Evidence-Based Practices to Promote Tobacco Cessation During Pregnancy in a Sample of Romanian General Practitioners

Abstract

Changes in confidence in implementing smoking cessation support for pregnant women was assessed among Romanian General Practitioners (GPs) before and after a training program of evidence-based clinical practices to promote quitting. The total number of physicians participating in the study was 69. Before training, 51% of GPs felt somewhat/very confident asking pregnant women about tobacco use, 39% assisted smokers with a quit plan, 38% arranged follow-up for patients. After training, 85–90% found the training informative/very informative on: how to ask patients if they smoke (89%), advising patients to quit (88%), talking about the benefits of quitting (85%), assessing patients readiness to quit (87%), assisting patients in setting a quit date (87%).

Introduction

Smoking is the leading preventable cause of death around the globe with an estimated 1 billion smokers worldwide, of whom 80% live in low-and middle-income countries (LMICs) (Ref.). Smoking rates during pregnancy are generally higher in Eastern Europe (e.g. 18.9% in Croatia, 18.4% in Serbia) than in Western Europe (e.g. 5.4% in Sweden, 6.9% in the United Kingdom) [12]. In Romania, an upper-middle income country, 25% of adults are current smokers and 39.2% want to quit [7]. The prevalence of smoking during pregnancy was 13% among women in the Transylvanian region of Romania [11]. Although national data obtained from representative sample of adults in Romania [7] suggested that healthcare providers ask and advise most smokers (Centers for Disease Control and Prevention [2], vulnerable patients such as pregnant women are generally not asked about smoking during prenatal visits [6].

Healthcare providers play a critical role in helping patients to quit smoking. According to the Framework Convention on Tobacco Control (FCTC), reducing demand for tobacco includes implementing affordable and accessible evidence-based tobacco cessation support (FCTC Article 14) [18]. A key strategy to fulfill the goals of Article 14 is building capacity of health care providers to offer evidence-based cessation support.

Implementing evidence-based cessation into routine clinical practice faces many challenges in LMICs, including high rates of smoking among healthcare workers, few cessation support interventions targeting an increasingly diverse tobacco product market, and limited understanding of how to effectively implement comprehensive support during routine care in low-resource settings [9]. Man et al. revealed that Romanian doctors and medical students have high rates of smoking (between 40 and 44%) and approximately half of respondents indicated a need for cessation training [5]. Physicians in Romania reported common barriers to cessation counseling such as lack of time, experience, and training [8].

Lando [4] and Ward [17] argued that low-cost interventions to support cessation are opportune and feasible in LMICs, and strategies need to include bolstering providers’ commitment and capacity to support cessation. Although Romania has made considerable progress towards a comprehensive tobacco control strategy addressing the entire population, including educational and public awareness programs for adults, children and young people and comprehensive national clean air laws, there are gaps in efforts to address high rates of smoking among vulnerable populations, such as pregnant women and ethnic minorities [19].

The aim of this study was to explore in a sample of Romanian General Practitioners (GPs), the confidence in and implementation of evidence-based clinical practices to promote tobacco cessation among pregnant women, and to assess the value of a GPs training on the same evidence-based practices.

Methods

Participants and Procedure

A 6-h training program was held on two separate days as part of routine monthly meetings of General Practitioners in the Mures County region. The topics and objectives of training program are outlined in Fig.1, and included: consequences of smoking on mother and child, evidence-based cessation strategies tailored to pregnant women, and skills building, including communication and motivational interviewing skills.

Fig. 1.

The topics and objectives of the training program

Training was co-led by a Gynecologist and a Public Health specialist and included didactic lectures and case-based learning methods. Pre-test and post-test surveys were conducted in a sample of General Practitioners from Mures County, Romania, in order to assess their confidence in and implementation of evidence-based tobacco cessation clinical guidelines before and after a training for pregnancy-focused smoking cessation. The survey was administered to 74 physicians, of whom 72 (97.3%) indicated that they provided care to pregnant patients, and they were considered eligible for our study. All GPs who completed the baseline assessment were invited to attend the training program. Three GPs (4.16%) did not attend the second session and were excluded from the analyses. The total number of physicians remaining in the study was 69. This study was approved by the Ethical Review Board of the University of Medicine and Pharmacy, Tirgu-Mures, Romania.

Measures

Analysis

Descriptive statistics were used to describe the sample and illustrated pre-training confidence and engagement in evidence-based clinical practice to promote tobacco cessation among pregnant women and post-training satisfaction with the training received on the same evidence-based topics.

Results

Sample Description

Most of respondents were females (86%), and 62.3% were practicing in urban areas. Approximately 73% of the GPs had more than 20 years of clinical experience, and 82% consulted 5 or fewer pregnant women every week.

Thirty-two percent reported having participated in formal training or clinician education on tobacco treatment and counseling, and 25% reported adequate familiarity with clinical practice guidelines for treating tobacco use and dependence. Most of GPs were working in practices within clinics or healthcare systems with limited structures to offer tobacco cessation: 28% indicated that their clinic has a tobacco user identification system (e.g., chart, electronic medical record), 13% have dedicated staff personnel to support tobacco dependence treatment, and 3% had referral mechanisms to refer patients to the national quitline Stop-Fumat! Also 65% of GPs reported availability of leaflets or other self-help materials in waiting rooms, hallways, or exam rooms to aid patients in quitting.

Providers highlighted a number of barriers to assist patients to quit smoking, including lack of time and reimbursement (45.5% and 43.3%, respectively). In addition to health system barriers to tobacco cessation in clinical practice, many providers (39.3%) reported that their patients are not motivated to quit, that they usually fail to quit (30.2%), and have more important problems than tobacco use (33.9%). Almost 1 in 4 GPs (24.1%) reported that they were unfamiliar with interventions for smoking cessation among pregnant women. A high percentage of GPs (85%) recognized tobacco use as a chronic, relapsing disorder (85.5%) that need to be managed more efficiently, but also 55.5% believed that brief intervention treatment is ineffective.

Confidence in and Self-Reported Implementation of the Evidence-Based Clinical Practice Guidelines Before Training

86.9% of GPs indicated that they always or usually advised tobacco users to quit and 86.9% talked about the dangers of tobacco use and benefits of quitting during pregnancy. However, fewer than a third of GPs reported using some of the strategies that can help patients quit, such as assisting patients in making a quit plan (15.9%), or arranging follow-up to support cessation (15.9%), or submitting referral forms to the national Stop Fumat quitline (17.4%) (Table 1).

Table 1.

Distribution of sample characteristics

	N (%)
GP’s Gender
Female GP	59 (85.5)
Male GP	10 (14.5)
Practice location
Urban	43 (62.3)
Rural	26 (37.7)
GP’s professional experience
< 20 years	10 (14.5)
> 20 years	50 (72.5)
GP’s daily consultations
Between 16–25	30 (43.5)
>25	35 (50.7)
Pregnant women consulted weekly
Between 1– 5	57 (82.6)
Between 6–10	9 (13.1)
>10	3 (4.3)
GP participated in a formal training or clinician education on tobacco treatment and counseling methods	22 (31.9)
GP is adequately familiar with clinical practice guidelines for treating tobacco use and dependence	17 (25)
GP’s practice has systems in place to address tobacco use	19 (28)
GP’s practice has dedicated staff to support tobacco dependence treatment	9 (13)
GP’s practice has mechanisms to refer patients to the national quitline StopFumat	2 (3)
GP’s practice has informational poster/pamphlets in waiting room, hallways, or exam rooms	45 (65)
Barriers in assisting patients to quit smoking
Lack of time	31 (45.5)
Reimbursement	30 (43.3)
Lack of motivation to quit smoking	27 (39.3)
Failure to quit smoking	21 (30.2)
More important issues than tobacco use	23 (33.9)
GP’s knowledge about tobacco smoking
GP unfamiliar with interventions for smoking cessation among pregnant women	17 (24.1)
GP recognized tobacco use as a chronic disorder	58 (85)
Tobacco smoking is a relapsing disorder that needs to be managed more efficiently	59 (85.5)
Brief intervention treatment is ineffective	38 (55.5)

Perceived Value of the Training to Promote Evidence-Based Clinical Guidelines to Support Cessation for Pregnant Women

After training, a majority of the GPs found the content of the training informative or very informative along the same evidence-based clinical practice guidelines assessed at baseline. Between 85 and 90% found the training informative or very informative related to asking patients if they use tobacco (89.4%), advising patients to quit using tobacco (88.4%), talking about the benefits of quitting (85.5%), assessing patients willingness/readiness to make a quit attempt (87%), and assisting patients setting a quit date (87%) (Table 2).

Table 2.

Romanian GPs’ confidence in and implementation of evidence-based tobacco cessation clinical practices among pregnant women, and the perceived value of a training focused on the same evidence-based practices

Evidence-based tobacco cessation clinical practices	Pre-training: I am very/somewhat confident…	Post-training: The training was very/somewhat informative on…
	No=69	No=69
Asking patients if they use tobacco	50.7%	89.4%
Advising tobacco-using patients to quit	60.9%	88.4%
Assessing patient willingness/readiness to make a quit attempt	56.5%	87.0%
Talking about the dangers of using tobacco products	62.3%	86.9%
Talking about the benefits of quitting	58.0%	85.5%
Assisting patients in making a quit plan	39.1%	78.2%
Discussing patients’ triggers for tobacco use	44.9%	76.8%
Submitting a Quit line Fax Referral Form	34.8%	69.5%
Arranging to follow-up with tobacco-using patients	38.38%	63.8%

Discussion

An important percentage (%) of our sample of Romanian General Practitioners, did not feel confident implementing evidence-based cessation into routine clinical practice prior to the training program. However, following a 6-h skills-based training program, they found the training informative and useful. There is evidence that patients who are treated by physicians who have undergone cessation training are more likely to quit and smoking counseling in the general practice is feasible [13]. GP’s typically have a large number of patients who are smokers, and frequent meeting with their patients promises a successful healthy smoking orientation. However, is not very well known about accessibility of smokers to general practice intervention and their motivation to quit smoking. There is a lack of information on the perceived responsibility of family doctors for smoking advice [14].

Verbiest at all showed in their study that just 1 h of training, can reduce the gap of smoking cessation care between trained and untrained GPs [16].

GP’s should know that they can discuss smoking cessation methods with each patient, followed by referral to a nurse for intensive and continuing behavioral support [15].

Training increase the motivation of physicians to assist smokers, especially when offered at no cost, either supported by public funds or paid at the institutional level [10].

One challenge of implementing cessation training and support is the high prevalence of smoking among physicians in in some eastern European countries.(in Ukraine, 57% of male and 15% of female physicians, in Estonia 39.7% of male and 13.2% of female physician are smoking) [1].

In our study, 15.9% of physicians self-reported that they are daily smokers. Similar studies have documented that physicians are less likely to counsel patients on behavior changes (e.g. smoking cessation) when themselves exhibit unhealthy behavior, which may account, in part, for the large share of GPs who believed brief intervention treatment was inefficient [3].

This is one of the first study upon Romania GPs regarding their knowledge, confidence, and skills to help pregnant patients quit smoking. Moreover, this is the first evaluation in Romania on providers’ receptivity to training providing didactic and case-based learning to develop GPs skills in promoting smoking cessation among patients. Although this is a novel study in Romania, nonetheless, we demonstrated that the vast majority of GPs could attend a tobacco cessation training program if offered at no cost, and reported that it is beneficial. In order to enhance the capacity of Romanian health professionals and other Eastern European countries also, to help patients to quit smoking, we believe smoking cessation knowledge and skills building should be a mandatory part of any health professional training.

Limitations

Due to the nature of the pre and post-intervention questions, the findings of GP’s confidence (pre) and GP’s finding training informative (post), although referring to the same tobacco control guidelines, cannot be compared in statistical tests. The small sample size, its regionally-based sample, and our lack of ability to validate self-reported implementation of guidelines with actual behavior can be considered major limitations.

Conclusions

Romanian GPs are generally not confident, are not engaging in evidence-based clinical practice guidelines for treating tobacco use, and need more training focused on addressing these guidelines. The majority of GPs found a 6-h training program informative and helpful for counselling and supporting pregnant women for cessation.