Smoking cessation counseling by primary care women physicians: Women Physicians' Health Study

Smoking Prevalence among Physicians: A Systematic Review and Meta-Analysis

BACKGROUND

Smoking is a major public health problem. Although physicians have a key role in the fight against smoking, some of them are still smoking. Thus, we aimed to conduct a systematic review and meta-analysis on the prevalence of smoking among physicians.

METHODS

PubMed, Cochrane, and Embase databases were searched. The prevalence of smoking among physicians was estimated and stratified, where possible, by specialties, continents, and periods of time. Then, meta-regressions were performed regarding putative influencing factors such as age and sex.

RESULTS

Among 246 studies and 497,081 physicians, the smoking prevalence among physicians was 21% (95CI 20 to 23%). Prevalence of smoking was 25% in medical students, 24% in family practitioners, 18% in surgical specialties, 17% in psychiatrists, 16% in medical specialties, 11% in anesthesiologists, 9% in radiologists, and 8% in pediatricians. Physicians in Europe and Asia had a higher smoking prevalence than in Oceania. The smoking prevalence among physicians has decreased over time. Male physicians had a higher smoking prevalence. Age did not influence smoking prevalence.

CONCLUSION

Prevalence of smoking among physicians is high, around 21%. Family practitioners and medical students have the highest percentage of smokers. All physicians should benefit from targeted preventive strategies.

A Systematic Literature Review of Self-Reported Smoking Cessation Counseling by Primary Care Physicians

Tobacco consumption is a risk factor for chronic diseases and worldwide around six million people die from long-term exposure to first- or second-hand smoke annually. One effective approach to tobacco control is smoking cessation counseling by primary care physicians. However, research suggests that smoking cessation counseling is not sufficiently implemented in primary care. In order to understand and address the discrepancy between evidence and practice, an overview of counseling practices is needed. Therefore, the aim of this systematic literature review is to assess the frequency of smoking cessation counseling in primary care. Self-reported counseling behavior by physicians is categorized according to the 5A's strategy (ask, advise, assess, assist, arrange). An electronic database search was performed in Embase, Medline, PsycINFO, CINAHL and the Cochrane Library and overall, 3491 records were identified. After duplicates were removed, the title and abstracts of 2468 articles were screened for eligibility according to inclusion/exclusion criteria. The remaining 97 full-text articles reporting smoking cessation counseling by primary care physicians were assessed for eligibility. Eligible studies were those that measured physicians' self-reported smoking cessation counseling activities via questionnaire. Thirty-five articles were included in the final review (1 intervention and 34 cross-sectional studies). On average, behavior corresponding to the 5A's was reported by 65% of physicians for "Ask", 63% for "Advise", 36% for "Assess", 44% for "Assist", and 22% of physicians for "Arrange", although the measurement and reporting of each of these counseling practices varied across studies. Overall, the results indicate that the first strategies (ask, advise) were more frequently reported than the subsequent strategies (assess, assist, arrange). Moreover, there was considerable variation in the items used to assess counseling behaviour and developing a standardized instrument to assess the counseling strategies implemented in primary care would help to identify and address current gaps in practice.

Do doctors' smoking habits influence their smoking cessation practices? A systematic review and meta-analysis

AIMS

To assess the association between doctors' smoking status and the use of the '5As' of smoking cessation.

METHODS

A systematic search of 11 databases covering English and Spanish language publications since 1996 was undertaken. Studies were included if they reported doctors' smoking status (current, former or never smoker) and rates of practising any of the 5As of smoking cessation (Ask; Advise; Assess; Assist; and Arrange). Frequencies and proportions were extracted from individual papers and risk ratios (RR) were calculated. A random-effects meta-analysis model was used to assess the effect of the doctor's personal smoking history. Covariate effects were explored using meta-regression for three pre-specified study characteristics: doctors' role, smoking prevalence of the sample and study quality.

RESULTS

Twenty studies were included in this systematic review. The RR of always asking patients about their smoking was not associated significantly with doctors' smoking status [RR = 0.98; 95% confidence interval (CI) = 0.94-1.02; P = 0.378; I(2)  = 0.00%; 10 studies]. Meta-analysis suggested that doctors who were current smokers had a 17% increased risk of not advising their patients to quit compared with never-smokers (RR = 0.83; 95% CI = 0.77-0.90; P < 0.000; I(2)  = 82.14%; 14 studies). However, high levels of heterogeneity were found that were not explained by the meta-regression. Regarding assisting patients to quit, never smokers were more likely to counsel than current smokers (RR = 0.92; 95% CI = 0.85-0.99; P = 0.036; I(2)  = 0.00%; three studies) but less likely to make a referral (RR = 1.40; 95% CI = 1.09-1.79; P = 0.009; I(2)  = 0.00%; five studies). No statistically significant differences were found in arranging future contact by smoking status (RR = 0.80; 95% CI = 0.52-1.23; P = 0.315; I(2)  = 47.03%; four studies).

CONCLUSIONS

Smoking status of doctors may affect their delivery of smoking cessation treatments to patients, with smokers being less likely than non-smokers or ex-smokers to advise and counsel their patients to quit but more likely to refer them to smoking cessation programmes.

Implementing tobacco dependence treatment during clinical consultations: a qualitative study of clinicians' experiences, perceptions and behaviours in a South African primary health care setting

Background

Evidence suggests that healthcare providers (HCPs) in South Africa do not consistently offer tobacco dependence treatment (TDT) during clinical consultations. In order to understand and explain this behaviour in a South African context, we conducted a qualitative exploration of HCPs’ experiences, perceptions and behaviours regarding TDT.

Methods

Individual qualitative interviews were conducted with physicians and nurses who were purposively selected. Themes were identified from interview transcripts using content analysis. Findings were triangulated and peer-reviewed, and were also verified by the participants.

Results

Fifteen physicians and four nurses were interviewed, none of whom used tobacco. These participants perceived TDT as an important task, but could not consistently implement it during clinical consultations due to health systems constraints (time-constraints because of patient-overload, the unavailability of cessation medications and a lack of support for referrals), misperceptions and misconceptions (negative outcome expectations about the effectiveness and feasibility of TDT), socio-cultural barriers (counselling older persons was perceived as challenging) and personal limitations (perceived low self-efficacy, poor knowledge and skills on implementing any evidence-based TDT framework). Patients are therefore selectively screened based on clinical relevance and offered only prescriptive brief advice. Participants recommended several systems changes, including academic detailing of tobacco status, training HCPs and incorporating tobacco cessation medications in the Essential Drug List.

Conclusion

The reported selective screening and limited TDT interventions offered by HCPs are related to interactions between health systems constraints, personal limitations, and misperceptions and misconceptions about the effectiveness and feasibility of TDT during clinical consultation. Implementing the recommended systems changes has the potential to improve the implementation of TDT in South African primary health care (PHC).

Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study

BACKGROUND

Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations.

METHODS

This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis.

RESULTS

Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95%CI = 2.13-9.88).

CONCLUSION

Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline

Background

The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short- and long term efficacy of the training program.

Methods

For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires.

Results

Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence.

Conclusions

The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.

Correlates of tobacco cessation counseling among Hispanic physicians in the US: a cross-sectional survey study

BACKGROUND

Physician advice is an important motivator for attempting to stop smoking. However, physicians' lack of intervention with smokers has only modestly improved in the last decade. Although the literature includes extensive research in the area of the smoking intervention practices of clinicians, few studies have focused on Hispanic physicians. The purpose of this study was to explore the correlates of tobacco cessation counseling practices among Hispanic physicians in the US.

METHODS

Data were collected through a validated survey instrument among a cross-sectional sample of self-reported Hispanic physicians practicing in New Mexico, and who were members of the New Mexico Hispanic Medical Society in the year 2001. Domains of interest included counseling practices, self-efficacy, attitudes/responsibility, and knowledge/skills. Returned surveys were analyzed to obtain frequencies and descriptive statistics for each survey item. Other analyses included: bivariate Pearson's correlation, factorial ANOVAs, and multiple linear regressions.

RESULTS

Respondents (n = 45) reported a low level of compliance with tobacco control guidelines and recommendations. Results indicate that physicians' familiarity with standard cessation protocols has a significant effect on their tobacco-related practices (r = .35, variance shared = 12%). Self-efficacy and gender were both significantly correlated to tobacco related practices (r = .42, variance shared = 17%). A significant correlation was also found between self-efficacy and knowledge/skills (r = .60, variance shared = 36%). Attitudes/responsibility was not significantly correlated with any of the other measures.

CONCLUSION

More resources should be dedicated to training Hispanic physicians in tobacco intervention. Training may facilitate practice by increasing knowledge, developing skills and, ultimately, enhancing feelings of self-efficacy.

Gender differences among general practitioners in smoking cessation counseling practices

OBJECTIVES

To describe gender differences in smoking cessation counseling practices among general practitioners (GPs), and to investigate the association between training for cessation counseling and counseling practices according to gender.

METHODS

Data were collected in two cross-sectional mail surveys conducted in independent random samples of GPs in Montreal, the first in 1998, and the second in 2000.

RESULTS

Respondents included 653 GPs (71% of 916 eligible). All indicators of smoking cessation counseling practices were more favorable among female GPs. Higher proportions of female GPs had received training (28% vs. 17%, p=0.002), and were aware of mailed print educational materials related to cessation counseling (81% vs. 57%, p<0.0001). Training among male GPs was associated with higher scores for ascertainment of smoking status (odds ratio (OR) (95% confidence interval)=1.69 (0.97, 2.96)), provision of advice (OR=2.20 (1.23, 3.95)), and provision of adjunct support (OR=2.86 (1.58, 5.16)). Training was not associated with counseling practices among female GPs.

CONCLUSIONS

Female GPs may not benefit from formal cessation counseling training to the same extent as male GPs, possibly because they read and integrate the content of (easily available) print educational materials into their clinical practice to a greater extent than male GPs. The gender-specific impact of print educational material and formal training on cessation counseling should be evaluated among GPs.

Health promoting attitudes and behaviors of emergency physicians

PURPOSE

The purpose of this paper is to report on gender differences in emergency physicians with respect to their attitudes, knowledge, and practices concerning health promotion and disease prevention.

DESIGN/METHODOLOGY/APPROACH

A mail survey of 325 male and 97 female Canadian emergency physicians.

FINDINGS

Results suggest female emergency physicians report having greater knowledge of health promotion topics, spend more time with each of their patients in the emergency setting, and engage in more health promotion counseling in the emergency setting than do their male counterparts.

ORIGINALITY/VALUE

The paper argues that in the future, educating and socializing emergency physicians, both male and female, in the practice of health promotion will enhance the potential of the emergency department to be a more effective resource for their community.

[Views, practices, barriers, and the will to change, when counselling to give up smoking is being given]

OBJECTIVE

To get to know the opinions, current practices, perceived barriers and stage of change in respect to the smoking cessation advice (SCA) offered to patients by the different health professionals (HP) from primary care.

DESIGN

Descriptive cross-sectional study.

LOCATION

Area Sanitaria 9's Health Centers, in Madrid, Spain.

PARTICIPANTS

480 HPs, including primary care doctors, pediatricians, primary care residents, and nursery staff.

MEASUREMENTS

Using a self-filled and anonymous questionnaire, we will gather sociodemographic variables and from the HP's office, regarding the attitudes towards tobacco, efficiency beliefs and use of strategies in the advice, and the perceived barriers to give it, as well as the state of change.

RESULTS

75.2% of the HPs filled the questionnaire (94.2%, 61.1%, 51.6%, and 88% by doctors, nurses, pediatricians, and residents respectively). 72% ask regularly, this rate increasing to 92.4% over tobacco-related diseases. No differences were made between sexes, professional types, tobacco habits, or previous attendance to courses. 85.8% offers tracing and 63.5% give written advices. Nearly 75% of non-smokers are considered social role models, that against only 40% of smokers. The main barriers found were lack of time and low motivation from the patients. 93.5% consider an specific education necessary to give efficient SCA.

CONCLUSIONS

Inquiries are made and SCA is given, independently of the smoking habits of the SCA. Likewise, there is a good state of change by the HPs to optimize the treatment of tobacco dependency.

Lifestyle Behavior Counseling for Women Patients among a Sample of California Physicians

BACKGROUND

Physical inactivity, poor diet, excessive alcohol consumption, and smoking are modifiable risk factors associated with development of chronic diseases. Although the prevalence of diseases associated with these detrimental lifestyle behaviors is high among women in the United States, they may not receive adequate counseling from physicians.

METHODS

To predict physicians' lifestyle counseling practices, we assessed personal, professional, and health behavior characteristics from responses to a self-administered survey of breast cancer risk reduction practices. Subjects were California physicians identified through AMA Masterfile, in family practice, internal medicine, or obstetrics/gynecology, who were asked to report the percentages of women patients they counseled on physical activity, diet, alcohol, and smoking.

RESULTS

Of 1647 eligible physicians, 822 (50.0%) responded. Fifty-six percent reported counseling at least 75% of patients about physical activity, 54.6% about diet, and 44.8% about alcohol. More than three quarters (78.7%) counseled at least 75% of patients about smoking. In logistic regression analyses, woman gender, family practice, and internal medicine specialties emerged as significant predictors of counseling for all lifestyle behaviors. Older age was associated with dietary and alcohol counseling. Race/ethnicity was associated only with smoking counseling, and country of medical school was associated with counseling for physical activity and smoking. Sources of new medical knowledge emerged as predictors for all types of counseling, whereas physicians' own level of physical activity only predicted counseling about physical activity.

CONCLUSIONS

Physicians' personal, professional, practice, and health behavior characteristics were associated with reported lifestyle counseling of women patients. Results reveal important directions for future physician-based interventions to improve counseling.

Meta-Analysis of the Efficacy of Tobacco Counseling by Health Care Providers

Given the proportion of American adults who smoke, even if health professionals only have a small effect on quit rates, the public health impact of this change could potentially be enormous. Yet, health care providers may differ in their cessation efficacy. The purpose of this study was to evaluate recent rigorous trials of smoking cessation counseling among physicians, nurses, dentists, and teams of providers: (1) to compare providers on the efficacy of cessation and (2)to determine which intervention and study characteristics explain variations in intervention effects. Thirty-seven randomized clinical trials or quasi-experiments (with control groups) of health care provider–delivered smoking cessation interventions, out of over 200 articles that were published between 1990 and 2004 were collected through searches of Medline, CINAHL, PSYCINFO, and dissertation abstracts, as well as hand searches. The outcome modeled was the mean difference between intervention and control groups in the cessation rates using Hedges g. The univariate results revealed that receiving advice from any health care professional produced increases in quit rates. Multivariate analyses of intervention effects on cessation revealed that physicians were most effective, followed by multiprovider teams, dentists, and nurses. The findings suggest that contact with a health care professional will increase cessation; however, additional training in tobacco control for nurses is warranted. Longer-term studies of smoking cessation, particularly among dentists, are necessary.

Smoking-related attitudes and clinical practices of medical personnel in Minnesota

CONTEXT

Effective clinic-based, smoking-cessation activities are not widely implemented.

OBJECTIVE

To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members.

DESIGN AND SETTING

From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs).

MAIN OUTCOME MEASURES

Factors associated with limited smoking-cessation service delivery.

RESULTS

The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders.

CONCLUSIONS

Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Non-primary care physicians and smoking cessation counseling: Women Physicians' Health Study

OBJECTIVES

The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians in various specialties. In this study we describe the prevalence of self-reported counseling on smoking cessation among non-primary care women physicians and examine the association between their demographic, professional, and personal characteristics and such counseling on smoking cessation.

METHODS

Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians with 4,501 respondents representing all major specialties. Physicians in 9 specialty areas were grouped in 6 categories: (1) anesthesiology; (2) general surgery and surgical subspecialties; (3) emergency medicine; (4) medical subspecialties; (5) psychiatry; and (6) other. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year.

RESULTS

Overall, 45% of the physicians frequently counseled smokers to quit. Medical subspecialists (80%) were most likely and psychiatrists (29%) least likely to counsel frequently. Specialty, perceived relevance of counseling to the physician's practice, and self-confidence in counseling about smoking cessation were associated with frequent counseling.

CONCLUSION

Cessation counseling by non-primary care physicians can reduce tobacco-related morbidity and mortality. Increasing perceived relevance and self-confidence among this group of physicians, combined with implementation of system changes and the creation of physician accountability can facilitate the provision of such counseling.