ANESTHESIOLOGISTS, GENERAL SURGEONS AND RESIDENTS PERCEPTIONS OF THE PERIOPERATIVE SMOKING CESSATION OF PATIENTS

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1 Acta Medica Mediterranea, 2014, 30: 1233 ANESTHESIOLOGISTS, GENERAL SURGEO AND RESIDENTS PERCEPTIO OF THE PERIOPERATIVE SMOKING CESSATION OF PATIENTS ISIL KARABEYOGLU 1, DERYA GOKCINAR 1, MELIH KARABEYOGLU 2, MUSTAFA BAYDAR 1, NERMIN GOGUS 1 1 Ankara Numune Training and Research Hospital, Department of Anesthesiology, Ankara - 2 Ankara Numune Training and Research Hospital, Department of General Surgery, Ankara, Turkey ABSTRACT Background: The perioperative period is generally considered to be a good time to explore with patients the habit of cigarette smoking and implement smoking cessation programs. To the best of our knowledge no one in Turkey has studied the views about cigarette cessation interventions of physicians in surgical subspecialties; as such, this study aimed to determine the perceptions of these physicians towards patients that smoke. Methods: This cross-sectional questionnaire study included anesthesiologists, general surgeons, and residents of these 2 specialties. The study questionnaire included closed-end questions designed to assess the physicians views and beliefs about which cigarette cessation interventions they preferred in daily clinical practice. Results: In all, 274 physicians/residents completed the questionnaire. The proportion of smokers among the anesthesiologists, general surgeons, and the residents of these 2 specialties was 32%, 40%, 41%, and 44%, respectively. In daily interactions with patients more anesthesiologists (67%) questioned the smoking habits of patients than did general surgeons (27%). Most of the participants thought that the perioperative period is a good time to convince patients to permanently quit smoking. Knowledge regarding smoking cessation interventions was poor in all participants. More than half of the participants indicated that they wanted to obtain more information about smoking cessation interventions. Conclusions: The smoking rate among the present study s physicians was high, whereas their level of knowledge of smoking cessation interventions was low. Nonetheless, most of the physicians thought that the perioperative period is a good time for patients to quit smoking and indicated that they wanted to learn more about smoking cessation interventions. Key words: Perioperative period, smoking cessation interventions, perceptions, anesthesiologists, general surgeons, residents. Received May 18, 2014; Accepted September 02, 2014 Introduction Tobacco use is one of the most significant, but preventable public health problems worldwide. Globally, approximately 1.1 billion people smoke tobacco and the number is expected to reach 1.6 billion by Despite a decrease in the number of cigarette smokers in developed countries, the percentage of smokers in developing countries is increasing (1). Cigarette smoking is very common in Turkey representing a major public health problem. In terms of tobacco consumption, Turkey ranks 3 rd among European countries and 7 th globally, with 33.4% of the population aged >18 years regularly smoking tobacco. In Turkey 50.6% of males and 16.6% of females aged >18 years consume tobacco (2). Current smoking rates among Turkish adolescents between 13 and 17 years old are 25.2% of males and 10.5% of females (3). It is estimated that in Turkey 54,699 deaths, (12.7% of all deaths) could be prevented annually via cessation of tobacco consumption (2). Despite the lack of definitive data on the number of smokers in Turkey that undergo surgery, the number is thought to be well in excess of thousands of cases annually. Not surprisingly, smokers undergoing surgery have an increased risk of cardiovascular and respiratory complications during the perioperative period. Post hospital discharge healthcare costs for inpatient surgical procedures were shown to be higher in both former and current smokers than in non-smokers (4).

2 1234 Isil Karabeyoglu, Derya Gokcinar et Al The World Health Organization (WHO) issued the Report on the Global Tobacco Epidemic: The MPOWER Package in 2008, in which based on an assessment of the current state of cigarette use and smoking cessation programs in different nations 6 principle strategies are proposed for reducing the number of smokers worldwide. Among the 6 principle strategies, 2 concerning healthcare systems are: 1. Provision of support for smokers and 2. Provision of information regarding the dangers associated with smoking. Existing legislation regarding tobacco use in Turkey was revised in 2008 in an effort to implement the strategies proposed in the WHO MPOWER package (5). The great success of the national tobacco control program implemented by the Turkish Ministry of Health between 2008 and 2012 in achieving WHO MPOW- ER goals was highly acclaimed internationally; however, as tobacco addiction is a chronic disease with a high risk of relapse, long-term follow-up is vitally important. As such, we think that all physicians (regardless of specialty) should be held responsible for paying an adequate level of attention and importance to this issue. Earlier studies have shown that smoking during the perioperative period is associated with an increase in the risk of complications. Anesthesiologists are more knowledgeable about perioperative complications related to smoking than physicians of other specialties. Perioperative physician advice has been shown to result in spontaneous smoking cessation in some patients undergoing surgery (6-12). In Turkey physicians are not legally obligated to advise patients to stop smoking during the perioperative period. Comprehensive studies on the role of physicians in smoking cessation will more clearly elucidate the contribution of perioperative interventions on smoking cessation, and provide useful data to support the inclusion of providing advice to stop smoking in guidelines. The present study aimed to determine the attitudes of anesthesiologists and general surgeons, as well as residents of these 2 specialties in Turkey towards smoking cessation in patients that smoke. Material and methods The study protocol was approved by the Ankara Numune Training and Research Hospital Ethics Committee, and was conducted at the Research and Training Hospitals of the Turkish Ministry of Health in Ankara, Turkey. The survey was planned for 600 physicians who were divided 4 groups (anesthesiologists, general surgeons, and residents of these specialties). Each subgroup consisted of 150 physicians. The questionnaire was based on that used in the study by Warner et al. (13) and was modified to ensure clear verbal expression via testing in a pilot group consisting of 20 physicians. The questions were close-ended and were presented as ordered choices designed to assess the level of agreement with a particular view or action. The questionnaire was used to collect data on the physicians personal characteristics, routine clinical interventions related to cigarette smoking, and, views and beliefs about cigarette cessation methods, awareness of smoking cessation interventions, and level of interest in obtaining more information about such interventions. Statistical analysis All data were analysed using Statistical Package for the Social Sciences version 11.5 for Windows. Descriptive statistics are shown as number and percentage for counted variables and mean ± SD or median (range) for measured variables. Between-group differences in counted variables were determined using the chi-square test and the Mann-Whitney U test was used for ordinal scales variables. The level of statistical significance was set at P < 0.5. Results A total of 274 physicians completed the questionnaire. The response rates were 72% for anesthesiologists, 62% for general surgeons, 27% anesthesiology residents, and 21% for general surgery residents. The demographic characteristics of the participating physicians are shown in Table 1. More anesthesiologists than general surgeons (67% vs. 27%) regularly talked to their patients about the dangers of cigarette smoking, and the difference was significant (P < 0.001). Physician beliefs and views about smoking cessation interventions are shown in Table 2. Most of the respondents thought that the perioperative period was a good time to talk to patients about smoking cessation. The level of knowledge about smoking cessation interventions was low in all groups. Approximately 68% of the anesthesiologists, 67% of the general surgeons, and 66% of anesthesiology residents answered with neutral and I don t know to the questionnaire item, nicotine gum and patches

3 Anesthesiologists, general surgeons and residents perceptions of the perioperative smoking cessation of patients 1235 Anesthesiologists General Surgeons P Anesthesiology Residents General Surgery Residents P Age (years) < (49) 5 (16) (57) 50 (54) 21 (51) 27 (84) (38) 32 (34) (5) 11 (12) - - Gender <0.001 <0.001 Female 70 (65) 14 (15) 22 (54) - Male 38 (35) 79 (85) 19 (46) 32 (100) Smoking status Never smoked 50 (46) 39 (42) 22 (54) 14 (44) Ex-smoker 23 (21) 17 (18) 2 (5) 4 (12) Table 1: Participant characteristics. Current smoker 35 (33) 37 (40) 17 (41) 14 (44) can be safely used in patients during surgery, whereas 47% of the general surgery residents answered neutral and I don t know. In total, 64% of anesthesiologists, 52% of general surgeons, 76% of anesthesiology residents, and 63% of general surgery residents agreed or strongly agreed with the questionnaire item, I should not discuss cigarette cessation before surgery, as patients are already anxious during this period. Among the participants, >50% disagreed with the questionnaire item, my advice will have no effect because I can only interact with patients for just a few minutes before surgery. Additionally, >50% of the participants agreed or strongly agreed with the questionnaire item, if an effective intervention is guaranteed, then I would be more willing to spend an extra 5 min helping a patient quit smoking. Approximately 68% of anesthesiologists, 67% of general surgeons, and 66% of anesthesiology residents agreed or strongly agreed with questionnaire item, I may be interested in learning more about how to help my patients quit smoking, versus 34% of general surgery residents. Discussion In this study we showed that physicians in surgical subspecialities were quite willing to help for smoking cessation of their patients. The perioperative period is known to be a good time to discuss cigarette cessation with patients, as they are considered more likely to respond favourably to such interventions during this time. Earlier studies reported that preoperative smoking cessation programs are effective in some cases (12-15). On the other hand, smoking is associated with significant cardiovascular and respiratory adverse consequences during the perioperative period. Providing perioperative guidance on cigarette cessation can help reduce the rate of postoperative respiratory (e.g. atelectasis and pneumonia), cardiovascular (e.g. myocardial ischemia), and wound-healing complications (12,15-17). While a similar percentage of anesthesiologists and general surgeons in the present study answered the questionnaire item, would you give advice to your patients on cigarette cessation with I would frequently give advice (P > 0.05), Warner et al. reported that only 30% of anesthesiologists and 58% of surgeons advised their patients to quit smoking (13). A tape-recorded smoking intervention produced by an anesthesiologist was shown to be effective in a group of patients, in which some were able to quit completely and others reduced the number of cigarettes they smoked (18). Egan and Wong (19) suggested that anesthesiologists should provide guidance on cigarette cessation during the postoperative period in patients with smoking-related problems during anaesthesia, as such patients were very receptive to advice on smoking cessation. The smoking rate among healthcare professionals - in particular physicians - is an important indicator of the rate of smoking in a given general population. Smoking among physicians may adversely affect patients smoking cessation. Similar to the present findings, 2 earlier studies on the prevalence of smoking among Turkish physi-

4 1236 Isil Karabeyoglu, Derya Gokcinar et Al Questions Group a Medianb (range) Strongly agree Agree Neutral Disagree Strongly disagree Don t know P 1. Cigarette cessation for 6 months before surgery significantly reduces the postoperative complication rate. A 1 (1-4) 78 (72) 28 (26) 2 (2) GS 2 (1-3) 44 (47) 46 (47) 6 (6) AR 1 (1-6) 31 (76) 10 (24) GSR 1 (1-3) 18 (56) 12 (38) 2 (6) Cigarette cessation for 1-30 d before surgery significantly reduces the postoperative complication rate. A 2 (1-5) 37 (34) 55 (51) 1 (1) 12 (11) 3 (3) GS 2 (1-5) 21 (23) 48 (52) 6 (6) 12 (13) 6 (6) AR 2 (1-4) 18 (44) 17 (41) 2 (5) 4 (10) GSR 2 (1-4) 14 (44) 11 (34) 2 (6) 5 (16) All patients should avoid smoking before and after surgery, for as long as possible. A 1 (1-4) 79 (73) 29 (27) GS 1 (1-4) 51 (55) 41 (44) 1 (1) AR 1 (1-2) 29 (71) 12 (29) GSR 1 (1-3) 22 (69) 7 (22) 3 (9) In my patients that smoke nicotine withdrawal symptoms developing after surgery may result in significant problems. A 3 (1-6) 15 (14) 30 (28) 17 (16) 25 (23) 6 (5) 15 (14) GS 3 (1-6) 6 (7) 31 (33) 14 (15) 18 (19) 12 (13) 12 (13) AR 3 (1-6) 2 (5) 12 (29) 14 (34) 10 (25) 1 (2) 2 (5) GSR 4 (2-4) 11 (34) 4 (13) 17 (53) 5. If a patient chooses to smoke, this is not my problem. A 3 (1-5) 6 (6) 30 (28) 21 (19) 34 (31) 17 (16) GS 3 (1-6) 14 (15) 20 (22) 16 (17) 29 (31) 12 (13) 2 (2) AR 3 (1-5) 3 (7) 11 (27) 12 (29) 13 (32) 2 (5) GSR 2 (1-5) 9 (28) 10 (31) 4 (13) 7 (22) 2 (6) 6. Provision of advice on cigarette cessation is one of my responsibilities. A 2 (1-4) 35 (32) 62 (58) 8 (7) 3 (3) GS 2 (1-5) 26 (28) 56 (61) 5 (5) 5 (5) 1 (1) AR 2 (1-3) 20 (49) 17 (41) 4 (10) GSR 2 (1-4) 13 (41) 10 (31) 7 (22) 2 (6) 7. Provision of support for patients during smoking cessation is one of my responsibilities. A 2 (1-5) 16 (15) 45 (41) 28 (26) 17 (16) 2 (2) GS 2 (1-5) 8 (9) 46 (49) 23 (25) 10 (11) 6 (6) AR 2 (1-4) 12 (29) 14 (34) 11 (27) 4 (10) GSR 3 (1-4) 6 (19) 6 (19) 12 (37) 8 (25) The perioperative period is a good time to convince patients to permanently quit smoking. A 2 (1-6) 17 (16) 62 (57) 12 (11) 14 (13) 2 (2) 1 (1) GS 2 (1-6) 13 (14) 57 (61) 7 (8) 12 (13) 2 (2) 3 (3) AR 2 (1-4) 12 (29) 18 (44) 7 (17) 2 (5) GSR 2 (1-4) 7 (22) 19 (59) 4 (13) 2 (6) Table 2: Beliefs and views about smoking interventions. : not significant. aa: Anesthesiologists; AR: anesthesiology residents; GS: general surgeons; GSR: general surgery residents. b1: Indicates strongly agree; 2: indicates agree; 3: indicates neutral: 4 indicates disagree; 5: indicates strongly disagree; 6: indicates don t know. cians reported rates as high as 37.5% and 16% (20,21) ; such high smoking rates among Turkish physicians might negatively affect their ability/desire to advise patients on smoking cessation. Shi et al. showed

5 Anesthesiologists, general surgeons and residents perceptions of the perioperative smoking cessation of patients 1237 that physicians that smoked were less likely to give advice on cigarette cessation than their non-smoking counterparts (22). In the present study the participants responses to the questionnaire items regarding nicotine gum and patches indicated a low level of knowledge of these cessation methods. Previous studies on attitudes toward nicotine replacement therapy (NRT) showed that they were associated with adverse effects on the cardiovascular system; however, NRT was not associated with an increase in the incidence of cardiac events (23,24). Sorensen et al. showed that the post-surgical risk of wound infection was dramatically reduced in patients that quit smoking, and that the observed effect was independent of NRT (25). In surgical candidates use of NRT was shown to be harmless, as compared to smoking. Conclusions In the present study most of participants agreed that it was beneficial to offer advice to their patients about the benefits of smoking cessation prior to surgery, and indicated that they would be willing to learn more about smoking cessation. We think that perioperative support and guidance on smoking cessation should be an essential professional responsibility of all physicians. Training programs to improve physician smoking cessation interventions should be made available. References 1) Chaloupka FJ. Curbing the epidemic: governments and the economics of tobacco control. Tob Control. 1999; 8(2): ) Ministry of Health Refik Saydam Hygiene Center Presidency School Of Public Health. National Burden Of Disease and Cost Effectiveness Project, ( 3) Erbaydar T, Lawrence S, Dagli E, Hayran O, Collishaw NE. Influence of social environment in smoking among adolescents in Turkey. Eur J Public Health 2005; 1: ) Warner DO, Borah BJ, Moriarty J, Schroeder DR, Shi Y, et al. Smoking status and health care costs in the perioperative period: a population-based study. JAMA Surg. 2014; 149(3): ) World Health Organization. WHO report on the global tobacco epidemic, the MPOWER package. Geneva, World Health Organization, 2008 ( 6) Warner DO. Perioperative abstinence from cigarettes: physiological and clinical consequences. Anesthesiology. 2006; 104: ) McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res. 2003; 18(2): ) Warner DO. Helping surgical patients quit smoking:why, when and how. Anesth Analg. 2005; 99: ) Warner DO. Preoperative smoking cessation: the role of the primary care provider. Mayo Clin Proc. 2005; 80: ) A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA. 2000; 283(24): ) Warner DO, Patten CA, Ames SC, Offord K, Schroeder D. Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. Anesthesiology. 2004; 100(5): ) Warner DO. Tobacco control for anesthesiologist. J Anesth. 2007; 21: ) Warner DO, Sarr MG, Offord KP, Dale LC. Anesthesiologist, General Surgeons, and Tobacco Interventions in the Perioperative Period. Anesth Analg 2004; 99: ) Lee SM, Landry J, Jones PM, Buhrmann O, Morley- Forster P. The effectiveness of a perioperative smoking cessation program: a randomized clinical trial. Anesth Analg. 2013;117(3): ) Shimizu Y, Baba Y, Nagamine Y, Kurahashi K. Smoking cessation program run by anesthesiologists in a preoperative clinic. Masui. 2013; 62(11): ) Ziedalski TM, Ruoss SJ. Smoking cessation: techniques and potential benefits. Thorac Surg Clin. 2005; 15(2): ) Cavichio BV, Pompeo DA, Oller GA, Rossi LA. Duration of smoking cessation for the prevention of surgical wound healing complications. Rev Esc Enferm USP. 2014; 48(1): ) Hughes JA, Sanders LD, Dunne JA, Tarpey J, Vickers MD. Reducing smoking. The effect of suggestion during general anaesthesia on postoperative smoking habits. Anaesthesia. 1994; 49(2): ) Egan TD, Wong KC. Perioperative smoking cessation and anesthesia. J Clin Anesth.1992; 4: ) Gunes G, Karaoglu L, Genc MF, Pehlivan E, Egri M. University hospital physicians attitudes and practices for smoking cessation counseling in Malatya, Turkey. Patient Educ Couns. 2005; 56(2): ) Uysal MA, Dilmen N, Karasulu L, Demir T. Smoking habits among physicians in Istanbul and their attitudes regarding anti-smoking legislation. Tuberk Toraks. 2007; 55(4): ) Shi Y, Yu C, Luo A, Huang Y, Warner DO. Perioperative tobacco interventions by Chinese anesthesiologists: practices and attitudes. Anesthesiology. 2010; 112(2): ) Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: Implications for nicotine replacement therapy. J Am Coll Cardiol 1997; 29: ) Mahmarian JJ, Moyé LA, Nasser GA, Nagueh SF, Bloom MF, et al. Nicotine patch therapy in smoking

6 1238 Isil Karabeyoglu, Derya Gokcinar et Al cessation reduces the extent of exercise-induced myocardial ischemia. J Am Coll Cardiol. 1997; 30: ) Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infections : A randomized controlled trial. Ann Surgery. 2003; 238:1-5. Correspnding author DERYA GOKCINAR, MD Ankara Numune Training and Research Hospital Department of Anesthesiology Talatpasa Bulvari, No: 5 Altindag, Ankara (Turkey)