Review of Respiratory Medicine - Volumen 24, Número 4 - December 2024

Original Articles

Prevalence and Attitudes Towards Tobacco Consumption Among Workers at Axxis Hospital de Especialidades, Quito – Ecuador

Prevalencia y actitudes acerca del consumo de tabaco en los trabajadores de Axxis Hospital de Especialidades, Quito - Ecuador

ABSTRACT

Background: Tobacco causes more than eight million deaths annually, seven million due to direct use and 1.2 million due to indirect exposure. In 2020, 118 million people in the Americas consumed tobacco, with a prevalence of 11.5% in Ecuador.

Objectives: To determine the prevalence of tobacco use among healthcare profession­als at Axxis Hospital de Especialidades.

Methods: An observational, cross-sectional study was conducted. The study population consisted of workers from all units of the Axxis Hospital de Especialidades in June 2024.

Results: The sample consisted of 239 completed surveys. The mean age was 37 years, and most of the respondents were female (68 %). The prevalence of smoking in the sample under study was nearly 20% (8.3 % active smokers and 10.5 % former smokers). The individuals began to smoke between the ages of 15 and 19, accounting for 56 % of cases. When asked about their intention to quit smoking, 73 % expressed a strong desire to quit, 60 % planned to do so within the next six months, and 53 % within the next 15 days.

Conclusions: We conclude that the prevalence of smoking among workers at the Axxis hospital is low, with a low dependence on tobacco and a high willingness to quit smoking.

Keywords: Tobacco, Dependence, Healthcare workers

RESUMEN

Introducción: El tabaco causa más de ocho millones de muertes anuales, siete millo­nes por uso directo y 1,2 millones por exposición indirecta. En 2020, 118 millones de personas en América consumían tabaco, con una prevalencia del 11,5 % en Ecuador.

Objetivos: Determinar la prevalencia de hábito tabáquico en los profesionales de la salud en Axxis Hospital de Especialidades.

Materiales y métodos: Se realizó un estudio observacional, transversal. La población de estudio lo constituyeron los trabajadores de todas las unidades de Axxis Hospital de Especialidades en el mes de junio del 2024.

Resultados: La muestra estuvo constituida por 239 encuestas respondidas. La edad promedio fue de 37 años, la mayor parte de encuestados fueron de género femenino con un 68 %. La prevalencia de tabaquismo en la muestra estudiada fue casi un 20 % (8,3 % de ellos fumadores activos y 10,5 % exfumadores). El inicio del consumo de tabaco estuvo en el rango de 15-19 años, con el 56 %. Cuando se preguntó sobre la intención de dejar de fumar, el 73 % respondió que tiene un alto interés por dejar de fumar, el 60 % se proponía hacerlo en los siguientes 6 meses y un 53 % dentro de los siguientes 15 días.

Conclusiones: Concluimos que la prevalencia en tabaquismo de los trabajadores de Axxis hospital es baja, existe una baja dependencia al tabaco con un alto deseo por dejar de fumar.

Palabras clave: Tabaco, Dependencia, Trabajadores de la salud

Received:11/28/2024

Accepted:01/08/2025

INTRODUCTION

Tobacco consumption is known to be associated with various diseases and causes high morbid­ity and mortality. According to the WHO (World Health Organization), tobacco causes more than eight million deaths annually, seven million re­lated to direct use and 1.2 million due to indirect exposure. In 2020, the prevalence of tobacco use in the Americas was estimated at 118 million people, while in Ecuador, it was calculated to be 11.5%.¹

Smoking is a significant risk factor for many chronic diseases, including many types of cancer, chronic respiratory diseases, cardiovascular dis­eases, and metabolic disorders such as diabetes. Therefore, smoking has been recognized as the single most important preventable cause of mor­bidity and premature mortality.

A key aspect of controlling this condition is the role of healthcare professionals, who are essential in health promotion and disease prevention, in­cluding smoking cessation. They provide counsel­ing on the risks of smoking and offer strategies to reduce tobacco use. However, a portion of health­care professionals themselves engage in tobacco consumption.

Thus, tobacco control policies depend largely on the commitment of healthcare workers, specifically their attitudes and behavior toward smoking, both personally and professionally.² Since 2004, Ecuador has been a signatory to the WHO Framework Con­vention on Tobacco Control, requiring the country to adopt policies aimed at protecting present and future generations from the potential environ­mental, health, social, and economic devastation caused by tobacco consumption, its derivatives, and exposure to tobacco smoke.³

The primary objective of this research is to analyze the prevalence of conventional and elec­tronic tobacco use in a tertiary care level hospital in the city of Quito, Ecuador. A previous study conducted in the city of Cuenca found that 32.4% of physicians were smokers, with a higher preva­lence among males.⁴

This study will provide an objective view of tobacco consumption among healthcare profes­sionals that will contribute to the development of effective strategies to reduce its prevalence in the hospital environment.

OBJECTIVES

General

To determine the prevalence of tobacco consump­tion among healthcare professionals at Axxis Hospital de Especialidades.

Specific

Establish the prevalence of patients who smoke or used to smoke.

Compare prevalence indicators according to occupation.

Characterize tobacco consumption among smok­ers.

Analyze the degree of dependence in smokers.

Assess the person’s willingness to quit smoking.

METHODS

An observational, cross-sectional study was conducted. The study population consisted of workers from all units of the Axxis Hospital de Especialidades in June 2024. Through the use of a survey, an anonymous questionnaire was provided which lasted approximately five minutes, and was sent digitally to all hospital workers.

The inclusion criterion was to be medical or non-medical staff working at Axxis Hospital. The exclusion criterion was failure to respond to the survey.

The variables studied included:

-Demographic variables: Age, gender, occupation.

-Variables regarding tobacco consumption: Dependence measured by the Fagerström test and time to the first cigarette, age of initiation, reason for initiation, type of tobacco consumed.

-Variables regarding the attitude towards smoking: Considering smoking as a disease, a habit, or as not being harmful to health; motivation to quit smoking.

-Variable regarding perceived risks of electronic and conventional cigarettes

Statistical analysis

The baseline characteristics of the patients were des­cribed using standard statistical methods. Continuous variables were compared using the Student’s t-test or the Mann-Whitney test, as appropriate. Categorical variables were compared using the Chi-Square test or the Fisher’s exact test when necessary.

The analyses were performed using the statistical soft­ware JASP, Version 0.17.2.1 5.

P-values< 0.05 were considered statistically significant.

RESULTS

The sample consisted of 239 completed surveys. The mean age was 37 years, and most of the respondents were female, as shown in Figure 1 (67.8%). The distribution of respondents by discipline was as follows: physicians 34.31%, ad­ministrative staff 25.5%, nurses 13.39%, nursing assistants 8.37%, and the rest belonged to other categories, shown in Figure 2. The distribution of smoking status is presented in Figure 3. The prevalence of smoking in the studied population was 18.8%, with 11.30% in men and a lower impact in women, at 7.53%. Of this total, 8.3% were daily or occasional smokers.

From the study group, a total of 45 people have been or are currently exposed to tobacco consumption. Of these, twenty-five respondents (55.56%) have quit smoking, which is a positive finding in terms of reducing smoking in this population. However, eleven people (24.44%) are still occasional smokers, while nine people (20%) smoke daily. Overall, 44.44% of the respondents continue to smoke, either occasionally or daily. These results highlight the importance of main­taining and strengthening strategies of smoking prevention and cessation to reduce its prevalence in this population.

The following table shows the distribution of smokers and former smokers across different age groups. The highest proportion of former smok­ers is in the 36 to 40-year-old range (15.56%). The percentage of daily smokers is relatively low in general, with the highest prevalence among those aged 26 to 30 and 31 to 35 years (4.44%). The highest concentration of occasional smokers is in the 26 to 30-year-old range (8.89%). The age range with the highest total proportion of smokers is 26 to 30 years (17.78%), followed by the 41 to 45-year-old range (17.78%).

Smoking in all its forms was higher among phy­sicians (46.67%), and lower among administrative staff (31%), accounting for 23% in other areas. Despite their knowledge of tobacco-related risks, physicians had the highest percentages of both former and active smokers. Administrative staff also showed high smoking rates, while students and nursing assistants had the lowest prevalence. The main reason why the population started consum­ing tobacco was peer influence, accounting for 78%. Daily smokers began to smoke between the ages of 15 and 19, accounting for 55.56% of cases. Men are not only the majority of daily smokers but also tend to start smoking at a younger age, especially between 15 and 19 years old, while women who smoke appear to have started later, after the age of 20 (Table 4).

This study showed that 56% of surveyed smok­ers smoke their first cigarette 60 minutes after waking up. Meanwhile, in the former smokers’ group, this percentage increases to 83% within the same time range. Most of the evaluated smokers have low to moderate nicotine dependence, with scores ranging from 0 to 3 points. Only smoker 143 exhibits high dependence, scoring 8 points, due to heavy smoking, difficulty quitting, and continuing to smoke even when sick. Smoker 153 has mod­erate dependence, with a score of 4, as shown in Figure 5. A total of 88.89% of smokers consume between 1 and 11 cigarettes per day, indicating that most smokers in this group have relatively low to moderate cigarette consumption. Meanwhile, 11.11% of respondents smoke between 21 and 30 cigarettes per day, representing a minority of high-consumption smokers.

The study found that 18% of daily smokers re­ported having used electronic cigarettes, while 73% indicated that they used conventional cigarettes. Additionally, 9% of respondents reported using cannabis. These results highlight the prevalence of conventional cigarettes over other forms of consumption, such as electronic cigarettes and cannabis.

Regarding the perception of electronic cigarettes and their harmfulness among current smokers, 22% believe they are less harmful than conven­tional cigarettes. Furthermore, 62% of respondents considered smoking a bad habit, while 29% of healthcare professionals viewed tobacco use as a chronic disease. However, 9% of people surveyed believe that tobacco consumption is not harmful to health.

The study also revealed that 77.78% of partici­pants (7 out of 9) have attempted to quit smok­ing at least once, reflecting a strong motivation to quit this bad habit. Regarding the frequency of cessation attempts, it was found that 14.29% of respondents attempted to quit twice; 28.57% tried three times, and 57.14% (4 out of 7) have attempted to quit smoking five or more times. This last finding suggests that, although these individuals show strong persistence, they also face significant barriers to achieving successful cessa­tion. These challenges may be related to factors such as nicotine dependence or the lack of adequate professional support.

When analyzing the type of support received during cessation attempts, 71.43% of smokers tried to quit on their own, without seeking help from healthcare professionals. In contrast, the remaining 28.57% sought professional support during their attempts; this group mainly consisted of people who had made five or more attempts.

Regarding the use of pharmacological treat­ments, it was observed that 71.43% (5 individuals) of those who attempted to quit did not use medi­cation, and all those attempts were made without professional support. On the other hand, 28.57% (2 individuals) who used medication for cessa­tion did so under the supervision of a healthcare professional.

When asked about their intention to quit smok­ing, 73% of respondents expressed a strong desire to quit, 60% planned to do so within the next six months, and 53% within the next 15 days.

DISCUSSION

Smoking is a major public health issue. In Ecuador, 15 people die each day due to tobacco consumption. 13% of the population aged 18 to 69 are smokers, with a higher prevalence among men (23%) than women (4%). Additionally, 3 out of 10 adolescents between the ages of 13 and 15 have smoked at least once in their lives.⁵

This study found that nearly 20% of the stud­ied population were smokers or former smokers, a significantly lower percentage compared to the study conducted by Juranik et al,⁶ where 35% of respondents were active smokers and 5.8% were former smokers. When compared to another study conducted in the province of Azuay by Sánchez and Lisanti, which reported a smoking prevalence of 32%, our study still reflects a lower percentage. The low prevalence of tobacco consumption is one of the most encouraging findings of our study, espe­cially when compared to data from Latin America, with a study conducted in Argentina⁷ among medi­cal students and graduates which reported 27% of smokers and 52% of former smokers. However, the prevalence of tobacco use in two similar studies conducted in Spain was 11.7% in a 2015 study on primary care health professionals, medical special­ists, and nursing staff, and 6% in a 2023 study on members of the Spanish Society of Pulmonology and Thoracic Surgery. This suggests that Spanish healthcare professionals are beginning to serve as role models for society as non-smokers.

Surprisingly, in our study, the prevalence of smoking among physicians was higher than among administrative staff. This may seem unlikely, as physicians should set an example for their patients and be fully aware of the health risks associated with tobacco use. Published data from Casals et al¹⁰ show the following smoking rates for healthcare professionals in Catalonia: more than one third of nurses (35.1%), nearly one-quarter of physicians (24.5%), and one-fifth of pharmacists (20.4%) are smokers. The literature suggests that disadvantaged populations smoke more than others. To some extent, doctors may also be considered a disadvantaged group due to their cumulative risk factors for smoking. They face a heavy workload, often exceeding 40 hours per week. This excessive stress can even contribute to depressive disorders, which are also risk factors for smoking. Addition­ally, many doctors work night shifts, disrupting their circadian rhythm, which may further in­crease smoking behavior. A study by Donovan¹¹ revealed that nurses working in psychiatric care (47.4%) and coronary care (33.3%) have the highest smoking rates. Therefore, we suggest promoting healthy habits such as maintaining a balanced diet, engaging in regular physical activity, and ensuring sufficient sleep for the purpose of managing the anxiety inherent in the medical profession and contributing to overall well-being.^10-13

According to specialized literature, most smok­ers adopt this habit before the age of 20. In our sample, 56% of smokers started smoking between the ages of 15 and 19, a finding similar to that of Sánchez⁴ and Minervini.¹⁴

Although the overall prevalence of smoking has declined in recent years in several countries, as shown by Ranchal¹⁵ who documented a 53.4% decrease in smoking rates between 1986 and 2016, partly due to stricter legislative measures, 9% of our respondents still consider tobacco to be harm­less to health. This perception, also observed by Pold,¹⁶ indicates that male smokers were six times more likely to agree that smoking is not as danger­ous as experts claim and seven times more likely to believe that smoking does not harm a person’s health if the person maintains a healthy lifestyle.

If we consider tobacco dependence, more than half of smokers—56%—light their first cigarette more than an hour after waking up. Overall, re­spondents showed low scores on the Fagerström test, indicating a mild physical dependence on nicotine. These findings are very similar to those observed in a study conducted on nursing staff by Schottlender¹⁷ et al. When compared to a study conducted within the Spanish Society of Pulmon­ology and Thoracic Surgery, published by Solano et al,¹⁸ 69% of participants reported smoking their first cigarette more than an hour after waking up—a higher percentage compared to our study. This difference may be due to the fact that thoracic specialists have greater knowledge about this topic and place significant importance on serving as role models for the general population by being non-smokers.

Based on these results, measures should be developed to reinforce smoking bans in the work­place, provide education and training on tobacco use and cessation, and offer intensive support and treatment options for those who wish to quit. Such intervention would be very timely, as a large pro­portion of participants expressed a strong desire to quit smoking in the near future.

CONCLUSIONS

The analysis of smoking prevalence among Axxis Hospital workers reveals important findings. Although the actual smoking prevalence stands at 8.3% –a percentage that may be considered low compared to the general population (11.5%)—it remains high for a healthcare workforce that should exhibit lower consumption due to their role as behavioral models for their patients. It is concerning that tobacco use persists even within a group that is expected to promote healthy habits.

Since healthcare professionals play a crucial role in the process of smoking cessation– both as advisors and role models for the population– it is essential to continuously assess their habits and attitudes toward tobacco. Despite the low tobacco dependence and strong desire to quit smoking observed in this group, we believe it is imperative to keep emphasizing the reduction of tobacco use among healthcare profession­als, who should lead by example in promoting healthy lifestyles.

To conclude, although smoking prevalence among Axxis Hospital workers is low, it is neces­sary to continue promoting initiatives to further reduce tobacco consumption among healthcare professionals, given their responsibility and key role in public health.

Conflict of interest

The authors of this work have no conflicts of interest to declare in relation to this publication.

REFERENCES

1. World Health Organization. WHO global report on trends in prevalence of tobacco use 2000-2025. Fourth edition. ISBN 978-92-4-003932-2.

2. Prado H, Prado H, González P, et al. Percepción y cono­cimiento del tabaquismo entre los profesionales sanitarios en dos áreas sanitarias de Galicia. Prev Tab 2024;26:63-8. https://doi.org/10.69703/pt.v26i2.3

3. República del Ecuador. Ley Orgánica Para La Regulación Y Control Del Tabaco.

4. Sánchez P, Lisanti N. Prevalencia de tabaquismo y actitud hacia ese hábito entre médicos del Azuay, Ecuador. Rev Panam Salud Publica/Pan Am J Public Health. 2003;14(1). https://doi.org/10.1590/S1020-49892003000600005

5. Hidalgo A, Ríos R, Rodríguez T. Caracterización de fuma­dores ecuatorianos según el cuestionario de Clasificación de Consumidores de Cigarrillos. Revista del Hospital Psiquiátrico de La Habana. 2023; 20(2).

6. Juranić B, Rakošec Z, Jakab J. Prevalence, habits and personal attitudes towards smoking among health care professionals. J Occup Med Toxicol. 2017;26:12:20. https://doi.org/10.1186/s12995-017-0166-5

7. Salgado M, Mejía R, Kaplan C, et al. Smoking-Related Attitudes and Knowledge Among Medical Students and Recent Graduates in Argentina: A Cross-Sectional Study. J Gen Intern Med 2016;32:549-55. https://doi.org/10.1007/ s11606-016-3890-0

8. Jiménez C, Riesgo J, Ramos A, et al. Prevalence of and Attitudes towards Smoking among Spanish Health Professionals. Respiration 2015;90:474-80. https://doi.org/10.1159/000441306

9. Jiménez C, Pitti-Pérez R, De Granda J, et al. Prevalence, Knowledge and Perceptions of Smoking and Tobacco Products and Vape Among SEPAR Members. Open Respir Arch. 2023;27:100260. https://doi.org/10.1016/j.opresp.2023.100260.

10. Casals E, Otero S, Cuenca E. Prevalence of smoking among dentists in Catalonia - Spain (2006). Literature review of smoking cessation practices in the dental office. Med Oral Patol Oral Cir Bucal. 2008;13:E671-7.

11. Donovan G. Smoking prevalence among qualified nurses in the Republic of Ireland and their role in smoking cessation. Int Nurs Rev. 2009;56:230-6. https://doi.org/10.1111/j.1466-7657.2008.00700.x.

12. Besson A, Tarpin A, Flaudias V, et al. Smoking Prevalence among Physicians: A Systematic Review and Meta-Anal­ysis. Int. J. Environ. Res. Public Health 2021;18:13328. https://doi.org/10.3390/ijerph182413328

13. Nilan K, McKeeve T, McNeill A, et al. Prevalence of to­bacco use in healthcare workers: A systematic review and metaanalysis 2019. PLoS ONE 14(7): e0220168. https://doi.org/10.1371/journal.pone.0220168

14. Minervini M, Zabert G, Rondelli M, et al. Tobacco use among Argentine Physicians: Personal Behaivor And At­titudes. Rev Am Med Resp 2006;6:100-5.

15. Ranchal Sánchez A, Pérula de Torres LÁ, Santos Luna F, et al. Prevalence of tobacco consumption among young physicians at a regional university hospital in southern Spain: a cross sectional study. BMJ Open 2018;8:e018728. https://doi.org/10.1136/bmjopen-2017-018728

16. Pold M, Parna K. Smoking prevalence and attitudes towards smoking among Estonian physicians: results from cross-sec­tional studies in 2002 and 2014. BMJ Open 2017;7:e017197. https://doi.org/10.1136/bmjopen-2017-017197

17. Schottlender J, Rey S, Sánchez O, et al. Encuesta de tabaquismo en personal de enfermería en dos hospitales especializados en patología respiratoria. Rev Am Med Resp. 2014;4:375-81.

18. Solano S, Jiménez C, Martínez E, et al. Prevalencia, cono­cimiento y actitudes acerca del consumo de tabaco en los miembros de SEPAR. Arch Bronconeumol. 2016;52:605-10. https://doi.org/10.1016/j.arbres.2016.01.006.