As healthcare practitioners, nurses are expected to avoid habits or practices that could put their health at risk. They know all too well how arduous and agonizing it is to suffer from illness, many of which result from an unhealthy lifestyle.

However, even knowing the dangers of smoking, and the many lives it has claimed and continued to claim worldwide, nurses are also human with weaknesses, especially when under extreme pressure at work, which is often the case.

So while they should be model citizens when it comes to healthy living, nurses who smoke are not uncommon. And since health facilities have a strict no-smoking policy, it's a challenge for these smokers to find a secluded area during breaks just to get their nicotine fix.

The number of smoking nurses is not scandalous, but it is disturbing that they pick up the habit at all or continue with it in spite the war against tobacco, and having first-hand experience about what it can do to the body.

By the numbers

A Nurses' Healthy Study in the United States showed that smoking nurses outnumbered physicians hooked on tobacco. Only one percent of doctors were cigarette smokers, according to the findings of a comparative data lifted from the Association of Medical Colleges in 2005.

And even as there has been a decrease in nurse smokers between 1976 to 2003 (from 33.2 to 8.4 percent), reconciling the habit with what they do and who they work with can be confusing.

In Ireland, smoking among nurses was assessed through 1,074 participants in 2006. Of the number, 55 percent never smoked, 19 percent used to smoke, and more than a quarter (26 percent) still engaged in the habit.

Expectedly, nurses who smoked rated their 'effectiveness in helping patients' lower compared to their colleagues who were ex- or non-smokers.

In 2008, a study by the University of California Los Angeles had similar results and cautioned that nurse-smokers were less likely to inspire patients to stop the habit.

In a comparative study in the United Kingdom, 30 percent of nurses smoked compared to only 9 percent of doctors.

Meanwhile, the one percent smoking prevalence among nurses in China's Shandong province of Longkou was encouraging, as well as the findings that there were no male nurses recorded as using tobacco. The figures were generally similar in China's other provinces.

The question remains: why, when nurses are at the forefront of smoking cessation campaigns, are they nicotine-addicted themselves?

Why nurses smoke

Kathy Rowe and Macleod Clark reviewed literature in 2000 and suggested that factors that made female smokers among the general population were similar for nurse smokers.

These include environment, socio-economic factors, education, and peer pressure.

Arnel Delos Santos (not his real name) is an ER and ward nurse in the Philippines. In an interview with MIMS, the healthcare professional said he started smoking out of curiosity and developed the habit due to peer pressure.

He would light a stick now and then in high school until it became a daily habit. Arnel had one stick with his coffee in the morning and would smoke after snacks or meals.

A significant influence was being with friends who were also smokers.

Unfortunately, Arnel is but one among 17.3 million Filipinos aged 15 and older who were hooked on smoking, according to the Philippine Statistics Authority, citing a report from the 2009 Global Audit Tobacco Survey.

About 23 percent are daily tobacco smokers like Nurse Arnel was, a year ago.

Working in a highly stressful environment was cited as one reason why nurses smoke.

High-stress workplace

An American Journal of Public Health study stated that the highest percentage of nurse smokers was in the psychiatric department at 28.6 percent, while the lowest was in the paediatric department at 12.2 percent. The ICU unit was likewise prone to high smoking rates.

The study confirmed that nurses who scored higher in the Nurse Stress Levels test were those who smoked, proving the initial hypothesis that nursing professionals who thought of their jobs as stressful are candidates to become smokers.

Other contributing factors are age and extended work hours. Nurses under 29 years old who work on a rotating shift, or put in 40 or more hours a week are more inclined to 'feel stressed' and perceive their job as physically and emotionally draining, which could lead them to smoke.

Another stress survey conducted by the Nursing Times revealed that one in 10 nurse respondents - from 1,300 polled - started smoking due to stress.

Cigarettes do not relieve stress

Doctors, however, are quick to clarify that smoking is not a recognized anti-stress activity. Rather than relieving stress, nicotine increases the user’s anxiety and tension.

The ‘relaxed’ sensation associated with smoking was only a form of psychological addiction, according to researchers from the University of East London. Studies have actually shown that smoking heightens stress.

Smokers become addicted to nicotine because of the need to maintain 'normal moods' when they're on smoking break but suffer from tension.

At the same time, daily smoking helps create a psychological link between cigarettes and 'feeling good' while preventing withdrawal symptoms, according to a study published in the journal American Psychologist.

In truth, cigarette's calming effects will be extinguished once people return to the scene of stress. The only way to reduce stress levels is to identify the stressor and form healthy coping measures.

The Nurses' Health Study likewise compared death rates of female nurses who are smokers, ex-smokers, and non-smokers and found that twice as many current smokers died compared to their non-smoking peers.

What should be done

Experts have questioned if nurses who smoked were able to provide effective guidance to patients who were also hooked on cigarettes.

Bob Smith, a nurse therapist from the South London and Maudsley NHS Foundation Trust - a programme for smoking cessation - underscored the importance of a non-smoking nurse helping out a patient to quit the habit.

"It is essential for them not to smoke themselves because their help may not appear genuine," he said.

Nurse Arnel shared that he often felt shame and guilt each time he would smoke then shift to health teaching afterward. 

Meanwhile, nurse-smokers who were surveyed lamented that while they had access to a wealth of information about smoking health risks, there was no professional or institutional support that would routinely help them to stop.

At the same time, a 2011 research published in the Journal of Advanced Nursing revealed that nurses who smoke were afraid of withdrawal symptoms which include more stress, weight gain, and anxiety.

Of the 115 nurse smokers involved in the research, 45 percent of them wanted to quit, and 89 percent experienced quit attempts, but only half received help for smoking cessation.

Meanwhile, Michelle Larkin, program officer of the UCLA team’s related research on nurses and smoking, said that “the devastating effects of smoking are all too real for those nurses who still smoke.”

She suggested that more research is needed to determine the exact cause of tobacco use in the profession and more resources to help nurses quit.

Nurses as role models

Nurse Alexandra Bianca Ocampo concedes that while nurses are expected to be role models, getting smokers to junk the habit is not something you can force on them.

It must come from within, the Filipino nurse emphasised, especially since nurses themselves are aware of the consequences of smoking. If quitting is not possible, then it must be kept private and at a minimum, she added.

One step at a time

Quitting the habit is a battle. And for many, quitting cold turkey does not work. Success comes one step at a time.

For the last two months since June, Nurse Arnel has not picked up a stick of cigarette. And it is cause for celebration considering he has attempted several times in the past to give up smoking. In his first few attempts to quit, he tried not to smoke whenever he was in uniform. 

He started slow, reducing his three sticks per day to a cigarette per day until he was completely free of the habit.

"It's a struggle," Arnel admitted. "I had to keep myself busy, so I don't feel bored." It's boredom that has him reaching for a stick. To distract himself, Arnel would play video games or go on TV binge watching.

It took him three years, from the time he began working as a nurse, to finally realise what tobacco could ultimately cost him. The effects, all the horrible consequences of smoking had been creeping up on him.

“I didn’t want to develop all sorts of lung diseases and cancers just because of a single stick of cigarette,” Arnel declared, commitment clearly evident in his tone. MIMS

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