Participants
An invitation to answer an online questionnaire on smoking cessation was sent to a random sample of 7830 Finnish physicians in December 2012, covering 39 % of all Finnish physicians at the time. The invitation was sent to physicians whose e-mail address was available for research projects in the membership register of the Finnish Medical Association. The sample covered both general practitioners and specialists from fields relevant to smoking cessation. The specialists that we targeted worked in general practice, occupational health care, obstetrics and gynaecology, surgery, respiratory diseases and allergology, internal medicine (covering, amongst others, hematology, infectious diseases and cardiology), psychiatry, and oncology. The respondents who did only administrative, research or other non-clinical work were excluded from the analyses. In the subset of analyses, primary care physicians and secondary care physicians were analyzed as separate groups.
Electronic data collection
The total number of targeted physicians was 7830 and data collection consisted of three rounds of e-mail invitations. The total number of physicians who entered the survey was 1390, of whom 1141 (82.1 %) completed the survey. Thus, 15 % of those invited to participate in the study completed the survey. The Webropol online survey tool was used for data collection (www.webropol.com).
Questionnaire and consultation sub-scales
The study questionnaire included questions about the respondent’s demographics, smoking status, attitudes and experiences on smoking and smoking cessation, implementation of smoking cessation in clinical practice, barriers in smoking cessation, and familiarity with the Finnish treatment guidelines for tobacco addiction and smoking cessation.
The questions on consultation activities were chosen from the well-known study by Pipe and colleagues to allow international comparison [7]. The activities were also in line with local clinical guidelines for smoking cessation [5]. There were a total of 10 items, for which a four-point grading system was applied: “nearly always” (3), “often” (2), “sometimes,” (1) and “never” (0). The consultation items were divided into two categories based on statistical and content-related analysis: conversation and practical actions. “Conversation” covered behavior that acts as a mini intervention; sending the patient a message that smoking is something the physician is deeply concerned about. “Practical actions” covered items that make it easier for the patient to quit once they have made the decision to do so, such as helping the patient make a quitting plan or offering pharmaceutical cessation aid. Pharmaceutical aid can be either over-the-counter nicotine replacement therapy or prescription medication (bupropion, varenicline, nortriptyline). These activities are listed in Fig. 1. The scores gained in the consultation sub-scales were utilized when searching for an association between consultation activities and smoking-related attitudes and experiences.
The scale for smoking-related attitudes and experiences was as follows: “completely agree,” “somewhat agree,” “somewhat disagree,” or “completely disagree.” Physicians answering either “completely” or “somewhat agree” were combined as an “agree” group, whereas the remaining respondents were included in the “disagree” group. The question concerning the Finnish treatment guidelines for smoking cessation was graded as follows: “familiarized myself thoroughly,” “familiarized myself in outline,” “browsed through,” “heard about the guideline but did not read,” and “do not know.” Physicians responding “familiarized myself thoroughly” and “familiarized myself in outline” were included in the “agree” group, and the others in the “disagree” group.
Statistical analysis
Distributions of continuous variables were expressed as mean and standard deviation (SD), and categorical variables as proportions. Pair-wise comparisons of continuous variables between groups were tested using the Mann–Whitney U-test (MW-U), and categorical data was tested with χ
2 or Fisher’s exact test, as appropriate.
Exploratory principal components analysis (PCA) was initially used to explore the dimension structure of the consultation activities. Promax rotation was applied. The scree plot and total-variance-explained variability criteria were used to specify the retained factor. This analysis produced two sub-scales: a) the conversation scale (5 items; each scored from 0 to 3) and b) the practical actions scale (4 items; each scored from 0 to 3). The action “refer patient to another health care provider, such as a nurse or specialist clinic” that was mapped in the survey remained alone in the PCA analysis, and was therefore excluded from the two sub-scales. The total variance explained was 72 %. A polychoric correlation matrix was used in the PCA. Reliability of the factor solution was determined by calculating internal consistency using Cronbach’s alpha with a corresponding 95 % confidence interval (CI).
All statistical tests were two-tailed, and p-values < 0.05 were considered statistically significant. Statistical analysis was performed using the R software environment, version 3.0.0 (R Core Team, 2013).