Prevalence of tobacco smoking among health-care physicians in Bahrain

According to the World Health Organization (WHO), tobacco smoking is the single largest preventable cause of death worldwide with an expected 1 billion smoking-related-deaths by the end of the 21st century [1]. Even though cigarettes remain the most common form of tobacco smoking, their prevalence has been slowly decreasing [2], while waterpipe use has been gaining popularity over the past two decades [3, 4].

Tobacco smoking constitutes a public health dilemma in the kingdom of Bahrain. The prevalence of cigarette and waterpipe smoking in 2007 was 13.8% and 8.4% respectively with the highest rates reported among males aged 20–29 years [5]. The Global Youth Tobacco Survey conducted in 2003 revealed smoking rates of 33.5% among males and 11.9% among females aged 13–15 years [6]. Recently, attempts were made to formulate new national guidelines on smoking cessation by integrating primary health care into smoking cessation services [7].

It is vital to assess health professionals’ smoking habits for two reasons. First, they have a direct effect on their health and wellbeing. Secondly, it has been shown that physicians who smoke tobacco are less likely to advise their patients regarding the health hazards of tobacco smoking [8‐10]. Provided that previous studies have proven the effectiveness of physicians’ simple advice on smoking cessation rates among patients [11‐14], reducing the smoking prevalence among physician may actually contribute to a reduction of the smoking prevalence among the general population. Furthermore, it has been shown that there is a relationship between physicians advice and smokers interest in quitting both; cigarettes [14] and waterpipe smoking [15].

One study (1999) conducted among primary health-care physicians in Bahrain reported that 26.6% of male physicians smoked tobacco, which is an alarming figure [16]. Another study, using a selective sample of physicians, reported smoking rates as high as 24.0% in 2005 [17]. It is important to monitor the change in smoking habits among the general population as well as individual populations such as primary health care physicians. Hence, we have conducted a cross sectional study to establish the prevalence and patterns of different methods of tobacco smoking among primary health care physicians in Bahrain.

It is evident that primary health care physicians play an important role in decreasing smoking rates among patients [20]. Further, their personal smoking habits have been shown to affect how frequently they provide cessation-related advice [8‐10]. Our study has revealed that 20% of male physicians and 3% of female physicians are current smokers, and that waterpipe is the most common form of tobacco smoking among both genders. These results also suggest that the physician population is one of the first in which waterpipe smoking prevalence has surpassed that of cigarette smoking.

The rates of smoking among male physicians were alarmingly high when compared with male physicians in Canada (8%) [21], Switzerland (12.6%) [22] and Japan (16.2%) [23]. However, observed differences might be affected by the definition of a smoker and distribution of gender and age among physicians. For example, in the Swiss study [21], smokers and former smokers were defined according to whether they smoked one cigarette daily while in our study we considered five packs or 100 cigarettes smoked in the past as the cut off point for former smokers as per CDC guidelines [17]. Additionally, there was a male predominance of 84% and a relatively older age compared with the population in our study (51 vs 45 years of age). In comparison with the Bahraini general population [5], the prevalence of current smokers of all forms was less (9% vs 19.9%). However, the rate of waterpipe smoking among male physicians was higher than in male adults in the general population (12% vs 10.8%) Table 3.

Former studies conducted among primary care physicians in Bahrain [16, 17] found a higher prevalence of male smokers (26.6% in 1999, 24% in 2005 and 20% in the current study), but they applied different methodologies compared with the current study. For example, the study conducted in 2005 did not define ‘smoker’ and used a selective sample as their population while in the study in 1999, ‘smoker’ was defined differently than in this study. However, our results revealed a higher percentage of waterpipe smokers (<1% in the 1998 study, 3% in the 2005 study, and 6% in the current study). The increasing use of waterpipes among physicians as well as the general population could be attributed to various reasons, including the common misconception that waterpipe smoking is less harmful than cigarette smoking [4], the introduction of flavoured tobacco to attract waterpipe users [24] and flattering images in the media of waterpipe tobacco smoking [25]. Therefore, our results have direct implications for necessary public health interventions targeting primary care physicians. Additionally, an attempt to reverse the current smoking patterns should be made by increasing awareness of the harmful effects associated with any method of tobacco smoking including waterpipe smoking and promoting legislation to remove all waterpipe tobacco flavours.

The high male predominance of smokers among our population, which is consistent with the previous study [16], could be attributed to cultural factors with a higher perceived stigma among females who smoke [26, 27]. This phenomenon has been observed to a lower extent for waterpipe smoking compared with cigarette smoking, and may potentially explain the smoking habits of female physicians in our sample (0% cigarette smokers compared with 2% waterpipe smokers).

Further research of physicians’ habits, attitudes and knowledge regarding waterpipe tobacco smoking has been gaining more attention because the role of the physician in influencing smoking cessation among their patients has been recognized. Furthermore, The WHO, CDC, and the Canadian Public Health Association have developed the Global Health Professional Survey to collect data on tobacco use and cessation counselling among health professional students. Physicians’ knowledge and attitudes towards waterpipe tobacco smoking and their related cessation advice practices have not yet been measured in Bahrain and represent a potential area for future research.

Limitations of our study include non-response bias. Non-responders, comprising 15% of the current sample could have affected the rates of smoking, which could have been higher, especially among female smokers who may have preferred to refrain from answering the questionnaire. This may have led to an underestimation of smoking prevalence. Another limitation is that we only studied smoking prevalence and did not look into perceptions and knowledge regarding waterpipe and cigarette smoking which could have given us more insight into conducting future interventions.

Educating patients and increasing awareness of the harmful effects of cigarette and waterpipe smoking are the responsibility of all physicians. By encouraging physicians to emulate the positive lifestyle choices they recommend, they can become better equipped to convince their patients to make real changes in their lives. This holds great potential and opportunity to make measurable changes in the prevalence of smoking in Bahrain.

There is a high prevalence of tobacco smoking among primary health care physicians in Bahrain. We have established that there has been a small decline in cigarette smoking since 1999 and that waterpipe is, currently, and for the first time, the most common form of tobacco smoking among physicians. We have also shown that there is a clear male predominance in smoking, consistent with the prevalence among the general population and previous studies conducted on primary care physicians.

This work was completed by medical students at the Royal College of Surgeons in Ireland – Bahrain and supervised by senior lecturer; Dr. Ghufran Jassim, as part of RCSI-Student Summer Research Programme.