Are physicians asking about tobacco use and assisting with cessation? Results from the 2001–2004 national ambulatory medical care survey (NAMCS)
Introduction
The prevalence estimates of smoking in the United States are currently 20.8% overall and 23.0% and 19.0% among males and females, respectively (Centers for Disease Control and Prevention (CDC), 2004a, Centers for Disease Control and Prevention (CDC), 2004b). Smoking is considered a chronic biobehavioral disorder, the psychological and biological basis for which is an addiction to nicotine (Patkar et al., 2003). While 70% of smokers want to quit smoking, only 41% make an attempt at cessation each year; and less than 5% are successful (Centers for Disease Control and Prevention (CDC), 2004a, Centers for Disease Control and Prevention (CDC), 2004b). To effectively treat a tobacco addiction, several steps must be taken. The current U.S. Public Health Service (USPHS) Clinical Practice Guideline for treating tobacco use and dependence suggests that the healthcare provider should employ the 5 A's: ask the patient about tobacco use, advise users to quit, assess willingness to quit, assist in the quit attempt, and arrange for follow-up (Fiore et al., 2000). The guideline also recommends the use of pharmacotherapy, such as nicotine replacement therapy (NRT) to supplement the counseling efforts by the healthcare provider.
Thorndike and colleagues examined trends between 1991 and 1995 in the treatment of smokers by physicians in a national sample of ambulatory visits using data from the National Ambulatory Medical Care Survey (NAMCS) (Thorndike et al., 1998). They found low rates of cessation assistance and prescription of NRT: 16–29% and 0.04–1.3%, respectively. Another important finding was that for approximately 33% of office visits tobacco use status was not identified. Because the Clinical Practice Guideline was updated in 2000, we have completed a new analysis of the 2001–2004 NAMCS data to determine if identifying tobacco use and providing cessation assistance have improved following the release and update of the Guideline and if the patterns varied with patient-related or physician-related variables.
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Methods
The NAMCS is an annual survey conducted by the National Center for Health Statistics that provides objective and reliable data from ambulatory medical care visits in the United States. The design involves a three-stage probability sampling plan (NCHS, 2001). At the first stage, 112 geographic regions are selected and these consist of counties, groups of counties, or towns and townships. At the second stage, practicing physicians are selected from the American Medical Association and the
Results
There were a total of 85,090 records for patients 18 years or older in the NAMCS between 2001 and 2004. Table 1 contains the unweighted frequency and percent distributions for each dependent and independent variable. Most of the variables had no missing data; however, method of payment and whether the physician was the patient's primary physician were missing from 4.3% of all records.
Discussion
In this analysis of the 2001–2004 NAMCS data, we found that 32% of patient charts did not include information about tobacco use status. A second important finding was that over for 80% of identified smokers, there was no documentation of receiving tobacco cessation assistance. Only 0.3% and 1.8% received a prescription for NRT or bupropion, respectively. These results vary little from the Thorndike et al. (1998) report and they are also in clear opposition to the recommendations stated in the
Conclusions
In conclusion, we found a low prevalence of ascertainment of smoking status, documentation of tobacco cessation assistance among tobacco users, and prescription of NRT and bupropion. The data indicate that providers are not following the Clinical Practice Guideline (Fiore et al., 2000). Methods for improving adherence, such as including tobacco cessation training in medical school curricula or delivering educational programs to practicing providers, should be examined in future investigations.
References (10)
- et al.
Self-report of delivery of clinical preventive services by U.S. Physicians. Comparing specialty, gender, age, setting of practice, and area of practice
Am. J. Prev. Med.
(1999) - et al.
A population-based survey of physician smoking cessation counseling practices
Prev. Med.
(1998) - et al.
Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs
Am. J. Prev. Med.
(2005) - Centers for Disease Control and Prevention (CDC) 2004a. Behavioral Risk Factor Surveillance System Survey Data....
- Centers for Disease Control and Prevention 2004b. State Medicaid Coverage for Tobacco-Dependence Treatments—United...
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