Results
Ninety-one practices participated in the study (57%). Data from 1 site was lost when the research nurse’s briefcase was stolen. Another site did not allow us to audit charts, so their data were not included. Responding sites did not differ from nonrespondents in terms of physician sex, rural or urban locale, and group versus solo practice. The resultant sample was 43% urban and 30% solo practices (urban vs rural locale: c2=1.14, P=.286).
All of the physicians voiced the belief that smoking poses a significant health problem in their patient population and agreed that they needed to address this problem with their patients. Additionally, the majority (74.4%) felt confident about their smoking cessation counseling skills.
These attitudes, however, did not translate into the use of office-based activities for the majority of practices. The office-based activity score had a mean of 5.93 (standard deviation=2.47) with actual scores ranging from 0 to 13 out of a possible maximum 15. The Figure shows the distribution of these scores.
Sixty-six percent of the sites were either posted as nonsmoking or did not provide receptacles for smoking (Table). All of the sites had either an official (written) policy (51%) or an informal policy restricting staff smoking on the premises. Twenty-eight percent of practices had no physicians or staff who were tobacco users. Only 10% provided waiting room reading materials that were free of smoking advertisements. Twenty-one percent advertised in the waiting or reception area that help was available to stop smoking.
The majority of sites (78%) had patient education materials on smoking cessation, and 52% of these had materials placed so they were directly accessible to patients. More than half of the sites relied on pharmaceutical companies to supply these materials, the majority of which suggested the use of a nicotine replacement system. Almost two thirds of the practices used printed materials as their sole educational avenue, as opposed to including audiotapes and videotapes.
Involvement of support staff in office-based smoking cessation activities was limited. Designating a staff member to maintain patient education materials (24%) was the most common. Only 3 practices used support staff to assess tobacco use by asking about it while taking vital signs; one of these also had a person on site to counsel. In 5 additional practices a support person was involved in tobacco counseling or follow-up with patients attempting to quit.
Most physicians were not able to readily use the patient’s chart as an effective cue for identifying smokers at each visit. Smoking status was documented in 51% of the 1951 medical records reviewed but was seldom documented on the face sheet (13% of all records). In the majority of cases, documentation was generally located in the back of the chart on a health history questionnaire.
Discussion
In a meta-analysis of 39 controlled smoking cessation trials, Kottke and colleagues13 identified having the patient receive multiple cessation messages from both physicians and nonphysicians as an important common attribute of successful interventions in medical practice. Hollis and coworkers14 have shown that nurse involvement in smoking cessation counseling reduces physician burden, makes counseling more likely to occur, and increases cessation rates compared with brief physician advice only. Fiore and colleagues15 and Robinson and coworkers16 have reported that adding a question about smoking status to the vital signs portion of the progress note increased the likelihood of smoking-related discussions between patients and their physicians. These are only a few of the multitude of articles similar to those reported in the NCI monograph that support the effectiveness of including staff and support activities in a comprehensive office-based approach rather than solely a physician-based approach to smoking cessation. Most of the activities recommended are simple and do not involve considerable costs or additional staff time.
In our study, however, most physicians did not use office-based activities to support what they did individually, to increase avenues to provide cessation messages, or to create a cessation-friendly environment. Although most of the practices had an office environment that reduced cues to smoke by restricting smoking of patients and staff in the clinic, almost all provided reading materials promoting smoking in their advertisements. Few practices proactively supported the importance of cessation by means of visual cues or information on available help in the waiting room. Most did have easily accessible smoking cessation patient education materials; however, the majority of these were from pharmaceutical companies and were designed to promote the use of nicotine replacement therapy. Although these materials could be helpful in promoting cessation for those patients ready to quit, they are of little use for motivating the 80% to 90% of smokers who are not currently interested in quitting.17 In a significant majority of these practices, physician time was used for both the most mundane (identification) and the most important (motivation and counseling) aspects of smoking cessation. All of the physicians in our study indicated that smoking was a significant health problem in their patient population and believed it was their responsibility to address cessation with smoking patients. Our knowledge of effective cessation techniques has clearly outpaced these practices’ ability or desire to implement them.