Physician and Other Health-Care Professional Counseling of Smokers to Quit -- United States, 1991

Physicians and other health-care professionals play a lead role in the prevention of tobacco smoking in the United States (1). In particular, health-care professionals can assist patients to stop smoking by counseling them about quitting (2,3). To monitor progress toward the national health objectives for the year 2000 on tobacco use (4), data from CDC's 1991 National Health Interview Survey - Health Promotion and Disease Prevention (NHIS-HPDP) supplement were used to estimate the prevalence of outpatient physician and other health-care professional counseling of smokers to quit. This report summarizes the results of that survey.

The NHIS-HPDP supplement collected information from a representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years regarding self-reported information on smoking and receipt of advice to quit. The overall response rate for the 1991 NHIS-HPDP was 87.7% (n=43,732). Participants who reported smoking cigarettes at any time during the preceding 12 months were asked the number of times during that period they had visited a doctor or other health-care professional in an outpatient setting and the number of visits during which they were advised to quit smoking by a doctor or other health-care professional. Doctor visits that occurred during overnight stays in hospitals were not counted. Data were adjusted for nonresponse and weighted to provide national estimates. Confidence intervals (CIs) were calculated using standard errors generated by the Software for Survey Data Analysis (SUDAAN) (5).

In 1991, an estimated 35.8 million (70.2% {95% CI=plus or minus 1.0%}) of the 51.0 million persons who smoked during the preceding 12 months reported at least one outpatient visit with a physician or other health-care professional during that time. Of these, 11.2 million (31.4% {CI=plus or minus 1.1%}) had had one visit, 10.7 million (29.9% {CI=plus or minus 1.1%}) had had two or three visits, and 13.8 million (38.7% {CI= plus or minus 1.2%}) had had four or more visits.

Overall, 12.8 million (37.2% {CI=plus or minus 1.3%}) of the persons who had smoked reported having received any advice to quit from a health-care professional during the preceding 12 months. The likelihood of having been counseled to quit was directly related to the number of doctor visits (45.5% {CI= plus or minus 2.0%} among persons with four or more visits compared with 28.1% {CI=plus or minus 1.9%} among those with one visit). Rates of receiving counseling were slightly higher for women and persons aged 45-64 years than for men and persons aged less than 45 years (Table_1). Rates were slightly lower for Hispanics than for white non-Hispanics but otherwise did not vary by race/ethnicity, education, or socioeconomic status.

Among persons who reported that they smoked at the time of the survey, the proportion who had received advice to quit increased with the number of cigarettes smoked per day (33.6% {CI=plus or minus 2.1%} of those who smoked one to 14 cigarettes per day, 41.4% {CI=plus or minus 2.1%} of those who smoked 15-24 per day, and 46.3% {CI=plus or minus 3.0%} of those who smoked greater than or equal to 25 per day). The likelihood of receiving advice to quit was greatest among persons who smoked greater than or equal to 25 cigarettes per day and had had four or more visits during the year (55.2% {CI=plus or minus 4.4%}). Reported by: Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report underscore that physicians and other health-care professionals are not yet maximizing their opportunities to counsel their patients who smoke to quit. These findings are consistent with previous reports indicating that patients who make multiple visits to the doctor -- among whom the overall prevalence of health problems is increased -- and patients who are heavier smokers are more likely to have received advice from their physician to quit (6). The inability of physicians and other health-care professionals to counsel all smokers to quit may reflect an orientation in the United States toward tertiary rather than primary or secondary prevention (4). Despite these findings, the percentage of smokers who have ever been advised by a physician to quit increased from 26.4% in 1976 to 56.1% in 1991 (7; CDC, unpublished data, 1993). In addition, the prevalence of cigarette smoking among physicians has declined rapidly (8); physicians who do not smoke are more likely than those who do to provide advice to quit (6).

Physician self-reported rates of providing cessation advice to smokers are generally higher than those indicated by the NHIS-HPDP and range from 52% to 97% (4). Potential explanations for the differences in rates reported by smokers and physicians are that patients may be unable to recall cessation advice that they actually received, a discrepancy between what physicians and patients consider to be advice to quit smoking, and methodologic considerations related to the phrasing of questions to physicians and to smokers. Two potential limitations of the analysis in this report are: 1) because the smoking status of respondents at the time of the doctor visit was unknown, some respondents may not have been smoking at that time and thus were not candidates for advice; and 2) because the reason for the visit was not included in this analysis, some visits may have been for emergencies and other conditions for which counseling would not have been appropriate.

The difference in receipt of advice to quit among racial/ethnic groups may be influenced by social and cultural factors. For example, among some Hispanics, language barriers may have played a role in the failure to receive advice to quit.

One national health objective for the year 2000 is to increase to 75% the proportion of primary-care providers who routinely advise smokers to quit smoking (objective 3.16) (4). The NHIS-HPDP results indicated that during 1991 approximately 20 million smokers visited a health-care professional and did not receive advice to quit smoking. This finding suggests that, if every primary-care provider offered brief counseling to all of their smoking patients, an additional 1 million persons could be assisted to stop smoking each year (4). This approach is at least as cost-effective per year-of-life saved as other preventive medical practices (3).

The basic components of a brief counseling session include asking each patient about whether they smoke, advising all smokers to stop, and providing assistance to the patient in stopping (e.g., establishing a quit date and providing self-help materials), and arranging follow-up visits for support (9). Use of office reminders can increase both the provision of cessation advice by providers and the rate of quitting by their patients (4,9). When used as an adjunct to behavioral therapy, nicotine replacement is also helpful (10).

The achievement of long-term health and economic benefits of reducing the overall smoking rate in the United States will require continuing efforts to increase smoking-cessation rates. Physicians and other health-care professionals can maximize their effectiveness in encouraging their smoking patients to quit by taking advantage of every opportunity to provide brief but effective counseling. Self-help and other reference materials for smoking cessation, including information to assist doctors in helping their patients to quit, are available from the National Cancer Institute, telephone (800) 422-6237. Additional materials on smoking cessation are available from CDC, telephone (800) 232-1311.

References

1. CDC. Reducing the health consequences of smoking: 25 years of progress-

-a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989; DHHS publication no. (CDC)89-8411.

2. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988;259:2883-9.

3. Cummings SR, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. JAMA 1989;261:75-9.

4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

5. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1989.

6. Cummings KM, Giovino G, Sciandra R, Koenigsberg M, Emont SL. Physician advice to quit smoking: who gets it and who doesn't. American Journal of Preventive Medicine 1987;3:69-75.

7. Gilpin E, Pierce J, Goodman J, Giovino G, Berry C, Burns D. Trends in physicians' giving advice to stop smoking, United States, 1974-87. Tobacco Control 1992;1:31-6.

8. Garfinkel L, Stellman SD. Cigarette smoking among physicians, dentists, and nurses. CA 1986;36:2-8.

9. Glynn TJ, Manley MW. How to help your patients stop smoking: a National Cancer Institute manual for physicians. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1992; DHHS publication no. (NIH)92-3064. 10. Fiore MC, Jorenby DE, Baker TB, Kenford SL. Tobacco dependence and the nicotine patch: clinical guidelines for effective use. JAMA 1992;268:2687- 94.
Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Percentage of adult smokers * who reported receiving advice to quit from a physician
or other health-care professional during the preceding 12 months, by number of visits, sex,
age group, race/ethnicity, educational level, and socioeconomic status -- United States,
National Health Interview Survey-Health Promotion and Disease Prevention Supplement, 1991 +
======================================================================================================
                                              No. of health-care professional visits
                             -----------------------------------------------------------------------
                                    1                2-3                >=4             Any visit
                             ---------------    --------------    ---------------    ---------------
Category                      %   (95% CI &)     %    (95% CI)     %     (95% CI)     %    (95% CI)
----------------------------------------------------------------------------------------------------
Sex
  Male                       27.2  (+/-2.7)     35.8  (+/-3.4)    43.9   (+/-3.4)    35.2  (+/- 1.8)
  Female                     29.2  (+/-2.9)     36.6  (+/-2.7)    46.4   (+/-2.5)    38.9  (+/- 1.6)

Age group (yrs)
  18--24                     18.0  (+/-4.8)     21.3  (+/-4.8)    42.9   (+/-6.1)    28.2  (+/- 3.2)
  25--44                     27.8  (+/-2.5)     37.6  (+/-3.0)    42.2   (+/-2.9)    35.7  (+/- 1.7)
  45--64                     34.8  (+/-4.1)     40.4  (+/-4.3)    52.0   (+/-3.8)    43.8  (+/- 2.5)
    >=65                     28.5  (+/-7.6)     36.7  (+/-7.5)    44.0   (+/-4.9)    38.8  (+/- 3.6)

Race/Ethnicity @
  White, non-Hispanic        29.4  (+/-2.3)     36.6  (+/-2.5)    46.5   (+/-2.3)    38.2  (+/- 1.5)
  Black, non-Hispanic        23.6  (+/-4.7)     35.9  (+/-5.9)    42.4   (+/-5.4)    34.4  (+/- 3.2)
  Hispanic                   24.5  (+/-8.2)     32.0  (+/-9.6)    36.2   (+/-8.8)    30.6  (+/- 5.1)
  Asian/Pacific Islander **  ---     ---        ---     ---       ---      ---       34.4  (+/-12.1)
  American Indian/
    Alaskan Native **        ---     ---        ---     ---       ---      ---       41.4  (+/-14.3)

Education ++
  Less than high school      27.8  (+/-4.7)     32.6  (+/-4.4)    47.8   (+/-3.9)    37.9  (+/- 2.7)
  High school graduate       28.5  (+/-2.9)     36.2  (+/-3.4)    46.5   (+/-3.0)    37.6  (+/- 1.9)
  Some college               29.2  (+/-4.2)     37.1  (+/-4.4)    42.4   (+/-4.2)    36.3  (+/- 2.5)
  College graduate           25.4  (+/-4.8)     40.9  (+/-6.1)    41.2   (+/-5.5)    36.1  (+/- 3.3)

Socioeconomic status &&
  At or above poverty level  29.0  (+/-2.2)     36.9  (+/-2.4)    45.6   (+/-2.3)    37.5  (+/- 1.4)
  Below poverty level        26.3  (+/-5.5)     33.5  (+/-5.9)    45.5   (+/-4.5)    37.7  (+/- 3.2)
  Unknown                    20.4  (+/-6.1)     31.4  (+/-7.9)    43.8   (+/-7.9)    32.5  (+/- 4.5)

Total                        28.1  (+/-1.9)     36.2  (+/-2.2)    45.5   (+/-2.0)    37.2  (+/- 1.3)
----------------------------------------------------------------------------------------------------
 * Persons aged >=18 years who reported they had smoked during the preceding 12 months.
 + Sample size=8778; excludes 369 respondents with an unknown number of doctor visits.
 & Confidence interval.
 @ Excludes 56 respondents in unknown, multiple, or other racial/ethnic categories.
** Not reported by number of visits because of insufficient sample sizes.
++ Excludes 384 respondents with unknown educational status.
&& Poverty statistics are based on definitions developed by the Social Security Administration
   that include a set of income thresholds that vary by family size and composition.
======================================================================================================

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