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THE EFFECT OF PHYSICIANS' SMOKING-RELATED KNOWLEDGE, ATTITUDE, AND PRACTICES ON THEIR SMOKING-CESSATION COUNSELING ________________________________________________

A THESIS PRESENTED TO THE FACULTY OF THE GRADUATE SCHOOL ATENEO DE ZAMBOANGA UNIVERSITY ZAMBOANGA CITY _______________________________________________

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN PUBLIC HEALTH ________________________________________________

BY: ELHAM A. ASID APRIL 2010

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APPROVAL SHEET

This thesis entitled THE EFFECT OF PHYSICIANS' SMOKING-RELATED KNOWLEDGE, ATTITUDE, AND PRACTICES ON THEIR SMOKINGCESSATION COUNSELING prepared and submitted by Elham A. Asid, in partial fulfillment of the requirements for the degree of MASTERS IN PUBLIC HEALTH.

Pascualito I. Concepcion Adviser

Approved by the Oral Examination Committee with a grade of PASSED ________________________ Rosemarie S. Arciaga, M.D. Chairman _______________________ Fortunato L. Cristobal, M.D. Member _______________________ Rex V. Samson, M.D. Member _____________________ Jocelyn D. Partosa, PhD Member _____________________ Iouistina S. Aranan, PhD Member

_________________________ Servando D. Halili Jr., PhD Member ____________________________________________________ _________________ ACCEPTED in partial fulfillment of the requirements for the degree of Masters in Public Health ____________________________ Servando D. Halili Jr., PhD Dean, Graduate School Ateneo de Zamboanga University

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ABSTRACT

This is an analytical cross-sectional study which aimed to determine the association between physicians' smoking-related knowledge, attitude, and practices and their smoking-cessation counseling. The participants of the study are physicians from the 8 selected hospitals of Zamboanga City in the 4 fields of specialty, namely; General Practitioners, Family Physicians, Internists, and Internal Medicine Residents. The study utilized a modified self-administered questionnaire in the data gathering process; descriptive statistics as well as Pearson Product-Moment Correlation were employed in data analysis. There were a total of 80 participants in this study which represent 82% of the total population of physicians in the fields of specialty mentioned. Results showed that 20% of the participants are current smokers and most of them are from the Internal Medicine fields (both specialists and residents). The most common reasons for smoking were to reduce or relieve stress-related work (56.25%) and to improve sociability among peers (31.25%); most of them cannot quit due to cravings for cigarettes (43.75%). Also, it was noted that most of the participants (76%) have correct knowledge on the health risks of smoking and 68.75% have a better attitude regarding role modeling on smoking cessation. Among the smokers, 62.5% have a better practice in relation to use of cigarettes. Results showed that majority (75%) of the participants have better counseling on smoking-cessation of patients. However, a low rate on use of other interventions to stop smoking was found; also, only about half (53.8%) of the participants felt very well prepared when they counsel on smoking cessation. Moreover, the Pearson Correlation Coefficient (r) showed that there is no significant association between knowledge versus counseling (-0.094), attitude versus counseling (-0.017), or smoking practice versus smoking-cessation counseling (see Chapter III). This means that knowledge, attitude, and smoking practice has no significant effect on the smoking-cessation counseling of the participants.

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TABLE OF CONTENTS

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APPROVAL SHEET ABSTRACT TABLE OF CONTENTS ACKNOWLEDGEMENT CHAPTER I INTRODUCTION

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a.) Background of the Study ...............................................1 c.) Review of Related Literature.................................3 d.) Statement of the Problem ...............................................7 e.) Objectives of the Study ..................................................7 f.) Hypotheses ......................................................7 g.) Significance of the Study ...............................................8 h.) Scope and Delimitation of the Study .............................8 i.) Definition of Terms .........................................................9 j.) Conceptual Framework ..................................................10 CHAPTER II METHODOLOGY a.) Research Design ............................................................11 b.) Selection of Research Participants..................................11 c.) Research Setting..............................................................11 d.) Sampling Design ...........................................................13 e.) Research Instrument...........................................13 f.) Data Gathering.................................................................14 g.) Data Analysis ................................................................14 h.) Flow of Activities ......................................................... 16 CHAPTER III RESULTS AND DISCUSSION 17

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CHAPTER IV BIBLIOGRAPHY APPENDICES

SUMMARY, CONCLUSION, AND RECOMMENDATION

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Appendix A Appendix B Appendix C CURRICULUM VITAE 57

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LIST OF TABLES

Table 1. Demographic Profile of the Participants Table 2. Smoking Status of Physicians Table 3. Smoking Status of Physicians among the Four Fields of Specialty Table 4. History of Family Exposure to Smoking Table 5. Smoking-Cessation Training of Participants Table 6. Age at Which Current and Previous Smokers Started Smoking Table 7. Common Reasons for Smoking among Current and Previous Smokers Table 8. Smoking-Related Knowledge among Participants Table 9. Number of Participants with Correct and Incorrect Knowledge Table 10. Smoking-Related Attitude among participants Table 11. Number of Participants with Better and Poor Attitude Table 12. Smoking Practices among Current Smokers Table 13. Number of Smokers with Better or Poor Smoking Practice Table 14. Smoking-Cessation Counseling among Participants Table 15. Smoking-Cessation Counseling of Physician Smokers and Non-Smokers Table 16. Number of Participant with Better and Poor Smoking-Cessation Counseling Table 17. Smoking-Cessation Counseling Beliefs of Physicians Table 18. Levels of Preparedness on Smoking-Cessation Counseling among Physicians Table 19. Previous Attempt to Quit Smoking among Current Smokers Table 20. Age at Which Previous Smokers Quitted Smoking Table 21. Current Smokers' Perception on the Negative Effects of Smoking on their Health Table 22. Percentage of Participants Who Scored Above or Below the Mean Score Table 23. Mean Scores for Smoking-Related Knowledge Table 24. Mean Scores for Smoking-Related Attitude Table 25. Mean Scores for Smoking Practices Table 26. Mean Scores for Smoking-Cessation Counseling

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LIST OF FIGURES Figure 1. Conceptual Framework of the Study Figure 2. Flow of Activities Figure 3. Types of Smoking-Cessation Intervention Commonly Provided by Physicians Figure 4. Correlation between Knowledge and Counseling Practices Figure 5. Correlation between Attitude and Counseling Practices Figure 6. Correlation between Smoking Practices and Counseling of Physicians

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ACKNOWLEDGEMENT

The researcher would like to express her sincerest gratitude to the people who shared their effort and valuable time in the conduct of this study: To Dr. Pascualito I. Concepcion, my research adviser, for all his guidance and suggestions, without whom this research would not have been richer and meaningful, To the panelists: Dr. Rosemarie S. Arciaga, Dr. Fortunato L. Cristobal, Dr. Jocelyn D. Partosa, Dr. Iouistina S. Aranan, Dr. Servando D. Halili Jr., and Dr. Rex V. Samson for the constructive criticisms, comments and suggestions, To my dearest cousin Khalmida T. Adjul for patiently helping me in my day to day data gathering in each hospital and clinic, To Anne, Joenna, and Weng, my cherished classmates, who were also of great help in my study, To my beloved parents, for the love, understanding, and the support that they have given me all throughout, and Above all, the Almighty Allah, for bestowing all the blessings, wisdom, and good health without which nothing would have come to reality. Thank you very much!!! Else A. Asid

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CHAPTER I INTRODUCTION Background of the Study Cigarette consumption has long been a global burden that poses a lot of negative health effects including the risks of heart disease, coronary artery disease, lung diseases, lung cancer, cerebrovascular accidents, etc. Physicians as well, who should serve as role models by not smoking, are sometimes influenced by the same unwanted habit. The question is: are physicians who smoke would be less likely to counsel patients to quit smoking than nonsmokers? With this, it is of great importance that we examine the physicians' smoking-cessation counseling especially among those who smoke. Smoking is perceived by many as a measure to promote social relations among peers. Other reasons for smoking include enhancement of memory and skills, improvement of skills and performance in work, relief from stress-related work, improvement of social relationships among peers, and weight reduction. However, the disadvantages of smoking far outweigh the benefits of smoking as mentioned above. In fact, smoking has no potential benefit at all. In the 20th century, the World Health Organization showed that deaths on tobacco smoking were over 1 million worldwide. In the 21st century, it could kill one billion. According to the previous year's report, tobacco death toll reaches 5.4 million globally every year and unless urgent action is taken, there will be more than 8 million deaths per year by 2030. (WHO, 2008)

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According to the WHO, tobacco is the single most preventable cause of death in the world today. In the previous year, it was reported that tobacco causes 1 in 10 deaths worldwide among adults. The current trends were less favorable in developing countries where the prevalence of smoking continues to rise. The use of tobacco is growing fast especially in low-income countries due to steady population growth. This is coupled with tobacco industries widely promoting their products. By 2030, the rate of tobacco-related deaths will be as much as 80% or more in the low- and middle-income countries. (WHO, 2008) In 2004, a study conducted in China showed that smoking prevalence was 23% among all Chinese physicians comprising 41% among men and only 1% among women. In another study in China in the same year, it was reported that the smoking prevalence was highest among male surgeons (45.2%). It was found that surgeon's knowledge on the harms of active and passive smoking and their attitudes toward smoke-free hospitals and health role modeling as physicians significantly affects their smoking status. In Yerevan, Armenia, the patterns of smoking behavior of physicians were also studied. Results showed that the prevalence of smoking was high and a large percentage would smoke in the presence of patients. It was also noted that their smoking knowledge and behavior influences whether they will counsel patients on smoking. Physicians play a significant role since they have ability and skills to advice patients who wants to quit smoking as well as smokers who do not intend to quit. For patients who are ready to quit smoking, a physician can offer ranges of methods or therapies to help them quit such as counseling, medications, self-help materials, behavioral strategies, etc. A simple advice from a physician has been shown to increase

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the quit rates compared to no advice and more intensive counseling can double the quit rates (Fiore et al, 2000). Many smokers quit on their own. However, most people would also act on the advice from a physician. Heavy smokers, especially, more likely needs medical advice because most people can quit smoking but staying off cigarettes would entail support and additional methods such as relapse prevention. The physicians' part in smoking prevention and control are hugely recognized. In this study, it is deemed necessary that the association between knowledge, attitude, and practices towards smoking among physicians and how it affects their smoking-cessation counseling to patients will be explored. This will be conducted among physicians who have more patient interactions with smoking patients, particularly the General Practitioners, Family Physicians, Internists, and Internal Medicine resident physicians. Review of Related Literature The epidemic use of tobacco and its associated negative health benefits has posed an alarming concern especially among developing countries. The problem is common not only among the general population. The physicians as well are faced with the same smoking issue. There are studies that aimed to identify or determine if their knowledge, attitude, and smoking behavior affects their role in smoking- cessation counseling. In a study conducted in China among male surgeons in 2004, it showed that smoking prevalence for Chinese male surgeons was 45.2, and 42.5% of respondents reported having smoked in front of their patients. Twenty-five percent of the respondents always asked patients about their smoking status whereas only 27.2% advised smokers to quit smoking. It was also found that current smoking status, smoking in front of patients,

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and smoking cessation activity were independently and significantly associated with the surgeons' knowledge of the harms of active and passive smoking and their attitudes toward smoke-free hospitals and health role modeling by physicians. (Yao, et al, 2009) In another study conducted between September 2003 and June 2005 among Greek physicians, results showed that 38.6% of the physicians (40% of men; 37% of women) currently smoked, 13.8% were former smokers, and 47.6% had never smoked. Most of the physician smokers (83%) reported starting smoking before the age of 25 years, with half of them during medical school (aged 19-24 years). Characteristics identified as risk factors for a physician to be more likely a current smoker includes male sex, unmarried, divorced or widowed, surgeons or anesthetists, and residents. Former smokers are those who are older, male and born in a rural area. Regardless of being a current or former smoker, both have a common history of parents who smoked. Furthermore, the number of physicians who reported counseling patients (often or always) to stop smoking was lower among current smokers compared with those who never smoked or those who were former smokers (74.4% vs. 85.3% vs. 84.7%). (Sotiropoulos A., et al, 2007) In a study among Hong Kong doctors in 2004, it was found that only 1 in 3 doctors advised all smoking patients to quit. More positive beliefs and higher confidence level was associated with advising patients to quit. However, there were potential barriers found in providing smoking cessation advice including low patient motivation to quit and lack of time and expertise to provide counseling. Low use on pharmacotherapy was also found due to doubts on effectiveness of products and was related doctors' lack of confidence and appropriate skills on counseling. The study showed that there is lack of

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knowledge and attitude towards smoking-cessation among doctors and lack of skills is reflected in their low confidence level who encountered smoking patients in real practice. In Yerevan, Armenia (2004), the percentage of current smokers was also significantly higher in men than women (48.5% vs. 12.8% regular and 6.8% vs. 4.5% occasional). It showed that physicians who smoke are less likely to ask their patients about their smoking behavior or believe their example is likely to influence their patients. It was concluded in this study that physician smoking behavior and knowledge of smoking related health outcomes in Yerevan influences whether they counsel patients regarding smoking. (Perrin, et al, 2006) In 2005, another study among French General Practitioners also showed a higher proportion of males who smoked compared to women (36.1% vs. 24.9%, p < 0.01). More than 52% of physicians regarded their role in reducing nicotine addiction to be important. Doctors who believed that the physician's role was limited were less likely to advise pregnant women to stop smoking whereas nonsmokers were more supportive of bans on smoking in public places. (Josseran L., 2005) In Jordan, smoking prevalence among physicians, attitude, perceived smoking prevention, and control responsibilities and behaviors were also determined. The prevalence of smoking is 22.4% for male and 9.1% for female physicians. Among current or former smokers, some had smoked in front of a patient (29.1%). Physicians with training on counseling patients about smoking cessation were significantly more likely to have counseled or to routinely counsel patients on smoking cessation and prevention.

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Finally, an international survey among the General and Family Practitioners across 16 countries showed that 42% of them were smokers. Perception on barriers to smoking showed that more non-smoking physicians identified weak willpower (37% vs 32%) and lack of interest to have healthy lifestyle (28% vs. 22%) as barriers to quitting. However, smoking physicians saw stress as a barrier (16% vs. 10%). The study concludes that smoking physicians are less likely to initiate cessation interventions than nonsmokers. (Pipe A., et al, 2009) Overall, the studies presented above shows that smoking is highest among male physicians. Differences in knowledge, attitude, and behavior on smoking define their perceived responsibilities on counseling or advising patients to quit smoking. Despite the high prevalence of smoking among physicians, they still play an important role in reducing smoking among patients. All practitioners may be encouraged to adopt systematic approaches to promote smoking prevention and control.

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Statement of the Problem What is the effect of the knowledge, attitude, and practices on smoking of physicians on their smoking-cessation counseling of patients? General Objective This study seeks to determine the effect of the knowledge, attitude, and practices on smoking of physicians on their smoking-cessation counseling of patients in the selected hospitals of Zamboanga City. Specifically, this study aims to: 1. determine the prevalence of smoking among physicians in the selected hospitals of Zamboanga City; 2. determine the physicians' knowledge, attitude, and practices on smoking; 3. determine the smoking-cessation counseling practices of physicians; and 4. determine the effect of physicians' smoking-related knowledge, attitude and practices on their smoking-cessation counseling.

Hypotheses Null: Physician's smoking-related knowledge, attitude, and practices has no effect on their smoking-cessation counseling. Alternative: Physician's smoking-related knowledge, attitude, and practices has an effect on their smoking-cessation counseling.

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Significance of the Study Much has been documented as to the ill-related effects of smoking on one's health. While physicians remain to be the role models by not smoking and are crucial health counselors for patients to quit smoking, but some physicians themselves succumb to the same unwanted habit. This study aimed to determine if physicians' knowledge, attitude and practice towards smoking is correlated with their smoking-cessation counseling practices. This study, hence, determines if having incorrect knowledge, poor attitude, or if being a smoker makes a physician less likely to counsel patients against smoking. Furthermore, the level of preparedness of physicians to counsel patients is determined. With this, the need for enhancement of smoking-cessation counseling skills and motivation to counsel among physicians is recognized in order for them to effectively counsel their patients to quit smoking. Scope and Delimitation of the Study The study was conducted among physicians in four fields of specialty in the selected hospitals of Zamboanga City, namely; Zamboanga City Medical Center, Zamboanga Doctor's Hospital, Ciudad Medical Center, Western Mindanao Medical Center, Brent Hospital, Unibersidad de Zamboanga Community Medical Center, Edwin Andrews Air Base Hospital, and Camp Navarro General Hospital. This study may not be representative of the entire population of physicians of Zamboanga City. The study focused only on the participants' knowledge, attitudes, and practices on smoking, and their smoking-cessation counseling practices.

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About 82% of the identified physicians were covered in this study. There were some physicians who refused to become participants mainly due to a very busy schedule and lack of convenient time to answer the questionnaires. Most of them were Internists. Despite that, majority of the smokers who served as respondents in this study were from this field. In addition, almost all of those who did not join were non-smokers. Hence, the participants in this study can be representative of the total population of smoking and non-smoking physicians in the four fields of specialty. Definition of Terms Physician ­ a health professional licensed to practice medicine in the following fields of specialty: Internal Medicine (both resident physicians and specialists), General Practice, and Family Medicine. Smoking-cessation counseling ­ the act of asking about the patient's smoking status, advising patients to quit smoking, challenging them to quit, and providing options of smoking-cessation methods or strategies. Smoking ­ refers to occasional or daily use of cigarettes. Smoker/Current smoker - a physician who, at present, smoke either occasionally or daily. Previous smoker ­ a physician who has smoked in the past and has already quit smoking. Non-smoker ­ a physician who has not tried smoking throughout his life.

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History of Family Exposure to Smoking, Age, Sex, etc.

Prevalence of Smoking among Physicians

Stress-Related Work, Influence of Peers, etc.

Smoking-Related Knowledge, Attitude, and Practices among Physicians

SMOKERS NON-SMOKERS

Presence/Absence of SmokingCessation Training

Effect on SmokingCessation Counseling on Patients

Level of Preparedness on SmokingCessation Counseling

Poor Smoking-Cessation Counseling of Physicians

Better Smoking-Cessation Counseling of Physicians

Figure 1. Conceptual Framework of the Study The figure above shows how smoking-related knowledge, attitude, and practices among physicians may have an effect on their smoking-cessation counseling. Correct or wrong knowledge and better or poor attitude may have an effect on the counseling of physicians. Also, smokers and non-smokers may differ in their counseling practices. Hence, a correlation may or may not exist between physicians' knowledge, attitude, and practices and their smoking-cessation counseling.

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CHAPTER II METHODOLOGY

Research Design This is an analytical cross-sectional study which aimed to determine the effect of physicians' smoking-related knowledge, attitude, and practices on their smokingcessation counseling among patients in the selected hospitals of Zamboanga City. Also, this study determined the prevalence of smoking among physicians in the selected fields of specialty. Selection of Research Participants The research participants were as follows: Inclusion criteria · Physicians in the following field of specialty: General Practice, Family Medicine, Internal Medicine, and residency training program for Internal Medicine · · Physicians practicing in the eight selected hospitals of Zamboanga City All age group of practicing physicians

Exclusion criteria · · Physicians who refuse to participate in the study Physicians who are not available on the duration of the study

Research Setting The study was conducted among the eight selected hospitals of Zamboanga City, including both the private and government-owned hospitals. Namely, these are: the

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Zamboanga City Medical Center (ZCMC), Zamboanga Doctor's Hospital, Ciudad Medical Center, Western Mindanao Medical Center (WMCC), Brent Hospital, Unibersidad de Zamboanga Community Medical Center, Edwin Andrews Air Base Hospital, and Camp Navarro General Hospital Hospitals serve an important role in providing smoking-cessation interventions including a smoke--free campaign in the hospital premises. Hospitals are portals of entry for many patients who require treatment of their medical conditions or need continuity of care from the health professionals. Therefore, it is the responsibility of every hospital to promote wellness to patients and safeguard them against further harm from the health risk of smoking, as well as encourage a healthy lifestyle to other healthcare providers and visitors of the hospital. In this study, most of the hospitals included in the selection of participants advocate a smoke-free policy. All health professionals, patients, and visitors are not allowed to smoke inside the hospital premises. However, according to some health professionals in some of these hospitals, smoking is in a way present in their institution. Most notably, third-hand smoking is quite evident among some physicians, wherein tobacco smoke contamination in clothing or hair still lingers even after the smoke has been extinguished. Third-hand smoke is proven to be hazardous especially among children. This shows that despite the presence of anti-smoking policy, there is a need to address third-hand smoking among the hospitals to improve campaign against smoking. Overall, most of the hospitals in this study have strict implementation of the smoke-free policy, particularly on first- and second-hand smoking.

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Sampling Design The study utilized a total count method in the selection of the participants. Physicians from the chosen fields of specialty in the eight hospitals mentioned above were identified. About 82% of the total population of physicians in these fields of specialty was involved in the study. Research Instruments Questionnaire The data collection process utilized a modified self-administered questionnaire which aimed to determine the prevalence of smoking among physicians in Zamboanga City. This questionnaire, called the Global Health Professional Survey (GHPS), was adopted from the World Health Organization designed to assess the smoking status of the health professionals worldwide, and modified by the Queen's University of Family Medicine Development Program in Balkan's region . This questionnaire, however, was further modified to meet the objectives of this study and was pretested. This 45-item questionnaire encompasses the following domains: (1) demographic profile of participants consisting of 5 items, (2) smoking status and history with 12 items, (3) participants' knowledge, attitudes, and practices towards smoking containing 17 items, and (4) practices on smoking-cessation counseling of patients consisting of 11 items (See Appendix B). This questionnaire can be accomplished roughly within four to six minutes.

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Data Gathering Procedure The data collection began with the distribution of questionnaires among the identified participants in the selected hospitals of Zamboanga City. The participants were instructed to completely answer and fill in all the questions provided in the questionnaire. The questionnaires were then collected after they were able to answer it, depending on the participants' convenience to answer and return the questionnaires. Usually, the researcher had to revisit the physicians in each hospital many times during the twomonth data collection period until such time that they were able to complete answering the questionnaires. Data Analysis The data was analyzed using descriptive statistics. Also, Pearson Product-Moment Correlation Coefficient (r) was utilized in the analysis of the association of smokingrelated knowledge, attitude, and practices of physicians with their smoking-cessation counseling. In the knowledge and attitude item questions, there are three answer choices provided for each item: agree, unsure, and disagree. A scoring system was assigned for each option: agree = 2, unsure = 1, disagree = 0. The mean scores for knowledge (11.16) and attitude (9.10) were obtained. Participants who scored at the level or above the mean score were categorized as having a correct knowledge or better attitude while those below the mean score were classified as having incorrect knowledge or poor attitude (See Appendix C). In the analysis of smoking practice, participants were categorized into smoking and non-smoking groups; the smoking group was then classified as having a

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better or poor practice. The analysis of item questions for smoking practice were treated separately due to different scoring system assigned, ranging from a score of zero (the lowest score) to six depending on the number of options per item. The smoking-cessation counseling practice was also assigned with a scoring system for the answer choices: always = 3, sometimes = 2, rarely = 1, never = 0. Participants who scored at the level or above the mean score of 10.3 were categorized as having a better practice and those below the mean score were classified as having a poor practice (See Appendix C). Finally, the Pearson Product-Moment Correlation Coefficients (r) were determined to examine for existing relationship or association between knowledge, attitude, and smoking practice and the counseling practice. The correlation coefficient can take values between -1 through 0 to +1. If the correlation is positive, when one variable increases, so does the other. If the correlation is negative, when one variable increases, the other decreases. If there is no relationship between the two variables, then as one variable increases, the other variable neither increases nor decreases. (Brannick, 2006)

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Formulation and Validation of Research Tool (Questionnaire)

Selection of Eight Hospitals of Zamboanga City

Coordination with Key Persons in Each Hospital

(Hospital Director, Hospital Administrator, etc.)

Identification of Physician Participants in the Four Fields of Specialty

(General Practitioners, Internists, Family Physicians, and IM Resident Physicians)

Distribution of Questionnaires to Participants in Each Hospital within Two-Month Period RESULTS of DataDISCUSSION AND Gathering

CHAPTER III

Collection of Questionnaires from Participants in Each Hospital upon Completion

Regular Follow-Up of Uncompleted Questionnaires from Participants

Interpretation and Analysis of Data

Figure 2. Flow of Activities

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CHAPTER III RESULTS AND DISCUSSION

Demographic Profile This study involves physicians from the selected hospitals in Zamboanga City in the four fields of specialty namely, General Practitioners, Internal Medicine resident physicians, Family Medicine physicians, and General or Internal Medicine Specialists. Table 1. Demographic Profile of the Participants Demographic Profile

Field of Specialty Internist General Practitioner IM Resident Physician Family Physician Total Age <30 30 - 39 40 - 49 50 ­ 59 >60 Total Gender Male Female Total Marital Status Single Married Total Years of Medical Practice <1 year 1-4 years 4-6 years 6-9 years >10 years Total

Frequency

31 27 14 8 80 10 44 16 10 0 80 42 38 80 25 55 80 9 20 17 6 28 80

Percent

38.8 33.8 17.5 10.0 100.0 12.5 55.0 20.0 12.5 0 100 52.5 47.5 100.0 31.3 68.8 100.0 11.3 25.0 21.3 7.5 35.0 100.0

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There were a total of eighty participants (81.6%) out of 98 physicians identified in the 8 hospitals of Zamboanga City in the four fields of specialty mentioned. The remaining 18 physicians were repeatedly followed-up to participate in this study but unfortunately, most of them were resistant due to a very busy schedule. Majority were Internal Medicine specialists. There were a few General Practitioners who were unable to participate and one family physician who was on maternity leave at the time of the data gathering, hence, was not included. As shown in Table 1, Internists comprises 31 out of 80 (38.8%) participants, followed by General Practitioners which makes up 27 (33.8%) of the total number of participants . There were 14 (17.5%) Internal Medicine resident physicians and only 8 (10%) family physicians included in the study. Most of the participants belong to age group 30 to 39 years old (44 out of 80 or 55%). Also, there were about 16 (20%) participants who belong to age group 40 to 49, followed by ages below 30 years old and ages within 50 to 59, which make up 10 (12.5%) participants each. The gender distribution is nearly close wherein male physicians consisted of 42 out of 80 (52.5%) participants and female physicians accounted for the remaining 38 (47.5%) participants. Majority (55 out of 80 or 68.8%) are married, while 25 (31.3%) of them are single. Finally, about 28 (35%) participants have practiced their profession for more than ten years, usually Internists and Family Physicians. Twenty (25%) physicians have been in practice for at least 1 to 4 years, 17 (21.3%) between 4 to 6 years, while 9 (11.3%)) and 6 (7.5%) of them have been practicing for less than a year and between 6 to 9 years, respectively.

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Smoking Status, History and Exposure

The participants were asked about their current smoking status and reviewed for history of smoking exposure. Table 2 shows the smoking status of participants. Table 2. Smoking Status of Physicians Smoking Status

Non-smoker Current Smoker Total Non-smoker Previous smoker Occasional smoker Daily smoker Total

Frequency

64 16 80 54 10 10 6 80

Percent

80 20 100.0 67.5 12.5 12.5 7.5 100.0

The prevalence of smoking among physicians is 20%. These are the current smokers. Of these, 10 (12.5%) are occasional smokers and 6 (7.5%) are daily smokers. At present, there were a total of 64 (80%) non-smokers and of these, 54 (67.5%) claimed to have never smoked cigarette while 10 (12.5%) were previous smokers. Table 3. Smoking Status of Physicians among the Four Fields of Specialty

Frequency (%) Field of specialty Internist General Practitioner IM Resident Physician Family Physician Total NON-SMOKER 26 (40.62) 20 (31.25) 11(17.19) 7 (10.94) 64 SMOKER 5 (31.25) 7 (43.75) 3 (18.75) 1 (6.25) 16 Total 31(38.75) 27 (33.75) 14 (17.5) 8 (10) 80

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Table 3 shows that most (7 out of 16 or 43.75%) of the smokers are General Practitioners, who are usually occasional smokers. However, Internists and Internal Medicine resident physicians consists of 5 (31.25%) and 3 (18.75%) smokers respectively. Hence, majority of the smokers are from these fields of specialty and were usually daily smokers. Also most of the currents smokers were male (15 out of 16 or 94%). Table 4 below shows previous history of smoking exposure among participants. Table 4. History of Family Exposure to Smoking Smoking Exposure Yes None Total Parents Siblings Grandparents Others Frequency 43 37 80 34 16 5 4 Percent 53.8 46.3 100.0 79 37.2 11.6 9.3

About 43 (53.8%) physicians said that they have been exposed to some members of the family who smoked during their childhood, while the remaining 37 (46.3%) does not have family exposure to smoking. Most of the smokers in the family were parents, usually the fathers, where 34 out of 43 (79%) participants recalled being exposed to. Others were siblings (37.2%), grandparents (11.6%) or cousins and uncles (9.3%). Each participant had been exposed to at least one or more family members who smoked.

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Table 5 below shows the smoking-cessation trainings attended by the participants. Table 5. Smoking-Cessation Training of Participants Smoking-Cessation Training

Yes None Total Special Conferences, Symposia, or Workshops Formal Training in Medical School Training during Specialization Others

Frequency

52 28 80 42 14 6 2

Percent

65 35 100 52.5 17.5 7.5 2.5

Fifty-two out of 80 (65%) physicians answered that they had attended smokingcessation conferences, symposia or workshops. However, about 28 (35%) did not have any training on smoking ­cessation approaches. Also, 14 (17.5%) physicians claimed to have smoking-cessation training during medical school and 6 (7.5%) during their specialization program (mostly internists and family physicians). Lastly, only 2 (2.5%) participants said that they went through other informal smoking-cessation trainings. According to previous studies, lack of training on smoking-cessation skills can impede physicians from effectively counseling their patients to quit smoking. Doctors can help patient to quit smoking but must have appropriate skills and training on smokingcessation. In a study among physicians in Hong Kong, it showed that previous training is associated with higher confidence in smoking-cessation counseling (Abdullah, 2004).

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Table 6 presents the age at which current and previous smokers began to smoke. Table 6. Age at Which Current and Previous Smokers Started Smoking Age (in years) 16 ­ 20 21 ­ 25 26 ­ 30 Total Frequency 18 6 2 26 Percent 69.23 23.08 7.69 100

The earliest age of smoking was noted at 16 years old and the oldest was at 30 years of age. Majority of the participants, both current and previous smokers, have started smoking between ages 16 to 20 (18 out of 26 or 69.23%) followed by ages between 21 to 25 (23.08%) and ages within 26 to 30 (7.69%). Among the current smokers, 8 out of 16 (50%) said that they have at least attempted to quit cigarette smoking. Most of the previous smokers (40%) have quit smoking between ages 31 to 40. Others have successfully quit between ages 21 to 30 (30%) and 41 to 50 (30%). (See Appendix B) Table 7 below presents the common reasons for smoking among current and previous smokers. Table 7. Common Reasons for Smoking among Current and Previous Smokers Reasons for Smoking Reduces/relieves stress-related work Improves sociability among peers Enhances memory and alertness Keeps weight down Others Frequency 15 11 5 1 7 Percent 57.69 42.31 19.23 3.85 26.92

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Reasons for Smoking. When the current and previous smokers were asked for their reason(s) of smoking, majority (57.69%) expressed that it has something to do with reducing or relieving stress-related work. About 11 (42.31%) of the participants smoke as part of their social interactions with peers. Some (19.3%) of the current smokers said that smoking can enhance their memory or alertness. Others (26.92%) smoke because accordingly, it enhances the taste of alcoholic beverage that they drink together while smoking or brings about a soothing effect after taking their meal. Reasons for Not Quitting. The common reasons for not being able to successfully quit smoking among current smokers were also examined. Seven out of 16 (43.75%) current smokers cannot stop their smoking habit due to cravings for cigarettes. Also, other 7 (43.75%) smokers said that they smoke for the same reason of socialization purposes in the circle of friends, they smoke only occasionally and there is no need to quit, or that there is also no plan to quit drinking alcoholic beverage as smoking enhances its taste. One smoker (6.25%) stated that he cannot stop the habit due to fear of loss of way to handle stress. Out of the 16 current smokers, 7 (43.74%) of them think that smoking has negatively affected their health in some way. (See Appendix B) In the following discussion, the participants' smoking-related knowledge, attitude, and practices as well as their smoking-cessation counseling of patients will be presented.

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Smoking-Related Knowledge, Attitude, and Practices

The participants' smoking-related knowledge, attitude and practices were determined in this research. In the following sections, each category (knowledge, attitude, and practices) will be correlated with their smoking-cessation counseling.

Knowledge

Physicians' knowledge on smoking was examined. The table below shows the level of agreement of the participants concerning smoking-related knowledge. Table 8. Smoking-Related Knowledge among Participants Smoking-Related Knowledge Active smoking increases the risk of ischemic heart disease among smokers Passive smoking increases the risk of lung disease in non-smoking adults. Passive smoking increases the risk of heart disease in non-smoking adults. Passive smoking increases the risk of lower respiratory tract illnesses such as pneumonia in exposed children. Neonatal death is associated with passive smoking. Maternal smoking during pregnancy increases the risk of Sudden Infant Death Syndrome. Frequency, N = 80 (%) Agree Unsure Disagree 80 0 0 (100%) (0%) (0%) 80 0 0 (100%) (0%) (0%) 71 7 2 (88.8%) (8.8%) (2.5%) 74 5 1 (92.5%) (6.3%) (1.3%) 51 (63.8%) 69 (86.3%) 22 (27.5%) 9 (11.3%) 7 (8.8%) 2 (2.5%)

In the first statement, all (80 or 100%) of the participants agree that active smoking increases the risk of ischemic heart disease among tobacco users. Also, all (100%) of them believe that passive smoking increases the risk of lung disease in nonsmoking adults.

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In the third item, majority (88.8%) agrees that passive smoking increases the risk of heart disease in non-smoking adults; however, 7 (8.8%) were unsure and 2 (2.5%) disagree on this statement. The 4th item also shows that majority (92.5%) agree that passive smoking increases the risk of lower respiratory tract illnesses such as pneumonia in exposed children whereas 5(6.3%) were unsure and one (1.3%) participant disagree on this matter. About 51 (63.8%) agrees that neonatal death is associated with passive smoking. However, at least 22 (27.5%) were unsure of this and 7(8.8%) of them disagree that an association between passive smoking and neonatal death exists. Lastly, 69 (86.3%) believes that maternal smoking during pregnancy increases the risk of Sudden Infant Death Syndrome (SIDS). Nine (11.3%) participants said that they are unsure of this risk while 2 (2.5%) of them disagree. Table 9. Number of Participants with Correct and Incorrect Knowledge Smoking status Non-smoker Smoker Total Knowledge Correct Incorrect 48 13 61 (76.25%) 16 3 19 (23.75%) Total 64 16 80 (100%)

Lack of knowledge and inappropriate attitude can influence physician's behavior as pointed out by previous studies. As shown in Table 9, it was found that most of the

participants (61 out of 80 or 76%) in this study have a correct knowledge on the health risks of smoking while 19 (23.75%) have incorrect smoking-related knowledge. Physicians' counseling on the health risks of smoking may become limited particularly among those who have incorrect knowledge. More specifically, some physicians may not

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be able to give significant impact when counseling regarding maternal smoking or passive smoking around children or pregnant mothers. The coverage of their counseling will be restricted only to their knowledge. Hence, it still imperative that all physicians are well informed on smoking health risks to be able to counsel patients appropriately and impart a better education to them. In the later sections, a correlation between smoking-related knowledge and counseling by physicians will be examined to determine if a good knowledge would relate to a good counseling practice on smoking cessation.

Attitude

Health professionals also play a major role in the smoking-cessation of patients by setting a good example of not smoking themselves. In this regard, the study would like to determine the participants' view on the role modeling aspect of physicians. The table below shows the participants smoking-related attitude. Table 10. Smoking-Related Attitude among participants Smoking-Related Attitude Health professionals should set a good example by not smoking. Patient's chances of quitting smoking are increased if a health professional advises him or her to quit. Health professionals should routinely ask about their patients smoking habits. Heath professionals should routinely advise their patients to quit smoking. Health professionals who smoke are less likely to advise people to stop smoking. Frequency, N = 80 (%) Agree Unsure Disagree 76 3 1 (95%) (3.8%) (1.3%) 75 3 2 (93.8%) (3.8%) (2.5%) 79 (98.8%) 77 (96.3%) 49 (61.3%) 0 (0%) 1 (1.3%) 9 (11.3%) 1 (1.3%) 2 (2.5%) 22 (27.5%)

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The table above shows the level of agreement of physicians on smoking-related attitude. Seventy-six out of 80 (95%) participants believe that health professionals should set a good example by not smoking. At least three (3.8%) and one (1.3%) of them were unsure and disagree on this viewpoint, respectively. Most of the participants (93.8%) agree that patients' chances of quitting smoking are increased if a health professional advises him or her to quit while 3 (3.8%) were unsure and 2 (2.5%) disagree. The concept that physicians should always ask about a patient's smoking habit and should advise him/her to quit were agreed upon by 79 (98.8%) and 77 (96.3%) participants, respectively. In the last item, although most of the participants (61.3%) believe that physicians who smoke are less likely to advise people to quit smoking, quite a number of them disagree (27.5%) or were at least unsure (11.3%) on this. In this study, majority of the participants were found to have favorable attitude towards setting a good example by not smoking, and routinely asking and advising patients to quit as seen in the first to fourth items. However, as observed in the last item, many physicians still doubt or disagree that being a smoker is a barrier to advice or counsel patients against smoking. The next table illustrates the number of participants with better and poor attitude towards smoking.

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Table 11. Number of Participants with Better and Poor Attitude Smoking Status Non-smoker Smoker Total Attitude Better 48 7 55 (68.75%) Poor 16 9 25 (31.25%) Total 64 16 80 (100%)

In general, majority (68.75%) have better attitude regarding role modeling of health professionals on smoking cessation. Most of the non-smokers (48 out of 64 or 75%) have better attitude while most of the smokers have poor attitude (9 out of 16 or 56.25%) towards smoking.

Smoking Practices

According to study by Polyzos in 1995, non-smoking physicians are more involved in smoking-cessation counseling compared to physicians who smoke. In this study, the counseling practices of both smokers and non-smokers will also be addressed and determine if such association exist. In the table below, the smoking practices of physician smokers were examined in terms of the frequency, duration, and number of cigarette consumption, smoking in front of a patient(s), presence of smoking during working hours or shift, and compliance to anti-smoking policy in non-smoking areas.

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Table 12. Smoking Practices among Current Smokers Smoking Practice

How often do you smoke? a. Very occasionally b. 2 to 3 times a week c. 4 to 5 times a week d. Almost everyday Total Estimated no. of months or years of smoking a. Less than 6 mos. b. 6 mos. to 1 yr. c. > 1 yr. to 2.5 yrs. d. > 2.5 yrs. to 5 yrs. e. > 5 yrs. to 10 yrs. f. Greater than 10 yrs. Total Estimated no. of cigarette(s) smoke per day a. Less than 5 sticks b. 5 to 10 sticks c. 11 to 15 sticks d. 16 to 20 sticks e. Greater than 20 sticks Total How frequently do you smoke in front of a patient(s)? Never Rarely Sometimes Always Total I have smoked during shift. Yes No Total I have good compliance to the smoke-free policy in nonsmoking areas. Yes No Total Frequency (%) 9 (56.25) 1 (6.25) 1 (6.25) 5 (31.25) 16 (100) 1 (6.25) 1 (6.25) 1 (6.25) 3 (18.75) -10 (62.5) 16 (100) 10 (62.5) 3 (18.75) -2 (12.5) 1 (6.25) 16 (100) 14 (87.5) 2 (12.5) --16 (100) 5 (31.25) 11 (68.75) 16 (100)

15 (93.75) 1 (6. 25) 16 (100)

As presented in the above table, most of the current smokers would tend to smoke very occasionally (56.25%). Again, they are likely to smoke especially during social occasions or when they are together with peers. Also, some of the smokers would

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smoke almost every day (31.25%). Most current smokers (62.5%) have been smoking for more than 10 years now while the rest have been smoking for less than six months to five years. Ten out of 16 (62.5%) smokers would consume less than 5 sticks of cigarette when they smoke, while some of the smokers would finish 5 to 10 sticks (18.75%) or 16 to 20 sticks (12.5%) of cigarettes per day. It can be seen that most of the participants had never smoked (14 out of 16 or 87.5%) or rarely (2 out of 16 or 33.33%) would they have smoked in front of a patient. Majority (11 out of 16 or 68.75%) of the smokers would not smoke during working hours but about 5 (31.25%) smokers do smoke during shift. Also, most of the smokers (15 out of 16 or 93.75%) have good compliance to the anti-smoking policy in non-smoking areas. Only one out of 16 current smokers, particularly a daily smoker, admits to have poor compliance to the anti-smoking policy in non-smoking areas. The table below shows the number of smokers with better and poor smoking practice. Table 13. Number of Smokers with Better or Poor Smoking Practice Smoking Status Smoker Smoking Practice Better Poor 10 (62.5%) 6 (37.5%) Total 16 (100%)

Among the smokers, 10 out of 16 (62.5%) current smokers have a better practice in terms of use of cigarettes while 6 (37.5%) have a poor smoking practice. Overall, nonsmokers are considered to have better practice than those who smoke The smoking practice will also be correlated with smoking-cessation counseling of physicians on later discussions.

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Smoking-Cessation Counseling

According to a study by Fiore in 2000, a simple advice to quit smoking has been shown to increase abstinence rates of patients by 30% with minimal contact (less than 3 minutes) compared to no advice at all. More intensive counseling (more than 10 minutes) could increase abstinence rate twice. Hence, in this study, it is imperative that the smoking- cessation counseling of physicians will be addressed due to its great impact in the abstinence rate of patient smokers. The table below shows the smoking-cessation practices of the participants. Table 14. Smoking-Cessation Counseling among Participants Smoking-Cessation Counseling I ask patients if they smoke I explain to my patients the consequences of smoking on one's health I encourage/challenge my patients to quit smoking I teach my patients with possible methods on how to quit smoking

Never 3 (3.8%) 3 (3.8%) 4 (5.0%) 6 (7.5%) Frequency, N = 80 (%) Rarely Sometimes 0 17 (0%) (21.3%) 1 22 (1.3%) (27.5%) 0 (0%) 3 (3.8%) 14 (17.5%) 24 (30%)

Always 60 (75.0%) 54 (67.5%) 62 (77.5%) 47 (58.8%)

As noted, most of the participants (60 out of 80 or 75%) would usually ask of their patients smoking status while 17 (21.3%) participants would sometimes ask and 3 (3.8%) would actually not do so. Also, 54 (67.5%) would always explain to their patients the health consequences of smoking, 22 (27.5%) would sometimes do, and at least 3 (3.8%) and 1 (1.3%) respectively would never or rarely explain it to their patients. In terms of encouraging or challenging patients to quit smoking, majority (62 or 77.5%) said

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they always do so and others would sometimes (14 or 17.5%) or never (4 or 5%) encourage patients at all. Lastly, about 47 (58.8%) physicians teach their patients possible methods on how to quit smoking, 24 (30%) sometimes do, but there are about 6 (7.8%) who never and 3 (3.1%) who rarely teach their patients. The number of participants with better and poor counseling is shown in the table below. In this study, we can see that most of the physicians would provide simple advice or counseling to patients to help them quit smoking. However, quite a number of them does not always teaches patients method of quitting cigarette smoking as presented in the last item above. In previous studies, there were obstacles noted in providing smokingcessation counseling. Among these were lack of patient motivation, lack of doctor's time in consultation, focus on other health measure of higher priority, lack of expertise in smoking-cessation, lack of incentives among doctors, doubts on efficacy of available therapies on smoking-cessation, and fear of damaging doctor-patient relationship. The same problems were noted in this study. Some of the participants specifically stated that there is no point in convincing patients to quit who themselves lack motivation or unwilling to quit because it would be a waste of time. Also some doctors reiterated the lack of time for a more intensive counseling program due to a great number of patients being seen everyday. Still, they provide simple and brief advice on

smoking-cessation to patients. Some participants also have doubts on the efficacy of the smoking-cessation medications, and so, do not recommend it to their patients.

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In another study by Lancaster, et al in 2004, it was confirmed that a brief advice from physicians is effective in promoting smoking cessation. A minimal intervention gives a difference in the cessation rate of about 2.5% between those who receive advice and those who did not. More intensive advice, classified as a longer consultation, additional visits, or with self-help manual, may result in rates of quitting. With this, the other types of intervention use by the participants to help their patients quit smoking were also examined. The figure below shows the smokingcessation interventions commonly used by the participants.

Figure 3. Types of Smoking-Cessation Intervention Commonly Provided by Physicians

Types of Intervention

1% 26%

slightly higher

47%

Counseling Traditional remedies Self-help materials Medication Others

19% 7%

As noted, the most common type of intervention used is counseling on smoking cessation (47%), followed by the use of medications to treat smoking (26%), and the use of self-help materials (19%). Other (7%) intervention use is a very simple advice to quit smoking or simply tell them to quit while only 1% use traditional remedies.

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In this study, brief counseling of patients on smoking-cessation contributes to a significant part of the participants' intervention. When more intensive intervention is use, other additional smoking-cessation methods are provided to patients. Previous studies have shown that there is no single approach to the exclusion of others in the treatment of tobacco dependence due to the variation in efficacy, acceptability, and costeffectiveness of the available methods or therapies. The success depends on the synergistic use of the interventions. Hence, in the above figure, it shows that the small proportion related to use of other methods such as medications or self-help materials suggests that only a few would provide intensive smoking-cessation strategies to patients. Again, this can be attributed to the previously mentioned obstacles in smoking-cessation practices of physicians.

Smoking-Cessation Counseling of Smokers versus Non-Smokers According to a study by Kawakami et al in 1997, non-smoking physicians are more likely to advice patients to stop smoking than smoking physicians. Also, nonsmoking physicians seriously felt the need for smoking-cessation interventions than physicians who smoke. Hence, in this study, we will examine if the smoking-cessation counseling of participants can be influenced by their smoking status. The items on smoking-cessation practice will be dissected to note if being a smoker would affect their counseling practice. Again, there are four items included: asking about patient's smoking status, explaining the consequences of smoking, challenging or encouraging patients to quit, and providing methods of smoking-cessation. Table 15 shows the smoking-cessation counseling of smokers and non-smokers.

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Table 15. Smoking-Cessation Counseling of Physician Smokers and Non-Smokers Smoking-Cessation Counseling

I ask my patients if they smoke. Always Sometimes Rarely Never Total I explain to my patients the consequences of smoking on one's health. Always Sometimes Rarely Never Total I encourage/challenge my patients to quit smoking. Always Sometimes Rarely Never Total I teach my patients with possible methods on how to quit smoking. Always Sometimes Rarely Never Total 7 (43.75) 7 (43.75) -2 (12.50) 16 40 (62.50) 17 (26.56) 3 (4.69) 4 (6.25) 64 47 (58.80) 24 (30.00) 3 (3.80) 6 (7.50) 80 11 (68.75) 5 (31.25) --16 51 (79.69) 9 (14.06) -4 (6.25) 64 62 (77.50) 14 (17.50) -4 (5.00) 80 10 (62.50) 5 (31.25) 1 (6.25) -16 44 (68.75) 17 (26.56) -3 (4.69) 64 54 (67.50) 22 (27.50) 1 (1.30) 3 (3.75) 80 10 (62.50) 6 (37.50) --16 50 (78.12) 11 (17.19) -3 (4.69) 64 60 (75.00) 17 (21.25) -3 (3.75) 80 Frequency (%) Smoker Non-Smoker Total

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The table above shows that both smokers and non-smokers would tend to always (75%) or sometimes (21.25%) ask of the smoking status of their patients. Only 3 (3.75%) would never ask their patients smoking status and were from the non-smoking group. In the practice of explaining the health consequences of smoking to patients, also noted was that most physician smokers and non-smokers would always (67.5%) or sometimes (27.5%) do so. Only one smoker would rarely explain to the patients. Again, there were 3 (3.75%) participants who never explain the ill-health effects of smoking among patients. These were the same non-smoking physicians who would also not ask the smoking status of their patients. Also, it can be noted that most smoker and non-smoker participants would always (77.5%) or sometimes (17.5%) encourage or challenge the patients to quit smoking. The same physicians who would not ask and explain to patients the consequences of smoking will not be able to encourage patients to quit. But this time, about 4 (5%) participants would never challenge their patients to stop smoking. Lastly, on both smokers and non-smokers, 47 (58.8%) and 24 (30%) would always and sometimes teach patients of other possible methods to quit smoking, respectively. Only 6 (7.5%) and 3 (3.8%) would never (6.25%) or rarely (4.69%) provide options on methods of quitting smoking to patients, respectively. Again, those were the same participants who never encourage patients to stop smoking. Table 16 presents the number of participants with better and poor smokingcessation counseling.

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Table 16. Number of Participant with Better and Poor Smoking-Cessation Counseling

Smoking Status Non-smoker Smoker Total

Counseling Better Poor 50 10 60 (75%) 14 6 20 (25%)

Total 64 16 80 (100%)

In general, as shown in the above table, majority (60 out of 80 or 75%) have better smoking-cessation counseling practice. Most of the smokers (10 out of 16 or 62.5%) and non-smokers (50 out of 64 or 78%) have better counseling practice. Surprisingly, many of the smokers have better smoking-cessation counseling practice. This tells us that the smoking status of the physicians does not really influence them from counseling against smoking. It shows that being a smoker is not really a barrier to the participants in smoking-cessation counseling. In addition, there are also counseling beliefs and experiences among the participants as presented in the next table. Table 17. Smoking-Cessation Counseling Beliefs of Physicians

Smoking-Cessation Counseling Belief Does (your) smoking affect the way you counsel patients to quit smoking? For non-smokers, do you think physician's smoking will affect counseling of patients to quit smoking? Are you less likely to convince patients to quit if you are a smoker? Does counseling on direct health harms of active smoking helps with smoking cessation among your patients? Does counseling on health harms of passive smoking helps with smoking cessation among your patients? Does counseling family members of your patients on health harms of second hand smoke helps with their smoking cessation? Yes Frequency (%) Unsure 20 (25.0%) 17 (21.3%) 4 (5.0%) 6 (7.5%) 7 (8.8%) No 21 (26.3%) 19 (23.8%) 2 (2.5%) 2 (2.5%) 0 (0%)

39 (48.8%) 44 (55.0%) 74 (92.5%) 72 (90.0%) 73 (91.3%)

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Almost half of the participants (48.8%) believe that smoking will affect counseling of patients to quit smoking. However, many were unsure (25%) or do not believe (26.3%) that it can influence the counseling of physicians. Also, almost half (55%) believes that physicians who smoke are less likely to counsel patients and many of them are unsure (21%) or do not believe (23%) it. Again as previously noted, many physicians still doubt or do not believe that smoking can hinder a doctor from advising or counseling on not smoking. Furthermore, most of them think that counseling smokers on the direct and indirect health harms of smoking and counseling their family members as well usually helps patient to quit smoking, as noted in the 3rd to 5th item. However, there were some participants who are unsure or do not believe so. Once more, some physicians may become limited in their counseling due to these beliefs. The next table shows the levels of preparedness of physicians when counseling on smoking-cessation.

Table 18. Levels of Preparedness on Smoking-Cessation Counseling among Physicians

Smoking-Cessation Counseling Preparedness Very well prepared Somewhat prepared Not at all prepared Total

How well prepared do you feel when you are counseling patients?

43 (53.8%)

31 (38.8%)

6 (7.5%)

80 (100%)

It can be seen that almost half of the participants (53.8%) said that they are very well prepared in terms of smoking-cessation counseling. However, many of the physicians are only somewhat prepared (38.7%) and some are not at all prepared (7.5%). This data shows that many physicians are still not confident to counsel patients. As we have noted earlier, 65% of the physicians were able to receive or experience smoking-cessation trainings. However, only 54% are confident when they are

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counseling patients. This data shows that there is a need to improve the smokingcessation skills of physicians to increase their level of preparedness and confidence in counseling. As noted in a previous study, physicians who receive a continuing education program on smoking-cessation are more effective and have higher rates of quit rates among their patients (Cummings, 1989).

Knowledge, Attitude, and Practices Correlation with Smoking-Cessation Counseling In this section, the smoking-related knowledge, attitude, and practices of participants will be examined for an existing correlation with their counseling on smoking cessation. Knowledge versus Counseling Figure 3 below is a scatter plot diagram showing the correlation between the mean knowledge scores and the mean score for smoking-cessation counseling practices obtain by the participants.

2.2

2.0

1.8

Mean Knowledge Scores

1.6

1.4

1.2

1.0 -.5 0.0 .5 1.0 1.5 2.0 2.5 3.0 3.5

Mean Smoking-Cessation Counseling Scores

Figure 4. Correlation between Knowledge and Counseling Practices

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It can be noted in the scatterplot diagram that an increase in knowledge scores is not associated with an increase in the counseling scores, nor an increase in knowledge scores is correlated to a decrease in the counseling scores. There is a -0.094* Pearson Correlation Coefficient (r) between physicians' smoking-related knowledge and counseling, which is almost close to zero. This means that physicians' knowledge on smoking is not significantly associated with the practices on smoking-cessation counseling. Neither correct nor wrong knowledge will influence if a physician is likely to counsel patients or not. Hence, in this study, knowledge on smoking and smoking-cessation counseling of physicians does not have significant association at all. Attitude versus Counseling In the same manner, a correlation between the physicians' attitude regarding smoking and their counseling practices is investigated. The figure below shows the scatterplot correlation of these two variables.

2.2 2.0 1.8 1.6 1.4 1.2 1.0 .8 .6 .4 -.5 0.0 .5 1.0 1.5 2.0 2.5 3.0 3.5

Mean Attitude Scores

Mean Smoking-Cessation Counseling Scores

Figure 5. Correlation between Attitude and Counseling Practices

* Knowledge vs. Counseling (r = - 0.094 ; Sig. (2-tailed) = 0.408)

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Similarly, we can see that an increase in the attitude scores does not connote an increase in the counseling scores on smoking-cessation, nor does an increase in attitude scores results to a decrease in the counseling scores of participants. The mean scores for attitude and counseling practices obtain a Pearson Correlation Coefficient (r) of -0.017**. This also denotes that there is no existing significant correlation between the two since it is very close to zero. Again, there is no significant association found between the physicians' attitude on smoking and their willingness to counsel patients to stop smoking. Smoking Practices versus Counseling There are 6 items involved in the smoking practices category: frequency of smoking, duration of smoking, number of cigarettes smoke per day, smoking during shift, smoking in front of a patient(s), and good compliance to policy on anti-smoking in nonsmoking areas. Each smoking practice is treated separately due to a different scoring assigned for each item.

7

6

Compliance vs. Counseling

5

Smoke in Front Px vs. Counseling

4

Smoking during Shift

3

vs. Counseling No. of Cigarettes vs. Counseling Duration of Smoking vs. Counseling

2

1

0 -1 -.5 0.0 .5 1.0 1.5 2.0 2.5 3.0 3.5

Frequency of Smoking Counseling

Figure 6. Correlation between Smoking Practices and Smoking-Cessation Counseling of Physicians 41

** Attitude vs. Counseling (r = - 0.017 ; Sig. (2-tailed) = 0.884)

The scatterplot above represents the association of physicians' smoking practices in all the items versus their smoking-cessation counseling. Again, there are no existing significant positive or negative relationships found. The smoking practice on the frequency of smoking versus counseling by physicians is noted to have no significant Pearson Correlation Coefficient (r) of 0.113* which is close to zero. Also, the duration of smoking and the number of cigarettes smoke per day is not associated with the counseling with an r of 0.10*1and 0.115*, respectively. The same is true for the practice on smoking during working hours (0.151*), smoking in front of a patient (0.193*), or having a good compliance to non-smoking policy in restricted areas (0.100*). Hence, it can be deduced that no significant association is found between any of the smoking practice of participants and their counseling of patients to quit smoking. Being a smoker or non-smoker does not influence physicians' counseling patients on smoking-cessation. The results of this study showed that there is no significant correlation or association between the counseling on smoking-cessation and the physicians' knowledge, attitude, or practices on smoking. Majority of the physicians have good smoking-

related knowledge, attitude and practices. Those who were found to have inappropriate knowledge, attitude or smoking practice were not necessarily hampered from counseling their patients on smoking cessation. However, inappropriate knowledge of some physicians may limit their coverage of counseling in terms of patient education especially on some health risks of passive smoking and maternal smoking. In addition, this study

*

Frequency of Smoking vs. Counseling (r = 0.113 ; Sig. (2-tailed) = 0.319) Duration of Smoking vs. Counseling (r = 0.101 ; Sig. (2-tailed) = 0.373) No. of Cigarettes Smoke per Day vs. Counseling (r = 0.115 ; Sig. (2-tailed) = 0.169) Smoking during Shift vs. Counseling (r = 0.151 ; Sig. (2-tailed) = 0.180) Smoking in Front of Patients (r = 0.193 ; Sig. (2-tailed) = 0.087) Good Compliance in Non-Smoking Areas vs. Counseling (r = 0.100 ; Sig. (2-tailed) = 0.376)

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found that only half of the participants have attended smoking-cessation training approaches. In counseling, other types or methods of smoking cessation are not always offered to patients, which can be due to lack of preparedness or confidence to counsel patients to quit smoking. Hence, the counseling skills among physicians must be enhanced and improved to provide better care to patients who want to quit as well as those who do not intend to quit.

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CHAPTER IV SUMMARY, CONCLUSION, AND RECOMMENDATION

In summary, this analytical cross-sectional study examined the effect of physicians' knowledge, attitude, and smoking practices on their smoking-cessation counseling. There were a total of eighty physician participants (82%) from the selected four fields of specialty involved in this study, particularly among General Practitioners, Family Physicians, and Internal Medicine Specialists and Resident Physicians. About 20% of the participants are current smokers, either occasional or daily smokers, and majority of them are from the Internal Medicine fields (residents and specialists). It was noted that about 53.8% of the participants had been exposed to family members who smoke during their childhood. The usual family members seen to be smoking are the fathers. It was also found that most physicians smoke to reduce or relieve stress-related work or activities (56.25%) or as part of social interactions among peers (31.25%) and majority of the smokers cannot quit smoking due to cravings for cigarettes (43.75%). In this study, it was found out that most of the participants (76%) have a correct knowledge on the health risks of smoking and 68.75% have a better attitude towards role modeling responsibility of physicians regarding smoking. Among the smokers, 62.5% have a better smoking practice. It was also revealed that majority (75%) of the participants have better smoking-cessation counseling practice. However, only 53.8% of the participants felt that they are very well prepared to counsel patients. In line with counseling, many physicians would not always provide patients with possible methods on

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how to quit, which explains the low rate of use of other smoking-cessation strategies such as medications or self-help materials. Finally, this study noted that there is no significant correlation between physicians' knowledge, attitude, or smoking practice with their smoking-cessation counseling. This means that having the right or incorrect knowledge, better or poor attitude, or having better or poor smoking practice does not influence whether physicians will counsel their patients or not on smoking cessation. In the light of this study, the following recommendations are presented: 1. There is a need to enhance and improve smoking-cessation counseling skills among physicians to be more effective counselors and raise their level of preparedness and confidence in counseling. Specifically; · · Smoking-cessation trainings should be part of the medical curriculum. A continuing education program on smoking-cessation should also be incorporated in residency training programs or subspecialty trainings. 2. Physicians may be encouraged to offer patients more intensive smoking-cessation methods by providing physicians appropriate incentive-motivation conditions. 3. Physician smokers should be motivated to quit and emphasize role modeling responsibilities. 4. Hospitals should formulate strategies to promote smoking-cessation counseling among physicians in their institution. 5. Most types of interventions on smoking-cessation (such as different sorts of medications) and support groups for quitting smoking should be made available.

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BIBLIOGRAPHY

Abu Saleh M. Abdullah, et al. Investigation of Hong Kong Doctors' Current Knowledge, Beliefs, Attitudes, Confidence and Practices: Implications for the Treatment of Tobacco Dependency. Department of International Health, Boston University School of Public Health. Journal of Chinese Medicine Association 2006;69(10):461­471 Yuan Jiang, MD, MPH, et al. Chinese Physicians and Their Smoking Knowledge, Attitudes, and Practices. American Journal of Preventive Medicine 2007; 33(1):15­22) Paul C Perrin, Ray M Merrill, Gordon B Lindsay, Patterns of Smoking Behavior Among Physicians in Yerevan, Armenia. Department of Health Science, College of Health and Human Performance, Brigham Young University, Provo, Utah, USA. BMC Public Health 2006, 6:139 Tingting Yao, Michael Ong, Anita Lee, Yuan Jiang, Zhengzhong Mao. Smoking Knowledge, Attitudes, Behavior, and Associated Factors among Chinese Male Surgeons. World J Surg 2009; 33:910­917 R.M. Merrill,H.N. Madanat, E. Cox, J.M. Merrill. Perceived Effectiveness of Counseling Patients about Smoking among Medical Students in Amman, Jordan. Department of Health Science, College of Health and Human Performance, Brigham Young University, Utah, United States of America. Eastern Mediterranean Health Journal, Vol. 15, No. 5, 2009 Polyzos A, Gennatas C, Veslemes M et al (1995) The Smoking Cessation Promotion Practices of Physician Smokers in Greece. J Cancer Educ 10:78­81 Loic Josseran, MD, et al. Smoking Behavior and Opinions of French General Practitioners. Paris, France and University Park, Pennsylvania. J Nat'l Med Assoc.

2000;92;382-390

Lancaster T, Stead LF. Physician Advice for Smoking Cessation. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000165. DOI: 10.1002/14651858. CD000165.pub2. Cornuz J, et al. Efficacy of Resident Training in Smoking Cessation: A Randomized, Controlled Trial of a Program Based on Application of Behavioral Theory and Practice with Standardized Patients. Ann Intern Med. 2002 Mar 19;136(6):429-37.

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Sotiropoulos A, Gikas A, Spanou E et al (2007) Smoking Habits and Associated Factors among Greek Physicians. Public Health 121:333­340 Young M, Ward J (1998) Improving Smoking Cessation Advice in Australian General Practice: What Do GPs Suggest is Needed? Aust N Z J Public Health 22:777­ 780 Abdullah A, Husten C (2004) Promotion of Smoking Cessation in Developing Countries: A Framework for Urgent Public Health Interventions. Thorax 59:623­ 630 Eckert T, Funker C (2001). Motivation for Smoking Cessation: What Role Do Doctors Play? Swiss Med Wkly 131:521­526 Kreuter M, Chheda S, Bull F (2000). How Does Physician Advice Influence Patient Behaviour? Evidence for a Priming Effect. Arch Fam Med 9:426­433 Fiore M, Bailey W, Cohen S (2000). Treating Tobacco Use And Dependence: Clinical Practice Guideline. US Department of Health and Human Services, Public Health Service, Rockville, MD, 2000 Kawakami M, Nakamura S, Fumimoto H, Takizawa J, Baba M: Relation Between Smoking Status of Physicians and their Enthusiasm to Offer Smoking Cessation Advice. Intern Med. 1997 Mar;36(3):162-5. Cummings SR, et al. Training Physicians about Smoking Cessation: A Controlled Trial in Private Practice. J Gen Intern Med. 1989 Nov-Dec;4(6):482-9. Michael T. Brannick (2006). Correlation and Regression. Retrieved April 25, 2010 from http://[email protected]

47

APPENDICES

48

APPENDIX A Questionnaire

Instructions: Encircle the appropriate answer. I - Demographic Profile

1. Age (in years) a. <30 b. 30-39 c. 40-49 d. 50-59

e. > 60

2. Gender a. Male 3. Marital Status a. Single 4. Field of Specialty a. General Practitioner b. IM Resident Physician c. Family Physician d. Internist (pls. specify subspecialty if any: ____________ ) 5. Years of medical practice

a. b. c. d. e.

b. Female b. Married c. Widowed d. Separated

Less than a year 1- 4 years 4 ­ 6 years 6 ­ 9 years > 10 yrs

II - Smoking Status and History

6. When you were a child, was there anyone in the family who regularly smoked? a. None b. Yes If yes, who was/were the smoker(s) in the family? b1. Parent(s) b3. Grandparent(s) b2. Sibling(s) b4. Others

49

7. Have you ever received any formal training on smoking-cessation approaches to use with your patients? (You may have more than one answer) . Formal training during medical school . Formal training during specialization programs . Special conferences, symposia or workshops . Other ( pls. specify _________________________ ) . None 8. Which of the following best describes your smoking behavior?

a. b. c.

d.

I have never smoked cigarettes I have quit smoking I currently smoke occasionally (Some days) I currently smoke almost every day

Go to question 18 Go to question 14 Go to question 9 Go to question 9

If you CURRENTLY smoke...

9. How old were you when you first started to smoke on a regular basis? Age _____

10. Have you ever attempted to quit smoking? a. Yes b. No 11. What is/are your reason(s) for smoking? (You may have more than one answer) a. It enhances memory and alertness b. It improves skills and performance c. It reduces/relieves stress-related work d. It improves sociability among peers e. It keeps my weight down f. Others ( pls. specify ________________________ )

12. What is/are your reason(s) for NOT trying to quit smoking? (You may have more than one answer) a. Cravings b. Fear of nicotine withdrawal symptoms c. Fear of loss of way to handle stress d. The cost of medicines use for quitting e. Fear of loss of social relations f. Discouragement from previous failure to quit smoking g. Fear of risk of gaining weight h. Others (pls. specify: __________________________ )

13. Do you think your tobacco use has negatively affected your health in any way? a. Yes b. No c. Not sure

50

If you smoked in the PAST...

14. How old were you when you first started to smoke on a regular basis? Age ____

15. How old were you when you stopped smoking completely? Age____ 16. Did you experience any relapse upon quitting use of tobacco? a. Yes b. No 17. What was/were your reason(s) for smoking? (You may have more than one answer) a. It enhances memory and alertness b. It improves skills and performance c. It reduces/relieves stress-related work d. It improves sociability among peers e. It keeps my weight down f. Others ( pls. specify ________________________ )

III ­ Smoking-Related Knowledge, Attitude, and Practices

a. Knowledge Check appropriate box 18. 19. 20. 21. Active smoking increases the risk of ischemic heart disease among smokers Passive smoking increases the risk of lung disease in non-smoking adults. Passive smoking increases the risk of heart disease in non-smoking adults. Passive smoking increases the risk of lower respiratory tract illnesses such as pneumonia in exposed children. Neonatal death is associated with passive smoking. Maternal smoking during pregnancy increases the risk of Sudden Infant Death Syndrome. Agree Unsure Disagree

22. 23.

51

b. Attitude Check appropriate box 24. 25. Health professionals should set a good example by not smoking. Patient's chances of quitting smoking are increased if a health professional advises him or her to quit. Health professionals should routinely ask about their patients smoking habits. Heath professionals should routinely advise their patients to quit smoking. Health professionals who smoke are less likely to advise people to stop smoking. Agree Unsure Disagree

26. 27. 28.

c. Practices

29. How often do you or did you smoke? a. Never b. Occasionally c. 2 to 3 times a week d. 4 to 5 times a week e. Daily Estimated number of months/years of smoking. a. Never b. Less than 6 months c. 6 months to 1 year d. >1 to 2.5 years e. >2.5 to 5 years f. >5 years to 10 years g. Greater than 10 years Estimated no. of cigarette sticks that you smoke or have smoked per day. a. None b. Less than 5 sticks c. 5 to 10 sticks d. 11 to 15 sticks e. 16 to 20 sticks f. Greater than 20 sticks How frequently do you smoke in front of a patient(s)? a. Never b. Rarely c. Sometimes d. Always I have smoked during shift a. Yes b. No I have good compliance to the smoke-free policy in non-smoking areas a. Yes b. No 52

30.

31.

32.

33. 34.

IV ­ Smoking-Cessation Counseling Practices Check appropriate box Never

35. 36. I ask patients if they smoke I explain to my patients the consequences of smoking on one's health I encourage/challenge my patients to quit smoking I teach my patients with possible methods on how to quit smoking

Rarely

Sometimes

Always

37. 38.

39. Which of the following other interventions do you USE to help your patients stop smoking? (You may have more than one answer) a. Counseling only b. Traditional remedies (Traditional Chinese Medicines e.g. acupuncture; herbal or home medicines) c. Self- help materials d. Medication (Nicotine gum, patch, buproprion) e. Other (pls. specify _________________________ ) 40. Does (your) smoking affect the way you counsel your patients to quit smoking? For non-smokers, do you think physician's smoking will affect counseling of patients to quit smoking? a. Yes b. No c. Not sure 41. Are you less likely to convince patients to quit smoking if you are a smoker? a. Yes b. No c. Not sure 42. Does counseling on direct health harms of smoking helps with smoking cessation among your patients? a. Yes b. No c. Not sure 43. Does counseling on health harms of passive smoking helps with smoking cessation among your patients? a. Yes b. No c. Not sure 44. Do you think counseling family members of your patients on health harms of second hand smoke helps with their smoking cessation? a. Yes b. No c. Not sure 45. How well prepared do you feel when you are counseling patients on how to stop cigarette smoking? a. Very well prepared b. Somewhat prepared c. Not at all prepared

- END ­

53

APPENDIX B

Smoking History Table 19. Previous Attempt to Quit Smoking among Current Smokers Attempted to Quit Frequency Percent Smoking Yes 8 50 No 8 50 Total 16 100 Table 20. Age at Which Previous Smokers Quitted Smoking Age (in years) 21 - 30 31 ­ 40 41 - 50 Total Frequency 3 4 3 10 Percent 30 40 30 100

Table 21. Current Smokers' Perception on the Negative Effects of Smoking on their Health Smoking Has Negatively Affected His/Her Health Unsure Yes No Total Frequency 3 7 6 16 Percent 18.75 43.75 37.5 100.0

54

APPENDIX C

Knowledge, Attitude, Practices and Smoking-Cessation Counseling Scores

Table 22. Percentage of Participants Who Scored Above or Below the Mean Score Category Knowledge Attitude Practices* Smoking-Cessation Counseling

* Smokers only

Above/level of mean score 61 (76.25%) 55 (68.75%) 10 (62.5%) 60 (75%)

Below mean score 19 (23.75%) 25(31.25%) 6 (37.5%) 20 (25%)

Table 23. Mean Scores for Smoking-Related Knowledge Knowledge Active smoking increases the risk of IHD Passive smoking increases the risk of Lung Ds. Passive smoking increases the risk IHD in nonsmoking adults Passive smoking increases the risk of LRTI in children Neonatal death is associated with passive smoking Maternal smoking increases the of risk of SIDS Total Mean 2.0000 2.0000 1.8625 1.9125 1.5500 Std. Deviation .00000 .00000 .41319 .32584 .65410

1.8375 11.1600

.43411 1.24721

55

Table 24. Mean Scores for Smoking-Related Attitude Attitude Health professional should set a good example by not smoking Patient's chances of quitting are increased if health professional advises him/her to quit Health professionals should routinely ask about their patients' smoking habits Health professionals should routinely advise patients to quit smoking Health professionals who smoke are less likely to advise patients to stop smoking Total Mean 1.9375 1.9125 1.9750 1.9375 1.3375 Std. Deviation .29095 .36261 .22361 .33161 .88509

9.1000

1.36502

Table 25. Mean Scores for Smoking Practices Smoking Practice Frequency of Smoking Duration of Smoking Number of Cigarettes Smoke per Day Smoking during Shift Smoking in Front of Patient(s) Good Compliance to Non-Smoking Areas Total Mean 1.6875 1.1250 3.1875 2.8750 .6875 .9375 10.5000 Std. Deviation 1.44770 1.66833 1.32759 .34157 .47871 .25000 3.75943

56

Table 26. Mean Scores for Smoking-Cessation Counseling Counseling I usually ask patients if they smoke i usually explain to my patients the consequences of smoking I usually encourage/challenge my patients to quit smoking I usually teach my patients with possible methods on how to quit smoking Total Mean 2.6750 2.5875 2.6750 2.4000 10.3000 Std. Deviation .67082 .70610 .72522 .88016 2.63830

57

CURRICULUM VITAE

PERSONAL INFORMATION Name : Age : Sex : Date of Birth : Address : Religion : Father : Mother : EDUCATIONAL BACKGROUND GRADUATE Degree : School : Place : Year(of Grad): COLLEGE Degree : School : Year (of Grad): HIGH SCHOOL: ELEMENTARY: Bachelor of Science in Biology Ateneo de Zamboanga University 2005 Doctor of Medicine Ateneo de Zamboanga UniversitySchool of Medicine La Purisima Street, Zamboanga City 2009 Female May 2, 1985 185 Lustre St. Zamboanga City Islam Engr. Abdurajan A. Asid Dra. Husna A. Asid Elham A. Asid 25 years old

Civil Status : Single

Notre Dame of Jolo for Girls Mohammad Tulawie Central School

58

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