Tailoring tobacco counseling to the competing demands in the clinical encounter

OBJECTIVES We identified patterns of tobacco cessation Counseling in primar y 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 2 0 family physicians in 7 Nebraska community family practices. OUTCOMES MEASURED We measured patterns and quality of tobacco Counseling as sessed 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 appr oximately three fourths of primary care Visits by smokers, clinical practic e guidelines that recommend intervention at every Visit are unrealistic. Ho wever, the finding that only one third of eligible visits addressed tobacco makes it imperative that tobacco cessation counseling be reliably integrat ed into visits for well care and tobacco-related illnesses that represent t eachable moments.