Authors:
Sahin EM1, Ozer C2, Dagdeviren N1, Akturk Z1

1 Assistant Professor, Trakya University Medical Faculty Department of Family Medicine, Edirne, Turkey
2 Clinical instructor, Trakya University Medical Faculty Department of Family Medicine, Edirne, Turkey

Correspondence:
Dr. E. Melih SAHIN
Trakya University Medical Faculty
Department of Family Medicine,
22030 Edirne, Turkey
Phone :+90 284 235 63 80 / 1463 (internal)
Fax: +90 284 2357652
Email: emsahin@trakya.edu.tr, emsahin@yahoo.com

Presented in Conference of The European Society of General Practice/Family Medicine-WONCA Region Europe. 2-7 June 2001, Tampere.

Date of manuscript submission: 07.Dec.2004 (Re-submitted after revision on 02 March 2005)
Key Words: smoking, physicians, Turkey.

ABSTRACT

Background: There are approximately 17 million smokers in Turkey. These smokers impacted the social and behavioural aspects of the community especially the younger age group which constitutes the majority of the Turkish population. Physicians' attitudes towards smoking transcend into their patients.

Methods: Attitudes and behaviours of physicians in Trakya University Hospital towards smoking were investigated using a questionnaire prepared with the help of WHO.

Results: One hundred and thirty eight physicians out of 413 agreed to participate and respond with a response rate of 33.4%. Of those, 55 (39.9%) were academic staff and 83 (60.1%) were residents. Smoking rate was 45.5% with another 12.9% who have stopped smoking within the last five years. According to their Fagerstrom Tolerance Scale scores 14 (25.5%) were nicotine dependent. Almost 41% of them never thought or tried to quit smoking. Almost 66% of the physicians asked their patients about their smoking habits during their routine visits and 77.4% of them strongly recommended their patients to stop smoking in the event a disease was suspected to be related to smoking. Physicians' recommendations were less strong if the disease in question was not related to tobacco use (36.9%).

Discussion: These results concur with others in Turkey. Smoking rates of Turkish physicians were higher than their colleagues in many other countries. They don't think of quitting and they don't even have any desire to quit. They are also unwilling to entertain or undergo smoking cessation counseling. Turkish physicians need more education on smoking cessation and counseling.

Key Words: smoking, physicians, Turkey.

INTRODUCTION

Due to established cause-effect relationship between tobacco use and some diseases like lung cancer and many other significant statistical associations with various negative outcomes and death, worldwide efforts to decrease smoking rates have been designed. The shift of common interest of health care from treatment to health promotion and prevention as well as risk management, increases the importance of smoking cessation programs. Anti-tobacco campaign succeeded to decrease smoking prevalence in developed countries (1). Unfortunately, in underdeveloped and developing countries smoking prevalence is controversially high. According to figures of smoking habits, Turkey can be included developing countries (2).

Physicians can play a significant role in decreasing the prevalence as well as the public health ramifications of the endemic smoking problem. Considered to be role models for their patients, physicians can identify and modify risk behaviours of their patients and smoking should be at their top priority health interventions and behavioural modification programs to tackle. Smoking prevalence among physicians in developed countries has dropped to less than 10% and smoking cessation counseling is always included in health promotion activities (3). Smoking is considered in any visits to physicians and accepted as a routine part of medical history taking. Anti-smoking media campaigns, activities to encourage, support and facilitate quitting smoking, legal regulations to limit smoking and access to cigarettes contribute to this decreasing trend of smoking habits in developed countries.

In this study we investigated the smoking status, attitudes and behaviours towards smoking and smoking cessation counseling of physicians in Trakya University Medical Faculty. The primary objective of our study was to describe smoking cessation counseling practices of smoker and non-smoker physicians.

METHODS

The study design was a cross-sectional, descriptive study and was carried out in March to May 2000. Voluntary 3rd and 4th year medical school students administered and collected the self-reported questionnaires. All professors, associate professors, assistant professors, lecturers and residents in the faculty were asked to participate in the study. One hundred and thirty two participants out of 413 were included in the analysis of this study with a response rate of 33.4%. The questionnaire included 29 items and consisted of 5 parts. The first part included demographic parameters like age, sex, marital and academic status. In the second part, three questions assessing smoking status were administered. Questions assessing the stages of change were in the third part (4). Fagerstrom Tolerance Scale, which is a standard instrument for assessing the intensity of physical addiction to nicotine, was included to assess the severity of dependence in the fourth part (5, 6). In the last part the practice and attitudes of the physicians towards smoking cessation counseling and anti-tobacco legislation were assessed.

RESULTS

One hundred (72.5%) of the participants were male, 38 (27.5%) of them were female and mean age was 33.64±8.36 (Range= min: 24 max: 64). Of 138 participants, 88 (63.8%) were married, 48 (34.8%) were single and 2 (1.4%) were divorced. There were participants from all academic degrees; 12 professors (8.7%), 9 associate professors (6.5%), 24 assistant professors (17.4%), 10 specialists (7.2%), and 83 residents (60.1%) and from all clinical medical specialties participated in the study.

There were 59 (42.8%) smokers, 17 (12.3%) ex-smokers, 62 (44.9 %) non-smokers. Males and females smoke 17 and 13 cigarettes respectively on a daily basis on average. All of the smokers preferred filtered and light cigarettes than other forms. Period of starting smoking was faculty years for 75 (54.3%), time after graduation for 36 (26.1%), high school for 20 (14.5%) and primary school for 7 (5.1%) of the participants. The most common reasons to start smoking was peer pressure (32.4%), stress (26.7%), interest (12.7%), imitation (9.9%), enjoyment (7%) and boredom (4.2%).

Smokers and ex-smokers were divided into 5 smoking cessation stages. Thirty-one (40.8%) participants were in pre-contemplation stage where no worry about smoking or no motivation for quitting exists. Four (5.3%) were in contemplation, 25 (32.9%) were in preparation, 6 were (7.9%) in action, 10 were (13.2%) in maintenance stage. The high percentage in the pre-contemplation stage showed the smokers had no motivation for change. In the Fagerstrom Tolerance Scale of smokers, 14 (25.5%) had scores of 7 or more and were accepted as nicotine dependent.

Only 69 (65.1%) of the participants who were making patient visits as their daily work (106 physicians) stated they asked patients about their smoking status routinely. But 82 (77.4%) of the physicians provided smoking cessation counseling if the patient had a smoking-related disease. There was a group of 6 (4.3%) physicians who never provided counseling in their practicing life. The rate of routine counseling decreased significantly if the patient had a disease not related to smoking (Table 1).

We assessed attitudes towards smoking cessation counseling using certain statements. The results were collected with 5 grade Likert scale (Table 2). All but 9 (6.8%) participants agreed that counseling should be provided to all patients in every visit. The statement of 'smoking cessation counseling is a responsibility for every physician' was agreed by nearly the same number of them (122 physicians, 92.4%), but strength of the agreement decreased. Only 107 (81.1%) physicians agreed or strongly agreed that they could manage smoking cessation counseling and 113 (85.7%) of them agreed or strongly agreed that the counseling rate should increase if they knew how effective the existing tools are in aiding to quit. It was accepted by a great majority (121 physicians, 91.6%) that in our hospital, there is a need for a special unit that provides smoking cessation counseling and treatment.

There is a legislation that forbids tobacco use in public places. We asked about the success rate of the legislation in the faculty. The legislation was thought to be successfully practiced in offices by 66.4%, in hospital by 52.4% and in educational areas by 39.4%. 43.5% of the smokers smoke in clinics or offices where their patients can see them smoking in daily practice. 4.8 % smoke often, 19.4 %smoke rare, 12.9 % smoke very rare.

DISCUSSION

There were some limitations of this study that should be mentioned. The study sample was quite small and included only physicians in a university hospital. Working place and conditions could affect smoking habits and smoking cessation practices of physicians, so before making comments about all physicians a study group that includes participants from all possible working conditions should be available. The participation rate of the physicians was also limited to cover all physicians (33.4%). But results were comparable to the equivalent studies (7-9). Smoking rate among physicians were found to be 54.9% for males, 39.5% for females in Elazig (7), 39.5% for males, 26.5% for females in Istanbul (8) and 42.3% for males and females in Samsun (9). Smoking prevalence in Turkey was found between 43.6% and 55.8% in previous trials and this means there are approximately 25 million smokers (10-13). Smoking prevalence in this study was found to be 45.5% concordant with previous trials made in Turkey representing that Turkish physicians smoke as much as their patients.

Studies from different countries revealed less smoking rates among physicians. In the United States, the smoking rate of physicians was found to be less than 10% (14, 15). In the United Kingdom the smoking rate of general practitioners was found in the range of 13-15% (16). In Mexico, Tapia-Conyer found 26.9 %, in Israel Samuels found 15.8 %, in Italy Zanetti found 39 %, and in Bahrain, Hamadeh found 35.9 % smoking rates among physicians (17-20). All of these rates are less than our finding for Turkish physicians.

In today's medical community, there is growing concern about smoking among physicians, not only because of their own health, but also because of the potential adverse effects on their clinical practices, and because of the model perceived by their patients and others. Personal habits of physicians are known to be affective on their practices (21). In this study two-thirds of physicians didn't ask their patients' about their smoking status although more than three-quarters of them reported to provide smoking cessation counseling if the patient had a smoking-related disease. The rate of counseling decreased significantly if the patient had a disease not related to smoking (Table 1). This study clearly demonstrates that respondents very rarely counsel smoking cessation as a part of preventive health care and physicians who smoke may have difficulty promoting healthy behaviors among their patients. It was shown that physicians who smoke were less successful in decreasing smoking habits among their patients than their non-smoking colleagues (22).

Respondents reported that they would counsel smoking cessation if they knew there was an effective tool for guiding them to quit. Physicians are expected to provide smoking cessation counseling in every visit and facilitate ready and motivated patients with behavioural and medical treatments. It is an area of intervention on which Turkish physicians need continuous medical education.

Almost half of the smokers smoke in clinics or offices where their patients can observe their behavior. Anti-smoking legislation did not show enough results yet, even amongst the physicians (23). It is a great concern that physicians who smoke are poor role models for the population. Medical practice of physicians may be affected by their life styles so physicians who smoke may have difficulty in promoting healthy behavior among their patients.

CONCLUSION

This study reveals the high smoking prevalence among physicians in Turkey. There is a need for mobilizing tobacco control efforts. Health care professionals are considered to be the best group where efforts would yield the best results and help in changing some smoking habits. They must be offered help in order to quit, and emphasis should be placed on prevention among medical students.

TABLE 2. Attitudes of physicians towards smoking cessation counseling (%)

	Strongly agree	Agree	Undecided	Disagree	Strongly disagree
Physicians should give smoking cessation counseling in every visit.	58.6	34.6	3.8	2.3	0.8
Smoking cessation counseling is a responsibility for every physician.	33.8	58.6	1.5	4.5	1.5
I could manage smoking cessation counseling.	39.4	41.7	13.6	2.3	3.0
More physicians will provide smoking cessation counseling if they know there is an effective tool for guiding to quit.	51.9	33.8	6.0	6.8	1.5
In our hospital, there is a need for a special unit that provides smoking cessation counseling and treatment.	67.9	23.7	6.1	0.8	1.5

FIGURE. Smoking in workplace

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