Knowledge, Attitude and Practices of Physicians Regarding Smoking in Makkah Region

Health professionals are in a unique position where they can participate in tobacco control activities by acting as a role model, while advising and counseling smokers. Saudi Arabia has a large and effective health care setup, with a total of 31,502 physicians; in 2070 health facilities (physician/population ratio of 17.1/1,000).[1] If appropriately utilized, this large pool of health manpower can be an active force for the control of smoking in the Kingdom. However, very little is known about the current knowledge, attitude and smoking behavior of physicians in Saudi Arabia. The objectives of this study were to assess the knowledge, attitude and practices of physicians in Makkah region regarding smoking and its ill effects on health, to quantify the relationship between knowledge and practice, and to provide a quantifiable basis for strengthening of different components of Tobacco Control Program.

This was a cross sectional survey, covering the Makkah Governorate / administrative region, which includes 3 health regions; Makkah, Jeddah and Taif. The study population included all physicians working in this region, whether in Government or Private sectors. A stratified random cluster sampling technique was used to identify subjects (physicians) to be recruited into the study. A structured self-administered data collection instrument was designed. It included information about demographic variables such as gender, date of birth, nationality and place of work; current and past tobacco use; knowledge of effect of active and passive smoking on health; knowledge and attitude about role of physicians in control of smoking; and current practices regarding control of smoking. A pretest was conducted to test the logistics of the methodology and the quality of the questionnaire, then necessary adjustments were made. Data was entered using Epi-Info then analyzed using SPSS. To take care of bias created by varying response rates from different strata of health facilities, a weight variable was created based on the original sampling proportion of each strata and its proportion among the received questionnaires. Throughout the analysis the weighted statistic are presented based on this weight variable.

A total of 1290 physicians participated in the study; 93.6% medical and 6.4°/0 dental. Among the respondents 27.7% were General Physicians, 68.1% Specialists, 3.4% Consultants, and 0.8% did not specify. 28.6% were from Makkah Health Region, 42.8% from Jeddah and 28.6% from Taif. 46.6% were working in MOH Hospitals, 8.0% in MOH Primary Health Care Centers, 7.7% in non-MOH government Hospitals, 23.6% in Private Hospitals and 14.1% in Private Health Centers. There were 79.5% males and 20.5% females. Their average age was 42.5 years (SD ±8.1).

The majority of the physicians were from Egypt (39.9%), Saudi Arabia (14.3%), India (12.7%), Pakistan (9.3%), Sudan (7.6%), Syria (6.5%), Bangladesh (1.7%), and 3.9% were from other Arab countries. 2.7% were from developed countries, 0.9% from the Far East, and 0.7% from other African countries.

Out of 1256 physicians who responded to the question on cigarette smoking practices, 74.4% claimed they had never smoked, 10.8% had quit smoking, 7.9% smoked occasionally and 7.0% smoked regularly. The prevalence of "current cigarette smoking" was 14.9% and "ever cigarette smoker" was 25.6%. Current smoking was significantly lower in females (4.7%) than males (17.5%), (P<0.001). There was practically no difference between dental surgeons (14.1%) and medical doctors (14.9%) in current cigarette smoking practices, and no difference between those working in Rural (17.0%) or Urban (14.4%) health facilities (P=0.380).

Bangladeshi physicians had the highest prevalence of current cigarette smokers (21.7%), followed by 21.4% among Syrians, 18.6% among Other Arabs, 17.1% among Saudis, 16.2% among Egyptians, 11.1% among Sudanese, 9.6% among Pakistanis, and 6.5% among developed countries. There were no smokers among the small group from other African and Far Eastern nations.

Among physicians who were current smokers at the time of the study, the mean age of starting smoking was 23.2 years (SD ±5.8), 1.4% had started smoking at 10 years of age and 15.9% were smoking by age 18.

A wide range in the number of cigarettes smoked per day was reported (1-60), but the average number was 10.6 (SD t9.67). Twenty-three different brands of cigarettes were being smoked. 79.4% of the current smokers had attempted to stop smoking sometime during their life, but then restarted. When asked about their current intentions to quit smoking, 40.4% of 152 respondents stated they were ready to quit immediately, 30.4% were thinking to quit within the next 6 months, and 29.2% had no intention of quitting in the next 6 months.

Among physicians who had quit smoking, 67.3% had been regular smokers and 32.7% occasional smokers. The mean age for starting smoking in this group was 22.3 years (SD ±4.3) and mean age of quitting was 35.6 years (SD ±7.4), with an average smoking duration of 13.3 years (SD ±7.8).

A smaller number of physicians reported using tobacco products other than cigarettes, either daily or occasionally, such as Shisha (6.2%), cigar (5.4%), and pipe (1.7%). 0.9% reported eating tobacco with betel quid, 0.7% chewed it alone, 0.5% smoked Bidi, 0.4% used oral snuff and 0.1% used nasal snuff. Shisha smoking was restricted to Arabs (94.4%) and a few Indian subcontinent doctors (5.6%). Among shisha smokers 37.8% were Egyptians, 36.4% were Saudis, 9.6% were Syrians, 6.7% were other Arabs and 3.9% were Sudanese.

Overall tobacco use in any form was 23.0%, and overall tobacco smoking was 22.4%. There was a strong correlation between current cigarette smoking and other tobacco use. Among cigarette smokers 36.9% reported smoking shisha, compared to 8.0% among non-cigarette smokers, and this difference was statistically significant (P<0.001). Similar significant relationships were observed between cigarette smoking and other tobacco use including Cigar (P<0.001), Pipe (P<0.001), Bidi (P<0.001) and oral snuff (P=0.006).

The physicians' responses varied on different aspects of knowledge and attitude towards smoking, as demonstrated in Table 1.

To assess the overall knowledge of each physician and study its relationship with the practices, it was considered appropriate to develop a composite score based on the 22 questions and use it for further analysis. As all the statements asked were positive in nature, each 'strongly agree' response was scored as 5, `agree' as 4, 'unsure' as 3, 'disagree' as 2 and 'strongly disagree' as 1. Non-response to any of the questions excluded the physician from scoring, thus restricting the data set to 1071 individuals who responded to all the 22 questions. In this manner, the possible score range was 22 to 110. The mean score was 98.29 (SD 8.66) and a median of 99, with a statistically non-significant negative skewness of -0.872. In the absence of any standard criteria of scoring for such knowledge and attitude questions for the given environment, median score of 99 was used as a cut off line to split the physicians into two categories according to knowledge-attitude (K-A): high knowledge group (score 99-110), which included 526 (49.1%) physicians; and a low knowledge group (score 55-98), which included 545 (50.9%). It was observed that there was a gradual, nonsignificant, decrease in the K-A score of older compared to younger physicians (P=0.82). There was no difference in K-A scores among males and females with 49.2% of males and 48.6% of females in the high score group (P=0.99). Physicians in hospitals had a higher proportion of high knowledge compared to those in PHCCs (P=0.866). The proportion of high score group was highest among physicians from far eastern countries (62.7%), followed by Indians (52.8%), Saudis (51.1%), Egyptians (48.8%) and Pakistanis (48.3%). Physicians who had a high K-A score were more likely to be current smokers (21.8%) compared to those with low score (9.7%) (P<0.001).

It was found that 46.2% worked in places without a smoke-free policy, 7.3% had smoking rooms available, and 46.5% worked in facilities where smoking was not allowed. Among those who responded that smoking was not allowed at their work place or smoking rooms were available, 37.0% responded that the policy was enforced at all times, 35.2% responded that it was enforced sometimes, while others responded as not enforced or did not know. 12.9% of physicians working in placer, with no smoke-free policy were current cigarette smokers, compared to 15.0% of those working in places where smoking was not allowed am 35.0% of those who had smoking rooms at their workplace (P<0.00 1).

Among the total respondents only 3.0% had received any formal training in smoking cessation approaches. Trained people were homogenously distributed across different health sectors, genders and nationalities.

Active cigarette smoking and involuntary exposure to tobacco are major preventable causes of morbidity and mortality.[2] Health care providers have a great potential to reach a majority of smokers because of their high contact rate with the general public. Although such data is not available for Saudi Arabia, in developed countries it has been estimated that 70-80% of smokers visit their family doctor at least once a year.[3] Multiple studies conducted in the UK, Australia and USA have shown that the advice of general physicians significantly decreased the prevalence of smoking among their patients.[4,5]

In a study conducted in the early 1990's in Riyadh, it was found that among 689 physicians, 48% were ever smokers and 34% were smoking at the time of the study, with male smokers (38%) significantly higher than females (16%). More than 60% agreed that smoking is a major contributing factor in the causation of coronary artery disease, lung cancer and chronic bronchitis; less than 20% said the same for bladder cancer and neonatal death. Setting a good example for children was the most important reason stated for not smoking.[6]

In this study, it is encouraging to note that 11% had quit smoking, 79% of current smokers had tried to quit, and 40% were willing to try to quit in the next 6 months. These indicate existing motivation among physicians but also highlight their need of external support. However, there were certain lacunae in their knowledge and attitudes of the effects of smoking and the role of health professionals in prevention, which need to be addressed in basic medical training, smoking cessation training programs and general health education programs.

It was also interesting to note that smokers in general had higher knowledge than non-smokers, which may suggest that smokers may be more motivated in gaining knowledge on the hazards of smoking. In about half the facilities there was no explicit smoke-free policy which exhibits a weakness in implementation of governmental regulations, which clearly prohibit smoking in health centers.

It was recommended to hold extensive Anti-smoking and health education training programs for physicians, targeting more physicians of Arab nationalities, explicitly warning them about shisha and cigars in addition to cigarettes. The smoke-free policy should be enforced in all health care facilities, big or small, governmental or private.