Patient satisfaction and discussion of smoking cessation during clinical visits

Current and Future Perspectives on Computed Tomography Screening for Lung Cancer: A Roadmap From 2023 to 2027 From the International Association for the Study of Lung Cancer

Low-dose computed tomography (LDCT) screening for lung cancer substantially reduces mortality from lung cancer, as revealed in randomized controlled trials and meta-analyses. This review is based on the ninth CT screening symposium of the International Association for the Study of Lung Cancer, which focuses on the major themes pertinent to the successful global implementation of LDCT screening and develops a strategy to further the implementation of lung cancer screening globally. These recommendations provide a 5-year roadmap to advance the implementation of LDCT screening globally, including the following: (1) establish universal screening program quality indicators; (2) establish evidence-based criteria to identify individuals who have never smoked but are at high-risk of developing lung cancer; (3) develop recommendations for incidentally detected lung nodule tracking and management protocols to complement programmatic lung cancer screening; (4) Integrate artificial intelligence and biomarkers to increase the prediction of malignancy in suspicious CT screen-detected lesions; and (5) standardize high-quality performance artificial intelligence protocols that lead to substantial reductions in costs, resource utilization and radiologist reporting time; (6) personalize CT screening intervals on the basis of an individual's lung cancer risk; (7) develop evidence to support clinical management and cost-effectiveness of other identified abnormalities on a lung cancer screening CT; (8) develop publicly accessible, easy-to-use geospatial tools to plan and monitor equitable access to screening services; and (9) establish a global shared education resource for lung cancer screening CT to ensure high-quality reading and reporting.

Feasibility of a primary care patient decision aid for smoking cessation with information about e-cigarettes

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Patients had higher confidence and readiness to quit after the decision aids.

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The decision aid helped prepare patients to make a decision about quitting smoking.

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Patients expressed satisfaction with the decision aid and clinician consultation.

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Smoking cessation decision aids are acceptable and may promote behavior change.

Decision aids can promote shared decision making and behavior change and may be effective in helping patients quit smoking. Patients are increasingly using e-cigarettes for smoking cessation; however, little is known about the impact of including e-cigarette information in smoking cessation decision aids. Our objective was to assess the feasibility and acceptability of a smoking cessation decision aid including e-cigarette information. This study was conducted at one family medicine clinic in the United States. We used a pre-post design. In Phase I, the decision aid presented information about approved cessation methods. In Phase II, current e-cigarette users and patients with no intention of quitting received additional information on switching to e-cigarettes. We assessed the impact of the decision aids on quit attempts and abstinence, confidence and readiness to quit, confidence and readiness to switch to e-cigarettes, and patient satisfaction. We enrolled 60 patients in each phase (N = 120). Patients reported higher confidence and readiness to quit after viewing the decision aids and consulting with their physician (p < 0.01). Patients reported the decision aid helped prepare them to make a decision about quitting smoking and expressed satisfaction with the decision aid and clinician consultation. We did not observe an impact of including e-cigarette information. Smoking cessation decision aids are acceptable to patients and may promote behavior change. Future studies should explore the impact of providing patients e-cigarette information using larger sample sizes and rigorous designs. Further research is needed to identify strategies to promote shared decision-making regarding e-cigarettes.

The barriers for tobacco cessation counseling in teaching health care institutions: A qualitative data analysis using MAXQDA software

Introduction:

Recently, Dental Council of India directed all the teaching dental institutions in the country to set up tobacco cessation centers (TCC). International experiences suggest that there are many barriers for the provision of tobacco cessation counseling at dental clinics. In this context, it is important to understand the dental students’ attitudes toward this initiative of tobacco cessation counseling at dental settings.

Materials and Methods:

This qualitative study to document the dental students’ perspectives toward the provision of tobacco cessation counseling using focus group interviews was conducted in two teaching dental institutions in the state of Andhra Pradesh, India. 133 house surgeons from two dental institutions participated in the study and were interviewed as 13 focus groups. MAXQDA (version 12, VERBI GmbH, Berlin, Germany) was used for data analysis. All the interviews were audio recorded and the transcripts were open coded by three independent investigators.

Results:

The response rate in this study was 78.45%. The following themes were extracted from the views and opinions shared by the students: the reluctance of patients to discuss tobacco-related problems; tobacco use among students discouraging them to actively participate in counseling; an opinion that dental clinics are not suitable for the provision of tobacco cessation counseling; belief among students that they are not qualified enough.

Conclusion:

The directives given by the Ministry of Health and Family Welfare in association with Dental council of India to set up TCC at every teaching dental institution are laudable and demonstrate the commitment at policy level toward bringing down tobacco consumption in the country. However, few reforms need to be made in the curriculum to better execute the delegated responsibilities, which include orientation programs for dental students on the scope of the dental profession and workshops on tobacco cessation counseling.

Behaviors and Attitudes Toward Smoking Among Health Care Workers at Health Facilities in 4 Provinces of Vietnam: A Representative Cross-Sectional Survey

Tobacco smoking is a leading cause of premature death. Smoking prevalence in Vietnam ranks among the highest in Southeast Asia. Given the important role of health care workers (HCWs) in promoting and supporting smoking cessation, this project aimed to characterize the prevalence of smoking among HCWs in Vietnam, and their attitudes toward smoking cessation interventions. A cross-sectional survey was conducted among care workers in 4 levels of the health system, within 4 provinces of Vietnam. Descriptive statistics evaluated participant attitudes, perception, behaviors, and knowledge about smoking. Multivariable logistic regression models evaluated risk factors for smoking. Among 3343 HCWs, 7.5% identified as current smokers, comprising 22.2% males and 0.5% of females. Males had substantially greater odds (adjusted odds ratio = 55.3; 95% confidence interval = 29.0-105.6) of identifying as current smokers compared with females. HCWs in urban settings had higher odds of identifying as smokers compared with rural workers (adjusted odds ratio = 1.72; 95% confidence interval = 1.23-2.24). Strong support for smoking cessation policies and interventions were identified, even among staff who smoked. HCWs play an integral role in identifying smokers and supporting smoking cessation interventions for their patients. Efforts to support affordable smoking cessation interventions within health facilities are likely to contribute to a reduction in smoking prevalence in Vietnam.

Does smoking impact trust in physicians and satisfaction with the health system in China?

INTRODUCTION

Trust and satisfaction play vital roles in how smokers react to smoking cessation treatment delivered by physicians. This paper aims to ascertain whether smoking status and pack-years of smoking affect trust in physicians and satisfaction with the health system in China.

METHODS

The current study used the ordered probit model to evaluate how smoking status affects trust in physicians and satisfaction with the health system in China. Data from the China Family Panel Studies (CFPS) 2018 were used for the analysis, and the final sample consisted of 29500 adults. The CFPS is a nationally representative, comprehensive, high-quality, biennial longitudinal survey of Chinese communities, families, and individuals. The survey was conducted in 25 provinces and their administrative equivalents. The population of 25 provinces represents 95% of the total population in Mainland China.

RESULTS

According to the ordered probit model, the results showed that current smokers were significantly negatively associated with trust in physicians, and more cigarette smoking was associated with decreased trust in physicians. Moreover, current smokers were also significantly negatively related to satisfaction with the health system.

CONCLUSIONS

The present study found that current smokers would be more likely to rate trust in physicians lower, and less likely to rate greater satisfaction with the health system, than never smokers. These results may have important implications for regaining trust in physicians from smokers and supporting health-system reform for tobacco treatment.

Machine learning to identify and understand key factors for provider-patient discussions about smoking

We sought to identify key determinants of the likelihood of provider-patient discussions about smoking and to understand the effects of these determinants. We used data on 3666 self-reported current smokers who talked to a health professional within a year of the time the survey was conducted using the 2017 National Health Interview Survey. We included wide-ranging information on 43 potential covariates across four domains, demographic and socio-economic status, behavior, health status and healthcare utilization. We exploited a principled nonparametric permutation based approach using Bayesian machine learning to identify and rank important determinants of discussions about smoking between health providers and patients. In the order of importance, frequency of doctor office visits, intensity of cigarette use, length of smoking history, chronic obstructive pulmonary disease, emphysema, marital status were major determinants of disparities in provider-patient discussions about smoking. There was a distinct interaction between intensity of cigarette use and length of smoking history. Our analysis may provide some insights into strategies for promoting discussions on smoking and facilitating smoking cessation. Health care resource usage, smoking intensity and duration and smoking-related conditions were key drivers. The "usual suspects", age, gender, race and ethnicity were less important, and gender, in particular, had little effect.

Family medicine physicians' confidence and perceived effectiveness in delivering health behaviour change interventions

BACKGROUND

Approximately 40% of deaths in the USA are attributable to modifiable health behaviours. Despite clear recommendations and practice guidelines, primary care physicians (PCPs) generally do not dedicate much time to addressing health behaviours, thereby missing opportunities to improve patient well-being.

OBJECTIVE(S)

To examine what health behaviour change techniques PCPs use with their patients, including frequency of use, confidence in and perceived effectiveness of those interventions.

METHODS

Using a cross-sectional study design, family medicine resident and faculty physicians (n = 68) from three residency training programs completed an anonymous online survey. Questions explored their use of, confidence in and perceived effectiveness of health behaviour change interventions for six domains: physical activity, healthy eating, medication adherence, smoking cessation, sleep and alcohol reduction. Qualitative responses to open-ended questions were double coded by two independent raters. PCPs' open-ended responses to questions regarding specific intervention techniques were coded using an evidence-based behaviour change taxonomy.

RESULTS

Although PCPs indicated that they address health behaviour topics quite frequently with their patients, they reported only moderate confidence and low-to-moderate perceived effectiveness with their interventions. The most frequently cited technique was providing instruction (telling patients what to do). PCPs reported lowest frequency of addressing, lowest confidence and lowest effectiveness regarding helping patients decrease their use of alcohol. Insufficient time and perceived low patient motivation were commonly cited barriers.

CONCLUSION

These findings highlight the need for the development and evaluation of educational curricula to teach physicians brief, evidence-based approaches to helping patients make these changes in their health-related behaviours.

The association between physician trust and smoking cessation: Implications for motivational interviewing

Although the relationship between cigarette smoking and increased risk of malignancy has been well established, smoking remains a major public health threat in the United States. Therefore, we examined the relationship between a person's level of trust in cancer information from their physician and the likelihood of quitting smoking in order to better understand the doctor-patient relationship in the context of smoking cessation. The Health Information Nation Trends Survey (2011-2015) was used to identify smokers (n = 2186). Multivariable logistic regression was used to assess the relationship between trust in physicians, the internet, and family members on smoking cessation, accounting for demographic variables. Smokers reported a significantly higher level of trust in cancer information from their physician than cancer information from the internet or family members. However, no significant association between level of trust in cancer information from their physician and wanting to quit smoking was observed (p_trend = 0.55). There was also no association between level of trust in the internet or family and quitting smoking (p_trend = 0.52 and p_trend = 0.83, respectively). These results were confirmed by multivariate analysis. Smoking cessation is not associated with the level of trust an individual has in cancer information from their physician, the internet, or from family members. These findings may impact the utility of standardized information campaigns.

Provider-Patient Discussions About Smoking and the Impact of Lung Cancer Screening Guidelines: NHIS 2011-2015

BACKGROUND

Clinical practice guidelines for treating tobacco use and lung cancer screening guidelines recommend smoking cessation counseling to current smokers by health care professionals.

OBJECTIVE

Our objective was to determine the contemporary patterns of current smokers' discussions about smoking with their health care professionals in the USA.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an observational study of 30,132 current smokers (weighted sample 40,126,006) for the years 2011 to 2015 using data from the National Health Interview Survey.

MAIN MEASURES

Our main outcome was the proportion of current smokers who had discussions about smoking with their health care professionals. We used the Cochran-Armitage trend test to evaluate the temporal trends in current smokers' discussions about smoking, and used a multivariable logistic model to determine the predictors of discussions about smoking, controlling for smokers' demographics, health status, and receipts of lung cancer screening.

KEY RESULTS

Our study found the proportion of current smokers who had discussions about smoking with their health care professionals increased from 51.3% in 2011 to 55.4% in 2015 (P-trend < 0.0001). However, about 15% of current smokers who underwent lung cancer screening did not have or could not recall discussions about smoking with their health care professionals. In multivariable analyses and sensitivity analysis, the predictors of discussions about smoking were being a heavy smoker, receipt of lung cancer screening, being non-Hispanic white, having a physician office visit in the past year, being diagnosed with respiratory conditions, having fair or poor health, and having insurance coverage.

CONCLUSIONS

The results demonstrated a steady but slow increase in current smokers' discussions about smoking with their health care professionals in recent years, especially among heavy smokers. More than 40% of current smokers did not have or could not recall any discussions about smoking with their health care professionals.

Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 (N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Physicians' Recommendations to Medicaid Patients About Tobacco Cessation

INTRODUCTION

Smoking is highly prevalent among low-income Medicaid beneficiaries and tobacco-cessation benefits are generally available. Nonetheless, use of cessation medications or counseling remains low, and many clinicians are hesitant to urge smokers to quit. This study examines the extent to which physicians provide advice to Medicaid patients about quitting.

METHODS

Data from the 2014-2015 Nationwide Adult Medicaid Consumer Assessment of Health Plans survey were merged with state Medicaid policy variables and analyzed in 2017-2018. Multivariate regression models examined factors associated with smoking status, physician advice to quit smoking, and discussion of cessation medications or other strategies, as well as patients' ratings of their personal physicians.

RESULTS

Almost one third (29%) of adult Medicaid beneficiaries smoke. Almost four fifths of smokers with a personal doctor (77%) say their doctor at least sometimes advised quitting and almost half of smokers discussed cessation medications (48%), or another strategy, such as counseling (42%). Smokers' ratings of satisfaction with their physicians and their health plans rose as the frequency of smoking recommendations increased. Those in Medicaid managed care plans smoked more, but received less advice about cessation medications than those in fee-for-service care.

CONCLUSIONS

Clinicians and Medicaid managed care plans can improve their efforts to motivate Medicaid patients to try to quit smoking. These findings indicate that patients value prevention-oriented advice and give better ratings to physicians and health plans that offer more support and advice about cessation.

Helping Patients With ESRD and Earlier Stages of CKD to Quit Smoking

Among the many adverse effects of tobacco exposure is the increased risk for progression of kidney disease. Individuals with chronic kidney disease (CKD), who already face increased cardiovascular event rates compared to the general population, are at even greater risk if they smoke. Despite these risks and the increased focus on smoking cessation in the general population in recent years, national guidelines have not specifically targeted individuals with CKD. There are similarly sparse data specific to individuals with CKD regarding the safety and efficacy of evidence-based smoking cessation modalities. This review aims to identify the risks of nicotine dependence in individuals with CKD and the potential benefits of smoking cessation; discuss current strategies for smoking cessation, including behavioral and pharmacologic therapies such as varenicline; and extrapolate these interventions to the unique challenges of this population. Much of the data presented stem from evidence for the general population but are described with additional consideration in dosing of nicotine replacement therapy, as well as non-nicotine pharmacotherapy and treatment modality for individuals with CKD.

Evaluation and Implementation of a Proactive Telephone Smoking Cessation Counseling for Parents: A Study Protocol of an Effectiveness Implementation Hybrid Design

Detrimental health consequences of smoking for both parents and children stress the importance for parents to quit. A Dutch efficacy trial supported the efficacy of proactive telephone counseling on parents. Still, how this program would function in "real world" conditions and how parents could be optimally reached is unclear. Therefore, this study will use an innovative method to examine the recruitment success of two implementation approaches (i.e., via a healthcare approach and a mass media approach) to test the (cost)effectiveness of the program. A two-arm randomized controlled trial and an implementation study (i.e., process evaluation) are conducted. Parents (N = 158) will be randomly assigned to the intervention (i.e., telephone counseling) or control conditions (i.e., self-help brochure). Primary outcome measure is 7-day point prevalence abstinence at three months post-intervention. Qualitative and quantitative research methods are used for the process evaluation. We expect that parents in the intervention condition have higher cessation rates than parents in the control condition. We also expect that the recruitment of parents via (youth) health care services is a more promising implementation approach compared to mass media. Results will have implications for the effectiveness of a proactive telephone counseling and provide directions for its successful implementation.

Combining intensive practice nurse counselling or brief general practitioner advice with varenicline for smoking cessation in primary care: study protocol of a pragmatic randomized controlled trial

INTRODUCTION

Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown.

MATERIALS AND METHODS

A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner; both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation.

DISCUSSION

This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects.

TRIAL REGISTRATION

Dutch Trial Register NTR3067.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Tobacco use and cessation in HIV-infected individuals

Smoking prevalence estimates among HIV-infected individuals range from 40% to 84%, much higher than the overall US adult prevalence. To date, few tobacco dependence treatment trials have been conducted among HIV-infected smokers. Recommendations for future research include examining underlying factors that contribute to persistent smoking and barriers to abstinence, identifying ways to increase motivation for quit attempts, increasing the number of multicentered 2-arm tobacco dependence treatment trials, and using highly efficacious first-line pharmacotherapy in tobacco dependence treatment intervention studies. Addressing these research gaps will help to reduce the tobacco-related disease burden of HIV-infected individuals in the future.

Health professional advice for smoking and weight in adults with and without diabetes: findings from BRFSS

Health risk behaviors including smoking and weight-gain can cause and exacerbate chronic diseases like diabetes. Brief provider advice is an effective intervention to reduce risk from these behaviors. However, behavioral advice is provided more often to those who already have a chronic illness when compared with those who are at risk. The purpose of this study is to determine whether the frequency of provider advice for smoking cessation and weight loss varies between overweight or obese smokers with and without diabetes. BRFSS data from a subset of overweight and obese smokers with (n = 848) and without (n = 6,279) diabetes were analyzed to determine differences in reported provider advice. Overweight and obese smokers with diabetes reported receiving more advice for both weight (46.4% vs. 23.4%, P < 0.001) and smoking (84.5% vs. 72.8%, P < 0.001) compared to those without diabetes. Advice for smoking cessation was reported two to three times more often than advice for weight. Nearly a quarter of those with diabetes and almost half of those without reported no receipt of advice about weight. Results indicate that providers are not adequately addressing overweight and obesity in patients with and at risk for diabetes.

Do respiratory therapists receive training and education in smoking cessation? A national study of post-secondary training programs

OBJECTIVE

To assess the tobacco-related education provided by post-secondary respiratory therapy training programs in the United States.

METHODS

A cross-sectional research design was used to survey the entire population of program directors of post-secondary, respiratory therapy training programs in the United States. A valid and reliable questionnaire was developed and mailed using a 2-wave mailing technique (73% return rate). Internal reliability coefficients (Cronbach alpha) for the various components of the questionnaire ranged from 0.78 to 0.91.

RESULTS

More than half of programs (56%) offered no teaching on the 5R's. Nearly half (47%) offered no teaching on the 5A's. Of the 13 tobacco-related topics listed in the basic science and clinical science sections of the questionnaire, only one topic (i.e., diseases linked to tobacco use) received 3h or more of instruction by approximately a third of programs (35.8%). The majority of programs (>90%) spent no time teaching students about the socio-political aspects of tobacco use cessation. Moreover, 41% of programs did not formally evaluate students' competence in providing smoking cessation counseling to patients.

CONCLUSIONS

Tobacco-related education is a very minor component of the education and training received by respiratory therapy students in the United States.

PRACTICE IMPLICATIONS

Respiratory therapy training programs in the United States have great potential to strengthen the tobacco-related education that they provide to students. Practicing respiratory therapists would likely benefit from continuing medical education focused on how to use evidence-based smoking cessation counseling techniques with patients.

Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider

PRIMARY CARE PROVIDERS SHOULD BE AWARE OF TWO NEW DEVELOPMENTS IN NICOTINE ADDICTION AND SMOKING CESSATION: 1) the emergence of a novel nicotine delivery system known as the electronic (e-) cigarette; and 2) new reports of residual environmental nicotine and other biopersistent toxicants found in cigarette smoke, recently described as "thirdhand smoke". The purpose of this article is to provide a clinician-friendly introduction to these two emerging issues so that clinicians are well prepared to counsel smokers about newly recognized health concerns relevant to tobacco use. E-cigarettes are battery powered devices that convert nicotine into a vapor that can be inhaled. The World Health Organization has termed these devices electronic nicotine delivery systems (ENDS). The vapors from ENDS are complex mixtures of chemicals, not pure nicotine. It is unknown whether inhalation of the complex mixture of chemicals found in ENDS vapors is safe. There is no evidence that e-cigarettes are effective treatment for nicotine addiction. ENDS are not approved as smoking cessation devices. Primary care givers should anticipate being questioned by patients about the advisability of using e-cigarettes as a smoking cessation device. The term thirdhand smoke first appeared in the medical literature in 2009 when investigators introduced the term to describe residual tobacco smoke contamination that remains after the cigarette is extinguished. Thirdhand smoke is a hazardous exposure resulting from cigarette smoke residue that accumulates in cars, homes, and other indoor spaces. Tobacco-derived toxicants can react to form potent cancer causing compounds. Exposure to thirdhand smoke can occur through the skin, by breathing, and by ingestion long after smoke has cleared from a room. Counseling patients about the hazards of thirdhand smoke may provide additional motivation to quit smoking.

Smoking cessation should have more emphasis within Tobacco Control? The case for

Smoking cessation is usually mentioned last in the chain of established measures to improve Tobacco Control. This seems logical, as smoking cessation is a secondary or tertiary preventative measure only. In the recently proposed Tobacco Control Scale (TCS) using 6 Tobacco Control measures pricing is considered most important, and smoking cessation least important. For current smokers secondary or tertiary preventative measures are necessary with smoking cessation being the most effective one as its impact on health is immediate. Pricing, on the other hand, is less effective in inciting current smokers to quit. Further, the vast majority of smokers would like to quit if they were able; so help in achieving this goal is welcome. Other Tobacco Control measures, on the other hand, are mostly negatively perceived by smokers because they perceive them as curtailment of their freedom. This is a psychological advantage the health professional active in this area has over other people involved in Tobacco Control and must be exploited. There is also strong evidence that smoking cessation is cost-effective, especially when comparing costs involved in addressing other important health risk factors, such as hyperlipidemia and arterial hypertension. Finally, the role of smoking cessation in helping to decrease social acceptability of smoking should not be underrated as every smoker who quits sets an example for other smokers to follow or for children not to start. In summary, smoking cessation continues to be of paramount importance among Tobacco Control measures, and should get more emphasis especially in health care settings.

Association of substance use discussion by pediatric providers with the parent-provider relationship and maternal behavior change

A cross-sectional study of data from a randomized, controlled trial was conducted to determine (1) provider and parent attributes associated with discussion of maternal substance use, (2) how substance use discussion related to the parent-provider relationship, and (3) whether discussion was associated with maternal attempts at behavior change. Of the 482 mothers, 34% reported discussing all 3 substance use items (smoking, alcohol, and drug use) with their child's provider. Mothers who discussed smoking were more likely to report discussing alcohol and other drug use (P < .001). Parent-provider relationship scores, measured by a modified version of the Primary Care Assessment Survey, were positively associated with discussion of each substance (P < .001). Discussion of smoking and drug use were significantly associated with attempted behavior change. Our findings suggest that discussion of parental substance use by pediatricians is positively associated with the parent-provider relationship and may lead to behavior change.

Effectiveness of the 5-As tobacco cessation treatments in nine HMOs

BACKGROUND

Smoking remains the leading cause of preventable mortality in the US. The national clinical guideline recommends an intervention for tobacco use known as the 5-As (Ask, Advise, Assess, Assist, and Arrange). Little is known about the model's effectiveness outside the research setting.

OBJECTIVE

To assess the effectiveness of tobacco treatments in HMOs.

PARTICIPANTS

Smokers identified from primary care visits in nine nonprofit health plans.

DESIGN/METHODS

Smokers were surveyed at baseline and at 12-month follow-up to assess smoking status and tobacco treatments offered by clinicians and used by smokers.

RESULTS

Analyses include the 80% of respondents who reported having had a visit in the previous year with their clinician when they were smoking (n = 2,325). Smokers were more often offered Advice (77%) than the more effective Assist treatments-classes/counseling (41%) and pharmacotherapy (33%). One third of smokers reported using pharmacotherapy, but only 16% used classes or counseling. At follow-up, 8.9% were abstinent for >30 days. Smokers who reported being offered pharmacotherapy were more likely to quit than those who did not (adjusted OR = 1.73, CI = 1.22-2.45). Compared with smokers who didn't use classes/counseling or pharmacotherapy, those who did use these services were more likely to quit (adjusted OR = 1.82, CI = 1.16-2.86 and OR = 2.23, CI = 1.56-3.20, respectively).

CONCLUSIONS

Smokers were more likely to report quitting if they were offered cessation medications or if they used either medications or counseling. Results are similar to findings from clinical trials and highlight the need for clinicians and health plans to provide more than just advice to quit.

In-hospital smoking cessation programs: what do VA patients and staff want and need?

In preparation for delivering an inpatient smoking cessation intervention, surveys and interviews of general inpatients and staff were conducted in two Veterans Affairs (VA) hospitals to determine the motivation of veterans to quit smoking and to identify facilitators and barriers to inpatient staff delivery of inpatient cessation services. Seventy percent of inpatients were "motivated smokers" (thinking of quitting in the next 30 days), yet only 17% stated that they received cessation services during their hospitalization. Most staff said that VA should do more to assist patients to quit, yet less than half said that they personally provided cessation services due to lack of confidence/training and hesitancy to upset patients. Given the high motivation to quit among hospitalized veterans and the lack of knowledge about providing cessation services among nurses, training health professionals may facilitate and overcome barriers to the provision of these services. As frontline providers, nurses are ideally positioned to deliver inpatient smoking cessation services to hospitalized veterans.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search: September 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomization and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were counted as smokers. Effects were expressed as relative risks. Where possible, meta-analysis was performed using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 41 trials, conducted between 1972 and 2007, including over 31,000 smokers. In some trials, subjects were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics. Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Treatment of tobacco dependence

Cigarette smoking continues to cause substantial death and disability, but more than 1 in 5 adults smoke despite the desire among most smokers to stop and the availability of effective treatments. A systematic process to identify all smokers is crucial. Because tobacco dependence is characterized by relapses and remissions, clinicians should be ready to engage smokers and reengage relapsed smokers with options for new medication strategies and additional counseling resources.

Cancer prevention in primary care: predictors of patient counseling across four risk behaviors over 24 months

OBJECTIVE

Rates of preventive counseling remain below national guidelines. We explored physician and patient predictors of preventive counseling across multiple cancer risk behaviors in at-risk primary care patients.

METHODS

We surveyed 3557 patients, with at least one of four cancer risk behaviors: smoking, diet, sun exposure, and/or mammography screening, at baseline and 24 months. Patients reported receipt of 4A's (Ask, Advise, Assist, Arrange follow-up); responses were weighted and combined to reflect more thorough counseling (Ask=1, Advise=2, Assist=3, Arrange=4, score range 0-10) for each target behavior. A series of linear-regression models, controlling for office clustering, examined patient, physician and other situational predictors at 24 months.

RESULTS

Risk behavior topics were brought up more often for mammography (90%) and smoking (79%) than diet (56%) and sun protection (30%). Assisting and Arranging follow-up were reported at low frequencies across all behaviors. More thorough counseling for all behaviors was associated with multiple visits and higher satisfaction with care. Prior counseling predicted further counseling on all behaviors except smoking, which was already at high levels. Other predictors varied by risk behavior.

CONCLUSIONS

More thorough risk behavior counseling can be delivered opportunistically across multiple visits; doing so is associated with more satisfaction with care.

Views of Ontarians about health professionals' smoking cessation advice

BACKGROUND

Health professionals have important roles in helping smokers quit. However, it is not known how the public, especially smokers, view smoking cessation advice from different health professionals.

METHODS

We added questions regarding opinions and experiences with health professionals' smoking cessation advice to the 2002 CAMH Monitor, an annual random-digit-dialled survey of adult Ontarians. We report on how good a source of advice physicians, pharmacists, and dentists are perceived to be, how likely smokers are to consult each of these professionals, who smokers would ask for advice on the use of NRT, and advice received by smokers in the past year.

RESULTS

About two thirds of respondents viewed physicians as a very good source of advice on quitting, compared to just over one third and about one quarter who thought this of pharmacists and dentists, respectively. Over half of current smokers would be very likely to ask a physician for quit advice, compared to about 20% and only 3% for a pharmacist or a dentist, respectively. Among smokers, over 40% would first ask a physician for advice on NRT; about 20% would first ask a pharmacist. About 42% and 8% of current smokers reported that they received advice in the past year from a physician and pharmacist, respectively.

INTERPRETATION

Smokers are receptive to quit advice from physicians, but less likely to ask other health professionals. Few smokers received advice from pharmacists and dentists. Increasing the reach of quit advice requires both increased professional intervention and education of the public.

Tobacco Cessation Counseling Across the Ages

OBJECTIVES

To examine recent rates of tobacco cessation counseling and whether patient age or sex was associated with providers' adherence to tobacco cessation guidelines.

DESIGN

Survey study.

SETTING

The 2002 National Ambulatory Medical Care Survey (NAMCS).

PARTICIPANTS

Analysis of 22,605 records representing 687 million ambulatory care appointments with adults from the 2002 NAMCS.

MEASUREMENTS

The proportion of visits by sex and age category during which physicians identified a patient's tobacco use status and counseled tobacco users to quit.

RESULTS

The rates at which providers inquired about tobacco use were similar across groups, ranging from 65% of visits with men aged 20 to 44 to 73% of visits with women aged 45 to 59, but providers' rates of tobacco cessation counseling differed by age, ranging from 27% of visits with male tobacco users aged 45 to 59 to 6% of visits with male tobacco users aged 75 old and older.

CONCLUSION

Although providers frequently ask their patients about tobacco use, they infrequently counsel patients to quit, especially if those patients are older men. Provider time constraints, misconceptions about older patients' ability and willingness to quit, or doubt about the potential health benefits of tobacco cessation in this age group may explain the lower counseling rates provided to older male patients. Because rates of counseling have declined in the last decade, providers should be reeducated about the need for and effectiveness of tobacco cessation counseling for men and women of all ages.

Knowing how to help tobacco users

BACKGROUND

A U.S. Public Health Service-sponsored clinical practice guideline urges all health care providers to make tobacco-use cessation counseling a routine part of clinical practice. This study assessed practices of dentists in east Texas, their adherence to the guideline and barriers to adherence.

METHODS

A cross-sectional survey mailed September 2003 through January 2004 assessed demographic characteristics and knowledge, attitudes and activities of 783 dentists. The survey focused on familiarity with the guideline, adherence to the recommended steps (including the "5 A's" for tobacco users willing to quit and the "5 R's" for tobacco users unwilling to quit), perceived barriers and time spent counseling.

RESULTS

Most dentists were unfamiliar with the guideline and usually did not follow its recommended steps. Less than 20 percent of dentists spent three or more minutes per patient on counseling. Knowledge of and training in using the guideline were significantly associated with adherence and time spent counseling. Lack of training was cited as the greatest barrier.

CONCLUSIONS

Most dentists in east Texas are unaware of the clinical practice guideline. Lack of training is a major barrier to adherence. Practice Implications. Opportunities for improving patients' health through brief counseling interventions are missed. Measures are needed to increase dentists' familiarity with and adherence to the guideline.

General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review

OBJECTIVE

To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients.

METHODS

A systematic review.

STUDY SELECTION

All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation.

DATA SYNTHESIS

Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported.

RESULTS

Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too time-consuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, and relatively few considered discussing smoking outside of their professional duty (5%), or that this intruded upon patients' privacy (5%), or that such discussion were inappropriate (3%).

CONCLUSIONS

In addition to providing skills training, interventions designed to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians' judgements about whether discussing smoking is an effective use of their time.

The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers' satisfaction with their health care

U.S. Public Health Service (USPHS) clinical guidelines for tobacco treatment recommend that providers routinely counsel smokers using a five-step algorithm (5A's): ask about tobacco use, advise smokers to quit, assess interest in quitting, assist with treatment, and arrange follow-up. A potential barrier to compliance is providers' concern that addressing smoking might alienate smokers, especially those not ready to quit. A survey was mailed to 1,985 patients seen at one of eight Boston-area primary care practices from January 1 to March 31, 2003, and identified as smokers by chart review. The survey assessed respondents' receipt of the 5A's at their visit and their satisfaction with the provider's tobacco treatment and with their overall health care. We used multivariable logistic regression models to assess the association between satisfaction with care and patient-reported receipt of each 5A step, adjusted for age, sex, education, race, health status, smoking intensity, readiness to quit, and length of relationship with provider. Of 1,160 respondents (58% response rate), 765 reported that they smoked at the time of the visit. They reported high levels of satisfaction with their tobacco-related care and overall care. Patient-reported receipt of each 5A step was significantly associated with greater patient satisfaction with tobacco-related care and with overall health care, even after adjusting for a smoker's readiness to quit smoking. Satisfaction with overall health care increased as counseling intensity increased. Patient reports of smoking cessation interventions delivered during primary care practice are associated with greater patient satisfaction with their health care, even among smokers not ready to quit. Providers can follow USPHS guidelines with smokers without fear of alienating those not yet considering quitting.

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.

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.

Use of the vital sign stamp as a systematic screening tool to promote smoking cessation

OBJECTIVES

To examine the ability of a simple system-wide screening assessment tool, an expanded vital sign stamp, to increase rates of smoker identification, physician advice to quit smoking, and physician assistance in quitting and abstinence rates.

PARTICIPANTS AND METHODS

This study is a pretest, posttest design in which 5 primary health care clinics were randomly assigned to either the intervention condition, which received the vital sign stamp, or the control condition. Participants (N = 9439) were surveyed by using exit interviews at the 5 clinics, both before and after the vital sign intervention was implemented. Participants who were identified as smokers were then contacted 1 year later for follow-up. The study began in February 1995, and all follow-up visits were completed by December 1998.

RESULTS

Implementation of the vital sign stamp significantly increased the rates at which physicians asked participants about their smoking status (17.2% vs 7.5%). However, the rates of physicians advising smokers to quit, assisting them in quitting, and arranging follow-up either stayed constant or decreased. The number of quit attempts and abstinence rates also stayed constant.

CONCLUSION

A simple system-wide screening assessment tool, while effective in identifying more tobacco users, did not increase the rates at which physicians advised or assisted smokers to quit. Further system-wide changes may be needed to ensure that effective tobacco-dependence treatments are given to smokers.

Possible lessons from the tobacco experience for obesity control

Although obesity is increasing to epidemic proportions in many developed countries, some of these same countries are reporting substantial reductions in tobacco use. Unlike tobacco, food and physical activity are essential to life. Yet similar psychological, social, and environmental factors as well as advertising pressures influence the usage patterns of all 3. These similarities suggest that there may be commonalities between factors involved in controlling obesity and tobacco. This review, therefore, seeks to draw lessons from the tobacco experience for the organization of more successful obesity control. Smoking cessation counseling by physicians has been found to be one of the most clinically effective and cost-effective of all disease prevention interventions. When used alone, however, it cannot decrease the cultural acceptability of tobacco and the pressures and cues to smoke. Research and evaluation have shown the key elements of tobacco control to be (1) clinical intervention and management, (2) educational strategies, (3) regulatory efforts, (4) economic approaches, and (5) the combination of all of these into comprehensive programs that address multiple facets of the environment simultaneously. For each element, we present the evidence outlining its importance for tobacco control, discuss its application to date in obesity control, and suggest areas for further research. Viewing all of the elements involved and recognizing their synergistic effects draws researchers and practitioners back from an exclusive concentration on their particular setting to consider how they might seek to influence other settings in which individuals and populations must negotiate desired changes in nutrition and physical activity.

Parent attitudes about pediatricians addressing parental smoking

OBJECTIVE

Pediatricians have a great opportunity to intervene in parental smoking, but few do so consistently. Pediatricians consistently cite concern about negative parental reaction as one barrier to addressing parental smoking. This study investigated parent attitudes about pediatricians addressing parental smoking at pediatric visits.

METHODS

Parents (N = 341) were interviewed immediately after a pediatric visit about their attitudes toward pediatricians addressing parental smoking. Chi-square analyses identified relevant factors in parents' responses.

RESULTS

Most parents (99%; n = 337) said that asking about smoking is a very important part of a pediatrician's job (89%; n = 302) or felt that it did not matter one way or the other (10%; n = 35). There was no difference between attitudes of smoking and nonsmoking parents on this variable (chi(2) = 5.9, df = 1, P >.05). Very few nonsmokers (1%; n = 2) or smokers (5%; n = 2) believed that pediatricians have no business asking about parental smoking. The results support recent reports from adult practice that patient satisfaction ratings are improved when physicians ask about tobacco use and advise about quitting.

CONCLUSIONS

Both smoking and nonsmoking parents strongly believe that pediatricians should address parental smoking in the context of pediatric visits.

Physician smoking-cessation actions: are they dependent on insurance coverage or on patients?

BACKGROUND

Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5A's.

METHODS

A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit.

RESULTS

There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both.

CONCLUSION

Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.

Does health habit counseling affect patient satisfaction?

BACKGROUND

Health behavior advice can potentially prevent a large burden of illness, but the acceptability of this advice to patients is not well understood. This study assessed whether physician discussion of behavioral risk factors decreases patient satisfaction with the outpatient visit.

METHODS

In a cross-sectional study of 2,459 consecutive adult outpatient visits to 138 community family physicians in Northeast Ohio, the association of health habit counseling, measured by direct observation, with patient satisfaction, assessed by a modified subscale of the MOS 9-item visit rating scale, was calculated by logistic regression.

RESULTS

In analyses controlling for patient mix, discussion of diet, exercise, alcohol and other substance use, sexually transmitted disease, and HIV prevention was not associated with patient satisfaction. Patients who were asked about their tobacco use or counseled about quitting were more likely to be very satisfied with the physician.

CONCLUSIONS

Discussion of health behavior change, as practiced by community family physicians, is not associated with diminished patient satisfaction. In fact, tobacco use assessment and cessation counseling are associated with greater satisfaction.