European Journal of Oncology Nursing 35 (2018) 39–46

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Attitudes, barriers and facilitators to smoking cessation among Central and T

Eastern European nurses: A focus group study
Mary Rezk-Hannaa, Linda Sarnaa, Anne Berit Petersenb,c, Marjorie Wellsa, Iveta Nohavovad,
Stella Bialousc,e,∗
a
School of Nursing, University of California, Los Angeles, CA, USA
b
School of Nursing, Loma Linda University, Loma Linda, CA, USA
c
Center for Tobacco Control Research and Education, University of California, San Francisco, CA, USA
d
Society for Treatment of Tobacco Dependence, Prague, Czech Republic
e
Department of Social Behavioral Sciences, School of Nursing, University of California, San Francisco, CA, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Purpose: Smoking among nurses is a barrier to providing smoking cessation interventions to patients. In Central
Europe and Eastern Europe—where tobacco use is the leading cause of preventable death and disease—there is limited
Nurses knowledge about nurses' attitudes toward cessation interventions. Our aim was to describe the attitudes of
Relapse triggers nurses who are former and current smokers toward providing cessation interventions to patients as well as
Smoking cessation
explore barriers and facilitators to their own quit efforts.
Tobacco control
Methods: Nine focus groups with 81 nurses (94% females) in five Central and Eastern European countries.
Content analysis was used to identify major themes.
Results: Nurses agreed that they should set a good example by not smoking; should be involved in helping
patients stop smoking; and needed additional training in tobacco control. Five common themes were identified
as barriers to quitting: smoking cues in the environment; presence of smokers in the environment; relapse
postpartum; stress and nicotine addiction; and misperceptions about the dangers of smoking. Former smokers
reported facilitators to quitting including: seeing the health consequences of smoking among their patients;
personal and family health concerns; receiving support from family; and pregnancy.
Conclusion: There is a need to build upon nurses' positive attitudes about engaging in smoking cessation in-
terventions with patients to ensure that cessation interventions are standard nursing practice. Future studies
should focus on programs that support nurses' quit efforts by addressing barriers to smoking cessation, which
will improve their health and patient care.

1. Introduction
Smoking is the single largest cause of preventable death and disease
worldwide, with over 1 billion people addicted to tobacco smoking
(World Health Organization, 2017a,b). In Europe, tobacco-related
deaths and disability are major public health challenges, with an esti-
mated 16% of all deaths (aged over 30 years) attributed to tobacco,
compared to a global average of 12% (World Health Organization,
2012a). In the European region, Health 2020 goals indicate a strong
commitment to reducing tobacco use (Jakab and Tsouros, 2015).
Despite the progress made in tobacco control in Europe, global re-
ports show that, compared to other regions, Europe has the highest
prevalence of adult smoking (28%) with the highest rates reported
among females (19%) (Cattaruzza and West, 2013; Juranic et al., 2017;
Vakeffliu et al., 2013; World Health Organization, 2015; World Health
Organization Regional Office for Europe, 2017). While nationally re-
presentative data is limited, the overall smoking prevalence among
female nurses is estimated to be equal or higher than the general female
population (Adamek et al., 2012; Dziankowska-Zaborszczyk et al.,
2009; Kralıkova, 2013). Ample evidence suggest that nurses' own
smoking behavior may be a barrier to promoting and providing tobacco
interventions to their patients (Becker et al., 1986; Dalton and Swenson,
1986; Goldstein et al., 1987; McCarty et al., 2001a,b; Sarna et al., 2015;
Sarna et al., 2000a,b). A critical systematic review and meta-analysis
showed that nurses who smoked were 13% less likely to advise their
patients to quit and 25% less likely to arrange smoking cessation follow-
up (Duaso et al., 2017).
A large majority of smokers, including nurses, would like to quit

∗
Corresponding author. Department of Social Behavioral Sciences, School of Nursing, University of California San Francisco, 3333 California Street, San Francisco, CA, USA.
E-mail address: stella.bialous@ucsf.edu (S. Bialous).

https://doi.org/10.1016/j.ejon.2018.04.001
Received 2 November 2017; Received in revised form 16 February 2018; Accepted 6 April 2018
1462-3889/ © 2018 Elsevier Ltd. All rights reserved.
M. Rezk-Hanna et al.
(Fiore et al., 2008; McKenna et al., 2001; Sarna et al., 2010). Little is
known about attitudes, barriers and facilitators to smoking cessation
among European nurses as well as their roles in providing smoking
cessation interventions to their patients. A study that focused on ex-
ploring United States (U.S.) nurses' attitudes toward smoking and
quitting and preferences for cessation interventions showed that among
nurses who smoked, a general lack of knowledge regarding cessation
and support for quitting influenced their quit efforts (Bialous et al.,
2004). In addition to describing their colleagues' lack of knowledge and
support about cessation as a barrier to quitting, nurses expressed myths
and misconceptions about smoking and quitting. Factors described by
nurses to be facilitators to smoking cessation attempts included health
concerns and presence of illnesses among family. In regards to nurses'
roles in providing smoking cessation interventions to their patients, a
study that examined factors affecting Korean nurses' intention to pro-
vide cessation interventions found that nurses' attitudes towards
smoking cessation interventions had a significant positive influence in
determining their intention to providing smoking cessation intervention
to their patients (Choi and Kim, 2016). A U.S. focus group study con-
ducted among 75 staff nurses showed that common barriers to pro-
viding smoking cessation to hospitalized patients included lack of
concrete techniques used and fear of alienating patients who were not
receptive to nurses' advice (McCarty et al., 2001a,b). In Ireland, similar
findings have been reported. In a descriptive cross-sectional study in-
volving 430 Ireland nurses, lack of training was cited by nurses as one
of the main reasons for not giving smoking cessation advice to patients
(O'Donovan, 2009).
In Central and Eastern Europe, research focused on tobacco use and
treatment among nurses is sparse. Importantly, data are limited about
factors affecting quit attempts among nurses who smoke. In a Czech
Republic study focusing on evaluating the effect of a brief smoking
cessation educational program on the frequency of nurses' interventions
with smokers, showed that while the program demonstrated promise in
building capacity among nurses to assist with smoking cessation, the
program was less effective in increasing cessation interventions for
patients among nurses who smoke (Sarna et al., 2014a,b).
Despite the immensity of the tobacco epidemic in Europe, few
countries have tobacco treatment guidelines (Pine-Abata et al., 2013).
There are currently no known nationally supported efforts focused on
increasing capacity among nurses in Central and Eastern Europe for
engagement in tobacco control. Although high smoking prevalence is
recognized as a problem among nurses, very little is known about
nurses' smoking cessation and quitting efforts. For the successful de-
velopment and implementation of programs to support patients in their
quit efforts, an in-depth understanding of nurses' attitudes and per-
ceptions regarding smoking cessation and quitting is imperative, espe-
cially among those nurses who smoke.
The purpose of this study was to explore Central and Eastern
European nurses' attitudes about their roles in providing smoking ces-
sation interventions to their patients among nurses who were current or
former smokers, as well as explore barriers and facilitators to their own
cessation experiences. We described differences in demographic (i.e.,
age, sex) and professional (i.e., years in the profession, level of edu-
cation, clinical practice setting) by smoking status as this might influ-
ence nurses' attitudes about their roles in providing smoking cessation
interventions to their patients. Smoking characteristics of current
smokers, including level of addiction (time to first cigarette), number of
prior quit attempts and current interest in quitting were also described.
2. Methods
2.1. Design
A qualitative descriptive study design utilizing nine focus groups
conducted in five Central and Eastern European countries: Czech
Republic, Hungary, Romania, Slovakia, and Slovenia between March
40
European Journal of Oncology Nursing 35 (2018) 39–46
2015 to February 2016.
2.2. Participant selection and recruitment
Nurse champions, at least one from each country, were responsible
for recruiting nurses through advertisements (email/web-based and
printed flyers) in hospitals and ambulatory settings. Nurse champions
were nurses who were experienced with the organizational culture of
nursing in their country. They were responsible for leading change
processes through the phases of initiation, development and im-
plementation evidenced-based practice (Shaw et al., 2012). Focus
groups' inclusion criteria were: practicing nurses who provide direct
patient care and who self-reported as being current or former smokers.
Exclusion criteria included: nurses who were never smokers and/or
who were in administrative positions.
2.2.1. Instrument
All participants were asked to complete a questionnaire adapted
from the originally developed and previously validated 19-item ques-
tionnaire “Nurses Helping Smokers Quit” (reliability α = 0.92) (Sarna
et al., 2000a,b), which was later translated by native speakers and
validity was re-established with test-retest reliability (93% of the
[kappa] values were in the acceptable range, i.e., > 0.7) (Sarna et al.,
2014a,b; Sarna et al., 2015). This questionnaire was used because it was
developed based on the Agency for Health Care Policy and Research
(AHCPR) Smoking Cessation Guideline as a framework (Fiore et al.,
1996) and was used previously to explore smoking cessation interven-
tions among nurses in Central and Eastern Europe (Sarna et al.,
2014a,b; Sarna et al., 2015; Sarna et al., 2000a,b). Items included de-
scription of their demographic (age, gender) and professional char-
acteristics (nursing practice duration, educational level, clinical prac-
tice setting). Additional items described the nurses' own smoking
history and current smoking status (time to first cigarette as a measure
of level of addiction, previous quit attempts, current interest in quit-
ting). To explore nurses' attitudes about their roles in providing
smoking cessation interventions to their patients, a series of statements
were presented about being non-smoking role models, involvement in
helping patients stop smoking and their perceived need for additional
skills or training in tobacco control. Nurses were asked to indicate their
level of agreement using a 5-point Likert scale, with 1 expressing strong
agreement and 5 expressing strong disagreement.
A moderator's guide, translated and culturally adapted for each
country, was used to guide the discussion (Bialous et al., 2004). This
moderator guide was reviewed by nurses and tobacco control experts in
each country and was deemed appropriate, based on the limited
available research, and experts' knowledge, on nurses and smoking in
each of the countries. While this guide was previously used to facilitate
an in-depth understanding of issues related to U.S. nurses' attitudes
toward smoking and quitting, and preferences for smoking cessation
interventions (Bialous et al., 2004), nurses and tobacco control experts
in each country validated the questions and no major changes were
required to specifically address issues raised in Central and Eastern
Europe. The guide included open-ended questions about nurses' views
and attitudes about helping patients quit and their own smoking ces-
sation experiences. Nurses were asked to discuss when they initiated
smoking, quit attempts as well as facilitators supporting quit efforts and
barriers to quitting influencing smoking relapse. Table 1 depicts the
specific questions asked during the focus group discussions.
2.3. Ethical consideration
Ethics approval was obtained from Institutional Review Boards at
the University of California, Los Angeles (UCLA), University of
California, San Francisco (UCSF), and from all participating sites in
each of the five countries: Centre for Tobacco-Dependent, Charles
University and General University Hospital in Prague (Czech Republic),
M. Rezk-Hanna et al.
Table 1
Moderator guide questions.
Questions
1. Please share your own experiences with smoking, and if you have had experiences
with quitting smoking
2. For those of you who have quit/tried to quit, think about your own experiences.
How easy or difficult is/was it? What were your reasons for wanting to quit?
3. If you are a current smoker, what were the significant factors that prevented/or
are preventing you from quitting? Think of personal and social factors (e.g.
friends and family) that contributed/or have contributed to your ability or
inability to quit. Which of these factors were most important?
4. Think about professional and institutional factors (e.g. nursing colleagues and
work setting) that have affected your ability or inability to quit smoking. Which
of these factors are/were most important?
5. Do you think your smoking affects/or did affect your relationship with your
nursing colleagues, non-nursing colleagues, and administrators at work? How do
you feel about this?
6. What about your patients, do you think they are/were affected by your smoking?
How do you feel about this?
7. Think about the stress in your work environment. What affect do you think that
stress and the work environment have on nurses who smoke or who are trying to
quit?
8. Have you or did you ever experienced any feelings of guilt about smoking or
pressures to quit? From family or friends? From nursing colleagues? What do you
expect people whom you know well and/or work with to do or say when they
notice that you are trying to quit/that you quit smoking?
9. Do you think that incentives (e.g. time of from work for cessation counseling, free
nicotine replacement therapy) in your work situation would help/or would have
helped you quit?
10. If you are a former smoker, what prompted you to quit? Did your nursing
colleagues support your quit efforts?
National Korányi Institute for Pulmonology (Hungary), Romanian
Nursing Association (Romania), National Institute of Cardiovascular
Diseases (Slovakia) and Institute of Oncology Ljubljana (Slovenia).
Informed written consent was obtained from all participants with the
assurance that all digitally recorded discussions would be strictly con-
fidential. All participants were assured anonymity and were informed
that any references to information that revealed their identity would be
removed or disguised. Participants were given the opportunity to ask
questions, and were encouraged to discuss any issues, which needed
clarification. In line with the principles of good practice, all research
materials were securely stored a locked cabinet and were accessible
only to the study researchers. Nurses received monetary incentives for
participation ($25–50 USD as deemed appropriate for each site).
2.4. Data collection
Using the moderator's guide, a trained native-speaking facilitator
from each of the five countries conducted focus group discussions, in-
cluding 8–10 nurses per group and lasting 1½-2 h each. To control for
differences in conducting group discussions among the facilitators, fa-
cilitators were either: Nurse Champions who were trained on focus
groups methodology and utilization of the study's moderator guide; or
moderators, who were familiar with the organizational culture of nur-
sing in their participating country and was trained by one of the Nurse
Champion.
Prior to the discussion, nurses completed the brief questionnaire
previously described. At the end of the discussions, the facilitator: (1)
provided a summary of the key points for validation by the participants;
and (2) prepared field notes about the experiences in each group to
better inform the interpretation of the transcripts. Focus group discus-
sions were held at each of the five countries' participating institution or
in a rented meeting room, at the discretion of the Nurse Champion in
each country, to ensure privacy.
Each focus group discussion was recorded using a digital recorder,
professionally transcribed word-for-word by a professional transcrip-
tion service and then translated verbatim to English by the Project
Nurse Champion. The process was as follows: after recording, Nurse
41
European Journal of Oncology Nursing 35 (2018) 39–46
champions from each country conducted reliability checks of tran-
scriptions where they each independently listened to, and compared a
randomly selected part of each digital recording, equaling at least 20%
of the recorded time. Comparisons were made between two listeners'
findings and revisions were done, if necessary. Once the transcripts
were final, they were translated into English and then a sample, re-
presenting about 20% of the total, back translated to the native lan-
guage and checked against the original audio recordings by a member
of the team for accuracy.
2.5. Data analysis
Quantitative data were analyzed using SPSS (Version 22; SPSS Inc.,
Chicago, IL). Descriptive statistics with means and standard deviations
were performed to describe the study sample by providing demo-
graphic, professional, and smoking profile of study participants.
Comparisons (X2, t-tests) were made between current and former
smokers on demographics, professional characteristics, and attitude
responses about involvement in helping patients quit smoking.
Statistical significance was set at the 0.05 level.
Dedoose, a cloud-based coding application software for integrating,
and analyzing data was used for qualitative data analysis (SocioCultural
Research Consultants, 2016; Dedoose V7.0.23, 2015). Focus group
transcripts were uploaded into Dedoose and were analyzed to identify
major themes using content analysis as described by Hsieh and Shannon
(2005) (Hsieh and Shannon, 2005). While other major themes focusing
on workplace impact on nurses' smoking behaviors have been reported
elsewhere (Petersen et al., Unpublished data), this report focuses on
themes related to personal barriers and facilitators to nurses quit ef-
forts. Using Dedoose, two investigators began by reading three tran-
scripts for themes and then developed first-line codes, which were es-
tablished based on a priori key concepts and themes from the
moderator's guide questions. The codes were then modified iteratively
during research team meetings where questions about coding and re-
liability were discussed. Using the established codebook, the authors
then independently read and coded all nine transcripts line-by-line,
while conducting on-going meetings and presentations with the re-
search team to ensure coding agreements throughout the entirety of
each transcript. After initial analysis was completed, the two in-
vestigators went back through the coded excerpts and identified sub-
themes in the initial coding, which were presented back to the research
team for discussions and to ensure validity of themes. Coding agree-
ment was assessed by having study investigators re-code subsets of the
transcripts. An inter-rater reliability score was computed from 20% of
each transcript (Cohen's k statistic, k = 0.92). Exemplars were selected
that best illustrated each identified theme and sub-theme.
3. Results
3.1. Sample characteristics
Two focus groups were conducted in each country except for
Hungary, which held only one focus group. A total of 82 nurses parti-
cipated in the focus groups: 24.7% Slovakia; 21.0% Czech Republic;
21.0% Romania; 21.0% Slovenia; and 12.3% Hungary. One nurse did
not complete the questionnaire, therefore descriptive statistics are
provided for 81 subjects. The sample characteristics and demographics
are shown in Table 2. Overall, participants in the study were primarily
women (94%). The average participant was 43 years old, with an
average of 20 years of nursing practice. The sample included nurses
from major clinical practice settings with the majority working on on-
cology (44%) and medical/surgical (26%) settings. The majority had a
Diploma nursing degree (64%). Sixty-five percent were current smokers
and 83% of the smokers reported smoking daily. No statistically sig-
nificant differences were noted between current and former smokers'
demographics and professional characteristics. Table 3 reflects smoking
M. Rezk-Hanna et al. European Journal of Oncology Nursing 35 (2018) 39–46

Table 2 nurses: (1) Smoking cues in the environment; (2) Presence of smokers in
Sample demographics. the environment at home and at work; (3) Relapse postpartum; (4)
Variable Total Subjectsa Current Smokers Former Smokers Nicotine addiction and stress; and (5) Misperceptions about the dangers
of smoking. Four major themes were cited as facilitating quitting: (1)
M (SD) M (SD) M (SD) Seeing the health consequences of smoking in their patients; (2)
Personal health concerns; (3) Support for quitting from family; and (4)
Age, years 43.0 ± 9.4 42.4 ± 9.5 44.1 ± 9.3
Nursing practice 20.2 ± 10.3 19.8 ± 10.5 20.8 ± 9.9 Pregnancy. Table 5 highlights exemplars relating to barriers and facil-
duration, years itators to quitting identified among nurses.

N (%) N (%) N (%) 3.3.1. Barriers to quitting

N 81 53 (65) 28 (35)
3.3.1.1. Smoking cues in the environment. Nurses described certain
Female 76 (94) 49 (92) 27 (96) “routines”, “rituals”, and sets of cues associated with smoking
Educational level cigarettes. Nurses' perceived drinking coffee, periods after lunch, and
Diploma 52 (64.2) 36 (67.9) 16 (57.1) the smell of cigarettes to be associated with smoking. The smell of
Associate degree 10 (12.3) 4 (7.5) 6 (21.4)
cigarettes was identified as a trigger for relapse to smoking even after
Bachelor's degree 6 (7.4) 5 (9.4) 1 (3.6)
Master's degree 13 (16) 8 (15.1) 5 (17.9) abstaining for a period of time.
Clinical practice setting The transcripts were replete with illustrative quotes in which
Critical/Intensive 11 (13.6) 4 (7.5) 7 (25.0) smoking and coffee consumption were used simultaneously—at home
care or at work. Drinking coffee was a “ritual” that was viewed by nurses as
Medical/Surgical 21 (25.9) 16 (30.2) 5 (17.9)
Oncology 36 (44.4) 23 (43.4) 13 (46.4)
providing a time during the day for “themselves” so they do not get
Psychiatric/Mental 12 (14.8) 9 (17.0) 3 (10.7) “burnt out” or “sick”. One nurse described this “morning routine” as a
health “way of life” while others discussed coffee and cigarettes to be “linked”
or “the typical combination” to feel “relieved, relaxed” and they felt
a
No statistically significant differences (P value < 0.05) between current “not inclined to stop”.
and former smokers; Data reported in mean ± SD.
3.3.1.2. Presence of smokers in the environment at work and at
Table 3 home. Repeatedly, nurses stated that their smoking was strongly
Smoking characteristics among current smokers (n = 53).
influenced by the surrounding social environment. The presence of
Variables N (%) Range smokers' in the environment—whether inside or outside the work
environment—was a strong motivator to not only increase smoking,
Frequency of Smoking
but also counteract cessation efforts and precipitate relapse.
Daily 44 (83) –
Time to Last Cigarette Work environment. Many nurses acknowledged that their motivation
Within 5 min 5 (11) – to continue to smoke and relapse back to smoking after quitting was
6–30 min 21 (46) – because they wanted to remain part to a “community” of nurses who
31–60 min 7 (15) –
smoked at the workplace. These nurses were able to take a break, “chat”
> 60 min 11 (24) –
Quitting Attempts and smoke at certain designated areas such as “those stairs”.
Tried quitting: Lifetime 44 (83) 1–20 Furthermore, nurses stated that smoking was a way of “forming cliques”
Tried quitting: Past 12 Months 22 (42) 1–15 and had “a positive effect on relationships”.
Interest in Quitting Home environment. Nurses described temptations to smoke outside of
Currently trying to quit 17 (32) –
work when the presence of other smokers precipitated their relapse
event. The home environment strongly influenced nurses' smoking be-
characteristics of current smokers (n = 53). When asked about time to havior. The lack of support from the home environment emerged as a
first cigarette after waking, 57% reported smoking their first cigarette factor affecting the likelihood of quitting smoking. Nurses argued that
≤30 min after waking up, indicating high nicotine addiction. Forty-two their quitting efforts might be strengthened and that they would be
percent reported making at least one serious quit attempts in past 12- more inclined to consider smoking cessation if their spouse (or partner)
months and 32% reported they were trying to quit at the time of the managed to quit smoking, or a loved one encouraged them to quit.
focus groups.
3.3.1.3. Relapse postpartum. The topic of spontaneously quitting
smoking during pregnancy was brought up in all five countries.
3.2. Nurses' attitudes towards providing smoking cessation interventions to Nurses expressed that although it was not difficult to stop smoking
their patients during pregnancy, it was difficult to maintain abstinence postpartum
especially after returning to work, when social interaction with other
The frequency distribution of nurses' attitudes about involvement in smokers was especially valued. One nurse discussed how she “can't wait
helping patients quit smoking are presented in Table 4, by smoking not to be pregnant so that I can have a cigarette”.
status. Overall, using the Likert scale (responses ranging from
1 = strongly agree to 5 = strongly disagree), nurses expressed agree- 3.3.1.4. Nicotine addiction and perceptions of stress. Nurses who smoked
ment that they: (1) should set a good example by not smoking did not appear to be aware of the power of nicotine and resulting
(1.91 ± 1.04); (2) should be and can be involved in actively helping withdrawal symptoms that would compel them to smoke. Smoking was
patients stop smoking (1.85 ± 0.85); and (3) would benefit from ad- perceived as a “habit”, a mechanism to cope with stress. They
ditional training in tobacco control (2.16 ± 1.04). No statistical sig- frequently referred to smoking as “the result of stress” or “caused by
nificant difference was noted between responses of current versus stress” and “is the only relaxing thing we have”. Some smokers stated
former smokers. that after successfully abstaining from smoking, they started smoking
again as they believed smoking “would help overcome” or “might get
3.3. Major themes for barriers and facilitators to nurses quitting smoking rid of the stress with a cigarette”.

Five common themes were recognized as barriers to quitting among 3.3.1.5. Misperceptions about the dangers of smoking. Nurses expressed

42
M. Rezk-Hanna et al. European Journal of Oncology Nursing 35 (2018) 39–46

Table 4
Nurses' smoking-related attitudes and perceptions by smoking status.a
Variable Strongly agree Agree Not sure Disagree Strongly disagree

N (%) N (%) N (%) N (%) N (%)

(1) Nurses should set a good example by not smoking 33 (41) 33 (41) 7 (9) 5 (6) 3 (4)
Total subjects 33 (41) 33 (41) 7 (9) 5 (6) 3 (4)
Current smokers 19 (36) 24 (45) 4 (8) 4 (8) 2 (4)
Former smokers 14 (50) 9 (32) 3 (11) 1 (4) 1 (4)
(2) Nurses should and can be involved in actively helping patients to stop smoking 32 (40) 33 (41) 12 (15) 4 (5) 0 (0)
Total subjects 32 (40) 33 (41) 12 (15) 4 (5) 0 (0)
Current smokers 17 (32) 23 (43) 10 (19) 3 (0) 0 (0)
Former smokers 15 (54) 10 (36) 2 (7) 1 (4) 0 (0)
(3) Nurses need additional training/skills in tobacco control 26 (32) 28 (34) 15 (19) 12 (15) 0 (0)
Total subjects 26 (32) 28 (34) 15 (19) 12 (15) 0 (0)
Current smokers 15 (28) 19 (36) 13 (25) 6 (11) 0 (0)
Former smokers 31 (39) 9 (32) 2 (7) 6 (21) 0 (0)

a
No statistically significant differences by smoking status (P < 0.05).

misperceptions about the dangers of smoking and exposure to
secondhand smoke. One nurse said, “research showing that smoking
may harm the fetus are not that valid”. Nurses who were unable to quit
smoking during pregnancy and breastfeeding, described risk reduction
strategies such as “reducing the number of cigarettes” in order to “do
something for the health of my baby”.
3.3.2. Facilitators to quitting
3.3.2.1. Seeing the health consequences of smoking in their
patients. Former smokers shared their experiences of how they
managed to quit and maintain abstinence. These smokers
acknowledged that quitting smoking was “hard work” and involved
many unsuccessful attempts and relapse episodes. As nurses, they
identified “seeing the health consequences from smoking” in their
patients was a factor that motivated them to quit and maintain long-
term abstinence.
3.3.2.2. Personal and family health concerns. Former smokers stated that
their own personal health concerns were major motivators of quitting.
Illness among family members, especially their children, also
encouraged them to quit smoking. One nurse discussed that after her
doctor informed her that she had a “coagulation rate disorder”, she
stopped smoking “overnight” without any assistance. While this nurse
acknowledged that she had an “opportunity [to smoke], [because of]
very stressful situations”, she wants to maintain abstinence and hopes
she “won't ever touch it again”.
3.3.2.3. Support for quitting from family. Many former smokers
reiterated the perception that support and encouragement,
particularly at home, was their single motivator to stop smoking and
maintain long-term abstinance. Nurses expressed that they “feel
ashamed” or “have such a bad feeling” when their children asked
them why they smoked or when they smoked in their company. They
noted how the presence of their spouse or children facilitated quitting,
describing them as “incentives” for quitting and often described feelings
of disappointment and guilt when smoking in their presence. One nurse
discussed how her son was the “the biggest incentive” for her to seek
treatment and maintain abstinance because he was afraid of losing her
as a result of her smoking. Another stated she did not “want to smell
bad” to her daughter and her partner, who was an ex-smoker.
3.3.2.4. Pregnancy. Former smokers as well as current smokers who
relapsed were aware that smoking during pregnancy was harmful to
their baby's health. This awareness was a motivator to quit. Expressions
such as “when I got pregnant, I stopped overnight” were common. In
addition to nurses' beliefs about the importance of not smoking during
pregnancy, some discussed the same feelings during the breast-feeding
period. A former smoker expressed that she managed to quit smoking
during pregnancy and she breastfeed for a “long-time” and “it did not
seem right to smoke” during breast-feeding. After the breast-feeding
period was over, the nurse said, “it was easy to go on without cigarettes.
I quit with ease, without any problems, and I said to myself that I won't
smoke, but if I ever felt like it, I would. It has been 10 years since I quit
smoking.”
4. Discussion
Our findings show that Central and Eastern European nurses ex-
pressed positive attitudes about engaging in smoking cessation inter-
ventions with patients. The complex array of barriers, as well as facil-
itators of smoking cessation which nurses experience, are similar to
those previously reported among U.S. nurses, in the general population
and other global settings (Bialous et al., 2004; McKenna et al., 2003;
Zhou et al., 2009).
4.1. Nurses' attitudes towards providing smoking cessation interventions to
their patients
A substantial majority (81.4%) expressed agreement that nurses
should set a good example by not smoking and should be involved in
helping patients quit (80.2%). Over half (66.6%) expressed the need for
more education and additional training on tobacco control. These
findings provide an opportunity to respond to the World Health
Organization's call for all health professionals to be non-smoking role
models and maximize the contributions of nurses in responding to the
tobacco use epidemic (World Health Organization, 2012b). Ad-
ditionally, these findings could lend support for inclusion of nurses in
national tobacco control efforts and capacity building initiatives. Fur-
thermore, provision of evidence-based programs focused on smoking
cessation would help to expand capacity and support nurses' own quit
efforts.
4.2. Nurses' perceived barriers and facilitators to their own quitting smoking
The barriers and facilitators to smoking cessation among Central
and Eastern European nurses, who were current and former smokers
that we found, are similar to reports by others. The exposure to coffee
as a cue for relapse is one example. The close relationship between
coffee drinking and cigarette smoking has been the subject of many
studies dating back decades (Dawber et al., 1974; Swanson et al.,
1994). Indeed, after a given quit attempt among coffee drinkers, ex-
posure to coffee was a significant predictor of smoking relapse (Krall
et al., 2002). Many of the nurses in our study struggled with urges to
smoke while being in the presence of other smokers. A large of body of

43
M. Rezk-Hanna et al.
Table 5
Exemplars quotes of barriers and facilitators to quitting smoking.
1. Barriers to quitting
Smoking cues in the environment
“I have a morning routine, every morning when I get up I put up
coffee, I make Turkish coffee, I sit down and smoke two cigarettes,
in peace. Those 15 min are my meditation, relaxation before a hard
day ahead of me, every day, and it's a way of life. I see it as a ritual,
when I take the time for myself, because basically, if I didn't take
that time, I would burn out, or get sick for other reasons.” Current
smoker
“You had a cigarette during a break, and you felt somehow relieved,
relaxed. You know, coffee and cigarettes, the typical combination,
and I felt like not inclined to stop”. Current smoker
Presence of smokers' in the environment at home and at work
“I didn't smoke for about 1.5 years … But then, I started to work and
there people smoked and went to “those stairs” … everyone who
smoked went to the stairs … And so I said “I'll go with you to the
staircase”, and I started smoking again.” Current smoker
“I tried it [quitting] three times. Once I was so content with the
money saved that I put aside, I soon bought things to cheer me up,
but it didn't last for long, because then I went on holiday with a
bunch of smokers and I fell for it again.” Current smoker
“I tried to stop smoking about 20 times …. we were at my parents'
weekend-house, and the postwoman comes in and says “come on,
you're so cool, let's have a smoke”. So I say “why not, I am an ex-
smoker anyway”, so I had a cigarette and I slid back into it again.”
Current smoker
Relapse postpartum
“Because I was breast-feeding for a short time, I actually didn't
smoke at all. And the truth is, once the period of lactation was over,
I returned to smoking with all the energy because I know how much
I missed it.” Former smoker
“I stopped smoking on the day I learnt I was pregnant … and then,
when I came back to work after maternity leave, on that day, it was
like “come, have a smoke with us”, and so I went.” Former smoker
“But when I got pregnant, I stopped overnight, but I still have a
craving for a cigarette, all the time. A lot of people around me
smoke, so when we are somewhere, I think, “I can't wait not to be
pregnant so that I can have a cigarette.” Current smoker
Stress and nicotine addiction
“I have 5 admissions at the same time … You know, I go for a
cigarette … I smoke one, come back, and it's fine … If I stayed there
I would get nervous …” Current smoker
“The number of smoked cigarette is the result of stress.” Current
smoker
“It's [smoking] probably above all just a habit …” Current smoker
Misperceptions about the dangers of smoking
“… When I was pregnant, I was aware that I need to do something
for the health of my baby. I reduced the number of cigarettes during
my pregnancy and during the breastfeeding.” Current smoker
44
European Journal of Oncology Nursing 35 (2018) 39–46
Table 5 (continued)
“It's better for you to smoke a little than to let the fetus suffer from
the stress.” Current smoker
2. Facilitators (motivations) to quitting
Seeing the health consequences of smoking in their patients
“Then I went to work at internal ICU … I began to watch the people
that were admitted to the ward … you cannot see a person there
who is [not] dying of suffocation because of 70 years of smoking … I
imagined how I would die of that horrible suffocation.” Former
smoker
“What bothers me is the fear that one day I will get sick and become
a patient. I started at C1, at the pulmonary, and I saw a lot there … I
see them every day, smelling of smoke.” Current smoker
“I smoked while I was working in abdominal surgery at the
University Medical Centre, but when I came here and was on duty at
the pulmonary department for the first time, I quit immediately, and
haven't smoked since then … When I saw our patients, it was
immediately clear to me that I would never smoke again.” Current
smoker
Personal or family health concerns
“The reasons [for quitting], well, because I do a lot of sports, and I
wanted to go ahead with extreme run race so I decided to quit.”
Former smoker
“And the only time I stopped, and maybe it was in consequence of it
or even because of my age, was when my daughter was born and she
was born prematurely and had to be in an incubator, so I had to be
with her in hospital and I didn't smoke there at all … it was maybe a
sort of motivation.” Current smoker
Support for quitting from family
“My motivation was my son who came from school. Very clever,
they had a panel [sic on smoking] and he was afraid I'd die, and
what would he do without me, like that blackmail from my son. But
that was the biggest incentive, the motivation.” Former smoker
“My guy doesn't smoke, and I didn't want to smell bad to him, he
minded, too, because he is an ex-smoker … And around me nobody
smokes, the daughter is 15, she was always rubbing it in, my smell,
like: “mom, have you been smoking again”. So because of that, too.”
Former smoker
“I feel ashamed before my younger daughter who asks me why I
smoke? She says it is unhealthy and that it will have consequences
and things like that … I would never quit because anybody else
complaints. My daughter is the only reason I want to quit …”
Current smoker
Pregnancy
“I decided to quit smoking when I'm pregnant … Then I breastfed for
a long time and it did not seem right to smoke then … It has been 10
years since I quit smoking.” Former smoker
“I quit smoking when I was pregnant, I had some complications in
the pregnancy” Former smoker
“I smoked for 10, 15 years and I quit when I got pregnant. It was
simple, I just cut the habit and haven't smoked a cigarette since then
for 15 years.” Former smoker
M. Rezk-Hanna et al.
tobacco control literature has demonstrated the strong effect of peer-
smokers and social situations on individual quit attempts; often trig-
gering and resulting in relapse (Chandola et al., 2004; Yang et al., 2006;
Zhou et al., 2009). Our findings are in line with the findings of Zhou
et al. (2009) who have identified predictors of smoking relapse from a
sample of 2432 smokers in the United States, United Kingdom, Canada,
France, and Spain (Zhou et al., 2009). This longitudinal, prospective,
cohort study assessed smoking relapse outcomes every 3 months for 18-
months. Eighty percent of smokers who made a quit attempt experi-
enced relapse; and the presence of other smokers predicted higher
likelihood of relapse.
Pregnancy and the postpartum period influenced smoking behaviors
among these predominately female Central and Eastern European
nurses. While nurses stated they were able to quit smoking sponta-
neously during pregnancy, many resumed smoking postpartum after
returning to work or after completion of breast-feeding. Although
pregnancy is a period known to offer a unique opportunity for smoking
cessation, postpartum relapse is common among women in all societies
and thus represents a major global public health challenge (McBride
and Pirie, 1990; Polanska et al., 2005; World Health Organization,
2010). Our findings reinforce results from prior research in the general
population, demonstrating that while pregnancy is a motivator for
smoking cessation, being in an environment with others who smoke and
where cigarette smoking is permitted are factors that contribute to
postpartum relapse (Ma et al., 2005; Polanska et al., 2011; Solomon
et al., 2007; Van't Hof et al., 2000).
Despite being health care providers, our findings indicate that
Central and Eastern European nurses lack understanding about nicotine
addiction, withdrawal symptoms, and have misperceptions about the
dangers of smoking. Nurses' who viewed smoking as a “habit” and only
as a response to stress, appeared to lack knowledge about the power of
nicotine addiction and withdrawal symptoms, often wrongly equating
withdrawal symptoms with “stress”, similar to findings in the general
population and nurse groups from other countries (Bialous et al., 2004;
Sarna et al., 2000a,b). These misperceptions as well as their demon-
strated lack of knowledge on tobacco control may reduce their ability to
quit and limit their ability to provide evidence-based interventions to
help their patients quit smoking. In Central and Eastern European
countries, a recent online program to educate nurses on evidenced-
based smoking cessation interventions for their patients, showed that
after program participation, nurses were significantly more likely to
provide smoking cessation interventions and have significantly im-
proved their views about the importance of nursing involvement in
tobacco control (Bialous et al., 2017). Thus, it is imperative that to-
bacco control educational programs for nurses to address and counter
common misperceptions surrounding nicotine withdrawal and health
effects of tobacco use.
Our study also identified common themes concerning factors that
facilitate smoking cessation. Former smokers provided insights on
quitting smoking and maintaining long-term abstinence. Participants
recognized that long-term cessation involved many unsuccessful quit-
ting attempts. Unlike the general public, nurses mentioned that wit-
nessing the health consequences of smoking in their patients was a
powerful motivator for quitting. The high percentage of nurses from
oncology settings might have influenced this finding although there
were no significant differences in clinical setting by smoking status.
Former smokers also noted the impact of personal and family health
concerns on their quit efforts. Similar to findings from the general
public, pregnancy, support for quitting from family and children were
strong motivators for smoking cessation (Appleton and Pharoah, 1998;
Coppotelli and Orleans, 1985; Curry et al., 2001; Mermelstein et al.,
1983).
Our study has several limitations. Focus group methodology utilizes
relatively small convenience samples and is not meant to be re-
presentative of all nurses' attitudes and perceptions from each of the
five countries involved in the study. The smoking status of all study
45
European Journal of Oncology Nursing 35 (2018) 39–46
participants was not verified by physiological or biochemical measures,
and prevalence of smoking was lower than previously reported for
nurses in the region. Participants might have been more interested in
the topic of quitting smoking than nurses who did not volunteer to
participate. Although our sample of nurse smokers were largely di-
ploma educated nurses and appear to be less educated than having a
baccalaureate degree, the demographic and professional characteristics
of our sample fairly mirror the overall characteristics of nurses in
Central and Eastern Europe, including the lower percentage of nurses
with academic degrees (World Health Organization, 2017a,b).
Although focus groups were conducted with a moderator's guide by
trained facilitators, variation from group to group and country to
country may have occurred. While efforts were made to ensure that the
transcription of the audio recorded sessions and translation to English
was accurate, there may have been undetected errors. We are unable to
determine if smoke-free work place policies influenced these nurses'
attitudes. Access and support for smoking cessation resources and po-
licies regarding smoke-free environments vary by country, but were
overall uncommon in the region. We did not examine differences in the
presence of tobacco control policies by professional nursing organiza-
tions in each country. These country-specific factors may also influence
perceptions about smoking and quitting. Finally, as there were no non-
smoker nurse groups, we are unable to determine if attitudes about
tobacco control are different among nurses who never smoked.
Despite these limitations, our findings provide the first descriptive
exploration about barriers and facilitators to smoking cessation, and
triggers precipitating relapse, among nurses in Central and Eastern
Europe, which can be used in developing programs to support quit ef-
forts. In the U.S., similar findings led to the development of the first
national program to support quit efforts of nurses, Tobacco Free Nurses
(Sarna et al., 2009). Nurse smoking prevalence in the U.S. has declined
since the initiation of this program and an increased professional focus
on the issue (Sarna et al., 2014a,b).
Tobacco smoking is a leading cause of preventable morbidity and
mortality in Europe (World Health Organization, 2014). In European
countries, the estimated proportion of deaths attributed to smoking is
higher than other countries (Ezzati and Lopez, 2003; Renteria et al.,
2016). To develop effective smoking cessation programs and interven-
tions, knowledge about attitudes and perceptions regarding smoking
and quitting is crucial. Research demonstrates that nurse-delivered
smoking cessation interventions are effective (Canga et al., 2000; Miller
et al., 1997; Rice et al., 2013). Because little is known about nurses'
cessation efforts in Central and Eastern Europe, our study begins to
address this gap. Nurses' positive attitudes about engaging in smoking
cessation with their patients are encouraging and support the accept-
ability for expanded capacity building efforts in Central and Eastern
Europe (Bialous and Sarna, 2016). Future studies should explore the
relationship between nurses' access to resources, smoke-free policies,
and professional policies on nurses and tobacco control. This informa-
tion can be useful in developing programs and policies that address
barriers and facilitators to smoking and quitting among nurses. Ad-
ditionally, expanded educational programs on tobacco control in nur-
sing education and for practicing nurses are needed to support nurses'
delivery of cessation interventions to their patients. Addressing
smoking among student nurses as part of these educational programs is
also important.
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