Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?

References:

U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/

This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

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