OBJECTIVES: We identified patterns of tobacco cessation counseling in primary care practices, including contextual factors that influence its provision.
STUDY DESIGN: A cross-sectional study was performed using direct observation of outpatient visits.
POPULATION: We included 91 outpatient visits by cigarette smokers visiting 20 family physicians in 7 Nebraska community family practices.
OUTCOMES MEASURED: We measured patterns and quality of tobacco counseling assessed by direct observation.
RESULTS: A hierarchy of 5 patterns was discernable, ranging from appropriate to inappropriate provision or nonprovision of tobacco cessation counseling.
CONCLUSIONS: Since tobacco-specific discussions are appropriate only in approximately three fourths of primary care visits by smokers, clinical practice guidelines that recommend intervention at every visit are unrealistic. However, the finding that only one third of eligible visits addressed tobacco makes it imperative that tobacco cessation counseling be reliably integrated into visits for well care and tobacco-related illnesses that represent teachable moments.
Approximately 17 million smokers attempt to stop smoking for more than 24 hours every year; only 1.2 million are successful.1 There is strong evidence that smokers attempting to quit could at least double their chances of success if they were assisted by clinicians using effective behavioral and pharmacologic interventions.2 Because 7 of 10 smokers will see a physician each year3 and the majority of these visits are made to primary care physicians,4 these physicians have multiple opportunities to assist smokers in their attempts to quit.
Clinicians should follow the “5 A’s” (ask, advise, assess, assist, and arrange) whenever appropriate. The current US Public Health Service smoking cessation clinical practice guideline offers specific directions for clinician intervention for all smokers, recommending a minimum of 3A’s (ask, advise, and assess) at every visit. That is, all smokers should be asked about their current smoking status, advised to quit, and assessed regarding their readiness to change. For smokers willing to quit, 2 additional A’s (assist and arrange follow-up) should be implemented; for smokers not willing to quit, a brief motivational intervention is recommended.2
Although there is a high level of agreement among primary care physicians about their responsibility to assist in tobacco cessation,5,6 there are significant gaps in practice.7-9 Reports of physicians’ rates of smoking cessation advice range from 21% to 78%,7-12 falling short of recommended levels.13
A recent direct observation study of community family physicians found that, on average, 25% of smokers were advised to stop smoking.14 The study also showed that smoking cessation advice was offered during 55% of well care visits and in 32% of chronic illness visits for tobacco-related problems. The average duration of smoking cessation advice was less than 90 seconds. Although the study’s authors were able to assess whether smoking cessation advice occurred during an encounter, limits of the data made it impossible to examine how the particular content of smoking cessation advice was delivered. Similar results were found in a study of direct observation of Australian physicians.15
For this study, we used direct observation of outpatient visits by smokers to describe the extent of tobacco counseling and the processes by which it was provided. The analyses also explore the contextual factors that influence the provision of smoking cessation counseling. We hypothesized that the low rates of smoking counseling reported in the literature were in part due to the competing demands brought on by the complex agenda of patients presenting with undifferentiated problems.16,17 We also hypothesized that the current care included missed opportunities to integrate tobacco counseling into the broad primary care agenda.
Methods
The data used for this analysis were collected as part of The Prevention and Competing Demands in Primary Care Study, an in-depth observational study that examined the organizational and clinical structures and process of community-based family practices.Each of 18 purposefully selected practices was studied using a multimethod comparative case study design that involved extensive direct observation of clinical encounters and office systems by field researchers who spent 4 weeks or more in each practice. Field researchers directly observed approximately 30 patient encounters with each of more than 50 clinicians, dictated descriptions of the visits, and audited the medical records of each of these patients. Detailed descriptive field notes documented day-to-day practice operations. Individual depth interviews with each clinician, many of the practice staff, and members of the community were used to obtain different perspectives on the practice. Details of the sampling and data collection are available elsewhere in this issue of JFP.18
From the exit survey administered to patients, 239 current cigarette smokers (14.7% of the study population) were identified from the 1624 encounters. To minimize observer variation in encounter content, only the narratives of a single research nurse were examined, reducing the sample of current smokers to 123. Only encounters with physicians were selected for analysis, further reducing the sample size to 91.