- Email: [email protected]
Nurses trying to quit smoking using the Internet
Nurses trying to quit smoking using the Internet Linda Sarna, DNSc, FAAN Stella Bialous, MSN, DrPH Mary Ellen Wewers, RN, MPH, PhD Erika Sivarajan Froelicher, RN, MA, PhD Marjorie J. Wells, RN, PhD Jenny Kotlerman, MS David Elashoff, PhD
ing quit attempts. Quitting was influenced by workplace factors.
Nurses QuitNet, an Internet-based smoking cessation program, was created to support nurses’ quit attempts. The purposes of this study were to evaluate quit attempts at 3, 6, and 12 months after the use of the program and to determine differences in demographic, professional, and smoking characteristics by smoking status. Differences in the use of quit methods, barriers, and facilitators to quitting also were assessed. Data among 246 smokers who responded to at least 1 follow-up email at 3, 6, or 12 months after registration were analyzed. Quit rates among respondents were 43% (3 months), 45% (6 months), and 53% (12 months). Total time on the website was significantly higher for those who quit. Barriers to quitting included lack of support from colleagues, stress, lack of cessation services, and fear of not getting a work-break. Facilitators included working in a smoke-free facility, support from colleagues, and workplace cessation services. The use of Nurses QuitNet demonstrated promise in support-
S
moking among nurses has been recognized as a serious concern affecting the profession since the 1970’s, when female registered nurses (RNs) smoked at a higher rate (38.9%) than women in the US population (32.0%) and at a substantially higher rate than physicians (21%).1 According to 2003 data from the Tobacco Use Supplement of the Current Population Survey,2 smoking among RNs has declined to 11.9% but remains markedly higher than that of physicians (1%).3 Nurses who smoke struggle with quitting,4 and their smoking influences workplace relationships.5 However, there are limited long-term prospective studies examining nurses’ quitting behaviors.6 Smoking is both a matter of personal health and a public health concern for healthcare providers; providers who smoke are less likely to offer cessation interventions for patients who smoke and more likely to have negative attitudes about tobacco control.7-10 Tobacco dependence is not just a bad ‘‘habit’’ or lifestyle ‘‘choice,’’ it is a chronic relapsing condition that may require repeated interventions. The US Public Health Service’s Clinical Practice Guideline Treating Tobacco Dependence: 2008 Update11 (Guideline), similar to the previous Guideline12 which was used to guide this study, recommends the use of a combination of behavioral support and pharmacotherapy as effective treatment which can double or triple the odds of successful quitting. Few smokers use evidence-based programs to support their quit attempts. The most common strategy used for quitting continues to be ‘‘cold turkey,’’ or no help, which results in a < 5% abstinence rate 1 year after the cessation attempt.11
Linda Sarna, DNSc, FAAN, is a Professor, School of Nursing, University of California, Los Angeles. Stella Bialous, MSN, DrPH, is President, Tobacco Policy International, San Francisco, California. Mary Ellen Wewers, RN, MPH, PhD, is Professor and Associate Dean for Research, The Ohio State College of Public Health, Columbus, OH. Erika Sivarajan Froelicher, RN, MA, PhD, is a Professor, Department of Physiological Nursing, School of Nursing & Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco. Marjorie J. Wells, RN, PhD, is Project Director, School of Nursing, University of California, Los Angeles. Jenny Kotlerman, MS, is Principal Statistician, David Geffen School of Medicine, University of California, Los Angeles. David Elashoff, PhD, is an Associate Professor, David Geffen School of Medicine, University of California, Los Angeles. Corresponding author: Dr. Linda Sarna, University of California, School of Nursing, 700 Tiverton Ave, Box 956918, Los Angeles, CA 90095. E-mail: [email protected]
INTERNET-BASED TOBACCO DEPENDENCE TREATMENT
Nurs Outlook 2009;57:246-256. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.03.002
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Evidence-based tobacco dependence treatment programs delivered through the Internet provide an opportunity to reach a large population of smokers at all 5
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hours. Focus group responses of nurses who were current and former smokers also supported the use of programs that would have flexible hours, ensure anonymity, and be low cost.4 QuitNet, one of the top rated Internet sites for smoking cessation with interactive capabilities for support,13,14 was selected to provide the cessation assistance for nurses in this study.13 Although Internet smoking cessation programs were not specifically recommended by the Guideline,11,12 consistent with limited research data, the Guideline did recommend further study of these innovative strategies to provide problem-solving skills and support.
The Creation of Nurses QuitNet The Tobacco Free Nurses (TFN) initiative, in partnership with QuitNet, created the nurse-only Nurses QuitNet website.15,16 This website was designed to help nurses quit and was the first national cessation program targeted at nurses who smoke. The focus of this article is the analysis of the outcomes of this program in helping nurses quit smoking. The overarching conceptual framework for this study was based upon the evidence of the addictiveness of nicotine and the variables (quit methods, nicotine dependence) projected to facilitate or to create barriers to quit attempts in general and quit attempts among those using the Internet. In addition to the use of the Nurses QuitNet program, the use of quit methods recommended by the Guideline12 (ie, behavioral counseling, along with the use of FDA-approved pharmacotherapy) was viewed as facilitating smoking cessation. The severity of nicotine dependence (as defined by shorter time to first cigarette in the morning and greater number of cigarettes smoked per day [CPD]) was considered as a barrier to quitting smoking. Based on previous studies, nurses’ perceived barriers and facilitators to smoking cessation in the workplace were hypothesized as influencing quit attempts among nurses.4,5 It was anticipated that smokers who experienced greater barriers and less support in the workplace would be less likely to quit. Demographic factors such as age, sex, race/ethnicity, and education were included in the framework as they may be related to the use of a Web-based cessation program and quit efforts in general.12 Smoking among family members was included as a variable influencing smoking status, as quitting is more challenging if there are other smokers in the household.12 Finally, willingness to make a quit attempt is recommended in appraisals of smokers’ interest in smoking cessation.12 Although the transtheoretical model for ‘‘stages of change’’17 was not included in the conceptual underpinnings of the study, data describing interest in quitting were collected. Purpose The purposes of this prospective study were: (1) to evaluate quit rates at 3, 6, and 12 months following the use of an evidence-based Internet smoking cessation proS
gram; (2) to determine the differences in demographic characteristics (age, race/ethnicity, household members who smoke), professional characteristics (RN, licensed practical nurse [LPN], or nursing student; education, clinical unit), and smoking characteristics (number of quit attempts, longest period without smoking, CPD) by smoking status (ie, smoking, not smoking); (3) to describe differences in the use of quit strategies (pharmacotherapy, counseling/skills training, other), including Nurses QuitNet, by smoking status at each time point; and (4) to identify perceived workplace barriers and facilitators to quitting.
METHODS Study Design A 12-month prospective study design was used to determine the use and impact of an Internet-based smoking cessation program geared for nurses on self-reported quit rates at 3, 6 and 12 months. Participants The sample included nurses (RNs, LPNs, and student nurses) who registered on Nurses QuitNet for assistance with smoking cessation. In the first 30 months, 1790 nurses registered online to receive help with smoking cessation. For inclusion in this analysis, nurse-registrants had to self-report as a current smoker at baseline and have at least 1 point of follow-up data: at 3, 6, or 12 months during January 2004–May 2006 (n ¼ 246). Excluded from this analysis were nurses who were non-smokers at registration, or who did not respond to the follow-up surveys (n ¼ 1544), or who were registered but were not interested in receiving support for smoking cessation (ie, researchers and others interested in reading more about the Web-based quit program). Non-respondents were not significantly different from respondents on demographic (age, sex, education, or race/ethnicity) or baseline smoking characteristics (CPD, time to first cigarette, number of quit attempts). A description of registrants is available elsewhere.18 Participants were not actively recruited for this prospective study; all registrants to Nurses QuitNet had the option to receive an electronic follow-up survey. Nurse registrants could select whether or not to complete the follow-up survey or answer any questions. Informed consent for participation was not specifically required; however, as part of the registration process all participants provided consent to receive follow-up emails and were informed that their responses may be used by researchers for scientific purposes. Encoded data (to protect individual identity) were extracted from the Nurses QuitNet program which allows for matching of responses for each participant at different points over time. This study was approved for exemption by the Office for Protection of Research Subjects, Institutional Review Board, University of California Los
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Angeles. All data were anonymous and are reported in the aggregate.
Quit methods. At each follow-up, the number of methods reported was calculated (use of no cessation method, use of 1 type of cessation method, use of R 2 cessation methods). Additionally, the type of method(s) used also was assessed and included those recommended by the Guideline12 and those not recommended. The recommended methods include use of counseling and support (ie, telephone counseling, other forms of counseling, and health provider support) and use of pharmacotherapy (nicotine gum, nicotine lozenge, nicotine patch, nicotine inhaler, nicotine nasal spray, buproprion). The use of Nurses QuitNet was considered as part of counseling and support. Cessation methods not recommended by the Guideline12 included acupuncture, biofeedback, hypnosis, and other medications. Respondents could select more than one method. Web traffic on Nurses QuitNet was monitored. This included total time online (reflected by the cumulative number of logins and average minutes online), total pages viewed, and total number of messages posted on the Nurses QuitNet forums. The number of log-ins was cumulative after the initial registration. Barriers and facilitators. Included in the 3-, 6-, and 12-month follow-up surveys were investigator-developed questions about the presence of workplace barriers to quitting and facilitators that supported quit efforts based upon previous studies.4,5,10 Barriers to quitting included: fear of missing work breaks, lack of support from colleagues, stress, reports of withdrawal symptoms, colleagues/friends who smoke, smoking in the nurses’ lounge, and lack of workplace cessation services. Workplace facilitators to support quitting included: working in a smoke-free facility, support from colleagues, absence of withdrawal symptoms, friends/colleagues who don’t smoke, wanting to be a role model, workplace cessation services, and having work breaks.
Study Procedures The Nurses QuitNet program, housed within the QuitNet website, was a web-based cessation program with services directly provided by QuitNet. In order to register to receive assistance with smoking cessation, all nurse participants were required to either enter the TFN website (www.tobaccofreenurses.org) directly to link with Nurses QuitNet or to enter through the American Nurses’ Association/American Nurses’ Foundation website, a TFN partner, to access the link to Nurses QuitNet. Once on the website, nurses interested in quitting completed a registration form to receive the evidence-based ‘‘Premium Package’’ of services, at no cost, including options for one-to-one counseling, skills to enhance cessation success, and access to medication information. This package of services was worth about $100. At the time of registration, smokers were asked to set a quit date. At 3, 6, and 12 months after registration, QuitNet sent an automatic email to all registrants who consented to receive email follow-ups with questions about their quit status. There were no incentives offered to return the follow-up online questionnaire and no reminders to encourage participants to complete the follow-up. Measures Demographic, professional, and smoking characteristics. The standard QuitNet registration instrument included questions about demographics (age, sex, race/ethnicity, education, employment status). At the 3-month follow-up Nurses QuitNet participants received 3 additional questions about professional characteristics (RN, LPN, nursing student), workplace clinical setting (acute, outpatient/primary care, psychiatric, other), and the presence of household members who smoke. Information about smoking characteristics at registration included questions about CPD (0, 1–9, 10–20, > 20 CPD), time to first cigarette after waking (< 5 minutes, 5–30 minutes, 31–60 minutes, > 60 minutes), and number of quit attempts in the past year. (A pack of cigarettes includes 20 cigarettes.) Questions regarding readiness to quit, also known as ‘‘stages of change’’18 (ie, precontemplation [not thinking about quitting], contemplation [thinking about quitting], preparation [getting ready to quit], action [quitting], and maintenance [avoiding relapse]) were assessed at baseline and at each follow-up period. Quit rates. For this study, 7-day point prevalence (smoking within the previous 7 days) was used to define current smokers (a ‘‘yes’’ response to ‘‘Have you smoked, even a puff, in the past seven days?’’) and to define those who had quit (ie, not smoking in the past 7 days) at each time period. Data on any quit attempts also were collected. 248
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Statistical Analysis Descriptive statistics were used to profile the sample’s demographic, professional, and smoking characteristics at baseline and at each time period. In this analysis, respondents were only required to complete 1 of the 3 follow-up questionnaires. A flow chart was created to describe smoking, quitting, and missing data at each point in time during the course of the 12-month study. A comparison of demographic and professional characteristics (Figure 1) of respondents and non-respondents to any of the follow-up surveys was conducted using t-tests and x2 tests as appropriate. For this study, quit rates using 7-day point prevalence rates were determined from respondents at each followup period, similar to a previous study reporting quit rates of smokers using QuitNet at 3 months.13 Quit rates were calculated for each of the follow-up periods using data from respondents only, as well as with a traditional intent-to-treat (ITT) analysis, labeling all non-respondents as smokers. O
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Baseline N = 246
246 smokers
3 Months N = 153
S 88
6 Months N = 116
12 Months N = 99
S 20
Q 65
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Q 35
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S = Smoking, Q = Quit, M = Missing
Figure 1. Smoking, quitting, and missing data patterns at 3, 6, and 12 months.
Comparisons of demographic, professional, and smoking characteristics were made at each time point by smoking status (smoking, not smoking) using x2 or t-tests as appropriate. The proportion of those who made quit attempts in the year prior to enrollment in Nurses QuitNet were compared with the proportion of those who made quit attempts at each of the followup periods. Because of the small sample of ‘‘non-White’’ participants, race was dichotomized as ‘‘White/nonWhite’’ for analysis. Additionally, level of education was collapsed to 3 categories so that those with less than a baccalaureate degree education, those with a baccalaureate degree, and those with graduate education could be compared. Significant differences in quit methods were examined by smoking status (smoking, not smoking) at each follow-up period and were determined using t-tests or x2 tests as appropriate for continuous and categorical data. After examination of the distribution of means and medians of the activity on Nurses QuitNet, non-parametric statistics (Wilcoxon 2 sample test) were used to examine utilization at each time period by smoking status. Differences in the perception of barriers and facilitators to quitting by smoking status (smoking, not smoking) also were compared using x2. Multiple logistic regressions (Odds Ratio [OR] with 95% confidence intervals [CI]) were used to compare characteristics of those who quit at any time during the study to characteristics of those who did not make a quit attempt. These characteristics include demographics (age, gender, race [White vs non-White], education [< baccalaureate degree vs graduate education]), smoking characteristics at baseline (CPD [1–9 vs 20þ, 10–19 vs 20þ]), time to first cigarette (< 5 minutes vs R 60 minutes, 6–30 minutes vs R 60 minutes, 31–60 minutes vs R 60 minutes), and prior quit attempts (0 vs R 6, 1 vs R 6, 2–5 vs R 6). All analyses were conducted using SAS 9.1.3. Level of significance was set at P < .05. S
FINDINGS Sample Characteristics and Differences at 3, 6, and 12 months The sample demographics and professional characteristics by smoking status at baseline and at each follow-up period are displayed in Table 1. The response rates of the 1790 nurses who registered with the program and completed follow-up surveys at 3, 6, and 12 months were 9%, 7%, and 6%, respectively. The typical respondent was female, age 45, White, had an RN license, a baccalaureate degree or higher, and worked fulltime. A plurality worked in an acute-care setting. Smoking characteristics varied. At registration, the majority of respondents smoked 10–20 CPD (n ¼ 166, 67%), and 23% (n ¼ 56) smoked > 20 CPD (more than a pack of cigarettes per day). A minority (n ¼ 24, 10%) smoked % 9 CPD. A majority (n ¼ 162, 69%) reported smoking the first cigarette within % 30 minutes after waking. Most (55%) had made R 2 quit attempts in the year prior to enrollment in Nurses QuitNet, including 9% who had made R 5 attempts. More than a quarter (n ¼ 66, 27%) reported not making an attempt to stop smoking in the previous year. Differences in Quit Rates As seen in Table 1, the percentages of people quitting at each time point varied. The majority of respondents reported smoking at 3 and 6 months. At 12 months, the majority of respondents reported not smoking, although the absolute number of respondents who quit did not increase. Using ITT, with all non-respondents viewed as smokers, the quit rates were 4% at 3 months, 3% at 6 months, and 3% at 12 months. The majority of respondents made quit attempts at each time period (3 months [67.3%], 6 months [55.2%], 12 months [54.6%]). There were significant differences in making a quit attempt during the program among those who made a quit attempt in the year prior to enrolling in Nurses QuitNet versus those who did not make an attempt to quit. Within the first
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3 months N [ 153 Smoking N [ 88 (58%)
Not Smoking N [ 65 (43%)
N (%)
N (%)
N (%)
227 (92)
82 (93) 45.2 11
59 (91) 45.4 9.8
213 (93) 17 (7)
74 (94) 5 (6)
58 (94) 4 (6)
121 (82) 10 (7) 17 (11)
68 (80) 5 (6) 12 (14)
53 (84) 5 (8) 5 (8)
190 (82)
60 (76)
56 (89)
68 (46) 10 (7) 12 (8) 59 (39)
41 (48) 5 (6) 9 (11) 30 (35)
27 (42) 5 (8) 3 (5) 29 (45)
103 (69)
60 (70)
43 (68)
N
Baseline N [ 246
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Sample Characteristics
6 months N [ 116 Not Smoking N [ 52 (45%)
P
N (%)
N (%)
.58 .93 .98
62 (97) 48 12.6
44 (85) 43.1 9.4
55 (95) 3 (5)
48 (94) 3 (6)
19 (86) 2 (9) 1 (4)
30 (83) 2 (6) 4 (11)
52 (88)
41 (80)
Smoking N [ 47 (48%)
Not Smoking N [ 52 (53%)
P
N (%)
N (%)
P
.02 .02 .87
46 (98) 47.4 10
47 (90) 45.7 9.1
.12 .38 .84
38 (86) 6 (14)
43 (88) 6 (12)
17 (94) 1 (6) 0 (0)
23 (85) 2 (7) 2 (7)
39 (89)
41 (84)
5
Smoking N [ 64 (55%)
12 months N [ 99
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Demographics Gender (Female) Age (Mean, SD) Ethnicity White Non-White Professional Characteristics RN LPN Student Nurse Education Baccalaureate or more Type of unit Acute care unit Outpatient** Psychiatric unit Other Employment status Full time
.47
.62
.06
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Table 1. Demographic and Professional Characteristics of Nurses QuitNet Registrants with Follow-up Data by Quit Status*
.47
.28
.49
.46
.80
*P values calculated using t-test or c2 test. **Outpatient/primary care/long-term care/home care.
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Table 2. Differences in the Type and Number of Methods Used to Quit by Respondents at 3, 6, and 12 Months by Smoking Status 3 months
6 months
Not Smoking smoking N (%)
N (%)
Methods used to quit No help (cold turkey) 15 (17) 0 (0) Pharmacotherapy only 5 (6) 3 (5) Counseling/support only 23 (26) 16 (25) Pharmacotherapy & 45 (51) 46 (71) counseling/support Types of pharmacotherapy 50 (57) 49 (75) Nicotine gum 17 (19) 14 (22) Nicotine lozenge 8 (9) 3 (5) Nicotine patch 26 (30) 22 (34) Nicotine inhaler 2 (2) 4 (6) Nicotine nasal spray 0 (0) 1 (2) Zyban/wellbutrin/bupropion 19 (22) 26 (40) Types of counseling/support Nurses QuitNet website 64 (73) 58 (89) Telephone quitline 0 (0) 2 (3) Counseling 7 (8) 5 (11) Advice from a healthcare 32 (36) 27 (42) provider Non-approved methods 15 (17) 15 (23) (acupuncture, biofeedback, hypnosis, other Internet site) Number of help methods 2.3 1.7 2.9 1.3 (mean, SD) None 15 (17) 0 (0) One help method 19 (22) 11 (17) Two or more help methods 54 (61) 54 (83)
12 months
Not Smoking smoking
Not Smoking smoking
P
N (%)
N (%)
P
N (%)
N (%)
P
.0005 .77 .83 .01
19 (30) 7 (11) 12 (19) 26 (41)
7 (13) 2 (4) 23 (44) 20 (38)
.04 .16 .003 .81
13 (28) 6 (13) 10 (21) 18 (38)
12 (23) 1 (2) 18 (35) 21 (40)
.60 .04 .14 .83
.004 .74 .29 .57 .22 .24 .01
33 (52) 10 (16) 4 (6) 14 (22) 5 (8) 0 (0) 15 (23)
22 (42) 5 (10) 2 (4) 9 (17) 2 (4) 1 (2) 12 (23)
.71 .34 .56 .54 .37 .27 .96
24 (51) 10 (21) 4 (9) 13 (28) 0 (0) 0 (0) 12 (26)
22 (42) 8 (15) 4 (8) 11 (21) 2 (4) 0 (0) 12 (23)
.14 .44 .88 .45 .17
.01 .10 .55 .52
34 (53) 3 (5) 2 (5) 18 (28)
41 (79) 2 (4) 2 (6) 13 (25)
.00 .82 .79 .71
23 (49) 1 (2) 3 (6) 14 (30)
35 (67) 1 (2) 1 (8) 9 (17)
.06 .94 .80 .14
.35
12 (19)
6 (12)
.29
5 (11)
5 (10)
.87
1.9 1.8 1.9 1.5 .88
.02 .0009
16 (25) 17 (27) 21 (48)
6 (12) 19 (37) 27 (52)
.15
.78
1.9 1.5 1.8 1.5 .68 13 (28) 6 (13) 28 (60)
10 (19) 17 (33) 25 (48)
.06
P values calculated using c2 test.
3 months, 71.9% (n ¼ 82) of those who had made an attempt to quit in the prior year made another quit attempt as compared to 53.9% (n ¼ 21) of those who did not make such an attempt, P <.038. These findings were similar at 6 months (n ¼ 49 [61.3%] vs n ¼ 15 [41.7%], P ¼.05, and at 12 months (n ¼ 43 [61.4%] vs n ¼ 11 [37.9%], P ¼.03). At 3 months, the only characteristic significantly different between smokers and those who quit was having a household member who smoked. Significantly more smokers (n ¼ 37, 44%) as compared to those who quit (n ¼ 10, 16%) had a household member who smoked (P ¼ .0004). Smoking among household members was only assessed at this follow-up period.
Differences in Use of Nurses QuitNet and Other Quit Strategies Differences in methods used to quit at each time period are displayed in Table 2. At 3 months, those who S
quit smoking used significantly more methods to quit than those who reported continuing to smoke. At 3 and 6 months, nurses who quit were significantly more likely to have used some form of help and used a combination of pharmacotherapy and behavioral counseling than nurses who continued to smoke. At 3 months, more frequent use of pharmacotherapy, specifically buproprion, was reported among those who quit. At 12 months, those who quit reported less use of pharmacotherapy only. The use of only counseling/support was higher in the quit group, including the use of the Nurses QuitNet site at 6 months. There were no statistically significant differences by smoking status in the proportion of participants in the different ‘‘stages of change’’ at each time point; the distribution of participants by stages did not significantly change over time. The majority of smokers were in the ‘‘contemplation’’ or ‘‘preparation’’ stage (ie, for
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Table 3. Nurses QuitNet Site Utilization by Respondents at 3, 6, and 12 Months by Smoking Status 3 months
Site utilization indicators Total minutes online
Not Smoking: Smoking: Mean Mean (SD) (SD) Median Median
Total pages viewed
P
132 (230) 965 (2324) .0001 41 6 (11)
Total number of logins Average minutes online
6 months
2 19 (18)
98 56 (144) .0001 11 17 (12)
.52
Smoking: Mean (SD) Median
Not Smoking: Mean (SD) Median
191 (427)
1617 (4502) .002
62 9.9 (24.3)
159 62 66.6 (152) .0001 13.9 (35.3)
3 21.1 (19.5)
69 1 (2)
223 46 (174) .02
3 16.5 (12.5)
1 (3)
1 (2)
.18
5 7
N
U M B E R
5
N
P
7408 (41122) .01 166 166.4 (573)
.004
18 19.9 (3)
.82
13 4180 (15460) .006
76 285 3.62 (16.91) 155.19 (811)
.20
0.82 (3.54)
0.70 (2.73)
.19
U R S I N G
1.79 (4)
.16
1.54 (3)
P ¼ .03). There were no other significant differences in demographics or smoking characteristics among those who made at least one quit attempt and those who did not at 12 months.
Barriers and Facilitators Differences between perceived barriers and facilitators to quitting between smokers and those who quit at each time period are displayed in Table 5. There are differences in factors related to smoking status at each time period. Comparing smokers with non-smokers, a higher frequency of smokers reported fears of not getting work breaks (at 12 months), lack of support from colleagues (at 6 months), and stress (at 6 months). Smokers also reported the presence of withdrawal symptoms (at 12 months), smoking in a lounge (at 3 months), and lack of workplace cessation programs (6 months) as barriers. A higher percentage of those who quit reported working in a smoke-free facility at 6 months, but significantly fewer quitters as compared to smokers described working in such a facility at 3 months. A significantly higher percentage of those who quit reported support from colleagues (6 months, trend at 3 months), absence of withdrawal symptoms (3 and 12 months), having nonsmoking friends and colleagues, and having available workplace cessation services.
Factors Associated with Making a Quit Attempt In multiple logistic regressions, comparing those who made at least one quit attempt with those who made no quit attempt during the 12-month period (Table 4), female nurses were found to be significantly less likely to have made a quit attempt than were male nurses (OR ¼ .23, 95% CI .07, 0.76, P ¼ .02). Those who smoked 10–19 CPD were more than twice as likely to have made a quit attempt than those who smoked R 20 cigarettes per day (OR ¼ 2.43, 95% CI 1.07, 5.52, O L U M E
.99
243 (584)
Not Smoking: Mean (SD) Median
84 251 2.64 (14.44) 126.1 (478) .04
smokers, 96%, 92%, 94%, at 3, 6, and 12 months, respectively). Those who quit had a similar proportion of participants in these stages: (94% at 3 months, 100% at 6 months, 94% at 12 months). Those who quit reported more frequent use of Nurses QuitNet (Table 2) than those who smoked at the 3- and 6-month follow-up period, with a trend toward increased quitting at 12 months. Utilization of the website (Table 3) demonstrated increased activity (ie, total time online, total number of logins, total pages viewed, and messages posted to the Nurses QuitNet forums) by those who quit at all time periods as compared to those who did not quit.
V
17 20.1 (15)
P
Smoking: Mean (SD) Median
15 13 16 15 12 211 (428) 1440 (3668) .0001 314.9 (744.8) 2443.6 (7541) .0005 375.1 (929.6)
Total messages posted on Nurses QuitNet forums Total # of buddies
252
12 months
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Table 4. Multiple Logistic Regression Analyses Among All Respondents with any Follow-up: Any Quit Attempt vs. No Quit Attempt (n ¼ 246) Sex Race/Ethnicity Education Cigarettes smoked per day Minutes to first cigarette
Quit attempts in the past year
Female vs. Male White vs. non-White < Baccalaureate vs. Graduate degree Baccalaureate vs. Graduate degree 1-9 vs. 20þ 10-19 vs. 20þ < 5 vs. 60þ 6-30 vs. 60þ 31- 60 vs. 60þ 0 vs. 6þ 1 vs. 6þ 2- 5 vs. 6þ
Age
OR (95% CI)
P
0.23 (0.07,0.76) 1.15 (0.41,3.28) 1.33 (0.49,3.67) 1.54 (0.65,3.66) 1.16 (0.31,4.38) 2.43 (1.07,5.52) 0.39 (0.13,1.14) 0.68 (0.26,1.77) 0.69 (0.25,1.89) 1.30 (0.42,4.02) 0.73 (0.22,2.40) 1.01 (0.35,2.92) 0.99 (0.97,1.02)
.02 .79 .58 .33 .82 .03 .08 .43 .47 .65 .60 .99 .70
OR ¼ Odds Ratio. CI ¼ Confidence Interval.
DISCUSSION This is the first known report to evaluate an Internetbased program to help nurses quit smoking, and one of the few reports describing quit rates after the use of the Internet for cessation beyond 3 months. The 3-month quit rate (42.5%) seen among respondents in this study (not ITT) is higher than the 7-day point prevalence (30%) reported in Cobb et al’s study of 1501 smokers using QuitNet who responded to a 3-month followup survey.13 As in these findings, a higher level of website use was associated with higher quit rates. However, Cobb’s study was based upon receipt of the standard free QuitNet features, whereas the Nurses QuitNet provided smokers with a higher level of support with the ‘‘Premium package,’’ offering additional services. Another important difference is that in the Cobb et al13 study, respondents were specifically recruited to participate in the study via a series of email invitations and received financial incentives for participation. In this study, only respondents to the usual QuitNet email follow-up surveys were included in the analysis. No efforts were made, in the form of additional mailings or other incentives, to increase response rate. These findings indicate that Nurses Quitnet had efficacy in supporting smokers with quit attempts. Although the Internet may not be the choice for all nurses who smoke and are trying to quit, clearly those smokers who were most involved benefited from the support. Of note, almost half of the respondents in both the smoker and quit groups were thinking about (ie, contemplation) or intending to take action (ie, preparation). Stage of change was not different by smoking status and did not change over time. Thus, the stage of change was S
not useful in describing those who had quit using this program. This finding is in keeping with other views of the limitations of this model in determining those ready to make a quit attempt and highlights the need to offer interventions to all smokers, regardless of their stated ‘‘readiness’’ to change.11,19 Nurses in this study had similar smoking patterns to adults in the general population in terms of the number of cigarettes smoked (ie, 18.1 CPD for men and 15.3 CPD for women).20 They also demonstrated a high level of addiction to nicotine, as 69% of participants smoked within 30 minutes of awakening. Similar to the 70% of Americans who smoke and are interested in quitting,20,21 the majority of nurses in this study had made a quit attempt in the past year, but over a quarter had not made such an attempt. These data provide evidence that the Nurses QuitNet program encouraged quit attempts. The findings that those who made quit attempts prior to enrollment were more likely to make quit attempts during the study is consistent with the evidence that most smokers make multiple quit attempts before they are able to obtain complete abstinence from smoking.11,12 Smokers who have made previous unsuccessful attempts to quit might be particularly receptive to this type of a program. Fewer than 50% of participants reported receiving advice to quit from a healthcare provider, lower than the national average.11 As a result, despite being nurses, these smokers may not have had access to effective medications for cessation requiring a prescription or have received information about the most effective strategies for quitting. A number of nurses used methods to quit (eg, acupuncture, biofeedback, hypnosis) which do not
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Table 5. Barriers and Facilitators to Quitting at 3, 6, and 12 months 3 months Characteristics
6 months
Smoking Not Smoking
Barriers* Fear of not getting break Lack of colleague support Stress Withdrawal Colleagues/friends smoke Smoking in the lounge Lack of workplace cessation services Facilitators* Work in a smoke-free facility Support from colleagues No withdrawal symptoms Friends/colleagues who don’t smoke Wanting to be a role model for patients Workplace cessation services Taking a break
12 months
Smoking Not Smoking
Smoking Not Smoking
N (%)
N (%)
P
N (%)
N (%)
P
N (%)
N (%)
P
16 (20%) 6 (8%) 66 (78%) 51 (65%) 31 (39%) 5 (6%) 20 (25%)
8 (14%) 9 (16%) 48 (80%) 36 (59%) 28 (48%) (0) 22 (37%)
.35 .14 .73 .50 .29 .05 .11
12 (20%) 52 (85%) 41 (67%) 25 (42%) 4 (7%) 14 (24%) 12 (21%)
5 (10%) 30 (64%) 22 (46%) 19 (40%) 1 (2%) 8 (17%) 2 (4%)
.16 .01 .02 .77 .24 .37 .01
12 (27%) 6 (14%) 37 (80%) 32 (70%) 15 (33%) 1 (2%) 10 (23%)
5 (10%) 2 (4%) 33 (69%) 20 (40%) 23 (46%) 3 (6%) 9 (18%)
.03 .10 .19 .00 .21 .37 .57
N (%) 72 (88%)
N (%) 44 (71%)
N (%) .01 24 (41%)
N (%) 36 (71%)
N (%) .00 33 (77%)
N (%) 35 (71%)
.56
41 (52%) 18 (22%) 44 (56%)
40 (68%) 4 (7%) 36 (60%)
.06 4 (7%) .02 27 (47%) .61 29 (50%)
18 (37%) 29 (59%) 5 (73%)
.00 21 (49%) .22 21 (49%) .02 21 (49%)
37 (71%) 37 (71%) 26 (52%)
.56 .03 .76
54 (68%)
42 (71%)
.64
5 (9%)
9 (18%)
.16 25 (58%)
34 (68%)
.32
14 (18%)
12 (21%)
.64
3 (5%)
11 (22%)
.01
3 (7%)
10 (20%)
.08
6 (8%)
9 (16%)
.13
6 (11%)
4 (9%)
.71
8 (19%)
9 (18%)
.94
*Respondents could check all that apply.
have proven efficacy.11 Very few used a telephone quitline to support their quit attempts. Nurses who smoke also may have misconceptions about the most effective strategies to quit smoking.4 These findings provide evidence that barriers and facilitators to quitting smoking are present in the workplace. Previously, nurses reported that stressors, including workplace factors, influenced their smoking status and quitting behaviors.5 The importance of workplace factors to smoking status was again revealed in this study. Those who were successful in their quit attempts viewed the workplace in a different way than those who continued to smoke. Smoking among family members also is a barrier to quitting that needs to be addressed in tobacco dependence treatment.
sample, is also a limitation.22 It is not possible to determine if characteristics of nurses who went to the Internet to quit smoking were similar to other nurse smokers trying to quit through other methods. However, the demographics are similar to the RN population in the United States with the exception of a higher education level in our sample.23 In order to maintain anonymity, professional licensure information that could be used as an identifier was not obtained. Thus it is possible that non-nurses registered for the program. The low response rate to the emails from Nurses QuitNet resulted in considerable missing data. Although responses to Internet surveys are notoriously low, even for healthcare professionals,22 intensive efforts to improve response rates in a follow-up evaluation have been successful in previous studies.24 Recommended strategies include sending reminders through multiple email messages to non-responders,22 obtaining a second email address, and asking for other methods of followup such as phone or mail.25 As this was an analysis of de-identified data, these strategies were not possible. Intent-to-treat analysis is the standard for clinical trials. This analytic strategy may have underestimated quitting in this study. Because of the missing data, only limited information about continuous quit rates is available. In this Internet-based survey, self-reported smoking status was not biochemically verified as is recommended.25
Limitations There are a number of limitations that should be considered in evaluating these findings. As this was a naturalistic experiment based upon real world data, there is no control group. Thus, it is impossible to determine if those smokers trying to quit would be more or less successful on Nurses QuitNet as compared to QuitNet alone, or as compared to other programs. However, these data suggest these nurses did as well, if not better, than smokers in a previous evaluation of QuitNet.13 External validity of Internet-surveys, especially representativeness of the 254
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Registrants reported using a variety of other methods to quit smoking (including specific medications), but it is not possible to determine if they would have used these methods without the linkages and advice from the Nurses QuitNet program. As the survey questions were part of the brief standard QuitNet procedure, some important data that might be related to quitting (such as information on years of smoking or age at initiation) were not collected. The listing of workplace barriers and facilitators was limited. Other factors such as concerns about weight gain and alcohol use—among many others—could have influenced quit rates.11
CONCLUSION In summary, despite limitations, the results of this study provide important and promising information about nurse smokers trying to quit by using the Internet. The evidence that workplace barriers and facilitators influence smoking cessation has received limited attention. It is important for administrators, employers, and nursing leaders to consider the workplace characteristics in efforts to support quit attempts among healthcare professionals in general and nurses in particular. Another contribution of this study was the addition of 6- and 12-month follow-up data on users of an Internet-based program, Nurses QuitNet. Future research is needed to determine if Internet programs are more effective than other evidence-based cessation methods and to determine what type of individual might benefit the most from this intervention format. As nursing is a primarily female profession, these data also provide findings of interest for women. For the past 40 years, female nurses have participated in the Nurses’ Health Study, contributing to our knowledge about the negative impact of smoking on women’s health,26 but there have been few attempts to address this issue in the workplace or the profession. These data have both practice and policy implications and provide a starting point to address this gap in the literature. Further efforts are needed to help nurses quit and to explore how circumstances in the workplace can be used to support quitting. These efforts are especially important as quitting smoking positively influences healthcare provider interventions with patients.27 Acknowledgments: Support for this study was provided by The Robert Wood Johnson Foundation # 041056.
REFERENCES 1. The Health Consequences of Smoking for Women: A Report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1980. Available at: http://profiles.nlm.nih.gov/NN/B/B/R/T/_/ nnbbrt.pdf. Accessed April 4, 2006.
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2. United States Department Health and Human Services. Tobacco Use Supplement: Current Population Survey, Tobacco Use Special Cessation Supplement, Revised May, 2006. 3. Association of American Medical Colleges in Cooperation for Center for Health Workforce Studies. Physician behavior and practice patterns related to smoking cessation. A report prepared for the American Legacy Foundation 2007. Available at: http://americanlegacy.org/Files/Files?Physicians_Study_ -Legacy_Report.pdf. Accessed July 1, 2007. 4. Bialous SA, Sarna L, Wewers ME, Froelicher ES, Danao L. Nurses’ perspectives of smoking initiation, addiction, and cessation. Nurs Res 2004;53:387-95. 5. Sarna L, Bialous SA, Wewers ME, Froelicher ES, Danao L. Nurses, smoking, and the workplace. Res Nurs Health 2005;28:79-90. 6. Smith D, Leggat PA. An international review of tobacco smoking research in the nursing profession, 1976-2006. J Res Nurs 2007;102:32-7. 7. Braun B, Jinnet B, Fowles J, Solberg LI, Kind EA, Lando H, et al. Smoking-related attitudes and clinical practices of medical personnel in Minnesota. Am J Prev Med 2004;27:316-22. 8. Slater P, McElwee G, Fleming P, McKenna H. Nurses’ smoking behaviour related to cessation practice. Nurs Times 2006;102:32-7. 9. Jenkins K, Ahijevych K. Nursing students’ beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention. Appl Nurs Res 2003;16:164-72. 10. Sarna L, Brown JK, Lillington L, Wewers ME, Brecht ML. Tobacco-control attitudes, advocacy, and smoking behaviors of oncology nurses. Oncol Nurs Forum 2000;27:1519-28. 11. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating Tobacco Dependence and Treatment: 2008 Update, Clinical Practice Guideline. U.S. Department of Health and Human Services 2008. 12. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service 2000. 13. Cobb N, Graham A, Bock B, Papandonatos G, Abrams D. Initial evaluation of a real-world Internet smoking cessation system. Nicotine Tob Res 2005;7:207-16. 14. Bock B, Graham A, Sciamanna C, Krishnamoorthy J, Whiteley J, Carmona-Barros R, et al. Smoking cessation treatment on the Internet: Content, quality, and usability. Nicotine Tob Res 2004;6:207-19. 15. Sarna L, Bialous S, Wewers M, Froelicher E, Wells M, Balbach E. Web log analysis of the first two years of the Tobacco Free Nurses website. Online J Nurs Informatics (OJNI) 2007;11(3). Available at: http://ojni.org/11_3/sarna.htm. Accessed on October 10, 2008. 16. Sarna L, Bialous S, Barbeau E, McLellan D. Strategies to implement tobacco control policy and advocacy initiatives. Crit Care Nurs Clin of North Am 2006;18:113-22, xiii. 17. Prochaska JO, Di Clemente CC. Stages and processes of selfchange of smoking: Toward an integrative model of change. J Consult Clin Psychol 1983;51:390-5. 18. Bialous SA, Sarna L, Wells M, Elashoff D, Wewers ME, Froelicher ES. Characteristics of nurses who used the Internet-based Nurses QuitNet for smoking cessation. Pub Health Nurs 2009;26:329-38. 19. West R. Time for a change: Putting the Transtheoretical (Stages of Change) model to rest. Addiction 2005;100:1036-9.
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20. Centers for Disease Control and Prevention. Cigarette Smoking Among Adults—United States, 2004. MMWR 2005;54:1121-7. 21. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2006. MMWR 2007;56: 1157-61. 22. Braithwaite D, Emery J, de Lusignan S, Sutton S. Using the Internet to conduct surveys of health professionals: A valid alternative? Fam Pract 2003;20:545-51. 23. US Department of Health and Human Services. The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses. Health Resources and Services Administration, Bureau of Health Professions, 2006. Available at: http://bhpr.hrsa.gov/healthworkforce/ rnsurvey04/. Accessed on August 8, 2007.
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ing quit attempts. Quitting was influenced by workplace factors.
Nurses QuitNet, an Internet-based smoking cessation program, was created to support nurses’ quit attempts. The purposes of this study were to evaluate quit attempts at 3, 6, and 12 months after the use of the program and to determine differences in demographic, professional, and smoking characteristics by smoking status. Differences in the use of quit methods, barriers, and facilitators to quitting also were assessed. Data among 246 smokers who responded to at least 1 follow-up email at 3, 6, or 12 months after registration were analyzed. Quit rates among respondents were 43% (3 months), 45% (6 months), and 53% (12 months). Total time on the website was significantly higher for those who quit. Barriers to quitting included lack of support from colleagues, stress, lack of cessation services, and fear of not getting a work-break. Facilitators included working in a smoke-free facility, support from colleagues, and workplace cessation services. The use of Nurses QuitNet demonstrated promise in support-
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moking among nurses has been recognized as a serious concern affecting the profession since the 1970’s, when female registered nurses (RNs) smoked at a higher rate (38.9%) than women in the US population (32.0%) and at a substantially higher rate than physicians (21%).1 According to 2003 data from the Tobacco Use Supplement of the Current Population Survey,2 smoking among RNs has declined to 11.9% but remains markedly higher than that of physicians (1%).3 Nurses who smoke struggle with quitting,4 and their smoking influences workplace relationships.5 However, there are limited long-term prospective studies examining nurses’ quitting behaviors.6 Smoking is both a matter of personal health and a public health concern for healthcare providers; providers who smoke are less likely to offer cessation interventions for patients who smoke and more likely to have negative attitudes about tobacco control.7-10 Tobacco dependence is not just a bad ‘‘habit’’ or lifestyle ‘‘choice,’’ it is a chronic relapsing condition that may require repeated interventions. The US Public Health Service’s Clinical Practice Guideline Treating Tobacco Dependence: 2008 Update11 (Guideline), similar to the previous Guideline12 which was used to guide this study, recommends the use of a combination of behavioral support and pharmacotherapy as effective treatment which can double or triple the odds of successful quitting. Few smokers use evidence-based programs to support their quit attempts. The most common strategy used for quitting continues to be ‘‘cold turkey,’’ or no help, which results in a < 5% abstinence rate 1 year after the cessation attempt.11
Linda Sarna, DNSc, FAAN, is a Professor, School of Nursing, University of California, Los Angeles. Stella Bialous, MSN, DrPH, is President, Tobacco Policy International, San Francisco, California. Mary Ellen Wewers, RN, MPH, PhD, is Professor and Associate Dean for Research, The Ohio State College of Public Health, Columbus, OH. Erika Sivarajan Froelicher, RN, MA, PhD, is a Professor, Department of Physiological Nursing, School of Nursing & Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco. Marjorie J. Wells, RN, PhD, is Project Director, School of Nursing, University of California, Los Angeles. Jenny Kotlerman, MS, is Principal Statistician, David Geffen School of Medicine, University of California, Los Angeles. David Elashoff, PhD, is an Associate Professor, David Geffen School of Medicine, University of California, Los Angeles. Corresponding author: Dr. Linda Sarna, University of California, School of Nursing, 700 Tiverton Ave, Box 956918, Los Angeles, CA 90095. E-mail: [email protected]
INTERNET-BASED TOBACCO DEPENDENCE TREATMENT
Nurs Outlook 2009;57:246-256. 0029-6554/09/$–see front matter Copyright ª 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2009.03.002
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Evidence-based tobacco dependence treatment programs delivered through the Internet provide an opportunity to reach a large population of smokers at all 5
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hours. Focus group responses of nurses who were current and former smokers also supported the use of programs that would have flexible hours, ensure anonymity, and be low cost.4 QuitNet, one of the top rated Internet sites for smoking cessation with interactive capabilities for support,13,14 was selected to provide the cessation assistance for nurses in this study.13 Although Internet smoking cessation programs were not specifically recommended by the Guideline,11,12 consistent with limited research data, the Guideline did recommend further study of these innovative strategies to provide problem-solving skills and support.
The Creation of Nurses QuitNet The Tobacco Free Nurses (TFN) initiative, in partnership with QuitNet, created the nurse-only Nurses QuitNet website.15,16 This website was designed to help nurses quit and was the first national cessation program targeted at nurses who smoke. The focus of this article is the analysis of the outcomes of this program in helping nurses quit smoking. The overarching conceptual framework for this study was based upon the evidence of the addictiveness of nicotine and the variables (quit methods, nicotine dependence) projected to facilitate or to create barriers to quit attempts in general and quit attempts among those using the Internet. In addition to the use of the Nurses QuitNet program, the use of quit methods recommended by the Guideline12 (ie, behavioral counseling, along with the use of FDA-approved pharmacotherapy) was viewed as facilitating smoking cessation. The severity of nicotine dependence (as defined by shorter time to first cigarette in the morning and greater number of cigarettes smoked per day [CPD]) was considered as a barrier to quitting smoking. Based on previous studies, nurses’ perceived barriers and facilitators to smoking cessation in the workplace were hypothesized as influencing quit attempts among nurses.4,5 It was anticipated that smokers who experienced greater barriers and less support in the workplace would be less likely to quit. Demographic factors such as age, sex, race/ethnicity, and education were included in the framework as they may be related to the use of a Web-based cessation program and quit efforts in general.12 Smoking among family members was included as a variable influencing smoking status, as quitting is more challenging if there are other smokers in the household.12 Finally, willingness to make a quit attempt is recommended in appraisals of smokers’ interest in smoking cessation.12 Although the transtheoretical model for ‘‘stages of change’’17 was not included in the conceptual underpinnings of the study, data describing interest in quitting were collected. Purpose The purposes of this prospective study were: (1) to evaluate quit rates at 3, 6, and 12 months following the use of an evidence-based Internet smoking cessation proS
gram; (2) to determine the differences in demographic characteristics (age, race/ethnicity, household members who smoke), professional characteristics (RN, licensed practical nurse [LPN], or nursing student; education, clinical unit), and smoking characteristics (number of quit attempts, longest period without smoking, CPD) by smoking status (ie, smoking, not smoking); (3) to describe differences in the use of quit strategies (pharmacotherapy, counseling/skills training, other), including Nurses QuitNet, by smoking status at each time point; and (4) to identify perceived workplace barriers and facilitators to quitting.
METHODS Study Design A 12-month prospective study design was used to determine the use and impact of an Internet-based smoking cessation program geared for nurses on self-reported quit rates at 3, 6 and 12 months. Participants The sample included nurses (RNs, LPNs, and student nurses) who registered on Nurses QuitNet for assistance with smoking cessation. In the first 30 months, 1790 nurses registered online to receive help with smoking cessation. For inclusion in this analysis, nurse-registrants had to self-report as a current smoker at baseline and have at least 1 point of follow-up data: at 3, 6, or 12 months during January 2004–May 2006 (n ¼ 246). Excluded from this analysis were nurses who were non-smokers at registration, or who did not respond to the follow-up surveys (n ¼ 1544), or who were registered but were not interested in receiving support for smoking cessation (ie, researchers and others interested in reading more about the Web-based quit program). Non-respondents were not significantly different from respondents on demographic (age, sex, education, or race/ethnicity) or baseline smoking characteristics (CPD, time to first cigarette, number of quit attempts). A description of registrants is available elsewhere.18 Participants were not actively recruited for this prospective study; all registrants to Nurses QuitNet had the option to receive an electronic follow-up survey. Nurse registrants could select whether or not to complete the follow-up survey or answer any questions. Informed consent for participation was not specifically required; however, as part of the registration process all participants provided consent to receive follow-up emails and were informed that their responses may be used by researchers for scientific purposes. Encoded data (to protect individual identity) were extracted from the Nurses QuitNet program which allows for matching of responses for each participant at different points over time. This study was approved for exemption by the Office for Protection of Research Subjects, Institutional Review Board, University of California Los
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Angeles. All data were anonymous and are reported in the aggregate.
Quit methods. At each follow-up, the number of methods reported was calculated (use of no cessation method, use of 1 type of cessation method, use of R 2 cessation methods). Additionally, the type of method(s) used also was assessed and included those recommended by the Guideline12 and those not recommended. The recommended methods include use of counseling and support (ie, telephone counseling, other forms of counseling, and health provider support) and use of pharmacotherapy (nicotine gum, nicotine lozenge, nicotine patch, nicotine inhaler, nicotine nasal spray, buproprion). The use of Nurses QuitNet was considered as part of counseling and support. Cessation methods not recommended by the Guideline12 included acupuncture, biofeedback, hypnosis, and other medications. Respondents could select more than one method. Web traffic on Nurses QuitNet was monitored. This included total time online (reflected by the cumulative number of logins and average minutes online), total pages viewed, and total number of messages posted on the Nurses QuitNet forums. The number of log-ins was cumulative after the initial registration. Barriers and facilitators. Included in the 3-, 6-, and 12-month follow-up surveys were investigator-developed questions about the presence of workplace barriers to quitting and facilitators that supported quit efforts based upon previous studies.4,5,10 Barriers to quitting included: fear of missing work breaks, lack of support from colleagues, stress, reports of withdrawal symptoms, colleagues/friends who smoke, smoking in the nurses’ lounge, and lack of workplace cessation services. Workplace facilitators to support quitting included: working in a smoke-free facility, support from colleagues, absence of withdrawal symptoms, friends/colleagues who don’t smoke, wanting to be a role model, workplace cessation services, and having work breaks.
Study Procedures The Nurses QuitNet program, housed within the QuitNet website, was a web-based cessation program with services directly provided by QuitNet. In order to register to receive assistance with smoking cessation, all nurse participants were required to either enter the TFN website (www.tobaccofreenurses.org) directly to link with Nurses QuitNet or to enter through the American Nurses’ Association/American Nurses’ Foundation website, a TFN partner, to access the link to Nurses QuitNet. Once on the website, nurses interested in quitting completed a registration form to receive the evidence-based ‘‘Premium Package’’ of services, at no cost, including options for one-to-one counseling, skills to enhance cessation success, and access to medication information. This package of services was worth about $100. At the time of registration, smokers were asked to set a quit date. At 3, 6, and 12 months after registration, QuitNet sent an automatic email to all registrants who consented to receive email follow-ups with questions about their quit status. There were no incentives offered to return the follow-up online questionnaire and no reminders to encourage participants to complete the follow-up. Measures Demographic, professional, and smoking characteristics. The standard QuitNet registration instrument included questions about demographics (age, sex, race/ethnicity, education, employment status). At the 3-month follow-up Nurses QuitNet participants received 3 additional questions about professional characteristics (RN, LPN, nursing student), workplace clinical setting (acute, outpatient/primary care, psychiatric, other), and the presence of household members who smoke. Information about smoking characteristics at registration included questions about CPD (0, 1–9, 10–20, > 20 CPD), time to first cigarette after waking (< 5 minutes, 5–30 minutes, 31–60 minutes, > 60 minutes), and number of quit attempts in the past year. (A pack of cigarettes includes 20 cigarettes.) Questions regarding readiness to quit, also known as ‘‘stages of change’’18 (ie, precontemplation [not thinking about quitting], contemplation [thinking about quitting], preparation [getting ready to quit], action [quitting], and maintenance [avoiding relapse]) were assessed at baseline and at each follow-up period. Quit rates. For this study, 7-day point prevalence (smoking within the previous 7 days) was used to define current smokers (a ‘‘yes’’ response to ‘‘Have you smoked, even a puff, in the past seven days?’’) and to define those who had quit (ie, not smoking in the past 7 days) at each time period. Data on any quit attempts also were collected. 248
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Statistical Analysis Descriptive statistics were used to profile the sample’s demographic, professional, and smoking characteristics at baseline and at each time period. In this analysis, respondents were only required to complete 1 of the 3 follow-up questionnaires. A flow chart was created to describe smoking, quitting, and missing data at each point in time during the course of the 12-month study. A comparison of demographic and professional characteristics (Figure 1) of respondents and non-respondents to any of the follow-up surveys was conducted using t-tests and x2 tests as appropriate. For this study, quit rates using 7-day point prevalence rates were determined from respondents at each followup period, similar to a previous study reporting quit rates of smokers using QuitNet at 3 months.13 Quit rates were calculated for each of the follow-up periods using data from respondents only, as well as with a traditional intent-to-treat (ITT) analysis, labeling all non-respondents as smokers. O
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Baseline N = 246
246 smokers
3 Months N = 153
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6 Months N = 116
12 Months N = 99
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S = Smoking, Q = Quit, M = Missing
Figure 1. Smoking, quitting, and missing data patterns at 3, 6, and 12 months.
Comparisons of demographic, professional, and smoking characteristics were made at each time point by smoking status (smoking, not smoking) using x2 or t-tests as appropriate. The proportion of those who made quit attempts in the year prior to enrollment in Nurses QuitNet were compared with the proportion of those who made quit attempts at each of the followup periods. Because of the small sample of ‘‘non-White’’ participants, race was dichotomized as ‘‘White/nonWhite’’ for analysis. Additionally, level of education was collapsed to 3 categories so that those with less than a baccalaureate degree education, those with a baccalaureate degree, and those with graduate education could be compared. Significant differences in quit methods were examined by smoking status (smoking, not smoking) at each follow-up period and were determined using t-tests or x2 tests as appropriate for continuous and categorical data. After examination of the distribution of means and medians of the activity on Nurses QuitNet, non-parametric statistics (Wilcoxon 2 sample test) were used to examine utilization at each time period by smoking status. Differences in the perception of barriers and facilitators to quitting by smoking status (smoking, not smoking) also were compared using x2. Multiple logistic regressions (Odds Ratio [OR] with 95% confidence intervals [CI]) were used to compare characteristics of those who quit at any time during the study to characteristics of those who did not make a quit attempt. These characteristics include demographics (age, gender, race [White vs non-White], education [< baccalaureate degree vs graduate education]), smoking characteristics at baseline (CPD [1–9 vs 20þ, 10–19 vs 20þ]), time to first cigarette (< 5 minutes vs R 60 minutes, 6–30 minutes vs R 60 minutes, 31–60 minutes vs R 60 minutes), and prior quit attempts (0 vs R 6, 1 vs R 6, 2–5 vs R 6). All analyses were conducted using SAS 9.1.3. Level of significance was set at P < .05. S
FINDINGS Sample Characteristics and Differences at 3, 6, and 12 months The sample demographics and professional characteristics by smoking status at baseline and at each follow-up period are displayed in Table 1. The response rates of the 1790 nurses who registered with the program and completed follow-up surveys at 3, 6, and 12 months were 9%, 7%, and 6%, respectively. The typical respondent was female, age 45, White, had an RN license, a baccalaureate degree or higher, and worked fulltime. A plurality worked in an acute-care setting. Smoking characteristics varied. At registration, the majority of respondents smoked 10–20 CPD (n ¼ 166, 67%), and 23% (n ¼ 56) smoked > 20 CPD (more than a pack of cigarettes per day). A minority (n ¼ 24, 10%) smoked % 9 CPD. A majority (n ¼ 162, 69%) reported smoking the first cigarette within % 30 minutes after waking. Most (55%) had made R 2 quit attempts in the year prior to enrollment in Nurses QuitNet, including 9% who had made R 5 attempts. More than a quarter (n ¼ 66, 27%) reported not making an attempt to stop smoking in the previous year. Differences in Quit Rates As seen in Table 1, the percentages of people quitting at each time point varied. The majority of respondents reported smoking at 3 and 6 months. At 12 months, the majority of respondents reported not smoking, although the absolute number of respondents who quit did not increase. Using ITT, with all non-respondents viewed as smokers, the quit rates were 4% at 3 months, 3% at 6 months, and 3% at 12 months. The majority of respondents made quit attempts at each time period (3 months [67.3%], 6 months [55.2%], 12 months [54.6%]). There were significant differences in making a quit attempt during the program among those who made a quit attempt in the year prior to enrolling in Nurses QuitNet versus those who did not make an attempt to quit. Within the first
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
U T L O O K
249
V O L U M E
5 7
3 months N [ 153 Smoking N [ 88 (58%)
Not Smoking N [ 65 (43%)
N (%)
N (%)
N (%)
227 (92)
82 (93) 45.2 11
59 (91) 45.4 9.8
213 (93) 17 (7)
74 (94) 5 (6)
58 (94) 4 (6)
121 (82) 10 (7) 17 (11)
68 (80) 5 (6) 12 (14)
53 (84) 5 (8) 5 (8)
190 (82)
60 (76)
56 (89)
68 (46) 10 (7) 12 (8) 59 (39)
41 (48) 5 (6) 9 (11) 30 (35)
27 (42) 5 (8) 3 (5) 29 (45)
103 (69)
60 (70)
43 (68)
N
Baseline N [ 246
U M B E R
Sample Characteristics
6 months N [ 116 Not Smoking N [ 52 (45%)
P
N (%)
N (%)
.58 .93 .98
62 (97) 48 12.6
44 (85) 43.1 9.4
55 (95) 3 (5)
48 (94) 3 (6)
19 (86) 2 (9) 1 (4)
30 (83) 2 (6) 4 (11)
52 (88)
41 (80)
Smoking N [ 47 (48%)
Not Smoking N [ 52 (53%)
P
N (%)
N (%)
P
.02 .02 .87
46 (98) 47.4 10
47 (90) 45.7 9.1
.12 .38 .84
38 (86) 6 (14)
43 (88) 6 (12)
17 (94) 1 (6) 0 (0)
23 (85) 2 (7) 2 (7)
39 (89)
41 (84)
5
Smoking N [ 64 (55%)
12 months N [ 99
N U R S I N G
O U T L O O K
Demographics Gender (Female) Age (Mean, SD) Ethnicity White Non-White Professional Characteristics RN LPN Student Nurse Education Baccalaureate or more Type of unit Acute care unit Outpatient** Psychiatric unit Other Employment status Full time
.47
.62
.06
Nurses trying to quit smoking using the Internet
250
Table 1. Demographic and Professional Characteristics of Nurses QuitNet Registrants with Follow-up Data by Quit Status*
.47
.28
.49
.46
.80
*P values calculated using t-test or c2 test. **Outpatient/primary care/long-term care/home care.
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Table 2. Differences in the Type and Number of Methods Used to Quit by Respondents at 3, 6, and 12 Months by Smoking Status 3 months
6 months
Not Smoking smoking N (%)
N (%)
Methods used to quit No help (cold turkey) 15 (17) 0 (0) Pharmacotherapy only 5 (6) 3 (5) Counseling/support only 23 (26) 16 (25) Pharmacotherapy & 45 (51) 46 (71) counseling/support Types of pharmacotherapy 50 (57) 49 (75) Nicotine gum 17 (19) 14 (22) Nicotine lozenge 8 (9) 3 (5) Nicotine patch 26 (30) 22 (34) Nicotine inhaler 2 (2) 4 (6) Nicotine nasal spray 0 (0) 1 (2) Zyban/wellbutrin/bupropion 19 (22) 26 (40) Types of counseling/support Nurses QuitNet website 64 (73) 58 (89) Telephone quitline 0 (0) 2 (3) Counseling 7 (8) 5 (11) Advice from a healthcare 32 (36) 27 (42) provider Non-approved methods 15 (17) 15 (23) (acupuncture, biofeedback, hypnosis, other Internet site) Number of help methods 2.3 1.7 2.9 1.3 (mean, SD) None 15 (17) 0 (0) One help method 19 (22) 11 (17) Two or more help methods 54 (61) 54 (83)
12 months
Not Smoking smoking
Not Smoking smoking
P
N (%)
N (%)
P
N (%)
N (%)
P
.0005 .77 .83 .01
19 (30) 7 (11) 12 (19) 26 (41)
7 (13) 2 (4) 23 (44) 20 (38)
.04 .16 .003 .81
13 (28) 6 (13) 10 (21) 18 (38)
12 (23) 1 (2) 18 (35) 21 (40)
.60 .04 .14 .83
.004 .74 .29 .57 .22 .24 .01
33 (52) 10 (16) 4 (6) 14 (22) 5 (8) 0 (0) 15 (23)
22 (42) 5 (10) 2 (4) 9 (17) 2 (4) 1 (2) 12 (23)
.71 .34 .56 .54 .37 .27 .96
24 (51) 10 (21) 4 (9) 13 (28) 0 (0) 0 (0) 12 (26)
22 (42) 8 (15) 4 (8) 11 (21) 2 (4) 0 (0) 12 (23)
.14 .44 .88 .45 .17
.01 .10 .55 .52
34 (53) 3 (5) 2 (5) 18 (28)
41 (79) 2 (4) 2 (6) 13 (25)
.00 .82 .79 .71
23 (49) 1 (2) 3 (6) 14 (30)
35 (67) 1 (2) 1 (8) 9 (17)
.06 .94 .80 .14
.35
12 (19)
6 (12)
.29
5 (11)
5 (10)
.87
1.9 1.8 1.9 1.5 .88
.02 .0009
16 (25) 17 (27) 21 (48)
6 (12) 19 (37) 27 (52)
.15
.78
1.9 1.5 1.8 1.5 .68 13 (28) 6 (13) 28 (60)
10 (19) 17 (33) 25 (48)
.06
P values calculated using c2 test.
3 months, 71.9% (n ¼ 82) of those who had made an attempt to quit in the prior year made another quit attempt as compared to 53.9% (n ¼ 21) of those who did not make such an attempt, P <.038. These findings were similar at 6 months (n ¼ 49 [61.3%] vs n ¼ 15 [41.7%], P ¼.05, and at 12 months (n ¼ 43 [61.4%] vs n ¼ 11 [37.9%], P ¼.03). At 3 months, the only characteristic significantly different between smokers and those who quit was having a household member who smoked. Significantly more smokers (n ¼ 37, 44%) as compared to those who quit (n ¼ 10, 16%) had a household member who smoked (P ¼ .0004). Smoking among household members was only assessed at this follow-up period.
Differences in Use of Nurses QuitNet and Other Quit Strategies Differences in methods used to quit at each time period are displayed in Table 2. At 3 months, those who S
quit smoking used significantly more methods to quit than those who reported continuing to smoke. At 3 and 6 months, nurses who quit were significantly more likely to have used some form of help and used a combination of pharmacotherapy and behavioral counseling than nurses who continued to smoke. At 3 months, more frequent use of pharmacotherapy, specifically buproprion, was reported among those who quit. At 12 months, those who quit reported less use of pharmacotherapy only. The use of only counseling/support was higher in the quit group, including the use of the Nurses QuitNet site at 6 months. There were no statistically significant differences by smoking status in the proportion of participants in the different ‘‘stages of change’’ at each time point; the distribution of participants by stages did not significantly change over time. The majority of smokers were in the ‘‘contemplation’’ or ‘‘preparation’’ stage (ie, for
E P T E M B E R
/ O
C T O B E R
N
U R S I N G
O
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Table 3. Nurses QuitNet Site Utilization by Respondents at 3, 6, and 12 Months by Smoking Status 3 months
Site utilization indicators Total minutes online
Not Smoking: Smoking: Mean Mean (SD) (SD) Median Median
Total pages viewed
P
132 (230) 965 (2324) .0001 41 6 (11)
Total number of logins Average minutes online
6 months
2 19 (18)
98 56 (144) .0001 11 17 (12)
.52
Smoking: Mean (SD) Median
Not Smoking: Mean (SD) Median
191 (427)
1617 (4502) .002
62 9.9 (24.3)
159 62 66.6 (152) .0001 13.9 (35.3)
3 21.1 (19.5)
69 1 (2)
223 46 (174) .02
3 16.5 (12.5)
1 (3)
1 (2)
.18
5 7
N
U M B E R
5
N
P
7408 (41122) .01 166 166.4 (573)
.004
18 19.9 (3)
.82
13 4180 (15460) .006
76 285 3.62 (16.91) 155.19 (811)
.20
0.82 (3.54)
0.70 (2.73)
.19
U R S I N G
1.79 (4)
.16
1.54 (3)
P ¼ .03). There were no other significant differences in demographics or smoking characteristics among those who made at least one quit attempt and those who did not at 12 months.
Barriers and Facilitators Differences between perceived barriers and facilitators to quitting between smokers and those who quit at each time period are displayed in Table 5. There are differences in factors related to smoking status at each time period. Comparing smokers with non-smokers, a higher frequency of smokers reported fears of not getting work breaks (at 12 months), lack of support from colleagues (at 6 months), and stress (at 6 months). Smokers also reported the presence of withdrawal symptoms (at 12 months), smoking in a lounge (at 3 months), and lack of workplace cessation programs (6 months) as barriers. A higher percentage of those who quit reported working in a smoke-free facility at 6 months, but significantly fewer quitters as compared to smokers described working in such a facility at 3 months. A significantly higher percentage of those who quit reported support from colleagues (6 months, trend at 3 months), absence of withdrawal symptoms (3 and 12 months), having nonsmoking friends and colleagues, and having available workplace cessation services.
Factors Associated with Making a Quit Attempt In multiple logistic regressions, comparing those who made at least one quit attempt with those who made no quit attempt during the 12-month period (Table 4), female nurses were found to be significantly less likely to have made a quit attempt than were male nurses (OR ¼ .23, 95% CI .07, 0.76, P ¼ .02). Those who smoked 10–19 CPD were more than twice as likely to have made a quit attempt than those who smoked R 20 cigarettes per day (OR ¼ 2.43, 95% CI 1.07, 5.52, O L U M E
.99
243 (584)
Not Smoking: Mean (SD) Median
84 251 2.64 (14.44) 126.1 (478) .04
smokers, 96%, 92%, 94%, at 3, 6, and 12 months, respectively). Those who quit had a similar proportion of participants in these stages: (94% at 3 months, 100% at 6 months, 94% at 12 months). Those who quit reported more frequent use of Nurses QuitNet (Table 2) than those who smoked at the 3- and 6-month follow-up period, with a trend toward increased quitting at 12 months. Utilization of the website (Table 3) demonstrated increased activity (ie, total time online, total number of logins, total pages viewed, and messages posted to the Nurses QuitNet forums) by those who quit at all time periods as compared to those who did not quit.
V
17 20.1 (15)
P
Smoking: Mean (SD) Median
15 13 16 15 12 211 (428) 1440 (3668) .0001 314.9 (744.8) 2443.6 (7541) .0005 375.1 (929.6)
Total messages posted on Nurses QuitNet forums Total # of buddies
252
12 months
O
U T L O O K
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Table 4. Multiple Logistic Regression Analyses Among All Respondents with any Follow-up: Any Quit Attempt vs. No Quit Attempt (n ¼ 246) Sex Race/Ethnicity Education Cigarettes smoked per day Minutes to first cigarette
Quit attempts in the past year
Female vs. Male White vs. non-White < Baccalaureate vs. Graduate degree Baccalaureate vs. Graduate degree 1-9 vs. 20þ 10-19 vs. 20þ < 5 vs. 60þ 6-30 vs. 60þ 31- 60 vs. 60þ 0 vs. 6þ 1 vs. 6þ 2- 5 vs. 6þ
Age
OR (95% CI)
P
0.23 (0.07,0.76) 1.15 (0.41,3.28) 1.33 (0.49,3.67) 1.54 (0.65,3.66) 1.16 (0.31,4.38) 2.43 (1.07,5.52) 0.39 (0.13,1.14) 0.68 (0.26,1.77) 0.69 (0.25,1.89) 1.30 (0.42,4.02) 0.73 (0.22,2.40) 1.01 (0.35,2.92) 0.99 (0.97,1.02)
.02 .79 .58 .33 .82 .03 .08 .43 .47 .65 .60 .99 .70
OR ¼ Odds Ratio. CI ¼ Confidence Interval.
DISCUSSION This is the first known report to evaluate an Internetbased program to help nurses quit smoking, and one of the few reports describing quit rates after the use of the Internet for cessation beyond 3 months. The 3-month quit rate (42.5%) seen among respondents in this study (not ITT) is higher than the 7-day point prevalence (30%) reported in Cobb et al’s study of 1501 smokers using QuitNet who responded to a 3-month followup survey.13 As in these findings, a higher level of website use was associated with higher quit rates. However, Cobb’s study was based upon receipt of the standard free QuitNet features, whereas the Nurses QuitNet provided smokers with a higher level of support with the ‘‘Premium package,’’ offering additional services. Another important difference is that in the Cobb et al13 study, respondents were specifically recruited to participate in the study via a series of email invitations and received financial incentives for participation. In this study, only respondents to the usual QuitNet email follow-up surveys were included in the analysis. No efforts were made, in the form of additional mailings or other incentives, to increase response rate. These findings indicate that Nurses Quitnet had efficacy in supporting smokers with quit attempts. Although the Internet may not be the choice for all nurses who smoke and are trying to quit, clearly those smokers who were most involved benefited from the support. Of note, almost half of the respondents in both the smoker and quit groups were thinking about (ie, contemplation) or intending to take action (ie, preparation). Stage of change was not different by smoking status and did not change over time. Thus, the stage of change was S
not useful in describing those who had quit using this program. This finding is in keeping with other views of the limitations of this model in determining those ready to make a quit attempt and highlights the need to offer interventions to all smokers, regardless of their stated ‘‘readiness’’ to change.11,19 Nurses in this study had similar smoking patterns to adults in the general population in terms of the number of cigarettes smoked (ie, 18.1 CPD for men and 15.3 CPD for women).20 They also demonstrated a high level of addiction to nicotine, as 69% of participants smoked within 30 minutes of awakening. Similar to the 70% of Americans who smoke and are interested in quitting,20,21 the majority of nurses in this study had made a quit attempt in the past year, but over a quarter had not made such an attempt. These data provide evidence that the Nurses QuitNet program encouraged quit attempts. The findings that those who made quit attempts prior to enrollment were more likely to make quit attempts during the study is consistent with the evidence that most smokers make multiple quit attempts before they are able to obtain complete abstinence from smoking.11,12 Smokers who have made previous unsuccessful attempts to quit might be particularly receptive to this type of a program. Fewer than 50% of participants reported receiving advice to quit from a healthcare provider, lower than the national average.11 As a result, despite being nurses, these smokers may not have had access to effective medications for cessation requiring a prescription or have received information about the most effective strategies for quitting. A number of nurses used methods to quit (eg, acupuncture, biofeedback, hypnosis) which do not
E P T E M B E R
/ O
C T O B E R
N
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O
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Table 5. Barriers and Facilitators to Quitting at 3, 6, and 12 months 3 months Characteristics
6 months
Smoking Not Smoking
Barriers* Fear of not getting break Lack of colleague support Stress Withdrawal Colleagues/friends smoke Smoking in the lounge Lack of workplace cessation services Facilitators* Work in a smoke-free facility Support from colleagues No withdrawal symptoms Friends/colleagues who don’t smoke Wanting to be a role model for patients Workplace cessation services Taking a break
12 months
Smoking Not Smoking
Smoking Not Smoking
N (%)
N (%)
P
N (%)
N (%)
P
N (%)
N (%)
P
16 (20%) 6 (8%) 66 (78%) 51 (65%) 31 (39%) 5 (6%) 20 (25%)
8 (14%) 9 (16%) 48 (80%) 36 (59%) 28 (48%) (0) 22 (37%)
.35 .14 .73 .50 .29 .05 .11
12 (20%) 52 (85%) 41 (67%) 25 (42%) 4 (7%) 14 (24%) 12 (21%)
5 (10%) 30 (64%) 22 (46%) 19 (40%) 1 (2%) 8 (17%) 2 (4%)
.16 .01 .02 .77 .24 .37 .01
12 (27%) 6 (14%) 37 (80%) 32 (70%) 15 (33%) 1 (2%) 10 (23%)
5 (10%) 2 (4%) 33 (69%) 20 (40%) 23 (46%) 3 (6%) 9 (18%)
.03 .10 .19 .00 .21 .37 .57
N (%) 72 (88%)
N (%) 44 (71%)
N (%) .01 24 (41%)
N (%) 36 (71%)
N (%) .00 33 (77%)
N (%) 35 (71%)
.56
41 (52%) 18 (22%) 44 (56%)
40 (68%) 4 (7%) 36 (60%)
.06 4 (7%) .02 27 (47%) .61 29 (50%)
18 (37%) 29 (59%) 5 (73%)
.00 21 (49%) .22 21 (49%) .02 21 (49%)
37 (71%) 37 (71%) 26 (52%)
.56 .03 .76
54 (68%)
42 (71%)
.64
5 (9%)
9 (18%)
.16 25 (58%)
34 (68%)
.32
14 (18%)
12 (21%)
.64
3 (5%)
11 (22%)
.01
3 (7%)
10 (20%)
.08
6 (8%)
9 (16%)
.13
6 (11%)
4 (9%)
.71
8 (19%)
9 (18%)
.94
*Respondents could check all that apply.
have proven efficacy.11 Very few used a telephone quitline to support their quit attempts. Nurses who smoke also may have misconceptions about the most effective strategies to quit smoking.4 These findings provide evidence that barriers and facilitators to quitting smoking are present in the workplace. Previously, nurses reported that stressors, including workplace factors, influenced their smoking status and quitting behaviors.5 The importance of workplace factors to smoking status was again revealed in this study. Those who were successful in their quit attempts viewed the workplace in a different way than those who continued to smoke. Smoking among family members also is a barrier to quitting that needs to be addressed in tobacco dependence treatment.
sample, is also a limitation.22 It is not possible to determine if characteristics of nurses who went to the Internet to quit smoking were similar to other nurse smokers trying to quit through other methods. However, the demographics are similar to the RN population in the United States with the exception of a higher education level in our sample.23 In order to maintain anonymity, professional licensure information that could be used as an identifier was not obtained. Thus it is possible that non-nurses registered for the program. The low response rate to the emails from Nurses QuitNet resulted in considerable missing data. Although responses to Internet surveys are notoriously low, even for healthcare professionals,22 intensive efforts to improve response rates in a follow-up evaluation have been successful in previous studies.24 Recommended strategies include sending reminders through multiple email messages to non-responders,22 obtaining a second email address, and asking for other methods of followup such as phone or mail.25 As this was an analysis of de-identified data, these strategies were not possible. Intent-to-treat analysis is the standard for clinical trials. This analytic strategy may have underestimated quitting in this study. Because of the missing data, only limited information about continuous quit rates is available. In this Internet-based survey, self-reported smoking status was not biochemically verified as is recommended.25
Limitations There are a number of limitations that should be considered in evaluating these findings. As this was a naturalistic experiment based upon real world data, there is no control group. Thus, it is impossible to determine if those smokers trying to quit would be more or less successful on Nurses QuitNet as compared to QuitNet alone, or as compared to other programs. However, these data suggest these nurses did as well, if not better, than smokers in a previous evaluation of QuitNet.13 External validity of Internet-surveys, especially representativeness of the 254
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5 7
N
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5
N
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O
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Registrants reported using a variety of other methods to quit smoking (including specific medications), but it is not possible to determine if they would have used these methods without the linkages and advice from the Nurses QuitNet program. As the survey questions were part of the brief standard QuitNet procedure, some important data that might be related to quitting (such as information on years of smoking or age at initiation) were not collected. The listing of workplace barriers and facilitators was limited. Other factors such as concerns about weight gain and alcohol use—among many others—could have influenced quit rates.11
CONCLUSION In summary, despite limitations, the results of this study provide important and promising information about nurse smokers trying to quit by using the Internet. The evidence that workplace barriers and facilitators influence smoking cessation has received limited attention. It is important for administrators, employers, and nursing leaders to consider the workplace characteristics in efforts to support quit attempts among healthcare professionals in general and nurses in particular. Another contribution of this study was the addition of 6- and 12-month follow-up data on users of an Internet-based program, Nurses QuitNet. Future research is needed to determine if Internet programs are more effective than other evidence-based cessation methods and to determine what type of individual might benefit the most from this intervention format. As nursing is a primarily female profession, these data also provide findings of interest for women. For the past 40 years, female nurses have participated in the Nurses’ Health Study, contributing to our knowledge about the negative impact of smoking on women’s health,26 but there have been few attempts to address this issue in the workplace or the profession. These data have both practice and policy implications and provide a starting point to address this gap in the literature. Further efforts are needed to help nurses quit and to explore how circumstances in the workplace can be used to support quitting. These efforts are especially important as quitting smoking positively influences healthcare provider interventions with patients.27 Acknowledgments: Support for this study was provided by The Robert Wood Johnson Foundation # 041056.
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2. United States Department Health and Human Services. Tobacco Use Supplement: Current Population Survey, Tobacco Use Special Cessation Supplement, Revised May, 2006. 3. Association of American Medical Colleges in Cooperation for Center for Health Workforce Studies. Physician behavior and practice patterns related to smoking cessation. A report prepared for the American Legacy Foundation 2007. Available at: http://americanlegacy.org/Files/Files?Physicians_Study_ -Legacy_Report.pdf. Accessed July 1, 2007. 4. Bialous SA, Sarna L, Wewers ME, Froelicher ES, Danao L. Nurses’ perspectives of smoking initiation, addiction, and cessation. Nurs Res 2004;53:387-95. 5. Sarna L, Bialous SA, Wewers ME, Froelicher ES, Danao L. Nurses, smoking, and the workplace. Res Nurs Health 2005;28:79-90. 6. Smith D, Leggat PA. An international review of tobacco smoking research in the nursing profession, 1976-2006. J Res Nurs 2007;102:32-7. 7. Braun B, Jinnet B, Fowles J, Solberg LI, Kind EA, Lando H, et al. Smoking-related attitudes and clinical practices of medical personnel in Minnesota. Am J Prev Med 2004;27:316-22. 8. Slater P, McElwee G, Fleming P, McKenna H. Nurses’ smoking behaviour related to cessation practice. Nurs Times 2006;102:32-7. 9. Jenkins K, Ahijevych K. Nursing students’ beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention. Appl Nurs Res 2003;16:164-72. 10. Sarna L, Brown JK, Lillington L, Wewers ME, Brecht ML. Tobacco-control attitudes, advocacy, and smoking behaviors of oncology nurses. Oncol Nurs Forum 2000;27:1519-28. 11. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating Tobacco Dependence and Treatment: 2008 Update, Clinical Practice Guideline. U.S. Department of Health and Human Services 2008. 12. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service 2000. 13. Cobb N, Graham A, Bock B, Papandonatos G, Abrams D. Initial evaluation of a real-world Internet smoking cessation system. Nicotine Tob Res 2005;7:207-16. 14. Bock B, Graham A, Sciamanna C, Krishnamoorthy J, Whiteley J, Carmona-Barros R, et al. Smoking cessation treatment on the Internet: Content, quality, and usability. Nicotine Tob Res 2004;6:207-19. 15. Sarna L, Bialous S, Wewers M, Froelicher E, Wells M, Balbach E. Web log analysis of the first two years of the Tobacco Free Nurses website. Online J Nurs Informatics (OJNI) 2007;11(3). Available at: http://ojni.org/11_3/sarna.htm. Accessed on October 10, 2008. 16. Sarna L, Bialous S, Barbeau E, McLellan D. Strategies to implement tobacco control policy and advocacy initiatives. Crit Care Nurs Clin of North Am 2006;18:113-22, xiii. 17. Prochaska JO, Di Clemente CC. Stages and processes of selfchange of smoking: Toward an integrative model of change. J Consult Clin Psychol 1983;51:390-5. 18. Bialous SA, Sarna L, Wells M, Elashoff D, Wewers ME, Froelicher ES. Characteristics of nurses who used the Internet-based Nurses QuitNet for smoking cessation. Pub Health Nurs 2009;26:329-38. 19. West R. Time for a change: Putting the Transtheoretical (Stages of Change) model to rest. Addiction 2005;100:1036-9.
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