Smoking Cessation Support Among Oncology Practitioners in a Regional Cancer Center in the Middle East—Improving a Critical Service for Cancer Care

Abstract

This study examined smoking cessation support (SCS) by oncologists in a Jordanian cancer center and found it to be deficient. Recommendations to improve SCS include improving patient-provider communication and building providers’ self-efficacy through continuing education.

Introduction

Integration of smoking cessation (SC) services within cancer treatment is essential for ensuring better quality of care [1–3]. Unfortunately, deficiencies exist in the availing, by oncology providers, of SC services [2, 4–7]. Reasons include lack of professional education, patient resistance, and time barriers [8–10].

In Middle Eastern countries such as Jordan, a scarcity of information exists with regard to provision of SC support (SCS) among oncology practitioners. Without such information, cancer centers are unable to identify opportunities for improvement. King Hussein Cancer Center (KHCC), which also operates a SC clinic and is a regional SC training center, is one of the few comprehensive cancer centers in the region. We thus sought, within KHCC, to study the status of provider-reported performance of SCS, focusing on provision of AAR (Ask about smoking, Advice against smoking, Refer to the SC clinic, and document smoking status); factors associated with provision of AAR; and perceived roles, barriers, and facilitators of providing SCS.

Methods

By using the Social Cognitive Theory [11] and reviewing other questionnaires that measured SC-related provider perceptions [12–15], an Arabic questionnaire was developed. Questions probed practices related to SCS (23 specific actions were measured) and perceptions regarding SC within the context of cancer care. Questionnaire content validity was ensured by sharing the questionnaire with KHCC’s SC clinic staff and by piloting the tool in a group of practitioners (n = 9). The questionnaire was then distributed to staff. A sample size of 99 physicians and 141 nursing/supportive staff was required. (The parameter used in sample size calculation was expected rate of referral to the SC clinic, which internal aggregate data indicate did not exceed 15%. A finite population correction factor was applied.)

Operational measures used during analysis included smoking status (any use of tobacco versus yes/no); age (≤27; >27 years of age, with 27 being the sample’s median age); gender; profession (physician/other); provision of AAR (yes/no: AAR provision was defined as—in >69% of new patients—asking, advising, and referring smokers, and documenting their status); confidence in providing AAR; and perceived importance of SCS.

Descriptive statistics were generated to present sample characteristics, the extent to which SC-related practices were performed, and perceived barriers and facilitators for providing general SCS. Bivariate and multivariable logistic regression analyses were conducted to determine factors that were significantly associated with provision of AAR to cancer patients in the center.

Results

A total of 272 surveys were collected after distributing 452 surveys (60.2% response). An analytic sample of 254 remained after dropping surveys of poor quality. The sample (Table 1) was composed of approximately 41% physicians and 59% supportive staff (largely nursing). Major results included the following.

Table 1.

Characteristics of oncology providers at King Hussein Cancer Center

Roughly half (51.6%) reported providing verbal information on tobacco effects, and 40.2% reported advising patients to quit. Approximately 26% referred smokers to the SC clinic. When asked to approximate the proportion of new patients for which specific activities were performed (Table 2), asking about cigarette use, advising cigarette smokers to quit, and asking about smoking frequency were the most frequently performed activities (in approximately 65% of new patients). Provision declined with activities such as assessing quit desire (49.2%), referring smokers to the SC clinic (47.3%), and continuing to track smokers during follow-up (39.4%). Approximately 21% of practitioners reported provision of AAR. This proportion was 13.8% when AAR was gauged for waterpipe use.

Table 2.

Practices of oncology providers at King Hussein Cancer Center

The majority of providers, 81.7%, felt that SCS for cancer patients was important. Particularly for a selection of basic activities such AAR, the majority (at least 70%) of respondents perceived that these should be part of their role as providers.

Patient-related factors (smokers’ unwillingness to stop, their lower educational status, and their being bothered by discussions regarding SC) were the most frequently—by 70% or more—identified barriers. The relapsing nature of tobacco addiction, medication costs, and time constraints also were frequently (65.0%, 58.6%, and 57%, respectively) cited as barriers. Approximately 66% of providers felt that the presence of a clear mechanism for referral to the SC clinic, having more SC-knowledgeable employees, and improving practitioners’ skills in SC would facilitate provision of SCS.

In multivariate analyses to evaluate factors associated with AAR provision to cigarette smokers, only confidence to provide AAR was significant (Table 3). Similar results were found for provision of AAR to waterpipe smokers (results not presented).

Table 3.

Factors associated with the provision of AAR by health care providers to cancer patients in a regional cancer center in the Middle East: Bivariate and multivariable associations

Discussion

Our study reveals that, although providers in a regional cancer center in the Middle East perform some elements of SCS with high frequency, collective provision of a basic set of tasks such as AAR to cancer patients who smoke is low. Lower rates of provision also were noticeable for actions that needed relatively more provider knowledge or effort. The general underprovision of multiple or more advanced SCS-related tasks we observed was more marked than in other studies [10, 16]. Improving patient-provider communication and building self-efficacy to provide SCS, both of which can be achieved at least in part through continuing education, can increase the provision of AAR.

Despite underprovision of AAR, we also found that most respondents identified the majority of SC-related activities listed as part of their role (although only 34% of providers reported confidence in performing AAR). Given that confidence was the only factor significantly associated with AAR provision, and can be improved through training, availing the latter offers a feasible way of potentially improving SCS. This need is also echoed by the respondents, approximately 66% of whom identified improving skills/education as a facilitator to providing SCS.

The covariates we explored to predict AAR provision did not reach statistical significance in multivariate analyses (our study may have been underpowered to detect a statistical significance). Nevertheless, the direction and magnitude of their effect suggest that educational efforts to improve the provision of SCS should more intensely target smokers, younger staff, and nonphysicians. In particular, with regard to practitioners' smoking status, differences in AAR provision between smokers and nonsmokers were the starkest (7.6% vs. 25.7%; Table 3); and in further analyses (not presented), results trended toward underprovision, across specific tasks, by practitioners who smoked. Thus, our findings also can be used to emphasize the value of institutional measures taken to deter the presence of practitioners who smoke (KHCC imposes strict smoking bans on its premises and offers free SC treatment for its employees).

Finally, with regard to barriers to SCS provision, patient-related barriers were the most frequently cited barriers. Thus, SCS training should be customized to improve communication between oncology providers in the center and their patients and help the former convey the importance of SC to patients in a compelling and empathic manner. Other cited barriers (e.g., time) may be due to providers being under the impression that SCS is necessarily lengthy. Promoting a well-defined scope of basic activities that should collectively fall under SCS and that require a reasonable amount of time (and are feasible to perform within the local working environment) will also be useful.

Our study has some limitations. Its relatively small sample size limited meaningful subgroup analyses of AAR provision within strata such as profession or gender. Furthermore, although the data represent an important regional cancer hub, individual institutions may face other challenges. Nevertheless, our findings demonstrate—within an oncology setting that has not been studied previously in this context—a great deficiency in SCS provision and enable us to offer recommendations relevant to the region with regard to how SCS may be improved.

Author Contributions

Conception/Design: Nour A. Obeidat, Hiba S. Ayub, Susan Abughosh, Feras I. Hawari

Provision of study material or patients: Feras I. Hawari

Collection and/or assembly of data: Rula Amarin, Barakat Aburajab Altamimi, Iyad Ghonimat, Feras I. Hawari

Data analysis and interpretation: Nour A. Obeidat, Hiba S. Ayub, Rula Amarin, Barakat Aburajab Altamimi, Iyad Ghonimat, Susan Abughosh, Feras I. Hawari

Manuscript writing: Nour A. Obeidat, Hiba S. Ayub, Rula Amarin, Barakat Aburajab Altamimi, Iyad Ghonimat, Susan Abughosh, Feras I. Hawari

Final approval of manuscript: Nour A. Obeidat, Hiba S. Ayub, Rula Amarin, Barakat Aburajab Altamimi, Iyad Ghonimat, Susan Abughosh, Feras I. Hawari

Disclosures

The authors indicated no financial relationships.