9th March 2018, Volume 131 Number 1471

Richard Edwards, Danny Tu, James Stanley, Greg Martin, Heather Gifford, Rhiannon Newcombe

New Zealand has an explicit “Smokefree 2025” goal often interpreted as reducing the prevalence of smoking to under 5% by 2025 including among all major population groups.1 Monitoring smoking among healthcare workers is important as they are potential societal role models for health-related behaviours, are frequently required to provide advice and support to smokers to quit, and could be exemplars for achieving very low smoking prevalence. As a result, smoking prevalence is often assessed among these workers. For example, systematic reviews published in 2006–2007 included 81, 73 and 35 English language papers describing smoking among doctors, nurses and dentists respectively.2–4

In New Zealand, surveys of smoking among doctors on the medical register were reported in 1963 and 1972.5,6 Several analyses of smoking among doctors and nurses were conducted subsequently using data from the 1976, 1981, 1996 and 2006 censuses,7–12 and a broader analysis of smoking among healthcare workers from the 2006 census.13 These studies showed a steady decline in smoking, particularly among doctors, with only 4% of male and 3% of female doctors regular smokers in 2006. Smoking among nurses was more common: 13% among female and 20% among male nurses, and as high as 26% for male and 30% for female psychiatric nurses.7

The purpose of this paper is to provide an update on smoking prevalence among New Zealand doctors and nurses using data from the 2013 census, and make comparisons with previous census data. We also set out to examine smoking among doctors and nurses by ethnicity as this has not previously been reported.

Methods

Analyses were based on responses to two questions on smoking in the 2013 New Zealand Census.14,15 Responses to the questions were used to categorise individuals as current regular smokers, ex-regular smokers or never-regular smokers. We excluded from the denominator all subjects who did not have valid data for either or both of the smoking questions (either did not respond to question or made an invalid response).

  1. Do you smoke cigarettes regularly (that is, one or more a day)? Count only tobacco cigarettes. Don’t count pipes, cigars or cigarillos. (Yes/No)
  2. Have you ever been a regular smoker of one or more cigarettes a day? (Yes/No)

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.16 Student nurses and medical students were not coded separately from other students in the census analyses, and are not included in the data presented.

Self-identified ethnicity was assigned according to the prioritised method used by Statistics New Zealand, each person was allocated to one of two prioritised ethnic groups. ‘Māori’ included persons who indicated New Zealand Māori as their only ethnic group or one of their ethnic groups (11.7% of those aged 15 plus in 2013 and 5.9% of doctors and nurses), while non-Māori includes all persons not prioritised to the Māori ethnic group.

For examining trends we considered data from surveys of doctors in 1963 and 1972,5,6 and from censuses that included questions on smoking (in 1976, 1981, 1996, 2006 and 2013).7–11

There are minor discrepancies in the totals between and within the tables as frequencies were random rounded to a multiple of three as per Statistics New Zealand protocol.17

Results

Number of respondents and response

There were 7,065 male and 5,619 female doctors, and 2,988 male and 36,138 female nurses included in the 2013 census. Non-response to the smoking status questions was 2.4% in male doctors, 2.1% for female doctors, 2.6% for male nurses and 2.9% among female nurses. This compared with a non-response for the smoking questions of 3.5% across all census respondents.13

Smoking among doctors in 2013

The prevalence of smoking among all doctors and all adults with an occupational classification stratified by age and sex is shown in Table 1. Only 2.3% of male and 1.8% of female doctors were regular smokers, with minor variations by age group. Smoking prevalence among doctors was substantially less than among the total employed population for males (16.3%) and females (13.8%) in all age groups. Around 90% of doctors aged 25–44 years had never been regular smokers. Smoking among Māori doctors (data not shown) was 6.8% (7.4% male and 6.5% female Māori doctors) compared to 2.2% among non-Māori doctors (2.2% male and 1.6% female non-Māori doctors). Over 85% of doctors had never smoked, including over 95% of doctors aged <25 years.

Table 1: Smoking prevalence among doctors in the 2013 New Zealand census.*

 

Doctors

Total employed population

Gender

N

Regular smokers   %

Ex-smokers    %

Never smokers  %

N

Regular

smokers

%

Male

15–24 years

324

2.8

3.7

92.6

 136,518

19.8

25–44 years

2,787

2.2

10.1

87.7

 399,738

19.2

45–64 years

3,375

2.6

17.0

80.4

 398,445

14.0

65 years and over

585

1.5

33.8

64.6

 74,142

7.2

Total 15 years and over

7,065

2.3

15.1

82.6

1,008,843

16.3

Female

15–24 years

477

1.9

1.9

96.9

 124,674

14.2

25–44 years

3,036

1.6

7.0

91.3

 365,556

14.9

45–64 years

1,995

2.0

11.6

86.3

 382,896

13.4

65 years and over

111

5.4

18.9

75.7

 49,704

7.7

Total 15 years and over

5,619

1.8

8.4

89.7

 922,827

13.8

Total 

15–24 years

801

2.2

2.6

95.5

 261,189

17.1

25–44 years

5,817

1.8

8.5

89.7

 765,297

17.1

45–64 years

5,367

2.3

15.0

82.6

 781,335

13.7

65 years and over

696

1.7

31.5

65.9

 123,846

7.4

Total 15 years and over

12,684

2.1

12.1

85.8

1,931,670

15.1

*There may be minor discrepancies in the totals within this table (and between other tables) as the numbers were random rounded to a multiple of three as per Statistics New Zealand protocol.17 

Table 2 shows smoking among doctors by speciality. Among male doctors, the highest smoking prevalence was among gynaecologists and obstetricians (6.7%) and the lowest among anaesthetists (0.9%). Among female doctors the highest smoking prevalence was among surgeons (5.7%) and the lowest among gynaecologists and obstetricians (0.0%).

Table 2: Smoking prevalence among doctors by specialty in the 2013 New Zealand census.*

Gender

N

Regular smokers %

Ex-smokers %

Never smokers %

Male

General practitioner

2,685

2.2

17.3

80.6

Resident medical officer

1,935

2.3

10.5

87.1

Surgeon

717

1.7

17.2

81.6

Physician

1,143

3.4

15.7

80.6

Gynaecologist and obstetrician

45

6.7

20.0

66.7

Radiologist, radiation oncologist

201

1.5

14.9

83.6

Anaesthetist

339

0.9

15.9

83.2

Female

General practitioner

2,358

 1.4

7.3

91.5

Resident medical officer

2,007

 1.5

6.3

92.1

Surgeon

105

 5.7

5.7

85.7

Physician

801

 3.4

15.4

80.9

Gynaecologist and obstetrician

54

 0.0

16.7

83.3

Radiologist, radiation oncologist

132

 2.3

15.9

81.8

Anaesthetist

165

 1.8

9.1

90.9

Total

General practitioner

5,049

1.8

12.5

85.6

Resident medical officer

3,942

1.9

8.4

89.6

Surgeon

825

2.2

15.6

82.2

Physician

1,947

3.5

15.7

80.6

Gynaecologist and obstetrician

99

3.0

18.2

75.8

Radiologist, radiation oncologist

330

1.8

15.5

83.6

Anaesthetist

501

1.2

13.8

85.6

*There may be minor discrepancies in the totals within this table (and between other tables) as the numbers were random rounded to a multiple of three as per Statistics New Zealand protocol.17 

Smoking among nurses in 2013

The prevalence of smoking among all nurses stratified by age and sex is shown in Table 3.

Table 3: Smoking prevalence among nurses in the 2013 New Zealand census.*

 

Nurses

Total employed population

Gender

N

Regular smokers %

Ex-smokers %

Never smokers %

N

Regular smokers %

15–24 years

 90

10.0

3.3

90.0

 136,518

19.8

25–44 years

 1,473

7.5

21.0

71.3

 399,738

19.2

45–64 years

 1,332

10.8

39.2

50.0

 398,445

14.0

65 years and over

 84

10.7

50.0

46.4

 74,142

7.2

Total 15 years and over

 2,988

9.2

29.3

61.4

1,008,843

16.3

Female

15–24 years

 1,554

6.2

6.6

87.3

 124,674

14.2

25–44 years

14,094

7.9

21.4

70.7

 365,556

14.9

45–64 years

18,774

8.2

30.4

61.5

 382,896

13.4

65 years and over

 1,719

6.5

37.0

56.7

 49,704

7.7

Total 15 years and over

36,138

7.9

26.2

65.9

 922,827

13.8

Total 

15–24 years

 1,644

6.6

6.2

87.4

 261,189

17.1

25–44 years

15,570

7.9

21.3

70.8

 765,297

17.1

45–64 years

20,106

8.3

31.0

60.7

 781,335

13.7

65 years and over

 1,809

6.6

37.3

55.9

 123,846

7.4

Total 15 years and over

39,129

8.0

26.4

65.6

1,931,670

15.1

*There may be minor discrepancies in the totals within this tables (and between other tables) as the numbers were random rounded to a multiple of three as per Statistics New Zealand protocol.17 

Only 7.9% of female nurses and 9.2% of male nurses were smokers. This compares with 13.8% of females and 16.3% of males among the total employed population. Smoking among nurses was lower than in the total employed population for all age groups of female nurses and for all age groups of male nurses, except those aged 65 years and over. Around two-thirds of nurses had never smoked, including 87% of nurses aged <25 years.

Smoking among Māori nurses (data not shown) was 19.3% (18.8% male and 19.4% female Māori nurses) compared to 7.2% among non-Māori nurses (8.6% male and 7.1% female non-Māori nurses).

Table 4 shows smoking among nurses by speciality. Smoking prevalence was higher among psychiatric nurses of both genders (males 14.9%; females 17.6%) and among male principal nurses (11.8%). Prevalence was below 9% in all other types of nurses among males and females.

Table 4: Smoking prevalence among nurses by specialty* in the 2013 New Zealand census.*#

Gender

N

Regular smokers %

Ex-smokers %

Never smokers %

Male

Principal nurse

 153

11.8

33.3

54.9

Registered nurse

 2,469

8.6

27.7

63.8

Psychiatric nurse

 303

14.9

37.6

48.5

Other nurse**

60

5.0

36.7

58.3

Female

Principal nurse

 1,518

8.9

32.8

58.3

Registered nurse

29,661

7.8

25.0

67.3

Psychiatric nurse

 699

17.6

42.1

40.3

Plunket nurse

 507

7.1

24.3

68.6

Public health and district nurse

 1,185

6.3

30.4

63.5

Occupational health nurse

 156

5.8

34.6

61.5

Midwife

2,409

7.2

29.8

62.9

Total 

Principal nurse

 1,674

9.3

32.6

57.9

Registered nurse

32,130

7.8

25.2

67.0

Psychiatric nurse

 1,002

16.8

41.0

42.5

Plunket nurse

 507

7.1

24.3

69.2

Public health and district nurse

 1,230

6.3

30.7

63.2

Occupational health nurse

 159

3.8

35.8

60.4

Midwife

 2,415

7.2

29.8

63.0

*Principal nurses are senior nurses including charge nurses. Registered nurses are general staff nurses working mainly in a hospital setting.
#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.17
**Pooled due to small numbers—includes Plunket nurses, public health and district nurses, occupational health nurses and midwives. 

Trends in smoking prevalence among doctors and nurses

Census data show 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 declined further from 3.6% in 2006 to 2.1% in 2013. Smoking among nurses has also decreased dramatically since first assessed in 1976, and declined further between 2006 and 2013 from 13.6% to 8.0% (Figure 1). Among psychiatric nurses, smoking reduced from 26% to 14.9% among males and 30% to 17.6% among females during the same period.

Figure 1: Trends in regular cigarette smoking prevalence among doctors and nurses in New Zealand from census data.

c 

Sources: 1976, 1981, 1996, 2006 and 2013 censuses.7,8,10,11 

Smoking prevalence among Māori doctors declined from 9.4% for males and 10.7% for females in 2006 to 7.4% males and 6.5% females in 2013 and for Māori nurses from 33.8% to 18.8% among males and from 30.6% to 19.4% among females.

Discussion

Smoking prevalence in the 2013 census was extremely low among doctors of all specialties, and over 90% of doctors aged under 45 years had never smoked. Smoking was also only 8% among nurses, a substantial reduction from around 14% in 2006. Smoking among nurses was almost half the prevalence found among the general employed population in New Zealand. These data are from 2013, so further declines in prevalence are likely to have occurred in the interim.

These findings suggest that doctors are now a virtually smokefree population and nurses are well on the way to being the same, and to meet the 2025 Smokefree target. Smoking prevalence was higher among Māori doctors and nurses, and while these figures have declined, which is encouraging, they remained substantially elevated compared with non-Māori. This suggests that specific interventions to support cessation targeting these groups may be warranted.

The findings add to the international literature on smoking prevalence among doctors. The 2% prevalence among New Zealand doctors adds to an increasing number of countries with very low smoking prevalence in this occupational group. A 2007 review of studies between 1974 and 2004 found highly variable prevalence, with the lowest (<5%) in the US, UK and Australia.3 As the studies in this review are now quite dated, it is likely that there are now many more countries with very low prevalence of smoking among doctors. Studies of trends in smoking among doctors generally show rapidly declining prevalence over time, for example in recent studies from China and Japan.18,19 However, a more recent review mostly found much higher smoking prevalence among doctors in many developing countries.20

A 2007 review of studies among nurses found great variation in smoking prevalence, with the lowest prevalence in east Asian countries such as Japan and China, as well as the US, UK and Australia. Studies of trends in smoking prevalence showed evidence of large reductions in prevalence over time in some countries such as Australia and Canada. Among studies of nurses’ smoking published between 1996 and 2006, the mean prevalence was 20%, so the overall smoking prevalence of 8% found in this study may be one of the lower smoking prevalence estimates among nurses internationally. The smoking prevalence of around 19% among Māori nurses in the 2013 census are similar to those of a 2012 national survey of smoking among New Zealand Māori nurses, which found a daily smoking prevalence of 16.6%.21

A strength of this study is that it is based on a census rather than a sample of healthcare workers and hence has large numbers of participants and is not susceptible to sampling variation. It updates and advances on previous studies of smoking among doctors and nurses in New Zealand by including data on smoking among Māori and non-Māori. Investigating smoking by ethnicity is particularly important given the evidence that smoking is much higher among Māori and that the current rate of decline in smoking prevalence is far too slow to meet the Smokefree 2025 goal for Māori peoples in New Zealand.22

A potential limitation of the study is that a small proportion did not complete the smoking status question, though this was less than 3% in the nurse and doctor 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.

The low and declining smoking prevalence among doctors and nurses is encouraging. The existence of rapid declines in prevalence among occupational groups, and that there are substantial occupations like doctors where smoking prevalence is well below 5%, provides encouragement that the Smokefree 2025 goal is achievable. However, doctors are a highly educated, high status, high-income group and such a low smoking prevalence may not be achievable in more marginalised groups without much more substantial tobacco control and smoking cessation interventions.

Low smoking prevalence among health professionals, particularly doctors and nurses, may be particularly important as these groups are potential role models to the rest of the community for health-related behaviours.23 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. Furthermore, systematic reviews24,25 and research with Māori nurses26 have found some evidence that doctors and nurses who don’t smoke are more likely to provide smoking cessation advice and support than their smoking colleagues. A possible mechanism for this is that nurses and other para-professionals who smoke experience cognitive dissonance. This dissonance may be generated by their belief that, as health professionals, they should be role modelling health-promoting behaviours, a belief that contrasts with their actual behaviour as smokers. Such dissonance may impact on practice by inhibiting nurses who smoke from providing smoking cessation advice to patients and potentially to wider family members.26,27

The substantial decline in prevalence among psychiatric nurses since 2006 is also a positive sign, though they remain the group of nurses with the highest rates of smoking. Since the study based on the 2006 census, there has been a greater focus on understanding smoking among psychiatric patients and the contribution of psychiatric health service settings to promoting smoking. For example, New Zealand studies have found high rates of mental illness among smokers,28 and higher smoking prevalence among people with mental illness.29 A qualitative study found that there was a ‘permissive culture’ towards smoking in some New Zealand mental healthcare facilities.30

The potential positive impacts of low smoking prevalence among doctors and nurses and persisting high smoking prevalence among psychiatric nurses and Māori nurses suggests that there is a case for targeted smoking cessation support among these key groups, including programmes designed specifically for Māori. Interventions targeted at Māori nurses will need to recognise the broader social environment and needs of this specific population.26 Workplace smoking cessation interventions have been shown to have a similar degree of effectiveness to cessation interventions in other settings.31 They have some potential advantages such as providing efficient access to priority groups, and potentially having higher participation rates than interventions in non-workplace environments.31 However, delivering workplace interventions to healthcare professionals in healthcare settings may also have some additional challenges that may need to be addressed. For example, enrolment may be inhibited by the perceived stigma of being identified as a smoker and shift-work patterns may create logistical difficulties for programme delivery.

Cessation interventions for selected groups of health professionals could be part of a comprehensive programme of workplace-based cessation interventions for occupational groups with a high smoking prevalence and/or where reductions in smoking prevalence may have additional positive effects on smoking and smoking cessation in the wider population; for example, among occupational groups who are potential role-models, such as teachers. There is also a strong case for implementing interventions to ensure healthcare settings are smokefree with a strong smokefree culture and norms. For example, in a qualitative study with Māori nurses, smokefree workplace policies were reported to reduce smoking in the workplace.26 This is particularly important in mental healthcare settings where smoking prevalence among staff and patients is often high, and cultures that support smoking—such as staff offering patients cigarettes and beliefs that smoking can be useful because it helps facilitate dialogue with patients—still persist in some settings.30

The results from the 2013 Census demonstrate that as an occupational group, New Zealand doctors had achieved the Smokefree 2025 goal of minimal smoking prevalence and all nurses except psychiatric nurses appeared to be on track to do so well before 2025. However, despite encouraging recent trends, smoking prevalence remained relatively high among Māori nurses. The results support the feasibility of the Smokefree 2025 goal by demonstrating that very rapid decreases in smoking prevalence and close to zero smoking prevalence can be achieved among some substantial occupational groups, albeit health professionals who may be among the group most likely to not smoke. Providing targeted smoking cessation support in healthcare workplaces may be an efficient means of reducing smoking among occupational groups with persisting high rates of smoking, and may assist with reducing smoking prevalence among the wider population.

Summary

We examined recent smoking trends among doctors and nurses in New Zealand using recent census data. We found that smoking had declined steadily and by 2013 only 2% of male and female doctors and 9% of male and 8% of female nurses were regular cigarette smokers. Smoking was more common among Māori doctors (7%) and nurses (19%), and also among psychiatric nurses. The findings suggest that New Zealand doctors had achieved the Smokefree 2025 goal of minimal (<5%) smoking prevalence and all nurses except psychiatric nurses were on track to do so. Targeted workplace smoking cessation support could be used to reduce smoking among key occupational groups such as Māori nurses.

Abstract

Aim

To examine recent smoking trends among doctors and nurses in New Zealand.

Method

Analysis of smoking prevalence in the 2013 New Zealand Census and comparison with previous census data.

Results

The 2013 census included 7,065 male and 5,619 female doctors, and 2,988 male and 36,138 female nurses. Non-response to smoking questions was less than 3%. In 2013, 2% of male and female doctors and 9% of male and 8% of female nurses were regular cigarette smokers. This compared with 4% male and 3% female doctors, and 20% male and 13% female nurses in 2006. Psychiatric nurses had the highest smoking prevalence (15% male, 18% female). More Māori doctors (6.8%) and nurses (19.3%) smoked. Around 96% of young (<25 years) doctors and 87% of young nurses had never been regular smokers.

Conclusion

By 2013, New Zealand doctors had achieved the Smokefree 2025 goal of minimal (<5%) smoking prevalence and all nurses except psychiatric nurses were on track to do so. This suggests smokefree cultures can be established among substantial occupational groups. However, smoking among Māori nurses was relatively high. Targeted workplace smoking cessation support may be an efficient means to reduce smoking among key occupational groups, and may help reduce population smoking prevalence.

Author Information

Richard Edwards, Co-Director, ASPIRE 2025, Department of Public Health, University of Otago, Wellington; Danny Tu, Senior Analyst, Evidence, Data and Knowledge Group, Ministry of Education, Wellington; James Stanley, Statistician, Dean’s Department, University of Otago, Wellington;
Greg Martin, Senior Analyst, Health Promotion Agency, Wellington;
Heather Gifford, Researcher, Whakauae Research for Māori Health and Development, Whanganui;
Rhiannon Newcombe, Independent Research and Evaluation Consultant, Wellington.

Acknowledgements

We thank Statistics New Zealand for having the foresight to include smoking questions in the census and for supplying the data.

Correspondence

Professor Richard Edwards, Professor of Public Health, Co-Director of ASPIRE 2025, Department of Public Health, University of Otago, Wellington.

Correspondence Email

richard.edwards@otago.ac.nz

Competing Interests

Nil.

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