==== Front BMC Nurs BMC Nurs BMC Nursing 1472-6955 BioMed Central London 37394472 1394 10.1186/s12912-023-01394-7 Research The knowledge, attitudes and behaviors of hospital nurses on smoking cessation interventions: a cross-sectional study http://orcid.org/0000-0001-6211-0174 Čivljak Marta marta.civljak@unicath.hr Ačkar Lovro lovroackar97@gmail.com http://orcid.org/0000-0002-8467-6061 Puljak Livia livia.puljak@unicath.hr livia.puljak@gmail.com grid.440823.9 0000 0004 0546 7013 Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, Zagreb, 10000 Croatia 3 7 2023 3 7 2023 2023 22 2289 2 2023 22 6 2023 © The Author(s) 2023 https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Background Smoking is a major public health problem in Croatia. It is unknown to what extent nurses in Croatia use interventions for smoking cessation to help their patients. This study aimed to analyze the knowledge, attitudes and behaviors of hospital nurses on smoking cessation interventions. Methods We conducted a cross-sectional study in Zagreb, Croatia, in 2022 on a convenient sample of hospital nurses. We collected data with a questionnaire that included sociodemographic questions and questions about the frequency of implementation of 5 A’s (Ask, Advise, Assess, Assist, Arrange) interventions for smoking cessation during their work using the Helping Smokers Quit (HSQ) survey, participants’ attitudes and knowledge about smoking cessation skills and the smoking status of the nurses. Results There were 824 nurses employed in the targeted departments; 258 nurses participated in the study (response rate: 31%). Among them, 43% responded that they always ask patients about their use of tobacco products. Only 2.7% indicated that they always help the patient to stop smoking. Very few (2%) attended any training in the past two years about helping patients to quit smoking, and 82% never had such training. 44% of the included nurses were smokers. Nurses who smoked stated more frequently than nonsmokers they should not be role models for their patients by avoiding smoking (P 0.001). Additionally, patients were less frequently questioned about their inability to stop smoking by nurses who smoked than nurses who did not smoke (P = 0.010). Conclusion Even though smoking cessation interventions delivered by nurses were proven effective, such interventions are used by a small number of surveyed nurses. A small number of nurses have received training to help them support smokers in quitting. The high smoking prevalence among nurses may impact their attitudes and the implementation of workplace smoking cessation efforts. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-023-01394-7. Keywords Tobacco smoking Nurses Smoking cessation Interventions Education issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2023 ==== Body pmcBackground Smoking is a global public health problem, with 1.3 billion smokers worldwide [1]. It is estimated that 8 million people die annually from the effects of smoking globally, of which 1.2 million deaths are associated with passive smoking [1]. Smoking is also a public health problem in Croatia, as evidenced by the results of the study conducted in 2014 and 2015 by the relevant Croatian and international public health authorities. According to the study results, 31% of the population aged over 15 smoked in Croatia (35.3% of men and 27.1% of women) [2]. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed in response to the globalization of the tobacco epidemic. The FCTC is the first international global health treaty and the evidence-based treaty that reaffirms the right of all people to the highest standard of health, which came into force in 2005 [3]. The WHO introduced the six MPOWER measures in 2008 to guide countries in this process, each corresponding to one or more FCTC provisions. The MPOWER package includes: monitoring tobacco use and tobacco control measures; protecting people from tobacco smoke; offering help (e.g., treatments) to quit tobacco; warning people about the dangers of tobacco; enforcing bans on tobacco advertising, promotion and sponsorship and raising tobacco taxes [4]. Although Croatia is one of the countries that are a Party to the WHO FCTC, comprehensive tobacco control policies are yet to be fully implemented. The least implemented FCTC article is cessation support through advice from healthcare providers, telephone quit lines and easily-accessible or low-cost medications (Article 14 of the FCTC) [5]. Nurses make up the largest healthcare profession in the world. Approximately 27 million men and women comprise the global nursing and midwifery workforce, accounting for nearly 50% of the global health workforce [6]. In addition, there is evidence that behavioral support to motivate and sustain smoking cessation delivered by nurses can increase the number of people who achieve prolonged abstinence [7]. Nurses play a vital role in primary health care delivery worldwide – including research, disease prevention, treating the injured, palliative care and more – which is represented through several World Health Assembly resolutions [6]. Among other roles, Croatian nursing law stipulates that a nurse has to be a counsellor to help people focus on a goal or outcome, develop strategies that support self-care, and enable individuals and their families to take responsibility for and participate in decisions about their health [8]. Thus, advising patients to stop smoking is part of a nurse’s role. Two well-known methods to help people quit smoking are the ABC method (ask, brief advice, cessation support) [9], and the 5As (ask for the smoking status, brief advice to quit, assess the motivation to quit, assist by providing evidence-based treatment, arrange follow-up) [10]. Furthermore, the counseling intervention can be captured by the 5Rs: relevance, risks, rewards, roadblocks, and repetition, which includes an additional brief intervention to enhance the motivation to quit in unmotivated smokers [10]. There is evidence that increasing the reach and intensity of smoking cessation services across the health sector might help people quit smoking. For example, a Cochrane systematic review published by Rigotti et al. in 2012 examined interventions offered to hospitalized patients for smoking cessation, including behavioral, pharmacological or multicomponent interventions. They concluded that intensive interventions that begin in the hospital with nicotine replacement therapy increase the rate of smoking cessation [11]. Additionally, multiple studies demonstrated that interventions provided by nurses could lead to an increase in the number of people who stop smoking or prolong abstinence [7, 12]. In 2015, Sarna et al. conducted a study in the Czech Republic and examined the frequency of nurses’ interventions in helping smokers to quit smoking, their attitudes and skills, and investigated the association between nurses’ smoking status and the level of intervention they implement [13]. The study showed that consistent intervention by nurses to help patients quit smoking was relatively rare in the Czech Republic, and some nurses were unwilling to intervene with patients on the topic of smoking cessation. Although the study of Sarna et al. included only nurses in the Czech Republic, it is possible that these results may be similar for nurses in other countries of Eastern and Southeastern Europe since smoking rates are very high in the countries of that area (both in the population and among nurses), and interventions by nurses (and other professions) are not part of routine clinical practice [13]. Nurses have an important window of opportunity to intervene with patients during their hospital stay or introduce the notion of not resuming smoking upon hospital discharge [7]. In addition, previous research shows that training nurses to implement smoking cessation interventions is extremely important and increases their willingness to participate in such programs [14, 15]. Li et al. have summarized literature about factors associated with nursing interventions for smoking cessation. They reported that nurses’ attitudes or perceptions, social influence, organizational factors and self-efficacy were associated with implementing smoking cessation interventions [16]. In addition, the authors highlighted that support and assistance are needed for nurses [16]. In Croatia, no continuous interventions are aimed at patients to stop smoking [5]. Furthermore, we could not find any studies in the literature about knowledge, attitudes and implementation of smoking cessation interventions among nurses in Croatia. Having such knowledge could help support nurses in implementing smoking cessation interventions in Croatia. Thus, this study aimed to examine which interventions for smoking cessation are carried out by nurses in Croatia and to examine their knowledge and attitudes about these interventions. Methods Study design This was a cross-sectional study. Ethics The study was conducted in accordance with the institutional Codes of Ethics. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all study participants. The study protocol was approved by the Ethics Committee of the Sestre Milosrdnice University Hospital Center (Document number: Klasa 003–06/22-03-003; Urbroj: 251-29-11-22-01-9). Participants The participants were nurses employed at the Sestre Milosrdnice University Hospital Center at the Department of Internal Medicine, the Department of Oncology and Nuclear Medicine, the Department of Cardiovascular Diseases, the Department of Neurology, the Department of Neurosurgery, the Department of Surgery, the Department of Psychiatry and the University Hospital for Tumors. Those departments were chosen as their patients are hospitalized longer than in other departments, so there are more opportunities for healthcare workers to implement interventions for smoking cessation. Data collection and study tool In agreement with the head nurses of the departments, the participants were approached at their workplaces. Participation in the study was voluntary and anonymous. The study was conducted via a questionnaire from April to June 2022 (Appendix 1). The participants were approached in person in their workplace by author Lovro Ackar. Since the survey was conducted in early 2022, during the COVID-19 pandemic, there were still heavy restrictions in the hospital to the in-person access to nurses, and thus not all nurses that worked in the targeted departments were invited. We invited a convenience sample of nurses that we could contact in person. The participants received written information about the study, informed consent and the survey, and the kind request to participate. Nurses filled out the questionnaire in their department after reading the study information and signing the written informed consent. Surveys were filled out in paper form. The first part of the questionnaire contained five questions about the sociodemographic data of the participants, including sex, professional education, smoking status, the department where they work and years of nursing experience. The second part of the questionnaire included the Helping Smokers Quit (HSQ) survey, developed and validated by Sarna et al. [17]. We obtained permission from Prof. Linda Sarna to use the questionnaire. The questionnaire consists of questions related to the frequency of implementation of the 5 A (Ask, Advise, Assess, Assist, Arrange) intervention for smoking cessation in addition to items about referring to a telephone quitline for cessation support, recommending tobacco cessation medications, reviewing barriers to quitting, and recommending a smoke-free home. Nurses assessed the frequency using one of five responses, including “always“, “usually“, “sometimes“, “rarely“, or “never“. Furthermore, the questionnaire contained questions about the smoking status of nurses and their education about smoking cessation. At the end of the questionnaire, items about their attitudes toward smoking cessation interventions and perceived skills for implementing such interventions were scored with a 5-item Likert scale ranging from “completely disagree” to “completely agree” [18, 19] (Appendix 1). The questionnaire was delivered in the Croatian language. For the study, the questions were translated into Croatian from English. Before delivering the survey to the nurses, the questionnaire was tested on a sample of nursing students employed in the healthcare system who were not part of the study sample. The pilot testing was used to assess the readability and understandability of the questionnaire. Following the pilot testing, there were no revisions to the questionnaire. Statistical analysis Data were analyzed using descriptive statistics, including frequencies, percentages, medians and interquartile range. A simple analysis of variance was used to compare the average number of respondents. We compared the association between the implementation of smoking cessation interventions among nurses who smoke and those who do not. We did not use any imputation methods. The value P < 0.05 was used as the level of significance. The SPSS software (version 20, IBM, New York, USA) was used for statistical analysis. Results There were 824 nurses employed in the targeted departments. However, due to COVID-19 restrictions on access to nurses, 340 questionnaires were distributed to nurses; 258 were filled out and returned (response rate: 31%). Raw data collected within this study are included in Appendix 2, which accompanies the manuscript. The median age of participants was 36 years (interquartile range: from 26 to 48 years). The participants had a median of 12 years of nursing experience (interquartile range: 4 to 12 years). Most participants (88%) were women. Most participants were employed at the Department of Cardiovascular Diseases and the Department of Surgery. Most nurses completed Bachelor’s degree in nursing as the highest educational degree (Table 1). Table 1 Characteristics of participants in terms of sex, education and department of employment Variable N %* Sex Man 32 12 Woman 226 88 Highest education level Nursing high school 110 43 Bachelor’s degree in nursing 116 45 Master’s degree in nursing 31 12 PhD degree 0 0.0 Department of employment Department of Internal Medicine 50 19 Department of Oncology and Nuclear Medicine 11 4 Department of Cardiovascular Diseases 53 21 Department of Neurology 13 5.0 Department of Neurosurgery 5 1.9 Department of Surgery 54 21 Department of Psychiatry 25 9.7 University Hospital for Tumors 47 18 *The percentages may not add up to exactly 100% due to rounding Among the participants, 44% (N = 110) were smokers, and 9.6% (N = 11) smoked within five minutes after waking up. More than half of nurses smoked daily (54%; N = 139). One hundred twenty-two participants responded to a question about whether they tried to stop smoking within the past year; 39% (N = 48) indicated they did. When asked if they were trying to quit smoking currently, 147 participants responded, and 15% (N = 22) indicated that they did (Table 2). The median age when they started smoking was 18 years (interquartile range: 16 to 20 years). For those who stopped smoking, the median age when they stopped smoking was 31 years (interquartile range: 24 to 40 years). Table 2 Smoking status of the participants Question N %* Have you ever smoked 100 or more cigarettes in your life? Yes 139 54 No 117 46 Do you smoke now? Yes 110 44 No 140 56 Do you smoke every day? Yes 100 54 No 87 47 How soon after you wake up do you smoke your first cigarette? Within 5 min 11 9.6 6–30 min 38 33 31–60 min 29 25 > 60 min 37 32 During the past 12 months, did you made a serious attempt to quit smoking (not smoking for 24 h or more)? Yes 48 39 No 74 61 Over your lifetime, how many times have you made a serious attempt to quit smoking (not smoking for 24 h or more)? 0 to1 53 43 2 to 4 51 41 5 to10 9 7.3 > 10 11 8.9 Are you currently trying to quit? Yes 22 15 No 125 85 *The percentages may not add up to exactly 100% due to rounding When asked about their training, 82% (214) of participants indicated that they did not participate in any smoking cessation education during their training. Furthermore, 96% (N = 243) of participants indicated that they did not take part in any education regarding smoking cessation within the past 24 months. There were 61% (N = 159) of nurses who indicated that they always or usually ask patients about their smoking status; 29% (N = 75) always or usually advise them to stop smoking; 24% (N = 61) assess readiness to quit smoking always or usually. There were 13% (N = 35) of nurses who indicated they always or usually assist with smoking cessation; 8% (N = 20) always or usually arrange smoking cessation follow-up; 5% (N = 13) always or usually recommend the telephone smoking quitline. There were 12% (N = 31) of nurses who indicated they always or usually refer patients to community cessation resources; 5% (N = 13) recommend always or usually tobacco cessation medications; 10% (N = 24) review barriers to quitting always or usually, and 13% recommend patients to create a smoke-free environment (Table 3). Table 3 Frequency of nurses’ delivery of smoking cessation interventions Delivery of 5As and Other Interventions N %* Ask about smoking/tobacco use Always 112 43 Usually 47 18 Sometimes 56 22 Rarely 31 12 Never 10 3.9 Advise patients to quit smoking Always 26 10 Usually 49 19 Sometimes 85 33 Rarely 63 25 Never 33 13 Assess readiness to quit smoking Always 16 6.3 Usually 45 18 Sometimes 78 31 Rarely 84 33 Never 32 13 Assist with smoking cessation Always 7 2.7 Usually 28 11 Sometimes 75 29 Rarely 85 33 Never 60 24 Arrange smoking cessation follow-up Always 3 1.2 Usually 17 6.7 Sometimes 38 15 Rarely 75 29 Never 122 48 Recommend the telephone quitline Always 3 1.2 Usually 10 3.9 Sometimes 30 12 Rarely 51 20 Never 161 63 Refer to community cessation resources Always 8 3.1 Usually 23 9.0 Sometimes 39 15 Rarely 69 27 Never 116 46 Recommend tobacco cessation medications Always 2 0.8 Usually 11 4.3 Sometimes 32 13 Rarely 64 25 Never 146 57 Review barriers to quitting Always 2 0.8 Usually 22 8.7 Sometimes 57 22 Rarely 76 30 Never 97 38 Recommend creating a smoke-free home environment Always 14 5.5 Usually 19 7.5 Sometimes 64 25 Rarely 61 24 Never 97 38 *The percentages may not add up to exactly 100% due to rounding Responses to items regarding nurses’ attitudes about helping patients quit smoking revealed that most participants chose neutral responses, i.e., they neither agreed nor disagreed with the items (Table 4). There were 24% (N = 62) of participants who agreed or strongly agreed that asking patients about smoking increases the likelihood that they will quit. 54% (N = 138) of participants agreed or strongly agreed that it is difficult for them to get people to quit smoking. 24% (N = 62) agreed or strongly agreed that counseling patients about quitting is not an efficient use of their time. 20% (N = 50) agreed or strongly agreed that patients appreciate it when they provide advice about quitting smoking. Only 13% (N = 33) agreed or strongly agreed that discussing smoking cessation improves their relationship with patients, while 15% (N = 46) agreed or strongly agreed that they feel uncomfortable asking patients whether they smoke (Table 4). Table 4 Nurses’ Attitudes About Helping Patients to Quit Smoking Item N %* Asking patients about smoking increases the likelihood that they will quit. Strongly disagree 25 9.8 Disagree 63 25 Neutral 104 41 Agree 51 20 Strongly agree 11 4.3 It is difficult for me to get people to quit smoking. Strongly disagree 6 2.4 Disagree 16 6.3 Neutral 94 37 Agree 105 41 Strongly agree 33 13 Counseling patients about quitting is not an efficient use of my time Strongly disagree 13 5.1 Disagree 79 31 Neutral 100 39 Agree 44 17 Strongly agree 18 7.1 Patients appreciate it when I provide advice about quitting smoking. Strongly disagree 20 7.9 Disagree 62 24 Neutral 122 48 Agree 40 16 Strongly agree 10 3.9 Discussing smoking cessation improves my relationship with patients. Strongly disagree 32 13 Disagree 74 29 Neutral 115 45 Agree 27 11 Strongly agree 6 2.4 I feel uncomfortable asking patients whether they smoke. Strongly disagree 41 16 Disagree 92 36 Neutral 77 30 Agree 38 15 Strongly agree 8 3.1 As a nurse, I can play an important role in helping patients quit. Strongly disagree 9 3.5 Disagree 31 12 Neutral 99 39 Agree 91 36 Strongly agree 24 9.4 I need more training to help patients quit smoking. Strongly disagree 20 7.9 Disagree 54 21 Neutral 84 33 Agree 68 27 Strongly agree 28 11 I have insufficient time to counsel patients about quitting smoking. Strongly disagree 9 3.5 Disagree 32 13 Neutral 77 30 Agree 89 35 Strongly agree 47 19 I should take a more active role in helping patients to quit smoking. Strongly disagree 13 5.1 Disagree 46 18 Neutral 112 44 Agree 66 26 Strongly agree 17 6.7 Patients will be offended if I inquire about their smoking status. Strongly disagree 17 6.7 Disagree 76 30 Neutral 113 45 Agree 41 16 Strongly agree 7 2.8 Providing tobacco cessation counseling is important to our hospital even if only a few patients quit. Strongly disagree 8 3.1 Disagree 18 7.1 Neutral 100 39 Agree 99 39 Strongly agree 29 11.4 I have an obligation to advise patients on the health risks associated with tobacco use. Strongly disagree 9 3.5 Disagree 28 11 Neutral 98 39 Agree 89 35 Strongly agree 30 12 How many patients do you estimate have you counseled for smoking cessation over the past week ? 0 158 62 1–2 71 28 3–5 15 5.9 More than 5 12 4.7 *The percentages may not add up to exactly 100% due to rounding 46% (N = 115) of participants agreed or strongly agreed that, as a nurse, they could play an important role in helping patients quit. 38% (N = 96) agreed or strongly agreed they need more training to help patients quit smoking. Among participants, 54% (N = 136) agreed or strongly agreed they have insufficient time to counsel patients about quitting smoking. 33% (N = 83) agreed or strongly agreed they should take a more active role in helping patients to quit smoking. 19% (N = 48) of participants agreed or strongly agreed that patients would be offended if they inquired about their smoking status (Table 4). Half (N = 128) of the participants agreed that providing tobacco cessation counseling is important to the hospital, even if only a few patients quit. There were 47% (N = 119) of nurses who agreed or strongly agreed with a statement that they have an obligation to advise patients on the health risks associated with tobacco use (Table 4). However, very few participants, only 4.7% (N = 12), indicated that over the past week, they counselled more than five patients about smoking cessation (Table 4). When they had to score statements about nurses and tobacco control, most nurses chose neutral responses (Table 5). 47% (N = 119) of participants agreed that nurses should set a good example by not smoking, 48% (N = 122) agreed that nurses should be involved in actively helping patients to stop smoking, and 48% (N = 121) agreed that nurses need additional training/skills in tobacco control (Table 5). Table 5 Participants’ responses regarding statements about nurses and tobacco control Items N %* Nurses should set a good example by not smoking Strongly disagree 28 11 Disagree 30 12 Neutral 75 30 Agree 74 29 Strongly agree 45 18 Nurses should be involved in actively helping patients to stop smoking Strongly disagree 12 4.7 Disagree 20 7.9 Neutral 100 39 Agree 92 36 Strongly agree 30 12 Nurses need additional training/skills in tobacco control Strongly disagree 19 7.5 Disagree 22 8.7 Neutral 90 36 Agree 78 31 Strongly agree 43 17 *The percentages may not add up to exactly 100% due to rounding At the end of the questionnaire, participants were asked to rate two questions with a Likert scale ranging from 1 (least important) to 5 (most important). Most participants chose a neutral response regarding the importance of nurses’ involvement in tobacco control activities (37%; N = 96). Also, when asked to assess how important it is for nurses to be involved in tobacco control activities, compared to other disease prevention activities (e.g., nutrition, exercise, etc.), most participants chose the neutral response (38%; N = 97). Analysis of variance was conducted to analyze the association of items regarding nursing interventions for smoking cessation and nurses’ smoking status (Table 6). Among all questions and items given to the participants, a significant difference in the frequency of responses was noted for the item on reviewing barriers to quitting (P = 0.010) – nurses who smoke were engaged in such behavior significantly less than those that do not smoke. Also, we found a significant difference in the responses to the statement “Nurses should set a good example by not smoking“– agreement with this statement was more common among nurses who did not smoke compared to those who smoke (P < 0.001) (Table 6). Table 6 Distribution of participants with regard to personal smoking status and questions/items regarding smoking cessation interventions implemented by nurses and their attitudes towards those interventions Do you smoke now? P Yes No N %* N %* Ask about smoking/tobacco use Always 55 50 56 40 0.167 Usually 13 12 31 22 Sometimes 27 25 28 20 Rarely 12 11 19 14 Never 3 2.7 6 4.3 Advise patients to quit smoking Always 8 7.3 16 12 0.078 Usually 17 16 31 22 Sometimes 34 31 48 35 Rarely 30 27 32 23 Never 21 19 12 8.6 Assess readiness to quit smoking Always 3 2.7 12 8.6 0.276 Usually 21 19 23 17 Sometimes 32 29 45 32 Rarely 37 33 44 32 Never 17 16 15 11 Assist with smoking cessation Always 3 2.7 4 2.9 0.682 Usually 11 10 16 12 Sometimes 34 31 38 27 Rarely 32 29 51 37 Never 30 27 30 22 Arrange smoking cessation follow-up Always 2 1.8 1 0.7 0.851 Usually 6 5.5 11 7.9 Sometimes 17 16 19 14 Rarely 33 30 40 29 Never 52 47 68 49 Recommend the telephone quitline Always 2 1.8 1 0.7 0.442 Usually 4 3.6 6 4.3 Sometimes 17 16 12 8.6 Rarely 20 18 31 22 Never 67 61 89 64 Refer to community cessation resources Always 4 3.6 4 2.9 0.312 Usually 9 8.2 14 10 Sometimes 15 14 23 17 Rarely 25 23 44 32 Never 57 52 54 39 Recommend tobacco cessation medications Always 1 0.9 1 0.7 0.665 Usually 4 3.6 7 5.0 Sometimes 13 12 17 12 Rarely 23 21 39 28 Never 69 63 75 54 Review barriers to quitting Always 2 1.8 0 0.0 0.010 Usually 6 5.5 16 12 Sometimes 21 19 32 23 Rarely 26 24 48 35 Never 54 50 43 31 Recommend creating a smoke-free home environment Always 5 4.5 9 6.5 0.166 Usually 4 3.6 15 11 Sometimes 29 26 33 24 Rarely 25 23 36 26 Never 47 43 46 31 Asking patients about smoking increases the likelihood that they will quit. Strongly disagree 14 13 10 7.2 0.178 Disagree 32 29 29 21 Neutral 42 39 61 44 Agree 18 17 32 23 Strongly agree 3 2.8 7 5.0 It is difficult for me to get people to quit smoking. Strongly disagree 2 1.8 4 2.9 0.451 Disagree 4 3.7 11 7.9 Neutral 41 38 50 36 Agree 45 41 60 43 Strongly agree 17 16 14 10 Counseling patients about quitting is not an efficient use of my time Strongly disagree 5 4.6 6 4.3 0.293 Disagree 28 26 51 37 Neutral 48 44 50 36 Agree 18 17 25 18 Strongly agree 10 9.2 7 5.0 Patients appreciate it when I provide advice about quitting smoking. Strongly disagree 12 11 8 5.8 0.170 Disagree 26 24 34 25 Neutral 51 47 69 50 Agree 13 12 25 18 Strongly agree 7 6.4 3 2.2 Discussing smoking cessation improves my relationship with patients. Strongly disagree 17 16 14 10 0.594 Disagree 28 26 46 33 Neutral 50 46 61 44 Agree 11 10 15 11 Strongly agree 3 2.8 3 2.2 I feel uncomfortable asking patients whether they smoke. Strongly disagree 17 16 21 15 0.526 Disagree 37 34 54 39 Neutral 31 28 44 32 Agree 21 19 16 12 Strongly agree 4 3.6 4 2.9 As a nurse, I can play an important role in helping patients quit. Strongly disagree 6 5.5 3 2.2 0.633 Disagree 11 10 18 13 Neutral 44 40 54 39 Agree 39 36 50 36 Strongly agree 9 8.3 14 10 I need more training to help patients quit smoking. Strongly disagree 10 9.2 8 5.8 0.715 Disagree 22 20 32 23 Neutral 34 31 48 35 Agree 29 27 38 27 Strongly agree 14 12.8 13 9.4 I have insufficient time to counsel patients about quitting smoking. Strongly disagree 5 4.6 4 2.9 0.943 Disagree 13 12 16 12 Neutral 34 31 42 30 Agree 36 33 51 37 Strongly agree 21 19 26 19 I should take a more active role in helping patients to quit smoking. Strongly disagree 6 5.5 7 5.0 0.985 Disagree 19 17 25 18 Neutral 46 42 63 45 Agree 30 28 35 25 Strongly agree 8 7.3 9 6.5 Patients will be offended if I inquire about their smoking status. Strongly disagree 9 8.3 8 5.8 0.494 Disagree 26 24 47 34 Neutral 51 47 60 43 Agree 20 18 20 14 Strongly agree 3 2.8 4 2.9 Providing tobacco cessation counseling is important to our hospital even if only a few patients quit. Strongly disagree 3 2.8 5 3.6 0.732 Disagree 8 7.3 9 6.5 Neutral 45 41 53 38 Agree 44 40 53 38 Strongly agree 9 8.3 19 14 I have an obligation to advise patients on the health risks associated with tobacco use. Strongly disagree 6 5.5 3 2.2 0.315 Disagree 14 13 14 10 Neutral 46 42 51 37 Agree 33 30 52 37 Strongly agree 10 9.2 19 13.7 How many patients do you estimate have you counseled for smoking cessation over the past week ? 0 75 68 79 57 0.160 1 to 2 25 23 45 32 3 to 5 4 3.6 10 7.2 More than 5 6 5.5 5 3.6 Nurses should set a good example by not smoking Strongly disagree 18 17 10 7.2 < 0.001 Disagree 19 18 11 8.0 Neutral 27 25 47 34.1 Agree 35 32 37 26.8 Strongly agree 9 8.3 33 24 Nurses should be involved in actively helping patients to stop smoking Strongly disagree 9 8.3 3 2.2 0.118 Disagree 11 10 9 6.5 Neutral 41 378 55 40 Agree 39 36 52 38 Strongly agree 9 8.3 19 14 Nurses need additional training/skills in tobacco control Strongly disagree 11 10 7 5.1 0.235 Disagree 10 9.3 11 8.0 Neutral 36 33 53 38 Agree 38 35 40 29 Strongly agree 13 12 27 20 How important is it for nurses to be involved in tobacco control activities? 1 – least important 9 8.3 14 10 0.372 2 23 21 17 12 3 43 39 53 38 4 27 25 42 30 5 – the most important 7 6.4 12 8.7 Compared to other disease prevention activities (e.g., nutrition, exercise, etc.), how important is it for nurses to be involved in tobacco control activities? 1 – least important 14 13 11 8.0 0.475 2 21 19 19 14 3 39 36 58 42 4 28 26 39 28 5 – the most important 7 6.4 11 8.0 *The percentages may not add up to exactly 100% due to rounding Discussion We found that almost half of the nurses (44%) who participated in the study were smokers. Slightly less than half of the respondents (43%) always ask the patient if they use tobacco products, thus opening up the possibility of using interventions to stop smoking. Very few respondents indicated that they always help the patient to quit smoking. Almost all respondents did not receive any education in the past two years that would have provided them with the knowledge and skills to assist in quitting smoking, and most never had such education while they were attending nursing school. Few differences in the use of nursing interventions and attitudes towards those interventions were observed between nurses who smoked versus those who did not. According to US Centers for Disease Control data, 25% of nurses worldwide consume tobacco products. Studies conducted during the COVID-19 pandemic indicated that a high percentage of nurses consumed tobacco, alcohol or other substances due to anxiety, stress and the effect of the pandemic [20, 21]. In 2019, Nilan et al. published a systematic review and meta-analysis of the prevalence of tobacco use in healthcare workers. They included 229 studies representing 457,415 healthcare workers from 63 countries. They found that the overall pooled prevalence of tobacco use in healthcare workers was 21%, with 31% in men and 17% in women. The highest estimates for the overall pooled prevalence of tobacco use were found for men physicians and women nurses. The percentage of women nurses smoking in high-income countries was 21%, and in upper-middle-income countries, it was 25% [22]. Compared to these countries, the percentage of smokers in this study was very high, as 44% of nurses in our sample indicated they were smokers. Furthermore, almost 10% of them have their first cigarette within five minutes of waking up. This finding indicates that many nurses probably have a problem with nicotine addiction since the time of the first cigarette upon waking is one of the indicators of the heaviness of smoking or high nicotine addiction [23]. A nurse should be sufficiently educated, eloquent, professional, kind, and must possess many skills to provide high-quality healthcare. Nursing interventions also include counseling and the promotion of a healthier lifestyle. For example, in this study, almost half of the nurses stated that they always ask patients about their smoking status. The same distribution of responses was found in a study from the Czech Republic conducted on a sample of 157 nurses [13]. We found that most nurses were not ready to help the patient quit smoking, and the question is whether they are even aware of the importance of their role in this. Research on this topic has been conducted in other countries as well. The same problem was encountered with registered nurses in China; most indicated that they asked patients about their smoking status, but few were willing to help with smoking cessation interventions [24]. In our sample, most nurses never advised patients to use the smoking cessation hotline. It is unclear whether the nurses are aware of the various existing resources for smoking cessation in the community. Also, most nurses rarely or never recommend patients’ treatment in the community (clinics, counseling centers, etc.), and most do not recommend medicines that help in smoking cessation. A study conducted by Sarna et al. in the Czech Republic showed that slightly less than 15% of nurses always recommend community treatment compared to surveyed nurses in Croatia, who always recommend community treatment in less than 3% [13]. Sarna et al. concluded that their data demonstrate that consistent nursing intervention to help patients quit smoking in the Czech Republic is relatively rare. Also, some nurses were reluctant to intervene with patients on this topic [13]. As for the nurses’ attitudes, they were mostly neutral about most of the statements about nurses and smoking cessation interventions. This could be seen as taking the “line of least resistance” and against making additional effort within their working framework. A third of nurses indicated that patients would not change their smoking habits if asked about their tobacco product consumption habits. More than 40% considered persuading the patient to quit smoking difficult. Such reasoning is likely due to the lack of nurses’ self-confidence and professional limitations since less than 10% of nurses agreed that they could persuade a patient to stop smoking. Professional self-confidence is a part of professional identity, competence, clinical knowledge and reasoning that could be lacking in this field [25]. Many nurses were aware that their role in smoking prevention is important, as 36% of them agreed that counseling on quitting is not a waste of time – this was in contrast to the 24% of nurses who agreed that counseling is a waste of time. However, less than a fifth of them indicated that patients appreciate being advised, and almost half indicated that discussing smoking will not lead to a better relationship with the patient. This is far from the recommendations of professionals who advise smoking cessation as part of health promotion. Health promotion is achieved by advocating the basic prerequisites for a healthy life, enabling the patient’s health potential and mediating between patients and their social interests [26]. Participants’ responses regarding their education about smoking cessation could be a reason for this inactivity. More than a third of respondents agreed that they need additional education regarding smoking cessation and that they should become active in the field of patient education and counseling. This is essential information that should be considered if programs for nurses were to be built on the control of tobacco products and patient counseling so that they could be empowered to engage in interventions that could help patients in smoking cessation. In addition, other research results strongly support the need for additional education for nurses regarding smoking cessation [13]. Few participants in our study received education on smoking cessation, and almost half of the respondents indicated they needed education on quitting smoking. Those results align with many prior studies that showed nurses report a lack of education regarding smoking cessation [7, 13, 27–29]. We found very few differences in behaviors and attitudes of nursing regarding interventions for smoking cessation. In a review regarding the smoking habits of nurses and interventions towards patients between 1996 and 2015, Duaso et al. showed that the personal smoking status of nurses is not significantly related to nurses questioning patients about their smoking. It was also confirmed that nurses who smoke were 13% less likely to advise their patients to stop smoking and 25% less likely to arrange to stop smoking afterwards [30]. The feasibility of the multimodal intervention for smoking cessation in a hospital setting in Croatia was proven in a recently published pilot study. Patients were very satisfied with the intervention, and high smoking abstinence rates were recorded at six-month after hospital discharge. Thus, healthcare workers employed in hospitals could be educated to provide such interventions regularly [31]. Nurses should engage in interventions for smoking cessation. Patients trust nurses the most among healthcare professionals; thus, they could play an important role in the smoking cessation effort among patients. Unfortunately, this research has shown that only some nurses engage in interventions that could help patients quit smoking. It is acknowledged that nurses may be overloaded with their other duties. However, if they became aware of the importance of participating in smoking cessation, they could help the patient and contribute to greater personal and work satisfaction. Nurses’ education on smoking cessation counseling could potentially reduce the number of smokers since nurses are the most numerous workforce in Croatia, and properly focused education of nurses about helping patients with smoking cessation would certainly have an impact [32]. A limitation of our study is that we have included only one hospital in Croatia. However, the study was conducted during the COVID-19 pandemic when personal contact with healthcare professionals in hospitals was extremely limited. Future studies in this area should explore interventions for helping nurses quit smoking. Also, researchers should test the efficacy of various interventions that will help nurses change their attitudes towards nursing smoking cessation interventions and foster their engagement in such interventions. Studies reporting the design and evaluation of such interventions and their acceptability to nurses will help us design and implement successful interventions in the future. After adopting such interventions, future follow-up studies should explore nurses’ attitudes, experiences and implementation of smoking cessation practices. In that respect, our study can serve as a benchmark, reporting the baseline data that can serve as a comparison for future studies in Croatia on this topic. Of note, there were missing data in several surveys, as not all participants answered all of the questions. The percentage of missing answers in any given question was at most 5%. Conclusion Our results point to the importance of educating nurses about smoking cessation interventions they could engage in. Furthermore, our results point to the need for introducing courses about smoking cessation during the nurses’ compulsory education, with which they would acquire competencies for implementing smoking cessation interventions in the workplace. Likewise, the high prevalence of smoking among nurses indicates the need to develop smoking cessation interventions targeting nurses and other healthcare workers who smoke. Electronic supplementary material Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 2 Acknowledgements We are grateful to the participants who took part in the study. Particularly, we would like to thank Prof. Linda Sarna for approving the use of the questionnaire. This study was conducted as a part of the Master of Nursing thesis of Lovro Ackar; the thesis was written and defended in the Croatian language. Author contributions MČ, LA and LP: study designLA: data collection and analysis; MČ, LA and LP: data interpretation; LP: writing first draft of the manuscript; MČ, LA and LP: revising the manuscript for critical intellectual content; MČ, LA and LP: approval of the final version of the manuscript. Funding The authors did not obtain any grants to support this work. Data Availability Raw data collected within this study are included in Appendix 2, which accompanies the manuscript. Declarations Ethics approval and consent to participate The study was conducted in accordance with the institutional Codes of Ethics. All methods were performed in accordance with the relevant guidelines and regulations. Written informed consent was obtained from all study participants. The study protocol was approved by the Ethics Committee of the Sestre Milosrdnice University Hospital Center (Document number: Klasa 003–06/22-03-003; Urbroj: 251-29-11-22-01-9). Consent for publication Not applicable. Competing interests The authors do not have any competing interests related to this work. Abbreviations 5A Ask, Advise, Assess, Assist, Arrange ABC method Ask, Brief advice, Cessation support FCTC Framework Convention on Tobacco Control HSQ Helping Smokers Quit WHO AWorld Health Organization Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. ==== Refs References 1. World Health Organization. Tobacco. 24 May 2022. Available at: https://www.who.int/news-room/fact-sheets/detail/tobacco. 2. Deckovic-Vukres V, Ivicevic Uhernik A, Mihel S. Survey on the use of tobacco in the adult population of the Republic of Croatia. 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