Smoking cessation counselling: who does best — pulmonologists or GPs?

Dear Sirs,

We were very interested to read the article by Zwar in the last issue of the PCRJ, in which he focused on the importance of smoking cessation support as the key intervention in managing a patient with COPD and one of the few measures that reduces disease progression.¹

Tobacco use continues to be the leading cause of preventable disease and death in the USA, accounting for one in every five deaths. As per the Center for Disease Control and Prevention (CDC), the prevalence of smoking in 2010 was 19.3%, slightly lower than the prevalence in 2009 (20.6%) and 2005 (20.9%).² As a grade A recommendation, the United States Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions. The same recommendations were given by the Joint Committee on smoking and health.³ However, the CDC reported recently in its National Health Interview Survey — Health Promotion and Disease Prevention (NHIS-HPDP) report,⁴ that approximately 20 million smokers visited a healthcare professional and did not receive advice to quit smoking.

Performance on smoking cessation counselling, one of the most important measures in the fight against tobacco use, has been assessed across all health professionals. In comparing groups including pharmacists, dentists, nurses, respiratory therapists and dental hygienists, general practitioners (GPs) were found to be the champions on smoking cessation counselling.⁵ Similarly, a multivariate analysis of intervention effects on cessation revealed that physicians were most effective, followed by multi-provider teams, dentists, and nurses. These findings suggest that contact with a healthcare professional will increase cessation.⁶ However, to our knowledge, no head-to-head comparisons have been conducted to date in the USA comparing the performance of GPs versus pulmonologists when performing smoking cessation counselling.

We have therefore conducted a pilot study project to compare the performances of pulmonologists and GPs. Data were collected using a survey questionnaire assessing 50 patients in an outpatient pulmonary setting and 50 in GP primary care clinics, both at Kings County Hospital Center in Brooklyn, New York, the largest municipal hospital in New York City. Only 6% of patients were smokers in the primary care clinic, whereas 36.73% of those in the pulmonary outpatient clinic smoked (P=0.0005) — a reasonable finding in view of the aetiological importance of smoking in pulmonary diseases.

When asked, “Did your health care provider question you about your tobacco use?”, there was no statistical difference between the GPs and pulmonologists (73.47% versus 85.71%, respectively; P=0.6232).

However, when asked, “Were you counselled on the dangers of tobacco use and advised cessation?”, pulmonary clinic patients had received counseling more often (73.47% vs. 42.86% in the primary care clinic, P=0.0135). These ratios are similar to those reported in the Women Physicians' Health Study (WPHS), which reported that (overall) 45% of physicians frequently asked about and counselled smokers to quit, but that medical subspecialists (80%) were most likely and psychiatrists (29%) least likely to counsel frequently.⁷ The CDC stated in its NHIS-HPDP report that 37.2% of smokers have ever received advice to quit from a healthcare professional.⁴ Similarly, visits to internal medicine physicians (32.5%) and cardiovascular disease specialists (35.4%) are more likely to include counseling than visits to GPs (23.5%) and obstetricians/gynecologists (19.7%).⁸ Finally, in a Dutch survey, more lung physicians recommended the use of the three aids (bupropion, nicotine gums and nicotine patches) than GPs and cardiologists, and a higher proportion of lung physicians (69.3%) had referred at least one smoker to a nurse for smoking cessation treatment than cardiologists (25%) and GPs (11.3%).⁹

The “Healthy People 2020” objectives for health systems changes related to tobacco cessation include increasing tobacco screening in office-based ambulatory care settings (to 68.6% from a baseline of 62.4%), and increasing tobacco cessation counselling in office-based ambulatory care settings (to 21.1% from a baseline of 19.2%) among current tobacco users.¹⁰ In the CDC NHIS-HPDP, Hispanic patients were less likely to receive screening for tobacco use (57.8%) during office-based physician visits than were non-Hispanic white patients (64.1%). In terms of smoking cessation counselling, rates were slightly higher for women and for patients aged 45–64 years (22.7%) than for patients aged 25–44 years (17.9%), and slightly lower for Hispanics than for white non-Hispanics, but otherwise did not vary by race/ethnicity, education, or socioeconomic status.⁴ In our pilot survey, there were no gender differences (P=0.1026), no age differences (P=0.6130), and no ethnic differences (P=1.00) in those patients who received counselling.

Our pilot study highlights an urgent and important weakness in our common daily practice. Although pulmonolgists performed better as regards smoking cessation counseling and advice to quit, they did not differ from GPs in their screening of patients regarding tobacco use. Given the importance of smoking as the leading cause of disability and death, both specialty clinics and primary care settings should improve their respective performances on tobacco screening and counselling. We are currently conducting a larger questionnaire study which we hope will provide further results and conclusions.