Original Research

Direct Observation of Smoking Cessation Activities in Primary Care Practice

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OBJECTIVE: Our goals were to determine how often family physicians incorporate smoking cessation efforts into routine office visits and to examine the effect of patient, physician, and office characteristics on the frequency of these efforts.

STUDY DESIGN: Data was gathered using direct observation of physician-patient encounters, a survey of physicians, and an on-site examination of office systems for supporting smoking cessation.

POPULATION: We included patients seen for routine office visits in 38 primary care physician practices.

OUTCOMES MEASURED: The frequency of tobacco discussions among all patients, the extent of these discussions among smokers, and the presence of tobacco-related systems and policies in physicians’ offices were measured.

RESULTS: Tobacco was discussed during 633 of 2963 encounters (21%; range among practices = 0%-90%). Discussion of tobacco was more common in the 58% of practices that had standard forms for recording smoking status (26% vs 16%; P=.01). Tobacco discussions were more common during new patient visits but occurred less often with older patients and among physicians in practice more than 10 years. Of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Although 68% of offices had smoking cessation materials for patients, few recorded tobacco use in the “vital signs” section of the patient history or assigned smoking-related tasks to nonphysician personnel.

CONCLUSIONS: Smoking cessation practices vary widely in primary care offices. Strategies are needed to assist physicians with incorporating systematic approaches to maximize smoking cessation rates.

Recent smoking cessation guidelines1 identify critical ways primary care physicians can intervene with their patients to improve cessation rates. These guidelines recommend that all patients be asked about their smoking status at every visit. Also at every visit all smokers should be advised to quit and should be assessed for their readiness to do so. The guidelines include recommendations for physicians to incorporate elements into their practices that will help them maximize smoking cessation rates. These elements include systems to routinely identify all smokers, reminder systems to encourage physicians to discuss smoking, tools for assisting their patients in quitting, and assignments for nonphysician personnel to assist in smoking cessation. Preliminary data suggest that few practices have adopted these types of systems2,3 and that many smokers have not been advised by their physicians to quit.4

Examining counseling behaviors, such as smoking cessation, in a physician’s office can be challenging. Previous attempts to examine such efforts have relied primarily on physician self-report5,6 and patient surveys.7,8 A few studies have employed direct observation as a method of data collection.3,9 Stange and colleagues10 have suggested that direct observation of clinical practices may be the gold standard for measuring counseling activities. Although patient reports appear to have a high degree of correlation with direct observation, the accuracy of these reports tend to deteriorate with time;10,11 medical records are frequently incomplete; and physician reports typically overestimate counseling activities.10

For our study, medical students directly observed physician-patient encounters in primary care physicians’ offices in Kansas. Our objectives were to describe physician activities related to smoking cessation efforts and to identify physician and office characteristics that support these efforts.


Study Setting

We identified 38 family physicians in 38 separate practices in Kansas who agreed to precept students for 6 weeks during June and July of 1999; 89% of these practices were in non-metropolitan areas. These physicians had served as preceptors to medical students in previous years and were familiar with data collection efforts by students. Each family physician consented to have students observe preventive care practices in their offices during the rotation.

Medical Student Training and Support

Students collected data on a summer research elective between their first and second years of medical school. They received extensive training on the research study. During the next 8 weeks, the students worked with their assigned physicians. They submitted weekly reports of research activities to the study coordinator, who was in contact with the students through electronic mail and telephone calls throughout the course of our study.

Sample Selection

Physician-patient encounters were included in our study if the patient was aged at least 18 years, the physician saw the patient during normal office hours, and the student was present for the entire visit. Encounters were excluded from data collection if the office visit was for a critical acute complaint or a procedure, if the patient appeared to be in immediate emotional distress, if the patient suffered from dementia, if there were language difficulties that precluded observation of counseling behaviors, or if the student had previously observed an encounter with that patient. The Human Subjects Committee of the University of Kansas Medical Center approved the protocol.


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