Prevalence of smoking in nursing professionals of a cardiovascular hospital

OBJECTIVE
to identify the prevalence of smoking in nursing professionals and to determine the relationship of the habit with clinical and socio-demographic characteristics.


METHOD
nursing professionals of a cardiovascular hospital answered a questionnaire on smoking and dependence degree, socio-demographic characteristics, personal and family background, smoking characteristics, motivational stages, depression, perceived and occupational stress. The relationship between the explanatory variables and smoking was investigated.


RESULTS
among 656 participants, 77.6% were non smokers, 12.2% former smokers, and 10.2% smokers. Most were female, with complete high school, Catholic, married, household income between three and five minimum wages, position as nursing assistant, had double shifts, and were responsible for family income. The nicotine dependence of smokers ranged from low to moderate.


CONCLUSION
the study has shown low prevalence of smoking in nursing professionals. Education level, religion, marital status, job position, responsibility for family income, history of depression and alcoholism, chest "wheezing" and other symptoms were significantly associated with being a smoker or former smoker.


INTRODUCTION
Smoking is one of the most important public health problems in the world (1)(2) .Regarded as an epidemic disease, it exposes individuals to more than 7,000 toxic substances that are risk factors for many chronic non-communicable diseases (2) , such as cancer, respiratory and cardiovascular diseases, among others (2)(3)(4)(5)(6) , persisting as one of the leading preventable causes of death (2,7) .
Worldwide, approximately 7 million people die each year due to smoking-related diseases, and projections point that in 2030 this number will surpass 8 million per year, and half the deaths will be of individuals in productive age (1) .Only in Brazil, in 2015, 156,216 deaths were caused by tobacco use, i.e., eighteen deaths per hour, representing 12.6% of the total deaths in the country.Of these, 16% are related to cardiovascular diseases and 13% is due to cerebrovascular accidents (3) .
The frequency of adult smokers in the 26 Brazilian States and the Federal District ranges between 5.1% in Salvador and 14.0% in Curitiba (5) .In the country, 52% of the smokers are planning to quit smoking (1) and, regardless of the difficulties associated with smoking cessation, the frequency of smokers has decreased on average by 0.62 percentage points per year between 2006 and 2016 (5) .
The difficulty in quitting smoking relates to the organic dependence and, probably, to the same reasons associated with experimentation and starting smoking: rebellious behavior, need to show maturity, imitate an idol, pressure from smoking peers or family, association of smoking with people well resolved from a professional, financial and sexual point of view, as well as neuropsychological characteristics of the individual (8)(9) .
Since the concern about health is the main motivation to stop smoking, questions arise regarding the maintenance of smoking habits amongst professionals of the hospital area, as most of them have formal education in the field of Health and, therefore, knowledge on the damages caused by cigarettes (10)(11)(12) .In a sample of 175 professionals from a University hospital, 20% were former smokers and 13.6% were smokers (13) .Among nursing workers, the occurrence of smoking ranges from 4.6 (14) to 7.1% (15) and the prevalence of former smokers ranges from 12.8% (14) to 25.7% (15) .

OBJECTIVE
To identify the prevalence of smoking in nursing professionals and determine the relationships of the habit with clinical and socio-demographic characteristics.

Ethical aspects
The study was submitted to the Committee of Ethics and Research with Humans Beings (CEP) of the Dante Pazzanese Institute of Cardiology, in São Paulo, and follows the ethical principles contained in the Declaration of Helsinki.Professionals were ensured of their anonymity and freedom to leave the study at any time.

Design, location and period
This is an analytical cross-sectional study of a quantitative approach, carried out between March and September 2016 in a large public institution in the State of São Paulo, which specializes in the cardiovascular area and is dedicated to caring, management, teaching, and research.

Sample: inclusion and exclusion criteria
Were considered eligible 763 nurses, nursing technicians and assistants from all sectors of the institution.Were excluded those who were not active in the period of data collection, like those on health leave, and those who have not returned the filled form within twenty days and or did not sign the Informed Consent Form (ICF).The total of participants included in the study amounted to 656.

Study protocol
The lead researcher invited professionals to participate in the study, explained the research objectives, and requested the ICF signature.Each participant was given an envelope containing self-filling forms and questionnaires for data collection.It was requested that forms were returned filled within up to ten days, with a maximum tolerance of twenty days.
Smoking was considered the dependent variable, according to the groups: nonsmoker, former smoker (at least twelve months without smoking) or smoker.
For those who declared themselves as smokers and former smokers, the nicotine dependence degree was investigated through the Fagerström Test of Nicotine Dependence (FTND) (16) , a questionnaire containing six questions of simple choice, whose score is categorized as: 0 to 2 (very low); 3 to 4 (low); 5 (moderate); 6 to 7 (high); 8 to 10 (very high).
Smokers were questioned about their reasons for maintaining the habit, with the options of liking smoking, anxiety, and nicotine dependence.For former smokers, the time of abstinence was questioned.
Independent variables of interest to the study and their respective evaluation tools were: • Socio-demographic and professional, evaluated through a form prepared by the researchers: religion, age, gender, education level, marital status, household income, responsibility for the household income, position in the institution., consisting of 24 items divided into four subscales, each with six items: pre-contemplation, contemplation, action, and maintenance.Responses are given in ranges from 1 (extremely disagree) to 5 (completely agree).Each statement is linked to a different motivational stage.
• The intensity of depression, measured using the Beck Depression Inventory (BDI) (18) , a questionnaire of 21 statements that categorizes patients by scores: from 0 to 14 (no depression symptoms); 15 to 19 (dysphoria symptoms) from 20 (depression symptoms).• Perceived stress, evaluated through the Perceived Stress Scale-10 (PSS-10) (19) .It addresses thoughts and feelings experienced in the daily life, regardless of occurring or not in the work environment.
Then, all items are summed, with a total score ranging from 0 to 40.The higher the score, the greater the stress.• Overall occupational stress, measured by the Work Stress Scale (WSS) (20) , composed of 23 questions about psychosocial factors identified as organizational stressors and emotional reactions before them.Participants respond on a scale ranging from 1 (strongly disagree) to 5 (completely agree).The score ranges from 23 to 115.The higher the score, the greater the stress.

Analysis of the results and statistics
In the descriptive analysis, was used the Statistical Package for the Social Sciences (IBM-SPSS) version 19.0 (SPSS Institute, Chicago, Illinois).For quantitative variables, mean and standard deviation (SD) were used and, for the categorical variables, absolute (n) and relative (%) frequencies.To evaluate the relationship between background variables and smoking, we used Fisher's exact test.Finally, the posttest of residue analysis was conducted on the results obtained (21) .
Among smokers, the mean Fagerström score was 4.84±1.60(low to moderate dependence), whereas for former smokers the mean was 4.0±3.0(low), there is no significant difference (P=0.606).Most smokers (n=26; 38.8%) used to light the first cigarette of the day between six and thirty minutes after waking, while thirteen others (19.4%) did it in less than five minutes after waking; twelve (17.9%) between 31 and 60 minutes; sixteen (23.9%) smoked more than one hour after waking.
Most smokers kept the habit because they like smoking (n=47; 32.0%), followed by those who declared anxiety (n=12; 8.2%) and nicotine dependence (n=8; 5.4%).Among former smokers, most were on abstinence for more than ten and less than fifteen years (n=38; 25.9%), followed by those who stopped smoking for more than five years (n=19; 12.9%); more than one and less than five years (n=12; 8.2%), and less than twelve months (n=10; 6.8%).
According to Table 1, most were female, with complete high school, Catholic, married, household income between three and five minimum wages, position as nursing assistant, had more than one work in the area, and were responsible for the household income.Regarding the time working in the institution, the mean was 8.5 years (minimum of six months and a maximum of 42 years).
Socio-demographic variables significantly associated with smoking were education level, religion, marital status, job position, and responsibility for the household income (Table 1).Different associations were obtained with the post-test of residue.A high education level was associated with a lower prevalence of smoking (p < 0.001).As to religious belief, the Evangelism was associated with nonsmoking (p < 0.001), Catholicism to former smoking (p = 0.046); and Spiritualism (p = 0.028) and other groups (agnostic, Christian, eclectic, Universalist, Umbanda, and Judaism) (p = 0.016) to smoking.Regarding marital status, marriage was associated with the group of nonsmokers (p = 0.014), divorce was related to former smokers (p = 0.045) and widowed status to smoking (p = 0.019).Nursing assistants are more common among smokers (p = 0.018).Finally, individuals who declared themselves as the single responsible for the household income had a higher prevalence of smoking than those who had the heal of other family members (p = 0.013).Among smokers and former smokers, most started smoking between 16 and 24 years of age, smoked for eleven to twenty years, twenty cigarettes per day, and never tried to quit smoking through therapy (Table 2).
History of depression and alcoholism, having smoking parents, chest "wheezing" and other symptoms were significantly associated with being a smoker or former smoker, when compared to nonsmokers.Having a significant other who is against smoking, in turn, was significantly associated with being a nonsmoker (Table 3).
Regarding motivational stages and readiness for change, there were some significant differences between smokers and former smokers.Concerning the statement 8 of Urica (Working hard to change the behavior with respect to cigarettes), former smokers fully agreed, whereas smokers disagreed (P=0.002).As for item 10 (I need to do something to prevent a relapse), former smokers fully agreed (P=0.002), as well as regarding items 11 (I am working on changing my behavior with respect to cigarettes) (P<0.001) and 18 (I am doing something regarding my cigarette problem) (P=0.019).
The professionals had no signs of depression nor presented significant differences among themselves.Levels of perceived and occupational stress also did not differ between groups (Table 4).

DISCUSSION
This study found a low prevalence of smoking and former smoking among nursing professionals of a hospital institution, coinciding with the variation found in Brazilian studies (14)(15) .In addition, professionals who smoked had a low to moderate degree of habit dependence, which is also compatible with answers of the participants regarding habit maintenance, as few of them considered themselves as nicotine dependents.
Studies have shown that individuals with less schooling present a prevalence of smoking up to 2.39 times higher than those of higher education level (22)(23)(24)(25)(26)(27) , since education provides greater knowledge about individual health and, therefore, allows to recognize the risks of smoking.This reality is corroborated in this study, since nursing assistants and technicians, positions that do not require higher education, reported smoking more than nurses, who have higher education.
Previous studies showed that religious affiliation or practice reduces in 39% the risk of exposure to tobacco use, reaching a reduction of 72% when comparing evangelicals with those without religious affiliations or practices (28)(29) .This association emerges, at least partially, from doctrines adopted and transmitted by these denominations, prohibiting practices that are harmful to health, such as smoking and alcoholism (29) .Similarly, in this study, evangelicals showed a lower prevalence of smoking in comparison with professionals from other religions.
In addition to education level, lower-income individuals present prevalence of smoking 2.15 times higher than the highest income group (22)(23)(30)(31) . In thisstudy, smokers, when compared to former and nonsmokers, were more frequently the sole responsible for household income.Nevertheless, this factor was not significant for the prevalence of smoking since the mean household income seemed relatively consistent among the subjects of the research, regardless of position held, due to the double work shift of assistants and technicians.
Stress is considered an important risk factor for smoking, as the act of smoking is described by smokers as relaxing (18,25) .Work-related stress is a condition capable of generating health, physical and mental problems, and may lead to the excessive consumption of tobacco (32)(33) .Furthermore, a study conducted with Portuguese health professionals identified that nurses showed levels of stress relatively higher than those of other professionals of the area (32) .However, in this study, there was no significant difference between the stress levels of nonsmokers, former smokers, and smokers.Just like stress, the depression also increases the risk of nicotine dependence, and this association increases twice the risk of heart disease.The risk of relapse varies according to the time of tobacco use, the start of consumption, and depression because these factors make it difficult to abandon the habit (34) .Stopping smoking is associated with the reduction of depression, anxiety, stress, and to improvements in quality of life when compared to individuals who maintain the smoking habits (6) .This study, however, did not reveal a statistically significant difference between the prevalence of depression among nonsmokers, former smokers, and smokers.
The age of tobacco use onset occurs predominantly between twelve and eighteen years of age (13,25,(35)(36) .A study that compared habits, knowledge and attitudes of doctors and nurses of the primary care identified similarity in the age of smoking initiation among these professionals (37) .Furthermore, having a father and mother smokers increases the chance of smoking in almost 2.2 times between young people from 15 to 24 years of age (38) , age at which most of the participants of this study started smoking.
The time that the individual takes to smoke the first cigarette soon after waking and the number of cigarettes consumed per day are important indicators of the nicotine dependence degree.It is also well known that the higher the dependence, the more difficult it is to stop smoking, due to symptoms of withdrawal.This study identified that most smokers used to light the first cigarette of the day between six to thirty minutes after waking and smoked twenty cigarettes per day.Different results showed that most smokers light the first cigarette of the day one hour after waking and smoke from one to ten cigarettes per day (26) .
Quitting smoking is linked, among other factors, to the level of motivation and readiness of the own individual to do as such.Based on the results of the Urica test, it was found that nursing professionals who were former smokers had a greater concern and commitment to not smoke than the group of smokers.Even so, there was no significant difference between the number of attempts to stop the habit between smokers and former smokers.These results resemble those obtained by a previous study, which found that 84.9% of abstainers tried to cease using tobacco, whereas 82.6% of the smokers also made attempts.However, regardless of the success of smoking cessation, a few reported that they never made any attempt, 15.1% of abstainers and 17.4% of smokers (39) .
In addition to individual motivation and readiness, the smoking cessation was also associated, in a previous study, with the presence of a spouse or cohabitant who is a nonsmoker or contrary to smoking (40) .It is known that the family, especially parents and siblings, has a strong influence on the initiation of smoking (41) .In the sample studies, the fact of the participants' significant others were against smoking was also more frequent among former smokers.

Study limitations
Certain limitations should be considered in the interpretation of results.Since the data were self-reported and the participants were professionals of the institution, the findings may have been underestimated, as the informants could suppose they would be harmed in the working environment due to their answers, as well as because of the use of licit and illicit drugs.

Contributions to the field of Nursing
The results demonstrate the need for rethinking and establishing new programs of health promotion and prevention that address the various socio-demographic and individual factors linked to smoking, to enable the reduction of this prevalence among nursing professionals.

CONCLUSION
The findings showed a low prevalence of smoking among nursing professionals.However, formal education in the area of Health and knowledge about the harms caused by the cigarette was not important to reduce the prevalence of the habit among these professionals.
Having a low education level, not professing any religion, being single, working as a nursing assistant, being the sole responsible for the household income, having a personal history of depression and alcoholism, having parent smokers, and presenting chest "wheezing" and other symptoms are significantly associated with being a smoker or former smoker.

Table 1 -
Socio-demographic characterization of nursing professionals of the hospital are according to smoking (n=656), São Paulo, Brazil, 2016 To be continuedPrevalence of smoking in nursing professionals of a cardiovascular hospitalAyoub AC, Sousa MG.

Table 2 -
Characteristics of smoking among nursing professionals of the hospital area (N=147), São Paulo, Brazil, 2016

Table 3 -
Personal and family background among nursing professionals of the hospital area in relation to smoking (N=656), São Paulo, Brazil, 2016

Table 4 -
Scores of the Perceived Stress Scale-10, Work Stress Scale, and Beck's Depression Inventory of nursing professionals of the hospital area in relation to smoking (N=656), São Paulo, Brazil, 2016