Author's response to reviews

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1 Author's response to reviews Title: Patterns of Smoking Behavior among Physicians in Yerevan, Armenia Authors: Paul C Perrin (Paul_Perrin@byu.edu) Ray M Merrill (Ray_Merrill@byu.edu) Gordan B Lindsay (Gordan_Lindsay@byu.edu) Version: 2 Date: 24 April 2006 see over Author's response to reviews:

2 Dear Editors: Here is a list of the reviewer comments with our corresponding responses. Sincerely, Ray M. Merrill Title: Patterns of Smoking Behavior among Armenian Physicians Reviewer: Mati Rahu This paper contains interesting information about smoking patterns and attitudes among physicians in the Republic of Armenia. Public health researchers still know little on this corner of the world, and thus each piece of additional knowledge is very welcome. A relatively small number of respondents in some categories suggest that the results should be viewed with a degree of caution Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 1. Title. As the study covers nearly one third of medical facilities in Yerevan, but not the whole of Armenia, it would be desirable to include the word "Yerevan" in the title (e.g., "...among physicians in Yerevan, Armenia"). Response. Done. 2. Introduction, p 3, para 2. Are you sure that Belarus, Kazakhstan, Kyrgyzstan, Moldova, the Russian Federation and Ukraine are the "neighboring" countries of Armenia? Response. The wording was changed to say nearby rather than neighboring. 3. p 4, para 3, lines 4 5. It is stated that there are no other studies on present smoking habits of healthcare workers in Armenia. But, the WHO recent factsheet "World No Tobacco Day 2005 Health Professionals and Tobacco Control" ( reveals that among medical doctors in Armenia, there are 80.6% and 42% of occasional smokers in males and females, respectively. Please confirm or refute, and discuss these findings (in the Discussion section). Response. The following change was made to the paper (paragraph 5 of the Introduction): The WHO recently reported that prevalence of current smokers among doctors in Armenia in the late 1990s was 80.6% of males and 42.0% of females (15). The report did not address physician attitudes toward smoking and potential obstacles they face in smoking prevention and control efforts. To date, no study has assessed the current smoking behaviors and attitudes of healthcare workers in Armenia. 4. Methods. Please give the total number of practicing male and female physicians both in Armenia and in Yerevan.

3 Response. The following change was made to the paper: In 2003, there were 11,728 (36.5 per 10,000) physicians of all specialties in Armenia (8). In 1999, there were 33.2 physicians per 10,000 (8), as compared with 27.9 in America in that same year (15). After considerable searching, we were unable to locate data on the total number of practicing physicians in Armenia by sex and specifically in Yerevan. 5. A clear definition of a "regular smoker" and an "occasional smoker" should be given. Response. The terms regular smoker and occasional smoker were included as choices under questions about smoking behavior. These terms have been used in other validated surveys where individuals self-select their level of smoking. We did not provide a specific definition of these terms in our questionnaire, so believe it would be incorrect to include in the paper a specific definition of these terms now. 6. p 5, para 1, first sentence. "...Yerevan is located in the central portion of the country". In the case of Armenia it is quite tricky business to figure out where the central area lies. But I am almost sure that Yerevan is situated out of it. Response. The sentence was changed as follows: Armenia is a highly centralized population with over a third of its 3.3 million citizens living in Yerevan, which is the capital located in the central portion of the country. 7. p 5, para 2, last sentence. This sentence should be presented in the Introduction section. Response. The sentence was moved to the end of the Introduction. 8. p 5, para 3, line 3, and p 6, para 2, line 1. It is mentioned twice that a survey was conducted in "licensed" medical facilities. Do you have any sense of the proportion of "non-licensed" medical facilities in Armenia? Response. We were unable to identify the proportion of non-licensed medical facilities in Armenia. 9. p 5, last para. The authors state that the Brigham University IRB approved this study. Please explain why approval was not needed from a local research ethics committee in Yerevan. Or, they have not such committees in Yerevan? Response. The medical facilities we worked with were informed that IRB had been received from Brigham Young University. There was no indication from the medical administrators that further IRB approval was required in Yerevan. 10. p 6, para 2 and 3. "Twelve facilities were randomly selected..." and "...questionnaires were distributed to 13 facilities...". Please correct or clarify. Response. This was an error in the manuscript. The following change was made: In total, 400 questionnaires were distributed to 1312 facilities...

4 11. Tables. More informative titles are needed. Table titles should include the study population ("physicians"), the place of study ("Yerevan, Armenia") and the study year ("2004"). Replace "Binary analysis..." (Table 2 title) with "Distribution of physicians by smoking status...". Revise text in tables to ensure consistency in using punctuation marks, and small and capital letters (e.g., "Is Smoking Policy Enforced" (Table 1) vs "Have you ever smoked in front of patients?" (Table 3)). Apply a consistent horizontal alignment of absolute numbers, percentages and p-values (Tables 1 6). Response. The recommended changes were made. 12. References. The reference list deserves much better treatment than the authors have given it. The list does not conform to the reference style of the BMC Public Health ( Also, in article titles, capital and small letters are used inconsistently (e.g., ref 28 vs ref 29). Check all bibliographic entries for accuracy (e.g., page range ref 2 vs ref 23; missing place of publication ref 22; delete journal issue numbers; etc.). Response. References are now in the style specified by BMC Public Health. I feel my colleague and co-author, Martin McKee from the LSHTM, would be happy if you could replace (ref 6) "Mckeem" with "McKee"; in addition, please replace "Torman" with "Rotman". The book "Applied Logistic Regression" 2nd ed. (ref 24) was published in Response. These references were fixed Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 13. Introduction, p 3, para 1, last 5 lines. "...the percentage of current smokers... was 51.9% for men, 33.9% for women; 42.1% for whites...". Omit all of the % symbols. Consider the same in the Results, p 7, last sentence. Response. Done. 14. Sometimes, reference to the same source is made in two consecutive sentences. See p 3, 4 and 11. Response. We deleted the second in each case. 15. p 4, para 1, lines 3-5. Explain that you mean per capita consumption. Respones. The following change was made: This cannot be solely attributed to population increase since annual per-capita cigarette consumption Methods, p 4, para 2, line 2. Specify, what kind of "rates of heart disease, cancer, and

5 respiratory diseases" are considered. Response. The following change was made: The health implications of high smoking prevalence in Armenia are now being manifest in higher crude rates of heart disease, cancer, and respiratory diseases in the resident population. 17. p 6, para 2, lines 5-6. It is written that the number of questionnaires distributed, reflected the "size of the hospital". On p 12, para 1, the last sentence informs that the number of surveys (i.e., questionnaires) was equal to the number of eligible physicians. The latter expression is more exact than the "size of the hospital" (number of inpatient beds). Response. The following change was made: The number of questionnaires given to each medical facility reflected the number of physicians in each hospitalsize of the hospital. 18. Results, p 8, last sentence "Logistic regression...". Delete it. The message it conveys is described in the Methods. Response. The sentence was deleted. 19. Limitations, p 12. The limitations of the study should be routinely addressed in the Discussion section. Thus no separate section is needed. Response. The sub heading Limitations was deleted and the section in the Discussion section. 20. Abstract. Calculate and include a corrected response rate. Response. The following change was made to the last sentence in the Methods section of the Abstract: Analyses are based on responses from 240 physicians, representing a 70% response rate Discretionary Revisions (which the author can choose to ignore) 21. Methods. I am not enthusiastic about using the chi-square test in this paper (Tables 3 and 6) because it adds nothing of value to the analysis. The tabulated absolute numbers and percentages are self-evident, and the better solution may be to construct a 95% confidence interval for each percentage in Table 3. Alternatively, instead of giving exact p-values, report them as less than some specified value (e.g., <0.05); delete chi-square values. Response. For Tables 3 and 6 we deleted the column with the chi-squares and corresponding p-values. In the footnote we put * χ² p-value < The asterisk identifies significant variables in the body of the table. 22. p 5, end of para 2. Some recent studies concerning smoking patterns/attitudes among physicians in Italy (Pizzo AM et al 2003), Finland (Barengo NC et al 2004), Ireland (Power B et al 2004), Estonia (Parna K et al 2005), France (Josseran L et al 2005) and Spain (Soto Mas FG et al 2005) may be added.

6 Response. We appreciate the reviewer identifying these highly relevant articles. They were included in the paper. 23. Discussion, p 11, lines 3-4. Please provide a bit more information about the Law of Tobacco Control in Armenia, e.g., date of implementing, major restrictions on smoking, etc. Response. The following changes were made to the paragraph: Social policies aimed at controlling cigarette smoking can also have a significant impact on smoking rates (41). Legislation passed by Armenia s parliament and adopted in January 2005 increased fines and outlawed smoking in schools, on public transportation, and in other public places. Smoking was also banned for teenagers under 16. The legislation further prohibited smoking in cultural institutions and at sporting events. Tobacco products without warnings on the dangers of smoking were to be destroyed. Health care workers can have a leadership role to play in supporting such policies. Armenia recently passed legislation banning the sale of tobacco to minors. In a consistent manner, the study participants expressed strong agreement that health professionals should routinely advise patients who smoke to avoid smoking around children. 24. Limitations, p 12, para 2. The sentence "Some of the completed questionnaires were not distributed to physicians..." needs further clarifying. Response. This was a typo. We deleted the word completed. Reviewer's report Title: Patterns of Smoking Behavior among Armenian Physicians Version: 1 Date: 6 April 2006 Reviewer: Erica Frank Reviewer's report: General You can't say that docs in Yerevan are representative of the whole population of Armenian docs (in fact, they're likely not). So you need to change your title and much more importantly, the conclusions in the abstract and elsewhere similarly overgeneralize even beyond docs in Armenia this needs to be carefully attended to. There are a substantial number of nuances to this, for example, the abstract's conclusion should specify high smoking (and smoking in front of patient) rates "among male physicians in these 12 health care facilities". Response. The title has been changed to specify Yerevan. In addition, the following change was made to the Conclusion in the Abstract: Smoking prevalence is high among physicians in the 12 health care facilities in Yerevan, and a large percentage of physician smoke in the presence of their patients. Physician smoking behavior and knowledge of smoking related

7 health outcomes in Yerevan influences whether they counsel patients regarding smoking. Also, it's noteworthy that while the male docs smoking rates are high, they are lower than those of other young men docs are people living in a context, too, and while they typically have better health practices than those of the general population, even in the US, they still smoke at about 4% rates. You should discuss this point, and reference the two most representative studies in the States, along with your refs 17-21: (1) Nelson, Giovino, and others in JAMA (study around 1995 of US docs and nurses personal smoking practices); and (2) Frank E, Brogan D, Mokdad AH, Simoes E, Kahn H, Greenberg RS "Health-related behaviors of women physicians vs other women in the United States." Archives of Internal Medicine, Vol.158, pgs Response. The following was added after paragraph 2 of the Discussion: Cultural acceptance of smoking in Armenia may help explain the high smoking prevalence among physicians. The current study found smoking prevalence among physicians in Yerevan to be 55.3% in males and 17.3% in females. These results are lower than the WHO recently reported for physicians in Armenia 80.6% in males and 42% in females (15). Compared with the general adult male population in Yerevan, smoking prevalence among physicians is similar (6). On the other hand, smoking prevalence is much higher among female physicians compared with the general female population in Yerevan (17.3% vs. 4.3%) (6). Furthermore, smoking prevalence among women in Yerevan is approximately four times greater than that in the other provinces of Armenia (5, 6). Higher smoking prevalence among female physicians may reflect an attempt to gain greater affluence and liberation from old rural culture. It may also be that tobacco companies are more aggressively targeting women with higher socioeconomic status. It has been shown that among women in India cigarette smoking exists primarily among the urban elite classes of large cosmopolitan cities (35). The results are contrary to two US studies conducted in the 1990s where physicians displayed considerably lower smoking prevalence than the general population (36, 37). These studies identified smoking prevalence among physicians at 3%-4%, which is consistent with physicians having healthier lifestyle behaviors than the general population (38). Health care professionals can help patients stop smoking by ensuring that counseling and pharmacological therapy is available (39), and actually counseling them about quitting (33). A study involving the Women Physicians Health Study in 1993 found that practicing a specific health habit (e.g., not smoking) significantly increased the likelihood of counseling patients about that habit (38, 40). Patients also find physicians more believable and motivating if the physician discloses their own positive health practice (38). You should also discuss the high rates for women docs, and the ways in which high SES women have elsewhere also been bell weathers for smoking habits in the population at large. Response. See the previous response. In addition to citation #29, you should look at the following refs, and emphasize this more in your discussion this is main reason why it matters if docs smoke! For the tobacco data, see: Frank E, Rothenberg R, Lewis C, Belodoff B "Correlates of physicians' preventionrelated practices; findings from the Women Physicians' Health Study." Archives of Family

8 Medicine, Vol. 9, pgs For a summary of the general principle of the relationship between docs personal and clinical practices, see: Frank E "Physician health and patient care." Journal of the American Medical Association, Vol. 291 (5), pg Which you can find at: Response. These references are now incorporated in the Discussion (see previous response in yellow). Specific comments Pg 6, 3rd sentence makes no sense. Response. We changed the sentence as follows: Although the validity of the instrument has been established in other settings, we assumed it was applicable in Armenia. Does citation #30 actually contain original evidence, not published elsewhere that nonsmoking behavior of physician and office personnel and the office setting reinforce the cessation advice Response. This is a review article. The reference and corresponding text has been dropped from the Discussion. You say: It would seem, based on the high smoking prevalence among health care workers, that smoking itself isn t considered socially undesirable. That seems a bit of a leap Response. The paragraph was modified as follows: Finally, there is a tendency for individuals to underreport items they consider to cause them to be viewed as deviant or behaving in a socially undesirable way (42). It would seem, based on the high smoking prevalence among health care workers, that smoking itself isn t considered socially undesirable. It is possible that smoking in front of patients and admitting that one is not prepared to help patients quit smoking might be underreported because the physicians are aware of the adverse health consequences that may result from their behavior. Underreporting may also result if smoking is perceived as socially unacceptable. Whether underreporting occurred in the data is unknown.