- Email: [email protected]
Physician advice about smoking and drinking
Brief Report
Physician Advice About Smoking and Drinking Are U.S. Adults Being Informed? Clark H. Denny, PhD, Mary K. Serdula, MD, MPH, Deborah Holtzman, PhD, David E. Nelson, MD, MPH Background: Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. Methods:
Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digitdial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated.
Results:
By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use.
Conclusions: Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help. (Am J Prev Med 2003;24(1):71–74)
Introduction
T
obacco and alcohol are recognized as the first and third leading avoidable causes of death in the United States, accounting for approximately 430,0001 and 100,0002 deaths, respectively, in 1990. Annual medical care expenditures attributable to smoking were estimated at $73 billion3 and the loss of productivity due to morbidity and premature death at $47 billion in 1993.4 Corresponding annual cost estimates for alcohol abuse and alcoholism were $19 billion and $99 billion, respectively, in 1992.5 Clinicians treating smokers and problem drinkers can improve the health of individual patients and reduce costs to society by implementing the guidelines developed by the U.S. Preventive Services Task Force.6 The guidelines recommend regular cessation counsel-
From the Division of Adult and Community Health (Denny, Holtzman), and Division of Nutrition and Physical Activity (Serdula), Centers for Disease Control and Prevention, Atlanta, Georgia; and National Cancer Institute, National Institutes of Health (Nelson), Bethesda, Maryland Address correspondence to: Clark H. Denny, PhD, Epidemiologist, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS K-66, Atlanta GA 30341. E-mail: [email protected].
Am J Prev Med 2003;24(1) Published by Elsevier Science Inc.
ing for all tobacco users, screening of all adults to detect alcohol abuse or hazardous drinking, brief counseling for those who screen positive for problem drinking, and counseling of all drinkers about the dangers of operating a motor vehicle after drinking. In this study, we focused on binge drinking, which has been associated with increased risk of mortality and morbidity due to injury, alcohol dependence, and social problems.7–10 Population-based estimates of health professional intervention for tobacco and alcohol use are not available either nationally or for most states, but estimates are necessary to measure progress toward the Healthy People 201011 objectives of increasing the proportion of persons appropriately counseled about smoking cessation and reduced alcohol consumption. In this study, we calculated population-based estimates of the prevalence of being advised to quit among smokers and being talked to about alcohol use among binge drinkers who had routine checkups in the past year. We stratified the estimates by gender, age, education, and race or ethnicity for a group of 10 states, using data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS). We also estimated how many at-risk patients did not receive these interventions.
0749-3797/03/$–see front matter PII S0749-3797(02)00568-8
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Table 1. Demographic factors associated with smoking and alcohol use behavioral interventionsa Smokers
Subpopulation characteristic Total Gender Male Female Age (years) 18–34 35–54 ⱖ55 Education ⬍High school High school diploma Some college ⱖCollege Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other
Binge drinkers
Received Unweighted advice, weighted number % (95% CI) AOR (95% CI)
Talked to about drinking, Unweighted weighted number % (95% CI) AOR (95% CI)b
3818
70.0 (67.9–72.1)
1783
23.2 (20.1–26.3)
1432 2386
66.2 (62.7–69.7) 0.71 (0.58–0.87) 73.3 (70.9–75.8) 1.00
1093 690
25.8 (21.7–29.8) 1.57 (1.09–2.28) 17.8 (13.6–22.0) 1.00
1172 1797 849
64.2 (60.2–68.2) 0.61 (0.46–0.82) 72.2 (69.3–75.1) 0.88 (0.67–1.16) 75.6 (71.4–79.8) 1.00
865 718 200
20.3 (16.0–24.6) 1.07 (0.56–2.03) 28.3 (23.2–33.3) 1.55 (0.83–2.90) 21.4 (12.3–30.4) 1.00
603 1571 1045 599
74.8 (69.9–79.6) 70.2 (67.0–73.5) 67.2 (62.9–71.5) 69.6 (64.4–74.8)
1.29 (0.90–1.86) 1.04 (0.77–1.40) 0.92 (0.66–1.26) 1.00
133 642 526 482
34.2 (21.6–46.9) 26.2 (21.0–31.3) 18.2 (13.2–23.2) 22.9 (16.6–29.1)
1.57 (0.80–3.08) 1.08 (0.69–1.68) 0.73 (0.45–1.20) 1.00
3046 384 199 189
70.2 (67.9–72.6) 73.5 (68.1–78.9) 63.4 (53.9–72.8) 66.5 (52.8–80.3)
1.00 1.11 (0.82–1.51) 0.80 (0.52–1.24) 0.90 (0.49–1.64)
1468 122 103 90
21.8 (18.5–25.2) 34.4 (23.0–45.8) 31.6 (17.6–45.6) 14.3 (1.5–27.1)
1.00 1.81 (1.08–3.03) 1.53 (0.76–3.05) 0.62 (0.22–1.73)
Smoking is defined as having smoked ⱖ100 cigarettes and currently smoking. Binge drinking is defined as having five or more on at least one occasion in the past month. All data are based on the Behavioral Risk Factor Surveillance System, 1997. b Adjusted for all other covariates. CI, confidence interval; AOR, adjusted odds ratio. a
Methods The BRFSS is a state-based, monthly, random-digit-dial telephone survey of non-institutionalized civilian adults, aged ⱖ18 years, that focuses on risk behavior related to chronic disease. The survey is conducted by the Centers for Disease Control and Prevention in collaboration with state health departments.12 In 1997, the following 10 states asked about intervention by a health professional in their surveys: Alaska, Colorado, Idaho, Louisiana, Missouri, New York, Oklahoma, Pennsylvania, Virginia, and Wyoming. Among persons reached by telephone, the median participation rate was 75%. Of the 26,629 respondents, 8165 reported smoking (having smoked ⱖ100 cigarettes and currently smoking cigarettes, n⫽6315) or binge drinking (consuming five or more drinks on at least one occasion in the past month, n⫽3292). Among the smokers and binge drinkers, we excluded respondents who did not receive a routine checkup in the past 12 months (n⫽3135; 2341 smokers, 1474 binge drinkers), were pregnant (n⫽36), or were missing demographic or behavioral intervention information (n⫽137). Our analytic sample consisted of 4857 participants, of whom 3818 reported smoking and 1783 binge drinking. Participants were asked, “Has a doctor or other health professional ever advised you to quit smoking?” and “Has a doctor or other health professional ever talked with you about alcohol use?” Respondents answering “yes” to either question were asked, “About how long ago was it?” Combining data across states, we calculated weighted prevalence estimates and adjusted odds ratios of intervention among smokers and binge drinkers by demographic characteristics, and estimated the number of smokers and binge
72
drinkers not receiving intervention by a health professional. Data were weighted to the respondent’s probability of selection and to demographic characteristics of each state. Analyses were conducted using SUDAAN (Release 7.5, Research Triangle Institute, Research Park NC, 1997) to account for the complex survey design.
Results By self-report, 70% of smokers who had a routine checkup in the past 12 months were advised to quit smoking by a health professional in that period (Table 1). Women were more likely than men, and adults aged ⱖ55 years were more likely than those aged 18 to 34 years, to be advised. Of binge drinkers with a routine checkup in the past 12 months, 23% had been talked to about their alcohol use during that period. Intervention was more likely among men than women, and among non-Hispanic blacks than non-Hispanic whites. In the 10 states combined, there was no intervention by a health professional for an estimated 1.915 million smokers and 2.269 million binge drinkers who had a routine checkup in the past year.
Discussion Only 23% of binge drinkers who had a routine checkup in the past year were talked to about their alcohol use
American Journal of Preventive Medicine, Volume 24, Number 1
by a health professional. This low figure shows that many intervention opportunities are being missed and that the Healthy People 200013 goal of 75% of primary care providers screening for alcohol use problems and providing counseling as needed was almost certainly not met. Unfortunately, comparison of our findings with other recent studies is difficult because they were based on clinical samples14,15 or physician report.16 –18 Furthermore, comparisons are complicated because “talked with you about your alcohol use” may mean anything from brief screening to lengthy counseling. Further research is needed to determine why men and black adults who binge drink are more likely than women and white adults to be talked to about their use of alcohol. In contrast to the low prevalence of intervention for alcohol use, we found that 70% of smokers were advised to quit within the last 12 months, a somewhat higher figure than the 64% of managed care organizations for 1997 in the Advising Smokers to Quit measure in the Health Plan Employer Data and Information Set.19 Consistent with our results, other tobacco intervention studies have found that women are more likely than men to be advised to quit and that such advice increases with age.20 –22 The correlation of gender and age with advice may, in part, be explained by the fact that women and older adults have more medical visits and thus more behavioral intervention opportunities.23–25 The higher prevalence of smoking intervention compared to drinking intervention may be due to a number of factors, such as relative burden of disease, clarity of intervention goals, and extent of implementation of office system interventions. Increasing the use of electronic reminders, chart stickers, and other office strategies for health promotion may help to augment the prevalence of intervention for both smoking and drinking.26 –28 Some limitations of our study should be noted. Although reports of smoking and binge drinking in the BRFSS have been shown to be reliable29,30 and valid in comparison with in-person survey estimates,31 reliability and validity studies have not been conducted on the BRFSS questions about clinician intervention for smoking and alcohol use. Earlier studies have shown a tendency to over-report advice to quit smoking.32,33 In addition, we believe that our findings from 10 states are representative of the country. We found similar percentages of respondents reporting smoking, binge drinking, and having had a checkup in the past 12 months for both areas. By applying the percentages of smoking and alcohol intervention for the 10 states to the estimated number of smokers and binge drinkers who had a routine checkup in the last year for all 50 states and the District of Columbia, we estimate that intervention for over 8 million smokers and almost 11 million binge drinkers could have occurred but did not. This is especially disappointing because both brief counseling by health
professionals for smoking cessation34,35 and reduction of alcohol use among problem drinkers36,37 have shown to be effective. Efforts to increase smoking and alcohol intervention through physician education38,39 and the reduction of barriers27,39,40 need to continue so that opportunities to decrease the mortality, morbidity, and the costs related to smoking and alcohol abuse are not lost.
References 1. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion smoking-attributable mortality and years of potential life lost—United States, 1984. MMWR Morb Mort Wkly Rep 1997;46:444 –51. 2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–12. 3. Miller LS, Zhang X, Rice DP, Max W. State estimates of total medical expenditures attributable to cigarette smoking, 1993. Public Health Rep 1998;113:447–58. 4. CDC. Medical-care expenditures attributable to cigarette smoking—United States, 1993. MMWR Morb Mort Wkly Rep 1994;43:469 –72. 5. National Institute on Alcohol Abuse and Alcoholism. The economic costs of alcohol and drug abuse in the United States, 1992. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 1998. 6. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams & Wilkins, 1996. 7. Anda RF, Williamson DF, Remington PL. Alcohol and fatal injuries among US adults: Findings from the NHANES I Epidemiologic Follow-up Study. JAMA 1988;260:2529 –32. 8. Li G, Smith GS, Baker SP. Drinking behavior in relation to cause of death among US adults. Am J Public Health 1994;84:1402–6. 9. Dawson DA, Archer LD. Relative frequency of heavy drinking and the risk of alcohol dependence. Addiction 1993;88:1509 –18. 10. Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. Health and behavioral consequences of binge drinking in college: a national survey of students at 140 campuses. JAMA 1994;272:1672–7. 11. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health and objectives for improving health. 2nd ed. Washington, DC: U.S. Government Printing Office, 2000. 12. Nelson DE, Holtzman D, Waller M, Leutzinger CL, Condon K. Objectives and design of the Behavioral Risk Factor Surveillance System. In: Proceedings of the section on survey research methods of the American Statistical Association National Meeting. Alexandria, VA: American Statistical Association, 1998:214 – 8. 13. National Center for Health Statistics. Healthy People 2000 final review. Hyattsville, MD: U.S. Public Health Service, 2001. 14. Fleming MF. Strategies to increase alcohol screening in health care settings. Alcohol Health Res World 1997;21:340 –7. 15. Rabiner DJ, Branch LG, Sullivan RJ. The receipt of prevention services by veterans using VA versus non-VA facilities. Prev Med 1998;27:690 –6. 16. American College of Preventive Medicine. 1998 National Prevention in Primary Care Study. Washington, DC: American College of Preventive Medicine, 1998. 17. Bradley KA, Curry SJ, Koepsell TD, Larson EB. Primary and secondary prevention of alcohol problems: U.S. internist attitudes and practices. J Gen Intern Med 1995;10:67–72. 18. Ewing GB, Selassie AW, Lopez CH, McCutcheon EP. Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice. Am J Prev Med 1999;17:62–72. 19. National Committee for Quality Assurance. The state of managed care quality, 2001. Washington, DC: National Committee for Quality Assurance, 2001. 20. Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians’ smoking cessation advice. JAMA 1991;266:3139 –44. 21. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med 1997; 157:1313–9. 22. Doescher MP, Saver BG. Physicians’ advice to quit smoking: the glass remains half empty. J Fam Pract 2000;49:543–7.
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23. Centers for Disease Control and Prevention. Physician and other healthcare professional counseling of smokers to quit: United States, 1991. MMWR Morb Mort Wkly Rep 1993;42:854 –7. 24. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604 –8. 25. Schappert SM, Nelson C. National Ambulatory Medical Care Survey, 1995–96 Summary. Hyattsville, MD: National Center for Health Statistics, 1999. 26. Dickey LL, Gemson DH, Carney P. Office system interventions supporting primary care-based health behavior change counseling. Am J Prev Med 1999;17:299 –308. 27. Adams A, Ockene JK, Wheller EV, Hurley TG. Alcohol counseling: physicians will do it. J Gen Intern Med 1998;13:692–8. 28. Ahluwalia JS, Gibson CA, Kenney RE, Wallace DD, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14:402–8. 29. Stein AD, Lederman RI, Shea S. The Behavioral Risk Factor Surveillance System questionnaire: its reliability in a statewide sample. Am J Public Health 1993;83:1768 –72. 30. Stein AD, Courval JM, Lederman RI, Shea S. Reproducibility of responses to telephone interviews: demographic predictors of discordance in risk factor status. Am J Epidemiol 1995;141:1097–106. 31. Anda RF, Dodson DL, Williamson DF, Remington PL. Health promotion data for state health departments: telephone versus in-person survey estimates of smoking and alcohol use. Am J Health Promot 1989;4:32–6. 32. Ward J, Sanson-Fisher R. Accuracy of patient recall of opportunistic smoking cessation advice in general practice. Tob Control 1996;5:110 –3.
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33. Pbert L, Adams A, Quirk M, Hebert JR, Ockene JK, Luippold RS. The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study. Health Psychol 1999;18:183–8. 34. Law M, Tang JL. An analysis of the effectiveness of interventions to help people stop smoking. Arch Intern Med 1995;155:1933–41. 35. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 36. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA 1997;277:1039 –45. 37. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physicianand nurse practitioner– delivered counseling for high-risk drinkers: Does it work? Arch Intern Med 1999;159:2198 –205. 38. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700 –5. 39. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458 – 65. 40. Fiore MC, Fleming MF, Burns ME. Tobacco and alcohol abuse: clinical opportunities for effective intervention. Proc Assoc Am Physicians 1999; 111:131–40.
American Journal of Preventive Medicine, Volume 24, Number 1
Physician Advice About Smoking and Drinking Are U.S. Adults Being Informed? Clark H. Denny, PhD, Mary K. Serdula, MD, MPH, Deborah Holtzman, PhD, David E. Nelson, MD, MPH Background: Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. Methods:
Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digitdial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated.
Results:
By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use.
Conclusions: Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help. (Am J Prev Med 2003;24(1):71–74)
Introduction
T
obacco and alcohol are recognized as the first and third leading avoidable causes of death in the United States, accounting for approximately 430,0001 and 100,0002 deaths, respectively, in 1990. Annual medical care expenditures attributable to smoking were estimated at $73 billion3 and the loss of productivity due to morbidity and premature death at $47 billion in 1993.4 Corresponding annual cost estimates for alcohol abuse and alcoholism were $19 billion and $99 billion, respectively, in 1992.5 Clinicians treating smokers and problem drinkers can improve the health of individual patients and reduce costs to society by implementing the guidelines developed by the U.S. Preventive Services Task Force.6 The guidelines recommend regular cessation counsel-
From the Division of Adult and Community Health (Denny, Holtzman), and Division of Nutrition and Physical Activity (Serdula), Centers for Disease Control and Prevention, Atlanta, Georgia; and National Cancer Institute, National Institutes of Health (Nelson), Bethesda, Maryland Address correspondence to: Clark H. Denny, PhD, Epidemiologist, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS K-66, Atlanta GA 30341. E-mail: [email protected].
Am J Prev Med 2003;24(1) Published by Elsevier Science Inc.
ing for all tobacco users, screening of all adults to detect alcohol abuse or hazardous drinking, brief counseling for those who screen positive for problem drinking, and counseling of all drinkers about the dangers of operating a motor vehicle after drinking. In this study, we focused on binge drinking, which has been associated with increased risk of mortality and morbidity due to injury, alcohol dependence, and social problems.7–10 Population-based estimates of health professional intervention for tobacco and alcohol use are not available either nationally or for most states, but estimates are necessary to measure progress toward the Healthy People 201011 objectives of increasing the proportion of persons appropriately counseled about smoking cessation and reduced alcohol consumption. In this study, we calculated population-based estimates of the prevalence of being advised to quit among smokers and being talked to about alcohol use among binge drinkers who had routine checkups in the past year. We stratified the estimates by gender, age, education, and race or ethnicity for a group of 10 states, using data from the 1997 Behavioral Risk Factor Surveillance System (BRFSS). We also estimated how many at-risk patients did not receive these interventions.
0749-3797/03/$–see front matter PII S0749-3797(02)00568-8
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Table 1. Demographic factors associated with smoking and alcohol use behavioral interventionsa Smokers
Subpopulation characteristic Total Gender Male Female Age (years) 18–34 35–54 ⱖ55 Education ⬍High school High school diploma Some college ⱖCollege Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Other
Binge drinkers
Received Unweighted advice, weighted number % (95% CI) AOR (95% CI)
Talked to about drinking, Unweighted weighted number % (95% CI) AOR (95% CI)b
3818
70.0 (67.9–72.1)
1783
23.2 (20.1–26.3)
1432 2386
66.2 (62.7–69.7) 0.71 (0.58–0.87) 73.3 (70.9–75.8) 1.00
1093 690
25.8 (21.7–29.8) 1.57 (1.09–2.28) 17.8 (13.6–22.0) 1.00
1172 1797 849
64.2 (60.2–68.2) 0.61 (0.46–0.82) 72.2 (69.3–75.1) 0.88 (0.67–1.16) 75.6 (71.4–79.8) 1.00
865 718 200
20.3 (16.0–24.6) 1.07 (0.56–2.03) 28.3 (23.2–33.3) 1.55 (0.83–2.90) 21.4 (12.3–30.4) 1.00
603 1571 1045 599
74.8 (69.9–79.6) 70.2 (67.0–73.5) 67.2 (62.9–71.5) 69.6 (64.4–74.8)
1.29 (0.90–1.86) 1.04 (0.77–1.40) 0.92 (0.66–1.26) 1.00
133 642 526 482
34.2 (21.6–46.9) 26.2 (21.0–31.3) 18.2 (13.2–23.2) 22.9 (16.6–29.1)
1.57 (0.80–3.08) 1.08 (0.69–1.68) 0.73 (0.45–1.20) 1.00
3046 384 199 189
70.2 (67.9–72.6) 73.5 (68.1–78.9) 63.4 (53.9–72.8) 66.5 (52.8–80.3)
1.00 1.11 (0.82–1.51) 0.80 (0.52–1.24) 0.90 (0.49–1.64)
1468 122 103 90
21.8 (18.5–25.2) 34.4 (23.0–45.8) 31.6 (17.6–45.6) 14.3 (1.5–27.1)
1.00 1.81 (1.08–3.03) 1.53 (0.76–3.05) 0.62 (0.22–1.73)
Smoking is defined as having smoked ⱖ100 cigarettes and currently smoking. Binge drinking is defined as having five or more on at least one occasion in the past month. All data are based on the Behavioral Risk Factor Surveillance System, 1997. b Adjusted for all other covariates. CI, confidence interval; AOR, adjusted odds ratio. a
Methods The BRFSS is a state-based, monthly, random-digit-dial telephone survey of non-institutionalized civilian adults, aged ⱖ18 years, that focuses on risk behavior related to chronic disease. The survey is conducted by the Centers for Disease Control and Prevention in collaboration with state health departments.12 In 1997, the following 10 states asked about intervention by a health professional in their surveys: Alaska, Colorado, Idaho, Louisiana, Missouri, New York, Oklahoma, Pennsylvania, Virginia, and Wyoming. Among persons reached by telephone, the median participation rate was 75%. Of the 26,629 respondents, 8165 reported smoking (having smoked ⱖ100 cigarettes and currently smoking cigarettes, n⫽6315) or binge drinking (consuming five or more drinks on at least one occasion in the past month, n⫽3292). Among the smokers and binge drinkers, we excluded respondents who did not receive a routine checkup in the past 12 months (n⫽3135; 2341 smokers, 1474 binge drinkers), were pregnant (n⫽36), or were missing demographic or behavioral intervention information (n⫽137). Our analytic sample consisted of 4857 participants, of whom 3818 reported smoking and 1783 binge drinking. Participants were asked, “Has a doctor or other health professional ever advised you to quit smoking?” and “Has a doctor or other health professional ever talked with you about alcohol use?” Respondents answering “yes” to either question were asked, “About how long ago was it?” Combining data across states, we calculated weighted prevalence estimates and adjusted odds ratios of intervention among smokers and binge drinkers by demographic characteristics, and estimated the number of smokers and binge
72
drinkers not receiving intervention by a health professional. Data were weighted to the respondent’s probability of selection and to demographic characteristics of each state. Analyses were conducted using SUDAAN (Release 7.5, Research Triangle Institute, Research Park NC, 1997) to account for the complex survey design.
Results By self-report, 70% of smokers who had a routine checkup in the past 12 months were advised to quit smoking by a health professional in that period (Table 1). Women were more likely than men, and adults aged ⱖ55 years were more likely than those aged 18 to 34 years, to be advised. Of binge drinkers with a routine checkup in the past 12 months, 23% had been talked to about their alcohol use during that period. Intervention was more likely among men than women, and among non-Hispanic blacks than non-Hispanic whites. In the 10 states combined, there was no intervention by a health professional for an estimated 1.915 million smokers and 2.269 million binge drinkers who had a routine checkup in the past year.
Discussion Only 23% of binge drinkers who had a routine checkup in the past year were talked to about their alcohol use
American Journal of Preventive Medicine, Volume 24, Number 1
by a health professional. This low figure shows that many intervention opportunities are being missed and that the Healthy People 200013 goal of 75% of primary care providers screening for alcohol use problems and providing counseling as needed was almost certainly not met. Unfortunately, comparison of our findings with other recent studies is difficult because they were based on clinical samples14,15 or physician report.16 –18 Furthermore, comparisons are complicated because “talked with you about your alcohol use” may mean anything from brief screening to lengthy counseling. Further research is needed to determine why men and black adults who binge drink are more likely than women and white adults to be talked to about their use of alcohol. In contrast to the low prevalence of intervention for alcohol use, we found that 70% of smokers were advised to quit within the last 12 months, a somewhat higher figure than the 64% of managed care organizations for 1997 in the Advising Smokers to Quit measure in the Health Plan Employer Data and Information Set.19 Consistent with our results, other tobacco intervention studies have found that women are more likely than men to be advised to quit and that such advice increases with age.20 –22 The correlation of gender and age with advice may, in part, be explained by the fact that women and older adults have more medical visits and thus more behavioral intervention opportunities.23–25 The higher prevalence of smoking intervention compared to drinking intervention may be due to a number of factors, such as relative burden of disease, clarity of intervention goals, and extent of implementation of office system interventions. Increasing the use of electronic reminders, chart stickers, and other office strategies for health promotion may help to augment the prevalence of intervention for both smoking and drinking.26 –28 Some limitations of our study should be noted. Although reports of smoking and binge drinking in the BRFSS have been shown to be reliable29,30 and valid in comparison with in-person survey estimates,31 reliability and validity studies have not been conducted on the BRFSS questions about clinician intervention for smoking and alcohol use. Earlier studies have shown a tendency to over-report advice to quit smoking.32,33 In addition, we believe that our findings from 10 states are representative of the country. We found similar percentages of respondents reporting smoking, binge drinking, and having had a checkup in the past 12 months for both areas. By applying the percentages of smoking and alcohol intervention for the 10 states to the estimated number of smokers and binge drinkers who had a routine checkup in the last year for all 50 states and the District of Columbia, we estimate that intervention for over 8 million smokers and almost 11 million binge drinkers could have occurred but did not. This is especially disappointing because both brief counseling by health
professionals for smoking cessation34,35 and reduction of alcohol use among problem drinkers36,37 have shown to be effective. Efforts to increase smoking and alcohol intervention through physician education38,39 and the reduction of barriers27,39,40 need to continue so that opportunities to decrease the mortality, morbidity, and the costs related to smoking and alcohol abuse are not lost.
References 1. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion smoking-attributable mortality and years of potential life lost—United States, 1984. MMWR Morb Mort Wkly Rep 1997;46:444 –51. 2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–12. 3. Miller LS, Zhang X, Rice DP, Max W. State estimates of total medical expenditures attributable to cigarette smoking, 1993. Public Health Rep 1998;113:447–58. 4. CDC. Medical-care expenditures attributable to cigarette smoking—United States, 1993. MMWR Morb Mort Wkly Rep 1994;43:469 –72. 5. National Institute on Alcohol Abuse and Alcoholism. The economic costs of alcohol and drug abuse in the United States, 1992. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 1998. 6. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, MD: Williams & Wilkins, 1996. 7. Anda RF, Williamson DF, Remington PL. Alcohol and fatal injuries among US adults: Findings from the NHANES I Epidemiologic Follow-up Study. JAMA 1988;260:2529 –32. 8. Li G, Smith GS, Baker SP. Drinking behavior in relation to cause of death among US adults. Am J Public Health 1994;84:1402–6. 9. Dawson DA, Archer LD. Relative frequency of heavy drinking and the risk of alcohol dependence. Addiction 1993;88:1509 –18. 10. Wechsler H, Davenport A, Dowdall G, Moeykens B, Castillo S. Health and behavioral consequences of binge drinking in college: a national survey of students at 140 campuses. JAMA 1994;272:1672–7. 11. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health and objectives for improving health. 2nd ed. Washington, DC: U.S. Government Printing Office, 2000. 12. Nelson DE, Holtzman D, Waller M, Leutzinger CL, Condon K. Objectives and design of the Behavioral Risk Factor Surveillance System. In: Proceedings of the section on survey research methods of the American Statistical Association National Meeting. Alexandria, VA: American Statistical Association, 1998:214 – 8. 13. National Center for Health Statistics. Healthy People 2000 final review. Hyattsville, MD: U.S. Public Health Service, 2001. 14. Fleming MF. Strategies to increase alcohol screening in health care settings. Alcohol Health Res World 1997;21:340 –7. 15. Rabiner DJ, Branch LG, Sullivan RJ. The receipt of prevention services by veterans using VA versus non-VA facilities. Prev Med 1998;27:690 –6. 16. American College of Preventive Medicine. 1998 National Prevention in Primary Care Study. Washington, DC: American College of Preventive Medicine, 1998. 17. Bradley KA, Curry SJ, Koepsell TD, Larson EB. Primary and secondary prevention of alcohol problems: U.S. internist attitudes and practices. J Gen Intern Med 1995;10:67–72. 18. Ewing GB, Selassie AW, Lopez CH, McCutcheon EP. Self-report of delivery of clinical preventive services by U.S. physicians. Comparing specialty, gender, age, setting of practice, and area of practice. Am J Prev Med 1999;17:62–72. 19. National Committee for Quality Assurance. The state of managed care quality, 2001. Washington, DC: National Committee for Quality Assurance, 2001. 20. Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians’ smoking cessation advice. JAMA 1991;266:3139 –44. 21. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider-delivered smoking cessation interventions. Arch Intern Med 1997; 157:1313–9. 22. Doescher MP, Saver BG. Physicians’ advice to quit smoking: the glass remains half empty. J Fam Pract 2000;49:543–7.
Am J Prev Med 2003;24(1)
73
23. Centers for Disease Control and Prevention. Physician and other healthcare professional counseling of smokers to quit: United States, 1991. MMWR Morb Mort Wkly Rep 1993;42:854 –7. 24. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604 –8. 25. Schappert SM, Nelson C. National Ambulatory Medical Care Survey, 1995–96 Summary. Hyattsville, MD: National Center for Health Statistics, 1999. 26. Dickey LL, Gemson DH, Carney P. Office system interventions supporting primary care-based health behavior change counseling. Am J Prev Med 1999;17:299 –308. 27. Adams A, Ockene JK, Wheller EV, Hurley TG. Alcohol counseling: physicians will do it. J Gen Intern Med 1998;13:692–8. 28. Ahluwalia JS, Gibson CA, Kenney RE, Wallace DD, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14:402–8. 29. Stein AD, Lederman RI, Shea S. The Behavioral Risk Factor Surveillance System questionnaire: its reliability in a statewide sample. Am J Public Health 1993;83:1768 –72. 30. Stein AD, Courval JM, Lederman RI, Shea S. Reproducibility of responses to telephone interviews: demographic predictors of discordance in risk factor status. Am J Epidemiol 1995;141:1097–106. 31. Anda RF, Dodson DL, Williamson DF, Remington PL. Health promotion data for state health departments: telephone versus in-person survey estimates of smoking and alcohol use. Am J Health Promot 1989;4:32–6. 32. Ward J, Sanson-Fisher R. Accuracy of patient recall of opportunistic smoking cessation advice in general practice. Tob Control 1996;5:110 –3.
74
33. Pbert L, Adams A, Quirk M, Hebert JR, Ockene JK, Luippold RS. The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study. Health Psychol 1999;18:183–8. 34. Law M, Tang JL. An analysis of the effectiveness of interventions to help people stop smoking. Arch Intern Med 1995;155:1933–41. 35. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 36. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices. JAMA 1997;277:1039 –45. 37. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physicianand nurse practitioner– delivered counseling for high-risk drinkers: Does it work? Arch Intern Med 1999;159:2198 –205. 38. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700 –5. 39. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458 – 65. 40. Fiore MC, Fleming MF, Burns ME. Tobacco and alcohol abuse: clinical opportunities for effective intervention. Proc Assoc Am Physicians 1999; 111:131–40.
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