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| Journal of the New Zealand Medical Association,
17-October-2008, Vol 121 No 1284
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Low and declining cigarette smoking rates among
doctors and nurses: 2006 New Zealand Census data
Richard Edwards, Tom Bowler, June Atkinson, Nick
Wilson
Smoking among health care workers, particularly doctors and
nurses, has been a commonly researched topic since the health effects of smoking
became widely known in the 1950s. Recent systematic reviews found 81 and 73
English language papers describing smoking among doctors and nurses
respectively.1,2 Health care workers are a key
potential role model group for promoting a smokefree society, and due to their
very high level of awareness of the major health effects of smoking are a
potential vanguard group for achieving very low smoking prevalence.
In New Zealand, surveys of smoking among doctors on the
medical register were carried out in 1963 and
1972.3,4 These were followed by a series of
analyses conducted by Sir David Hay of smoking among doctors and nurses based on
data from the 1976, 1981, and 1996
censuses.5–8 Each of these censuses
included a question on smoking status. On the basis of the encouraging trends in
these analyses, Sir David speculated that by 2000 there could be a generation of
non-smoking doctors.7
A recent letter to the Journal noted that no such
similar analysis had been carried out using the 2006 Census
data,9 in response to which the prevalence
among broad categories of health professionals has recently been
reported.10 There has also been a recent report
on smoking among nurses in New Zealand giving overall prevalence of smoking and
smoking by area of practice in the 2006
Census.11 This report also covered a more
detailed survey of beliefs and practices about smoking cessation among 371
nurses.
The purpose of this paper is to examine in more detail the
smoking status of doctors and nurses using data from the 2006 Census and to
describe recent trends in cigarette smoking prevalence among these health
professionals.
MethodsAnalyses are based on responses to two questions on
smoking in the 2006 New Zealand Census. 12
Responses to the questions are used to categorise individuals as current regular
smoker, ex-regular smoker, and never-regular smoker. We excluded from the
denominator all subjects who did not have valid data for the smoking
questions.
Responses to the smoking questions were
analysed by age in four groups (15–24 years, 25–44 years,
45–64 years, 65+ years), by sex, and by occupation using levels 4 and 5 of
the Australian and New Zealand Standard Classification of
Occupations.13 Student nurses and medical
students were not separately coded in the census analyses, and are not included
in the data presented.
For examining trends we considered data from surveys of
doctors in 1963 and 1972,3,4 and from censuses
that included questions on smoking (in 1976, 1981, 1996, and
2006).5–8
There are minor discrepancies in the totals between and
within the tables as all the numbers were random rounded to a multiple of three
as per Statistics New Zealand protocol.
ResultsNumber of respondents and
response—There were 6312 male and 4197 female doctors, and 2469
male and 32,682 female nurses included in the census. Non-response to the
smoking status questions was 2.9% in male doctors, 3.3% for female doctors, 4.5%
for male nurses, and 3.5% among female nurses. This compared with a non-response
for the smoking questions of 5.2% in all census
respondents.12 Percentages of current smokers,
ex-smokers, and never-smokers in analyses presented exclude subjects who did not
respond to either or both of the smoking status questions.
Smoking among doctors in 2006—The
prevalence of smoking among all doctors and all those in the census with an
occupational classification stratified by age and sex is shown in Table 1. Only
4.0% of male doctors and 3.0% of female doctors were regular smokers, with minor
variations by age group. Smoking prevalence among doctors is substantially less
than among the total employed population for males and females and all age
groups. Around 90% of male doctors aged less than 25 years and of female doctors
aged less than 45 years had never been regular smokers.
Table 1. Smoking prevalence among doctors in
the 2006 New Zealand Census*
 *There may be minor discrepancies in the totals within this
table (and between other tables) as all the numbers were random rounded to a
multiple of three as per Statistics New Zealand protocol.
Table 2 shows smoking among doctors by speciality:
Smoking among nurses in
2006—The prevalence of smoking among all nurses stratified by age
and sex is shown in Table 3.
Only 13.2% of female nurses were smokers, and 19.6% of male
nurses. These compare with 20.2% of females and 22.4% of males among the total
employed population. Smoking among nurses was higher than in the total employed
population for the male nurses aged 45–64 and >65 years, and for female
nurses over 65 years. Otherwise regular smoking was less common among nurses
than in the total employed population in all other age groups for both genders.
The proportion of smokers was highest in male and female nurses in the
15–24 years age group. However, there was also a very high proportion of
female nurses in this age group who had never smoked regularly (72%).
Table 2. Smoking prevalence among doctors by
specialty in the 2006 New Zealand Census*
 * There may be minor discrepancies in the totals within
this table (and between other tables) as all the numbers were random rounded to
a multiple of three as per Statistics New Zealand protocol.
Table 3. Smoking prevalence among nurses in the
2006 New Zealand Census
 * There may be minor discrepancies in the totals within
this tables (and between other tables) as all the numbers were random rounded to
a multiple of three as per Statistics New Zealand protocol.
Table 4 shows smoking among nurses by speciality. Smoking
prevalence was higher among male “principal” and psychiatric nurses.
Among female nurses, smoking prevalence was 15% or lower for all groups of
nurses, except for psychiatric nurses who had a particularly high prevalence
(30%). Male and female psychiatric nurses had higher smoking prevalences than
the overall male and female census population.
The lowest smoking prevalences (<10%) were among midwives
and Plunket nurses (the latter being community-based nurses who focus
particularly on child health and development). Midwives and Plunket nurses
provide smoking cessation support and advice about smokefree homes, so are
potentially key smokefree role models within communities.
Table 4. Smoking
prevalence among nurses by specialty* in the 2006 New Zealand Census
#
 * Principal nurses are senior nurses including charge
nurses. Registered nurses are general staff nurses working mainly in a hospital
setting. See text for a description of Plunket nurses.
# There may be minor discrepancies in the totals within
this tables (and between other tables) as all the numbers were random rounded to
a multiple of three as per Statistics New Zealand protocol.
Trends in smoking prevalence among doctors and
nurses
Census data shows that regular cigarette smoking among
doctors has declined steadily since 1976 (Figure 1). Smoking prevalence was only
5% by the 1996 census for male and female doctors, and by 2006 had declined to
4% and 3% respectively.
Cigarette smoking prevalence was also assessed in samples of
doctors in 1963 and 1972 (2623 in 1963 and 3113 in 1972). In 1963 only
occasional and regular cigarette smoking combined was measured, and was 35.5%
among men and 28.8% among women. 4
By 1972 this had declined to 22.0% in men and 14.6% among
women doctors. Regular cigarette smoking was 17.4% for male doctors and 12.2%
among female doctors in 1972. 3
Smoking among nurses has also decreased regularly since
first assessed in 1976, and has declined further in 2006. Smoking prevalence
among psychiatric nurses has remained high. In 1976 49% of female and 50% of
male psychiatric nurses were regular cigarette smokers. This reduced to 46% of
females and 38% males in 1981, and to 31% for males and female psychiatric
nurses in 1996.
Table 4 shows that there has been little further decline
among female psychiatric nurses, though male smoking prevalence has reduced to
26%.
Figure 1. Trends in regular cigarette smoking
prevalence among doctors and nurses in New Zealand from New Zealand census
data
 Sources: 1976, 1981, 1996, and 2006
censuses.5–8
DiscussionThe results from the 2006 Census demonstrate that
non-smoking among doctors and nurses is increasingly the norm. The vast majority
of doctors are now non-smokers, and among younger doctors, around 90% have never
been regular smokers. Among nurses there has been a steady decline, so that
female nurses now have a smoking prevalence well below the population level, in
contrast to the situation in 1976 and 1981.5,7
Male nurses formerly had a very high smoking prevalence. This too has also
decreased and is now slightly below overall male smoking prevalence in New
Zealand. If recent trends continue, smoking will soon also be a rarity among
nurses.
A major strength of this study is that uniquely it is based
on a census rather than a sample of health care workers. A potential limitation
is that there was a proportion who did not complete the smoking status question
(less than 5% in the occupational groups included in this study). It is
plausible that these individuals may be more likely to be smokers (and not
report this due to social desirability bias) and hence the smoking prevalence
figures may be a slight underestimate. However, given the low non-response rate
this is unlikely to greatly affect the findings. Another limitation is that even
the level 5 occupational categories are aggregations of a broad range of types
of doctors and nurses, so a more finely focused assessment of smoking status by
particular specialties was not possible.
In the international review of smoking among doctors, from
15 studies which have been published since 2000, smoking prevalences varied
between 2% and 40% in all doctors, 5% to 32% among male doctors, and 0 to 23%
among female doctors.1 Smoking prevalence among
New Zealand doctors is therefore probably one of the lowest in the world. Among
studies of nurses published between 1996 and 2006, the mean smoking prevalence
was 20%.2 Since this prevalence was largely
among female nurses, this shows that the New Zealand smoking prevalence for
female nurses of 13% is also lower than in most other countries where surveys
have been performed.
These figures are encouraging as health professionals,
particularly doctors and nurses are likely to be important role models to the
rest of the community for health-related behaviours. These health workers are
also important for delivering smoking cessation services and the credibility of
this service delivery may be undermined if the provider is known to be a smoker.
The persisting high smoking prevalence among psychiatric
nurses is of concern, and has been reported in other
countries.14-17 It identifies a high risk group
who may particularly benefit from targeted smoking cessation advice and support.
It is also of concern because of the possible impact on smoking among patients
attending mental health services, which have been shown to be very high in
numerous studies around the world.18 Further
research would be useful to explore the reasons for continued high smoking
prevalence in this group and to examine the effect of interventions to reduce
smoking among all those working and living in mental health service settings
given the important links between mental health and smoking.
19
Nevertheless, all health workers who continue to smoke could
benefit from targeted smoking cessation support using evidence-based
pharmacotherapy and counselling support.20
These can be delivered (and ideally paid for) by employing health sector
agencies. This could be justified on the grounds of reducing absenteeism levels,
improving work productivity and reducing the adverse role model of have smoking
health professionals in healthcare settings and in the community.
In conclusion, data from the 2006 census in New Zealand
confirms the very low prevalence of smoking among doctors and low and decreasing
smoking prevalence among nurses. The results show that it is possible to achieve
very substantial decreases in smoking prevalence and that smokefree cultures can
become established and be maintained among substantial occupational groups who
are well informed about the degree of risk, are aware of the reality of the
health consequences of smoking, and work in a substantially non-smoking
environment. This provides hope that with strong tobacco control policies a
similar smokefree culture and very low prevalence of smoking could be
established much more widely in the population.
Competing interests: Wilson and Edwards
have previously worked for NGOs and the Ministry of Health on tobacco control
issues.
Author information: Richard Edwards,
Director, Health Promotion and Policy Research Unit; Tom Bowler, Visiting
Researcher, Health Promotion and Policy Research Unit; June Atkinson, Senior
Analyst, Health Inequalities Research Programme; Nick Wilson, Senior Lecturer,
Health Promotion and Policy Research Unit
Department of Public Health, University of Otago,
Wellington
Acknowledgements: The authors thank the
Marsden Fund for funding support (RE and NW) as this work was partly undertaken
as background work in considering trends for social groups at the
“frontier” of low smoking prevalence. We also thank Statistics New
Zealand for having the foresight to include smoking questions in the census and
for supplying the data.
Correspondence: Dr Richard Edwards,
Department of Public Health, University of Otago, Wellington, New
Zealand. Fax: +64 (0)4 3895319; email: Richard.Edwards@otago.ac.nz
References:
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