Failure in non–smoking-related visit
A third common pattern was seen in 27% of encounters in which the physician failed to address smoking cessation in a non–smoking-related illness visit during which competing demands were low. In the vast majority of these (14 of 20), failure occurred despite having a reminder system for smoking cessation in place. Examples of visits in this pattern included consults for skin conditions (eg, boil or rash) or follow-up of stable back pain.
Failure in smoking-related visit
Although a smoking related-illness often triggered counseling, another common pattern was for physicians to fail to address smoking in patients presenting with acute respiratory illnesses or other chronic conditions related to smoking. This occurred in 22% of cases, including 10 encounters in which the physician failed to even ask the patient’s smoking status. In 7 of 17 encounters the physician did ask the patient if he or she smoked; in 3 they advised patients to stop smoking, but did not follow though with assessing readiness to change or offering assistance to help the patient quit smoking. Most visits (12 cases) following this pattern failed to address tobacco use for acute upper respiratory symptoms (eg, sore throat, nasal congestion, “sinus,” severe cough).
Failure in health maintenance visit
Finally, a fifth pattern emerged when smoking cessation was not fully addressed in health maintenance visits. In the 2 encounters where this occurred, the physician did ask about smoking status as part of the history taking but did not assess the patient’s readiness to change or offer assistance. It should be noted that 3 of the 5 health maintenance examinations were of good quality tobacco counseling.
Discussion
Our study confirms previous reports of poor compliance with a smoking cessation practice guideline that recommends assessment and consideration of counseling at every visit.7-12 We found that reliance on a reminder system to identify smokers was often not sufficient to prompt smoking cessation interventions, even during visits for tobacco-related problems.20 In our study, however, more than one half of the physicians demonstrated that they have the skills needed to provide good quality brief intervention for smoking cessation,2 and one fourth of the smokers received good quality tobacco counseling.
An important new finding in our study is the documentation of competing demands and priorities during encounters with smokers in primary care practices. In almost 25% of visits by smokers the smoking cessation agenda was appropriately overridden by competing demands (eg, acute pain, acute psychological distress, and other important demands). This finding shows that guidelines that recommend assessment and counseling at every visit are unrealistic, and if followed may not lead to optimal integration and individualization of primary care services.17 However, the finding of “appropriately missed opportunities” makes it imperative that tobacco cessation counseling be reliably integrated during all other visits with smokers when these competing demands are not present. Visits for well care and tobacco-related illnesses represent teachable moments that should not be missed.
Limitations
Although our study provides important and novel insights into the delivery of tobacco interventions in primary care, it has limitations. The physicians and practices represented here were purposely selected from the larger Prevention and Competing Demands Study and are not representative of the universe of family practices in Nebraska or the United States. Because the study relied on descriptions recorded by an observer, it is possible that subtle communication nuances between the patient and physician may have been missed. Nevertheless, the observer was specifically focused on preventive service delivery, so important details of the encounter are likely to have been captured. We explored the possibility of observer bias by a single observer by expanding an audit of encounters to other practices, physicians, and observers, and we failed to detect additional patterns of delivery. Finally, these patient encounters are only a cross-sectional window into these physicians’ smoking cessation practices.
Conclusions
Our study has important implications for improving delivery of tobacco cessation services in primary care practices. Although many physicians demonstrated basic skills for delivering brief smoking cessation interventions, it is clear that most have not adopted the model of tobacco use disorder as a chronic disease that needs to be addressed at every visit.2 Reliance on guidelines and office system tools without the adoption of this model is unlikely to result in higher rates of tobacco cessation. Thus, there is a need to develop interventions that encourage the adoption of this illness model and to develop systems to support tobacco counseling during visits that don’t include overriding important competing opportunities.
Acknowledgments
Our study was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS08776) and a Family Practice Research Center grant from the American Academy of Family Physicians. Drs Jaén, Flocke, and Crabtree are associated with the Center for Research in Family Practice and Primary Care Cleveland, New Brunswick, Allentown, and San Antonio. We are grateful to the physicians, staff, and patients from the 12 practices, without whose participation this study would not have been possible. We also wish to acknowledge the dedicated work of Angela Henke from the Department of Family Medicine of the State University of New York at Buffalo, who provided coordination support for the analyses and collated the data tables. Evangeline Rodriguez from the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio assisted with manuscript preparation. Kurt C. Stange, MD, PhD, provided helpful comments on earlier drafts of this paper.