Smoking screening and management in primary care practices

Documentation of Behavioral Health Risk Factors in a Large Academic Primary Care Clinic

Objective:

To determine the prevalence of alcohol, smoking, and physical activity status documentation at a family health team in Toronto, Ontario, and to explore the patient characteristics that predict documentation of these lifestyle risk factor statuses.

Design:

Manual retrospective review of electronic medical records (EMRs).

Setting:

Large, urban, academic family health team in Toronto, Ontario.

Participants:

Patients over the age of 18 that had attended a routine clinical appointment in March, 2018.

Main Outcome Measures:

Prevalence and content of risk factor status in electronic medical records for alcohol, smoking, and physical activity.

Results:

The prevalence of alcohol, smoking, and physical activity documentation was 86.4%, 90.4%, and 66.1%, respectively. These lifestyle risk factor statuses were most often documented in the “risk factors” section of the EMR (83.7% for alcohol, 88.1% for smoking, and 47.9% for physical activity). Completion of a periodic health review within 1 year was most strongly associated with documentation (alcohol odds ratio [OR] 9.79, 95% Confidence Interval [CI] 2.12, 45.15; smoking OR 1.77 95% CI 0.51, 6.20; physical activity OR 3.52 95% CI 1.67, 7.40).

Conclusion:

Documentation of lifestyle risk factor statuses is strongly associated with having a recent periodic health review. If “annual physicals” continue to decline, primary care providers should final additional opportunities to address these key determinants of health.

Tobacco Cessation Counseling and Medications Provided by Physicians to Tobacco Users During Primary Care Visits

INTRODUCTION

The established guidelines for treating tobacco use and dependency is brief provider intervention to assist those willing to quit by providing access to medication and/or behavioral counseling. The purpose of the study is to determine the extent of cessation treatment offered by providers during primary care visits by patients who are current tobacco users, and to examine associations between patient factors and treatment received.

METHODS

Using data from the 2015 to 2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications from 4590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by age, gender, race/ethnicity, and payment source.

RESULTS

Of visits by current tobacco users, 18.4% included cessation counseling, 5.5% included cessation medication, and 22.1% included at least 1 type of treatment. Visits by patients with Medicare had 44% greater odds of including counseling (CI = 1%-205%) and treatment (OR = 1.44; 95% CI = 1.01-2.06). Visits classified as "other payment type" had 73% greater odds of including counseling (OR = 1.73; 95% CI = 1.05-2.84). Visits by women had 86% greater odds of including medication (CI = 17%-294%).

CONCLUSIONS

Tobacco cessation treatment is underutilized by providers during primary care visits. Further research is necessary to understand and address barriers to providing routine cessation assistance.

Utilizing clinical support staff and electronic health records to increase tobacco use documentation and referrals to a state quitline

The purpose of this study was to determine if incorporation of a workflow in the electronic health record (EHR) that empowered medical assistants (MA) to become tobacco-cessation promoters, would increase tobacco documentation and referral for cessation counseling. MAs in three primary care centers were trained to ask every patient, at every visit, about tobacco use then document this status in the EHR. Patients ready to quit were electronically referred to the quitline for tobacco cessation counseling. Documentation of tobacco status, ongoing verification of tobacco use, and chief complaint recording was compared before and after the intervention. Logistic regression analysis indicated that after adjusting for differences between care centers, there were increased odds in initial documentation (OR = 1.52; 95% CI = 1.42 - 1.62) and ongoing verification (OR = 2.86; 95% CI = 1.42 - 1.62) in 2010 in comparison with 2009. Recording of tobacco cessation as the chief complaint in current smokers increased 91% (OR = 1.91; 95% CI = 1.56 - 2.34). Documentation and referrals for smoking cessation can be increased in organizations using EHR by empowering MAs to promote tobacco cessation and providing electronic referral options.

How can we use our knowledge of alcohol-tobacco interactions to reduce alcohol use?

Currently, 8.5% of the US population meets criteria for alcohol use disorders, with a total cost to the US economy estimated at $234 billion per year. Alcohol and tobacco use share a high degree of comorbidity and interact across many levels of analysis. This review begins by highlighting alcohol and tobacco comorbidity and presenting evidence that tobacco increases the risk for alcohol misuse and likely has a causal role in this relationship. We then discuss how knowledge of alcohol and tobacco interactions can be used to reduce alcohol use, focusing on whether (a) smoking status can be used as a clinical indicator for alcohol misuse, (b) tobacco policies reduce alcohol use, and (c) nicotinic-based medications can be used to treat alcohol use disorders.

The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling

OBJECTIVES

The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling.

METHODS

The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.

RESULTS

Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians.

CONCLUSIONS

Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.

Prevalence and correlates of smoking cessation pharmacotherapy in hospitalized smokers with acute myocardial infarction

BACKGROUND

Although current performance measures recommend smoking cessation counseling at the time of acute myocardial infarction (AMI), the American College of Cardiology/American Heart Association guidelines recommend pharmacotherapy as well. The aim of this study was to describe the prevalence and correlates of smoking cessation pharmacotherapy in hospitalized patients with AMI.

METHODS

In the 24-center TRIUMPH registry, 4,340 AMI patients underwent detailed interviews; and 1,631 reported smoking within 30 days of admission. Prescription of first-line smoking cessation medications at discharge was assessed by medical record review. All patient-related factors associated with smoking cessation treatment, based on literature review, were included in hierarchical modified log Poisson models.

RESULTS

Only 14% (222/1,631) of AMI patients who smoked were prescribed smoking cessation medication at discharge. After multivariable adjustment for patient characteristics, there was significant variation across sites (range 0%-28%, median rate ratio 1.41, 95% CI 1.23-2.67). Independent factors associated with smoking cessation pharmacotherapy included older age (rate ratio 0.81 per 10-year increment, 95% CI 0.71-0.93), high school graduation (rate ratio 1.37, 95% CI 1.10-1.66), heavy cigarette usage (>20/d) (rate ratio 3.08, 95% CI 2.20-4.12), in-hospital revascularization (rate ratio 1.41, 95% CI 1.0-1.94), and instructions on smoking cessation (rate ratio 2.37, 95% CI 1.40-4.01).

CONCLUSIONS

Smokers surviving an AMI are infrequently prescribed guideline-recommended smoking cessation treatments, and there is considerable variation across hospitals. Older, less educated, and lighter smokers are less likely to receive aggressive smoking cessation treatment. Novel strategies to augment current practice are needed.

Smoking cessation assistance for patients with bladder cancer: a national survey of American urologists

PURPOSE

Cigarette smoking is a known risk factor for bladder cancer. How urologists address smoking cessation among patients with bladder cancer is not well-known. We assessed the practice patterns of American urologists regarding smoking cessation assistance for patients with bladder cancer.

MATERIALS AND METHODS

A questionnaire regarding smoking cessation practice patterns was sent to 1,821 American urologists in the 2008 American Urological Association membership directory. Responses were summarized with frequency and percent. Statistical comparison was made using chi-square tests. Multiple logistic regression was used to detect significant predictors of providing smoking cessation assistance.

RESULTS

Responses were received from 601 urologists who collectively treated an estimated 14,713 patients with bladder cancer in the last year. More than half (55.6%) of urologists never discuss smoking cessation while only 19.8% always discuss smoking cessation with patients with bladder cancer. Of urologists who never discuss smoking cessation 40.7% believe that smoking cessation may not alter the course or outcome of the disease and 37.7% do not feel qualified giving smoking cessation counseling. Most urologists (93.7%) have never had formal smoking cessation training. Urologists with smoking cessation training were more likely to always provide smoking cessation assistance compared to those without training (20.6% vs 6.0%, p = 0.0011). Number of patients with bladder cancer treated (OR 3.96) and formal smoking cessation training (OR 13.49) were significant predictors of providing smoking cessation assistance.

CONCLUSIONS

American urologists demonstrate a low rate of providing smoking cessation assistance to patients with bladder cancer. Urologists who are trained in smoking cessation most commonly provide smoking cessation assistance. We recommend integrating formal smoking cessation instruction into courses that address bladder cancer and strongly encourage the American Urological Association to adopt practice pattern guidelines.

Chronic respiratory disease and multimorbidity: prevalence and impact in a general practice setting

BACKGROUND

Multimorbidity is defined as two or more co-existing chronic conditions in an individual and is common in general practice. It is associated with poorer outcomes for patients. This study aimed to establish the prevalence of multimorbidity in patients with chronic respiratory disease in general practice and to describe its impact on health service use.

METHODS

Cross-sectional study based in general practice in Dublin. Drug and disease code searches were performed to identify adult patients with a diagnosis of chronic respiratory disease. Medical records were reviewed for chronic respiratory diagnosis, other chronic conditions, demographic characteristics, General Practitioner (GP) and practice nurse utilisation rates, and numbers of medications.

RESULTS

In a general practice population of 16,946 patients 3.9% had chronic respiratory disease and 60% of these had one or more co-existing chronic condition(s). GP and practice nurse utilisation rates, and number of medications were significantly higher among those with multimorbidity compared with those with respiratory disease alone. Multivariate analysis showed that increasing age and low socio-economic status were significantly associated with multimorbidity.

CONCLUSION

The majority of patients with chronic respiratory disease have multimorbidity. Clinical guidelines based on single disease entities and outcomes are not as easy to implement and may not be as effective in this group.

Racial and ethnic differences in delivery of tobacco-cessation services

BACKGROUND

Reducing racial and ethnic disparities in health care is an important national goal. Racial and ethnic differences in the delivery of tobacco-cessation services were examined in the course of visits to primary care physicians.

METHODS

In 2007, data about tobacco screening were analyzed from 29,470 visits by adult patients to 2153 physicians in the 2001-2005 National Ambulatory Medical Care Survey, a cross-sectional survey. Counseling was examined for visits by patients with known current tobacco use. Logistic regression models included age, gender, visit diagnoses, expected payment source, and past-year visits to the provider.

RESULTS

The respective percentages of visits with tobacco screening and counseling were 79.2% and 28.8% for non-Hispanic white patients, 79.3% and 29.2% for non-Hispanic black patients, 80.2% and 30.6% for non-Hispanic Asian patients, and 68.2% and 21.4% for Hispanic patients. In multivariable models, the adjusted difference between Hispanics and non-Hispanic whites in the percentage of visits with screening was -7.9 (95% CI=-15.5, -0.3) and of visits with counseling was -7.6 (95% CI=-15.2, 0.0).

CONCLUSIONS

Tobacco screening and counseling were less common at visits made by Hispanics compared to non-Hispanic whites. Traditional barriers to care among Hispanic patients, such as lack of insurance and more new-patient visits, did not explain the observed differences.

Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty

We report on the findings of a national survey that examined factors that influence faculty's intentions to integrate tobacco education in their advanced practice nursing curricula. The addiction component of tobacco use is taking its toll on the health of 48 million smokers in the United States. Several national health authorities recommend and/or mandate that tobacco prevention and tobacco cessation be addressed at every point of entry in the health care delivery system. However, there is increasing evidence that health care providers may not be adequately prepared to meet national goals and/or standards. One hundred sixty-one advanced practice nursing faculty in the United States completed an 88-item survey regarding external factors (e.g., personal history of tobacco use, clinical practice, and current tobacco topics taught) and components of the Theory of Reasoned Action model (including perceived self-efficacy, behavioral beliefs, subjective norms, and control beliefs related to tobacco education). Descriptive statistics, chi(2) analysis, Pearson correlation, and linear regression were used to analyze the data. The findings revealed that sex (chi(2) = 7.949, P = .024), level of education (chi(2) = 26.853, P = .0005), years of academic teaching (chi(2) = 19.418, P = .013), and combined clinical and course responsibility (chi(2) = 10.430, P = .0236) were significant external (demographic) factors and that behavioral beliefs (attitude about tobacco education) demonstrated the strongest relationship with intention scores (r = 0.876, P < .0005). Overall, 62.7% of nurse practitioners reported high scores (>or=5, on a scale of 1-7) for intentions to integrate tobacco education, as compared with 37.5% of nurse midwives, 30.3% of clinical nurse specialists, and 8.7% of nurse anesthetists. This study adds to the growing body of evidence that nursing curricular gaps with tobacco education exist and that national efforts are needed to ensure that widespread changes occur to help reduce the morbidity and mortality related to tobacco use.

Determinants of physician discussion regarding tobacco and alcohol abuse

The U.S. Preventive Services Task Force recommends that clinicians screen adults for tobacco and alcohol abuse and provide appropriate interventions. This study employed direct observation and interactional analysis of medical visits to investigate factors associated with physician discussion of tobacco and alcohol use with patients. New adult patients were randomly assigned to primary care at a university medical center. Videotapes of the visits were analyzed using the Davis observation code. Regression equations related discussions of substance use (alcohol and other substances), smoking, and health promotion to patient health status, depression, age, education, income, gender, alcohol abuse, and current smoking. Patients reporting better physical health were more likely to have their physicians employ a practice style emphasizing addiction behaviors (p = .0186). Substance use (p = .0117) and health promotion counseling (p = .0130) occurred more frequently with younger patients. Physicians discussed substance use (p = < .0001) and addiction (p < .0001) more often with male patients. Problem drinkers were more likely to have physicians address their substance use (p = .0069) and focus on addiction behaviors (p = .0017). Physicians adopted an addiction-oriented practice style (p < .0001), addressing substance use (p = .0009) and smoking (p < .0001), more often with patients who smoked. Physicians appear more apt to discuss these behavioral risk factors with healthier, younger, male patients who abuse tobacco and alcohol.

Smoking status as a clinical indicator for alcohol misuse in US adults

BACKGROUND

Screening for alcohol use in primary care settings is recommended by clinical care guidelines but is not adhered to as strongly as screening for smoking. It has been proposed that smoking status could be used to enhance the identification of alcohol misuse in primary care and other medical settings, but national data are lacking. Our objective was to investigate smoking status as a clinical indicator for alcohol misuse in a national sample of US adults, following clinical care guidelines for the assessment of these behaviors.

METHODS

Analyses are based on a sample of 42 374 US adults from the National Epidemiological Survey on Alcohol and Related Conditions (Wave I, 2001-2002). Odds ratios (ORs), 95% confidence intervals (CIs), and test characteristics (sensitivity, specificity, positive and negative predictive values, and positive likelihood ratio of smoking behavior [daily, occasional, or former]) were determined for the detection of hazardous drinking behavior and alcohol-related diagnoses, assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV.

RESULTS

Daily, occasional, and ex-smokers were more likely than never smokers to be hazardous drinkers (OR, 3.23 [95% CI, 3.02-3.46]; OR, 5.33 [95% CI, 4.70-6.04]; OR, 1.19 [95% CI, 1.10-1.28], respectively). Daily and occasional smokers were more likely to meet criteria for alcohol diagnoses (OR, 3.52 [95% CI, 3.19-3.90] and OR, 5.39 [95% CI, 4.60-6.31], respectively). For the detection of hazardous drinking by current smoking (occasional smokers + daily smokers), sensitivity was 42.5%; specificity, 81.9%; positive predictive value, 45.3% (vs population rate of 26.1%); and positive likelihood ratio, 2.34. For the detection of alcohol diagnoses by current smoking, sensitivity was 51.4%; specificity, 78.0%; positive predictive value, 17.8% (vs population rate of 8.5%); and positive likelihood ratio, 2.33.

CONCLUSIONS

Occasional and daily smokers were at heightened risk for hazardous drinking and alcohol use diagnoses. Smoking status can be used as a clinical indicator for alcohol misuse and as a reminder for alcohol screening in general.

Smoking cessation treatment by primary care physicians: An update and call for training

BACKGROUND

Public health and government organizations have invested considerably to increase physician adherence to smoking-cessation practice guidelines.

METHODS

A random sample of 2000 U.S. primary care physicians was ascertained from the American Medical Association (AMA) in 2002. Respondents (n = 1120, 62.3%) provided self-reported data about individual and practice characteristics and smoking-cessation practices. Data were analyzed in 2005.

RESULTS

Most primary care physicians (75%) advised cessation, 64% recommended nicotine patches, 67% recommended bupropion, 32% recommended nicotine gum, 10% referred to cessation experts, and 26% referred to cessation programs "often or always." Advising cessation was related to being older, having a faculty appointment, having trained staff for smoking counseling, and having confidence to counsel patients about smoking. Physicians who were internists, younger, and those with greater confidence to counsel patients about smoking recommended nicotine replacement more often. Prescribing bupropion was less common among older physicians, in the Northeast, with trained staff available for counseling, and with a greater proportion of minority or Medicaid patients. Prescribing bupropion was more common among AMA-member physicians and physicians with greater confidence to counsel patients about smoking. Providing a referral to an outside expert or program was more common among female physicians, and physicians in the Northeast or West, with larger clinical practices, and with trained staff for cessation counseling.

CONCLUSIONS

Current physician self-reported practices for smoking cessation suggest opportunity for improvement. Targeted efforts to educate and support subsets of primary care physicians may improve physician adherence and smoking outcomes.

Office Systems for Heart Disease Prevention

The provision of heart disease prevention services in primary care is currently inadequate, but can be improved with the establishment of a practice system. The system process involves all members of the practice in a clearly defined, well-organized approach to patient care. An initial review of patient care services will help practices identify prevention areas that they would like to improve by defining protocols, roles, and routines within the practice. Once established, the prevention system can improve patient care and satisfaction of practice staff and physicians, but requires on-going assessment, modification, and commitment.

Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs

BACKGROUND

The U.S. Public Health Service clinical practice guideline calls for clinicians and healthcare organizations to identify and treat every tobacco user seen in a healthcare setting. There is little information on the extent of compliance with the guideline's treatment model described by the "5A's" (Ask, Advise, Assess, Assist, Arrange).

METHODS

In 1999-2000 a survey was mailed to 64,764 members aged 25 to 75 years, of nine nonprofit HMOs participating in the National Cancer Institute-funded Cancer Research Network. These plans provide medical care to more than 8 million Americans including a minority enrollment of 30%. Smokers were asked about tobacco-cessation treatments received during primary care visits in the past year.

RESULTS

A 70% response rate identified a smoking prevalence of 10% (n=4207). Results indicated that 90% of smokers were asked about smoking, 71% were advised to quit, 56% were assessed for their willingness to quit, 49% received assistance interventions, and 9% had follow-up arranged. Treatment was provided more often to smokers who asked for help and/or intended to quit. Few and only modest associations were found between other patient characteristics and receipt of 5A's cessation services. In contrast to widely reported concerns about smokers' resistance to tobacco interventions, smokers who received treatment were more satisfied with health plan services.

CONCLUSIONS

Results demonstrate substantial clinician compliance with the first two steps-Ask and Advise. Greater efforts are needed in providing the more effective tobacco treatments-Assist and Arrange. Compliance with the guideline is associated with greater patient satisfaction.

Design and testing of an interactive smoking cessation intervention for inner-city women

The purpose of this study was to design and test the usability of a computer-mediated smoking cessation program for inner-city women. Design and content were developed consistent with principles of user-centered design. Formative and summative evaluation strategies were utilized in its testing. The summative evaluation was designed to test usability in a naturalistic environment. A sample of 100 women who receive care at an inner-city community health center participated in the study. Average time for completing the computer program was 13.9 minutes. Participants reported a high level of satisfaction with usability of the program. Standardized instruments to measure cognitive processes of change related to smoking were completed at baseline and at 1 week. Participants reported a decrease in favorable attitudes toward smoking (P=0.014) and an increase in cognitive change processes at follow-up (P=0.037). These results indicate that interactive computer technology is acceptable to, and potentially useful for, promoting smoking cessation in low-income women.

Measuring provider adherence to tobacco treatment guidelines: A comparison of electronic medical record review, patient survey, and provider survey

An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.

Results of a randomized controlled trial of intervention to implement smoking guidelines in Veterans Affairs medical centers: increased use of medications without cessation benefit

BACKGROUND

The AHRQ Clinical Practice Guideline for Treating Tobacco Use and Dependence recommends screening and treatment of all tobacco users. Effective methods to implement recommendations are needed because simple guideline dissemination does not necessarily result in changes in practice.

OBJECTIVES

The Guideline Implementation for Tobacco (GIFT) study tested an organizational intervention to improve Guideline implementation.

RESEARCH DESIGN

GIFT randomized 20 Veterans Affairs medical centers to intervention or control conditions. We trained prime movers at each site to improve identification of smoking status, promote primary care interventions and increase availability of smoking cessation medications. Sites and patients were evaluated before and after intervention.

SUBJECTS

GIFT included 20 Veterans Affairs medical centers and 5678 subjects.

MEASURES

Data regarding smoking status, delivery of treatment, medication use, and smoking cessation were collected from participant surveys, medical record review, survey of site leaders, and Pharmacy Benefits Management.

RESULTS

The intervention did not increase participant report of being asked about smoking status or receipt of counseling. It did increase the rate of identification of smoking status in the medical record (P = 0.0001) but did not increase the rate of counseling to stop smoking. Site level data showed no increase in the number of patients receiving smoking cessation medications or dollars spent on medications. Individual smoker data showed a significant increase in the use of medications for smoking cessation in intervention sites (odds ratio = 6.89, P < 0.0001); however, only a small minority of smokers received medication even after the intervention. There was no difference in smoking cessation rates between participants at the intervention and treatment sites.

CONCLUSIONS

We conclude that improvements in smoking cessation rates are likely to require more intensive intervention in this population.

Office-based intervention for tobacco dependence

A successful office approach for any behavior change, including for tobacco, makes the intervention part of the everyday work of the medical practice. This article recommends how to integrate tobacco treatments efficiently into clinical practice. Specific ways to think systematically about smoking cessation and intervene with patients are discussed. Strategies to implement office-based changes to improve tobacco intervention are then presented.

Smoking-related attitudes and clinical practices of medical personnel in Minnesota

CONTEXT

Effective clinic-based, smoking-cessation activities are not widely implemented.

OBJECTIVE

To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members.

DESIGN AND SETTING

From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs).

MAIN OUTCOME MEASURES

Factors associated with limited smoking-cessation service delivery.

RESULTS

The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders.

CONCLUSIONS

Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

Effectiveness of implementing the agency for healthcare research and quality smoking cessation clinical practice guideline: a randomized, controlled trial

BACKGROUND

The Agency for Healthcare Research and Quality (AHRQ) Smoking Cessation Clinical Practice Guideline recommends that all clinicians strongly advise their patients who use tobacco to quit.

METHODS

We conducted a randomized, controlled trial of the effectiveness of Guideline implementation at eight community-based primary care clinics in southern Wisconsin (four test sites, four control sites) among 2163 consecutively enrolled adult patients who smoked at least one cigarette per day and presented for nonemergency care during the baseline period (June 16, 1999, to June 20, 2000) or the intervention period (from June 21, 2000, to May 3, 2001). After collecting baseline data, staff at test sites implemented the intervention over a 2-month period. The intervention included a tutorial for intake clinicians, group and individual performance feedback for intake clinicians, use of a modified vital signs stamp, an offer of free nicotine replacement therapy, and proactive telephone counseling. Staff at control sites received only general information about the AHRQ Guideline. Self-reported abstinence from smoking was determined by telephone interviews at 2- and 6-month follow-up assessments. Hierarchical logistic regression models were used to estimate the odds ratios (ORs) for treatment assignment after adjustment for patient characteristics. All statistical tests were two-sided.

RESULTS

There were no statistically significant differences in smoking cessation rates between participants at test and control sites during the baseline period. Among participants treated during the intervention period, those at test sites were more likely than those at control sites to report being abstinent at the 2-month (16.4% versus 5.8%; adjusted OR = 3.3, 95% confidence interval [CI] = 1.9 to 5.6; P<.001) and 6-month (15.4% versus 9.8%; adjusted OR = 1.7, 95% CI = 1.2 to 2.6; P =.009) follow-up assessments and to report continuous abstinence, that is, abstinence at both 2 and 6 months (10.9% versus 3.8%; adjusted OR = 3.4, 95% CI = 1.8 to 6.3; P<.001).

CONCLUSION

Implementation of a guideline-based smoking cessation intervention by intake clinicians in primary care is associated with higher abstinence among smokers.

Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions

BACKGROUND

Many primary care practices do not have systematic protocols to identify patients who smoke or to encourage clinicians to provide smoking cessation advice. We designed a study to assess the relative effectiveness of two brief interventions on screening for smoking, physician cessation advice and patient smoking cessation rates.

METHODS

We performed a nonrandomized comparison of alternative strategies for smoking cessation at a hospital-based adult primary care practice. Each intervention was implemented on a separate practice team. The "minimal" intervention consisted of a smoking status "vital sign" stamp which documented patient smoking status. The "enhanced" intervention consisted of a five-question form that assessed patient level of cessation readiness and provided cessation-counseling prompts for clinicians. Medical record documentation of screening for smoking and cessation advice and self-reported patient smoking cessation rates were collected 8-10 months after implementation.

RESULTS

Smoking status was documented at 86%, 91%, and 49%, and cessation advice at 38%, 47%, and 30% of visits on the minimal, enhanced, and control teams, respectively (P < 0.001 for smoking status and P = 0.014 for advice). Self-reported patient smoking cessation was higher on the enhanced team (12%) compared with the minimal (2%) and control (4%) teams (P < 0.001).

CONCLUSIONS

A short questionnaire that assesses readiness-to-quit and provides documentation of cessation advice improves rates of clinician cessation advice and patient smoking cessation compared with no intervention.

Adolescent smoking: epidemiology and approaches for achieving cessation

The initiation of smoking typically occurs during adolescence. To date, most adolescent smoking control efforts have focused on prevention; attempting to identify and influence factors that contribute to experimentation and initiation. However, given the large number of adolescent smokers, it is important that effort also be directed toward facilitating cessation. Many adolescents are addicted to cigarettes and report withdrawal symptoms that are similar to those experienced by adults. Relapse rates are high; few adolescents who try to quit on their own are successful. Clinician-delivered smoking cessation interventions have a positive impact in adults and should be applied to adolescents to promote and sustain abstinence. Although pharmaceutical aids for cessation have been shown to be well tolerated and effective in adults, less is known about their use in adolescents. As such, clinicians are encouraged to explore whether pharmaceutical aids have been approved for use in adolescents in their country and to use discretion when considering their use in patients <18 years of age. Because pediatricians are in a unique position to facilitate tobacco cessation counseling, they should routinely ask their patients whether they use tobacco, advise users to quit, assess readiness to quit, assist with quitting, and arrange follow-up counseling. Tobacco cessation efforts can be enhanced by teaming with other health professionals (e.g. nurses, dentists, pharmacists, social workers) or worksite and community-based organizations that provide health promotion services.

Screening for colorectal cancer on the front line

OBJECTIVE

The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening.

METHODS

We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening.

RESULTS

Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequently refused, 60% reported sigmoidoscopy was. Frequently cited patient barriers to sigmoidoscopy compliance included fear the procedure would hurt and that patients assume symptoms occur if there is a problem. Perceptions of health systems barriers to sigmoidoscopy were less strong.

CONCLUSIONS

Most providers recommended guideline-endorsed colorectal cancer screening. However, patient refusal for sigmoidoscopy was common. Results indicate that multiple levels of intervention, including patient and provider education and systems strategies, may help increase prevalence.

Paying for quality improvement: compliance with tobacco cessation guidelines

BACKGROUND

Identification and treatment of routine tobacco use in medical practice is an effective intervention but is not used consistently. A study was conducted at HealthPartners, a large network-model health plan in Minnesota, to determine the effect of an outcomes recognition strategy that involved bonus funds and the rates at which network physicians document that tobacco users are identified and advised to quit.

METHODS

Audits of 14,489 ambulatory patient records from 19-20 medical groups were conducted to determine the proportion of charts from each medical group that demonstrated identification of smoking status and counseling to encourage quitting at the most recent office visit in each year.

RESULTS

Overall mean tobacco use identification increased from 49% +/- 7% (95% confidence interval [CI]) in 1996 to 73% +/- 7% in 1999 (p < .001), while advice to quit increased from 32% +/- 10% in 1996 to 53% +/- 10% CI in 1999 (p < .005). The number of medical groups with tobacco status identified at > 80% of visits and > 80% of tobacco users advised to quit increased from 0 in 1996 to 8 in 1999.

DISCUSSION

Data feedback combined with a financial incentive appear to be an effective way for a health plan to improve physician compliance with the tobacco treatment guideline. Other health plans might consider similar reporting and incentive approaches to effectively engage medical group leadership and to improve the health of their members who use tobacco.

Lung cancer: the oncologist's role in smoking cessation

Cigarette smoking is by far the most common preventable cause of lung cancer in our society, and is therefore responsible for the leading cause of cancer death in both men and women. Physicians are uniquely positioned to impact smoking rates, but frequently fail to address the issue in practice because of competing concerns and a sense of frustration. Oncologists, though not typically thought of as preventive care providers, can be empowered to advocate for more effective smoking cessation strategies, and to implement treatment guidelines in their practice in an effort to improve cancer outcomes in their community. Pharmacologic and behavioral interventions for smokers, including the role of nicotine replacement therapies and bupropion, and their relevance to oncologic practice are reviewed.

Development and implementation of a tobacco cessation training program for students in the health professions

BACKGROUND

A comprehensive tobacco cessation training program, Rx for Change, was developed and implemented as required coursework at all California schools of pharmacy and at the University of California San Francisco Schools of Medicine and Dentistry.

RESULTS

Post-training evaluations administered to pharmacy students (n = 544; 89% participation) show a positive impact of the training on students' self-reported abilities for providing tobacco cessation counseling to patients.

CONCLUSION

Designed as a vehicle for nationwide dissemination of the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence, Rx for Change equips students with skills to intervene with all tobacco users, including patients who are not yet considering quitting.

Effectiveness of a clinic-based strategy for implementing the AHRQ Smoking Cessation Guideline in primary care

BACKGROUND

The Agency for Healthcare Research and Quality Smoking Cessation Practice Guideline recommends systematic assessment of smoking status and counseling of smokers at every visit, but the actual effectiveness of the guideline in primary care practice is unknown.

METHODS

We conducted a nonrandomized, controlled before-after trial of a guideline-derived intervention that includes routine identification and brief counseling of smokers by nurses and medical assistants, coupled with free nicotine replacement therapy (NRT) and telephone counseling of those smokers who are willing to make a quit attempt, and feedback on performance of guideline-recommended activities. The intervention was pilot tested at 1 family practice (FP) clinic over a 2-month period; patterns of usual care were observed concurrently at four control FP clinics. We obtained exit interviews of 651 consecutive adult smokers who presented for routine, nonemergency care. Abstinence (7-day point prevalence) was determined by telephone interview during 6-month follow-up.

RESULTS

Concordance with guidelines was significantly greater for all recommended actions at the test site during the intervention versus baseline (P < or = 0.05). Significantly more intervention versus baseline patients at the test site reported abstinence at 2-month follow-up (21 vs. 4%, P = 0.0004), and more patients tended to be abstinent at 6-month follow-up (21 vs. 11%, P = 0.08). No significant differences in 2- or 6-month quit rates between intervention and baseline patients were observed at the control sites.

CONCLUSIONS

Implementation of a guideline-driven smoking cessation intervention that focuses primarily on smokers who are interested in making a quit attempt is associated with increased abstinence in primary care practice.

Detection and diagnosis of psychiatric disorders in primary medical care settings

Research efforts accelerated in the 1990s to define the presentation of common psychiatric disorders in primary care settings. Two diagnostic instruments, the DSM-IV-PC and the PRIME-MD, were introduced in 1994, and a self-report form of the PRIME-MD, the PHQ, was published in 1999. These tools have streamlined the larger, often cumbersome psychiatric nomenclature of the DSM-III and DSM-IV and appear to be more useful in general medical settings. It still is not practical to use either instrument in its entirety for all patients in a busy primary care practice. Studies have suggested an efficient and effective, two-step method of screening primary care patients for psychiatric disorders, however. In this approach, a limited number of probing questions extracted from the PRIME-MD or PHQ (or DSM-IV-PC) are posed to patients, either in person or by a written self-report (i.e., a general health update or review of systems). Then a follow-up evaluation is done to confirm or refute positive screening results. Short, simple questionnaires that address specific topics (e.g., CAGE for alcohol screening or the GDS for mood disorders in older adults) complete and complement this approach. This method has the advantage of being easy to incorporate into routine office practice using minimal physician or office staff time, while showing acceptable sensitivity and specificity in studies to date. More research, particularly prospective studies, is needed to confirm the effectiveness of this approach and expand it beyond the few available studies that have focused mostly on depressive disorders.

Patient satisfaction and discussion of smoking cessation during clinical visits

OBJECTIVE

To learn whether patients who smoke and who receive smoking cessation information during medical office visits were less likely to be satisfied with the smoking cessation help they received than patients who smoke but who did not receive such information.

PATIENTS AND METHODS

A total of 3703 current cigarette smokers were identified by a mailing in November 1998 to 163,596 members of 2 Minnesota health plans, and 2714 (77.3%) responses to a 44-item questionnaire were available for analysis. Using hierarchical analysis to control confounding variables, we assessed the relationship between patient-reported smoking cessation support actions at the last physician visit and satisfaction "with the help received from your doctor about quitting smoking."

RESULTS

Smokers were very satisfied (12.0%), satisfied (25.3%), neutral (48.6%), and dissatisfied or very dissatisfied (13.5%) with physician help. After controlling for other characteristics, the 1898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10 percentage point greater satisfaction ratings and 5 percentage point less dissatisfaction than those not reporting such discussions (P<.001). Smokers reporting no interest in quitting at the time of the latest visit also demonstrated greater satisfaction in association with these actions.

CONCLUSION

Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke. This information should reduce concerns of physicians or nurses about providing tobacco cessation assistance to patients during office visits.

Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers

OBJECTIVES

This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers.

METHODS

WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis.

RESULTS

Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance.

CONCLUSIONS

Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.

Promoting tobacco cessation in primary care practice

Promoting tobacco cessation is an important part of the work of clinicians and staff in primary care practice. This article describes the significant public health impact of helping patients quit using tobacco through the use of an effective clinic-based intervention. The most effective strategies are to develop organization commitment, ask every patient about tobacco use at every visit and document it, advise all tobacco users to quit, assess readiness to quit, provide at least brief behavioral counseling, provide follow-up soon after quit date, conduct at least basic evaluations of each component of the process, and assess the quit rate for the practice as a whole.

An automated telephone-based smoking cessation education and counseling system

Automated patient education and counseling over the telephone is a convenient and inexpensive method for modifying health-related behaviors. A computer-controlled, telecommunications technology called Telephone-Linked Care (TLC) was used to develop a behavioral intervention to assist smokers to quit and to prevent relapse. The education and counseling is offered through a series of interactive telephone conversations which can take place in the smoker's home. The system's automated dialogues are driven by an expert system that controls the logic. The content is derived from the Transtheoretical Model of behavioral change, principles of Social Cognitive Theory, strategies of patient-centered counseling and recommendations of clinical experts in smoking cessation. The system asks questions, provides information, gives positive reinforcement and feedback, and makes suggestions for behavioral change. Information that the patient communicates is stored and is used to influence the content of subsequent conversations.

Physician-based smoking intervention: a rededication to a five-step strategy to smoking research

It is well established that physicians can have a significant effect on the smoking behavior of their patients. To do this, attention must be paid to putting in place multiple strategies or mechanisms in the organization where the physician practices, as well as in the macroenvironment (i.e., social and public policy). It has been questioned whether or not there is stagnation in the field of clinical smoking intervention requiring a rededication to basic research regarding smoking. With respect to physician-based smoking intervention, we alternatively suggest that recommitment to all phases of research is essential for moving forward physician-based smoking interventions in the rapidly changing health services and social environment. In this article, we first review the essential framework of the National Cancer Institute's research science approach to cancer prevention and control. Evidence concerning physician-based interventions is then reviewed, followed by a schematic of a comprehensive framework for thinking about the process and intervention components needed for physician-based smoking intervention to take place in the health-care setting, the impact they have, and the eventual outcome of such interventions. There is a discussion of the challenges for the delivery of smoking-cessation services presented by the rapidly changing healthy delivery system of the 1990s. Finally, we present recommendations concerning research priorities for physician-based smoking intervention and the research funding process.