Introduction
Tobacco smoking is considered to be a major health issues around the globe and is also claimed to be the most preventable cause of death in current time (Borgan, et al. 2014). Tobacco smoking is associated with 6 million deaths per year around the globe and is considered as one of the biggest public health issues by the World Health Organization (WHO) (Behbehani, et al. 2014). Based on current evidence and a report published by the WHO, 5 out of 6 million deaths are associated with direct tobacco smoking while nearly 600,000 deaths are due to non-smokers exposed to tobacco. There are currently 1 billion smokers in the world of which 80% of the total belong to low- and middle-income countries (Borgan, et al. 2014).
There has been significant increase in tobacco consumption in the Middle East since 19995 to 2000 with a rate consumption of 22.6% annually which reflects the high prevalence of smoking in Arab nations. In Arab countries, the rate of smoking has become much more prevalent and has been termed as an epidemic by most researchers. Some of the examples include Lebanon, Jordan, Egypt, Tunisia and Syria. The rate of prevalence of tobacco smoking is the highest is Yemen and Djibouti with a more than 75% population considered to be smokers followed by Syria with more than 50% of the population considered to be smokers (Behbehani, et al. 2014). There is a high prevalence of women smokers in Lebanon with a rate of 29.9%. The number of smokers is considered to be equal or higher than the general population among healthcare professionals/physicians in most Arab countries (Behbehani, et al. 2014). In other developing countries, there is a significant prevalence rate for tobacco smoking, wherein nearly 40% of the population is Egypt is considered to be tobacco smokers while Greece and Italy have the same prevalence of 40% tobacco smokers (Borgan, et al. 2014). Other developing nations also had a similar prevalence rate such as Algeria, Iran, and Tunisia with a 40% prevalence of tobacco smoking. Only 4 regions were reported to have prevalence rates below the general population such as Catalonia (31%), Lebanon (38%), Morocco (30%), and Syria (30–35%) (Pärna, et al. 2005).
Based on a current report on age-standardized estimated prevalence of current smoking among adult by the KSA WHO, the prevalence of tobacco smoking was estimated to be 26.8 % in men and 3.0% in women. It was estimated that there is a significant increase in the smoking among men compared to women owing to religious and cultural beliefs. However, the prevalence rate of women tobacco smokers has been on a moderate increase since 2000 in the eastern Mediterranean regions. Most researchers state that tobacco smoking becomes an addiction from a habit which is associated with serious health conditions and a multitude of tobacco consumption options. Some of the most common forms of tobacco consumption include cigarettes, smokeless tobacco, cigars and wastepipe (hookah, shisha) (Behbehani, et al. 2014). It is estimated that a single buff of tobacco may contain more than 7,000 chemicals of which 70 chemical are known to be carcinogenic (Borgan, et al. 2014). The most common chemicals found in tobacco smoke include nicotine, cyanide, ammonia and poison gases carbon monoxide (Behbehani, et al. 2014). There is a strong association of emphysema, cardiovascular disease and multiple cancers of the lungs, lips, and mouth and tobacco smoking or consumption based on a multitude of studies (Behbehani, et al. 2014). Coronary heart disease is a serious but preventable medical condition but cigarette smoking is said to increase the risk of coronary heart disease (Behbehani, et al. 2014).
In Saudi Arabia, the total number of communicable disease is estimated to account for 48% as per the WHO Pärna, et al. 2005).
Water pipe is another form or method for tobacco consumption which comprises of nicotine smoking with the help of specially devised dive filters that filer water with mixed flavours of tobacco on top of the dives. Water pipe is a traditional method of tobacco consumption in the Middle East, mainly preferred by the elderly. The concept of water pipe was first introduced in the early 19990s for the elderly but has now become a common fashion modem for the youth. The use of water pipe among the youth in the Middle East help in spreading and making the concept famous in other nations, especially among university students. Today, water pipe has been socially accepted in most Western countries with most preference for flavoured tobacco. The concept of water pipe has gained significant fame owing to lack of regulations and certain myths such as safer than smoking and also its help in smoking cessation. However, water pipe has also been associated with chronic disease and early death. Tobacco cessation has played a major role in health improvement, disease prevention, and quality of life. There is no ideal age to smoke, the better the early (Behbehani, et al. 2014). Some of the key effective methods included in tobacco cessation include brief tobacco cessation counselling interventions, and brief behavioural counselling, with or without pharmacotherapy (Zhou, et al. 2010).
It is recommended that ‘Clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products’ as per The United States Preventative Services Task Force (USPSTF) (Grade: A recommendation).
Family physicians and general practitioners come across patients with tobacco smoking issues quiet often and play an important role in the management and smoking cessation. FNPs or GPs play a key role in counselling and understanding the patient’s knowledge on tobacco smoking and cessation (Behbehani, et al. 2014). FNPs or GPs have an advantage since they are the first point of contact to the patient along with a strong relationship development with family members. One of the critical factors in the success of smoking abstinence include the knowledge, attitude and practices of the physician regarding smoking cessation. Unlike in other regions of the world, there are no data on such practices on smoking cessation among physicians in eastern region Saudi Arabia (Zhou, et al. 2010). The aim of this study was to: (a) To evaluate the smoking rates among general practice & Specialists working in PHC QATIF and KSA and (b) To estimate the degree of knowledge, attitude and practices of smoking cessation among of the primary care physicians(general practice & specialist) in MOH toward tobacco smoking between ever smokers and non- smokers.
Methodology:
The researchers conducted a cross-sectional study for 21 days at 32 governmental primary health-care centre (PHCCs) in Qatif city. A total of 100 PHCPs (GP and FM specialist) were included in the study with data collection from 80 physicians. The exclusion criteria for the study was those physicians who could not be available for the entire study duration which accounted for a total of 20 physicians. Informed consent was taken from all participating physicians with a brief instruction on the purpose of the study along with a questionnaire. The questionnaire comprise of questions from the Global Health Professional Survey (English version), a self-administered questionnaire developed by the Tobacco Free Initiative, a project of the World Health Organization, in collaboration with the Centres for Disease Control and a number of additional partners with modifications to meet the objectives of this study. A pilot study was also conducted among 10 PHCPs working in Dammam city to evaluate the clarity of the questions; however, the results of the pilot study were not included in the main study results. The by the scientific and ethics committee was involved in the approval of the research proposal. The questionnaire comprised of 5 sections (I) Basic demographic questions including gander, age, job, and socioeconomic status (II) Personal smoking behaviour: It included tow sub0sections (water pipe use and/or cigarette use). The water pipe use section included questions on frequency, history of use, and feelings towards water pipe habit. The cigarette use section included questions on frequency, smoker classification as "currently smoker", never smoker, and ex-smoker. Some detailed analytical questions included: Feelings towards smoking in terms of "stages of change" (Not ready to quit within the next 6 months; thinking about quitting within 6 months; ready to quit now) (III) Knowledge of and attitudes towards the adverse effects of smoking: It comprised of 22 questions including an assessment on the role of HCPs regarding smoking cessation on their patients (IV) Worksite practice: It included discussion on some policy issues of smoking (V) Physicians interview: To evaluate the physician they may have received in smoking cessation counselling, as well as their preparation level in in counselling patients to stop smoking.
Literature Review
1. Smoking Behaviour among Medical Doctors
Based on current evidence, there is a high rate smoking prevalence among physicians in China. Cumulative analysis revealed that smoking prevalence was higher among men (36%) compared to women physicians (3%). The overall prevalence was estimated to be 26% as pet the report (Zhou, p15). In a similar analysis in Pakistan, researchers reported an overall smoking prevalence among healthcare professionals (HCPs) at 43%, with a higher rate observed among male doctors (50.31%) and female doctors (7%) (Malik. 512). The rate of smoking prevalence is high among HCPs owing to work stress and long work hours. (Hodgetts et al. 12). A survey among family physicians in Bosnia and Herzegovina revealed that the overall prevalence accounted to 45% with a high rate of prevalence (51%) among nurses and (40%) among male physicians. (Hodgetts et al. 12). Smoking is most common among HCPs with high burn out rates and long work hours. Based on these factors a team of experts assessed the rate of smoking among HCPs in two Gulf countries, Bahrain and Kuwait. Bahrain accounted for over 15% of HCP smokers while Kuwait accounted for over 18.4% of smokers. There was a significant prevalence of Shisha smokers, with 12% in Kuwait and 6.4% in Bahrain (Behbehani, 581).
In Gulf countries, there is a mixed view on smoking with a few preferences for Shisha smoking in comparison to cigarette smoking. A systematic review revealed that there was a significant low rate of smokers in UAE, accounting for only 8.3% of smokers and the majority of 88.4% were non-smokes. Shisha smoking accounted for 25% of the total smokers while cigarette smoking accounted for 88.4% of smokers. (Behbehani, 580-582). In a similar study, researchers also assessed the smoking prevalence among physicians in Bahrain. (Borgan, et al. 931). It was observed that the current rate of smokers was 8.6% compared to previous smokers at 11%. (Borgan, et al. 931). However, compared to cigarette smoking, physicians preferred water-pipe smoking in Bahrain. In comparison to the prevalence of cigarette or water-pipe smokers, there was a significant rate of 12% water-pipe smokers compared to only 4% to 2% who smoked cigarettes or both (Borgan, et al. 931).
The prevalence of smoking is also high among developing and low-income nations such as Iraq. Based on cross-sectional web-based survey among physicians in Sulaymaniyah City/Iraq, it was observed that the overall smoking prevalence was 26%. It was also observed that the rate of smoking including attitude and knowledge was more among male HCPs compared to female HCPs. There was limited knowledge or training in smoking cessation among all HCPs which accounted for only 7% of the total smoker (Darya, et al. 1-3).
In developed nations such a USA and Canada, there is a high rate of prevalence among HCPs which account for nearly 8% of the total HCPs. In Canada, nearly 3.3% of the physicians admitted that they were current smokers. Based on a recent survey, nearly 5% male physicians smoke compared to only 1% of female physicians; however, less than 1% of physicians either had sex of smoked from a pipe (Frank & Segura. 810). In a similar developed nation like Vientiane, Loa PDR, there is high prevalence rate of smoking among male doctors which accounts for 35% while occasional smokers account for 19%. It was the only country where female doctors reported to have never smoked (Vanphanom. 144).
In a similar observational study, researchers evaluated the current smoking prevalence among physicians and HCPs in Estonia. The report stated revealed that 24% of smokers were male HCPs while 10.8% were female HCPs. Based on the same study, it was also revealed that the rate of ex-smokers accounted to 16,8% for females and 32.9% for makes (Pärna, et al. 392). A team of experts conducted a cross-sectional study to assess the rate of smokers among healthcare centres in Makkah city. It was observed that more than half (66.4%) were non-smokers; however, 18.7% were daily and 7.3% were occasional smokers while the reminder 7.6% were ex-smokers. Nearly 45% of the ex-smokers stopped smoking after the average age of 38 years based on the review (Turkstani et al. 720).
2.2. Knowledge and Attitudes Regarding Smoking
Based on the research findings by Darya, et al., it was observed that 91% of physicians and dentists understood the consequences of smoking including lung cancer. Most of the doctors also believed that smoking could be associated with heart attack (55.1%), oral cancer (47.5%), and atherosclerosis (47.3). However, a significant low amount of doctors (295) related smoking to hypertension and preterm birth as one of the most common consequences of smoking. Based on their views and opinions on the positive impact of HCP smokers and their patients, most of them likely disagreed to show interest in setting a positive impact on new smokers.
In a similar case scenario, the research findings by Borgan, et al. revealed that most doctors were knowledgeable on the adverse effects of smoking. Most of the family physicians in Bosnia accepted that fact that smoking is injurious to health and can also have a significant health impact on others. However, there many doctors who understood the relation of passive smoking and neonatal death. Nearly 80% of HCPs agreed while only 65% of smoking doctors agreed that passive smoke resulted in neonatal death. The views and opinions of health policies by ever smokers and occasional smokers among HCPs were mixed. However, it was observed that smokers had a negative attitude towards non-smokers regarding health policy or health reforms for the betterment of society. HCPs who smoked were also less likely to agree on the statements to change their views on the freedom to smoke. Most physicians also agreed that tobacco sale should be banned, especially among the youth and children. Lastly, almost all HCPs agreed to advise their patients that smoking around children should be avoided which could result to serious chronic respiratory or growth abnormalities (Borgan, et al. 931-935).
In a cross-sectional, self-administered, anonymous survey, researchers evaluated the knowledge and attitude of Armenian physicians on the level of agreement on smoking whilst interacting with their patients (Perrin et al. 139). Most HCPs agreed that they conveyed their patients on key factors such as, do not smoke around children, if smoke then quit as soon as possible, and regular assessment of smoking cessation (if any). Most patients were satisfied with the agreement of not smoking around children or to quit smoking (Perrin et al. 139). There was mutual understanding among patients and HCPs on the context of smoking. Patients consider their physicians as role models and that physicians should not smoke or quit smoking to have a positive impact on their patients. The most significant statements that were not agreed by either of the two. These statements include training or smoking cessation for physicians and that physicians who smoked were less likely to counsel or advise patients to quit or stop smoking. Nearly 90% of Estonian physicians understood the relation between smoking and chronic health issues such as hypertension, stroke, and heart disease (Perrin et al. 139). There was significant difference with respect to knowledge, attitude, and beliefs among smokers and non-smokers. It was also observed that physicians who did not smoke were more active and had a profound effect on patient interaction including discussion about smoking habits to their patients. Lastly, most Estonian physicians who smoked lacked self-esteem and failed to perceive themselves as positive role models among their patients (Perrin et al. 139).
2.3. Relationship between Knowledge, Attitudes and Smoking Practices
Based on a retrospective observational study, a team of researchers evaluated the hospital physicians' attitudes and practices for smoking cessation counselling in Malatya, Turkey. It was observed that the negative attitudes of physicians on smoking cessation had a profound negative impact on their practices (Gunes, et al. 150). Based on the review, 26% of the physicians agreed and accepted that they always asked their patients on smoking habits while 22.6% reported to have advised their patients to quit smoking. It was also observed that non-smoking physicians practiced more on counselling on smoking cessation that physicians who smoked (Gunes, et al. 150). The negative attitudes and smoking practices of physician who smoked had a profound effect on overall health outcomes of patients (Gunes, et al. 150). In a similar report on negative attitudes of physicians, it was observed that non-smoking physicians had more unfavourable views toward smoking (Kaneita, et al. 165). They also played an active role in the management and treatment of patients with smoking issues including counselling on smoking cessation compared to physicians who smoked (Kaneita, et al. 165).
In an observation study, a team of two nursing professionals reported that smoking-related knowledge, attitudes, and counselling practices were associated with individual smoking behaviour among hospital staff (Willaing & Ladelund. 372-374). A systematic review of research findings revealed that a multitude of factors are associated with the smoking behaviour among physicians. Some of the key factors include gender, age, education background, revenue, section, hospital administration, level of knowledge of tobacco harmful effects, relationship between smoking and illness scale, doctors' social norm attitude (Igić . 120). In a similar study, researchers reported that there was significant relationship between smoking pattern of GPs and some factors such as their age of onset of smoking, gender, knowledge about smoking side effects, and attitude towards smoking (Igić . 120-125).
References
Behbehani NN1, Hamadeh RR, Macklai NS. (2004). Knowledge of and attitudes towards tobacco control among smoking and non-smoking physicians in 2 Gulf Arab states. Saudi Med J. 2004 May;25(5):585-91.
Borgan, Saif M et al. (2014). “Prevalence of Tobacco Smoking among Health-Care Physicians in Bahrain.” BMC Public Health 14: 931.
Darya SAet al. (2016). “Smoking Knowledge, Attitude, and Practices among Health Care Professionals from Sulaymaniyah City/Iraq.” Tobacco Use Insights 9: 1–6.
Frank E & Segura C. (2009). Health practices of Canadian physicians. Can Fam Physician. 55(8):810-811.e7.
Gunes G, Karaoglu L, Genc MF, Pehlivan E, Egri M. (2005). University hospital physicians' attitudes and practices for smoking cessation counseling in Malatya, Turkey. Patient Educ Couns. 56(2):147-53.
Igić R. (2000). Doctors and smoking. Med Pregl. 53(3-4):117-27.
Kaneita Y, Uchida T, Ohida T. (2010). Epidemiological study of smoking among Japanese physicians. Prev Med. 51(2):164-7.
Malik AK et al. (2010). Cigarette smoking and health care professionals at Mayo Hospital, Lahore, Pakistan. J Pak Med Assoc. 60(6):509-12.
Pärna K, Rahu K, Rahu M. (2005). Smoking habits and attitudes towards smoking among Estonian physicians. Public Health. 119(5):390-9.
Perrin PC, Merrill RM, Lindsay GB. Patterns of smoking behavior among physicians in Yerevan, Armenia. BMC Public Health. 23;6:139.
Turkstani, et al. "Knowledge, attitude, and practice among primary health-care physicians toward smoking cessation in Makkah, Saudi Arabia." International Journal of Medical Science and Public Health 5.4, 714-724.
Vanphanom S, et al. (2011). Smoking among Lao medical doctors: challenges and opportunities for tobacco control. Tob Control. 20(2):144-50.
Willaing & Ladelund S. (2004). Smoking behavior among hospital staff still influences attitudes and counseling on smoking. Nicotine Tob Res. 6(2):369-75.
Zhou J1, Abdullah AS, Pun VC, Huang D, Lu S, Luo S. (2010). “Smoking Status and Cessation Counseling Practices Among Physicians, Guangxi, China, 2007.” Preventing Chronic Disease 7.1 (2010): A15
