Sarna, L. P., Bialous, S. A., Kraliková, E., Kmetova, A., Felbrová, V., Kulovaná, S., & ... Brook, J. K. (2014). Impact of a smoking cessation educational program on nurses' interventions. Journal of Nursing Scholarship, 46(5), 314-321. doi:10.1111/jnu.12086
CLINICAL SCHOLARSHIP
Impact of a Smoking Cessation Educational Program on Nurses’
Interventions
Linda P. Sarna, RN, PhD, FAAN1, Stella Aguinaga Bialous, RN, DrPH, FAAN2, Eva Kralikova´ , MD, PhD3,
Alexandra Kmetova, MD4, Vladislava Felbrova´ , RN5, Stanislava Kulovana´ , RN6, Katerina Mala´ , RN7,
Eva Roubickova´ , RN8, Marjorie J. Wells, RN, PhD9, & Jenny K. Brook, MS10
1 Gamma Tau Chapter, Professor and Lulu Wolf Hassenplug Endowed Chair, School of Nursing, University of California, Los Angeles, CA and
2 President, Tobacco Policy International, San Francisco, CA, USA
3 Associate Professor, Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles University in Prague and the General University Hospital
& Centre for Tobacco-Dependent of the Third Medical Department, First Faculty of Medicine, Charles University in Prague and the General University
Hospital, Czech Republic
4 Institute of Hygiene and Epidemiology, First Faculty of Medicine, Charles University in Prague and the General University Hospital & Centre for
Tobacco-Dependent of the Third Medical Department, Czech Republic
5 Centre for Tobacco-Dependent of the Third Medical Department, First Faculty of Medicine, Charles University in Prague and the General University
Hospital, Czech Republic
6 Centre for Tobacco-Dependent of the Third Medical Department, First Faculty of Medicine, Charles University in Prague and the General University
Hospital, Czech Republic
7Military University Hospital, First Faculty of Medicine, Charles University in Prague, Czech Republic
8 Faculty Hospital Kralovske Vinohrady, Clinic of Radiotherapy & Oncology, Prague, Czech Republic
9 Psi Chapter-at-Large, Project Director, Tobacco Free Nurses, School of Nursing, University of California, Los Angeles, CA, USA
10 Statistician, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
Key words
Smoking, nurses, intervention, tobacco, Eastern
Europe, Czech Republic
Correspondence
Dr. Linda Sarna, UCLA School of Nursing, 700
Tiverton Avenue, Los Angeles, CA 90095-6918.
E-mail: [email protected]
Accepted: March 1, 2014
doi: 10.1111/jnu.12086
Abstract
Purpose: To evaluate a brief educational program about smoking cessation
on the frequency of nurses’ interventions with smokers, and impact of nurses’
smoking status on outcomes.
Design: Prospective, single group design with prestudy and 3 months poststudy
data.
Methods: Nurses in the Czech Republic attended hospital-based 1-hr educational
programs about helping smokers quit. They completed surveys about
the frequency (i.e., always, usually, sometimes, rarely, never) of their smoking
cessation interventions with patients using the five A’s framework (i.e.,
ask, advise, assess, assist, arrange), and their attitudes prior to and 3 months
after the course. Demographic data included smoking status.
Findings: Among the 98 nurses with prestudy and post-study data, all were
female, mean age was 43 years, 33% were current smokers, and 64% worked
in a medical or surgical or oncology settings. At 3 months, compared to baseline,
significantly (p < .05) more nurses assessed patients’ interest in quitting,
assisted with quit attempts, and recommended the use of the quitline for cessation.
At 3 months after the program, nurses who smoked were less likely to
ask about smoking status (odds ratio [OR] = 4.24, 95% confidence interval
[CI; 1.71, 10.53]), advise smokers to quit (OR = 3.03, 95% CI [1.24,7.45]),
and refer patients to a quitline (OR = 2.92, 95% CI [0.99, 8.63]) compared to
nonsmokers, despite no differences in delivery of interventions at baseline.
Conclusions: Three months after attendance at an educational program focused
on the nurses’ role in supporting smoking cessation efforts, more nurses
engaged in interventions to help smokers quit. However, the program was less
effective for nurses who smoked.
Clinical Relevance: This program demonstrated promise in building capacity
among Czech nurses to assist with smoking cessation, but nurses’ smoking
poses a challenge.
314 Journal of Nursing Scholarship, 2014; 46:5, 314–321.
C
2014 Sigma Theta Tau International
Sarna et al. Nurses and Smoking Sessation
The World Health Organization Framework Convention
on Tobacco Control (WHO FCTC), the first global health
treaty, focuses on reducing the health consequences of
tobacco use worldwide (WHO, 2013). Article 14 of the
treaty addresses the need for treatment of tobacco dependence
and recommends capacity building of all healthcare
professionals to meet this need (WHO, 2013). In order
for the goals of the WHO FCTC to be realized, nurses, the
largest group of healthcare professionals worldwide, need
to be educated about tobacco dependence treatment.
Similar to statistics about preventable death worldwide,
tobacco use is the main cause of preventable disease
and death in the Czech Republic. Approximately 16,000
deaths a year are attributed to tobacco (Peto, Lopez,
Boreham, & Thun, 2012); 36.9% of the population ages
15 to 64 years use tobacco (41.3% of men and 32.3%
of women), and 24.5% of the population over the age
of 15 years are daily smokers (WHO, 2013). This study
describes the impact of efforts to educate nurses in the
Czech Republic about implementing smoking cessation
interventions in clinical practice using a train-the-trainer
approach.
Background
Relatively few of the over 1 billion smokers worldwide
receive evidence-based assistance with quitting (WHO,
2013). The majority of smokers in the Czech Republic
(60%) express a desire to quit, but few healthcare
providers are adequately prepared to assist (Sovinova,
2013; Sovinova, Sadilek, & Csemy, 2012). Involving
the over 100,000 Czech nurses (Czech Nurses Association,
2013) in delivering smoking cessation interventions
could accelerate national efforts to address
this major health risk. The importance of the role of
nurses in addressing tobacco dependence to reduce noncommunicable
diseases is supported by policy statements
from the 2012 WHO Global Forum for Government
Chief Nursing and Midwifery Officers and the
fourth triad meeting of the International Council of
Nurses, WHO, and the International Confederation of
Midwives (WHO, 2012). Nursing intervention to help
smokers quit can be effective. A review of 49 randomized
trials (Rice, Hartmann-Boyce, & Stead, 2013)
found that smokers who receive even minimal intervention
from nurses are more likely to quit smoking
than those who receive no assistance (relative risk [RR]
1.29, 95% confidence interval [CI] 1.20, 1.39). Similar
to the United States (Fiore et al., 2008), a guideline for
addressing tobacco dependence treatment in the Czech
Republic recommends a five A’s approach (i.e., asking
about a patient’s smoking status, advising smokers to
quit, assessing interest in quitting, assisting with cessation,
arranging follow-up) for smoking cessation interventions
utilizing social support and pharmacotherapy
(Kr´ al´ıkov´a et al., 2005).
Additionally, Czech nurses have a guideline supporting
their role and responsibilities in smoking cessation
(Mala´ , Felbrova´ , Kulovana´ , Kra´ l´ıkova´ , & Sˇ teˇpa´nkova´ ,
2009). Nurses are involved in interventions at the 40
cessation centers in the country (www.slzt.cz/centralecby),
a website is available to support quit efforts
(www.stop-koureni.cz, www.odvykanikoureni.cz), and
smokers have access to a national telephone quitline
(paying half-tariff) that provides counseling and support
during quit attempts. Nonetheless, support for smoking
cessation is still unusual in hospital settings, and nurses
are rarely involved, even in providing a brief intervention
and referring smokers to the quitline.
Over 70% of third-year nursing students in the Czech
Republic believed that health professionals have a role in
providing cessation intervention, but only 7.4% received
training in nursing school (Warren, Sinha, Lee, Lea, &
Jones, 2009). Healthcare providers who receive training
about tobacco cessation are more likely to intervene with
patients who smoke than those who do not. A metaanalysis
of eight studies confirmed that educational programs
for healthcare professionals had a positive impact
on patients’ quitting as assessed by 7-day point prevalence
and continuous abstinence (odds ratio [OR] = 1.60,
95% CI [1.26, 2.03]; Hartmann-Boyce, Stead, Cahill,
& Lancaster, 2013). The majority of these studies were
conducted in the United States, with three in Europe
(Scotland, United Kingdom, and Germany), and none in
Eastern Europe. None were conducted in hospital-based
settings. The analysis did not consider the impact of the
healthcare providers’ smoking status on outcomes.
A review of 17 randomized trials (three studies
included nurses but none focused solely on nurses) evaluating
training of health professionals in smoking cessation
on patient smoking outcomes at least 6 months after
intervention found that those who received education
were significantly more likely to intervene with smokers
(Carson et al., 2012). Several other studies provide
a foundation for educational programs to foster capacity
building with nurses. After hospital-based nurses’ receipt
of a 1-hr educational session based on the five A’s, more
patients who smoked reported receiving an intervention
and quitting 30 days after discharge (Vick, Duffy, Ewing,
Rugen, & Zak, 2012). A study targeting hospital-based
nurses (Matten et al., 2011) using a 3-hr course based
on the Rx for ChangeC program (Corelli et al., 2005)
reported improvement in attitudes, knowledge, cessation
counseling, and referrals up to 1 year after the program.
Nurse-initiated interventions with patients who smoked
and received care in an emergency room increased
Journal of Nursing Scholarship, 2014; 46:5, 314–321. 315
C
2014 Sigma Theta Tau International
Nurses and Smoking Sessation Sarna et al.
after an educational program involving 20-min face-toface
training and a 45-min online tutorial focused on brief
interventions (Katz et al., 2012).
Smoking among nurses is a barrier to delivery of
smoking cessation interventions (WHO, 2012). Smoking
among nurses varies worldwide (Smith, 2007), and it is
estimated that 40% of female nurses in the Czech Republic
smoke, a prevalence that is higher than the female
population (E. Kr ´ al´ıkov´ a, personal communication, June
23, 2011, regarding unpublished data from Kr´ al´ıkov´ a,
Kmetova, & Rames). The prevalence of smoking among
nursing students in the Czech Republic is 33.2%, similar
to rates in the region (e.g., Lithuania, 36.6%; Slovakia,
41.8%), and is a serious concern that must be addressed
as part of capacity-building efforts to address patients’
smoking cessation needs (Warren et al., 2009). Smoking
among nurses has been associated with more negative
attitudes and decreased involvement in smoking cessation
(Lenz, 2008). However, there areminimal data about
the impact of healthcare providers’ smoking on the outcomes
of educational programs on tobacco dependence
treatment.
Purpose
The aim of this study was to evaluate a brief hospitalbased
educational program focused on increasing nurses’
delivery of smoking cessation interventions according to
the five A’s and referral to a quitline, and promoting positive
attitudes about their involvement in smoking cessation.
We also examined the impact of the nurses’ smoking
status on program outcomes.
Methods
Design
A prospective design was used to assess changes in selfreported
frequency of nursing interventions to support
patients’ quit efforts in their nursing practice, prestudy
and 3 months after a brief educational program. The
study was approved by the institutional review board
of the principal investigator’s institution and the Charles
Hospital in Prague, which served as the ethics approval
body for all participating hospitals in the country.
Participants and Recruitment
Participants in this study included a convenience sample
of nurses from the Czech Republic who attended 1 of
10 educational programs about brief smoking cessation
interventions for hospitalized smokers. Nurses at each
hospital were invited to attend the educational program
and were recruited to participate in this study by the
nurse faculty member who had received special education
through a train-the-trainer program. Attending the
educational program was not contingent on participation
in the study, which was voluntary.
Measures
A survey administered before and after the educational
intervention, which included items based on a previously
developed and validated questionnaire, “Helping
Smokers Quit” (Sarna, Bialous, Ong, Wells, & Kotlerman,
2012a), was used to assess nursing interventions in
smoking cessation. Native speakers translated the Czech
Republic Helping Smokers Quit (CR-HSQ) survey. Reliability
was reestablished by test-retest (93% of the K values
were in the acceptable range, i.e., >.7). A nine-item
subscale evaluated nurses’ frequency (“always, usually,
sometimes, rarely, or never”) of self-reported delivery of
smoking cessation interventions using the five A’s, plus
items about recommending use of a telephone quitline
for cessation, recommending tobacco cessation medications,
reviewing barriers to quitting for patients unwilling
to make a quit attempt, and recommending a smokefree
home. A three-item subscale assessed attitudes about
nurses’ smoking, involvement in helping patients stop
smoking, and need for additional skills or training (rated
on a 5-point scale from strongly agree to strongly disagree).
A 13-item subscale evaluated attitudes and confidence in
counseling patients to quit smoking (responses on a 5-
point scale ranged from strongly disagree to strongly agree),
and a six-item subscale evaluated level of counseling proficiency
(responses on a 5-point scale ranged from poor
to excellent) (Corelli et al., 2005). Additional items asked
about nurses’ sex, age, and smoking status. Nurses were
asked if they ever smoked 100 or more cigarettes in their
lifetime, and if they smoked now and were classified as
current, former, or never smokers. Professional characteristics
included work setting and years since their basic
nursing educational program. The survey administered
before and after the educational program contained the
same items.
Educational Program
The 1-hr educational program on the nurses’ role
in smoking cessation was based on the abbreviated Rx
for ChangeC program (Corelli et al., 2005) tailored to
nurses in the Czech Republic. The program was delivered
by nurses who participated in a 1-day train-the-trainer
workshop, developed by the authors, using PowerPoint
slides (Microsoft, Inc., Redmond, WA, USA). Content included
tobacco epidemiology; principles of dependence;
316 Journal of Nursing Scholarship, 2014; 46:5, 314–321.
C
2014 Sigma Theta Tau International
Sarna et al. Nurses and Smoking Sessation
assessing tobacco dependence and withdrawal symptoms;
treatment of tobacco dependence using the five A’s; role
of the nurse in tobacco dependence treatment; community
resources, including the tobacco cessation centers
and the telephone quitline; role playing with motivated
and unmotivated smokers; and practical steps for implementing
the educational program for hospital-based
nurses. Subsequently, each workshop attendee received a
46-slide PowerPoint set with a script for each slide based
on the content described in the preceding sentence, educational
materials such as pamphlets, and informed consent
and pre- and postevaluation questionnaires. Trained
nurse faculty in eight hospitals throughout the Czech
Republic delivered educational programs to their staff
nurses (two hospitals ran two programs).
Data Collection
The nurse faculty collected the pretests of the nurses
who agreed to participate in the evaluation at each facility.
At the time of the 3-month post-test, the nurse faculty
sent notices to participants about the need to complete
the survey and provided a secure location for submitting
the anonymous surveys. After completion, the surveys
were sent to a central data collection address in Prague
and then to the investigators in the United States.
Data Analysis
Data entry was performed at the University of California
at Los Angeles by one of the authors (Brook).
All analyses used SAS 9.2 (SAS Institute, Inc., Cary,
NC, USA). Descriptive statistics were used to characterize
study variables. The primary outcome used to evaluate
the program was the change in the nurses’ self
-reported frequency of cessation interventions and referral
of patients to the quitline. Differences between
responses about clinical practice before and after the educational
intervention were examined using nonparametric
sign tests. We used the McNemar test to examine the
increase, from baseline to 3 months, in the proportion
of nurses who consistently (“always” or “usually”) intervened
using the five A’s and referral to the quitline. Additionally,
we compared the frequency of those who consistently
(“always” or “usually”) intervened with smokers
using the five A’s, and referred smokers to a quitline by
the nurses’ smoking status (dichotomized as current vs.
former/never smoker). Baseline and 3-month data were
analyzed separately for smokers versus nonsmokers using
chi-square tests. Subsequently, proportional differences
of pre-post change in frequency of use of the various elements
of the intervention by smoking status were examined
with nested analysis of participants within hos-
Table 1. Demographic and Professional Characteristics of the Nurses
(N = 98)
M (SD)
Age (years) 42.78 (11.49)
Years since graduated from nursing school 24.11 (11.62)
n (%)
Sex
Female 98 (100)
Smoking status
Never 44 (45.36)
Former 21 (21.65)
Current 32 (32.99)
Clinical practice setting
Medical 27 (27.55)
Oncology 28 (28.57)
Urgent care 14 (14.29)
Intensive care/emergency room 15 (15.31)
Surgical 8 (8.16)
Psychiatric 1 (1.02)
Rehabilitation 3 (3.06)
Obstetrics 2 (2.04)
pitals using generalized estimating equation modeling for
dichotomous outcomes.We calculated the OR for the difference
in performance between the smokers and nonsmokers
at baseline and 3 months.
Results
One hundred fifty-seven nurses completed the baseline
survey and 106 completed the 3-month survey. Of these,
98 (62.4% of 157) had both pre- and posttest data and
are the subject of this analysis. Table 1 displays the demographics
of the sample. Participants were female, average
43 years of age, and had over 20 years of practice.
Almost a third were current smokers. There were
no significant differences in demographic characteristics
between nurses who completed the 3-month survey and
those who dropped out after the baseline.
Three months after the educational program, there was
significant improvement in the overall frequency of assessment
of a smoker’s readiness to quit, the provision
of assistance with quitting, recommendations for use of
the quitline, and recommendations about medications
for cessation. Additionally, significantly more nurses reported
reviewing patients’ barriers to quitting and recommending
a smoke-free home after discharge (Table 2).
An analysis showed that after the educational program,
there was an increase in the percentage of nurses who
consistently (“always/usually”) assessed smoking status
(22.68%, p = .02) and referred smokers to the telephone
quitline (15.63%, p = .04). Nurses reported improved
confidence in their overall ability to help smokers
Journal of Nursing Scholarship, 2014; 46:5, 314–321. 317
C
2014 Sigma Theta Tau International
Nurses and Smoking Sessation Sarna et al.
Table 2. Changes in Nurses’ Delivery of Smoking Cessation Interventions
Before and 3 Months After Attendance of an Educational Workshop
Nurses’ tobacco Baseline 3 months Sign
dependence interventions n (%) n (%) test
Ask a patient’s smoking status
Always 49 (50.00) 46 (47.42) .57
Usually 12 (12.24) 16 (16.49)
Sometimes 22 (22.45) 19 (19.59)
Rarely 9 (9.18) 9 (9.28)
Never 6 (6.12) 7 (7.22)
Advise a patient to quit smoking .21
Always 17 (17.71) 27 (27.55)
Usually 26 (27.08) 22 (22.45)
Sometimes 33 (34.38) 33 (33.67)
Rarely 16 (16.77) 12 (12.24)
Never 4 (4.17) 4 (4.08)
Assess patients interest in quit smoking .002
Always 12 (12.24) 22 (22.68)
Usually 23 (23.47) 26 (26.80)
Sometimes 34 (34.69) 28 (28.87)
Rarely 17 (17.35) 15 (15.46)
Never 12 (12.24) 6 (6.19)
Assist a patient quit smoking .007
Always 13 (13.27) 15 (15.79)
Usually 13 (13.27) 21 (22.11)
Sometimes 19 (19.39) 14 (14.74)
Rarely 26 (26.53) 29 (30.53)
Never 27 (27.55) 16 (16.84)
Arrange smoking cessation follow-up .10
Always 8 (8.16) 5 (5.26)
Usually 4 (4.08) 6 (6.32)
Sometimes 6 (6.12) 13 (13.68)
Rarely 8 (8.16) 11 (11.58)
Never 72 (73.47) 60 (63.16)
Recommend the telephone quitline .03
Always 8 (8.16) 7 (7.29)
Usually 11 (11.22) 22 (22.92)
Sometimes 20 (20.41) 23 (23.96)
Rarely 20 (20.41) 16 (16.67)
Never 39 (39.80) 28 (29.17)
Refer to community resources .03
Always 14 (14.29) 15 (15.96)
Usually 14 (14.29) 16 (17.02)
Sometimes 19 (19.39) 26 (27.66)
Rarely 22 (22.45) 16 (17.02)
Never 29 (29.59) 21 (22.34)
Provide medication recommendations .0007
Always 4 (4.08) 11 (11.96)
Usually 8 (8.16) 13(14.13)
Sometimes 26 (26.53) 24 (26.09)
Rarely 19 (19.39) 19 (20.65)
Never 41 (41.84) 25 (27.17)
Review barriers to quitting .005
Always 6 (6.12) 8 (8.42)
Usually 15 (15.31) 22 (23.16)
Sometimes 29 (29.59) 29 (30.53)
Rarely 25 (25.51) 21 (22.11)
Never 23 (23.47) 15 (15.79)
Continued
Table 2. Continued
Nurses’ tobacco Baseline 3 months Sign
dependence interventions n (%) n (%) test
Recommend smoke-free home .02
Always 9 (9.18) 10 (10.31)
Usually 16 (16.33) 22 (22.68)
Sometimes 22 (22.45) 23 (23.71)
Rarely 22 (22.45) 21 (21.65)
Never 29 (29.59) 21 (21.65)
quit after the program and assisting patients with quitting
(Table 3).
The nurses’ smoking status made a difference in
the impact of the educational program on delivery
of smoking cessation interventions. There were
no statistically significant differences in the consistent
(“always/usually”) delivery of the five A’s prior to the
educational program between nurses who were current
smokers and those who were not. When comparing
changes in consistent intervention between smokers and
nonsmokers at 3 months, we see significant differences
(Table 4). Four times more nonsmokers reported consistently
asking about a patient’s smoking status. Three
times as many nurses who were nonsmokers consistently
advised smokers to quit. None of the nurses who smoked
consistently arranged for follow-up. Almost three times
as many nurses who were nonsmokers consistently recommended
use of the telephone quitline as compared to
current smokers.
Discussion
This study demonstrates that a brief educational program
about nurses’ role in smoking cessation can have a
positive impact on nursing practice in the Czech Republic.
Three months after the program, nurses’ self-reported
frequency of interventions to help smokers quit and confidence
to assist smokers significantly increased. To our
knowledge, this is the first study to report the efficacy of
such a program for nurses in the Czech Republic. There
is over a decade of evidence to support the positive impact
of educational programs on clinical practice (Carson
et al., 2012), and more recently, on patient outcomes
(Hartmann-Boyce et al., 2013). However, few studies
have addressed the impact on nursing practice.
In order for tobacco dependence treatment to increase
in Eastern Europe, the expansion of educational programs
for healthcare professionals is essential. One third
of the parties to the WHO FCTC reported that they had
no specialized services to assist smokers to quit (Pin´ e-
Abata et al., 2013; WHO, 2013). Even a small increase in
318 Journal of Nursing Scholarship, 2014; 46:5, 314–321.
C
2014 Sigma Theta Tau International
Sarna et al. Nurses and Smoking Sessation
Table 3. Changes in Attitudes About Nurses’ Ability to Assist Patients
With Smoking Cessation Before and 3 Months After an Educational
Program on Smoking Cessation
Baseline 3 months
n (%) n (%) Sign test
Overall ability to help patients quit smoking .02
Poor 35 (36.08) 28 (29.17)
Fair 28 (28.87) 21 (21.88)
Good 30 (30.93) 39 (40.63)
Very good 4 (4.12) 6 (6.25)
Excellent 0 (0) 2 (2.08)
Ability to ask about smoking .13
Poor 16 (16.49) 15 (15.46)
Fair 25 (25.77) 22 (22.68)
Good 30 (30.93) 30 (30.93)
Very good 17 (17.53) 18 (18.56)
Excellent 9 (9.28) 12 (12.37)
Ability to advise patients to quit smoking .32
Poor 16 (16.49) 17 (17.71)
Fair 32 (32.99) 29 (30.21)
Good 37(38.14) 32(33.33)
Very good 9 (9.28) 12 (12.50)
Excellent 3 (3.09) 6 (6.25)
Ability to assess patients’ readiness to quit .14
Poor 38 (39.58) 31 (32.98)
Fair 24 (25.00) 19 (20.21)
Good 25 (26.04) 38 (40.43)
Very good 9 (9.38) 3 (3.19)
Excellent 0 (0) 3 (3.19)
Ability to assist patients in quitting .01
Poor 42 (43.30) 28 (29.79)
Fair 23 (23.71) 22 (23.40)
Good 23 (23.71) 35 (37.23)
Very good 7 (7.22) 6 (6.38)
Excellent 2 (2.06) 3(3.19)
Ability to arrange for follow-up 0.86
Poor 62 (63.92) 55 (59.78)
Fair 13 (13.40) 17 (18.48)
Good 14 (14.43) 12 (13.04)
Very good 2 (2.06) 2 (2.17)
Excellent 6 (6.19) 6 (6.52)
nursing intervention following attendance at a brief educational
program could have a profound impact on
helping smokers quit. For example, the over 10% improvement
in nurses consistently referring patients to
the telephone quitline for cessation support could result
in 10 additional smokers out of 100 receiving
treatment.
In this study, the cost of the educational program was
relatively low, but depended on the support of the hospital
administration to release time for the nurses. With
rapidly advancing technology, web-based programs focused
on smoking cessation may provide nurses easier
access to educational programs. A quasi-experimental
study of nurses in the United States demonstrated the
efficacy of a webinar in significantly improving referral
to the quitlines compared to print materials alone
6 months after participation in the program (Sarna
et al., 2012b). A randomized clinical trial of a webbased
program tailored for pediatric nurses and respiratory
therapists also demonstrated efficacy in improving
interventions and attitudes 3 months after the program
(Gordon, Mahabee-Gittens, Andrews, Christiansen, &
Byron, 2013).
Smoking status of healthcare providers is rarely reported,
or considered, in evaluations of educational programs
focused on smoking cessation interventions, but
it was an important factor in this study. As recommended
by the WHO (2012), these data should be collected
and analyzed in future studies. Future educational
programs could also include support for quitting among
healthcare providers. Our findings are similar to findings
reporting the negative impact of smoking among
nurses on their clinical practice (e.g., Raupach et al.,
2012). In countries where smoking prevalence among
nurses is high, smoking status should be given special
attention.
Limitations
In addition to the convenience sample and the small
sample size, there are a number of factors that should be
considered in the interpretation of these findings. Without
a comparison group, we are unable to confirm if
the improvement in the frequency of nurses’ interventions
was due to attendance at the educational program
or other factors. The nurses who attended these programs
and completed the surveys may have been more
interested in tobacco control than nurses who did not
participate, and thus provided more positive responses.
The sample size did not allow for subgroup analysis such
as the comparison of never, former, and current smokers.
Although each nurse faculty who led the workshop
was provided with a packet of educational materials, we
were not able to guarantee the fidelity of the delivery
of the program at each of the hospitals. This study did
not assess increases in knowledge per se, or link nurses’
self-reported frequency of cessation interventions with
changes in the number of smokers who received interventions.
Similar to the protocol by Katz et al. (2012),
future studies might consider providing a direct feedback
loop to nurses about their performance.
Including smoking cessation interventions as a core
part of day-to-day nursing care may be a role change for
nurses in the Czech Republic, with competing demands
on nurses’ time. In order to attend the program, nurses
Journal of Nursing Scholarship, 2014; 46:5, 314–321. 319
C
2014 Sigma Theta Tau International
Nurses and Smoking Sessation Sarna et al.
Table 4. Differences in Consistent Interventionsa by the Nurses’ Smoking Status Before and After an Educational Program on Smoking Cessation
(N = 98)
Prestudy Prestudy Post-study Post-study
rate rate OR rate among rate among nonsmokers OR
among smokers among nonsmokers [95% smokers nonsmokers [95%
n (%) n (%) CI] p n(%) n (%) CI] p
Ask 16 (50.00) 44 (67.69) 2.10 [0.88, 4.98] .09 13 (41.94) 49 (75.38) 4.24 [1.71, 10.53] .002
Advise 9 (30.00) 33 (50.77) 2.41 [0.96, 6.04] .06 10 (32.26) 39 (59.09) 3.03 [1.24, 7.45] .02
Assess 8 (25.00) 26 (40.00) 2.00 [0.78, 5.13] .15 11 (35.48) 36 (55.38) 2.26 [0.93, 5.46] .08
Assist 8 (25.00) 17 (26.15) 1.06 [0.40, 2.81] .90 11 (35.48) 25 (39.06) 1.17 [0.48, 2.84] .74
Arrange 1 (3.13) 11 (16.92) 6.32 [0.78, 51.30] .08 1 (3.33) 10 (15.63) 5.37 [0.66, 44.06] .12
Quitline 3 (9.38) 16 (24.62) 3.16 [0.85, 11.80] .09 5 (16.13) 23 (35.94) 2.92 [0.99, 8.63] .05
Note. OR = odds ratio; CI = confidence interval. aNested analysis of participants within hospitals using generalized estimating equation modelings for
dichotomous outcomes for frequency of interventions: “always/usually” versus “sometimes, rarely, never.”
needed to be released from patient care, which might
have limited the reach of the program. Additionally, although
reported in other studies, validation of the nursing
education on patient outcomes in terms of actual quit
attempts and abstinence with biochemical verification is
warranted.
Conclusions
This positive evaluation of an educational program
about smoking cessation for nurses in the Czech Republic
is encouraging and enhances our understanding of the
potential of brief programs to address this critical health
issue. Further study is needed to determine if this or other
educational programs should be disseminated to nurses
throughout the country and the region. Future research
might examine the value added of more comprehensive
programs as well as the impact of web-based programs on
changing clinical practice. The fact that there was a significant
difference in outcomes by nurses’ smoking status
suggests that educational programs about how to help patients
quit smoking implies the need to include efforts to
support cessation among healthcare providers as part of
capacity-building efforts.
Acknowledgments
This project was supported by a grant to the International
Society of Nurses in Cancer Care (ISNCC) from
the Bristol-Myers Squibb Foundation, Bridging Cancer
Care; the Lulu Wolf Hassenplug Endowed Chair fund
provided additional funding to support the analysis. We
thank the nurses in the participating hospitals in the
Czech Republic and Sarah McCarthy, MSc, MBA, Executive
Director, ISNCC, for her support throughout the
project.
Clinical Resources
Tobacco Free Nurses:
http://www.tobaccofreenurses.org/
Smoking Cessation Leadership Center:
http://smokingcessationleadership.ucsf.edu/
References
Carson, K. V., Verbiest, M. E., Crone, M. R., Brinn, M. P.,
Esterman, A. J., Assendelft, W. J., & Smith, B. J. (2012,
May 16). Training health professionals in smoking
cessation. Cochrane Database of Systematic Reviews, Article no.
CD000214. doi:10.1002/14651858.CD000214.pub2
Corelli, R. L., Kroon, L. A., Chung, E. P., Sakamoto, L. M.,
Gundersen, B., Fenlon, C. M., & Hudmon, K. S. (2005).
Statewide evaluation of a tobacco cessation curriculum for
pharmacy students. Preventive Medicine, 40, 888–895.
doi:10.1016/j.ypmed.2004.10.003
Czech Nurses Association. (2013). About our organization.
Retrieved from
http://www.cnna.cz/en/about-the-company
Fiore, M. C., Ja´en, C. R., Baker, T. B., Bailey, W. C.,
Benowitz, N. L., Curry, S. J., . . . Wewers,M. E. (2008,
May). Treating tobacco use and dependence: 2008 update.
Clinical practice guideline. Rockville, MD: U.S. Department of
Health and Human Services, Public Health Service.
Gordon, J. S., Mahabee-Gittens, M., Andrews, J. A.,
Christiansen, S. M., & Byron, D. J. (2013). A randomized
clinical trial of a web-based tobacco cessation education
program. Pediatrics, 131, e455. doi:10.1542/peds.2012-0611
Hartmann-Boyce, J., Stead, L. F., Cahill, K., & Lancaster, T.
(2013). Efficacy of interventions to combat tobacco
addiction: Cochrane update of 2012 reviews. Addiction,
108(10), 1711–1721. doi:10.1111/add.12291
Katz, D. A, Weg,M.W. V., Holman, J., Nugent, A., Baker, L.,
Johnson, S., . . . Titler, M. (2012). The emergency
320 Journal of Nursing Scholarship, 2014; 46:5, 314–321.
C
2014 Sigma Theta Tau International
Sarna et al. Nurses and Smoking Sessation
department action in smoking cessation (EDASC) Trial:
Impact on delivery of smoking cessation. Academy of
Emergency Medicine, 19, 409–420.
doi:10.1111/j.1553-2712.2012.01331.x
Kra´ l´ıkova´ , E., By´ma, S., C´ıfkova´ , R., Cˇ esˇka, R., Dvorˇa´k, V., &
Hamanov´ a, J. (2005). Doporuˇcen´ı pro l´eˇebu z´ avislosti na
tab´aku [Guidelines for treatment of tobacco dependence].
Cˇasopis le´karˇuˇ cˇesky´ch, 144, 327–333.
Lenz, B. K. (2008). Beliefs, knowledge, and self-efficacy of
nursing students regarding tobacco cessation. American
Journal of Preventive Medicine, 35(Suppl.), S494–
S500.
Mal´ a, K., Felbrov´ a, V., Kulovan´ a, S., Kr ´ al´ıkov´ a, E., &
Sˇ t?pa´nkova´ , L. (2009). Guidelines for smoking cessation.
Czech Association of Nurses and Society for Treatment of
Tobacco Dependence. Retrieved from
http://www.slzt.cz/odborna-doporuceni
Matten, P., Morrison, V., Rutledge, D. N., Chen, T., Chung, E.,
& Wong, S-F. (2011). Evaluation of tobacco cessation
classes aimed at hospital staff nurses. Oncology Nursing
Forum, 38, 67–73.
Peto, R., Lopez, A. D., Boreham, J., & Thun, M. (2012).
Mortality from smoking in developed countries 1950–2000 or
later, updated March 2012. Retrieved from www.ctsu.
ox.ac.uk/˜tobacco/
Pin´e-Abata, H., McNeill, A., Murray, R., Bitton, A., Rigotti, N.,
& Raw, M. (2013). A survey of tobacco dependence
treatment services in 121 countries. Addiction, 108,
1476–1484. doi:10.1111/add.12172
Raupach, T., Falk, J., Vangeli, E., Schiekirka, S., Rustler, C.,
Grassi, M. C., . . . & West, R. (2012, September 24).
Structured smoking cessation training for health
professionals on cardiology wards: A prospective study.
European Journal of Preventive Cardiology.
doi:10.1177/2047487312462803
Rice, V., Hartmann-Boyce, J., & Stead, L. F. (2013). Nursing
interventions for smoking cessation. Cochrane Database of
Systematic Reviews, Issue 8, Art. No.: CD001188.
doi:10.1002/14651858.CD001188.pub4
Sarna, L., Bialous, S., Ong, M., Wells, M., & Kotlerman, J.
(2012a). Nurses’ treatment of tobacco dependence in
hospitalized smokers in three states. Research in Nursing and
Health, 35, 250–264. doi:10.1002/nur.21476
Sarna, L., Bialous, S. A., Ong, M. K., Wells, M., & Kotlerman,
J. (2012b). Increasing nursing referral to telephone
quitlines for smoking cessation using a web-based program.
Nursing Research, 6, 433–440.
doi:10.1097/NNR.0b013e3182707237
Smith, D. (2007). A systematic review of tobacco smoking
among nursing students. Nurse Education in Practice, 7,
239–302. doi:10.1016/j.nepr.2006.09.003
Sovinova, H. (2013). Czech Republic 2011 country report:
Global health professions student survey (GHPSS). Retrieved
from http://www.szu.cz/uploads/documents/czzp/
zavislosti/koureni/2013/GHPSS Country Report CR.pdf
Sovinova, H., Sadilek, P., & Csemy, L. (2012). Smoking
prevalence in the adult population of the Czech Republic
and opinions and attitudes to smoking in the population
(1997-2011). National Institute of Public Health. Retrieved
from http://www.szu.cz/tema/podpora-zdravi/studiekuractvi?
highlightWords=koureni
Vick, L., Duffy, S. A., Ewing, L. A., Rugen, K., & Zak, C.
(2012). Implementation of an inpatient smoking cessation
programme in a Veterans Affairs facility. Journal of Clinical
Nursing, 22, 866–880.
doi:10.1111/j.1365-2702.2012.04188.x
Warren, C. W., Sinha, D. N., Lee, J., Lea, V., & Jones, N. R.
(2009). Tobacco use, exposure to secondhand smoke, and
training on cessation counseling among nursing students:
Cross-country data from the Global Health Professions
Student Survey (GHPSS), 2005–2009. International Journal
of Environmental Research and Public Health, 6, 2534–2549.
doi:10.3390/ijerph6102534
World Health Organization. (2012). Enhancing nursing and
midwifery capacity to contribute to the prevention,
treatment, and management of noncommunicable
diseases. Human Resources for Health Observer, Issue No. 12.
Retrieved from http://www.who.int/hrh/resources/observer12/
en/index.html
World Health Organization. (2013). WHO report on the
global tobacco epidemic. Retrieved from
http://www.who.int/tobacco/global report/2013/en/
Journal of Nursing Scholarship, 2014; 46:5, 314–321. 321
C
2014 Sigma Theta Tau International
Copyright of Journal of Nursing Scholarship is the property of Wiley-Blackwell and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
nurselen
article_1.docx
0
