Nurses and smoking: where does duty of care end?

1 March 2012

About one in seven nurses smoke. Should they know better? Quitting is easier said than done. FIONA CASSIE talks to smokefree nurse advocates and nurse smokers about the battle to quit. And shares some top tips and research for nurses wanting to quit.

Don’t go it alone: giving up an addiction isn’t easy

Nurses know better than most that smoking is harmful, and yet still nurses smoke – less now than the general population but at far higher rates than their doctor colleagues.

Why haven’t they given it up? Probably for the same reason why most people struggle to quit – nicotine is as an addictive a drug as heroin, cocaine, and alcohol. It just isn’t that easy.

In recent years, there has been a national push for nurses and other health professionals to encourage and support patients to quit, including making it a national health target. The government has raised tobacco tax by 30 per cent in the past 18 months, and the Maori Affairs Select Committee inquiry into the tobacco industry ended with a call for a smokefree New Zealand by 2025.

It has become a duty of care for nurses to promote tobacco control, leaving nurses who smoke feeling hypocritical.

If nurses are to be role models, the New Zealand Nurses Organisation’s kaiwhakahaere Kerri Nuku has argued, supportive programmes have to be offered to help them quit without feeling guilty about their addiction.

Compounding the issue, nurses who smoke are less likely to raise the topic of smoking and quitting with their patients.

Smokefree nurse advocates agree the answer is not to judge but understand and support smoking colleagues in their journey to quitting.

The fear of judgment makes many nurses avoid specialist quit services and try to go it alone, says Jennifer Percival, a UK nurse expert in quitting (see research story below). The unaided quit success rate is only four per cent. However, Percival says many smokers, nurses amongst them, think they should be able to quit by themselves as ‘after all, it’s only smoking’ or ‘God, anyone can just stop’.

“The truth is it’s an addiction and you can’t – and that’s what keeps people hooked in,” she says. “And you wouldn’t try to manage your diabetes on your own because you are a nurse and know a lot about it … you would go to a specialist.”

Employer backing needed

It is important for employers to encourage and support health professionals to be smokefree, says Carleine Receveur, the smokefree team leader at Hawke’s Bay District Health Board.

Receveur gave a presentation on supporting smokefree health professionals to last year’s Health of the Health Professional Conference on behalf of nurse advocacy body Smokefree Nurses Aotearoa/New Zealand.

She points out the obvious reasons for employers to promote quitting – the wellbeing of your staff. On average, each smoker cuts short their life by 15 years and one out of every two smokers will die as a direct result of their smoking.

Smoking also impacts on an organisation’s productivity and impacts on clients, as a smoking nurse may be less likely to raise the topic of quitting.Receveur again stresses that the message is not about judging but providing a supportive environment for quitting.What she and fellow Hawke’s Bay smokefree nurse Rebecca Missen have found is that campaigns aimed primarily at helping nurses support their patients quit indirectly help the nurse smokers themselves.

“It’s actually made them think about their own personal habits and addictions around tobacco and they have made the choices to change as well,” says Receveur.

Missen, the DHB’s smokefree project co-coordinator for mental health and addiction services, agrees and believes increased understanding of the addiction process is also a powerful tool to help people try quitting again.

“People acknowledge it’s often a journey and relapse actually isn’t due to their own failings,” Missen says.

Challenge for mental health services

Having a smokefree work environment also helps, and the last of the health services to go smokefree is mental health. Mental health and addiction service clients have much higher smoking rates than the national average – many using tobacco to ‘self-medicate’ – and so do the nurses that care for them (see smoking statistics sidebar).

Missen says history provides an added challenge for mental health nurses in going smokefree.

“They’ve worked in a culture where tobacco has been utilised as a tool to build rapport or reward behaviour and so forth,” she says. “So it’s quite an extreme change from historic practice.”

Two years ago, Hawke’s Bay became one of the first DHB’s to have their acute and community mental health services go smokefree.

“It would be pretty fair to say that it isn’t an easy smooth journey, and like any change process, you get resistance from some,” says Missen.

“I still hear of people going smokefree at work and that’s leading into their home life and then into 24/7 and they become smokefree.

Some are still persevering. “I hear over and over again of people trying again and again and again.”

Understanding nicotine addiction and withdrawal

Repeated attempts to quit are not unusual.Demystifying what happens to your body when you stop smoking and go through nicotine withdrawal is an important step, believes Percival, and may help you stop blaming your symptoms as side effects of nicotine replacement therapy (NRT).

“If you go cold turkey and take nothing, you are likely to get spots, coughs and cold, nightmares, constipation, mouth ulcers, a hacking cough … plus being really irritable and tense. All of those symptoms could be put down to NRT if you happened to start it the day you stop smoking,” says Percival.

Nicotine is addictive but not carcinogenic – it is the tar and carbon monoxide in tobacco smoke that does the harm to your health.

The side effects of NRT are most commonly from underdosing, says Percival, as the majority of people take too little rather than too much.

Percival stresses this is where the importance of an experienced quit counselor comes in. Someone who can you help you get the dosage right, help alleviate the symptoms, remind you of your goals, and support you through the tough times.


Nurses are seen as patient educators and role models, but that doesn’t make it any easier to for them to quit, it can actually make it tougher.

Jennifer Percival, the Royal College of Nursing’s tobacco policy advisor, was commissioned several years ago to find out why UK nurses smoked and why they didn’t use the quit smoking services available.

She found the main barrier was an underlying fear that as nurses they would be criticised or judged if they approached a quit service.

“I’m not going to talk to someone as they will have a go at me,” was the fear, says Percival.

British nurse smokers also told her that having a ‘fag break’ meant they actually got a break. As even during stressed or understaffed shifts, colleagues accepted you taking a break for a cigarette when nicotine withdrawal kicked in. In the same situation, non-smoking colleagues were often expected to put their tea or coffee break on hold until it was convenient.

The other misassumption, says Percival, was that cigarettes helped them cope with the stress and demands of nursing. The reality, however, is that nicotine addiction increases stress.

“Everyone who smokes feels unusually stressed towards the time when the nicotine in your blood system is dropping … and when you put nicotine back into your system, that stress goes away.” The smoker associates the stress with the situation rather than nicotine withdrawal, but actually, the “brilliant news” is that nurses who stop smoking report feeling less stressed, says Percival.

The majority of nurses interviewed had been smoking for as long as they had been nursing, and for some, smoking felt “part and parcel” of being a nurse, so giving it up felt like giving up part of who they were.

Percival also found that nurse smokers were often in denial about the risks of smoking even though they saw the impact on patients daily.

“I’ll stop before that happens to me – my patients are in my 60s, and I’m in my 40s – I’m not going to be like that,” was a not uncommon sentiment, says Percival.

The research was used to draw up a special National Health Service/RCN campaign targeting at supporting nurses to quit.

It including a glossy stop smoking guide just for nurses, a special “Quitline” number for nurses only, free nicotine replacement therapy for 12 weeks, paid-for NHS nurse quit support groups, and team rewards for successful quitters.

Regrettably, an NHS funding crisis saw the plug pulled at the last minute.

“I personally thought it was very shortsighted.”

Jennifer Percival will be in New Zealand for a series of free Smokefree Nurses Aotearoa workshops and seminars from April 4-19. For more information see


Kody’s story

I started smoking at the age of 15, and I’m now 32. The longest I have been smoke free was for two years (cold turkey) during and after my pregnancy with my third daughter. I tried giving up again just over a year ago (using Zyban) and lasted nine months. My husband gave up just prior to this and has remained smoke free. I currently smoke 30g of tobacco weekly and have my first cigarette within ten minutes of getting up in the morning. My home and car are smokefree. As a mum to three girls, I’m aware that my daughters (12, 10, and 6 years olds) look up to me, which is my primary reason for wanting to quit. I always tell myself that that should be enough. However remaining smoke free is a constant struggle. I enjoy my sport, and I have noticed more recently that my stamina is lacking and I have a slight wheeze on occasion when I inhale. My health overall is suffering. All members of my immediate family smoke or have smoked, and I don’t want that for my children or grandchildren. Being a positive role model for my daughters, being healthy, and living longer is what I want to achieve. As a community nurse, I feel I should be role-modeling good health practices, especially for the age group I work with (10–13 year olds). I am constantly aware that I am the face of “health” for clients and their families so I am often checking my surroundings before lighting up.

I’ve set a quit date of February 20. After my last attempt, I gained nearly ten kilograms, so I wanted to avoid that this time. I’ve set up a fitness programme and have been going to boxing three times a week religiously for about five weeks. I believe I’m addicted to boxing, which is fabulous. I’ve also signed up with our Aukati Kaipapa Crew, who will support me through this journey.

Kody Young, Taitamaraiki RN

Mike’s story

Mike started smoking as a 16-year-old as a teenage act of rebellion. When he started his psychiatric nurse training more than 20 years ago, smoking was the norm. “I was told at the start to always make sure I had a lighter with me. I get more response from clients by not smoking.”

He’s been attempting to quit smoking on and off for three years; he last lapsed in November after quitting for four months. Now he’s reached 50, he wants to make a real effort. Over his quitting attempts, he’s learnt how to use patches, what his triggers are, and the need for rewards for reinforcements. He also no longer smokes at work, “which is good”. He is also down to about 20 cigarettes every five days.

His aim was to give up in the New Year while on holiday with the support of NRT, Quitline, friends and family.

He started quitting on Jan 2 with patches, although he lapsed twice when out with friends and this quit attempt came to a halt when he went away camping for the weekend without his patches. He ended up buying a packet of tobacco and has continued to smoke since then.

“At the moment, I’m somewhat disappointed, and will try again but I have no set date yet.”

Mike Connolly Mental health clinical nurse specialist

Top quitting tips

  • Don’t go it alone – going cold turkey has only a 4% success rate.
  • Take a two-prong approach – using nicotine replacement therapy and counseling/behavioural support has the greatest success.
  • Contact Quitline or your local smoking cessation service to get practical help and advice
  • Understand possible nicotine withdrawal symptoms like mood swings, coughing, cravings and sleep disruption.
  • Use Nicotine Replacement Therapy (or other pharmacotherapy help) to help you manage symptoms along with new habits and coping strategies
  • Yes nicotine does suppress appetite, but on average a year after quitting people have only put on a small amount of weight and the risk of gaining a few pounds is much less harmful than smoking.
  • If you tried giving up before, think about what happened and what will help you cope better this time.
  • Plan ahead to help you cope with stressful situations.
  • Pick a quit date that will be stress-free, and stick to it.
  • Take it one day at a time, and congratulate yourself every day.
  • Pair up with someone else who wants to stop so you can support each other.
  • At first, avoid situations where you might be tempted to smoke.
  • Keep track of the money you’re saving – and treat yourself!
  • There’s no such thing as having ‘just one’ cigarette.
  • Think positive – you CAN do it!

Source: Jennifer Percival’s unreleased Give Yourself a Break: the step-by-step stop smoking guide for nurses.



Smokefree Nurses Aotearoa New Zealand

Advocacy group for nurses supporting people to quit smoking

Information on ABC smoking cessation training/being a Quit Card provider/research and policy on quitting smoking.


Phone quit counseling/Online Quit Coach tool/Quit blogs & other quit support

Access to nearly free nicotine patches, gum or lozenges - $3 for eight-week supply.

Smoking Cessation - ABC

Go to this site to access a 20-30 online education programme on ABC smoking cessation (under heading Helping people to stop smoking) so you can become a Quit Card provider of subsidised nicotine patches, gum or lozenges.

Auahi Kore/Smokefree Tool resources

Smokefree resources including interactive tools to calculate the cost of smoking and what smoking does to the body.

*All above links updated and accessed on January 19 2016



2006 Census results

• 14% of all nurses smoked (compared to 18% in 1996)

• 13% of female nurses (36% in 1976)

• 19% of male nurses (49% in 1976)

• 29% of mental health nurses smoked (50% in 1976)

• 22% of aged care nurses smoked

• 4% of male doctors and 3% of female doctors smoked (22% and 12% in 1972)

• 21% of general population smoked.

2006-2007 Nurse survey results

• 7% of the 371 nurses who responded to survey currently smoked

• 35% had smoked in the past and 58% said they had never smoked

• 88% of the smokers wanted to quit and nearly all had tried to quit in past

• 68% of nurse smokers expressed a need for help to quit smoking

• 82% agreed that nurses who smoked set a bad example to patients

• 72% thought patients were less likely to take smoking cessation advice from a nurse who smoked.

Sources: Smoking and Nurses in New Zealand, by Grace Wong et al, ASH-KAN Aotearoa 2007.

Low and declining cigarette smoking rates among doctors and nurses: 2006 New Zealand Census data, by Tom Edwards et al, NZMJ 2008

SMOKING: A drag on your budget

• $13.80 a pack of 20 cigarettes for most popular brand

• $31 for a 30g pack of loose tobacco

• A pack a day habit costs more than $4500 a year OR

• A tank of petrol a week OR A week’s rent every month

Source: Quitline press release December 31 2011