Study Finds Most Doctors Don't Smoke; But They Don't Press Patients to Quit
From July 2003 to February 2004, researchers from Mathematica Policy Research (Princeton, N.J.) conducted a national survey of 2,804 health professionals to determine their knowledge, attitudes, beliefs and behavior regarding smoking and smoking cessation.
Researchers reported the following key findings to the Robert Wood Johnson Foundation (RWJF) and in an unpublished manuscript:
- Few clinicians currently smoke.
- Primary care physicians are more likely to counsel smokers and offer cessation assistance than other clinicians, but quit advice and support are infrequent across groups.
- Few clinicians are aware of treatment guidelines.
- The structure of clinical practices raises barriers to improved cessation practices.
- There are differences in assessment, treatment and perceived barriers by clinician ethnic group, tobacco use and practice setting.
RWJF provided $724,777 to support this solicited contract from October 2002 through October 2004.
Most smokers would like to quit, but each year less than 5 percent of smokers are able to quit without assistance (Fiore et al., Respiratory Care, 45(10): 2000). Several studies have shown that counseling by physicians is effective in increasing the number of smokers who quit (e.g., Cromwell, Journal of the American Medical Association, 278(21): 1997, Lightwood, Circulation, 96(4): 1997).
Studies by the Centers for Disease Control and Prevention and others show that between one-third and one-half of smokers say they receive smoking cessation advice from a physician in a given year.
RWJF needed more information (1) to inform the work of its programs that are focused on increasing the number of health care providers who assist their patients to quit smoking and (2) to inform future program efforts.
RWJF has been actively engaged in improving and advancing smoking cessation treatment since 1996. It awarded grants to:
- Disseminate the original Public Health Service guidelines on tobacco cessation treatment, (see Grant Results on ID#s 029389, 030254, 030329, 030520, 030375 and 030525).
- Develop a primary care practitioners' pocket guide (see Grant Results on ID# 029466).
- Develop an update to the original guideline (see Grant Results on ID# 034068).
- Develop conference proceedings about the guidelines (see Grant Results on ID# 030465).
- Conduct an evaluation of the implementation of the guideline by Allina Medical Clinic (see Grant Results on ID# 030499) that helped inform Addressing Tobacco in Managed Care (see Grant Results on the program).
In conjunction with other organizations, RWJF funded the development of a blueprint for adolescent treatment (see Grant Results on ID#s 037525 and 041053 to form the Youth Tobacco Cessation Collaborative).
Also in conjunction with other organizations, RWJF funded the development of a blueprint for pregnant smokers through Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy, working with the National Partnership to Help Pregnant Smokers Quit (see Grant Results).
Researchers from Mathematica Policy Research conducted a national survey of seven types of health professionals primary care physicians, emergency room physicians, psychiatrists, registered nurses, dentists, dental hygienists and pharmacists to determine their knowledge, attitudes, beliefs and behavior regarding smoking and smoking cessation.
The survey included questions on:
- Identification, assessment and treatment of patients' tobacco use.
- Availability of cessation materials and quitlines.
- Use of referrals.
- Use of practice guidelines.
- Perceived effectiveness of drug and counseling programs.
- Barriers to following assessment and treatment guidelines.
- Patient profiles; personal tobacco use.
- Demographic characteristics.
Researchers surveyed 2,804 clinicians (approximately 400 from each group) from July 2003 to February 2004. They conducted the survey primarily by computer-assisted telephone interview (68 percent of responses), supplemented by questionnaires mailed to clinicians who were difficult to reach by telephone (32 percent of responses). For more information about the survey, see Appendix 1.
Researchers reported the following key findings to RWJF and in an unpublished manuscript:
- Few clinicians currently smoke. Fewer than 6 percent of each group of clinicians smoke cigarettes except for registered nurses, of whom 13 percent smoke.
- Primary care physicians are more likely to counsel smokers and offer cessation assistance than other clinicians, but quit advice and support are infrequent across groups. About one-third of primary care physicians said they always encourage smokers to set a date by which they will stop smoking (a "quit date") and another third said they often do so. About one-half of primary care physicians, registered nurses and pharmacists, and one-third of emergency physicians, dentists and dental hygienists, offer quitlines and smoking cessation programs to their patients.
- Few clinicians are aware of treatment guidelines. Forty percent of primary care physicians and from 13 to 30 percent of the other clinician groups surveyed were aware of the U.S. Public Health Service's Treating Tobacco Use and Dependence: A Clinical Practice Guideline (2000). Nine percent of primary care physicians and fewer than 5 percent of the other clinical groups implement the guidelines in their practices.
- The structure of clinical practices raises barriers to improved cessation practices. Clinicians cited such barriers as time constraints, perceptions about their personal roles in helping smokers quit, inadequate information or training, and reimbursement issues. Primary care physicians are least likely to cite barriers to assisting smokers and are most likely to see cessation support as an important part of their responsibilities. Of all groups surveyed, emergency room physicians are least likely to provide smoking cessation assistance. A majority of registered nurses, dentists and dental hygienists felt that patients would resist their advice because they are not the patients' regular doctors.
- There are differences in assessment, treatment and perceived barriers by clinician ethnic group, tobacco use and practice setting. See Appendix 2 for details.
Researchers made the following recommendations to RWJF and in an unpublished manuscript:
- Increased dissemination on best practices, access to quitlines and smoking cessation programs, and reimbursement by insurers may translate into greater clinical support for cessation programs. Disseminating information on the effectiveness of various treatments, access to and funding sources for quitlines, and reimbursement by third-party payers will alleviate clinicians' concerns and may increase support for smoking cessation efforts. Many clinicians across all groups expressed interest in receiving the U.S. Public Health Service Treating Tobacco Use and Dependence: A Clinical Practice Guideline (2000) and training in cessation education.
- Dissemination efforts targeted to national pharmacy chains could reach many smokers. While pharmacists typically do not have enough patient contact to screen and assess patients, they are receptive to tobacco control messages and most would support dissemination of smoking cessation materials.
- Future research could investigate the role of cultural barriers in assessing and treating smokers. Since Hispanic and black non-Hispanic clinicians were less likely to have concerns about reimbursement and demands on their time and more likely to encourage smokers to quit, practices staffed primarily by these minority clinicians may be more receptive to cessation efforts than other practices. Given the increasing proportion of Asians in the health professions, evidence that these clinicians expressed greater concern about patient resistance, competing priorities and reimbursement may have implications for cessation efforts.
- The increased use of voice messaging makes telephone surveys less effective than in the past. Voicemail has made telephone surveys less efficient and response rates lower. Regular mail combined with telephone is now necessary to generate sufficient responses, particularly for physicians and dentists who have a low response rate to Web-based surveys. Researchers spent more time and money obtaining survey responses than originally anticipated because of these factors. The most cost-effective alternative appears to be self-administered surveys sent by mail. (Project Director)
AFTER THE GRANT
Steven Schroeder, M.D., former president of RWJF and now head of the RWJF National Program Smoking Cessation Leadership Center, uses project findings in the center's work, which aims to increase cessation rates and increase the number of health professionals who help smokers quit.
GRANT DETAILS & CONTACT INFORMATION
Surveys of Health Professionals' Knowledge, Attitudes, Beliefs and Behaviors about Tobacco Cessation Counseling
Mathematica Policy Research (Princeton, NJ)
Dates: October 2002 to October 2004
Richard C. Strouse
Methodology of Survey of Health Professionals' Knowledge, Attitudes, Beliefs and Behaviors about Tobacco Cessation Counseling
Project staff, in collaboration with RWJF staff, designed two versions of the survey: one for pharmacists and the second for all other health professionals. Staff obtained most clinician names from Medical Marketing Services (which licenses such data from health professions associations, licensing boards, directories and other sources); they obtained nurses' names from a database compiled from state licensing boards.
To increase the likelihood of responses, researchers sent advance letters on RWJF letterhead from President and CEO Risa Lavizzo-Mourey, M.D., M.B.A., along with the promise of a small honorarium to physicians and dentists, who are accustomed to receiving such incentives. The letter also included endorsements from such organizations as the American College of Physicians and the American Nurses Association.
Differences in Assessment, Treatment and Perceived Barriers by Clinician Ethnic Group, Tobacco Use and Practice Setting
- Asian clinicians were less likely than non-Hispanic whites to refer patients to cessation programs and more likely to cite competing priorities. Other minorities (non-Hispanic black, Hispanic and biracial) were more likely than non-Hispanic whites to encourage patients to set quit dates and were less likely to agree that they have competing priorities.
- Current smokers were less likely than colleagues who did not smoke to encourage their patients who smoke to set a quit date, to offer cessation materials or to refer them to treatment programs. They were more likely to agree they were uncomfortable asking patients if they smoke and were less likely to agree that smoking cessation is an important part of their responsibilities.
- Former smokers also were less likely than those who had never smoked to refer patients to smoking cessation programs, and were slightly more likely to agree that cessation is not an appropriate service to offer and that their patients would resist their advice. Former smokers were more likely than current smokers or those who had never smoked to agree that health insurance plans provide little reimbursement for smoking cessation in their areas of the country.
- Clinicians practicing in hospitals are less likely than those in private practice to encourage quit dates and to refer patients to smoking cessation programs but are more likely to offer cessation materials with quitline information. Hospital-based clinicians also are slightly more likely to agree they have competing priorities and do not have time to help smokers quit. Clinicians practicing in other facilities, such as extended care facilities and health centers, were also less likely than clinicians in private practice to refer patients to cessation programs.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Strouse R, Schroeder S, Zheng Y and Gerlach K. "Why Don't Health Professionals Do Better at Helping Smokers Quit? Results of a Survey of 2,804 Members of Seven Disciplines." Unpublished.
Strouse R, Hall J and Kovac M. Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors Regarding Smoking Cessation Assistance and Counseling. Princeton, N.J.: Mathematica Policy Research, Inc., 2004.
"Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors Regarding Smoking Cessation Assistance and Counseling," Mathematica Policy Research, Inc., fielded July 2003 to February 2004.
Report prepared by: Nanci Healy
Reviewed by: Lori De Milto
Reviewed by: Molly McKaughan
Program Officer: Karen K. Gerlach
Program Officer: Michelle A. Larkin