Smoking habits and attitude toward smoking cessation interventions among healthcare professionals in Pakistan.

BACKGROUND: Tobacco smoking is considered as the second main cause of increased mortality rate and one of the major preventable causes of cardiovascular and pulmonary diseases worldwide. Although the damages caused by smoking are known, the prevalence of smoking is increasing among healthcare professionals (HCPs). Increased smoking rates among HCPs may compromise the ability to effectively counsel patients who are addicted to smoking. The purpose of this study was to assess the smoking habits and attitude toward smoking cessation interventions among HCPs in Pakistan.
METHODS: A descriptive cross-sectional study design was used. A prevalidated semi-structured question developed by the University of Arizona was used. The sample size was calculated to be 382 with 95% confidence interval and 5% level of error. Data were cleaned, coded, and analyzed statistically using SPSS 21. Chi-square test (P ≥ 0.05) was used to find association among different variables.
RESULTS: The results of the study showed that a majority of the HCPs were smokers (57.6%, n = 220). Use of nicotine patches and other cessation medications, educational programs, and discussion with other healthcare providers were most effective methods for quitting smoking. Significant association (P < 0.05) was found among smokers and nonsmokers regarding self-respect and feeling of loneliness.
CONCLUSION: The study concluded that a majority of the HCPs in twin cities were smokers and smoke more than five cigarettes a day. Training programs should be designed and implemented for HCPs to reduce the rate of tobacco smoking.

Introduction

Tobacco smoking is one of the main causes of preventable deaths worldwide.[1] Globally, 4 million individuals die due to tobacco-related diseases, which is expected to increase by 10 million each year in the next 20 years.[2] Over the past decades, smoking cessation has emerged as a crucial public health problem and the fourth major health risk factor. Smokers are more prone to develop lung cancer, coronary heart disease, double stroke, and chronic obstructive lung disease. Smoking not only deteriorates physiological processes but also lowers self-esteem and quality of life of an individual.[3] Developing countries including Pakistan still face an alarming increase in rate of cigarette smokers. The current prevalence of cigarette smoking among adults is 15.2% in Pakistan which indicates an enormous health and economic burden in the country.[4]

Interventions to stop this dilemma are gaining much importance as the prevalence of smoking is elevating rapidly each year. The interventions made by healthcare professionals (HCPs) are quite effective however; medical settings have numerous hurdles in implementation of smoking cessation interventions, including insufficient skills, lack of knowledge, inadequate incentives, and time limitation. One of the most noticeable and low-cost forms of smoking prevention is the recommendation of smoking cessation by HCPs to their patients. Despite the fact, participation of HCPs in such activities is relatively low.[5] Another major barrier for effective cessation interventions is that a majority of HCPs are smokers themselves. As a role model, it is important that HCPs must not smoke, only then they could best persuade patients to quit smoking.[6]

Assessment of smoking habits and attitude toward smoking cessation strategies among HCPs can be helpful to identify the barriers faced by them in effective counseling of smokers. So far, limited studies have been conducted on prescribers, but no such study has been conducted among entire HCPs. Thus, this study was designed to assess the smoking habits and attitude toward smoking cessation interventions among HCPs in Pakistan.

Methods

Aim, design, and setting of study

The aim of the study was to assess the smoking habits and attitude toward smoking cessation interventions among HCPs, that is, physicians, nurses, and pharmacists working in twin cities of Pakistan. A cross-sectional study design was used. Study approval was taken from the Ethical Committee of Hamdard University (Ref. no. HU/DRA/2017/558). For collection of data, approval was taken from MS of hospitals, chief executives of pharmaceutical industries, proprietors of community pharmacies, and heads of healthcare educational organizations. Informed consent for participation was also taken from the respondents.

Study settings and respondents

Study site for this research included public and private healthcare facilities, specialist clinics, general practitioner clinics, pharmacies, healthcare educational institutes, and pharmaceutical industries of Pakistan. Study respondents included prescribers, pharmacists, and nurses working in academia, hospitals, specialist clinics, general practitioner clinics, community pharmacies, industries, marketing, and regulatory authority.

Sample size and sampling technique

Calculation of sample size was performed by Raosoft® sample size calculator to determine the size of sample representing the study population. The calculated sample size was 382 to achieve 95% confidence interval and 5% margin of error. As there is no updated list of HCPs, therefore, convenient sampling technique was used for the study and all the respondents who were available at the time of data collection and willing to participate in the study were selected.

Data collection tool

Data were collected using prevalidated semi-structured questionnaire developed by the University of Arizona, USA. Prior permission for using the questionnaire was obtained by the university. The questionnaire comprised four sections. The first section included information regarding respondent demographic characteristics such as gender, age, occupation, marital status, religion, and qualification. In the second section, perceptions of HCPs regarding different sources for obtaining information regarding smoking and nonsmoking were explored. In the third section, practices of HCPs regarding tobacco usage and smoking trends were explored, while section 4 included questions regarding effective strategies for smoking cessation. Two focused group discussions were carried out at different time intervals with four different groups of experts including clinicians, specialists, physicians, and doctors from academia. Each group comprised three to four participants for the development, finalization, face, and content validity of data collection tool. Pilot testing was carried out on 10% of the total sample size before execution of the final study. A Cronbach's alpha value of 0.71 confirmed the reliability and internal consistency of the questionnaire.

Statistical analysis

After data collection, data were cleaned, coded, and entered in SPSS version 21. Skewness test was performed to check the distribution of data. Descriptive statistics comprises frequency and was calculated. Chi-square (P ≤ 0.05) test was performed to find out association among different variables.

Results

Demographic characteristics

Of 382 respondents, 85.3% (n = 326) were male, whereas 14.7% (n = 56) were female. Of 382 respondents, 156 (n = 40.8) were prescribers, 48.7% (n = 186) were pharmacists, and 10.5 (n = 40) were nurses. Regarding qualification, 57.6 (n = 220) hold bachelor's degree, 38.5% (n = 38.5) master's/FCPS, whereas 3.9% (n = 15) had done PhD [Table 1].

Table 1

Demographic characteristics

Indicator	n (%)
Gender
Male	326 (85.3)
Female	56 (14.7)
Age (years)
20-30	236 (61.8)
31-40	108 (28.3)
41-50	21 (5.5)
51-60	17 (4.5)
Marital status
Married	220 (57.6)
Unmarried	156 (40.8)
Divorce	6 (1.6)
Profession
Prescribers	156 (40.8)
Pharmacists	186 (48.7)
Nurses	40 (10.5)
Education
Bachelor	220 (57.6)
Master’s/FCPS	147 (38.5)
PhD	15 (3.9)
Religion
Muslims	373 (97.6)
Non-Muslims	9 (2.4)
Income level
≤30,000	136 (35.6)
≤60,000	136 (35.6)
≤90,000	43 (11.3)
≥100,000	67 (17.5)

Smoking status and pattern of smoking among healthcare professionals

Regarding current smokers, of 382 respondents, 57.6 (n = 220) were smoking currently, whereas 16.2% (n = 62) were smoking in the past [Table 2].

Table 2

Smoking status of healthcare professionals

Indicator	Yes, n (%)	No, n (%)	Not applicable, n (%)
Do you currently smoke?	220 (57.6)	162 (41.9)	-
If you do not currently smoke, did you smoke in the past?	62 (16.2)	113 (29.6)	207 (54.3)

Of the total respondents, 67% (n = 256) had tried smoking cigarettes greater than four times in their lifetime, whereas 55.2% (n = 211) tried to smoke in the last 30 days. Regarding smoking cigars, 73.8% (n = 282) never smoked cigars in their entire life, whereas only 2.9% (n = 11) had smoked cigars greater than four in the last 30 days. Most of the respondents, 76.7% (n = 293) never smoked hookah in their life, whereas only 3.9% (n = 15) smoked hookah in the last 30 days. A detailed description is given in Table 3.

Table 3

Pattern of smoking among healthcare professionals

Indicator	Lifetime	n (%)	Last 30 days	n (%)
Cigarettes	None	100 (26.2)	None	154 (40.3)
	One time	14 (3.7)	One time	10 (2.6)
	Two times	10 (2.6)	Two times	4 (1)
	Three times	2 (0.5)	Three times	3 (0.8)
	Equal and greater than four	256 (67)	Equal and greater than four	211 (55.2)
Cigars	None	282 (73.8)	None	352 (92.1)
	One time	13 (3.4)	One time	6 (1.6)
	Two times	13 (3.4)	Two times	6 (1.6)
	Three times	11 (2.9)	Three times	7 (1.8)
	Equal and greater than four	63 (16.5)	Equal and greater than four	11 (2.9)
Hookah	None	293 (76.7)	None	340 (89)
	One time	9 (2.4)	One time	10 (2.6)
	Two times	20 (5.2)	Two times	10 (2.6)
	Three times	8 (2.1)	Three times	7 (1.8)
	Equal and greater than four	52 (13.6)	Equal and greater than four	15 (3.9)

Perception of healthcare professionals toward different smoking cessation strategies

Different smoking cessation strategies considered effective by HCPs were as follows: nicotine gum or lozenges (68.1%, n = 260), nicotine patch (62.9%, n = 240), cessation medication (60.4%, n = 231), discussion with healthcare provider (58.9%, n = 225), educational programs (59.7%, n = 228), and stop smoking programs (55.8%, n = 213) [Table 4].

Table 4

Perception of healthcare professionals toward different smoking cessation strategies

Indicators	Agree, n (%)	Neutral, n (%)	Disagree, n (%)
Nicotine gum or lozenges	260 (68.1)	64 (16.8)	58 (15.2)
Nicotine patch	240 (62.9)	80 (20.9)	62 (16.4)
Nicotine inhaler or nasal spray	205 (53.6)	101 (26.4)	76 (20)
Cessation medication	231 (60.4)	88 (23)	63 (16.5)
Discussion with healthcare provider	225 (58.9)	102 (26.7)	55 (14.4)
Educational program	228 (59.7)	97 (25.4)	57 (15)
TV and radio programs against smoking	204 (53.4)	89 (23.3)	89 (23.3)
Discussion at a temple or mosque or church	216 (56.6)	77 (20.2)	89 (23.3)
Stop smoking program	213 (55.8)	92 (24.1)	77 (20.2)

Assessment of mental state among smokers and nonsmokers

Significant association (P < 0.05) was found among smokers and nonsmokers when feeling lonely. The majority of the smokers (10.4%, n = 23) agreed that they felt lonely (10.4%, n = 23). A detailed description is given in Table 5.

Table 5

Assessment of mental state among smokers and nonsmokers

Indicator	None, n (%)	A little, n (%)	Some, n (%)	A lot, n (%)	P
I was bothered by things that usually don’t bother me
Smokers	95 (43.1)	85 (38.6)	29 (13.1)	11 (5)	0.473
Nonsmoker	80 (49.3)	53 (32.7)	25 (15.4)	4 (2.4)
I didn’t feel like eating; I wasn’t very hungry
Smokers	78 (35.4)	81 (36.8)	49 (22.2)	12 (5.4)	0.583
Nonsmoker	77 (47.5)	42 (25.9)	34 (20.9)	9 (5)
I felt like something good was going to happen
Smokers	55 (25)	66 (30)	72 (32.7)	27 (12.2)	0.171
Nonsmoker	48 (29.6)	50 (30.8)	51 (31.4)	13 (8)
I felt like I was too tired to do things this past week
Smokers	53 (24)	95 (43.1)	59 (26.8)	13 (5.9)	1.00
Nonsmoker	57 (35.1)	49 (30.2)	40 (24.6)	16 (9.8)
I felt down and unhappy this week
Smokers	73 (33.1)	83 (37.7)	53 (24)	11 (5)	0.251
Nonsmoker	73 (45)	45 (27.7)	34 (20.9)	10 (6)
I didn’t sleep as well as I usually sleep this week
Smokers	68 (30.9)	70 (31.8)	53 (24)	29 (13.1)	0.103
Nonsmoker	75 (46.2)	37 (22.8)	35 (21.6)	15 (9.2)
I was happy this week
Smokers	39 (17.7)	48 (21.8)	97 (44)	36 (16.36)	0.851
Nonsmoker	23 (14.1)	41 (25.3)	67 (41.3)	31 (19.1)
I felt lonely, like I didn’t have any friends
Smokers	83 (37.7)	70 (31.81)	44 (20)	23 (10.4)	0.009
Nonsmoker	99 (61.1)	34 (20.98)	16 (9.8)	13 (8)

Assessment of self-esteem in smokers and nonsmokers

Significant association (P < 0.05) was found among smokers and nonsmokers’ self-respect as they wish to have more respect. A detailed description is given in Table 6.

Table 6

Assessment of self-esteem in smokers and nonsmokers

Indicator	Agree, n (%)	Neutral, n (%)	Disagree, n (%)	P
On the whole, I am satisfied with myself
Smokers	149	64	7	0.219
Nonsmoker	120	32	10
I take a positive attitude toward myself
Smokers	149	64	7	0.219
Nonsmoker	121	32	10
I am able to do things as well as most other people
Smokers	160	45	14	0.801
Nonsmoker	121	31	10
I feel I do not have much to be proud of
Smokers	66	79	75	0.198
Nonsmoker	45	51	66
I certainly feel useless at times
Smokers	47	55	118	0.808
Nonsmoker	38	46	78
I wish I could have more respect for myself
Smokers	61	58	101	0.004
Nonsmoker	67	37	58

Effective methods to quit smoking

The results of this study highlighted that most of the respondents were of the view that the effective methods to quit smoking were nicotine gums (68.1%, n = 260), educational programs (59.7%, n = 228), and medications (60.4%, n = 231). A detailed description is given in Table 7.

Table 7

Effective methods to quit smoking

Indicators	Agree, n (%)	Neutral, n (%)	Disagree, n (%)
Nicotine gum or lozenges	260 (68.1)	64 (16.8)	58 (15.2)
Nicotine patch	240 (62.9)	80 (20.9)	62 (16.4)
Nicotine inhaler or nasal spray	205 (53.6)	101 (26.4)	76 (20)
Cessation medication	231 (60.4)	88 (23)	63 (16.5)
Discussion with healthcare provider	225 (58.9)	102 (26.7)	55 (14.4)
Educational program	228 (59.7)	97 (25.4)	57 (15)
TV and radio programs against smoking	204 (53.4)	89 (23.3)	89 (23.3)
Discussion at a temple or mosque or church	216 (56.6)	77 (20.2)	89 (23.3)
Stop smoking program	213 (55.8)	92 (24.1)	77 (20.2)

Discussion

Smoking can lead to a variety of long-term complications such as lung cancer, heart diseases, and oral cancer. This study reported that most of the HCPs were smokers and smoke on average more than five cigarettes a day. Most of them had smoked tobacco in the last 30 days. Cigars and hookah were never used by most of the HCPs. Similar results were reported in a study conducted in Saudi Arabia which showed that some of the respondents smoked less than 10 cigarettes a day, whereas most of the respondents smoked more than 20 cigarettes a day.[7] In this study, most of the respondents were currently smoking, whereas few were smoking in the past. Similar findings were reported from a study conducted in Saudi Arabia.[8]

Smoking can deteriorate mental health and well-being of individuals. The results of this study reported that nearly all the respondents were satisfied and had positive attitude. More than half of them were able to do everyday activities and had no feelings of hopelessness. Similar results were reported from a study conducted in Jordan highlighting high level of satisfaction with profession and self-esteem.[9]

Different strategies have been developed to cope with high smoking consumption worldwide. This study reported that nicotine gum or lozenges and nicotine patch, smoking cessation strategies, stop smoking programs, cessation medication, and discussion with healthcare providers were effective strategies for smoking cessation. On contrary, the results of a study in France reported that nicotine gum or patches were not effective in quitting smoke, but cessation strategies, stop smoking programs, and counseling HCPs can be effective in quitting smoking.[10]

The recent study was conducted in twin cities of Pakistan, and therefore the outcomes of the study may not be generalizable to different parts of the country. Financial constraints were faced during conduction of the study.

Conclusion

The study concluded that the majority of the HCPs in twin cities were smokers and smoke more than five cigarettes a day. Smoking cessation programs were effective in quitting smoking, as well as nicotine gum and nicotine patches were considered to be ideal strategies for quitting smoking. There is a need of designing regulatory and educational interventions by concerned stakeholders to control tobacco epidemic. Increasing the prices of cigarettes and other tobacco containing products may help reduce sales of such products. Furthermore, education programs focused on smoking cessation strategies should be designed for HCPs. The implementation of on-job training programs on smoking cessation is the need of the hour to control tobacco epidemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.