Workplace Tobacco Policies and Smoking Cessation Practices of Physicians: DISCUSSION

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The findings are encouraging in that physicians in Nigeria demonstrated an awareness of smoking among their patients, routinely assessed smoking status, and believed that counseling patients about smoking would help them quit. Physician estimates of smoking among adults in Nigeria (31% for males, 7% for females) were somewhat higher than published prevalence data (15% for adult males, 2% for adult females), indicating that they either have inflated perceptions of smoking or smokers are disproportionately represented in their patient population. Also encouraging is that the majority of physicians made an effort to identify patients who are smokers and believed it was important for these patients to quit. Additionally, physicians in Nigeria thought that counseling smokers would help them quit, suggesting their belief in the importance of physician-assisted smoking cessation interventions.

The findings also indicate a number of areas where improvement is needed. Most apparent is the lack of smoking cessation guidelines/policies and infrequent use of pharmacotherapy within physician practices. While the majority of physicians assessed smoking status, this is negated by a general failure to offer interventions that would increase the likelihood of quitting. This may be due in part to the lack of cessation guidelines and limited availability of pharmacotherapy. Progress could be made by promoting physician practices that adhere to AHRQ guidelines as a model for other practices. Our findings suggest the need for programs that increase the use of recommended smoking cessation guidelines across all specialties. Physicians could benefit from systems-level interventions that enhance their screening of patients for tobacco use and assessment of their motivation to quit. Physicians could further facilitate quitting by offering advice on how to quit, establishing a quit date, and prescribing recommended pharmacotherapy. silagra 100

Findings from developed countries provide support for the improvements recommended in each of these areas. Specifically, meta-analyses conducted within developed countries examining the implementation and efficacy of AHRQ standard practice guidelines support the utility of screening for tobacco use, offering brief advice to quit, and prescribing pharmacotherapy for smoking cessation (see Fiore et al., 2000 for a review). Results from nine randomized clinical trials suggest that clinical practices with screening systems in place to identify and record smoking status have markedly higher rates at which clinicians intervene with their patients than those practices with no screening system in place. Furthermore, the results suggest that higher rates of screening by clinicians result in higher rates of smoking cessation among the patient population. Physician advice to quit has also been found to be an important component of smoking cessation treatment within developed countries. Specifically, results of a meta-analysis comparing advice with no advice indicate that brief physician advice to quit significantly increases smoking abstinence. Abstinence rates continue to increase with longer and more frequent clinician-patient contact. Finally, the efficacy of pharmacotherapy for smoking cessation has been supported through a multitude of studies comparing pharmacotherapy to placebo controls. Although the efficacy of each of the first-line pharmacotherapies (bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch) varies, all have been shown to markedly increase long-term abstinence compared to placebo controls. Taken together, these findings from developed countries suggest that the most effective treatment of tobacco dependence requires the use of multiple modalities, including systems-wide approaches to increase tobacco screening, physician advice to quit, and the prescription of recommended pharmacotherapy.

Another area in need of improvement is workplace smoking restrictions. Almost half of physicians reported having no established smoking policy in the building where they work and significant differences were found between the two teaching hospitals in regard to workplace smoking policies. In addition, analyses examining the impact of workplace smoking policies on physicians’ smoking cessation attitudes and practices indicate that those practicing in a completely nonsmoking building perceived a lower prevalence of smoking among male and female physicians, were more likely to have been asked by their patients for help in quitting, and were more likely to have guidelines/policies in their practices to help smokers quit. The lack of smoking restrictions within approximately half of the hospitals surveyed suggests a norm of acceptance toward smoking. Similarly, the relationship between workplace smoking restrictions, smoking cessation attitudes, practices, and smoking guidelines/policies highlights the impact of smoking policies in the workplace. In developed countries, workplace tobacco control policies have been found to not only shift social norms but also positively impact adult smoking behaviors, including reducing daily cigarette consumption, increasing motivation to quit, and boosting success at quitting. The implementation of smoking bans within healthcare organizations may represent one component of a multipronged approach for reducing smoking uptake and increasing quitting in Nigeria over the upcoming decades. buy antibiotics canada

A number of limitations warrant mentioning. The study was a convenience sample of physician’s self-reported use of cessation guidelines over the last three months and is, therefore, subject to response and recall bias. Although this study examined physicians’ smoking cessation practices, it did not directly assess whether physicians had advised their patients to quit smoking over the last three months. Future studies could benefit from a more direct assessment of physician’s advice to quit, as well as from chart review and exit interviews with patients to validate physician self-report. Additionally, physicians were from two teaching hospitals in southwestern Nigeria; therefore, caution should be used in generalizing our findings to physicians practicing outside of this setting. Only a small percentage of the physicians in our sample (3%) reported currently smoking, which is considerably lower than the actual smoking prevalence among physicians in Nigeria (24%). While our data indicate that physician smokers were under-represented in the present study, it is important to note that estimates regarding the smoking prevalence among physicians in Nigerian are dated (circa 1983). Future studies are needed to provide a more accurate and current estimate of the smoking prevalence among male and female physicians in Nigeria. Additionally, the mean age of physicians in our sample was 33 years, therefore, limiting the generaliz-ability of our findings to older, more experienced physicians. Despite the limitations of our sample, the data do, however, provide an initial estimate of physician practices in teaching hospitals, which serve as an important training center for physicians in Nigeria. Targeting these hospitals is an important first step in improving the smoking cessation guidelines/practices within Nigeria, as physicians take the knowledge and standards of care learned at these training centers to their future practices.
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In summary, little attention has been given to workplace smoking policies and physician-initiated smoking cessation practices in Nigeria. Results of the current study indicate three areas for future intervention and study: 1) a systematic adoption and enforcement of workplace tobacco control policies among Nigerian hospitals; 2) the provision and education of physicians regarding use of the AHRQ standard practice guidelines; 3) the facilitation of system wide changes to promote screening for smoking status among all patients, as well as the counseling and prescription of recommended pharmacotherapy for those interested in quitting. It is also recommended that tailored health communication materials be developed to target the specific needs of physicians in Nigeria and the general public as they begin to address the tobacco epidemic within their country. If current estimates are correct, Nigeria and other developing countries will be disproportionately impacted by tobacco-related disease and mortality in the upcoming decades. Helping physicians in Nigeria to institute guidelines and intervene with patients who smoke is critical to reducing the tobacco-related health problems that will increasingly burden the healthcare system in the future.

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