Are physicians aware of their role in tobacco control? A conference-based survey in Portugal

The tobacco epidemic continues to expand globally and remains a leading cause of morbidity and premature death [1]. The World Health Organization (WHO) estimates that tobacco use and exposure to second-hand smoke (SHS) will cause over 8 million deaths in 2030 unless urgent action is taken [2]. Tobacco remains, however, the most readily preventable cause of death. In order to curb the pandemic, WHO recommends the implementation of comprehensive tobacco control (TC) policies, including price policies, and smoke-free policies (SFPs); bans on tobacco advertising, promotion and sponsorship; health education on the hazards of tobacco use and access to tobacco dependence treatment; regulation of tobacco products and other evidence-based interventions. These are based on the WHO Framework Convention on Tobacco Control (WHO-FCTC) [2]. Currently, all EU countries have ratified the WHO-FCTC. Despite this commitment, most European countries have failed to implement comprehensive policies due to tobacco industry interference in policy-making and inconsistent advocacy; underfunding and poor enforcement of TC policies [3–6].

In fact, TC progress remains deadly slow in several European countries such as Portugal [3, 6]. In January 2008, Portugal enacted a TC law [7]. A non-comprehensive and poorly-enforced smoke-free policy (SFP) was implemented disregarding FCTC guidelines. Many exemptions apply, particularly in hospitality venues, and frequent breaches have been reported [8, 9]. The role of healthcare professionals (HCPs) and its organizations has been highlighted by the WHO. Among HCPs, TC efforts should discourage tobacco use, disseminate TC training and promote smoke-free environments and other evidence-based strategies. Similarly, physicians should publicly lead TC advocacy and monitor policy impact over time [10, 11]. The roles of physicians as both exemplars and leaders are, moreover, crucial to the TC movement and to social norm change. Note too that TC progress has been greater in countries where few physicians smoke and their commitment to public health policy is strongest [10, 12]. Given this evidence, physicians’ TC awareness and training should be top priorities. Although this matter is a TC and a research relevant goal, knowledge gaps persist. This may be partially explained by the fact that surveying physicians is particularly challenging. In survey research, physicians have been appointed as a professional group from which it is difficult to obtain collaboration. Low response rates reduce sample size and can allow non-response bias and uncertainty regarding the survey findings [13, 14]. Several authors have consistently reported low response rates when surveying Portuguese physicians’ smoking behaviour and TC attitudes and practices [15–18]. The Portuguese tobacco law highlights the need to engage all HCPs, and particularly physicians, with TC activities, including training [7]. To date, little information is available concerning this requirement’s implementation. In 2009, a conference-survey was carried out to explore Portuguese physicians’ smoking behaviour trends and their engagement in tobacco control [19]. The purpose of the present study was to explore Portuguese physicians’ engagement in TC, by evaluating the following issues: 1) attendance at TC training and awareness of training needs; 2) participation in TC activities; 3) attitudes and beliefs regarding SFPs/SHS; and support for comprehensive SFPs. Additionally, the study aimed to identify factors associated with physicians’ participation in TC and their support for comprehensive SFPs.

This exploratory study suggests that few Portuguese physicians are engaged in tobacco control. While the overwhelming majority strongly agree that SHS endangers health, strong awareness of SFP public health benefits and the current TC law is limited; a significant minority believes that SHS can be eliminated by ventilation systems. Furthermore, most physicians lacked specific TC training and only a minority participated regularly in smoking prevention or cessation activities. General agreement with SFPs was high, but significantly lower for indoor leisure settings, outdoors bans and private smoking restrictions. Moreover, participants reported high smoking rates. Among smokers, smoking in the home or car was common. GPs were more involved in TC activities, including training, than hospitalists. Younger physicians reported UGT more often and being more aware of training needs than the older ones; they also reported participating more often in cessation activities. Among physicians, 2/3 recognize that they should receive training on TC, but less than 1/3 received undergraduate training and less than half reported graduate training. Training was the most consistent predictor of participation in TC activities, followed by being a GP. As underscored by other authors [16, 17, 25–31], these findings highlight the need for engaging medical and professional continuous education, as well as medical associations, with TC; and to disseminate TC training both in medical schools, and in primary care and hospital settings. Recently, Do and Bautista have surveyed TC attitudes among a world-wide large sample of medical students. They have observed that only 25% of students have received undergraduate training on TC [30]. On the other hand, two recent national surveys have observed that around half of the Portuguese GPs and a minority (4.9%) of hospitalists have received graduate training in TC; only a minority of physicians have received extensive GT or participate in cessation programmes [17, 18]. Whereas physicians receive special training to provide effective and safe health care to populations, there is a need for specific training on smoking cessation to guarantee systematic and effective cessation counselling and support [21, 25]. Similarly, specific TC training is crucial to engage physicians and other HCPs in advocacy and policy-making [10, 11, 28, 30]. It is also worth noting that training influenced few items in SFP support and SHS/SFP beliefs, suggesting that those concerned received inadequate training on TC policy. This finding also has been reported by several authors, both nationally and internationally [16, 17, 28, 30]. In fact, following the preparation of Portugal’s TC law, HCPs’ training and engagement in smoking cessation expanded to different healthcare settings. Nevertheless, training and awareness of TC policy and capacity building are seldom included in these programmes [32]. When comparing physicians’ overall support in public settings, acceptance was significantly higher where the ban is long-standing and has fewer exemptions; and also for role-model professional workplaces, i.e. healthcare and school settings. These findings are consistent with past research that has concluded that support is stronger where bans have been implemented for a longer time and where there are fewer exemptions [33, 34]; and that additionally, workplaces rules and beliefs influence support for SFP [35]. Furthermore, cross-country research has consistently shown that smoke-free bars and pubs are significantly less well accepted than smoke-free workplaces and restaurants [36]. This same trend was observed in this study; moreover, physicians reported slightly less support for smoke-free restaurants and bars than the general population [36]. Likewise, a recent wide cross-country survey has observed that European medical students were among those reporting less favourable attitudes regarding smoking bans in restaurants and bars [30]. It should be emphasized that since there is no safe level of SHS exposure, strong SFP support should apply for all settings. These findings clearly indicate that physicians are not particularly aware of public health science or more specifically of the fact that only comprehensive SFPs protect populations against SHS. Moreover, the great majority of physicians reported low compliance with the partial ban; suggesting that they should be more aware of the need for a comprehensive policy. Factors associated with stronger support for SFPs followed the same pattern as for general population. Being a non-smoker strongly predicted support for smoking restrictions in outdoors, leisure and private settings. These settings were, in turn, those with lower physicians’ support. As reported by other studies [16, 17, 28, 37, 38], these findings clearly indicate that smoking among physicians is still a major barrier to social norm change. On the other hand, reporting a smoke-free home was the most consistent factor associated with strong SFP support. In fact, regulation of smoking in the home is a strong predictor of self-enforcement and compliance with SFPs and social norm change, even among smokers [39, 40]. Furthermore, younger physicians did not consistently report stronger support for SFPs, which may suggest that they are not trained on TC policy and that the social norm did not change after the implementation of the partial ban. In sum, all these findings suggest that physicians’ attitudes to SFP are not influenced by evidence-based public health science. This, in turn, is in line with previous studies [16, 17, 28]. Physicians’ attitudes and behaviours do, however, clearly influence their clinical and public health practice [12, 20, 26, 27]. In Portugal, the great majority of physicians are not active in leading public health policy and TC advocacy. The Portuguese Medical Association is not engaged in tobacco control; an official policy on tobacco use and advocacy is lacking [41, 42]. Meanwhile, many HCPs and physicians continue to smoke [15, 16, 19, 32]. When physicians are noticed smoking in public, this reinforces smoking visibility and social acceptance, undermining social norm change [16, 19, 29]. In addition, smoking physicians are less likely to provide cessation support or to actively advocate for tobacco control policies [30]. By contrast, when smoking physicians and HCPs are enrolled in a cessation programme, this promotes their advice on tobacco cessation [43]. Similarly, physicians’ training in TC is associated to willingness to quit [19]. Thus to promote tobacco control, especially in countries where tobacco use is prevalent among HCPs, it is crucial to implement cessation programmes targeting medical/health sciences students, physicians and other healthcare workers, both in medical/health sciences schools and healthcare settings [16, 19, 28–31, 44]. These programmes should be funded and evidence-based; they should be linked to comprehensive TC training focusing on tobacco health hazards, the role of physicians/HCPs in TC, policy and capacity building and not only tobacco cessation skills. An effective health promotion/TC national strategy should prioritise comprehensive, integrated and adequately-funded TC programmes led by TC experts and actively engaging medical/health sciences schools, medical associations and HCPs networks/societies, hospital managers and healthcare systems [10, 16, 19, 28–31, 44–47]. These programmes have a key role to play, and should contemplate the following:

The findings suggest that Portuguese physicians are not aware of their role in tobacco control. Furthermore, physicians’ smoking prevalence is high. This highlights the need for engaging medical schools and medical professional organisations with tobacco control and physicians’ smoking prevention. Poor engagement of physicians in tobacco control may contribute to the current lack of comprehensive policies in Portugal and Europe, and undermine social norm change. Medical associations/organisations should acknowledge their leadership role and assume a core responsibility in promoting smoke-free environments and tobacco control best practices. To achieve this, medical and continuing education on tobacco control should be made top priorities. Training should be adequately-funded, led by TC experts and include tobacco health hazards, emphasis on the role of physicians in TC, capacity building, benefits of tobacco cessation and cessation skills.