This study’s findings are based on data from health professionals working in one large hospital, and therefore, may not be representative of all healthcare providers in Armenia. The anonymous questionnaire limited a social desirability bias, however, the extent of over-reporting of positive attitudes and under-reporting of smoking behavior cannot be assessed. The research team pre-tested a survey instrument adapted from one used elsewhere, but its validity in the study population has not been studied formally. The participation in the survey was high and the response rates are comparable with other studies in this population
Furthermore, the study was conducted in the largest cancer hospital in the country, where one would presume that the providers have the most knowledge of and first-hand experience with the consequences of smoking. The combination of quantitative and qualitative methods enriched our understanding of the survey results and helped to reveal unforeseen issues related to postoperative care of cancer patients.
Similar to the results of Perrin et al.
, worksite smoking was normative among the doctors; however, it was limited to physicians’ offices. Nurses smoked fewer cigarettes at work than physicians, likely due to the lack of private space and time afforded. The survey showed that nurses more often reported to receive smoking cessation training and they were more likely to consider health professionals as role models for patients and the public than physicians. Nurses and physicians of the oncology center strongly supported and shared the view that health professionals in general should routinely advise their patients to quit smoking. However, the qualitative study demonstrated that physicians were likely to underestimate the value of their own advice and participation in smoking cessation counseling and they were more prone to delegating the counseling role to other specialists, such as primary health care providers or cardiologists. This lack of oncologists’ interest to be closely involved in smoking cessation assistance could be explained by lack of appropriate training on smoking cessation counseling along with lack of time and incentives as suggested by both qualitative and quantitative findings.
More nurses than physicians reported having received training on smoking cessation. This is consonant with the earlier study by Warren et al. that found a similar gap in the reported smoking cessation training among nursing (43.1%) and medical (32.3%) students in Armenia
. Furthermore, more than a third of physicians in our study reported not being taught about risks of smoking in a medical school which calls for a critical review of the current medical training curriculum in Armenia.
While skeptical of its effectiveness, both the survey and FGDs demonstrated that both nurses and physicians supported indoor smoking ban in the hospital. Current smokers, understandably, were not as supportive of the smoke-free policy and were less willing to assist smokers in quitting; these findings were consistent with other studies that reported about association between the smoking status and attitudes towards smoke-free policies
[19–22]. The findings of this study also indicate about a very early stage in the movement for smoke-free hospitals in Armenia that could be compared, for example, to the situation in the US in late 80s prior to adopting standards for smoke-free hospitals by the Joint Commission on Accreditation of Healthcare Organizations
[23–25]. Presently, hospitals in high income countries are making a transition from indoor smoking ban toward smoke-free campuses
[26, 27]. Such a transition is not feasible yet in Armenia where implementing hospital indoor smoking ban has been a challenge.
Another important, unexpected, finding was the knowledge gap related to tobacco addiction and treatment of nicotine dependence among these health professionals. The oncologists questioned the rationale for smoking cessation efforts targeting cancer patients. Advising a patient in intensive care to light a cigarette was a common practice and believed to be a measure to prevent post-surgical complications. This finding confirms previous assertions that the quality of cancer care in Armenia needs more attention and improvement
Smoking remains normative not only in population at large but also among Armenian physicians
[13, 16]. While lower than the population prevalence in general, physicians’ smoking prevalence was almost five times that of the nurses. Part of this disparity reflects the wide gender differences in smoking prevalence rates among health care providers (44.6% for male physicians, 19.7% for female physicians, 6.5% for female nurses) as well as the general population (59.6% males, 2.1% females)
. These results are consistent with Perrin et al. (2004) findings on physicians’ smoking in Yerevan, Armenia
. However, the patterns of smoking among physicians and nurses in our study are different from the trends observed in many high income countries, where the smoking prevalence is higher among nurses compared to physicians
[15, 18, 21, 28, 29]. The low smoking prevalence of 6.5% among Armenian nurses in this study is still 3 times higher than the general rate for women and also over two times higher than the 2006 Global Survey of Nursing Students that reported a smoking prevalence of 2.4% for female nurses in Armenia, the lowest of the ten countries surveyed in the European region
. However, smoking prevalence in male physicians was much lower than in the general male population, suggesting that socio-cultural influences outside the scope of this study could be driving the relationships between smoking behavior, gender, and occupation.
This study adds to our knowledge of the barriers to more effective participation of health professionals as key players in smoking cessation efforts in Armenia and other similar economies in transition. Healthcare professionals in high income countries were the first to quit, paving the way for others as role models and as advocates for environmental and policy change
[8, 9, 11]. No such trend is yet apparent in Armenia. Our study identified a critical lack of appropriate knowledge and skills needed to help patients quit. It also revealed that oncologists’ motivation to personally serve as a role model for patients was low; this finding needs to be considered in a broader context such as normalcy of smoking behavior in the society and overload and stressful work environment for cancer care providers. All mentioned above are only a few of the challenges to building capacities for smoking cessation services within the Armenian healthcare system.