Tob Induc DisTob Induc DisTobacco Induced Diseases2070-72661617-9625BioMed Central2274819834341181617-9625-10-1010.1186/1617-9625-10-10ResearchPhysician advice on avoiding secondhand smoke exposure and referrals for smoking cessation servicesKrugerJudy1jkruger@cdc.govTrosclairAngela1aat6@cdc.govRosenthalAbby1abbyrosenthal@bellsouth.netBabbSteve1zur4@cdc.govRodesRobert1rur9@cdc.govCenters for Disease Control and Prevention, Office on Smoking and Health, 4770 Buford Highway, M/S-K-50, Atlanta, GA, 30341, USA2012272012101101024122011962012Copyright ©2012 Kruger et al.; BioMed Central Ltd.2012Kruger et al.; BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background

Secondhand smoke (SHS) exposure causes premature death and disease. Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from SHS exposure, and also contributes to helping smokers quit smoking. Primary health care providers can play an important role in advising nonsmoking patients to avoid SHS exposure, cautioning current smokers against exposing others to SHS, and referring tobacco users to cessation programs.

Methods

The purpose of this paper is to examine primary care provider (obstetricians/gynecologists, pediatricians, and general practitioners) advice regarding SHS exposure and referral to cessation programs. Using data from the 2008 DocStyles survey (n = 1,454), we calculated the prevalence and adjusted odds ratios for offering patients advice regarding SHS exposure and referring adults who smoked or used other tobacco products to a cessation program.

Results

The current study found that among a convenience sample of primary care providers, 94.9% encouraged parents to take steps to protect children from SHS exposure, 86.1% encouraged smokers to make their homes and cars smoke-free, and 77.4% encouraged nonsmokers to avoid SHS exposure. Approximately 44.0% of primary care providers usually or always referred patients who smoked or used tobacco products to cessation programs such as a quitline, a group cessation class, or one-on-one counseling.

Conclusion

Findings from a convenience sample of primary care providers who participated in a web-based survey, suggests that many primary care providers are advising parents to protect children from SHS exposure, encouraging patients who smoke to maintain smoke-free homes and cars, and advising smokers on ways to avoid exposing others to SHS. Healthcare providers are encouraged to advise patients to avoid SHS exposure and to refer patients who use tobacco products to cessation services.

Secondhand smokeCessationPhysicianAdvice and Referral
Background

There is strong evidence that exposure to secondhand smoke (SHS) is harmful to people. It causes heart disease and lung cancer in nonsmoking adults [1-3], and sudden infant death syndrome, acute respiratory infections, ear infections, worsened asthma symptoms, and other health conditions in children [1,3]. Research suggests that 100% smoke-free indoor air environments are the only effective way to fully protect nonsmokers from SHS exposure [1,4]. Additionally, smoke-free environments and policies have been found to encourage current smokers to quit [1,3].

In response to growing concerns about the health effects of SHS, as discussed in the 2006 Surgeon General’s Report on the health consequences of involuntary exposure to tobacco smoke [1], and the number of studies reporting that smoke-free laws were associated with rapid and substantial reductions in heart attack hospitalizations, the Institute of Medicine (IOM) conducted a review on the plausibility of these findings. Upon completion of the review, the IOM published a report which concluded that even brief exposure to SHS could trigger a heart attack and that smoke-free laws reduce their occurrence [5]. These investigations helped to shed light on the need for more patient counseling about SHS exposure and the deleterious health effects of passive smoking.

Clearly, treating tobacco use and dependence should be a high priority for physicians as well as for all those who organize, provide, and pay for healthcare [6]. Prior studies have used currently available healthcare criteria that included patient advice to quit and a discussion of smoking cessation medications and cessation strategies during the office visit. In the Medicaid population, the proportion of smokers who received advice to quit from a physician increased from 65.6% in 2005 to 69.3% in 2008 [7]. State Medicaid cessation coverage is gradually expanding, with 47 states offering coverage for tobacco-dependence treatment as of 2009 [8].

Offering help to quit tobacco use is 1 of 6 evidence-based tobacco-control strategies included in the World Health Organization’s MPOWER package [2]. Specifically, healthcare providers are urged to incorporate cessation advice into primary care settings and practice [2]. In the US Public Health Service guideline Treating Tobacco Use and Dependence: 2008 Update, Fiore and colleagues concluded that, in order for primary care providers to intervene with tobacco users, there needs to be ample institutional support by clinicians, administrators, insurers, and purchasers [9]. The Task Force on Community Preventive Services [10] has published updated guidelines on tobacco prevention to assist healthcare providers in incorporating counseling on cessation and reduction of exposure to SHS into standard care. Despite the existence of national guidelines [9-11], limited information is available on the extent to which healthcare providers are promoting such services.

Advice from healthcare providers to their patients to avoid SHS exposure and to quit smoking can broaden population-based support for smoke-free environments and reduce smoking rates. This study examines physician advice regarding avoidance of SHS exposure and referral to a smoking cessation program.

MethodsStudy design

We selected our study population from respondents to the 2008 DocStyles survey, which was conducted by Porter Novelli, a social marketing and public relations firm. DocStyles is an annual web survey that provides insight into physicians’ attitudes, behaviors, knowledge, and counseling behaviors on health issues, and assesses their use and trust of available health information sources. The sampling was conducted by Epocrates, Inc. using respondents identified from the Epocrates Honors Panel, an opt-in, verified panel of 135,000 medical practitioners. The primary recruitment method was based on healthcare providers’ self-selection to join the panel and complete the online healthcare survey at http://www.epocrates.com/honors, after receiving an initial email from Epocrates.

Eligible physician verification was achieved by checking each physician’s first name, last name, date of birth, medical school, and graduation date against the American Medical Association’s (AMA) master file at the time of panel registration. Physicians were screened to include only those who practice in the US; actively see patients; work in an individual, group, or hospital practice; and have been practicing medicine for at least 3 years. Epocrates randomly selected a sample of eligible physicians from their main database to load into their invitation database. In order for Epocrates to reach the needed pre-determined sample size for the current study, 14,346 physicians were invited to participate. Of those invited to participate in the DocStyles survey, 1,880 completed the entire survey, 33 did not complete the entire survey, 141 did not meet the screening criteria, 1,088 logged in to take the survey but were terminated due to filled quotas for their specialty, and 11,204 did not respond to the invitation or tried to respond after the survey closed, resulting in a response rate of 22%. The response rate http://www.researchinfo.com/docs/calculators/response.cfm was calculated by weighting respondents who were terminated due to filled quotas as a factor of the overall sample pool [12]. The sample was drawn to match AMA master file proportions for age, gender, and region. In 2008, the goal was to recruit 1,000 primary care physician (family physicians, general practitioners, internists), 250 pediatricians, 250 obstetricians/gynecologists (OB/GYN), 250 dermatologists and 130 registered dieticians. The different physician specialties were included because there were of particular interest to the data collectors and the total sample by itself was not intended to be representative of the national population of physicians or physician specialties. Physicians were paid an honorarium of $50-$75 for completing the survey. Respondents were not required to participate in the 140-question survey, which had multiple subparts designed to provide insights into physicians’ counseling behaviors, and were able to exit the survey at any point.

Study variables

Primary healthcare provider personal characteristics consisted of sex, age (18–35, 36–45, 46–55, and ≥56), race/ethnicity (white, black, Hispanic, Asian, other), and smoking status. Smoking status was dichotomized into current smokers (smoked 1 to 7 days/week) and nonsmokers since lifetime use of cigarettes was not obtained. Professional characteristics included years in practice, number of doctors in practice, type of practice (individual practice, group practice, hospital/clinic practice), number of patients seen per week, and whether they maintained teaching privileges.

The 2008 DocStyles survey included a series of questions on provider practices regarding giving health-related advice. Respondents were first asked whether they advised parents or guardians to keep their children from being exposed to smoke from cigarettes or other tobacco products. If they answered yes, they were asked (1) whether they advised patients who do not smoke tobacco or use other tobacco products to avoid being exposed to SHS, and (2) whether they advised their patients who smoke tobacco or use other tobacco products to create smoke-free homes and cars (i.e., not to smoke or allow smoking inside their homes or cars at any time). A single question was used to determine whether healthcare providers referred patients who smoked or used tobacco products to cessation programs such as a telephone quitline, a smoking cessation class, or one-on-one counseling. Respondents were asked to select one response from the possible options (always, usually, sometimes, rarely, never). In the logistic regression analyses, these responses were dichotomized into “always/usually” vs. “sometimes/never/rarely.”

Statistical analyses

Advice and referral practices were examined using the entire sample from the 2008 DocStyles survey. The primary outcomes of interest were advice regarding avoidance of SHS exposure, and referral to a smoking cessation program. Because there was no significant difference between the entire sample (consisting of OB/GYNs, pediatricians, internists, general practitioners, dermatologists, and registered dieticians) and the selected sample of primary care providers (internists, general practitioners, pediatricians and OB/GYNs) on the outcomes of interest, this paper focused on the selected sample. We excluded respondents who were not family practitioners, general practitioners, internists, obstetricians/gynecologists or pediatricians, and those who were missing data on demographic characteristics or did not respond to all of the questions of interest. The final analytic sample consisted of 1,454 primary care providers. Of the 1,454 physicians included in the current analysis, 496 were family/general practitioners, 473 were internists, 244 were pediatricians, and 241 were OB/GYNs.

Descriptive statistics of personal and practice characteristics were used to characterize primary care providers in the selected sample population. The analysis focused on calculating the prevalence and odds of primary care providers’ providing advice on avoiding SHS exposure and referring smokers to smoking cessation resources. A 2-sided t-test with an alpha level of P < 0.05 was used to determine the statistical significance. Logistic regression was used to adjust for healthcare provider characteristics (sex, age, and race/ethnicity). Separate models were analyzed initially for patient smoking status (smoker vs. nonsmoker) as a confounder or effect modifier on SHS avoidance advice and cessation referral. All analyses were performed using SAS version 9.2 (SAS Institute Inc., Cary, North Carolina).

Results

Frequencies for primary care provider personal and professional characteristics are provided in Table 1. Respondents were more commonly men (75.1%), aged 36–45 years (40.6%), and nonsmokers (93.3%). One-third of the sample self-identified as family/general practitioners (34.1%). Over half the sample maintained teaching privileges (57.0%). Approximately two-thirds of the sample physicians had been in practice 6–20 years (64.2%), one-third worked in practices with 3–5 physicians (27.2%), and one-third consulted with 76–100 patients per week (34.4%). The final weighted sample was comparable to the AMA master file, in terms of gender (74.0% men), average age (45 years), and years in practice (13.1 years) (data not shown).

Personal and practice characteristics of primary care providers— DocStyles Survey, 2008

Physician CharacteristicsTotal
Men
Women
(n = 1,454)
(n = 1,092)
(n = 362)
(%)(%)(%)
Age
 
 
 
26-35
17.9
15.7
24.6
36-45
40.6
39.7
43.1
46-55
28.3
29.4
25.1
≥56
13.2
15.2
7.2
Race/ethnicity
 
 
 
White
72.0
73.4
67.7
Black
3.4
2.6
5.8
Hispanic
4.3
4.3
4.4
Asian
15.7
15.0
18.0
Other
4.5
4.7
4.1
Smoking status
 
 
 
Smoker
6.7
8.3
1.7
Nonsmoker
93.3
91.7
98.3
Health care provider
 
 
 
Family/general practitioners
34.1
34.3
33.7
Internists
32.5
34.4
26.5
Pediatricians
16.8
14.1
24.9
Obstetricians/gynecologists
16.6
17.2
14.9
Teaching privileges
 
 
 
Yes
57.0
57.4
55.8
No
43.0
42.6
44.2
Type of practice
 
 
 
Individual
16.7
17.9
13.0
Group
64.0
64.7
61.9
Hospital/clinic
19.3
17.3
25.1
Years in practice
 
 
 
0-5
13.5
11.9
18.5
6-10
31.8
30.7
35.1
11-20
32.4
31.6
34.8
≥21
22.3
25.8
11.6
Number of physicians in practice
 
 
 
1-2
26.0
26.5
24.6
3-5
27.2
27.2
27.1
6-10
22.5
21.9
24.6
11-25
12.9
13.0
12.4
≥26
11.5
11.5
11.3
Number of patients per week
 
 
 
1-75
21.3
17.9
31.2
76-100
34.4
32.5
40.1
101-150
32.8
36.4
22.1
≥151
11.6
13.2
6.6
Total75.124.9

Table 2 describes advice provided by primary care providers on avoiding SHS exposure. Almost ninety-five percent (94.9%) of primary care providers reported encouraging parents to take steps to protect children from SHS exposure, 86.1% reported encouraging smokers to maintain smoke-free homes and cars, and 77.4% reported encouraging nonsmokers to avoid SHS exposure. Advice on SHS was most common among primary care providers who were women, those ≤5 years in practice, and those who see ≥151 patients per week.

Types of primary care providers’ advice about exposure to secondhand smoke—DocStyles Survey, 2008

PhysicianEncouraged protecting children from SHS exposureEncouraged smokers to maintain smoke-free homes/carsEncouraged nonsmokers to avoid SHS exposure
Characteristics
N
% (95%C.I.)
N
% (95%C.I.)
N
% (95%C.I.)
Sex
 
 
 
 
 
 
Men
1,028
94.1 (91.8-96.4)
925
84.7 (82.3-87.1)
828
75.8 (73.2-78.4)
Women
352
97.2 (94.9-99.5)
327
90.3 (87.9-92.8)
297
82.0 (79.5-84.6)
Age
 
 
 
 
 
 
26-35
250
96.2 (94.1-98.2)
230
88.5 (86.3-90.6)
199
76.5 (74.3-78.8)
36-45
562
95.3 (92.7-97.8)
513
86.9 (84.2-89.7)
466
79.0 (76.1-81.9)
46-55
385
93.4 (91.1-95.8)
353
85.7 (83.2-88.2)
311
75.5 (72.9-78.1)
≥56
183
95.3 (93.5-97.1)
156
81.3 (79.4-83.1)
149
77.6 (75.6-79.6)
Race/ethnicity
 
 
 
 
 
 
White
987
94.3 (91.9-96.7)
901
86.1 (83.6-88.5)
787
75.2 (72.5-77.8)
Black
47
95.9 (95.0-96.9)
42
85.7 (84.7-86.7)
36
73.5 (72.4-74.5)
Hispanic
61
96.8 (95.7-97.9)
53
84.1 (83.0-85.2)
56
88.9 (87.6-90.2)
Asian
221
96.5 (94.6-98.4)
198
86.5 (84.4-88.5)
187
81.7 (79.5-83.8)
Other
64
97.0 (95.9-98.1)
58
87.9 (86.7-89.0)
59
89.4 (88.1-90.7)
Smoking status
 
 
 
 
 
 
Smoker
96
99.0 (97.6-100))
82
84.5 (83.2-85.9)
74
76.3 (74.8-77.7)
Nonsmoker
1,284
94.6 (93.3-96.0)
1,170
86.2 (84.8-87.6)
1,051
77.5 (76.0-78.9)
Health care provider
 
 
 
 
 
 
Family/general practitioners
485
97.8 (96.5-99.1)
439
88.5 (85.7-91.3)
382
77.0 (73.3-80.7)
Internists
442
93.6 (91.4-95.8)
395
83.7 (80.4-87.0)
379
80.3 (76.7-83.9)
Pediatricians
242
99.2 (98.0-100)
236
96.7 (94.5-99.0)
211
86.5 (82.2-90.8)
Obstetricians/gynecologists
211
87.2 (83.0-91.4)
182
75.2 (69.8-80.6)
153
63.2 (57.1-69.3)
Teaching privileges
 
 
 
 
 
 
Yes
783
94.5 (91.8-97.1)
714
86.1(83.4-88.9)
648
78.2 (75.3-81.1)
No
597
95.5 (92.9-98.1)
538
86.1(83.3-88.8)
477
76.3 (73.4-79.2)
Type of practice
 
 
 
 
 
 
Individual
233
95.9 (93.9-97.9)
204
84.0 (81.9-86.0)
196
80.7 (78.4-82.9)
Group
880
94.5 (92.0-97.1)
806
86.6 (83.9-89.2)
705
75.7 (72.9-78.6)
Hospital/clinic
267
95.4 (93.3-97.4)
242
86.4 (84.2-88.6)
224
80.0 (77.7-82.3)
Years in practice
 
 
 
 
 
 
0-5
192
97.5 (95.6-99.3)
176
89.3 (87.4-91.3)
156
79.2 (77.2-81.2)
6-10
445
96.3 (93.9-98.8)
410
88.7 (86.1-91.3)
361
78.1 (75.4-80.9)
11-20
436
92.6 (90.1-95.0)
397
84.3 (81.7-86.9)
357
75.8 (73.1-78.5)
≥21
307
94.8 (92.6-96.9)
269
83.0 (80.7-85.3)
251
77.5 (75.0-79.9)
Number of physicians in practice
 
 
 
 
 
 
1-2
357
94.4 (92.1-96.8)
315
83.3 (80.9-85.7)
294
77.8 (75.2-80.3)
3-5
373
94.4 (92.1-96.8)
343
86.8 (84.4-89.3)
306
77.5 (74.9-80.1)
6-10
313
95.7 (93.5-97.9)
291
89.0 (86.7-91.3)
256
78.3 (75.8-80.7)
11-25
178
95.2 (93.4-97.0)
160
85.6 (83.7-87.4)
145
77.5 (75.6-79.5)
≥26
159
95.2 (93.5-96.9)
143
85.6 (83.9-87.4)
124
74.3 (72.4-76.1)
Number of patients per week
 
 
 
 
 
 
1-75
296
95.8 (93.6-98.0)
265
85.8 (83.5-88.0)
238
77.0 (74.6-79.4)
76-100
464
92.8 (90.3-95.3)
424
84.8 (82.2-87.4)
369
73.8 (71.1-76.5)
101-150
457
95.8 (93.3-98.3)
413
86.6 (84.0-89.2)
381
79.9 (77.1-82.6)
≥151
163
97.0 (95.3-98.7)
150
89.3 (87.5-91.1)
137
81.5 (79.6-83.5)
Total1,38094.91,25286.11,12577.4

SHS = secondhand smoke.

C.I. = confidence interval.

Logistic regression analysis showed that female primary care providers were more likely than their male peers to counsel patients about avoiding SHS exposure (Table 3). Primary care providers who were Hispanic (AOR: 2.61; 95% CI: 1.18-5.80), Asian (AOR: 1.47; 95% CI: 1.02-2.13) or from another racial/ethnic group (AOR: 2.87; 95% CI: 1.28-6.41) were more likely to encourage nonsmokers to avoid exposure to SHS than whites. Internists (AOR: 0.31; 95% CI: 0.15-0.62) were less likely than family/general practitioners to encourage parents to take steps to protect children from SHS exposure. Primary care providers who were pediatricians were more likely to encourage smokers to maintain smoke-free homes and cars (AOR: 3.69; 95% CI: 1.72-7.92) and to encourage nonsmokers to avoid SHS exposure (AOR: 1.82; 95% CI: 1.08-2.79) than family/general practitioners. Obstetricians/gynecologists were less likely than family/general practitioners to counsel patients about avoiding SHS exposure.

Primary care providers’ advice about exposure to secondhand smoke—DocStyles Survey, 2008

PhysicianEncouraged protecting children from SHS exposureEncouraged smokers to maintain smoke-free homes/carsEncouraged nonsmokers to avoid SHS exposure
Characteristics
AOR
95%C.I.
AOR
95%C.I.
AOR
95%C.I.
Sex
 
 
 
 
 
 
Men
1.0

1.0

1.0

Women
2.14
1.10-4.17
1.62
1.10-2.39
1.49
1.09-2.03
Age
 
 
 
 
 
 
26-35
1.0

1.0

1.0

36-45
0.88
0.42-1.84
0.90
0.58-1.42
1.24
0.87-1.77
46-55
0.68
0.33-1.40
0.82
0.51-1.31
1.09
0.75-1.57
≥56
1.03
0.42-2.54
0.61
0.36-1.04
1.29
0.82-2.03
Race/ethnicity
 
 
 
 
 
 
White
1.0

1.0

1.0

Black
1.23
0.29-5.24
0.86
0.38-1.95
0.85
0.44-1.63
Hispanic
1.81
0.43-7.56
0.82
0.41-1.67
2.61
1.18-5.80
Asian
1.56
0.74-3.26
0.95
0.62-1.45
1.47
1.02-2.13
Other
1.89
0.46-7.85
1.11
0.52-2.38
2.87
1.28-6.41
Smoking status
 
 
 
 
 
 
Smoker
3.98
0.81-4.18
0.94
0.53-1.69
0.96
0.59-1.56
Nonsmoker
1.0

1.0

1.0

Health care provider
 
 
 
 
 
 
Family/general practitioners
1.0

1.0

1.0

Internists
0.31
0.15-0.62
0.68
0.46-1.00
1.17
0.85-1.61
Pediatricians
2.40
0.52-11.02
3.69
1.72-7.92
1.82
1.18-2.79
Obstetricians/gynecologists
0.15
0.08-0.31
0.40
0.27-0.60
0.52
0.37-0.73
Teaching privileges
 
 
 
 
 
 
Yes
1.0

1.0

1.0

No
1.27
0.78-2.08
0.99
0.73-1.35
0.90
0.70-1.16
Type of practice
 
 
 
 
 
 
Individual
1.38
0.60-3.20
0.95
0.58-1.56
1.09
0.70-1.71
Group
0.99
0.54-1.84
1.09
0.73-1.63
0.84
0.59-1.17
Hospital/clinic
1.0

1.0

1.0

Years in practice
 
 
 
 
 
 
0-5
2.61
0.73-9.28
1.68
0.75-3.78
0.97
0.50-1.86
6-10
1.61
0.63-4.12
1.55
0.80-3.00
0.84
0.50-1.42
11-20
0.70
0.34-1.42
0.97
0.60-1.58
0.78
0.51-1.19
≥21
1.0

1.0

1.0

Number of physicians in practice
 
 
 
 
 
 
1-2
1.0

1.0

1.0

3-5
0.96
0.52-1.79
1.29
0.86-1.93
0.97
0.68-1.36
6-10
1.26
0.63-2.54
1.54
0.99-2.40
1.02
0.71-1.46
11-25
1.06
0.47-2.38
1.13
0.69-1.86
0.93
0.61-1.43
≥26
1.13
0.49-2.63
1.13
0.67-1.91
0.81
0.52-1.24
Number of patients per week
 
 
 
 
 
 
1-75
0.58
0.20-1.67
0.63
0.35-1.14
0.69
0.43-1.12
76-100
0.35
0.14-0.92
0.61
0.35-1.06
0.60
0.38-0.93
101-150
0.70
0.26-1.89
0.77
0.44-1.34
0.89
0.57-1.39
≥1511.01.01.0

SHS = secondhand smoke.

AOR = odds ratio adjusted for sex, age, and race/ethnicity; odds ratios compare yes to no answer for each item.

C.I. = confidence interval.

Table 4 shows the prevalence of primary care referral of a smoker or tobacco user to a tobacco cessation program. Referral by primary care providers was most common among providers 36–45 years of age (46.1%), those who were classified as other race/ethnicity (51.5%), those who were family/general practitioners (50.8%), those with teaching privileges (45.5%), those who worked in a hospital or clinic practice (50.4%), and those who were in a practice with ≥11 physicians (49.7%). Primary care providers who were classified as other racial/ethnic groups (AOR: 1.41; 95% CI: 1.85-2.34) were more likely to usually/always refer tobacco users to a cessation program than whites. Internists (AOR: 0.74; 95% CI: 0.57-0.96) and pediatricians (AOR: 0.39; 95% CI: 0.28-0.54) were less likely to refer patients to cessation programs than were family/general practitioners. Those who worked in group practices (AOR: 0.75; 95% CI: 0.57-1.00) were less likely to refer patients to cessation programs than primary care providers who work in hospitals or clinics.

Prevalence and odds of referral of primary care providers to a cessation program—DocStyles Survey, 2008

PhysicianReferral provided: Usually/AlwaysReferral provided: Sometimes/Never/RarelyOdds of referral
Characteristics
n
%
95%C.I.
n
%
95%C.I.
AOR
95%C.I.
Sex
 
 
 
 
 
 
 
 
Men
467
42.8
39.9-45.7
625
57.2
54.3-60.1
1.0

Women
172
47.5
42.4-52.7
190
52.5
47.3-57.6
1.19
0.93-1.52
Age
 
 
 
 
 
 
 
 
26-35
117
43.8
37.9-49.9
146
56.2
50.1-62.1
1.0

36-45
272
46.1
42.1-50.1
318
53.9
49.9-57.9
1.13
0.84-1.52
46-55
185
44.9
40.2-49.7
227
55.1
50.3-59.8
1.10
0.80-1.52
≥56
68
35.4
29.0-42.4
124
64.6
57.6-71.0
0.76
0.51-1.12
Race/ethnicity
 
 
 
 
 
 
 
 
White
447
42.7
39.7-45.7
600
57.3
54.3-60.3
1.0

Black
20
40.8
28.1-55.0
29
59.2
45.0-71.9
0.88
0.49-1.58
Hispanic
31
49.2
37.1-61.4
32
50.8
38.6-62.9
1.27
0.76-2.11
Asian
107
46.7
40.3-53.2
122
53.3
46.8-59.7
1.15
0.85-1.54
Other
34
51.5
39.6-63.3
32
48.5
36.7-60.4
1.41
1.85-2.34
Smoking status
 
 
 
 
 
 
 
 
Smoker
46
47.7
37.7-57.3
51
52.6
42.7-62.3
1.18
0.78-1.79
Nonsmoker
593
43.7
41.1-46.4
764
56.3
53.6-58.9
1.0

Health care provider
 
 
 
 
 
 
 
 
Family/general practitioners
252
50.8
46.4-55.2
244
49.2
44.8-53.6
1.0

Internists
207
43.9
39.4-48.4
265
56.1
51.6-60.6
0.74
0.57-0.96*
Pediatricians
73
29.9
24.5-36.0
171
70.1
64.0-75.5
0.39
0.28-0.54**
Obstetricians/gynecologists
107
44.2
38.1-50.5
135
55.8
49.5-61.9
0.79
0.58-1.08
Teaching privileges
 
 
 
 
 
 
 
 
Yes
377
45.5
42.1-48.9
452
54.5
51.1-57.9
1.0

No
262
41.9
38.1-45.8
363
58.1
54.2-61.9
0.86
0.70-1.06
Type of practice
 
 
 
 
 
 
 
 
Individual
99
40.7
34.7-47.0
144
59.3
53.0-65.3
0.70
0.49-0.1.01
Group
399
42.9
39.7-46.1
532
57.1
53.9-60.3
0.75
0.57-1.00*
Hospital/clinic
141
50.4
44.5-56.2
139
49.6
43.8-55.5
1.0

Years in practice
 
 
 
 
 
 
 
 
0-5
92
46.7
39.8-53.7
105
53.3
46.3-60.2
1.45
0.84-2.50
6-10
214
46.3
41.8-50.9
248
53.7
49.1-58.2
1.33
0.84-2.10
11-20
209
44.4
39.9-48.9
262
55.6
51.1-60.1
1.14
0.78-1.66
≥21
124
38.3
33.1-43.7
200
61.7
56.3-60.1
1.0

Number of physicians in practice
 
 
 
 
 
 
 
 
1-2
152
40.2
35.4-45.2
226
59.8
54.8-64.6
1.0

3-5
165
41.8.
37.0-46.7
230
58.2
53.3-63.0
1.06
0.79-1.41
6-10
146
44.6
39.3-50.1
181
55.4
49.9-60.7
1.18
0.87-1.60
11-25
93
49.7
42.6-56.9
94
50.3
43.1-57.4
1.43
1.00-2.05*
≥26
83
49.7
42.2-57.2
84
50.3
42.8-57.8
1.43
0.99-2.08
Number of patients per week
 
 
 
 
 
 
 
 
1-75
138
44.7
39.2-50.3
171
55.3
49.7-60.8
0.97
0.66-1.43
76-100
215
43.0
38.7-47.4
285
57.0
52.6-61.3
0.90
0.63-1.29
101-150
211
44.2
39.8-48.7
266
55.8
51.3-60.2
0.97
0.68-1.39
≥151
75
44.6
37.3-52.2
93
55.4
47.8-62.7
1.0

Total63943.941.4-46.581556.153.5-58.6

AOR = odds ratio adjusted for sex, age, and race/ethnicity; odds ratios compare yes to no answer for each item.

C.I. = confidence interval.

*P < 0.05.

**P < 0.001.

Discussion

The current study provides novel findings on advice given by a convenience sample of primary care providers regarding avoidance of SHS exposure and referral to a smoking cessation program. In this sample, a large proportion of primary care providers reported encouraging their patients to protect children from SHS, to make their homes and cars smoke-free, and to avoid SHS exposure. Although there may be differences between this opt-in web-based physician sample and the full universe of primary care providers, these findings suggest that many health care providers provide SHS counseling in clinical practice. Since SHS causes premature death and disease in both children (especially asthmatics) [1] and adults (especially those with respiratory conditions, those at increased risk for heart disease, or those with a history of heart disease) [1,5], health care providers are encouraged to counsel smokers and nonsmokers on the risks of SHS exposure. In essence, the US Public Health Service’s updated publication [9] is a clinical practice guide for all clinicians, and it serves as the basis for specific sub-specialty groups that may prepare specific guides for their organizations. Although this guide does not universally address SHS exposure, it emphasizes the importance of the clinician’s role in managing tobacco use by encouraging patients to avoid SHS as part of the medical visit. The American Academy of Pediatrics encourages clinicians to be active in eliminating tobacco use and SHS exposure of children [13], and although the US Preventive Services Task Force does not have a specific recommendation to prevent SHS exposure, they do have recommendations for smoking cessation among adults and young people [14].

Exposure to SHS has been found to be harmful to adults and children alike, and nonsmokers are frequently exposed to SHS in homes, workplaces, vehicles, and public places [15,16]. Healthcare providers are in a unique role to raise awareness of the negative health effects of SHS, and may consider incorporating elements from the framework and intervention known as CEASE, the Clinical Effort Against Secondhand Smoke Exposure [17]. Williams and colleagues (2005) suggest that clinicians should actively engage in screening and SHS counseling with all of their patients who use tobacco and that intervening with nonsmokers to create smoke-free homes may help increase cessation among smokers [18]. In our study, 80.0% of primary care providers in hospitals and clinics encouraged nonsmokers to avoid SHS exposure, and 86.4% encouraged smokers to maintain smoke-free homes and cars. However, in communities and states that have yet to enact comprehensive smoke-free laws [19], patient education by healthcare providers on the dangers posed by SHS and on the importance of avoiding locations where smoking is allowed could contribute to the expansion of smoke-free environments by changing people’s expectations and behavior regarding smoking in public places, and motivating parents to protect their children [20].

This analysis found that, among this convenience sample, only 43.9% of primary care providers referred patients who smoked or used tobacco products to a cessation program, a figure somewhat higher than the 25.9% reported in a 2006 US study [21]. It is likely that our findings may be attributable in part to a ‘healthy respondent’ effect, since 93.3% of physicians who responded to the survey were nonsmokers, and might therefore be more likely to advise patients to avoid SHS exposure and to quit smoking. However, research shows that the proportion of health professionals who smoke has decreased over time [22]. Referral to cessation services is only one part of the clinical practice guidelines for smoking cessation [9], and providing tobacco cessation advice for those who use tobacco products may not be appropriate for all patients. In addition, there is some uncertainty as to the validity of this measure as an isolated indicator for quality of service for patients who smoke. Some physicians may elect to provide cessation treatment themselves rather than refer patients for counseling, and some smokers not interested in quitting may not be appropriate for referral to resources that focus on supporting cessation attempts.

Practice size is likely to influence referral patterns as well. In our study, smaller practices (individual or group) were less likely to refer patients to cessation services than larger practices (hospital or clinic); in larger clinical settings, there are perhaps more resources available to facilitate adherence to smoking cessation guidelines, and there may be greater potential for coordination of services. Regardless of practice size, referral to smoking cessation services may require addressing the obstacles identified by healthcare providers, including lack of time (especially for counseling), lack of availability or awareness of resources, lack of adequate reimbursement, and competing demands for other services.

There are several limitations to this study. First, the sampling methodology that was used for the survey drew from a self-selected group (Epocrates Honor Panel) and, thus, resulted in a convenience sample. Although the method used quotas and weighting to produce a dataset that matched the specialty breakdown of the AMA membership, the findings may not be representative of all primary care providers in the US, especially those who were not members of the AMA. Thus, findings may not reflect the primary health care reality in terms of being nationally representative. Second, response rates for 2008 were lower than for previous years, which may also affect the representativeness of participants. This may be because the survey was almost twice as long as in previous years and potential participants were informed of the survey length in the invitational email, which may have dissuaded participation. Third, the questions did not address the type or amount of tobacco products patients were using, and the questions used to ascertain provider advice on avoiding SHS exposure and referral to cessation services had not been formally validated. The questions relied on recall over the previous 12 months and it is possible that providers failed to remember providing advice or referral. Thus, questions may not accurately capture providers’ actual behavior. Fourth, brief counseling is multifaceted, and there are distinctions between asking, advising, providing assistance, and referring in clinical practice. Referral may not be appropriate for all patients, since this is only one way to fulfill components of the “5 As” (ask, advise, assess, assist, arrange follow-up) of the clinical practice guidelines for smoking cessation [9]. In addition, providers using self-reporting tend to over-report behaviors that they assume they should be doing [18]. However, this tendency toward high self-reported response rates has been found in other studies such as those examining counseling and referral to outpatient psychiatry and clinical psychology [23]. Fifth, in this survey, respondents were asked only about advising patients to avoid SHS exposure and referring them to cessation services. An expanded list of survey responses for specific evidence-based cessation services may have identified specific service preferences (e.g., quitline, group cessation class, one-on-one counseling, clinic check-backs). Future research should utilize other measures of physician behavior such as post-visit patient surveys, chart audits, and direct observation.

Conclusions

The findings of this web-based survey provide a glimpse into primary care providers’ practices regarding advising nonsmokers to avoid SHS exposure and referring smokers to a smoking cessation program. We observed that many providers in this sample are advising their patients to take steps to protect themselves and their children from SHS exposure. They also appear to be identifying patients who use tobacco products and who want to quit and referring them to cessation resources. These resources could potentially include in-clinic follow-up, the toll-free phone number 1-800-QUIT-NOW, which transfers callers to their state quitlines, or the National Cancer Institute cessation website http://www.smokefree.gov.

Consistent education and advice on SHS from providers would increase patients’ awareness of the serious health effects of SHS and motivate them to avoid SHS exposure. In addition to prompting individual behavior change, SHS counseling could play an important role in spurring broader population-level efforts to expand smoke-free environments and in changing public attitudes regarding the social acceptability of smoking. These combined individual-level and population-level effects could yield significant reductions in child and adult morbidity and mortality, especially among high-risk groups such as children with asthma and adults with heart disease or respiratory conditions.

Abbreviations

SHS, Refers to secondhand smoke; IOM, Refers to Institute of Medicine; AMA, Refers to the American Medical Association; OB/GYN, Refers to obstetricians/gynecologists; CI, Refers to confidence interval; AOR, Refers to adjusted odds ratio..

Competing interests

None of the authors have competing interests. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Authors’ contributions

JK conceived the research idea and held the primary responsibility for drafting the manuscript. AT participated in the analysis and interpretation of the data. AR, SB and RR participated in finalizing the study design, reviewing the literature and writing the manuscript. All authors read and approved the final manuscript.

Acknowledgments

Special thanks to Dr. Deanne L. Weber, Senior Vice President Strategic Planning and Research, Porter Novelli for her assistance in obtaining the data. Porter Novelli is credited as the data owner per the licensing agreement. We acknowledge Dr. Michael C. Fiore for his assistance in interpreting the US Public Health Service’s Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update for all clinicians.

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