Individual and Contextual Factors Related to Family Practice
Individual and Contextual Factors Related to Family Practice
Background: Tobacco use is the chief avoidable cause of death in the United States. Physicians, however, are not routinely assessing this risk and providing counseling for risk reduction. This study examines tobacco cessation counseling practices among family practice residents and explores the determinants of residents' smoking-counseling behaviors and counseling duration.
Methods: One hundred ten family practice residents (response rate = 93.2%) from four Texas residency training programs completed a survey designed to assess tobacco cessation counseling practices.
Results: A high proportion of residents reported that they usually or always assessed tobacco use (59.3%) and advised their patients to quit smoking (80.9%), with a lower proportion reporting specific counseling behaviors (7.3% - 21.9%), referrals (1.8%), or follow-up visits (1.8%). Year of residency, perceived effectiveness, and the interaction between perceived effectiveness and residency year were significantly associated with number of counseling behaviors, and year of residency and perceived effectiveness were significantly associated with counseling duration.
Conclusions: Faculty physicians should assist residents to implement the Public Health Service-sponsored clinical practice guideline for tobacco control. There is a need to increase behavioral skills and perceived effectiveness for assessing and counseling smokers among first-year residents.
Although tobacco use is the chief avoidable cause of death in the United States, physicians and other health care providers are not routinely assessing this risk and providing counseling for risk reduction. According to the National Ambulatory Care Survey, physicians assessed smoking status at 61% of all visits in 1995 and reported counseling 21% of smoking patients in that year. Primary care physicians are more likely to provide treatments to smokers than are specialists or other providers.
Meta-analyses conducted by the Agency for Health Care Policy Research (AHCPR) estimated the cessation rate of patients who received physician advice to quit to be 10.2%, compared with 7.9% for the no-advice reference group; the cessation rate for patients in practices with a screening system to determine smoking status was 6.4%, compared with 3.1% for the reference group. Elements of clinician counseling include advice to quit, setting a specific quit date, follow-up, referring patients to an intensive smoking-cessation program, preparing the patient for withdrawal symptoms, prescribing a nicotine patch or gum, and providing self-help material. Cromwell and colleagues found smoking counseling based on AHCPR guidelines to be cost-effective, and the more time (up to 35 minutes at the first visit) and follow-up visits (up to two) of the counseling process, the more cost-effective its estimated effect. The National Cancer Institute (NCI) summarizes its physician counseling guidelines as, "Ask about smoking at every opportunity. Advise all smokers to stop. Assist the patient in stopping. Arrange follow-up visits."
Recent studies suggest that physicians give different amounts of antismoking advice to their patients. During the past two decades, various correlates of physicians' smoking counseling behaviors have been noted. In a 1983 representative sample of Texas general practitioners, internists, and family physicians, internists were found to be most likely to report taking smoking histories and making outside referrals for cessation, whereas family physicians were most likely to report cessation counseling. Internists were more likely than family physicians to inquire about tobacco use and to discuss strategies to quit in the national 1992 primary care provider surveys. Younger physicians were found to be more likely to report history taking and outside referrals for smoking, although faculty physicians have been shown to perform more counseling behaviors than internal medicine residents.
Self-efficacy or confidence in counseling behaviors has been associated with performing counseling and history taking but not with obtaining outside referrals. Expectations for patients to follow through on advice and satisfaction with counseling efforts were positively related to bringing up the subject of smoking and negatively associated with outside referrals. Several studies have found physicians' preparedness and self-efficacy to counsel smokers to be higher than their belief that patients will comply with their recommendation.
The purpose of this study was to examine tobacco cessation counseling practices among family practice residents and to explore the determinants of residents' use of specific counseling behaviors and counseling duration.
Background: Tobacco use is the chief avoidable cause of death in the United States. Physicians, however, are not routinely assessing this risk and providing counseling for risk reduction. This study examines tobacco cessation counseling practices among family practice residents and explores the determinants of residents' smoking-counseling behaviors and counseling duration.
Methods: One hundred ten family practice residents (response rate = 93.2%) from four Texas residency training programs completed a survey designed to assess tobacco cessation counseling practices.
Results: A high proportion of residents reported that they usually or always assessed tobacco use (59.3%) and advised their patients to quit smoking (80.9%), with a lower proportion reporting specific counseling behaviors (7.3% - 21.9%), referrals (1.8%), or follow-up visits (1.8%). Year of residency, perceived effectiveness, and the interaction between perceived effectiveness and residency year were significantly associated with number of counseling behaviors, and year of residency and perceived effectiveness were significantly associated with counseling duration.
Conclusions: Faculty physicians should assist residents to implement the Public Health Service-sponsored clinical practice guideline for tobacco control. There is a need to increase behavioral skills and perceived effectiveness for assessing and counseling smokers among first-year residents.
Although tobacco use is the chief avoidable cause of death in the United States, physicians and other health care providers are not routinely assessing this risk and providing counseling for risk reduction. According to the National Ambulatory Care Survey, physicians assessed smoking status at 61% of all visits in 1995 and reported counseling 21% of smoking patients in that year. Primary care physicians are more likely to provide treatments to smokers than are specialists or other providers.
Meta-analyses conducted by the Agency for Health Care Policy Research (AHCPR) estimated the cessation rate of patients who received physician advice to quit to be 10.2%, compared with 7.9% for the no-advice reference group; the cessation rate for patients in practices with a screening system to determine smoking status was 6.4%, compared with 3.1% for the reference group. Elements of clinician counseling include advice to quit, setting a specific quit date, follow-up, referring patients to an intensive smoking-cessation program, preparing the patient for withdrawal symptoms, prescribing a nicotine patch or gum, and providing self-help material. Cromwell and colleagues found smoking counseling based on AHCPR guidelines to be cost-effective, and the more time (up to 35 minutes at the first visit) and follow-up visits (up to two) of the counseling process, the more cost-effective its estimated effect. The National Cancer Institute (NCI) summarizes its physician counseling guidelines as, "Ask about smoking at every opportunity. Advise all smokers to stop. Assist the patient in stopping. Arrange follow-up visits."
Recent studies suggest that physicians give different amounts of antismoking advice to their patients. During the past two decades, various correlates of physicians' smoking counseling behaviors have been noted. In a 1983 representative sample of Texas general practitioners, internists, and family physicians, internists were found to be most likely to report taking smoking histories and making outside referrals for cessation, whereas family physicians were most likely to report cessation counseling. Internists were more likely than family physicians to inquire about tobacco use and to discuss strategies to quit in the national 1992 primary care provider surveys. Younger physicians were found to be more likely to report history taking and outside referrals for smoking, although faculty physicians have been shown to perform more counseling behaviors than internal medicine residents.
Self-efficacy or confidence in counseling behaviors has been associated with performing counseling and history taking but not with obtaining outside referrals. Expectations for patients to follow through on advice and satisfaction with counseling efforts were positively related to bringing up the subject of smoking and negatively associated with outside referrals. Several studies have found physicians' preparedness and self-efficacy to counsel smokers to be higher than their belief that patients will comply with their recommendation.
The purpose of this study was to examine tobacco cessation counseling practices among family practice residents and to explore the determinants of residents' use of specific counseling behaviors and counseling duration.
