Receiving family physician s advice and the stages of change in smoking cessation among Arab minority men in Israel

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1 Fmily Prctice, 2016, Vol. 33, No. 6, doi: /fmpr/cmw090 Advnce Access puliction 2 Septemer 2016 Epidemiology Receiving fmily physicin s dvice nd the stges of chnge in smoking cesstion mong Ar minority men in Isrel Nihy Doud, *, Smh Hyek, Ay Bidermn c,d, Adllh Mshl c,d, Yel Br-Zeev c nd Ofr Klter-Leiovici e,f Deprtment of Pulic Helth, Fculty of Helth Sciences, Ben-Gurion University of the Negev, Beer-Shev, Isrel, School of Pulic Helth, Deprtment of Epidemiology, Fculty of Socil Welfre nd Helth Science, University of Hif, Hif, Isrel, c Deprtment of Fmily Medicine, Division of Community Helth, Fculty of Helth Sciences, Ben-Gurion University of the Negev, Beer Shev, Isrel, d Cllit Helth Services, South district, Beer Shev, Isrel, e Unit of Crdiovsculr Epidemiology, Gertner Institute of Epidemiology nd Helth Policy Reserch, Tel-Hshomer, Isrel nd f Sckler Fculty of Medicine, Tel-Aviv University, Tel-Aviv, Isrel. *Correspondence to Nihy Doud, Deprtment of Pulic Helth, Fculty of Helth Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer Shev 84015, Isrel; E-mil: doud@gu.c.il Astrct Bckground. Receiving physicin dvice (PA) cn increse ptient s willingness to quit smoking nd influence the stges of chnge in quitting. However, less is known out this ssocition mong minority groups for whom cesstion is more chllenging. Ojective. We exmined whether receiving dvice on smoking cesstion from fmily physicin is ssocited with the stges of chnge in quitting smoking i.e. pre-contempltion, contempltion, preprtion or ction mong Ar minority men in Isrel with high smoking prevlence. Methods. In , strtified rndom smple of 964 Ar men current nd pst smokers, ged 18 64, were interviewed fce-to-fce. We used ordered logistic regression models to exmine the ssocition etween PA nd stges of quitting smoking, djusted for socioeconomic sttus, helth sttus, sociodemogrphics, Helth Mintennce Orgniztions (HMO) nd smoking-relted vriles. Results. Aout 40% of Ar men reported ever receiving PA to quit smoking. Prticipnts with chronic disese(s) nd higher nicotine dependence were more likely to receive PA. PA ws significntly ssocited with the stges of chnge, ut not with ctul quitting. In multivrile nlysis, receiving PA ws ssocited with greter likelihood of eing t the contempltion or preprtion stges of cesstion, compred to pre-contempltion; odds rtio (OR) nd 95% confidence intervl (CI) were 1.95 (95% CI = ) nd 1.14 (95% CI = ), respectively. Conclusions. Receiving PA mong minority men is ssocited with dvnced motivtionl stges of chnge in quitting smoking, ut not with ctul smoking cesstion. Culturlly, sensitive interventions nd involvement of other helth cre providers my e considered for more comprehensive smoking cesstion, in ddition to PA. Key words: Fmily physicin, minority men, physicin dvice, primry cre clinics, smoking cesstion, stges of chnge. The Author Pulished y Oxford University Press. All rights reserved. For permissions, plese e-mil: journls.permissions@oup.com. 626 Downloded from

2 Physicin dvice to quit smoking nd the stges of chnge 627 Introduction Cigrette smoking is ssocited with chllenging ddiction nd tkes hevy toll in glol helth (1). Mny countries hve developed smoking cesstion policies nd progrms (2), in order to reduce the urden of this leding preventle cuse of chronic moridity nd mortlity (3). Smoking cesstion is considered s cost-effective intervention for helth cre systems (4). As result, the 5As (Ask, Advise, Assess, Assist nd Arrnge) (5) intervention is now routine prctice in mny helth cre systems, nd fmily physicins in primry cre clinics re expected to determine ptients motivtion to quit nd offer ssistnce sed on tht motivtion (6,7). Physicin dvice (PA) to quit smoking hs proven effective: delivery of rief dvice y physicins hs een ssocited with 1 3% increse in quit rtes (8); ptients who receive PA re more likely to rememer helth eduction mterils on smoking nd to report more ttempts to quit (9). Compred to no intervention, PA hs een shown to increses quit rtes y 24% (10). Nevertheless, some studies reveled disprities mong ptients who receive PA to quit smoking (11 13), with ptient s ethnicity nd socioeconomic sttus ffecting the likelihood of receiving this dvice (13 15). For exmple, in US study of current smokers, ethnic minorities reported less frequently receiving PA to quit compred to Whites (13). A recent review of studies showed tht the likelihood of physicins providing dvice on smoking cesstion lso vries cross countries (12). In developing countries where smoking is highly prevlent (1), receiving PA is less common (12). The STOP survey, conducted mong fmily physicins in 16 medium high income countries, reveled tht ~40% of physicins provide counselling on smoking or discuss smoking hits during every visit (16). In Isrel, evidence shows some inconsistency etween physicin nd ptient s reports on PA on smoking cesstion. A study conducted in 23 primry cre clinics in the Tel-Aviv re showed tht 41% of ptients reclled eing sked out smoking, while only 31% reported receiving dvice to quit (17). In hospitl-sed study, 90% of physicins reported tht they dvise their ptients to quit smoking (18). As of 2010, Isrel introduced new smoking cesstion regultions in primry cre clinics s prt of the sket of services provided y ll of the four HMOs (Helth Mintennce Orgniztions): physicins re now expected to sk ll ptients out their smoking hits, dvise those who smoke to quit, refer them to free-of-chrge smoking cesstion groups nd offer susidized smoking cesstion medictions to those who ttend group meetings (19). Smoking is highly prevlent mong Ar men in Isrel (46%), nd this high rte hs persisted over the lst decde. In contrst, mong Jewish men smoking hs declined y 48% over 30 yers (to ~20% in 2014) (20). However, little is known out whether Ar men in Isrel receive PA on smoking cesstion nd its effectiveness. In the current study, we im to fill this gp y studying the reltionship etween receiving n dvice to quit smoking from fmily physicin nd motivtion to quit mong Ar men in Isrel. Specificlly, we exmine whether receiving PA is ssocited with the stges of chnge set out in the trns-theoreticl model (21). This model suggests tht smoking cesstion, rther thn eing one-time event (7), occurs cross motivtionl phses (21,22). Ech stge cptures the motivtion nd timefrme for intentions or ction to quit (21): pre-contempltion, where smokers re uninterested in quitting; contempltion, where smokers think out quitting within 6 months; preprtion, where smokers express desire to quit during the next month; ction, when smokers stop smoking for 1 6 months; mintennce, where smoking stinence is mintined from 6 months to 5 yers nd termintion, when smoker hs cesed smoking for >5 yers. Behviourl interventions to ssist smoking cesstion sed on the stges of chnges hve een shown to e s effective s phrmcologicl interventions (22). Since PA cn increse the motivtion to quit (7), we ssume tht it is lso ssocited with the stges of chnge. However, few studies hve exmined this ssocition. We hypothesized tht receiving PA would e ssocited with more dvnced stges of chnge compred to not receiving such dvice. We lso tested the ssocitions etween severl demogrphic chrcteristics, helth sttus, socioeconomic position, HMO memership nd smoking-relted vriles nd PA nd the stges of chnge. Methods Study smple nd dt collection Dt for the current study re sed on the originl cross-sectionl study tht ws conducted in The originl study imed to exmine fctors ssocited with smoking cesstion nd the stges of chnge to quit smoking mong Ar men in Isrel. A detiled description of the study smple nd methods ws previously descried (19). In rief, the study smple, consisted of Ar men yers of ge, rndomly selected from Ar towns with >5000 residents, nd strtified y country re (north, centre or south), the size nd socioeconomic position of the loclity. Out of 1620 men screened y phone or home visits, 1165 met the inclusion criteri (i.e. were current or pst smokers), nd 964 greed to prticipte (response rte = 83%). Prticipnts in the current study (N = 964) were interviewed fter signing n informed consent form. The interviews were conducted fce-to-fce t the prticipnt s home y trined Aricspeking interviewers, using structured questionnire in Aric. The Ethics Review Bord of the Fculty of Helth Sciences t Ben- Gurion University of the Negev pproved the study protocol. Mesures Reception of fmily PA ws mesured y n yes/no nswer to the question: Hve you ever een dvised y your fmily physicin to quit smoking? Prticipnts who replied, Yes, I smoke now to the screening question Do you smoke? were ctegorized s current smokers nd were susequently sked out their stge of chnge y the following question: Do you intend to quit smoking? Answer ctegories included: 1. No, never (pre-contempltors), 2. Yes, thinking out quitting within the next 6 months (contempltors) nd 3. Yes, thinking out quitting within the next month (preprtion). Prticipnts who replied tht they do not smoke were sked if they smoked in the pst. If nswered ffirmtively, they were chrcterized s pst smokers nd sked when they hd quit smoking; nswer ctegories were 4. Within the lst 6 months (ction stge), 5. >6 months nd <5 yers (mintennce) or 6. >5 yers (termintion). We reclssified smokers in the lst three stges into one ctegory clled ction, due to smll numers in ech of these stges [ction, 3.3% (N = 30), mintennce 8.6% (N = 78) nd termintion 6.6% (N = 60)] We lso tested ssocitions with the following covrites: Sociodemogrphic chrcteristics, including: ge (ctegories were 18 25, 26 35, nd yers) nd mritl sttus (1. mrried or 2. unmrried, including single, divorced, seprted or widowed]. Socioeconomic sttus, included three self-reported mesures: eduction, mesured y the question wht is the highest eductionl level you completed? (1. less thn high school, 2. high school nd 3. more thn high school); source of income, mesured y the question wht is your fmily s source of income? (1. work or 2. socil Downloded from

3 628 Fmily Prctice, 2016, Vol. 33, No. 6 llownces/other); nd employment sttus, mesured y the question Do you currently work? (1. Yes, full time nd 2. not employed or working prt time). Helth sttus: mesured y one vrile on chronic disese n yes/no question: Hs your physicin ever informed you tht you hve chronic disese? Smoking-relted vriles included: 1. The numers of smoking yers, ctegorized s <5, 6 10, nd 21+ nd 2. Nicotine dependence ws mesured only mong current smokers using the extensively used Fgerstrom Test for Nicotine Dependence (FTND) (23), rnging from 0 (lest dependent) to 10 (most dependent). Scores re clssified s: 0 2, very low; 3 4, low; 5, moderte; 6 7, high nd 8 10, very high. Finlly, we determined HMO memership y direct question: wht HMO you elong to? In Isrel, there re four orgniztions (Cllit, Mci, Meuhedet nd Leumit) tht provide universl nd comprehensive sket of primry-to-tertiry helth cre services ccording to Ntionl Helth Insurnce Lw. The smoking cesstion interventions re provided s prt of the services in the primry cre clinics strting from Dt nlysis We used SAS (version 9.3. Cry, NC: SAS Institute Inc., 2011) for the dt nlysis. First, we exmined the ssocitions etween hving received PA to quit smoking nd oth smoking sttus (current or pst smoking) nd the stges of chnge in quitting (pre-contempltion, contempltion, preprtion nd ction). We then exmined ivrite ssocitions etween the covrites (demogrphics, socioeconomic sttus, chronic moridity, HMO memership nd smoking relted vriles i.e. numer of yers smoking nd nicotine dependence) nd hving received PA, nd etween these covrites nd the stges of chnge. Associtions etween independent vriles, PA nd stges of chnge were tested using the chi-squre sttistic. We conducted multivrile logistic regression nlysis for hving received PA, djusted for covrites found ssocited with PA t the significnce level of P < 0.05 in univrite nlysis. Finlly, we used ordered logistic regression nlysis to test the ssocition etween receiving PA to quit smoking nd the stges of chnge of quit smoking. All covrites tht were significntly ssocited (P < 0.05) with receiving PA nd the stges of chnge were entered into the ordered regression model, fter testing the proportionl odds ssumption. The reference ctegory for the ordered regression ws the pre-contempltion stge. The rte of missing informtion in the study ws low (<10%) nd ~6% for the stges of chnge. Results Aout 40% of prticipnts reported ever hving received PA to quit smoking. Hving received this dvice ws significntly ssocited with the stges of chnge for quit smoking (P < 0.001); reception of PA ws reported y 33%, 52%, 46% nd 43% of prticipnts t the pre-contempltion, contempltion, preprtion nd ction stge, respectively. However, we found no significnt ssocition etween ever hving received PA nd smoking sttus; the proportion of prticipnts who reported receiving PA ws similr mong current nd pst smokers (Figure 1). The univrite ssocitions showed tht prticipnts who reported hving received PA to quit smoking were significntly older, more often mrried nd hd lower eduction nd income (Tle 1, column A). They lso reported more frequently hving chronic disese(s). The mjority of prticipnts who reported hving received PA hd een smoking for 21 yers or more nd hd higher men scores of nicotine dependence. Receiving PA ws not significntly ssocited with employment sttus or with the HMO ssignment. In the multivrile logistic nlysis (Tle 1, column B), we found tht smokers with one or more chronic disese were more likely to report receiving PA to quit, compred to smokers without ny chronic disese; odds rtio (OR) nd 95% confidence intervl (CI): 2.10 ( ). Smokers with higher nicotine dependence scores were lso more likely to report receiving PA. Compred to smokers with very high FTND, the OR (95% CI) of receiving PA for smokers with very low FTND ws 0.35 ( ). The other covrites (ge, mritl sttus, eduction, min source of income, numer of yers of smoking nd HMO memership) were not significntly ssocited with ever receiving PA to quit smoking. In Tle 2, we present the ssocitions etween the covrites nd the stges of chnge in quitting smoking. Age, mritl sttus, eduction nd hving one or more chronic disese were significntly ssocited with the stges of chnge (P < 0.05). A higher Figure 1. The proportion nd 95% CI of Ar men who reported ever receiving physicin to quite smoking y smoking sttus nd stges of chnge to quit Downloded from

4 Physicin dvice to quit smoking nd the stges of chnge 629 Tle 1. Univrite nd multivrile ssocitions etween prticipnt chrcteristics nd ever hving received physicin dvice to quit smoking mong rndom smple of Ar men smokers interviewed in N A. Univrite ssocitions (N = 964) B. Multivrile ssocitions c (N = 606) No, N (%) Yes, N (%) P Odds Rtio (95% confidence intervl) Age < (76.7) 57 (23.3) 0.70 ( ) (69.5) 71 (30.5) 0.51 ( ) (57.5) 82 (42.5) 0.72 ( ) (40.8) 170 (59.2) 1 Mritl sttus Mrried (54.5) 287 (45.5) 1.10 ( ) Unmrried (71.9) 92 (28.5) 1 Eduction <0.001 Less thn high school (48.8) 104 (51.2) 0.97 ( ) High school (66.1) 197 (33.9) 1.71 ( ) More thn high school (47.2) 69 (41.8) 1 Min source of income <0.001 Socil llownces/other (47.8) 84 (52.2) 0.81 ( ) Work (63.4) 277 (36.4) 1 Employment Unemployed or prt time (55.8) 122 (44.2) Full time (62.2) 257 (37.8) Chronic disese <0.001 No (70.6) 187 (29.4) 1 Yes (40.6) 193 (59.4) 2.10 ( ) Numer of yers smoking < or more (40.5) 179 (59.5) 1.49 ( ) (61.8) 81 (38.2) 1.93 ( ) (72.2) 47 (27.8) 2.63 ( ) 5 or less (81.5) 32 (18.5) 1 Helth cre orgniztion Cllit (60.5) 297 (39.5) Mci (65.9) 14 (34.1) Meuhedet (59.3) 35 (40.7) Leumit (57.7) 33 (42.3) Nicotine dependence (FTND) d 726 <0.001 Very low (0 2) (76.4) 53 (23.6) 0.35 ( ) Low (3,4) (55.4) 75 (44.6) 0.89 ( ) Moderte (5) (55.3) 42 (44.6) 0.77 ( ) High (6,7) (51) 75 (53.5) 0.82 ( ) Very high (8 10) (46.5) 46 (53.5) 1 FTND, Fgerstrom test for nicotine dependence. P-vlue ws clculted y chi-squre test Vrile ws not included in the multivrile nlysis, s it ws not significnt in the univrite ssocition with physicin dvice. c The chi-squre of likelihood rtio test ws Chi-squre (Hosmer nd Lemeshow) = 9.78, significnce of the Model = 0.28 nd R squre = d FTND ws collected nd clculted only for current smokers.- percentge of prticipnts t the pre-contempltion stge were young (18 25 yers of ge) (59.7%), unmrried (57.8%), hd high school eduction (52.5%) nd did not report hving ny chronic disese (56.6%). Prticipnts t the ction stge were more likely to e older (46 64) (20%), more often mrried (21.8%), hd higher eduction (more thn high school) (22.8%) nd more likely to hve chronic disese(s) (26%). Prticipnts min source of income, employment sttus, numer of smoking yers, HMO nd level of nicotine dependence (FTND) were not significntly ssocited with the stges of chnge for quit smoking nd therefore were not included in the ordered regression nlysis. Results of the ordered logistic regression model (Tle 3) showed tht prticipnts who received PA to quit smoking were more likely to e t the contempltion (OR = 1. 95, 95% CI = ) or preprtion stge of quitting (OR = 1.74, 95% CI = ), compred to the pre-contempltion stge. However, receiving PA ws not significntly ssocited with eing t the ction stge of quitting. Tle 3 lso shows tht hving high school eduction (compred to less thn high school) ws significntly ssocited with eing t the preprtion (OR = 2.77, 95% CI = ) or ction (OR = 2.40, 95% CI = ) stges of chnge, compred to pre-contempltion. Hving more thn high school eduction ws ssocited with eing further long in the stges of quitting t the ction stge, compred to the pre-contempltion stge (OR = 1.73, 95% CI = ). Hving chronic disese ws ssocited with higher likelihood of eing t more dvnced stges of chnge i.e. preprtion (OR = 2.36, ) nd ction (OR = 2.34, ), compred to pre-contempltion. Downloded from

5 630 Fmily Prctice, 2016, Vol. 33, No. 6 Tle 2. Associtions etween independent study vriles nd stges of chnge leding to quitting smoking mong rndom smple of Ar men smokers interviewed in N Stges of chnge leding to quitting smoking N (%) P Pre-contempltion (N = 454) Contempltion (N = 175) Preprtion (N = 106) Action (N = 168) Age N (%) N (%) N (%) N (%) < (59.7) 32 (14) 36 (15.8) 24 (10.5) (48.8) 47 (21.5) 24 (11) 41 (18.7) (50.5) 37 (20.1) 19 (10.3) 35 (19.1) (43) 59 (21.8) 27 (10.0) 68 (20.0) Mritl sttus <0.001 Mrried (46.4) 125 (21.0) 64 (10.8) 130 (21.8) Unmrried (57.8) 50 (16.4) 42 (13.7) 37 (12.1) Eduction Less thn high school (51.5) 44 (22.5) 18 (9.2) 33 (16.8) High school (52.5) 102 (18.0) 59 (11.0) 94 (17.5) More thn high school (41.8) 27 (17.1) 29 (18.3) 36 (22.8) Min source of income Socil llownces/other (51.7) 25 (16.8) 11 (7.4) 36 (24.1) Work (50.6) 139 (19.5) 88 (12.4) 125 (17.5) Employment Unemployed or prt time (45.6) 49 (19.6) 32 (12.8) 55 (22.0) Full time (51.7) 126 (19.4) 74 (11.4) 113 (17.5) Chronic disese <0.001 No (56.6) 107 (18.0) 64 (10.7) 88 (14.7) Yes (38.1) 68 (22.1) 42 (13.7) 80 (26.0) Numer of yers smoking 21 or more yers (50.7) 62 (21.4) 29 (10.0) 52 (17.9) yers (42.9) 42 (21.2) 28 (14.1) 43 (21.7) 6 10 yers (54.0) 31 (19.0) 14 (8.6) 30 (18.6) 5 or less yers (52.2) 17 (10.6) 24 (14.9) 36 (22.3) Nicotine dependence (FTND) 673 Very low (0 2) (63.2) 46 (22.6) 29 (14.2) Low (3,4) (56.1) 40 (25.5) 29 (18.5) Moderte (5) (61.8) 22 (24.7) 12 (13.5) High (6,7) (63.4) 37 (26.1) 15 (10.6) Helth cre orgniztion Cllit (51.4) 129 (18.5) 82 (11.7) 129 (18.5) Mci (48.7) 9 (23.1) 3 (7.7) 8 (20.5) Meuhedet (47.1) 18 (21.2) 13 (15.3) 14 (16.5) Leumit (44.6) 18 (24.3) 8 (10.8) 15 (20.3) P-vlues were clculted y chi-squre test. In the ction stge, there were no oservtions for FTND; thus, we did not clculte the proportions for the ctegories. Discussion Few studies hve looked t the ssocition etween receiving PA from fmily physicin on smoking cesstion nd the stges of chnge in quitting mong minority groups. We imed to ddress this gp of knowledge y studying smple of Ar minority men in Isrel. Our min finding ws tht receiving PA is ssocited with greter likelihood of eing t the contempltion nd preprtion stges of quitting smoking, ut not with the ction stge. This my men tht physicin s dvice is not ssocited with smoking cesstion per se, ut with incresed motivtion to quit. Our results suggest tht receiving PA my increse smokers motivtion to contemplte nd prepre to quit, ut tht this dvice is less effective in chieving ctul smoking cesstion. However, it is lso possile tht those lredy further long in quitting (contempltion nd preprtion stges) re more likely to report receiving PA, s they re more redy to quit nd will e more ffected y such dvice. This would e consistent with previous studies tht suggest tht motivtionl interventions (including PA for smoking cesstion) might e more effective in smokers who re more prepred to quit (7). Another possile explntion for the lck of n ssocition etween PA nd smoking cesstion my e lso due to individuls who quit without help or dvice from their fmily physicin (24,25). Aout 33% of Ar men in the current study who received PA were t the pre-contempltion stge or not redy to quit (19). Receiving PA ws not ssocited with the ction stge (quitting). This my e explined y either the low prevlence of ever receiving PA, or y low effectiveness of this dvice. Although this finding requires further investigtion using longitudinl dt, our study my suggest tht more trining is needed to help fmily physicins provide more effective dvice nd counselling to Ar mle smokers. Development of culturlly sensitive progrms on smoking cesstion (26), mong Ar men my improve the PA effectiveness especilly if other helth cre providers such s nurses, phrmcists nd expert physicins would lso provide culturlly sensitive dvice for smoking cesstion. Only 40% of the study prticipnts hd ever received PA on cesstion. Although this is low percentge, it is consistent with Downloded from

6 Physicin dvice to quit smoking nd the stges of chnge 631 Tle 3. Ordered logistic regression for the stges of chnge leding to quitting smoking djusted for ever hving received physicin dvice to quit nd other covrites mong rndom smple of Ar men smokers interviewed in (N = 884) Pre-contempltion Contempltion Preprtion Action Overll sig. OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) Ever receiving physicin dvice P = Yes Ref 1.95 ( ) 1.74 ( ) 1.14 ( ) No Age P = Ref 0.79 ( ) 2.78 ( ) 0.58 ( ) Ref 1.27 ( ) 1.61 ( ) 0.95 ( ) Ref 0.95 ( ) 1.10 ( ) 0.80 ( ) Mritl sttus P = Mrried Ref 0.89 ( ) 0.71 ( ) 0.68 ( ) Unmrried Eduction P = More thn high school Ref 1.14 ( ) 1.42 ( ) 1.73 ( ) High school Ref 1.14 ( ) 2.77 ( ) 2.40 ( ) Less thn high school Chronic disese P < Yes Ref 1.52 ( ) 2.36 ( ) 2.34 ( ) No CI, confidence intervl; OR, odds rtio. The chi-squre of the likelihood rtio test ws Pseudo R 2 of the Model ws = We suggest interpreting this sttistics with gret cution, s it does not men the proportion of vrince for the response vrile explined y the predictors, nd it is not equivlent to R 2 in OLS regression. Reference ctegory. some previous reserch in Isrel (14,27). A study in Tel-Aviv re showed tht 31% of ptients in primry cre clinics reported receiving PA to quit (17) nd 13.9% received specific ids to quit smoking. A US study showed tht Africn Americn nd Hispnic minority ptients reported receiving less dvice: 50% nd 61% respectively, thn White ptients (69%) (13). One possile reson some physicins my not provide dvice is tht they re themselves smokers struggling with cesstion (3,12). A study in Turkey showed tht GPs who smoke were less likely to provide dvice on smoking cesstion (27). These physicins considered discussions with ptients on this topic to e ineffective, were not confident in their knowledge, or hd unplesnt experiences providing such dvice (27). In Isrel, ntionwide dt out smoking prevlence mong fmily physicins or other specilists is lcking. A smll study conducted in single medicl center found lower smoking rtes mong physicins thn in the generl popultion (16.7% versus 24%, respectively) (18). However, this study ws not representtive of the ethnic composition of physicins in Isrel. A cohort study in the UK found tht prevlence of smoking mong physicins is similr to the prevlence in the generl popultion (3). If this pplies to our study popultion, then Ar mle physicins my e more likely to e smokers thn Jewish mle physicins, since prevlence of smoking mong Ar men in Isrel is lmost twice tht of Jewish men (46% nd 23%, respectively) (20). Future reserch is needed to ssess smoking prevlence mong fmily physicins y ethnic groups in Isrel, prticulrly since Ar fmily physicins re more likely to e employed in primry cre clinics in Ar villges nd towns, s prt of culturl competence helth cre services policy of the HMOs (28). Since the new smoking cesstion technologies were included in the universl sket of helth cre services provided y the HMOs strting from 2010, there hs een more emphsis on providing cesstion dvice in primry cre clinics in Isrel (19). Smoking cesstion services re provided in similr rtes (free workshops nd susidized medictions) y ll HMOs. We did not find ny significnt ssocitions etween HMO memership nd receiving PA, suggesting no differences in providing PA cross the four HMOs. Furthermore, we found tht socioeconomic position ws not ssocited with ever receiving PA to quit smoking. These results re inconsistent with previous reserch indicting tht providing PA is ssocited with socioeconomic sttus (13,15). However, the vritions in eduction nd income levels in our study popultion were smll. Therefore, socioeconomic sttus might ply minor role in explining whether individuls receive PA. Our finding tht smokers with chronic disese(s) or high nicotine dependence re more likely to receive PA to quit smoking grees with Houston et l. (13) study, which found tht some physicins tend to provide more dvice on secondry prevention when ptients hve more severe helth conditions. This suggests tht lthough there re opportunities for erlier smoking cesstion dvice, physicins re more likely to provide such dvice when there is chronic helth condition, or tht the ptient with the chronic disese is more open to receive nd recll this dvice. This finding might lso relte to the numer of visits to physicins, s chronic ptients often hve more frequent interctions with their doctors. We did not hve ccess to documenttion of pst clinicl encounters with the physicin, which cn e collected in future reserch. Study strength nd limittions Due to our study design, inference on cusl ssocition etween receiving PA nd the stges of chnge is limited. However, our results cn provide seline informtion for future longitudinl reserch on the effectiveness of PA. In ddition, we did not determine the intensity of dvice (rief or repeted). Previous reserch suggests tht different intensities cn led to different results (10). Since PA ws self-reported, recll is could hve occurred. Ar men might e Downloded from

7 632 Fmily Prctice, 2016, Vol. 33, No. 6 less likely to recll such dvice specificlly if they re t the precontempltion stge. In ddition, psychosocil mechnisms, such s denil, my ffect smokers reports out receiving PA to quit smoking. For exmple, they might e less likely to perceive the informtion out cesstion s PA to quit smoking. Also, self-quitters might e less likely to report receiving PA (24,25). Future reserch should include collection of ojective informtion from the HMO computerized dt regrding the proportion of smokers whom were dvised to quit y their physicins. Informtion sed on the physicins perspective would vlidte ptient self-reported dt. Conclusion Our study suggests tht receiving PA to quit smoking might e ssocited with smokers think out quitting smoking (contemplting), nd prepring to quit (preprtion) ut it is not ssocited with smoking cesstion. Given tht smoking prevlence is very high mong Ar men in Isrel, voiding to provide this dvice represents missed opportunity, regrdless of the ptients helth sttus or nicotine dependence. In ddition, the fct tht out one-third of those who received PA were still t the pre-contempltion stge, suggests tht the PA in itself my e insufficient, nd more effective techniques such s motivtionl strtegies ccompnied y culturlly congruent dvice re needed, lso provided y other helth cre professionls specificlly trined for this gol. Acknowledgements We would like to thnk the men who prticipted in the study. Declrtion Funding: this study ws supported y grnt numer R/152/10 of the Isrel Ntionl Institution for Helth Policy nd Reserch (NIHP). Ethicl pprovl: the study ws pproved y the Fculty of Helth Sciences Review Bord t Ben-Gurion University of the Negev. Conflicts of interest: none. References 1. WHO. WHO Report on the Glol Tocco Epidemic: Enforcing Bns on Tocco Advertising, Promotion nd Sponsorship. 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