INTRODUCTION

In 2018, an estimated 26.6% of Chinese adults were current smokers, more in men (50.5%) than in women (2.1%), implying that the number of current smokers was more than 300 million¹. Even though smoking has proven to be a significant cause of diseases such as cardiovascular disease, chronic obstructive lung disease, and lung cancer, only 19.8% of current smokers tried to quit smoking within one year. Among those people, 8.4 % of smokers used pharmacotherapies and counseling for smoking cessation^1,2. Trust and satisfaction play essential roles in how smokers react to smoking cessation treatment delivered by physicians^3,4. Trust in physicians increases healthcare utilization⁵. Increasing patient trust of physicians is likely to increase the use of preventive services⁶. Moreover, patient satisfaction is significantly associated with the performance of preventive services⁷. Therefore, it is necessary to examine trust in physicians and satisfaction in healthcare among smokers to promote smokers’ utilization of preventive care and adherence to prescribed care.

Although previous studies have analyzed the relationship between smoking status and trust, the relationship between smoking status and trust is complicated. Rural Medicaid-insured smokers have a high level of trust in their healthcare provider⁸. Smokers have a significantly higher level of trust in cancer information obtained from their physicians⁹. Interestingly, some studies found that current smokers report a low level of trust in physicians than never smokers¹⁰, and daily smokers are less likely to trust physicians compared to never smokers^11,12. In addition, lower satisfaction with healthcare providers is associated with being a current smoker¹³, but smokers who receive smoking cessation treatment are associated with higher satisfaction with their healthcare^14,15.

As the above relationship has not been examined in China, a national survey was used to ascertain trust in physicians and satisfaction with the health system among Chinese smokers. This paper aims to ascertain whether smoking status and pack-years of smoking affect trust in physicians and satisfaction with the health system in China.

METHODS

Statistical analysis

To detect smoking status affecting trust in physicians in China, the current study used the ordered probit model. The ordered probit model is based on a latent regression and is defined as follows:

y*=x' a+ε

where x' is a vector of independent variables including smoking status or pack-years of smoking, sociodemographic characteristics, health status, drinking, and healthcare utilization, a is the coefficient vector, y* is an unobserved latent variable linked to the observed ordinal response categories of ‘Trust in physicians’ (TIP):

The unknown parameter μ is to be estimated with a. We assume that ε is normally distributed across observations and normalize the mean and variance of ε to 0 and 1, respectively. We then have the following probabilities:

Prob(TIP=0│x)=Φ(-x' β)

Prob(TIP=1│x)=Φ(u₁-x' β)-Φ(-x' β)

⋮

Prob(TIP=10│x)=1-Φ(u₉-x' β)

In order for all the probabilities to be positive, we must have 0<u₁<u₂<···<u₉. The ordered probit model was estimated using maximum likelihood in the statistical software package STATA 14.0. The present study also employed the ordered probit model to explore smoking status affecting satisfaction with the health system in China.

RESULTS

Table 1 reports the characteristics of the sample. Nearly 30% of the study population were current smokers. Only about 2% of the study population were ex-smokers. The mean trust score and satisfaction score were 6.74 and 3.34, respectively. Figure 1 presents the mean trust score and satisfaction score by smoking status. Compared to never smokers and ex-smokers, current smokers had a low level of trust in physicians and low satisfaction with the health system. One-way ANOVA showed significant differences in trust in physicians across smoking status. However, there were no significant satisfaction differences across smoking status.

Figure 1

The mean trust score and satisfaction score by smoking status

Table 2 shows the results of smoking status and pack-years affecting trust in physicians. The coefficient estimates for Model 1 are shown in column (i) of Table 2 for the categories of smoking status. When the individual was a current smoker, he/she would be more likely to rate his/her trust in physicians lower than a never smoker (Coefficient = -0.0609; 95% CI: -0.0938, -0.0280). Ex-smokers were more likely to rate trust in physicians higher than never smokers, but not statistically significant (Coefficient = 0.0470; 95% CI: -0.0334, 0.1280). The coefficient estimates for Model 2 are shown in column (iii) of Table 2 for pack-years categories. More cigarette smoking, measured in pack-years, was associated with decreased trust in physicians (Coefficient = -0.000974; 95% CI: -0.001510, -0.000439).

Table 3 shows the results of smoking status and pack-years affecting satisfaction with the health system. Column (i) reports the coefficient estimates for Model 1 in which smoking-status variables are included. Individuals who currently smoke cigarettes were less likely to rate greater satisfaction with the health system compared with those who never smoked (Coefficient = -0.0737; 95% CI: -0.1060, -0.0405). Column (iii) reports the coefficient estimates for Model 2 in which pack-years are included. More cigarette smoking, measured in pack-years, was associated with lower satisfaction with the health system, but not statistically significant (Coefficient = 0.000122; 95% CI: -0.000415, 0.000659).

Table 4 presents the results of the average marginal effects of smoking status on trust in physicians and satisfaction with the health system. Trust in physicians or satisfaction with the health system had a significant negative coefficient concerning current smokers, i.e. current smokers were less likely to rate complete trust in physicians compared to those who never smoked. Moreover, current smokers were less likely to rate completely satisfied with the health system than never smokers. In particular, ex-smokers were more likely to rate complete trust in physicians than never smokers, but not statistically significant.

DISCUSSION

To the best of our knowledge, this is the first report on trust in physicians and satisfaction with the health system among Chinese smokers. The current study found that, in general, current smokers had a low level of trust in physicians. Current smokers would be more likely to rate trust in physicians lower than never smokers. Trust in physicians is the optimistic acceptance of a vulnerable situation in which the patient believes that the physician will act in the patient’s best interest¹⁹. Previous studies indicated that health issues, functional decline, and premature mortality are strongly related to smoking^20,21. Considering the profound vulnerability created by smoking-related disease and mortality, the greater the sense of vulnerability, the greater the potential for either trust or distrust¹⁹. Smoking is associated with higher healthcare utilization by current smokers than those who never smoked^22,23. Smoking patients may be more likely to stay with the practice and continue to see the same physician and thus have more continuity. Sufficient continuity with the same physician to allow for the establishment of a positive relationship between patient and physician, may help to improve trust²⁴. However, profound vulnerability may also give rise to distrust in physicians^25,26. Smoking is linked with worse health conditions². Persons in the worse health conditions are more likely to have negative experiences in healthcare and be less satisfied with it¹¹. Alternatively, worse health conditions may cause depressive symptoms or other negative feelings that cloud evaluations of trust in physicians¹⁹. Moreover, this study found that more cigarette smoking was associated with lower trust in physicians. Ever smokers with more pack-years have increased incidence of smoking-related disease²⁷. More pack-years come with a greater sense of vulnerability and, therefore, more cigarette smoking creates higher distrust.

The present study also found that current smokers were less likely to rate greater satisfaction with the health system than never smokers. Individuals assess the health system on the basis of health outcomes. When the health system underperforms to produce inadequate health outcomes for whatever reason, satisfaction will decrease²⁸. Previous studies have reported that current smokers are more likely to report their health as poor or very poor than never smokers^21,29,30. Individuals who report being in poor or very poor health are less likely to be satisfied with the health system³¹.

Trust in physicians is decisive in patients’ willingness to seek care, reveal sensitive information, submit to treatment, adhere to treatment plans, remain with a physician, and recommend physicians to others^19,32. There are more than 800 smoking cessation clinics in China. However, 5.6% of current smokers planned to quit smoking within one month in 2018, and only 1–2 patients per week per hospital sought assistance from these cessation clinics^1,33. Lack of knowledge about the health hazards of tobacco and the absence of physician’s advice on smoking cession contribute to the low cessation rates in China³³. Patients with higher trust in physicians are significantly more likely to understand smoking-related health problems and engage in smoking cessation²⁴. This result may have significant implications for regaining trust in physicians by smokers. A trusting relationship between physician and smoker should be established before introducing smoking-related health problems and smoking cessation advice.

Trust looks forward, an expectation of future behavior, while satisfaction looks backward grounded on past experience²⁴. Satisfaction with the health system has identified ways to improve health, reduce costs, and implement reform²¹. Current smokers had a relatively low level of satisfaction with the health system, and this result may have important implications for supporting health-system reform for tobacco treatment. First, the Chinese government should integrate tobacco dependence diagnosis, treatment, and monitoring, into the primary health system. Second, the medical insurance plans in China should consider covering smoking cessation treatment.

CONCLUSIONS

Current smokers had a low level of trust in physicians and low satisfaction with the health system. Current smokers were less likely to have a higher trust in physicians and satisfaction with the health system than never smokers. These results may have important implications for regaining trust in physicians from smokers and supporting health-system reform for tobacco treatment.