Globally, tobacco use kills approximately 6 million people every year, including over 600 000 individuals who will die due to exposure to second-hand smoke. If current trends continue smoking will be responsible for over 8 million deaths annually by 2030, of which approximately 80% will occur in low and middle income regions (WHO, 2012). Tobacco use also represents one of the leading causes of preventable death in the world today, which puts healthcare professionals in an ideal position to help meet the threat that smoking currently poses. Nurses occupy a critical position at the forefront of primary health care, both as trusted healthcare providers and also as role models for appropriate health behavior. Despite this fact, however, the nursing profession is not entirely smoke-free, and in certain countries a sizable proportion of their demographic continues to use tobacco (Smith & Leggat, 2011). Much can be learned from tobacco usage data collected among healthcare professionals, not the least of which is understanding exactly how many of them smoke. Although there are at least 1.6 million nurses in China (Yun et al., 2010), surprisingly few studies have investigated the smoking rates of Chinese nurses, with no data being available in regions such as Shandong.
From 100 surveys distributed, a total of 88 nurses responded (88%), from whom tobacco-related data were provided by 83 respondents (94%). Most of the respondents (95%) were female, with almost two-thirds (64%) aged between 25 and 35 years. Most (66%) worked an average of between 40 and 50 h per week, one-third (33%) had a career duration of less than 5 years, with 42% having a career duration of between 5 and 9 years. The overall smoking rate among nurses in this study was very low (1%) and no male nurses reported themselves to be current tobacco users.
This study was undertaken as one of the first investigations of nurses' smoking habits in Shandong Province, China. For a country with over 1.6 million nurses, surprisingly few studies have described their smoking rates, as shown in Table 1. One of the earliest investigations appears to have been conducted in 1989 and indicated that less than 2% of Chinese nurses smoked. A study conducted in Beijing during 1993 reported a 7% smoking prevalence rate among nurses (Wu & Weng, 1997). Other, more contemporary research has reported nurse smoking rates of 3% in Hebei (Smith et al., 2005a), 2% in Guangdong, Shanghai, Beijing and Chongqing (Chan et al., 2007), and 1% in Hunan (Yan et al., 2008). Such results are consistent with the 1% rate identified in the current study conducted in Shandong. The consistently low rate of smoking among Chinese nurses in various geographical locations is particularly impressive, given that regional differences have been documented with regard to community smoking rates (Li et al., 2012) and smokers' awareness of tobacco advertising, promotion, and sponsorship (Yang et al., 2010). Furthermore, some evidence suggests that this relatively low rate may continue in future years, with a recent study of Chinese nursing students, for example, reporting that less than 4% of their respondents smoked (Zhang et al., 2012b). Higher smoking rates have been reported among nursing students in other countries (Smith & Leggat, 2007b). The general low smoking rates among Chinese nurses is also encouraging from an international perspective, given that research from other countries has documented tobacco usage rates of up to 50% among nurses. A selection of some recent publications in this regard is displayed in Table 2 – an examination of which suggests that, when compared internationally, smoking rates are very low among Chinese nurses.
Table 1. Research studies describing the smoking rates of Chinese nurses
|Beijing||1993||–||–||7||3||90||1214||86||Wu & Weng, 1997|
|Hong Kong||1997*||16||–||–||3||81||92||46||Callaghan et al., 1997|
|Various¶||2003||2||–||–||1||97||1690||78||Chan et al., 2007|
|Hunan||2003||1||–||–||1||98||278||78††||Yan et al., 2008|
|Hong Kong||2005*||1||–||–||–||–||1843||50||Johnston et al., 2005|
|Hebei||2005*||3||52||–||0||97||509||98||Smith et al., 2005a|
|Fujian/Henan||2008||1||–||–||–||–||1012||78||Wu et al., 2011a|
|Fujian||2008||–||–||2||–||–||947||79||Wu et al., 2011b|
|Hong Kong||2010*||–||–||7||–||–||617||63||Twinn et al., 2010|
Table 2. International smoking rates among nurses
|Australia||Berkelmans et al., 2011||11||22||10|
|France||Fathallah et al., 2012||30||32||30|
|Italy||Ficarra et al., 2011||50||–||–|
|Japan||Taniguchi et al., 2011||8||–||–|
|Macedonia||Minov et al., 2011||–||–||29|
|Portugal||Ravara et al., 2011||26||–||–|
|Spain||Fernandez et al., 2010||29||29||30|
|United Kingdom||Lewis et al., 2011||9||–||–|
|United States||Sarna et al., 2012||–||–||12|
Nursing professionals in various other countries have also been setting positive examples by not smoking. For example, it has been reported that only 8% of Japanese nurses (Taniguchi et al., 2011) and 9% of nurses from the United Kingdom currently smoke (Lewis et al., 2011). Data from the New Zealand census, which has included a question on smoking status since 1976, suggests that the smoking prevalence of nurses in that country (17%) is below that of the general working population (22%) (Edwards et al., 2012). On the other hand, the current rate of smoking among female nurses in the United States, while being lower than that of the general female population (12% vs 17%) (Sarna et al., 2012), is still above 10%. Furthermore, a variety of studies have documented relatively high smoking rates among nurses in other countries; including 26% in Portugal (Ravara et al., 2011) and 29% in Spain (Fernandez et al., 2010). Nurse smoking rates of 30% have been documented recently in France (Fathallah et al., 2012), while a study from Italy (Ficarra et al., 2011) found that half of their respondents smoked.
While tobacco usage rates can fluctuate, longitudinal research of the nursing profession suggests that in many countries, smoking rates have generally declined over time (Smith & Leggat, 2007a). For example, certain Australian studies reported the prevalence of nurses' smoking to have declined from around 50% in the 1970s to approximately 20% in the 1990s (Smith & Leggat, 2011), with the most recent study suggesting that the current rate may be around 11% (Berkelmans et al., 2011). Despite this fact, however, not all longitudinal tobacco research has documented consistent downward trends, especially in Asia. In Japan, for example, the national smoking rate among female nurses was reported to be 19% in the late 1990s (Ohida et al., 1999), while a study published in 2002 reported that 34% of female nurses were smoking (Kitajima et al., 2002). In 2006 it was reported that 11% of Japanese nurses used tobacco (Smith et al., 2006a), while the most recently published data suggests that only 8% of Japanese nurses now smoke (Taniguchi et al., 2011). Why Chinese nurses would smoke at lower rates than their international nursing counterparts is unclear, although it may relate to the high proportion of females in Chinese nursing practice, combined with a cultural reluctance for Chinese women to smoke. Such phenomena have already been demonstrated in other areas of the Chinese healthcare profession. Two investigations of Chinese doctors, for example (Smith et al., 2006b; Ceraso et al., 2009), reported having no females smokers at all. A similar finding has also been documented among Chinese medical students (Xiang et al., 1999).
While results from the current study suggest major progress in reducing tobacco consumption within the Chinese nursing profession, the battle is far from over and many challenges still remain (Smith, 2010). Nursing colleges play a vital role in educating nurses on the dangers of smoking, although they may not have yet maximized their capacity in this regard, especially in Asia. An earlier study of baccalaureate nursing programs in China, Japan, Korea, and the Philippines, for example, found that while the majority of nursing schools included content on the health risks of smoking, almost half did not provide smoking cessation content and most did not cover it in depth (Sarna et al., 2006b). Such findings have not been limited to Asia, however, with a study from the United States reporting that nurses' delivery of comprehensive smoking cessation interventions was also suboptimal among their American counterparts (Sarna et al., 2009b). Lack of appropriate knowledge, and/or skill, has been suggested as an ongoing barrier to the implementation of effective tobacco control in nursing, at least part of which may relate to a less than adequate tobacco control content in nursing educational programs (Sarna et al., 2009a).
Another issue for tobacco control may relate to role modelling behaviour and a general acceptability for smoking among staff within nursing Asian schools. A study of Chinese nursing schools, for example, found that over 90% of the institutions surveyed had faculty members who smoked, while one-quarter had students who smoked (Chan et al., 2008). A Japanese investigation conducted in two nursing colleges, a university, and teaching hospital, reported that while 16% of staff and 6% of students smoked, many lacked the necessary skills to routinely involve themselves in anti-tobacco interventions. Furthermore, while 36% of nursing students in the same study agreed that nurses should not smoke, only 25% of staff agreed with this statement (Sekijima et al., 2005). The issue of tobacco use among nursing students themselves appears to be one area that has not been well studied in China. This may be partly due to low rates of smoking within the nursing student demographic: 0% in one study from Hebei Province (Smith et al., 2004) and only 4% in a study from Shaanxi Province (Zhang et al., 2012b). Relatively higher rates have been documented among Chinese medical students, however, ranging from 6% (Smith et al., 2005b) to 41% (Zhu et al., 2004), suggesting that the implementation of effective tobacco control solutions may not necessarily be a straightforward process in the tertiary education sector.
Nevertheless changes are beginning to occur regarding tobacco control in China. The first stop smoking program in China was established in 1996 (Zhang et al., 2012a), for example, and the Chinese health ministry launched a campaign to stop smoking among doctors and other medical workers in 2009 (Bland, 2009). In March 2011, China's 12th 5-year Plan mentioned tobacco control for the first time (Chen et al., 2012). On the other hand, however, to our knowledge there are no active tobacco control programs targeting nurses in Shandong. This situation is not entirely surprising as research from the United States suggests that even though their involvement in tobacco control policy is essential (Sarna et al., 2006a), nurses have often been an underutilized resource (Sarna et al., 2005). Results from the current study suggest, however, that Chinese nurses may now be in an ideal position to lead the fight against tobacco, given that very few of them smoke, especially females. Teaching hospitals and other learning institutions also represent an ideal venue for helping to set positive examples in tobacco control (Smith & Takahashi, 2008). Health care facilities and their staff in Shandong would be in an ideal position to lead such initiatives.