The Frequency of Tobacco Smoking and E-Cigarettes Use among Primary Health Care Patients—The Association between Anti-Tobacco Interventions and Smoking in Poland

The aim of this study was to assess the prevalence of smoking and e-cigarette use among primary care patients during the COVID-19 pandemic and to assess the frequency of minimal anti-tobacco interventions by family doctors. A cross-sectional study was conducted from January 2020 to December 2021 encompassing 896 patients over 18 years of age who used primary health care in the city of Lodz, Poland. In total, 21.2% of the respondents were smokers, 11.6% were e-cigarette users, and 7.3% dual users. In addition, 68.4% of smokers had been asked about smoking, while 62.9% of non-smokers and 33.7% of smokers were advised to quit smoking; furthermore, 71.1% of e-cigarette users and 72.3% of dual users were asked about tobacco use, and 17.3% and 21.5%, respectively, had been advised to quit smoking. Multivariate logistic regression analysis found men and alcohol users to receive more minimal anti-tobacco advice than women and non-alcohol users (OR = 1.46; p < 0.05 and OR = 1.45; p < 0.05), socio-demographic and health correlates did not increase the chances of obtaining minimal anti-tobacco interventions among smokers. People with a medium level of education had a higher chance of receiving minimal anti-tobacco intervention from their family doctor when using e-cigarettes and when they were dual users (OR = 2.06; p < 0.05 and OR = 2.51; p < 0.05). Smokers were less likely to receive minimal anti-tobacco interventions than reported in previous studies. Measures should be implemented to increase the minimum interventions provided by GPs in their daily work among all patients, not only those who use tobacco. Non-smokers should be encouraged to abstain.


Introduction
Globally, tobacco kills more than 8 million people each year, of which more than 7 million are due to direct tobacco use [1]. Smoking is also responsible for the loss of 2,060,000 years of healthy life, which accounts for 16.3% of the total DALY value (disabilityadjusted life-year) [2].
Smoking is a risk factor for premature mortality associated with common chronic diseases, such as cardiovascular disease, cancer, diabetes, and chronic respiratory diseases [3]. In 2020, 22.3% of the world's population smoked tobacco: 36.7% of all men and 7.8% of women (World Health Organization data) [1].
Together with alcohol consumption and behavior leading to overweight and obesity, smoking is a major public health problem in Europe [3]. Nearly 27% of the population in the WHO European Region use tobacco, and more than 35% of men [4]. Tobacco consumption is also a public health concern in Poland [5], where in 2018, 20.2% of women and 30.9% of men smoked cigarettes; of these, the percentage for women was slightly below the mean European Union value (20.8%) while the men were slightly above (28.1%) [2]. In 2019, 21% of Polish citizens reported smoking addiction [6].

Study Design and Population
From January 2020 to December 2021, a cross-sectional study was conducted among 896 adult primary care patients in Lodz, Poland. From the list of 211 primary health care facilities in the city of Lodz, every fifth clinic was selected randomly. Thirty-four primary healthcare facilities agreed to conduct the study among patients. Every fifth patient leaving the doctor's office was randomly selected and asked to participate in the study. Inclusion criteria: people over 18 years of age who consulted a doctor in primary care and agreed to participate in the study. The methodology, the study sample and the examined region are given elsewhere [28]. The study design was approved by the Bioethics Committee of the Medical University of Lodz (on 18 September 2018; RNN/315/18/ KE). Informed consent was obtained from all the study respondents.

Study Variables
The research tool was an anonymous questionnaire containing standardized questions that had been used in other studies [29,30]. Detailed information on smoking and e-cigarette use and anti-tobacco counseling was obtained through a questionnaire completed during a face-to-face interview conducted by the principal researcher.
The questionnaire included questions about socio-demographic characteristics (gender, age, marital status, employment status, and education), tobacco smoking and e-cigarette use, information about visits to family doctors, and questions about anti-tobacco counseling provided by GPs. This present article covers four of the seven sections included in the questionnaire: information on tobacco smoking, passive exposure to tobacco smoke, ecigarette use, and information about appointments with a primary healthcare doctor.
The current smoking status was assessed based on the question "Do you currently smoke cigarettes?" Subjects who answered "no" were classified as compliant with smoking recommendations [31]. A daily tobacco smoker is defined as a person who smokes at least one cigarette every day during a period of 30 days. An occasional smoker is someone who has smoked less than one cigarette per day in the last 30 days.
The current use of e-cigarettes was assessed by the question "Do you currently use e-cigarettes?". Daily e-cigarette users are people who have used an e-cigarette at least once per day for the last 30 days. Those who qualified as both cigarette users and e-cigarette users were defined as dual users.
Information on minimal anti-tobacco counseling provided by a family doctor was obtained based on the following survey questions: ''How often does your family doctor give you advice about smoking/ e-cigarette use". People who have never been counseled on anti-tobacco smoking are respondents who answered "never", and those who answered "always", "often," or "sometimes", were classified as patients who received minimal counseling on tobacco smoking.
The answer "always" related to advice given at each visit to a family doctor. The answer "sometimes" indicated less than 50% of all medical appointments in primary care, and "often" as 50% or more medical appointments in primary care [28].
Participants were divided into four groups based on questions about chronic diseases treated by a GP: no disease, one, two, and three or more diseases. The participants were also asked about alcohol consumption (Table 1).

Statistical Analysis
The results are presented as numbers and percentage rates. Descriptive statistics were used, and the analyzed variables were distributed. Single-and multivariable logistic regression analyses were performed to obtain OR (odds ratio) and 95% confidence interval (CI) for each anti-tobacco advice indicator. Variables with a p value of 0.1 or less from the univariate analysis were included in the multivariate model. A p value < 0.05 was considered statistically significant. STATISTICA software, version 13.3 (StatSoft, Tulsa, OK, USA), was used for the calculations.

Characteristics of the Studied Population
The characteristics of the studied population of primary care patients are presented in Table 1. The majority of the respondents were people with secondary education (56.9%), professionally active (61.6%), aged <30 (28.6%), and aged 40-49 (24.0%). Women constituted 74.2% of the respondents, and men 25.8%.
In addition, 81.9% of participants admitted to drinking alcohol, 22.9% were being treated for one chronic disease, 18% for three or more chronic diseases. The response rate of participants was high compared to other surveys in Poland (80%). There was no lack of data in the responses included in the analysis.

Smoking Tobacco
In total, 21.2% of the respondents were smokers. There were no occasional smokers. The prevalence of daily tobacco smoking is presented in Figure 1.

Characteristics of the Studied Population
The characteristics of the studied population of primary care patients are presented in Table 1.
In addition, 81.9% of participants admitted to drinking alcohol, 22.9% were being treated for one chronic disease, 18% for three or more chronic diseases. The response rate of participants was high compared to other surveys in Poland (80%). There was no lack of data in the responses included in the analysis.

Smoking Tobacco
In total, 21.2% of the respondents were smokers. There were no occasional smokers. The prevalence of daily tobacco smoking is presented in Figure 1. The largest group consisted of smokers who smoked 5-10 cigarettes a day. Among the smokers, 56.8% smoked filtered cigarettes and 24.7% menthol cigarettes ( Table 2). In addition, 37.9% of smokers smoke their first cigarette within 30 min after waking up, 33.2% smoke cigarettes during illness that makes them stay in bed, and 22.6% of smokers find it difficult to refrain from smoking in non-smoking areas. In addition, 35.8% of respondents answered that the most difficult thing was to give up the first cigarette. In total, 58.9% of daily smokers have attempted to quit, and 62.5% of respondents made two to five attempts to quit smoking. More than half (53.6%) of the respondents made the last attempt to quit smoking for 24 h more than one year previously. Finally, 56.8% of respondents reported smoking tobacco for one to ten years.  The largest group consisted of smokers who smoked 5-10 cigarettes a day. Among the smokers, 56.8% smoked filtered cigarettes and 24.7% menthol cigarettes ( Table 2). In addition, 37.9% of smokers smoke their first cigarette within 30 min after waking up, 33.2% smoke cigarettes during illness that makes them stay in bed, and 22.6% of smokers find it difficult to refrain from smoking in non-smoking areas. In addition, 35.8% of respondents answered that the most difficult thing was to give up the first cigarette. In total, 58.9% of daily smokers have attempted to quit, and 62.5% of respondents made two to five attempts to quit smoking. More than half (53.6%) of the respondents made the last attempt to quit smoking for 24 h more than one year previously. Finally, 56.8% of respondents reported smoking tobacco for one to ten years. It was also found that 42% of respondents are exposed to secondhand smoke, most often at home (16.0%) and in other situations (17.8%). Participants staying in rooms where someone smokes tobacco usually stay there for less than one hour during the day (24.6%).

Use of E-Cigarettes and Dual-Use
In total, 28.6% of respondents indicated that they had ever used e-cigarettes, 5.9% of all participants use e-cigarettes every day and 5.7% use e-cigarettes occasionally. The prevalence of daily use of e-cigarettes is presented in Figure 2. The respondents most often used e-cigarettes containing nicotine (83.7%). E-cigarettes were most often used once per day (40.4%). In addition, 7.3% of participants were dual users.

Minimal Anti-Tobacco Intervention in Primary Health Care
A total of 36% of respondents had never been asked about smoking during their GP visit, and 31.6% of smoking patients and 37.1% of non-smoking patients were never asked about smoking (Table 3). Among smoking patients, 68.4% were asked about smoking, and 62.9% among non-smokers.  The respondents most often used e-cigarettes containing nicotine (83.7%). E-cigarettes were most often used once per day (40.4%). In addition, 7.3% of participants were dual users.

Minimal Anti-Tobacco Intervention in Primary Health Care
A total of 36% of respondents had never been asked about smoking during their GP visit, and 31.6% of smoking patients and 37.1% of non-smoking patients were never asked about smoking (Table 3). Among smoking patients, 68.4% were asked about smoking, and 62.9% among non-smokers. Among the smoking subjects, 33.7% had been advised to quit smoking, most commonly in the last three years or more. It was also reported that GPs had presented methods and ways of quitting smoking or presented appropriate materials to 21.1% of smokers and 1.3% of non-smokers.
In addition, 34.2% of smoking patients were asked about the number of cigarettes smoked, and 27.4% had been advised to reduce the number of cigarettes smoked during the day. In addition, 27.9% of smokers reported that the GPs wrote in their documentation that they smoked cigarettes, and 42.1% of smokers were not interested in registering.
Our findings indicate that 34.7% of smokers and 11% of non-smokers were informed about the negative effects of smoking and the health consequences of smoking. In addition, 29.5% of smokers and 6.7% of non-smokers were informed by the GP about the negative impact of smoking during treatment for other diseases.
It was found that 28.9% of e-cigarette users and 27.7% of dual users had never been asked about smoking; however, 71.1% of e-cigarette users and 72.3% of dual users were asked about smoking (Table 4). In addition, 17.3% of e-cigarette users and 21.5% of dual users were advised to quit smoking. The GPs presented different methods and ways of quitting smoking or presented appropriate materials to 21.1% of e-cigarette users and 13.8% of dual users. Among these groups, 19.2% of e-cigarette users and 27.7% of dual users were asked about the amount of e-cigarettes used or cigarettes smoked, and 16.3% of e-cigarette users and 20% of dual users were recommended to reduce the number of cigarettes or e-cigarettes smoked during the day. The health care physician recorded e-cigarette or tobacco use in the medical records of 17.3% of e-cigarette users and 18.5% of dual users. In addition, 27.9% of e-cigarette users and 32.3% of dual users were informed about the negative effects of smoking, health consequences, and the possibility of smoking-related diseases, while 18.3% of e-cigarette users and 20% of dual users were informed about the negative effects on the treatment of other diseases.
The relationships between personal characteristics (sex, age, education, professional status, marital status), total minimum anti-tobacco intervention and minimum anti-tobacco intervention for smokers, e-cigarette users, and dual users were investigated using logistic regression analysis. The strengths of any associations were determined using OR (odds ratio) and the 95% confidence interval (Cl). The results of the univariate and multivariate logistic regression analysis for general practitioner MAI with health and socio-demographic correlates are given in Tables 5 and 6. Any variables that were found to be significant in the univariate logistic regression analysis were included in a multivariate logistic regression analysis. Age 50-59 years (p < 0.05), primary education (p < 0.05) and secondary education (p < 0.001), and three or more chronic diseases (p < 0.05) were found to be statistically significant in the univariate analysis but statistically insignificant in the multivariate analysis. In the multivariate logistic regression analysis, male participants and alcohol consumers received minimal anti-tobacco advice more often than female and non-alcoholic consumers (OR = 1.46; p < 0.05 and OR = 1.45; p < 0.05). In the case of smokers, primary education (p < 0.05) and secondary education (p < 0.01), and two chronic diseases (p < 0.05) were found to be statistically significant in the univariate analysis. The results are presented in Table 5. The multivariate analysis did not indicate that socio-demographic or health correlates increased the chances of obtaining minimal anti-tobacco interventions among smokers.
Moreover, the relationship between personal characteristics and the minimal antitobacco intervention given to e-cigarette users and the minimal anti-tobacco intervention given to dual users was examined (Table 6). For e-cigarette users, variables such as age 30-39 (p < 0.05), 40-49 (p < 0.05), 60+ (p < 0.001), single (p < 0.01) and pensioner (p < 0.001) were statistically significant in the univariate analysis but not in the multivariate logistic regression analysis. In the case of dual users, age 60+, single, unemployed, and student were statistically significant in the univariate analysis (p < 0.05), but not in the multivariate analysis.
The multivariate analysis found that people with medium education were twice as likely to receive minimal anti-tobacco intervention when using e-cigarettes and when they were dual users (OR = 2.06; p < 0.05 and OR = 2.51; p < 0.05).

Discussion
Our cross-sectional study is one of the first in Poland to address the subject of minimal anti-tobacco intervention by family doctors in primary care during COVID-19. It was found that 21% of the respondents smoke tobacco: 22.1% of the women and 18.6% of the men. These results are higher than those obtained in another study in Poland in 2020 [2], which found that 14.9% of women and 23.1% of men smoked, but lower than those obtained in 2018 (23.1% and 27.8%). In addition, 5.9% declared e-cigarette use (5.9% of women and 6.1% of men). A similar study in Poland yielded higher results: e-cigarette use was declared by 7.1% of women and 10.8% of men, of whom 4.1% of women and 7.0% of men were non-smokers [2].
The mean prevalence of smoking in the EU is 20.8% for women and 28.1% for men, with women ranging from 13.8% (Romania) to 30.0% (Croatia) and men from 18.5% (Denmark) to 49.1% (Cyprus) [32]. In addition, the percentage of smoking in Poland is slightly below the mean European Union value for women, and slightly above the value for men (20.2% for women in Poland and 30.9% for men) [32]. Smoking rates are higher in some regions of Asia (China and India) but are lower in Australia and North America [33]. In Poland, 1% of the population are current e-cigarette users (for EU + UK 2%) [34].
Various guidelines and protocols for healthcare professionals have been developed to help quit smoking. The minimum anti-tobacco intervention recommended in Poland is based on the WHO recommendations for the treatment of tobacco dependence and the guidelines adopted by the American Medical Association (AMA) [12].
According to the guidelines of the College of Family Physicians in Poland, a family doctor should conduct a minimal anti-tobacco intervention with each smoking patient at least once a year and record it in the patient's documentation [12]. Due to the low effectiveness of a single MAI, an interview with a smoking patient should be conducted at each visit [35]. In its modified form, the MAI should also be used for non-smoking patients who are sometimes passively exposed to smoking. Non-smokers should be encouraged to abstain [12].
Our study found a low percentage of GPs administering minimal tobacco control interventions. Only every second person who joined our study admitted to having received MAI advice from their GP; this advice was offered sometimes, i.e., not at every routine visit. Only every twentieth respondent indicated that the doctor asked about smoking during each routine visit. Smokers were advised more often than non-smokers. Our data confirm previous findings indicating that MAI advice is given infrequently [36][37][38].
If the patient wants to quit smoking, the family doctor should provide advice, covering all available treatments or other supportive methods of therapy [12]. In our study, 64% of respondents received brief advice as a part of minimal intervention, while 10% received an intensive intervention. Other studies conducted in Europe (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania, and Spain) and the United States have also noted that primary care patients reported a small percentage of minimal tobacco control counseling [39][40][41]. These findings indicate that anti-tobacco counseling was provided at a low level before the COVID-19 pandemic, in developed and developing countries. It is unclear whether COVID-19 was the cause of consultation.
However, higher minimal intervention rates were found elsewhere, where more than 2/3 of patients were asked about tobacco use, and about half were advised to quit (Indie) [42].
Research shows that motivational interviews (MI) produce a small but significant increase in smoking cessation compared to quick advice. In addition, MIs conducted by the primary care physician were more effective at quitting smoking than those provided by counselors or nurses. Shorter motivational conversation sessions of less than 20 min were more effective than longer ones [13]. Even three-minute tips can improve quitting rates [43,44]. However, studies have found MIs to be more effective than short quitting advice [45][46][47][48].
Various meta-analyses have found that quick advice increases the number of attempts to quit smoking by 1% to 3% [11], while short advice showed a significant increase in the rate of smoking cessation compared to no advice [11,47,[49][50][51]. In addition, brief counseling and MI have comparable results for quitting smoking [11,47,52], and minimal tobacco control interventions (e.g., short advice) are less effective than behavioral counseling [53,54].
Guidelines also indicate that more intensive counseling (≥20 min per session) is more effective than less intensive counseling (<20 min per session) [55]. A more complex MI is needed when a healthcare professional encounters people with low motivation to change behavior [56]. Even so, with lifestyle modifications, a motivational conversation can be more effective than simply trying to change smoking habits [57]. Either way, MAI increases the chance of quitting smoking versus no such intervention [58,59].
Unlike previous studies, our present study evaluated the effect of minimal anti-tobacco interventions (MAI) given to e-cigarette users and dual users. The e-cigarette is a new form of nicotine delivery for people switching from flammable cigarettes [60,61]. In some countries (e.g., the United Kingdom), e-cigarettes are used as an aid to stop smoking [33]. Our findings indicate that e-cigarette users and dual users were more likely to receive advice than smokers, as noted previously [34,56]. Studies performed in other countries found that few smokers received advice on e-cigarettes from health professionals [41].
The inclusion of 5As intervention in primary health care increases patient satisfaction with the services provided by doctors. Satisfaction with counseling services can increase the willingness to quit smoking among primary care patients [62].
Our study found that the likelihood of receiving counseling was influenced by sex and alcohol consumption. GPs were more likely to advise when the patient was male and consumed alcohol, as in other studies [63]. The results reflect the fact that a number of preventive programs in Poland (e.g., cardiovascular diseases, metabolic diseases) are more often directed toward men [36,64]. Prophylaxis should be provided to patients at the same level, regardless of sex.
Quitting can reduce the chance of chronic diseases caused by smoking, including diseases of the respiratory system and cardiovascular systems. This is all the more important in the time of the COVID-19 pandemic, as it increases the risk of cardiovascular complications and other serious complications related to COVID-19 in smokers and vapers [65,66].
Our study found that GPs do not generally explain to patients that tobacco use has a negative effect on any chronic diseases they may have, with only one in every ten primary care patients being informed. Informing patients about the negative effects of smoking during the COVID-19 pandemic may have influenced their attempt to quit smoking; messages linking COVID-19 with smoking and the potential damage may hold promise for discouraging smoking and vaping [67].
Our findings indicate a lack of education in primary care facilities, which represent the first point of contact for patients. They also demonstrate that proper training of staff in this area can have a considerable overall impact.
In Poland, preventive actions are generally scattered and uncoordinated, and not only during the COVID-19 pandemic. They lack a clear strategy regarding their structure and direction. Preventive measures are underfunded, and their organization is generally poor; furthermore, the staff is used ineffectively, and there is no evaluation of preventive activities. In addition, at the level of family doctors in primary care, anti-tobacco interventions are underfinanced and are carried out without attention or proper implementation. While it is recommended that a minimum of EUR 2 per capita per year be spent on tobacco control, the 2018 Tobacco Control Budget (TCB) in Poland allocated EUR 0.006 per capita [68].
The persistent high prevalence of smoking in Poland, along with the increasing use of e-cigarettes and the low level of anti-smoking advice provided, should be of concern to both the government and medical organizations. The situation requires strong and comprehensive action by government and health authorities to implement the comprehensive approach recommended by the WHO; this includes measures set out in the WHO Framework Convention on Tobacco Control (FCTC) including Article 14, which outlines best practice approaches to smoking cessation, together with other measures needed to reduce smoking in the community, such as strong curbs on tobacco industry marketing and other activity, strong health warnings, price/tax policy and public education [69]. In line with the provisions of the FCTC, each country should promote and strengthen public awareness of tobacco control issues (Article 12) [70]. Effective action on tobacco by governments around the world has generally been prompted by calls for action by medical and health organizations; therefore, there may well be a role for such approaches in Poland.
In Poland, due to poor enforcement of the earmarking law, the 2000-2018 Tobacco Control Program was beset by inadequate planning and insufficient financing. This should be regarded as a warning to other countries to create legislation that can be verified and controlled [70].
The study has limitations. First, as it is a cross-sectional study performed at a single point in time, changes cannot be seen over longer periods; one-time minimal anti-tobacco intervention is insufficient, it must be carried out over a long period. Second, the study was conducted during the COVID-19 pandemic, which complicated access to patients in primary care, and not all patients visited their GP during this period. Finally, minimal anti-tobacco intervention by a GP was assessed based on patient questionnaire data; as such, a bias associated with recall may exist. Furthermore, the questionnaire did not address the reason for the patient visiting the doctor; however, minimal anti-tobacco intervention should be provided at least once per year during such visits, regardless. In addition, the small size of the sample could have affected the lack of association of variables in multivariate analyses. Finally, the study was anonymous, and hence, it was not possible to connect the study participants with their family doctors.
Nevertheless, this study is the first to evaluate the conduct of MIA in Poland by family doctors during the COVID-19 pandemic. It also examines many determinants that may influence primary health care counseling in the study population. In addition, it describes an urban population, which allows for further generalization of the results to other urban areas and populations.
Our findings may be important for the development of preventive measures aimed at reducing tobacco consumption in Poland and other countries.

Conclusions
Higher levels of counseling were found to be associated with male sex and alcohol consumption. The COVID-19 pandemic was a difficult period that contributed to a rise in harmful health behaviors. The study confirms that the frequency of minimal antitobacco interventions by family doctors is not sufficient: GPs in primary care appear to treat patients rather than prevent disease. Prophylaxis is not working, which was further demonstrated by the COVID-19 pandemic. Family doctors should take steps to educate and promote a healthy lifestyle among patients in order to increase positive pro-health behaviors, particularly during the COVID-19 pandemic. During routine visits, the family doctor has the opportunity to constantly motivate and prepare the patient to quit smoking.
Minimal anti-tobacco interventions should be provided to all patients, not only smokers. Non-smokers should also be encouraged to abstain.
Early prophylaxis can provide more benefits than modifying the treatment, and such strategies can play an important role in improving the health of the population.