Links between nurses and cigarette smoking?

Nursr Eduotion Today (1986) 6, I7Gl82 Q Longman Group UK Ltd 1986

Links between nurses and cigarette smoking?

Katie Booth and Ann Faulkner

The thoughts and feelings of nurses in training about cigarette smoking were studied by means of a survey of nurses in four schools of nursing in the north-west of England. Questionnaire data, together with material from in-depth interviews

with a 10% sample from those nurses who were current smokers was the basis of an

exploration of various issues concerned with nurses and smoking cessation. Analysis of the data suggested that the prevalence of cigarette smoking amongst

nurses in training was similar to that amongst comparable members of the general population, and that nurses did not attribute increased cigarette consumption to

specifically nursing situations. In comparison with their colleagues, nurses who were

current smokers appeared to believe that cigarettes are less dangerous to health, and demonstrated some differences in their responses to a situation which had

potential for health education. A considerable proportion of the current smokers both wanted to stop smoking

and were prepared to give up time in order to do so; many others had made a

previous attempt at smoking cessation. Interview data suggested that many felt guilty about their smoking, and considered their smoking to be linked with social

activities, the management of difficult situations and (for female nurses) weight control.

Encouragement, especially from other smokers trying to stop smoking, help with cessation techniques, regular opportunities to monitor progress and receive support were all features identified by current smokers and ex-smokers as being useful in the

design of a support system which might help those nurses who wished to stop smoking.

There has been considerable concern about the smoking habits of hospital nurses since 1977 when the Office of Population Census and Surveys ‘Smoking and Professional People’ suggested that 48% of hospital nurses smoked. This was a much higher percentage than those in ‘compar+ble’ groups, e.g. hospital doctors

K Booth MSc BSc RGN HVCert, Research Associate. Department of Nursing, University of Manchester A Faulkner PhD MA ML& SRN RCNT DipEd, Project Director, Department of Nursing, University of Manchester

Manuscript accepted April 1986

176

(25%). One explanation frequently offered has been that nurses smoke because the task of nursing is very stressful, for instance, the work of Hillier (1981).

That there was a high prevalence of smoking amongst nurses was thought to be an important issue, as nurses are considered to have a health education role in the context of their clinical practice. The professional difficulties, encountered by nurses who smoke, are pointed out by Faulkner & Ward (1983). They des- cribe a situation where nurses, accepting that

NURSE EDUCATION TODAY 177

they had a health education role, knew insufi- cient about smoking to offer education to their patients; nurses’ own smoking habits caused further complications. Many who smoked thought patients less likely to heed advice from a nurse known to smoke herself.

There are other causes for concern about nurses’ smoking behaviour. If nurses are smoking cigarettes, this may not only jeopardise their professional credibility as health educators and expose their families to the risks of passive

smoking, but also pose a real danger to the health of nurses themselves. In 1982 Health and Social Services Statistics reported that 9076 of nurses were female. So it follows that the majority of nurses who smoke are taking the same health risks as other women who smoke cigarettes. This is a subject under con- sideration at the present time because the 30 year gap between the establishment of smoking habits and the statistics reflecting disease trends has meant that large numbers of female smokers in the population since the Second World War have only recently been showing up as casualties of smoking. For example, in the USA a quarter of those dying from lung cancer in 1979 were women and the Surgeon General (US Department of Health Education and Welfare 1980) estimated that this would increase within a few years of the Report. A similar pattern is emerging in the UK (Royal College of Physicians 1983).

It could be argued that a nursing profession which demands a health education function from its members must have an obligation to help those same people protect their own health. This paper describes a project in which methods of helping nurses give up smoking were explored.

THE PROJECT

If effective help was to be offered to those who wished to give up smoking, some information had to be gained on the thoughts and feelings of the nurses themselves. An early aim was to establish whether or not those who smoked

cigarettes wished to stop, and if they were able to identify the sort of help they might need.

The research was funded .by the Health Education Council (HEC), the survey part of the study being conducted within four general hospitals in the north-west of England in the summer of 1983. A pilot study had indicated that a separate document each for smokers, non-smokers and ex-smokers was acceptable if the choice of which to select was left to the respondents. In the main study, questionnaires were given to groups of nurses receiving tuition within the schools of nursing during a IO-week data collection period. All nurses involved agreed to participate, 563 nurses completing questionnaires. Of the sample 95% were student and pupil nurses with an age range of 18- 49 years. Many of the questions uZd were open-ended in order to minimise cued re-

sponses. In-depth interviews were tape- recorded later with a 10% sample of the 205 who smoked.

RESULTS

There were 36.4% current smokers amongst the nurses in this study. Of the sample 11% were male nurses. It was therefore considered valuable to compare the study figures with those reported for female smokers in a similar age range. The General Household Survey (OPCS 1983) for female smokers of 1649 years gives a figure of 36.85% smokers. It is argued that the close similarity in these figures would support the claim made by Hawkins et al (1982) that nurses may be no more and no less likely to smoke than other women.

Table 1

To show percentage of sample regularty smoking 7 cigarettes a week

% of sample

205 Smokers 36.4 57 Ex-smokfJls 10.1

301 Non-smokers 53.5

563 (Total) 100

178 NURSE EDUCATION TODAY

Patterns and prevalence of smoking

In terms of numbers of cigarettes smoked, the nurses reported a lower daily cigarette consumption than their counterparts in the genera1 population (89.6% of the nurses smoked under 20 a day whereas the General Household Survey [OPCS 19831, reports that 63% of

women smokers consume less than 20 cigarettes). The results from the cross-sectional sample, which cannot demonstrate changes in individual behaviour, do not show an increase in the percentage of smokers as the students progressed through training. The slight pupil nurse increase did not reach the level of statis- tical significance. So it seems that, as a group, the nurses did not take up smoking as they progressed through training. Moreover, 73% of the current smokers claimed to have been smoking for longer than three years. Since 95yo of the sample were in basic training it seems that for most nurses in this sample, their smoking predated their nursing.

Table 2

To show distribution of smokers in the grades of training (26 of the sample were not in basic training. Total in training 537)

Year Smokers Ex-smokers Non-smokers Total thought these changes might make matters W (W W W worse.

1st (St)* isi)

48 (37) 9 (7) 71 (55) Nurses’ negative thoughts about cigarette

2nd 45 (35j 14 (loj 71 (55j 128 (99) 130 (iooj smoking were hiihlighted during the interview

3rd GO &)t

40 132) 7 (61 79 (62) 126 (1001 1st 31 i36j 10 (iii 46 i53j 87 ilOOj

stage of the study. Of the 22 smokers inter-

2nd (Pu) 29 (44) 9 (14) 28 (42) 66 (loo) viewed in depth, all but two indicated feeling ashamed or feeling disapproval. One pupil

Totals 193 49 295 537 nurse describing her smoking when in the

“St=student nurse company of non-smokers said ‘I feel so em- tPu=pupil nurse barrassed, really, I feel dirty, feel I shouldn’t

be doing it’. Of those nurses who had never smoked 60% expressed distaste and a quarter

Nurses’ views about stopping smoking stated that smoking was dirty or anti-social. It could be argued that this climate of guilt about

Of those nurses who were smokers 80% re- smoking within the hospitals, perhaps fuelled ported a past attempt to give up cigarettes, a by the implementation of the sort of smoking proportion which can be compared, in the policies suggested by the Royal College of nurses’ favour, with the 70% of smokers Physicians (1983), might make it very diff%zult reporting a cessation attempt in the Marsh & for a nurse to identify herself as someone in Matheson (1983) survey. Of the nurses described need of help with smoking, or to seek in this current study, 14O<, of those smoking assistance.

reported an effort to stop, lasting at least a week, in the 6 months prior to the survey. Many nurses were prepared to try again: 57% of all current smokers reported that they wanted to stop, and 43% of all current cigarette smokers indicated both that they wanted to stop smoking and that they would be prepared to give up some of their own time in order to do so. The heaviest smokers in the sample were those most willing to make the effort to cease smoking.

In response to a multiple choice item, a very large proportion of current smokers identified encouragement as an important factor which might help them to stop smoking. Family, friends and colleagues were all suggested as sources of this encouragement, but the largest response (from 63% of all smokers) was one which suggested that smokers making the attempt could encourage each other. Ex-smokers and smokers thought that help with specific techniques of stopping and regular opportunities for the nurse to monitor her progress would be valuable. Only 9 out of 205 smokers and 4 out of 57 non-smokers considered that a ‘no smoking’ policy in the hospital would be of value to nurses wishing to become ex-smokers, whereas 54 current smokers indicated that they

NURSE EDUCATION TODAY 179

Factors nurses associate ,with their smoking

Stress

Although several authors have described nurses’ smoking within a concept of stress, for instance Hillier (1981) and Jacobson (1981a), direct links between smoking behaviour, stress and nursing do not seem to have been es- tablished (Hawkins et al 1982, Spencer 1982).

Cox (1978) uses a model of stress which suggests an imbalance between perceived demands and perceived ability to meet those demands. It is this concept of personal percep- tion which has been drawn on in this study, in that nurses’ own accounts of smoking behaviour and the associations with which it is connected, have been examined. When both smokers and ex-smokers in the study were asked about the events and circumstances which tended to lead to increases in their smoking, there was considerable agreement between the two groups. For example, over half in each group (smokers 58.3%, ex-smokers 55.5%) reported worry, stress or tension as contributing to smoking. Very few however (4.4% of current smokers) reported specific nursing situations as being associated with increased smoking. Boredom, examination and social settings (especially those with alcohol) also rated highly.

During the interview stage of the survey the general ‘worry, tension, stress’ responses were further explored. Eighteen (of 22 interviewees) did say that cigarettes helped with problems, for example the nurses who said ‘We both stopped (smoking) for three years and then a lot of things happened’ (husband made re- dundant, difficulties with her stepson) ‘and we both started smoking’.

Only 9 of the 22 mentioned work or nursing at all, and 4 of these nurses seemed to inter- weave nursing with outside factors in their lives. For instance a nurse said she smoked more ‘when I’m nervous like now, interviews, reports I suppose, sitting in company when you don’t know anybody, . . . tension, when I’m depressed, frightened . . . deaths - when my granddad died, when my bovfiiend leaves me

. . .‘. Five described cigarettes solely in the context of nursing, for example the student nurse who said ‘I still worry every time I go on a new ward . . . sitting down (with a cigarette) makes me feel more relaxed’. From the survey sample, under 25% of interviewees and very few questionnaire respondents indicate that they considered nursing to be a major factor in their habit. However, many did feel that they used cigarettes to help them cope with general difficulties. This may be associated with the separate finding that relaxation and calming of nerves was given by over half of all smokers and ex-smokers as an enjoyable aspect of their habit. From this it could be argued that the nurses surveyed did feel that their smoking was connected with stress in their lives, but that few identified a specific link with nursing.

Weight management

A few nurses, both smokers (7.8%) and ex- smokers (3.7%) from the questionnaire survey suggested that ‘trying to diet’ was significant in their increased cigarette consumption. However, material from the interviews suggested that this topic may be of considerable importance. Fifteen (all female) of the 22 nurses interviewed mentioned weight control as a problem, and several claimed that a gain in weight underlay their decision to start smoking again. One nurse describing an attempt to stop said ‘I felt old and fat and horrible. If I could get over the weight problem I would feel better’. There may be a connection with the suggestion of Chorlton (1984) that teenage girls may see smoking as a method of weight control, and also Jacobson (1981b) who suggests that women may see control of their weight as a more urgent priority in their lives than stopping smoking.

The findings of this study lead to the conclu- sion that nurses consider their smoking

behaviour to be interwoven with many aspects of their lives, and do not support the suggestion (Hillier 1981, Jacobson 1981a, Leather 1979) that nurses’ smoking may be reinforced by the uniauelv stressful nature of their hosoital work.


Links between health education and Table 4

nurses’ smoking To show linking advice to medical condition and nurses’ smoking behaviour

Estimations of ‘safe’ level of consumption

Nurses who were current smokers were signifi- Smokers Non-smokers Ex-smokers Total

cantly more likely to estimate a higher ‘safe’ AbilitY to relate information about smoking to patient’s

daily-level of cigarette consumption than nurses condition

who did not smoke. This would support Yes 24 66 No 179 233

evidence from Knopf-Elkind (1980) and Ward (1982) that nurses-who smoke themselves are Tot& 197 299

less likely to believe in the health risks of smoking (Table 3).

Chi squared=8.09 (2 DF) p=o.o1743

8 98 43 449

51 647

Table 3

To show differences in estimation of ‘safe’ level between smokers, ex-smokers and non-smokers

show ‘smoking’ nurses being less likely than their colleagues to relate advice about smoking to the medical condition of the patient. Table 5

‘Safe’ number shows that non-smoking nurses would be more

of cigarettes Ex- Non- likely than others to show disapproval to the

per day Smokers smokers smokers Totals patient.

0 153 47 259 459 I-10 45 8 38 91

11-20 6 0 0 6 Table 5

Nurses who would ‘disapprove’ of a patient 204 55 297 556 smoking

(7 respondents gave no answer) Smokers Non-smckers Ex-smokers Total

Chi squared=1 9.06 (4 DF) p-O.001 14 (Chochran’s relaxed rule) Disapprove

Yes 2 26 2 30 No 195 273 49 517

Source of information Totals 197 299 51 547 Nurses seen in interview expressed a need for more information about smoking to be Chi squared=l3.77 (2 DF)

available on the wards, their sources of infor- p=o.O014

mation at the time of interview being those available to the lay public, i.e. their own general practitioner and the television.

Opportunities for health education

Nurses were asked ‘How would you react to a request to be allowed to smoke from a patient who has been strongly advised by the doctors not to smoke?’

Respondents were allowed as many responses to this question as they wished and the answers were coded into a wide range of categories in order to try and preserve as much as possible of the flavour of the replies. There was evidence that the nurse’s smoking behaviour could affect her advice. Table -4 appears to

Very few respondents mentioned help for the patient such as provision of relevant information, focused discussion, or advice specific to the patient’s needs. In all only 16.7% of nurses identified the situation as one where specific education and discussion about cigarette smoking might be appropriate. This supports sug-

gestions such as Knopf-Elkind (1983) and Faulkner & Ward (1983) that nurses lack understanding of and skill in health education, especially in respect of smoking. A further finding from this study is that a nurse who smokes may be even lessable than her colleagues to help a patient understand how his habit and his disease are related.

NURSE EDUCATION TODAY 18 1

SUMMARY AND IMPLICATIONS

This investigation of the thoughts and feelings of nurses about cigarette smoking has provided evidence to suggest that nurses in training do not have a higher cigarette consumption than comparable members of the general population, and that most of those who did smoke had started the habit prior to their nurse training. Few of the nurses studied attributed increased cigarette consumption to specifically nursing situations. In comparison to nurses who are not current smokers, nurses who smoked believed cigarettes to be less dangerous to health, and demonstrated differences in their responses to giving advice on health education to patients. Like other smokers in the population, many of those nurses who currently smoked wanted to stop smoking and had made attempts to do so. In addition to this it was shown that nurses frequently felt guilty about their habit and considered that a direct assault by ‘policy’ would be unhelpful in their attempts to give up cigarette smoking.

family) who would like to consider stopping smoking. Such a programme might be most beneficial if it enabled nurses to identify situations where educational effort was appropriate and to develop the skills necessary to perform the task.

It is suggested here that although nursing may not lie at the root of nurses’ smoking behaviour, the problems of cigarette smokers

are very relevant to the professional practice of a nurse who wishes to take on the role of health educator. Indeed, the Statutory Instru- ment (HMSO 1983) suggests that she must accept this role.

It is hoped that in the future nurses could work towards: an understanding of the difficulties and choices which face cigarette smokers; an enhanced facility for exploiting a situation where health education might be effective; and a feeling amongst nurses that the well-being of colleagues is important. Perhaps then, all cigarette smokers with whom the nurse comes into contact would receive the skilled help and support they may need.

It is argued that a programme of effective help for nurses would need to incorporate such features as acceptance, mutual support, specific information and regular opportunities for moni- toring progress; all this, without the initiative being seen as coercive. It would also be help- ful if nurses were enabled to work on those features of their lives which they considered were influenced by cigarette smoking, for instance, weight control, social contacts and managing difficult (but not necessarily nursing) situations. It is also likely that nurses who do not smoke might value some aspects of such a programme. Help might be best if it focused on the nurse as a whole person, and was not just an isolated attack on smoking habits. Indeed given the evidence that many nurses have tried to stop smoking, are prepared to make further efforts and may feel guilty, attempts to offer assistance which is perceived as judgmental may be ineffective or even counter-productive. In addition there seems to be a need to help all nurses to understand more about the needs of smokers (whether colleagues, patients or

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Cox T 1978 Stress. Macmillan Press, Basingstoke

Faulkner A, Ward L 1983 Nurses as health educators in

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Links between nurses and cigarette smoking?