Direct Observation of Smoking Cessation Activities in Primary Care Practice

Ellerbeck, Edward F.

Original Research

Direct Observation of Smoking Cessation Activities in Primary Care Practice

J Fam Pract. 2001 August;50(8):688-693

References

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Discussion

Our study shows that tobacco is a common issue in primary care that is discussed in more than 1 in 5 office visits. There is substantial variation, however, in the extent to which primary care physicians incorporate smoking cessation activities into their practices. We saw some practices in which tobacco was rarely, if ever, mentioned and 1 practice in which smoking was addressed during 90% of visits. This widespread variation illustrates an opportunity for improvement.¹³

It can be difficult to address behavioral problems such as nicotine addiction in a busy primary care practice. Other barriers include perceived patient attitudes about quitting,⁶ a lack of office support systems, time constraints, and the need to respond to other urgent health needs.¹⁴ When patients are presenting with a variety of acute and chronic ailments, it is easy to forget preventive care issues, such as nicotine dependence.

There is a large and growing body of evidence showing that changes in office systems can improve smoking cessation practices.^1,4,15,16 We showed that some of the variation between offices in smoking cessation practices can be explained by the presence of charting systems that routinely identify smokers. Although only a handful of offices in our study documented smoking status at each visit, those that did discussed tobacco 3 times as often as those that did not do so routinely. Although the physicians in our study reported that they were confident in their abilities to develop systems to support smoking cessation, most offices had not implemented the types of office systems described in published guidelines available at the time of the study.¹⁷

Further improvements and greater efficiencies can be obtained by delegating specific activities to nonphysician personnel in the office.^18-20 Our data showed a greater than 50% increased frequency of tobacco discussions in offices that assigned specific staff persons to address smoking cessation. This difference, however, was not statistically significant. This may have been because of the small number of offices that had such a dedicated staff person, resulting in a small percentage of the total patient encounters with this factor present and therefore a loss of power to detect differences.

Tobacco was more than twice as likely to be addressed during office visits with new patients, perhaps as part of a comprehensive health assessment. This is consistent with a recent report showing that when smoking status was recorded, it was usually on a health history form at the back of the chart.²¹

Consistent with previous studies,^22-24 we found that women physicians and physicians more recently trained were more likely to ask about smoking. These same physicians were more likely to have a standard form to record smoking status. It may be that newer physicians were more likely to be exposed to protocols or similar charting materials during their training; this is only speculation, however, since it appears that few medical schools routinely include smoking cessation training in their curricula.²⁵

One of the strategies recommended by Prochaska and Goldstein²⁶ and others^27,28 is to tailor smoking cessation strategies to a patient’s readiness to quit, yet assessments of readiness to quit were rarely seen in our study. Although it is possible that physicians had established readiness to quit during previous encounters with these patients, current guidelines recommend that this readiness be re-established at each visit. Because we do not know what proportion of smokers were ready to quit, we do not know what proportion of patients should have received assistance in smoking cessation, such as discussing pharmacotherapy, setting a quit date, or arranging follow-up.

In the 1995 National Ambulatory Medical Care Survey, nicotine-replacement therapy was prescribed during 1.3% of office visits with smokers.²⁹ (At that time, nicotine-replacement therapy was only available by prescription, and bupropion was not yet a standard treatment for nicotine addiction.) In contrast, our more recent data suggest that discussions of pharmacotherapy are a very common feature of physicians’ smoking cessation activities and that bupropion is being discussed more often than nicotine replacement.

Limitations

Direct observation of clinical practices has the advantage of reducing recall bias and increasing objectivity, yet there are limitations to this method as well. First, the use of separate observers precluded us from measuring the reliability of data collection. Second, we did not collect information regarding the reason for patient visits, which may include situations where the discussion of tobacco was not feasible or appropriate. Third, our study did not allow us to identify all smokers seen in the clinic and used volunteer physicians. Both of these factors could lead to an overestimate of the frequency in which assistance is provided. Although we found that assistance with smoking cessation was offered during 33% of visits with smokers, physicians participating in the National Ambulatory Medical Care Survey only reported offering assistance during 21% of visits. Finally, our study was limited to practices in Kansas and may not reflect those in other areas of the country.