ABSTRACT

Objective: To identify characteristics related to smoking in hospitalized patients and to assess the knowledge that such patients have regarding the relationship between nicotine dependence and smoking-related diseases. Methods: The study included 186 patients (males, 59%; mean age, 51.3 ± 16.8 years) who were evaluated regarding demographic characteristics, diagnosis at admission, smoking history and passive smoke exposure. All of the patients completed a questionnaire regarding their knowledge of the relationship between smoking and disease. Results: Of the 186 patients, 42 (22.6%) were smokers, 64 (34.4%) were former smokers and 80 (43%) stated they were never smokers; 136 (73%) reported passive smoke exposure. In the sample as a whole, 21.5% of the patients were diagnosed with a smoking-related disease at admission, compared with 39% of those who were smokers or former smokers. The proportion of individuals who were unaware of the relationship between smoking and the cause of hospitalization was similar among current smokers and former smokers (56% and 65%, respectively). Only 19% of the current smokers believed that smoking might have affected their health, compared with 32% of the former smokers (p = 0.22). The proportion of individuals who believed that quitting smoking depends on willpower was significantly higher among former smokers and never smokers than among current smokers (64% and 53%, respectively, vs. 24%; p < 0.001 and p = 0.008). Although 96% of the patients believed that smoking causes dependence, only 60% identified smoking as a disease. Conclusions: This study shows the disconnect between the recognition of smoking as a cause of dependence and the recognition of smoking as a disease, as well as the general lack of awareness that former and current smoking constitute a risk factor for the development and progression of disease.

Keywords: Smoking; Tobacco use disorder; Smoking cessation.

RESUMO

Objetivo: Determinar características relacionadas ao tabagismo e avaliar o conhecimento sobre a relação entre dependência nicotínica e doenças relacionadas ao tabaco em pacientes internados. Métodos: Foram avaliados em 186 pacientes (59% de homens; média de idade = 51,3 ± 16,8 anos) internados em um hospital público quanto a características demográficas, diagnóstico de internação, história tabágica e tabagismo passivo. Todos os pacientes responderam um questionário sobre o conhecimento da relação tabagismo/doença. Resultados: Dos 186 pacientes, 42 (22,6%) eram fumantes, 64 (34,4%) eram ex-tabagistas e 80 (43%) referiam nunca ter fumado; 136 (73%) referiam exposição passiva ao fumo. O diagnóstico de admissão foi o de doença possivelmente relacionada ao tabaco em 21,5% dos pacientes e em 39% dos fumantes ativos e ex-fumantes. A proporção de fumantes e ex-fumantes que não conheciam a associação entre o tabagismo e a causa de internação foi similar (56% vs. 65%). Apenas 19% dos fumantes e 32% dos ex-fumantes acreditavam que o tabagismo tivesse afetado sua saúde (p = 0,22). A proporção de ex-fumantes e de não fumantes que acreditavam que parar de fumar é uma questão de vontade foi significativamente maior que aquela de fumantes ativos (64% e 53%, respectivamente, vs. 24%; p < 0,001 e p = 0,008). Embora 96% dos pacientes acreditassem que o tabagismo cause dependência, apenas 60% identificavam o tabagismo como uma doença. Conclusões: Este estudo mostra a contradição entre o reconhecimento do tabagismo como causa de dependência e o reconhecimento do tabagismo como uma doença, além do desconhecimento de que o tabagismo atual e pregresso é um fator de risco para o desenvolvimento e a evolução de doenças.

Palavras-chave: Tabagismo; Transtorno por uso de tabaco; Abandono do hábito de fumar.

Introduction

Smoking is considered the principal preventable cause of death worldwide. Data from the World Health Organization (WHO) show that smoking accounted for over 100 million deaths worldwide in the 20th century, and estimates for the 21st century are that this number will surpass one billion.(1) In addition, the global economic loss due to smoking-related diseases, which principally affects developing countries, is estimated to be US$ 200 million dollars per year.(1) In Brazil, the estimation model for smoking-related mortality showed that, in 2003, 24,222 deaths (13.64% of all deaths) were associated with smoking, and the estimated number of years of life lost was 419,935.(2)

The WHO has recommended the adoption of six effective policies to control the smoking pandemic, and Brazil has proven committed to pursuing each and every one of them. There is monitoring of tobacco consumption by means of policies of prevention, protection from passive smoke exposure, programs for smoking cessation and warnings about the health hazards of smoking, as well as bans on tobacco advertising and sponsorship by tobacco companies.(1) In addition, there has been an increase in cigarette prices.(1) Illustrations of smoking-related diseases on cigarette packs and televised warnings about the risks of passive smoke exposure, together with national and international campaigns aimed at promoting smoking cessation, have heightened public awareness regarding the dangers of smoking.(1,3) However, data from the latest monitoring showed the prevalence of smoking to be high (21%) among adults (over 18 years of age) in the city São Paulo.(4) Smoking-related health complications are still the leading causes of hospitalization and death, in Brazil and in other countries.(1,4,5)

There have been few studies evaluating the knowledge that the population has regarding smoking-related diseases.(6,7) Some studies have shown that people recognize the fact that smoking can affect their health; however, others have shown that, compared with nonsmokers, a lower percentage of smokers recognize the risk of smoking for the development of chronic diseases and cancer.(8,9) When the awareness of risk factors for the development of cancer, such as having a sedentary lifestyle, eating an unhealthy diet and drinking excessive alcohol, was evaluated, smoking was the risk factor most often recognized by the general population, although not unanimously.(10) In addition, there are myths related to tobacco, such as the fact that a reduction in smoking will reduce the risk for smoking-related diseases, or even that the danger is reduced when using other nicotine delivery systems, such as hand-rolled cigarettes or a narghile (water pipe).(11-13) Therefore, despite the current awareness-raising campaigns, we must enlighten the population by countering the disinformation regarding tobacco consumption and dispelling the related myths.

The evaluation of the knowledge that patients have regarding smoking can aid in the development of efficient strategies to train health care professionals to properly approach this disease. However, there have been no studies evaluating the knowledge that patients hospitalized in Brazil have regarding smoking.

The objective of the present study was to determine, in hospitalized patients, the characteristics related to smoking and to evaluate patient knowledge regarding the relationship between nicotine dependence and the reason for their admission (with or without smoking-related diseases) at a public hospital.

Methods

We interviewed 186 patients (with or without smoking-related diseases) hospitalized at the Botucatu School of Medicine Hospital das Clínicas in May of 2008. The Brazilian Thoracic Association Smoking Cessation Guidelines(3,14) and the WHO Report on the Global Tobacco Epidemic(1) list the following as smoking-related diseases: COPD; interstitial lung diseases (desquamative pulmonary fibrosis, idiopathic pulmonary fibrosis, respiratory bronchiolitis and histiocytosis X); stroke; coronary diseases; peripheral arterial disease; venous thromboembolism; gastritis; gastric ulcers; duodenal ulcers; preterm labor; and cancer at various sites, such as the lung, oral cavity, larynx, esophagus, bladder, kidneys, pancreas, stomach, colon, rectus, breast and uterus. Patients who were not clinically stable (on mechanical ventilation, with hemodynamic instability or with an altered level of consciousness) were excluded from the present study, as were those who were not able to understand the study protocol. All patients included in the study gave written informed consent using a form that had been approved by the research ethics committee of the institution.

The questionnaire employed assessed the following demographic characteristics: age; gender; marital status; level of education; occupation; and reason for hospitalization. The following were also assessed: smoking status (smoker/former smoker/nonsmoker); contact with smokers at home or at work; age at smoking onset; time since smoking cessation; and (for current or former smokers) number of cigarettes smoked per day. The knowledge that the patients had regarding smoking was investigated by assessing the following: their knowledge of the relationship between current smoking or prior smoking and the disease for which they were hospitalized (in cases diagnosed with smoking-related diseases); whether they recognized smoking as a disease; whether they believed that smoking causes dependence; whether they held the opinion that quitting smoking depends on willpower; whether they were aware of any smoking cessation treatment; and whether they knew of any health care facility that provided smoking cessation treatment.

A descriptive analysis of the results was performed, and the data are presented in absolute numbers, percentages or mean and standard deviation. To compare the proportions of the answers of smokers, former smokers and nonsmokers, the chi-square test was used. The level of significance was set at 5%, and this value was adjusted when the Bonferroni test for multiple comparisons was applied.

Results

The general characteristics of the 186 patients are shown in Table 1. The mean age of the patients, 59% of whom were male, was 51.3 ± 16.8 years (range, 14-86 years). Most of the patients (60%) had attended school for less than 9 years, and the majority (72%) were married. Of the patients investigated, 30% were retired.



Of the 186 patients, 42 (22.6%) were smokers, 64 (34.4%) were former smokers and 80 (43.0%) stated that they were never smokers; 136 (73%) reported past or present exposure to passive smoke at home or at work.

Among the former smokers, the time since smoking cessation ranged from 1 to 54 years, 17% having quit within the last 12 months. In the sample as a whole, 21.5% of the patients were diagnosed with a smoking-related disease at admission, compared with 39% of those who were current smokers or former smokers. Of the smoking-related diseases, lung cancer and coronary disease were those most often diagnosed (in 48% of the sample).

The data related to the knowledge that the patients had regarding smoking are shown in Table 2. The proportion of individuals who were unaware of the relationship between smoking and the disease that was the cause of hospitalization was similar among current smokers and former smokers (56% and 65%, respectively; p = 0.50). Only 19% of the current smokers believed that smoking might have affected their health, compared with 32% of the former smokers (p = 0.22). Of the 186 patients, 146 (78.5%) had knowledge of some type of smoking treatment and 59.7% knew of specialized clinics for smoking cessation.



The proportion of individuals who believed that quitting smoking depends on willpower was significantly higher among former smokers and never smokers than among current smokers (64% and 53%, respectively, vs. 24%; p < 0.001 and p = 0.008). There were no significant differences among the groups when considering whether patients believed smoking is a disease (p = 0.43) and when considering whether patients believed smoking causes dependence (p = 0.58). Although 96% of the patients believed that smoking causes dependence, only 60% believed that smoking is a disease.

The level of education presented a statistically significant association with the question of whether patients believed that quitting smoking depends on willpower (p = 0.02). The questions regarding whether patients believed smoking is a disease (p = 0.68) and whether patients believed smoking causes dependence (p = 0.63) were not associated with the level of education.

Discussion

One of the principal findings of the present study was the identification of the disconnect between the recognition of smoking as a cause of dependence and the recognition of this dependence as a disease. The vast majority of the patients reported that smoking can cause dependence, but 40% of the patients were not of the opinion that this dependence is a disease. In addition, most of the current smokers recognized that they were not able to stop smoking at will.

The present study is the first to investigate the knowledge that patients hospitalized in a Brazilian public hospital have regarding smoking. The results confirm that, despite the information in the media and provided on cigarette packs, these strategies have not significantly increased the knowledge of the general population regarding smoking. Similarly, some studies carried out in other countries have shown that the lay population still has little knowledge regarding smoking and its consequences.(6,8-10,15) Data in the literature suggest that the knowledge regarding the relationship between smoking and smoking-related diseases is restricted to certain pathologies, such as lung cancer and coronary disease.
(6,10,15) This might be related to the significant number of studies on the prevention of cancer and heart diseases, which has led, in recent decades, to the dissemination of information in the mass media.(9,16)

One study that investigated the knowledge regarding the risk factors (smoking, drinking excessive alcohol, having a sedentary lifestyle and eating an unhealthy diet) for the development of cancer and heart diseases showed that more than 60% of the population studied recognized only smoking as a risk factor. However, there are still myths regarding the individual risk for the development of cancer.(15) A study carried out in France showed that 44% of the smokers believed that smoking might lead to cancer only if tobacco consumption were higher than their own and that 20% of the smokers believed that their cancer risk would be increased only if the number of pack-years were greater than their own.(15) Another factor that is associated with smoking cessation attempts in patients with smoking-related diseases is the motivation that appears when certain diseases are diagnosed.(17,18) Patients who are informed about their lung age and about the influence of smoking on the evolution of airway obstruction show a higher smoking cessation rate. One study that evaluated the motivation to quit smoking after smokers were told their lung age (evaluated by means of pulmonary function tests) showed that the smoking cessation rate was higher among individuals who were informed of their lung age than among individuals who were not so informed.(17) In another study, after patients had been informed of the influence of smoking on the evolution of COPD, the smoking cessation rate was higher among those who had been diagnosed with airway obstruction than among those who had not.(18)

Another important finding of the present study was that most of the hospitalized patients had a history of passive smoke exposure, which shows the need to inform patients about the risks for developing diseases associated with passive smoking. International and national consensuses show that exposure to cigarette smoke causes the same diseases as does smoking, and this fact is not generally recognized by the population.(14,19) A study that evaluated the knowledge that 318 parents of children treated in an ICU had regarding smoking revealed that 70% of the parents believed that smoking could affect the health of children.(20)

The current level of knowledge regarding smoking can be improved by means of health promotion campaigns in schools, at health care facilities and in the mass media.(1,21-23) The present study showed that the lack of knowledge regarding smoking is associated with a lower level of education, which shows that it is necessary to improve the access that the general population has to information. The easy access to virtual information and the availability of internet sites that offer educational material on smoking and its consequences can improve the understanding of smoking and its consequences, as well as aiding in the control of the smoking epidemic.(23) In a study carried out in schools in China, it was shown that the implementation of specific measures, such as educating students, teachers, family members and members of the community on the psychological and physical treatment of smoking, resulted in less smoking, as well as in a better understanding of and a better attitude toward health.(22) Another fact that must always be clarified to smokers is that nicotine dependence makes smoking cessation difficult, and that willpower does not always suffice. The present study showed that most of the subjects believed that quitting smoking depends on willpower, and this finding was associated with the level of education.

However, a meta-analysis showed that, at one year after smoking cessation with minimal intervention, the abstinence rate was only 5%,(24) and that intensive intervention and the prescription of medication were central to treating this chronic disease.

The prevalence of current smoking in the present study (22.6%) was similar to the 9.8-21.0% found among adult individuals (≥ 18 years of age) in a recent study conducted in Brazilian capitals,(4) as well as to the 17% found in a study that investigated patients treated at a public hospital.(25)

The present study has some limitations. First, only the perspective of the patient was assessed, and this perspective can be influenced by a number of factors (such as memory or even denial). The evaluation of the point of view of health care professionals would provide additional information and allow the delineation of appropriate intervention strategies to approach the problem. The rate of smoking might have been underestimated, since it was not confirmed by means of biological measurements (such as the determination of exhaled carbon monoxide), which might have produced a proportional bias among the groups studied. In addition, the patients were not monitored after being discharged from the hospital in order to evaluate the smoking cessation rate after the intervention made during the hospitalization period.

In summary, the present study showed that, despite the campaigns designed to educate the population, there is still a lack of knowledge regarding the role of smoking as a risk factor for the development and, principally, the evolution of diseases. In addition, this study showed that information regarding smoking control needs to be more readily available and broadly disseminated. Furthermore, there should be more smoking cessation centers, the necessary resources being allocated to that end.

References


1. World Health Organization. [homepage on the Internet]. Geneva: World Health Organization [cited 2009 Jan 2]. WHO Report on the Global Tobacco Epidemic, 2008 - The MPOWER package. Available from: http://www.who.int/tobacco/mpower/2008/en/index.html

2. Corrêa PC, Barreto SM, Passos VM. Smoking-attributable mortality and years of potential life lost in 16 Brazilian capitals, 2003: a prevalence-based study. BMC Public Health. 2009;9:206.

3. Reichert J, de Araújo AJ, Gonçalves CM, Godoy I, Chatkin JM, Sales MP, et al. Smoking cessation guidelines - 2008. J Bras Pneumol. 2008;34(10):845-80.

4. Brasil. Ministério da Saúde; Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégica e Participativa. Vigitel Brasil 2008: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico Brasília: Ministério da Saúde; 2009.

5. Bunting L, Boivin J. Knowledge about infertility risk factors, fertility myths and illusory benefits of healthy habits in young people. Hum Reprod. 2008;23(8):1858-64.

6. Houfek JF, Atwood JR, Wolfe RM, Agrawal S, Reiser GM, Schaefer GB, et al. Knowledge and beliefs about genetics and smoking among visitors and staff at a health care facility. Public Health Nurs. 2008;25(1):77-87.

7. Tanni SE, Iritsu NI, Tani M, de Camargo PA, Sampaio MG, Godoy I, et al. Risk perceptions and behavior among hospitalized patients with smoking-related diseases. Prev Chronic Dis. 2009;6(4):A138.

8. Hay JL, Ostroff JS, Cruz GD, LeGeros RZ, Kenigsberg H, Franklin DM. Oral cancer risk perception among participants in an oral cancer screening program. Cancer Epidemiol Biomarkers Prev. 2002;11(2):155-8.

9. Finney Rutten LJ, Augustson EM, Moser RP, Beckjord EB, Hesse BW. Smoking knowledge and behavior in the United States: sociodemographic, smoking status, and geographic patterns. Nicotine Tob Res. 2008;10(10):1559-70.

10. Sanderson SC, Waller J, Jarvis MJ, Humphries SE, Wardle J. Awareness of lifestyle risk factors for cancer and heart disease among adults in the UK. Patient Educ Couns. 2009;74(2):221-7.

11. Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A critical review of the relevant literature and the public health consequences. Int J Environ Res Public Health. 2009;6(2):798-843.

12. Mohammad Y, Kakah M, Mohammad Y. Chronic respiratory effect of narguileh smoking compared with cigarette smoking in women from the East Mediterranean region. Int J Chron Obstruct Pulmon Dis. 2008;3(3):405-14.

13. Prignot JJ, Sasco AJ, Poulet E, Gupta PC, Aditama TY. Alternative forms of tobacco use. Int J Tuberc Lung Dis. 2008;12(7):718-27.

14. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes para cessação do tabagismo. J Bras Pneumol. 2004;30(Suppl 2):S3-S76.

15. Peretti-Watel P, Constance J, Guilbert P, Gautier A, Beck F, Moatti JP. Smoking too few cigarettes to be at risk? Smokers' perceptions of risk and risk denial, a French survey. Tob Control. 2007;16(5):351-6.

16. Khwaja A, Silverman D, Sloan F, Wang Y. Are mature smokers misinformed? J Health Econ. 2009;28(2):385‑97.

17. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008;336(7644):598-600.

18. Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J, Mieszko-Filipczyk G, et al. Smokers with airway obstruction are more likely to quit smoking. Thorax. 2006;61(10):869-73.

19. U.S. Department of Health and Human Services; Public Health Service; Fiore MC, Jaén CR, Baker TB, Bailey WC, et al. Treating tobacco use and dependence: 2008 update. Rockville (MD): US Department of Health and Human Services, Public Health Service; 2008.

20. Bock BC, Becker BM, Borrelli B. Smoking behavior and risk perception among the parents of infants in the neonatal intensive care unit. Nicotine Tob Res. 2008;10(1):47-54.

21. Instituto Nacional do Câncer [homepage on the Internet]. Brasília: Ministério da Saúde [cited 2009 Jan 2]. Vigescola - Vigilância de tabagismo em escolares. Available from: http://www.inca.gov.br/vigescola/

22. Aldinger C, Zhang XW, Liu LQ, Pan XD, Yu SH, Jones J, et al. Changes in attitudes, knowledge and behavior associated with implementing a comprehensive school health program in a province of China. Health Educ Res. 2008;23(6):1049-67.

23. Dr. Barto - Doutores da Saúde [homepage on the Internet]. São Paulo: Dr. Barto [cited 2009 Aug 1]. Available from: http://www.drbarto.com.br

24. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008;(2):CD000165.

25. Oliveira MV, Oliveira TR, Pereira CA, Bonfim AV, Leitão Filho FS, Voss LR. Smoking among hospitalized patients in a general hospital. J Bras Pneumol. 2008;34(11):936‑41.



Study carried out at the Botucatu Hospital das Clínicas, Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.
Correspondence to: Suzana E. Tanni. Disciplina de Pneumologia do Departamento de Clínica Médica da Faculdade de Medicina de Botucatu, CEP 18618-000, Botucatu, SP, Brasil.
Tel 55 14 3811-6213. Fax 55 14 3882-2238. E-mail: suzanapneumo@hotmail.com
Financial support: This study received financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, Foundation for the Support of Research in the State of São Paulo; grant nos. 07/53266-7 and 07/51595-3).
Submitted: 21 July 2009. Accepted, after review: 17 November 2009.




About the authors

Suzana Erico Tanni
Pulmonologist. Department of Clinical Medicine, Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Nathalie Izumi Iritsu
Medical Student. Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Masaki Tani
Medical Student. Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Paula Angeleli Bueno de Camargo
Physician. Botucatu Hospital das Clínicas, Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Marina Gonçalves Elias Sampaio
Medical Student. Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Ilda Godoy
Adjunct Professor. Department of Nursing, Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.

Irma Godoy
Adjunct Professor. Department of Clinical Medicine, Botucatu School of Medicine, São Paulo State University, Botucatu, Brazil.