Chinese pediatrician beliefs about counseling and medications for parents who smoke: a survey in southern China

Background Pediatricians play an important role in promoting smoking cessation among the parents of young children as more behavioral counseling and cessation treatment are made available in the Chinese healthcare system. However, beliefs about the effectiveness of these interventions can influence pediatricians’ recommendations to their patients. This study examined pediatricians’ beliefs regarding effectiveness of counseling and medications for smoking cessation. Methods A cross-sectional survey of pediatricians was conducted in thirteen conveniently selected southern Chinese hospitals, during September to December 2013. A self-administered questionnaire was used for data collection. We used chi square tests and multinomial logistic regression analysis to identify factors associated with beliefs regarding effectiveness of counseling and medications for smoking cessation. Results Beliefs of the respondents (504/550; 92% response rate) were divided regarding the effectiveness of counseling and medications for smoking cessation. Sixty percent believed that physician counseling is effective for smoking cessation; 53% believed pharmacological products (or medications) are effective. Factors that were associated with positive beliefs towards the effectiveness of counseling included: believing about the professional responsibility to discuss smoking cessation, being confident in discussing smoking cessation or SHS exposure reduction with patients’ parents, believing that health professionals should routinely ask about their patients smoking habits, believing that health professionals should routinely advise their smoking patients to quit smoking, possessing adequate knowledge in quitting smoking, and being able to assess smokers different stages of readiness to quit. Most of the above factors were also associated with the belief that medication is effective for smoking cessation. Conclusions A substantial proportion of Chinese pediatricians believed that cessation counseling and medications are not effective, which is not supported by current evidence in the field. Several factors including individual, practice level and health system level characteristics were associated with their belief. Training efforts are needed to influence pediatricians’ beliefs regarding the effectiveness of cessation counseling and medications.


Background
China is the world's largest producer and consumer of tobacco with 350 million smokers [1]. China has 740 million non-smokers passively exposed to SHS, including 180 million children under the age of 15 [2,3]. At present, an estimated 1 million deaths from smoking occur in China each year, and if the current smoking rates continue, as many as 100 million people currently under the age of 30 in China will die from tobacco use [1,2]. Thus, it is clear that tobacco control efforts in China must be intensified to combat the tobacco-induced morbidity and mortality.
Smoking cessation is a priority for preventing smokingattributable disease and reducing its burden [4,5]. However, promotion of smoking cessation counseling and cessation medications by physicians is an obstacle for China [6]. Among the physicians group, pediatricians who can address both secondhand smoke (SHS) exposure to children as well as parental smoking cessation are in a critical position. Because, the SHS exposure to children due to parental tobacco use is a serious and prevalent health issue, with over twenty-four percent of children living in a home with a smoking parent [7]. Parental smokers often see their child's doctor more frequently than their own, with an average of over 10 visits in the first two years of a child's life [8,9]. However, very small proportions of pediatrician's visits by a smoker result in cessation counseling or prescription for an effective smoking cessation medication [10]. It was argued that physicians are more likely to recommend treatments that they believe are effective [11]. In studies among physicians in overseas, belief regarding the effectiveness of counseling and cessation medications varied [12][13][14] with a substantial proportion holding misconceptions about the intervention effectiveness [13,14]. An exploratory study among Chinese pediatricians also reported misconceptions about the effectiveness of counseling and medications for smoking cessation [15]. Therefore, it is critical that the Chinese pediatrician's beliefs are appropriate and evidencebased as they play a key role in clinical decision making. This study describes the beliefs of a sample of Chinese pediatricians regarding the effectiveness of counseling and medication for tobacco dependency treatment.

Sample
Participants were pediatricians working in the conveniently selected thirteen hospitals (twelve grade III and one grade I) in four major cities of Guangxi province (a Southern Chinese province), the People's Republic of China.

Data collection
A standardized Mandarin Chinese language questionnaire was used for data collection. Questionnaires were distributed through the director of pediatrics department in each of the participating hospitals. The director distributed a copy of the questionnaire to each pediatrician working in his or her department and requested them to put the completed questionnaire in a sealed envelope and drop the questionnaire in the designated box kept in the doctor's office. Our study coordinator then collected the sealed questionnaire from each of the directors. For clarity on any unfinished questions, our study coordinator contacted the individual pediatrician by telephone. To compensate for their time, each participant was given a cash amount of RMB 100 ($15). The study was approved by the institutional review board of Guangxi Medical University.

Questionnaire
The questionnaire was developed with reference to the questionnaires previously used by the investigators team in the United States [9] and in China [6]. The questionnaire obtained demographic information on the subject's demographic background (sex, age, physician type, number of years studied at medical school), smoking behavior (smoker, non-smoker) and other questions on "counseling practices for smoking cessation and secondhand smoke (SHS) exposure to children", "perceiving barriers for smoking cessation service", "whether their workplace is smoke-free", "whether they received any training on smoking cessation counseling", which should be answered "yes" or "no".
Belief of effectiveness for smoking cessation counseling was assessed by asking "physician counseling about smoking cessation is a cost-effective intervention compared to other preventive interventions?", with response categories of "strongly agree, agree, disagree and strongly disagree". Belief of effectiveness for pharmacological products was assessed by asking, "pharmacological products or medications (i.e., nicotine patch, nicotine gum, nicotine lozenges, bupropion, varenicline) are effective in helping smokers quit smoking", with response categories of "strongly agree, agree, disagree and strongly disagree". And responses were categorized as 1 for "strongly agree and agree", 2 for "disagree and strongly disagree".

Analyses
Two members of the research team coded each questionnaire and entered all data with Epidata 3.1, and then made a data consistency check. We used χ 2 procedures to compare differences between the belief of effectiveness and demographic characteristics or other relevant variables, and then used multinomial logistic regression analysis to analyze the factors with p-value <0.2 in χ 2 procedures. A p-value of <0.05 (two-tailed) was considered statistically significant.

Demographic and other characteristics
A total of 550 questionnaires were handed out and 504 pediatricians completed the questionnaires, with a response rate of 92% (504/550). Response rates were almost identical in all the hospitals. Of the respondents, 64% were female, 77% received 5 years of education at medical school and 17% were current smokers (Table 1). More than one-third of the respondents didn't hear about e-cigarettes. As a non-smoker, 46% of all pediatricians inhaled secondhand smoke for more than 15 minutes daily for more than 1 day during the past week; 81% of the samples didn't receive formal training in smoking cessation and 64% of all pediatricians didn't read China smoking cessation guidelines. Of the respondents, 60% and 53% believed that physician counseling and pharmacological products are effective for smoking cessation, respectively.
The belief that physician counseling is effective for smoking cessation Table 2 describes the pediatrician's beliefs regarding effectiveness of smoking cessation counseling. A significantly higher proportion of female (64%) than male (54%) pediatricians believed that cessation counseling is effective (p < .05). A higher proportion of pediatricians who reported that their hospital have a policy to advise smokers to quit smoking (64%) than those which have no policy (55%) believed that cessation counseling were effective (p < .05). Pediatricians who received formal training in smoking cessation (71%) than those who did not receive training (58%) believed that cessation counseling were effective (p < .02). A significantly higher proportion of those who had read China smoking cessation guidelines (66%) than those who did not hear about the guidelines (49%) believed that cessation counseling is effective (p < .05). Other significant characteristics related to the belief that cessation counseling is effective included being confident (65%) than not at all confident (32%) in discussing smoking or SHS exposure reduction with parents, believing that pediatricians can help parents stop smoking (77%) than not believing so (40%), in the usual practice advising (64%) than not advising (17%) parents not to smoke around children, agreeing (65%) than not agreeing (37%) with the statements that health professionals should routinely ask about parents smoking habits, believing (69%) than not believing (27%) that health professionals should advise smoking parents to quit smoking, believing that they possess adequate knowledge (81%) than not believing so (56%) to help parents in quitting smoking, and those who could assess smokers different stages of readiness to quit (75%) than those who do not believe so (58%).
Multinomial logistic regression analysis showed that "believing about the professional responsibility to discuss smoking cessation", "being confident in discussing smoking cessation or SHS exposure reduction with patients' parents", "believing that health professionals should routinely ask about their patients smoking habits", "believing that health professionals should routinely advise their smoking patients to quit smoking", "possessing adequate knowledge in quitting smoking", and "being able to assess smokers different stages of readiness to quit" were the factors associated with the belief that physician counseling is effective for smoking cessation (see Table 3).
The belief that pharmacological products are effective for smoking cessation Table 4 describes that nine factors were associated with pediatrician's beliefs regarding the effectiveness of pharmacological products for smoking cessation. These factors are: receiving (65%) than not receiving (50%) formal training in smoking cessation (p < .02), reading (66%) than not reading (53%) China smoking cessation guidelines (p < .01), being confident (55%) than not at all confident (38%) in discussing smoking or SHS exposure reduction with parents (p < .01), believing that pediatricians can help parents stop smoking (67%) than not believing so (35%) (p < .001), in the usual practice advising (55%) than not advising (23%) parents not to smoke around children (p < .001), agreeing (59%) than not agreeing (29%) with the statements that health professionals should routinely ask about parents smoking habits (p < .001), believing (61%) than not believing (24%) that health professionals should advise smoking parents to quit smoking (p < .001), believing that they possess adequate knowledge (74%) to help parents in quitting smoking than not believing so (48%) (p < .001), and those who could assess smokers different stages of readiness to quit (67%) than those who do not believe so (50%) (p < .01).
Multinomial logistic regression analysis showed that "being confident in discussing smoking cessation or SHS exposure reduction with patients' parents", "believing that pediatricians can help parents stop smoking", "believing that health professionals should routinely ask about their patients smoking habits", "believing that health professionals should routinely advise their smoking patients to quit smoking", "possessing adequate knowledge in quitting smoking", and "being able to assess smokers different stages of readiness to quit" were the factors associated with the belief that pharmacological products are effective for smoking cessation (See Table 5).

Discussion
To the best of our knowledge, this is the first study of pediatrician beliefs regarding the effectiveness of counseling and pharmacological products for smoking cessation in a developing country and in China. In the current study, 79% pediatricians did not receive any formal training on tobacco control or smoking cessation, although 84% of the pediatricians were very or somewhat confident about discussing smoking cessation or SHS exposure reduction with children's parents. Studies elsewhere reported low rates of implementation of effective SHS exposure reduction interventions on parents who smoke among the pediatricians [16][17][18]. In an earlier study among Chinese parents [10], few parents (8/33, 24%) had positive experiences about the way they have been asked about SHS exposure to the children or about parental smoking status,  Note: Due to the missing values in some variables, the total number may not equal to the same. *exposed to SHS for more than 15 minutes daily for more than 1 day in the past week.  and rarely were told by their child's pediatricians to quit smoking.
Our findings show that about half of the pediatricians did not believe the fact that smoking cessation counseling and medication are effective in promoting smoking cessation. Evidence suggests that counseling [19,20] and cessation medications [21][22][23][24][25] are effective for smoking cessation. Factors that were associated with pediatricians' beliefs included individual characteristics (i.e. female gender, perceived knowledge), clinical practice (i.e. receiving cessation training, advising to quit) and health system (i.e. hospital policy to ask about smoking) related factors. However, many other factors could influence these beliefs among the pediatricians. An earlier survey in China showed that, through creating smoke-free hospital activities, the rate of often asking patients' smoking status increased from 55.0% to 68.9%, the rate of often advising patients to quit smoking from 67.8% to 77.3% [26]. The same study also reported higher confidence to provide smoking cessation service among physicians who received training on tobacco use prevention and cessation [26].
The low perceived effectiveness of counseling and medications for smoking cessation among Chinese pediatricians are not supported by the current evidence which suggests that these are effective intervention strategies [27][28][29]. The scarcity of smoking cessation services within    the Chinese hospitals and the unavailability of cessation medications contributed significantly to possessing such beliefs among the pediatricians. It may be the fact that pediatricians were reluctant to know more about the effectiveness of these intervention modalities (i.e. counseling and medication) as they will not utilize these in their clinical practice. If these modalities for smoking cessation are to be fully implemented within the healthcare system, physicians need to be trained and aware of their effectiveness. At the same time, the Chinese healthcare system needs to realize the need for smoking cessation services with provision for medications. In this study, receiving formal training in smoking cessation or reading China smoking cessation guidelines were associated with the belief that cessation counseling and pharmacological products were effective.

Limitations
Several factors may limit the generalizability of the findings. First, the sample may not be representative of the whole pediatric population in China. Second, although it is expected that the characteristics of pediatricians working in all the similar grade level hospitals would be similar, there may be regional variations. However, responses to key items did not differ as a function of hospital type or physician type so this is unlikely to have affected the results. Third, one might expect that attitudes would change over time as more information about the smoking cessation intervention was available in China since this study was conducted. A follow-up survey may examine the changes of beliefs over time.

Conclusion
The findings suggest that a substantial proportion of Chinese pediatricians believed that cessation counseling and medications are not effective, which is not supported by current evidence in the field. Several factors including individual, practice level and health system level characteristics were associated with their belief regarding the effectiveness of cessation counseling and medications. Perceived effectiveness of cessation counseling and medication may affect pediatricians' clinical practice and recommendations for tobacco use reduction and cessation. Therefore, training efforts are needed to influence pediatricians' beliefs about the available evidence-based interventions (i.e., counseling and medications). At the same time, health system-level change to incorporate cessation service within the healthcare delivery system will increase pediatricians' participation in the training, enhance their understanding about the evidence-based intervention available for smoking cessation and generate positive beliefs towards cessation counseling and medication.