Tailoring tobacco counseling to the competing demands in the clinical encounter

OBJECTIVES: We identified patterns of tobacco cessation counseling in primary care practices, including contextual factors that influence its provision. STUDY DESIGN: A cross-sectional study was performed using direct observation of outpatient visits. POPULATION: We included 91 outpatient visits by cigarette smokers visiting 20 family physicians in 7 Nebraska community family practices. OUTCOMES MEASURED: We measured patterns and quality of tobacco counseling assessed by direct observation. RESULTS: A hierarchy of 5 patterns was discernable, ranging from appropriate to inappropriate provision or nonprovision of tobacco cessation counseling. CONCLUSIONS: Since tobacco-specific discussions are appropriate only in approximately three fourths of primary care visits by smokers, clinical practice guidelines that recommend intervention at every visit are unrealistic. However, the finding that only one third of eligible visits addressed tobacco makes it imperative that tobacco cessation counseling be reliably integrated into visits for well care and tobacco-related illnesses that represent teachable moments.