Doctors failing to record smoking on death certificates
MedWire News: Smoking is rarely cited as an underlying cause of death (COD) on death certificates, even in cases such as lung cancer that are known to be linked to smoking, UK researchers report.
Doctors are far less reluctant, however, to cite alcohol as a factor in cases known to be associated with alcohol use, observe Ian Proctor and colleagues from University College London.
This may be because alcohol use is generally more accepted culturally, suggest the authors, adding that doctors may not want to cause relatives distress by stigmatizing the deceased and their smoking habit.
Proctor and team explain that, since 1992, doctors in the UK have been permitted to cite smoking and alcohol use as a COD without having to refer the case to the coroner, suggesting that there is no reason why it should not be reported.
In the present study, they assessed how frequently smoking is cited as a COD by retrospectively reviewing 1986 death certificates issued at a large teaching hospital between 2003 and 2009.
The researchers report in the Journal of Clinical Pathology that, even though 407 deaths were due to conditions in which smoking is thought to have a substantial role, only two (0.1%) death certificates actually cited smoking as an underlying COD. These were in one case of lung cancer, and one case of chronic obstructive pulmonary disease (COPD).
Furthermore, smoking was included in part II as a contributory factor on just 10 death certificates, yet 279 cited lung cancer (n=145) or COPD (n=134) as the COD, and in the majority of these cases the deceased was a smoker (45.4%) or ex-smoker (23.3%).
A review of 236 postmortem reports from the same period failed to identify a single case in which smoking was cited as the COD or as a contributory factor. The authors describe this finding as "surprising."
By comparison, there were 54 cases known to have a causal link to alcohol use, including alcoholic liver disease, cirrhosis, and pancreatitis. Alcohol use was cited as an underlying cause of death in 31 (57.4%) of these cases.
"There are many reasons why smoking is not cited on death certificates," write Proctor et al. These include not wanting to stigmatize the deceased, being unaware or unsure of the deceased's smoking habits, or being unaware that smoking can actually be cited as a COD.
In spite of these difficulties, the researchers say that "given the overwhelming evidence showing a causal link between smoking and certain terminal conditions, more effort should be made to record smoking on the death certificate."
They suggest that including a tick box on the death certificate, where doctors can indicate whether the deceased was a smoker, ex-smoker, or nonsmoker, could improve the collection of smoking related mortality data.
Indeed, this method "has been successfully adopted in several US states including Texas where the incidence of recorded tobacco use increased almost 10-fold following its introduction," Proctor et al note.
The researchers therefore "strongly recommend" the introduction of this system, because "by not recording smoking on death certificates doctors are failing to gather important epidemiological and pathological data."
By Laura Dean