Scientific Papers

Arab male physicians’ perceptions about their own smoking behaviors: a qualitative study | Israel Journal of Health Policy Research

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Participants

We interviewed the 25 Arab male physician participants between January-June, 2022. Their demographic information is presented in Table 1.

Table 1 Demographic Information (N = 25)

Findings

We sorted all the data into three categories and two sub-categories. Fifteen themes emerged.

They are summarized in Fig. 1.

Fig. 1
figure 1

Arab smoking physicians: a schematic model of categories, sub-categories, themes, and relationships among them

For the category “Antecedents: smoking-related factors prior to becoming a physician”, we identified the following themes:

Smoking experience during adolescence

Most (64%) of the physicians started smoking at younger ages (16–27 years) during high school and university. They talked about their earlier smoking experience. For example, a 36-year-old internal medicine physician said:

”Most people start to smoke at a young age, while in [high] school… When you learn and see how much [cigarettes] cause damage, you are already in a situation in which it will not be easy to stop.”

Social and ethnic culture factors

A 29-year-old physician working in the community said:

“I started smoking as a result of peer pressure from my Arab friends. When we had social gatherings, they would give me [cigarettes], and at a certain point, it was not comfortable for me [to keep taking cigarettes from them]. So I started to buy packs of cigarettes.”

Moreover, participants reported that smoking was prevalent amongst their peer group of Arab physicians at their place of work. One physician, a 30-year-old rehabilitation physician, noted:

“Of course, the percentage of smokers is more amongst [Arab] physicians; I know physicians that, before they begin a shift that starts at 3:00 or 4:00, go to the supermarket and buy two packs of cigarettes or [even] four so they will not run out. They are my friends, Arab [smoking physicians]. I have never seen a Jew[ish] [physician] smoke.”

These physicians’ reports illustrate the frequent smoking of Arab male physicians and how this can affect the likelihood of a physician smoking in the workplace.

Medical studies and exams

A salient theme emerged throughout interviews whereby participants reported that medical school and the state medical licensing exam were periods of smoking initiation or intensification. A rehabilitation physician working in a hospital and the community remarked:

“When I was young and started [smoking] during the examination period, I understood that this was not so good, and when I came back here, there was the state test. That raised the emotional stressors, and I started smoking heavily.”

Periods of quitting smoking

The participants discussed the difficulty of quitting smoking and mentioned that they had experienced attempts to quit and then returned to smoking for various reasons.

Physicians’ perceptions toward their own smoking

We sorted the category “Physicians’ perceptions toward smoking” into two sub-categories: Personal aspects (2.1) and Professional aspects (2.2).

Personal aspects

Personal motivations for smoking included three further sub-categories:

Relaxation from stress

Participants identified many stressors affecting their decision to begin smoking. They noted that general life stressors (work, family, finances, and “other”) were related to their initiating and continuing smoking and felt that their smoking helped them in coping with these stressors.

“Shift work, stress from work, being on call. With the hard shifts, despite the stress, you have to make the appropriate decisions for the patient. Therefore, you feel stressed and need to escape to smoke, calm down, and return to work.”

Because of the difficulties they experience on a daily basis, the physicians reported finding comfort in smoking, as expressed in the above example.

Addiction

While for some physicians smoking was a behavior they could maintain without seeming to develop an addiction, (i.e., they could smoke sporadically), for others, smoking became an addiction. They describe how in Arab society, smoking behaviors learned in adolescence can develop into powerful addictions. Even when physicians fully understand the impacts of smoking, they find these addictions very difficult to break.

Furthermore, in most cases, the learned behavior of smoking in a social context with a peer group led to more severe addictions among the physicians.

Enjoyable experiences

Other physicians reported that smoking was a recreational activity that they specifically enjoyed while off-shift. One physician stated that smoking a cigarette is a leisure activity that makes him feel good. He said:

“I do not smoke because I am stressed, the opposite, I smoke only when I am relaxed with my family and friends.

Professional aspects

We identified four themes related to professional aspects of smoking:

Lack of knowledge about cessation

Physicians participating in this study expressed limited knowledge regarding pathways to smoking cessation and treatment options. For example, when asked what methods they knew about quitting smoking, a 29-year-old geriatrics physician responded:

“There is gum and all kinds of pills…”

Further, when asked the same question, a 30-year-old neurology physician responded: “I do not know, but I heard there are lectures and stickers and gum that can help…”

On the other hand, physicians also reported an openness to, and interest in, learning more methods for smoking cessation.

Inadequate workplace support

The participants indicated that their workplaces do not support them in the smoking cessation process. They provided several suggestions about ways their workplaces could assist them.

For example, a 29-year-old community physician working in a hospital setting noted:

“…In my opinion, there need to be smoking cessation workshops for physicians. If they are at the hospital, I will sign up because it is accessible and easy to participate. I think limiting smoking in public places does not help. If you isolate them [smokers] and make them feel like outcasts – that will not help them stop smoking. It is not a matter of knowledge but rather psychology – how much you can influence them to leave the addiction. The physicians know the risks of smoking, so it is not about raising knowledge.”

Some physicians suggested gyms or sports teams that they would be able to attend during working hours as a means of coping with the professional stressors that they experience.

Motivation to counsel patients

Physicians experience conflict in counseling patients to quit smoking when they have not succeeded in doing so themselves. Some find it stressful to be in that situation, while others go so far as to reject the premise that they should be a role model for their patients.

However, one 30-year-old internal medicine physician working in a hospital setting noted:

“The truth is that it [the encounter with patients about smoking] influences me a lot, not just them seeing me smoking, but the smell when I go to the patient, and I tell them to stop smoking, and I smell like a smoker. In general, at work, I try not to smoke.”

Despite this, all the physicians in this study did report that they counseled patients to reduce and quit smoking.

Apparent in the responses from the participants is that this internal conflict and dialogue has a daily impact on the level of tension the physicians’ experience regarding their smoking habits. It causes some level of reflection in each patient encounter.

The Primary Care Physician’s (PCP) role regarding smoking

A salient theme emerged in the division of labor between hospital-based specialist physicians and family physicians. Specialists understood themselves as responsible for explaining continued smoking risks to their patients and referring them to their family physicians for follow-up. The family physician was identified as the relevant figure to encourage smoking cessation based on their relationship with the patient. A 30-year-old hospital-based internal medicine physician explains:

“…the patient always trusts the physician – [family physician]. There is a connection between them – beyond the physician-patient relationship in a hospital…a patient comes for 2 or 3 days, is treated, and leaves. ….. So, when I suggest to the patient [to stop smoking, let us say I have known him for 2 days. They will not relate to that like they would to their family physician, who knows them for 10 or 15 years.”

Physicians in this study reported that upon discharge, they referred patients to their family physician for further guidance about smoking cessation.

We found three themes in the last category “Impacts:”

Impacts

Physicians’ health and well-being

Participants were highly aware of the risks of smoking and being smokers. However, despite this, some of them continued smoking.

A 27-year-old community physician reflected on his smoking behaviors:

“Look, I know it is dangerous, but I say – I am still young, so [smoking] will not do anything to me right now.”

Inadequate conditions and training

Hospital-based physicians expressed a lack of time and resources to counsel patients to quit smoking. These physicians felt they did not have enough time or knowledge to provide the level of counseling a patient might need to quit smoking. A 30-year-old internal medicine physician remarked:

“… There is not enough time to speak with the patient. For instance, if there is a patient after a heart attack, you tell [the patient] that [they] need to take care, etc., and say a few words to them. I do not have the tools or ways to help them stop smoking. Because of this, we refer them to their clinics [family physicians] who can help them.”

Overall, physicians expressed openness to, and interest in, more training to gain more skills to counsel patients toward smoking cessation.

Professional image in public

Physicians understand that they need to serve as role models in the field of health promotion. Therefore, they refrain from smoking in the presence of others, both to avoid harming the public and because they realize that it negatively impacts their professional image.

A 29-year-old geriatrics physician working in a community setting reflected:

“I try to smoke in places where there are [other] smokers so that I will not harm someone [not smoking]; I look for places where smoking is permitted and smoke.”

The physicians also shared the conflict between the public’s expectations of them to serve as role models for health-promoting behavior and their smoking habits. A 30-year-old internal medicine physician who works in a hospital reflected,

“The truth is, I do not like the feeling [of being seen smoking at the hospital], I try and avoid patients and people who relate to me like a physician. When I want to smoke, I go to the smoking corner by the M.R.I., where usually most [of the smokers] are staff and not patients and their families.”

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