BJA Advance Access originally published online on January 29, 2008
British Journal of Anaesthesia 2008 100(3):404-410; doi:10.1093/bja/aem400
Perioperative tobacco use interventions in Japan: a survey of thoracic surgeons and anaesthesiologists
1 Department of Anesthesiology and Critical Care Medicine, Kyushu University, Fukuoka, Japan
2 Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
* Corresponding author. E-mail: warner.david{at}mayo.edu
Accepted for publication December 11, 2007.
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Abstract |
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Background: Tobacco use interventions in surgical patients who smoke could benefit both their short-term outcome and long-term health. Anaesthesiologists and surgeons can play key roles in delivering these interventions. This study determined the practices, attitudes, and beliefs of these physicians regarding tobacco use interventions in Japan.
Methods: Questionnaires were mailed to a national random sampling of Japanese anaesthesiologists and thoracic surgeons (1000 in each group).
Results: The survey response rate was 62%. More than 80% of respondents agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking. Compared with anaesthesiologists, surgeons were more likely to perform the elements of current recommendations for brief intervention, and to have attitudes favourable to tobacco use interventions. The most significant barrier to intervention identified by both groups was a lack of time to perform counselling. Compared with non-smokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions
Conclusions: Although current rates of intervention provided by anaesthesiologists and surgeons are low, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a ‘teachable moment’ to promote abstinence from smoking, leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan.
Keywords: complications, smokers; education; surgery, preoperative period
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Introduction |
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Smoking is a serious public health problem in Japan, with 47% of males and 12% of females smoking cigarettes in 2000.1 Consistent with these rates in the general population, in 2000, 42% of males and 19% of females undergoing surgery at a Japanese public hospital smoked cigarettes.2 Thus, millions of cigarette smokers undergo surgery and anaesthesia in Japan each year. Their smoking has both immediate potential consequences to perioperative outcomes and long-term consequences to their overall health; efforts to help smokers quit in the perioperative period could benefit both.3 Even temporary abstinence from smoking may reduce the risk of perioperative complications and improve surgical outcomes.4 In addition, surgery may be a powerful motivator for long-term abstinence, such that tobacco use interventions may be particularly effective during this period.3 5 The surgical process provides multiple opportunities for healthcare providers to intervene. In addition, in May 2003, the Japanese government implemented a health promotion law that mandates prevention of passive smoking in public spaces, encouraging many healthcare facilities in Japan to change their smoking polices. Such forced abstinence mandated by smoke-free policies may facilitate perioperative interventions to stop smoking.6
Although there are many opportunities to intervene in surgical patients who smoke, these opportunities remain largely unexploited. Anaesthesiologists assess each patient before surgery, and so are well positioned to intervene. There are also excellent opportunities for surgeons, especially those such as thoracic surgeons who frequently treat smoking-related diseases such as lung cancer. However, very few surgeons and anaesthesiologists have expertise in tobacco control techniques, and many may not feel that this is their responsibility. A recent survey of anaesthesiologists and surgeons in the USA found that few incorporated tobacco control interventions into their practices, although there was considerable interest in learning more about how to do so.7 8 The practices and attitudes of Japanese anaesthesiologists and surgeons regarding tobacco control are not known. Compared with American physicians, smoking rates among Japanese physicians are relatively high: 27% of male and 7% of female physicians smoke cigarettes9 compared with <2% of American physicians.10 Physicians' smoking behaviour is an important determinant of their approach to tobacco control.9 In addition, there may be cultural factors that determine attitudes and practices towards tobacco control.
As an initial step to promote tobacco control interventions in Japanese surgical patients, we surveyed the practices, attitudes, and beliefs of anaesthesiologists and surgeons in regard to tobacco use interventions in Japan.
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Methods |
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The study was approved by Institutional Review Board of Kyushu University Graduate School of Medical Sciences. On February 1, 2005, questionnaires were mailed to 1000 anaesthesiologists who were randomly selected from a list of board certified anaesthesiologists (as of November 2004) maintained by the Japanese Society of Anaesthesiologists. Questionnaires were also mailed on the same date to 1000 thoracic surgeons who were randomly selected from a list of board certified surgeons (as of January 2005) maintained by the Japanese Association for Thoracic Surgery. Permission for the usage of each list was obtained from each respective society.
In order to compare with the previous study that surveyed anaesthesiologists and general surgeons in the USA,7 we first planned to survey anaesthesiologists and general surgeons in Japan by using the respective societies' list. However, the usage of the member list was declined by Japan Surgical Society. We therefore asked the Japanese Association for Thoracic Surgery as an alternative option to provide a list of board certified surgeons, since thoracic surgeons frequently deal with the consequences of tobacco-related diseases.
Subject lists of anaesthesiologists and surgeons were created with systematic sampling from the society's lists, that is, from the list of 5329 board certified anaesthesiologists sorted by alphabetical order of institutions and names, every fifth anaesthesiologist was selected, and from the list of 1492 board certified thoracic surgeons, two of every three were initially selected from a similarly sorted list, then the remainder were selected in descending order from initially excluded members.
Survey packets including the cover letter, survey instrument, comment sheet, and stamped return envelope were prepared specific to each group. Return envelopes were marked with a subject-specific number in advance so that subjects who responded could be identified for follow-up of non-responders. However, once opened the envelope was detached, such that the survey was anonymous. After 2 months from initial mailing date, reminder postcards were sent to non-responders.
The survey items themselves were similar to those utilized in the prior survey of general surgeons and anaesthesiologists in the USA.7 Questions were grouped into the following categories. Demographics included personal information (including smoking history) and practice characteristics, including whether they were currently in active practice. Current practices included what tobacco control measures are currently being provided by these physicians. Attitudes and beliefs included items querying the perceptions of these physicians regarding various elements of tobacco use interventions.
Statistical methods
Those respondents not currently engaged in active practice were excluded from analysis. Summary statistics of responses were prepared and are the primary focus of this report. We also compared the responses of anaesthesiologists and thoracic surgeons. The two groups were compared employing non-parametric tests for each of the demographic variables, using a rank sum test for the continuous variables, and 
2 test for categorical variables. Some respondents provided two responses for a single question. Unless an appropriate single response could be inferred, these responses were excluded from analysis. For the question of average number of cigarettes consumed per day, the midpoint was used for analysis if a range was provided in an individual response. The questions regarding the practitioner's current practices had four options ranging from ‘never’ to ‘almost always (more than 75% of the time)’. These ordinal responses were compared between the groups with a rank sum test. For items querying the respondent's attitudes/beliefs and interest in learning about interventions, there were five levels of agreement ranging from ‘strongly agree’ to ‘strongly disagree’ and a ‘don't know’ option. Seven of the items had more than 3% of the respondents in one or both groups selecting the ‘don't know’ option. For these seven items, comparisons were made with a 2 test. Otherwise, the ‘don't know’ responses were excluded from the analysis and the rank sum test was used to compare the ordinal response between the two groups. The proportion of usable completed surveys (i.e. response rate) in each group was compared using a 2 test. In all cases, P-values of <0.05 were considered significant.
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Results |
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Surveys were returned from the initial mailing by 538 anaesthesiologists and 556 surgeons. Surveys were eventually received from 623 and 625 anaesthesiologists and surgeons, respectively (Table 1). A total of 542 surveys from anaesthesiologists and 521 surveys from surgeons were included in analysis; the majority of exclusions were because the respondents were not in active clinical practice. The demographics of these respondents are shown in Table 2. The surgeons were significantly older and more likely to be male. All respondents practiced in environments with some restrictions on smoking, although only approximately 20% of these hospitals prohibited all smoking on hospital grounds.
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Eleven per cent (11%) of anaesthesiologists and 13% of surgeons were active or occasional smokers, and 22% and 39% of anaesthesiologists and surgeons, respectively, were ex-smokers (Table 2). Thus, approximately one-third of anaesthesiologists and half of surgeons had personal experience with using tobacco. The majority of physician smokers recognize the personal risks of smoking, have made at least one quit attempt, and want to quit (Table 3). Approximately 40% would try to quit smoking if their hospital became smoke free (Table 3).
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Current practices
Surgeons were more likely to perform the elements of current recommendations for brief intervention compared with anaesthesiologists (Table 4). For example, 64% of surgeons reported almost always advising patients to quit smoking for good, compared with 17% of anaesthesiologists. However, only 26% of surgeons and 6% of anaesthesiologists reported almost always providing help to their patients to quit smoking.
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Attitudes and beliefs
More than 80% of surgeons and anaesthesiologists agreed or strongly agreed with the statements affirming the benefits of abstinence to surgical patients (Table 5). More surgeons (88%) than anaesthesiologists (62%) agreed or strongly agreed that it was their responsibility to advise their patients to quit smoking (Table 5). Overall, surgeons were more likely than anaesthesiologists to affirm responsibility for addressing tobacco use, although strong majorities of both groups agreed that the perioperative period was a good time to get patients to permanently stop smoking (Table 5). The most significant barrier identified by both groups was a lack of time to perform counselling (Table 5). As with other categories, overall the attitudes of the surgeons were more favourable to interventions.
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3% of both groups responded ‘don't know’, these responses were excluded and the groups were compared using Wilcoxon rank sum test. A, anaesthesiologists; TS, thoracic surgeonsOverall, surgeons were more confident than anaesthesiologists regarding their ability to intervene and in their knowledge of interventions (Table 6). More than half of the anaesthesiologists agreed or strongly agreed that they did not know how to counsel their patients (Table 6), and only 32% agreed or strongly agreed that they know how to get help for their patients who smoke.
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Majorities of both groups expressed interest in learning more about interventions (Table 6), and
85% of both groups would be willing to refer patients to effective intervention services. To analyse the impact of smoking status on the responses, the responses of surgeons and anaesthesiologists who reported regular or occasional smoking were combined and compared with the combined responses of never or ex-smokers. Compared with non-smokers, physicians who smoked were less likely to perform each of the recommended tobacco interventions (Table 4), with the exception of advising patient to stop smoking perioperatively. Regarding attitudes and beliefs, the responses of non-smokers were consistently more favourable towards interventions compared with smokers (data not shown). For example, non-smokers were more than twice as likely as smokers to strongly agree that the perioperative period is a good time to get patients to stop smoking (36% and 15% of non-smokers and smokers, respectively, P<0.0001). Although 27% of non-smokers strongly agreed that it was their responsibility to advise their patients to quit smoking, only 15% of smokers did so (P<0.01). Smokers were also more likely to oppose strict hospital smoking policies; 52% of non-smokers and 23% of smokers supported complete prohibition of smoking on hospital grounds (P<0.0001).
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Discussion |
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Recent evidence suggests that surgery represents an excellent opportunity to intervene in patients who smoke, with potential benefits to both immediate surgical outcomes and long-term health.3 4 8 11–14 Because physicians have an important role in these efforts, it is important to assess their practices and attitudes if effective intervention strategies are to be implemented in surgical settings.
The evolution of tobacco use within societies can be conceptualized as an epidemic.15 Its prevalence increases rapidly as manufactured cigarettes are intensively marketed, first among men, then among women. The peak prevalence in most societies exceeds 50% in males. With the application of effective tobacco control measures, the prevalence of tobacco use declines. In general, physician smoking rates decline earlier and more rapidly compared with the general population.10 A survey of physician members of the Japan Medical Association in 2000 found that 27% of male and 7% of female respondents reported smoking cigarettes, which was approximately half the rate of the general population and less than previous surveys.9 Although the current survey (conducted in 2005) samples only a subset of physician specialties, the observed rates suggest that the prevalence of smoking among Japanese physicians continues to decline. In countries in the more advanced stages of epidemic (i.e. when population prevalence is decreasing), physician smoking rates approach zero. For example, in a similar survey of anaesthesiologists and general surgeons in the USA, 1% of physicians reported current smoking.7 These rates are relevant to tobacco control efforts, because physicians who smoke are less likely to provide and support tobacco interventions.9 16 The results of the current study support this conclusion, as smokers were less likely to intervene in their patients, and reported less favourable attitudes towards interventions. They were also less likely to support smoke-free hospital facilities, an important public health tobacco control measure beneficial both to employees and to hospital patients.6 17 These results support prior recommendations that efforts to encourage Japanese physicians to quit smoking should be intensified.9
The current study surveyed two physician specialties of particular relevance to the provision of tobacco use interventions to surgical patients. Anaesthesiologists are intimately involved in many aspects of care provided to patients undergoing a wide variety of surgical procedures. The majority of the procedures performed by thoracic surgeons are for conditions directly related to tobacco use, such as coronary artery disease and lung cancer. As such, they might be expected to be the surgical subspecialists most interested in tobacco control. As found in a similar study of anaesthesiologists and general surgeons in the USA, the practices and attitudes of thoracic surgeons were generally more favourable to interventions compared with anaesthesiologists.7 Prior work suggests that physicians are more likely to intervene when patient disease is clearly related to smoking.18 19 Although anaesthesiologists may recognize the consequences of smoking to their perioperative management, these consequences may be perceived as minor or transient, without long-term consequences in most instances. In contrast, smoking is often directly related to the need for cardiothoracic surgery, which may better motivate thoracic surgeons to intervene.
The results of the current study are in most instances very similar to the prior survey of anaesthesiologists and surgeons in the USA conducted using a similar methodology7 and indicate that there is much potential for the application of tobacco interventions in surgical patients by these Japanese physicians. If anything, responses were more favourable towards intervention among Japanese anaesthesiologists and surgeons. For example, 83% of Japanese anaesthesiologists agreed or strongly agreed that relatively brief preoperative abstinence (<30 days) would reduce perioperative complications, compared with 52% of US anaesthesiologists.7 Also, 76% of Japanese anaesthesiologists agreed or strongly agreed that the perioperative period was a good time to get patients to permanently stop smoking, compared with 60% of US anaesthesiologists. These attitudes are remarkable, considering that in many ways tobacco control efforts are better developed in the USA compared with Japan, and that the prevalence of smoking is higher among Japanese physicians.9 Majorities of both specialties surveyed expressed interest in learning more about how to intervene, and almost all would refer patients to intervention services. As with the prior survey, a major barrier was a lack of time, indicating that a referral strategy would be desirable.
A prior survey of US physicians found that surgical subspecialists provide smoking cessation counselling at lower rates compared with medical subspecialists and primary care practitioners.20 Although it is not possible to directly compare our results with the prior survey of Ohida and colleagues9 that sampled all Japanese physicians because of differences in timeframe and content, it does appear that the attitudes and practices of anaesthesiologists and surgeons compare quite favourably to this more broad assessment across specialties. For example, Ohida and colleagues9 found that only 25% of Japanese physicians always asked about smoking history, and only 43% agreed that patients should not smoke. This again suggests that anaesthesiologists and thoracic surgeons may be especially receptive to education regarding tobacco use interventions.
There are limitations inherent to any survey. The response rate of 62% compares favourably with other recent physician surveys.7 21 However, there is still a potential for response bias, with those physicians most interested in tobacco control more likely to respond. These results thus may overestimate actual interest in tobacco interventions among anaesthesiologists and thoracic surgeons. Recall bias may also favour overestimation of the actual frequency of intervention, as prior studies suggest that physicians tend to exaggerate that frequency with which they provide tobacco interventions when their self-reports of their practices are compared with contemporaneous observations of actual practices.18 22
In summary, this survey provides information that can promote efforts to implement tobacco use interventions in Japanese surgical patients. Although current rates of intervention provided by anaesthesiologists and surgeons are low, especially among anaesthesiologists, there is considerable interest among these physicians in learning more about interventions. Given the relatively high prevalence of smoking in Japan and the potential for surgery to serve as a ‘teachable moment’ (i.e. an event that motivates individuals to change risky health behaviours) for smoking abstinence,23 leadership by these specialists in the area of tobacco control could have a major impact on public health in Japan. Towards this goal, these specialists should3 (1) personally maintain tobacco abstinence, (2) receive education in basic principles of tobacco control, (3) consistently recommend that their patients quit smoking for surgery, and (4) encourage the design of pre-surgical care systems that would provide pharmacotherapy, counselling, and other effective tobacco use interventions to their patients. These efforts would be best coordinated by the appropriate specialty societies, aided by the well-developed international community of tobacco control specialists.
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Kyushu University Hospital; Mayo Foundation.
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