Primary care physician smoking screening and counseling for patients with chronic disease
Introduction
Smoking and tobacco use remain the largest preventable causes of U.S. medical disease and costs (Centers for Disease Control and Prevention, 2006, Centers for Disease Control and Prevention, 2008). Annually, over 480,000 preventable smoking-related deaths occur, and $280 billion in smoking-related costs are primarily manifested through chronic diseases exacerbated by smoking (Centers for Disease Control and Prevention, 2008, Centers for Disease Control and Prevention, 2014). In response to these concerns, the U.S. Public Health Service created the evidence-based Treating Tobacco Use and Dependence: Clinical Practice Guideline to reduce the effects of smoking (Fiore et al., 2000, Fiore et al., 2008). These guidelines recommended a chronic disease treatment strategy that includes systematically screening every patient to determine patient readiness to make a quit attempt and providing smoking cessation counseling with smoking cessation, prevention and referral information. The Guideline concluded that smoking screening and smoking cessation counseling improved cessation rates (Fiore et al., 2000). Therefore, routine preventive and chronic care visits for patients with chronic smoking-sensitive cardiopulmonary disease present important opportunities to address smoking screening and counseling to improve cessation rates in a population with substantial potential for benefit.
Despite the obvious benefits of smoking cessation, multiple studies report poor uptake of smoking treatment guidelines in clinical practice. Outpatient physicians screen 60% of patients (Jamal et al., 2012) and provide smoking counseling to approximately 20% of patients who smoke (Payne et al., 2012, Bernstein et al., 2013, Jamal et al., 2012). Poor delivery of smoking interventions is also reflected by infrequent use of evidence-based smoking cessation treatments among smokers (Shiffman et al., 2008). Recent studies have not addressed smoking cessation treatment in preventive care among patients with chronic smoking-sensitive diseases. Multiple barriers to physician compliance with smoking treatment guidelines exist, including beliefs that evidence-based interventions will not change patient smoking behavior, competing clinical priorities, and insufficient time, knowledge, and training (Barnes Dodge et al., 2008, Burnett and Young, 1999, Cabana et al., 2000, Cabana et al., 2004, Frankowski et al., 1993, Kaplan et al., 2004, Nader et al., 1987, Tanski et al., 2003, Thorndike et al., 1999, Zapka et al., 1999, Bonollo et al., 2002). Available studies are also limited by small sample sizes and the absence of data regarding practice changes over time (Bernstein et al., 2013, Jamal et al., 2012, Collins et al., 2007, Ferketich et al., 2006, Payne et al., 2012, Tanski et al., 2003, Thorndike et al., 2007). Gaps remain in understanding adult and child primary care physician (PCP) smoking screening and counseling practice patterns among patients with chronic smoking-sensitive diseases (Bernstein et al., 2013, Jamal et al., 2012, Payne et al., 2012).
To address these gaps, we examined the 2001–2009 national practice patterns for PCP delivery of smoking screening and counseling at PCP visits among smokers with chronic smoking-sensitive cardiopulmonary diseases. Our goal was to identify key factors (patient, physician, disease, and healthcare system) associated with delivery of smoking counseling to smokers with chronic smoking-sensitive diseases.
Section snippets
Data source
PCP smoking treatment was examined from the frequencies of PCP smoking screening and smoking counseling delivery during preventive care office visits using the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets from 2001–2009. NAMCS and NHAMCS are nationally representative datasets capturing visits to physician offices and hospital outpatient departments and include data on smoking screening and counseling during each visit.
Smoking screening
From 2001–2009, 136,062 unweighted physician visits were sampled. Smoking screening was delivered at 68% of visits. The frequency of PCP smoking screening was unchanged over the nine years after guideline introduction (Fig. 1). Higher frequencies of smoking screening were observed for patients with the smoking-sensitive diseases asthma, cardiovascular disease, COPD, or hypertension, compared with patients with other smoking-sensitive diseases and without chronic smoking-sensitive diseases (
Discussion
Over 2001–2009, fewer than one-third of smokers with chronic smoking-sensitive diseases received counseling about cessation during primary care visits. Smoking cessation counseling was highest for patients with COPD and PVD but only reached 54% and 51%, respectively. Smoking cessation counseling was also more likely to be delivered at preventive visits, by an established PCP, at longer visits, to adolescents and for patients with non-private insurance. Despite dissemination of smoking treatment
Conclusions
Our findings demonstrate that delivery of smoking cessation counseling to patients with chronic smoking-sensitive diseases remains underused and has not improved over a decade, despite dissemination of smoking treatment guidelines. The patient and healthcare factors – preventive visits, an established PCP, longer visit length, adolescent age, and non-private insurance – were identified as potential facilitators that may be used to support smoking counseling at visits for preventive or chronic
Funding
KEN is supported by grants from the American Academy of Pediatrics Julius B. Richmond Center of Excellence and the Primary Children's Hospital Foundation. FLN is supported by grants from the Agency for Healthcare Research and Quality (1R18HS018166-01A1 and 1R18HS018678-01A1) and the Patient Centered Outcomes Research Institute (5330). Funding sources had no role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to
Conflict of interest statement
The authors declare that there are no conflicts of interest.
Acknowledgment
We thank Dr. Christopher G. Maloney, Dr. Bryan L. Stone, and Heather Oldroyd, CRC from the University of Utah, Department of Pediatrics and Dr. Karen Wilson from the University of Colorado, Denver, Department of Pediatrics for technical comments on the manuscript. We acknowledge the study design assistance from Tom Greene, PhD and Greg Stoddard, MPH, MBA from the University of Utah, Study Design and Biostatistics Center, with funding in part from the National Center for Research Resources and
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