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d o i : 1 0 . 1 1 1 1 / j . 1 3 6 8 - 5 0 3 1 . 2 0 0 5 . 0 0 4 9 2 . x The participation of health professionals in a smoking-cessationprogramme positively influences the smoking cessation advicegiven to patients P . M . J . P U S K A , 1 M . B A R R U E C O , 2 C . R O U S S O S , 3 A . H I D E R , 4 S . H O G U E 5National Public Health Institute,1 Helsinki, Finland, Salamanca University,2 Salamanca, Spain, Evangelismos General Hospital,3Athens, Greece, GlaxoSmithKline Research and Development,4 Greenford, Middlesex, UK, GlaxoSmithKline Research andDevelopment,5 Research Triangle Park, NC, USA study participants became more proactive with their smok- ing cessation advice. A positive shift from baseline to end This study assessed the degree of smoking cessation advice of study was observed with respect to the advice and given by health professionals, before and after their parti- support they gave to their smoking patients. These changes cipation in a smoking cessation study using bupropion- were not related to study treatment or current smoking sustained release (bupropion SR, ZybanÒ). A total of 690 status. An increase in advising patients to quit smoking and physicians and nurses who had smoked an average of 10 in offering cessation counselling was observed. Participa- cigarettes/day over the previous year and were motivated to tion in a smoking-cessation study by physicians and nurses quit smoking, were randomised in a double-blind manner who smoke has a positive effect, regardless of study med- to receive bupropion SR (days 1–3, 150 mg/day; days ication, in smoking cessation advice and counselling given 4–49, 150 mg twice daily) or placebo for 7 weeks, with follow-up to week 52. All subjects received regular follow- Keywords: Smoking; cessation; attitudes; support; physi- up and brief motivational support throughout the study.
Questions regarding their smoking cessation advice formedpart of the study, with the aim of determining whether (5,6). Smoking among nurses also tends to be high, with rates up to 40% in countries such as Northern Ireland and Italy (7,8).
Tobacco smoking is one of the most significant causes of Nardini et al. have previously reported that physicians who morbidity and mortality in modern society. Approximately smoke tend to underestimate the health hazards associated half of all continuing smokers die from smoking-related dis- with smoking compared with their nonsmoking counterparts eases, with an average loss of 20–25 years life expectancy per (9). A review of the literature suggests that health profes- smoker (1). Smoking causes the majority of lung cancers, sionals who smoke may not be as effective in counselling accounting for approximately 30% of all cancer deaths (2).
patients to quit smoking as health professionals who do not Similarly, 30% of deaths because of cardiovascular diseases are smoke (10). Physicians who regularly smoke tend to convey a as a result of smoking (3). Many smokers wish to give up their more negative attitude towards smoking-cessation interven- smoking because of these health risks.
tion, and they often downplay their role in highlighting the As an aid to successful smoking cessation, the help and advice health risks associated with smoking (11,12). Also, physicians of health professionals such as doctors and nurses is important who smoke do not recognise that they should set an example (4). However, many health professionals continue to smoke, as a positive role model to patients (13).
despite the health risks involved. According to recent World The interaction of health professionals with their patients Health Organization (WHO) figures, smoking rates among who smoke, therefore, appears to be a relevant factor in the physicians vary considerably; 4–5% of physicians in the UK success of their patients’ attempts to stop smoking. Indeed, regularly smoke compared with 34% in Italy and France, many studies have shown that health professionals have an whereas in countries such as Spain the rate may exceed 50% important role to play in reducing smoking prevalence and ininfluencing smoking cessation. For example, the Agency forHealth Care Policy and Research has given smoking-cessationcounselling from physicians its highest recommendation (14).
Smokers have been shown to cite a physician’s advice to quit Pekka Puska, MD, PhD, MPolSc, National Public Health Institute as an important motivator for attempting to stop smoking (KTL), Mannerheimintie 166, FIN 00300 Helsinki, FinlandEmail: pekka.puska@ktl.fi (15), and the WHO has stated that health professionals ª 2005 Blackwell Publishing Ltd Int J Clin Pract, April 2005, 59, 4, 447–452 CHANGING HEALTH PROFESSIONALS’ ATTITUDES TO SMOKING should be involved in an active and exemplary way in quitting smoking (5). It has been suggested that if smoking prevalence This was a multicentre, randomised, double-blind, placebo- amongst physicians fell below that of the general population, controlled study conducted at 26 centres across 12 countries.
in a few decades the smoking prevalence among the general The majority of the study centres were from the secondary population would also decrease (16).
care setting. The study was approved by the investigational The present study assessed the degree of smoking cessation centre ethics committee or the Institutional Review Board of advice given by health professionals (defined as qualified the participating centres and was performed in accordance physicians and nurses), before and after participation in a with the Declaration of Helsinki, June 1964, as modified by study of smoking cessation using bupropion-sustained release the 48th World Medical Association, Republic of South (bupropion SR, ZybanÒ), the first non–nicotine-based pharma- Africa, October 1996. Written informed consent was cological aid to smoking cessation. Bupropion SR has been obtained from all study participants prior to entry into the shown to be an effective aid to smoking cessation in clinical studies (17,18), which has been acknowledged in smoking The study consisted of a 1–2-week screening/baseline cessation guidelines (19–21). The smoking cessation results phase, a 7-week treatment phase and follow-up at 12, 26 from the current study are presented elsewhere and showed and 52 weeks. Regardless of treatment assignment, all patients higher quit rates with bupropion SR as compared with pla- received brief motivation support (approximately 10 min) cebo with statistical differences through the treatment phase (22).
provided by trained counsellors either in person or byphone, weekly during the treatment phase and monthly dur- ing the follow-up phase. This report represents the analysis ofthe answers to questions regarding advice given to smoking patients by these health professionals (Table 1). The responses Subjects in the study were healthcare professionals (defined as a to questions were either dichotomous or Likert type as iden- practising physician or nurse), aged 18 years of age, who had tified in Table 1. The questions were included in the study smoked on average 10 cigarettes per day during the previous after assessment of content validity by experts in the field. The year and who had not made a serious attempt (lasting > 3 questions were completed during the study at baseline, week 7 months) to stop smoking during this period. All participants (end of treatment) and week 52 or at premature discontinua- were motivated to quit smoking and were free from significant tion. The number of participants completing each question cardiac, pulmonary, gastrointestinal, hepatic, renal, haemato- varied, as not all questions were applicable to each subject logical, neurological and psychiatric disease.
depending on their professional degree and the nature of their Subjects were excluded if they had experienced seizures pre- viously or were predisposed to seizures, had a current diagnosisof severe cardiac, pulmonary, hepatic, renal, haematological or neurological disease or had a history or current diagnosis ofbulimia, anorexia nervosa, panic disorder, psychosis or bipolar For the purpose of this subanalysis, the main outcome was the disorder or were depressed. Participants were also ineligible assessment of the responses to the smoking advice questions.
if they had uncontrolled hypertension, had used nicotine- Primary analyses were performed on the population of partici- replacement therapy for a serious quit attempt during the pants who completed a questionnaire at baseline and at week 52.
previous 3 months, had previously used bupropion SR for smoking cessation or were using other treatments for smoking using McNemar’s test (23). Primary analyses were conducted which assessed the change in healthcare professionals’ Table 1 Questions used to assess the degree of smoking cessation advice given by healthcare professionals at baseline, week 7 and week 52 orpremature discontinuation Do you determine the smoking status of your patients regularly?†Do you inform patients that smoking is harmful?‡Do you advise patients to quit smoking?‡Do you provide patients with behavioural counselling during a quit attempt?†Do you think the fact that you smoke influences the advice you give to patients regarding smoking?†Do you agree that your personal experience with smoking-cessation products influences your prescribing practices?§ *Post baseline questions 1, 2, 3 and 4 changed to ‘Will you …; †Yes/no; ‡Always/only if they ask/only if they are symptomatic/never/other;§Strongly agree/agree/neutral/disagree/strongly disagree.
ª 2005 Blackwell Publishing Ltd Int J Clin Pract, April 2005, 59, 4, 447–452 CHANGING HEALTH PROFESSIONALS’ ATTITUDES TO SMOKING responses from baseline to week 52. A sensitivity analysis was determine the smoking status of their patients (Figure 1A), also conducted, which considered the latest questions to be inform their patients that smoking was harmful (Figure 1B) completed for each subject, whether this was at week 7, week and would advise their patients to quit smoking (Figure 1C).
52 or at the withdrawal visit (if the subject withdrew from the There was an increase in the percentage of healthcare profes- study at an early stage). Subjects withdrawing or not complet- sionals who provided behavioural counselling while attempt- ing the questions at week 52 may not have had similar change ing to quit smoking (Figure 1D). Additionally, when asked compared with those subjects who completed the questions at whether or not their personal experience with smoking- week 52. Therefore, to assess bias, a secondary analysis was cessation products influenced their prescribing practice, a performed, with the responses to the last questions carried greater percentage of participants either agreed or strongly agreed than they did at baseline (Figure 1E).
Shift Analysis by Health Professionals’ Involvement in aSmoking-Cessation Programme For the shift analysis, patient responses at baseline and week A total of 690 health professionals were enrolled in the study, of which 687 formed the ITT population. Of these, 517 and At week 52, there was a significantly positive shift in the 170 subjects were randomised to receive either bupropion SR number of subjects answering that they would determine the or placebo, respectively. A total of 568 patients remained in smoking status of their patients [based on 468 subjects who the study at the end of week 7 (83%) and 501 at the end of completed, 14.1% increase; 95% confidence interval (CI) week 52 (73%). Following an audit, the data from one centre 9.1–19.1%; p < 0.001] compared with baseline. A similar in the study were excluded from the efficacy analyses, as the result was observed when the responses for last questions validity and integrity of the data from this centre (20 subjects) completed were carried forward (586 subjects, 13.0% could not be confirmed. Therefore, the data are presented increase; 95% CI 8.6–17.4%; p < 0.001).
based upon the results from 25 (n 5 501, bupropion SR; A total of 471 health professionals answered the question n 5 166, placebo) of the 26 centres. The treatment groups ‘Do you inform patients that smoking is harmful?’ at baseline were comparable in terms of age, gender, occupation and and week 52. There was a positive shift in subjects answering ‘always’ to this question (19.5% increase; 95% CI 14.8–24.3%), Overall, a comparison of responses at baseline vs. those which was highly significant (p < 0.001). The sensitivity from the end of treatment (week 7) and the end of the analysis provided similar results (585 subjects, 18.1% increase; study (week 52) indicated a positive shift towards a more proactive approach to smoking cessation. This shift appeared Based upon those subjects (n 5 469) who answered the unrelated to treatment received or smoking status.
question ‘Do you advise patients to quit smoking?’, therewas a significant positive shift in the number of health profes- Health Professionals’ Response to Individual Questions sionals who answered ‘always’ at the end of the study com- Responses from subjects at the specified time points during pared with baseline (22.4% increase; 95% CI 17.5–27.3%; the study are displayed graphically in Figure 1A–E. All data p < 0.001). Results from the sensitivity analysis including the described in this section are comparisons of the baseline last questions completed were also comparable (586 subjects, responses with those at the end of treatment (week 7) and 21.1% increase; 95% CI 16.8–25.5%; p < 0.001).
the end of the study (week 52) (population of completers). A A total of 445 subjects responded to the question ‘Do you greater percentage of health professionals said that they would provide patients with behavioural counselling during a quit Table 2 Demographics of study participants *Bupropion SR, n 5 501; placebo, n 5 165; †Pack year history 5 [(number of years smoking) · (number of cigarettes/day)]/20.
ª 2005 Blackwell Publishing Ltd Int J Clin Pract, April 2005, 59, 4, 447–452 CHANGING HEALTH PROFESSIONALS’ ATTITUDES TO SMOKING attempt?’ at baseline and at week 52, and a 36.6% increase (95% CI 31.7–41.5%; p < 0.001) in those answering ‘yes’ was recorded. The sensitivity analysis provided similar results (558 subjects, 36.2% increase; 95% CI 31.8–40.6%; p < 0.001).
From the health professionals (n 5 234) who responded to the question ‘Does your experience with smoking cessation products influence your prescribing practices?’, a significant shift was observed in the number of subjects who answered ‘yes’ at baseline to those who gave this answer at week 52 (12.0% increase; 95% CI 4.8–19.1%; p 5 0.002). Results from the sensitivity analysis including the last questions com- pleted were also comparable (280 subjects, 11.8% increase; Across all questions, the results from the sensitivity analyses were highly consistent with those from the primary analyses.
While many health professionals agree that intervention in smoking cessation is an intrinsic part of their role, many physicians and nurses in either a primary or secondary care setting do not provide smoking cessation advice to their patients (14). However, patients who are heavy smokers, suffering from ill health or have multiple physician visits are more likely to be advised to quit smoking (14). Based on the results of our study, only 36% of health professionals at baseline always advised patients to quit smoking. This figure is within the range reported in other studies. Twenty-one percent of smokers in Finland who had visited a physician during the previous year received advice to stop (24), 34% of smokers in Switzerland recalled being advised to stop (15), and 50% of general practitioners sampled in England and Wales advised all smokers to quit at most or all consultations Such moderate rates of smoking cessation advice from physicians may reflect the lack of understanding that health professionals have of their important role in smoking cessa- tion and how they can become actively involved. It is clear that when physicians engage their patients, almost 40% of smokers make some form of attempt to quit in response to a physician’s advice (26,27) and this can lead to moderate quit rates of up to 10% (28–30). However, for health profes- sionals, many barriers exist to the routine provision of smok- ing cessation advice to smokers, including the pressures of time during consultation and pessimism about their own efficacy, skills and expertise at counselling and their patients’ Figure 1 Responses given by health professionals at baseline, week 7 capacity to change lifestyle behaviour (31).
and week 52 (population of completers) to the following questions It is not surprising that these healthcare professionals regarding smoking and smoking cessation: (A) Do you determine the became more proactive in providing smoking cessation smoking status of your patients regularly? (B) Do you inform patientsthat smoking is harmful? (C) Do you advise patients to quit smoking? advice. Although this study did not train the participants in (D) Do you provide patients with behavioural counselling during a quit the provision of smoking-cessation support and treatment, attempt? (E) Do you agree that your personal experience with smoking- these professionals were probably influenced by the education cessation products influences your prescribing practice? they received as a smoking cessation study participant. The ª 2005 Blackwell Publishing Ltd Int J Clin Pract, April 2005, 59, 4, 447–452 CHANGING HEALTH PROFESSIONALS’ ATTITUDES TO SMOKING provision of education or even simple advice to physicians smoking-cessation advice, irrespective of study treatment or and nurses on how to engage patients who are smokers about final study outcome (i.e. abstainers or non-abstainers). The cessation can help health professionals overcome some of the significant and positive shift among these health professionals obstacles hindering counselling by health professionals.
led many subjects to indicate that, in future, they would Equally, building a rapport with their patients who are smokers determine the smoking status of their patients regularly, and assessing their patients’ motivation and confidence to inform them that smoking is harmful and advise them to quit, can be key elements in the smoking-cessation process quit, whilst also providing counselling during a quit attempt.
(31). Unfortunately, physicians tend to feel more comfortable The adoption of a more proactive approach to smoking with providing assistance when smokers request it, for cessation by health professionals is particularly relevant instance when suffering from smoking-related diseases (32).
when it has been shown that during a recent 12-month It is also perceived by physicians to be more in line with what period, over 60% of people attempting to stop smoking in the patient expects from their visit to a physician (25).
the UK did not seek any help or advice, and of those who did, How health professionals view smoking is equally import- only 7% contacted a physician or other health professional ant – is it perceived as a lifestyle or a strong health risk, i.e. do physicians and nurses attempt to educate their patients about In conclusion, the present study emphasises the need for this risk and provide advice on how to eliminate it? It has effective education of health professionals on appropriate been suggested that health professionals may see unsolicited strategies to engage their staff and patients in smoking cessa- lifestyle advice, such as that relating to smoking cessation, as tion. It also highlights the value of involving physicians and incompatible with their caring role and as a risk to the nurses who smoke in smoking-cessation programmes. Such physician–patient relationship (4). Furthermore, some phys- involvement should be widely considered in national icians may fear alienating patients who are not receptive to smoking-control programmes for both health professionals such advice (33). In addition, health professionals who smoke themselves may not be as effective in counselling theirpatients compared with their nonsmoking colleagues, and consequently, their own smoking behaviour may impactnegatively upon that of their patients (10,12).
We gratefully acknowledge the assistance of the Principal Counselling of smokers by health professionals is recom- Investigators in the ZybanÒ Healthcare Professionals Study mended by numerous smoking cessation guidelines (19,34); yet, when questioned almost 50% of smokers had not Austria: Aigner K, Irsigler K and Schinko H. Estonia: received such counselling during a previous 12-month period Sepper R. Finland: Puska P. Greece: Siafakas N, Roussos C when they had previously visited a physician in a primary or and Patakas D. Germany: Batra A, Boelcskei P, Moecke H secondary healthcare setting (14). A similar percentage of and Schmidt L. Israel: Kramer M. Italy: Dezio A and health professionals in the present study had also failed to Giuntini C. Latvia: Raibarts J. Lithuania: Blaziene A. Poland: provide patient counselling prior to study entry. Although Gorecka D and Sadowski Z. Spain: Alvarez Sala J, Barrueco M, physicians and nurses are advised to help patients quit smok- Izquierdo J, Jiminez Ruiz C and Rubio M. Switzerland: ing, counselling/motivational support is only a component of the cessation process, albeit an important component.
Furthermore, despite the comprehensive pharmacotherapeu- St Bartholomew’s and the Royal London School of Medicine tic strategies currently available for helping smokers to quit and Dentistry, London, UK, who developed the motivational and their recommendation for use by health guidelines support protocol used in this study.
(19,20), many physicians remain unaware of the beneficialrole pharmacological treatments can play in assisting smokers to stop (25). Indeed, the combined use of behavioural therapyand pharmacotherapy can dramatically improve the patient’s 1 Peto R. Smoking and death: The past 40 years and the next 40.
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Paper received July 2004, accepted December 2004 ª 2005 Blackwell Publishing Ltd Int J Clin Pract, April 2005, 59, 4, 447–452

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