Smoking prevalence, attitudes towards tobacco and levels of stress among Spanish nursing students

Bachelor Thesis, 2005

30 Pages, Grade: 68 %


Table of contents



Tobacco prevalence among nursing students
Smoking attitudes among nursing students
Stress and nursing

Information sheet (Questionnaire 1)
Nicotine dependence
Attitudes statements (Questionnaire 2)
Attitudinal scale

Data analysis
Smoking prevalence and history
Nicotine dependence
Smoking beliefs
Is tobacco a drug?
Does tobacco help to alleviate stress?
Attitudinal statements
Attitudinal scale

Smoking prevalence
Smoking attitudes and beliefs.



I am very grateful to my supervisor, William Farnsworth, who has guided me throughout this project. I am also very appreciative to my personal tutor Jill Arnold for her help and support during the last three years. I would like also to thank all academic tutors (Virginia Eatough, Mark Griffiths, and Keith Laws) who have taught me throughout the course of the degree. And also to the rest of the academic and administrative staff.

Obviously I am very grateful to my family and friends for their support, with special mention to M.H. De la Sienra y de la Fuente.


The aim of this study was to investigate the student nurses’ attitudes, beliefs and personal behaviour in relation to tobacco issues and the nursing profession, and their levels of stress. A cross-sectional questionnaire survey was used. Year of study (first, second, and final year) and smoking status (smokers and non-smokers) were independent variables, while responses regarding tobacco behaviour, perceived stress as measured by the GHQ-12 (Goldberg, 1978) and by the PSQ (Levenstein et al, 1991), and different attitudes and beliefs questions were dependent variables. One hundred and sixty-one Spanish undergraduate nursing students (aged 18-42 years) were administered and returned the questionnaires. High prevalence of tobacco used was found. Levels of stress were similar for all years although smokers were found to have higher levels than non smokers. Misperception of information related to the effects of smoking on stress might be a tobacco maintenance factor.


Tobacco is responsible for at least 650,000 deaths each year in the European Union (Byrne, 2004) where its consumption is still widespread (Tessier, 1994). The European Community has considered tobacco as a major public health priority since 1985 (Byrne, 2004) and it has launched a series of regulations and recommendations over the years. Nonetheless the public health competence of the European Union is constrained, thus members should act according to their recommendations and have their own initiatives to succeed against tobacco (Joosens, Raw, Godfrey, 2004). Spain, which has been EU member since 1985, has a poor history of implementing laws against tobacco (Villalbí, 2003). Nonetheless the situation has changed over the recent years with new laws and strategies are in progress at national and regional level. The most ambitious approach is the “National Plan of Prevention and Control of Tobacco 2003-2007” which was launched, with the royal decree status in 2003 (B.O.E., 2003), and which hopefully will reduce the at least 56,000 deaths attributed to tobacco every year in Spain (Banegas, Díez Gañan, Rodríguez-Artalejo, González Enríquez, Graciani, & Villar, 2001). The authors of this plan explicitly expressed concerns regarding the high prevalence of smoking amongst healthcare professionals (Saiz Martínez-Acitores, Rubio Colavida, Espiga López, Alonso de la Iglesia, Blanco Aguilar, Cortés Mancha, Cabrera Ortega, Pont Martínez, Saavedra Rodríguez, & Toledo Pallarés, 2003).

Health care professionals, being nurses the largest group amongst them, play an important role in the prevention of smoking (see Salvador Llivina, 1990). Moreover nurses are seen as role models and health educators by the general population and by themselves (Gorin, 2001). Thus their degree of credibility can be undermined if they do not accomplish their expected healthy image (Clarke, 1991). However, amongst nurses it has been found that the prevalence of tobacco smoking is similar, or even higher, to that of the general population (Fernández Ruiz & Sánchez Bayle, 2003; Rowe & Macleod Clark, 2000; Heras Tébar, García Sanchón, Hernández López, Ballestín, & Nebot, 1997; Adriansee, Van Reek, Zandbelt, & Evers, 1991).

Student nurses, as future professionals, are an important group to be examined as they are in a formative period which is critical for establishing their attitudes and beliefs towards nursing and health issues (Gorin, 2001).

Tobacco prevalence among nursing students

Investigations of smoking prevalence among nursing students are relatively few and only recent studies can be taken into consideration as trends of smoking are likely to change rapidly in those countries devoted to reducing smoking rates (Melani, Verponziani, Boccoli, Federici, & Sestini, 2001). Moreover it is not advisable to compare the prevalence of tobacco use between different countries (WHO, 2002), thus the following data is contrasted against the levels of the country of the study. In addition many studies are fraught with methodological flaws such as lack of definition of what is considered to be a “smoker” and lack of information about the response rate (Rowe & Macleod Clark, 2000).

Recent studies which have overcome those methodology problems have shown a discrepancy of results regarding smoking rates for nursing students; while some of them have found that smoking among nursing students has increased over the years (Sejr & Osler, 2002) or even during the nursing training program (Boccoli, Federici, Trianni, & Melani, 1997), others have, conversely, reported that it is decreasing (Melani et al., 2001; Casas Martínez & Sánchez Bayle, 2004). Nevertheless what appears to be consistent across developed countries is that nursing students follow or exceed their national age cohort trend for smoking behaviour (Clark, McCann, Rowe, & Lazenbatt, 2004; Chalmers, Seguire, & Brown, 2002; Melani et al., 2001; Ohida, Kamal, Takemura, Sone, Minowa, & Nozaki, 2001; Boccoli et al., 1997; Sejr & Osler, 2002; Gorin, 2001).

Spain is not an exception regarding this trend. The downwards trend appreciated over the years in the prevalence of tobacco use among the general population is similar to the downwards pattern observed in studies focused on nursing students. For example in 1986, Velasco, Alvárez, & Queipo (1986) reported that smoking prevalence among nursing students was situated at 55.3 and 45.6 per cent for males and females respectively, while in 1987 the prevalence of tobacco use, among Spaniards in the cohort of 16 to 24 years, was estimated by the Department of Health at 54.5% and 49.0% for males and females respectively (M.S.C., 1989). Approximately 10 years later Heras Tébar et al. (1997) reported that the prevalence of tobacco use among nursing students was of 44.0% for males and 37.9% for females. In that year the official figures for the general population were estimated at 45.7% and 42.2% -males and females respectively- in the 15 to 29 years cohort (INJUVE, 2001). Finally recent studies focused on nursing students have reported that 37.34% of nursing students are smokers (Casas Martínez & Sánchez Bayle, 2004). For the general population the figures in the year 2001 were established at 40.8% and 42.7% for males and females respectively in the 16 to 24 years cohort (MEC, 2001).

Smoking attitudes among nursing students

Although nurses have the inherent responsibility to promote health and raise awareness of hazards of tobacco use, there is conflicting evidence regarding these matters. In Spain, for example, Heras Tébar et al. (1997) reported several statistical differences between smokers and non-smokers. For example, 10.6% of smoking nursing students thought tobacco was not a drug while non-smokers decreased that percentage to 3.6%. When asked if tobacco was harmful for the health 97.1% of non- smokers agreed, while only 91.1% of smokers did the same. However, other statements were not statistically different. For example, 88.8% would give information against tobacco if the patient has symptoms, and 86.5% would give information against tobacco if the patient raise the question. More recently, Casas Martínez & Sánchez Bayle (2004) has reported that 93.68% of nursing students thought it would be appropriate to give advice on stopping smoking if the patient was a smoker, however 81.36% of smokers against 96.94% of non smokers (statistically different) thought it should not be allowed to smoke in public premises.

Elsewhere, an Australian study revealed that only about 50% of nurses thought that helping patients to stop smoking was part of their duty. Differences in responses were statistically between smokers and non smokers. For example, the latter group was more likely to state it was definitely part of their duty (Feeney, Kelly, Griffin, & Young, 1997, cited in Clark et al., 2004). In Italy, it was found that only 38% of nursing students were thinking of giving advice against smoking in the future, and 38.5% believed that advising about tobacco hazards was not a substantial part of their role as a nurse (Melani, Verponziani, Boccoli, Trianni, Federici, Amerini, Vichi, & Sestini, 2000).

Stress and nursing

One reason commonly put forward to explain the high prevalence of smoking amongst nurses and student nurses is stress (see Padula, 1992; Elkind, 1988).

The nursing profession is acknowledged to be a stressful occupation (Hillhouse & Adler, 1997; McGrath, Reid, & Boore, 2003). Research suggests that nursing students are also affected by occupational stress (Kleehammer, Hart, & Keck, 1990; Wheeler & Riding, 1994). In fact, clinical and learning environments are potentially stressful (Cox, 1993, cited in Tully, 2004), and nursing students are usually involved in both environments. Stressors found over the years regarding the clinical practice embrace issues such as dealing with death and dying (Knight & Field, 1981; Birch, 1975, cited in Lindop, 1999) to changing wards (Jack, 1992). Examinations and academic workload were some of the stressors detected in the learning environment (Lindop, 1991, cited in Lindop 1999). Moreover several personal problems and interface worries need to be added as potential stressors (Jones & Johnston, 1999).

Conflicting results appear when trying to identify which stage of the nursing program is more stressful. Some authors argued that those students enrolled in the first and last year of the program have higher levels of stress (Birch, 1975; Parkes, 1985; Lindop 1991, all cited in Lindop 1999). Others have identified that stress levels increase as students progress through their training (Lindop, 1996, cited in Lindop, 1999). In addition, other investigators have concluded that the most stressful stage is the initial period of clinical training (Admi, 1997; Jones and Johnston, 1997; Martyn, 1997).

Lazarus & Folkman (1984) put forward that “psychological stress is a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 19). Lazarus & Folkman (1984) argued that stress arises when external and/or internal demands overwhelm the individual. That is, when the situation has been appraised as taxing as he/she lacks of resources to overcome it. As consequence his/her well being may become affected. Nonetheless it is individual perception that assesses a situation as stressful; therefore stressors are subjective and are unique for each individual.

Lazarus and Folkamn (1984, p.141) defined coping as “constantly changing cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”. Two broad methods of coping with stress are differentiated within in this model; problem and emotion-focused coping. The former one is directed to defining the problem, seeking alternative solutions, weighing, evaluating costs and befits of alternatives and action, in other words, it is related to managing or changing the situation causing the distress. The latter “is directed at regulating emotional response to the problem” (Lazarus & Folkman, 1984, p. 150). Emotional-focused coping can include the use of defensive mechanisms such as denial or crying, or even symptom directed as caffeine, alcohol and nicotine intake. The latter group is known as maladaptative coping strategies, and it has been reported to be adopted by nurses and nursing students (Robinson & Lewis, 1990; Pelkonen & Kankkunen, 2000).


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Smoking prevalence, attitudes towards tobacco and levels of stress among Spanish nursing students
Nottingham Trent University
68 %
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smoking, spanish
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Marcos Alonso Rodriguez (Author), 2005, Smoking prevalence, attitudes towards tobacco and levels of stress among Spanish nursing students, Munich, GRIN Verlag,


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