Tailoring Tobacco Counseling to the Competing Demands in the Clinical Encounter

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.

The research team included 6 members representing a broad range of perspectives, including family medicine, health services research, epidemiology, psychology, anthropology, and sociology. We used an iterative analysis and interpretation process that evolved over time as the team became more familiar with the data.¹⁹ Two immediate objectives were identified: (1) to develop a classification system that could be used to describe how physicians address smoking cessation, and (2) to identify factors that may enhance or impede the degree of adherence to the clinical smoking cessation guideline.² First, the team selected 18 encounters for reading and discussion by all research team members. For each of these encounters, one team member read the narrative out loud, and then the team discussed at length their understanding and assessment of what had taken place. Narrative data from the chart audit and physician interviews were considered as the discussion proceeded. During these discussions, preliminary schemes for classifying and assessing the encounters were developed.

The team was then divided into 3 groups of 2, and each group was assigned approximately 10 encounters for reading and for further development of the initial schemes. To ensure that each group member’s evaluation was independent, each member wrote a description and evaluation of each encounter without having read what the other member had written. The classifications and evaluations were then shared with the other member and the entire research team. Multiple team discussions were used to address differences in interpretation and to identify salient patterns within the data.

After discussing the initial 48 encounters, the remaining 43 encounters were analyzed. The same process of intragroup blind review was followed, and at this point, a nearly complete list of patterns and other important features seen within the encounters was established. Analysis and discussion by the entire research team led to agreement on the classification and evaluation of each of the 91 encounters.

To test the possibility that a single observer may introduce observer bias, the research team analyzed 51 additional clinical encounters with 9 family physicians in 5 different practices by a different research nurse. The 3 teams used the same blinded iterative process. These encounters were reviewed, looking for new patterns of smoking cessation counseling or confirmation of the patterns previously identified.

Results

We observed between 2 and 7 encounters of 20 family physicians in 7 practices Table 1. Five clear patterns were discernable according to the level of tobacco counseling and the type of visit. They represent a hierarchy that ranges from optimal smoking cessation counseling during visits when it was appropriate, to visits during which other agendas were appropriately given higher priority, to deficient missed opportunities. No additional patterns of interaction of smoking cessation counseling were identified among the 51 additional encounters audited.

In nearly half of the visits physicians either followed recommendations (21%), or competing priorities within the encounter reasonably overrode tobacco counseling (24%). In the other encounters tobacco cessation counseling fell short of recommendations, including visits among patients being seen for acute respiratory illnesses or other smoking-related illnesses. This failure often occurred despite the presence of a reminder system that identified the patient as a smoker. In 9% (8 cases) the physicians explicitly told the observing research nurse that they would not address tobacco with a specific patient because of a preconception that the patient would not respond.

Patterns of Tobacco Counseling

Good counseling
Good quality cessation counseling occurred in 21% of the encounters, during which physicians offered appropriate brief interventions depending on patients’ willingness to quit at that visit. Three levels of intervention were discernible within this first pattern. The 5A’s occurred when patients requested help, emphatically said “yes” when asked if they were interested in quitting, or when they responded positively to the physician’s description of pharmacologic options to help quit smoking. Patients were offered only 3A’s if they indicated they were not ready to quit by explicitly saying so or by staying quiet after an inquiry about their willingness to quit. Eleven physicians (55%) had at least 1 encounter with a smoker in which the physicians demonstrated good quality smoking cessation intervention, indicating that they had the knowledge and skill to provide recommended smoking cessation strategies.

Competing demands
Another common pattern was when a smoking cessation agenda was appropriately overridden by higher priorities. This occurred in 24% of the encounters. These were visits during which the physician-patient interaction was less straightforward than simply history taking, diagnosis, and treatment. In 10 encounters the top priority was alleviation of acute pain. Examples included abdominal pain, chest pain, back pain related to pyelonephritis, and severe rib pain after trauma. During 6 encounters patients were experiencing psychological distress, including anxiety attack, anger, a hypomanic breakdown, and depression. In some encounters it became clear that higher-priority competing demands took precedence as a result of a patient-driven agenda (eg, a discussion about care from multiple consultants or a lengthy discussion about multiple medications) or a physician-driven agenda (eg, a first visit for a patient with a complex medical problem squeezed into an acute visit time slot). In reviewing these encounters, the research team agreed that the competing priorities were appropriately important to reasonably not expect discussion of tobacco cessation.

Failure in non–smoking-related visit
A third common pattern was seen in 27% of encounters in which the physician failed to address smoking cessation in a non–smoking-related illness visit during which competing demands were low. In the vast majority of these (14 of 20), failure occurred despite having a reminder system for smoking cessation in place. Examples of visits in this pattern included consults for skin conditions (eg, boil or rash) or follow-up of stable back pain.

Failure in smoking-related visit
Although a smoking related-illness often triggered counseling, another common pattern was for physicians to fail to address smoking in patients presenting with acute respiratory illnesses or other chronic conditions related to smoking. This occurred in 22% of cases, including 10 encounters in which the physician failed to even ask the patient’s smoking status. In 7 of 17 encounters the physician did ask the patient if he or she smoked; in 3 they advised patients to stop smoking, but did not follow though with assessing readiness to change or offering assistance to help the patient quit smoking. Most visits (12 cases) following this pattern failed to address tobacco use for acute upper respiratory symptoms (eg, sore throat, nasal congestion, “sinus,” severe cough).

Failure in health maintenance visit
Finally, a fifth pattern emerged when smoking cessation was not fully addressed in health maintenance visits. In the 2 encounters where this occurred, the physician did ask about smoking status as part of the history taking but did not assess the patient’s readiness to change or offer assistance. It should be noted that 3 of the 5 health maintenance examinations were of good quality tobacco counseling.

Discussion

Our study confirms previous reports of poor compliance with a smoking cessation practice guideline that recommends assessment and consideration of counseling at every visit.^7-12 We found that reliance on a reminder system to identify smokers was often not sufficient to prompt smoking cessation interventions, even during visits for tobacco-related problems.²⁰ In our study, however, more than one half of the physicians demonstrated that they have the skills needed to provide good quality brief intervention for smoking cessation,² and one fourth of the smokers received good quality tobacco counseling.

An important new finding in our study is the documentation of competing demands and priorities during encounters with smokers in primary care practices. In almost 25% of visits by smokers the smoking cessation agenda was appropriately overridden by competing demands (eg, acute pain, acute psychological distress, and other important demands). This finding shows that guidelines that recommend assessment and counseling at every visit are unrealistic, and if followed may not lead to optimal integration and individualization of primary care services.¹⁷ However, the finding of “appropriately missed opportunities” makes it imperative that tobacco cessation counseling be reliably integrated during all other visits with smokers when these competing demands are not present. Visits for well care and tobacco-related illnesses represent teachable moments that should not be missed.

Limitations

Although our study provides important and novel insights into the delivery of tobacco interventions in primary care, it has limitations. The physicians and practices represented here were purposely selected from the larger Prevention and Competing Demands Study and are not representative of the universe of family practices in Nebraska or the United States. Because the study relied on descriptions recorded by an observer, it is possible that subtle communication nuances between the patient and physician may have been missed. Nevertheless, the observer was specifically focused on preventive service delivery, so important details of the encounter are likely to have been captured. We explored the possibility of observer bias by a single observer by expanding an audit of encounters to other practices, physicians, and observers, and we failed to detect additional patterns of delivery. Finally, these patient encounters are only a cross-sectional window into these physicians’ smoking cessation practices.

Conclusions

Our study has important implications for improving delivery of tobacco cessation services in primary care practices. Although many physicians demonstrated basic skills for delivering brief smoking cessation interventions, it is clear that most have not adopted the model of tobacco use disorder as a chronic disease that needs to be addressed at every visit.² Reliance on guidelines and office system tools without the adoption of this model is unlikely to result in higher rates of tobacco cessation. Thus, there is a need to develop interventions that encourage the adoption of this illness model and to develop systems to support tobacco counseling during visits that don’t include overriding important competing opportunities.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a Family Practice Research Center grant from the American Academy of Family Physicians. Drs Jaén, Flocke, and Crabtree are associated with the Center for Research in Family Practice and Primary Care Cleveland, New Brunswick, Allentown, and San Antonio. We are grateful to the physicians, staff, and patients from the 12 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Angela Henke from the Department of Family Medicine of the State University of New York at Buffalo, who provided coordination support for the analyses and collated the data tables. Evangeline Rodriguez from the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio assisted with manuscript preparation. Kurt C. Stange, MD, PhD, provided helpful comments on earlier drafts of this paper.

Related Resources

• The Virtual Office of the Surgeon General http://www.surgeongeneral.gov/tobacco/ This site contains several PDF files of patient-oriented materials based on the Public Health Service Clinical practice guideline.
• U.S. Centers for Disease Control and Prevention—Tobacco Information and Prevention Source (TIPS) http://www.cdc.gov/tobacco Tips for adults, clinicians and youths about how to treat and prevent tobacco use.
• QuitNet " target="_blank">http://www.quitnet.com/BR> QuitNet offers an online support community, forums moderated by counselors, and individually tailored advice to help smokers kick their nicotine addiction.
• California Smokers’ Helpline http://www.nobutts.ucsd.edu/ This site was created to be both fun and informative. A must for patients who are ready to quit or just thinking about it.

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.

The research team included 6 members representing a broad range of perspectives, including family medicine, health services research, epidemiology, psychology, anthropology, and sociology. We used an iterative analysis and interpretation process that evolved over time as the team became more familiar with the data.¹⁹ Two immediate objectives were identified: (1) to develop a classification system that could be used to describe how physicians address smoking cessation, and (2) to identify factors that may enhance or impede the degree of adherence to the clinical smoking cessation guideline.² First, the team selected 18 encounters for reading and discussion by all research team members. For each of these encounters, one team member read the narrative out loud, and then the team discussed at length their understanding and assessment of what had taken place. Narrative data from the chart audit and physician interviews were considered as the discussion proceeded. During these discussions, preliminary schemes for classifying and assessing the encounters were developed.

The team was then divided into 3 groups of 2, and each group was assigned approximately 10 encounters for reading and for further development of the initial schemes. To ensure that each group member’s evaluation was independent, each member wrote a description and evaluation of each encounter without having read what the other member had written. The classifications and evaluations were then shared with the other member and the entire research team. Multiple team discussions were used to address differences in interpretation and to identify salient patterns within the data.

After discussing the initial 48 encounters, the remaining 43 encounters were analyzed. The same process of intragroup blind review was followed, and at this point, a nearly complete list of patterns and other important features seen within the encounters was established. Analysis and discussion by the entire research team led to agreement on the classification and evaluation of each of the 91 encounters.

To test the possibility that a single observer may introduce observer bias, the research team analyzed 51 additional clinical encounters with 9 family physicians in 5 different practices by a different research nurse. The 3 teams used the same blinded iterative process. These encounters were reviewed, looking for new patterns of smoking cessation counseling or confirmation of the patterns previously identified.

Results

We observed between 2 and 7 encounters of 20 family physicians in 7 practices Table 1. Five clear patterns were discernable according to the level of tobacco counseling and the type of visit. They represent a hierarchy that ranges from optimal smoking cessation counseling during visits when it was appropriate, to visits during which other agendas were appropriately given higher priority, to deficient missed opportunities. No additional patterns of interaction of smoking cessation counseling were identified among the 51 additional encounters audited.

In nearly half of the visits physicians either followed recommendations (21%), or competing priorities within the encounter reasonably overrode tobacco counseling (24%). In the other encounters tobacco cessation counseling fell short of recommendations, including visits among patients being seen for acute respiratory illnesses or other smoking-related illnesses. This failure often occurred despite the presence of a reminder system that identified the patient as a smoker. In 9% (8 cases) the physicians explicitly told the observing research nurse that they would not address tobacco with a specific patient because of a preconception that the patient would not respond.

Patterns of Tobacco Counseling

Good counseling
Good quality cessation counseling occurred in 21% of the encounters, during which physicians offered appropriate brief interventions depending on patients’ willingness to quit at that visit. Three levels of intervention were discernible within this first pattern. The 5A’s occurred when patients requested help, emphatically said “yes” when asked if they were interested in quitting, or when they responded positively to the physician’s description of pharmacologic options to help quit smoking. Patients were offered only 3A’s if they indicated they were not ready to quit by explicitly saying so or by staying quiet after an inquiry about their willingness to quit. Eleven physicians (55%) had at least 1 encounter with a smoker in which the physicians demonstrated good quality smoking cessation intervention, indicating that they had the knowledge and skill to provide recommended smoking cessation strategies.

Competing demands
Another common pattern was when a smoking cessation agenda was appropriately overridden by higher priorities. This occurred in 24% of the encounters. These were visits during which the physician-patient interaction was less straightforward than simply history taking, diagnosis, and treatment. In 10 encounters the top priority was alleviation of acute pain. Examples included abdominal pain, chest pain, back pain related to pyelonephritis, and severe rib pain after trauma. During 6 encounters patients were experiencing psychological distress, including anxiety attack, anger, a hypomanic breakdown, and depression. In some encounters it became clear that higher-priority competing demands took precedence as a result of a patient-driven agenda (eg, a discussion about care from multiple consultants or a lengthy discussion about multiple medications) or a physician-driven agenda (eg, a first visit for a patient with a complex medical problem squeezed into an acute visit time slot). In reviewing these encounters, the research team agreed that the competing priorities were appropriately important to reasonably not expect discussion of tobacco cessation.

Failure in non–smoking-related visit
A third common pattern was seen in 27% of encounters in which the physician failed to address smoking cessation in a non–smoking-related illness visit during which competing demands were low. In the vast majority of these (14 of 20), failure occurred despite having a reminder system for smoking cessation in place. Examples of visits in this pattern included consults for skin conditions (eg, boil or rash) or follow-up of stable back pain.

Failure in smoking-related visit
Although a smoking related-illness often triggered counseling, another common pattern was for physicians to fail to address smoking in patients presenting with acute respiratory illnesses or other chronic conditions related to smoking. This occurred in 22% of cases, including 10 encounters in which the physician failed to even ask the patient’s smoking status. In 7 of 17 encounters the physician did ask the patient if he or she smoked; in 3 they advised patients to stop smoking, but did not follow though with assessing readiness to change or offering assistance to help the patient quit smoking. Most visits (12 cases) following this pattern failed to address tobacco use for acute upper respiratory symptoms (eg, sore throat, nasal congestion, “sinus,” severe cough).

Failure in health maintenance visit
Finally, a fifth pattern emerged when smoking cessation was not fully addressed in health maintenance visits. In the 2 encounters where this occurred, the physician did ask about smoking status as part of the history taking but did not assess the patient’s readiness to change or offer assistance. It should be noted that 3 of the 5 health maintenance examinations were of good quality tobacco counseling.

Discussion

Our study confirms previous reports of poor compliance with a smoking cessation practice guideline that recommends assessment and consideration of counseling at every visit.^7-12 We found that reliance on a reminder system to identify smokers was often not sufficient to prompt smoking cessation interventions, even during visits for tobacco-related problems.²⁰ In our study, however, more than one half of the physicians demonstrated that they have the skills needed to provide good quality brief intervention for smoking cessation,² and one fourth of the smokers received good quality tobacco counseling.

An important new finding in our study is the documentation of competing demands and priorities during encounters with smokers in primary care practices. In almost 25% of visits by smokers the smoking cessation agenda was appropriately overridden by competing demands (eg, acute pain, acute psychological distress, and other important demands). This finding shows that guidelines that recommend assessment and counseling at every visit are unrealistic, and if followed may not lead to optimal integration and individualization of primary care services.¹⁷ However, the finding of “appropriately missed opportunities” makes it imperative that tobacco cessation counseling be reliably integrated during all other visits with smokers when these competing demands are not present. Visits for well care and tobacco-related illnesses represent teachable moments that should not be missed.

Limitations

Although our study provides important and novel insights into the delivery of tobacco interventions in primary care, it has limitations. The physicians and practices represented here were purposely selected from the larger Prevention and Competing Demands Study and are not representative of the universe of family practices in Nebraska or the United States. Because the study relied on descriptions recorded by an observer, it is possible that subtle communication nuances between the patient and physician may have been missed. Nevertheless, the observer was specifically focused on preventive service delivery, so important details of the encounter are likely to have been captured. We explored the possibility of observer bias by a single observer by expanding an audit of encounters to other practices, physicians, and observers, and we failed to detect additional patterns of delivery. Finally, these patient encounters are only a cross-sectional window into these physicians’ smoking cessation practices.

Conclusions

Our study has important implications for improving delivery of tobacco cessation services in primary care practices. Although many physicians demonstrated basic skills for delivering brief smoking cessation interventions, it is clear that most have not adopted the model of tobacco use disorder as a chronic disease that needs to be addressed at every visit.² Reliance on guidelines and office system tools without the adoption of this model is unlikely to result in higher rates of tobacco cessation. Thus, there is a need to develop interventions that encourage the adoption of this illness model and to develop systems to support tobacco counseling during visits that don’t include overriding important competing opportunities.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a Family Practice Research Center grant from the American Academy of Family Physicians. Drs Jaén, Flocke, and Crabtree are associated with the Center for Research in Family Practice and Primary Care Cleveland, New Brunswick, Allentown, and San Antonio. We are grateful to the physicians, staff, and patients from the 12 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Angela Henke from the Department of Family Medicine of the State University of New York at Buffalo, who provided coordination support for the analyses and collated the data tables. Evangeline Rodriguez from the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio assisted with manuscript preparation. Kurt C. Stange, MD, PhD, provided helpful comments on earlier drafts of this paper.

Related Resources

• The Virtual Office of the Surgeon General http://www.surgeongeneral.gov/tobacco/ This site contains several PDF files of patient-oriented materials based on the Public Health Service Clinical practice guideline.
• U.S. Centers for Disease Control and Prevention—Tobacco Information and Prevention Source (TIPS) http://www.cdc.gov/tobacco Tips for adults, clinicians and youths about how to treat and prevent tobacco use.
• QuitNet " target="_blank">http://www.quitnet.com/BR> QuitNet offers an online support community, forums moderated by counselors, and individually tailored advice to help smokers kick their nicotine addiction.
• California Smokers’ Helpline http://www.nobutts.ucsd.edu/ This site was created to be both fun and informative. A must for patients who are ready to quit or just thinking about it.

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.

The research team included 6 members representing a broad range of perspectives, including family medicine, health services research, epidemiology, psychology, anthropology, and sociology. We used an iterative analysis and interpretation process that evolved over time as the team became more familiar with the data.¹⁹ Two immediate objectives were identified: (1) to develop a classification system that could be used to describe how physicians address smoking cessation, and (2) to identify factors that may enhance or impede the degree of adherence to the clinical smoking cessation guideline.² First, the team selected 18 encounters for reading and discussion by all research team members. For each of these encounters, one team member read the narrative out loud, and then the team discussed at length their understanding and assessment of what had taken place. Narrative data from the chart audit and physician interviews were considered as the discussion proceeded. During these discussions, preliminary schemes for classifying and assessing the encounters were developed.

The team was then divided into 3 groups of 2, and each group was assigned approximately 10 encounters for reading and for further development of the initial schemes. To ensure that each group member’s evaluation was independent, each member wrote a description and evaluation of each encounter without having read what the other member had written. The classifications and evaluations were then shared with the other member and the entire research team. Multiple team discussions were used to address differences in interpretation and to identify salient patterns within the data.

After discussing the initial 48 encounters, the remaining 43 encounters were analyzed. The same process of intragroup blind review was followed, and at this point, a nearly complete list of patterns and other important features seen within the encounters was established. Analysis and discussion by the entire research team led to agreement on the classification and evaluation of each of the 91 encounters.

To test the possibility that a single observer may introduce observer bias, the research team analyzed 51 additional clinical encounters with 9 family physicians in 5 different practices by a different research nurse. The 3 teams used the same blinded iterative process. These encounters were reviewed, looking for new patterns of smoking cessation counseling or confirmation of the patterns previously identified.

Results

We observed between 2 and 7 encounters of 20 family physicians in 7 practices Table 1. Five clear patterns were discernable according to the level of tobacco counseling and the type of visit. They represent a hierarchy that ranges from optimal smoking cessation counseling during visits when it was appropriate, to visits during which other agendas were appropriately given higher priority, to deficient missed opportunities. No additional patterns of interaction of smoking cessation counseling were identified among the 51 additional encounters audited.

In nearly half of the visits physicians either followed recommendations (21%), or competing priorities within the encounter reasonably overrode tobacco counseling (24%). In the other encounters tobacco cessation counseling fell short of recommendations, including visits among patients being seen for acute respiratory illnesses or other smoking-related illnesses. This failure often occurred despite the presence of a reminder system that identified the patient as a smoker. In 9% (8 cases) the physicians explicitly told the observing research nurse that they would not address tobacco with a specific patient because of a preconception that the patient would not respond.

Patterns of Tobacco Counseling

Good counseling
Good quality cessation counseling occurred in 21% of the encounters, during which physicians offered appropriate brief interventions depending on patients’ willingness to quit at that visit. Three levels of intervention were discernible within this first pattern. The 5A’s occurred when patients requested help, emphatically said “yes” when asked if they were interested in quitting, or when they responded positively to the physician’s description of pharmacologic options to help quit smoking. Patients were offered only 3A’s if they indicated they were not ready to quit by explicitly saying so or by staying quiet after an inquiry about their willingness to quit. Eleven physicians (55%) had at least 1 encounter with a smoker in which the physicians demonstrated good quality smoking cessation intervention, indicating that they had the knowledge and skill to provide recommended smoking cessation strategies.

Competing demands
Another common pattern was when a smoking cessation agenda was appropriately overridden by higher priorities. This occurred in 24% of the encounters. These were visits during which the physician-patient interaction was less straightforward than simply history taking, diagnosis, and treatment. In 10 encounters the top priority was alleviation of acute pain. Examples included abdominal pain, chest pain, back pain related to pyelonephritis, and severe rib pain after trauma. During 6 encounters patients were experiencing psychological distress, including anxiety attack, anger, a hypomanic breakdown, and depression. In some encounters it became clear that higher-priority competing demands took precedence as a result of a patient-driven agenda (eg, a discussion about care from multiple consultants or a lengthy discussion about multiple medications) or a physician-driven agenda (eg, a first visit for a patient with a complex medical problem squeezed into an acute visit time slot). In reviewing these encounters, the research team agreed that the competing priorities were appropriately important to reasonably not expect discussion of tobacco cessation.

Failure in non–smoking-related visit
A third common pattern was seen in 27% of encounters in which the physician failed to address smoking cessation in a non–smoking-related illness visit during which competing demands were low. In the vast majority of these (14 of 20), failure occurred despite having a reminder system for smoking cessation in place. Examples of visits in this pattern included consults for skin conditions (eg, boil or rash) or follow-up of stable back pain.

Failure in smoking-related visit
Although a smoking related-illness often triggered counseling, another common pattern was for physicians to fail to address smoking in patients presenting with acute respiratory illnesses or other chronic conditions related to smoking. This occurred in 22% of cases, including 10 encounters in which the physician failed to even ask the patient’s smoking status. In 7 of 17 encounters the physician did ask the patient if he or she smoked; in 3 they advised patients to stop smoking, but did not follow though with assessing readiness to change or offering assistance to help the patient quit smoking. Most visits (12 cases) following this pattern failed to address tobacco use for acute upper respiratory symptoms (eg, sore throat, nasal congestion, “sinus,” severe cough).

Failure in health maintenance visit
Finally, a fifth pattern emerged when smoking cessation was not fully addressed in health maintenance visits. In the 2 encounters where this occurred, the physician did ask about smoking status as part of the history taking but did not assess the patient’s readiness to change or offer assistance. It should be noted that 3 of the 5 health maintenance examinations were of good quality tobacco counseling.

Discussion

Our study confirms previous reports of poor compliance with a smoking cessation practice guideline that recommends assessment and consideration of counseling at every visit.^7-12 We found that reliance on a reminder system to identify smokers was often not sufficient to prompt smoking cessation interventions, even during visits for tobacco-related problems.²⁰ In our study, however, more than one half of the physicians demonstrated that they have the skills needed to provide good quality brief intervention for smoking cessation,² and one fourth of the smokers received good quality tobacco counseling.

An important new finding in our study is the documentation of competing demands and priorities during encounters with smokers in primary care practices. In almost 25% of visits by smokers the smoking cessation agenda was appropriately overridden by competing demands (eg, acute pain, acute psychological distress, and other important demands). This finding shows that guidelines that recommend assessment and counseling at every visit are unrealistic, and if followed may not lead to optimal integration and individualization of primary care services.¹⁷ However, the finding of “appropriately missed opportunities” makes it imperative that tobacco cessation counseling be reliably integrated during all other visits with smokers when these competing demands are not present. Visits for well care and tobacco-related illnesses represent teachable moments that should not be missed.

Limitations

Although our study provides important and novel insights into the delivery of tobacco interventions in primary care, it has limitations. The physicians and practices represented here were purposely selected from the larger Prevention and Competing Demands Study and are not representative of the universe of family practices in Nebraska or the United States. Because the study relied on descriptions recorded by an observer, it is possible that subtle communication nuances between the patient and physician may have been missed. Nevertheless, the observer was specifically focused on preventive service delivery, so important details of the encounter are likely to have been captured. We explored the possibility of observer bias by a single observer by expanding an audit of encounters to other practices, physicians, and observers, and we failed to detect additional patterns of delivery. Finally, these patient encounters are only a cross-sectional window into these physicians’ smoking cessation practices.

Conclusions

Our study has important implications for improving delivery of tobacco cessation services in primary care practices. Although many physicians demonstrated basic skills for delivering brief smoking cessation interventions, it is clear that most have not adopted the model of tobacco use disorder as a chronic disease that needs to be addressed at every visit.² Reliance on guidelines and office system tools without the adoption of this model is unlikely to result in higher rates of tobacco cessation. Thus, there is a need to develop interventions that encourage the adoption of this illness model and to develop systems to support tobacco counseling during visits that don’t include overriding important competing opportunities.

Acknowledgments

Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a Family Practice Research Center grant from the American Academy of Family Physicians. Drs Jaén, Flocke, and Crabtree are associated with the Center for Research in Family Practice and Primary Care Cleveland, New Brunswick, Allentown, and San Antonio. We are grateful to the physicians, staff, and patients from the 12 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Angela Henke from the Department of Family Medicine of the State University of New York at Buffalo, who provided coordination support for the analyses and collated the data tables. Evangeline Rodriguez from the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio assisted with manuscript preparation. Kurt C. Stange, MD, PhD, provided helpful comments on earlier drafts of this paper.

Related Resources

• The Virtual Office of the Surgeon General http://www.surgeongeneral.gov/tobacco/ This site contains several PDF files of patient-oriented materials based on the Public Health Service Clinical practice guideline.
• U.S. Centers for Disease Control and Prevention—Tobacco Information and Prevention Source (TIPS) http://www.cdc.gov/tobacco Tips for adults, clinicians and youths about how to treat and prevent tobacco use.
• QuitNet " target="_blank">http://www.quitnet.com/BR> QuitNet offers an online support community, forums moderated by counselors, and individually tailored advice to help smokers kick their nicotine addiction.
• California Smokers’ Helpline http://www.nobutts.ucsd.edu/ This site was created to be both fun and informative. A must for patients who are ready to quit or just thinking about it.