ABSTRACT

Smoking is a medical condition, since there is drug dependence, and health professionals should treat it as a chronic disease. In order to understand the attitudes of Brazilian pulmonologists toward smokers, we conducted a national survey, using a questionnaire posted on the Internet, of 2,800 pulmonologists, 587 (21%) of whom completed and returned the questionnaires. We found that 3.2% of the respondents did not believe that smoking is a medical condition. Only 14.7% treated smokers, and 32.4% stated that they would refer smokers to another professional for treatment. These results suggest that Brazilian pulmonologists have insufficient knowledge of smoking cessation therapies.

Keywords: Physicians; Tobacco use cessation; Smoking/therapy.

RESUMO

O tabagismo é uma condição médica por haver dependência de droga, devendo ser abordado por todos os profissionais de saúde como uma doença crônica. Objetivando conhecer a conduta dos pneumologistas brasileiros perante fumantes, realizamos um inquérito nacional, por meio da aplicação de um questionário via internet, enviado para 2.800 desses profissionais, com um retorno de 587 questionários (21%). Observamos que 3,2% dos respondedores não entendem o tabagismo como uma condição médica. Somente 14,7% responderam tratar o tabagismo, e 32,4% disseram encaminhar o fumante para outro colega tratá-lo. Os resultados sugerem que os pneumologistas brasileiros não têm conhecimento suficiente sobre as terapias de cessação do tabagismo.

Palavras-chave: Médicos; Abandono do uso de tabaco; Tabagismo/terapia.

Similar to diabetes and systemic arterial hypertension, nicotine dependence is a chronic disease(1) and should be treated as such by all health professionals, particularly pulmonologists. In comparison with any other group in society, medical professionals probably have the greatest potential to promote a reduction in smoking and thus reduce smoking-related morbidity and mortality. These professionals can contribute to smoking control in various complementary ways: being models of behavior (not smoking); advising patients to quit smoking; offering smoking cessation treatment; and organizing and aiding in the creation of public policies to control tobacco use.(2) The objective of the present study was to understand the attitudes of Brazilian pulmonologists toward smoking control in terms of approach and treatment.

Between January and June of 2008, a questionnaire regarding attitudes toward smoking was sent, via the Internet, to all physicians who were members in good standing of the Brazilian Thoracic Association (BTA).

The questionnaire consisted of 11 questions regarding demographic data and physician attitudes toward smokers. Physicians who answered and returned the questionnaire participated in a drawing to win free transportation and accommodation for the XXXIV Brazilian Pulmonology Conference, which was held in the national capital of Brazil (Brasília) in November of the same year. The drawing was a means to encourage BTA member physicians to complete and return the questionnaire. By the deadline for returning the questionnaires via the Internet, we had received 587 valid questionnaires, which corresponded to 21% of the pulmonologists enrolled in the BTA. For the analysis of the data (but not for the drawing), we excluded the questionnaires of 15 pediatric pulmonologists, 8 thoracic surgeons and 3 general practitioners. The number of questionnaires received from each region of the country, as well as the answers to questions regarding attitudes toward smoking, can be seen in Table 1. When asked whether they considered smoking to be a medical condition, 3.2% of the respondents said no, and, although only 14.7% said that they treated smoking, 32.4% stated that they referred smokers to another professional for treatment. These data show that pulmonologists in Brazil do not recognize smoking as a medical condition. This is in contrast with their peers in other countries. For example, in Poland, 87.4% of pulmonologists always advise their patients to stop smoking cessation and 48% offer pharmacological or other types of support.(3) In contrast, 64% of the Chinese physicians who work in hospitals habitually advise smokers regarding smoking cessation; however, only 48% of these physicians inquire about smoking habits/history, which therefore indicates that further education regarding smoking cessation techniques is required.(4) It is noteworthy that, when asked about their reasons for not treating smokers, 10.6% of the participants in the present study reported that they did not know why; 9% said that they were not interested in treating smokers; 17% said that they did not have time to treat smokers; 43.5% said that the treatment is ineffective; and 48% believed that they needed further training. These answers were similar to those given by pulmonologists in the Netherlands, the majority of whom are pessimistic regarding to their ability to persuade smokers with COPD to quit smoking.(5) It is also noteworthy that the beliefs regarding the effectiveness of smoking cessation treatment influence the medical recommendations regarding the treatment, principally if these recommendations are evidence-based,(6) which avoids attitudes such as those observed among nonsmoking Turkish doctors, of whom only 29% believe in the effectiveness of pharmacological treatment.(7) A recent study, based on a survey of family doctors and general practitioners from 16 countries, reported that only 45% of those physicians always addressed the issue of smoking. This decreased to 34% when the nonsmoking physicians were excluded.(8)



Our survey revealed that, considering that the accepted best treatment consists of a combination of cognitive-behavioral therapy and either nicotine replacement therapy, pharmacological treatment (bupropion or varenicline) or both, only 35.3% of pulmonologists who provide smoking cessation treatment in Brazil do it correctly.

On the basis of our results, despite some contradictory answers, the number of our fellow pulmonologists who are not interested in treating smoking, who feel that they do not have time to treat smoking or who do not know how to treat smoking is a cause for concern.

Our concern stems from the fact that smoking causes or aggravates most of the diseases we treat, as pulmonologists, and that we therefore have an excellent opportunity to counsel smokers: when patients are emotionally vulnerable due to any given medical complication. It is known that patients who seek treatment in emergency rooms smoke more than does the general population, and that those who have been diagnosed with any given tobacco-related disease or who believe that their stay in the emergency room is related to smoking are more interested in quitting smoking. Therefore, visits to patients in the emergency room are excellent occasions to approach smokers,(9) especially because those who are advised, in the emergency room, to undergo smoking cessation treatment generally feel more satisfied with the treatment. Likewise, hospitalization provides a good opportunity to aid patients in quitting smoking, bearing in mind that advising hospitalized smokers is effective provided that we follow these patients to offer support for up to one month after discharge. Initiation of nicotine replacement therapy during the hospital stay increases the rates of cessation, especially among hospitalized smokers who present with withdrawal syndrome.(10) It is known that smoking cessation during the early stages of COPD slows the progression of the disease. It has been reported that there is an association between smoking cessation and advising patients to undergo smoking cessation treatment immediately after they have been diagnosed, through spirometry, with airway obstruction, which makes the time of diagnosis a special occasion to approach smokers.(11) Unfortunately, it seems that the problem of not approaching smokers is not exclusively our own. A recent study conducted in the United States investigated over 85,000 outpatient medical records created between 2001 and 2004. The authors reported that 32% of the records contained no information as to whether patients smoked or not, over 80% of the patients identified as smokers were not advised to quit smoking, and pharmacological treatment for smoking was prescribed for less than 2% of the smokers.(12)

In most countries with middle or high per capita incomes, health professional training programs include programs for training in nicotine dependence treatment. However, the greatest problem is the financing of such programs, especially in low per capita income countries.(13) It should be borne in mind that even physicians who are aware of the health risks of smoking and work in countries in which concrete efforts are made to control tobacco use commonly fail at taking responsibility for controlling tobacco use. Some physicians do not realize that their professional responsibilities are far greater than treating and controlling tobacco-related diseases: they also include preventing and treating smoking. If we consider the adage "doctors believe in doctors", we accept that doctors are, in general, receptive to the messages that come from other medical professionals, as well as to those that come from medical societies and leaders. Therefore, it is extremely important that medical associations keep their members well informed of the latest evidence regarding smoking cessation techniques and their effectiveness. Regardless of the point at which, during their training, physicians receive instruction regarding smoking, we can all benefit from the knowledge of how to help patients who wish to quit smoking,(14) since it is the duty of physicians to provide appropriate treatment for any medical problems that patients might have.



References



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11. Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J, Mieszko-Filipczyk G, et al. Smokers with airway obstruction are more likely to quit smoking. Thorax. 2006;61(10):869-73.

12. Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001-2004 national ambulatory medical care survey (NAMCS). Prev Med. 2006;43(6):472-6.

13. Rigotti NA, Bitton A, Richards AE, Reyen M, Wassum K, Raw M. An international survey of training programs for treating tobacco dependence. Addiction. 2009;104(2):288-96.

14. American Cancer Society Inc; UICC. Engaging doctors in tobacco control. Washington, D.C; American Cancer Society, Inc; 2003.



* Study carried out at the University Hospital of Brasília, University of Brasília, Brasília, Brazil.
Correspondence to: Carlos Alberto de Assis Viegas. SQN 305, Bloco L, apto. 309, CEP 70737-120, Brasília, DF, Brasil.
Tel 55 61 3201-4786. E-mail: viegasc@uol.com.br
Financial support: None.
Submitted: 22 October 2009. Accepted, after review: 24 November 2009.



About the authors

Carlos Alberto de Assis Viegas
Adjunct Professor. School of Medicine, University of Brasília, Brasília, Brasil.

Antonio Gabriel Teles Valentim
Medical Student. School of Medicine, University of Brasília, Brasília, Brasil.

Jaene Andrade Pacheco Amoras
Medical Student. School of Medicine, University of Brasília, Brasília, Brasil.

Euler Junior Moreira Nascimento
Medical Student. School of Medicine, University of Brasília, Brasília, Brasil.