Is Making Smoking Status a Vital Sign Sufficient to Increase Cessation Support Actions in Clinical Practice?

INTRODUCTION

The current Tobacco Use and Dependence Clinical Practice Guideline from the US Public Health Service (PHS) provides clear evidence that identification of smokers and providing support for smoking cessation in medical practice are effective.¹ The US Preventive Services Task Force also has placed a high priority on offering tobacco cessation support on a regular basis to all smoking patients.² The goal of increasing physician advice about tobacco use is also found in the National Health Promotion and Disease Prevention objectives for the year 2000,³ where the objective is an advice rate of 75% among primary care and oral health care providers. Despite the evidence of efficacy and effectiveness for smoking cessation support, however, physicians still are not providing advice and assistance as often as desirable.^{4, 5}

A strategy for increasing the support rate for smoking cessation by health care providers was highlighted in 1991, when Fiore⁶ suggested that smoking status become a routine vital sign. Elevating smoking status to a vital sign serves to remind clinicians of the need to address smoking during office visits for any reason. This component of office systems has been seen as key to changing physician behavior.⁷ Although some studies have shown support for this idea, the results have been mixed. Recent research suggests that using chart reminders increases the proportion of physicians who ask and advise smoking patients.^{8– 12} Other research suggests that the concept of smoking status as a vital sign has not yet caught on widely.^{5, 13, 14}

We had an opportunity to study the effects of adding smoking status as a vital sign in 2 primary care clinics that implemented a smoking cessation guideline. Both clinics adopted a routine place to record tobacco use and smoking status during clinic visits. In addition, they assigned a lead person to coordinate implementation; however, no other systematic changes to support-cessation actions were taken.

METHODS

This study was conducted at HealthPartners, a mixed-model managed care organization serving 650,000 members in the metropolitan cities of Minneapolis and St. Paul. Adult members of HealthPartners attending 2 primary care clinics were surveyed in 1994 and formed the basis for this study. Clinic A was a staff model (owned) primary care clinic with 3,100 adult members served by 4 family physicians. Clinic B was a group practice of 10 family physicians serving 3,200 members of HealthPartners plus many other nonmembers.

RESULTS

The baseline characteristics of the respondents across the 2 clinics are displayed in Table 1⇓. The respondents in the staff model clinic were older, but there were no other differences. Compared with the preguideline period, we found no difference at follow-up in the proportion of smokers reporting advice to quit smoking after the guideline was implemented (66.3% vs 66.5%).

DISCUSSION

The clinical practice guideline for tobacco recommended stepped delivery of care from determination of tobacco use at nearly every primary care clinic visit to delivery of appropriate assistance and follow-up for smokers who are receptive to quitting smoking. Although this study showed a striking increase in the documentation of tobacco use, rates of advice to quit smoking, as well as other cessation support activities, did not improve. The results of this study suggest that the using smoking status as a vital sign is not sufficient to effect change in clinician behavior. At least in these 2 clinics, marked increase in the identification of smokers as a first step did not necessarily lead to further smoking advice, counseling, or follow-up.

One limitation of this study is that the smoking advice rates reported by smokers in this study (66%) are higher than are usually reported, ranging from 37% to 46%.^{15– 17} We also recognize that there are some problems with the methods of assessing clinician smoking-cessation activities. For example, it has been documented that smokers tend to overestimate these actions, at least if they occurred recently.^{18, 19} On the other hand, chart audits clearly underestimate counseling actions, so the correct answers are probably somewhere between results obtained by these 2 methods. In addition, all the patients studied were relatively long-term members of a single health plan (HealthPartners). Thus, any difference in the reports or experiences of other types of patients could affect the results.

The main finding from this study is that determining a patient’s smoking status might be a necessary first-step component of implementing a smoking cessation system in clinical practice, but it does not necessarily lead to further smoking counseling, advice, or follow-up. Overall, the findings reinforce previous research suggesting that calling attention to desired clinical actions will not change clinician behavior if there are no strong environmental changes that make new behavior easier to comply with than to avoid.^{20– 22} Clearly, more comprehensive systems changes are needed.