The influence of social environment on the smoking status of women employed in health care facilities

© 2013 Nikšiæ et al.; licensee University of Sarajevo Faculty of Health Studies. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. UNIVERSITY OF SARAJEVO FACULTY OF HEALTH STUDIES ABSTRACT


INTRODUCTION
Social environment is one of the important factors that aff ect the prevalence of smoking habits in the world.In most countries, especially that with high incomes smoking is characterized as an unacceptable form of behavior.Th e pressures of the social environment in terms of the smoking ban in public places, including health and educational institutions in Western countries are the key motivating factor for smoking cessation both among women and men.However, in countries where smoking is perceived as socially acceptable habit, the impact of the society is negligible.Cultural heritage which accepts smoking especially among men seems to destroy the positive impact the environment.It is known that populations eventually freethemselves from poor legacy.Th e process of liberation from the unhealthy habits in low-income countries is slower, due to changes in social and economic status of women.Recent trends show that the symbolic value of smoking for women

RESEARCH ARTICLE
Open Access is the freedom and independence (1,2).Data from the World Health Survey conducted in 50 countries showed that the use of tobacco among women is spreading into countries with low incomes, which increase in revenue increase their buying power, while better educational status changes their cultural and social position.Increased employment and greater accountability seems that makes women more exposed to stress, which increases the urge to smoke (3,4).Th e family has a motivating eff ect usually only for mothers, and symbolic for younger women and men (5).Bosnia and Herzegovina is a country with a low income and in the process of altering social standards of conduct.(7)(8)(9)(10)(11)(12).Work environment is one of the dominant factors that promote smoking.Failure to comply with the prohibition of smoking at the workplace is supported by the aggravating circumstances of the health professions, such as a high professional requirements, workplace stress and expectations of the role of nurses as health professionals.Lack of social support from colleagues and managers, as accepting smoking as acceptable form of behavior and the absence of protective mechanisms contribute to higher rates of smoking in health care facilities (9,10) Th e aim of this study was to examine the infl uence of the social environment of women employed in health care facilities in relation to their smoking status.

Research sample
Th e target group in this study was female employees of public health facilities in the Sarajevo Canton.
Criteria for selectionof health facilities were its activities and management approval for the research.Th e basic principle of choice of institutions was the representation of all forms and levels of health care employees in the health system of the country.Occupation wasobserved in following categories: physician, master pharmacist, nurse, administrative (accounting, management, etc.), technical staff (technical and utility services) and others, and also are the womenat the managerial position.Social environment is defi ned as the presence of the nearest colleagues, the best friend and family members who are also smokers.Work environment is reviewed through the questions about: diversity of work, working hours, thinking whether the environment, meetings and management support smoking at the workplace.Th e characteristics of women smokers are treated in rela-tion to: the number of cigarettes smoked per day, the time for the fi rst cigarette, smoking place, an environment that supports smoking and their attitudes about smoking cessation.

Statistical analysis
Statistical analysis of data was performed in statistical package SPSS17, using standard tests, ANOVA and chi square test, at the level of statistical significance of p<0.005.

Respondent's characteristics
Survey included 477 women employed in Smoking status statistically signifi cantly diff er by occupation (p=0.002).Most smokers are among nurse (58.1%) and technical staff (55.6%), and not far behind is the administrative staff (48.1%).Th ere were 37.4% physicians smokers and 27.6% pharmacists (Table 1).Statistically signifi cant diff erence also exists by the current smoking status according to the level of edu-cation: majority of the smokers are women with low and medium level of education, while women that are mostly nonsmokers have higher levels of education (p=0.000).According to the place of employment there is no statistically signifi cant diff erences in relation to smoking habits (p=0.314),but most women smokers are employed in Primary health care centers

Respondent's social and working environment
Working environment of smokers is correlated with smoking status: the closest work colleagues/fellow of smokers are also smokers, while of former smokers are smokers and formersmokers (p=0.001).It can benoticedthatthere is a high percentage of fellow smokers (60.1%,Table 2).It also can be noted the high percentage of friends smokers (54.0%).Statistically signifi cantly are morelikely for women smokers to socialize with smokers (66.2%), while most former smokers with former smokers (69.6%, p=0.000,Table 2).Th e other members of the families of smokers are often also smokers (59.6%), but without statistically signifi cant diff erences between the groups (p=0.092).Female employees in health care institutions often performs same tasks (68.9%) and are less likely to have a diversityin jobs, according to smoking status without signifi cant diff erence (p=0.777,Table 3).Th ey often work only during the day, 28.3% stated that they occasionally works at night and very rarely work only night shifts.According to smoking habits there are no statistically signifi cant diff erences between the working hours of employees (p=0.654).
A third of women (27.8%) believe that the work environment supports smoking among employees, signifi cantly more nonsmokers (51.3%) than smokers (43.7%, p=0.003).Approximately 75% of an employee believes that meetings supports smoking, as well as 65% that the management of the health facilities is not against smoking at the workplace (Table 3).Attitudes of  women smokers are opposite to attitudes of smokers when it comes to smoking in the meetings and activities of the institutionsmanagement on the implementation of the smoking prohibitionat the workplace.Signifi cantly more non-smokers feel that working meetings supports smoking (p=0.007), and that the management of the institution indirectly supports smoking at the workplace (p=0.000).Women smokers employed in health care facilities, which are mostly nurses and doctors, are heavy smokers, usually smoke more than 20 cigarettes a day (43.3%),their fi rst cigarette is usually 6 to 60 min after awakening (61.3 %) and 25% smokes in all places including the workplace (p=0.000,Table 4).Concerned by the fact that 60.9% of women do not generally intended to quit smoking, a negligible few women see the danger of smoking and want to quit in the next 3 or 6 months (8.4%).Attitudes toward women smokers according to the need to stop smoking were statistically signifi cant diff erent (p=0.000).

DISCUSSION
Tobacco consumption has risen alarmingly among women worldwide.Without eff ective intervention, the prevalence of tobacco use will triple in the next generation.Th ese trends are potentially more dangerous for women and their health (1,16).Women employed in health care facilities, especially medical professionals, according to a number of studies are smokers (7,10,11).Th e results of our study have shown that the number of smokers is higher than the prevalence in the general population and the number of former smokers is lower than the prevalence of former smokers in the general population of the Federation of Bosnia and Herzegovina (15).Over 50% of women smokers working in primary health care facilities and Institute for Emergency Medical Services.Th e high rate of smoking in Institute for Emergency Medical Services may be explained by the diffi cultwork conditions (sometimes work at night and deal with emergencies).Qualifi cations and educational status of women signifi cantly aff ect the prevalence of smoking, which was confi rmed in our study: the least number of smokers was among masters of pharmacy and doctors probably the reason is that they best know the consequences of smoking on health.Th e most com-mon smokers are nurses, of which 56% are regular smokers, far more than in other hospitals in the world (7,9,10,11).
Causes of the high rates of smoking can be found in the fact that smoking is widely accepted cultural behavior as socially acceptable habit, as in the general population and among women, health care workers in our country.Women and young people are more prone to overestimation of smoking in general, and especially in their environment, thus justifying their own smoking, and not only underestimated the risk of the consequences of smoking, but also the diffi culties of smoking cessation (16).
In the culture of smoking women, especially at younger ages, they appear as a phenomenon of "social" smokers.Th ey are usingtobacco smoking for their social activities and they need tobaccofor work and social contacts and often do not perceive the risk of diseases associated with tobacco.In our study, women smokers for friends and work colleagues have often smokers, which may explain the phenomenon of "social" smokers, and that by belonging to the group is easier to justify risky behavior and avoid condemnation of nonsmokers.Nonsmokers and former smokers are forced to be in an environment with smokers, resulting in a high exposure to passive smoking.Th e cause of this is the high prevalence of smokers and the environment that does not sanction smoking among employees, although in the Federation of Bosnia and Herzegovina there is a law that prohibits smoking in health care facilities (17).Family environment according to our results can be considered as stimulating environment, as a model of behavior for its members.Other studies confi rm our fi ndings (18).In similar research type of work and night shifts are extenuating circumstances and are associated with smoking status (9) Our results did not confi rm this, because there is high proportion of smokers among the administrative staff who perform the same jobs and does not work at night.Th e attitude of nonsmokers is that the working environment and the management of the institution support the freedom of smoking among employees, which is less common opinion among women smokers.Th e right to full freedom of smokers for smoking that is present in the work environment is challengedby respondents from a small number of former smokers and nonsmokers.Th e reason lies in the fact that there are no sanctions for smoking in health care facilities, and that the acceptance of the traditional right of nonsmokers to tobacco smokefree environment has been disputed (17).Social acceptance of smoking as a positive habit in public is not condemned by colleagues in our research.Th ese fi ndings contribute also the characteristics of women smokers, showing that 38% of them smoke their fi rst cigarette after waking up to 30min and smokes up to 30 cigarettes a day.Similar results have been confi rmed in a number of studies among nurses (19).
A signifi cant number of employees do not realize smoking addiction as a disease, which is confi rmedby 60% of women smokers who do not intend to quit smoking Reasons for that are developed tobacco dependence which in a lesser extent impairs psychosocial functioning than other addictions and that a phases of acute intoxication are rare and the sanctions from the environment does not exist.Today in the world are present trends that lead to the creation of smoke-free health care institutions with a complete smoking prohibition.Th ey have contributed to reducing the number of its employees who are smokers (20).Given the widespread incidence of smoking in diff erent health institutions it is needed to ensure compliance with existing legislation.Th is might be the fi rst step towards a complete prohibition of smoking in health care facilities.Management of health institutions should play a crucial role in monitoring the implementation of this legislation (19,21).Our research shows that women are rarely managers of health institutions (7.7%) and thus do not have the legal power in the implementation of smoke-free policies.

CONSLUSION
Conducted study among women employed in health institutions of the Sarajevo Canton shows that 50% of them are current smokers.Women smokers were at younger age, with lower education level and the highest prevalence is found among nurses and administrative staff .Health-care employees are smokers who smoke in all areas including the workplace.Working and social environment support smoking as an acceptable cultural habit among medical staff and is a barrier to the implementation of policies of control and supervision over smoking in a health institution.

TABLE 1 .
Education, occupation, location and position of women at the workplace according to smoking status p*<0.005;IHCWM** -Institute for Health Care of Women and Motherhood; PHI*** -Institute of Public Health; IAS**** -Institute for Alcoholism and Substance Abuse; IEMS*****-Institute for Emergency Medical Services 7health institutions of Sarajevo Canton, of which 136 (25.5%) from the Primary health care centers, 82 (17.2%) from the General Hospital, 59 (12.4%) from the Institute for Emergency Medical Services, 60 (12.6%) from the Institute of Public Health, 62 (13.0%) from the Institute for Health Care of Women and Motherhood, 50 (10.5%)frompublicpharmacies and 31 (6.5%) from the Institute for Alcoholism and Substance Abuse.Among the surveyed women majority were nurses (51.women who are former smokersthe oldest (p=0.006).According to the current smoking status there was 49.9% smokers, 44.2% of non-smokers and only 5.9% former smokers (Table1).

TABLE 2 .
Social environment of women according to smoking status

TABLE 3 .
Working environment to women by smoking status

TABLE 4 .
Working environment to women by smoking status p*<0.005