Stages of change analysis of smokers attending clinics for the medically underserved

Discussion

The smoking rates of people attending clinics providing care for the medically underserved were higher than national figures for people with less than a high school education (44% vs 35%).⁴ In agreement with previous findings, however, the majority of the smokers had tried to quit smoking at some time in the past or wanted to quit at some point within the next 6 months Table 1.^6-8 Only 75 of 245 people who were current smokers or had quit within the past 5 years stated that they were not planning to quit within 6 months Figure 1. Most patients therefore were interested in smoking cessation, which may serve as reinforcement for the physician to continue to provide smoking cessation counseling. Approximately 60% of the current smokers reported that they had ever been counseled to quit smoking Table 1, which is similar to figures reported in larger scale studies (approximately 50% of smokers who visited a physician during the previous year received smoking cessation advice),^29,30 but this counseling rate is less than optimal. Constraints inherent in primary care practices that limit the time available for preventive services are recognized,³¹ but additional constraints may be operating in the provision of health care for the medically underserved. Health care providers may be hesitant about providing smoking cessation advice because they believe that the underserved have more immediate health care needs that have to be met and have a different outlook on smoking that precludes them from responding to a brief intervention about smoking.^21,23 Data from this study, however, suggest that patients attending these clinics are responding to the information provided and should be counseled about smoking cessation.

The distribution of smokers in the stages of change was similar to figures in previous studies, suggesting that approximately 40% of smokers are in the precontemplation stage, 40% are in the contemplation stage, and 20% are in the preparation stage.²⁴ People who reported that they were planning to quit in the near future (within 30 days or within 6 months) differed consistently from people who claimed that they would not quit within 6 months. They were more likely to report having experiences that are consistent with quitting (both experientially and behaviorally) than people who were not planning to quit. They recalled information they had been given about the benefits of quitting and reacted emotionally to the warnings about smoking, reported that they got upset and felt disappointed in themselves when they thought about smoking, were embarrassed to have to smoke, and were aware that their smoking bothers other people. These are all areas that can be used as the basis for providing counseling advice. In contrast, smokers in the precontemplation stage responded to many questions in a manner that indicated they were accepting of their smoking and that their smoking did not bother others ( Table 2,Table 3,Table 4). These findings would appear consistent with the transtheoretical model in identifying a group of people resistant to the idea of behavior change. Research is needed to determine which processes will best motivate precontemplators to change their assessment of their behavior, so that they become more willing to contemplate change.

People planning to quit reported that statements concerning the cons of smoking were more important to them than were statements concerning the pros of smoking. This effect has been seen in almost all studies and appears to represent a reliable difference between people in the precontemplation stage and those in the preparation stage.¹³ There were no differences, however, in the response of smokers who were and were not planning to quit on the assessment of the pros of smoking. It may be that the positive aspects of smoking are more accepted. This possibility suggests that interventions should focus on reinforcing the negative aspects of smoking. Although this study provides examples of statements that these smokers agree with Table 4, further work should be conducted to determine whether there are specific negative aspects of smoking that may have more relevance to people from this population (eg, health consequences rather than social consequences).

There were no clear-cut differences between people who claimed they would quit within 30 days and people who claimed they would quit within 6 months. There may not have been a strong distinction between within 1 month and within 6 months in this group, and further research may provide information as to whether the time frames currently used in the transtheoretical model represent real differences to smokers or whether cutoffs of 30 days or 6 months are arbitrary.¹⁵ It may be that the idea of quitting within the near future (within 6 months) vs not quitting is of primary importance.