Abstract
Hypertensive patients who smoke are in particular need of lifestyle modification counseling because they are at increased risk for poorer outcomes. The authors examined whether hypertensive smokers were more or less likely than nonsmokers to report receiving recommendations for diet, salt intake, exercise, alcohol use, and medication and whether receipt of recommendations was differentially associated with lifestyle changes among smokers vs nonsmokers. In an analysis of data from the 2011 Behavioral Risk Factor Surveillance System on a representative sample of hypertensive adults from 9 US states (N=23,093), smokers were less likely than nonsmokers to report being told by a provider to exercise (odds ratio [OR], 0.66; P<.001) and change their diet (OR, 0.83; P<.05). Receiving dietary recommendations was more strongly associated with self‐reported dietary improvements among smokers (OR, 7.08; P<.001) compared with nonsmokers (OR, 4.17; P<.001) P<.01. Delivery of counseling may vary by smoking status. When provided, lifestyle counseling may be equally or more effective for smokers compared with nonsmokers.
Hypertension is responsible for approximately 395,000 annual deaths in the United States, making it one of the leading causes of preventable death, second only to smoking.1 Hypertension is a major cause of morbidity and mortality because of its association with coronary heart disease, cerebrovascular disease, renal disease, and other medical complications.2, 3 It is the most common diagnosis given by primary care doctors in the United States,4 with approximately 1 in every 3 American adults with the condition.5
A core component of hypertension treatment involves encouraging patients to adopt health‐promoting lifestyle changes, including weight reduction for patients who are overweight or obese, dietary changes, reduction of salt intake, regular physical exercise, and moderation of alcohol consumption.6, 7 Lifestyle modifications have been shown to have effects similar in magnitude to single‐drug therapy and can also enhance the efficacy of antihypertensive drugs.6 However, substandard patient education has been cited as one of the primary barriers to effective hypertension control.7
As a group, cigarette smokers are in particular need of information and encouragement regarding lifestyle changes. Among its many negative effects, smoking increases the harms associated with hypertension by damaging blood vessels and hardening arteries (atherosclerosis), which can lead to impaired organ function and blood clots.8 Moreover, as a group, smokers tend to have more behavioral risk factors than do nonsmokers, including poorer diet,9, 10 less frequent exercise,11, 12 and higher alcohol consumption,13 which also puts them at greater risk for developing more severe forms of hypertension.14
Despite smokers' increased need for advice and encouragement concerning lifestyle factors, one previous study suggests that smokers may be less likely than nonsmokers to receive lifestyle modification counseling. Analyzing data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS), Caban‐Martinez and colleagues15 found that smokers were less likely than nonsmokers to report receiving counseling to exercise, cut down on salt intake, and take hypertensive medication, but they were more likely to report receiving advice to reduce their alcohol consumption. Caban‐Martinez and associates argued that health professionals may be less likely to provide lifestyle counseling to smokers because they “may have lower expectations for patients who smoke with regard to likelihood of following recommendations” or they may fear confronting reluctant patients.
The present study sought to use a more recent BRFSS survey to replicate this important finding and provide information about the robustness of smoking‐related disparities in lifestyle modification counseling for hypertension. Also, because of the hypothesized role of health professionals' perceptions of smokers' responsiveness to lifestyle recommendations, the study also examined whether smokers may be less adherent to lifestyle modification counseling provided by health professionals.
Methods
Data and Participants
Data were drawn from the 2011 BRFSS, a collaborative project between the Centers for Disease Control and Prevention and US states and territories.16 BRFSS is an ongoing system of health surveys that collects data on health risk behaviors and health practices to identify emerging public health trends and guide health policies and programs. Data were collected via telephone interviews with a random sample of adults using a combination of cell phone and landline interviews. In total, 504,408 respondents were surveyed. The questionnaire included core modules with questions asked in all US states and territories, as well as a range of 34 optional modules that states could choose from in order to tailor their questionnaires. The questions analyzed in this study were drawn from the core module and an optional module on “actions to control high blood pressure,” which was administered in 9 US states: Connecticut, Hawaii, Illinois, Minnesota, Montana, North Carolina, Pennsylvania, South Carolina, and West Virginia. Other details of survey administration can be found elsewhere.16
Measures
Respondents were asked how long it had been since they last visited a doctor for a routine checkup, which was defined as “a general physical exam, not an exam for a specific injury, illness, or condition” (Within past year/Within past 2 years/Within past 5 years/5 or more years ago/Never). In addition, respondents were asked, “Have you EVER been told by a doctor, nurse or other health professional that you have high blood pressure?” (Yes/No). Women who responded “yes” were then asked, “Was this only when you were pregnant?” (Yes/No). Those responding that they had been told that they had high blood pressure and, for women, that this was when they were not pregnant, were subsequently asked about health professionals' recommendations about lowering or controlling their blood pressure. Specifically, they were asked, “Has a doctor or other health professional ever advised you to do any of the following to help lower or control your high blood pressure?” Separate items assessed whether a doctor or other health professional had ever advised respondents to “change your eating habits,” “cut down on salt,” “reduce alcohol use,” “exercise,” and “take medication” (Yes/No). A subsequent series of questions asked whether respondents were “now doing any of the following to help lower or control your high blood pressure”: “changing your eating habits,” “exercising,” “cutting down on salt,” and “reducing alcohol use” (Yes/No). A separate item asked respondents whether they were “currently taking medicine for your high blood pressure” (Yes/No).
Smoking status was assessed using two questions. First, respondents were asked whether they had smoked at least 100 cigarettes in their lifetime (Yes/No). If they answered “Yes,” they were asked whether they currently smoked (Every day/Some days/Not at all). Respondents who reported that they smoked at least 100 cigarettes in their lifetime and currently smoked “Every day” or “Some days” were defined as current smokers. Respondents who reported that they had not smoked 100 cigarettes in their lifetime or smoked 100 cigarettes but currently smoked “Not at all” were defined as nonsmokers.
Respondents also reported their height and weight, which were used to compute body mass index (BMI) scores. Respondents were classified as either (1) normal or underweight (BMI <25), (2) overweight (BMI ≥25 and <30), or (3) obese (BMI ≥30).17 Respondents reported their frequency of alcohol consumption and were coded as heavy drinkers if they were male and consumed >2 alcoholic drinks per day on average, or if they were female and consumed >1 alcoholic drink per day on average.18 Sociodemographic variables included age, sex, annual household income, educational attainment, race or ethnicity, marital status, and whether the respondent had “any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service.”
Statistical Analyses
As in the study by Caban‐Martinez and colleagues,15 analyses were restricted to respondents who reported visiting a doctor for a routine checkup during the past 24 months to reduce recall bias and ensure that all respondents had recently visited a health care professional. The analytic sample was also restricted to respondents who had valid data on all demographics, had been told by a health professional that they had high blood pressure, and were sampled from 1 of the 9 US states in which respondents were queried about lifestyle modification counseling. Data were weighted using iterative proportional fitting (or “raking”) in order to adjust for noncoverage and nonresponse bias in underrepresented groups, to incorporate cell phone survey data, and to match demographic characteristics of the sample to those of the adult populations of each US state.
We first conducted weighted binary logistic regressions to examine whether reports of each recommendation (ie, exercise, diet, salt intake, alcohol use, medication) were related to smoking status, controlling for all sociodemographic factors. Next, weighted binary logistic regressions were used to examine predictors of whether respondents reported actually making each lifestyle change to help lower or control their high blood pressure. In step 1, we entered all sociodemographic factors, smoking status, and whether respondents reported receiving counseling concerning the respective lifestyle modification factor (exercise, eating habits, salt intake, alcohol use, medication). In step 2, we entered the interaction between smoking status and whether respondents reported receiving counseling concerning the respective lifestyle factor. This interaction tested whether smoking status moderated the association between lifestyle modification counseling and self‐reported changes in lifestyle.
Results
Sociodemographic characteristics of respondents are shown in Table 1. Overall, 90% of respondents reported being advised to take medication to help lower or control their high blood pressure; 78% said they were advised to exercise; 74% said they were advised to cut down on salt; 67% said they were advised to change their diet; and 39% said they were advised to consume less alcohol.1 A total of 84% of respondents reported that they were currently taking medicine for their high blood pressure; 67% said they were now exercising to help lower or control their high blood pressure; 86% said they were cutting down on salt; 77% said they were changing their eating habits; and 60% said they were reducing alcohol use.
Table 1.
Demographic Characteristics
| Characteristic | No. (%) |
|---|---|
| Sex | |
| Male | 9941 (51.8) |
| Female | 13,152 (48.2) |
| Age, y | |
| 18–24 | 116 (1.7) |
| 25–34 | 518 (5.3) |
| 35–44 | 1433 (10.9) |
| 45–54 | 3506 (20.4) |
| 55–64 | 6396 (25.8) |
| >64 | 11,124 (35.9) |
| Education | |
| Some high school or less | 2358 (14.8) |
| High school graduate | 7812 (34.0) |
| Some college | 6139 (29.5) |
| College graduate | 6784 (21.7) |
| Annual household income, $ | |
| <15,000 | 3208 (12.5) |
| 15,000 to <25,000 | 4962 (20.5) |
| 25,000 to <35,000 | 3175 (13.2) |
| 35,000 to <50,000 | 3700 (15.0) |
| ≥50,000 | 8048 (38.9) |
| Race/ethnicity | |
| Non‐Hispanic white | 17,640 (74.4) |
| Black/African American | 2826 (16.0) |
| Hispanic | 570 (4.7) |
| Other | 2057 (4.9) |
| Health insurance | |
| Yes | 21,573 (90.8) |
| No | 1520 (9.2) |
| Body mass index | |
| Normal or underweight | 5276 (19.4) |
| Overweight | 8633 (36.9) |
| Obese | 9184 (43.7) |
| Alcohol use | |
| Heavy | 1264 (5.7) |
| Not heavy | 21,829 (94.3) |
| Marital status | |
| Married | 11,816 (56.3) |
| Not married | 11,277 (43.7) |
| Smoking status | |
| Smoker | 3445 (18.2) |
| Nonsmoker | 19,648 (81.8) |
| Total No. | 23,093 (100) |
Values are expressed as unweighted counts (No.) and weighted percentages (%).
Associations With Lifestyle Modification Counseling
As shown in Table 2, smokers were less likely than nonsmokers to report receiving recommendations to exercise and change their diet to lower or control their blood pressure (BP). Significant differences did not emerge between smokers and nonsmokers in recommendations to cut down on salt intake, reduce alcohol use, and take medication to control their BP.
Table 2.
Weighted Associations With Reported Hypertension Treatment Recommendations
| Characteristic | Recommendation | ||||
|---|---|---|---|---|---|
| Medication (N=23,010) | Exercise (N=22,901) | Diet (N=22,930) | Salt (N=22,038) | Alcohol (N=15,826) | |
| Sex | |||||
| Male | 0.80a | 1.15a | 1.29b | 1.22c | 1.77b |
| Female | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Age, y | |||||
| 18–24 | 0.01b | 1.29 | 1.13 | 0.63 | 0.93 |
| 25–34 | 0.06b | 1.30 | 1.49 | 0.96 | 1.21 |
| 35–44 | 0.17b | 1.56c | 1.98b | 0.97 | 2.10b |
| 45–54 | 0.34b | 1.92b | 1.66b | 1.12 | 1.63b |
| 55–64 | 0.62c | 1.69b | 1.68b | 1.30b | 1.65b |
| >64 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Education | |||||
| Some high school or less | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| High school graduate | 1.55a | 1.11 | 1.20 | 1.08 | 1.05 |
| Some college | 1.54a | 1.09 | 1.02 | 0.80 | 0.79 |
| College graduate | 1.12 | 1.20 | 0.96 | 0.82 | 0.63c |
| Annual household income, $ | |||||
| <15,000 | 1.05 | 0.88 | 0.90 | 1.41c | 1.46a |
| 15,000 to <25,000 | 1.00 | 0.89 | 1.00 | 1.20 | 1.34a |
| 25,000 to <35,000 | 0.89 | 0.97 | 1.02 | 1.18 | 1.34a |
| 35,000 to <50,000 | 1.06 | 1.05 | 1.02 | 1.13 | 1.17 |
| ≥50,000 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Race/ethnicity | |||||
| Non‐Hispanic white | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Black/African American | 1.43 | 1.61b | 1.87b | 1.94b | 1.70b |
| Hispanic | 0.52c | 1.02 | 1.48 | 1.23 | 1.94a |
| Other | 1.34 | 1.34a | 1.47c | 1.24 | 1.27 |
| Health insurance | |||||
| Yes | 0.96 | 0.93 | 0.86 | 1.13 | 0.95 |
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Body mass index | 1.41b | 1.53b | 1.75b | 1.31b | 1.12c |
| Alcohol use | |||||
| Heavy | 0.77 | 0.88 | 0.76a | 0.76a | 1.62b |
| Not heavy | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Marital status | |||||
| Married | 1.11 | 1.30c | 1.11 | 1.17a | 1.03 |
| Not married | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Smoking status | |||||
| Smoker | 1.10 | 0.66b | 0.83a | 0.86 | 1.10 |
| Nonsmoker | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Values are adjusted odds ratios from weighted logistic regressions. a P<.05. b P<.001. c P<.01.
Also shown in Table 2, men were more likely than women to report receiving lifestyle modification counseling for exercise, diet, salt intake, and alcohol use, as were black respondents compared with non‐Hispanic whites. Respondents in the oldest age group (65 years or older) were more likely than younger respondents to report receiving recommendations for treatment using medication but were less likely to report receiving recommendations for changes in exercise, diet, salt intake, and alcohol use. Respondents with higher BMIs were more likely than those with lower BMIs to report receiving recommendations for medication and all 4 lifestyle modifications. Respondents in the highest income group were less likely than those in the lowest income group to report receiving recommendations to reduce salt intake, and less likely than those in the lower 3 income groups to report receiving recommendations to reduce their alcohol use. Heavy alcohol users were less likely to report receiving recommendations to change their diet and cut down on salt intake but were more likely to receive recommendations to reduce their alcohol use. Respondents who were married were more likely than others to report receiving recommendations to exercise and cut down on salt.
Associations With Lifestyle Changes
As shown in Table 3, receiving lifestyle modification counseling was strongly associated with all lifestyle changes, including exercising, changing eating habits, cutting down on salt, reducing alcohol use, and taking medication. Current smokers were significantly less likely than nonsmokers to report exercising, changing their diet, and cutting down on their salt intake to lower or control their BP.
Table 3.
Weighted Associations With Reported Lifestyle Modifications
| Characteristic | Lifestyle Modification | ||||
|---|---|---|---|---|---|
| Medication (N=22,993) | Exercise (N=22,796) | Diet (N=22,796) | Salt (N=20,557) | Alcohol (N=11,917) | |
| Sex | |||||
| Male | 0.95 | 1.22a | 0.74a | 0.76a | 0.87 |
| Female | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Age, y | |||||
| 18–24 | 0.06a | 2.55b | 0.78 | 0.92 | 1.09 |
| 25–34 | 0.09a | 1.12 | 0.83 | 0.50b | 1.10 |
| 35–44 | 0.10a | 1.44b | 1.57b | 0.99 | 1.32 |
| 45–54 | 0.23a | 1.11 | 1.46a | 0.77c | 1.19 |
| 55–64 | 0.52a | 0.97 | 1.23b | 1.02 | 1.40a |
| >64 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Education | |||||
| Some high school or less | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| High school graduate | 0.81 | 1.32b | 1.10 | 1.04 | 1.09 |
| Some college | 0.68 | 1.40b | 1.12 | 1.05 | 0.71 |
| College graduate | 0.59c | 1.70a | 1.14 | 0.86 | 0.58b |
| Annual household income, $ | |||||
| <15,000 | 1.01 | 0.90 | 1.22 | 1.11 | 1.51c |
| 15,000 to <25,000 | 0.94 | 0.91 | 1.17 | 1.26 | 1.71a |
| 25,000 to <35,000 | 1.16 | 0.91 | 1.06 | 1.07 | 1.46b |
| 35,000 to <50,000 | 0.97 | 0.81b | 1.17 | 1.20 | 1.33b |
| ≥50,000 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Race/ethnicity | |||||
| Non‐Hispanic white | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Black/African American | 1.22 | 1.26b | 1.67a | 1.80a | 1.60b |
| Hispanic | 0.57 | 0.99 | 0.88 | 1.05 | 1.67 |
| Other | 1.32 | 1.48b | 1.51b | 1.02 | 1.59c |
| Health insurance | |||||
| Yes | 1.51c | 1.15 | 0.72c | 0.81 | 1.08 |
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Body mass index | 1.26a | 0.71a | 1.06 | 1.04 | 1.07 |
| Alcohol use | |||||
| Heavy | 0.86 | 0.78c | 0.68b | 0.71c | 0.30a |
| Not heavy | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Marital status | |||||
| Married | 1.19 | 0.99 | 1.10 | 1.05 | 0.99 |
| Not married | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Smoking status | |||||
| Smoker | 0.80 | 0.71a | 0.74b | 0.71b | 0.99 |
| Nonsmoker | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Received recommendation | |||||
| Yes | 55.93a | 2.36a | 4.58a | 6.62a | 4.94a |
| No | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Smoker × recommendation | 0.90 | 1.35 | 1.59b | 1.05 | 0.80 |
Values are adjusted odds ratios from two‐step weighted logistic regressions. The smoker × recommendation interactions were added in step 2 of each model. a P<.001. b P<.01. c P≤.05.
Importantly, as shown in Table 3, when the interaction between smoking status and lifestyle modification counseling was added in step 2 of each model, being a current smoker did not moderate the impact of lifestyle modification counseling on self‐reported changes in exercise, salt intake, alcohol consumption, or taking medication. However, there was a significant interaction between smoking status and lifestyle modification counseling to improve diet (Table 3), such that receiving counseling for improving one's diet was more strongly associated with self‐reported dietary improvements for smokers (odds ratio [OR], 7.08; P<.001) than for nonsmokers (OR, 4.17; P<.001).
Supplementary Analyses
To test the sensitivity of the findings reported here, follow‐up analyses were conducted in which the analytic sample was restricted to respondents who reported having a routine checkup within the past 1 year, as opposed to the past 2 years. With regard to the associations between smoking status and lifestyle modification counseling, the results of these analyses confirmed the strength and directionality of the findings reported here, with the exception that the effect of smoking status on reports of recommendations for cutting down on salt intake now approached significance (OR, 0.82; P=.078). Predictors of self‐reported lifestyle changes, including receipt of lifestyle modification counseling, smoking status, and their interaction, were also consistent with the results reported here.
Discussion
This study explored disparities between smokers and nonsmokers in reports of health professionals' recommendations for controlling hypertension in a large, population‐based survey. Smokers were less likely than nonsmokers to report receiving recommendations for exercise and diet, even after controlling for sociodemographic factors. These results support and build on the findings of Caban‐Martinez and colleagues,15 who found in BRFSS 2007 that hypertensive smokers were less likely than nonsmokers to report receiving counseling to reduce salt intake, exercise, and take hypertensive medication. Our findings further show that recommendations were related to self‐reported behavior changes for both smokers and nonsmokers.
Lifestyle recommendations concerning factors such as diet and exercise are critical for hypertension treatment.7, 19 Disparities in recommendations for exercise and diet are especially striking since smokers, as a group, tend to be less physically active than nonsmokers,11, 12 tend to have worse diets,9, 10 and are at greater risk for developing more severe forms of hypertension.14 Thus, hypertensive smokers are in particular need of lifestyle modification counseling for diet and exercise but may be less likely to receive it.
One potential explanation for smoking‐related disparities in lifestyle modification counseling is that health professionals may view smokers as less likely to adhere to lifestyle recommendations.15 This study provides encouraging results concerning smokers' self‐reported adherence to lifestyle modification recommendations. Receiving recommendations to exercise, cut down on salt, reduce alcohol use, and take medication were equally strongly associated with self‐reported changes in these behaviors for smokers and nonsmokers. For recommendations to improve diet, receiving recommendations from a health provider was more strongly associated with improved eating habits among smokers than nonsmokers. Possible reasons why dietary recommendations may be more effective among smokers could be that smokers initially had poorer diets9, 10 or were less knowledgeable about appropriate dietary changes to lower or control high BP. It may also be that smokers view improving their diet as more achievable than smoking cessation. This finding should encourage health professionals to provide lifestyle recommendations to all hypertensive patients, including those who smoke, without doubting their willingness to adhere.
A second factor that may contribute to smoking‐related disparities in lifestyle modification counseling for hypertension is time constraints on physician visits,20, 21 which may disproportionately affect hypertensive smokers. Cigarette smoking is the leading preventable cause of death and disease in the United States,1 and, as such, it warrants considerable discussion during patient visits. The US Public Health Service Guidelines encourage physicians to ask patients at every visit whether they smoke, advise them to quit, assess willingness to quit, assist with cessation and referral, and arrange to follow‐up on cessation efforts (ie, the “5 A's”).22, 23 Smoking is especially detrimental among people with hypertension,8 making it all the more important for health professionals to encourage and support quitting.
The present findings linking lifestyle modification counseling with demographic characteristics were consistent with previous research. Reports of lifestyle modification counseling were more common among men compared with women and among black people compared with non‐Hispanic whites.24 Reports of lifestyle modification counseling were also more common among younger adults compared with the oldest age group (65 or older).25 Research is needed to examine the sources and consequences of potential age‐related biases in the provision of recommendations for behavioral change. For example, it may be that health professionals see some elderly patients as less able to implement lifestyle changes (for example, unable to exercise), or they may perceive that medication has a higher likelihood of benefit than do lifestyle changes in this population. Overweight and obese people were more likely than non‐overweight and underweight people to report receiving all recommendations, including for medication, a result that is consistent with findings from previous studies.24, 25 Since overweight and obesity are visible risk factors for hypertension, they may serve as cues that remind health professionals to discuss lifestyle factors. Finally, consistent with Caban‐Martinez and colleagues,15 heavy alcohol users were more likely to report receiving recommendations to reduce their alcohol use but were less likely to receive recommendations to change their eating habits and cut down on salt.
Limitations
This study was based on secondary data analysis and thus was limited to the items included in the original study. Lack of key measures (eg, health professionals' discussion of smoking cessation) limited our ability to investigate the mechanisms of the effects observed here. The study's reliance on self‐reported data also means that our findings are subject to recall bias. To reduce the potential for bias, we limited analyses to respondents who reported visiting a provider for a routine checkup within the past 2 years.15, 26, 27, 28, 29 Also, we re‐ran all analyses only among respondents with a routine checkup within the past year and found consistent results. Despite these precautions, it remains possible that the disparities observed were caused by differences in recall between smokers and nonsmokers rather than actual differences in health care received. Indeed, certain psychosocial characteristics of smokers may impact their receptivity to (and likelihood of remembering) lifestyle modification counseling.10, 12 Given this alternative potential explanation of the present findings, the results reported here also need to be explored using different methodologies such as patient records or direct observations of patient‐doctor interactions.
Our study is also limited because hypertension diagnoses and adherence to lifestyle modifications were self‐reported. Without objective measures of BP, we were unable to distinguish between cases of hypertension vs prehypertension, which may impact health professionals' decisions concerning lifestyle modification counseling.30 With respect to self‐reported lifestyle modifications, the measures used here were not validated through objective methods, and many of the lifestyle modifications were reported with surprising frequency (eg, 86% of respondents said they were now cutting down on salt and 67% said they were now exercising to help control their BP). This raises the possibility that social desirability bias may be at play in these self‐reports31, 32, 33 and suggests the need for follow‐up studies with validated measures of lifestyle changes.
Lastly, our study assessed only whether respondents reported receiving recommendations about lifestyle modifications, and did not assess the intensity or consistency of behavioral counseling.34 It is critical for future studies to continue to evaluate the provision of behavioral counseling and potential variations in delivery by smoking status.
Implications
This study provides generalizable results concerning a potentially important phenomenon in healthcare delivery.16 In the United States, doctors and other health professionals tend to be the most trusted sources of health information, even as other information channels such as the Internet have proliferated.35 Most people expect to receive advice and help from health professionals on key behaviors such as exercise, diet, and substance abuse,36 and health professionals' recommendations have been found to be strong predictors of patient behavior in the self‐management of disease.37, 38, 39 Differential recommendations for lifestyle change may thus represent a mechanism through which existing health disparities between smokers and nonsmokers may be maintained. Our finding that smoking status did not moderate the impact of health professionals' recommendation on self‐reported changes in lifestyle further emphasizes the need to address these potential disparities in counseling.15
Several strategies exist that may help to address smoking‐related disparities in healthcare delivery. First, the popularization of health communication tools such as videos and print media can be harnessed to ensure that hypertensive patients receive basic information about lifestyle changes that can reduce their risk. Although videos and other standardized health communications cannot replace the doctor‐patient relationship, they can be an effective component of interventions designed to motivate positive changes. In one recent study, a video‐based lifestyle intervention led to changes in diet and exercise that were reflected in improvements across a wide range of health outcomes including body weight, resting heart rate, and cholesterol.40 One possibility may be to deliver such interventions in the waiting room prior to physician visits.41,2
Similarly, recent advances in communication technologies can be harnessed to prolong contact with patients well beyond a doctor visit. Information concerning lifestyle modifications can now be transmitted via the Internet and mobile phones, allowing for timely reminders, tips for overcoming perceived barriers, and other functionality such as assistance with scheduling weekly exercise sessions.42 Along similar lines, decision support systems and feedback reminders may also be used to prompt health professionals to advance therapy when patients' BP remains uncontrolled.19 Given that physicians often cite barriers to the delivery of counseling such as inadequate confidence and lack of knowledge and skill, continued efforts are also needed to build training on lifestyle counseling into medical school curricula, residency education, and continuing medical education.43, 44 Each of these techniques holds promise for eliminating potential smoking‐related disparities in lifestyle modification counseling.45,3
The present findings also call for further research on smoking‐related disparities in the provision of health services. Most importantly, different methodologies should be used to explore the effects observed here. For instance, examining patient records would provide more conclusive evidence regarding the existence of disparities in healthcare delivery and would also be useful in investigating the sources of these disparities. Replication of the present results using nationally representative datasets would also be useful. Qualitative studies of physicians and smokers in clinical contexts may also help to identify systemic issues in the treatment of smokers. On the practical side, there is also a need for creative thinking about additional potential solutions. For example, there may be a need to assess policies surrounding the lack of time in clinical encounters and build incentives to ensure adequate counseling of patients. Finally, although this study assessed disparities in lifestyle modification counseling for hypertension,19 future studies might assess differences in other services such as referral for follow‐up or specialized care.
Conclusions
This study identified important disparities in self‐reports of treatment between hypertensive smokers and nonsmokers,15 focusing on lifestyle recommendations that are particularly needed in the population of current smokers.9, 10, 11, 12, 13, 14 Differences emerged in reported recommendations for changes in exercise and diet, with smokers significantly less likely to report receiving recommendations concerning these lifestyle changes. Our results also suggest that, when provided, lifestyle counseling may be equally or more effective for hypertensive smokers compared with nonsmokers. Addressing smoking‐related disparities may require a combination of efforts, including (1) overcoming health professionals' lack of focus on lifestyle modification counseling to hypertensive patients who smoke, (2) alleviating the time constraints in clinical encounters, and (3) using communication technologies to educate patients prior to physician visits and to prolong contact with patients beyond the clinical encounter.
Conflict of Interest:
The authors have no conflict of interest to disclose.
J Clin Hypertens (Greenwich). 2014;16:429–436. DOI: 10.1111/jch.12314. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
Footnotes
In response to the question about recommendations to cut down on salt, 3% of respondents indicated that they “do not use salt.” In response to the question about recommendations to reduce alcohol use, 26% of respondents indicated that they “do not drink.” These responses were excluded from analyses.
Unfortunately, it is unclear whether (or how much) lifestyle modification counseling in the present study was delivered through these types of health communication tools as opposed to face‐to‐face interactions, as this was not assessed in BRFSS 2011.
It should also be noted that lifestyle modification counseling by clinicians is not the only effective strategy through which to impact hypertension prevention and management, as is indicated by the many respondents in this study who reported making lifestyle changes without receiving recommendations from a healthcare provider. Alternative strategies include, for example, national media campaigns.
References
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