ORIGINAL ARTICLE
Analysis of the Role of Physicians in the Cessation of
Cigarette Smoking Based on Medical Specialization
Seyhan Dülger,I,* Canan Doğan,II Özlem Şengören Dikiş,I Eylem Yıldırım,III Utku Tapan,IV İpek Özmen,V
Birsen Şahin Satılmış,VI Yavuz Selim İntepe,III Birsen Ocaklı,V Cevriye Yüksel Kaçan,VII Ersin Budak,VIII
Tekin YıldızI
IPulmonary Diseases Department, Health Sciences University Bursa Yüksek İhtisas Education & Research Hospital, Bursa, Turkey. II Pulmonary Diseases
Department, Isparta State Hospital, Isparta, Turkey. IIIPulmonary Diseases Department, Bozok University, Yozgat, Turkey. IVPulmonary Diseases
Department, Health Sciences University Suat Seren Chest Disease Education & Research Hospital, İzmir, Turkey. V Pulmonary Diseases Department, Health
Sciences University Sureyyapasa Pulmonary Disease Education & Research Hospital, İstanbul, Turkey. VIPulmonary Diseases Department, Baskent University
Zübeyde Hanım Education & Research Hospital, İzmir, Turkey. VIIUludag University Health Sciences Faculty, Bursa, Turkey. VIII Psychology Department,
Health Sciences University Bursa Yüksek İhtisas Education & Research Hospital, Bursa, Turkey.
Dulger S, Dogan C, Dikis OS, Yildirim E, Tapan U, Ozmen I, et al. Analysis of the Role of Physicians in the Cessation of Cigarette Smoking Based on Medical
Specialization. Clinics. 2018;73:e347
*Corresponding author. E-mail: drsdulger@gmail.com
OBJECTIVE: Physicians do not adequately use their unique professional privilege to prevent patients from
smoking. The aim of this study was to investigate the type and extent of advice given to patients by physicians
of different medical specialties regarding smoking cessation.
METHODS: In total, 317 volunteer physicians were included in this study. The participants rated their attitudes
toward the smoking habits of their patients by completing a questionnaire. The approaches used to address the
smoking habits of patients significantly differed among physicians working at polyclinics, clinics and emergency
service departments (po0.001). Physicians working at clinics exhibited the highest frequency of inquiring about
the smoking habits of their patients, while physicians working at emergency service departments exhibited the
lowest frequency.
RESULTS: Physicians from different medical specialties significantly differed in their responses. Physicians
specializing in lung diseases, thoracic surgery, and cardiology were more committed to preventing their patients
from cigarette smoking.
CONCLUSIONS: The role of physicians, particularly pulmonologists and thoracic surgeons, is critical in the fight
against cigarette smoking. Promoting physician awareness of this subject is highly important in all other
branches of medicine.
KEYWORDS: Smoking Cessation; Physician’s Role; Dependency.
’ INTRODUCTION annually (2). The World Health Organization (WHO) has
drawn attention to the potential power of health care
This study was presented as a controversial poster in The workers in the fight against tobacco smoking (3). Even a
Turkish Thoracic Society 20th Annual Congress. short-term clinical intervention by a physician has been
Currently, cigarette smoking is among the highly signifi- found to be highly effective in the cessation of cigarette
cant public health problems, and the mortality rates asso- smoking in patients (4-6). However, physicians do not fully
ciated with cigarette smoking exceed the total mortality from exploit this power (7,8). In the U.S.A., more than 70% of
tuberculosis, human immune deficiency virus and malaria cigarette smokers have sought medical consultation for
(1). The tobacco epidemic is among the greatest public health varying reasons (9). These consultations can be useful for
threats worldwide, leading to the deaths of 7 million people short-term clinical interventions by physicians. Physicians
who inquire about their patients cigarette smoking habits
and advise against smoking can make a significant contribu-
Copyright & 2018 CLINICS – This is an Open Access article distributed under the tion to public health regardless of their branch of medical
terms of the Creative Commons License (http://creativecommons.org/licenses/by/ specialization and the circumstances of the patients’ visits.
4.0/) which permits unrestricted use, distribution, and reproduction in any The aim of this study was to investigate the approaches used
medium or format, provided the original work is properly cited.
by professionals to the smoking habits of their patients in
No potential conflict of interest was reported. various medical specializations under various conditions.
Received for publication on September 4, 2017. Accepted for Thus, the aim of this study was to examine the approaches
publication on December 11, 2017 used to address the smoking habits of patients according to
DOI: 10.6061/clinics/2018/e347 the medical specialty of the physician. Furthermore, to reveal
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Role of Physicians in Smoking Cessation CLINICS 2018;73:e347
Dülger S et al.
the physicians’ awareness of the harmful effects of cigarette Statistical Analysis
smoking, the physicians were also questioned about diseases The relationships among the responses to the question-
associated with their patients’ smoking habits. naire items, the medical specialization branches, and the
types of approach used to address patients’ smoking habits
’ MATERIALS AND METHODS were analyzed using the Statistical Package for Social Sci-
ences (SPSS) (IBM SPSS Statistics for Windows version 23.0,
This study was conducted according to the Helsinki SPSS, Armonk, NY, USA). The numerical data are expressed
Declaration and was approved by the Bursa Post Graduate as the mean±standard deviation (M±SD), and their distri-
Education and Research Hospital Ethical Committee (2011- bution was assessed by performing a Kolmogorov-Smirnov
KAEK-25 2016/14-07). test. The categorical data are expressed as percentages (%).
The mean number of patients visiting physicians with dif-
Participants ferent specialties at polyclinics, clinics and emergency service
In total, 317 volunteer physicians were included in this departments and the median scores of their responses to
study, including 176 (55.5%) males and 141 (44.5%) females the study questionnaire were compared using the Mann-
working at 6 different health care centers. Participants from Whitney-U test and the Kruskal-Wallis test. Pearson cor-
polyclinics, specialty clinics and emergency service depart- relation tests were performed to evaluate the relationships
ments completed a study-specific questionnaire in which among the physicians’ responses to the questionnaire at
they rated their attitudes toward the cigarette smoking habits polyclinics, clinics and emergency service departments, the
of their patients and their degree of professional burnout. monthly number of patients treated and the scores on
Preclinical and pediatric physicians in were excluded from the professional burnout rating scale. Chi-square tests
the study due to the inapplicability of the questionnaire. were performed to assess the relationship between the
Since children are passive smokers, physicians should ask responses to the questionnaire and the demographic infor-
parents about their smoking habits. Childhood illnesses mation of the physicians. A p-value of o0.05 indicated
caused or adversely affected by passive smoking differ from statistical significance.
adult illnesses. Thus, preparing a different questionnaire for
pediatrics and performing a separate study were considered ’ RESULTS
appropriate. Three pulmonologists working at polyclinics
specializing in cigarette smoking cessation were also exclu- The mean age of the participants was 39.61 (±7.65) years.
ded from the study. A preliminary study involving 64 The entire sample consisted of 176 (55.5%) males and 141
physicians was performed at our hospital, and the results (44.5%) females, and 23.4% (n=74) of the participants were
have been published (10). Subsequently, this study was per- smokers. Physicians working at polyclinics who responded
formed to obtain data from different regions and increase that they ‘‘specifically’’ and ‘‘always/frequently’’ inquired
participation from other health care centers. about their patients’ cigarette smoking habits constituted
66.88% of the sample, and those who responded that they
Questionnaire ‘‘frequently or generally’’ advised their patients to stop smok-
To design an appropriate questionnaire, a preliminary ing constituted 76.58% of the sample.
version was prepared and assessed by consulting pulmonol- Statistically significant correlations were not found between
ogists and thoracic surgeons at our hospital. The questionnaire the professional burnout ratings and the likelihood of query-
consisted of the following three parts: sociodemographic ing about or advising against cigarette smoking among phy-
details of the participating physicians, questions designed sicians working at polyclinics (p=0.48), specialty clinics
to reveal the type and frequency of approaches used by (p=0.37), and emergency service departments (p=0.28). In
physicians to address the cigarette smoking habits of addition, correlations were not observed between the
patients at polyclinics, clinics or emergency service depart- personal cigarette smoking habits of the physicians and
ments (Table 1), and a rating scale (based on the Maslach their attitudes toward their patients’ smoking habits among
Burnout Inventory-MBI) to assess professional burnout. physicians working at polyclinics (p=0.07), specialty clinics
(p=0.97) and emergency service departments (p=0.45). Unmar-
Table 1 - ried physicians working at emergency services tended toQuestionnaires distributed to physicians working at
polyclinics, clinics and emergency service departments. query their patients more frequently regarding their smok-
ing habits than married physicians (p=0.026). However, this
A- Are you following up an inpatient at any clinic? (If your answer is associated was not statistically significant among physi-
‘’Yes’’, answer the questions on this page. If your answer is ‘’No’’, you cians working at polyclinics (p=0.13) and specialty clinics
may continue with the following pages) (p=0.19).
1. What is the mean number of patients you have seen at the polyclinics Physicians working at polyclinics, clinics and emergency
in a single month? service departments used significantly different approaches
2. I query whether the polyclinic patients smoke or do not smoke to address the cigarette smoking habits of their patients
cigarettes. (po0.001). The highest incidence of inquiring about patients’
A) Never B) Rarely C) Generally D) Frequently E) Always smoking habits was reported by physicians working at
3. I inform the polyclinic patients on the harmful effects of cigarette specialty clinics, and the lowest incidence was reported
smoking.
A) Never B) Rarely C) Generally D) Frequently E) Always by physicians working at emergency service departments
4. I Advise the polyclinic patients to give up smoking cigarettes. (Figure 1). The variation in the attitudes toward the
A) Never B) Rarely C) Generally D) Frequently E) Always patients’ smoking habits differed among physicians work-
5. I refer the polyclinic patients to the Cigarette Smoking Cesation ing at polyclinics (po0.001), clinics (po0.001) and emergency
polyclinic after the completion of their treatment. service departments (p=0.004). At polyclinics, pulmonolo-
A) Never B) Rarely C) Generally D) Frequently E) Always gists (4.45±0.53), cardiologists (3.98±0.74), thoracic surgeons
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Dülger S et al.
Figure 1 - Mean ranks of the responses to the questionnaire at the polyclinics, clinics and emergency service department (po0.001).
Figure 2 - Questionnaire scores of all medical branches at the polyclinics.
(3.57±0.5), ear nose throat (ENT) specialists (3.6±0.51) and ’ DISCUSSION
cardiovascular surgeons (3.53±0.23) demonstrated a higher
sensitivity to their patients’ smoking habits (Figure 2). How- Strikingly, we observed a relatively low interest in patients’
ever, among the specialty clinics, physicians working at eye smoking habits among physicians working at polyclinics,
clinics (1.71±0.38), physical medicine departments (2.53± except for those specializing in pulmonology, thoracic surgery
0.24) and infectious diseases departments (2.93±0.87) and ENT because these physicians are directly interested
displayed the lower interest in their patients’ smoking in the respiratory system. In particular, ophthalmologists,
habits, and the mean values among the other specialties infectious disease specialists, and general surgeons were
were similar (Figure 3). At emergency service departments, not interested in the cigarette smoking habits of their patients.
physicians working in pulmonology (3.58±1.53), cardiology Survey studies investigating this topic are lacking from the
(3.55±0.41), gynecology (3.2±1.11) and thoracic surgery literature. King et al. (11) investigated interventions performed
(3.12±0.75) displayed a relatively higher interest in their by health care providers for smoking cessation, but their study
patients’ smoking habits than physicians working in other is limited because the medical specializations of the health care
disciplines (Figure 4). providers were not evaluated.
At the polyclinics, the high incidences of COPD (67.5%), In our study, physicians working at specialty clinics were
CAD (55.4%), and CF (50.6%) and the high number of most likely to inquire about their patients’ smoking habits,
patients in the preoperative stage (63.9%) prompted the followed by physicians working at polyclinics and emer-
physicians to ‘‘always’’ or ‘‘frequently’’ inquire about the smok- gency service departments. Physicians working at specialty
ing habits of their patients. Similarly, at the specialty clinics, clinics spent more time with their patients than physicians
the incidence of COPD (44.5%) and CAD (42.3%) and the working at polyclinics and emergency service departments.
number of preoperative patients (39.1%) were high, and at In addition, fewer patients visit specialty clinics, which may
the emergency service departments, the incidences of COPD explain the more favorable results at these clinics. Although
(53.5%) and CAD (44.2%) and the number of patients at the similar studies are not available in the literature and despite
preoperative stage (37.2%) with a smoker’s sociocultural the relatively short duration of patient contact, we posit that
background (37.2%) were high and conditioned the physicians physicians working at emergency service departments should
to inquire about the history of the patients’ smoking habits. incorporate an assessment of their patients’ smoking habits
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Dülger S et al.
Figure 3 - Questionnaire responses of all medical branches at the clinics.
Figure 4 - Questionnaire responses of all medical branches at the emergency service department.
into the assessment of the presenting complaint of the patient. King et al. (11) also reported that 65.8% of patients had
Even a few minutes spent by the physician on the subject can been recommended to stop smoking by a healthcare profes-
result in a 5-15% reduction in cigarette smoking (7). sional, while Demir & Simsek (12) and Lindorff & Hill (13)
King et al. (11) reported that 87.9% of patients had been reported that 71.5% and 48.6% of patients, respectively,
asked whether they smoke cigarettes. Demir & Simsek (12) receive this recommendation. Because it is impossible for the
reported that 56.7% of physicians generally or always ask percentage of physicians recommending smoking cessation
their patients whether they smoke. In the present study, 56% to exceed the percentage of those who ask about the habit,
of the physicians working at polyclinics asked about cigarette the result reported by Demir & Simsek (12) may represent
smoking, indicating that a lack of improvement in our country 71.5% of physicians who queried, suggesting that 56.7% of
over the previous 3 years. all physicians recommend smoking cessation. In our study,
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Dülger S et al.
42.36% of the physicians reported that they ‘‘always’’, ‘‘fre- unlikely to ask about smoking in patients who do not
quently,’’ or ‘‘generally’’ informed their patients about the have COPD, CAD and CF. Furthermore, physicians do not
harmful effects of cigarette smoking. We were unable to have basic knowledge regarding the effects of cigarettes on
locate this information in the literature. the course of many illnesses and the efficacy of many drugs.
Approximately 3-5% of the general population quit smok- We believe that the education of physicians of all medical
ing on their own, and up to 40% of smokers seek consul- specialties should emphasize the issue of cigarette use and
tation at polyclinics for smoking cessation (13). Although the dependence.
Cigarette Smoking Cessation Polyclinic at our hospital is
active 7 days a week, approximately 29.7% of physicians
generally’’ or ‘‘frequently’’ provided referrals. In the study ’ AUTHOR CONTRIBUTIONS
by Demir & Simsek (12), one-third of the participating Seyhan Dülger S generated the hypothesis, planned the methodology,
physicians were unaware of the smoking cessation poly- performed the statistical analysis, and wrote the manuscript. Doğan C,
clinic, and only 57.3% of those who were aware of the Yıldırım E, Tapan U, Özmen İ, Satılmış BŞ, İntepe YS and Ocaklı B
service (or 38.2% of the total physicians participating in performed the data collection at their center, data compilation, and
the study) made referrals. Although several studies have literature review. Dikiş ÖŞ performed data collection at her center, data
suggested that physicians who are not smokers are more compilation, literature review, and critical review of the manuscript. Kaçan
interested in their patients’ smoking habits (14–16), we did CY and Budak E performed the survey preparation, data collection, data
not observe similar findings. In our study, the physicians compilation, and literature review. Yıldız T planned the methodology, and
who smoked appeared to be more aware of smoking as an organized and critically reviewed the manuscript.
issue despite being smokers.
In this study, no significant differences were observed in
the responses to the questionnaires based on the physicians ’ REFERENCES’
gender; however, compared to married physicians, unmarried 1. Mathers CD, Loncar D. Projections of global mortality and burden of
physicians working at emergency service departments were disease from 2002 to 2030. PloS Med. 2006;3(11):e442, http://dx.doi.org/
10.1371/journal.pmed.0030442.
more aware of their patients’ smoking habits. The relatively 2. World Health Organization, WHO updates fact sheet on tobacco 2017
lower number of physicians employed at emergency service may 16. Available from http://www.who.int/mediacentre/factsheets/
departments may have contributed to this finding. Further- fs339/en/
more, this positive finding may be due to the younger age and 3. World Health Organization, WHO Global Status Report on Non-comminicable Diseases, 2010. Available from http://www.who.int/
more recent graduation of the unmarried physicians. nmh/publications/ncd_report2010/en/
Patients with COPD, CAD, or CF and patients present- 4. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER.
ing for preoperative consultation appeared to remind the Treating Tobacco Use and Dependence: An Evidence Based ClinicalPractice Guideline for Tobacco Cessation. U. S. Department of Health and
physicians to inquire about smoking habits. At emergency Human Services, Public Health Service; 2000.
service departments, the sociocultural background of the 5. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ. Treating
patients also prompted the physicians to obtain the patients’ tobacco use and dependence: Clinical Practice Guideline. Department ofHealth and Human Services, Public Health Service; 2008 update.
smoking history. The relatively low rates of inquiry about 6. Centers for Disease Control and Prevention. Quitting smoking among
cigarette smoking habits in patients with diabetes mellitus adults—United States, 2001–2010. MMWR. 2011;60:1513-9.
and collagen tissue diseases, which are adversely affected by 7. Prochazka AV, Boyko EJ. How physicians can help their patients quit
smoking. A practical guide. West J Med. 1988;149(2):188-94.
smoking, are alarming. We did not identify any reports 8. Smith DR, Leggat PA. An international review of tobacco smoking in the
related to this subject in the literature. However, we believe medical profession: 1974–2004. BMC Public Health. 2007;7:115, http://dx.
that physicians should be specifically informed of the rela- doi.org/10.1186/1471-2458-7-115.
9. Association of American Medical Colleges Physician Behavior and
tionship between cigarette smoking and chronic illnesses as Practice Patterns Related to Smoking Cessation. Summary Report 2007.
a part of their education. Available from https://members.aamc.org/eweb/upload/Physician%
One limitation of this study is the self-reported nature of 20Behavior%20and%20Practice%20Patterns.pdf
the data, which were based on a study-specific questionnaire, 10. Dulger S, Budak E, Sengoren Dikis O, Yildiz T. Physician versus thesmoking habit of the patient. Eur Res J. 2017;3(3):243-9, http://dx.doi.
and direct observations of the participants at the polyclinics, org/10.18621/eurj.271084.
clinics and emergency service departments were not per- 11. King BA, Dube SR, Babb SD, McAfee TA. Patient-reported recall of
formed. Furthermore, feedback from the patients regarding smoking cessation interventions from a health Professional. Prev Med.2013;57(5):715-7, http://dx.doi.org/10.1016/j.ypmed.2013.07.010.
the approaches used by the physicians to address their smok- 12. Demir C, Simsek Z. Physicians’ Smoking Cessation Behavior and Related
ing habits was not collected; only physicians were ques- Factors. TAF Prev Med Bull. 2013;12(5):501-10, http://dx.doi.org/10.5455/
tioned about the approach used to address their patients’ pmb.1-1344603200.13. Lindorff KJ, Hill DJ. Physicians’ role in advancing tobacco control in
smoking habits. Pediatricians caring for children who are China. Zhongguo Fei Ai Za Zhi. 2010;13(6):632-6.
passive smokers were also excluded from this study. 14. West R, McNeill A, Raw M. Smoking cessation guidelines for health
Cigarette smoking is a serious threat to public health in professionals: an update. Health Education Authority. Thorax. 2000;55(12):
987-99, http://dx.doi.org/10.1136/thorax.55.12.987.
this century, and physicians must fully perform their duty 15. Talay F, Altin S, Cetinkaya E. [The smoking habits of health care workers
in fighting against this problem. This study revealed that and their approach to smoking in Gaziosmanpaşa and Eyüp counties of
physicians of various medical specialties are not equally aware Istanbul]. Tuberk Toraks. 2007;55(1):43-50
16. Uysal MA, Dilmen N, Karasulu L, Demir T. Smoking Habits Among
of and informed about the appropriate approaches that can Physicians in Istanbul and Their Attitudes Regarding Anti-smoking
be used to address patients who are smokers. Physicians are Legislation. Tuberk Toraks. 2007;55(4):350-5
5