Smoking prevalence and associated risk factors among healthcare professionals in Nicosia general hospital, Cyprus: a cross-sectional study

Tobacco use has been generally acknowledged as one of the biggest public health threats ever faced, with more than one billion smokers worldwide [1]. According to the World Health Organization (WHO), smoking kills nearly 6 million people annually, an average of one person every six seconds, and accounts for 6 and 12 % of all female and male deaths respectively [1, 2]. In addition, in 2014, World Health Organization after the revision of relevant data regarding smoking, reports that tobacco use is the direct cause of more than five million deaths, while more than 600,000 deaths are attributable to second-hand smoking [1]. If current trends continue and drastic measures are not taken to control tobacco use, annual tobacco deaths are expected to rise to 10 million worldwide by 2030 [2]. The biggest impact of smoking is through non-communicable diseases, although it may also increase the risk of communicable diseases such as tuberculosis and lower tract respiratory infections [3]. It is responsible for 87 % of all lung cancer deaths [4], 42 % of chronic respiratory diseases and nearly 10 % of cardiovascular diseases [5].

Healthcare professionals should be active in smoking prevention, as part of their daily practice [6]. They should discuss with their patients the harmful effects of smoking and available smoking cessation interventions and support them through any smoking cessation process [7‐11]. There is evidence that when physicians and nurses offer specific assistance and appropriate support, a large percentage of their patients who smoke will try to quit, even those with low motivation to quit [12]. Furthermore, the smoking status of healthcare professionals appears to be a critically important determinant of their ability to assist their patients to control tobacco use. Studies suggest that as smoking rates among physicians decline, a similar reduction will be observed in the general population as well [13]. However, while in most developed countries the rate of physicians and nurses who smoke has declined significantly over the last 30 years [14], in other countries it has been maintained at very high levels and without a significant difference to that of the general population [14].

In Cyprus, smoking prevalence among the general population is 26.5 % [9] and so far, no studies have been performed regarding the prevalence of smoking among physicians and nurses. This study aims to estimate smoking prevalence among physicians and nurses working at Nicosia General Hospital (NGH), the largest hospital in Cyprus and to investigate their knowledge and attitudes towards smoking and smoking cessation strategies, as well as possible interactions with their own smoking status.

The present study examined the smoking behavior among Cypriot physicians and nurses working in NGH, which is the largest tertiary hospital of Cyprus. Smoking prevalence among physicians and nurses was slightly higher (28.6 and 28.1 %) compared to that of the general population (26.5 %) [9]. Smoking prevalence among healthcare professionals in this study was lower in comparison to results from other neighboring countries such as Greece [7, 19] (39 % among physicians and 46 % among nurses, respectively) and Turkey [14, 20] (38 % among physicians and 45 % among nurses, respectively). An encouraging finding was that the majority of the participants were classified as having low nicotine dependence (61.3 %), and 71.8 % of current smokers expressed the wish to quit.

Several countries have achieved a considerable decline in tobacco consumption among healthcare professionals in the last decades. In Cyprus however, it is not known whether smoking prevalence among physicians and nurses has increased or declined, since this is the first survey of its kind. According to some of the earliest epidemiological studies in the USA, almost 40 % of physicians smoked in 1959, a finding which has shown remarkable decline, reaching less than10% by the mid-1990s [14]. Contemporary data reveal that only 2 % of American physicians smoke [14]. A similar downward trend was also seen in the UK, where smoking rates among British doctors fell from 62 to 18 % during the period 1951–1990 [21]. A survey performed in 2011 indicated that only 7 % of doctors were current smokers, which is a significantly lower rate than in the general population (24 %) [22]. On the contrary, 45 % of Chinese and 43 % of Japanese physicians respectively, were identified as current smokers [12]. Similar results were also reported for Kuwait (38 %), Estonia (24.9 % for males and 10.8 % for female doctors) and France (34 %) [14]. Smoking rates have also declined among nurses during the last decades, this decline however, was of a smaller magnitude compared to doctors whereas, in some countries the percentage of nurses who smoke is still very high [8]. Findings from Spanish and Italian studies reported high smoking prevalence among nurses (28 % [23] and 41 % [20, 24] respectively), while according to a survey in Britain, in 2011, nurses were more likely to be current smokers (8.7 %) than doctors (7 %) [22].

Results of the present study showed that gender, age, marital status and family history of smoking were significantly and independently associated with smoking status, whereas occupation (physician vs. nurse) was not found to be associated with smoking status. This is consistent with results of other studies that showed that male and unmarried physicians [6, 7, 11, 25] and nurses [26], with a family history of tobacco use, were more likely to become smokers. Both physicians and nurses reported that their main motive to quit smoking was health problems, which is consistent with results from other studies [6, 7, 11, 25]. Nearly all surveys that have studied the smoking habits of healthcare professionals, showed that a high percentage had made at least one attempt for smoking cessation [7, 11, 19, 27, 28]. In this study, about half of physicians (48.5 %) and nurses (51.9 %) who were smokers had attempted to quit smoking in the past. An interesting finding was that physicians reported a significantly higher success rate compared to nurses (62.5 % vs. 31.5 %). Nevertheless, only 6.5 % of the participants used smoking cessation programs in their attempt to quit smoking questioning thus the availability and usefulness of such programs in Cyprus.

Other studies have suggested that the majority of physicians and nurses agree that their smoking behavior possibly influences their attitude towards counseling patients to quit smoking [19, 28, 29]. A study regarding smoking prevalence of qualified nurses in Northern Ireland, found that nurses who continue to smoke were less willing to take on the role of a health promoter towards patients who smoke [30]. This finding is supported by the results of the present study showing that current smokers discuss less often with their patients about smoking cessation interventions, compared to former and never-smokers. In addition, nurses counseled their patients more often than physicians. This may be attributed to the fact that nurses spend more time with the patients and feel that counseling may be part of their responsibilities. A study which was performed in San Francisco in 1990, found that nurse practitioners discussed smoking with patients more often than did physicians (64 % vs. 50 %; p < 0.01), asked patients more often whether they were interested in quitting (49 % vs. 40 %; p < 0.01), distributed more smoking-cessation literature to patients (37 % vs. 25 %; p < 0.01) and made more follow-up appointments (36 % vs. 19 %; p < 0.01) [31]. In contrast, an Australian study reported that nurses are too busy to discuss with their patients about smoking cessation [26].

Studies in Italian [27] and Chinese [32] populations revealed that chest physicians and healthcare providers respectively, reported lack of formal medical teaching about smoking cessation strategies. Similarly, in Bosnia-Herzegovina more than half of the healthcare professionals reported that they were inadequately prepared to counsel patients [29]. However, in our study the majority of both physicians and nurses felt confident about their knowledge regarding smoking cessation interventions. This is encouraging, since data suggest that healthcare professionals who felt confident about their knowledge, counsel their patients to quit smoking more often. An encouraging finding of this study was the fact that current smokers were positive towards receiving specialized training for smoking cessation, during their career. However, there was a group of doctors who seem to ignore the harmful properties of smoking and admitted that they do not recommend smoking cessation in situations like lung problems (7.5 %), use of contraception pills (44.8 %), damage in mouth and lips (47.8 %), pregnancy (13 %), nervousness and anorexia (58.2 %), and insomnia (59.7 %). This could be attributed to possible knowledge gaps about the destructive effects of smoking or due to their own smoking behaviors. The latter finding is in line with other studies reporting that many healthcare professionals smoke in front of their patients [7, 25, 28] and agree with the statement that smoking is not as harmful as experts declare [11]. In our study, only a small group of participants reported smoking in front of their patients (5.9 % of physicians and 8 % of nurses respectively), indicating failure to fulfill their function as role models for their patients and society.

In the context of harmonization of Cypriot legislation with European directives on smoking, the provisions of the law “Protection of Health-Tobacco Control” were applied in 2010. The law specifically prohibits smoking in recreational areas and in enclosed public places. However, the main problem observed is the failure to practically apply the legislation in most areas, even in hospitals. Healthcare professionals who are smokers, still smoke even at the hospital setting. So far additional measures to ban smoking have not been taken among healthcare professionals, however the Ministry of Health will proceed with the preparation of Regulations in an effort to improve legislation and enhance the efforts for its implementation [33].

According to the results of this study, smoking prevalence among healthcare professionals was 28.2 % in Cyprus, reflecting the prevalence of the general population. Factors associated with smoking status were age, gender, marital status and family history of smoking. Regarding the attitudes of healthcare professionals towards counseling patients to quit smoking, the study showed that their personal smoking behavior affected their intention to counsel patients to quit smoking. The results of this study support the need for further training of healthcare professionals towards smoking cessation strategies in order to improve their knowledge and consequently their efforts of providing counseling and support to their patients who wish to quit smoking.