Tobacco use is the leading cause of preventable mortality in the world (1). Article
14 of the World Health Organization (WHO) Framework Convention on Tobacco Control
(FCTC) states that countries should promote cessation of tobacco use and adequate
treatment for tobacco dependence (2). Health-care providers asking all patients about
their tobacco use and advising tobacco users to quit are evidence-based strategies
that increase tobacco abstinence (3). This report examines the proportion of tobacco
smokers in 17 countries responding to the Global Adult Tobacco Survey (GATS) who saw
a health-care provider in the past year and who reported that a health-care provider
asked them about smoking and advised them to quit. Respondents were tobacco smokers
aged ≥15 years surveyed during 2008–2011 in Bangladesh, Brazil, China, Egypt, India,
Indonesia, Malaysia, Mexico, Philippines, Poland, Romania, Russia, Thailand, Turkey,
Ukraine, Uruguay, and Vietnam. The proportion of smokers who had visited a health-care
provider during the previous 12 months ranged from 21.6% in Egypt to 62.3% in Poland.
Among these, the proportion reporting that a health-care provider asked if they smoked
ranged from 34.9% in Vietnam to 82.1% in Romania. Among those screened for tobacco
use, those who reported their health-care providers advised them to quit ranged from
17.3% in Mexico to 67.3% in Romania. In most countries, persons aged ≥45 years were
more likely to report being screened and advised to quit than were persons aged ≤24
years. Health-care providers should identify smokers and provide advice and assistance
in quitting at each visit (3) as an adjunct to effective community interventions (e.g.,
increased price of tobacco products; smoke-free policies, mass media campaigns, and
tobacco quitlines).
GATS is an ongoing, nationally representative, in-person household survey of persons
aged ≥15 years (4). GATS was conducted in each of the 17 countries during 2008–2011
using a standardized questionnaire, sample design, data collection method, and analysis
protocol to enhance data comparability.* Data were weighted to reflect the noninstitutionalized
population aged ≥15 years in each country by sex and age groups. Smokers included
persons who currently smoked tobacco† and former smokers who were abstinent for <12
months (5). Only smokers were asked, “Have you visited a doctor or other health-care
provider in the past 12 months?” If they had been to see a health-care provider, they
were then asked two follow-up questions. The first was, “During any visit to a doctor
or health-care provider in the past 12 months, were you asked if you smoke tobacco?”
Only those who answered “yes” were then asked, “During any visit to a doctor or health-care
provider in the past 12 months, were you advised to quit smoking tobacco?”
Survey sampling and analysis followed standard global protocols but were conducted
separately for each country. Overall response rates (number of interviews conducted
divided by the number of eligible respondents, including those not interviewed) ranged
from 65.1% in Poland (2009–2010) to 97.7% in Russia (2009). Survey sample sizes ranged
from 4,250 in Malaysia to 69,296 in India (1). Proportions of smokers who were asked
about smoking and advised to quit by a health-care provider were calculated by sex,
age group, residence (urban versus rural) and education level. Logistic regression
for complex sample designs was used to analyze two dependent variables: 1) whether
or not the health-care provider asked if the respondent smokes and, 2) whether or
not the health-care provider advised the respondent to quit smoking. The demographic
characteristics of current smokers (i.e., sex, age group, residence, and education)
were used as independent variables in the models. Estimates and 95% confidence intervals
were calculated using statistical software. Differences in proportions were considered
to be statistically significant if 95% confidence intervals did not overlap.
With the exception of Poland, the prevalence of smokers who reported that they visited
a health-care provider in the past year was <60% in all countries surveyed (Table
1). Health-care provider screening for tobacco smoking during any visit in the past
12 months varied and was highest in Romania (82.1%), Uruguay (76.6%), and Egypt (74.1%)
and lowest in Vietnam (34.9%), Indonesia (40.5%), and China (40.8%). Report of health-care
providers asking and advising to quit varied across countries and was highest in Romania
(67.3%), Egypt (67.0%), and Brazil (57.1%) and lowest in Mexico (17.3%), Vietnam (29.7%),
and Ukraine (30.8%).
After multivariate adjustment (Table 2), in five of 17 countries, men were more likely
to report being asked and advised to quit than women (China, Egypt, India, Indonesia,
Thailand), with adjusted odds ratios (AORs) ranging from 1.6 to 8.5. In 14 of the
17 countries, older smokers (aged 45–64 years) were more likely to report being asked
and advised to quit than younger smokers (aged ≤24 years), with AORs ranging from
1.8 to 6.7. In India and Mexico, rural smokers who had a health-care visit were less
likely to report being screened for tobacco use than urban smokers.
Editorial Note
The findings in this report indicate that opportunities exist globally for health-care
providers to screen for tobacco use and provide smokers with advice to quit. Health-care
providers should screen all patients for tobacco use, and for those who use tobacco,
provide advice to quit, offer assistance (i.e., counseling and medications), and arrange
for follow-up (3). In January 2004, a unified code of practice on tobacco control
for health professionals was adopted and signed by the participants at a WHO informal
meeting on health professionals and tobacco control in Geneva, Switzerland, to encourage
tobacco use prevention and cessation counseling internationally (6).
This international consensus for promoting effective cessation treatment can be used
to further promote these practices in the clinical setting. “Offering help to quit
tobacco use” is one of the six key focus areas in WHO’s MPOWER package, which is intended
to assist countries with the implementation of the WHO FCTC recommendations for tobacco
control. Cessation assistance also is a key part of decreasing tobacco use, which
is one of CDC’s 10 winnable battles for public health action.§ The WHO MPOWER package
also acknowledges the important role health-care systems play in ensuring that health
professionals routinely ask all patients about their tobacco use and provide advice
to quit (7). Countries might consider implementing community-based tobacco control
policies and interventions that both create an environment in which users can successfully
stop and increase the likelihood of cessation, including increasing the price of tobacco
products and implementing smoke-free policies, mass media campaigns, and tobacco cessation
quitlines; these strategies are particularly important because, in some countries,
a minority of smokers visited a health-care provider in the last year (7). Low- and
middle-income countries might also consider optimizing population coverage and using
health services, promoting community-based interventions, and developing partnerships
with health-care systems to support cessation and treatment (8).
What is already known on this topic?
Smokers who quit reduce their risk for developing and dying from tobacco-related diseases.
Identification of tobacco use and advice to quit by health professionals increases
cessation among smokers. Health-care providers should screen all patients for tobacco
use, and for those who use tobacco, provide advice to quit, offer assistance, and
arrange for follow-up.
What is added by this report?
The proportion of tobacco smokers responding to the Global Adult Tobacco Surveys during
2008–2011 in 17 countries who saw a health-care provider in the past year and who
reported that a health-care provider asked them about smoking ranged from 34.9% in
Vietnam to 82.1% in Romania; the proportion who said that they were advised to quit
ranged from 17.3% in Mexico to 67.3% in Romania. In five of the 17 countries, men
were significantly more likely than women to report that a health-care provider asked
about smoking and advised them to quit, with adjusted odds ratios ranging from 1.6
to 8.5. In 14 of the 17 countries, older (aged 45–64 years) compared with younger
smokers (aged ≤24 years) were significantly more likely to report that a health-care
provider asked or advised them to quit, with adjusted odds ratios ranging from 1.8
to 6.7.
What are the implications for public health practice?
Globally, health-care provider screening for tobacco smoking and advice to quit varies
widely, and many opportunities to offer effective cessation treatment to tobacco users
are being missed.
Disparities across demographic subgroups (sex, age group, and residence) in screening
and cessation advice were observed across countries. Barriers to health-care provider
counseling at the provider-level typically include time constraints, lack of reimbursement,
and lack of professional training (3,9). Data from the 2005 Global Health Professionals
Survey indicated that, whereas 87%–99% of health professions students believed they
should have a role in counseling patients to quit smoking, only 5%–37% reported that
they had received formal training on how to conduct such counseling (10). Reducing
barriers to counseling is critical to increasing the number of tobacco users who successfully
quit (9). To promote cessation counseling by all health-care providers, their training
should include training on smoking cessation counseling (9,10).
The findings in this report are subject to at least six limitations. First, GATS data
are self-reported and thus subject to recall bias that might vary across different
cultural settings. Second, only screening for tobacco smoking and advice to quit questions
were administered; other aspects promoting cessation counseling or medication, reasons
for the health-care visit, type of advice provided, or whether follow-up occurred,
were not assessed. Third, screening for smoking was only assessed among smokers aged
≥15 years, whereas all adolescents and adults should be screened for tobacco use (3).
Fourth, some smokers might have quit before they visited a health-care provider and
might, therefore, not have been advised to quit by a health-care provider. Fifth,
because response rates ranged from 97.7% to 65.1%, survey respondents might not represent
all smokers in some countries. Finally, screening was only assessed among tobacco
smokers and not users of other forms of tobacco.
Globally, health-care provider screening for tobacco smoking and advice to quit varies
widely, and many opportunities to offer effective cessation treatment to tobacco users
are being missed. To reduce the worldwide burden of tobacco use, implementation of
WHO FCTC, WHO’s MPOWER package, and further implementation of the cessation guidelines
to promote cessation and increase tobacco dependence treatment is warranted.