Few studies have been published on the prevalence of smoking among healthcare workers and smoking triggers. This study sought to determine smoking prevalence and identify factors associated with the initiation of smoking.
The pre-designed questionnaire in this cross-sectional study on healthcare workers at Prince Mohammed bin Abdulaziz Hospital in Riyadh, Saudi Arabia included items on demographics, smoking habits and smoking history, factors associated with smoking, and beliefs about smoking.
The study sample comprised 343 healthcare workers, of whom 117 (34.1%) were current and past smokers. The most common reason for smoking was stress relief (n = 78, 22.7%). In the 12 months before the survey, 48 respondents (14.0%) tried to quit smoking. Ninety-two (26.8%) stated that their workplace forbids smoking; however, 95 (27.7%) would smoke in the gardens and 59 (17.2%), in smoking-designated areas. Around half of the respondents (n = 161, 46.9%) said their co-workers also smoke. Smoking was significantly correlated with male gender, tight work schedules, obesity, high monthly income, and co-workers who also smoked.
More than One-third of our surveyed healthcare professionals smoke. Tendency to smoke is higher among workers who have tight work schedules and co-workers who also smoke. Smoking policies and strict no smoking rules are failing to deter individuals from smoking.
Healthcare workers, Prevalence, Smoking, Tobacco products, Saudi Arabia
Tobacco smoking is a major public health concern. The global smoking prevalence is about 12%, which translates into over one billion tobacco smokers [1]. The annual worldwide mortality rate secondary to tobacco smoking was projected to reach 7 million by 2030, and rates can be higher in low- and middle-income countries [1]. Smoking prevalence in Middle Eastern and African countries is increasing [2]. In Saudi Arabia, the prevalence ranges from 2.4% to 52.3%, depending on region [3].
Although conventional cigarettes remained the most common form of tobacco smoking, prevalence of waterpipe smoking (hookah, hubbly-bubbly, and narghile smoking) has increased in the past decade [4-6]. Electronic cigarettes (e-cigarettes or vapes), which are battery-powered devices that convert nicotine into vapor, have become increasingly common and popular among youth [7-9]. Studies have reported varying prevalence's of waterpipe smoking: 4%-12% in the Arab Gulf region, 6% in Pakistan, 9%-12% in Syria, and 11% in Australia [10,11].
The prevalence of e-cigarettes has risen in many countries; a study conducted among 27,460 Europeans from 28 countries in 2014 reported a prevalence of 31.1% [12-14]. In 2014, a survey including 480 university students in Riyadh city showed that 51.1% of smokers were e-cigarette users [15,16].
Studies on tobacco smoking among healthcare professionals in Saudi Arabia found prevalence's of 14.8%-25.3%, with hospital medical residents having the highest prevalence (25.3%), followed by primary health care physicians (20.5%), and medical consultants (18.6%); and higher among males than females (19.3% versus 9.4%) [17]. Few studies, however, address the safety of e-cigarettes and their effectiveness as a smoking cessation aid [18,19]. Limited studies identified potential risk factors for tobacco smoking among healthcare workers including age, gender, nationality, level of education, place of work, place of birth, and parental smoking [17-29].
Despite several studies in Saudi Arabia on the prevalence of smoking among different populations, few studies have investigated the prevalence of tobacco products among healthcare workers and factors associated with smoking initiation. Our study sought to determine the prevalence of various tobacco products (conventional cigarettes, e-cigarettes, and waterpipes), and identify smoking triggers.
The present cross-sectional study between January 2018 and January 2019 determined the prevalence of tobacco users among healthcare workers at Prince Mohammed bin Abdulaziz Hospital in Riyadh city, Saudi Arabia. The target population was healthcare workers involved in direct patient care (doctors, nurses, pharmacists, and technicians/technologists) of any age, gender, and nationality. Thus, we excluded receptionists, housekeepers, administrative staff, and other workers.
The base population of healthcare workers at the hospital numbered approximately 1,430. To achieve 80% power with a 95% confidence level and a level of significance set at p < 0.5, the power analysis calculated that a sample of 303 participants would be needed. We used a proportionate sampling technique for recruiting participants; a random sampling technique accounted for the size of each group in the overall study sample (71% were nurses; 20%, doctors; 5%, technicians/technologists; and 4%, pharmacists) so that the study sample reflected this distribution.
The present study was conducted via modified, self-administered, validated paper questionnaire in the English language based on the validated Global Adult Tobacco Survey (GATS) questions to the selected participants. We had first piloted the modified questionnaire on 36 participants to ensure construct and content validity. The questionnaire had a Cronbach's alpha of 0.80. Data variables included demographics (age, gender, marital status, occupation, nationality, education level, monthly income, working hours); smoking habits and smoking status (type of tobacco product smoked, smoking frequency, place of smoking, age of smoking onset); and peer pressure, social pressure, lifestyles, and smoking beliefs (stress relief and social acceptance). All participants gave their informed consent. We distributed the questionnaires to the study participants in-person after explaining the purpose of the study.
Data were encoded and analyzed using version 23.0 of the Statistical Package for the Social Sciences (SPSS; SPSS Inc., IBM, Armonk, New York, USA). Results are presented as means and Standard Deviations (SDs) for categorical variables and as numbers and frequencies (percentages) for continuous variables. The Pearson chi-square test determined the association between categorical variables and the independent t-test, continuous variables. A p-value of ≤ 0.05 was considered statistically significant. The Institutional Review Board, King Fahad Medical City, Riyadh, Saudi Arabia approved the present study.
The study sample comprised 343 healthcare workers (61.5% were Saudis): 101 (29.4%) were doctors; 133 (38.8%), nurses; 19 (5.5%), pharmacists; 21 (6.1%), technicians; 23 (6.7%), physiotherapists; and 46 (13.5%), others (Table 1). The gender distribution was nearly equal: 168 (49.0%) males and 175 (51.0%) females. Half of the respondents were married (n = 172, 50.1%), 194 (56.6%) had fixed work schedules, and 250 (72.9%) were 26-35 years old. Nearly half of the respondents had 2-5 years of work experience (n = 146, 42.6%), 150 (43.7%) had a normal body mass index (BMI), and 248 (72.3%) had a bachelor's degree.
Table 1: Demographic characteristics of the study sample (n = 343). View Table 1
Table 2 lists the smoking details and history of smoking of the 343 respondents. Of the 117 (34.1%) current and past smokers, 105 currently smoke. Sixty-nine participants began smoking one year before the study. Thirty-five (10.2%) said they usually smoke at home. The most common reason for smoking was stress relief (n = 78, 22.7%) followed by a relaxed feeling when smoking (n = 76, 22.2%). In the 12 months before the survey, 48 respondents (14.0%) had tried to quit smoking. Ninety-two (26.8%) said that smoking was forbidden at their workplace, however, 95 (27.7%) would smoke in the gardens and 59 (17.2%), in smoking designated areas in the workplace. Nearly half of the respondents (n = 161, 46.9%) said that their co-workers also smoked. The majority (203, 59.2%) said that their workplace forbids smoking in all indoor areas; however, 67 (19.5%) reported smoking in an indoor work area in the last 30 days. Nearly all respondents (318, 92.7%) drank caffeinated beverages, 296 (86.3%) drank coffee or tea, and 131 (38.2%) drank caffeinated drinks once or twice a day.
Table 2: Smoking history and other characteristics (n = 343 respondents). View Table 2
Males smoked significantly more than females (p < 0.001; Table 3). Respondents who were on shifts and on call smoked more than those on fixed work schedules (p < 0.05). Saudi nationals smoked significantly more than non-Saudis (p < 0.001). More doctors smoked than not (p < 0.05). Significantly more smokers had a monthly income of SAR8000-23,000 than of < SAR8,000 (p < 0.001). Significantly more smokers worked where smoking is allowed everywhere or at least in some indoor areas (p < 0.001). Differences in smoking versus non-smoking frequencies were non-significant concerning marital status, age group, years of work experience, BMI, education, chronic illness, long working hours, smoking forbidden in the workplace, working outside of home, and drinking caffeinated drinks.
Table 3: Comparison of all variables between smokers and non-smokers (chi-square test). View Table 3
Smoking correlated significantly with male gender, tight work schedules, Saudi nationality, obesity, higher monthly income, perception that smoking is cool, and co-workers who also smoked (data not shown). Among the respondents who did smoke, variables significantly correlated with pleasure in smoking, feeling relaxed while smoking, increased focus and concentration, and relief of stress.
The present study found a smoking prevalence of 34.1% among healthcare workers in a Saudi Arabian hospital. This rate is higher than that reported by other studies in Saudi Arabia [3,13,17,18]. Despite the introduction of e-cigarettes, the most common form of smoking is still conventional cigarettes, which has a convenience advantage over the traditional use of waterpipes. Less than 10% of the respondents smoked a waterpipe or engaged in shisha smoking, similar to previously reported rates from the Arab Gulf region but lower than prevalences reported for Syria, Australia, and Lebanon [10,11]. Use of e-cigarettes was even lower than conventional cigarettes and waterpipes. We had expected the rate of e-cigarette use to be substantially higher since the use of e-cigarettes has begun to be more popular among Saudi students, and by extension, other social groups [15,16].
In comparison to a local study by Mahfouz, et al. [17],our study found a higher prevalence of smoking among doctors (18.6% to 25.3% versus our rate of 35.9%), while another study reported even higher rates (> 25%) in Italy, France, and Japan [24]. Cattaruzza and West suggest that doctors smoke because they disregard the harmful effects of smoking ("fatalistic attitude") or they do not see smoking cessation as a priority [24]. Other probable reasons include insufficient knowledge of smoking cessation therapies and of the laws regarding tobacco use [25].
Smoking was significantly correlated with male gender in the present study. This is true in most countries where males predominantly smoke more than females [17]. Our results showed that smoking is significantly correlated with obesity; however, among 117 smokers, only 18 were obese and male. It may be that individuals who have high salaries understandably have the means to indulge in smoking [22]. Tight work schedules were also significantly related to smoking, confirming results of previous studies [23]. In particular those who work night shifts, like nurses, doctors, and call-center employees, have a tendency to develop unhealthy lifestyles and behaviors [28,29]. One of the most significant smoking triggers was peer influence. Our study found a strong association of a person starting and continuing to smoke with co-workers who smoke and peer pressure, compatible to previous studies [19-21]. This occurred despite warnings and workplace restrictions on smoking.
A strength of our study is that it identifies several issues that make it a valuable contribution to the literature, such as considering triggers like peer pressure, stress, and even work schedules, that may address and curb smoking among healthcare workers in the work place. Our study highlights the pressing need to implement smoking cessation programs at the workplace while considering the main associated factors identified in our study for a healthier lifestyle. The bottom line is that healthcare professionals know and understand the ill effects of smoking, and they should be the front liners for disseminating information on non-smoking. The main limitation was study design; a causal relationship cannot be inferred. Additionally, the study sample included a single workplace in Riyadh and was not representative of the general population. A third limitation was the self-recorded weight and height of participants, which is a possible source of error.
More than One-third of healthcare professionals in the present study smoke. Tight work schedules and peer influence (having co-workers who smoke) are significant triggers to begin and continue smoking, especially among males. Smoking policies and strict no smoking rules in the workplace are failing to deter individuals from smoking, thus smoking cessation programs and methods to improve employee health should be implemented. These findings can serve as guidelines for planning and implementing healthy workplace policies in hospitals.
This research project was supported by a grant from the Research Center of the Female Scientific and Medical Colleges, Deanship of Scientific Research, King Saud University.
The author declares no conflicts of interest.