European Journal of Cardiovascular Nursing http://cnu.sagepub.

com/

Smoking Patterns among Jordanian Health Professionals: A Study about the Impediments to Tobacco Control in Jordan
Kawkab Shishani, Hani Nawafleh, Samiha Jarrah and Erika Sivarajan Froelicher Eur J Cardiovasc Nurs 2011 10: 221 DOI: 10.1016/j.ejcnurse.2010.08.001 The online version of this article can be found at: http://cnu.sagepub.com/content/10/4/221

Published by:
http://www.sagepublications.com

On behalf of:

European Society of Cardiology

Additional services and information for European Journal of Cardiovascular Nursing can be found at: Email Alerts: http://cnu.sagepub.com/cgi/alerts Subscriptions: http://cnu.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Dec 1, 2011 What is This?

Downloaded from cnu.sagepub.com by guest on March 24, 2014

European Journal of Cardiovascular Nursing 10 (2011) 221 227 www.elsevier.com/locate/ejcnurse

Smoking patterns among Jordanian health professionals: A study about the impediments to tobacco control in Jordan
Kawkab Shishani a,b , Hani Nawafleh c , Samiha Jarrah d , Erika Sivarajan Froelicher e,f,g,
College of Nursing, Washington State University, P.O. Box 1459, Spokane, WA 99210, USA b The Hashemite University, Jordan c Mu'tah University, Mu'tah, Jordan d Applied Science Private University, Amman, Jordan e Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USA g University of Jordan, Amman, Jordan Received 7 April 2010; received in revised form 6 July 2010; accepted 10 August 2010 Available online 9 September 2010
a

Abstract Background: Little is known about Arab health professionals' smoking practices. Aim: This is the first study to examine smoking practices among Arab health professionals. Methods: Background: Little is known about Arab nurses and physicians' smoking patterns. Aim: This study aims to examine smoking patterns among Arab nurses and physicians. Methods: A total of 918 nurses and physicians participated in this study. Data were collected using the Global Professional Health Survey. Results: About 38.8% are current smokers. The smoking percentages for male nurses and male physicians were high (83.8%, 94.6% respectively) compared to female nurses and female physicians (16.2%, 5.4% respectively). Approximately 53.8% wanted to quit and 60.6% had made previous quit attempts that lasted for more than two days. About 64.1% believed that nurses and physicians who smoke were less likely to advise patients to stop smoking. The predictors of smoking were: age when tried first cigarettes OR = 6.36, 95% CI = 4.48, 9.04; father smokes OR = 1.95, 95% CI = 1.40, 2.72; mother smokes OR = 1.99, 95% CI = 1.18, 3.39; shift work OR = 1.45, 95% CI = 1.04, 2.03; and the interaction (gender and profession) OR = 1.82, 95% CI = 1.55, 2.14. Discussion: Effective interventions often begin with and/or depend on nurses and physicians being committed to smoking cessation. Given the very high smoking rates among nurses and physicians a key priority must be to provide quit smoking programs and to enable them to become effective champions of smoking cessation nationwide. 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.
Keywords: Global health; Smoking; Waterpipe; Nurses; Physicians; Training

1. Introduction Health professionals, particularly nurses and physicians, serve as strong role models for patients. They are also in a first line position to screen smokers and advise them to quit smoking [1]. Nurses and physicians' commitment to help smokers to quit smoking is linked to their own smoking behaviors [25]. In fact, nurses and physicians influence patients' attitudes and receptivity toward adopting smoking

Corresponding author. 2 Koret Way Box 0610, San Francisco, CA 94143-0610, USA. Tel.: +1 415 476 4833, +1 650 766 4833 (Mobile); fax: +1 415 476 8899. E-mail addresses: hnawafleh@hotmail.com (H. Nawafleh), jarrahs@ju.edu.jo (S. Jarrah), Erika.froelicher@nursing.ucsf.edu (E.S. Froelicher).

1474-5151/$ - see front matter 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejcnurse.2010.08.001

Downloaded from cnu.sagepub.com by guest on March 24, 2014

222

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227

cessation interventions [6]. Thus, nurses and physicians who smoke may not be credible role models and may thus be ineffective in this role. Significant numbers of nurses and physicians who are smokers and non-smokers believe that physicians who smoke are less likely to advise their patients to stop smoking [7,8]. In addition, nurses who smoke are less likely to take on the role of health promotion with patients who smoke [9]. Nurses and physicians who smoke send conflicting messages to patients and to the public. However, nurses and physicians who have successfully quit smoking are known to be some of the most effective smoking cessation interventionists [10]. Between 2002 and 2004, a survey including 10,939 nurses and physicians in five countries of the World Health Organization's (WHO) Eastern Mediterranean Region (EMRO) were surveyed using a Global Health Professionals Survey (GHPS). Of the respondents, 70% (7613) were physicians, 13% (1394) were nurses, 6% (701) were dentists, and 11% (1226) worked in allied professions. Of the total sample, 23% were reported to be current smokers and 10% former smokers [7]. Smoking rates among nurses were reported to be higher than those of physicians [2,3,11]. A report from Greece showed a greater proportion of Greek nurses who smoke than what was reported in the general Greek population [3]. On the other hand, in a study conducted in a cancer center in Jordan, smoking rates were slightly higher among physicians (43%) compared to nurses (42%) [12]. Jordan was studied as a model Arab country in this study because it shares the culture and the language with the rest of the Arab world. Jordan also is ranked as the fourth highest Arab country with regard to smoking rates in the EMRO [13]. The data reported from EMRO is on smoking prevalence in the general population, but none measured smoking prevalence in Jordanian nurses and physicians. Limited reports suggest that smoking rates among nurses and physicians are high in Jordan; therefore, it is essential to have regular surveillance of smoking rates and keep a database to observe changes in behaviors. It seems paramount that a survey begins with nurses and physicians in order to build a strong infrastructure, skill sets, and expertise among nurses and physicians who can then be deployed to provide interventions for the public. While the focus of this paper is to examine smoking prevalence rates among Jordanian nurses and physicians, this concern is not country specific because smoking is a global health issue. The WHO in its second report on measures to stop the tobacco epidemic, MPOWER, highlights health professionals' contributions to tobacco control nationally and internationally [14]. Nurses and physicians are on the frontline in their frequent encounters with the public. Therefore, addressing nurses and physicians' smoking behaviors is a priority because their involvement in tobacco control measures and programs are associated with their own smoking behaviors. An example from the U.S. demonstrates that over three decades significant drops in smoking rates

were measured in nurses and physicians [2]. A study compared smoking rates of physicians and nurses in the U.S. with those in a country with low levels of tobacco control efforts, and demonstrated that changes in rates of smoking among nurses and physicians can have a positive influence on national tobacco control activities [15]. The research questions are: 1. What are the smoking rates among Jordanian nurses and physicians? 2. Are there differences in frequency and patterns of smoking between nurses and physicians, and are there differences in gender, and in work settings (Emergency Room [ER], Intensive Care Units [ICU's], Coronary Care Unit [CCU], Psychiatric Units)? 3. What are the independent predictors of smoking status among Jordanian nurses and physicians? 2. Methods 2.1. Design A descriptive cross sectional design was used to answer the above research questions. 2.2. Setting and sample There are 98 hospitals in Jordan of which ten hospitals were selected as study sites according to the three major regions of Jordan (north, central Amman and south), representing urban and rural hospitals [16]. All nurses and physicians were recruited from the selected ten hospitals. Eligibility criteria included all nurses and physicians who were current employees of the ten hospitals. Exclusion criteria: (1) part-time employee; and (2) cannot read and respond in English. English is the formal instructional language used in teaching at nursing and medical colleges in Jordan. The core clinical course requirements are given in English and Jordanian nurses and physicians are accustomed to participating in research in the English language. 2.3. Ethical consideration Approval for this study was obtained from the Ministry of Health Research Ethics Committee. The investigation conforms to the principles outlined in the Declaration of Helsinki (Br Med J 1964; ii: 177). 2.4. Sample size calculation Assuming that 30% of nurses and 50% of physicians smoke, and setting beta as 20% and alpha 0.05 and using a 2-sided test a sample size of 459 per group, thus n = 918 is needed to answer all research questions. This sample size is more than sufficient to estimate 30 to 40 independent

Downloaded from cnu.sagepub.com by guest on March 24, 2014

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227

223

predictors using the approximation of 10 to 15 subjects per variable to be estimated [17]. 2.5. Data collection procedures The WHO, Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) developed the Global Health Professional Survey (GHPS) in 2004 that was used to collect data on tobacco use and cessation counseling among health professionals. The GHPS is part of the Global Tobacco Surveillance System (GTSS). The GHPS is a valid and reliable measurement tool [18]. The GHPS consists of a 66-item questionnaire with 7 domains: 1) demographic questions (11 items); 2) tobacco use prevalence among health professionals (8 items); 3) exposure to environmental tobacco smoke (8 items); 4) attitudes toward tobacco (13 items); 5) smoking cessation (10 items); 6) curriculum/training (7 items); 7) assessment of waterpipe use (9 items). Waterpipe, also known as hookah, is a common form of smoking in the Middle East with rising popularity in many European and US cities; therefore, assessment of waterpipe use was added to the measurement tool by researchers. This section was adapted from a standardized questionnaire recommended and used by well-established researchers in waterpipe smoking [19]. The GHPS items response options consist of ordinal responses yes/no. As other forms of tobacco use (e.g., chewing tobacco) are not practiced in Jordan, questions on their consumption were excluded. Four research assistants (RA's) who were senior nursing students were selected and trained (by the primary investigator) for data collection to ensure standardization of protocol. Training included handling of possible questions or requests from subjects regarding explanations of certain items or words. For example, waterpipe has more than ten names and it was thought that some subjects would not be familiar with this form of smoking or terminology. Data were collected between March and August of 2007. Nursing and medical offices at each hospital were contacted to identify potential subjects. The estimated time to complete the survey was 30 min. Subjects were given the option to complete the survey immediately or later and they were asked to return the survey to the assigned boxes at the nursing and medical offices. RA's collected the surveys daily. 2.6. Data analysis Statistical analysis procedures were performed using SPSS for Windows (version 11.5). Frequencies and percentages were reported for dichotomous and nominal variables; and ranges, and means (s.d.) were reported for ratio and interval data. Logistic regression analyses estimated the independent predictors of smoking status among Jordanian nurses and physicians and were reported as Odds Ratio's (OR) with 95% Confidence Intervals (CI) [20].

3. Results This study enrolled 918 subjects from 10 hospitals in Jordan representing the north, the south and the capital of Amman, including public and private hospitals. Table 1 describes the characteristics of the study sample for men, women and total. The participants were nurses (72.7%) and physicians (27.3%); most were men (66.3%), and married (50.9%). The sample ranged in age from 20 to 74 years; mean 30.8 (s.d.7.9). Of the 11 units that were identified, 14.9% worked on a medical unit, 13.4% in an ICU, 13.3% surgical unit and 15.1% stated other. Rotating shift work was the most common schedule (55.2%). 3.1. Smoking patterns by hospital units The highest proportions who were smokers were found in the ER (15.6%), medical units (15.3%), surgical units (15%), ICU's (12.1%), and psychiatric units (12.1%). A significant relationship was found between being a smoker and working in ICU, ER, and psychiatric units (p = 0.00).
Table 1 Characteristics of the sample (n = 918). Characteristic Marital status Single Married Widowed Divorced Separated Profession Registered nurse Physician Mother smoker Father smoker Type of shift Day Evening Night Rotating Type of unit Medical unit ICU Surgical unit Emergency room Psychiatric unit CCU Operating room Pediatric unit Obstetric unit Burn unit Recovery room Other Men % (n) 48.6 (290) 49.7 (296) 0.3 (2) 0.7 (4) 0.7 (4) Women % (n) 44.6 (135) 53.5 (162) 0.3 (1) 1.3 (4) 0.3 (1) Total % (n) 47.3 (425) 50.9 (458) 0.3 (3) 0.9 (8) 0.6 (5)

64.6 (379) 35.4 (208) 4.0 (12) 1.6 (5)

88.6 (265) 11.4 (34) 5.0 (26) 3.2 (19)

72.7 (644) 27.3 (244) 4.3 (38) 2.7 (24)

28.6 (170) 6.6 (39) 9.9 (59) 54.9 (326)

36.3 (110) 4.3 (13) 4.0 (12) 55.4 (168)

31.2 (280) 5.8 (52) 7.8 (71) 55.2 (494)

15.5 (92) 11.8 (90) 15.1 (90) 13.6 (81) 7.6 (45) 8.1 (48) 6.4 (38) 2.2 (13) 1.2 (7) 1.7 (10) 1.5 (9) 15.5 (92)

13.87 (42) 15.5 (47) 9.9 (30) 9.5 (29) 6.9 (21) 2.3 (7) 4.6 (14) 8.9 (27) 9.5 (29) 3.3 (10) 1.6 (5) 14.1 (43)

14.9 (134) 13.4 (119) 13.3 (120) 12.5 (113) 7.3 (66) 6.1 (55) 5.7 (52) 4.0 (40) 4.0 (36) 2.2 (20) 1.5 (14) 15.1 (135)

Due to missing values, rounding may not always add to exactly 100%. CVD = cardiovascular diseases. ICU = Intensive Care Unit. CCU = Coronary Care Unit.

Downloaded from cnu.sagepub.com by guest on March 24, 2014

224

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227 Table 3 Smoking patterns by profession. Smoking patterns Smoking status Current smoker Former smoker Non-smoker Forms of smoking Cigarettes Waterpipe Age when first tried a 10 and younger 1115 1617 1819 2029 30 and older Nurses % (n) 36.1 (230) 9.8 (63) 54.1 (345) Physicians % (n) 46.9 (113) 12.4 (30) 40.7 (98) Total % (n) 39.0 (343) 10.6 (93) 50.4 (879)

3.2. Smoking patterns by gender The smoking percentages for male nurses and male physicians were high (83.8%, 94.6% respectively) compared to female nurses and female physicians (16.2%, 5.4% respectively). Waterpipe use was prevalent in women (29.1%) more than men (17.3%) (Table 2). 3.3. Smoking patterns by profession The overall smoking rate was 39.0% (Table 3). Smoking was higher in physicians (46.9%) compared to nurses (36.1%). More physicians started smoking after they entered the university (59.9%) compared to nurses (44.9%). Of the total 161 smokers who considered quitting smoking by answering yes to the question Do you want to quit now? 53.9% were physicians and 43.4% were nurses; the difference was not statistically significant. 3.4. Characteristics of smokers A series of exploratory analyses were conducted using sets of demographic, clinical and smoking history variables. A final parsimonious logistic regression model was tested to evaluate the independent contribution of five variables and
Table 2 Smoking patterns by gender. Smoking patterns Smoking status Smoker Former smoker Non-smoker Forms of smoking Cigarettes Waterpipe Men % (n) 50.6 (300) 13.0 (77) 36.4 (216) Women % (n) 14.9 (44) 6.4 (19) 78.6 (232) Total % (n) 38.8 (347) 10.9 (98) 50.3 (450)

78.6 (261) 21.4 (71) cigarette 1.0 (5) 5.8 (29) 11.8 (59) 18.9 (94) 28.9 (144) 2.6 (13)

86.8 (132) 13.2 (20)

81.2 (393) 18.8 (91)

1.2 (6) 1.8 (9) 5.0 (25) 7.4 (37) 14.4 (72) 1.0 (5)

2.2 (11) 7.6 (38) 16.9 (84) 26.3 (84) 42.3 (216) 3.6 (18)

When started smoking? Before entering the 55.1 (190) university After entering the 44.9 (155) university Do you want to quit smoking? Yes 51.6 (181) No 48.4 (170) Have you ever tried to quit? Yes 59.9 (212) No 40.1 (142)

40.1 (63) 59.9 (94)

50.4 (253) 49.6 (249)

59.2 (87) 40.8 (60)

53.8 (268) 46.2 (230)

63.4 (92) 63.6 (53)

60.9 (304) 39.1 (195)

How many times have you tried to quit smoking? 13 times 62.6 (126) 78.7 (63) More than 3 times 37.4 (50) 21.3 (17) Yes 76.7 (467) 79.1 (185) No 23.3 (142) 20.9 (49)

64.4 (189) 35.6 (67) 68.8 (652) 31.2 (191)

82.7 (339) 17.3 (71)

70.9 (56) 29.1 (23)

80.8 (395) 19.2 (94)

Health professionals who smoke are less likely to advise patients to quit Yes 71.0 (353) 63.4 (128) 62.7 (481) No 29.0 (144) 36.6 (74) 31.2 (218) Due to missing values, rounding may not always add to exactly 100%.

Age when first tried a cigarette 10 and younger 2.6 (11) 1115 8.6 (36) 1617 19.5 (82) 1819 27.1 (114) 2029 39.8 (168) 30 and older 2.4 (10) Do you want to quit smoking? Yes 52.0 (216) No 48.0 (199) Have you ever tried to quit? Yes 61.9 (255) No 38.1 (157) Yes 77.7 (442) No 22.3 (127)

0.0 (0) 4.9 (4) 4.9 (4) 23.2 (19) 56.1 (46) 11.0 (9)

2.2 (11) 8.0 (40) 17.1 (86) 26.4 (133) 42.0 (214) 3.8 (19)

included an interaction term (gender x profession) (Table 4). The odds ratios (OR) and 95% Confidence Intervals (CI) for the five variables (and the interaction term) were: age when tried first cigarette OR = 6.36, 95% CI = 4.48, 9.04; father smokes OR = 1.95, 95% CI = 1.40, 2.72; mother smokes
Table 4 Logistic regression to estimate the independent contribution of 5 variables on smoking status. Independent variables Marital status Type of shift Age started smoking Father smokes Mother smokes Gender *Profession OR 95.0% C.I. for OR Lower 1.38 1.45 6.36 1.95 1.99 1.82 0.98 1.04 4.48 1.40 1.18 1.55 Upper 1.93 2.03 9.04 2.72 3.39 2.14

62.0 (54) 37.9 (33)

53.8 (270) 46.2 (232)

54.9 (50) 45.1 (41) 75.6 (214) 24.4 (69)

60.6 (305) 39.4 (198) 77.0 (656) 23.0 (852)

Health professionals who smoke are less likely to advise patients to quit Yes 64.8 (330) 79.5 (155) 68.9 (485) No 35.2 (179) 20.5 (40) 31.1 (219) Due to missing values, rounding may not always add to exactly 100%.

Downloaded from cnu.sagepub.com by guest on March 24, 2014

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227

225

OR = 1.99, 95% CI = 1.18, 3.39; shift work OR = 1.45, 95% CI = 1.04, 2.03; and the interaction (gender and profession) OR = .82, 95% CI = 1.55, 2.14. Marital status was not significant. 3.5. Smoking patterns Cigarette smoking was reported by 80.8% and waterpipe by 19.2% of the sample as the primary methods of smoking. Initiation of smoking ranged from 10 to more than 30 years. However, most started smoking first when they were in their 20's; 44.6% reported that a modal cigarette consumption patterns was 1120 per day; and of those who reported smoking waterpipe, 97.0% stated that they smoked 13 sessions per week. With respect to the tobacco dependence measures, 57.3% reported smoking within the first 30 min of awakening. A total of 53.8% said yes to the question Do you want to quit smoking? and 60.6% had made a previous quit attempts that lasted more than two days. 3.6. Smoking knowledge and beliefs The knowledge and beliefs of smokers show that about one fourth did not believe that smoking is harmful to health and answered no when they were asked My smoking is harming my health; 53.4% believe that there is very little benefit from quitting smoking after having smoked for 20 years. When asked: Are a patient's chances of quitting smoking increased if a health professional advises him or her to quit? 74.5% of the smokers answered yes and 25.5% answered no. Also, when asked Are health professionals who smoke less likely to advise patients to stop smoking? 64.1% stated yes; and 35.9% answered no. Nurses and physicians were where asked about the addictive properties of tobacco: 31.5% stated that cigarettes are addictive; 7.6% stated that waterpipe is addictive, and 40.4% stated that both are addictive; while 20.5% of these nurses and physicians endorsed that None are addictive. 4. Discussion This study addresses an urgent health problem because nurses and physicians influence the public. This study sought to explore the smoking patterns of nurses and physicians who worked in Jordanian hospitals. These sites represented government, private, as well as rural and urban hospitals. Comparisons between the nurses and physicians and the general population indicate that the largest group of smokers in the general population are in the 3549 years age group unlike nurses and physicians who smoke are mostly in their 20's [21]. Interestingly, smoking rates by males in the general population (50.5%) were similar in male nurses and physicians (50.6%). However, smoking rates were higher in female nurses and physicians (14.9%) than females in the general population (8.3%) [22]. According to forms of smoking, men reported

smoking cigarettes as their first choice of tobacco products, whereas women reported smoking waterpipe use. Waterpipe is not considered as a form of smoking and is a widely acceptable social practice in many Arab countries [2325]. The sample consisted of 73% nurses and 27% physicians; higher smoking rates were reported by male nurses and male physicians than by female nurses and physicians. The presence of an interaction between gender and profession on smoking status is apparent, as there are more nurses and physicians who are males in Jordan, and men smoke at much higher rates than women. An analysis that does not take this interaction effect into consideration is potentially flawed. About 45% of nurses in Jordan are males. Furthermore, 60% of the nursing graduates over the last four years have been males. The Jordanian nursing council took several initiatives to encourage more females to consider studying nursing. Additionally, cultural norms show that women's smoking behaviors are perceived negatively in the Arab cultures [26]. Social image is an essential element in theses cultures. Therefore, many Arab women who smoke tend to avoid smoking in public and even under report their smoking behavior. Nurses working in specialties such as in the operating room, psychiatric units, and ICUs report higher smoking rates than those working in other specialties [27]. This finding is consistent with the present study, in that nurses working in ICUs, Emergency room, and Psychiatric Nursing reported higher smoking rates than those working in other units and wards of the hospital. The reasons for this observation are not totally clear, but may be due to stress, personal characteristics, and professional role conflicts [28]. Both male and female smokers reported smoking their first cigarette of the day within 30 min of awakening, suggesting a very high level of addiction [29]. More than half of the sample expressed the desire to quit smoking. A higher proportion of women (62%) indicated the desire to quit compared to men (52%); however, more men actually attempted to quit and a higher proportion made more quit attempts. About 70.4% acknowledged having made 13 previous quit attempts; the high interest in quitting was confirmed by prior reported quit attempts. It is obvious that smokers were highly addicted to nicotine, were unsuccessful in the previous quit attempts and most importantly were interested in quitting. This can serve as evidence that there is a need for training nurses and physicians in smoking cessation counseling and the use of pharmacological interventions to help them with successful smoking cessation. It is of interest that in contrast to physicians, a higher proportion of nurses started smoking before entering the university and both nurses and physicians increased their smoking once they started clinical work. This finding has important implications for deans and educators of schools of nursing and medicine. Incorporating such information into the student orientation program for incoming freshman is a strong message about the importance of smoking cessation, given that they are pursuing a profession in health care, and offer them on

Downloaded from cnu.sagepub.com by guest on March 24, 2014

226

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227

campus smoking cessation programs. Additionally, the awareness that smoking increases when students in nursing and medicine begin their clinical work calls for an additional action during this critical transition phase. The most worrisome finding was that many nurses and physicians who smoke are highly addicted, yet do not acknowledge or know the addictive properties of tobacco products (cigarettes or waterpipe). Theses nurses and physicians lacked knowledge in evidence-based interventions for smoking cessation. This is a global concern, as growing number of research studies indicate that nurses and physicians need formal training in treating tobacco dependence [30]. In an international study that examined various regions of the WHO, upper and middle income countries had evidence-based training programs for tobacco treatment [31], yet more could be done to assure that such programs exist around the world. The updated clinical guidelines even demonstrate that the involvement of more than one type of clinician in providing tobacco treatment programs ensures better outcomes [32]. Thus, there is a window of opportunity to adopt evidencebased clinical guidelines that are culturally sensitive and target nurses as well as physicians. Nurses and physicians who smoke are less likely to advise their patients to quit [5,6]. Therefore, helping nurses and physicians to quit, means not only does the nurse or physician gain personally from being smoke free, but equally importantly, their patients will also benefit. While not a random sample, it nevertheless represents a broad spectrum of practitioners. Also, the extent to which nurses and physicians who are not in this sample are similar to those who were is unknown and there is no reliable way to estimate any potential selection bias.

While the findings of this study were obtained in Jordan, they are likely to be relevant to Arabs in other Arab counties. Global tobacco control organizations can benefit from the findings of this study when working with these countries on developing national tobacco control programs. Acknowledgment
The authors would like to thank Marian Wilson for assisting with the preparation of the manuscript. This work was supported by the Jordanian Nurses and Midwives Council (JNMC).

References
[1] Robins H, Krakow M, Warner D. Adult smoking intervention programs in Massachusetts: a comprehensive approach with promising results. Tob Control 2002;11:ii47. [2] Nelson D, Giovino G, Emont S, Brackbill R, Cameron L, Peddicord J, et al. Trends in cigarette smoking among US physicians and nurses. JAMA 1994;271:2731275. [3] Beletsioti-Stika P, Scriven A. Smoking among Greek nurses and their readiness to quit. Int Nurs Rev Jun 2006;53:1506. [4] Eshah N, Bond E, Froelicher E. The effects of a cardiovascular disease prevention program on knowledge and adoption of a heart healthy lifestyle in Jordanian working adults. Eur J Cardiovasc Nurs Mar 16 2010. [5] Gjeilo K, Stenseth R, Klepstad P, Lydersen S, Wahba A. Smoking cessation after cardiac surgery. A window of opportunity? Eur J Cardiovasc Nurs 2007;6:S8. [6] Schroeder S. What to do with a patient who smokes. JAMA Jul 27 2005;294(4):4827. [7] Tobacco free initiative. http://www.emro.who.int/tfi/wntd2005/kitfactsheets-overview.htm2005. [8] Sivarajan Froelicher E, David T. The facts on nurses and smoking. Eur J Cardiovasc Nurs 2005;4:12. [9] McKenna H, Slater P, McCance T, Bunting B, Spiers A, McElwee G. Qualified nurses' smoking prevalence: their reasons for smoking and desire to quit. J Adv Nurs Sep 2001;35:76975. [10] Tobacco free nurses initiative. http://www.tobaccofreenurses.org/ about.php 2010. [11] Smith D, Leggat P. An international review of tobacco smoking in the medical profession: 19742004. BMC Public Health 2007;7:115. [12] El-Khushman H, Sharara A, Al-Laham Y, Hijazi M. Cigarette smoking among health care workers at King Hussein Medical Center. J Hosp Med May 2008;3:2814. [13] World Health Organization. EMR country profile. http://www.emro. who.int/TFI/countryprofile.htm2005. [14] World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. http://whqlibdoc.who.int/ publications/2009/9789241563918_eng_full.pdf2009. [15] John U, Hanke M. Tobacco-smoking prevalence among physicians and nurses in countries with different tobacco-control activities. Eur J Cancer Prev 2003;12:2357. [16] Ministry of Health. Hospitals in Jordan. http://www.moh.gov.jo2009. [17] Hulley S, Cummings S, Browner W, Grady D, Hearst N, Newman T. Designing clinical research. Philadelphia: Lippincott Williams & Wilkins; 2001. [18] Shishani K, Nawafleh H, Sivarajan Froelicher E. Jordanian nurses' and physicians' learning needs for promoting smoking cessation. Prog Cardiovasc Nurs 2008;23:7983. [19] Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Standardizing questionnaire items for the assessment of waterpipe tobacco use in epidemiological studies. Public Health May 2005;119:4004.

4.1. Summary The findings from our study provide strong evidence for the need of an urgent action with respect to providing formal smoking cessation training to nurses and physicians. By making nurses and physicians a priority for intervention allows them to gain personal health benefits, and as the literature suggests, would create tobacco use control advocates in all settings. Training programs that target physicians and nurses can increase the chances of successful reduction of smoking on an individual level, and reduction of preventable smokingrelated diseases. Further study is needed to see if worldwide reductions may be achieved by targeting Jordan and similar countries, where nurses and physicians monitor their national trends for high smoking rates. Nurses and physicians are in an excellent position to influence behaviors of the public through role modeling. They are instrumental in promoting healthy lifestyles among individuals and populations. Increasing their access to information and evidence-based strategies that improve their own health habits can optimize their impact on others.

Downloaded from cnu.sagepub.com by guest on March 24, 2014

K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221227 [20] Afifi M, Clark V. Computer aided-multivariate analysis. 3rd ed. Boca Raton: Chapman & Hall; 2003. [21] MMWR. Prevalence of selected risk factors for chronic disease Jordan, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm5243a3.htm2003. [22] MMWR. Assessing risk factors for chronic disease Jordan, 2004. http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5523a3.htm2006. [23] Maziak W, Ward KD, Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev (Online) 2007, doi:10.1002/14651858.CD005549.pub2. [24] Maziak W, Ward K, Afifi S, Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tob Control Dec 2004;13:32733. [25] Maziak W, Rastam S, Eissenberg T, Asfar T, Hammal F, Bachir M, et al. Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria. Prev Med Apr 2004;38:47984.

227

[26] Trinkoff A, Storr C. Substance use among nurses: differences between specialties. AJPH 1998;88:5815. [27] Padula C. Nurses and smoking: review and implications. J Prof Nurs 1992;8:12032. [28] Fagerstrom K. Can reduced smoking be a way for smokers not interested in quitting to actually quit? Respiration MarApr 2005;72:21620. [29] Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev (Online) 2008;1:CD001188. [30] Rigotti NA, Bitton A, Richards AE, Reyen M, Wassum K, Raw M. An international survey of training programs for treating tobacco dependence. Addiction Feb 2009;104(2):28896. [31] Fiore M, Jaen C, Baker B, Benowitz N, Curry S, Dorfman S, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: Department of Health and Human Services Public Health Service; 2009.

Downloaded from cnu.sagepub.com by guest on March 24, 2014