Helen E. McIlvain, PhD

Despite efforts by the public health community and individual clinicians, tobacco use remains a significant health problem.¹ After funding a series of research projects to develop more effective intervention methods for use by physicians and dentists, the National Cancer Institute (NCI)² published a monograph highlighting findings in this area. One of their recommendations was that physicians and dentists initiate office-based activities to enhance and support their tobacco cessation messages. This comprehensive organized effort would increase patient exposure to consistent environmental cues and facilitate patients’ movement along the stages of the readiness to change mode^1,3 resulting in additional cessation attempts and lower smoking rates. Recommended office-based strategies included creating an environment that encouraged cessation, training clinicians in cessation skills, using nurses and other staff in identification and counseling of smokers, and systematically identifying and tracking smokers. Two years after the publication of that monograph and during the time of our study, the Agency for Health Care Policy and Research (AHCPR)⁴ released a clinical practice guideline on smoking cessation that included recommendations for the use of office-based activities. The primary objective of our study was to describe the extent to which family physician practices have implemented 15 office-based activities (Table) for smoking cessation abstracted from the NCI monograph.

Methods

The study consisted of family physician practices recruited from the membership list of the Nebraska Academy of Family Physicians (NAFP). Approximately 95% of Nebraska family physicians are members of NAFP. Individual physicians on the membership list were grouped according to practice address, resulting in a pool of 209 practices. We stratified these practices as urban or rural based on county population density and sampled them proportionally to ensure a representative sample. To include a sufficient number of practices with a minimum of unnecessary contact, practices were recruited in successive waves. We randomly generated a short list of practices from each density stratum. A letter explaining the general outline of our study was sent randomly to one physician in each practice and followed a week later by a telephone call to that physician. Three recruitment waves (for a total of 155 practices) were conducted in an attempt to recruit 100 practices.

We employed a cross-sectional integrated research design.^5-8 A research nurse collected data in 1995 and 1996 during a 1-day visit to each practice. Data included a practice environment checklist identifying smoking cessation activities. Focused observation of the practice environment⁹ and key informant interviews¹⁰ were used to identify environmental cues for smoking cessation, physician and staff use of tobacco, type and placement of smoking cessation patient education materials, and office staff roles relative to smoking cessation activities. We identified physician attitude and beliefs about smoking cessation through audiotaped semistructured in-depth interviews.¹¹ Medical records were reviewed to identify methods of documentation of smoking status and smoking cessation efforts.

Successful adoption of office-based cessation activities was determined using the summed score of 15 items (Table) abstracted from the NCI monograph (coded as 0 if not implemented and 1 if implemented). We then used the summed scores to identify and describe general findings across practices. Data from the interviews and field notes were analyzed qualitatively using the template organizing style.¹² We generated common themes and compared them with the descriptive statistics.

Results

Ninety-one practices participated in the study (57%). Data from 1 site was lost when the research nurse’s briefcase was stolen. Another site did not allow us to audit charts, so their data were not included. Responding sites did not differ from nonrespondents in terms of physician sex, rural or urban locale, and group versus solo practice. The resultant sample was 43% urban and 30% solo practices (urban vs rural locale: c2=1.14, P=.286).

All of the physicians voiced the belief that smoking poses a significant health problem in their patient population and agreed that they needed to address this problem with their patients. Additionally, the majority (74.4%) felt confident about their smoking cessation counseling skills.

These attitudes, however, did not translate into the use of office-based activities for the majority of practices. The office-based activity score had a mean of 5.93 (standard deviation=2.47) with actual scores ranging from 0 to 13 out of a possible maximum 15. The Figure shows the distribution of these scores.

Sixty-six percent of the sites were either posted as nonsmoking or did not provide receptacles for smoking (Table). All of the sites had either an official (written) policy (51%) or an informal policy restricting staff smoking on the premises. Twenty-eight percent of practices had no physicians or staff who were tobacco users. Only 10% provided waiting room reading materials that were free of smoking advertisements. Twenty-one percent advertised in the waiting or reception area that help was available to stop smoking.

The majority of sites (78%) had patient education materials on smoking cessation, and 52% of these had materials placed so they were directly accessible to patients. More than half of the sites relied on pharmaceutical companies to supply these materials, the majority of which suggested the use of a nicotine replacement system. Almost two thirds of the practices used printed materials as their sole educational avenue, as opposed to including audiotapes and videotapes.

Involvement of support staff in office-based smoking cessation activities was limited. Designating a staff member to maintain patient education materials (24%) was the most common. Only 3 practices used support staff to assess tobacco use by asking about it while taking vital signs; one of these also had a person on site to counsel. In 5 additional practices a support person was involved in tobacco counseling or follow-up with patients attempting to quit.

Most physicians were not able to readily use the patient’s chart as an effective cue for identifying smokers at each visit. Smoking status was documented in 51% of the 1951 medical records reviewed but was seldom documented on the face sheet (13% of all records). In the majority of cases, documentation was generally located in the back of the chart on a health history questionnaire.

Discussion

In a meta-analysis of 39 controlled smoking cessation trials, Kottke and colleagues¹³ identified having the patient receive multiple cessation messages from both physicians and nonphysicians as an important common attribute of successful interventions in medical practice. Hollis and coworkers¹⁴ have shown that nurse involvement in smoking cessation counseling reduces physician burden, makes counseling more likely to occur, and increases cessation rates compared with brief physician advice only. Fiore and colleagues¹⁵ and Robinson and coworkers¹⁶ have reported that adding a question about smoking status to the vital signs portion of the progress note increased the likelihood of smoking-related discussions between patients and their physicians. These are only a few of the multitude of articles similar to those reported in the NCI monograph that support the effectiveness of including staff and support activities in a comprehensive office-based approach rather than solely a physician-based approach to smoking cessation. Most of the activities recommended are simple and do not involve considerable costs or additional staff time.

In our study, however, most physicians did not use office-based activities to support what they did individually, to increase avenues to provide cessation messages, or to create a cessation-friendly environment. Although most of the practices had an office environment that reduced cues to smoke by restricting smoking of patients and staff in the clinic, almost all provided reading materials promoting smoking in their advertisements. Few practices proactively supported the importance of cessation by means of visual cues or information on available help in the waiting room. Most did have easily accessible smoking cessation patient education materials; however, the majority of these were from pharmaceutical companies and were designed to promote the use of nicotine replacement therapy. Although these materials could be helpful in promoting cessation for those patients ready to quit, they are of little use for motivating the 80% to 90% of smokers who are not currently interested in quitting.¹⁷ In a significant majority of these practices, physician time was used for both the most mundane (identification) and the most important (motivation and counseling) aspects of smoking cessation. All of the physicians in our study indicated that smoking was a significant health problem in their patient population and believed it was their responsibility to address cessation with smoking patients. Our knowledge of effective cessation techniques has clearly outpaced these practices’ ability or desire to implement them.

There are a number of strengths that make our study unique. The most important of these is that our results are based on direct observation of activities in 89 practices, almost half of all the family practices in Nebraska. It is very likely that our results reflect actual typical practice in our area. Additionally, our use of a multimethod approach enhances the validity of the results by triangulating data (eg, comparing our key informant information about documentation with audits of the medical record).

Limitations

There are some factors that affect the generalizability of our results. Our sample was composed of Nebraska family practices and may not represent other states that differ in smoking rates, taxes on tobacco, or other factors affecting smoking rates. Our assessment of practices focused primarily on the occurrence of office-based activities, so our office-based activity score does not reflect the activities of the individual target physician in the practice. It is possible that a practice could have a low score and a very proactive physician. However, since office-based activities are designed to support the physician’s message, not eliminate it, this practice would still be missing opportunities to reinforce and support the physician’s ability to provide effective cessation messages. Finally, although the NCI monograph and the AHCPR practice guideline outline the suggested best practice for office-based activities, it may not be one that all physicians embrace. Some may consciously choose to limit these activities in their practice.

Conclusions

The NCI monograph suggests that practices are like patients in their stage of readiness¹⁸ to implement office-based strategies. We speculate that movement of a practice out of the first basic level (where the majority of our practices fell) would require acceptance of the use of office-based systems as the standard of care. Examples would include seeing and hearing their peers use office-based activities effectively, being reimbursed for having these activities in place, training residents in a system that uses office-based activities, and providing help to practices interested in implementing and maintaining activities suited to their needs. Our efforts must now focus on helping practices implement the knowledge we have gained.

Acknowledgments

Our study was supported by a grant from the Nebraska Department of Health and Human Services, Cancer and Smoking Disease Program (96-05B). We wish to express our thanks to Connie Gibb, RN, for her invaluable assistance in data collection, Naomi Lacy, PhD, for her editing, and all of the family physicians in Nebraska who were willing to open their practices to us.

Despite efforts by the public health community and individual clinicians, tobacco use remains a significant health problem.¹ After funding a series of research projects to develop more effective intervention methods for use by physicians and dentists, the National Cancer Institute (NCI)² published a monograph highlighting findings in this area. One of their recommendations was that physicians and dentists initiate office-based activities to enhance and support their tobacco cessation messages. This comprehensive organized effort would increase patient exposure to consistent environmental cues and facilitate patients’ movement along the stages of the readiness to change mode^1,3 resulting in additional cessation attempts and lower smoking rates. Recommended office-based strategies included creating an environment that encouraged cessation, training clinicians in cessation skills, using nurses and other staff in identification and counseling of smokers, and systematically identifying and tracking smokers. Two years after the publication of that monograph and during the time of our study, the Agency for Health Care Policy and Research (AHCPR)⁴ released a clinical practice guideline on smoking cessation that included recommendations for the use of office-based activities. The primary objective of our study was to describe the extent to which family physician practices have implemented 15 office-based activities (Table) for smoking cessation abstracted from the NCI monograph.

Methods

The study consisted of family physician practices recruited from the membership list of the Nebraska Academy of Family Physicians (NAFP). Approximately 95% of Nebraska family physicians are members of NAFP. Individual physicians on the membership list were grouped according to practice address, resulting in a pool of 209 practices. We stratified these practices as urban or rural based on county population density and sampled them proportionally to ensure a representative sample. To include a sufficient number of practices with a minimum of unnecessary contact, practices were recruited in successive waves. We randomly generated a short list of practices from each density stratum. A letter explaining the general outline of our study was sent randomly to one physician in each practice and followed a week later by a telephone call to that physician. Three recruitment waves (for a total of 155 practices) were conducted in an attempt to recruit 100 practices.

We employed a cross-sectional integrated research design.^5-8 A research nurse collected data in 1995 and 1996 during a 1-day visit to each practice. Data included a practice environment checklist identifying smoking cessation activities. Focused observation of the practice environment⁹ and key informant interviews¹⁰ were used to identify environmental cues for smoking cessation, physician and staff use of tobacco, type and placement of smoking cessation patient education materials, and office staff roles relative to smoking cessation activities. We identified physician attitude and beliefs about smoking cessation through audiotaped semistructured in-depth interviews.¹¹ Medical records were reviewed to identify methods of documentation of smoking status and smoking cessation efforts.

Successful adoption of office-based cessation activities was determined using the summed score of 15 items (Table) abstracted from the NCI monograph (coded as 0 if not implemented and 1 if implemented). We then used the summed scores to identify and describe general findings across practices. Data from the interviews and field notes were analyzed qualitatively using the template organizing style.¹² We generated common themes and compared them with the descriptive statistics.

Results

Ninety-one practices participated in the study (57%). Data from 1 site was lost when the research nurse’s briefcase was stolen. Another site did not allow us to audit charts, so their data were not included. Responding sites did not differ from nonrespondents in terms of physician sex, rural or urban locale, and group versus solo practice. The resultant sample was 43% urban and 30% solo practices (urban vs rural locale: c2=1.14, P=.286).

All of the physicians voiced the belief that smoking poses a significant health problem in their patient population and agreed that they needed to address this problem with their patients. Additionally, the majority (74.4%) felt confident about their smoking cessation counseling skills.

These attitudes, however, did not translate into the use of office-based activities for the majority of practices. The office-based activity score had a mean of 5.93 (standard deviation=2.47) with actual scores ranging from 0 to 13 out of a possible maximum 15. The Figure shows the distribution of these scores.

Sixty-six percent of the sites were either posted as nonsmoking or did not provide receptacles for smoking (Table). All of the sites had either an official (written) policy (51%) or an informal policy restricting staff smoking on the premises. Twenty-eight percent of practices had no physicians or staff who were tobacco users. Only 10% provided waiting room reading materials that were free of smoking advertisements. Twenty-one percent advertised in the waiting or reception area that help was available to stop smoking.

The majority of sites (78%) had patient education materials on smoking cessation, and 52% of these had materials placed so they were directly accessible to patients. More than half of the sites relied on pharmaceutical companies to supply these materials, the majority of which suggested the use of a nicotine replacement system. Almost two thirds of the practices used printed materials as their sole educational avenue, as opposed to including audiotapes and videotapes.

Involvement of support staff in office-based smoking cessation activities was limited. Designating a staff member to maintain patient education materials (24%) was the most common. Only 3 practices used support staff to assess tobacco use by asking about it while taking vital signs; one of these also had a person on site to counsel. In 5 additional practices a support person was involved in tobacco counseling or follow-up with patients attempting to quit.

Most physicians were not able to readily use the patient’s chart as an effective cue for identifying smokers at each visit. Smoking status was documented in 51% of the 1951 medical records reviewed but was seldom documented on the face sheet (13% of all records). In the majority of cases, documentation was generally located in the back of the chart on a health history questionnaire.

Discussion

In a meta-analysis of 39 controlled smoking cessation trials, Kottke and colleagues¹³ identified having the patient receive multiple cessation messages from both physicians and nonphysicians as an important common attribute of successful interventions in medical practice. Hollis and coworkers¹⁴ have shown that nurse involvement in smoking cessation counseling reduces physician burden, makes counseling more likely to occur, and increases cessation rates compared with brief physician advice only. Fiore and colleagues¹⁵ and Robinson and coworkers¹⁶ have reported that adding a question about smoking status to the vital signs portion of the progress note increased the likelihood of smoking-related discussions between patients and their physicians. These are only a few of the multitude of articles similar to those reported in the NCI monograph that support the effectiveness of including staff and support activities in a comprehensive office-based approach rather than solely a physician-based approach to smoking cessation. Most of the activities recommended are simple and do not involve considerable costs or additional staff time.

In our study, however, most physicians did not use office-based activities to support what they did individually, to increase avenues to provide cessation messages, or to create a cessation-friendly environment. Although most of the practices had an office environment that reduced cues to smoke by restricting smoking of patients and staff in the clinic, almost all provided reading materials promoting smoking in their advertisements. Few practices proactively supported the importance of cessation by means of visual cues or information on available help in the waiting room. Most did have easily accessible smoking cessation patient education materials; however, the majority of these were from pharmaceutical companies and were designed to promote the use of nicotine replacement therapy. Although these materials could be helpful in promoting cessation for those patients ready to quit, they are of little use for motivating the 80% to 90% of smokers who are not currently interested in quitting.¹⁷ In a significant majority of these practices, physician time was used for both the most mundane (identification) and the most important (motivation and counseling) aspects of smoking cessation. All of the physicians in our study indicated that smoking was a significant health problem in their patient population and believed it was their responsibility to address cessation with smoking patients. Our knowledge of effective cessation techniques has clearly outpaced these practices’ ability or desire to implement them.

There are a number of strengths that make our study unique. The most important of these is that our results are based on direct observation of activities in 89 practices, almost half of all the family practices in Nebraska. It is very likely that our results reflect actual typical practice in our area. Additionally, our use of a multimethod approach enhances the validity of the results by triangulating data (eg, comparing our key informant information about documentation with audits of the medical record).

Limitations

There are some factors that affect the generalizability of our results. Our sample was composed of Nebraska family practices and may not represent other states that differ in smoking rates, taxes on tobacco, or other factors affecting smoking rates. Our assessment of practices focused primarily on the occurrence of office-based activities, so our office-based activity score does not reflect the activities of the individual target physician in the practice. It is possible that a practice could have a low score and a very proactive physician. However, since office-based activities are designed to support the physician’s message, not eliminate it, this practice would still be missing opportunities to reinforce and support the physician’s ability to provide effective cessation messages. Finally, although the NCI monograph and the AHCPR practice guideline outline the suggested best practice for office-based activities, it may not be one that all physicians embrace. Some may consciously choose to limit these activities in their practice.

Conclusions

The NCI monograph suggests that practices are like patients in their stage of readiness¹⁸ to implement office-based strategies. We speculate that movement of a practice out of the first basic level (where the majority of our practices fell) would require acceptance of the use of office-based systems as the standard of care. Examples would include seeing and hearing their peers use office-based activities effectively, being reimbursed for having these activities in place, training residents in a system that uses office-based activities, and providing help to practices interested in implementing and maintaining activities suited to their needs. Our efforts must now focus on helping practices implement the knowledge we have gained.

Acknowledgments

Our study was supported by a grant from the Nebraska Department of Health and Human Services, Cancer and Smoking Disease Program (96-05B). We wish to express our thanks to Connie Gibb, RN, for her invaluable assistance in data collection, Naomi Lacy, PhD, for her editing, and all of the family physicians in Nebraska who were willing to open their practices to us.

Despite efforts by the public health community and individual clinicians, tobacco use remains a significant health problem.¹ After funding a series of research projects to develop more effective intervention methods for use by physicians and dentists, the National Cancer Institute (NCI)² published a monograph highlighting findings in this area. One of their recommendations was that physicians and dentists initiate office-based activities to enhance and support their tobacco cessation messages. This comprehensive organized effort would increase patient exposure to consistent environmental cues and facilitate patients’ movement along the stages of the readiness to change mode^1,3 resulting in additional cessation attempts and lower smoking rates. Recommended office-based strategies included creating an environment that encouraged cessation, training clinicians in cessation skills, using nurses and other staff in identification and counseling of smokers, and systematically identifying and tracking smokers. Two years after the publication of that monograph and during the time of our study, the Agency for Health Care Policy and Research (AHCPR)⁴ released a clinical practice guideline on smoking cessation that included recommendations for the use of office-based activities. The primary objective of our study was to describe the extent to which family physician practices have implemented 15 office-based activities (Table) for smoking cessation abstracted from the NCI monograph.

Methods

The study consisted of family physician practices recruited from the membership list of the Nebraska Academy of Family Physicians (NAFP). Approximately 95% of Nebraska family physicians are members of NAFP. Individual physicians on the membership list were grouped according to practice address, resulting in a pool of 209 practices. We stratified these practices as urban or rural based on county population density and sampled them proportionally to ensure a representative sample. To include a sufficient number of practices with a minimum of unnecessary contact, practices were recruited in successive waves. We randomly generated a short list of practices from each density stratum. A letter explaining the general outline of our study was sent randomly to one physician in each practice and followed a week later by a telephone call to that physician. Three recruitment waves (for a total of 155 practices) were conducted in an attempt to recruit 100 practices.

We employed a cross-sectional integrated research design.^5-8 A research nurse collected data in 1995 and 1996 during a 1-day visit to each practice. Data included a practice environment checklist identifying smoking cessation activities. Focused observation of the practice environment⁹ and key informant interviews¹⁰ were used to identify environmental cues for smoking cessation, physician and staff use of tobacco, type and placement of smoking cessation patient education materials, and office staff roles relative to smoking cessation activities. We identified physician attitude and beliefs about smoking cessation through audiotaped semistructured in-depth interviews.¹¹ Medical records were reviewed to identify methods of documentation of smoking status and smoking cessation efforts.

Successful adoption of office-based cessation activities was determined using the summed score of 15 items (Table) abstracted from the NCI monograph (coded as 0 if not implemented and 1 if implemented). We then used the summed scores to identify and describe general findings across practices. Data from the interviews and field notes were analyzed qualitatively using the template organizing style.¹² We generated common themes and compared them with the descriptive statistics.

Results

Ninety-one practices participated in the study (57%). Data from 1 site was lost when the research nurse’s briefcase was stolen. Another site did not allow us to audit charts, so their data were not included. Responding sites did not differ from nonrespondents in terms of physician sex, rural or urban locale, and group versus solo practice. The resultant sample was 43% urban and 30% solo practices (urban vs rural locale: c2=1.14, P=.286).

All of the physicians voiced the belief that smoking poses a significant health problem in their patient population and agreed that they needed to address this problem with their patients. Additionally, the majority (74.4%) felt confident about their smoking cessation counseling skills.

These attitudes, however, did not translate into the use of office-based activities for the majority of practices. The office-based activity score had a mean of 5.93 (standard deviation=2.47) with actual scores ranging from 0 to 13 out of a possible maximum 15. The Figure shows the distribution of these scores.

Sixty-six percent of the sites were either posted as nonsmoking or did not provide receptacles for smoking (Table). All of the sites had either an official (written) policy (51%) or an informal policy restricting staff smoking on the premises. Twenty-eight percent of practices had no physicians or staff who were tobacco users. Only 10% provided waiting room reading materials that were free of smoking advertisements. Twenty-one percent advertised in the waiting or reception area that help was available to stop smoking.

The majority of sites (78%) had patient education materials on smoking cessation, and 52% of these had materials placed so they were directly accessible to patients. More than half of the sites relied on pharmaceutical companies to supply these materials, the majority of which suggested the use of a nicotine replacement system. Almost two thirds of the practices used printed materials as their sole educational avenue, as opposed to including audiotapes and videotapes.

Involvement of support staff in office-based smoking cessation activities was limited. Designating a staff member to maintain patient education materials (24%) was the most common. Only 3 practices used support staff to assess tobacco use by asking about it while taking vital signs; one of these also had a person on site to counsel. In 5 additional practices a support person was involved in tobacco counseling or follow-up with patients attempting to quit.

Most physicians were not able to readily use the patient’s chart as an effective cue for identifying smokers at each visit. Smoking status was documented in 51% of the 1951 medical records reviewed but was seldom documented on the face sheet (13% of all records). In the majority of cases, documentation was generally located in the back of the chart on a health history questionnaire.

Discussion

In a meta-analysis of 39 controlled smoking cessation trials, Kottke and colleagues¹³ identified having the patient receive multiple cessation messages from both physicians and nonphysicians as an important common attribute of successful interventions in medical practice. Hollis and coworkers¹⁴ have shown that nurse involvement in smoking cessation counseling reduces physician burden, makes counseling more likely to occur, and increases cessation rates compared with brief physician advice only. Fiore and colleagues¹⁵ and Robinson and coworkers¹⁶ have reported that adding a question about smoking status to the vital signs portion of the progress note increased the likelihood of smoking-related discussions between patients and their physicians. These are only a few of the multitude of articles similar to those reported in the NCI monograph that support the effectiveness of including staff and support activities in a comprehensive office-based approach rather than solely a physician-based approach to smoking cessation. Most of the activities recommended are simple and do not involve considerable costs or additional staff time.

In our study, however, most physicians did not use office-based activities to support what they did individually, to increase avenues to provide cessation messages, or to create a cessation-friendly environment. Although most of the practices had an office environment that reduced cues to smoke by restricting smoking of patients and staff in the clinic, almost all provided reading materials promoting smoking in their advertisements. Few practices proactively supported the importance of cessation by means of visual cues or information on available help in the waiting room. Most did have easily accessible smoking cessation patient education materials; however, the majority of these were from pharmaceutical companies and were designed to promote the use of nicotine replacement therapy. Although these materials could be helpful in promoting cessation for those patients ready to quit, they are of little use for motivating the 80% to 90% of smokers who are not currently interested in quitting.¹⁷ In a significant majority of these practices, physician time was used for both the most mundane (identification) and the most important (motivation and counseling) aspects of smoking cessation. All of the physicians in our study indicated that smoking was a significant health problem in their patient population and believed it was their responsibility to address cessation with smoking patients. Our knowledge of effective cessation techniques has clearly outpaced these practices’ ability or desire to implement them.

There are a number of strengths that make our study unique. The most important of these is that our results are based on direct observation of activities in 89 practices, almost half of all the family practices in Nebraska. It is very likely that our results reflect actual typical practice in our area. Additionally, our use of a multimethod approach enhances the validity of the results by triangulating data (eg, comparing our key informant information about documentation with audits of the medical record).

Limitations

There are some factors that affect the generalizability of our results. Our sample was composed of Nebraska family practices and may not represent other states that differ in smoking rates, taxes on tobacco, or other factors affecting smoking rates. Our assessment of practices focused primarily on the occurrence of office-based activities, so our office-based activity score does not reflect the activities of the individual target physician in the practice. It is possible that a practice could have a low score and a very proactive physician. However, since office-based activities are designed to support the physician’s message, not eliminate it, this practice would still be missing opportunities to reinforce and support the physician’s ability to provide effective cessation messages. Finally, although the NCI monograph and the AHCPR practice guideline outline the suggested best practice for office-based activities, it may not be one that all physicians embrace. Some may consciously choose to limit these activities in their practice.

Conclusions

The NCI monograph suggests that practices are like patients in their stage of readiness¹⁸ to implement office-based strategies. We speculate that movement of a practice out of the first basic level (where the majority of our practices fell) would require acceptance of the use of office-based systems as the standard of care. Examples would include seeing and hearing their peers use office-based activities effectively, being reimbursed for having these activities in place, training residents in a system that uses office-based activities, and providing help to practices interested in implementing and maintaining activities suited to their needs. Our efforts must now focus on helping practices implement the knowledge we have gained.

Acknowledgments

Our study was supported by a grant from the Nebraska Department of Health and Human Services, Cancer and Smoking Disease Program (96-05B). We wish to express our thanks to Connie Gibb, RN, for her invaluable assistance in data collection, Naomi Lacy, PhD, for her editing, and all of the family physicians in Nebraska who were willing to open their practices to us.