Why is smoking behaviour among nursing students worldwide still prevalent?—a literature-based reflective discussion

Introduction

This editorial aims to reflect on the published article, “Association between smoking and vaping usage and perceived stress levels of undergraduate nursing students in Manila, Philippines”, by Resano, Regencia, and Baja (1). Resano et al. concluded that smoking is prevalent among nursing students in Manila, Philippines, and they use it as a coping mechanism to manage their stressors. Most worldwide studies found that the smoking rate is still high among nursing students for different reasons. In this reflection, I will reflect on and discuss two questions that were raised when I read Resano et al.’s article. The first question is, why is smoking still prevalent among nursing students worldwide? And the second one is, why do nursing students smoke cigarettes or electronic cigarettes to cope with stress? In developed countries, smoking manufactured cigarettes is one of the most prominent causes of premature death, which can be referred to as death before age 70 (2). Smoking is associated with causing many health disorders like cancers, cardiovascular diseases, diabetes and respiratory disorders. For example, over 16 million Americans are estimated to suffer from a smoking-associated disorder (3).

With the persistent increment in healthcare costs, unhealthy behaviours that tend to increase the risk of developing several disorders have attracted the attention of stakeholders. Nursing students are crucial in this connection as they can intervene at various levels to promote a healthy lifestyle and prevent unhealthy behaviours. Therefore, it is usually recommended that nursing students be given support and training to make efficient interventions for smokers. However, smoking among nursing students or other healthcare professionals impedes efforts to promote healthy lifestyles and prevent unhealthy behaviours (4). The nursing staff represents the most prominent professional group of healthcare workers. Nurses constitute an essential resource for affecting the lifestyles adopted by society and can play a crucial role in discouraging unhealthy behaviours like smoking. Yet, recent reports indicate high rates of smoking among nurses and nursing students worldwide (5). It has been established that smoking has become a common behaviour among nursing students all across the globe. However, epidemiological reports indicate inconsistent data on smoking prevalence among nursing students. Zeng et al. (6) reported that the pooled prevalence of current and previous smoking among nursing students was 26.6% and 15.5%, respectively. The researchers, therefore, concluded that smoking is a common behaviour among nursing students and recommended suitable interventions to be made for smoking cessation for nursing students (6). Still, the prevalence of smoking in this particular group of students has not declined, posing a threat to the status of health across the globe (7). Hence, the ensuing paragraphs discuss how the smoking status of family members, peer pressure, availability of money, stress, perception and behaviours of nursing students related to smoking, and gaps in different strategies for addressing smoking prevalence as different general reasons that led nursing students to smoke.

Smoking status of family members

Researchers have found that the smoking status of family members considerably influences the attitude and perception of a nurse student towards smoking (4). Singh et al. found that nurse students are more susceptible to developing smoking behaviour s if their fathers are smokers as well. Surprisingly, this was not the case with mothers. In particular, no correlation was found between smoking nurse students and smoking among their mothers. This association between the smoking behaviour of a nursing student and that of his/her father together with the absence of such association with the smoking behaviour of mothers highlights the divergent role of mothers and fathers in a student’s life. It is also worth mentioning that students whose parents had discussions about different health hazards of smoking were less susceptible to smoking. Similarly, nurse students are more susceptible to smoking if their mothers have vocational or secondary education (8).

Peer pressure

Peer pressure has proven to be a significant predisposing factor for the development of smoking behaviours as well as for drug abuse and utilization of illicit substances. Reports indicate a strong correlation between susceptibility to smoking and the presence of a smoker friend (9). For instance, Yiğitalp investigated different causes of smoking initiation. According to this research, 35.8% of selected nursing students revealed that they started smoking due to the influence of a friend (10). A smoker friend can encourage an individual to initiate smoking in several ways. Most importantly, it makes cigarettes and other smoking products accessible to non-smokers. Previous studies also identified curiosity, socialization and joy-seeking as causes of smoking initiation. These causes are, in turn, associated with peer pressure since friends encourage non-smokers to smoke and enjoy. Similarly, non-smokers experience more curiosity when accompanied by smoker friends (9). It is worth mentioning that peer pressure does affect not only the initiation of the smoking behaviour but also the willingness of an individual to continue smoking in the future (11).

Availability of money

In the case of students, pocket money has also served to be a crucial factor that affects smoking behaviour (8). This is compatible with the finding that different factors encourage a smoker to consider smoking cessation, and economic factors hold the third position. In other words, smokers tend to quit smoking when they find this behaviour quite expensive. Accordingly, an increment in the cost of cigarettes and electronic cigarettes can substantially decrease the prevalence of smoking among students (4).

Stress

Besides the before mentioned reasons, previous studies identified stress among nursing students as one of the most compelling reasons that lead to smoking behaviour as a coping mechanism to deal with stressors. Stress, originating from several different factors, has turned into the most important factor that compels nursing students to adopt some unhealthy behaviour like smoking. In other words, nurses tend to smoke cigarettes or electronic cigarettes to cope with stress, control their anger or other negative emotions, and relax or distract themselves from problems they face (1,9). Nursing students may experience stress due to some personal, social and academic factors. Besides personal or family socio-economic issues, workload, the requirement of attending relevant courses, exam pressure, clinical environment and night duties may contribute to the development of stress. According to research conducted in Hong Kong, 20% of nursing students had stress, 39.9% of students had anxiety and 24.3% of students suffered from moderate to severe levels of depression. 14% of these students consumed alcohol, and 1% adopted smoking to manage their stress. Moreover, 85.7% of undergraduate students in nursing programs at a state university have reported daytime sleepiness. Sleep deprivation also makes an individual susceptible to developing depression, stress and anxiety and can potentially contribute to the adoption of unhealthy behaviours like smoking (12). The recent COVID-19 pandemic and associated quarantine periods have negatively affected nursing students’ mental health, leading to increased smoking and other unhealthy behaviours (13). Although the prevalence of stress among nurses and nursing students has attracted substantial attention from researchers, coping strategies have not been reviewed extensively. Labrague et al. have conducted a systematic review of studies investigating stress and coping strategies among nursing students. As per this review, the most used coping strategies adopted by nursing students included finding the meaning of stressful events, utilizing different approaches for solving problems and developing objectives for resolving problems (14). McCarthy et al. reviewed the literature on stress, coping strategies and interventions for undergraduate nursing and midwifery students. As per this review, nursing students utilize adaptive and/or maladaptive coping strategies to cope with stress. The selection of a coping strategy is influenced by several factors, including past or present circumstances, level of education, and interventions at work for supporting such students (15). Nursing students may adopt any positive or negative strategy for coping with their stress; however, they may commence smoking because of one of the abovementioned reasons, like peer pressure and family history. It is also a general belief that smoking does not cause any immediate damage, i.e., different diseases associated with smoking behaviour usually develop in later phases of life. This perceived idea which is not factual, is termed the “onset time delaying effect”. Previous studies have identified the onset time delaying effect as a novel risk factor for developing and continuing smoking behaviour (5). Nursing students may adopt smoking to cope with their stress or for other purposes after being affected by their perceptions about smoking and/or due to gaps in interventions that discourage smoking in nursing students. These two aspects are elaborated on in the following paragraphs.

Perception and behaviours of nurses related to smoking

Nursing students have significant knowledge about health hazards caused by smoking. They are also aware of the fact that the general public considers smoking, especially by a healthcare worker, as a negative behaviour. Moreover, in a healthcare setting, smoking by a healthcare provider can be stigmatizing and may lead to penalties like fines, warnings and job loss. However, nursing students have adopted and practised certain behaviours that allow them to be smokers and future healthcare professionals. These behaviours not only encourage a student smoker to continue smoking; but also encourage non-smokers to use smoking to cope with stress (16). These behaviours include (I) normalization: smoker nurses describe smoking as normal behaviour, and they justify this by saying that their family members and/or friends also smoke. Normalization is the process by which any action or idea is turned into a natural phenomenon and accepted in a specific group. Smoker nurses report that their family members view smoking as a normal behaviour (16). (II) Controlled Smoking: many smokers, including nursing students who smoke, perceive their smoking behaviour as under control. They use it only as a break from the stressful environment. Hence, they use smoking only for a certain period to motivate or control emotions. When it is not needed, they quit smoking (16). (III) Smoker’s identity: smoking is viewed by smokers as a part of their personality and identity. It is also considered a means of connecting family members and friends. Asking for a cigarette is viewed as an important social connection. Moreover, smokers think that smoking allows individuals of similar thinking to sit together and socialize. Smokers report that smoking gives them a better identity as they become more capable of controlling their stress and negative emotions (16).

Gaps in different strategies for addressing smoking prevalence

The recent literature indicates that although there are several different strategies at work for reducing smoking rates, these campaigns have not been fruitful in the case of nursing students who demonstrate the same rates of smoking as reported a decade ago. Despite several interventions to lower the prevalence of smoking among nursing students and encourage smoking cessation, smoking behaviour is continually being reported by many nursing students. This indicates the presence of gaps in these interventions. Fernández-García et al. found that 15.8% of smokers initiated smoking during the early years of university with persistent increment over ensuing years in the institution. Considering the knowledge attained during academic training, one expects a considerable reduction in smoking behaviours, but this does not happen (4). It is therefore highly recommended that besides making targeted interventions like offering online courses and support to nurse smokers, smoking cessation education, smoking hazards, and positive strategies for coping with stress and negative emotions must be included in the compulsory nursing curriculum (17-19). Some strategies, like warnings on the packaging of cigarettes, have proven ineffective in reducing smoking prevalence among smokers, including nursing students who smoke. In conclusion, smoking among healthcare professionals can impede their efforts to promote healthy lifestyles in the community. Considering the persistently high prevalence of smoking among nursing students must be given effective education and counselling about smoking hazards, smoking cessation and positive strategies to cope with stress (18,19). This can have a substantial influence on future professional practice and can help in lowering smoking rates across the globe.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-4/coif). The author reports that medical writing assistance was performed by a medical writer (SBA) from paraphrasing services company. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Resano JEP, Regencia ZJG, Baja ES. Association between smoking and vaping usage and perceived stress levels of undergraduate nursing students in Manila, Philippines. J Public Health Emerg 2023;7:6. [Crossref]
2. Jha P. The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries. Elife 2020;9:e49979. [Crossref] [PubMed]
3. Zhu D, Zhao G, Wang X. Association of Smoking and Smoking Cessation With Overall and Cause-Specific Mortality. Am J Prev Med 2021;60:504-12. [Crossref] [PubMed]
4. Fernández-García D, Ordás B, Fernández-Peña R, et al. Smoking in nursing students: A prevalence multicenter study. Medicine (Baltimore) 2020;99:e19414. [Crossref] [PubMed]
5. Provenzano S, Santangelo OE, Grigis D, et al. Smoking behaviour among nursing students: attitudes toward smoking cessation. J Prev Med Hyg 2019;60:E203-10. [PubMed]
6. Zeng LN, Zong QQ, Zhang JW, et al. Prevalence of smoking in nursing students worldwide: A meta-analysis of observational studies. Nurse Educ Today 2020;84:104205. [Crossref] [PubMed]
7. Adouard V, Menecier P, Chapalain F, et al. Smoking prevalence among nursing students and nursing assistants in Mâcon: 2021 survey and evolution over 13 years. Rev Mal Respir 2022;39:328-33. [Crossref] [PubMed]
8. Singh B, Chand SS, Chen H. Tobacco smoking initiation among students in Samoa and health concerns. PLoS One 2021;16:e0258669. [Crossref] [PubMed]
9. Syed W, Iqbal A, Siddiqui NA, et al. Attitudes and Associated Demographic Factors Contributing towards the Abuse of Illicit Drugs: A Cross-Sectional Study from Health Care Students in Saudi Arabia. Medicina (Kaunas) 2022;58:322. [Crossref] [PubMed]
10. Yiğitalp G. Factors Affecting Smoking Status of Nursing Students and Their Addiction Levels. Turk Thorac J 2015;16:121-7. [Crossref] [PubMed]
11. Leshargie CT, Alebel A, Kibret GD, et al. The impact of peer pressure on cigarette smoking among high school and university students in Ethiopia: A systemic review and meta-analysis. PLoS One 2019;14:e0222572. [Crossref] [PubMed]
12. Lacerda MS, Rossi MB, Abuchaim ESV, et al. Modifiable risk factors for cardiovascular diseases and quality of life among first-year nursing students. Rev Gaucha Enferm 2022;43:e20210066. [Crossref] [PubMed]
13. Mechili EA, Saliaj A, Kamberi F, et al. Is the mental health of young students and their family members affected during the quarantine period? Evidence from the COVID-19 pandemic in Albania. J Psychiatr Ment Health Nurs 2021;28:317-25. [Crossref] [PubMed]
14. Labrague LJ, McEnroe-Petitte DM, Gloe D, et al. A literature review on stress and coping strategies in nursing students. J Ment Health 2017;26:471-80. [Crossref] [PubMed]
15. McCarthy B, Trace A, O'Donovan M, et al. Nursing and midwifery students' stress and coping during their undergraduate education programmes: An integrative review. Nurse Educ Today 2018;61:197-209. [Crossref] [PubMed]
16. Aho H, Pietilä I, Joronen K. Practical nursing students' discursive practices on smoking in Finland. Int J Qual Stud Health Well-being 2019;14:1610274. [Crossref] [PubMed]
17. Zhang L, Huang XL, Luo TY, et al. Impact of tobacco cessation education on behaviors of nursing undergraduates in helping smokers to quit smoking. Tob Induc Dis 2021;19:58. [Crossref] [PubMed]
18. Aldiabat KM, Clinton M. How male Jordanian psychiatric nurses became regular smokers at university: Lessons intolerance, cultural identity and stress reduction. Nurs Health 2013;1:52-60. [Crossref]
19. M Aldiabat K, Aquino-Russell C, Alsrayheen E, et al. Barriers to Providing Smoking Cessation Intervention by Nursing Students: What is the Solution in Nursing Education? Florence Nightingale J Nurs 2022;30:83-91. [Crossref] [PubMed]