THE SMOKING BEHAVIOR OF HEALTH WORKERS IN ASIA: A LITERATURE REVIEW

Health workers are role models in preventing smoking behavior, yet many are smokers themselves. This study reviews and analyzes the smoking behavior of health workers in Asian countries, based on databases such as PubMed, EBSCO, and Google Scholar in 2013–2018. It is shown that the prevalence of smoking amongst health workers was 4.6–44%, with the nursing profession showing a higher level than other health professions and with a higher ratio of male to female smokers. Health workers are aware of the dangers of smoking, including the effects of cardiovascular disease, respiratory disease, oral cancer, atherosclerosis, hypertension, fetal disorders, and infertility. However, the factors that lead to smoking include stress, the influence of friends or family who smoke, and addiction. Health workers are responsible for providing smoking prevention education. However, there are still obstacles to its implementation due to their smoking habits and lack of expertise in educating others. Smoking prohibition policies in the workplace, the training of health workers, and smoking prevention service facilities need to be considered by Asian countries to prevent smoking.


Introduction
Smoking is a major health problem, causing increased cardiovascular disease, lung disease, and cancer. Cigarettes have contributed to killing 7 million people in the world. WHO estimates that 20.2% of the world's population aged ≥ 15 (34.1% of men and 6.4% of women) were ac-tive smokers in 2015 (WHO, 2018). The prevalence of smoking in the Southeast Asian region in 2015 reached 17.2% of the total population, including 32.1% of men and 2.3% of women (WHO, 2018).
Efforts to prevent and reduce smoking are a primary concern of health workers in reducing smoking-related problems (La Torre et al., 2013). In addition to playing an important role (being a role model) in the promotion of healthy behavior and prevention of smoking, health workers must also personally value their health, shape health values in the community, and influence people to stop smoking (Hurley et al., 2015;La Torre et al., 2014).
The prevalence of health workers' smoking behavior in Bernadini Italia Hospital in 2012 showed a relatively high number, reaching 47% of the general population of 90.000 (Giorgi et al., 2015). Low smoking prevention education and training in the health education curriculum leading to the high incidence of smoking among health workers (Sreeramareddy et al., 2018). The smoking behavior of health workers is influenced by social status, politics, the economy, culture, and stress due to workload (Lillard & Christopoulou, 2015). Other factors influencing smoking behavior are education, the influence of friends who smoke, previous smoking experience, addiction, and feelings of calm (Juranić et al., 2017;Hamadeh et al., 2018;Sheals et al., 2016).
The attitudes and behaviors of health workers have been proven to be determinants of the effectiveness of smoking policies in the workplace; the implementation of 100% smoking prohibition regulations would reduce the prevalence of employees' smoking behavior (Centers for Disease Control and Prevention US et al., 2010). Health workers must be an excellent example by quitting smoking to benefit themselves and their patients (La Torre et al., 2013). By smoking, health workers have weakened their role as providers of promotive and preventive health services for the community and are less likely to advise patients to quit smoking (Duaso et al., 2017).
Health workers need to be trained to acquire competencies and skills to assist patients in preventing smoking through smoking prevention training programs. Several studies have shown that health professionals who undergo smoking prevention training will improve the competency and consistency in advising patients to quit smoking more significantly than those who do not . Based on these problems, the researchers in this study are interested in further examining published articles on the smoking behavior of health workers in Asia.

Methods
Data Sources. Articles were obtained through various online journal databases, such as Pub-Med, EBSCO, and Google Scholar. The literature search was conducted by identifying relevant articles using specific keywords such as smoking behavior, cigarettes, and health workers. The literature identification was also limited by the inclusion criteria, namely articles with a statement of research authenticity published in 2013-2018, whose research location was in Asian countries. Moreover, the article had to meet the following methodology criteria: (1) explanation of the research objectives; (2) explanation of the research population or sample; (3) use of a suitable data collection method; (4) use of valid measurement tools; (5) presentation of clear and measurable analysis results; and (6) presentation of clear and precise findings.
Data Selection and Analysis. In the data extraction process, irrelevant articles such as those on smoking behavior in the general population and those using research locations outside of the Asian region were omitted, resulting in 302 relevant articles based on the titles and abstracts. These were then reselected, and 20 were omitted due to duplication, leaving 282 relevant articles based on the titles and abstracts. Of these 282, 193 were eliminated because they did not meet the inclusion criteria, leaving 89 articles identified based on their eligibility. Subsequently, 71 of these 89 were omitted because they did not meet the methodological criteria, leaving 18 complete articles that met the inclusion and methodological criteria. The data selection strategy and data analysis adopted the Prisma-P 2015 flowchart (Moher et al., 2015).
All the articles used were published during 2013 -2018; more precisely, four were published in 2013, four in 2014, two in 2015, five in 2016, two in 2017, and one in 2018. They were mostly published in international journals indexed on reputable databases such as Scopus, Medline, PubMed, and EBSCO, with three from Google Scholar. Seventeen of the articles employed quantitative methods with a cross-sectional design (n = 12), survey (n = 2), population study (n = 1), descriptive study (n = 1), or randomized controlled trial (RCT) (n = 1), while one article used a focus group-qualitative method with interview guidelines.

Demographic Characteristics of Healthcare Workers in Relation to Smoking Behavior.
The demographic characteristics of the respondents in each study included data on gender, age, marital status, education level, and citizenship. These scientific research articles involved respondents who worked as doctors, nurses, dentists, medical assistants, public health workers, pharmacists, midwives, and other health workers (see Table 1).
This research categorized respondents based on gender (male or female). Two articles did not include this, while one only included female respondents. Based on the respondents' age, 14 articles were based on respondents aged 22 to 53, while the other four did not include age. Concerning marital status, seven articles were dominated by married respondents, followed by single, divorced (widow/widower), and undisclosed status. Meanwhile, in relation to educational level, two articles involved respondents with a high school education, seven articles involved ones with undergraduate or postgraduate degrees, while the remainder did not include educational information.
The research location of the articles is shown in Table 1. The research sites consisted of public hospitals, teaching hospitals at universities, community health service centers, and smoking cessation service clinics. Mahfouz et al. (2013) focused on respondents from Saudi Arabia, with a minority from India and Egypt. On the other hand, Al Hosani et al. (2015) employed two nationality groups, the United Arab Emirates and the non-United Arab Emirates. Moreover, Hamadeh et al. (2018) refer to two nationalities, Bahrain and a minority of Arab and South Asian communities.

Smoking Behavior in Health Professionals.
Out of the total of 18 articles, five specifically discuss the smoking behavior of doctors and dentists, two discuss the smoking behavior of nurses, and two discuss the smoking behavior of doctors and nurses. The other nine articles discuss health professionals in general (doctors, nurses, dentists, medical assistants, public health workers, pharmacists, midwives, and other health workers).
The smoking behavior of health professionals showed a prevalence of 4.6% to 44% (Chang et al., 2016;. Moreover, another article was based on a large sample of 112 smokers (26.5%), with a higher prevalence of smoking among nurses (40.2%) than other health professions (Alkhatatbeh et al., 2016).
Regarding gender-based smoking behavior, nine articles showed that the number of male smokers was 106 (44.49%), higher than that of female smokers, at only five (2.7%). Health workers' smoking intensity of fewer than five cigarettes per day was 25.5% for males and 22.6% for females. In comparison, a smoking intensity of more than ten cigarettes per day was shown by 32.1% of the males and 6.5% of the females (Mahfouz et al., 2013).

Knowledge of Health Workers of Smoking
Behavior. As explained in 15 research articles, the health workers agreed that both active and passive smoking harmed health because it increased the risk of cardiovascular disease, respiratory disease, oral cancer, atherosclerosis, and hypertension, amongst other diseases (Abdulateef et al., 2016;Hamadeh et al., 2018). The respondents believed that smoking was harmful to the fetus in pregnant women and increased the risk of neonatal death (Alkhatatbeh et al., 2016). They also believed that the nicotine content in cigarettes could lead to a risk of male infertility (Chang et al., 2016).
Respondents who were doctors were aware of the benefits of quitting smoking, one of which is a reduction in the risk of coronary heart disease (Tang et al., 2013). Hoseinrezaee et al. (2013) report that the emergence of smoking-related diseases in the children of health workers was due to smoking habits in their family environment. Three other articles reported that health workers' motives to quit smoking were related to health factors (Shkedy et al., 2013;AlTurkstani et al., 2016;Hamadeh et al., 2018).
Six articles mentioned the factors influencing the smoking behavior of health workers, namely stress, the influence of friends and family who smoked, and addiction. Hamadeh et al. (2018) report that the main reason their respondents started smoking was the influence of friends. Similarly, AlTurkstani et al. (2016) found that in addition to the factors of stress, nicotine addiction, and personal desires, living or working with friends or colleagues who smoked could also influence health professionals' decision to smoke.

The Attitude of Health Workers towards
Smoking Behavior. As health service providers, health workers are responsible for providing education on the dangers of smoking and giving advice on quitting. Alkhatatbeh et al. (2016) found that 92% of health workers were responsible for advising patients on giving up smoking. In another study, it was found that 89.9% of doctors advised smokers not to smoke around children (AlTurkstani et al., 2016).
The smoking behavior of health workers can be an inhibiting factor in educating people on its dangers. Seven articles explain that one of the factors inhibiting health workers from educating people on the dangers of smoking and providing smoking cessation services was their smoking behavior. Other inhibiting factors were that health workers were not comfortable providing education, considered it useless, or felt irrelevant to their professional expertise (Shkedy et al., 2013).
In addition, according to public health workers in Vietnam, the inhibiting factors in providing health education on the dangers of smoking in-cluded the lack of special programs provided by the Ministry of Health, the lack of policies and support, low involvement of health workers, the lack of government-issued smoking cessation program regulations, and the absence of specialized smoking prevention training by health workers .
Public health workers in Vietnam supported good communication training for smoking cessation counseling. In this literature review, a lack of smoking prevention training for health workers was found in several articles. Around 72% of health workers in the United Arab Emirates and 78.4% of public health workers in Vietnam had not received specialized smoking prevention training (Al Hosani et al., 2015;Nguyen et al., 2017). This literature review also found a low acceptance rate for smoking prevention training in several articles, such as in Iraq (6.5%), Jordan (25.5%), Thailand (24%), Saudi Arabia (23.6%), and Vietnam (29%). In addition, only 63.6% of health workers in the United Arab Emirates were interested in joining smoking cessation and prevention training AlTurkstani et al. 2016;Chatdokmaiprai et al., 2017;Al-khatatbeh et al., 2016;Abdulateef et al., 2016). Khaeradmand et al. (2013) found that health workers supported smoking prohibition policies in public places and workplaces, while a study in Iran also showed that most health workers (80.9%) agreed with smoking bans in the workplace Hoseinrezaee et al. (2013). The same support was given by 101 health workers (82.5%) in the United Arab Emirates, who stated that smoking in public places should be prohibited, while 88.3% of health workers supported smokefree health care centers and hospitals (Al Hosani et al., 2015). In Jordan, a total of 381 (95.2%) health workers supported the prohibition of smoking in public places, especially in hospitals and health care centers (Alkhatatbeh et al., 2016). In line with this, a qualitative study in Vietnam showed that health workers agreed with smoking prohibition regulations in public areas, including public transport .

Discussion
This literature review analyzed the research findings of the 18 articles on the smoking behavior of health workers in the Asian region, which had met the inclusion criteria with various populations. Despite not representing the entire population of health workers, the results of this review can provide an overview of such behavior. We analyzed research articles on health workers' smoking behavior, knowledge, and attitudes toward smoking.

Health Workers' Smoking Behavior.
Previous studies have found that the prevalence of health workers' smoking behavior was 4.6 to 44% (Chang et al., 2016;, with the most significant sample being that of 112 smokers (26.5%) (Alkhatatbeh et al., 2016), and the profession with the highest rate of smoking being nursing. According to a study in Jordan, the smoking rates of health workers in primary health care were 40.2% for nurses, 11.8% for doctors, 13.7% for dentists, 10.8% for pharmacists, and 23.5% for other health workers (Alkhatatbeh et al., 2016). The smoking behavior of doctors is consistently lower than that of nurses, but this trend could change and is influenced by national cultural factors (Chambers, 2016).
This study also discovered that the smoking behavior of male health workers was higher than that of female health workers. Fifteen articles explained the high prevalence of smoking in men, supported by an almost balanced gender representation. A research article in Thailand even found only one out of 231 female respondents who smoked (Chatdokmaiprai et al., 2017). In China, smoking behavior was 48.9% for men and 2.1% for women . This result is consistent with a cohort study of ten countries that reported higher cigarette consumption in men than women (Lillard & Christopoulou, 2015).
Fourteen articles revealed that the average age of health workers who smoked was 22-55, categorized as the productive age range. Based on a study in India, 50% of health workers who smoked were aged 20-29 (Aggarwal et al., 2015). In addition, a study in Israel reported that the age at which people started smoking was between 6 and 25, with an average age of 18, and without gender differences (Shkedy et al., 2013).
The smoking intensity of health workers was 1-10 cigarettes per day (42.9%) or 10-20 cigarettes per day (66.7%). Six articles mentioned that the types of cigarettes commonly consumed were tobacco, shisha, cigars, midwakh, pipes, and mousel. A study in Bahrain reported that the smoking duration of shisha smokers was more than ten years (Hamadeh et al., 2018).

Knowledge of Health Workers on Smoking
Behavior. Smoking behavior and exposure to smoke are hazardous to health and can increase the risk of cancer, cardiovascular disease, lung disease, reproductive disorders, including embryonic and fetal disorders (Centers for Disease Control and Prevention US et al., 2010).
Health workers agree that active and passive smoking behavior can increase the risk of these diseases (Abdulateef et al., 2016;Hamadeh et al., 2018). Similarly, Alkhatatbeh et al. (2016) suggest that smoking is harmful to health and that health workers are aware of this. Exposure to cigarette smoke is very dangerous to health. As stated by health workers in the literature review, the nicotine content in cigarette smoke can harm the fetus, increase the risk of neonatal death, and result in the risk of infertility in females (Alkhatatbeh et al., 2016). Health workers even believe that the nicotine content in cigarettes can pose a risk of male infertility (Chang et al., 2016). Studies in Israel, Saudi Arabia, and Bahrain suggest that health workers' factor in quitting smoking is their health.
Factors stimulating health workers to smoke include stress, the influence of smoking friends or family, addiction, and previous smoking experiences. According to Rezk-Hanna et al. (2018), factors inhibiting health workers from quitting smoking were the environment, stress, and nicotine addiction. AlTurkstani et al. (2016) found that the population of health workers in Bahrain and Mecca started smoking for the first time due to the influence of both playmates and coworkers.

The attitude of Health Workers towards
Smoking Behavior. Health workers are role models responsible for preventing smoking behavior by educating people (patients) about the dangers of smoking for health. Alkhatatbeh et al. (2016) reveal that 92% of health workers were responsible for advising patients to quit smoking. In addition, 98% of doctors in Saudi Arabia recommend that smokers should not smoke around children (AlTurkstani et al., 2016). Providing education about the dangers of smoking and advising on smoking cessation is a form of responsible attitude shown by health workers. However, several factors hamper its implementation. Seven research articles in several countries indicate that the personal factors of health workers impeded the delivery of education and socialization of smoking prevention to patients. Based on a study in Israel, health workers were not comfortable providing education, considering it useless, and feeling irrelevant to their professional expertise. These were inhibiting factors in the prevention of smoking behavior. Other obstacles faced by public health workers in Vietnam are a lack of smoking cessation programs, a lack of government support for smoking cessation programs, and the absence of training for health workers.
Health workers in Vietnam supported training on smoking cessation counseling. Other studies found that only a small proportion of health workers received smoking prevention training, such as in Iraq (6.5%), Jordan (25.5%), Thailand (24%), Saudi Arabia (23.6%), and Vietnam (29%). These percentages indicate the lack of training in smoking prevention counseling. A total of 72% of health workers in the United Arab Emirates and 78.4% of public health workers in Vietnam had not received specialized smoking prevention training.
Health workers also supported policies related to smoking bans in workplaces to reduce and prevent smoking behavior. Smoking prevention policies have been a WHO priority since 2008. This policy is outlined in the MPOWER program: Monitoring (monitoring tobacco use and prevention policies); Protecting (protecting people from exposure to cigarette smoke); Offering (offering assistance to quit smoking); Warning (warning about the dangers of tobacco); Enforcing (prohibiting tobacco advertising, sponsorship, and promotion), and Raising (increasing tobacco-related taxes). Such measures have been proven to be effective in reducing smoking behavior globally (WHO, 2017). Smoking prohibition policies in workplaces have been widely implemented in countries worldwide. They have been proven to lower the prevalence of smoking in workplaces by 6-22% and reduce smoking consumption by 14% every day (Centers for Disease Control and Prevention US et al., 2010). Even health workers in Iran, the United Arab Emirates, Jordan, and Vietnam widely support smoking prohibition policies in workplaces.

Conclusion
Health workers play an essential role in preventing smoking behavior, both as education providers and role models. Smoking prohibittion policies in workplaces, specialized training for health workers in smoking behavior control, and smoking prevention service facilities are considered to prevent smoking behavior in Asian countries with a high population of smokers.