Background

Smoking is a global public health problem, with 1.3 billion smokers worldwide [1]. It is estimated that 8 million people die annually from the effects of smoking globally, of which 1.2 million deaths are associated with passive smoking [1].

Smoking is also a public health problem in Croatia, as evidenced by the results of the study conducted in 2014 and 2015 by the relevant Croatian and international public health authorities. According to the study results, 31% of the population aged over 15 smoked in Croatia (35.3% of men and 27.1% of women) [2].

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed in response to the globalization of the tobacco epidemic. The FCTC is the first international global health treaty and the evidence-based treaty that reaffirms the right of all people to the highest standard of health, which came into force in 2005 [3]. The WHO introduced the six MPOWER measures in 2008 to guide countries in this process, each corresponding to one or more FCTC provisions. The MPOWER package includes: monitoring tobacco use and tobacco control measures; protecting people from tobacco smoke; offering help (e.g., treatments) to quit tobacco; warning people about the dangers of tobacco; enforcing bans on tobacco advertising, promotion and sponsorship and raising tobacco taxes [4].

Although Croatia is one of the countries that are a Party to the WHO FCTC, comprehensive tobacco control policies are yet to be fully implemented. The least implemented FCTC article is cessation support through advice from healthcare providers, telephone quit lines and easily-accessible or low-cost medications (Article 14 of the FCTC) [5].

Nurses make up the largest healthcare profession in the world. Approximately 27 million men and women comprise the global nursing and midwifery workforce, accounting for nearly 50% of the global health workforce [6]. In addition, there is evidence that behavioral support to motivate and sustain smoking cessation delivered by nurses can increase the number of people who achieve prolonged abstinence [7].

Nurses play a vital role in primary health care delivery worldwide – including research, disease prevention, treating the injured, palliative care and more – which is represented through several World Health Assembly resolutions [6]. Among other roles, Croatian nursing law stipulates that a nurse has to be a counsellor to help people focus on a goal or outcome, develop strategies that support self-care, and enable individuals and their families to take responsibility for and participate in decisions about their health [8]. Thus, advising patients to stop smoking is part of a nurse’s role.

Two well-known methods to help people quit smoking are the ABC method (ask, brief advice, cessation support) [9], and the 5As (ask for the smoking status, brief advice to quit, assess the motivation to quit, assist by providing evidence-based treatment, arrange follow-up) [10].

Furthermore, the counseling intervention can be captured by the 5Rs: relevance, risks, rewards, roadblocks, and repetition, which includes an additional brief intervention to enhance the motivation to quit in unmotivated smokers [10].

There is evidence that increasing the reach and intensity of smoking cessation services across the health sector might help people quit smoking. For example, a Cochrane systematic review published by Rigotti et al. in 2012 examined interventions offered to hospitalized patients for smoking cessation, including behavioral, pharmacological or multicomponent interventions. They concluded that intensive interventions that begin in the hospital with nicotine replacement therapy increase the rate of smoking cessation [11]. Additionally, multiple studies demonstrated that interventions provided by nurses could lead to an increase in the number of people who stop smoking or prolong abstinence [7, 12].

In 2015, Sarna et al. conducted a study in the Czech Republic and examined the frequency of nurses’ interventions in helping smokers to quit smoking, their attitudes and skills, and investigated the association between nurses’ smoking status and the level of intervention they implement [13]. The study showed that consistent intervention by nurses to help patients quit smoking was relatively rare in the Czech Republic, and some nurses were unwilling to intervene with patients on the topic of smoking cessation. Although the study of Sarna et al. included only nurses in the Czech Republic, it is possible that these results may be similar for nurses in other countries of Eastern and Southeastern Europe since smoking rates are very high in the countries of that area (both in the population and among nurses), and interventions by nurses (and other professions) are not part of routine clinical practice [13].

Nurses have an important window of opportunity to intervene with patients during their hospital stay or introduce the notion of not resuming smoking upon hospital discharge [7]. In addition, previous research shows that training nurses to implement smoking cessation interventions is extremely important and increases their willingness to participate in such programs [14, 15].

Li et al. have summarized literature about factors associated with nursing interventions for smoking cessation. They reported that nurses’ attitudes or perceptions, social influence, organizational factors and self-efficacy were associated with implementing smoking cessation interventions [16]. In addition, the authors highlighted that support and assistance are needed for nurses [16].

In Croatia, no continuous interventions are aimed at patients to stop smoking [5]. Furthermore, we could not find any studies in the literature about knowledge, attitudes and implementation of smoking cessation interventions among nurses in Croatia. Having such knowledge could help support nurses in implementing smoking cessation interventions in Croatia.

Thus, this study aimed to examine which interventions for smoking cessation are carried out by nurses in Croatia and to examine their knowledge and attitudes about these interventions.

Methods

Study design

This was a cross-sectional study.

Ethics

The study was conducted in accordance with the institutional Codes of Ethics. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all study participants.

The study protocol was approved by the Ethics Committee of the Sestre Milosrdnice University Hospital Center (Document number: Klasa 003–06/22-03-003; Urbroj: 251-29-11-22-01-9).

Participants

The participants were nurses employed at the Sestre Milosrdnice University Hospital Center at the Department of Internal Medicine, the Department of Oncology and Nuclear Medicine, the Department of Cardiovascular Diseases, the Department of Neurology, the Department of Neurosurgery, the Department of Surgery, the Department of Psychiatry and the University Hospital for Tumors. Those departments were chosen as their patients are hospitalized longer than in other departments, so there are more opportunities for healthcare workers to implement interventions for smoking cessation.

Data collection and study tool

In agreement with the head nurses of the departments, the participants were approached at their workplaces. Participation in the study was voluntary and anonymous. The study was conducted via a questionnaire from April to June 2022 (Appendix 1). The participants were approached in person in their workplace by author Lovro Ackar. Since the survey was conducted in early 2022, during the COVID-19 pandemic, there were still heavy restrictions in the hospital to the in-person access to nurses, and thus not all nurses that worked in the targeted departments were invited. We invited a convenience sample of nurses that we could contact in person. The participants received written information about the study, informed consent and the survey, and the kind request to participate. Nurses filled out the questionnaire in their department after reading the study information and signing the written informed consent. Surveys were filled out in paper form.

The first part of the questionnaire contained five questions about the sociodemographic data of the participants, including sex, professional education, smoking status, the department where they work and years of nursing experience. The second part of the questionnaire included the Helping Smokers Quit (HSQ) survey, developed and validated by Sarna et al. [17]. We obtained permission from Prof. Linda Sarna to use the questionnaire. The questionnaire consists of questions related to the frequency of implementation of the 5 A (Ask, Advise, Assess, Assist, Arrange) intervention for smoking cessation in addition to items about referring to a telephone quitline for cessation support, recommending tobacco cessation medications, reviewing barriers to quitting, and recommending a smoke-free home. Nurses assessed the frequency using one of five responses, including “always“, “usually“, “sometimes“, “rarely“, or “never“.

Furthermore, the questionnaire contained questions about the smoking status of nurses and their education about smoking cessation. At the end of the questionnaire, items about their attitudes toward smoking cessation interventions and perceived skills for implementing such interventions were scored with a 5-item Likert scale ranging from “completely disagree” to “completely agree” [18, 19] (Appendix 1).

The questionnaire was delivered in the Croatian language. For the study, the questions were translated into Croatian from English. Before delivering the survey to the nurses, the questionnaire was tested on a sample of nursing students employed in the healthcare system who were not part of the study sample. The pilot testing was used to assess the readability and understandability of the questionnaire. Following the pilot testing, there were no revisions to the questionnaire.

Statistical analysis

Data were analyzed using descriptive statistics, including frequencies, percentages, medians and interquartile range. A simple analysis of variance was used to compare the average number of respondents. We compared the association between the implementation of smoking cessation interventions among nurses who smoke and those who do not. We did not use any imputation methods. The value P < 0.05 was used as the level of significance. The SPSS software (version 20, IBM, New York, USA) was used for statistical analysis.

Results

There were 824 nurses employed in the targeted departments. However, due to COVID-19 restrictions on access to nurses, 340 questionnaires were distributed to nurses; 258 were filled out and returned (response rate: 31%). Raw data collected within this study are included in Appendix 2, which accompanies the manuscript.

The median age of participants was 36 years (interquartile range: from 26 to 48 years). The participants had a median of 12 years of nursing experience (interquartile range: 4 to 12 years). Most participants (88%) were women. Most participants were employed at the Department of Cardiovascular Diseases and the Department of Surgery. Most nurses completed Bachelor’s degree in nursing as the highest educational degree (Table 1).

Table 1 Characteristics of participants in terms of sex, education and department of employment
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Among the participants, 44% (N = 110) were smokers, and 9.6% (N = 11) smoked within five minutes after waking up. More than half of nurses smoked daily (54%; N = 139). One hundred twenty-two participants responded to a question about whether they tried to stop smoking within the past year; 39% (N = 48) indicated they did. When asked if they were trying to quit smoking currently, 147 participants responded, and 15% (N = 22) indicated that they did (Table 2). The median age when they started smoking was 18 years (interquartile range: 16 to 20 years). For those who stopped smoking, the median age when they stopped smoking was 31 years (interquartile range: 24 to 40 years).

Table 2 Smoking status of the participants
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When asked about their training, 82% (214) of participants indicated that they did not participate in any smoking cessation education during their training. Furthermore, 96% (N = 243) of participants indicated that they did not take part in any education regarding smoking cessation within the past 24 months.

There were 61% (N = 159) of nurses who indicated that they always or usually ask patients about their smoking status; 29% (N = 75) always or usually advise them to stop smoking; 24% (N = 61) assess readiness to quit smoking always or usually. There were 13% (N = 35) of nurses who indicated they always or usually assist with smoking cessation; 8% (N = 20) always or usually arrange smoking cessation follow-up; 5% (N = 13) always or usually recommend the telephone smoking quitline. There were 12% (N = 31) of nurses who indicated they always or usually refer patients to community cessation resources; 5% (N = 13) recommend always or usually tobacco cessation medications; 10% (N = 24) review barriers to quitting always or usually, and 13% recommend patients to create a smoke-free environment (Table 3).

Table 3 Frequency of nurses’ delivery of smoking cessation interventions
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Responses to items regarding nurses’ attitudes about helping patients quit smoking revealed that most participants chose neutral responses, i.e., they neither agreed nor disagreed with the items (Table 4). There were 24% (N = 62) of participants who agreed or strongly agreed that asking patients about smoking increases the likelihood that they will quit. 54% (N = 138) of participants agreed or strongly agreed that it is difficult for them to get people to quit smoking. 24% (N = 62) agreed or strongly agreed that counseling patients about quitting is not an efficient use of their time. 20% (N = 50) agreed or strongly agreed that patients appreciate it when they provide advice about quitting smoking. Only 13% (N = 33) agreed or strongly agreed that discussing smoking cessation improves their relationship with patients, while 15% (N = 46) agreed or strongly agreed that they feel uncomfortable asking patients whether they smoke (Table 4).

Table 4 Nurses’ Attitudes About Helping Patients to Quit Smoking
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46% (N = 115) of participants agreed or strongly agreed that, as a nurse, they could play an important role in helping patients quit. 38% (N = 96) agreed or strongly agreed they need more training to help patients quit smoking. Among participants, 54% (N = 136) agreed or strongly agreed they have insufficient time to counsel patients about quitting smoking. 33% (N = 83) agreed or strongly agreed they should take a more active role in helping patients to quit smoking. 19% (N = 48) of participants agreed or strongly agreed that patients would be offended if they inquired about their smoking status (Table 4).

Half (N = 128) of the participants agreed that providing tobacco cessation counseling is important to the hospital, even if only a few patients quit. There were 47% (N = 119) of nurses who agreed or strongly agreed with a statement that they have an obligation to advise patients on the health risks associated with tobacco use (Table 4). However, very few participants, only 4.7% (N = 12), indicated that over the past week, they counselled more than five patients about smoking cessation (Table 4).

When they had to score statements about nurses and tobacco control, most nurses chose neutral responses (Table 5). 47% (N = 119) of participants agreed that nurses should set a good example by not smoking, 48% (N = 122) agreed that nurses should be involved in actively helping patients to stop smoking, and 48% (N = 121) agreed that nurses need additional training/skills in tobacco control (Table 5).

Table 5 Participants’ responses regarding statements about nurses and tobacco control
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At the end of the questionnaire, participants were asked to rate two questions with a Likert scale ranging from 1 (least important) to 5 (most important). Most participants chose a neutral response regarding the importance of nurses’ involvement in tobacco control activities (37%; N = 96). Also, when asked to assess how important it is for nurses to be involved in tobacco control activities, compared to other disease prevention activities (e.g., nutrition, exercise, etc.), most participants chose the neutral response (38%; N = 97).

Analysis of variance was conducted to analyze the association of items regarding nursing interventions for smoking cessation and nurses’ smoking status (Table 6). Among all questions and items given to the participants, a significant difference in the frequency of responses was noted for the item on reviewing barriers to quitting (P = 0.010) – nurses who smoke were engaged in such behavior significantly less than those that do not smoke. Also, we found a significant difference in the responses to the statement “Nurses should set a good example by not smoking“– agreement with this statement was more common among nurses who did not smoke compared to those who smoke (P < 0.001) (Table 6).

Table 6 Distribution of participants with regard to personal smoking status and questions/items regarding smoking cessation interventions implemented by nurses and their attitudes towards those interventions
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Discussion

We found that almost half of the nurses (44%) who participated in the study were smokers. Slightly less than half of the respondents (43%) always ask the patient if they use tobacco products, thus opening up the possibility of using interventions to stop smoking. Very few respondents indicated that they always help the patient to quit smoking. Almost all respondents did not receive any education in the past two years that would have provided them with the knowledge and skills to assist in quitting smoking, and most never had such education while they were attending nursing school. Few differences in the use of nursing interventions and attitudes towards those interventions were observed between nurses who smoked versus those who did not.

According to US Centers for Disease Control data, 25% of nurses worldwide consume tobacco products. Studies conducted during the COVID-19 pandemic indicated that a high percentage of nurses consumed tobacco, alcohol or other substances due to anxiety, stress and the effect of the pandemic [20, 21]. In 2019, Nilan et al. published a systematic review and meta-analysis of the prevalence of tobacco use in healthcare workers. They included 229 studies representing 457,415 healthcare workers from 63 countries. They found that the overall pooled prevalence of tobacco use in healthcare workers was 21%, with 31% in men and 17% in women. The highest estimates for the overall pooled prevalence of tobacco use were found for men physicians and women nurses. The percentage of women nurses smoking in high-income countries was 21%, and in upper-middle-income countries, it was 25% [22].

Compared to these countries, the percentage of smokers in this study was very high, as 44% of nurses in our sample indicated they were smokers. Furthermore, almost 10% of them have their first cigarette within five minutes of waking up. This finding indicates that many nurses probably have a problem with nicotine addiction since the time of the first cigarette upon waking is one of the indicators of the heaviness of smoking or high nicotine addiction [23].

A nurse should be sufficiently educated, eloquent, professional, kind, and must possess many skills to provide high-quality healthcare. Nursing interventions also include counseling and the promotion of a healthier lifestyle. For example, in this study, almost half of the nurses stated that they always ask patients about their smoking status. The same distribution of responses was found in a study from the Czech Republic conducted on a sample of 157 nurses [13].

We found that most nurses were not ready to help the patient quit smoking, and the question is whether they are even aware of the importance of their role in this. Research on this topic has been conducted in other countries as well. The same problem was encountered with registered nurses in China; most indicated that they asked patients about their smoking status, but few were willing to help with smoking cessation interventions [24].

In our sample, most nurses never advised patients to use the smoking cessation hotline. It is unclear whether the nurses are aware of the various existing resources for smoking cessation in the community. Also, most nurses rarely or never recommend patients’ treatment in the community (clinics, counseling centers, etc.), and most do not recommend medicines that help in smoking cessation. A study conducted by Sarna et al. in the Czech Republic showed that slightly less than 15% of nurses always recommend community treatment compared to surveyed nurses in Croatia, who always recommend community treatment in less than 3% [13].

Sarna et al. concluded that their data demonstrate that consistent nursing intervention to help patients quit smoking in the Czech Republic is relatively rare. Also, some nurses were reluctant to intervene with patients on this topic [13].

As for the nurses’ attitudes, they were mostly neutral about most of the statements about nurses and smoking cessation interventions. This could be seen as taking the “line of least resistance” and against making additional effort within their working framework. A third of nurses indicated that patients would not change their smoking habits if asked about their tobacco product consumption habits. More than 40% considered persuading the patient to quit smoking difficult. Such reasoning is likely due to the lack of nurses’ self-confidence and professional limitations since less than 10% of nurses agreed that they could persuade a patient to stop smoking. Professional self-confidence is a part of professional identity, competence, clinical knowledge and reasoning that could be lacking in this field [25].

Many nurses were aware that their role in smoking prevention is important, as 36% of them agreed that counseling on quitting is not a waste of time – this was in contrast to the 24% of nurses who agreed that counseling is a waste of time. However, less than a fifth of them indicated that patients appreciate being advised, and almost half indicated that discussing smoking will not lead to a better relationship with the patient. This is far from the recommendations of professionals who advise smoking cessation as part of health promotion. Health promotion is achieved by advocating the basic prerequisites for a healthy life, enabling the patient’s health potential and mediating between patients and their social interests [26].

Participants’ responses regarding their education about smoking cessation could be a reason for this inactivity. More than a third of respondents agreed that they need additional education regarding smoking cessation and that they should become active in the field of patient education and counseling. This is essential information that should be considered if programs for nurses were to be built on the control of tobacco products and patient counseling so that they could be empowered to engage in interventions that could help patients in smoking cessation. In addition, other research results strongly support the need for additional education for nurses regarding smoking cessation [13].

Few participants in our study received education on smoking cessation, and almost half of the respondents indicated they needed education on quitting smoking. Those results align with many prior studies that showed nurses report a lack of education regarding smoking cessation [7, 13, 27,28,29].

We found very few differences in behaviors and attitudes of nursing regarding interventions for smoking cessation. In a review regarding the smoking habits of nurses and interventions towards patients between 1996 and 2015, Duaso et al. showed that the personal smoking status of nurses is not significantly related to nurses questioning patients about their smoking. It was also confirmed that nurses who smoke were 13% less likely to advise their patients to stop smoking and 25% less likely to arrange to stop smoking afterwards [30].

The feasibility of the multimodal intervention for smoking cessation in a hospital setting in Croatia was proven in a recently published pilot study. Patients were very satisfied with the intervention, and high smoking abstinence rates were recorded at six-month after hospital discharge. Thus, healthcare workers employed in hospitals could be educated to provide such interventions regularly [31].

Nurses should engage in interventions for smoking cessation. Patients trust nurses the most among healthcare professionals; thus, they could play an important role in the smoking cessation effort among patients. Unfortunately, this research has shown that only some nurses engage in interventions that could help patients quit smoking. It is acknowledged that nurses may be overloaded with their other duties. However, if they became aware of the importance of participating in smoking cessation, they could help the patient and contribute to greater personal and work satisfaction.

Nurses’ education on smoking cessation counseling could potentially reduce the number of smokers since nurses are the most numerous workforce in Croatia, and properly focused education of nurses about helping patients with smoking cessation would certainly have an impact [32].

A limitation of our study is that we have included only one hospital in Croatia. However, the study was conducted during the COVID-19 pandemic when personal contact with healthcare professionals in hospitals was extremely limited. Future studies in this area should explore interventions for helping nurses quit smoking. Also, researchers should test the efficacy of various interventions that will help nurses change their attitudes towards nursing smoking cessation interventions and foster their engagement in such interventions. Studies reporting the design and evaluation of such interventions and their acceptability to nurses will help us design and implement successful interventions in the future. After adopting such interventions, future follow-up studies should explore nurses’ attitudes, experiences and implementation of smoking cessation practices. In that respect, our study can serve as a benchmark, reporting the baseline data that can serve as a comparison for future studies in Croatia on this topic.

Of note, there were missing data in several surveys, as not all participants answered all of the questions. The percentage of missing answers in any given question was at most 5%.

Conclusion

Our results point to the importance of educating nurses about smoking cessation interventions they could engage in. Furthermore, our results point to the need for introducing courses about smoking cessation during the nurses’ compulsory education, with which they would acquire competencies for implementing smoking cessation interventions in the workplace. Likewise, the high prevalence of smoking among nurses indicates the need to develop smoking cessation interventions targeting nurses and other healthcare workers who smoke.