Advising All Patients Who Smoke to Quit Would Add Only 11 Minutes to Family Physician's Day

BUFFALO, N.Y. -- Family physicians would add only about 11 minutes to their workday if they counseled all of their smoking patients to quit at every visit, a study published in The Journal of Family Practice has shown.

Those 11 minutes could make a major difference in the public health, said Carlos R. Jaén, M.D. Ph.D., lead investigator on the study and associate professor of family medicine in the School of Medicine and Biomedical Sciences at the University at Buffalo.

He suggested that physicians should stop thinking of smoking as a bad habit and start thinking of it as a chronic disease.

"We know that advice from family physicians about the dangers of smoking can be very effective," said Jaén, a member of the federal panel that developed the 1996 clinical practice guidelines on smoking cessation. "One of the reasons physicians give for not doing it is time.

"We've shown it takes an average of 90 seconds per patient. Even if a physician sees 30 patients a day, and a quarter of them are smokers (the national average), that amounts to only about 11 extra minutes a day."

Smoking cessation advice is the most important preventive service physicians can offer patients who smoke, according to a 1990 report of the Surgeon General. A 1996 study showed that most family physicians are confident they can help patients change their smoking behavior.

Yet researchers on the current study found that while physicians advised patients to stop smoking during more than half of "wellness" visits, they did so with only one-fourth of smokers seen for a chronic illness, and only one-third of smokers suffering from chronic illnesses related to smoking.

The study was designed to find out how often, and under what circumstances, family physicians provide non-smoking advice, and how long they spend doing it. It involved 138 family physicians in northeastern Ohio and 2,655 of their patients.

Nurse researchers sat in on consecutive office visits on two separate days and recorded in seconds and minutes the amount of time the physicians devoted to each subject or activity. They also noted the reason for each patient's visit, i.e., for a chronic, or long-term condition; an acute, or sudden illness, or a regular "wellness" check-up.

Patients completed questionnaires after the visit that included their smoking history. Assessment of the data from questionnaires and office visits showed that:

• Only 25 percent of smoking patients received advice on quitting.

• Fifty-five percent of "wellness-visit" patients received non-smoking advice.

• Among smokers with chronic conditions, those with smoking-related illnesses were more likely to receive advice on quitting than those whose illnesses were not smoking-related.

• Only 32 percent of smokers with chronic conditions related to smoking received advice on quitting.

Jaén said there are many reasons -- time is one -- why physicians don't talk to patients about smoking.

"Most people are sick when they go to the doctor, and physicians have a long list of things they have to attend to. There are many competing demands on the physician's time. Or, the physician may know the patient is uncomfortable talking about smoking and is waiting for a good time to bring it up."

Physicians also may feel their efforts are a waste of time, knowing smokers won't quit the habit unless they are ready, Jaén noted.

"There is the notion that the physician is a failure if he can't convince the patient to quit right on the spot. We don't hold ourselves to that same standard when we are dealing with high blood pressure or diabetes."

The clinical practice guidelines on smoking cessation now call for including smoking history and advice on quitting as part of taking vital signs, along with blood pressure, heart rate, etc. Jaén said this approach seems to be increasing the number of patients receiving advice on smoking.

"Nevertheless, we ought to strive for 100 percent," he stated.

Also participating in the study were Benjamin F. Crabtree, Ph.D., University of Nebraska Medical Center; and Stephen J. Zyzanski, Ph.D., Meredith A. Goodwin, and Kurt C. Stange, M.D., Ph.D., Case Western Reserve University.