Edward F. Ellerbeck, MD, MPH

Recent smoking cessation guidelines¹ identify critical ways primary care physicians can intervene with their patients to improve cessation rates. These guidelines recommend that all patients be asked about their smoking status at every visit. Also at every visit all smokers should be advised to quit and should be assessed for their readiness to do so. The guidelines include recommendations for physicians to incorporate elements into their practices that will help them maximize smoking cessation rates. These elements include systems to routinely identify all smokers, reminder systems to encourage physicians to discuss smoking, tools for assisting their patients in quitting, and assignments for nonphysician personnel to assist in smoking cessation. Preliminary data suggest that few practices have adopted these types of systems^2,3 and that many smokers have not been advised by their physicians to quit.⁴

Examining counseling behaviors, such as smoking cessation, in a physician’s office can be challenging. Previous attempts to examine such efforts have relied primarily on physician self-report^5,6 and patient surveys.^7,8 A few studies have employed direct observation as a method of data collection.^3,9 Stange and colleagues¹⁰ have suggested that direct observation of clinical practices may be the gold standard for measuring counseling activities. Although patient reports appear to have a high degree of correlation with direct observation, the accuracy of these reports tend to deteriorate with time;^10,11 medical records are frequently incomplete; and physician reports typically overestimate counseling activities.¹⁰

For our study, medical students directly observed physician-patient encounters in primary care physicians’ offices in Kansas. Our objectives were to describe physician activities related to smoking cessation efforts and to identify physician and office characteristics that support these efforts.

Methods

Study Setting

We identified 38 family physicians in 38 separate practices in Kansas who agreed to precept students for 6 weeks during June and July of 1999; 89% of these practices were in non-metropolitan areas. These physicians had served as preceptors to medical students in previous years and were familiar with data collection efforts by students. Each family physician consented to have students observe preventive care practices in their offices during the rotation.

Medical Student Training and Support

Students collected data on a summer research elective between their first and second years of medical school. They received extensive training on the research study. During the next 8 weeks, the students worked with their assigned physicians. They submitted weekly reports of research activities to the study coordinator, who was in contact with the students through electronic mail and telephone calls throughout the course of our study.

Sample Selection

Physician-patient encounters were included in our study if the patient was aged at least 18 years, the physician saw the patient during normal office hours, and the student was present for the entire visit. Encounters were excluded from data collection if the office visit was for a critical acute complaint or a procedure, if the patient appeared to be in immediate emotional distress, if the patient suffered from dementia, if there were language difficulties that precluded observation of counseling behaviors, or if the student had previously observed an encounter with that patient. The Human Subjects Committee of the University of Kansas Medical Center approved the protocol.

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.

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.

Conclusions

Although smoking cessation is be a common topic in some physician-patient encounters, there are widespread variations in how it is addressed in primary care practices. More comprehensive and efficient management of nicotine dependence may be possible if physicians addressed the infrastructure in their offices that can support smoking cessation activities. Many physicians may not yet be considering changing their office systems to enhance smoking cessation activities. Further efforts will be needed to identify the barriers to system changes and to help physicians integrate effective and efficient smoking cessation systems into their practices.

Acknowledgments

Partial funding for this project was provided through the following grants: The Robert Wood Johnson Foundation Generalist Physicians Faculty Scholars award (#032686, J.S. Ahluwalia); Kansas Academy of Family Physicians (J. Gladden); J.H. Baker Trust of La Crosse, Kansas (J Gladden); Kansas Association for Medically Underserved (J. Gladden); and a Primary Care Physician Education grant from the Kansas Health Foundation. We would like to thank the family physicians who not only provided a valuable learning experience for the students but also allowed the data collection necessary for our paper. We appreciate the commitment of the students who collected the data. We would like to thank Kristin Hedberg, MA, for preliminary data analysis and Timothy P. Daaleman, DO, and Delwyn Catley, PhD, for their careful review of early versions of this manuscript.

Related Resources

For Patients:

• QuitNet http://www.quitnet.com/qn_main.jtml Developed by Boston University, this site provides information and tools to people trying to quit smoking. It contains peer support programs, information on pharmaceuticals, a directory of local smoking cessation programs, and the latest news from the tobacco front.
• Quitsmokingsupport.com http://www.quitsmokingsupport.com/intro.htm This advertiser-supported site has dozens of pages on weight control, methods, interactive chat/support rooms, quit smoking articles, smokers’ lungs, etc.

For physicians:

• Smoking cessation guidelines. http://www.surgeongeneral.gov/tobacco/default.htm Clinical practice guidelines from the Surgeon General’s Web site with full text and references for online retrieval. Patient education materials and posters for the doctor’s office are also available.
• PSNonline http://psnonline.org/Medical%20Management%20Program/Smoking% 20Cessation/smoking_cessation_front_page.htm This site provides a copy of the sticker or stamp that includes smoking cessation in the vital signs. Several studies have shown that this can significantly improve smoking cessation counseling in the doctor’s office.

Recent smoking cessation guidelines¹ identify critical ways primary care physicians can intervene with their patients to improve cessation rates. These guidelines recommend that all patients be asked about their smoking status at every visit. Also at every visit all smokers should be advised to quit and should be assessed for their readiness to do so. The guidelines include recommendations for physicians to incorporate elements into their practices that will help them maximize smoking cessation rates. These elements include systems to routinely identify all smokers, reminder systems to encourage physicians to discuss smoking, tools for assisting their patients in quitting, and assignments for nonphysician personnel to assist in smoking cessation. Preliminary data suggest that few practices have adopted these types of systems^2,3 and that many smokers have not been advised by their physicians to quit.⁴

Examining counseling behaviors, such as smoking cessation, in a physician’s office can be challenging. Previous attempts to examine such efforts have relied primarily on physician self-report^5,6 and patient surveys.^7,8 A few studies have employed direct observation as a method of data collection.^3,9 Stange and colleagues¹⁰ have suggested that direct observation of clinical practices may be the gold standard for measuring counseling activities. Although patient reports appear to have a high degree of correlation with direct observation, the accuracy of these reports tend to deteriorate with time;^10,11 medical records are frequently incomplete; and physician reports typically overestimate counseling activities.¹⁰

For our study, medical students directly observed physician-patient encounters in primary care physicians’ offices in Kansas. Our objectives were to describe physician activities related to smoking cessation efforts and to identify physician and office characteristics that support these efforts.

Methods

Study Setting

We identified 38 family physicians in 38 separate practices in Kansas who agreed to precept students for 6 weeks during June and July of 1999; 89% of these practices were in non-metropolitan areas. These physicians had served as preceptors to medical students in previous years and were familiar with data collection efforts by students. Each family physician consented to have students observe preventive care practices in their offices during the rotation.

Medical Student Training and Support

Students collected data on a summer research elective between their first and second years of medical school. They received extensive training on the research study. During the next 8 weeks, the students worked with their assigned physicians. They submitted weekly reports of research activities to the study coordinator, who was in contact with the students through electronic mail and telephone calls throughout the course of our study.

Sample Selection

Physician-patient encounters were included in our study if the patient was aged at least 18 years, the physician saw the patient during normal office hours, and the student was present for the entire visit. Encounters were excluded from data collection if the office visit was for a critical acute complaint or a procedure, if the patient appeared to be in immediate emotional distress, if the patient suffered from dementia, if there were language difficulties that precluded observation of counseling behaviors, or if the student had previously observed an encounter with that patient. The Human Subjects Committee of the University of Kansas Medical Center approved the protocol.

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.

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.

Conclusions

Although smoking cessation is be a common topic in some physician-patient encounters, there are widespread variations in how it is addressed in primary care practices. More comprehensive and efficient management of nicotine dependence may be possible if physicians addressed the infrastructure in their offices that can support smoking cessation activities. Many physicians may not yet be considering changing their office systems to enhance smoking cessation activities. Further efforts will be needed to identify the barriers to system changes and to help physicians integrate effective and efficient smoking cessation systems into their practices.

Acknowledgments

Partial funding for this project was provided through the following grants: The Robert Wood Johnson Foundation Generalist Physicians Faculty Scholars award (#032686, J.S. Ahluwalia); Kansas Academy of Family Physicians (J. Gladden); J.H. Baker Trust of La Crosse, Kansas (J Gladden); Kansas Association for Medically Underserved (J. Gladden); and a Primary Care Physician Education grant from the Kansas Health Foundation. We would like to thank the family physicians who not only provided a valuable learning experience for the students but also allowed the data collection necessary for our paper. We appreciate the commitment of the students who collected the data. We would like to thank Kristin Hedberg, MA, for preliminary data analysis and Timothy P. Daaleman, DO, and Delwyn Catley, PhD, for their careful review of early versions of this manuscript.

Related Resources

For Patients:

• QuitNet http://www.quitnet.com/qn_main.jtml Developed by Boston University, this site provides information and tools to people trying to quit smoking. It contains peer support programs, information on pharmaceuticals, a directory of local smoking cessation programs, and the latest news from the tobacco front.
• Quitsmokingsupport.com http://www.quitsmokingsupport.com/intro.htm This advertiser-supported site has dozens of pages on weight control, methods, interactive chat/support rooms, quit smoking articles, smokers’ lungs, etc.

For physicians:

• Smoking cessation guidelines. http://www.surgeongeneral.gov/tobacco/default.htm Clinical practice guidelines from the Surgeon General’s Web site with full text and references for online retrieval. Patient education materials and posters for the doctor’s office are also available.
• PSNonline http://psnonline.org/Medical%20Management%20Program/Smoking% 20Cessation/smoking_cessation_front_page.htm This site provides a copy of the sticker or stamp that includes smoking cessation in the vital signs. Several studies have shown that this can significantly improve smoking cessation counseling in the doctor’s office.

Recent smoking cessation guidelines¹ identify critical ways primary care physicians can intervene with their patients to improve cessation rates. These guidelines recommend that all patients be asked about their smoking status at every visit. Also at every visit all smokers should be advised to quit and should be assessed for their readiness to do so. The guidelines include recommendations for physicians to incorporate elements into their practices that will help them maximize smoking cessation rates. These elements include systems to routinely identify all smokers, reminder systems to encourage physicians to discuss smoking, tools for assisting their patients in quitting, and assignments for nonphysician personnel to assist in smoking cessation. Preliminary data suggest that few practices have adopted these types of systems^2,3 and that many smokers have not been advised by their physicians to quit.⁴

Examining counseling behaviors, such as smoking cessation, in a physician’s office can be challenging. Previous attempts to examine such efforts have relied primarily on physician self-report^5,6 and patient surveys.^7,8 A few studies have employed direct observation as a method of data collection.^3,9 Stange and colleagues¹⁰ have suggested that direct observation of clinical practices may be the gold standard for measuring counseling activities. Although patient reports appear to have a high degree of correlation with direct observation, the accuracy of these reports tend to deteriorate with time;^10,11 medical records are frequently incomplete; and physician reports typically overestimate counseling activities.¹⁰

For our study, medical students directly observed physician-patient encounters in primary care physicians’ offices in Kansas. Our objectives were to describe physician activities related to smoking cessation efforts and to identify physician and office characteristics that support these efforts.

Methods

Study Setting

We identified 38 family physicians in 38 separate practices in Kansas who agreed to precept students for 6 weeks during June and July of 1999; 89% of these practices were in non-metropolitan areas. These physicians had served as preceptors to medical students in previous years and were familiar with data collection efforts by students. Each family physician consented to have students observe preventive care practices in their offices during the rotation.

Medical Student Training and Support

Students collected data on a summer research elective between their first and second years of medical school. They received extensive training on the research study. During the next 8 weeks, the students worked with their assigned physicians. They submitted weekly reports of research activities to the study coordinator, who was in contact with the students through electronic mail and telephone calls throughout the course of our study.

Sample Selection

Physician-patient encounters were included in our study if the patient was aged at least 18 years, the physician saw the patient during normal office hours, and the student was present for the entire visit. Encounters were excluded from data collection if the office visit was for a critical acute complaint or a procedure, if the patient appeared to be in immediate emotional distress, if the patient suffered from dementia, if there were language difficulties that precluded observation of counseling behaviors, or if the student had previously observed an encounter with that patient. The Human Subjects Committee of the University of Kansas Medical Center approved the protocol.

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.

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.

Conclusions

Although smoking cessation is be a common topic in some physician-patient encounters, there are widespread variations in how it is addressed in primary care practices. More comprehensive and efficient management of nicotine dependence may be possible if physicians addressed the infrastructure in their offices that can support smoking cessation activities. Many physicians may not yet be considering changing their office systems to enhance smoking cessation activities. Further efforts will be needed to identify the barriers to system changes and to help physicians integrate effective and efficient smoking cessation systems into their practices.

Acknowledgments

Partial funding for this project was provided through the following grants: The Robert Wood Johnson Foundation Generalist Physicians Faculty Scholars award (#032686, J.S. Ahluwalia); Kansas Academy of Family Physicians (J. Gladden); J.H. Baker Trust of La Crosse, Kansas (J Gladden); Kansas Association for Medically Underserved (J. Gladden); and a Primary Care Physician Education grant from the Kansas Health Foundation. We would like to thank the family physicians who not only provided a valuable learning experience for the students but also allowed the data collection necessary for our paper. We appreciate the commitment of the students who collected the data. We would like to thank Kristin Hedberg, MA, for preliminary data analysis and Timothy P. Daaleman, DO, and Delwyn Catley, PhD, for their careful review of early versions of this manuscript.

Related Resources

For Patients:

• QuitNet http://www.quitnet.com/qn_main.jtml Developed by Boston University, this site provides information and tools to people trying to quit smoking. It contains peer support programs, information on pharmaceuticals, a directory of local smoking cessation programs, and the latest news from the tobacco front.
• Quitsmokingsupport.com http://www.quitsmokingsupport.com/intro.htm This advertiser-supported site has dozens of pages on weight control, methods, interactive chat/support rooms, quit smoking articles, smokers’ lungs, etc.

For physicians:

• Smoking cessation guidelines. http://www.surgeongeneral.gov/tobacco/default.htm Clinical practice guidelines from the Surgeon General’s Web site with full text and references for online retrieval. Patient education materials and posters for the doctor’s office are also available.
• PSNonline http://psnonline.org/Medical%20Management%20Program/Smoking% 20Cessation/smoking_cessation_front_page.htm This site provides a copy of the sticker or stamp that includes smoking cessation in the vital signs. Several studies have shown that this can significantly improve smoking cessation counseling in the doctor’s office.