Knowledge, attitude, and behaviors of health professionals towards smoking cessation in primary healthcare settings

Knowledge, attitude, and behaviors of health professionals towards smoking cessation in primary... Abstract This study aimed to assess the behaviors of multiple health professionals in primary healthcare settings in Jordan towards smoking cessation counseling and to determine the barriers to effective smoking cessation behaviors. A survey of 456 health professionals in primary healthcare settings was conducted. A self-administrated questionnaire was used to collect the data. About half of health professionals reported that they usually ask patients about smoking status and advise them to stop smoking (51.4% and 50.5%, respectively). Only 23.7% reported assessing the willingness of the patients to quit smoking and 17.9% reported discussing counseling options with smokers. Considerably fewer percentages of health professionals reported preparing their patients for withdrawal symptoms (6.0%), discussing pharmacotherapies (3.8%), and prescribing nicotine patches (6.4%). Key barriers to smoking cessation counseling, as reported by health professionals, included: insufficient resources and organizational support, limited coverage of cessation interventions, and lack of motivation to quit. Smoking cessation counseling was not routinely implemented by Jordanian health professionals. Barriers to effective delivery of smoking cessation counseling need to be integrated within relevant strategies aiming at enhancing the frequency and quality of health professionals’ engagement in smoking cessation. Implications Practice: Health professionals in primary healthcare settings should participate in smoking cessation counseling activities. Policy: Policymakers should develop strategies to enhance the health professionals’ engagement in smoking cessation and to address barriers to the delivery of smoking cessation counseling. Research: Future research should be aimed at identifying proper interventions to overcome the barriers to the delivery of smoking cessation counseling. INTRODUCTION Tobacco use is currently widespread in most populations in industrialized and developing countries and has been associated with morbidity and mortality [1]. According to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2015 [2], the age-standardized prevalence of daily smoking was 25.0% for men and 5.4% for women. In 2015, about 11.5% of global deaths were attributed to smoking. Although the majority of smokers express a desire to quit smoking, overcoming the addiction is difficult and may require both pharmacologic and behavioral treatments. Smoking cessation counseling by various health professionals has been shown to be cost-effective in increasing quit rate [3–6]. However, there is a significant gap between available guidelines and their implementation by healthcare professionals [7, 8]. Several interventions including behavioral [9], counseling, self-help materials, and prescribing nicotine replacement have been shown effective in enhancing smoking cessation [10]. Screening for tobacco smoking and relevant cessation interventions are very essential preventive services and need to be implemented in various levels of the healthcare system [11]. Previous studies reported a number of barriers to smoking cessation counseling including time constraints, lack of motivation to quit, lack of health professionals’ training on counseling, competing demands and lack of familiarity with effective treatment [7, 12–14]. In Jordan, 15%–30% of school children and 50% of adults are smokers [15]. The impact of smoking-related diseases in Jordan is evident as more than 50% of all Jordanian deaths were attributed to chronic noncommunicable diseases [16]. About 92% of primary healthcare professionals in Jordan believed that they should advise patients to quit smoking, 15.3% felt that they are well prepared for smoking cessation counseling, and 92.8% believed that they need training on smoking cessation counseling [17]. In Jordan, there is insufficient data about barriers and facilitators of smoking cessation counseling behaviors by health professionals. Identifying such factors is essential in order to develop strategies for effective counseling. The current study aimed to assess knowledge, attitudes, and behaviors of various health professionals in primary healthcare settings regarding smoking cessation counseling in Jordan and to determine the barriers to effective smoking cessation behaviors. METHODS The study population consisted of selected health professionals (family physicians, internists, dentists, and nurses) at university teaching centers and the Ministry of Health comprehensive health centers in Jordan. All health centers in Jordan, whether teaching health center or comprehensive health center, were approached by a trained research assistant who invited all available health professionals at the time of visit to participate in the study. Of those who were invited, 124 family physicians, 103 internist, 72 dentists, and 157 nurses agreed to participate in the study and filled a self-administrated questionnaire. The overall response rate was 95%. The questionnaire was structured into sections. The first section sought information about personal and professional characteristics of participants including gender, age, number of years in practice, number of patients seen per month, and place of work. The second section listed the smoking counseling behaviors, for which all participants were asked about whether they perform that behavior or not. These behaviors included screening patient smoking status, providing assistance to help patients stop smoking, discussing quitting options with smokers, preparing smokers for possible withdrawal symptoms, and discussing different pharmacotherapies with smokers. The third section of the questionnaire was structured to identify the availability of resources, guidelines, posters or pamphlets, and web-based smoking cessation programs. In the fourth section, all participants were asked about the barriers to effective smoking cessation counseling. A list of possible barriers was developed based on the review of previous literature. The list of possible barriers included lack of available cessation programs, lack of training on smoking cessation counseling, insufficient services, resources and organizational support, limited coverage of cessation interventions, lack of patient’s motivation, lack of effective educational materials, limited efficacy of available interventions, uncertainty about what preventive services to provide, limited experience in intervening with smokers, and limited time spent with patients. Moreover, participants were asked about how they perceive their skills in changing smokers’ behavior and about the use of educational resources to change smoking behavior. Data were analyzed using Statistical Package for Social Sciences (SPSS, Inc., Chicago, ΙΙΙ, Version 15). Frequency and percentages were used to describe data. Chi-square test was used to compare percentages among different health professionals groups. A p value of less than .05 was considered statistically significant. RESULTS Participant characteristics The current study included 124 family physicians, 103 internists, 72 dentists, and 157 nurses. Their age ranged between 20 and 62 years old with a mean (SD) of 34.1 (9.1) years. Of all participants, 30.2% reported working in teaching health centers and the rest in Ministry of Health centers. Less than one-third of health professionals (28.9%) were smokers. Overall, 18.4% had received training on smoking cessation counseling. The demographic and relevant characteristics of health professionals are shown in Table 1. About 30.5% of health professionals reported the availability of guidelines and protocols regarding smoking cessation and 48.6% reported the availability of posters or pamphlets regarding smoking cessation. Only 24.5% of health professionals reported that they were familiar with assessing nicotine dependency. Table 1 | The demographic, practice, and relevant characteristics of health professionals practicing in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)  View Large Table 1 | The demographic, practice, and relevant characteristics of health professionals practicing in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)  View Large Smoking counseling practices About half of health professionals reported that they usually ask patients about smoking status and advise them to stop smoking (51.4% and 50.5%, respectively). However, they did not regularly provide extensive assistance to help their patients to quit smoking (Table 2). Only 23.7% reported assessing the willingness of the patients to quit smoking and 17.9% reported discussing counseling options with smokers. Considerably fewer percentages of health professionals reported preparing their patients for withdrawal symptoms (6.0%), discussing pharmacotherapies (3.8%), prescribing nicotine patches (6.4%), and providing patients with self-help materials (5.6%). Other smoking cessation activities reported by few health professionals included monitoring progress in attempting to quit, arranging follow-up visits with patients to address smoking, and referring smokers to other appropriate cessation treatments. Table 2 | Smoking cessation activities reported by health professionals working in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439  View Large Table 2 | Smoking cessation activities reported by health professionals working in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439  View Large Participating health professionals differed significantly in reporting some smoking cessation activities such as asking about smoking status, advising patients to quit, assessing patient’s willingness to quit, discussing counseling options, and preparing patients for withdrawal symptoms. Nurses reported the least smoking cessation activities whereas family physicians reported the highest compared to other health professionals. About 55.0% of health professionals reported they are somewhat effective and 4.4% reported they are very effective in changing their patients’ behaviors with respect to smoking cessation. Dentists were less likely than other health professionals to report being effective in changing their patients’ behaviors related to smoking cessation (Table 3). About half of health professionals (51.9%) indicated that the educational resources for educating patients are sometimes effective in changing the behaviors. Only 6.5% reported that they are very effective. Table 3 | The perceived effectiveness in changing smoking behavior and the use of educational resources to change smoking behavior   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)      Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)    View Large Table 3 | The perceived effectiveness in changing smoking behavior and the use of educational resources to change smoking behavior   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)      Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)    View Large Barriers to effective smoking cessation behaviors The most important barriers to smoking cessation counseling reported by health professional groups are shown in Table 4. Insufficient services and organizational support, limited coverage of cessation interventions, and lack of motivation to quit were reported by high percentage of health professionals. Table 4 | Perceived barriers to effective smoking cessation counseling practices as reported by health professionals in Ministry of Health and teaching health centers Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  View Large Table 4 | Perceived barriers to effective smoking cessation counseling practices as reported by health professionals in Ministry of Health and teaching health centers Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  View Large DISCUSSION This study showed that half of health professionals reported asking patients about smoking status and advising smokers to quit. However, fewer number of health professionals reported that they participated in other activities such as assessing patient’s willingness to quit, discussing counseling options, preparing the patient for withdrawal symptoms and discussing pharmacotherapies. This finding is similar to that reported in a Canadian survey where about half of health professionals surveyed reported asking about smoking status and advising patients to quit smoking. In the Canadian survey, less than one-third of health professionals stated they assess patient’s willingness to quit and assist them to quit [18]. In the USA, a national survey [14] showed that the majority of health professionals reported asking about smoking status and advising smokers to quit, with much less reported assessing, assisting and arranging follow-up. In Europe, a multicenter study in 12 European countries, only one-third (36%) of health professionals reported always advising smokers to quit [19]. In Belgium [20], Ireland [21], and England [22], the rates of asking patients about their smoking status by general practitioners were 28%, 47%, and 63%, respectively. The 5As approach (five components of effective tobacco cessation counseling: ask, assess, advise, assist, and arrange follow-up) provides health professionals with a framework for structuring smoking cessation by identifying all smokers and offering support to help them quit. In the current study, physicians reported performing multiple components of the 5A’s including interventions more than dentists and nurses, a finding that is similar to previous studies in which doctors assisted more patients than nurses or dentists [18, 23, 24]. Training in smoking cessation is still inadequate in spite of its cost effectiveness. Previous studies suggested that smoking cessation training is strongly associated with a higher level of confidence, less perceived barriers, and more interventions [7, 23]. In the current study, only 18.4% of the health professionals surveyed received smoking cessation training. In the USA, less than one-third of health professionals received smoking cessation training [14] and only a quarter of primary care providers received training [23]. In the UK, the vast majority of new medical graduates receive little or no cessation training [24]. Similarly, a Canadian study showed that one quarter to one-third of general practitioners and pharmacists received smoking cessation training and less than 2% in the other groups [18]. In another study in 10 countries, 5.2%–36.6% of third year medical students received smoking cessation training. In Sweden, Norway, Iceland and Finland, the proportion of general practitioners who received training in smoking cessation were 60%, 55%, 48%, and 28%, respectively [25]. The three most important perceived barriers towards smoking cessation in our survey were lack or few available cessation programs (84%), limited training on smoking cessation (79%) and lack of patients motivation to quit (77.5%). Such barriers had been reported in many previous studies [7, 12–14, 18, 25, 26]. In two U.S. surveys, limited cessation training and low motivation of patients were the most perceived barriers against provision of smoking cessation interventions by health professionals [14]. Time constraints, high workload and lack of training were the most perceived barriers in France [12]. In Germany, lack of time and patient insufficient motivation to change were the two major barriers [7, 25]. In a Canadian survey, that the health professionals have three major barriers were identified including the low perceptions of smoking counseling as part of health professionals’ role, perceived self efficacy and knowledge of community cessation services [18]. In Europe, general practitioners’ own smoking status, attitudes towards giving smoking cessation advice, time constraints, lack of training, and lack of knowledge and skills were perceived as barriers against provision of smoking cessation intervention [13]. Implementing evidence-based strategies to encourage involvement of health professionals in tobacco use prevention and cessation counseling and to assess the efficacy of handling perceived barriers to address smoking cessation are warranted to overcome tobacco-induced diseases and death. Assisting patients to quit smoking is considered to be one of the most cost-effective measures in clinical practice and should be a standard of care for all health professionals. Each of the healthcare providers can have a critical role in smoking cessation counseling. There is a strong evidence that quitting rates can be substantially increased by even simple advice provided by health professionals [24]. In the present study, about one-third (28.9%) of health professionals surveyed were current smokers, a percentage which is high compared to less than 6% of U.S. health professionals [14] who were smokers. The prevalence rates of tobacco use among healthcare providers were 15.1% in Saudi Arabia [12], 16.4% in Oman [27], and 8.2% among Dutch general practitioners [28]. Studies found that general practitioners who smoke were less engaged in cessation advice [29]. In conclusion, smoking cessation counseling was not routinely implemented by Jordanian health professionals. Strategies to enhance the frequency and quality of health professionals’ engagement in smoking cessation need to address barriers to the delivery of smoking cessation counseling. Acknowledgments: The authors would like to acknowledge the Training Programs in Epidemiology & Public ealth Interventions Network (TEPHINET) and Jordan Field Epidemiology Training Program for their technical support. Funding: The study had not received any fund. Compliance with Ethical Standards Ethics: Authors confirm that subjects have given their informed consent and that the study protocol has been approved by the Jordan University of Science Technology Institutional Review Board. Statement on the Welfare of Animals: This article does not contain any studies with animals performed by any of the authors. The author wishes to confirm that neither the manuscript nor any part of it has been published or is being considered for publication elsewhere. All authors confirm that the manuscript is not under simultaneous consideration with another journal. The data from this manuscript had not been previously reported. The authors have full control of all primary data and agree to allow the journal to review the data if requested. Authors acknowledge that they participated sufficiently in the work to take public responsibility for its content. Conflicts of Interest: All authors have no conflict of interest to declare. References 1. Fine LJ, Philogene GS, Gramling R, Coups EJ, Sinha S. Prevalence of multiple chronic disease risk factors. 2001 National Health Interview Survey. Am J Prev Med . 2004; 27( 2 Suppl): 18– 24. Google Scholar CrossRef Search ADS PubMed  2. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet . 2017;389(10082):1885–1906. doi: 10.1016/S0140-6736(17)30819-X 3. Alba LH, Murillo R, Castillo JS; Grupo elaborador de guías de cesación de tabaco del INC. [Counseling interventions for smoking cessation: systematic review]. Salud Publica Mex . 2013; 55( 2): 196– 206. Google Scholar CrossRef Search ADS PubMed  4. Fiore MC, Jaen CR, Baker TB. Treating tobacco use and dependence: 2008 update. Clinical practice guideline, Rockville, MD: US Department of Health and Human Public Health Services, Public Health Service; 2008. 5. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev . 2004;( 1): CD003698. 6. Rice VH, Hartmann-Boyce J, Stead LF: Nursing interventions for smoking cessation. Cochrane Database Syst Rev . 2013;( 8): CD001188. 7. Twardella D, Brenner H. Lack of training as a central barrier to the promotion of smoking cessation: a survey among general practitioners in Germany. Eur J Public Health . 2005; 15( 2): 140– 145. Google Scholar CrossRef Search ADS PubMed  8. Cantor SB, Deshmukh AA, Luca NS, Nogueras-González GM, Rajan T, Prokhorov AV. Cost-effectiveness analysis of smoking-cessation counseling training for physicians and pharmacists. Addict Behav . 2015; 45: 79– 86. Google Scholar CrossRef Search ADS PubMed  9. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev . 2013;( 5): CD000165. 10. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ . 2000; 321( 7257): 355– 358. Google Scholar CrossRef Search ADS PubMed  11. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med . 2006; 31( 1): 52– 61. Google Scholar CrossRef Search ADS PubMed  12. Berlin I. Physicians perceived barriers to promoting smoking cessation. Journal of Smoking Cessation  2008; 3( 2): 92– 100. Google Scholar CrossRef Search ADS   13. Stead M, Angus K, Holme I, Cohen D, Tait G; PESCE European Research Team. Factors influencing European GPs’ engagement in smoking cessation: a multi-country literature review. Br J Gen Pract . 2009; 59( 566): 682– 690. Google Scholar CrossRef Search ADS PubMed  14. Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res . 2010; 12( 7): 724– 733. Google Scholar CrossRef Search ADS PubMed  15. Belbeisi A, Al Nsour M, Batieha A, Brown DW, Walke HT. A surveillance summary of smoking and review of tobacco control in Jordan. Global Health . 2009; 5: 18. Google Scholar CrossRef Search ADS PubMed  16. Belbeisi A, Zindah M, Walke H, Jarrar B, Mokdad AH. Assessing risk factors for chronic disease--Jordan, 2004. MMWR Morb Mortal Wkly Rep . 2006; 55: 653– 655. Google Scholar PubMed  17. Alkhatatbeh MJ, Alefan Q, Alzghool M. Smoking prevalence, knowledge and attitudes among primary healthcare professionals: a study from Jordan. East Mediterr Health J . 2017; 22( 12): 872– 879. Google Scholar CrossRef Search ADS PubMed  18. Tremblay M, Cournoyer D, O’Loughlin J. Do the correlates of smoking cessation counseling differ across health professional groups? Nicotine Tob Res . 2009; 11( 11): 1330– 1338. Google Scholar CrossRef Search ADS PubMed  19. Puska PM, Barrueco M, Roussos C, Hider A, Hogue S. The participation of health professionals in a smoking-cessation programme positively influences the smoking cessation advice given to patients. Int J Clin Pract . 2005; 59( 4): 447– 452. Google Scholar CrossRef Search ADS PubMed  20. Prignot J, Bartsch P, Vermeire Pet al.   Physician’s involvement in the smoking cessation process of their patients. Results of a 1998 survey among 4,643 Belgian physicians. Acta Clin Belg . 2000; 55( 5): 266– 275. Google Scholar CrossRef Search ADS PubMed  21. O’Sullivan J. An evaluation of general practitioners’ interactions with the smoking cessation service and the impact of a desktop resource on the service. In MA thesis. Cork: University College Cork, Department of Epidemiology and Public Health. National University of Ireland; 2006. 22. McEwen A, West R, Owen L, Raw M. General practitioners’ views on and referral to NHS smoking cessation services. Public Health . 2005; 119( 4): 262– 268. Google Scholar CrossRef Search ADS PubMed  23. Applegate BW, Sheffer CE, Crews KM, Payne TJ, Smith PO. A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi. J Eval Clin Pract . 2008; 14( 4): 537– 544. Google Scholar CrossRef Search ADS PubMed  24. Roddy E, Rubin P, Britton J; Tobacco Advisory Group of the Royal College of Physicians. A study of smoking and smoking cessation on the curricula of UK medical schools. Tob Control . 2004; 13( 1): 74– 77. Google Scholar CrossRef Search ADS PubMed  25. Helgason AR, Lund KE. General practitioners’ perceived barriers to smoking cessation-results from four Nordic countries. Scand J Public Health . 2002; 30( 2): 141– 147. Google Scholar PubMed  26. Ulbricht S, Meyer C, Schumann A, Rumpf HJ, Hapke U, John U. Provision of smoking cessation counseling by general practitioners assisted by training and screening procedure. Patient Educ Couns . 2006; 63( 1–2): 232– 238. Google Scholar CrossRef Search ADS PubMed  27. Al-Lawati JA, Nooyi SC, Al-Lawati AM. Knowledge, attitudes and prevalence of tobacco use among physicians and dentists in Oman. Ann Saudi Med . 2009; 29( 2): 128– 133. Google Scholar CrossRef Search ADS PubMed  28. Kotz D, Wagena EJ, Wesseling G. Smoking cessation practices of Dutch general practitioners, cardiologists, and lung physicians. Respir Med . 2007; 101( 3): 568– 573. Google Scholar CrossRef Search ADS PubMed  29. Brotons C, Björkelund C, Bulc Met al.   EUROPREV network. Prevention and health promotion in clinical practice, the views of general practitioner in Europe. Prev Med  2005; 5: 595– 601. Google Scholar CrossRef Search ADS   © Society of Behavioral Medicine 2018. All rights reserved. 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Knowledge, attitude, and behaviors of health professionals towards smoking cessation in primary healthcare settings

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Abstract

Abstract This study aimed to assess the behaviors of multiple health professionals in primary healthcare settings in Jordan towards smoking cessation counseling and to determine the barriers to effective smoking cessation behaviors. A survey of 456 health professionals in primary healthcare settings was conducted. A self-administrated questionnaire was used to collect the data. About half of health professionals reported that they usually ask patients about smoking status and advise them to stop smoking (51.4% and 50.5%, respectively). Only 23.7% reported assessing the willingness of the patients to quit smoking and 17.9% reported discussing counseling options with smokers. Considerably fewer percentages of health professionals reported preparing their patients for withdrawal symptoms (6.0%), discussing pharmacotherapies (3.8%), and prescribing nicotine patches (6.4%). Key barriers to smoking cessation counseling, as reported by health professionals, included: insufficient resources and organizational support, limited coverage of cessation interventions, and lack of motivation to quit. Smoking cessation counseling was not routinely implemented by Jordanian health professionals. Barriers to effective delivery of smoking cessation counseling need to be integrated within relevant strategies aiming at enhancing the frequency and quality of health professionals’ engagement in smoking cessation. Implications Practice: Health professionals in primary healthcare settings should participate in smoking cessation counseling activities. Policy: Policymakers should develop strategies to enhance the health professionals’ engagement in smoking cessation and to address barriers to the delivery of smoking cessation counseling. Research: Future research should be aimed at identifying proper interventions to overcome the barriers to the delivery of smoking cessation counseling. INTRODUCTION Tobacco use is currently widespread in most populations in industrialized and developing countries and has been associated with morbidity and mortality [1]. According to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2015 [2], the age-standardized prevalence of daily smoking was 25.0% for men and 5.4% for women. In 2015, about 11.5% of global deaths were attributed to smoking. Although the majority of smokers express a desire to quit smoking, overcoming the addiction is difficult and may require both pharmacologic and behavioral treatments. Smoking cessation counseling by various health professionals has been shown to be cost-effective in increasing quit rate [3–6]. However, there is a significant gap between available guidelines and their implementation by healthcare professionals [7, 8]. Several interventions including behavioral [9], counseling, self-help materials, and prescribing nicotine replacement have been shown effective in enhancing smoking cessation [10]. Screening for tobacco smoking and relevant cessation interventions are very essential preventive services and need to be implemented in various levels of the healthcare system [11]. Previous studies reported a number of barriers to smoking cessation counseling including time constraints, lack of motivation to quit, lack of health professionals’ training on counseling, competing demands and lack of familiarity with effective treatment [7, 12–14]. In Jordan, 15%–30% of school children and 50% of adults are smokers [15]. The impact of smoking-related diseases in Jordan is evident as more than 50% of all Jordanian deaths were attributed to chronic noncommunicable diseases [16]. About 92% of primary healthcare professionals in Jordan believed that they should advise patients to quit smoking, 15.3% felt that they are well prepared for smoking cessation counseling, and 92.8% believed that they need training on smoking cessation counseling [17]. In Jordan, there is insufficient data about barriers and facilitators of smoking cessation counseling behaviors by health professionals. Identifying such factors is essential in order to develop strategies for effective counseling. The current study aimed to assess knowledge, attitudes, and behaviors of various health professionals in primary healthcare settings regarding smoking cessation counseling in Jordan and to determine the barriers to effective smoking cessation behaviors. METHODS The study population consisted of selected health professionals (family physicians, internists, dentists, and nurses) at university teaching centers and the Ministry of Health comprehensive health centers in Jordan. All health centers in Jordan, whether teaching health center or comprehensive health center, were approached by a trained research assistant who invited all available health professionals at the time of visit to participate in the study. Of those who were invited, 124 family physicians, 103 internist, 72 dentists, and 157 nurses agreed to participate in the study and filled a self-administrated questionnaire. The overall response rate was 95%. The questionnaire was structured into sections. The first section sought information about personal and professional characteristics of participants including gender, age, number of years in practice, number of patients seen per month, and place of work. The second section listed the smoking counseling behaviors, for which all participants were asked about whether they perform that behavior or not. These behaviors included screening patient smoking status, providing assistance to help patients stop smoking, discussing quitting options with smokers, preparing smokers for possible withdrawal symptoms, and discussing different pharmacotherapies with smokers. The third section of the questionnaire was structured to identify the availability of resources, guidelines, posters or pamphlets, and web-based smoking cessation programs. In the fourth section, all participants were asked about the barriers to effective smoking cessation counseling. A list of possible barriers was developed based on the review of previous literature. The list of possible barriers included lack of available cessation programs, lack of training on smoking cessation counseling, insufficient services, resources and organizational support, limited coverage of cessation interventions, lack of patient’s motivation, lack of effective educational materials, limited efficacy of available interventions, uncertainty about what preventive services to provide, limited experience in intervening with smokers, and limited time spent with patients. Moreover, participants were asked about how they perceive their skills in changing smokers’ behavior and about the use of educational resources to change smoking behavior. Data were analyzed using Statistical Package for Social Sciences (SPSS, Inc., Chicago, ΙΙΙ, Version 15). Frequency and percentages were used to describe data. Chi-square test was used to compare percentages among different health professionals groups. A p value of less than .05 was considered statistically significant. RESULTS Participant characteristics The current study included 124 family physicians, 103 internists, 72 dentists, and 157 nurses. Their age ranged between 20 and 62 years old with a mean (SD) of 34.1 (9.1) years. Of all participants, 30.2% reported working in teaching health centers and the rest in Ministry of Health centers. Less than one-third of health professionals (28.9%) were smokers. Overall, 18.4% had received training on smoking cessation counseling. The demographic and relevant characteristics of health professionals are shown in Table 1. About 30.5% of health professionals reported the availability of guidelines and protocols regarding smoking cessation and 48.6% reported the availability of posters or pamphlets regarding smoking cessation. Only 24.5% of health professionals reported that they were familiar with assessing nicotine dependency. Table 1 | The demographic, practice, and relevant characteristics of health professionals practicing in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)  View Large Table 1 | The demographic, practice, and relevant characteristics of health professionals practicing in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  Gender   Male  60 (48.4)  67 (65.0)  62 (86.1)  53 (33.8)  242 (52.2)   Female  64 (51.6)  36 (35.0)  10 (13.9)  104 (66.2)  214 (46.2)  Current smokers  36 (29.0)  28 (26.4)  27 (37.5)  43 (27.4)  134 (28.9)  Place of work   Teaching health centers  33 (26.6)  42 (48.8)  24 (32.9)  41 (26.6)  140 (30.2)   Ministry of health centers  91 (73.3)  44 (51.1)  49 (67.1)  113 (73.3)  297 (64.1)  Received training on smoking cessation  13 (16.0)  21 (22.8)  18 (29.5)  20 (12.7)  72 (18.4)  Familiar with assessing nicotine dependency  20 (21.3)  15 (14.6)  17 (23.9)  105 (66.9)  104 (24.5)  Having smoking cessation guidelines/protocols  13 (14.0)  30 (28.3)  11 (15.1)  74 (50.0)  128 (30.5)  Having posters/pamphlet about smoking  24 (26.1)  47 (44.3)  28 (38.4)  107 (69.9)  206 (48.6)  View Large Smoking counseling practices About half of health professionals reported that they usually ask patients about smoking status and advise them to stop smoking (51.4% and 50.5%, respectively). However, they did not regularly provide extensive assistance to help their patients to quit smoking (Table 2). Only 23.7% reported assessing the willingness of the patients to quit smoking and 17.9% reported discussing counseling options with smokers. Considerably fewer percentages of health professionals reported preparing their patients for withdrawal symptoms (6.0%), discussing pharmacotherapies (3.8%), prescribing nicotine patches (6.4%), and providing patients with self-help materials (5.6%). Other smoking cessation activities reported by few health professionals included monitoring progress in attempting to quit, arranging follow-up visits with patients to address smoking, and referring smokers to other appropriate cessation treatments. Table 2 | Smoking cessation activities reported by health professionals working in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439  View Large Table 2 | Smoking cessation activities reported by health professionals working in Ministry of Health and teaching health centers   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439    Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Ask about smoking status  83 (66.9)  61 (58.1)  47 (65.3)  47 (29.7)  238 (51.4)  <.001  Advice patients to quite smoking  92 (66.1)  51 (48.1)  42 (59.2)  49 (32.5)  234 (50.5)  <.001  Assess patient willingness to quit  46 (39.8)  19 (17.9)  20 (27.8)  22 (14.2)  110 (23.7)  <.001  Discuss counseling options  35 (28.2)  18 (17.0)  17 (23.3)  13 (8.5)  83 (17.9)  <.001  Prepare the patient for withdrawal symptoms  14 (11.6)  5 (4.7)  2 (2.7)  7 (4.5)  28 (6.0)  .026  Discuss pharmacotherapy  6 (4.9)  6 (5.6)  3 (4.1)  3 (1.9)  18 (3.8)  .424  Prescribe nicotine patches  6 (5.0)  8 (7.5)  3 (4.1)  13 (8.4)  30 (6.4)  .668  Provide self-help materials  6 (6.2)  7 (6.7)  5 (6.8)  8 (5.2)  26 (5.6)  .947  Monitor patient progress in attempting to quit  7 (5.9)  6 (5.7)  3 (4.1)  6 (3.9)  22 (4.7)  .649  Arrange follow-up visits with patients to address smoking  8 (6.6)  5 (4.7)  3 (4.1)  9 (5.8)  25 (5.3)  .919  Refer patients who smoke to others for appropriate cessation treatment  13 (10.6)  11 (10.3)  3 (4.1)  12 (7.8)  39 (8.4)  .439  View Large Participating health professionals differed significantly in reporting some smoking cessation activities such as asking about smoking status, advising patients to quit, assessing patient’s willingness to quit, discussing counseling options, and preparing patients for withdrawal symptoms. Nurses reported the least smoking cessation activities whereas family physicians reported the highest compared to other health professionals. About 55.0% of health professionals reported they are somewhat effective and 4.4% reported they are very effective in changing their patients’ behaviors with respect to smoking cessation. Dentists were less likely than other health professionals to report being effective in changing their patients’ behaviors related to smoking cessation (Table 3). About half of health professionals (51.9%) indicated that the educational resources for educating patients are sometimes effective in changing the behaviors. Only 6.5% reported that they are very effective. Table 3 | The perceived effectiveness in changing smoking behavior and the use of educational resources to change smoking behavior   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)      Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)    View Large Table 3 | The perceived effectiveness in changing smoking behavior and the use of educational resources to change smoking behavior   Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)      Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Perceived effectiveness in changing smoking behavior            .002   Not very effective  29 (29.3)  61 (57.5)  25 (34.2)  60 (39.2)  175 (40.6)     Sometimes  64 (64.6)  44 (41.5)  43 (58.9)  86 (56.2)  237 (55.0)     Very effective  6 (6.1)  1 (0.9)  5 (6.8)  7 (4.6)  19 (4.4)    Use educational resources            .001   Never  51 (52.0)  58 (54.2)  34 (47.2)  36 (23.5)  179 (41.6)     Sometimes  45 (45.9)  45 (42.1)  33 (45.8)  100 (65.4)  223 (51.9)    Routine  2 (2.0)  4 (3.7)  5 (6.9)  17 (11.1)  28 (6.5)    View Large Barriers to effective smoking cessation behaviors The most important barriers to smoking cessation counseling reported by health professional groups are shown in Table 4. Insufficient services and organizational support, limited coverage of cessation interventions, and lack of motivation to quit were reported by high percentage of health professionals. Table 4 | Perceived barriers to effective smoking cessation counseling practices as reported by health professionals in Ministry of Health and teaching health centers Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  View Large Table 4 | Perceived barriers to effective smoking cessation counseling practices as reported by health professionals in Ministry of Health and teaching health centers Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  Barrier  Family physicians (N = 124) n (%)  Internists (N = 103) n (%)  Dentists (N = 72) n (%)  Nurses (N = 157) n (%)  Total (N = 456) n (%)  p value  Lack or too few available cessation programs  112 (90.3)  96 (90.6)  64 (87.7)  117 (75.0)  389 (84.0)  .002  Limited training on tobacco and cessation interventions  112 (90.3)  88 (82.2)  48 (66.7)  118 (75.2)  366 (79.0)  .019  Insufficient services, resources and organizational support  110 (88.7)  89 (83.2)  59 (83.1)  112 (73.2)  370 (79.9)  <.001  Limited coverage of cessation interventions  108 (87.1)  79 (78.2)  59 (83.1)  115 (77.2)  361 (77.9)  .074  Lack of patient’s motivation  98 (79.0)  92 (86.0)  48 (66.7)  121 (77.1)  359 (77.5)  .019  Lack of effective educational materials  98 (79.0)  88 (82.2)  58 (79.5)  115 (73.7)  359 (77.5)  .418  Interventions available have limited efficacy  93 (75.0)  77 (72.0)  55 (76.4)  109 (70.8)  334 (72.1)  .689  Uncertainty about what preventive services to provide  91 (73.4)  73 (68.9)  45 (61.6)  109 (69.9)  318 (68.6)  .390  Limited experience in intervening with smokers  90 (72.6)  73 (68.9)  50 (69.4)  111 (71.2)  324 (69.9)  .734  Limited time spent with patient  88 (71.0)  63 (58.9)  34 (46.6)  108 (68.8)  293 (63.2)  .002  View Large DISCUSSION This study showed that half of health professionals reported asking patients about smoking status and advising smokers to quit. However, fewer number of health professionals reported that they participated in other activities such as assessing patient’s willingness to quit, discussing counseling options, preparing the patient for withdrawal symptoms and discussing pharmacotherapies. This finding is similar to that reported in a Canadian survey where about half of health professionals surveyed reported asking about smoking status and advising patients to quit smoking. In the Canadian survey, less than one-third of health professionals stated they assess patient’s willingness to quit and assist them to quit [18]. In the USA, a national survey [14] showed that the majority of health professionals reported asking about smoking status and advising smokers to quit, with much less reported assessing, assisting and arranging follow-up. In Europe, a multicenter study in 12 European countries, only one-third (36%) of health professionals reported always advising smokers to quit [19]. In Belgium [20], Ireland [21], and England [22], the rates of asking patients about their smoking status by general practitioners were 28%, 47%, and 63%, respectively. The 5As approach (five components of effective tobacco cessation counseling: ask, assess, advise, assist, and arrange follow-up) provides health professionals with a framework for structuring smoking cessation by identifying all smokers and offering support to help them quit. In the current study, physicians reported performing multiple components of the 5A’s including interventions more than dentists and nurses, a finding that is similar to previous studies in which doctors assisted more patients than nurses or dentists [18, 23, 24]. Training in smoking cessation is still inadequate in spite of its cost effectiveness. Previous studies suggested that smoking cessation training is strongly associated with a higher level of confidence, less perceived barriers, and more interventions [7, 23]. In the current study, only 18.4% of the health professionals surveyed received smoking cessation training. In the USA, less than one-third of health professionals received smoking cessation training [14] and only a quarter of primary care providers received training [23]. In the UK, the vast majority of new medical graduates receive little or no cessation training [24]. Similarly, a Canadian study showed that one quarter to one-third of general practitioners and pharmacists received smoking cessation training and less than 2% in the other groups [18]. In another study in 10 countries, 5.2%–36.6% of third year medical students received smoking cessation training. In Sweden, Norway, Iceland and Finland, the proportion of general practitioners who received training in smoking cessation were 60%, 55%, 48%, and 28%, respectively [25]. The three most important perceived barriers towards smoking cessation in our survey were lack or few available cessation programs (84%), limited training on smoking cessation (79%) and lack of patients motivation to quit (77.5%). Such barriers had been reported in many previous studies [7, 12–14, 18, 25, 26]. In two U.S. surveys, limited cessation training and low motivation of patients were the most perceived barriers against provision of smoking cessation interventions by health professionals [14]. Time constraints, high workload and lack of training were the most perceived barriers in France [12]. In Germany, lack of time and patient insufficient motivation to change were the two major barriers [7, 25]. In a Canadian survey, that the health professionals have three major barriers were identified including the low perceptions of smoking counseling as part of health professionals’ role, perceived self efficacy and knowledge of community cessation services [18]. In Europe, general practitioners’ own smoking status, attitudes towards giving smoking cessation advice, time constraints, lack of training, and lack of knowledge and skills were perceived as barriers against provision of smoking cessation intervention [13]. Implementing evidence-based strategies to encourage involvement of health professionals in tobacco use prevention and cessation counseling and to assess the efficacy of handling perceived barriers to address smoking cessation are warranted to overcome tobacco-induced diseases and death. Assisting patients to quit smoking is considered to be one of the most cost-effective measures in clinical practice and should be a standard of care for all health professionals. Each of the healthcare providers can have a critical role in smoking cessation counseling. There is a strong evidence that quitting rates can be substantially increased by even simple advice provided by health professionals [24]. In the present study, about one-third (28.9%) of health professionals surveyed were current smokers, a percentage which is high compared to less than 6% of U.S. health professionals [14] who were smokers. The prevalence rates of tobacco use among healthcare providers were 15.1% in Saudi Arabia [12], 16.4% in Oman [27], and 8.2% among Dutch general practitioners [28]. Studies found that general practitioners who smoke were less engaged in cessation advice [29]. In conclusion, smoking cessation counseling was not routinely implemented by Jordanian health professionals. Strategies to enhance the frequency and quality of health professionals’ engagement in smoking cessation need to address barriers to the delivery of smoking cessation counseling. Acknowledgments: The authors would like to acknowledge the Training Programs in Epidemiology & Public ealth Interventions Network (TEPHINET) and Jordan Field Epidemiology Training Program for their technical support. Funding: The study had not received any fund. Compliance with Ethical Standards Ethics: Authors confirm that subjects have given their informed consent and that the study protocol has been approved by the Jordan University of Science Technology Institutional Review Board. Statement on the Welfare of Animals: This article does not contain any studies with animals performed by any of the authors. The author wishes to confirm that neither the manuscript nor any part of it has been published or is being considered for publication elsewhere. All authors confirm that the manuscript is not under simultaneous consideration with another journal. The data from this manuscript had not been previously reported. The authors have full control of all primary data and agree to allow the journal to review the data if requested. Authors acknowledge that they participated sufficiently in the work to take public responsibility for its content. Conflicts of Interest: All authors have no conflict of interest to declare. References 1. Fine LJ, Philogene GS, Gramling R, Coups EJ, Sinha S. Prevalence of multiple chronic disease risk factors. 2001 National Health Interview Survey. Am J Prev Med . 2004; 27( 2 Suppl): 18– 24. Google Scholar CrossRef Search ADS PubMed  2. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet . 2017;389(10082):1885–1906. doi: 10.1016/S0140-6736(17)30819-X 3. Alba LH, Murillo R, Castillo JS; Grupo elaborador de guías de cesación de tabaco del INC. [Counseling interventions for smoking cessation: systematic review]. Salud Publica Mex . 2013; 55( 2): 196– 206. Google Scholar CrossRef Search ADS PubMed  4. Fiore MC, Jaen CR, Baker TB. Treating tobacco use and dependence: 2008 update. Clinical practice guideline, Rockville, MD: US Department of Health and Human Public Health Services, Public Health Service; 2008. 5. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev . 2004;( 1): CD003698. 6. Rice VH, Hartmann-Boyce J, Stead LF: Nursing interventions for smoking cessation. Cochrane Database Syst Rev . 2013;( 8): CD001188. 7. Twardella D, Brenner H. Lack of training as a central barrier to the promotion of smoking cessation: a survey among general practitioners in Germany. Eur J Public Health . 2005; 15( 2): 140– 145. Google Scholar CrossRef Search ADS PubMed  8. Cantor SB, Deshmukh AA, Luca NS, Nogueras-González GM, Rajan T, Prokhorov AV. Cost-effectiveness analysis of smoking-cessation counseling training for physicians and pharmacists. Addict Behav . 2015; 45: 79– 86. Google Scholar CrossRef Search ADS PubMed  9. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev . 2013;( 5): CD000165. 10. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ . 2000; 321( 7257): 355– 358. Google Scholar CrossRef Search ADS PubMed  11. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med . 2006; 31( 1): 52– 61. Google Scholar CrossRef Search ADS PubMed  12. Berlin I. Physicians perceived barriers to promoting smoking cessation. Journal of Smoking Cessation  2008; 3( 2): 92– 100. Google Scholar CrossRef Search ADS   13. Stead M, Angus K, Holme I, Cohen D, Tait G; PESCE European Research Team. Factors influencing European GPs’ engagement in smoking cessation: a multi-country literature review. Br J Gen Pract . 2009; 59( 566): 682– 690. Google Scholar CrossRef Search ADS PubMed  14. Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National survey of U.S. health professionals’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res . 2010; 12( 7): 724– 733. Google Scholar CrossRef Search ADS PubMed  15. Belbeisi A, Al Nsour M, Batieha A, Brown DW, Walke HT. A surveillance summary of smoking and review of tobacco control in Jordan. Global Health . 2009; 5: 18. Google Scholar CrossRef Search ADS PubMed  16. Belbeisi A, Zindah M, Walke H, Jarrar B, Mokdad AH. Assessing risk factors for chronic disease--Jordan, 2004. MMWR Morb Mortal Wkly Rep . 2006; 55: 653– 655. Google Scholar PubMed  17. Alkhatatbeh MJ, Alefan Q, Alzghool M. Smoking prevalence, knowledge and attitudes among primary healthcare professionals: a study from Jordan. East Mediterr Health J . 2017; 22( 12): 872– 879. Google Scholar CrossRef Search ADS PubMed  18. Tremblay M, Cournoyer D, O’Loughlin J. Do the correlates of smoking cessation counseling differ across health professional groups? Nicotine Tob Res . 2009; 11( 11): 1330– 1338. Google Scholar CrossRef Search ADS PubMed  19. Puska PM, Barrueco M, Roussos C, Hider A, Hogue S. The participation of health professionals in a smoking-cessation programme positively influences the smoking cessation advice given to patients. Int J Clin Pract . 2005; 59( 4): 447– 452. Google Scholar CrossRef Search ADS PubMed  20. Prignot J, Bartsch P, Vermeire Pet al.   Physician’s involvement in the smoking cessation process of their patients. Results of a 1998 survey among 4,643 Belgian physicians. Acta Clin Belg . 2000; 55( 5): 266– 275. Google Scholar CrossRef Search ADS PubMed  21. O’Sullivan J. An evaluation of general practitioners’ interactions with the smoking cessation service and the impact of a desktop resource on the service. In MA thesis. Cork: University College Cork, Department of Epidemiology and Public Health. National University of Ireland; 2006. 22. McEwen A, West R, Owen L, Raw M. General practitioners’ views on and referral to NHS smoking cessation services. Public Health . 2005; 119( 4): 262– 268. Google Scholar CrossRef Search ADS PubMed  23. Applegate BW, Sheffer CE, Crews KM, Payne TJ, Smith PO. A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi. J Eval Clin Pract . 2008; 14( 4): 537– 544. Google Scholar CrossRef Search ADS PubMed  24. Roddy E, Rubin P, Britton J; Tobacco Advisory Group of the Royal College of Physicians. A study of smoking and smoking cessation on the curricula of UK medical schools. Tob Control . 2004; 13( 1): 74– 77. Google Scholar CrossRef Search ADS PubMed  25. Helgason AR, Lund KE. General practitioners’ perceived barriers to smoking cessation-results from four Nordic countries. Scand J Public Health . 2002; 30( 2): 141– 147. Google Scholar PubMed  26. Ulbricht S, Meyer C, Schumann A, Rumpf HJ, Hapke U, John U. Provision of smoking cessation counseling by general practitioners assisted by training and screening procedure. Patient Educ Couns . 2006; 63( 1–2): 232– 238. Google Scholar CrossRef Search ADS PubMed  27. Al-Lawati JA, Nooyi SC, Al-Lawati AM. Knowledge, attitudes and prevalence of tobacco use among physicians and dentists in Oman. Ann Saudi Med . 2009; 29( 2): 128– 133. Google Scholar CrossRef Search ADS PubMed  28. Kotz D, Wagena EJ, Wesseling G. Smoking cessation practices of Dutch general practitioners, cardiologists, and lung physicians. Respir Med . 2007; 101( 3): 568– 573. Google Scholar CrossRef Search ADS PubMed  29. Brotons C, Björkelund C, Bulc Met al.   EUROPREV network. Prevention and health promotion in clinical practice, the views of general practitioner in Europe. Prev Med  2005; 5: 595– 601. Google Scholar CrossRef Search ADS   © Society of Behavioral Medicine 2018. All rights reserved. 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Translational Behavioral MedicineOxford University Press

Published: Feb 10, 2018

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