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 DOI: 10.1016/j.ejcnurse.2010.08.001

2011 10: 221Eur J Cardiovasc NursKawkab Shishani, Hani Nawafleh, Samiha Jarrah and Erika Sivarajan Froelicher

Control in JordanSmoking Patterns among Jordanian Health Professionals: A Study about the Impediments to Tobacco

  

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European Journal of Cardiovascular Nursing 10 (2011) 221–227www.elsevier.com/locate/ejcnurse

Smoking patterns among Jordanian health professionals: A study about theimpediments to tobacco control in Jordan

Kawkab Shishani a,b, Hani Nawafleh c, Samiha Jarrah d, Erika Sivarajan Froelicher e,f,g,⁎

a College of Nursing, Washington State University, P.O. Box 1459, Spokane, WA 99210, USAb The Hashemite University, Jordanc Mu'tah University, Mu'tah, Jordan

d Applied Science Private University, Amman, Jordane Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA

f Department of Epidemiology & Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA, USAg University of Jordan, Amman, Jordan

Received 7 April 2010; received in revised form 6 July 2010; accepted 10 August 2010Available online 9 September 2010

Abstract

Background: Little is known about Arab health professionals' smoking practices.Aim: This is the first study to examine smoking practices among Arab health professionals.Methods: Background: Little is known about Arab nurses and physicians' smoking patterns.Aim: This study aims to examine smoking patterns among Arab nurses and physicians.Methods: A total of 918 nurses and physicians participated in this study. Data were collected using the Global Professional Health Survey.Results: About 38.8% are current smokers. The smoking percentages for male nurses and male physicians were high (83.8%, 94.6%respectively) compared to female nurses and female physicians (16.2%, 5.4% respectively). Approximately 53.8% wanted to quit and 60.6%had made previous quit attempts that lasted for more than two days. About 64.1% believed that nurses and physicians who smoke were lesslikely to advise patients to stop smoking. The predictors of smoking were: age when tried first cigarettes OR=6.36, 95% CI=4.48, 9.04;father smokes OR=1.95, 95% CI=1.40, 2.72; mother smokes OR=1.99, 95% CI=1.18, 3.39; shift work OR=1.45, 95% CI=1.04, 2.03; andthe interaction (gender and profession) OR=1.82, 95% CI=1.55, 2.14.Discussion: Effective interventions often begin with and/or depend on nurses and physicians being committed to smoking cessation. Giventhe very high smoking rates among nurses and physicians a key priority must be to provide quit smoking programs and to enable them tobecome effective champions of smoking cessation nationwide.© 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Global health; Smoking; Waterpipe; Nurses; Physicians; Training

⁎ Corresponding author. 2 Koret Way Box 0610, San Francisco, CA94143-0610, USA. Tel.: +1 415 476 4833, +1 650 766 4833 (Mobile); fax:+1 415 476 8899.

E-mail addresses: hnawafleh@hotmail.com (H. Nawafleh),jarrahs@ju.edu.jo (S. Jarrah), Erika.froelicher@nursing.ucsf.edu(E.S. Froelicher).

1474-5151/$ - see front matter © 2010 European Society of Cardiology. Publishdoi:10.1016/j.ejcnurse.2010.08.001

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1. Introduction

Health professionals, particularly nurses and physicians,serve as strong role models for patients. They are also in afirst line position to screen smokers and advise them to quitsmoking [1]. Nurses and physicians' commitment to helpsmokers to quit smoking is linked to their own smokingbehaviors [2–5]. In fact, nurses and physicians influencepatients' attitudes and receptivity toward adopting smoking

ed by Elsevier B.V. All rights reserved.

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cessation interventions [6]. Thus, nurses and physicians whosmoke may not be credible role models and may thus beineffective in this role.

Significant numbers of nurses and physicians who aresmokers and non-smokers believe that physicians whosmoke are less likely to advise their patients to stop smoking[7,8]. In addition, nurses who smoke are less likely to take onthe role of health promotion with patients who smoke [9].Nurses and physicians who smoke send conflicting messagesto patients and to the public. However, nurses and physicianswho have successfully quit smoking are known to be some ofthe most effective smoking cessation interventionists [10].

Between 2002 and 2004, a survey including 10,939nurses and physicians in five countries of the World HealthOrganization's (WHO) Eastern Mediterranean Region(EMRO) were surveyed using a Global Health ProfessionalsSurvey (GHPS). Of the respondents, 70% (7613) werephysicians, 13% (1394) were nurses, 6% (701) were dentists,and 11% (1226) worked in allied professions. Of the totalsample, 23% were reported to be current smokers and 10%former smokers [7]. Smoking rates among nurses werereported to be higher than those of physicians [2,3,11]. Areport from Greece showed a greater proportion of Greeknurses who smoke than what was reported in the generalGreek population [3]. On the other hand, in a studyconducted in a cancer center in Jordan, smoking rates wereslightly higher among physicians (43%) compared to nurses(42%) [12].

Jordan was studied as a model Arab country in this studybecause it shares the culture and the language with the rest ofthe Arab world. Jordan also is ranked as the fourth highestArab country with regard to smoking rates in the EMRO[13]. The data reported from EMRO is on smokingprevalence in the general population, but none measuredsmoking prevalence in Jordanian nurses and physicians.Limited reports suggest that smoking rates among nurses andphysicians are high in Jordan; therefore, it is essential to haveregular surveillance of smoking rates and keep a database toobserve changes in behaviors. It seems paramount that asurvey begins with nurses and physicians in order to build astrong infrastructure, skill sets, and expertise among nursesand physicians who can then be deployed to provideinterventions for the public.

While the focus of this paper is to examine smokingprevalence rates among Jordanian nurses and physicians, thisconcern is not country specific because smoking is a globalhealth issue. The WHO in its second report on measures tostop the tobacco epidemic, “MPOWER,” highlights healthprofessionals' contributions to tobacco control nationallyand internationally [14]. Nurses and physicians are on thefrontline in their frequent encounters with the public.Therefore, addressing nurses and physicians' smokingbehaviors is a priority because their involvement in tobaccocontrol measures and programs are associated with their ownsmoking behaviors. An example from the U.S. demonstratesthat over three decades significant drops in smoking rates

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were measured in nurses and physicians [2]. A studycompared smoking rates of physicians and nurses in the U.S.with those in a country with low levels of tobacco controlefforts, and demonstrated that changes in rates of smokingamong nurses and physicians can have a positive influenceon national tobacco control activities [15].

The research questions are:

1. What are the smoking rates among Jordanian nurses andphysicians?

2. Are there differences in frequency and patterns ofsmoking between nurses and physicians, and are theredifferences in gender, and in work settings (EmergencyRoom [ER], Intensive Care Units [ICU's], Coronary CareUnit [CCU], Psychiatric Units)?

3. What are the independent predictors of smoking statusamong Jordanian nurses and physicians?

2. Methods

2.1. Design

A descriptive cross sectional design was used to answerthe above research questions.

2.2. Setting and sample

There are 98 hospitals in Jordan ofwhich ten hospitals wereselected as study sites according to the three major regions ofJordan (north, central Amman and south), representing urbanand rural hospitals [16]. All nurses and physicians wererecruited from the selected ten hospitals. Eligibility criteriaincluded all nurses and physicians who were current employ-ees of the ten hospitals. Exclusion criteria: (1) part-timeemployee; and (2) cannot read and respond in English. Englishis the formal instructional language used in teaching at nursingand medical colleges in Jordan. The core clinical courserequirements are given in English and Jordanian nurses andphysicians are accustomed to participating in research in theEnglish language.

2.3. Ethical consideration

Approval for this study was obtained from the Ministry ofHealth Research Ethics Committee. The investigation con-forms to the principles outlined in the Declaration ofHelsinki (Br Med J 1964; ii: 177).

2.4. Sample size calculation

Assuming that 30% of nurses and 50% of physicianssmoke, and setting beta as 20% and alpha 0.05 and using a2-sided test a sample size of 459 per group, thus n=918 isneeded to answer all research questions. This sample sizeis more than sufficient to estimate 30 to 40 independent

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predictors using the approximation of 10 to 15 subjects pervariable to be estimated [17].

Table 1Characteristics of the sample (n=918).

Characteristic Men % (n) Women % (n) Total % (n)

Marital statusSingle 48.6 (290) 44.6 (135) 47.3 (425)Married 49.7 (296) 53.5 (162) 50.9 (458)Widowed 0.3 (2) 0.3 (1) 0.3 (3)Divorced 0.7 (4) 1.3 (4) 0.9 (8)Separated 0.7 (4) 0.3 (1) 0.6 (5)

ProfessionRegistered nurse 64.6 (379) 88.6 (265) 72.7 (644)Physician 35.4 (208) 11.4 (34) 27.3 (244)

Mother smoker 4.0 (12) 5.0 (26) 4.3 (38)Father smoker 1.6 (5) 3.2 (19) 2.7 (24)

Type of shiftDay 28.6 (170) 36.3 (110) 31.2 (280)Evening 6.6 (39) 4.3 (13) 5.8 (52)Night 9.9 (59) 4.0 (12) 7.8 (71)Rotating 54.9 (326) 55.4 (168) 55.2 (494)

Type of unitMedical unit 15.5 (92) 13.87 (42) 14.9 (134)ICU 11.8 (90) 15.5 (47) 13.4 (119)

2.5. Data collection procedures

The WHO, Centers for Disease Control and Prevention(CDC), and the Canadian Public Health Association (CPHA)developed the Global Health Professional Survey (GHPS) in2004 that was used to collect data on tobacco use and cessationcounseling among health professionals. The GHPS is part ofthe Global Tobacco Surveillance System (GTSS). The GHPSis a valid and reliable measurement tool [18]. The GHPSconsists of a 66-item questionnaire with 7 domains:1) demographic questions (11 items); 2) tobacco useprevalence among health professionals (8 items); 3) exposureto environmental tobacco smoke (8 items); 4) attitudes towardtobacco (13 items); 5) smoking cessation (10 items);6) curriculum/training (7 items); 7) assessment of waterpipeuse (9 items). Waterpipe, also known as hookah, is a commonform of smoking in the Middle East with rising popularity inmany European and US cities; therefore, assessment ofwaterpipe use was added to the measurement tool byresearchers. This section was adapted from a standardizedquestionnaire recommended and used by well-establishedresearchers in waterpipe smoking [19]. The GHPS itemsresponse options consist of ordinal responses yes/no. As otherforms of tobacco use (e.g., chewing tobacco) are not practicedin Jordan, questions on their consumption were excluded.

Four research assistants (RA's) who were senior nursingstudents were selected and trained (by the primaryinvestigator) for data collection to ensure standardizationof protocol. Training included handling of possible questionsor requests from subjects regarding explanations of certainitems or words. For example, waterpipe has more than tennames and it was thought that some subjects would not befamiliar with this form of smoking or terminology.

Data were collected between March and August of 2007.Nursing and medical offices at each hospital were contactedto identify potential subjects. The estimated time to completethe survey was 30 min. Subjects were given the option tocomplete the survey immediately or later and they wereasked to return the survey to the assigned boxes at thenursing and medical offices. RA's collected the surveysdaily.

Surgical unit 15.1 (90) 9.9 (30) 13.3 (120)Emergency room 13.6 (81) 9.5 (29) 12.5 (113)Psychiatric unit 7.6 (45) 6.9 (21) 7.3 (66)CCU 8.1 (48) 2.3 (7) 6.1 (55)Operating room 6.4 (38) 4.6 (14) 5.7 (52)Pediatric unit 2.2 (13) 8.9 (27) 4.0 (40)Obstetric unit 1.2 (7) 9.5 (29) 4.0 (36)Burn unit 1.7 (10) 3.3 (10) 2.2 (20)Recovery room 1.5 (9) 1.6 (5) 1.5 (14)Other 15.5 (92) 14.1 (43) 15.1 (135)

Due to missing values, rounding may not always add to exactly 100%.CVD = cardiovascular diseases. ICU = Intensive Care Unit. CCU = CoronaryCare Unit.

2.6. Data analysis

Statistical analysis procedures were performed usingSPSS for Windows (version 11.5). Frequencies andpercentages were reported for dichotomous and nominalvariables; and ranges, and means (s.d.) were reported forratio and interval data. Logistic regression analyses estimat-ed the independent predictors of smoking status amongJordanian nurses and physicians and were reported as OddsRatio's (OR) with 95% Confidence Intervals (CI) [20].

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3. Results

This study enrolled 918 subjects from 10 hospitals inJordan representing the north, the south and the capital ofAmman, including public and private hospitals. Table 1describes the characteristics of the study sample for men,women and total. The participants were nurses (72.7%) andphysicians (27.3%); most were men (66.3%), and married(50.9%). The sample ranged in age from 20 to 74 years;mean 30.8 (s.d.±7.9). Of the 11 units that were identified,14.9% worked on a medical unit, 13.4% in an ICU, 13.3%surgical unit and 15.1% stated “other”. Rotating shift workwas the most common schedule (55.2%).

3.1. Smoking patterns by hospital units

The highest proportions who were smokers were found inthe ER (15.6%), medical units (15.3%), surgical units (15%),ICU's (12.1%), and psychiatric units (12.1%). A significantrelationship was found between being a smoker and workingin ICU, ER, and psychiatric units (p=0.00).

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Table 3Smoking patterns by profession.

Smoking patterns Nurses % (n) Physicians % (n) Total % (n)

Smoking statusCurrent smoker 36.1 (230) 46.9 (113) 39.0 (343)Former smoker 9.8 (63) 12.4 (30) 10.6 (93)Non-smoker 54.1 (345) 40.7 (98) 50.4 (879)

Forms of smokingCigarettes 78.6 (261) 86.8 (132) 81.2 (393)Waterpipe 21.4 (71) 13.2 (20) 18.8 (91)

Age when first tried a cigarette10 and younger 1.0 (5) 1.2 (6) 2.2 (11)11–15 5.8 (29) 1.8 (9) 7.6 (38)16–17 11.8 (59) 5.0 (25) 16.9 (84)18–19 18.9 (94) 7.4 (37) 26.3 (84)20–29 28.9 (144) 14.4 (72) 42.3 (216)30 and older 2.6 (13) 1.0 (5) 3.6 (18)

When started smoking?Before entering the

university55.1 (190) 40.1 (63) 50.4 (253)

After entering theuniversity

44.9 (155) 59.9 (94) 49.6 (249)

Do you want to quit smoking?Yes 51.6 (181) 59.2 (87) 53.8 (268)No 48.4 (170) 40.8 (60) 46.2 (230)

224 K. Shishani et al. / European Journal of Cardiovascular Nursing 10 (2011) 221–227

3.2. Smoking patterns by gender

The smoking percentages for male nurses and malephysicians were high (83.8%, 94.6% respectively) comparedto female nurses and female physicians (16.2%, 5.4%respectively). Waterpipe use was prevalent in women(29.1%) more than men (17.3%) (Table 2).

3.3. Smoking patterns by profession

The overall smoking rate was 39.0% (Table 3). Smokingwas higher in physicians (46.9%) compared to nurses(36.1%). More physicians started smoking after they enteredthe university (59.9%) compared to nurses (44.9%). Of thetotal 161 smokers who considered quitting smoking byanswering yes to the question “Do you want to quit now?”53.9% were physicians and 43.4% were nurses; thedifference was not statistically significant.

3.4. Characteristics of smokers

A series of exploratory analyses were conducted usingsets of demographic, clinical and smoking history variables.A final parsimonious logistic regression model was tested toevaluate the independent contribution of five variables and

Table 2Smoking patterns by gender.

Smoking patterns Men % (n) Women % (n) Total % (n)

Smoking statusSmoker 50.6 (300) 14.9 (44) 38.8 (347)Former smoker 13.0 (77) 6.4 (19) 10.9 (98)Non-smoker 36.4 (216) 78.6 (232) 50.3 (450)

Forms of smokingCigarettes 82.7 (339) 70.9 (56) 80.8 (395)Waterpipe 17.3 (71) 29.1 (23) 19.2 (94)

Age when first tried a cigarette10 and younger 2.6 (11) 0.0 (0) 2.2 (11)11–15 8.6 (36) 4.9 (4) 8.0 (40)16–17 19.5 (82) 4.9 (4) 17.1 (86)18–19 27.1 (114) 23.2 (19) 26.4 (133)20–29 39.8 (168) 56.1 (46) 42.0 (214)30 and older 2.4 (10) 11.0 (9) 3.8 (19)

Do you want to quit smoking?Yes 52.0 (216) 62.0 (54) 53.8 (270)No 48.0 (199) 37.9 (33) 46.2 (232)

Have you ever tried to quit?Yes 61.9 (255) 54.9 (50) 60.6 (305)No 38.1 (157) 45.1 (41) 39.4 (198)Yes 77.7 (442) 75.6 (214) 77.0 (656)No 22.3 (127) 24.4 (69) 23.0 (852)

Health professionals who smoke are less likely to advise patients to quitYes 64.8 (330) 79.5 (155) 68.9 (485)No 35.2 (179) 20.5 (40) 31.1 (219)

Due to missing values, rounding may not always add to exactly 100%.

Have you ever tried to quit?Yes 59.9 (212) 63.4 (92) 60.9 (304)No 40.1 (142) 63.6 (53) 39.1 (195)

How many times have you tried to quit smoking?1–3 times 62.6 (126) 78.7 (63) 64.4 (189)More than 3 times 37.4 (50) 21.3 (17) 35.6 (67)Yes 76.7 (467) 79.1 (185) 68.8 (652)No 23.3 (142) 20.9 (49) 31.2 (191)

Health professionals who smoke are less likely to advise patients to quitYes 71.0 (353) 63.4 (128) 62.7 (481)No 29.0 (144) 36.6 (74) 31.2 (218)

Due to missing values, rounding may not always add to exactly 100%.

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included an interaction term (gender x profession) (Table 4).The odds ratios (OR) and 95% Confidence Intervals (CI) forthe five variables (and the interaction term) were: age whentried first cigarette OR=6.36, 95% CI=4.48, 9.04; fathersmokes OR=1.95, 95% CI=1.40, 2.72; mother smokes

Table 4Logistic regression to estimate the independent contribution of 5 variableson smoking status.

Independentvariables

OR 95.0% C.I. for OR

Lower Upper

Marital status 1.38 0.98 1.93Type of shift 1.45 1.04 2.03Age started smoking 6.36 4.48 9.04Father smokes 1.95 1.40 2.72Mother smokes 1.99 1.18 3.39Gender *Profession 1.82 1.55 2.14

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OR=1.99, 95% CI=1.18, 3.39; shift work OR=1.45, 95%CI=1.04, 2.03; and the interaction (gender and profession)OR= .82, 95% CI=1.55, 2.14. Marital status was notsignificant.

3.5. Smoking patterns

Cigarette smoking was reported by 80.8% and waterpipeby 19.2% of the sample as the primary methods of smoking.Initiation of smoking ranged from 10 to more than 30 years.However, most started smoking first when they were in their20's; 44.6% reported that a modal cigarette consumptionpatterns was 11–20 per day; and of those who reportedsmoking waterpipe, 97.0% stated that they smoked 1–3sessions per week. With respect to the tobacco dependencemeasures, 57.3% reported smoking within the first 30 min ofawakening. A total of 53.8% said “yes” to the question “Doyou want to quit smoking?” and 60.6% had made a previousquit attempts that lasted more than two days.

3.6. Smoking knowledge and beliefs

The knowledge and beliefs of smokers show that aboutone fourth did not believe that smoking is harmful to healthand answered “no” when they were asked “My smoking isharming my health”; 53.4% believe that there is very littlebenefit from quitting smoking after having smoked for20 years.

When asked: “Are a patient's chances of quitting smokingincreased if a health professional advises him or her to quit?”74.5% of the smokers answered “yes” and 25.5% answered“no”. Also, when asked “Are health professionals whosmoke less likely to advise patients to stop smoking?” 64.1%stated “yes”; and 35.9% answered “no”.

Nurses and physicians were where asked about theaddictive properties of tobacco: 31.5% stated that cigarettesare addictive; 7.6% stated that waterpipe is addictive, and40.4% stated that both are addictive; while 20.5% of thesenurses and physicians endorsed that “None” are addictive.

4. Discussion

This study addresses an urgent health problem becausenurses and physicians influence the public. This study soughtto explore the smoking patterns of nurses and physicianswho worked in Jordanian hospitals. These sites representedgovernment, private, as well as rural and urban hospitals.

Comparisons between the nurses and physicians and thegeneral population indicate that the largest group of smokers inthe general population are in the 35–49 years age group unlikenurses and physicians who smoke are mostly in their 20's [21].Interestingly, smoking rates bymales in the general population(50.5%) were similar in male nurses and physicians (50.6%).However, smoking rates were higher in female nurses andphysicians (14.9%) than females in the general population(8.3%) [22]. According to forms of smoking, men reported

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smoking cigarettes as their first choice of tobacco products,whereas women reported smokingwaterpipe use.Waterpipe isnot considered as a form of smoking and is a widely acceptablesocial practice in many Arab countries [23–25].

The sample consisted of 73% nurses and 27% physicians;higher smoking rates were reported by male nurses and malephysicians than by female nurses and physicians. Thepresence of an interaction between gender and professionon smoking status is apparent, as there are more nurses andphysicians who are males in Jordan, and men smoke at muchhigher rates than women. An analysis that does not take thisinteraction effect into consideration is potentially flawed.About 45% of nurses in Jordan are males. Furthermore, 60%of the nursing graduates over the last four years have beenmales. The Jordanian nursing council took several initiativesto encourage more females to consider studying nursing.Additionally, cultural norms show that women's smokingbehaviors are perceived negatively in the Arab cultures [26].Social image is an essential element in theses cultures.Therefore, many Arab women who smoke tend to avoidsmoking in public and even under report their smokingbehavior.

Nurses working in specialties such as in the operatingroom, psychiatric units, and ICUs report higher smokingrates than those working in other specialties [27]. Thisfinding is consistent with the present study, in that nursesworking in ICUs, Emergency room, and Psychiatric Nursingreported higher smoking rates than those working in otherunits and wards of the hospital. The reasons for thisobservation are not totally clear, but may be due to stress,personal characteristics, and professional role conflicts [28].

Both male and female smokers reported smoking their firstcigarette of the day within 30 min of awakening, suggesting avery high level of addiction [29]. More than half of the sampleexpressed the desire to quit smoking. A higher proportion ofwomen (62%) indicated the desire to quit compared to men(52%); however, more men actually attempted to quit and ahigher proportion made more quit attempts. About 70.4%acknowledged having made 1–3 previous quit attempts; thehigh interest in quitting was confirmed by prior reported quitattempts. It is obvious that smokers were highly addicted tonicotine, were unsuccessful in the previous quit attempts andmost importantly were interested in quitting. This can serve asevidence that there is a need for training nurses and physiciansin smoking cessation counseling and the use of pharmacolog-ical interventions to help them with successful smokingcessation.

It is of interest that in contrast to physicians, a higherproportion of nurses started smoking before entering theuniversity and both nurses and physicians increased theirsmoking once they started clinical work. This finding hasimportant implications for deans and educators of schools ofnursing and medicine. Incorporating such information into thestudent orientation program for incoming freshman is a strongmessage about the importance of smoking cessation, given thatthey are pursuing a profession in health care, and offer them on

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campus smoking cessation programs. Additionally, theawareness that smoking increases when students in nursingand medicine begin their clinical work calls for an additionalaction during this critical transition phase.

The most worrisome finding was that many nurses andphysicians who smoke are highly addicted, yet do notacknowledge or know the addictive properties of tobaccoproducts (cigarettes or waterpipe). Theses nurses andphysicians lacked knowledge in evidence-based interven-tions for smoking cessation. This is a global concern, asgrowing number of research studies indicate that nurses andphysicians need formal training in treating tobacco depen-dence [30]. In an international study that examined variousregions of the WHO, upper and middle income countries hadevidence-based training programs for tobacco treatment[31], yet more could be done to assure that such programsexist around the world.

The updated clinical guidelines even demonstrate that theinvolvement of more than one type of clinician in providingtobacco treatment programs ensures better outcomes [32].Thus, there is a window of opportunity to adopt evidence-based clinical guidelines that are culturally sensitive andtarget nurses as well as physicians. Nurses and physicianswho smoke are less likely to advise their patients to quit[5,6]. Therefore, helping nurses and physicians to quit,means not only does the nurse or physician gain personallyfrom being smoke free, but equally importantly, theirpatients will also benefit.

While not a random sample, it nevertheless represents abroad spectrum of practitioners. Also, the extent to whichnurses and physicians who are not in this sample are similarto those who were is unknown and there is no reliable way toestimate any potential selection bias.

4.1. Summary

The findings fromour study provide strong evidence for theneed of an urgent action with respect to providing formalsmoking cessation training to nurses and physicians. Bymaking nurses and physicians a priority for intervention allowsthem to gain personal health benefits, and as the literaturesuggests, would create tobacco use control advocates in allsettings. Training programs that target physicians and nursescan increase the chances of successful reduction of smoking onan individual level, and reduction of preventable smoking-related diseases. Further study is needed to see if worldwidereductions may be achieved by targeting Jordan and similarcountries, where nurses and physicians monitor their nationaltrends for high smoking rates.

Nurses and physicians are in an excellent position toinfluence behaviors of the public through role modeling.They are instrumental in promoting healthy lifestyles amongindividuals and populations. Increasing their access toinformation and evidence-based strategies that improvetheir own health habits can optimize their impact on others.

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While the findings of this study were obtained in Jordan,they are likely to be relevant to Arabs in other Arab counties.Global tobacco control organizations can benefit from thefindings of this study when working with these countries ondeveloping national tobacco control programs.

Acknowledgment

The authors would like to thank Marian Wilson for assistingwith the preparation of the manuscript. This work was supportedby the Jordanian Nurses and Midwives Council (JNMC).

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