree that nurses should setexamples for patients by not smoking. In comparison with physicians, nurses spendmore time with patients, especially in-patients. In a culture where people are used toobeying authorities, advice from nurses could be very helpful because nurses carrydoctors’ orders and are next-to-the-highest health authority. However, less than one-thirdof the nurses in this study felt that their anti-smoking efforts were successful. On thecontrary, the vast majority thought that their efforts were unsuccessful. A study in JinZhou city, Hubei province, asked 173 nurses whether they received any training inhelping patients reduce or quit smoking, only 9.8 percent said that they received trainingon the subject; the rest did not receive any training in behavioral medicine (Ni and Chen,2006). Furthermore, only 54.8 percent of the 173 nurses had profound understanding ofhealth hazards of cigarette smoking to the human body (Ni and Chen, 2006). The findingsof our study also point to the suggestion that measures need to be taken to train nurses inthe workforce about preventive medicine, and relevant information and instructionsshould be added to the curriculum in nursing schools. If nurses can be properly trainedand encouraged to counsel patients about their smoking behavior, especially relatingsmoking with their current and possible illnesses, the day may not be too far away whena significant number of patients quit smoking.

RecommendationsWe would like to make three recommendations in future efforts to help smokers to quitor reduce smoking in China:

(1) To adopt the “5 A” model advocated by the US Public Health Service for healthcare workers (Tobacco Use and Dependence Guideline Panel, 2008). “5 A” refers toask (systematically identify tobacco users at every visit), advise (i.e. strongly urgeall tobacco users to quit), assess (i.e. determine willingness to make a quit attempt),assist (i.e. aid the patient in quitting), and arrange (i.e. ensure follow-up contact).

(2) To combine efforts of multiple-health professionals such as nurses, westernmedicine doctors, traditional Chinese medicine doctors, and dentists. Researchin the US indicates that the multiple health professional approach is an effectiveapproach (e.g. An et al., 2008).

(3) To combine multiple pharmacologic aids with counseling of professionals. Inour study, 54 percent of the nurses think that pharmacologic aids can be usefulin aiding patients to quit smoking. In other parts of the world, pharmacotherapy(i.e. gum, transdermal pat spray, inhaler and sublingual tablets) has beenreported to increase the odds of quitting (Karnath, 2002; Nørregaard et al., 1993;Okuyemi et al., 2007; Silagy et al., 2005).

LimitationsAlthough our study has found several significant results, it has at least threelimitations. First, it was a convenience sample, and all participants are female. The fewmale nurses who did not participate in this study may have very different cigarettesmoking and anti-smoking counseling practices than the female nurses in the sample.Second, the standardized questionnaire did not allow for explorations of certain topics

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of interest of the participants. In order to have in-depth views of health professionalsregarding their opinions on cigarette smoking and smoking cessation counseling,qualitative interviews should be used to compliment quantitative data in futureresearch. Finally, when collecting data, the researcher, also a physician in the hospitalwhere the data were collected; stayed nearby while the nurses filled out thequestionnaires. There is a slight possibility for social desirability to occur in that thenurses may have wanted to provide socially desirable answers. Nevertheless, wereason that this possibility is minimal for three grounds:

(1) In a state-owned hospital, the nurses have “iron-rice bowls” (permanent jobs),there is no need for them to please a physician.

(2) The physician is not a cadre of the nurses, thus having no power over thenurses.

(3) Smoking cessation counseling is not in the nurses’ job description; it is avoluntary deed.

In spite of the limitations, our research is one of the few systematic studies on cigarettesmoking habits and antismoking counseling of Chinese nurses. It is hoped that thisstudy will spearhead more research on the specific role of nurses in assisting patientsin their smoking cessation efforts. Specifically, we recommend smoking cessationcounseling be delivered in pediatric settings. Nurses and pediatricians should askparents, especially fathers, about tobacco use, relate the child’s illness to passivesmoking and offer parents cessation advice. Due to the large population, Chinese citydwellers mostly live in apartments (versus houses) and indoor smoking is common.Young children are constantly exposed to passive smoking which may have a negativeimpact on their health. With the one-child policy implemented since the early 1980s,each couple can have only one child. If a man does not quit smoking for his own health,he may well consider quitting for the sake of his child. This hypothesis can be tested ina clinical setting in which parents in the experimental group, be compared with thecontrol group of parents who receive no such attention. Experimental group parentscould receive inquiries about their tobacco use, detailed explanation of the child’sillness and its relationship to passive smoking, warnings of the possible negativehealth consequences to the child’s health if the child continues to be exposed in thesame environment, as well as directions and assistance to quit smoking.

To summarize, the nurses in our sample do think that cigarette smoking is aproblem in China, with an estimated 80 percent of male and 10 percent of femalepatients being current smokers. Reasons for smoking identified were to deal withstress and to smooth interpersonal relationships. The nurses suggested two methods tohelp smokers to reduce or quit smoking: using aids such as patches, acupuncture andnicotine gum, and counseling by health professionals. They also said that cigarettesmoking is well accepted in the Chinese culture. Therefore, cigarette smoking behaviorcannot truly be changed unless cultural norms concerning smoking undergo a drasticchange, and that may take time.

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Corresponding authorHan Zao Li can be contacted at: lih@unbc.ca

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