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Anne N. Thorndike, MD; Nancy A. Rigotti, MD; Randall S. Stafford, MD, PhD; Daniel E. Singer, MD

JAMA. 1998;279:604-608.

Context.— Routine treatment of smokers by physicians is a national health objective for the year 2000, a quality measure for health care plans, and the subject of evidence-based clinical guidelines. There are few national data on how physicians' practices compare with these standards.

Objective.— To assess recent trends in the treatment of smokers by US physicians in ambulatory care and to determine whether physicians' practices meet current standards.

Design.— Analysis of 1991-1995 data from the National Ambulatory Medical Care Survey, an annual survey of a random sample of US office-based physicians.

Setting.— Physicians' offices.

Patients.— A total of 3254 physicians recorded data on 145716 adult patient visits.

Main Outcome Measures.— The proportion of visits at which physicians (1) identified a patient's smoking status, (2) counseled a smoker to quit, and (3) used nicotine replacement therapy.

Results.— Smoking counseling by physicians increased from 16% of smokers' visits in 1991 to 29% in 1993 (P<.001) and then decreased to 21% of smokers' visits in 1995 (P<.001). Nicotine replacement therapy use followed a similar pattern, increasing from 0.4% of smokers' visits in 1991 to 2.2% in 1993 (P<.001) and decreasing to 1.3% of smokers' visits in 1995 (P=.007). Physicians identified patients' smoking status at 67% of all visits in 1991; this proportion did not increase over time. Primary care physicians were more likely to provide treatment to smokers than were specialists. All physicians were more likely to treat patients with smoking-related diagnoses.

Conclusions.— US physicians' treatment of smokers improved little in the first half of the 1990s, although a transient peak in counseling and nicotine replacement use occurred in 1993 after the introduction of the nicotine patch. Physicians' practices fell far short of national health objectives and practice guidelines. In particular, patient visits for diagnoses not related to smoking represent important missed opportunities for intervention.

From the Medical Services, Massachusetts General Hospital, General Medicine Division, and the Department of Medicine, Harvard Medical School (Drs Thorndike, Rigotti, Stafford, and Singer), Tobacco Research and Treatment Center (Dr Rigotti), Health Policy Research and Development Unit (Dr Stafford), and Clinical Epidemiology Unit (Dr Singer), Boston, Mass.

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