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Smoking Doctors

Do you know that approximately one-third of the world’s smokers reside in China. where the national smoking prevalence is about 30%. Nearly 800,000 Chinese die each year as a result of smoking, and the number will increase to 2 million by 2025 if current smoking rates continue. Smoking is expected to cause one-third of all deaths among Chinese men by 2030.

Medical interventions can be effective in helping smokers to quit. Not only are physicians primarily responsible for delivering such interventions, they are usually viewed as role models for health-related behavior such as smoking. Although the dangers of smoking are well known throughout the medical profession, physicians do not always set a good example for patients. The World Health Organization (WHO) documents that the prevalence of smoking among physicians in China is 61% for men and 12% for women. Other studies have reported different prevalence rates. For example, a study of 3,553 physicians from 6 Chinese cities reported a smoking prevalence of 23% (men, 41%; women, 1%). In another study of 786 physicians, overall smoking prevalence was 20%. Annually, 76% of smokers are seen by physicians in China, creating an opportunity to counsel patients about quitting. However, few physicians ask about smoking status or advise smokers to quit. Studies showed that less than half of physicians “often” or “always” advise smokers to quit.

A cross-sectional survey was conducted in 5 hospitals in China from March 5 through March 15, 2007. The reported smoking rates ranged from 13% to 57%; such a wide range could be partially explained by geographical and sociocultural variations in China, the year when the study was taking place or the specialty of the physicians. The rates, shown during this survey, are lower than those conducted among physicians in the Netherlands (38%), Japan (34%), and France (32%), but higher than those reported for the USA (3%), New Zealand (5%) and the United Kingdom (7%). It was found that smoking is more prevalent among male than female physicians.

The study showed that physicians who smoke are less likely to believe that health professionals should serve as nonsmoker role models for their patients and the public. It was suggested that interventions aimed at reducing cigarette smoking among physicians would lower the overall smoking rate.

It was found that Chinese physicians lack sufficient knowledge about the health hazards of smoking. They need more education about the link between maternal smoking and neonatal death. In addition, physicians, especially those who smoke, need more education about the links between secondhand smoke and risk of lung disease, heart disease, and lower respiratory tract disease. Incorporating and adapting best practices for counseling patients about cessation into the medical school curriculum may increase knowledge and prevent smoking in young medical students.

The finding that working in a hospital with smoke-free policies was negatively associated with cessation counseling was counterintuitive. In follow-up interviews with key hospital personnel and physicians, it was learned that hospitals with smoke-free policies often did not enforce them. In addition, many physicians in this follow-up did not know whether their hospital was smoke-free. As a result, it was suggested that smoke-free policies need to be better communicated and enforced.

Also it was observed that younger physicians were more likely to follow good cessation counseling practices. Counseling practices may, therefore, improve with time. Continuing education on smoking cessation should be offered to all age groups of physicians, and clinical staff should routinely assess and record the smoking status of every patient in the hospital’s medical record systems as a vital sign.

Asking about smoking (71%) was less common than advising to quit smoking (78%) among the physicians. Although it is consistent with another study among the physicians in China, it is in contrast with studies among the US and Hong Kong physicians. US physicians ask about smoking status during two thirds of all visits, but only advise about 20% of smokers to quit. Similarly, 77% of the Hong Kong physicians usually ask about smoking and only 29% advise smokers to quit. The higher rate of advising to quit than asking about smoking in the current study may be due to the fact that patients raise the issue themselves because of  increased awareness. As many physicians smoke they are reluctant to proactively ask about smoking status of the patients. Also, it is possible that physicians who did advise smokers to quit wished to encourage patients to buy cessation medications. Cessation medications are not subsidized by the health care system; smokers have to buy these medications with their own money. In many cases, physicians get incentives from pharmaceutical companies for prescribing branded medications which might have encouraged physicians to advise their patients to quit and, probably, to suggest buying certain cessation products. In contrast, asking and recording smoking status is not mandatory in the Chinese health care system and there is no incentive for doing so.

Reading any guidelines about counseling patients to quit smoking was positively associated with recording smoking status and advising smokers to quit. However, most guidelines were available in English, but most Chinese physicians cannot read English. A brief Chinese language guideline was developed in 2007 (written communication, Dr Jiang Yuan, Director of the National Tobacco Control Office, China CDC, Beijing, China, June 2008), after this study was completed, and is not yet available to all physicians. In a follow-up investigation, it was found out that most physicians were not aware of this brief Chinese guideline. However, many had heard about the international guidelines, mostly US and UK guidelines, and a few had briefly investigated these international guidelines through the Internet, but did not understand the details of the recommendations because of the language barriers. Hopefully, the developing a national guideline in Chinese and promoting it to the physicians would be useful. Some limitations of this study should be noted. First, the response rate of 85% may have been higher if a second survey would have been delivered. Second, because the survey was anonymous, no information on the characteristics of nonresponding physicians is available, and respondents may have differed from nonrespondents, which may limit the generalizability of the study findings. Finally, respondents may have underreported behaviors viewed as deviant or socially undesirable.

Overall, the findings stress the need to enforce smoke-free hospital policies, to develop a national guideline in Chinese and promote it to the physicians, to increase interventions that will help physicians to quit smoking.

Source: Smoking Status and Cessation Counseling Practices Among Physicians, Guangxi, China, 2007