Hemşirelerde sigara içme sıklığı ve sigara içmeyi etkileyen faktörlerin değerlendirilmesi

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Introduction
Cigarette smoking is the most important preventable risk to human health and an important cause
of premature death worldwide (1). The harmful effects
of smoking on health are now well accepted (2).
Increasing incidence of smoking in the developing
world is likely to lead to a new epidemic of smokingrelated diseases. Smoking contributes to the onset of
many diseases, and is thought to account for 87% of
deaths from lung cancer, 82% from chronic obstructive
pulmonary disease (COPD), 21% from coronary heart
disease (CHD) and 18% from stroke cases (3). The
World Health Organization (WHO) estimates that
there are about 1100 million smokers in the world.
*Department of Family Physician, Medicine Faculty of Meram,
University of Selcuk, Konya
Reprint request: Dr. Ruhuþen Kutlu, Department of Family Physician,
Medicine Faculty of Meram, University of Selcuk, 42080 Konya
E-mail: ruhuse@yahoo.com
Date submitted: January 03, 2008
Accepted: March 19, 2008
ARAÞTIRMA/ORIGINAL ARTICLE Gülhane Týp Dergisi 2008; 50: 65-70
© Gülhane Askeri Týp Akademisi 2008
Summary
In this descriptive and cross-sectional study, the frequency
of and factors affecting smoking among 919 nurses were
examined. Nurses working at the Medicine Faculty of Meram
Maternity Hospital, Social Security Hospital, Province
Health Administration of Konya and State Hospital were
included in this study. Data were obtained via a standardized questionnaire form. Of all the nurses, (13.3% male and
86.7% female) 52.4% were ever-smokers, 38.5% never-smokers, 9.1% ex-smokers and the quit ratio was 14.7%. The lowest age of starting smoking was 7, the highest age was 38
and the median value was 20. Of the participants, 51%
started to smoke at the age of 26 and over. Social factors
(environment, friends, etc.) were the first reasons to start
smoking (43.8%). Approximately, 70.2% of ever-smokers had
tried to stop smoking. In the families of non-smokers, the
ratio of never-smoking was significantly high (p<0.001). The
ratio of smoking among the close friends who were eversmokers was significantly higher than the ratio among the
non-smokers (p<0.001). Our study indicates that nearly half
of the nurses are smokers. Therefore, to prevent and
reduce smoking among nurses, further researches and more
effective smoking cessation programs should be carried out.
Key words: Health education, nurse, smoking
Özet
Hemþirelerde sigara içme sýklýðý ve sigara içmeyi etkileyen faktörlerin deðerlendirilmesi
Tanýmlayýcý ve kesitsel tipteki bu çalýþmada 919 hemþirede
sigara içme sýklýðý ve sigara içmeyi etkileyen faktörler
araþtýrýldý. Bu çalýþmaya Meram Týp Fakültesi Doðumevi,
Sosyal Sigortalar Kurumu Hastanesi, Konya Ýl Saðlýk
Müdürlüðü ve Devlet Hastanesinde çalýþan hemþireler
katýldýlar. Veriler standart bir anket ile elde edildi. Tüm
hemþirelerin (%86.7'si kadýn, %13.3'ü erkek) %52.4'ü halen
sigara içiyor, %9.1'i sigara içmeyi býrakmýþ, %38.5'i hiç
içmemiþ ve sigara býrakma oraný ("quit ratio") %14.7 idi.
Sigaraya baþlamada en küçük yaþ 7, en büyük yaþ 38, ortanca deðer 20 idi. Katýlanlarýn, %51'i sigara içmeye 26 yaþ ve
üzerinde baþlamýþlardý. Sigaraya baþlamada birinci sebep
%43.8 ile sosyal faktörler (çevre, arkadaþlar, v.d.) idi. Halen
içenlerin yaklaþýk %70.2'si sigara býrakmayý denemiþlerdi.
Sigara içmeyenlerin ailelerinde sigara içmeme oraný önemli
ölçüde yüksek idi (p<0.001). Sigara içenlerin yakýn arkadaþ
grubunda sigara içme oraný, sigara içmeyenlere oranla istatistiksel olarak oldukça yüksek idi (p<0.001). Bu çalýþmada,
yaklaþýk olarak hemþirelerin yarýsýnýn sigara içtiði görülmektedir. Bu yüzden, hemþireler arasýnda sigara içmeyi önlemek
ve azaltmak için daha ileri araþtýrmalar ve daha etkili sigara
býrakma programlarý yapýlmalýdýr.
Anahtar kelimeler: Saðlýk eðitimi, hemþire, sigara içme66 · Haziran 2008 · Gülhane TD Kutlu
Approximately 4 million deaths per year, an average of
11.000 per day are attributed to smoking (4). The WHO
has estimated that the number of deaths each year from
smoking-attributable diseases will reach to 10 million
within the next 30 years (5). If this prediction is correct,
the tobacco-related deaths are projected to surpass diarrhea, perinatal diseases and tuberculosis (6).
Cigarette smoking not only increases the risk of
death among adults, but also affects the quality of life
and physical functioning (7). According to Public
Union Survey Company results, smoking rates among
the general population in Turkey are extremely high
(62.5% in men and 24.8% in women) (8). Tobacco use
recently is the single and most important health disorder in our country. Tobacco, whether as a user or not,
transcends the multidimensional social, economic,
political and health forces impacting women (8).
Both physicians and nurses have a special opportunity to influence the health of people. The nurse should
act as a role model by not smoking and by creating a
smoke-free environment in the hospital. Nurses should
be aware that public policy regarding smoking can be an
effective instrument of public health and they have a
responsibility to participate effectively in public debate,
not only as individuals but also as the members of medical organizations (9). Since smoking represents a threat
to the public health, nurses must take a strong and
active role seeking its control. Nurses are strongly
encouraged to provide people information about the
hazards of tobacco and strategies for avoiding tobacco
use (10). To contribute to the effectiveness of antismoking campaigns targeting nurses, we conducted a
survey on the prevalence of and attitudes towards
smoking among nurses.
This study aims to monitor and document the
prevalence of tobacco use among nurses and assess their
knowledge, attitudes and behaviors towards tobacco.
Material and Methods
This descriptive and cross-sectional study was conducted between January 15 and July 20, 2005. The universe of this study consisted of 919 nurses working at
different hospitals in Konya. They were working at the
Medicine Faculty of Meram Maternity Hospital, Social
Security Hospital, Province Health Administration of
Konya and State Hospital. Participants were randomly
selected from these health-care facilities. In this study,
919 nurses (76%) were reached out of 1209 nurses
working at these health-care organizations. A standardized and anonymous questionnaire was designed.
Questionnaires were distributed with the official permission and cooperation of the hospital directors, the
directors of nursing or the general supervisors of nursing at the hospitals. In each hospital, questionnaires
were distributed and collected by the directors of nursing or the general supervising nurses. Data were
obtained via this questionnaire form. The questionnaires were collected within two weeks of distribution.
The questionnaire included 32 items and revealed
socio-demographic characteristics, smoking-related
attitude and behaviors, the status of smoking in family
and close-friends of the nurses. Current smokers were
defined as those who had smoked 100 cigarettes and
now smoked either every day (i.e., daily smokers) or
some days (i.e., some-day smokers). Ex-smokers had
smoked at least 100 cigarettes in their lives but were not
currently smoking. The minimum quitting period for
the ex-smokers was accepted as 6 months. Neversmokers were defined as those who had never smoked
(11). In this study, basically the questionnaire models
recommended by Prochaska and colleagues to identify
stages of change (12) and Fagerstrom nicotine dependence test questions (13) were used. The stages of
change model for smoking cessation identifies five
stages:
Stage 1: Precontemplation shows that no intention
to quit within next 6 months. Limited knowledge about
the consequences of smoking and resistant to change.
Overestimation of the benefits and underestimation of
the hazards of smoking.
Stage 2: Contemplation shows that seriously thinking about quitting in the next 6 months, but can be
quite ambivalent about quitting. Unsure if the long
term benefits of smoking outweighs the short term
cost.
Stage 3: Preparation shows that ready to quit within
one month. Have tried to quit in the last year or are taking steps towards quitting. Believe that the cons of
smoking clearly outweigh the pros.
Stage 4: Action shows that concrete steps towards
quitting and first 6 months after quitting. These individuals are at great risk of relapse.
Stage 5: Maintenance shows that effort to continue
life free from tobacco use.
This model has been substantiated in multiple studies. The smoker must acquire specific skills and knowledge to graduate from one step to the next before quitting. Only a small percentage of smokers (5%) move
straight from precontemplation to maintenance (12).
The quick and easy test, called the Fagerstrom Test
for Nicotine Dependence was used to determine the
level of nicotine dependence. It was developed by Dr.Cilt 50 · Sayý 2 · Gülhane TD Smoking among nurses · 67
Karl Fagerstrom, one of the world's leading authorities
on the effects of cigarette smoking. In this test, there
were six different questions related to smoking status.
For each question, the number of points indicated by
one’s answer was written down. Then we tabulated the
results. The results were evaluated as evidence of low,
medium, and high nicotine dependence (13).
What is already known about this topic?
* Nurses are always in the first step of improving of
health care.
* Cigarette smoking is the most important preventable risk to human health and an important cause
of premature death worldwide.
What this paper adds
* The nurse should act as a model by not smoking.
* Nurses have an instrumental role in tobacco
reduction. Unfortunately, they did not receive formal
training on strategies for smoking cessation.
* A special training program, seminars on the
adverse effects of smoking and smoking cessation
strategies for nurses should be prepared and carried out.
The SPSS 13.0 statistical software package was used
in data entry and analysis. The statistical analysis and
evaluations were carried out by the author. The variables were described by mean, frequency and standard
deviation (SD). To assess statistical significance between
the groups, chi-square test was used. Statistical significance was defined as p<0.05.
Results
Sociodemographic characteristics
The universe of this study consisted of 919 nurses
working at different hospitals in Konya. Of the nurses
in this study, 13.3% were male, 86.7% were female and
72.9% were married. The age interval of participants
was 19 and 59, and the median value was 27. In our
country, especially women prefer to be a nurse.
Consequently, the rate of female nurses (86.7%) was
higher than the rate of male nurses (13.3%). The
sociodemographic characteristics of the nurses surveyed
are presented in Table I.
Prevalence of smoking
In this study, of the nurses, 52.5% were current
smokers, 38.5% were never-smokers and 9.1% were exsmokers. Quit ratio (The quit ratio is the proportion of
people who have ever smoked to those who are now exsmokers) was 14.7%. The lowest age starting smoking
was 7, the highest age was 38 and the median value was
20.
Smoking-related habits
Of the participants, 51.0% started smoking at the age
of 26 and over. Social factors (environment, friend
groups, etc.) were the first reasons to start smoking
(43.8%), the second reason was stress and anxiety
(28.6%). In the majority of smokers (85.6%), duration
of smoking (year) was 10 years and over. Ninety five
point three percent of the participants thought that
smoking had no harmful effects on human health. The
habits related to smoking are shown in Table II.
In the families of non-smokers, the ratio of neversmoking was significantly high (p<0.001). The ratio of
smoking among the close friends who were ever-smokTable I. Sociodemographic characteristics of the nurses
______________________________________________________
Characteristics n %
______________________________________________________
Gender
Female 797 86.7
Male 122 13.3
Marital status
Single 249 27.1
Married 662 72.9
Age
19-24 143 15.6
25-29 308 33.5
30-34 206 22.4
35 and over 262 28.5
______________________________________________________
Total 919 100.0
_____________________________________________________
Table II. Smoking-related habits of the participants
______________________________________________________
Habits n %
______________________________________________________
Smoking status
Current-smokers 481 52.4
Ex-smoker 84 9.1
Never-smoker 354 38.5
Total 919 100.0
Daily cigarette consumption (number)
0-10 236 49.1
11-20 184 38.3
21-30 44 9.1
31 17 3.5
Age of starting smoking
7-18 100 20.7
19-25 136 28.3
26 245 51.0
Duration of smoking (years)
0-1 5 1.0
2-5 22 4.6
6-9 42 8.8
10 412 85.6
The reason to start smoking
Social factors (Environment, friend groups, etc.) 211 43.8
Distress and anxiety 142 29.6
Pleasure and fun 68 14.2
Emulation and enthusiasm 60 12.4
Stage of quitting
Precontemplators 226 47.0
Contemplators 101 21.0
Preparators 154 32.0
_____________________________________________________
≤
≤
≤68 · Haziran 2008 · Gülhane TD Kutlu
ers was significantly higher than the ratio of non-smokers (p<0.001). Smoking status of family and close
friends are shown in Table III and Table IV.
Tobacco addiction
The levels of nicotine addiction determined using
the Fagerstrom score were 0-2 (very low degree) in
51.7%, 3-4 (low degree) in 21.1%, 5 (medium) in 9.0%,
6-7 (high) in 11.6% and 8-10 (very high) in 6.6% (Table
V).
Quitting
Approximately, 70.2% of ever-smokers tried to stop
smoking. The quit ratio was 14.7%. When the smokers
were classified according to Prochaska and Goldstein's
staged changing period model of quitting, 47.0% did
not plan to quit (precontemplators), 21.0% planned to
quit (contemplators), and 31.9% was preparing to quit
(preparators). The quitters were classified according to
the period that their quitting lasted and 20.5% was in
the trial period (less than 6 months they quit). Seventy
eight point five percent was in the maintenance period
(more than 6 months). The reasons of smoking cessation were health problems (42.9%), harmful effects
(42.9%) and other reasons (14.3%).
Discussion
Before discussing the results, the limitations of the
present study must be considered. Although the overall
sample was relatively large, we could reach only 76% of
the nurses. In this context, one of the reasons can be
attributed to the stressful working conditions of nurses
and what is more, the research period (15th January-
20th July 2005) could be found as short by some. In
addition, although a quite close match, the sample was
not entirely representative of the Turkish population.
Smoking as a major public-health concern is still a
widespread habit among nurses. Nurses are in the
encouraging position to enpower individuals, families,
communities and nations in the prevention and treatment of tobacco use (14). Furthermore, nurses should
also play an active role in the control of smoking.
Reduction of nurse smoking is significant, since the
tutors of the people in matters of health have a responsibility to present a proper image (14). Although nurses
should be "exemplars" to their patients and communities, cigarette smoking is still highly prevalent among
nurses in some countries (15). Of the nurses in this
study, 52.4% were ever-smokers. This rate was particularly high when we compared with the other countries.
Ohida et al. stressed that smoking prevalence of female
nurses in the national hospitals of Japan was 18.6% (14).
This rate was higher than the prevalence of the general
Table III. Smoking status of the family
_________________________________________________________________________________________________________________
Family Never smoker Ex-smoker Current smoker Total ² p
n % n % n % n %
_________________________________________________________________________________________________________________
Mother 8 2.3 2 2.4 33 7.1 43 4.8
Father 87 25.1 21 25.6 133 28.6 241 27.0
Mother and father 1 0.3 1 1.2 10 2.2 12 1.3 15.075 0.000
Partner 87 25.1 19 23.2 113 24.3 219 24.5
Children ---- 3 3.7 6 1.3 9 1.0
Sister/brother 63 18.2 15 18.3 92 19.8 170 19.0
None 101 29.1 21 25.6 78 16.8 200 22.4
Total 347 100.0 82 100.0 465 100.0 894 100.0
_________________________________________________________________________________________________________________
*: 25 participants did not answer the question related to the smoking status of the family
Table IV. Smoking status of the close friends
_________________________________________________________________________________________________________________
Friends Never smoker Ex-smoker Current smoker Total ² p
n % n % n % n %
_________________________________________________________________________________________________________________
Mostly 144 41.1 47 56.6 309 65.9 500 55.4
Some 185 52.9 30 36.1 155 33.0 370 41.0
None 21 6.0 6 7.2 5 1.1 32 3.5
Total 350 100.0 83 100.0 469 100.0 902 100.0
_________________________________________________________________________________________________________________
*: 17 participants did not answer the question related to the smoking status of close friends
55,163 0.000
Table V. Addiction degree by using Fagerstrom test for nicotine
dependence
_____________________________________________________
The level of nicotine addiction n %
_____________________________________________________
0-2 (very low degree) 248 51.7
3-4 (low degree) 102 21.1
5 (medium) 43 9.0
6-7 (high) 56 11.6
8-10 (very high) 32 6.6
_____________________________________________________Cilt 50 · Sayý 2 · Gülhane TD Smoking among nurses · 69
female adult population (6.8%). A study with Spanish
nurses determined that the prevalence of current smokers among nurses was 34.4% (15). In the Netherlands,
while overall smoking prevalence was 33% in adults in
2001, another study found that 44% of nurses were
smokers (16). A study on Italian nurses showed that
41.0% smoked, while National Statistical Institute of
Italy found the rate of daily adult smokers to be around
25.0% in 2001 (16). Other studies determined that the
smoking prevalence of nurses varied among different
countries (18.0% in New Zealand, 21.0% in Australia,
25.0% in France, 43.0% in England, 17.0% in Canada,
37.9% in the Ninth Region of Chile, 47.7% in Madrid
and 41% in the Northern Italy) (17-22).
Nelson et al. stressed that in the United States,
while nurses had a smoking prevalence of 31.7% in
1974, this rate was 18.3% in 1991. Because banning
smoking in the hospital and anti-smoking campaigns in
which nurses have participated have been successful in
the United States and Canada (23).
Smoking rates among the general population in
Turkey are extremely high (62.5% in men and 24.8% in
women) (8). According to the research conducted by
Erbaycu et al. on health-care professionals in Ýzmir,
smoking frequency was found as 59.3% among nurses
(24). On the other hand, the research of Dilbaz et al.
revealed that the rate of smoking was 58.8% among the
nurses of Ankara State Hospital (25). In our country,
among other occupations also similar findings were
found. For example among high school teachers in
Manisa, the rate of smoking was 40.7% (26).
The rate of current-smokers was 28.7% (the rates of
smoking in females and males were 13.4% (n=15) and
35.6% (n=89), respectively) among physicians of
Meram Medical Faculty (27).
In the majority of the smokers (51.0%), the initiation age of smoking was 26 and over. The major reasons
to start smoking in 43.8% of smokers were social factors
(environment, friend groups). Unfortunately, Turkish
laws are inadequately enforced to combat smoking.
There is a light legislation against tobacco and inadequate educational program.
The prevalence of smoking among nurses was
52.4%, which was higher than the prevalence of the
general female population (24.6%). Personal factors
such as age, position, family status, social factors, distress and anxiety can be responsible for this high rate.
Our results showed that smoking status in family and
close friends negatively affected nurses.
In this study, the rate of smoking in family (only
father, only mother, partner, children, sister/brother or
both parents) was 83.2% among current smokers. The
rate of smoking in family was 70.9% among neversmokers. In the families of current smokers, the rate of
smoking was significantly higher than never-smokers
(χ²=15.075, p<0.001).
The results suggest that current smokers tend to
have more close friends who also smoke. In our survey,
65.9% of current smokers had a close friend who
smoked, while only 41.1% of never-smokers had a close
friend who smoked. The ratio of smoking among the
close friends who were ever-smokers was significantly
higher than the ratio of never smokers (χ²=55.163,
p<0.001).
Nurses have an instrumental role in tobacco reduction, which is one strategy used to address tobacco use;
a primary source of preventable morbidity and mortality globally (27). Unfortunately, they did not receive formal training on strategies for smoking cessation and felt
prepared to counsel patients on how to stop smoking.
Our study indicates that almost half of all nurses in
Konya were smokers. Having an important role nurses
should help their patients on smoking cessation techniques and inform that this high smoking rate disturbs
and indicates a severe public health problem.
Therefore, a special training program, seminars on the
adverse effects of smoking and smoking cessation
strategies for nurses should be prepared and carried out.
Acknowledgement
The author acknowledges the hospital directors, the
directors of nursing and the general supervisors of
nursing of Medicine Faculty of Meram, Maternity
Hospital, Social Security Hospital, Province Health
Administration of Konya and State Hospital for their
efforts in collecting information. The author thanks
Prof. Dr. Selma Çivi, Dr. Kamile Marakoðlu and
Z.Gözde Kutlu for their supports.