We found a relatively low reported prevalence of physician initiated smoking cessation discussion, particularly among currently employed workers with potentially synergistic occupational exposures and high current smoking prevalence. Workers with more than a high school education were more likely to report receipt of smoking cessation advice relative to high school graduates and those with less than a high school education. In our multivariable models, educational attainment greater than high school remained significantly associated with an increased likelihood of receiving smoking counselling, while occupational classification was generally not significant. Our multivariable results should be interpreted with caution given the correlation between occupation and education and sample size differences across the occupation groups. However, numerous studies have shown that the quality of doctor‐patient communications is lower among less versus more educated patients.27
Therefore, one possible explanation for the lower rates of smoking cessation discussion among many of the blue collar occupational groups may be because of the communication challenges posed by differences in educational attainment between patient and HCP.
A large percentage of primary care physicians practising in the US and in other industrialised countries believe that smoking cessation discussions with their patients are too time consuming (42%) and ineffective (38%).28
Despite these beliefs, quit rates are approximately 2.3% higher in smokers who are advised by their physicians to stop smoking relative to smokers who do not receive this advice.10
Based on table 1, this suggests that there could have been over 242
000 employed smokers who might have quit in the year 2000 if all US patient encounters during that year included a direct message from their HCP to stop smoking.
Unfortunately, the current analysis suggests that just over half of employed smokers with an HCP contact in the previous 12 months reported being advised to quit smoking. Furthermore, there was no increase in this prevalence when only the primary care physician and/or obstetrician/gynaecologist visits were examined, even though these are HCPs with specialised preventive medicine training. Similar results were recently obtained from participants of the 2000 Behavioral Risk Factor Surveillance System (BRFSS), which found that nearly 55% of smokers with an HCP encounter in the previous 12 months reported being advised to quit smoking.29
It should be noted that smokers in the BRFSS and in the present analysis may tend to under‐report advice to quit smoking. Nevertheless, counselling rates from the BRFSS and the present study are similar to those reported two decades earlier,8,30
indicating that the increasing availability of anti‐smoking educational materials and programmes have been insufficient to motivate more HCPs to communicate smoking cessation messages to their patients.
Tobacco use counselling in healthcare settings is currently monitored in the US by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA). Other national medical organisations are moving towards performance standards that include the monitoring and delivery of smoking cessation services.31
Continued development and implementation of these standards, along with more favourable reimbursement policies for the provision of such services, established by the Centers for Medicaid and Medicare services in 2005,32
should ultimately lead to improved delivery of smoking cessation services.
Online clinical practice guidelines on smoking cessation advice and treatment are available (http://www.surgeongeneral.gov/tobacco/
) and include the brief clinical interventions such as the five A's: Ask (about smoking status), Advise (the patient to quit), Assess (determine willingness to quit), Assist (help the patient with a plan to quit), and Arrange (a follow‐up contact).10,11
While intensive clinical interventions are more efficacious, there is strong evidence that brief clinical interventions are cost effective.10
All HCPs should, at minimum, know if their patients use tobacco and provide information to their smoking patients on the new national quitline launched in 2004 (1‐800‐QUITNOW; http://www.smokefree.gov/
Telephone counselling is a proven, relatively low cost, and barrier free method for smoking cessation,33,34
and referral mechanisms can be integrated into HCP office practices.35
Pairing of telephone counselling with nicotine replacement therapy further enhances quit rates.36
The relatively low prevalence of smoking cessation discussion with their HCP reported by US workers, particularly among workers with potentially synergistic occupational exposures and high current smoking prevalence, may reflect a lack of knowledge of the occupational exposures and risks of their worker patients on the part of HCPs.37,38,39
There are limited online resources available for HCPs who seek additional information on the unique occupational risks of their smoking patients.40,41
Educational campaigns targeting HCPs, enhanced curricula for medical students, and user friendly internet and telephone based resources are needed so that physicians can quickly identify potentially hazardous exposures that may be affecting the health of their patients.37
Knowledge of these risks represents an opportunity for HCPs to open discussions with their patients regarding the need to quit smoking. HCPs also need to be aware of the challenges of encouraging a therapeutic dialogue with the many patients in these high risk groups who have lower educational levels.27
Finally, the development of worksite based programmes is needed to reach smokers who do not routinely come in contact with the healthcare system.42,43
Widespread adoption of these worksite based smoking cessation services will almost certainly require the support of the federal government—for example, through the provision of tax credits for employers who offer smoking cessation services to their employees.44
Such approaches not only will serve to reduce tobacco related health disparities noted among worker groups in dusty occupations, but will also lower healthcare and productivity costs as employees quit smoking.5,44,45,46
What this paper adds
Among workers in dusty occupations (for example, construction, mining, machine operators, farming), tobacco use is particularly hazardous because of the potential synergistic effects of occupational exposures in causing lung disease. Results from this nationally representative sample of US workers indicated that workers in these occupations report high rates of smoking, but often are not told by their healthcare provider (HCP) to quit smoking. Workers with less education were also less likely to report receiving advice from their HCP to quit smoking. In the year 2000, there were an estimated 10.5 million employed smokers with HCP contacts who were not advised to quit smoking. Previous research indicates quit rates are 2.3% higher in smokers receiving stop smoking advice from HCP. Therefore, an estimated 242
000 additional smokers would have quit in the year 2000 if they had received advice from their HCP to stop smoking. All HCPs must communicate this message to their smoking patients, and furthermore educate themselves about the potential occupational synergistic chemical and respiratory exposures which may place their patients at additional risk for smoking related disease. Obtaining information on occupational respiratory exposures can serve as a powerful tool for opening discussion of the hazards of smoking in high risk worker groups. HCPs also need to be aware of the challenges of encouraging a therapeutic dialogue with the many patients in these high risk groups who have educational levels that do not approach their own.