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Abstract
Background Tobacco use by physicians represents a significant barrier in promoting smoking cessation through physician interventions. To assess the need for and nature of smoking cessation services among physicians in China, a detailed literature review was conducted.
Methods A literature review of studies published, in Chinese or in English, between 1987 and 2010, was carried out. The Medline, PubMed and Wanfang Data (a Chinese literature search database) electronic databases were searched for published studies.
Results It was found that the overall current smoking prevalence among Chinese physicians ranged from 14% to 64% (men: 26% to 61%; women: 0% to 19%). There were significant gender differences in the smoking prevalence across studies with men smoking more than women. Though inconsistent, there were variations in smoking rates by professional posts and medical specialty. The quit smoking rates ranged from 5% to 14% across studies, with a higher rate among female physicians. Asking about smoking status or advising patients to quit smoking was not common practice among the physicians.
Conclusions The results of this review suggest that while smoking habits of Chinese physicians vary among studies and across physicians in different specialties; prevalence rates tend to be higher than in physicians in the developed countries. Quitting rates were low among Chinese physicians, and the delivery of advice on quitting smoking was not common across the studies. Strategies to improve Chinese physicians' engagement in smoking cessation should address multiple factors including tobacco use and quitting practices among the physicians, their training needs and awareness of their professional responsibility with a healthcare system change approach.
- Tobacco smoking
- medical profession
- Chinese physicians
- smoking cessation
- primary healthcare
- cessation
- prevention
- addiction
- carcinogens
- global health
- surveillance and monitoring
- environmental tobacco smoke
- evaluation
- young adults
- qualitative study
- international
- smoking caused disease
- secondhand smoke
- litigation
Statistics from Altmetric.com
- Tobacco smoking
- medical profession
- Chinese physicians
- smoking cessation
- primary healthcare
- cessation
- prevention
- addiction
- carcinogens
- global health
- surveillance and monitoring
- environmental tobacco smoke
- evaluation
- young adults
- qualitative study
- international
- smoking caused disease
- secondhand smoke
- litigation
Background
Smoking is one of the most preventable causes of premature death and morbidity worldwide and kills 5 million people each year.1 Half the people who smoke cigarettes today, approximately 650 million, will eventually be killed prematurely by smoking unless effective measures are taken urgently.1 Research has shown that smoking cessation interventions by physicians are efficacious and cost effective in terms of patient smoking outcomes.2 Smoking cessation in large number of smokers, as could be delivered by physicians, could reduce the epidemic of tobacco deaths in the next few decades.3 In recent years, significant developments have been made in the promotion of smoking cessation, but most are limited to the developed countries or those in the Western world. Some of the possible reasons for scarce smoking cessation services in the countries of the developing world are: (1) lack of trained physicians with appropriate knowledge and skills in tobacco control, (2) the smoking habit of physicians, which is as high as 61% in some countries, (3) lack of available evidence from research-based programmes in local settings to convince policymakers to initiate appropriate action; and (4) lack of primary care/preventive service infrastructure supporting smoking cessation programme.4 Given the fact that physicians are highly respected and influential community leaders who also act as role models in not smoking,5 engaging physicians in the tobacco control and cessation process will facilitate the implementation of evidence based policy and service recommendations.
China is the world's largest producer and consumer of tobacco with an estimated 360 million adults aged 15 and older who have ever smoked.6 The prevalence of smoking among the general public is high, at 28% overall (53% in men and 2% in women).7 China already experiences a tremendous burden of tobacco-induced diseases with 800 000 smoking-attributable deaths annually.8 That figure will rise to an estimated 2 million by the year 2025 if current smoking rates continue.3 Public health interventions are urgently needed to combat the tobacco use among the Chinese, including legislation on smoke-free public places, increasing cigarette prices, tobacco advertising bans and promoting smoking cessation services.9 In developed countries physicians play a key role in promoting smoking cessation10 and recommendations have long been made to engage physicians more actively in the smoking cessation effort.11 However, in China physicians are less involved in tobacco control and smoking cessation efforts,5 perhaps because a substantial proportion of Chinese physicians are smokers themselves. Over the last two decades, a number of studies have addressed tobacco use among the Chinese physicians, but many have been published in Chinese language journals and are not accessible.
We reviewed available studies on tobacco use and smoking counselling cessation practices among physicians in China. This report covers literature from English and Chinese language literature databases to generate as full a picture as possible of tobacco use and smoking cessation-related researches in China involving physicians to guide the development of a comprehensive smoking cessation strategy for China.
Methods
An extensive literature review targeting all manuscripts published in peer-reviewed journals relating to the topic of tobacco smoking and smoking cessation among Chinese physicians was conducted. The literature review began with a search on Medline, PubMed and Wanfang Data (an affiliate information provider of the Chinese Ministry of Science & Technology) using the most appropriate medical subject headings (MeSH) such as ‘smoking’, ‘tobacco’, ‘physician’ and ‘smoking cessation’. After identifying initial studies, the search was repeated using the additional keyword variations of ‘smoke’, ‘cigarette’, ‘Chinese’, ‘doctor’, ‘medical professional’ and ‘smoking prevention’. These keywords were also translated into Chinese language when searching via Wanfang Data. Due to the large volume of relevant Chinese-language articles on Wanfang Data, our review was extended to manuscripts written in Chinese language. We restricted our review to materials published in the last 24 years (1987–2010). We used publication date rather than study date for consistency, since publication dates were always available and study dates were not. Manuscripts located using these initial criteria were manually examined to find additional publications in the reference list.
We assigned each manuscript a reference number based on the criteria mentioned above. We included the title of the article with English translation for Chinese language articles, response rate, setting, sample size and key findings. Smoking prevalence is reported with gender breakdown where available.
A significant amount of literature was available targeting medical students, but was not included in this review, which focuses on Chinese physicians. Also, some studies combined physicians and other healthcare workers in the report without providing any specific details for each group and some only mentioned healthcare workers. These studies were excluded from our present review.
Results
We identified 67 published studies that initially fit our criteria. Of these studies, 24 included Chinese medical staff (ie, physicians, nurse, administrative officers and laboratory technicians) without separate data for physicians and 13 studies evaluated interventions and/or tobacco control policy strategies. These 36 studies were excluded. The remaining 30 studies focusing only on Chinese physicians were included in the present review (figure 1).
Process of study selection in the review.
As shown in online table 1,12–40 most of these studies were cross-sectional in nature and had been conducted as self-reported surveys (n=22) or by face-to-face interviews and/or self-reported surveys (n=7) or by utilising census data (n=1). Responses rates of the published studies ranged from as low as 61%17 to 100%.28 Eight studies did not specify the response rates, while nine studies only mentioned healthcare workers without defining a category. Sample sizes in these studies ranged from as low as 14133 to as high as 16 407.34 Men comprised ≥50% of the sample in most of the studies. Three studies focused only on male physicians.18 ,35 ,36
Smoking among Chinese physicians
Prevalence of tobacco use
The overall smoking prevalence among Chinese physicians ranged from 14%33 to 64%13 across studies. The average number of cigarettes smoked per day was 10–1329 ,30 ,32 with the majority smoking >5 cigarettes per day.35 ,36 ,39 The average number of years smoked was 10–13 years20 ,29 ,30 ,39 and over half of the smoking physicians started smoking at ages around 15–26.27 ,34 ,37 ,40
Demographic differences in smoking
Male physicians smoked more than female physicians. Smoking prevalence among men ranged from 26%26 ,31 to 61%.37 Among women it ranged from as low as 0%23 ,26 ,30 ,31 ,39 to as high as 19%14 across the studies. Such marked gender differences in smoking rates were reported in almost all studies that reported smoking rates by gender.
Many studies documented that smoking rates increased with age; more specifically, physicians aged 40–59 had higher smoking rates than other age groups.21 ,25 ,29–32 ,36
Tobacco smoking by professional backgrounds also varied. Surgeons had the highest reported smoking rate (>30%)20 ,21 ,24 ,30 ,32; however, one study reported highest smoking rates (54%) among male physicians who worked in the Otolaryngology Department.21 In one study, physicians working in non-clinical departments had 9% higher smoking rate than physicians working in clinical departments.36
Smoking rates by hospital grades
Hospitals in China are classified by their geographical areas into province, city, district, county and township levels. Many investigations revealed that physicians from township level hospitals had 4% to 26% higher smoking prevalence than other hospitals, and physicians from city level hospitals had the lowest smoking prevalence.19–21 ,23 Jiang et al 16 reported the current smoking rates following the three levels of hospital classification system, a new classification system that classifies hospitals into grade 3 (the large provincial/city level hospitals), grade 2 (medium city/district level hospitals) and grade 1 (community health centres or other small township level healthcare centres). In this study, smoking rates increased with the decrease of hospital grades: grade 1 (42%), grade 2 (40%) and grade 3 (36%).
Wang et al 35 suggest that societal environment and more free time among physicians in township level hospitals might explain their higher rates. However, one study reported similar smoking rates among physicians from city, county and township level hospitals, and the lowest smoking rates among those from district level hospitals.24
Smoking in front of patients
Between 15% to 43% of the smoking physicians had ‘sometimes’ or ‘often’ smoked in front of patients.21 ,24–26 ,28 ,31 One study reported that nearly all smoking physicians had smoked during their work shift.22 ,25 ,26 Over a 25% of the smoking physicians smoked in the offices or patients' rooms,24 ,29 and slightly over one-third smoked in the designated smoking areas in the hospital.24 One study showed that surgeons were more likely to smoke in front of patients than physicians from other specialties.32
Reasons for smoking among Chinese physicians
A total of 10 studies in this review reported social context (51% to 78%) as the main reason for physicians' smoking.19 ,24 ,26–28 ,31 ,32 ,35 ,36 ,38 One study documented that over half of the physicians reported smoking, willingly or unwillingly, when a cigarette was presented to them,35 and slightly over one-third would accept it only when they wanted to smoke. Relaxation, reinvigoration and habit were other common reasons among over half of the smoking physicians. Some studies documented that an average one-third of the smoking physicians continued to smoke because of their failure to quit in previous quit attempts.19 ,25–27 ,31 ,32 ,35 Receiving tobacco products as gift from others was another reason for smoking given by one-third of physicians.19 ,27 ,31 ,32 ,35 Ironically, 2% to 13% of smoking physicians continued smoking because they thought smoking could help them maintain good health.19 ,20 ,24 ,27 ,31 ,32 Smith et al 30 argued that male physicians might not view themselves as role models for healthy behaviour in the community and continued smoking.
Quitting smoking among Chinese physicians
Physician quit smoking rates, defined as physicians who were smoking in the past but had quitted smoking for at least 3 months before the survey or interview,19 ,21 ,27 ,31 ranged from 5%19 ,24 to 14%.36 Characteristics of the quitters varied across studies. Two studies reported the quitting rate among female physicians was 9% to 16% higher than among male physicians (p<0.01),27 ,32 whereas one reported 7% higher quitting rate among male physicians.19 Some studies reported a higher quit rate among physicians aged 40–59,27 ,36 while others reported higher cessation rates among physicians aged >60.32 ,36 One study showed that internal medicine physicians had the highest quitting rate (16%), approximately two times higher than surgeons (8%).32 In a study in Henan, most physicians who had quit24 expressed that personal and family health concerns were the primary reasons to quit smoking, and slightly less than half reported that a physicians' good image was the main reason to quit.
Previous quit attempts and reasons for failure
About one-third of the physicians tried to quit smoking.19 ,24 ,26 ,27 ,31 ,32 ,35 Slightly less than half of the participants were unable to quit smoking because they perceived smoking as essential for social contacts.15 ,16 Habit and withdrawal symptoms were also reported as reasons for failure.15 ,17
Smoking related knowledge, training received and cessation practices among Chinese physicians
Physicians' knowledge about hazards of smoking
A significant proportion of Chinese physicians lacked knowledge on different aspects of tobacco smoking. For example, about 25% of the physicians did not recognise that smoking causes bronchitis, lung cancer, emphysema, coronary heart disease and chronic obstructive pulmonary disease.24 ,27 ,28 ,31 ,32 ,35 A small percentage of physicians (13% to 14%) also did not recognise that passive smoking causes lung cancer, bronchitis and asthma.28 ,31 Similarly, less than one-third did not think smoking is associated with hypertension, ischaemic heart disease, acute necrotising ulcerative gingivitis and gastroenteritis.28 ,31 Even more (86%) did not recognise that smoking causes gastric cancer.28 ,33 About two-thirds of physicians did not recognise that passive smoking causes stroke27 ,31 or ischaemic heart disease.27 ,32 Also, in several studies more than 80% of the physicians did not know that passive smoking causes sudden infant death syndrome and otitis media.27 ,28 ,31 ,32
Smoking status was associated with possessing appropriate knowledge about smoking. In four studies, smoking physicians were significantly less likely to hold correct knowledge and beliefs about the hazards of smoking.23 ,32 ,39 One study showed that, more smoking than non-smoking physicians did not perceive smoking as hazardous.39
Training received on smoking cessation among physicians
Our review found a lack of organised training on tobacco control or smoking cessation among physicians. A study in Beijing33 showed that about one-third of the physicians did not receive training on smoking cessation counselling, and more than three-quarters of physicians did not receive training on how to ease patient withdrawal symptoms. Physicians also demonstrated lack of interest to learn about tobacco and its health effects. For example, three studies26–28 found that physicians did not express a desire to learn more about the chemical components of cigarettes, epidemiology of smoking, health effects of smoking, smoking cessation methods and available interventions and policies on tobacco control.26–28
Physicians who learnt about smoking cessation reportedly learnt it from different sources. Two studies28 ,33 reported that over one-third of physicians learnt about smoking cessation through public media and medical journals. A Zhengzhou study28 reported that only 1% of physicians learnt about smoking cessation from school trainings, while a Beijing study33 reported that more than half of physicians received anti-smoking training from the Chinese Center for Disease Control & Prevention. A Yunnan study26 among smoking physicians reported that three-quarters received smoking and health knowledge through newspaper, magazines and TV, and about half received it from medical schools.
Smoking cessation practices among physicians
About one-fifth of physicians never or ‘rarely’ inquired about patients' smoking status.26 ,29 The reasons physicians gave for not asking patients if they smoked included the beliefs that smoking was irrelevant to current illness and that patients would not take their advice seriously.19 ,24 ,26 ,32 Wang et al 28 suggest that whether or not physicians inquire about patients' smoking status was dependant on their years of working experience, medical specialty, volume of patients seen per day, and knowledge of anti-smoking practices.
Giving advice to quit was not common. Several studies showed that only slightly less than half of physicians on average ‘often’ or ‘always’ advised patients to quit.26 ,28 ,40 More female than male physicians,26 ,37 non-smoking than smoking physicians27 ,40 and internal medicine physicians than surgeons32 were likely to advise patients to quit smoking. Physicians who were reportedly more confident in their smoking cessation skills engaged in significantly more anti-smoking counselling than those who were less confident.36 Only two-thirds of physicians believed that they should offer help to patients who smoke in quitting smoking,32 and slightly over half supported or did not oppose active provision of smoking cessation counselling to patients by physicians.31
Physicians as role models
Over four-fifths of physicians thought that they should set an example for their patients by not smoking and that smoking should be banned on the hospitals grounds.20 ,23 ,26–28 ,31 ,32 Smoking physicians were significantly more likely to disagree with these attitudes than non-smoking physicians (p<0.05).32 One study reported that two-thirds of physicians thought they should not smoke while seeing patients.20 Of physicians who engaged in anti-smoking activities, one-third felt that their anti-smoking efforts were ‘very’ or ‘somewhat’ successful.40 Physicians who believed their past smoking cessation counselling to be successful tended to provide more counselling than physicians who considered themselves less successful (p<0.004).40
Discussion
This review brings together studies from across China on tobacco smoking and smoking cessation practices among the physicians. We identified a substantial and informative body of literature on smoking among physicians in China. Studies that focus solely on smoking cessation among physicians are infrequent and many combined physicians with other hospital workers in a single study population. Many of the studies are published in local journals and some lack scientific rigour. However, these studies provide a useful picture of smoking cessation initiatives in China targeting physicians.
This review finds that there are wide variations in smoking rate across studies. This variation might be related to different factors including methodological differences of data collection, the differing sample sizes across studies, gender ratio of the samples, and the grade or the region of the hospital where the study was conducted. For example, the lowest rate (14%) reported by Zhang et al 33 had a sample size of 141, while Ye et al 13 reported the highest smoking rate (64%) in their study with 503 subjects. Similarly, Yao et al 18 only studied male physicians. Overall, the prevalence of current smoking among Chinese physicians is high, especially among male physicians. This is a matter of concern as a physician's smoking behaviour will affect their own health and also undermine the effective delivery of anti-tobacco counselling to patients.10 ,30 In general, studies find that non-smoking physicians are more successful in getting their patients to attempt to quit than smoking physicians.41 The professional practice of physicians may be affected by their smoking habits. In several studies,5 ,23 ,25 ,27 ,40 smoking physicians were less likely to ask about patients' smoking status or to give quit smoking advice. However, in several studies,20 ,27 ,28 ,35 a significant proportion of Chinese physicians thought that physicians should be a role model of non-smoking for patients. This favourable attitude towards being a non-smoker role model among physicians underscores the need to support policy initiatives and targeted interventions to address smoking among physicians.
The low smoking rate among female physicians reflects the Chinese cultural norm that discourages smoking among women.5 In their review, Smith et al 42 also documented cultural reluctance for professional women to smoke in certain regions of Asia. The high prevalence of smoking among male physicians suggests the need for targeted programmes for male physicians, while efforts to maintain low smoking rate among women should be continued.16 ,32
Social context plays a major role in sustaining smoking by Chinese physicians. Yang et al 43 identified social situation as the main reason for smoking and the main triggering factor for relapse among Chinese male smokers. Ma et al 44 identified several myths and misconceptions around smoking among the public in China including the identification of smoking as a symbol of personal freedom, the importance of tobacco in social and cultural interactions, the ability to control the health effects of smoking through ‘reasonable’ and ‘measured’ use, and the importance of tobacco to the economy. These myths, some of which could also be true for physicians, should be considered in designing interventions. Initiatives to encourage physicians to act as role models and health promoters are necessary because physicians can play an important role in assisting their patients to optimise their health and well-being.45 At the same time, there is a need to address social norms that will label smoking by physician as a negative.46
Anthropological studies47–50 discussed several cultural issues as contributing factors to the growing tobacco use among the Chinese public including physicians. These factors included cigarette gifting from patients to doctors, the importance of male masculinity in the Chinese culture, expression of personal and economic development by smoking and maintaining social interactions with peers or colleagues. Any long-term remedy to combat tobacco use in China should address these cultural issues in a culturally sensitive manner.51 Any remedial intervention should be focused towards the denormalisation of tobacco use among men, including physicians, in China.
There is a well documented need to develop awareness of the risks of smoking and competency in smoking cessation among Chinese physicians, given the evidence that a significant proportion of physicians have inadequate knowledge of the health effects of smoking16 ,20 ,28 and only a small proportion ask about smoking status16 ,25 ,27 or give smoking cessation advice.16 ,17 ,26 Only a small number of studies considered the training needs of physicians, but they did find a low prevalence of smoking cessation training among physicians. As previous training was associated with better knowledge of and higher confidence in smoking cessation skills,23 ,46 training should be encouraged to promote tobacco control and smoking cessation among physicians in China. Within the current medical curriculum in Chinese medical schools, there are some educational components that teach the harms of tobacco use but without greater details on public health policy or clinical skills on tobacco dependency treatment. Incorporating smoking cessation skills training in medical schools could prepare physicians with appropriate skills to provide cessation services.52 ,53 Although, many hospitals organise training programmes on an ad hoc basis, an organised training programme should be developed and promoted. Incorporation of smoking cessation skills training within the continuous medical education programme for physicians should be considered.4 Surgeons and non-internists might need specific training on smoking cessation, as their rate of smoking was high and the rate of giving advice was low among surgeons and non-internists.19 ,30 ,32 This result might be also due to the lack of smoking cessation information that reaches surgeons and non-internists because professional meetings for surgeons and non-internists usually do not include reports on tobacco control or smoking cessation measures.
Smoking cessation rates (ie, ex-smokers) among physicians was low (5% to 14%). Social acceptability of male smoking, inappropriate attitudes towards smoking and quitting among physicians, lack of hospital-based policies to stop smoking and lack of training on smoking cessation among physicians are the main barriers for physicians to quit smoking or promote cessation programmes for patients.46 Although ex-smokers are few in numbers, they can serve as role models in encouraging quitting, and can provide social support to individual physician who want to quit.5 ,46 Other innovative approaches, such as, mobilising key leaders to promote smoking cessation could also play a major role in China.54 ,55 In these studies,54 ,55 participation of hospital directors in promoting tobacco control was a key factor for successfully establishing anti-smoking policies and tobacco-control networks within hospitals, and encouraging physicians to quit smoking. There is also need to make nicotine replacement therapy (NRT) widely available to physicians and the public, which is effective in supporting quitting efforts.56 At present NRT is not widely available in China, which discourages physicians, who are knowledgeable about the product, to recommend the product to their patients to quit smoking. Smoker physicians who are unable to quit without pharmacological help would also benefit from the wider availability, probably with free access, of NRT.
This study has strengths and limitations. To the best of our knowledge, it is the first comprehensive review on the topic including literature in Chinese and English. We attempted to cover the grey literature as well, although we did not find any additional studies by contacting selected authors. Methodological differences across studies (ie, how the data was collected, gender ratio of the collected subjects, grade of the hospital from where data were collected) and varying sample sizes across studies were an unavoidable limitation and we had access to the published data only. Although some studies used different definitions to report current smoking rate, there was a good agreement across the definitions used in China.57 However, the current smoking rate that we reported was generalised following the WHO definition (Do you currently smoke cigarette?).43 Finally, the findings we summarised are based on the reports in the published paper. No attempts were made to validate the findings or conclusions of the reported studies. Therefore, the findings of the current paper need to be extrapolated considering these limitations.
We strongly believe that there is a need for uniform measures to gather tobacco use and cessation related data from Chinese physicians. We strongly recommend that future studies should consider the following methodological aspects while designing studies: use of standard questionnaire for Chinese health professionals, precise description of data collection methods (ie, self-reported surveys collected via mail or collected immediately after completion, face-to-face interviews), use of appropriate sample size considering the differences in smoking rates between men and women, describing the grade of the hospital use of uniform definition for current smoking among physician (ie, WHO definition) and collection of smoking cessation practices following 5As format.58 The 5As process includes: (1) asking every patient about tobacco use, (2) advising all smokers to quit, (3) assessing smokers' willingness to make a quit-attempt, (4) assisting smokers with tobacco dependency treatment and referrals and (5) arranging follow-up contacts.
Conclusions and policy implications
This study has provided additional knowledge of the issue of tobacco use behaviour and cessation efforts among physicians in China. It will allow public health policymakers to determine how to design comprehensive tobacco control programmes that will have an impact in the overall smoking reduction in the population level. Our review suggests that smoking rate is high among the male physicians and providing routine cessation support is low among the Chinese physicians. The high smoking rates among the physicians underscore the need for interventions targeting physicians,59 which should be part of China's comprehensive tobacco control programme. Also, to achieve maximum benefits from China's anti-smoking campaigns in the population level, tobacco use among the physicians must be curtailed. It would be difficult to convince the general public not to smoke if their physician role model continues to do so.42 Implementing smoke-free healthcare facility with provisions for smoking cessation support and other culturally appropriate interventions are recommended.60 There is evidence that smoke-free hospital policies would promote smoking cessation among physicians.61 To promote sound public health policy, it is important to increase awareness of the role of physicians in public health issues including tobacco control, possibly through appropriate pregraduate and postgraduate training and specific training on tobacco control advocacy programmes52 and smoking cessation skills46 ,53 for those working in the public health and healthcare settings. Engaging physicians in promoting tobacco use prevention and cessation would require a holistic approach that would involve the Ministry of Education to develop educational guidelines for medical schools, and the involvement of professional medical societies to develop clinical practice guidelines with provision for continuous medical education (CME) training on tobacco use prevention and cessation.
What this paper adds
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This article is the first comprehensive review on tobacco smoking and smoking cessation practices among physicians in China.
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It was found that while smoking habits of Chinese physicians vary among studies and across physicians in different specialties; prevalence rates tend to be higher than in physicians in the developed countries.
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Quitting rates were low among Chinese physicians, and the delivery of advice on quitting smoking was not common across the studies.
References
Supplementary materials
Supplementary Data
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Footnotes
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Funding This work was supported by the Fogarty International Center of the National Institute of Health (NIH) through the Institute for Global Tobacco Control, The Johns Hopkins Bloomberg School of Public Health; grant number 5RO1TW007949.
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing statement We plan to share our research data with appropriate institutional approval.