Influence of physician and patient gender on provision of smoking cessation advice in general practice

Comfort levels in discussing tobacco smoking among hospital staff in a children's hospital

INTRODUCTION

Hospital staff discussing smoking with children and their families can impact tobacco control, which is crucial in reducing the harmful effects of tobacco smoke exposure. Our study aims to assess staff comfort level in discussing smoking with patients or their families, and coworkers, after the implementation of a hospital-wide tobacco control policy.

METHODS

This cross-sectional study included 2340 staff members who completed an anonymous online survey in a large urban children's hospital in 2019. The main outcomes of interest were the comfort level in discussing smoking with patients or their families, and co-workers. We used multivariable logistic regression to identify whether the comfort level varied by sex, age, job type, and smoking status.

RESULTS

Most of the respondents (83.8%) were female, 41.2% were aged 18-35 years, 57.6% worked as clinical staff, and 15.5% were ever smokers. Compared to males, females were less likely to feel very comfortable in asking patients or their families about their smoking tobacco (adjusted odds ratio, AOR=0.72; 95% CI: 0.56-0.92) or talking to co-workers about the health risks associated with their smoking (AOR=0.71; 95% CI: 0.54-0.93). Staff who were non-smokers were less likely to feel very comfortable in talking to co-workers about the health risks associated with their smoking (AOR=0.60; 95% CI: 0.45-0.78). The odds of feeling very comfortable in discussing smoking were consistently lower among those aged 18-35 years than their older counterparts. Clinical staff were more likely than non-clinical staff to feel very comfortable in discussing with patients and their parents about smoking, but there was no difference when talking to co-workers.

CONCLUSIONS

We found differences in staff comfort level in discussing smoking with patients or their families, and coworkers, by sex, age, job type, and smoking status. These results can guide training and identify potential barriers and improve tailored tobacco control training programs and policies for hospital staff.

Perceptions of Facilitators and Barriers to Smoking Cessation Among Patients and Providers in a Cancer Center: A Single Institution Qualitative Exploratory Study

PURPOSE

Cancer patients who remain tobacco users have poorer outcomes, including increased mortality and decreased treatment tolerance; however, cessation post-diagnosis is challenging. Our formative research explored cessation-related perspectives among patients and staff at one National Cancer Institute-designated cancer center, to inform improving cessation services within oncology care.

METHODS

Using a descriptive phenomenological approach, a purposive sample of current cancer patients (n = 13) and cancer center physicians and cessation program staff (n = 9) were recruited to complete one-on-one audio-recorded in-depth qualitative interviews, to explore experiences providing or receiving cessation support, and perspectives on patients' readiness and needs regarding cessation. Thematic coding utilized Green's predisposing, enabling, and reinforcing framework to identify factors having positive, negative, or mixed impact on delivery of best-practices cessation services (ie, 5As) and patient cessation success.

RESULTS

Patients identified cancer diagnosis as a wake-up call, existing health problems, persistent healthcare providers, cost of cigarettes, and societal disapproval of smoking as factors facilitating quitting. Futility of quitting after a cancer diagnosis, cost and logistics of program participation, clinician time constraints, and lifetime addiction made quitting harder. Family, friends, stigma and motivation, and pharmacotherapies played mixed roles. Patients felt survivor-focused cessation programs, including stress management, could better enable quitting. Provider-anticipated problems with implementing cessation counseling included so-called "therapeutic nihilism" (ie, pessimism regarding cessation post-diagnosis), lack of training and standardized approaches, and time and documentation burden. Clinicians saw both policies and peer clinician "champions" as potentially increasing prioritization of cessation within oncology.

CONCLUSIONS

Findings highlight unmet needs for patients and providers regarding provision of effective cessation care. Despite survival benefit, cessation is still not standard within cancer care. Our results show that many patients would benefit from standardized programs where they are routinely asked about cessation. Providers would benefit from both structural enhancements and professional education to ensure that evidence-based cessation services tailored to cancer patients, are offered throughout treatment and survivorship.

Characteristics in Stages of Change and Decisional Balance among Smokers: The Burden of Obstructive Lung Diseases (BOLD)-Australia Study

Smoking cessation remains a health promotion target. Applying the Transtheoretical Model to Australian Burden of Obstructive Lung Diseases (BOLD) data, we examined differences in stages of change (SoC) and readiness to quit decisional behaviours. Factors were identified likely to influence readiness of smokers, ≥40 years old, to quit. Analysis was restricted to current smokers classified to one of three stages: pre-contemplation (PC), contemplation (C) or preparation (P) to quit. Their ability to balance positive and negative consequences was measured using decisional balance. Among 314 smokers, 43.0% females and 60.8% overweight/obese, the distribution of SoC was: 38.1% PC, 38.3% C and 23.5% P. Overweight/obesity was associated with readiness to quit in stages C and P and there were more negative than positive attitudes towards smoking in those stages. Males were significantly heavier smokers in PC and C stages. Females used smoking cessation medication more frequently in PC stage, were more embarrassed about smoking and had greater negative reinforcements from smoking. Age started smoking and factors related to smoking history were associated with readiness to quit and increased the odds of being in stage C or P. An overweight/obese smoker was likely to be contemplating or preparing to quit. In these stages, smokers have more negative attitudes toward smoking. Starting smoking later, taking advice on cessation from health providers and using quit medications indicate increased readiness to quit. Evaluating these factors in smokers and developing cessation gain-framed messages may prove useful to healthcare providers.

Improving Medical Education Using a Sex- and Gender-Based Medicine Lens

Sex- and Gender-Based Medicine (SGBM) is an emerging discipline within healthcare research, education, and practice. It addresses both the similarities and differences in men and women and it considers both biological and sociocultural factors that impact on the health of all individuals. On a basic level, sex refers to biology and gender refers to sociocultural factors. SGBM emerged after a body of knowledge had been established about health differences between women and men. However, these differences are not consistently considered and misperceptions are propagated when translations from the bench to the bedside are based on a predominantly one-sex model. Medical curricula are not yet integrating the evidence of sex and gender across students' educational experiences. We propose adopting a sex and gender lens to enable physicians and students to critically examine the scientific evidence and assess its applicability to specific patients. A Sex and Gender Medical Education Summit was held in 2015 to create a roadmap for integrating SGBM into medical education. We present examples that led to successful integration of SGBM in U.S. medical schools, as well as resources for medical educators and researchers, so that the health of both women and men can be positively impacted.

Sociodemographic characteristics of tobacco users as determinants of tobacco use screening done by healthcare providers: Global Adult Tobacco Survey India 2009-2010

INTRODUCTION

World Health Organization and Indian Public Health Standards recommend provision of tobacco use screening and cessation help at primary care settings. Evidence shows that brief advice by healthcare provider helps tobacco user quit. It starts with asking the patient about his tobacco use status. The rate of tobacco use screening done by healthcare providers is very low and also depends on sociodemographic characteristics of patients along with several other factors.

OBJECTIVES

This paper intends to study how sociodemographic characteristics (age, gender, residence [rural/urban], education, and occupation) of tobacco users influence the tobacco use screening done by healthcare providers.

MATERIALS AND METHODS

The study was a secondary data analysis of the Global Adult Tobacco Survey India 2009-2010. There were 4958 smokers and 7255 smokeless tobacco users included in the study who visited healthcare provider in the past 12 months prior to the survey.

RESULTS AND DISCUSSION

The results showed that male smokers were more likely to be screened for smoking by healthcare providers as compared to female smokers. Furthermore, tobacco users in younger age groups were less likely to be screened for tobacco use by healthcare providers as compared to tobacco users in older age groups. Urban smokeless tobacco users were more likely to be screened for tobacco use by healthcare provider as compared to rural smokeless tobacco users.

CONCLUSION

Healthcare providers were being biased in tobacco use screening of their patients based on demographic characteristics of patients, i.e., their age, gender, and rural/urban residence. However, the evidence shows that it is very imperative to screen each and every patient for tobacco use habit.

The multidimensional impact of total laryngectomy on women

Based on society's expectations of what defines the norms for what is deemed "masculine" and "feminine", and a propensity for society's members to adhere to these expectations, women may face a unique set of circumstances and pressures following surgical treatment for laryngeal cancer. This is primarily due to the changes that occur to women's physical, psychological, and social functioning when dealing with cancer diagnosis and treatment outcomes. Because of concerns related to physical disfigurement, acoustic and perceptual changes to one's voice, and threat of the psychological sequelae associated with total laryngectomy (TL) (or, the surgical removal of one's voicebox and surrounding structures), there is an increased potential for violation of social expectations that cross these areas of functioning. As such, efforts that seek to better understand the potentially differential impact of TL on women and identify the specific needs they may have leading up to and after such treatment pursuant to contemporary societal expectations are warranted. Thus, this paper provides an examination of the potentially differential impact of TL on women. In addressing this position, this paper examines the unique challenges women may face postlaryngectomy through the framework of the International Classification of Functioning, Disability, and Health (ICF). Through the use of the ICF, this paper will provide an expanded perspective related to the interactions between body functioning, active participation in daily activities, and contextual factors that may act as facilitators or barriers to women's societal reintegration secondary to TL.

LEARNING OUTCOMES

Readers will be able to describe the multiple factors that may contribute to the differential impact of total laryngectomy (TL) on women. More specifically, readers will gain an understanding about women's physical, psychological, and social functioning secondary to TL. This paper also provides readers with exposure to the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework. This framework provides readers with an expanded perspective related to the interactions between body functioning, active participation in daily activities, and contextual factors that may act as either facilitators or barriers to the societal reintegration of women secondary to TL.

We can do better than last place: improving the health of us women

Life expectancy for US women lags behind that for women in other countries. Factors contributing to inequitable health for women are complex and include policy, community, healthcare access, and the interaction between the patient and her healthcare provider working within the healthcare system. We propose a societal pyramid of health accounting for the effects of these different factors and their impact on prevention, screening, diagnosis, and management of disease using the examples of smoking and obesity, two of the most important yet modifiable risk factors for chronic disease and death among US women.

Talking about smoking in primary care medical practice--results of experimental studies from the US, UK and Germany

OBJECTIVE

To analyse effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences.

METHODS

We conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice.

RESULTS

Female and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice.

CONCLUSIONS

Although all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited.

PRACTICE IMPLICATIONS

Findings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.

Do general medical practice characteristics influence the effectiveness of smoking cessation programs? A multilevel analysis

INTRODUCTION

General practice is a recommended setting for the delivery of smoking cessation programs. Little is known about the types of practice that achieve higher cessation rates. To address this gap in knowledge, we assessed the impact of general practice characteristics on the outcomes of a large scale smoking cessation intervention delivered in general practice settings.

METHOD

A cross-sectional study was undertaken of 7,778 participants enrolled on a structured cessation program comprising repeated brief interventions in one-to-one sessions and nicotine replacement therapy in Christchurch New Zealand, 2001-2007. We employed a logistic multilevel analysis of respondents nested in general practices with cessation at 6 months as the outcome measure.

RESULTS

After taking into account relevant individual-level predictors (age, sex, smoking intensity) and area-level surrogates for individual predictors (socioeconomic status and access to tobacco retail outlets), there remained significant variation in quit rates between practices. This variation reduced when practice characteristics were included. Practices with a majority of male doctors and practices with fewer male patients were associated with better quit rates. Practices with large numbers of doctors were less effective in achieving cessation with heavy smokers.

CONCLUSIONS

The effectiveness of smoking cessation programs can be influenced significantly by practice characteristics. To increase quit rates, more attention should be paid to the institutional setting of smoking cessation programs. Assessments of the effectiveness of cessation programs should give appropriate recognition to the fact that some practices may find higher quit rates more difficult to achieve.

Gender influences in tobacco use and cessation interventions

Smoking rates among and between men and women are in large part a reflection of the influence of gender and its intersections with other social factors including ethnicity, age, and social class that influence tobacco use and, ultimately, tobacco reduction and cessation. In this article, opportunities for developing and delivering gender-sensitive (programs addressing gender) and gender-specific (programs designed for men or women) interventions in the context of tobacco dependence treatment are discussed.

Australian smokers increasingly use help to quit, but number of attempts remains stable: findings from the International Tobacco Control Study 2002-09

OBJECTIVE

To assess interest in quitting smoking and quitting activity, and the use of pharmacotherapy and behavioural cessation support, among Australian smokers between 2002 and 2009.

METHODS

Data were taken from 3303 daily smokers taking part in a minimum of two consecutive waves of the International Tobacco Control Four Country Survey. Using weighted data to control for sampling and attrition, we explored any effects due to age, sex, whether living in a metropolitan or regional area, and nicotine dependence.

RESULTS

Around 40% of smokers reported trying to quit and, of these, about 23% remained abstinent for at least one month when surveyed. Low socioeconomic smokers were less likely to be interested in quitting and less likely to make a quit attempt. Reported use of prescription medication to quit smoking rose sharply at the last wave with the addition of varenicline to the pharmaceutical benefits scheme. Among those who tried, use of help rose gradually from 37% in 2002 to almost 59% in 2009 (including 52% using pharmacotherapy and 15% using behavioural forms of support).

IMPLICATIONS

Use of help to quit is now the norm, especially among more dependent smokers. This may reflect a realization among smokers that quitting unassisted is more likely to fail than quitting with help, as well as the cumulative effect of promoting the use of help. Given the continuing high levels of failed quit attempts, services need to be able to expand to meet this increasing demand.

Smoking counseling practices of physicians in the United Arab Emirates

Background. Despite the cost effectiveness of physician smoking cessation counseling, many physicians do not adhere to current clinical practice guidelines. Methods. A cross-sectional mail survey was conducted in a sample of general practitioners in the United Arab Emirates (UAE), emirates of Sharjah, Dubai and Abu Dhabi, to document cessation-counseling practices and identify correlates of these activities. Results. Of 391 eligible GPs, 218 (56%) completed the questionnaire. Despite favorable beliefs/attitudes about cessation counseling, less than half of GPs (47%) indicated that they have the skills to help their patients quit smoking and only 24% knew of community resources to refer patients to. GPs who perceived physician barriers in offering smoking counseling as very important were significantly less likely to ascertain smoking status of most of their patients (OR: 0.28, 95% CI: 0.09,0.88). Moreover, high self-efficacy and favorable beliefs/attitudes were significantly associated with high level of counseling completeness (OR: 4.44, 95% CI: 1.21, 16.37; OR: 3.78, 95% CI: 1.25, 11.35; respectively). Conclusion. Support, training and intervention programs to overcome lack of awareness and knowledge, unfavorable beliefs/attitudes, and low self-efficacy could increase and enhance cessation-counseling practices among general practitioners in the UAE.

The accuracy of physicians' perceptions of patients' suffering: findings from two teaching hospitals

PURPOSE

How accurately physicians perceive patient suffering remains unclear. The authors sought to quantitatively compare physicians' estimates of their patients' suffering with the patients' ratings of their own suffering, using a paired survey.

METHOD

Six major domains of suffering (DOSs) were derived from narrative descriptions of suffering by physicians and patients in a preliminary multicenter pilot study. From September 2005 through July 2006 at two teaching hospitals in Washington, DC, and Bethesda, Maryland, before a clinical encounter between a patient and physician, patients rated the impact of each of these DOSs on their overall suffering. After the same encounter, physicians rated the same DOSs according to their perception of suffering experienced by that patient. Patient responses were compared with physician responses using the Wilcoxon signed ranks and Spearman correlation tests.

RESULTS

Two hundred twenty-seven adult patients and their treating physicians completed the survey. Cooperation rates among patients and physicians were 94% and 97%, respectively. For two of the six DOSs (pain and physically nonpainful symptoms), there was no significant difference between the physicians' estimates of suffering and the patients' ratings of the DOS. For the remaining four DOSs (communication, emotional factors, loss, and systems factors), there was significant disagreement between the physicians' estimates and the actual suffering of the patients (P < .01). When all six DOSs were combined to ascertain how well perceptions of overall suffering correlated, significant discordance was also observed between physicians' perceptions and patients' descriptions (P < .001).

CONCLUSIONS

This study suggests that the physicians who participated might need more training in the recognition of patient suffering. Because these physicians were trained in medical schools across the country, the deficiencies noted here may not be limited to only the physicians in this study. More studies of physicians' ability to detect and manage suffering are needed, especially at nonteaching hospitals.

Listen to the consumer: designing a tailored smoking-cessation program for women

We used a consumer-driven approach to develop a model smoking-cessation program for women. Four focus groups (N = 23 [5-7/group]), each lasting 2 hours, were led by a professional moderator and audiotaped in 2004. Researchers reviewed transcripts; key themes were identified using scrutiny techniques (Ryan and Bernard, 2003). Necessary elements of a smoking-cessation program for women included support and choice (i.e., control over the program components), suggesting the need for an individualized program. Identifying appropriate components is a critical step in the development of efficacious programs that target substance-abusing populations; focus group methodology is useful in this endeavor. The study's implications and limitations are noted.

Detection and prevalence of abuse of older males: perspectives from family practice

Family doctors' frequent contact with seniors put them in reasonable positions to detect elder abuse and initiate referral to adult protective services. Since doctor reporting is low, however, this paper explores whether the gender of patient and/or doctor impacts on identification of elder mistreatment, or creates differential detection of one gender over the other. Use of the validated Elder Abuse Suspicion Index (EASI), and a structured social work evaluation, is described to provide some gender-based data from Canadian family practice. Specifically, while the prevalence of elder abuse is estimated to range from 12.0% to 13.3%, the specific prevalence was found for females to be 13.6% to 15.2% and for males 9.1% to 9.7%.

Gender differences among general practitioners in smoking cessation counseling practices

OBJECTIVES

To describe gender differences in smoking cessation counseling practices among general practitioners (GPs), and to investigate the association between training for cessation counseling and counseling practices according to gender.

METHODS

Data were collected in two cross-sectional mail surveys conducted in independent random samples of GPs in Montreal, the first in 1998, and the second in 2000.

RESULTS

Respondents included 653 GPs (71% of 916 eligible). All indicators of smoking cessation counseling practices were more favorable among female GPs. Higher proportions of female GPs had received training (28% vs. 17%, p=0.002), and were aware of mailed print educational materials related to cessation counseling (81% vs. 57%, p<0.0001). Training among male GPs was associated with higher scores for ascertainment of smoking status (odds ratio (OR) (95% confidence interval)=1.69 (0.97, 2.96)), provision of advice (OR=2.20 (1.23, 3.95)), and provision of adjunct support (OR=2.86 (1.58, 5.16)). Training was not associated with counseling practices among female GPs.

CONCLUSIONS

Female GPs may not benefit from formal cessation counseling training to the same extent as male GPs, possibly because they read and integrate the content of (easily available) print educational materials into their clinical practice to a greater extent than male GPs. The gender-specific impact of print educational material and formal training on cessation counseling should be evaluated among GPs.

Pediatrician self-efficacy for counseling parents of asthmatic children to quit smoking

BACKGROUND

Although environmental tobacco smoke is a common trigger for asthma exacerbations in children, pediatricians infrequently counsel parents who smoke to quit. High physician self-efficacy, or self-confidence, in the ability to counsel parents about smoking cessation is associated with increased physician screening and counseling on this topic. However, it is not clear which factors are associated with high physician self-efficacy for counseling, such as previous training in smoking-cessation counseling or number of years in pediatric practice.

OBJECTIVE

To identify factors associated with high levels of physician self-efficacy for 4 skills associated with smoking-cessation counseling.

DESIGN

Cross-sectional survey.

PARTICIPANTS

A national random sample of 829 primary care pediatricians.

RESULTS

The response rate was 55% (457 of 829). The percentage of physicians with high levels of self-efficacy for screening parents and screening patients to identify smokers was 87% and 84%, respectively. The percentage of physicians with high levels of self-efficacy for counseling parents and patients was 59% for both groups. The presence of previous training in smoking-cessation counseling was associated with high levels of self-efficacy for all 4 skills including inquiring about an asthma patient's smoking status (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.63, 9.37); inquiring about a parent's smoking status (OR: 2.51; 95% CI: 1.09, 5.75); counseling a patient to quit smoking (OR: 5.30; 95% CI: 3.02, 9.31); and counseling a parent to quit (OR: 4.96; 95% CI: 2.85, 8.61). Years since completion of residency were not associated with high self-efficacy.

CONCLUSIONS

These findings suggest that formal training in smoking cessation has a significant impact on physician self-efficacy related to smoking cessation throughout a physician's career.

Sex differences in the effects of stressful life events on changes in smoking status

AIMS

Stressful life events known to be associated with substance use were examined to determine if there were sex-specific responses to stress resulting in changes in smoking status.

PARTICIPANTS AND MEASUREMENTS

A community-based sample of ever smokers from the Americans' Changing Lives study (n = 1512, 45% female based on sample weights) was used to examine the interactive effects of sex and stressful life events on the likelihood of two outcomes; relapse among former smokers and failure to quit among current smokers. Logistic regression procedures were used to calculate odds ratios. Factors known to be associated with smoking status (e.g. depression, self-esteem, social support) were assessed as control variables.

FINDINGS

In the sample of former smokers (n = 729) interpersonal loss events were associated with continued abstinence, whereas change of residence and adverse financial events were associated with increased occurrence of relapse. Women were more likely than men to relapse in response to a financial event. In the sample of current smokers (n = 783), financial events were associated with continued smoking, whereas health events were associated with increased likelihood of quitting. Women were more likely than men to continue smoking in the presence of an adverse financial event and less likely than men to quit in response to an adverse health event.

CONCLUSIONS

Overall, stressful life events appear to have a greater deleterious effect on continued abstinence and the ability to quit smoking for women when compared to men. In particular, health and financial events are important risk factors for women and tobacco use.

Vascular disease risk factor management 4 years after carotid endarterectomy: are opportunities missed?

BACKGROUND

Because a large percentage of patients surviving carotid endarterectomy (CEA) subsequently die from a vascular cause, the aim of the present paper was to determine risk factor management for a cohort of patients 4 years after their CEA.

METHODS

Surviving patients who had a CEA within the region administered by the Central Sydney Area Health Service in 1995 were asked to complete a self-administered questionnaire to determine vascular risk factors.

RESULTS

Of the 181 patients eligible to participate, 162 returned questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that they had been diagnosed with high blood pressure either before or after their CEA, only 79.2% recalled that their latest blood pressure reading was 'about right for my age'. Nearly one in five (16.7%) who had had their cholesterol level checked in the last 12 months (n = 120) indicated that the reading was 'too high'. Only 76.5% reported taking medications to 'thin the blood'. Almost one-fifth of patients (17.3%) were current smokers. Only 35.2% of patients participated in a level of physical activity sufficient to confer a health benefit. Further, 30.2% of patients were overweight and 14.8% were obese. The majority of patients (98.1%) reported having a regular general practitioner (GP). Of these, 98.7% had visited their GP at least once within the previous 6 months.

CONCLUSIONS

Vascular risk factor management following CEA is suboptimal, inviting the implementation and evaluation of strategies to improve outcomes.

Dissemination of the AHCPR clinical practice guideline in community health centres

OBJECTIVE

To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres.

DESIGN

Pre- and post-trial.

SETTING

Fourteen community health centres in Rhode Island.

SUBJECTS

Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up.

INTERVENTIONS

Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building.

OUTCOME MEASURES

Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit.

RESULTS

While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points.

CONCLUSIONS

This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

Factors associated with patient-recalled smoking cessation advice in a low-income clinic

It is recommended that providers advise cessation to their patients who smoke. However, patients' reports of cessation advice indicate disparities based on patients' race, gender, age, and smoking level. Providers' reports do not corroborate these disparities. We investigated whether smokers who receive their care in a community health center recalled their providers advising them to quit smoking when their providers documented such advice. We examined 219 patient-provider dyads to assess factors associated with lack of agreement between providers' documentation and patient recall. Patients were asked to recall any provider advice to quit smoking in the post 2 years. After every visit, providers completed a form to record the content of the visit. Most of the patients were African American, married, and uninsured. Sixty-eight percent of the dyads agreed in their documentation/recall. Patient race was the only factor associated with lack of agreement; African-American patients were more likely than white patients to provide discrepant reports. Although this study can not disentangle the racial difference in patient-provider recall/documentation, results may indicate an important area in which health disparities exist. Future studies should address the dynamics of patient-provider communication about smoking cessation, especially in populations that include ethnically diverse patients.

Smoking cessation in women. Special considerations

Women may be at relatively greater risk of smoking-related diseases than men but tend to have less success than men in quitting smoking. The failure of most outcome studies to report results by gender and the lack of statistical power for detecting significant gender differences currently do not allow for many firm conclusions to be drawn about smoking cessation rates in women, but several trends warrant attention and further study. First, the difference in cessation rates for women versus men may be even greater in trials of nicotine replacement therapies (NRT). This suggests that women benefit less from NRT relative to men, although this difference may depend on the particular form of NRT (e.g. inhaler versus gum). On the other hand, some non-NRT medications may reverse the poorer outcome of women, producing quit rates in women comparable with those in men. Gender differences in outcome, as well as overall success rates, with NRT and some of the non-NRT medications appear to be enhanced when treatment includes substantial behavioural counselling. However, while several of the non-NRT medications may be particularly appropriate to consider for treating women trying to quit smoking, adverse effects may limit widespread use of some of these drugs, such as clonidine and naltrexone. Thus, even if the gender differences in outcome with NRT versus non-NRT drugs are confirmed in further research, such findings do not necessarily justify limiting NRT use in women, because such treatment is clearly effective and is likely to be safer and more readily available than non-NRT medications. Nevertheless, study of the mechanisms by which some non-NRT drugs are effective in women may aid our understanding of factors that are more influential in smoking behaviour in women than in men. Secondly, smoking cessation treatment for women must address several other issues that often emerge, and these are most likely to require behavioural counselling that is tailored to these problems. These issues include concern about bodyweight gain, restrictions on medication use in pregnant smokers, variability in mood and withdrawal as a function of menstrual cycle phase, harnessing social support to foster abstinence, and the possibility that smoking-associated environmental cues may be more influential in smoking behaviour in women than men. Greater attention to gender differences in clinical trial outcomes and to addressing concerns of women smokers may aid in the development of substantially improved smoking cessation interventions for women.

Smoking cessation counseling practices of general practitioners in Montreal

BACKGROUND

Despite the cost-effectiveness of physician smoking cessation counseling, many physicians do not adhere to current clinical practice guidelines.

METHODS

A cross-sectional mail survey was conducted in a random sample of general practitioners in Montreal to document cessation-counseling practices and identify correlates of these activities.

RESULTS

Of 440 eligible general practitioners, 337 (77%) completed the questionnaire. Despite favorable beliefs/attitudes about cessation counseling, only 10.5% of general practitioners provided "thorough" counseling. While high proportions of general practitioners ascertained smoking status and encouraged patients to quit, relatively few offered adjunct support (i.e., for patients preparing to quit, 49.8% offered follow-up visits; 42.5% offered educational material; 20% referred patients to community resources). Correlates of counseling completeness included high self-efficacy to provide counseling (odds ratio (OR) = 2.0, 95% confidence interval (1.1-3.6)) and favorable beliefs/attitudes about counseling (OR = 3.6 (2.0-6.4)). Correlates of ascertaining smoking status included female gender (OR = 2.3 (1.5-3.5)), high self-efficacy (OR = 3.5 (2.0-5.9)), and favorable beliefs/attitudes (OR = 2.7 (1.6-4.5)). Correlates of offering adjunct support included female gender (OR = 1.9 (1.1-3.2)), awareness of stages of change (OR = 2.4 (1.3-4.4)), and knowledge of community resources to help patients quit (OR = 2.3 (1.3-3.9)).

CONCLUSION

Support, training, and intervention programs to overcome lack of awareness and knowledge, unfavorable beliefs/attitudes, and low self-efficacy could increase and enhance cessation counseling practices among general practitioners.

Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers

OBJECTIVE

The aim of this study was to ascertain opinions, current practices, likely readiness to change and perceived barriers to change among Australian GPs in order to develop a plan to implement national guidelines for smoking cessation advice.

METHOD

A postal survey of randomly selected GPs in New South Wales, Australia was carried out.

RESULTS

We received 311 returned questionnaires (73% response rate). Only 34% of respondents reported providing cessation advice during every routine consultation with a smoker, in accordance with national guidelines. Specific evidence-based approaches recommended in guidelines were under-utilized, with only 54% 'always' or 'frequently' arranging follow-up, 32% providing written materials and 28% setting a 'quit date'. Respondents were no more likely to advise quitting completely than the less effective method of nicotine fading. More than one in four respondents (28%) indicated readiness to change their behaviour. Respondents rated their patients' lack of motivation and uninterest as the most important barriers to smoking cessation advice in general practice. Neither uncertainty about effective smoking cessation strategies nor lack of reimbursement for smoking cessation advice were identified as barriers.

CONCLUSIONS

A multicomponent intervention to address suboptimal behaviour and barriers as revealed by this survey holds considerable potential to plan effective implementation of smoking cessation guidelines in general practice. The use of readiness to change as a tool to 'individualize' strategies for guideline implementation should be explored.