Smoking practices of nurses have been a research concern of many investigators (Dalton & Swenson, 1986; Elkind, 1988; Garfinkel & Stillman, 1986; Lenehan, 1985; Murray, Swan, & Mattar, 1983; Rausch, Hopp, & White, 1987; Small & Tucker, 1978; Spencer, 1983; Wagner, 1985; Yuson, 1981). Studies about smoking habits of nursing students, however, are less prevalent. Research on this topic is valuable because of the potential implications for nursing education curricula, particularly in terms of influencing health behaviors congruent with the professional nursing role.
Results of previous inquiries of student nurses' smoking behavior are difficult to compare because of differences in sampling and data collection procedures. Thus, to validate findings, it is important to carry out studies similar in design. The purpose of this article is to compare and contrast the results of an investigation by Haughey, et al in Buffalo, New York (Haughey, O'Shea, Dittmar, et al, 1986) with the findings observed in a replication of this research by Casey (1986) in Portland, Maine.
Smoking prevalence rates of 6% to 57% have been identified in inquiries of smoking behavior among student nurses (Burk & Nilson, 1975; Haughey et al, 1986; Small & Tucker, 1978). Previous studies suggest that nursing students are more likely to start smoking during their education than students in other professions (Leathar, 1980; Neil, Clark, & Muller, 1980; Small & Tucker, 1978) and that the type of nursing program in which students are enrolled may have an affect on smoking habits, with the highest proportion of smokers reported in non-university settings (Small & Tucker, 1978). Other proposed determinants of smoking behavior include peer pressure, social and developmental stress, and entry hito a profession perceived to be stressful (Burk & Nilson, 1975; Hillier, 1973; Kirby, Baashkawi, Drew, et al, 1976; Leather, 1980; Small & Tucker, 1978).
Lack of knowledge about health consequences of smoking also has been observed among samples of student nurses. In the early 70's, Burk and Nilson studied smoking behavior among nursing students in Maine and found that their ability to associate smoking with certain health conditions was weak (Burk & Nilson, 1975). Subsequent studies have reinforced this finding. For example, a study conducted at Chelsea College, England (Gaze, 1986) also documents that nursing students have inadequate knowledge of the hazards of smoking, as do a number of other studies recently reviewed by Elkind (Elkind, 1988); however, findings relative to the knowledge of students are not consistent. Elkind notes that students do acknowledge the importance of smoking as a health issue and Haughey et al (1986) found students were knowledgeable about the association between smoking and adverse health outcomes. Leathar (1980) describes nursing students as "highly aware" of all the health arguments against smoking.
A recent consideration in studies of determinants of smoking behavior among student and graduate nurses is the role that nursing education may play. Failure of nursing education to emphasize health behaviors and use of the medical model in the nursing curriculum may explain why nurses perceive themselves more as providers of care and helpers to the ill than as health models and educators (Rausch et al, 1987).
The role modeling to which student nurses are exposed during their basic education has also been implicated as a determinant of smoking habits. In a survey of smoking in institutions that educate health professionals, smoking prevalence among baccalaureate degree and associate degree nursing administrators was the highest, 33.3% and 28.4%, respectively (Rausch et al, 1987).
An emerging trend to include health promotion practices in some nursing school curricula may serve to prevent smoking initiation and encourage cessation among student nurses. To continue studying their smoking practices, it is important to carry out studies not only similar in design but also in sampling and data collection procedures. Thus, comparisons of studies as presented in this article can yield findings suggestive of successful intervention not only in improving the health behaviors of nursing students, but also in the health promotion and disease prevention of the future clients of nursing.
The sample in the Buffalo study included 1,163 students attending three diploma programs, four associate degree programs, and three programs leading to the baccalaureate degree; 89% were generic students and 11% were registered nurses. All subjects voluntarily agreed to participate in the research. The mean response rate for the sample was 59%. Data were gathered in spring 1984.
The Portland study included 102 senior nursing students attending three collegiate programs; 22.5% of the students were seniors in one associate degree nursing program, while 77.5% were seniors in two baccalaureate degree nursing programs. The mean response rate for the entire sample was 74.6%. Data were collected during fall 1986.
The instrument used for data collection was the same as that developed at Buffalo by Haughey and colleagues. Modifications in the questionnaire for the Portland study included the addition of questions to elicit student perceptions of the influence of nursing faculty and the curriculum on their smoking behavior, their perceptions of smoking behavior as a private matter (not related to their professional role), and their perceived sense of responsibility for practicing healthy behaviors because of their student nurse status and future role as health exemplars.
To establish content validity, the original instrument was submitted to a panel of experts composed of the Evaluation Committee of the Buffalo Chapter of the American Lung Association. The consensus of this group was that the items included in the questionnaire were valid measures of the smoking-related concepts under study. The few suggestions for changes made by the committee members were incorporated into a revised version of the instrument. The questionnaire was then pilot tested among a volunteer sample of 42 graduate nursing students. Further revisions were made to improve clarity of items and expand response options.
Reliability studies of the instrument assessing smokingrelated behavior data obtained in this research were not undertaken. Although concern about the reliability of information on smoking behavior ascertained by selfreports has pervaded the smoking-related research literature, there is some evidence that questionnaire responses are internally consistent and reproducible (Petitti, Friedman, & Kahn, 1985). The researchers urge cautious interpretation of results, however, in view of the lack of empirical documentation of reliability data estimates.
As would be expected from national profiles of nurses, both samples included few males (7%). Age ranges in both studies were similar, 17 to 55 years of age in Buffalo and 18 to 42 in Portland. The mean age (24 years) was the same in both samples. Seventy-three percent of the students in Buffalo were single as were 77% of the students in Portland. More than three quarters (84%) of the students in Buffalo were engaged in full-time study, compared with 94% in Portland.
Whereas 30% of the student nurses in Buffalo reported that they currently smoked cigarettes, 23% of students in Portland reported themselves as current smokers. Twentyfive percent of the Buffalo students and 28% of those in Portland were ex-smokers, with students who denied any smoking history comprising 45% and 50% of the samples, respectively.
Among current smokers, more than half (57%) of the Buffalo students expressed the desire to quit. In Portland, the proportion was lower (39%). Fewer students in Buffalo (29%) were undecided about quitting than in Portland (39%). In both Buffalo and Portland, some current smokers had no desire to quit (14% and 22%, respectively).
REASONS REPORTED BY STUDENT NURSES FOR STARTING TO SMOKE
There were similar percentages of students in both samples who reported having attempted to stop smoking (Buffalo, 81%; Portland, 87%). There were differences, however, in the number of quitting attempts reported: 56% of Buffalo students had attempted between one and three times, whereas a larger proportion in Portland had tried as frequently to stop.
Ninety percent of the Buffalo students and 100% of the Portland students who were current smokers had tried to quit on their own. Only 5% and 19% of the Buffalo and Portland samples, respectively, had taken advantage of any formal program. When they were asked if they would participate in a smoking cessation program if offered, 76% of the Buffalo sample, as compared with only 47% of Portland students, responded affirmatively.
Smoking histories of students who were current or exsmokers in both samples were similar. They were asked a number of questions about their smoking histories, including age at smoking initiation. Most students in both samples (Buffalo, 88%; Portland 77%) began smoking at or before age 18, thus prior to entering nursing school. Comparison of the extent of smoking (number of cigarettes per day) revealed that 87% of students in Buffalo smoked one pack per day, whereas 64% of students in Portland smoked this amount.
Students' reasons for smoking initiation are given in the Table. While the most frequent reason, stated by 65% of Buffalo students, was that it was the thing to do, Portland students' most frequent reason was the pleasure of smoking. The next highest ranking reasons for Buffalo students were the pleasure of smoking, peer pressure, and the relaxing effects in social situations. For Portland students, the next most frequent reasons were similar: peer pressure, it was the thing to do, and to be more relaxed in social situations. Thus, although priorities were different, top rankings of reasons were similar.
When changes in students' smoking habits during their nursing education programs were examined, it was found in both studies that more than half of those who currently or formerly smoked had changed their smoking habits after starting nursing school. The proportion of those who reduced (Buffalo, 13%; Portland, 23%) or quit smoking (Buffalo, 12%; Portland, 7%) was smaller than those who either started to smoke (Buffalo, 13%; Portland, 50%) or smoked more (Buffalo, 62%; Portland, 20%).
Smokers who had tried to give up cigarettes and those who had successfully quit were queried about their motives. In both samples, protection of future health was the most frequent response (Buffalo, 78%; Portland, 91%). Saving money and self-discipline were the next highest ranking reasons.
In both samples, more than 90% of the students knew that smoking is associated with coronary artery disease, lung cancer, chronic bronchitis, oral cancer, pulmonary emphysema, laryngeal cancer, and low-birth weight syndrome. Knowledge regarding diseases of blood vessels and precancerous lesions was less impressive. The least known health association with smoking found in both samples pertained to bladder cancer. The percentages of students who were not aware of this association were very similar (Buffalo, 28.7%; Portland, 28.3%).
Although nurses comprise the largest group of healthcare professionals in the nation, the problem of smoking and health has not been adequately addressed by nurses. Nursing educators teach students who, in turn, teach patients by example, as well as through instruction ( Aucoin, 1986). It is crucial for nursing educators to serve as role models for their students if they expect students to serve as exemplars for their patients.
Nurses, more than any other health professionals, have frequent, direct, and prolonged contact with patients. They also have the knowledge and skills to teach others about the effects of smoking Dalton & Swenson, 1986). Health professionals who smoke, however, are less likely than non-smokers or ex-smokers to encourage their patients to quit (O'Shea & Corah, 1984; Pincherle & Wright, 1970), and may even undermine the efforts of other health professionals in influencing patients' smoking cessation efforts (KeIman, 1986).
In these two independent studies of smoking behavior among nursing students, smoking rates were similar to those of the female population in the US and not unlike the national estimates (29%) for registered nurses (US Department of Health and Human Services, 1985). The reported 30% of students who smoke in the Buffalo sample was higher than that in the Portland sample (23%). The decreased rate in the Portland students may reflect differences in the time frames of the two studies and the trend toward decreased smoking rates observed by some investigators. (Frankel, 1988; "From the Centers for Disease Control," 1988; Warner, 1987).
Both studies revealed the disturbing finding that of the students who smoke, many (75% in Buffalo and 70% in Portland) either started to smoke or began smoking more while they were in nursing school. This finding suggests the need to assess students' health behaviors and evaluate how their needs for health promotion are being met. It also indicates the salience of greater involvement by nursing faculty members in health promotion efforts among their students.
Another consistent finding in both studies was that, in general, the knowledge level of health hazards of smoking was high. This suggests that approaches to smoking cessation efforts may need to include more than the provision of facts alone. To accomplish this, nursing interventions that include smoking cessation counseling and teaching techniques could be included in every basic nursing education curriculum.
Although the Buffalo study reports the encouraging finding that 57% of the current smokers appeared to be motivated to quit, the comparable figure reported in Portland (39%) was less encouraging. Forty-three percent of the Buffalo students and 61% of the Portland students either had no desire or were unsure about their decision to quit. In view of the information now available about the decreased likelihood of nurses who smoke to teach and counsel patients about their smoking habits, it is clear that strategies need to be planned and implemented to discourage smoking among students. Otherwise, resources for patients could be seriously compromised.
High percentages of smokers in both samples (Buffalo, 81%; Portland, 87%) indicated they had tried to quit in the past, with the most frequent method being "on their own." This observation indicates that these students chose to change their smoking behavior at least once, but were not successful. Without success or attention to smoking cessation behavior, the motivation to quit may be very difficult to sustain. Thus, again, inclusion of smoking-related education takes on importance for the curriculum in that it might help students gain control over their smoking practices and thereby reduce their health risks and promote their effectiveness as health exemplars.
Further studies of student nurses' smoking habits need to be undertaken to provide a database for intervention strategies. Also, students' perceptions of their roles as health teachers and exemplars for patients should be examined further. The impact of faculty and the nursing curriculum on the development of health promotion and disease prevention behaviors also warrants consideration in future investigations.
It is encouraging to note the indication from published studies that work in this area has begun. For example, health promotion behaviors in nursing students were examined at the University of Northern Colorado (Richter, Malkiewicz, & Shaw, 1987). Specifically, differences in wellness behaviors were studied in three groups of nursing students, one that completed a course in health promotion behaviors, another that completed a personalized health promotion experience through an assessment in a nursing clinic, and a third group without specific health promotion experiences that served as a control. Based on findings from this study, the faculty plan to design an ongoing project that will describe the influence of stress on wellness behaviors in nursing students
Additionally, a unique teaching technique that uses microcomputers to appraise and stimulate adoption of positive health behaviors in nursing students has been described by two faculty members in Ohio (Boyle & Ahijevych, 1987). The technique, which includes their creative use of self, health appraisal resources, and technology to promote health in nursing students, resulted in modification of health behaviors in sophomore nursing students. These included increased percentages in recommended weight ranges, increased exercise calories per week, decreased problem drinking scores, improvements in nutrition, smoking cessation for some students, and a reduction in the number of cigarettes smoked for others.
Studies such as the two described above indicate that efforts on the part of nurse faculty can make a difference in the health behaviors and attitudes of nursing students. This interest is overdue, but suggests a promising trend toward developing future nurses who can serve as role models for health behavior, and as such can have positive influences on the patients they teach.
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REASONS REPORTED BY STUDENT NURSES FOR STARTING TO SMOKE