BACKGROUND: Smoking is the leading cause of morbidity and mortality in the United States. Recommendations for increasing physician effectiveness in smoking cessation through the use of office-based activities have been disseminated, but the extent of implementation is unknown. We describe the degree to which selected family practices in Nebraska have implemented 15 specific office-based activities.
METHODS: We employed a cross-sectional integrated multimethod design. A research nurse observed a target physician and his or her staff during a 1-day visit in a random sample of 89 family practices. Data collection consisted of focused observation of the practice environment, key informant interviews, medical record reviews, and in-depth interviews with the physicians.
RESULTS: The majority of the practices sampled had an office environment that restricted smoking, but few used visual cessation messages or information in the waiting room offering help and encouraging patients to quit. Most had educational materials that were supplied by pharmaceutical companies for promoting nicotine replacement systems. These materials were easily accessible in more than half of the practices. Smoking cessation activities were initiated and carried out by physicians with minimal use of their staff. Smoking status was documented in 51% of the medical records reviewed but seldom in a place readily accessible to the physician. All physicians were very aware of the importance of smoking cessation counseling, and most felt confident in their skills.
CONCLUSIONS: Despite identification of patient smoking as a problem, most practices were not using office-based activities to enhance and support physician counseling. New perspectives for helping practices with this task need to be explored.
Despite efforts by the public health community and individual clinicians, tobacco use remains a significant health problem.1 After funding a series of research projects to develop more effective intervention methods for use by physicians and dentists, the National Cancer Institute (NCI)2 published a monograph highlighting findings in this area. One of their recommendations was that physicians and dentists initiate office-based activities to enhance and support their tobacco cessation messages. This comprehensive organized effort would increase patient exposure to consistent environmental cues and facilitate patients’ movement along the stages of the readiness to change mode1,3 resulting in additional cessation attempts and lower smoking rates. Recommended office-based strategies included creating an environment that encouraged cessation, training clinicians in cessation skills, using nurses and other staff in identification and counseling of smokers, and systematically identifying and tracking smokers. Two years after the publication of that monograph and during the time of our study, the Agency for Health Care Policy and Research (AHCPR)4 released a clinical practice guideline on smoking cessation that included recommendations for the use of office-based activities. The primary objective of our study was to describe the extent to which family physician practices have implemented 15 office-based activities (Table) for smoking cessation abstracted from the NCI monograph.
Methods
The study consisted of family physician practices recruited from the membership list of the Nebraska Academy of Family Physicians (NAFP). Approximately 95% of Nebraska family physicians are members of NAFP. Individual physicians on the membership list were grouped according to practice address, resulting in a pool of 209 practices. We stratified these practices as urban or rural based on county population density and sampled them proportionally to ensure a representative sample. To include a sufficient number of practices with a minimum of unnecessary contact, practices were recruited in successive waves. We randomly generated a short list of practices from each density stratum. A letter explaining the general outline of our study was sent randomly to one physician in each practice and followed a week later by a telephone call to that physician. Three recruitment waves (for a total of 155 practices) were conducted in an attempt to recruit 100 practices.
We employed a cross-sectional integrated research design.5-8 A research nurse collected data in 1995 and 1996 during a 1-day visit to each practice. Data included a practice environment checklist identifying smoking cessation activities. Focused observation of the practice environment9 and key informant interviews10 were used to identify environmental cues for smoking cessation, physician and staff use of tobacco, type and placement of smoking cessation patient education materials, and office staff roles relative to smoking cessation activities. We identified physician attitude and beliefs about smoking cessation through audiotaped semistructured in-depth interviews.11 Medical records were reviewed to identify methods of documentation of smoking status and smoking cessation efforts.
Successful adoption of office-based cessation activities was determined using the summed score of 15 items (Table) abstracted from the NCI monograph (coded as 0 if not implemented and 1 if implemented). We then used the summed scores to identify and describe general findings across practices. Data from the interviews and field notes were analyzed qualitatively using the template organizing style.12 We generated common themes and compared them with the descriptive statistics.