Medical professionals, of all people, should know how harmful smoking is. In Britain, almost no doctors smoke. Yet in many countries, such as Italy, smoking is commonplace among medical students and doctors. The question arises as to why this is so, and what can be done about it. It is important to analyse this issue not only for the health of medical professionals but also because if they smoke themselves, they are in no position to advise or help their patients to stop.
Tobacco products would not be sold legally if they were invented today—there is no other product on the market with such high levels of known toxins and carcinogens!
The World Health Organization estimates that each year, more than 5 million deaths worldwide are attributable to smoking.
According to the 2012 Eurobarometer Report ‘Attitudes of Europeans towards Tobacco’, the prevalence of smoking in the European population aged ≥15 years is 28%, with a maximum observed in Greece (40%) and a minimum in Sweden (13%). Italy (as the Netherlands) is classified fourth from the last with a prevalence of 24%. The 2012 Italian DOXA survey, requested each year by the Istituto Superiore di Sanità, reported a lower estimate of 21%.
Nevertheless, according to a study published in 2010, the prevalence of smoking among health professionals in Italy is 44%, more than double that of the general population, and this is not only due to the high prevalence in nurses (48.2%), but it is also observed in medical doctors (33.9%), medical students (35%) and postgraduate students (52.9%).1
This finding is not peculiar to Italy, as high prevalence of smoking (∼29%) was also observed among medical students in Spain, Poland and Germany.
Two different patterns of physician smoking prevalence seem to exist: the first applies to most developed countries that have experienced a steady decline, like USA, Australia and UK; doctors have notably been among the first to reduce their smoking rate (now <10%), usually preceding a decrease in smoking rate among the general public. In this scenario, however, trends are not uniform across all countries, and there are important exceptions like Italy, France and Japan, where physician smoking prevalence rates are >25%. On the other hand, some newly developing countries like China, Bosnia/Herzegovina, Turkey and India have high male smoking prevalence rates, approximately 50%.
The Italian experience is really peculiar: although Italy was the third European country to enact smoking bans in all indoor public places in 2005, and the overall smoking prevalence in the general population seems to be slowly declining, the number of smokers in the health occupations still remains high.
This is a key problem from a public health perspective, not only because the physician is an important model for patients, colleagues and medical students, but also because physicians’ personal use of tobacco impairs interactions with patients about smoking. Statistically significant associations have been observed between physician’s smoking status and beliefs and clinical practice in an international survey of general and family practitioners. Pipe and colleagues reported that smoking doctors were significantly less likely to view smoking as harmful than their non-smoking colleagues and less likely to discuss smoking at each patient visit.
Moreover ‘smoking physician were more likely than non-smoking physicians to believe that they had other priorities than helping patients to quit smoking (52% vs 44%; p < 0.001)’.2
Cessation counselling delivered by non-smoking general practitioners resulted in higher rates of prolonged abstinence than when counselling was delivered by smoking general practitioners.
In Italy, in 2012, only 14% of smokers had received unsolicited advice to quit by their physicians, but this percentage has declined from 20% in 2009, and smokers are less likely to receive such advice when their physicians are smokers.
Given the overwhelming evidence of the health consequences of smoking and the documented detrimental effect that smoking physicians have on their ability to assist their smoking patients, a paramount question arises: Why do physicians smoke?
Is it because they do not know or do not believe that smoking is harmful?
Is it because they do not study this topic in their training as a regular course and thus they do not consider it important?
Or, perhaps they consider it important, but not a priority. They may think that helping a patient to quit smoking is doing prevention, and prevention is not promoted by most physicians who concentrate on treating their patients rather than helping them to avoid becoming ill. A study from Japan ‘found that 80% of medical students did not consider counselling on smoking cessation necessary as long as patients did not have smoking-related diseases’.3 But, in reality, smokers are already sick; they are affected by nicotine dependence, which the World Health Organization and the American Association of Psychiatry included, respectively, in the International Classification of Diseases and in the Diagnostic and Statistical Manual of Mental Disorders. Moreover, if they wait until they have a smoking-related disease before they stop, a huge amount of damage will already have been done, and they will have lost significant life expectancy.
So, is it is just a question on how to focus on the smoking problem?
It is of crucial importance to try to answer this question because it could give important clues on how to intervene in the health community and in the medical schools.
Recently, the COM-B (Capability, Opportunity, Motivation, Behaviour) model has been proposed as a basis for analysing behaviour with a view to finding ways of changing it.4
The primary goal is to determine what it would take to get a target group to stop behaving in a way that is damaging or to start doing something that would be beneficial; this implies to think about a hierarchy of possible explanations. For example, when a group of people are doing something harmful, one might think they never heard it was harmful, or perhaps they heard it was, but did not understand, or perhaps they understood, but did not believe it, or perhaps they believed it, but did not think they personally would be harmed and so on.
Which of these explanations applies would effect how one intervenes to change the behaviour. For example, if ignorance was the problem, it may be enough to provide better information.
Indeed, it seems that Italian medical students, like their European mates, have limited knowledge: they underestimate the risks associated with smoking, the smoking-related mortality and the benefits of cessation.3,5 As suggested by the authors, this lack of knowledge seems responsible for a ‘fatalistic attitude toward tobacco dependence’.5
Improving knowledge will certainly increase awareness, but will it be enough? Is a fatalist attitude really present? If yes, what would be opportune to do?
It would be of great importance to understand what medical students think and feel about smoking, and it would be interesting for those who smoke to explore their inner ‘position’ towards smoking: do they smoke because they ignore the risk or because they deny or even seek it? Or are they just fatalist, or do they accept the risk but procrastinate the attempt to quit? We do not know! To help find out, we could build a ‘behavioural/motivational ladder’ to locate their blockage for change. According to the results of Grassi and co-authors, almost 45% of Italian medical students tried to quit and relapsed in the past, 60% would like to give up smoking altogether but 40% feel they are not ready to try.5 These are important percentages that could mean that Italian medical students are addicted and may require help specifically addressed to them. Facing this issue would also fulfil the ethical obligation to act in the best interest of public and patients’ health, as the smoking status of physicians can impact their professional practice.2