Preventive Medicine 66 (2014) 107–112
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Are primary care physicians prepared to assist patients for smoking cessation? Results of a national Italian cross-sectional web survey Carmelo G.A. Nobile, Aida Bianco, Alessio D. Biafore, Benedetto Manuti, Claudia Pileggi, Maria Pavia ⁎ Department of Health Sciences, University of Catanzaro “Magna Græcia”, Catanzaro, Italy
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Available online 16 June 2014 Keywords: Dependence Primary care physicians Smoking cessation interventions Tobacco use
a b s t r a c t Objective: The primary purpose of this study is to explore primary care physicians' (PCPs') knowledge, attitudes and self-reported activities provided to patients for smoking cessation. The secondary purpose is to identify the relationships between physician-related characteristics and knowledge, attitudes and self-reported activities for smoking cessation. Method: A national cross-sectional web survey was conducted in Italy from April through September 2012. Results: 722 PCPs completed the questionnaire. The great majority indicated the correct proportion of smokers among patients with lung cancer, the smoking abstention required for risk reduction after smoking cessation, and tobacco as a known major risk factor for chronic obstructive pulmonary disease (COPD), whereas 28.7% knew the Fagerstrom test for the assessment of nicotine dependence. Almost all PCPs reported that they ask all patients if they smoke, inform about the dangers of smoking and recommend to quit smoking, whereas prescription of recommended drugs for smoking cessation varied from 37.7% for nicotine replacement therapy to 4.9% for varenicline. Conclusion: Despite a positive attitude, Italian PCPs are not prepared to deliver effective interventions for smoking cessation in their patients. © 2014 Elsevier Inc. All rights reserved.
Introduction Treatment of tobacco use and dependence are recommended by World Health Organization (WHO) as part of a comprehensive strategy for prevention and control of chronic diseases in primary care (World Health Organization, 2013), and WHO mandates to the European Community Member States the development and dissemination of guidelines aimed at promoting cessation of tobacco use (Shibuya et al., 2003; World Health Organization, 2003). Moreover, recommendations for effective treatments of tobacco use and dependence have been developed by the Agency for Healthcare Research and Quality (Fiore et al., 2008). In Italy, National Health Plans have set goals for prevention of chronic diseases related to unhealthy lifestyles, including tobacco use, through the contribution of primary care physicians (PCPs), and National Guidelines have been developed, specifically addressed to PCPs, to treat tobacco dependence (Ministero della Salute, Istituto Superiore di Sanità, 2008).
Despite the evidence on the effectiveness and cost-effectiveness of tobacco interventions in primary care settings (Rigotti et al., 2011), several studies have shown that PCPs do not routinely deliver the recommended interventions (Manuti et al., 2010; Jamal et al., 2012). Moreover, previous studies (Meshefedjian et al., 2010; Sheffer et al., 2012), have found that physician-related characteristics may be significant barriers to the provision of effective tobacco interventions. To our knowledge, very few data are available in Italy on this topic (Ferketich et al., 2008), particularly regarding the PCPs' perspective (Pizzo et al., 2003). The primary purpose of this study is to explore PCPs' knowledge and attitudes about health consequences of smoking and evidence-based interventions for smoking cessation, and to estimate the self-reported activities provided to patients in their current practices. The secondary purpose is to identify the relationships between physician-related characteristics and knowledge, attitudes and self-reported activities provided to patients for smoking cessation.
Methods Abbreviations: CIs, confidence intervals; COPD, chronic obstructive pulmonary disease; LHUs, local health units; NHS, National Health Service; ORs, odds ratio; PCP, primary care physicians; SD, standard deviation; WHO, World Health Organization. ⁎ Corresponding author at: Medical School, University of Catanzaro “Magna Græcia”, Via Tommaso Campanella, 88100 Catanzaro, Italy. Fax: +39 961 712382. E-mail address: [email protected] (M. Pavia).
http://dx.doi.org/10.1016/j.ypmed.2014.06.009 0091-7435/© 2014 Elsevier Inc. All rights reserved.
Study population The target population consisted of the PCPs practicing within the Italian National Health Service (NHS). It is a regionally based system: within each region, healthcare is provided through the Local Health Units (LHUs) and PCPs are
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contractors of LHUs, responsible for the provision of primary care and of the access to other health services. Study design From April through September 2012 a national cross-sectional web survey was conducted in Italy performing a multi-stage sampling. We randomly selected one LHU for each of the 21 Italian regions and 50 PCPs from the lists provided by each selected LHU, for an overall sample of 1050 PCPs. All selected PCPs were contacted by phone to explain the purposes of the study, and to collect the email addresses of those who agreed to participate. Enrolled PCPs were invited to follow a link that registered a masked code for each responder but did not allow further identification of the participant. A pretested web-based anonymous self-administered questionnaire was used. Nonrespondent PCPs were further contacted by phone and by two e-mailing reminders. Review instrument The web-questionnaire was divided into four sections: 1) sociodemographic and practice characteristics; 2) PCPs' knowledge regarding the health consequences of smoking, such as smoking attributable mortality in Italy, proportion of smokers among patients with lung cancer, decrease of lung cancer risk in former smokers and diseases correlated to tobacco smoking, and the interventions that have been proven to be effective for smoking cessation, such as Fagerstrom test and screening for tobacco use; moreover, two interventions of unproven effectiveness, acupuncture sessions and homeopathic products, were also investigated; 3) PCPs' attitudes towards smoking habits among the health professionals, the anti-smoking legislation and the effective strategies or interventions for smoking cessation; 4) PCPs' personal smoking habit and self-reported activities provided to their patients for smoking cessation, such as screening for tobacco use, types of counseling and behavioral therapies, and appropriate medications. The study was approved by the Institutional Ethical Committee (“Mater Domini” Hospital of Catanzaro, Italy, 20.4.2012). Statistical analysis Multivariate logistic regression analysis was performed, with the following outcomes of interest: knowledge about the health consequences of smoking and evidence-based interventions (Model 1); attitudes towards tobacco use and strategies for smoking cessation (Model 2); self-reported activities provided to patients in their current practices (Model 3). In Model 1, PCPs were divided in those who were aware of the proportion of smokers among patients with lung cancer and were able to correctly indicate a series of interventions of proven effectiveness for smoking cessation, versus all others; in Model 2, PCPs were divided in those who agreed to all the following statements: smoking habits of health professionals are a bad example for patients, need to implement anti-smoking legislation, physicians' training-course in smoking cessation is important, versus all others; in Model 3, PCPs were divided in those who provided to their patients all activities for smoking cessation, versus all others. Socio-demographic and practice characteristics, as well as smoking status, knowledge of smoking abstention required for risk reduction, and the smoking-related annual mortality in Italy were included in all models as explanatory variables. In Model 2, we also included some variables exploring knowledge. In Model 3, we also included variables exploring attitudes. Data were analyzed using the Stata software program (StataCorp, 2009).
Results 722 PCPs completed the web questionnaire, for a response rate of 68.8%. Subject characteristics Current smokers were 13.4%, almost all had tried to quit smoking during entire life and 74.7% in the previous year (Table 1).
Knowledge Almost all PCPs indicated the correct proportion of smokers among lung cancer patients and the smoking abstention required for risk reduction after smoking cessation, while only 15.4% correctly identified the number of smoking-related deaths/year in Italy, since 81.8% indicated a larger number. Only 34.2% indicated tobacco as a major risk factor for low birth weight, only 28.7% knew the Fagerstrom test, whereas almost all PCPs were aware of the effectiveness of asking all patients if they smoke and advise all smokers to quit smoking, while less than a third were aware of the role of drug therapy for smoking patients. About 60% indicated at least two first-line medications, in particular nicotine replacement therapy (NRT) was recognized by 99.4%, bupropion by 60.7%, and varenicline by half of the sample. The vast majority knows that there is no evidence of effectiveness for acupuncture (90%) and homeopathy (85.4%). Moreover, only 17.8% could report about the availability of a Smoking Cessation Center in their LHU (Table 2). Knowledge of effective interventions was significantly higher in PCPs with more years in practice and in those who were aware of the cancer risk reduction after smoking cessation, whereas it was significantly lower in current smokers and in those who graduated many years ago (Model 1 in Table 3).
Attitudes Positive attitudes were revealed by 80% who agreed that health professionals should not smoke because they should be a good example for the patients, and about two thirds were favorable to a stricter antismoking legislation. More than half perceived the role of PCPs and Smoking Cessation Center and the implementation of specific training among healthcare personnel as important (Table 2). A positive attitude was significantly more likely in PCPs who were aware of the burden of smoking-related deaths, of the effectiveness of increasing the price of cigarettes and that homeopathic products are not effective for smoking cessation, whereas it was significantly less likely in current smokers, in those who recognized smoking as a risk factor for myocardial infarction, and who were aware of the role of written material to support smoking cessation (Model 2 in Table 3).
Practices Almost all PCPs reported that they ask all patients if they smoke, inform about the dangers of smoking and recommend to quit smoking, providing tobacco dependence counseling. Three-quarters was declared to provide additional treatment for patients who failed previous quitting attempts, more than 60% higher intensity counseling for pregnant smokers, and for reducing passive smoke exposure in households, whereas only 17% provide Fagerstrom test. Prescription of recommended drugs varied from 37.7% for NRT, to 4.9% for varenicline, whereas 8.3% of PCPs refers the heavily dependent smokers to a Smoking Cessation Center (Table 2). PCPs who provided all investigated practices for smoking cessation to their patients were significantly more likely to be younger, to be aware of the proportion of smokers among their patients, and of many of the practices of proven effectiveness, such as documenting the smoking status, providing professional counseling to subjects attempting to quit smoking, and they knew at least two effective drugs for smoking cessation, whereas, unexpectedly, they do not believe that increasing the price of cigarettes is an effective practice; finally they were significantly more likely to believe that physicians' smoking habits is a bad example for patients (Model 3 in Table 3).
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Table 1 Selected characteristics of the study population. Characteristics Gender Male Female Age group, year ≤50 51–59 ≥60 Marital status Single/separated/divorced/widowed Married/cohabitant Years after graduation ≤20 21–29 ≥30 Number of years in practice ≤10 11–20 ≥21 Number of assisted ≤1000 1001–1300 ≥1301 Specialization No Yes Smoking status (715; 99%)a Never smoker Ex-smoker Current smoker Frequency of cigarette smoking among current smokers (96; 13.3%)a Some days Every day Cigarettes smoked per day, (70; 9.7%)a ≤10 10–19 ≥20 Attempts to quit smoking in entire life among current smokers (88; 12.2%)a Yes No Attempts to quit smoking in the previous year among current smokers (87; 12%)a Yes No a
N
%
493 229
68.3 31.7
180 390 152
24.9 54 21.1
161 561
22.3 77.7
106 309 307
14.7 42.8 42.5
129 320 273
17.9 44.3 37.8
233 320 169
32.3 44.3 23.4
390 332
54 46
459 160 96
64.2 22.4 13.4
50 46
52.1 47.9
17 34 19
24.3 48.6 27.1
87 1
98.9 1.1
65 22
74.7 25.3
Mean ± SD
54.3 ± 5.7
27.6 ± 6.2
18.5 ± 6.9
1168.2 ± 219.6
12 ± 5.8
In brackets the number and the percentage of the total sample of 722 PCPs responding to the question.
Discussion Although a large body of evidence has demonstrated that smokers may count on several effective interventions, and that PCPs can play a major role in the patients' decision and process of smoking cessation, numerous studies have reported that most past smokers have not taken advantage of smoking cessation effective interventions (Shiffman et al., 2008; Land et al., 2010). Moreover, there is also a need to improve delivery of clinical preventive services in the smoking cessation area. In particular, in a study conducted by some of us on primary care patients, we found that less than 20% of smokers had received a smoking cessation counseling visit within the previous 3 months, and even less (12%) smoking cessation pharmacotherapy (Manuti et al., 2010). Similar results have been reported in the US, where only 20.9% and 7.6% current tobacco users received tobacco cessation counseling and medication in PCP visits, respectively (Jamal et al., 2012). The present survey demonstrates that PCPs have acquainted definitively positive attitude to the provision of smoking cessation interventions, but there is need to increase their knowledge and their ability to provide them. The most evident gaps of knowledge do not pertain to basic awareness of the health risks of smoking, but on the interventions of proven effectiveness. It is unacceptable that only a quarter of PCPs knows about Fagerstrom test and less than two thirds is aware of the
effective drugs for smoking cessation. Moreover, it is evident that Smoking Cessation Centers are not considered by the majority of PCPs as a useful resource; further research is needed to investigate whether PCPs are not aware of their role or the centers are not yet prepared to deliver effective interventions. As already reported (Applegate et al., 2008) PCPs tend to provide with higher frequency the first few of the “5A's”, whereas more challenging interventions, such as the assessment of dependence through Fagerstrom test, assistance along the smoking quit attempt process, drug prescription, and related follow-ups were infrequently provided to smoker patients. These findings suggest that knowledge on tobacco health effects and positive attitude towards the role of PCPs for patients' smoking cessation are not sufficient, and there is a strong need to improve PCPs' knowledge on effective interventions and to empower them on the practical skills required to assist smoker patients in their quit attempts. It has already been reported that tobacco-related undergraduate medical and postgraduate PCPs' education and training are limited in our country, representing a barrier to the provision of smoking cessation support (Unim et al., 2013). Analogous barriers have been reported by some of us for other PCPs' missed opportunities, such as vaccinations in the elderly (Pavia et al., 2003), and also in this case PCPs had a positive attitude, but poor knowledge. These and other barriers that can
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Table 2 Knowledge, attitudes and reported interventions about smoking cessation. Items Knowledge Smoking-related risks Lung cancer risk reduction after smoking cessation among former smokers (721; 99.9%) Proportion of smokers among patients with lung cancer (720; 99.7%) Diseases for which tobacco is a known major risk factor (719; 99.6%) COPD Myocardial infarction Low birth weight Stroke Numbers of deaths per year in Italy (720; 99.7%) Interventions for smoking cessation First-line medications for tobacco dependence (717; 99.3%) Nicotine replacement therapy (NRT) Bupropion Varenicline Fagerstrom test for nicotine dependence Smoking Cessation Centers (718; 99.4%) Quit smoking methods Advise all smokers to quit smoking (719; 99.6%) Ask all patients if they smoke Documentation of smoking status (721; 99.9%) Professional counseling to subjects attempting to quit smoking (718; 99.4%) Increase the price of cigarettes Tougher sanctions against anti-smoking law violation (716; 99.2%) Drug therapy for patients smoking more than 10 cigarettes a day (719; 99.6%) Provision of written material to support other interventions (718; 99.4%) Attitudes and perceptions Smoking habits of health professionals is a bad example for patients (720; 99.7%) The need to implement anti-smoking legislation (719; 99.6%) Smoking Cessation Center is important or very important in smoking cessation (715; 99.1%) Physicians' training-course is important or very important in smoking cessation (715; 99.1%) PCPs' role is important or very important in smoking cessation (715; 99.1%) Self-reported activities provided to their patients for smoking prevention and cessation Recommend all smokers to quit smoking (716; 99.2%) Ask all patients if they smoke (718; 99.4%) Provide low intensity counseling (3–10 min) to patients without other risk factors (713; 98.8%) Inform all patients about the dangers of smoking (716; 99.2%) Record the smoking status of patients (717; 99.3%) Provide or arrange additional treatment for smoking patients with previous attempts to quit smoking (708; 98.1%) Provide higher intensity counseling to smokers to reduce passive smoke exposure in households (708; 98.1%) Provide higher intensity counseling to pregnant smokers (708; 98.1%) Provide higher intensity counseling (10–30 min) to patients with other risk factors (710; 98.3%) Provide NRT to patients with chronic diseases (708; 98.1%) Refer the heavily dependent smokers to a Smoking Cessation Center (710; 98.3%) Classify smoking patients in relation to their motivation to quit (718; 99.4%) Check if the children of smokers smoke (717; 99.3%) Provide Fagerstrom test for nicotine dependence (202; 27.9%) Provide treatment with bupropion to patients with chronic diseases (708; 98.1%) Refer the patients with chronic diseases to a Smoking Cessation Center (708; 98.1%) Provide treatment with varenicline to patients with chronic diseases (708; 98.1%)
N
%
700 678
97.1 94.2
716 413 247 222 111
99.6 57.2 34.2 30.7 15.4
713 435 369 207 128
99.4 60.7 51.5 28.7 17.8
674 602 570 487 415 380 226 169
93.7 83.4 79.1 67.8 57.5 53.1 31.4 23.5
578 475 436 425 413
80.3 66.1 61.0 59.4 57.8
711 705 616 588 577 533 442 432 303 267 243 185 156 123 60 59 35
99.3 98.2 86.4 82.1 80.5 75.3 62.4 61 42.7 37.7 34.2 25.8 21.8 17 8.5 8.3 4.9
In brackets the number and the percentage of the total sample of 722 PCPs responding to the question.
interfere with PCPs' assessment and treatment of smokers, such as lack of time, inadequate payment, and lack of institutional support, have been mentioned in a previous research (Fiore et al., 2008). Moreover, knowledge of effective interventions was significantly lower in PCPs who graduated many years ago, thus emphasizing that continuing education and training on these topics is not satisfactory. This issue is confirmed by the finding that younger PCPs and those who know many of the effective practices are more likely to provide all effective interventions to their patients. Several studies carried out in Italy have shown that education and training is needed to improve the evidence-based professional behaviors of physicians (Bianco et al., 2005; De Vito et al., 2009a, 2009b) and that improvement initiatives should be focused more on domains of healthcare than on specific conditions, in particular in preventive care (Flotta et al., 2012). Our results are similar to those of other European and US surveys. The most frequently used behavioral interventions by Dutch physicians were those less time-consuming, whereas the most frequently
prescribed drug was bupropion (Kotz et al., 2007); in a US survey responders were highly motivated to help patients quit, but were moderately knowledgeable, confident, and prepared (Sheffer et al., 2012). The 13.4% current smokers is higher compared to Dutch (8.2%) (Kotz et al., 2007) and Swiss PCPs (7.2%) (Jacot Sadowski et al., 2009), and it is alarming since in our study current smoking PCPs were significantly less likely to know effective interventions and to have a positive attitude towards smoking cessation. Strength and limitations of the study The national level of the study participants, the large sample size and the high response rate (almost 70%) represent key strengths of this survey. To our knowledge, this is the first survey conducted at a national level on this topic, and it acquires further importance since, despite in Italy approximately 70% of patients visit their PCP each year (Pileggi et al., 2004), only a small percentage receives advice and support to
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Table 3 Multivariate stepwise logistic regression analysis indicating association between several variables and the different outcomes. Variable Model 1. Outcome: Knowledge about the health consequences of smoking and evidence-based interventions for smoking cessation Log-likelihood = −467.59, χ2 = 33.40, P value ≤ 0.0001, No. of obs. = 704 Years after graduation, ordinala Number of years in practice, ordinalb Smoking status (never smokers as reference) Knowledge of lung cancer risk reduction after smoking cessation among former smokers (lack of knowledge as reference) Number of assisted, ordinalc Marital status (unmarried as reference) Gender (male as reference) Age, ordinald Model 2. Outcome: Positive attitudes towards tobacco use and strategies for smoking cessation Log-likelihood = −418.59, χ2 = 102.09, P value ≤ 0.0001, no. of obs. = 678 Socio-demographic profile Smoking status (never smokers as reference) Age, ordinald Number of years in practice, ordinalb Years after graduation, ordinala Gender (male as reference) Number of assisted, ordinalc Knowledge Tobacco is a major risk factor for myocardial infarction (lack of knowledge as reference) Effectiveness of increasing the price of cigarettes (lack of knowledge as reference) Effectiveness of providing written material to support other interventions (lack of knowledge as reference) Number of smoking-related deaths per year in Italy (lack of knowledge as reference) Ineffectiveness to recommend homeopathic products (lack of knowledge as reference) Proportion of smokers among patients with lung cancer (lack of knowledge as reference) Proportion of female patients who smoke (lack of knowledge as reference) Effectiveness of drug therapy for patients smoking more than 10 cigarettes a day (lack of knowledge as reference) Effectiveness of professional counseling to subjects attempting to quit smoking (lack of knowledge as reference) Proportion of male patients who smoke (lack of knowledge as reference) Model 3. Outcome: Self-reported activities for smoking cessation provided to patients in their current practices Log-likelihood = −363.501, χ2 = 91.58, P value ≤ 0.0001, no. of obs. = 634 Socio-demographic profile Age, ordinald Number of assisted, ordinalc Smoking status (never smokers as reference) Number of years in practice, ordinalb Years after graduation, ordinala Knowledge Effectiveness of documenting the smoking status (lack of knowledge as reference) At least two effective drugs (lack of knowledge as reference) Effectiveness of professional counseling to subjects attempting to quit smoking (lack of knowledge as reference) Effectiveness of drug therapy for patients smoking more than 10 cigarettes a day (lack of knowledge as reference) Effectiveness of increasing the price of cigarettes (lack of knowledge as reference) Proportion of female patients who smoke (lack of knowledge as reference) Number of smoking-related deaths per year in Italy (lack of knowledge as reference) Ineffectiveness to recommend homeopathic products (lack of knowledge as reference) Proportion of smokers among patients with lung cancer (lack of knowledge as reference) Fagerstrom test for nicotine dependence (lack of knowledge as reference) Tobacco is a major risk factor for low birth weight (lack of knowledge as reference) Effectiveness of recommending to quit smoking to patients who smoke Attitudes Physicians' training-course is important or very important in smoking cessation (disagreement as reference) Need to implement anti-smoking legislation (disagreement as reference) Physicians' smoking habits are a bad example for patients (agreement as reference) a b c d
OR
95% CI
0.52 1.89 0.62 3.38 0.79 0.77 0.81 1.2
0.35–0.76 1.31–2.72 0.45–0.86 1.11–10.26 0.60–1.02 0.53–1.12 0.58–1.13 0.85–1.69
0.56 0.75 1.34 0.74 1.29 1.14
0.39–0.8 0.51–1.09 0.9–1.99 0.49–1.12 0.9–1.86 0.85–1.53
0.54 2.34 0.46 2.16 1.64 0.59 0.73 1.33 1.18 1.23
0.39–0.76 1.63–3.37 0.31–0.71 1.35–3.46 1–2.68 0.3–1.19 0.46–1.16 0.84–2.1 0.81–1.73 0.77–1.94
0.59 0.82 0.76 1.29 1.24
0.39–0.88 0.59–1.12 0.51–1.12 0.85–1.99 0.78–1.95
3.18 2.27 1.78 1.19 0.61 1.59 1.55 1.4 1.84 1.24 0.78 1.77
1.83–5.54 1.52–3.39 1.16–2.73 0.9–1.57 0.4–0.92 1.08–2.33 0.94–2.54 0.8–2.44 0.81–4.17 0.82–1.86 0.49–1.12 0.7–4.5
1.27 0.74 1.71
0.76–2.14 0.49–1.12 0.15–2.52
Years after graduation (b 21 = 0, 21-29 = 1, N29 = 2). Number of years in practice (b 11 = 0, 11-20 = 1, N ;20 =2). Number of assisted (b 1001 = 0, 1001-1300 = 1, N 1300 = 2). Age (b 51 = 0, 51-59 = 1, N 59 = 2).
quit smoking (Ferketich et al., 2008; Sheffer et al., 2012). A similar survey, carried out before the development of the National Guidelines, collected data from only two Italian areas and reported findings consistent with ours, since the need for a more in depth training of PCPs on smoking cessation procedures was underscored (Pizzo et al., 2003). The almost 70% response rate is very satisfactory and higher than that of similar surveys conducted in the Netherlands (38%) (Kotz et al., 2007) and Switzerland (54.8%) (Jacot Sadowski et al., 2009). Therefore selection bias, with responders selectively more active on smoking cessation interventions, does not represent a main concern in our results.
Moreover, there were no substantial differences between responders and non-responders with respect to sex and geographic area, with 43.6% of non-responders working in the South, while, as expected, non-responder PCPs were older (mean age 58.6). Interpretation of our findings should take into account potential limitations. The survey was cross-sectional, not allowing to draw conclusions on causality about the observed associations. However, this was not our goal since we wanted only to assess PCPs' knowledge, attitudes, and evidence-based practices related to patients' smoking cessation, and whether knowledge and attitudes could influence effective
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smoking cessation practices. Moreover, since data were self-reported, “social desirability” answers cannot be excluded. However, assurance of confidentiality has substantially minimized this issue in our data. Conclusions Despite a positive predisposing attitude, Italian PCPs are not prepared to deliver effective interventions for smoking cessation in their patients. Efforts should be made to improve PCPs' education and training in the assistance of these patients, as well as to identify enabling and reinforcing factors to enhance PCPs' commitment to this and other preventive interventions. Conflict of interest statement The authors declare that there are no conflicts of interests.
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Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Are primary care physicians prepared to assist patients for smoking cessation? Results of a national Italian cross-sectional web survey Carmelo G.A. Nobile, Aida Bianco, Alessio D. Biafore, Benedetto Manuti, Claudia Pileggi, Maria Pavia ⁎ Department of Health Sciences, University of Catanzaro “Magna Græcia”, Catanzaro, Italy
a r t i c l e
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Available online 16 June 2014 Keywords: Dependence Primary care physicians Smoking cessation interventions Tobacco use
a b s t r a c t Objective: The primary purpose of this study is to explore primary care physicians' (PCPs') knowledge, attitudes and self-reported activities provided to patients for smoking cessation. The secondary purpose is to identify the relationships between physician-related characteristics and knowledge, attitudes and self-reported activities for smoking cessation. Method: A national cross-sectional web survey was conducted in Italy from April through September 2012. Results: 722 PCPs completed the questionnaire. The great majority indicated the correct proportion of smokers among patients with lung cancer, the smoking abstention required for risk reduction after smoking cessation, and tobacco as a known major risk factor for chronic obstructive pulmonary disease (COPD), whereas 28.7% knew the Fagerstrom test for the assessment of nicotine dependence. Almost all PCPs reported that they ask all patients if they smoke, inform about the dangers of smoking and recommend to quit smoking, whereas prescription of recommended drugs for smoking cessation varied from 37.7% for nicotine replacement therapy to 4.9% for varenicline. Conclusion: Despite a positive attitude, Italian PCPs are not prepared to deliver effective interventions for smoking cessation in their patients. © 2014 Elsevier Inc. All rights reserved.
Introduction Treatment of tobacco use and dependence are recommended by World Health Organization (WHO) as part of a comprehensive strategy for prevention and control of chronic diseases in primary care (World Health Organization, 2013), and WHO mandates to the European Community Member States the development and dissemination of guidelines aimed at promoting cessation of tobacco use (Shibuya et al., 2003; World Health Organization, 2003). Moreover, recommendations for effective treatments of tobacco use and dependence have been developed by the Agency for Healthcare Research and Quality (Fiore et al., 2008). In Italy, National Health Plans have set goals for prevention of chronic diseases related to unhealthy lifestyles, including tobacco use, through the contribution of primary care physicians (PCPs), and National Guidelines have been developed, specifically addressed to PCPs, to treat tobacco dependence (Ministero della Salute, Istituto Superiore di Sanità, 2008).
Despite the evidence on the effectiveness and cost-effectiveness of tobacco interventions in primary care settings (Rigotti et al., 2011), several studies have shown that PCPs do not routinely deliver the recommended interventions (Manuti et al., 2010; Jamal et al., 2012). Moreover, previous studies (Meshefedjian et al., 2010; Sheffer et al., 2012), have found that physician-related characteristics may be significant barriers to the provision of effective tobacco interventions. To our knowledge, very few data are available in Italy on this topic (Ferketich et al., 2008), particularly regarding the PCPs' perspective (Pizzo et al., 2003). The primary purpose of this study is to explore PCPs' knowledge and attitudes about health consequences of smoking and evidence-based interventions for smoking cessation, and to estimate the self-reported activities provided to patients in their current practices. The secondary purpose is to identify the relationships between physician-related characteristics and knowledge, attitudes and self-reported activities provided to patients for smoking cessation.
Methods Abbreviations: CIs, confidence intervals; COPD, chronic obstructive pulmonary disease; LHUs, local health units; NHS, National Health Service; ORs, odds ratio; PCP, primary care physicians; SD, standard deviation; WHO, World Health Organization. ⁎ Corresponding author at: Medical School, University of Catanzaro “Magna Græcia”, Via Tommaso Campanella, 88100 Catanzaro, Italy. Fax: +39 961 712382. E-mail address: [email protected] (M. Pavia).
http://dx.doi.org/10.1016/j.ypmed.2014.06.009 0091-7435/© 2014 Elsevier Inc. All rights reserved.
Study population The target population consisted of the PCPs practicing within the Italian National Health Service (NHS). It is a regionally based system: within each region, healthcare is provided through the Local Health Units (LHUs) and PCPs are
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contractors of LHUs, responsible for the provision of primary care and of the access to other health services. Study design From April through September 2012 a national cross-sectional web survey was conducted in Italy performing a multi-stage sampling. We randomly selected one LHU for each of the 21 Italian regions and 50 PCPs from the lists provided by each selected LHU, for an overall sample of 1050 PCPs. All selected PCPs were contacted by phone to explain the purposes of the study, and to collect the email addresses of those who agreed to participate. Enrolled PCPs were invited to follow a link that registered a masked code for each responder but did not allow further identification of the participant. A pretested web-based anonymous self-administered questionnaire was used. Nonrespondent PCPs were further contacted by phone and by two e-mailing reminders. Review instrument The web-questionnaire was divided into four sections: 1) sociodemographic and practice characteristics; 2) PCPs' knowledge regarding the health consequences of smoking, such as smoking attributable mortality in Italy, proportion of smokers among patients with lung cancer, decrease of lung cancer risk in former smokers and diseases correlated to tobacco smoking, and the interventions that have been proven to be effective for smoking cessation, such as Fagerstrom test and screening for tobacco use; moreover, two interventions of unproven effectiveness, acupuncture sessions and homeopathic products, were also investigated; 3) PCPs' attitudes towards smoking habits among the health professionals, the anti-smoking legislation and the effective strategies or interventions for smoking cessation; 4) PCPs' personal smoking habit and self-reported activities provided to their patients for smoking cessation, such as screening for tobacco use, types of counseling and behavioral therapies, and appropriate medications. The study was approved by the Institutional Ethical Committee (“Mater Domini” Hospital of Catanzaro, Italy, 20.4.2012). Statistical analysis Multivariate logistic regression analysis was performed, with the following outcomes of interest: knowledge about the health consequences of smoking and evidence-based interventions (Model 1); attitudes towards tobacco use and strategies for smoking cessation (Model 2); self-reported activities provided to patients in their current practices (Model 3). In Model 1, PCPs were divided in those who were aware of the proportion of smokers among patients with lung cancer and were able to correctly indicate a series of interventions of proven effectiveness for smoking cessation, versus all others; in Model 2, PCPs were divided in those who agreed to all the following statements: smoking habits of health professionals are a bad example for patients, need to implement anti-smoking legislation, physicians' training-course in smoking cessation is important, versus all others; in Model 3, PCPs were divided in those who provided to their patients all activities for smoking cessation, versus all others. Socio-demographic and practice characteristics, as well as smoking status, knowledge of smoking abstention required for risk reduction, and the smoking-related annual mortality in Italy were included in all models as explanatory variables. In Model 2, we also included some variables exploring knowledge. In Model 3, we also included variables exploring attitudes. Data were analyzed using the Stata software program (StataCorp, 2009).
Results 722 PCPs completed the web questionnaire, for a response rate of 68.8%. Subject characteristics Current smokers were 13.4%, almost all had tried to quit smoking during entire life and 74.7% in the previous year (Table 1).
Knowledge Almost all PCPs indicated the correct proportion of smokers among lung cancer patients and the smoking abstention required for risk reduction after smoking cessation, while only 15.4% correctly identified the number of smoking-related deaths/year in Italy, since 81.8% indicated a larger number. Only 34.2% indicated tobacco as a major risk factor for low birth weight, only 28.7% knew the Fagerstrom test, whereas almost all PCPs were aware of the effectiveness of asking all patients if they smoke and advise all smokers to quit smoking, while less than a third were aware of the role of drug therapy for smoking patients. About 60% indicated at least two first-line medications, in particular nicotine replacement therapy (NRT) was recognized by 99.4%, bupropion by 60.7%, and varenicline by half of the sample. The vast majority knows that there is no evidence of effectiveness for acupuncture (90%) and homeopathy (85.4%). Moreover, only 17.8% could report about the availability of a Smoking Cessation Center in their LHU (Table 2). Knowledge of effective interventions was significantly higher in PCPs with more years in practice and in those who were aware of the cancer risk reduction after smoking cessation, whereas it was significantly lower in current smokers and in those who graduated many years ago (Model 1 in Table 3).
Attitudes Positive attitudes were revealed by 80% who agreed that health professionals should not smoke because they should be a good example for the patients, and about two thirds were favorable to a stricter antismoking legislation. More than half perceived the role of PCPs and Smoking Cessation Center and the implementation of specific training among healthcare personnel as important (Table 2). A positive attitude was significantly more likely in PCPs who were aware of the burden of smoking-related deaths, of the effectiveness of increasing the price of cigarettes and that homeopathic products are not effective for smoking cessation, whereas it was significantly less likely in current smokers, in those who recognized smoking as a risk factor for myocardial infarction, and who were aware of the role of written material to support smoking cessation (Model 2 in Table 3).
Practices Almost all PCPs reported that they ask all patients if they smoke, inform about the dangers of smoking and recommend to quit smoking, providing tobacco dependence counseling. Three-quarters was declared to provide additional treatment for patients who failed previous quitting attempts, more than 60% higher intensity counseling for pregnant smokers, and for reducing passive smoke exposure in households, whereas only 17% provide Fagerstrom test. Prescription of recommended drugs varied from 37.7% for NRT, to 4.9% for varenicline, whereas 8.3% of PCPs refers the heavily dependent smokers to a Smoking Cessation Center (Table 2). PCPs who provided all investigated practices for smoking cessation to their patients were significantly more likely to be younger, to be aware of the proportion of smokers among their patients, and of many of the practices of proven effectiveness, such as documenting the smoking status, providing professional counseling to subjects attempting to quit smoking, and they knew at least two effective drugs for smoking cessation, whereas, unexpectedly, they do not believe that increasing the price of cigarettes is an effective practice; finally they were significantly more likely to believe that physicians' smoking habits is a bad example for patients (Model 3 in Table 3).
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Table 1 Selected characteristics of the study population. Characteristics Gender Male Female Age group, year ≤50 51–59 ≥60 Marital status Single/separated/divorced/widowed Married/cohabitant Years after graduation ≤20 21–29 ≥30 Number of years in practice ≤10 11–20 ≥21 Number of assisted ≤1000 1001–1300 ≥1301 Specialization No Yes Smoking status (715; 99%)a Never smoker Ex-smoker Current smoker Frequency of cigarette smoking among current smokers (96; 13.3%)a Some days Every day Cigarettes smoked per day, (70; 9.7%)a ≤10 10–19 ≥20 Attempts to quit smoking in entire life among current smokers (88; 12.2%)a Yes No Attempts to quit smoking in the previous year among current smokers (87; 12%)a Yes No a
N
%
493 229
68.3 31.7
180 390 152
24.9 54 21.1
161 561
22.3 77.7
106 309 307
14.7 42.8 42.5
129 320 273
17.9 44.3 37.8
233 320 169
32.3 44.3 23.4
390 332
54 46
459 160 96
64.2 22.4 13.4
50 46
52.1 47.9
17 34 19
24.3 48.6 27.1
87 1
98.9 1.1
65 22
74.7 25.3
Mean ± SD
54.3 ± 5.7
27.6 ± 6.2
18.5 ± 6.9
1168.2 ± 219.6
12 ± 5.8
In brackets the number and the percentage of the total sample of 722 PCPs responding to the question.
Discussion Although a large body of evidence has demonstrated that smokers may count on several effective interventions, and that PCPs can play a major role in the patients' decision and process of smoking cessation, numerous studies have reported that most past smokers have not taken advantage of smoking cessation effective interventions (Shiffman et al., 2008; Land et al., 2010). Moreover, there is also a need to improve delivery of clinical preventive services in the smoking cessation area. In particular, in a study conducted by some of us on primary care patients, we found that less than 20% of smokers had received a smoking cessation counseling visit within the previous 3 months, and even less (12%) smoking cessation pharmacotherapy (Manuti et al., 2010). Similar results have been reported in the US, where only 20.9% and 7.6% current tobacco users received tobacco cessation counseling and medication in PCP visits, respectively (Jamal et al., 2012). The present survey demonstrates that PCPs have acquainted definitively positive attitude to the provision of smoking cessation interventions, but there is need to increase their knowledge and their ability to provide them. The most evident gaps of knowledge do not pertain to basic awareness of the health risks of smoking, but on the interventions of proven effectiveness. It is unacceptable that only a quarter of PCPs knows about Fagerstrom test and less than two thirds is aware of the
effective drugs for smoking cessation. Moreover, it is evident that Smoking Cessation Centers are not considered by the majority of PCPs as a useful resource; further research is needed to investigate whether PCPs are not aware of their role or the centers are not yet prepared to deliver effective interventions. As already reported (Applegate et al., 2008) PCPs tend to provide with higher frequency the first few of the “5A's”, whereas more challenging interventions, such as the assessment of dependence through Fagerstrom test, assistance along the smoking quit attempt process, drug prescription, and related follow-ups were infrequently provided to smoker patients. These findings suggest that knowledge on tobacco health effects and positive attitude towards the role of PCPs for patients' smoking cessation are not sufficient, and there is a strong need to improve PCPs' knowledge on effective interventions and to empower them on the practical skills required to assist smoker patients in their quit attempts. It has already been reported that tobacco-related undergraduate medical and postgraduate PCPs' education and training are limited in our country, representing a barrier to the provision of smoking cessation support (Unim et al., 2013). Analogous barriers have been reported by some of us for other PCPs' missed opportunities, such as vaccinations in the elderly (Pavia et al., 2003), and also in this case PCPs had a positive attitude, but poor knowledge. These and other barriers that can
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Table 2 Knowledge, attitudes and reported interventions about smoking cessation. Items Knowledge Smoking-related risks Lung cancer risk reduction after smoking cessation among former smokers (721; 99.9%) Proportion of smokers among patients with lung cancer (720; 99.7%) Diseases for which tobacco is a known major risk factor (719; 99.6%) COPD Myocardial infarction Low birth weight Stroke Numbers of deaths per year in Italy (720; 99.7%) Interventions for smoking cessation First-line medications for tobacco dependence (717; 99.3%) Nicotine replacement therapy (NRT) Bupropion Varenicline Fagerstrom test for nicotine dependence Smoking Cessation Centers (718; 99.4%) Quit smoking methods Advise all smokers to quit smoking (719; 99.6%) Ask all patients if they smoke Documentation of smoking status (721; 99.9%) Professional counseling to subjects attempting to quit smoking (718; 99.4%) Increase the price of cigarettes Tougher sanctions against anti-smoking law violation (716; 99.2%) Drug therapy for patients smoking more than 10 cigarettes a day (719; 99.6%) Provision of written material to support other interventions (718; 99.4%) Attitudes and perceptions Smoking habits of health professionals is a bad example for patients (720; 99.7%) The need to implement anti-smoking legislation (719; 99.6%) Smoking Cessation Center is important or very important in smoking cessation (715; 99.1%) Physicians' training-course is important or very important in smoking cessation (715; 99.1%) PCPs' role is important or very important in smoking cessation (715; 99.1%) Self-reported activities provided to their patients for smoking prevention and cessation Recommend all smokers to quit smoking (716; 99.2%) Ask all patients if they smoke (718; 99.4%) Provide low intensity counseling (3–10 min) to patients without other risk factors (713; 98.8%) Inform all patients about the dangers of smoking (716; 99.2%) Record the smoking status of patients (717; 99.3%) Provide or arrange additional treatment for smoking patients with previous attempts to quit smoking (708; 98.1%) Provide higher intensity counseling to smokers to reduce passive smoke exposure in households (708; 98.1%) Provide higher intensity counseling to pregnant smokers (708; 98.1%) Provide higher intensity counseling (10–30 min) to patients with other risk factors (710; 98.3%) Provide NRT to patients with chronic diseases (708; 98.1%) Refer the heavily dependent smokers to a Smoking Cessation Center (710; 98.3%) Classify smoking patients in relation to their motivation to quit (718; 99.4%) Check if the children of smokers smoke (717; 99.3%) Provide Fagerstrom test for nicotine dependence (202; 27.9%) Provide treatment with bupropion to patients with chronic diseases (708; 98.1%) Refer the patients with chronic diseases to a Smoking Cessation Center (708; 98.1%) Provide treatment with varenicline to patients with chronic diseases (708; 98.1%)
N
%
700 678
97.1 94.2
716 413 247 222 111
99.6 57.2 34.2 30.7 15.4
713 435 369 207 128
99.4 60.7 51.5 28.7 17.8
674 602 570 487 415 380 226 169
93.7 83.4 79.1 67.8 57.5 53.1 31.4 23.5
578 475 436 425 413
80.3 66.1 61.0 59.4 57.8
711 705 616 588 577 533 442 432 303 267 243 185 156 123 60 59 35
99.3 98.2 86.4 82.1 80.5 75.3 62.4 61 42.7 37.7 34.2 25.8 21.8 17 8.5 8.3 4.9
In brackets the number and the percentage of the total sample of 722 PCPs responding to the question.
interfere with PCPs' assessment and treatment of smokers, such as lack of time, inadequate payment, and lack of institutional support, have been mentioned in a previous research (Fiore et al., 2008). Moreover, knowledge of effective interventions was significantly lower in PCPs who graduated many years ago, thus emphasizing that continuing education and training on these topics is not satisfactory. This issue is confirmed by the finding that younger PCPs and those who know many of the effective practices are more likely to provide all effective interventions to their patients. Several studies carried out in Italy have shown that education and training is needed to improve the evidence-based professional behaviors of physicians (Bianco et al., 2005; De Vito et al., 2009a, 2009b) and that improvement initiatives should be focused more on domains of healthcare than on specific conditions, in particular in preventive care (Flotta et al., 2012). Our results are similar to those of other European and US surveys. The most frequently used behavioral interventions by Dutch physicians were those less time-consuming, whereas the most frequently
prescribed drug was bupropion (Kotz et al., 2007); in a US survey responders were highly motivated to help patients quit, but were moderately knowledgeable, confident, and prepared (Sheffer et al., 2012). The 13.4% current smokers is higher compared to Dutch (8.2%) (Kotz et al., 2007) and Swiss PCPs (7.2%) (Jacot Sadowski et al., 2009), and it is alarming since in our study current smoking PCPs were significantly less likely to know effective interventions and to have a positive attitude towards smoking cessation. Strength and limitations of the study The national level of the study participants, the large sample size and the high response rate (almost 70%) represent key strengths of this survey. To our knowledge, this is the first survey conducted at a national level on this topic, and it acquires further importance since, despite in Italy approximately 70% of patients visit their PCP each year (Pileggi et al., 2004), only a small percentage receives advice and support to
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Table 3 Multivariate stepwise logistic regression analysis indicating association between several variables and the different outcomes. Variable Model 1. Outcome: Knowledge about the health consequences of smoking and evidence-based interventions for smoking cessation Log-likelihood = −467.59, χ2 = 33.40, P value ≤ 0.0001, No. of obs. = 704 Years after graduation, ordinala Number of years in practice, ordinalb Smoking status (never smokers as reference) Knowledge of lung cancer risk reduction after smoking cessation among former smokers (lack of knowledge as reference) Number of assisted, ordinalc Marital status (unmarried as reference) Gender (male as reference) Age, ordinald Model 2. Outcome: Positive attitudes towards tobacco use and strategies for smoking cessation Log-likelihood = −418.59, χ2 = 102.09, P value ≤ 0.0001, no. of obs. = 678 Socio-demographic profile Smoking status (never smokers as reference) Age, ordinald Number of years in practice, ordinalb Years after graduation, ordinala Gender (male as reference) Number of assisted, ordinalc Knowledge Tobacco is a major risk factor for myocardial infarction (lack of knowledge as reference) Effectiveness of increasing the price of cigarettes (lack of knowledge as reference) Effectiveness of providing written material to support other interventions (lack of knowledge as reference) Number of smoking-related deaths per year in Italy (lack of knowledge as reference) Ineffectiveness to recommend homeopathic products (lack of knowledge as reference) Proportion of smokers among patients with lung cancer (lack of knowledge as reference) Proportion of female patients who smoke (lack of knowledge as reference) Effectiveness of drug therapy for patients smoking more than 10 cigarettes a day (lack of knowledge as reference) Effectiveness of professional counseling to subjects attempting to quit smoking (lack of knowledge as reference) Proportion of male patients who smoke (lack of knowledge as reference) Model 3. Outcome: Self-reported activities for smoking cessation provided to patients in their current practices Log-likelihood = −363.501, χ2 = 91.58, P value ≤ 0.0001, no. of obs. = 634 Socio-demographic profile Age, ordinald Number of assisted, ordinalc Smoking status (never smokers as reference) Number of years in practice, ordinalb Years after graduation, ordinala Knowledge Effectiveness of documenting the smoking status (lack of knowledge as reference) At least two effective drugs (lack of knowledge as reference) Effectiveness of professional counseling to subjects attempting to quit smoking (lack of knowledge as reference) Effectiveness of drug therapy for patients smoking more than 10 cigarettes a day (lack of knowledge as reference) Effectiveness of increasing the price of cigarettes (lack of knowledge as reference) Proportion of female patients who smoke (lack of knowledge as reference) Number of smoking-related deaths per year in Italy (lack of knowledge as reference) Ineffectiveness to recommend homeopathic products (lack of knowledge as reference) Proportion of smokers among patients with lung cancer (lack of knowledge as reference) Fagerstrom test for nicotine dependence (lack of knowledge as reference) Tobacco is a major risk factor for low birth weight (lack of knowledge as reference) Effectiveness of recommending to quit smoking to patients who smoke Attitudes Physicians' training-course is important or very important in smoking cessation (disagreement as reference) Need to implement anti-smoking legislation (disagreement as reference) Physicians' smoking habits are a bad example for patients (agreement as reference) a b c d
OR
95% CI
0.52 1.89 0.62 3.38 0.79 0.77 0.81 1.2
0.35–0.76 1.31–2.72 0.45–0.86 1.11–10.26 0.60–1.02 0.53–1.12 0.58–1.13 0.85–1.69
0.56 0.75 1.34 0.74 1.29 1.14
0.39–0.8 0.51–1.09 0.9–1.99 0.49–1.12 0.9–1.86 0.85–1.53
0.54 2.34 0.46 2.16 1.64 0.59 0.73 1.33 1.18 1.23
0.39–0.76 1.63–3.37 0.31–0.71 1.35–3.46 1–2.68 0.3–1.19 0.46–1.16 0.84–2.1 0.81–1.73 0.77–1.94
0.59 0.82 0.76 1.29 1.24
0.39–0.88 0.59–1.12 0.51–1.12 0.85–1.99 0.78–1.95
3.18 2.27 1.78 1.19 0.61 1.59 1.55 1.4 1.84 1.24 0.78 1.77
1.83–5.54 1.52–3.39 1.16–2.73 0.9–1.57 0.4–0.92 1.08–2.33 0.94–2.54 0.8–2.44 0.81–4.17 0.82–1.86 0.49–1.12 0.7–4.5
1.27 0.74 1.71
0.76–2.14 0.49–1.12 0.15–2.52
Years after graduation (b 21 = 0, 21-29 = 1, N29 = 2). Number of years in practice (b 11 = 0, 11-20 = 1, N ;20 =2). Number of assisted (b 1001 = 0, 1001-1300 = 1, N 1300 = 2). Age (b 51 = 0, 51-59 = 1, N 59 = 2).
quit smoking (Ferketich et al., 2008; Sheffer et al., 2012). A similar survey, carried out before the development of the National Guidelines, collected data from only two Italian areas and reported findings consistent with ours, since the need for a more in depth training of PCPs on smoking cessation procedures was underscored (Pizzo et al., 2003). The almost 70% response rate is very satisfactory and higher than that of similar surveys conducted in the Netherlands (38%) (Kotz et al., 2007) and Switzerland (54.8%) (Jacot Sadowski et al., 2009). Therefore selection bias, with responders selectively more active on smoking cessation interventions, does not represent a main concern in our results.
Moreover, there were no substantial differences between responders and non-responders with respect to sex and geographic area, with 43.6% of non-responders working in the South, while, as expected, non-responder PCPs were older (mean age 58.6). Interpretation of our findings should take into account potential limitations. The survey was cross-sectional, not allowing to draw conclusions on causality about the observed associations. However, this was not our goal since we wanted only to assess PCPs' knowledge, attitudes, and evidence-based practices related to patients' smoking cessation, and whether knowledge and attitudes could influence effective
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smoking cessation practices. Moreover, since data were self-reported, “social desirability” answers cannot be excluded. However, assurance of confidentiality has substantially minimized this issue in our data. Conclusions Despite a positive predisposing attitude, Italian PCPs are not prepared to deliver effective interventions for smoking cessation in their patients. Efforts should be made to improve PCPs' education and training in the assistance of these patients, as well as to identify enabling and reinforcing factors to enhance PCPs' commitment to this and other preventive interventions. Conflict of interest statement The authors declare that there are no conflicts of interests.
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