Smoking screening and management in primary care practices

Objectives: To describe the screening and management of patients who smoke by primary care physicians and to review practice factors associated with smoking services. Design and Methods: A descriptive study based on physician and patient questionnaires and medical record retrospective reviews. Setting and Subjects: Forty-five nonacademic primary care practices, including 160 physicians (whose subspecialty is family practice, internal medicine, or general practice) in 4 Midwest states and 4879 adult patients who completed questionnaires and consented for medical record review. Main Outcome Measures: The a priori hypothesis was that screening by physicians would detect most persons who smoke, but that the lack of systematic methods to screen, intervene, or follow-up would limit the provision of smoking cessation services. Results: Eighty-one percent of all patients and 93% of patients who smoked in the past 2 years reported being asked if they smoked. Patients who smoked reported being told to quit (78%), discussing a quit date (60%), receiving a nicotine prescription (20%) or referral (25%) at higher rates than prior reports. Patients with coronary heart disease (CHD) or CHD risk factors, who smoked more, visited the physician more, or who wanted help were more likely to receive smoking cessation services. Few practices had developed systems to routinely provide services, and a lack of systems was associated with fewer interventions. Conclusions: Physician screening and management of their practice patients is higher than reported in population surveys. Most patients who smoke report that they were asked whether they smoke, but smoking status is not routinely documented or updated. Significant variability is noted between physicians in smoking-related screening and interventions, and proved methods to improve services are infrequently used.