Nurses say their smoking affects patient care

Some less likely to intervene with smoking patients

Nurses who smoke experience feelings of guilt and embarrassment, and also might be less likely to intercede with patients to encourage them to quit smoking because they feel to do so would be hypocritical.

"Nurses who smoke feel terrible about smoking; there are very, very few nurses who feel good about it, just like there are very few smokers at all who feel good about it," says Stella Aguinaga Bialous, RN, DrPH, president of Tobacco Policy International in San Francisco, who consults for the World Health Organization and is an investigator for the Tobacco Free Nurses Initiative (TFNI), which is providing nurses tools especially tailored for their career and schedules to help them kick the habit and help their patients.

"Like most smokers, the nurses we talk to want to quit. They wish they could quit, but it’s a powerful addiction, and it’s hard to quit," Bialous notes.

For nurses and other health care professionals, there’s an added twist to the addiction. "They feel worse because there’s a social expectation for them to be a role model for healthy behavior, and they realize they’re not if they smoke," she says.

TFNI interviews with nurses revealed that nurses who smoke sometimes fail to intercede with patients about cigarette smoking because they themselves are smokers, and so feel hypocritical in telling others to quit. In addition, they have not been trained effectively to intervene with patients about smoking.

TFNI provides nurses ways to address both problems, and research has provided much new information on women and tobacco use, according to Linda Sarna, RN, DNSC, FAAN, lead investigator for TFNI and a professor at the UCLA School of Nursing. "Nurses describe becoming addicted when they were very young," she adds. "Then, coming into schools of nursing and going on to employment, quitting was very difficult. And they didn’t have support available to them to help them quit."

Much of what Sarna has learned about nurses and smoking came from a study she and other researchers from UCLA’s Jonsson Cancer Center conducted, in which they talked with smokers, nonsmokers, and former smokers in the nursing profession. They found that smoking is a workplace issue — not just an individual behavior.

Smoke breaks, or no breaks

Sarna says that in the sometimes grueling schedule of a nurse, the only available excuse to leave for a break was to satisfy a craving for nicotine. "Smoking among nurses was described as an integral part of their work routine, affecting management of patient care and timing of breaks," the study explains. "The perception that smokers take more and longer breaks, and are less available for patient care, was an important theme in discussions with both smokers and former smokers, and clearly created conflict in the work environment," the study continues.

Sarna says some nurses told her the only breaks they get are smoking breaks. "One critical care nurse, a nonsmoker, told us that she never gets a break — that only the smokers got a break because they needed it," she adds.

This line of thinking leads, in some cases, to "war between smokers and nonsmokers," Sarna explains, because it causes a perception that the smokers, because they take breaks, are less involved in patient care. The smokers, however, contend that they get just as much work done and are more organized because they don’t want anything to interfere with their smoke breaks.

Smoking among nurses affects interactions with patients, Sarna says. Nurses who smoke are less likely to intervene with patients who smoke, and they experience a high degree of shame and guilt about their smoking, taking steps to try to hide the evidence of their smoking, such as repeated brushing of teeth, frequent hand washing, and wearing cologne.

The study shows the need to develop work-based strategies and programs to support cessation efforts.

"The benefits of supporting smoking cessation in the workplace could have an immediate positive impact on nurses’ health, and might result in other positive outcomes [e.g., reduced sick time]," the study concludes. "The benefit to patients must also be emphasized, as nonsmoking clinicians are more likely to provide cessation interventions than their smoking counterparts."

Bialous says the resentment some nurses feel about being singled out compounds the guilt they carry as a result of their smoking. "Some nurses feel resentment that they are held to a different standard, and that’s probably just another expression of that conflict they feel," she says. "They said, over and over, that the least helpful thing people can do is point fingers, yell, or say, Don’t you know any better?’ because, of course, they do know better.

"The point is not whether they know they shouldn’t be smoking, but how we can help them stop," Bialous stresses.

Research leads to on-line help site

While the majority of nurses do not smoke, Sarna notes, about 16% of the 2.3 million nurses in the United States do smoke — the highest rate among all health care professionals. Compounding the problem is the lack of support for cessation programs. Nurses often are too embarrassed to admit their smoking habits, so do not seek out cessation programs if they are offered at the workplace.

What Sarna and the other Jonsson researchers found led to the creation of a web site — www.tobaccofreenurses.org — a resource for cessation programs, evidence-based facts about smoking and cessation, and 24-hour support for nurses wanting to quit the habit. "Nurses are working in a very stressful environment, and that makes it even more difficult to quit," Sarna notes.

Plus, going into a public cessation group and saying "I’m a nurse" is a prospect some nurses find humiliating, Bialous adds. "That’s why we went with an Internet-based program," she says. "Some hospitals have hospital-based programs open just to other nurses and doctors, and they do feel comfortable with those, but not everyone has them."

Sarna and Bialous say nurses have told them that workplace support as they try to kick the habit is critical.

Armed with evidence that nurses provide their peers with the best support in efforts to quit smoking, tobaccofreenurses.org provides facts, downloadable brochures, and a link to Nurses QuitNet, a site affiliated with Boston University School of Public Health that provides on-line support and community for nurses who want to quit smoking. The free service allows nurses to create their own quit-smoking plan, get advice from experts, and peer support from other nurses who are quitting or have quit.

Bialous says there are benefits to patients when nurses are able to quit smoking. "Nurses who have successfully quit smoking can identify with the addiction and can tell the patients, Hey, I’ve been there, and this is how I did it, and I am here to help,’" she notes. "They feel stronger about their ability to help.

"And by helping nurses, we will be helping improve the quality of care for all patients, because the nurses will be better prepared to provide intervention and cessation help to their patients," adds Bialous.

For more information, contact:

  • Stella Aguinaga Bialous, RN, DrPH, President, Tobacco Policy International, San Francisco; Investigator, The Tobacco Free Nurses Initiative. Web: www.tobaccofreenurses.org.
  • Linda Sarna, RN, DNSC, FAAN, Lead Investigator, The Tobacco Free Nurses Initiative; professor, UCLA School of Nursing. Phone: (877) 203-4144. E-mail: lsarna@ucla.edu.

For resources to help nurses quit smoking, contact:

  • Tobacco Free Nurses Initiative, UCLA School of Nursing, Factor Building, R4-262, Box 956918, Los Angeles, CA 90095. Phone: (877) 203-4144. Web: www.tobaccofreenurses.org.
  • Nurses Quitnet, nurses.quitnet.com. Phone: (617) 437-1500.