Introduction
Smoking is a long-standing problem in our society and is still socially tolerated unlike other addictions. Until the beginning of the 60s, everyone and everywhere smoked. Those who did not smoke were socially disabled. A significant change occurred in 1964 after the publication of a study in the USA on the harmful effects of smoking. During the anti-smoking campaign, tobacco companies paid over 200 billion dollars to victims of smoking. Despite many measures, about a billion people in the world still smoke (Kulkovský, 2020). Smoking is a societal and health problem. In Slovakia, 30% of doctors and 40% of non-medical workers smoked, in the Czech Republic 33% of doctors and 49% of nurses, in the USA 5% of doctors and 17% of nurses. There is still a high percentage of health professionals who are a bad example for their patients precisely because they are smokers themselves (Bernadičová et al., 2008).
The legislation prohibits smoking in the workplace, including medical facilities. In 2006, Act No. 124/2006 Coll. on safety and health protection at work, which orders employers to issue a smoking ban at workplaces where non-smokers also work and to ensure compliance with this ban. In 2009, Act No. 377/2004 on the protection of non-smokers in public spaces, in which smoking was excluded, for example, in medical facilities (hospitals, clinics). If there is even one non-smoker in the workplace, the employer has two obligations:
- is obliged to draw up an internal directive on the prohibition of smoking in the workplace, which lists the premises of the operation in which smoking is prohibited. At the same time, the directive must state in which places smoking is allowed (smoking room, terrace, in the yard, in front of the building).
- is obliged to designate a responsible person who will supervise the observance of this prohibition and what threatens the employee in the event of its violation (Megelová, 2019).
The question of discrimination in connection with smoking is not a content of discrimination according to the anti-discrimination law. According to the Labor Code, the employer can only request information related to the performance of the job from the job applicant. During the interview, the employer may not request information, e.g. about pregnancy, family relationships, political affiliation and etc. Smoking is not among the prohibited topics. Therefore, it is not a violation of the Labor Code if the employer asks about smoking (Nemec, 2010, p. 49). Neither the Labor Code nor any other legal regulation regulates the employee's right to a smoking break, so the employee is not entitled to such a break. At the same time, the employee is obliged according to § 81 letter b) of the Labor Code to use working time for work. If the employer has not agreed directly with the employee, e.g. in the employment contract or with employee representatives on the fact that he would provide the employee-smoker with a longer break for rest and eating than 30 minutes, or on the fact that he would also provide other breaks during the work shift, so from a legal point of view, in the time exceeding the specified 30 minutes, during which the employee spends time smoking, he violates the basic obligation of the employee - to use working time for work (Megelová, 2019). Issuance of a smoking ban can include e.g. work order. At the same time, the employer can define what penalties will be imposed for violating the ban. In particular, it is advisable for the employer to determine whether the violation of the smoking ban will be considered a violation of work discipline, and whether it will be a serious or minor violation. The employer is obliged to ensure compliance with the smoking ban. For this purpose, he is authorized to carry out checks aimed at finding out how the ban is observed by employees. In connection with smoking in the workplace, an undesirable event in the form of a fire may occur. Employees are obliged to respect the issued smoking ban at the employer's workplaces. If the employer has designated areas for smoking, the so-called "smoking rooms", the employee is obliged to use these spaces for this purpose and refrain from smoking outside this space. The employer is not obliged to set special smoking breaks for employees who smoke. Failure to comply with the imposed ban may be considered a violation of work discipline.
The position of smokers in companies is usually a very good indicator of the type of company culture. Our legal regulations do not regulate the obligation to overwork smoking breaks. If an employee decides to arbitrarily leave the workplace, not fulfill his work tasks and spend more time with a lit cigarette, the employer can draw consequences from him for a violation of work discipline to the termination of the employment relationship if other legal conditions are met. Target The aims of our study were to compare the attitudes of non-smoking nurses, tobacco-dependent nurses (smokers) and managers towards smoking during working hours and to assess the impact of smoking in the workplace on work performance and on the provision of nursing care; to determine the time and economic loss during working hours for nurses addicted to tobacco.
File and Methodology The research group consisted of 381 nurses working in healthcare facilities in Slovakia and the Czech Republic. The method of data collection was non-standardized questionnaires, which were intended for non-smoking nurses, tobacco-dependent nurses (smokers) and nurse managers. The questionnaires were administered electronically through contact persons. Data collection took place from July 2020 to March 2021. Non-smoking and smoking nurses were most represented in the age group of 18-29 years, female managers in the age group of 40-49 years. The highest level of education for non-smoking nurses was university level I (45%), for smoking nurses secondary education (51%) and for female managers, university level II. degree (52%).
Statistical processing Categorical data were processed with the help of McNemar's test, which we chose because of monitoring two variables with two answer options (yes-no) on the same sample of respondents. If the p-value of the test criterion of the test was less than the numerical value of 0.05, we considered the differences in the proportional representation of the observed categories to be non-random. We compared the categorical data of the relationship of two independent subsets with the help of contingency tables, which were evaluated either by the chi-square test or the Fisher test. If the p-value of the test criterion was less than the number 0.05, we considered the differences between the observed and expected frequencies of individual categories of the contingency table to be non-random. We report the correlation between variables using the non-parametric Spearman correlation coefficient along with the 95 percent confidence interval and the p-value of the statistical significance of its difference from zero.
Results and Discussion In the set of respondents we monitored, 17% were nurses-smokers. The percentage representation is comparable to the findings of several authors. Simočková, Zamboriová (2011) in their study focused on monitoring the health of nurses in Slovakia and the Czech Republic (n=1397) found that 25% of nurses regularly smoked, in the Czech Republic 29%. The survey conducted by Madziová, Janíková (2013) on a sample of nurses in the Czech Republic showed that 47% of respondents smoke, of which 30% are nurses regularly and an average of ten cigarettes a day.
In a questionnaire addressed to nurses addicted to tobacco, we asked them to rate their nicotine addiction. 33.5% of nurses reported weak addiction, 49% moderate and 17.5% strong addiction to nicotine, while up to 74% of nurses would like to stop smoking. The average number of years of smoking among our respondents was 12.4 years, the shortest time the respondent smoked was one year and the longest was 40 years. We were also interested in the time interval after waking up, when smoking nurses light their first cigarette. 46% of female respondents indicated the time after 60 minutes. On average, they smoke 12 cigarettes a day. Only one respondent stated that she smokes up to 40 cigarettes a day, two sisters 30 cigarettes and twelve sisters 20 cigarettes a day. 63% of female smokers admitted that they smoke even when they are sick. Bialous et al. conducted a study in 2009 on a sample of 1,790 nurses, most nurses were aged 45-54 (34%) and had a university degree (57.5%). More than 68% of nurses smoked 10-20 cigarettes a day and 66.4% smoked within 30 minutes of waking up. 30% of nurses were not interested in being cured of nicotine addiction.
We asked all respondents the same questions in the questionnaires. We wondered if nurses consider smoking a work handicap. 49% of non-smoking nurses and 52% of female managers answered positively, but up to 70% of female smokers do not consider smoking to be a work handicap. 78.5% of non-smoking nurses and 76% of female managers are of the opinion that non-smoking nurses perform or partially perform work for smoking nurses during their smoking break. It is important to note that only a very small proportion of smoking nurses admit that smoking affects their work performance. Only 30% of female smokers consider smoking a work handicap. Out of the total number of 57 respondents-smoking nurses in our group, only one admitted that she spends less time on nursing care than a non-smoking nurse, and one nurse marked the answer partly as paying less attention to patients.
We focused on finding out the number of smoking breaks during working hours, which means that smoking nurses knowingly violate the Labor Code "with the tacit approval" of their colleagues and superiors. 63% of nurses use 1-3 breaks during their shift to smoke, 25% of female smokers use 4-6 breaks and 12% of nurses 7 or more. The results are consistent with the data provided by the Czech company PEAL. According to the calculation of the Czech company PEAL (wholesale supplier of tobacco and alcohol products), one cigarette costs the company almost 1EURO (96 cents) and on average the employee loses up to 15 working days a year. One cigarette interrupts the working time for 6 minutes. The average smoker indulges in about 5 cigarettes during working hours. This amounts to 30 minutes a day, and therefore 15 days a year (author unknown, www.kariera, 2018). The nurses in our study smoke an average of 5 cigarettes during five breaks, which means that they miss at least 30 minutes of their working time per day. Of course, the loss of time is much greater and is related to leaving the workplace and moving to a place designated for smokers. One cigarette "costs" the employer about 1 EURO, roughly 5 EUR per day and 75 EUR per month, if we count the average of 15 days worked by nurses in shift work. Annually, time lost due to smoking rises to 15 days. If we take into account that the value of the average nominal monthly salary of an employee in the Slovak economy in the 3rd quarter of 2021 reached EUR 1,185 (Statistical Office of the Slovak Republic, 2022), which is about EUR 57.50 per day, then the financial loss for the employer in connection with smoking is EUR 862.50 for one employee-nurse-smoker per year.
From the point of view of the dependence of nurses' time losses on the number of cigarettes smoked and related breaks, we verified the correlation between both parameters with the help of the non-parametric Spearman correlation coefficient. The results are shown in Table 1. From the given data, it follows that a moderately strong positive correlation (R=0.40) was found between the two variables, while the value of the correlation coefficient is statistically significantly different from the zero value (p=0.002). We conclude that there is a relationship between tobacco addiction in nurses and time loss during working hours. The relatively low value of the correlation coefficient can be caused by two factors. The first is the construction of the questionnaire, in which the frequency of smoking breaks was rescaled into three categories. The second reason may be the nurses' subjective perception of the insignificance of time loss, or their underestimation of the frequency of smoking breaks.
Table 1 Correlation of number of cigarettes with breaks in nurses
Only a minimum of companies regulate smoking breaks. PEAL itself regulates cigarette breaks for its employees. Workers must smoke outside the building and sign out of the electronic attendance system on their way out. Then they have to make up for the missing time. 75% of companies do not address the time their employees spend smoking. At the same time, however, they do not even provide (86% of employers) a program to help smokers who would like to quit. Employers could draw inspiration from Japan when motivating employees to quit smoking. Non-smoking employees are entitled to a few extra vacation days (unknown author, www.kariera, 2018).
After analyzing the answers, we also assessed the perception of time loss by female managers (n=46). We focused on the question: "Do you think that non-smoking nurses do work for smoking nurses during their smoking break?", dividing the nurse-managers into two groups (smokers/non-smokers). There were 7 smokers and 39 non-smokers in the ensemble. Due to the lower number of categories, we merged the response items of the above question by merging the yes+partly options into one category against the "no" response. The results are presented in Table 2. Due to lower frequencies, Fisher's test was used. The results show that the differences are statistically significant and the p-value of the Fisher test criterion is just below the p=0.05 threshold. Considering the lower number of smokers (n=7) among female managers, we have to interpret the results with caution. However, it seems that even in this case there is a double discrepancy in the perception of nicotineism in the workplace. The majority of non-smoking female managers (82.1%) perceive the nicotinism of their colleagues as a reason for substitute work that non-smoking women have to do instead of them (Table 3). On the contrary, the majority of the small group of female smokers (n=4) do not perceive nicotinism as a problem that causes forced substitute work by non-smoking nurses for their smoking colleagues. Nurses' views on smoking during working hours do not differ depending on the job position. We note that, even in the case of female managers, the perception is essentially similar to that of their subordinates: female smokers do not perceive substitute work as such a significant problem as non-smokers.
Table 2 Perception of substitute work by non-smokers for smokers from the point of view of female managers
Supervisors are not interested in time loss during smoking breaks during working hours. The disinterest of the management or their neutral attitude is alarming. The higher the number of cigarettes smoked per day, the higher the time loss caused by smoking. This is related to more smoking breaks and the impact on the provision of nursing care. It is therefore obvious that with regard to the number of absences of the smoking nurse at the workplace, the provision of nursing care is limited.
Employers do not deal with the time and economic losses caused by smoking workers. 82.5% of smoking nurses stated that the issue of smoking and efficient use of working time was not addressed at their workplaces, the same answer was confirmed by 82% of non-smoking women and 70% of female managers. Employers' lack of interest in solving this labor-legal problem was also confirmed by the answers to the item in the questionnaire, which we used to monitor whether the employer provides any programs to help smoking nurses quit their addiction to tobacco. 93.5% of female managers and 88% of smoking nurses gave a negative answer, while 54% of smoking nurses would be willing to quit smoking if their employer provided them with some benefits to support a healthy lifestyle. In this context, it is interesting that there is a significant difference between the internal "want" to quit smoking and the proportionality of the representation of female respondents who are or are not willing to quit smoking in exchange for benefits provided by the employer (table no. 3, McNemar's test, p=0.003). From table no. 3 shows that in the case of reluctance to quit smoking (n=15), the absolute majority of female respondents (n=14) do not even accept the benefits that the employer would offer them to support a healthy lifestyle. It can be concluded that in their case, smoking is not only perceived as a bad habit, but perhaps as psychological compensation, anti-stress behavior, belonging to a group, etc., and these aspects seem to outweigh the conscious negatives of nicotinism. On the contrary, in the case of an internal willingness to quit smoking (n=42), although most nurses are willing to accept employer benefits (n=30), a remarkably large number of female respondents in their answers declare their reluctance to accept employer benefits (n=12).
It seems that even in this case, there is a subset of female respondents who do not perceive nicotineism only as a bad habit, but, similar to the previous case, are aware of the broader context of smoking, not only as an addictive behavior. Berkelmans et al. (2011) conducted a study on a sample of 1029 nurses in Victoria, Australia, to assess nurses' smoking behaviour. 11% of smoking nurses worked most often in psychiatric and emergency departments. Among nurses who smoked, 45% wanted to quit smoking and 89% were trying to quit smoking, 50% of nurses received help or advice to quit smoking. The most common factors preventing smoking cessation included fear of withdrawal symptoms, weight gain, anxiety and stress. Smoking as a maladaptive pattern of behavior is also mentioned by Dimunová et al. (2016).
Table 3 Relationship between declaration of willingness to quit smoking in the case of employer bonuses versus internal willingness to quit smoking among female smokers
We also put the item regarding motivational bonuses to non-smoking nurses and managers. 71% of non-smoking nurses would welcome incentive bonuses for non-smokers at their workplace, for example in the form of a few extra days of vacation. 99% of female managers confirmed with their answers that there are no incentive bonuses for non-smokers in the medical facilities where they hold a managerial position. The non-smoking sisters gave identical answers.
A French study by Fathallah et al. (2012) collected data on the prevalence of smoking among nurses working in hospitals in the south of France three years after the entry into force of legislation banning smoking in the workplace. 30% of the nurses were smokers. After the law was passed, up to 72% of smoking nurses reported that they had reduced their daily cigarette consumption during working hours. Among the smoking nurses, 20% reported that they had quit smoking. O'Donovan (2009) states that the Republic of Ireland was the first country to ban smoking in all workplaces from March 29, 2004. The author conducted a study on a sample of 430 Irish nurses using a structured questionnaire and found that 44% of nurses were smokers, with the highest prevalence of smokers in the 20-30 age group. It looked at the correlation between smoking and the type of workplace, and the research showed that nurses working in psychiatric wards (47%) and coronary care (33%) were the most likely to smoke. Only 14% of the interviewed nurses completed smoking cessation training. Kapka et al. (2019) conducted a systematic review and meta-analysis of 229 studies on smoking in healthcare workers. They found that a total of 45% of nurses smoke. They provided evidence of declining smoking prevalence among nurses in the US and New Zealand. In 2015, an international survey of smoking among healthcare professionals was carried out and smoking rates for nurses range from 2% in China to 26% in Northern Ireland, over 30% in Italy, Serbia and Spain. Out of 142 states, only 44% of countries offer health care professionals help in quitting tobacco addiction.
The next item was the tolerance of smoking breaks during working hours. 88.8% of non-smoking nurses, 57% of smoking nurses and 76% of female managers responded positively. Mladá (2018) presented at the conference of the Joint Accreditation Commission in Prague the experience of introducing a smoke-free environment in the Central Military Hospital in Prague, which became a member of the GLOBAL NETWORK FOR TOBACCO FREE HEALTHCARE SERVICES in 2018 and joined the International Network of Health Promoting Hospitals and Health Services. The management of ÚVN conducted a survey and found that 35% of nurses and 17% of doctors smoke. Nurses spend 10 minutes of their working time smoking one cigarette and an average of 5 cigarettes per 12-hour shift, which represents 10 days a year for which they are paid but work because they smoke during working time. The management's intention within the no-smoking policy at the workplace was to ensure equal working conditions for all employees. As part of the strategy to promote non-smoking in ÚVN and the treatment of tobacco addiction, internal directive no. 06/2017 "Smoking rules at ÚVN", educational programs during the Days of the Healthy Hospital, opened "Center for tobacco addicts at ÚVN", realized project "Smoking cessation for employees", published several educational materials about the harmful effects of smoking and many other activities. By gradually applying the measures, they are trying to overcome obstacles, because not all employees-smokers are identified with the new concept.
There were three open items in the questionnaire intended for non-smoking nurses. We categorized the answers according to repeated statements. We asked nurses why they consider smoking a work handicap. This question was answered by nurses who answered positively in the previous question and consider smoking a work handicap. The most common reasons given by nurses were: "it delays work, I don't like smoking, smoking bothers me, nurses who don't smoke are at the workplace longer, have fewer breaks and also work for smoking nurses, it's at the expense of working time, nicotine addiction causes nervousness and lack of concentration, smokers don't pay enough attention to patients, less time for work, a bad role model for patients." In another open item, we found out how a non-smoking environment is enforced in medical facilities. The most common answer was that it is not enforced. From the other answers, we select the methods: "from the directorate: threats of sanctions for smoking at the workplace, withdrawal of personal allowance, in our collective we are all non-smokers and we support each other in not smoking, balconies are locked so that no one smokes there, the department management constantly admonishes the nurses not to smoke during working hours." In the third open item, we monitored how they perceive the smoking breaks of superiors, heads of departments or hospitals. In general, it can be concluded that the nurses' answers were identical - it depends on whether the superior is a smoker or a non-smoker. "They do not tolerate smoking in the workplace, if smoking is detected in the workplace, it is dealt with by personal agreement. There are not many smokers in our workplace, but those who smoke - smoke exclusively when their work is done. Smoking never lasts longer than 5 minutes. The problem is if one of the nurses does not take care not to "stink", then the superiors intervene with a verbal warning. They tolerate or ignore smoking breaks. Superiors smoke with their subordinates. Superiors don't care. The non-smokers comment on it, but the smokers' superiors join the side of the smokers.' Also from the study by Sarna et al. (2005) found that smoking nurses spent less time with patients than non-smoking nurses and had more smoking breaks during working hours. Weng et al. (2012) conducted a systematic review and meta-analysis of 29 studies conducted between 1960 and 2011 in Europe, Australia, New Zealand, the United States, and Japan, with a total of more than 71,000 workers in the public and private sectors, in which they focused on the correlation between smoking and absenteeism at work. They found that smokers miss work two to three days longer than non-smokers. Their absence from the workplace costs UK businesses a total of £1.4 billion or $2.25 billion a year. However, the authors of the study emphasize that this amount does not include other costs associated with smoking - for example, more frequent work breaks, which lead to a decrease in employee productivity. According to the authors, the loss of £1.4 billion in the UK due to smoking-related absenteeism is just one of the costs of smoking in the workplace. Others include lost productivity due to smoking breaks and the cost of damage caused by cigarette fires. The study shows that smokers are 33% more likely to be absent than non-smokers. The study authors also calculated that smokers are 19% more likely to be absent from work than people who have stopped smoking. The results of this study suggest that smoking cessation in the workplace could potentially lead to cost savings for employers due to reduced absenteeism. Around one in five adults in both the UK and US are current smokers. According to the US Centers for Disease Control and Prevention, between 2000 and 2004, cigarette smoking was responsible for $193 billion in health-related economic losses in the US each year, about half of which was due to lost productivity.
We also focused on the assessment of smoking in nurses from the point of view of safety at work. We verified this intention in the questionnaire with several items. 86% of female smokers said that they were instructed about the prohibition of smoking in the workplace, but only 72% of them know that there is an internal regulation on the prohibition of smoking at their workplace, and 70% were familiar with this internal directive. In table no. 4 we present the answers of female respondents-smokers. Differences in symmetry appear to be statistically insignificant when processed by the McNemar test (p=1.00). We can interpret these findings in such a way that the reasons for not familiarizing ourselves with the developed guideline can be a short employment relationship or the memory trace being covered by other obligations and regulations at the workplace as well as a subjective perception of the hierarchy of importance of the workplace regulations depending on the nurse's position. 73% of non-smoking nurses and 85% of female managers also declared internal documentation on the ban on smoking.
Table 4 The relationship between the declaration of the prepared directive on smoking and familiarization with it by the employer among female smokers
Conclusion
Smoking in the workplace causes an organization to lose productivity and increase absenteeism. By offering smoking cessation programs in the workplace, organizations can improve employee health and, in the long term, strengthen their bottom line by reducing healthcare costs and improving productivity. Some organizations do not employ or hire smokers due to the negative effects of smoking on other employees, and the organization or the smoking employee's working hours do not include a smoking break of 30 minutes in addition to the rest and meal break time according to § 91 of the Labor Code.
The smoking ban is not fully respected in medical facilities, neither by patients nor by nursing staff. Among other things, it is also related to the fact that there is still a high number of smokers among health workers. The indoor smoking ban is observed, but smoking employees in work clothes can be seen in front of the building, by the side entrance, which creates a bad impression.
Smoking nurses use their working time inefficiently. In the case of smoking nurses, mutual interaction is evident, where the time-consuming nature of nursing care meets the need to satisfy their nicotine addiction. The consequences of smoking will be manifested in the deterioration of the state of health, which will affect the requirements for the performance of the nurse's profession. Smoking limits the provision of nursing care and management function. Nurses should be an example for the public in taking care of their own health, they come into contact with patients who cause illnesses by their own irresponsible behavior (Dimunová et al., 2016; Dimunová, Mechírová, 2013). Nurse managers should begin to perceive the smoking of nurses as a limiting factor in the work performance of nurses with regard to the shorter time devoted to providing nursing care, but also the impact of smoking on the health status of nurses.
Research Limitations Individual categories of respondents were not homogeneous. The size of the sample of respondents is also a limiting factor. Even so, we believe that the results can be considered for acceptable. The results point to the need for targeted measures to address the situation, it is necessary to take this issue into account when creating strategic plans in management in nursing, when providing support and programs for nurses to quit smoking, when introducing a no-smoking policy in medical facilities. Tobacco dependence in nurses is a neglected area from the point of view of nursing management.
Authors: *** doc. PhDr. Viera Hulková, PhD., MPH Department of Nursing, Faculty of Health Sciences, Alexander Dubček University of Trenčín in Trenčín RNDr. Vladimír Meluš, PhD., MPH Faculty of Health Sciences, Alexander Dubček University of Trenčín in Trenčín prof. PhDr. Mária Kilíková, PhD., MPH*** VŠZ and SP St. Elizabeth Bratislava, n. o., Detached workplace bl. Sáry Salkaházi, Rožňava
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SR Act No. 377/2004 Coll. on the protection of non-smokers and on the amendment of some laws
SR Act No. 311/2001 Coll. Labor Code as amended
SR Act No. 124/2006 Coll. on safety and health protection at work, as amended