Tobacco use interventions in surgical patients Although there are many opportunities to intervene in surgical patients who smoke, these opportunities

Transcription

1 RESPIRATION AND THE AIRWAY Perioperative tobacco use interventions in Japan: a survey of thoracic surgeons and anaesthesiologists T. Kai 1, T. Maki 1, S. Takahashi 1 and D. O. Warner 2 * 1 Department of Anesthesiology and Critical Care Medicine, Kyushu University, Fukuoka, Japan. 2 Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA *Corresponding author. warner.david@mayo.edu Background. Tobacco use interventions in surgical patients who smoke could benefit both their short-term outcome and long-term health. Anaesthesiologists and surgeons can play key roles in delivering these interventions. This study determined the practices, attitudes, and beliefs of these physicians regarding tobacco use interventions in Japan. Methods. Questionnaires were mailed to a national random sampling of Japanese anaesthesiologists and thoracic surgeons (1000 in each group). Results. The survey response rate was 62%. More than 80% of respondents agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking. Compared with anaesthesiologists, surgeons were more likely to perform the elements of current recommendations for brief intervention, and to have attitudes favourable to tobacco use interventions. The most significant barrier to intervention identified by both groups was a lack of time to perform counselling. Compared with nonsmokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions Conclusions. Although current rates of intervention provided by anaesthesiologists and surgeons are low, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a teachable moment to promote abstinence from smoking, leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan. Br J Anaesth 2008; 100: British Journal of Anaesthesia 100 (3): (2008) doi: /bja/aem400 Advance Access publication January 29, 2008 Keywords: complications, smokers; education; surgery, preoperative period Accepted for publication: December 11, 2007 Smoking is a serious public health problem in Japan, with 47% of males and 12% of females smoking cigarettes in Consistent with these rates in the general population, in 2000, 42% of males and 19% of females undergoing surgery at a Japanese public hospital smoked cigarettes. 2 Thus, millions of cigarette smokers undergo surgery and anaesthesia in Japan each year. Their smoking has both immediate potential consequences to perioperative outcomes and long-term consequences to their overall health; efforts to help smokers quit in the perioperative period could benefit both. 3 Even temporary abstinence from smoking may reduce the risk of perioperative complications and improve surgical outcomes. 4 In addition, surgery may be a powerful motivator for longterm abstinence, such that tobacco use interventions may be particularly effective during this period. 35 The surgical process provides multiple opportunities for healthcare providers to intervene. In addition, in May 2003, the Japanese government implemented a health promotion law that mandates prevention of passive smoking in public spaces, encouraging many healthcare facilities in Japan to change their smoking polices. Such forced abstinence mandated by smoke-free policies may facilitate perioperative interventions to stop smoking. 6 # The Board of Management and Trustees of the British Journal of Anaesthesia All rights reserved. For Permissions, please journals.permissions@oxfordjournals.org

2 Tobacco use interventions in surgical patients Although there are many opportunities to intervene in surgical patients who smoke, these opportunities remain largely unexploited. Anaesthesiologists assess each patient before surgery, and so are well positioned to intervene. There are also excellent opportunities for surgeons, especially those such as thoracic surgeons who frequently treat smoking-related diseases such as lung cancer. However, very few surgeons and anaesthesiologists have expertise in tobacco control techniques, and many may not feel that this is their responsibility. A recent survey of anaesthesiologists and surgeons in the USA found that few incorporated tobacco control interventions into their practices, although there was considerable interest in learning more about how to do so. 78 The practices and attitudes of Japanese anaesthesiologists and surgeons regarding tobacco control are not known. Compared with American physicians, smoking rates among Japanese physicians are relatively high: 27% of male and 7% of female physicians smoke cigarettes 9 compared with,2% of American physicians. 10 Physicians smoking behaviour is an important determinant of their approach to tobacco control. 9 In addition, there may be cultural factors that determine attitudes and practices towards tobacco control. As an initial step to promote tobacco control interventions in Japanese surgical patients, we surveyed the practices, attitudes, and beliefs of anaesthesiologists and surgeons in regard to tobacco use interventions in Japan. Methods The study was approved by Institutional Review Board of Kyushu University Graduate School of Medical Sciences. On February 1, 2005, questionnaires were mailed to 1000 anaesthesiologists who were randomly selected from a list of board certified anaesthesiologists (as of November 2004) maintained by the Japanese Society of Anaesthesiologists. Questionnaires were also mailed on the same date to 1000 thoracic surgeons who were randomly selected from a list of board certified surgeons (as of January 2005) maintained by the Japanese Association for Thoracic Surgery. Permission for the usage of each list was obtained from each respective society. In order to compare with the previous study that surveyed anaesthesiologists and general surgeons in the USA, 7 we first planned to survey anaesthesiologists and general surgeons in Japan by using the respective societies list. However, the usage of the member list was declined by Japan Surgical Society. We therefore asked the Japanese Association for Thoracic Surgery as an alternative option to provide a list of board certified surgeons, since thoracic surgeons frequently deal with the consequences of tobacco-related diseases. Subject lists of anaesthesiologists and surgeons were created with systematic sampling from the society s lists, that is, from the list of 5329 board certified anaesthesiologists sorted by alphabetical order of institutions and names, every fifth anaesthesiologist was selected, and from the list of 1492 board certified thoracic surgeons, two of every three were initially selected from a similarly sorted list, then the remainder were selected in descending order from initially excluded members. Survey packets including the cover letter, survey instrument, comment sheet, and stamped return envelope were prepared specific to each group. Return envelopes were marked with a subject-specific number in advance so that subjects who responded could be identified for follow-up of non-responders. However, once opened the envelope was detached, such that the survey was anonymous. After 2 months from initial mailing date, reminder postcards were sent to non-responders. The survey items themselves were similar to those utilized in the prior survey of general surgeons and anaesthesiologists in the USA. 7 Questions were grouped into the following categories. Demographics included personal information (including smoking history) and practice characteristics, including whether they were currently in active practice. Current practices included what tobacco control measures are currently being provided by these physicians. Attitudes and beliefs included items querying the perceptions of these physicians regarding various elements of tobacco use interventions. Statistical methods Those respondents not currently engaged in active practice were excluded from analysis. Summary statistics of responses were prepared and are the primary focus of this report. We also compared the responses of anaesthesiologists and thoracic surgeons. The two groups were compared employing non-parametric tests for each of the demographic variables, using a rank sum test for the continuous variables, and x 2 test for categorical variables. Some respondents provided two responses for a single question. Unless an appropriate single response could be inferred, these responses were excluded from analysis. For the question of average number of cigarettes consumed per day, the midpoint was used for analysis if a range was provided in an individual response. The questions regarding the practitioner s current practices had four options ranging from never to almost always (more than 75% of the time). These ordinal responses were compared between the groups with a rank sum test. For items querying the respondent s attitudes/beliefs and interest in learning about interventions, there were five levels of agreement ranging from strongly agree to strongly disagree and a don t know option. Seven of the items had more than 3% of the respondents in one or both groups selecting the don t know option. For these seven items, comparisons were made with a x 2 test. Otherwise, the don t know responses were excluded from the analysis and the rank sum test was used to compare the ordinal 405

3 Kai et al. Table 1 Survey responses. Reasons for self-exclusion included paediatric practice or no current practice Response Anaesthesiologists (1000 mailings) Surgeons (1000 mailings) n % n % Returned surveys Not currently practicing Usable (basis of report) Invalid (blank) No survey sheets enclosed Unreturned surveys Undelivered mail Self-exclusion by No response response between the two groups. The proportion of usable completed surveys (i.e. response rate) in each group was compared using a x 2 test. In all cases, P-values of,0.05 were considered significant. Results Surveys were returned from the initial mailing by 538 anaesthesiologists and 556 surgeons. Surveys were eventually received from 623 and 625 anaesthesiologists and surgeons, respectively (Table 1). A total of 542 surveys from anaesthesiologists and 521 surveys from surgeons were included in analysis; the majority of exclusions were because the respondents were not in active clinical practice. The demographics of these respondents are shown in Table 2. The surgeons were significantly older and more likely to be male. All respondents practiced in environments with some restrictions on smoking, although only approximately 20% of these hospitals prohibited all smoking on hospital grounds. Eleven per cent (11%) of anaesthesiologists and 13% of surgeons were active or occasional smokers, and 22% and 39% of anaesthesiologists and surgeons, respectively, were ex-smokers (Table 2). Thus, approximately one-third of anaesthesiologists and half of surgeons had personal Table 3 Characteristics of regular and occasional smokers. *P-values for continuous variables from Wilcoxon rank sum test, comparing anaesthesiologists and surgeon responses; P-values for categorical variables from x 2 test Table 2 Respondent demographics. *x 2 P-values Characteristic Anaesthesiologists (n559) Surgeons (n565) Characteristic Anaesthesiologists (n5542) Surgeons (n5521) Practice environment 0.44 University or college hospital Public hospital (200 beds) Public hospital (,200 beds) 2 2 Private hospital (200 beds) Private hospital (,200 beds) Private practice (including clinics with few beds) 6 3 Age (yr), Under or older 4 17 Sex, Male Female 28 1 Cigarette smoking status, Regular smoker 9 8 Occasional smoker 2 5 Ex-smoker Non-smoker Current hospital smoking 0.15 policy No restrictions 0 0 Smoking allowed in specific 9 8 non-enclosed spaces Smoking allowed in specific enclosed spaces Smoking prohibited within the building Smoking prohibited on hospital grounds Don t know 1 0 Number of cigarettes a day, 10 ( ) 10 (0 60) 0.21 median (range) Number of years smoked, 20 (0.5 35) 30 (0 50), median (range) Feelings towards their smoking, % in agreement My smoking is harmful to me My smoking is harmful to surrounding personnel As a healthcare provider, I should not smoke My smoking affects my ability to help patients stop smoking Number of attempts to stop smoking None or more 7 16 Do you want to quit smoking? Yes No If your hospital becomes smoke-free (no smoking on the grounds), what would you do? Quit smoking without assistance Quit smoking using with 7 2 assistance provided by hospital Continue to smoke where allowed Move to another hospital 9 3 where smoking is not prohibited Don t know

4 Tobacco use interventions in surgical patients experience with using tobacco. The majority of physician smokers recognize the personal risks of smoking, have made at least one quit attempt, and want to quit (Table 3). Approximately 40% would try to quit smoking if their hospital became smoke free (Table 3). Current practices Surgeons were more likely to perform the elements of current recommendations for brief intervention compared with anaesthesiologists (Table 4). For example, 64% of surgeons reported almost always advising patients to quit smoking for good, compared with 17% of anaesthesiologists. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking. Attitudes and beliefs More than 80% of surgeons and anaesthesiologists agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients (Table 5). More surgeons (88%) than anaesthesiologists (62%) agreed or strongly agreed that it was their responsibility to advise their patients to quit smoking (Table 5). Overall, surgeons were more likely than anaesthesiologists to affirm responsibility for addressing tobacco use, although strong majorities of both groups agreed that the perioperative period was a good time to get patients to permanently stop smoking (Table 5). The most significant barrier identified by both groups was a lack of time to perform counselling (Table 5). As with other categories, overall the attitudes of the surgeons were more favourable to interventions. Overall, surgeons were more confident than anaesthesiologists regarding their ability to intervene and in their knowledge of interventions (Table 6). More than half of the anaesthesiologists agreed or strongly agreed that they did not know how to counsel their patients (Table 6), and only 32% agreed or strongly agreed that they know how to get help for their patients who smoke. Majorities of both groups expressed interest in learning more about interventions (Table 6), and 85% of both groups would be willing to refer patients to effective intervention services. To analyse the impact of smoking status on the responses, the responses of surgeons and anaesthesiologists who reported regular or occasional smoking were combined and compared with the combined responses of never or ex-smokers. Compared with non-smokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions (Table 4), with the exception of advising patient to stop smoking perioperatively. Regarding attitudes and beliefs, the responses of nonsmokers were consistently more favourable towards interventions compared with smokers (data not shown). For example, non-smokers were more than twice as likely as smokers to strongly agree that the perioperative period is a good time to get patients to stop smoking (36% and 15% of non-smokers and smokers, respectively, P,0.0001). Although 27% of non-smokers strongly agreed that it was their responsibility to advise their patients to quit smoking, only 15% of smokers did so (P,0.01). Smokers were also Table 4 Current practices. *Wilcoxon rank sum, comparing either anaesthesiologist (A) and thoracic surgeon (TS) responses, or the responses of regular or occasional smokers (S, both anaesthesiologists and surgeons) and non-smokers (NS, both surgeons and anaesthesiologists). N is the number of valid responses The following questions deal with your interactions with patients. How often do you Group N Never or rarely Sometimes (<25% of the time) Frequently (25 5% of the time) Almost always (>75% of the time) Ask your patients if they smoke? A ,00001 TS S NS Advise your patients who smoke about the health risk of smoking? Advise your patients who smoke to stop smoking perioperatively? Advise your patients who smoke to quit permanently? Help your patients who smoke to stop smoking? (counsel, medications, education, or referral) A , TS S , NS A , TS S NS A , TS S , NS A , TS S NS

5 Kai et al. Table 5 Attitudes and beliefs: perceptions of benefits, responsibility, and barriers. *If.3% of either group responded don t know, the x 2 test was used to compare anaesthesiologist and surgeon responses. If 3% of both groups responded don t know, these responses were excluded and the groups were compared using Wilcoxon rank sum test. A, anaesthesiologists; TS, thoracic surgeons Question Group N Strongly agree Agree Neutral Disagree Strongly disagree Don t know Benefits of abstinence Quitting smoking for 2 months or longer before surgery will significantly reduce perioperative complications Abstinence from smoking even for 1 30 days before surgery will reduce perioperative complications All patients should refrain from smoking for as long as possible before and after surgery Perceptions of responsibility It is none of my business if a patient chooses to smoke It is part of my responsibility to advise my patients to quit smoking It is part of my responsibility to make sure that patients get the help they need to quit smoking The perioperative period is a good time to get patients to permanently stop smoking Perception of barriers In general, efforts at any time (not just around the time of surgery) to help people quit smoking just are not very effective I should not talk to patients before operation about smoking because they may already be nervous and upset about the surgery I do not have time to counsel my patients about how to quit smoking I only see a patient for a few minutes before operation, and any advice I give to stop smoking will not be effective A TS A TS A , TS A , TS A , TS A , TS A , TS A , TS A , TS A , TS A , TS more likely to oppose strict hospital smoking policies; 52% of non-smokers and 23% of smokers supported complete prohibition of smoking on hospital grounds (P,0.0001). Discussion Recent evidence suggests that surgery represents an excellent opportunity to intervene in patients who smoke, with potential benefits to both immediate surgical outcomes and long-term health Because physicians have an important role in these efforts, it is important to assess their practices and attitudes if effective intervention strategies are to be implemented in surgical settings. The evolution of tobacco use within societies can be conceptualized as an epidemic. 15 Its prevalence increases rapidly as manufactured cigarettes are intensively marketed, first among men, then among women. The peak prevalence in most societies exceeds 50% in males. With the application of effective tobacco control measures, the prevalence of tobacco use declines. In general, physician smoking rates decline earlier and more rapidly compared with the general population. 10 A survey of physician members of the Japan Medical Association in 2000 found that 27% of male and 7% of female respondents reported smoking cigarettes, which was approximately half the rate of the general population and less than previous surveys. 9 Although the current survey (conducted in 2005) samples only a subset of physician specialties, the observed rates suggest that the prevalence of smoking among Japanese physicians continues to decline. In countries in the more advanced stages of epidemic (i.e. when population prevalence is decreasing), physician smoking rates approach zero. For example, in a similar survey of anaesthesiologists and general surgeons in the USA, 1% of physicians reported current smoking. 7 These rates are relevant to tobacco control efforts, because physicians who smoke are less likely to provide and support tobacco interventions The results of the current study support this conclusion, as smokers were less likely to intervene in their patients, 408

6 Tobacco use interventions in surgical patients Table 6 Knowledge and interest regarding interventions. *If.3% of either group responded don t know, the x 2 test was used to compare anaesthesiologist and surgeon responses. If 3% of both group responded don t know, these responses were excluded and the groups were compared using Wilcoxon rank sum test. A, anaesthesiologists; TS, thoracic surgeons Question Group N Strongly agree Agree Neutral Disagree Strongly disagree Don t know Knowledge regarding interventions I do not know how to counsel my patients about how to quit smoking I know about nicotine replacement therapies such as nicotine patch or gum to help stop smoking I know how to help my patients get the help they need to quit smoking Nicotine replacement therapies such as nicotine patch or gum are safe for perioperative use Interest in learning about interventions I would be interested in learning more about how to help my patients quit smoking If I could effectively intervene, I would be willing to spend an extra five minutes preoperatively helping a patient who smokes to quit A , TS A , TS A , TS A , TS A TS A , TS I would refer a patient who is interested in quitting smoking to an effective intervention service if it were available in my practice setting A TS and reported less favourable attitudes towards interventions. They were also less likely to support smoke-free hospital facilities, an important public health tobacco control measure beneficial both to employees and to hospital patients These results support prior recommendations that efforts to encourage Japanese physicians to quit smoking should be intensified. 9 The current study surveyed two physician specialties of particular relevance to the provision of tobacco use interventions to surgical patients. Anaesthesiologists are intimately involved in many aspects of care provided to patients undergoing a wide variety of surgical procedures. The majority of the procedures performed by thoracic surgeons are for conditions directly related to tobacco use, such as coronary artery disease and lung cancer. As such, they might be expected to be the surgical subspecialists most interested in tobacco control. As found in a similar study of anaesthesiologists and general surgeons in the USA, the practices and attitudes of thoracic surgeons were generally more favourable to interventions compared with anaesthesiologists. 7 Prior work suggests that physicians are more likely to intervene when patient disease is clearly related to smoking Although anaesthesiologists may recognize the consequences of smoking to their perioperative management, these consequences may be perceived as minor or transient, without long-term consequences in most instances. In contrast, smoking is often directly related to the need for cardiothoracic surgery, which may better motivate thoracic surgeons to intervene. The results of the current study are in most instances very similar to the prior survey of anaesthesiologists and surgeons in the USA conducted using a similar methodology 7 and indicate that there is much potential for the application of tobacco interventions in surgical patients by these Japanese physicians. If anything, responses were more favourable towards intervention among Japanese anaesthesiologists and surgeons. For example, 83% of Japanese anaesthesiologists agreed or strongly agreed that relatively brief preoperative abstinence (,30 days) would reduce perioperative complications, compared with 52% of US anaesthesiologists. 7 Also, 76% of Japanese anaesthesiologists agreed or strongly agreed that the perioperative period was a good time to get patients to permanently stop smoking, compared with 60% of US anaesthesiologists. These attitudes are remarkable, considering that in many ways tobacco control efforts are better developed in the USA compared with Japan, and that the prevalence of smoking is higher among Japanese physicians. 9 Majorities of both specialties surveyed expressed interest in learning more about how to intervene, and almost all would refer patients to intervention services. As with the prior survey, a major barrier was a lack of time, indicating that a referral strategy would be desirable. A prior survey of US physicians found that surgical subspecialists provide smoking cessation counselling at lower rates compared with medical subspecialists and primary care practitioners. 20 Although it is not possible to directly compare our results with the prior survey of Ohida and colleagues 9 that sampled all Japanese physicians because of differences in timeframe and content, it does appear that the attitudes and practices of anaesthesiologists and surgeons compare quite favourably to this more broad 409

7 Kai et al. assessment across specialties. For example, Ohida and colleagues 9 found that only 25% of Japanese physicians always asked about smoking history, and only 43% agreed that patients should not smoke. This again suggests that anaesthesiologists and thoracic surgeons may be especially receptive to education regarding tobacco use interventions. There are limitations inherent to any survey. The response rate of 62% compares favourably with other recent physician surveys However, there is still a potential for response bias, with those physicians most interested in tobacco control more likely to respond. These results thus may overestimate actual interest in tobacco interventions among anaesthesiologists and thoracic surgeons. Recall bias may also favour overestimation of the actual frequency of intervention, as prior studies suggest that physicians tend to exaggerate that frequency with which they provide tobacco interventions when their selfreports of their practices are compared with contemporaneous observations of actual practices In summary, this survey provides information that can promote efforts to implement tobacco use interventions in Japanese surgical patients. Although current rates of intervention provided by anaesthesiologists and surgeons are low, especially among anaesthesiologists, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a teachable moment (i.e. an event that motivates individuals to change risky health behaviours) for smoking abstinence, 23 leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan. Towards this goal, these specialists should 3 (1) personally maintain tobacco abstinence, (2) receive education in basic principles of tobacco control, (3) consistently recommend that their patients quit smoking for surgery, and (4) encourage the design of presurgical care systems that would provide pharmacotherapy, counselling, and other effective tobacco use interventions to their patients. These efforts would be best coordinated by the appropriate specialty societies, aided by the welldeveloped international community of tobacco control specialists. Funding Kyushu University Hospital; Mayo Foundation. References 1 Shafey O, Dolwick S, Guindon GE. Tobacco Control Country Profiles. Atlanta, GA: American Cancer Society, Nakagawa M, Tanaka H, Shibata SC, et al. Survey of smoking status among preoperative patients and characteristics of smokers. Masui 2002; 51: Warner DO. Helping surgical patients quit smoking: why, when, and how. Anesth Analg 2005; 99: Warner DO. Perioperative abstinence from cigarettes: physiological and clinical consequences. Anesthesiology 2006; 104: McBride CM, Ostroff JS. Teachable moments for promoting smoking cessation: the context of cancer care and survivorship. Cancer Control 2003; 10: Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. Br Med J 2002; 325: Warner DO, Sarr MG, Offord K, Dale LC. Anaesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesth Analg 2004; 99: Warner DO. Preoperative smoking cessation: the role of the primary care provider. Mayo Clin Proc 2005; 80: Ohida T, Sakurai H, Mochizuki Y, et al. Smoking prevalence and attitudes toward smoking among Japanese physicians. JAMA 2001; 285: Nelson DE, Giovino GA, Emont SL, et al. Trends in cigarette smoking among US physicians and nurses. JAMA 1994; 271: Warner DO, Patten CA, Ames SC, Offord K, Schroeder D. Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. Anesthesiology 2004; 100: Warner DO, Patten CA, Ames SC, Offord KP, Schroeder DR. Effect of nicotine replacement therapy on stress and smoking behavior in surgical patients. Anesthesiology 2005; 102: Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002; 359: Simon JA, Solkowitz SN, Carmody TP, Browner WS. Smoking cessation after surgery. A randomized trial. Arch Intern Med 1997; 157: Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tobacco Control 1994; 3: Goldberg RJ, Ockene IS, Ockene JK, Merriam P, Kristeller J. Physicians attitudes and reported practices toward smoking intervention. J Cancer Educ 1993; 8: Longo DR, Brownson RC, Johnson JC, et al. Hospital smoking bans and employee smoking behavior: results of a national survey. JAMA 1996; 275: Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998; 279: Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physician s smoking cessation advice. JAMA 1991; 266: Easton A, Husten C, Elon L, Pederson L, Frank E. Non-primary care physicians and smoking cessation counseling: Women Physicians Health Study. Women Health 2001; 34: Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med 2001; 20: Wechsler H, Levine S, Idelson RK, Schor EL, Coakley E. The physician s role in health promotion revisited a survey of primary care practitioners. N Engl J Med 1996; 334: McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003; 18: