Smoking-Cessation Advice from Health-Care Providers --- Canada, 2005

Tobacco use is the most preventable cause of premature death and disease in Canada. In 2002, an estimated 37,209 Canadians died from illnesses related to tobacco use, accounting for 16.6% of all deaths in Canada (1). One of the objectives of the Canadian Federal Tobacco Control Strategy (FTCS) 2001--2011 is to reduce smoking prevalence in Canada from 25% to 20%. Although evidence indicates that an effective and efficient way of providing smoking-cessation information to smokers is through contact with health-care providers (2,3), little data in Canada exist regarding smoking-cessation advice from this group. In 2005, the Canadian Tobacco Use Monitoring Survey (CTUMS) included questions to assess self-reported provision of cessation advice by health-care providers. This report summarizes the results of that survey, which indicate that only half of persons who visited health-care providers in the preceding 12 months received smoking-cessation advice, suggesting that health-care providers need to take greater advantage of opportunities to provide such advice to smokers.

CTUMS was developed to provide Canada's federal health department (Health Canada) and its partners with timely, reliable data on tobacco use and related topics. The 2005 CTUMS collected data from approximately 20,800 respondents during February--December 2005. The target population was residents of all provinces of Canada aged >15 years; residents of the three territories (Yukon, Northwest Territories, and Nunavut) were excluded because of poor telephone coverage, as were institutionalized persons. The sample design was a two-phase stratified random sample of telephone numbers. In the first phase, households were selected using a random-digit--dialing method. In the second phase, one or two persons (or none) from the household were selected according to household composition. Data were collected using computer-assisted telephone interviewing, which ensured that only valid responses were entered and that all the correct procedures were followed. Data were weighted to provide national estimates.

CTUMS respondents who identified themselves as current smokers* were asked about their visits to various types of health-care providers, including physicians, dentists or dental hygienists, and pharmacists, in the 12 months before the survey.^† For each health-care provider visited in the preceding 12 months, respondents were asked whether they were advised by the provider to reduce or quit smoking.^§ Those who said they had received advice were then asked whether they received any information on smoking-cessation aids such as nicotine patches, a product such as Zyban^®, or counseling programs.^¶

According to the 2005 CTUMS, approximately 5 million residents in Canada (weighted data), representing 19% of the population aged >15 years, were current smokers, of whom 88% reported visiting one or more of the specified health-care providers (physician, dentist or dental hygienist, and pharmacist) in the 12 months before the survey (Table 1). A greater proportion of female smokers (94%) visited a health-care provider in the preceding 12 months than male smokers (83%). Among female smokers, the highest rate of visiting a health-care provider was among respondents aged 25--34 years (97%), and the lowest was among those aged 15--19 years (91%). In contrast, among male smokers, the highest rate of visiting a health-care provider was among respondents aged 15--19 years (87%), and the lowest was among those aged 25--34 years (79%). Among the current smokers who reported visiting a health-care provider in the preceding 12 months, 54% said that they were advised to reduce or quit smoking. Rates of advice to reduce or quit smoking were lowest among smokers aged 15--19 years (36%) and increased by age group (Table 1).

Regarding types of health-care providers, 73% of current smokers reported visiting a physician in the preceding 12 months, whereas a smaller proportion reported visiting a dentist or dental hygienist (60%) or a pharmacist (38%) (Table 2). A greater portion of female smokers visited a physician (85%), dentist or dental hygienist (64%), or a pharmacist (44%) compared with male smokers (65%, 57%, and 33%, respectively). The highest rate of visiting a physician was among respondents aged >45 years (81%), visiting a dentist or dental hygienist was highest among those aged 15--19 years (71%), and visiting a pharmacist was highest among those aged >45 years (42%) (Table 2).

Among the current smokers who reported visiting a physician in the preceding 12 months, approximately half (51%) said that they were advised to reduce or quit smoking. Rates of advice to reduce or quit smoking by a physician were lowest among the youngest smokers (i.e., aged 15--19 years) (38%) and increased by age group (Table 2). The prevalence of being advised to reduce or quit smoking by a physician among young adult (aged 20--24 years) males and females was significantly different: 33% among males and 50% among females. Approximately 36% of respondents were advised to reduce or quit smoking by dentists or dental hygienists, whereas 16% of respondents received this advice from pharmacists. Overall, respondents reported a greater prevalence of pharmacists providing information on smoking-cessation aids (84%) compared with the other two categories of health-care providers (physician, 57%, and dentist or dental hygienist, 31%).

Reported by: J Stevenson, MA, J Snider, MSc, MJ Kaiserman, PhD, Tobacco Control Programme, Health Canada.

Editorial Note:

Although 88% of current smokers in Canada reported visiting a health-care provider in the preceding 12 months, only half of these smokers reported being advised to reduce or quit smoking. Health-care providers are in a unique position to offer smoking-cessation advice and provide information on smoking-cessation aids to their patients; however, the results of this analysis indicate that many of these opportunities are being missed.

In 2001, several Canadian health associations, including the Canadian Medical Association, Canadian Dental Association, and Canadian Pharmacists Association, prepared a joint statement outlining the role of the health-care provider in smoking cessation (4). The statement focused on smoking cessation as part of a comprehensive strategy, specifically on the role of health-care providers in helping Canadians to stop smoking. The strategy highlighted the need for a collaborative, multidisciplinary approach to smoking cessation, requiring members to be prepared to discuss counseling, pharmacotherapy, ongoing support mechanisms, and relapse-prevention strategies with patients.

Although the need for smoking-cessation counseling has been recognized, barriers exist among health-care providers, including a need for additional training regarding smoking-cessation counseling, lack of time, low priority for tobacco-related matters, and a perceived lack of interest in quitting among patients (5,6). Certain clinicians simply might not know how to identify smokers quickly or know which treatments are effective and how these treatments can be provided (7). Health-care--provider associations need to develop innovative approaches to support and motivate health-care providers to counsel patients who smoke (8).

The medical, dental, and pharmacist associations in Canada endorse the need to educate members regarding their role in smoking cessation, provide members with current training and tools that will motivate and assist them in their roles as counselors and referral agents, and increase public awareness that health-care providers can offer support and resources to help persons stop smoking (4). Continuing education programs have been shown to substantially change the way health-care providers counsel smokers, resulting in higher quit rates (3). In addition, evidence-based studies have documented that health-care--provider advice alone can increase smoking-cessation rates from approximately 5% to 10%, and following up with patients who are trying to quit can double smoking-cessation rates (2,3,9). Even brief interventions by health-care providers can help adult smokers to quit (10). In addition, use of smoking-cessation drugs has been documented to increase the cessation rate for many patients (2).

Despite missed opportunities in smoking-cessation consultation among health-care providers, progress has been made in decreasing smoking prevalence overall in Canada. In 2001, the Canadian government established FTCS, with the goal of reducing the prevalence of smokers to 20% by 2011. CTUMS demonstrated a reduction in smoking prevalence during 2001--2006 from 25% to 20% and achievement of the original 2011 goal. FTCS was recently renewed, and new targets for 2007--2011 include further reducing smoking rates from 19% to 12%.

The findings in this report are subject to at least five limitations. First, CTUMS does not sample households without landline telephones. Second, the survey methodology did not determine the frequency, timing, and nature of respondent visits to health-care providers or health-care--provider advice to reduce or quit smoking or offers of information on smoking-cessation aids. The variation in results by age might be explained, in part, by the number of visits to health-care providers by respondents during the preceding 12 months because the frequency of visits increases with age. In addition, the survey did not determine whether the respondents told their health-care providers that they smoked, which would affect the prevalence of providers offering advice. For example, pharmacists might have been less likely to ask patients whether they were smokers and might therefore have had a lower prevalence of giving cessation advice. Likewise, the type of encounter (e.g., emergency treatment versus routine or preventive care) would affect the likelihood that a provider would ask about smoking status and offer advice about smoking. The higher prevalence of advice to quit or reduce smoking among females aged 20--24 years compared with males of the same age might be a result of the nature of the visit, which was not assessed; for example, more females might have been advised to reduce or quit as they entered their childbearing and rearing years because of 1) the health effects of smoking during pregnancy and on children and 2) the contraindications of certain forms of birth control (i.e., pills or patches). Third, information on visits with health-care providers is self-reported and might be influenced by social-desirability bias or recall bias. Fourth, although CTUMS describes the association between smoking behaviors and selected variables, conclusions regarding causation cannot be drawn from CTUMS cross-sectional data. Finally, the presented estimates of health-care--provider provision of smoking cessation advice to reduce or quit smoking and the provision of information on cessation aids might be an underestimate because the survey questions were only asked of current smokers. No information was collected from persons who had recently quit smoking but who might also have visited health-care providers and received cessation advice and information on cessation aids.

A smoker's chance of quitting increases after receiving smoking-cessation information and support from various health-care providers in different disciplines (2,10). Although certain health-care providers have included smoking-cessation activities in their practices, the results indicate that either many health professionals are missing this opportunity to provide smoking-cessation advice or that smokers are not seeking this advice from their health-care providers. Practice guidelines to identify smokers and encourage cessation could help increase the number of smokers who receive smoking-cessation counseling from their health-care providers.

References

1. Canadian Centre on Substance Abuse. The costs of substance abuse in Canada 2002: highlights. Ottawa, Ontario: Canadian Centre on Substance Abuse; 2006.
2. Prochazka A. New developments in smoking cessation. Chest 2000;117:169--75.
3. Cummings SR, Coates TJ, Richard RJ, et al. Training physicians in counselling about smoking cessation. A randomized trial of the "Quit for Life" program. Ann Intern Med 1989;110:640--7.
4. Canadian Pharmacists Association. Joint statement on smoking cessation. Tobacco---the role of health professionals in smoking cessation. Ottawa, Ontario: Canadian Pharmacists Association; 2001. Available at http://www.pharmacists.ca/content/about_cpha/who_we_are/policy_position/pdf/smoking_cessation_joint_stat.pdf.
5. Campbell HS, Macdonald JM. Tobacco counselling among Alberta dentists. J Can Dent Assoc 1994;60:218--26.
6. Goldberg R, Ockene I, Ockene J. Physicians' attitudes and reported practices toward smoking intervention. J Cancer Educ 1993;8:133--9.
7. Orleans CT. Treating nicotine dependence in medical settings: a stepped-care model. In: Orleans CT, Slade J, eds. Nicotine addiction: principles and management. New York, NY: Oxford University Press; 1993.
8. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Prev Med 1998;27(5 Pt 1):720--9.
9. Strecher VJ, O'Malley MS, Villagra VG, et al. Can residents be trained to counsel patients about quitting smoking? J Gen Intern Med 1991;6:9--17.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000.

* Determined by response to the question: "At the present time, do you smoke every day, occasionally, or not at all?" Respondents who answered "every day" or "occasionally" were classified as current smokers.

^† "In the past 12 months, did you see a doctor?" "In the past 12 months, did you see a dentist or dental hygienist?" "In the past 12 months, did you talk with a pharmacist?"

^§ "Did the doctor advise you to reduce or quit smoking?" "Did the dentist or dental hygienist advise you to reduce or quit smoking?" "Did the pharmacist advise you to reduce or quit smoking?"

^¶ "Did the doctor provide you with information on quit-smoking aids such as the patch, a product like Zyban, or counseling programs?" "Did the dentist or dental hygienist provide you with information on quit-smoking aids such as the patch, a product like Zyban, or counseling programs?" "Did the pharmacist provide you with information on quit smoking aids such as the patch, a product like Zyban, or counseling programs?"

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Date last reviewed: 7/18/2007