Prevalence and personal attitudes towards tobacco smoking among Palestinian healthcare professionals: a cross-sectional study

This was a cross-sectional study that targeted healthcare professionals in two governmental and five non-governmental hospitals in the city of Nablus. The number of healthcare professionals in Nablus city is estimated to be less than 2000 while the estimated number of healthcare professionals in the selected seven hospitals is estimated to be 800. None of the hospitals included in the study had a clear, written, and implemented no-smoking policy. However, verbal recommendations and wall signs of “no smoking” are loosely adopted in these hospitals.

Sample size was calculated using the Raosoft sample size calculator [20]. The sample size was calculated by anticipating at least 20% prevalence of tobacco smoking with z = 1.96 for a 95% confidence level, margin of error of 5%, and a response rate of 50%. The minimum sample size required to estimate a population parameters was estimated as 323. The study was conducted from September 01, 2017 to November 01, 2017.

Two senior medical students visited the target hospitals three times weekly (Sunday, Tuesday, and Thursday) during the study period. The study questionnaire was distributed to healthcare professionals in all hospital departments on Sundays and Tuesdays and the filled questionnaire were collected back on Thursdays. Healthcare professionals were asked to fill in the questionnaire during working hours in their workplace. Completing the questionnaire took an average of 10 min. The participants were assured of the confidentiality of the information that they provided.

A self-administered questionnaire was developed for the purpose of this study. The questionnaire was developed based on previously published studies [21, 22]. The questionnaire consisted of three parts. The first part was about demographic characteristics of the participants, night shifts, family history of smoking, and their attitudes in dealing with patients who smoke. The first part included several questions about the role of the healthcare provider in advising patients about smoking and explaining its health hazards. The second part included questions to current tobacco smokers while the third part included questions to ex-smokers. Current smokers were asked about forms of tobacco smoking they use (cigarettes, waterpipe, or both), at what age they started smoking, for how long, and the quantity they smoke by day or week. Current smokers were also asked if they smoke inside the hospital and weather stressful conditions (yes, no) inside the hospital increase their tendency to smoke. Current smokers were also asked if they think of quitting smoking and by which means. Ex-smokers were asked about the age and the reason (medical, financial, other) for quitting smoking. In the current study, definitions of current and former cigarette smokers were obtained the Centre for Disease Control and Prevention guidelines [23] while waterpipe smokers were defined as in the study of Bahrain [22].

Data collected were coded and entered into Statistical Package for Social Sciences (IBM SPSS statistics; version 21; Armonk, NY: IBM Corporation program. The main outcome variable was prevalence of current tobacco smoking expressed as a proportion (%). Most variables, such as gender, marital status, place of study, night shifts, place of living were entered as dichotomous variables (0; 1). Age variable was divided into four categories. Smoking status was divided into three categories: current smokers, never smokers, and ex-smokers. Descriptive categorical variables were expressed as proportion while descriptive continuous variables were expressed as mean ± standard deviation (SD) and/or medians and interquartile range (25th quartile–75th quartile). Statistical analysis for the association of various variables with smoking status was carried out using Chi square test using a significance level of less than 5%. Variables that showed significant association with smoking status in univariate analysis were entered into binary logistic regression to find significant predictors of smoking status. For the part pertaining to the attitudes of healthcare professionals towards smoking in clinical settings, the frequency of “yes” and “no” answers were calculated and statistically tested using Chi square test. Finally, for the ex-smokers, analysis was carried out separately because this category turned out to be small and because it is a unique category compared with current smokers and never smokers.

Ethical approval was obtained from NNU-IRB committee, the Palestinian Ministry of Health (MOH), and each hospital’s medical director. A verbal consent was taken from each participant before filling in the questionnaire.

When asked about how long they have been smoking, 50% reported that they have been smoking for at least 9 years. The mean ± SD of the starting age of smoking among current smokers was 21.1 ± 5.1 years. One hundred and forty-two (58.2%) current smokers reported that they smoke inside the hospital and 137 (56.1%) reported doing so because of the stressful conditions inside the hospital. When asked about where they smoke inside the hospital, the majority reported that they do so in hospital corridors or inside the medical staff rooms or food court. Sixty-eight (27.9%) of current smokers reported feeling embarrassed to smoke in the presence of patients and 170 (69.7%) reported that they wish they were not smokers. Only 5 (2.0%) reported that they would smoke in close distance to patients. Approximately half (119; 48.8%) of the current smokers reported that they think of quitting smoking using nicotine patches (30; 25.2%) or by strong will (89; 74.8%). When asked about why they think of quitting smoking, 87 (35.7%) cited economic reasons while the remaining stated health reasons. More than half (126; 51.9%) of current smokers reported smoking cigarettes only while the remaining (48.1%) reported smoking both cigarettes and waterpipe.

Never and current smokers included 192 (29.0%) physicians and 471 (71%) nurses and other healthcare professionals. The non-physician group include 325 (49.0%) nurses while the remaining were medical laboratory technologists, pharmacists, and medical technicians. One hundred and twenty-three (18.6%) physicians were specialists. Socio-demographic characteristics of current smokers and never-smokers are shown in Table 1. The majority (363; 54.8%) of participants were in the age category of 25–34.9 years. Younger age category (< 25 years) had significantly lower odds [OR = 0.231; 95% CI (0.124–0.427)] of being smokers compared to older age category (> 45 years). The participants included 349 males and 314 females. Male healthcare professionals had significantly higher odds of being smokers than female healthcare professionals [OR = 7.099, 95% CI (4.889–10.309)]. The majority of participants were unmarried (383; 57%). Married healthcare professionals had significantly lower odds of being smokers than unmarried health professionals [OR = 0.685; 95% CI (0.496–0.948)]. More than half of the participants (358; 54%) had a family history of at least one of their parents being smoker. Healthcare professionals with positive family history of smoking had significantly higher odds of being smokers [OR = 2.446, 95% CI (1.759–3.401)]. When asked about place of study, the majority of participants were graduates of local Palestinian Universities (522, 78%). Healthcare professionals who studied in local universities had significantly lower odds of being smokers than health professionals who studied abroad [OR = 0.454, 95% CI (0.311–0.662)]. Approximately two-thirds of the participants reported having night shifts or having on-call shifts. Healthcare professional who had night or on-call shifts had significantly higher odds of being a smoker than those who do not [OR = 1.511, 95% CI (1.085–2.106)]. No significant difference in frequency of smoking was found between physicians and other healthcare professionals (p = 0.156). Similarly, both place of work and living address were not significantly associated with the status of smoking.

Significant variables in univariate analysis were entered in binary logistic regression using enter method to find the predictors of smoking status. The dependent variable was smoking status (current smoker vs. never smoker) while the independent variables were age category, gender, marital status, place of study, family history of smoking, and having night/on-call shifts. The results of binary logistic regression indicated that older age categories, male gender, and positive family history of smoking were significant predictors of a healthcare professional being a smoker (Table 2).

The attitude of current smokers and never-smokers toward smoking was investigated. Approximately 92% of non-smokers were convinced that health professionals should advise patients to quit smoking while 81% of current smokers reported that they were convinced that they should advise patients to quit smoking (p < 0.001). Approximately 45% of non-smoker healthcare professionals reported that they always advise their patients to quit smoking while only 32% of current smokers reported doing so (p < 0.005). Furthermore, 116 (27.7%) of non-smokers reported that they follow up with their patients in smoking cessation while only 45 (18.4%) of current smokers said that they do so with their patients (p < 0.007). Approximately 89% of non-smokers reported that they endorse regulations to ban smoking of healthcare professionals in hospitals and clinical settings while 73% of smokers reported to agree on regulations that ban smoking of healthcare professionals in hospitals and clinical settings (p < 0.000). No significant difference was found between current smokers and non-smokers with regard to efforts and time spent with patients to explain negative health effects of smoking (p = 0.112) (Table 3).

Of the 708 participants, there were 45 healthcare professionals who identified themselves as ex-smokers. The majority of ex-smokers (26; 55.6%) stated that they were regular smokers for at least 5 years. Ex-smokers were 38 (84.4%) males and 7 (15.6%) females. Mean ± SD age of ex-smokers was 37 ± 12.1 years. Approximately half (51.1%) of ex-smokers had a positive family history of smoking. The majority of ex-smokers were married (77.8%). Ex-smokers included 19 (42.2%) physicians. When asked about the cause of quitting smoking, the majority (31; 68.9%) stated that they were concerned about the health consequences of smoking while the remaining stated economic reasons for quitting smoking. When asked about the method they used to quit smoking, only 6 (13.3%) stated using nicotine replacement therapy while the remaining stated strong will and sports as methods of quitting smoking.