Data Collection
After using the first week to identify any local problems in the data collection process, the students observed up to 40 consecutive eligible physician-patient encounters per week. They discontinued data collection after observing a total of 80 such encounters. Students recorded their observations on preprinted standardized observational assessment cards that were designed to facilitate recording data in as unobtrusive a manner as possible.
If tobacco use was discussed and the patient was a smoker, the student recorded additional information about the discussion. This included whether the physician asked if the patient wanted to quit smoker, advised the patient to quit smoking, offered assistance with smoking cessation, asked the patient to set a quit date, arranged follow-up for smoking cessation, or discussed either nicotine replacement or bupropion.
During the final week in the practice, students conducted a formal examination of the office to identify smoking policies, the designation of office personnel to handle smoking cessation efforts, the presence of smoking cessation materials and pharmaceutical samples in the office, patient follow-up procedures, and charting tools used to record or prompt discussion of tobacco use.
During the last few days of the rotation the students administered a survey to the physicians to obtain demographic data about the physician, recent training or education on smoking cessation, and perceived confidence in providing assistance with smoking cessation (used with permission of DePue and colleagues, unpublished).
Data Analysis
We examined the relationship between characteristics of the patient, the physician, and the physician’s office with the presence or absence of tobacco discussions during a physician-patient encounter. Simple chi-square tests were not appropriate for many of the analyses in our study, because of the clustering of multiple patients within individual office practices. For this reason, we used logistic regression with generalized estimating equations to determine the association of patient, physician, and office characteristics with the outcomes, while simultaneously controlling for the clustering of patients within practices.12
Results
We completed observations of 2963 physician-patient encounters. The mean age of the patients was 56 years (range = 18 to 99 years); 66% were women. New patient visits accounted for 130 (4.4%) of the observations.
Tobacco was mentioned or discussed in 633 (21%) visits, with 560 (88%) of these discussions initiated by the physician. The rate at which tobacco was discussed varied substantially among the practices Figure 1. In one practice, tobacco was not discussed during any of the patient encounters observed. Another practice, which designated a nurse to provide assistance with smoking cessation and follow-up of patients, addressed tobacco use during 90% of patient encounters.
Of the 633 patients with whom tobacco was discussed, 244 (39%) were identified as current smokers. The content of these tobacco-related discussions is shown in Table 1. The most common type of assistance given to smokers was pharmacotherapy. Physicians discussed bupropion and nicotine replacement therapy during 31% and 17% of encounters with smokers, respectively, with both agents discussed during 15% of encounters. Of the 24 practices in which tobacco was discussed with at least 5 smokers, the rate at which assistance was provided ranged from 0% to 100%.
The majority of physicians (68%) reported spending 1 to 6 hours during the past year developing knowledge or skills specific to smoking cessation. Using a Likert scale of 1 to 10 (where 10 = definitely confident and 1 = definitely not confident), an 8 or higher was reported by 58% of the physicians for their ability to incorporate smoking cessation strategies into regular office visits and by 34% for their ability to set up an office environment to support smoking cessation strategies.
Although all of the physicians maintained smoke-free offices, resources to support smoking cessation varied among the practices. Of the 38 offices, 26 (68%) had patient education materials; 22 (58%) maintained a standard location in the medical record to document the patient’s smoking status; 2 (5%) recorded the patient’s smoking status at every visit; and 6 (16%) had a staff person assigned to smoking cessation activities. Although pharmaceutical samples of bupropion were available in 35 (92%) offices, only 12 (32%) had samples of nicotine-replacement therapy.
Women physicians, physicians with 10 years or fewer in practice, and those practicing in offices with a form for recording smoking status in a standard location in the medical record were significantly more likely to discuss tobacco with their patients Table 1. The 2 patient characteristics associated with discussion of tobacco were being younger than 65 years and being a new patient.
When these factors were included in a multivariable logistic regression model, patient age, new patient status, and the presence of a form for recording smoking status were found to be important independent predictors of tobacco discussion Table 3. One variable that was not retained in the model was being in practice for 10 years or fewer (this variable was highly correlated with having a form for recording smoking status). An additional finding in the model was an interaction between patient sex and age, with women 65 years and older being the group least likely to have tobacco discussed during the visit.