INTRODUCTION

The detrimental effects of tobacco smoke on the human body, especially for children, have been well-documented^1-3. Parental smoking is a significant source of secondhand smoke among children, and an elevated risk of initiating smoking by children growing up^4,5. Tobacco control and prevention are essential to reduce tobacco smoke exposure and the risk of adverse health effects both in children and adults⁶. Increasing workplace tobacco control policies and utilizing the 5As framework and the ‘Making Every Contact Count’ (MECC) approach, have contributed to more negative attitudes about smoking and resulted in a decrease in secondhand smoke exposure^7-9. Studies based on nationally representative samples found that indoor workers who self-reported a 100% smoke-free policy at work, were less likely to smoke combustible tobacco and were more likely to quit smoking^10,11. The hospitalization of a child is an important opportunity to practice tobacco control, and to include evidence-based cessation programs for healthcare providers, supporting staff, and parents. However, it has been demonstrated in the literature that not all hospital staff members are equally capable of providing high-quality tobacco control services to patients. For example, a recent cross-sectional study conducted in Wales (UK) found that female staff members and younger professionals were less likely to report feeling comfortable initiating health behavior conversations, including discussions about smoking cessation, across all topics¹². A systematic review focused on nurses found no differences in the delivery of smoking cessation interventions based on the nurses’ smoking status¹³.

The level of comfort in discussing smoking for hospital staff could potentially contribute to the success in reducing tobacco smoking and secondhand smoke exposure for patients, their parents, and workers in the children’s hospital; some demographic characteristics such as sex, age, job type, and smoking status might potentially influence the level of comfort in such discussions. Our study assessed the comfort level in discussing smoking with patients or their families, and co-workers, and examined potential differences by these subgroups. These findings will help improve tobacco control related training among pediatric hospital staff in the future and warrant future analysis in identifying potential gaps and barriers in implementing tobacco control policies within the hospital setting.

METHODS

RESULTS

Table 1 shows the characteristics of the overall study population of 2340 participants. Of the respondents without missing data: 1942 (83.8%) were female staff and 374 (16.2%) were male staff; staff aged 18–35 years represented 41.2%; clinical staff represented 57.6%; and there were 362 (15.5%) staff who self-reported as having smoked 100 cigarettes in their lifetime. Overall, of the total sample of 2340 participants, 33 (1.4%) currently smoked cigarettes every day.

Table 2 shows the awareness and support of smoking cessation programs for hospital staff and patients’ parents. Over 95% of the respondents agreed that the hospital should provide tobacco control related programs to staff, while the percentage supporting such programs for patients’ parents was over 85%. About two-thirds of the respondents were aware that the hospital had programs helping staff to quit smoking tobacco, where 41.8% of the respondents were aware of such a program for parents.

We found that the level of comfort in talking about smoking differed by sex, age, job type, and smoking status, and the difference varied by the topics of the discussion and with whom were the discussions, adjusting for all other variables (Table 3). Overall, 41.4% of the respondents felt very comfortable asking patients or their families about their smoking status, 25.8% felt very comfortable educating patients/families about the health risks of their smoking tobacco, and 19.5% felt very comfortable talking to co-workers about the health risks associated with their tobacco smoking. Compared to males, females were less likely to feel very comfortable in asking patients or their families about their smoking tobacco (AOR=0.72; 95% CI: 0.56–0.92) or talking to co-workers about the health risk associated with their tobacco smoking (AOR=0.71; 95% CI: 0.54–0.93). The youngest age group (18–35 years) was the least comfortable in all three outcomes regarding the discussion on tobacco smoking (Table 3). The proportion of those who felt very comfortable in discussing smoking was higher among clinical staff than non-clinical staff. Clinical staff were also more likely to feel very comfortable in asking patients/families about their smoking tobacco (AOR=2.81; 95% CI: 2.34–3.39), and educating patients/families about the health risk of tobacco smoking (AOR=1.99; 95% CI: 1.61– 2.45), while the association was not statistically significant for talking to co-workers about the health risks of tobacco smoking (AOR=1.03; 95% CI: 0.83–1.29). Compared to ever and current smokers, non-smokers were less likely to feel ‘very comfortable’ talking to co-workers about smoking (AOR=0.60; 95% CI: 0.45–0.78) (Table 3).

DISCUSSION

We utilized a cross-sectional survey to assess staff comfort level in discussing smoking with patients and their families, as well as co-workers, in a large urban children’s hospital. We found that differences existed in the comfort levels of discussing smoking with patients/families and co-workers by sex, age, job type, and smoking status. The results may help identify barriers for discussing smoking and improve tailored tobacco control training for hospital staff.

Our study results indicated a notable predominance of female respondents, which is consistent with the sex distribution of the hospital workforce in the United States. As of 2022, women hold 75% of total employment in hospitals¹⁶. The high proportion (over 80%) of female respondents in our study may also be attributed to the increasing percentage of women in the healthcare workforce, particularly in pediatric, obstetrics and gynecology, child and adolescent psychiatry, and neonatal–perinatal medicine specialties¹⁷. Moreover, female staff might potentially have more concerns about tobacco control, but it is unknown how largely this effect would be. Additionally, the age distribution observed in our study was also in line with the national trend, with a median age range that matched the reported range (35–45 years) for the overall hospital workforce in the US¹⁸.

The age and sex differences we found were consistent with previous studies. As a previous study from the same hospital indicated, older male general physicians were more likely to initiate smoking cessation conversation with their patients¹⁹. This finding suggests that younger and female staff and providers may have barriers to discussing smoking with others; these barriers may have to do with dynamics of gender and age. To address this, a study provided evidence on using special education content on smoking cessation to boost the comfort level of behavioral counselling in bedside nurses²⁰. Such a finding suggested that the management of the hospital should provide support and specialized education content regarding tobacco control to our female and younger staff. Future studies to identify such barriers and implement targeted interventions are thus warranted.

Our study showed that about 57% of the hospital staff were working clinically, which was also consistent with the national data²¹. When looking into the differences between clinical and non-clinical staff, we found that non-clinical staff were less comfortable in discussing smoking. This is not surprising, as they may in general lack specific training in asking patients/families about their smoking and providing advice on tobacco control and prevention^22,23. The proportion of respondents who were highly aware of the available smoking cessation programs in the hospital to parents/families were approximately 30% lower than that reported in the previous survey, which was limited to clinicians. The inclusion of non-clinical staff in the current survey may help explain some of the discrepancies. The current results suggest non-clinical staff could be an important group to be included in a wider campaign to increase staff knowledge and confidence in tobacco control and prevention policy. Future tobacco control training should have a particular focus on non-clinical staff.

About 9% of our respondents reported ever smoking, which is between the reported smoking prevalence from a national data studying healthcare professionals and hospital workers^24,25. Interestingly, hospital staff who identified as ever smokers were more comfortable discussing smoking in all 3 questions. Non-smokers tend to be younger than smokers, and ever smokers might have more previous or current interactions with tobacco that help them proceed with more confidence, compared to non-smokers. However, limited literature was found on this topic. Since most of the respondents were non-smokers, continuing to provide education to support knowledge about tobacco will be critical.

The current analysis revealed a significant level of cognizance and endorsement for tobacco control policies among hospital staff, but relatively low awareness of the existing tobacco cessation programs either targeting hospital employees or patient’s parents. To enhance the effectiveness of tobacco control policies, efforts should be directed towards increasing awareness and improving utilization rates of such programs.

There is a need to provide appropriate support and bolster confidence, especially for younger, female, and non-clinical hospital staff, in strategies of initiating conversations about tobacco control with patients, which could be generalized from other topics such as palliative care and learn to target patient concern based on their objections^26,27. A culture of teamwork and collaboration among staff may also be helpful, for example, pairing with older male clinicians may also be an effective strategy to improve communication and confidence²⁸. To target younger staff, an innovative approach such as in the context of age-specific training programs or web-based educational tools, might be more effective than traditional meetings or training approaches. Additionally, providing ongoing feedback and support to these staff members may be effective in reinforcing and improving their skills over time.

CONCLUSIONS

Strong perceptions of tobacco control policies and awareness of the smoking cessation programs for staff and patients’ parents were found in this hospital after the implementation of a tobacco cessation program for parents and educational interventions within the hospital. As we seek to have more effective tobacco control and innovative ways to discuss smoking cessation, understanding the disparities in different subgroups of hospital staff is critical to bridging gaps. Our study suggests that female staff, younger staff, non-clinical staff, and staff who were non-smokers may benefit from studies identifying barriers and using targeted programs to boost their comfort level in discussing smoking to further protect patients/families and create a healthier work environment.