METHODS: We examined data from the ationally representative 1996-1997 Community Tracking Study Household Survey. We used multivariate logistic regression to model receipt of cessation advice in a sample of 8229 smokers aged 18 years and older who made at least one visit to a physician in the past year.
RESULTS: Less than 50% of the subjects reported receiving cessation advice. Advice was less likely for patients who were younger, men, African American, uninsured, healthier, lower health care services users, or lighter smokers, and more likely for those with military health insurance, who attended hospital outpatient clinics, or who belonged to health maintenance organizations.
CONCLUSIONS: Physicians continue to miss opportunities to provide smoking cessation advice, a potentially lifesaving intervention. Given the adverse health consequences of tobacco use and the demonstrated benefit of advice to quit, physicians need to improve their cessation counseling efforts.
Cigarette smoking is the leading preventable cause of death and disability in the United States.1 Because the majority of people who smoke visit a physician each year, physicians are in a key position to promote cessation.2 Although some research has suggested that simple physician cessation counseling without additional counseling or pharmacotherapy does not improve long-term cessation rates,3-5 most studies,6-8 including the 1996 Agency for Health Care Policy and Research (AHCPR) Tobacco Cessation Guideline9 and a recent Cochrane Collaboration review,10 suggest that even simple advice from a physician is effective in promoting long-term cessation, and the AHCPR guideline gave cessation counseling its highest recommendation.
However, in 1991 only 37% of smokers nationally reported being advised to quit by their providers during the previous year.2 The authors of another study11 estimated that 46% of smokers in Rhode Island had been advised to quit in 1990, and the Stanford Five-City Project12 reported that only 50% of smokers in 1989 to 1990 had ever been advised to quit. Although cessation counseling was reported to have almost doubled from 1991 to 1993, it then declined by 1995.13 Factors observed to be associated with a greater likelihood of cessation advice include seeing a primary care physician, having a routine checkup, having cardiovascular or chronic pulmonary disease, and being pregnant.2,11,14,15 Some studies have shown that minority group members are less likely to have received cessation advice.2,15 Other studies have revealed a mixed picture, showing Hispanics to be less likely to receive counseling12,14 and African Americans more likely to receive this advice,14 or no difference.13
We measured the percentage of smokers reporting they had received smoking cessation advice from a physician during a 12-month interval, using data from a recent nationally representative survey. Also, we investigated relationships between the odds of respondents reporting cessation advice from a physician and respondents’ characteristics, including sociodemographic factors, health insurance status, physician continuity, intensity of smoking, and health status.
We used data from the Community Tracking Study (CTS) Household Survey conducted in 1996 and 1997,16 a telephone survey of individuals representing the US housed, noninstitutionalized population. The survey used a stratified multistage area probability sampling design, and information was recorded about smoking behaviors and interventions, sociodemographics, health insurance, utilization, and health status. For our study, we included the 8229 subjects aged 18 years and older who were current smokers and had made at least one visit to a physician in the previous 12 months.
We included sociodemographics (age, sex, education, household income as a percentage of poverty level, race or ethnicity, employment status, and residence location), health insurance status, usual care location, provider continuity, smoking intensity, utilization (number of physician visits, emergency room visits, and hospitalizations) and the physical and mental component summary scales of the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) for perceived health status.18
We used weights provided on the public use files to yield population estimates adjusted for survey oversampling and nonresponse. Because of the complex survey design of the CTS, we conducted analyses with SUDAAN19 software, which uses the method of Taylor series linearization for producing appropriate standard errors and 95% confidence intervals. Logistic regression analyses were performed to obtain odds ratios adjusted for potential confounders.
The baseline characteristics of the sample are presented in Table 1. Overall, 48% of subjects, all of whom were smokers who had visited a clinic at least once in 12 months, had received cessation advice from a physician during this time period. Persons reporting the highest prevalence of cessation advice (>56%) included those who smoked more than 2 packs per day, had perceived health status categorized as fair or poor, had at least one hospitalization, made 4 or more physician visits, were aged 65 years or older, had Medicare, or had military coverage. Persons reporting the lowest prevalence of cessation advice (<40%) included those who lacked health insurance, did not smoke every day, lacked a usual care site or identified an emergency room or other location, had perceived health status categorized as excellent, or had made only one visit to a physician in 12 months.