User login
Physicians’ Advice to Quit Smoking
METHODS: We examined data from the ationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year.
RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations.
CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.
Cigarette smoking is the leading preventable cause of death and disability in the United States.1 Because the majority of people who smoke visit a physician each year, physicians are in a key position to promote cessation.2 Although some research has suggested that simple physician cessation counseling without additional counseling or pharmacotherapy does not improve long-term cessation rates,3-5 most studies,6-8 including the 1996 Agency for Health Care Policy and Research (AHCPR) Tobacco Cessation Guideline9 and a recent Cochrane Collaboration review,10 suggest that even simple advice from a physician is effective in promoting long-term cessation, and the AHCPR guideline gave cessation counseling its highest recommendation.
However, in 1991 only 37% of smokers nationally reported being advised to quit by their providers during the previous year.2 The authors of another study11 estimated that 46% of smokers in Rhode Island had been advised to quit in 1990, and the Stanford Five-City Project12 reported that only 50% of smokers in 1989 to 1990 had ever been advised to quit. Although cessation counseling was reported to have almost doubled from 1991 to 1993, it then declined by 1995.13 Factors observed to be associated with a greater likelihood of cessation advice include seeing a primary care physician, having a routine checkup, having cardiovascular or chronic pulmonary disease, and being pregnant.2,11,14,15 Some studies have shown that minority group members are less likely to have received cessation advice.2,15 Other studies have revealed a mixed picture, showing Hispanics to be less likely to receive counseling12,14 and African Americans more likely to receive this advice,14 or no difference.13
We measured the percentage of smokers reporting they had received smoking cessation advice from a physician during a 12-month interval, using data from a recent nationally representative survey. Also, we investigated relationships between the odds of respondents reporting cessation advice from a physician and respondents’ characteristics, including sociodemographic factors, health insurance status, physician continuity, intensity of smoking, and health status.
Methods
Data Source
We used data from the Community Tracking Study (CTS) Household Survey conducted in 1996 and 1997,16 a telephone survey of individuals representing the US housed, noninstitutionalized population. The survey used a stratified multistage area probability sampling design, and information was recorded about smoking behaviors and interventions, sociodemographics, health insurance, utilization, and health status. For our study, we included the 8229 subjects aged 18 years and older who were current smokers and had made at least one visit to a physician in the previous 12 months.
Dependent Variable
Subjects were asked: “During the past 12 months, did any medical doctor advise you to stop smoking?” This measure has demonstrated reliability and validity.12,17
Independent Variables
We included sociodemographics (age, sex, education, household income as a percentage of poverty level, race or ethnicity, employment status, and residence location), health insurance status, usual care location, provider continuity, smoking intensity, utilization (number of physician visits, emergency room visits, and hospitalizations) and the physical and mental component summary scales of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) for perceived health status.18
Analysis
We used weights provided on the public use files to yield population estimates adjusted for survey oversampling and nonresponse. Because of the complex survey design of the CTS, we conducted analyses with SUDAAN19 software, which uses the method of Taylor series linearization for producing appropriate standard errors and 95% confidence intervals. Logistic regression analyses were performed to obtain odds ratios adjusted for potential confounders.
Results
The baseline characteristics of the sample are presented in Table 1. Overall, 48% of subjects, all of whom were smokers who had visited a clinic at least once in 12 months, had received cessation advice from a physician during this time period. Persons reporting the highest prevalence of cessation advice (>56%) included those who smoked more than 2 packs per day, had perceived health status categorized as fair or poor, had at least one hospitalization, made 4 or more physician visits, were aged 65 years or older, had Medicare, or had military coverage. Persons reporting the lowest prevalence of cessation advice (<40%) included those who lacked health insurance, did not smoke every day, lacked a usual care site or identified an emergency room or other location, had perceived health status categorized as excellent, or had made only one visit to a physician in 12 months.
Multivariate evaluation Table 2 revealed lower odds of receiving advice among persons who were younger, men, African American, uninsured, healthier on the SF-12 subscales, lower users of health care services, lighter smokers, or who lacked a usual care location or used an emergency room or other location. The odds of receiving advice were increased for persons with military health insurance and those who received their care in hospital clinics.
Discussion
Less than 50% of the surveyed patients reported that they had been counseled to quit smoking by a physician during the 12-month period. This finding is similar to earlier published reports,2,11-13 indicating that little progress has been made toward achieving national health goals for 20009,20 and performance standards for health plans.21 Since by 1996 and 1997, the years the CTS was administered, ample evidence supported use of brief motivational counseling,6-9 it is unfortunate that rates of physicians’ cessation counseling advice had not improved substantially compared with earlier reports. Further, the low rate of physician cessation advice we observed likely indicates that more intensive cessation services were even less frequently offered. For example, the benefits of pharmacotherapy had been well documented by the time the CTS was administered,22 but it seems unlikely that medications for cessation would have been recommended to respondents who reported they did not receive cessation advice.
We observed significant associations between lower rates of physicians’ cessation advice and several patient factors. First, lower rates of physician counseling were reported by persons with the lowest current burden of smoking-related illness, including those who were younger, had better perceived health status, and had lower smoking intensity. Although greater attention to persons with end-organ damage is understandable, cessation advice for primary prevention, such as to younger persons, might yield the greatest long-term benefit. Second, men were less likely to report receiving cessation advice, even after adjusting for their lower utilization of health care services. This finding, consistent with observations indicating that men are much less likely than women to receive preventive care,23 suggests that approaches to helping men become more effective consumers of health care need to be developed.24 Third, respondents who lacked a usual care location or used an emergency room or other location were less likely to report they received cessation advice, supporting approaches to health care delivery that promote continuity of care. Fourth, persons who lacked health insurance were less likely to report they received cessation advice independent of other factors. Given that such persons frequently face myriad obstacles to accessing health care, including financial barriers to pharmacotherapy for cessation, efforts aimed at increasing the provision of cessation counseling services to these persons are warranted. Finally, the lower rates of physician counseling among African Americans, independent of other factors, demands attention, especially because African Americans have been targeted by cigarette manufacturers, advertisers, and merchants.24-28 Efforts to increase cessation counseling provided to African Americans who smoke might help reduce disparities in health status.
Limitations
Our study is subject to several limitations. It is difficult to assess the reliability and validity of patient reports, and it is possible that recall of physicians’ advice to quit could deteriorate as the interval between administration of the survey and the clinical encounter lengthened. However, past studies have supported the validity of patient report of physicians’ cessation advice.12,17 Also, although we were not able to account for the time interval since the last visit, we were able to adjust for respondents’ total number of clinical encounters in 12 months. Given that respondents had roughly 4 visits on average, we believe the magnitude of recall bias would be low.
Although it is possible that the observed relationships could be the result of confounding by unmeasured or incompletely measured factors, the richness of our data source allowed us to control for a wide range of potential confounders. The inferences that can be drawn from these results are further strengthened by the survey design and the recency of the data.
Many physician-level and system-level factors could not be evaluated, so future exploration of contextual factors is warranted. What specific features of hospital clinics, health maintenance organizations, or military coverage account for higher rates of cessation advice? Might physicians who practice in such settings have greater access to systems that help identify smokers, thereby improving cessation interventions?
Conclusions
Although the 1996 AHCPR smoking cessation guideline9 gives counseling its highest recommendation, our findings suggest that physicians are performing poorly on this measure, with little improvement since the early 1990s. Many physicians might benefit from being trained in the use of brief counseling techniques that have been found effective.9,10 System changes designed to promote cessation should be implemented in clinical settings. For example, physicians are more likely to provide cessation advice when patients’ smoking status is routinely identified in the medical record.29,30,31 Funds from tobacco settlements could provide the funding for system-level interventions but reportedly are infrequently being applied toward smoking cessation efforts.32
Tobacco cessation has received increasing attention, especially because the effectiveness of counseling and pharmacotherapy has been unequivocally demonstrated during the past several years. However, this study reveals a troubling lack of improvement in physicians’ cessation advice during this time. Sometimes 50% means the glass is half full. However, given the serious health consequences of tobacco use and the demonstrated benefit of physicians’ advice to quit,6-10 in this situation the glass remains half empty.
Acknowledgments
Our study was funded in part through the Robert Wood Johnson Foundation under its Changes in Health Care Financing and Organization Program.
1. for Disease Control and Prevention. Reducing the health consequences of smoking: 25 years of progress-a report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1989. DHHS publication no. (CDC) 89-8411.
2. for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit: United States, 1991. MMWR Morb Mortal Wkly Rep 1993;42:854-57.
3. SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation: a randomized trial of the “Quit for Life” program. Ann Intern Med 1989;110:640-47.
4. SR, Richard RJ, Duncan CL, et al. Training physicians about smoking cessation: a controlled trial in private practices. J Gen Intern Med 1989;4:482-29.
5. H, Susman JL, Davis C, Gilbert C. Physician counseling for smoking cessation: is the glass half empty? J Fam Pract 1995;40:148-52.
6. MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. BMJ 1979;2:231-35.
7. D, Wood G, Johnston N, Sicuvella J. Randomized clinical trial of supportive follow-up for cigarette smokers in a family practice. Can Med Assoc J 1982;126:127-29.
8. JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1-8.
9. MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1996. AHCPR publication no. 96-0692.
10. C, Ketteridge S. Physician advice for smoking cessation. In: The Cochrane library Oxford, England: Update Software; 1999.
11. MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med 1997;157:1313-19.
12. E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physician’s smoking cessation advice. JAMA 1991;266:3139-44.
13. AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604-8.
14. EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549-53.
15. RF, Remington PL, Sienko DG, Davis RM. Are physicians advising smokers to quit? The patient’s perspective. JAMA 1987;257:1916-19.
16. P, Blumenthal D, Corrigan JM, et al. The design of the community tracking study: a longitudinal study of health system change and its effects on people. Inquiry 1996;33:195-206.
17. SP, Sallis JF, Magnus PM, Farquhar JW. Attitudes and practices of physicians regarding hypertension and smoking: the Stanford Five City Project. Prev Med 1985;14:70-80.
18. J , Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33.
19. Triangle Institute. SUDAAN. Professional software for survey data analysis. Version 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
20. Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services; 1991. Publication (PHS) 91-50213.
21. Committee for Quality Assurance. HEDIS 3.0, vol 2: technical specifications. Washington, DC: National Committee for Quality Assurance; 1997.
22. MC, Smith SS, Jorenby DE, Baker TB. The effectiveness of the nicotine patch for smoking cessation: a meta-analysis. JAMA 1994;271:1940-47.
23. R, Lion J, Anderson OW. Two decades of health services research: social survey trends in use and expenditures. Cambridge, Mass: Ballinger; 1976.
24. P, Clancy CM, Naumburg EH. Sex, access, and excess. Ann Intern Med 1995;123:548-50.
25. CC, Yanek LR, Stillman FA, Becker DM. Reducing cigarette sales to minors in an urban setting: issues and opportunities for merchant intervention. Am J Prev Med 1998;14:138-42.
26. CC, Swank RT, Stillman FA, Harris DX, Watson HW, Becker DM. Cigarette sales to African-American and white minors in low-income areas of Baltimore. Am J Public Health 1997;87:652-54.
27. RM. Current trends in cigarette advertising and marketing. N Engl J Med 1987;216:725-32.
28. R. Race, sex, economics and tobacco advertising. J Natl Med Assoc 1989;81:1119-24.
29. KM, Giovino G, Mendicino AJ. Cigarette advertising and black-white differences in brand preference. Public Health Rep 1987;102:699-701.
30. MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70:209-13.
31. SJ, Christen AG, Katz BP, et al. Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders. Am J Public Health 1987;77:313-16.
32. G. States plan assorted uses for tobacco settlement. Wall Street Journal New York, NY; August 24, 1999:A4.
METHODS: We examined data from the ationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year.
RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations.
CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.
Cigarette smoking is the leading preventable cause of death and disability in the United States.1 Because the majority of people who smoke visit a physician each year, physicians are in a key position to promote cessation.2 Although some research has suggested that simple physician cessation counseling without additional counseling or pharmacotherapy does not improve long-term cessation rates,3-5 most studies,6-8 including the 1996 Agency for Health Care Policy and Research (AHCPR) Tobacco Cessation Guideline9 and a recent Cochrane Collaboration review,10 suggest that even simple advice from a physician is effective in promoting long-term cessation, and the AHCPR guideline gave cessation counseling its highest recommendation.
However, in 1991 only 37% of smokers nationally reported being advised to quit by their providers during the previous year.2 The authors of another study11 estimated that 46% of smokers in Rhode Island had been advised to quit in 1990, and the Stanford Five-City Project12 reported that only 50% of smokers in 1989 to 1990 had ever been advised to quit. Although cessation counseling was reported to have almost doubled from 1991 to 1993, it then declined by 1995.13 Factors observed to be associated with a greater likelihood of cessation advice include seeing a primary care physician, having a routine checkup, having cardiovascular or chronic pulmonary disease, and being pregnant.2,11,14,15 Some studies have shown that minority group members are less likely to have received cessation advice.2,15 Other studies have revealed a mixed picture, showing Hispanics to be less likely to receive counseling12,14 and African Americans more likely to receive this advice,14 or no difference.13
We measured the percentage of smokers reporting they had received smoking cessation advice from a physician during a 12-month interval, using data from a recent nationally representative survey. Also, we investigated relationships between the odds of respondents reporting cessation advice from a physician and respondents’ characteristics, including sociodemographic factors, health insurance status, physician continuity, intensity of smoking, and health status.
Methods
Data Source
We used data from the Community Tracking Study (CTS) Household Survey conducted in 1996 and 1997,16 a telephone survey of individuals representing the US housed, noninstitutionalized population. The survey used a stratified multistage area probability sampling design, and information was recorded about smoking behaviors and interventions, sociodemographics, health insurance, utilization, and health status. For our study, we included the 8229 subjects aged 18 years and older who were current smokers and had made at least one visit to a physician in the previous 12 months.
Dependent Variable
Subjects were asked: “During the past 12 months, did any medical doctor advise you to stop smoking?” This measure has demonstrated reliability and validity.12,17
Independent Variables
We included sociodemographics (age, sex, education, household income as a percentage of poverty level, race or ethnicity, employment status, and residence location), health insurance status, usual care location, provider continuity, smoking intensity, utilization (number of physician visits, emergency room visits, and hospitalizations) and the physical and mental component summary scales of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) for perceived health status.18
Analysis
We used weights provided on the public use files to yield population estimates adjusted for survey oversampling and nonresponse. Because of the complex survey design of the CTS, we conducted analyses with SUDAAN19 software, which uses the method of Taylor series linearization for producing appropriate standard errors and 95% confidence intervals. Logistic regression analyses were performed to obtain odds ratios adjusted for potential confounders.
Results
The baseline characteristics of the sample are presented in Table 1. Overall, 48% of subjects, all of whom were smokers who had visited a clinic at least once in 12 months, had received cessation advice from a physician during this time period. Persons reporting the highest prevalence of cessation advice (>56%) included those who smoked more than 2 packs per day, had perceived health status categorized as fair or poor, had at least one hospitalization, made 4 or more physician visits, were aged 65 years or older, had Medicare, or had military coverage. Persons reporting the lowest prevalence of cessation advice (<40%) included those who lacked health insurance, did not smoke every day, lacked a usual care site or identified an emergency room or other location, had perceived health status categorized as excellent, or had made only one visit to a physician in 12 months.
Multivariate evaluation Table 2 revealed lower odds of receiving advice among persons who were younger, men, African American, uninsured, healthier on the SF-12 subscales, lower users of health care services, lighter smokers, or who lacked a usual care location or used an emergency room or other location. The odds of receiving advice were increased for persons with military health insurance and those who received their care in hospital clinics.
Discussion
Less than 50% of the surveyed patients reported that they had been counseled to quit smoking by a physician during the 12-month period. This finding is similar to earlier published reports,2,11-13 indicating that little progress has been made toward achieving national health goals for 20009,20 and performance standards for health plans.21 Since by 1996 and 1997, the years the CTS was administered, ample evidence supported use of brief motivational counseling,6-9 it is unfortunate that rates of physicians’ cessation counseling advice had not improved substantially compared with earlier reports. Further, the low rate of physician cessation advice we observed likely indicates that more intensive cessation services were even less frequently offered. For example, the benefits of pharmacotherapy had been well documented by the time the CTS was administered,22 but it seems unlikely that medications for cessation would have been recommended to respondents who reported they did not receive cessation advice.
We observed significant associations between lower rates of physicians’ cessation advice and several patient factors. First, lower rates of physician counseling were reported by persons with the lowest current burden of smoking-related illness, including those who were younger, had better perceived health status, and had lower smoking intensity. Although greater attention to persons with end-organ damage is understandable, cessation advice for primary prevention, such as to younger persons, might yield the greatest long-term benefit. Second, men were less likely to report receiving cessation advice, even after adjusting for their lower utilization of health care services. This finding, consistent with observations indicating that men are much less likely than women to receive preventive care,23 suggests that approaches to helping men become more effective consumers of health care need to be developed.24 Third, respondents who lacked a usual care location or used an emergency room or other location were less likely to report they received cessation advice, supporting approaches to health care delivery that promote continuity of care. Fourth, persons who lacked health insurance were less likely to report they received cessation advice independent of other factors. Given that such persons frequently face myriad obstacles to accessing health care, including financial barriers to pharmacotherapy for cessation, efforts aimed at increasing the provision of cessation counseling services to these persons are warranted. Finally, the lower rates of physician counseling among African Americans, independent of other factors, demands attention, especially because African Americans have been targeted by cigarette manufacturers, advertisers, and merchants.24-28 Efforts to increase cessation counseling provided to African Americans who smoke might help reduce disparities in health status.
Limitations
Our study is subject to several limitations. It is difficult to assess the reliability and validity of patient reports, and it is possible that recall of physicians’ advice to quit could deteriorate as the interval between administration of the survey and the clinical encounter lengthened. However, past studies have supported the validity of patient report of physicians’ cessation advice.12,17 Also, although we were not able to account for the time interval since the last visit, we were able to adjust for respondents’ total number of clinical encounters in 12 months. Given that respondents had roughly 4 visits on average, we believe the magnitude of recall bias would be low.
Although it is possible that the observed relationships could be the result of confounding by unmeasured or incompletely measured factors, the richness of our data source allowed us to control for a wide range of potential confounders. The inferences that can be drawn from these results are further strengthened by the survey design and the recency of the data.
Many physician-level and system-level factors could not be evaluated, so future exploration of contextual factors is warranted. What specific features of hospital clinics, health maintenance organizations, or military coverage account for higher rates of cessation advice? Might physicians who practice in such settings have greater access to systems that help identify smokers, thereby improving cessation interventions?
Conclusions
Although the 1996 AHCPR smoking cessation guideline9 gives counseling its highest recommendation, our findings suggest that physicians are performing poorly on this measure, with little improvement since the early 1990s. Many physicians might benefit from being trained in the use of brief counseling techniques that have been found effective.9,10 System changes designed to promote cessation should be implemented in clinical settings. For example, physicians are more likely to provide cessation advice when patients’ smoking status is routinely identified in the medical record.29,30,31 Funds from tobacco settlements could provide the funding for system-level interventions but reportedly are infrequently being applied toward smoking cessation efforts.32
Tobacco cessation has received increasing attention, especially because the effectiveness of counseling and pharmacotherapy has been unequivocally demonstrated during the past several years. However, this study reveals a troubling lack of improvement in physicians’ cessation advice during this time. Sometimes 50% means the glass is half full. However, given the serious health consequences of tobacco use and the demonstrated benefit of physicians’ advice to quit,6-10 in this situation the glass remains half empty.
Acknowledgments
Our study was funded in part through the Robert Wood Johnson Foundation under its Changes in Health Care Financing and Organization Program.
METHODS: We examined data from the ationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year.
RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations.
CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.
Cigarette smoking is the leading preventable cause of death and disability in the United States.1 Because the majority of people who smoke visit a physician each year, physicians are in a key position to promote cessation.2 Although some research has suggested that simple physician cessation counseling without additional counseling or pharmacotherapy does not improve long-term cessation rates,3-5 most studies,6-8 including the 1996 Agency for Health Care Policy and Research (AHCPR) Tobacco Cessation Guideline9 and a recent Cochrane Collaboration review,10 suggest that even simple advice from a physician is effective in promoting long-term cessation, and the AHCPR guideline gave cessation counseling its highest recommendation.
However, in 1991 only 37% of smokers nationally reported being advised to quit by their providers during the previous year.2 The authors of another study11 estimated that 46% of smokers in Rhode Island had been advised to quit in 1990, and the Stanford Five-City Project12 reported that only 50% of smokers in 1989 to 1990 had ever been advised to quit. Although cessation counseling was reported to have almost doubled from 1991 to 1993, it then declined by 1995.13 Factors observed to be associated with a greater likelihood of cessation advice include seeing a primary care physician, having a routine checkup, having cardiovascular or chronic pulmonary disease, and being pregnant.2,11,14,15 Some studies have shown that minority group members are less likely to have received cessation advice.2,15 Other studies have revealed a mixed picture, showing Hispanics to be less likely to receive counseling12,14 and African Americans more likely to receive this advice,14 or no difference.13
We measured the percentage of smokers reporting they had received smoking cessation advice from a physician during a 12-month interval, using data from a recent nationally representative survey. Also, we investigated relationships between the odds of respondents reporting cessation advice from a physician and respondents’ characteristics, including sociodemographic factors, health insurance status, physician continuity, intensity of smoking, and health status.
Methods
Data Source
We used data from the Community Tracking Study (CTS) Household Survey conducted in 1996 and 1997,16 a telephone survey of individuals representing the US housed, noninstitutionalized population. The survey used a stratified multistage area probability sampling design, and information was recorded about smoking behaviors and interventions, sociodemographics, health insurance, utilization, and health status. For our study, we included the 8229 subjects aged 18 years and older who were current smokers and had made at least one visit to a physician in the previous 12 months.
Dependent Variable
Subjects were asked: “During the past 12 months, did any medical doctor advise you to stop smoking?” This measure has demonstrated reliability and validity.12,17
Independent Variables
We included sociodemographics (age, sex, education, household income as a percentage of poverty level, race or ethnicity, employment status, and residence location), health insurance status, usual care location, provider continuity, smoking intensity, utilization (number of physician visits, emergency room visits, and hospitalizations) and the physical and mental component summary scales of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) for perceived health status.18
Analysis
We used weights provided on the public use files to yield population estimates adjusted for survey oversampling and nonresponse. Because of the complex survey design of the CTS, we conducted analyses with SUDAAN19 software, which uses the method of Taylor series linearization for producing appropriate standard errors and 95% confidence intervals. Logistic regression analyses were performed to obtain odds ratios adjusted for potential confounders.
Results
The baseline characteristics of the sample are presented in Table 1. Overall, 48% of subjects, all of whom were smokers who had visited a clinic at least once in 12 months, had received cessation advice from a physician during this time period. Persons reporting the highest prevalence of cessation advice (>56%) included those who smoked more than 2 packs per day, had perceived health status categorized as fair or poor, had at least one hospitalization, made 4 or more physician visits, were aged 65 years or older, had Medicare, or had military coverage. Persons reporting the lowest prevalence of cessation advice (<40%) included those who lacked health insurance, did not smoke every day, lacked a usual care site or identified an emergency room or other location, had perceived health status categorized as excellent, or had made only one visit to a physician in 12 months.
Multivariate evaluation Table 2 revealed lower odds of receiving advice among persons who were younger, men, African American, uninsured, healthier on the SF-12 subscales, lower users of health care services, lighter smokers, or who lacked a usual care location or used an emergency room or other location. The odds of receiving advice were increased for persons with military health insurance and those who received their care in hospital clinics.
Discussion
Less than 50% of the surveyed patients reported that they had been counseled to quit smoking by a physician during the 12-month period. This finding is similar to earlier published reports,2,11-13 indicating that little progress has been made toward achieving national health goals for 20009,20 and performance standards for health plans.21 Since by 1996 and 1997, the years the CTS was administered, ample evidence supported use of brief motivational counseling,6-9 it is unfortunate that rates of physicians’ cessation counseling advice had not improved substantially compared with earlier reports. Further, the low rate of physician cessation advice we observed likely indicates that more intensive cessation services were even less frequently offered. For example, the benefits of pharmacotherapy had been well documented by the time the CTS was administered,22 but it seems unlikely that medications for cessation would have been recommended to respondents who reported they did not receive cessation advice.
We observed significant associations between lower rates of physicians’ cessation advice and several patient factors. First, lower rates of physician counseling were reported by persons with the lowest current burden of smoking-related illness, including those who were younger, had better perceived health status, and had lower smoking intensity. Although greater attention to persons with end-organ damage is understandable, cessation advice for primary prevention, such as to younger persons, might yield the greatest long-term benefit. Second, men were less likely to report receiving cessation advice, even after adjusting for their lower utilization of health care services. This finding, consistent with observations indicating that men are much less likely than women to receive preventive care,23 suggests that approaches to helping men become more effective consumers of health care need to be developed.24 Third, respondents who lacked a usual care location or used an emergency room or other location were less likely to report they received cessation advice, supporting approaches to health care delivery that promote continuity of care. Fourth, persons who lacked health insurance were less likely to report they received cessation advice independent of other factors. Given that such persons frequently face myriad obstacles to accessing health care, including financial barriers to pharmacotherapy for cessation, efforts aimed at increasing the provision of cessation counseling services to these persons are warranted. Finally, the lower rates of physician counseling among African Americans, independent of other factors, demands attention, especially because African Americans have been targeted by cigarette manufacturers, advertisers, and merchants.24-28 Efforts to increase cessation counseling provided to African Americans who smoke might help reduce disparities in health status.
Limitations
Our study is subject to several limitations. It is difficult to assess the reliability and validity of patient reports, and it is possible that recall of physicians’ advice to quit could deteriorate as the interval between administration of the survey and the clinical encounter lengthened. However, past studies have supported the validity of patient report of physicians’ cessation advice.12,17 Also, although we were not able to account for the time interval since the last visit, we were able to adjust for respondents’ total number of clinical encounters in 12 months. Given that respondents had roughly 4 visits on average, we believe the magnitude of recall bias would be low.
Although it is possible that the observed relationships could be the result of confounding by unmeasured or incompletely measured factors, the richness of our data source allowed us to control for a wide range of potential confounders. The inferences that can be drawn from these results are further strengthened by the survey design and the recency of the data.
Many physician-level and system-level factors could not be evaluated, so future exploration of contextual factors is warranted. What specific features of hospital clinics, health maintenance organizations, or military coverage account for higher rates of cessation advice? Might physicians who practice in such settings have greater access to systems that help identify smokers, thereby improving cessation interventions?
Conclusions
Although the 1996 AHCPR smoking cessation guideline9 gives counseling its highest recommendation, our findings suggest that physicians are performing poorly on this measure, with little improvement since the early 1990s. Many physicians might benefit from being trained in the use of brief counseling techniques that have been found effective.9,10 System changes designed to promote cessation should be implemented in clinical settings. For example, physicians are more likely to provide cessation advice when patients’ smoking status is routinely identified in the medical record.29,30,31 Funds from tobacco settlements could provide the funding for system-level interventions but reportedly are infrequently being applied toward smoking cessation efforts.32
Tobacco cessation has received increasing attention, especially because the effectiveness of counseling and pharmacotherapy has been unequivocally demonstrated during the past several years. However, this study reveals a troubling lack of improvement in physicians’ cessation advice during this time. Sometimes 50% means the glass is half full. However, given the serious health consequences of tobacco use and the demonstrated benefit of physicians’ advice to quit,6-10 in this situation the glass remains half empty.
Acknowledgments
Our study was funded in part through the Robert Wood Johnson Foundation under its Changes in Health Care Financing and Organization Program.
1. for Disease Control and Prevention. Reducing the health consequences of smoking: 25 years of progress-a report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1989. DHHS publication no. (CDC) 89-8411.
2. for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit: United States, 1991. MMWR Morb Mortal Wkly Rep 1993;42:854-57.
3. SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation: a randomized trial of the “Quit for Life” program. Ann Intern Med 1989;110:640-47.
4. SR, Richard RJ, Duncan CL, et al. Training physicians about smoking cessation: a controlled trial in private practices. J Gen Intern Med 1989;4:482-29.
5. H, Susman JL, Davis C, Gilbert C. Physician counseling for smoking cessation: is the glass half empty? J Fam Pract 1995;40:148-52.
6. MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. BMJ 1979;2:231-35.
7. D, Wood G, Johnston N, Sicuvella J. Randomized clinical trial of supportive follow-up for cigarette smokers in a family practice. Can Med Assoc J 1982;126:127-29.
8. JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1-8.
9. MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1996. AHCPR publication no. 96-0692.
10. C, Ketteridge S. Physician advice for smoking cessation. In: The Cochrane library Oxford, England: Update Software; 1999.
11. MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med 1997;157:1313-19.
12. E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physician’s smoking cessation advice. JAMA 1991;266:3139-44.
13. AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604-8.
14. EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549-53.
15. RF, Remington PL, Sienko DG, Davis RM. Are physicians advising smokers to quit? The patient’s perspective. JAMA 1987;257:1916-19.
16. P, Blumenthal D, Corrigan JM, et al. The design of the community tracking study: a longitudinal study of health system change and its effects on people. Inquiry 1996;33:195-206.
17. SP, Sallis JF, Magnus PM, Farquhar JW. Attitudes and practices of physicians regarding hypertension and smoking: the Stanford Five City Project. Prev Med 1985;14:70-80.
18. J , Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33.
19. Triangle Institute. SUDAAN. Professional software for survey data analysis. Version 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
20. Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services; 1991. Publication (PHS) 91-50213.
21. Committee for Quality Assurance. HEDIS 3.0, vol 2: technical specifications. Washington, DC: National Committee for Quality Assurance; 1997.
22. MC, Smith SS, Jorenby DE, Baker TB. The effectiveness of the nicotine patch for smoking cessation: a meta-analysis. JAMA 1994;271:1940-47.
23. R, Lion J, Anderson OW. Two decades of health services research: social survey trends in use and expenditures. Cambridge, Mass: Ballinger; 1976.
24. P, Clancy CM, Naumburg EH. Sex, access, and excess. Ann Intern Med 1995;123:548-50.
25. CC, Yanek LR, Stillman FA, Becker DM. Reducing cigarette sales to minors in an urban setting: issues and opportunities for merchant intervention. Am J Prev Med 1998;14:138-42.
26. CC, Swank RT, Stillman FA, Harris DX, Watson HW, Becker DM. Cigarette sales to African-American and white minors in low-income areas of Baltimore. Am J Public Health 1997;87:652-54.
27. RM. Current trends in cigarette advertising and marketing. N Engl J Med 1987;216:725-32.
28. R. Race, sex, economics and tobacco advertising. J Natl Med Assoc 1989;81:1119-24.
29. KM, Giovino G, Mendicino AJ. Cigarette advertising and black-white differences in brand preference. Public Health Rep 1987;102:699-701.
30. MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70:209-13.
31. SJ, Christen AG, Katz BP, et al. Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders. Am J Public Health 1987;77:313-16.
32. G. States plan assorted uses for tobacco settlement. Wall Street Journal New York, NY; August 24, 1999:A4.
1. for Disease Control and Prevention. Reducing the health consequences of smoking: 25 years of progress-a report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1989. DHHS publication no. (CDC) 89-8411.
2. for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit: United States, 1991. MMWR Morb Mortal Wkly Rep 1993;42:854-57.
3. SR, Coates TJ, Richard RJ, et al. Training physicians in counseling about smoking cessation: a randomized trial of the “Quit for Life” program. Ann Intern Med 1989;110:640-47.
4. SR, Richard RJ, Duncan CL, et al. Training physicians about smoking cessation: a controlled trial in private practices. J Gen Intern Med 1989;4:482-29.
5. H, Susman JL, Davis C, Gilbert C. Physician counseling for smoking cessation: is the glass half empty? J Fam Pract 1995;40:148-52.
6. MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. BMJ 1979;2:231-35.
7. D, Wood G, Johnston N, Sicuvella J. Randomized clinical trial of supportive follow-up for cigarette smokers in a family practice. Can Med Assoc J 1982;126:127-29.
8. JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1-8.
9. MC, Bailey WC, Cohen SJ, et al. Smoking cessation. Rockville, Md: US Department of Health and Human Services, Public Health Service; 1996. AHCPR publication no. 96-0692.
10. C, Ketteridge S. Physician advice for smoking cessation. In: The Cochrane library Oxford, England: Update Software; 1999.
11. MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med 1997;157:1313-19.
12. E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physician’s smoking cessation advice. JAMA 1991;266:3139-44.
13. AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604-8.
14. EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549-53.
15. RF, Remington PL, Sienko DG, Davis RM. Are physicians advising smokers to quit? The patient’s perspective. JAMA 1987;257:1916-19.
16. P, Blumenthal D, Corrigan JM, et al. The design of the community tracking study: a longitudinal study of health system change and its effects on people. Inquiry 1996;33:195-206.
17. SP, Sallis JF, Magnus PM, Farquhar JW. Attitudes and practices of physicians regarding hypertension and smoking: the Stanford Five City Project. Prev Med 1985;14:70-80.
18. J , Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220-33.
19. Triangle Institute. SUDAAN. Professional software for survey data analysis. Version 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
20. Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services; 1991. Publication (PHS) 91-50213.
21. Committee for Quality Assurance. HEDIS 3.0, vol 2: technical specifications. Washington, DC: National Committee for Quality Assurance; 1997.
22. MC, Smith SS, Jorenby DE, Baker TB. The effectiveness of the nicotine patch for smoking cessation: a meta-analysis. JAMA 1994;271:1940-47.
23. R, Lion J, Anderson OW. Two decades of health services research: social survey trends in use and expenditures. Cambridge, Mass: Ballinger; 1976.
24. P, Clancy CM, Naumburg EH. Sex, access, and excess. Ann Intern Med 1995;123:548-50.
25. CC, Yanek LR, Stillman FA, Becker DM. Reducing cigarette sales to minors in an urban setting: issues and opportunities for merchant intervention. Am J Prev Med 1998;14:138-42.
26. CC, Swank RT, Stillman FA, Harris DX, Watson HW, Becker DM. Cigarette sales to African-American and white minors in low-income areas of Baltimore. Am J Public Health 1997;87:652-54.
27. RM. Current trends in cigarette advertising and marketing. N Engl J Med 1987;216:725-32.
28. R. Race, sex, economics and tobacco advertising. J Natl Med Assoc 1989;81:1119-24.
29. KM, Giovino G, Mendicino AJ. Cigarette advertising and black-white differences in brand preference. Public Health Rep 1987;102:699-701.
30. MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70:209-13.
31. SJ, Christen AG, Katz BP, et al. Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders. Am J Public Health 1987;77:313-16.
32. G. States plan assorted uses for tobacco settlement. Wall Street Journal New York, NY; August 24, 1999:A4.