Ending the Tobacco Problem - Resources for Local Action
Institute of Medicine

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Health Care Providers Discouraging Smoking


Health care providers are seen by patients as credible sources of health-related information and assistance. Specifically, studies have shown that teens who think clinicians such as physicians, dentists, and pharmacists will keep their information private are more likely to share more about their smoking behavior. Yet these health professionals counsel and screen their teenage patients for tobacco use less than is recommended in the national guidelines of the Department of Health and Human Services (HHS) [1].

Although brief interventions can be effective in helping patients quit smoking and tobacco users are more open to cessation advice when they or their children are being treated for tobacco-related illnesses, fewer than half of all smokers report having ever been asked about their tobacco use or being encouraged to quit by their physicians [2].

Doctors listed several barriers to providing preventive services to their patients, including the lack of time they had to spend with patients because of the number of patients they saw. They also listed a lack of training, a lack of knowledge about where to refer their patients, and lack of knowledge about the effectiveness of preventive services [2].

Few studies have explained how teaching doctors to counsel and screen patients reduces the rate of tobacco use. However, doctors who are trained screen and counsel more patients about tobacco use.


A Cessation Intervention for Health Care Providers

One intervention designed to promote tobacco cessation in primary care practices was very effective in helping patients quit smoking.  Minor changes and adjustments can be made to each step to fit each unique practice without altering the overall plan. The model incorporated the following seven strategies to achieve the greatest success:

  1. The clinic or office must develop an organizational commitment to help its patients quit smoking. This may include appointing a tobacco cessation coordinator to provide training, information, and support to clinical staff and support staff.  It is also important to provide formal training. Do not assume that health professionals know what to do or that providing information is enough. All encouragement should be provided in a supportive, empathetic, and non-judgmental manner. 
  2. The practice develops a systematic approach to ask about and document tobacco-use status for every patient at every clinic visit. It is important to include both teenagers and adults and to ask about tobacco use, not just cigarette smoking. This step should occur in a private area where patients will not be overheard. Perhaps most important is that the information gathered must be documented in the patient’s medical record. The Agency for Health Care Policy and Research (AHCPR) found that asking about tobacco use as part of the collection of vital signs worked best. Patients who are at least 25 years old and quit long ago or never used tobacco are unlikely to begin and do not need to be asked. Young patients, smokers, and smokers who have recently quit should be asked about their tobacco use at every visit. 
  3. All clinicians should advise all smokers to quit. The message by the clinician should be clear, strong, and personalized, advising the patient to quit. The clinician can use the patient’s medical record to personalize the message. Advice to quit smoking should be given as often as possible. 
  4. Clinicians should assess the level of interest in quitting, so they can identify all smokers willing to make a quit attempt. Clinicians should also ask how interested the patient is in quitting and provide information and advice based on the patient’s answer. Clinicians should also refer their patients to other resources in the health system or in the community.
  5. Clinicians and staff should assist patients in quitting through educational, counseling, and pharmacological means. Counseling should focus on soliciting information from the smoker rather than providing information. The clinician should help the patient develop a quit plan that includes preparation for quitting by telling people; making their home, workplace, and car free of cigarettes, ashtrays, and lighters; identifying any lessons learned from previous quit attempts; and anticipating any problems for this quit attempt. 
  6. Clinicians and staff should arrange follow-up contact. Research has shown that patients who receive follow-up are nearly three times more likely to quit than smokers who did not receive follow–up, and a greater number of follow-up contacts results in higher quit rates. A follow-up visit or a phone call should be scheduled.  If a phone call is scheduled, the specific time and the person in the office who will make the call should be chosen with the patient. Nurse or doctors can make the call, but it is more effective if the clinician knows and has at least met the patient.  It is also helpful to get a general time frame when the patient is free for a phone call as a back-up plan. The patient should be encouraged to continue with follow up plans even if a relapse occurs. 
  7. The clinicians and staff should evaluate each strategy to provide feedback for continuous improvement.

The intervention described above followed best practices. Tobacco cessation advice is most effective when it:

  • Is provided at nearly every visit over the longest time possible
  • Is provided by clinicians and staff
  • Is presented in a clear and supportive manner
  • Is focused on specific plans, assistance, and follow-up for quit attempts
  • Includes the ready availability of assistance through counseling, self-help materials, nicotine replacement therapy, and referrals
  • Assures that follow-up contact will be provided soon after quit dates
  • Reinforces any quit effort repeatedly in various ways

[1] HHS, Clinician’s Handbook of Preventative Services, (2nd ed.), 1998.
[2] Kulig, J. (2005). Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse. Pediatrics 115(3): 816-821 

Reference: Pine, D., Sullivan, S., Conn, S., & David, C., (1999) Promoting Tobacco Cessation in Primary Care Practice, Primary Care: Clinics in Office Practice, 26 (3), 591-610.