Study design and participants
Between June 2010 and February 2011, we conducted this cross-sectional study among active members of the TTS, which is an organization for health-care professionals, mostly including pulmonologists. The results of this study were derived through reanalyzing the data from a TTS scientific research project called “Attitudes and behavior of the pulmonologist members of TTS toward smoking cessation help.” The study protocol was approved by the TTS Scientific Ethical Committee.
We used information from TTS to identify all of their active pulmonologist members, who were defined as having a current membership with a valid e-mail address. The number of active pulmonologist members during the study period was 1701. After performing a pretest, the TTS secretariat distributed an e-mail inviting these members to participate in the study about their routine smoking cessation counseling practices. The e-mail included a link to the Internet-based self-administered questionnaire, containing a written informed consent form for participation. After 30 days, a reminder was sent to improve the number of participants, and then every 15 days, regardless of whether respondents had responded previously. The reminders told recipients not to return the questionnaire if they had submitted a completed questionnaire previously. The Internet-based survey only allowed fully completed questionnaires; therefore, physicians who started but failed to complete the survey were considered as nonresponders. We had no way to monitor which physicians started the survey and failed to complete it, and no way to monitor who did not receive the e-mails. The response rate was calculated as the number of fully answered questionnaires divided by the number of active pulmonologist members of the TTS.
The survey included questions about demographics (gender, age, graduation date from medical institution, specialist or resident, academic title, and institution), smoking status of responders, and routine clinical practices using the basic items of smoking cessation counseling [
16]. Any specific training on smoking cessation counseling was not performed with the study group before data collection. Only physicians who had been educated about providing smoking cessation help previously could create a difference. For this reason, the question about physician education was included in the questionnaire. In Turkey, only Ministry of Health-certified physicians can actively practice in SCOCs. Questions about this subject were also included in the questionnaire.
The survey addressed the 5A’s (Ask, Advise, Assess, Assist, and Arrange) of smoking cessation counseling [
17,
18]. Each of the 5A’s protocol items were measured on a 4-point Likert scale from “never” to “always” that dichotomized responses (0 points for “never or sometimes” and 1 point for “frequently or always”). Scores were added across the five components. According to the total 5A’s protocol score, smoking cessation counseling was dichotomized into low-and high-effort groups in promoting smoking cessation, which were defined as having scores of 1–3 and ≥4, respectively.
For the analyses, the date of graduation was dichotomized into graduated before and after 1996 (the year of the first tobacco control legislation in Turkey). Physicians’ characteristics were defined as: being a specialist or resident; working in urban clinics; working in a training hospital; having an academic title; practicing in a SCOC; educated in smoking cessation help; and being a member of the Local Tobacco Control Committee (LTCC).
We used the WHO classification to define smoking status [
19]. Current smokers were defined as individuals who had smoked for at least 6 months during their lifetime and were still smoking at the time of the survey. Noncurrent smokers were defined as former (ex-) smokers (smoked for at least 6 months during their lifetime, but had not smoked within the 6 months before the survey), recent quitters (smoked for at least 6 months during their lifetime, but had not smoked for less than 6 months before the survey), and never smokers (had never smoked or had smoked for fewer than 6 months or <100 cigarettes during their lifetime). We included recent quitters as noncurrent smokers—although they were not actually former smokers—because recent quitters are usually more willing to participate in interventions against smoking.
Statistical methods
A descriptive analysis was performed for demographic features. Differences in proportion were assessed by Pearson’s chi-square test. For statistical analyses, an independent samples t-test was used for continuous data with normal distribution, and the Mann–Whitney U test was used for the data not normally distributed. Logistic regression was used to assess the association between pulmonologists’ tobacco use and their efforts in promoting smoking cessation after controlling for the potential confounders. Odds ratios (OR) and corresponding 95 % confidence intervals (95 % CI) were computed to assess the strength of associations. A P value <0.05 was considered statistically significant. All analyses were conducted with SPSS software for Windows (v. 13.0; SPSS Inc., Chicago, IL, USA).