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Smoking Behaviors and Regular Source of Health Care among African Americans
Preventive Medicine 34, 393–396 (2002) doi:10.1006/pmed.2001.1004, available online at http://www.idealibrary.com on
Smoking Behaviors and Regular Source of Health Care among African Americans 1 Jasjit S. Ahluwalia, M.D., M.P.H., M.S.,* ,† ,‡ ,2 Kulmeet S. Dang, B.S.,* Won S. Choi, Ph.D., M.P.H.,* ,‡ and Kari Jo Harris, Ph.D., M.P.H.* ,‡ *Department of Preventive Medicine, †Department of Medicine, and ‡Kansas Cancer Institute, University of Kansas School of Medicine
Objectives. The purpose of the study was to determine associations between having a regular source of health care, advice from a physician to quit smoking, and smoking-related behaviors among African American smokers. Methods. A secondary analysis was conducted on data obtained from an intervention study with a posttest assessment of the effectiveness of smoking status as a vital sign. The setting was an adult walk-in clinic at a large inner-city hospital and 879 African American adult current smokers were examined. Results. Among African American smokers, there was an association between having a regular source of health care and planning to quit smoking within the next 30 days (OR ⴝ 1.46; 95% CI: 1.04 –2.05), receiving physician advice to quit (OR ⴝ 1.46; 95% CI: 1.02–2.10), and smoking <10 cigarettes a day (OR ⴝ 1.42; 95% CI: 1.00 –2.03). Conclusions. African American current smokers with a regular source of health care were further along the quitting process than those without a regular source of health care. Our findings indicate a potential benefit of complementing programs that increase physician cessation advice rates with policies that increase rates of health insurance and the likelihood that individuals have a regular source of health care. © 2002 American Health Foundation and Elsevier Science (USA) Key Words: smoking; smoking cessation; primary health care; Blacks; urban health. INTRODUCTION
Cigarette smoking leads to over 430,000 deaths annually through cancer, cardiovascular disease, and re1 Supported in part by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholars award to Dr. Ahluwalia (No. 032586) and the National Cancer Institute (RO1 CA77856 and K07CA87714). 2 To whom correspondence and reprint requests should be addressed at Department of Preventive Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KA 66160. Fax: 913-588-2759. E-mail: [email protected].
spiratory disease [1–3]. Among the population of smokers, African Americans experience a disproportionate amount of tobacco-related morbidity and mortality [4]. Physicians have an opportunity to intervene early and the physician–patient relationship affords a setting for promoting smoking cessation. Smokers who were advised to quit at their last physician visit have been found to be more likely to make a quit attempt over smokers who did not receive advice [5]. Furthermore, coupling pharmacotherapy with physician counseling increases cessation rates among smokers [6]. Unfortunately, only 37% of smokers report ever receiving any advice to quit from a physician [7]. This low figure probably represents recall bias with the true value lying somewhere between 37% and the 55% that is reported by physicians themselves [8]. There is limited evidence that a regular source of health care impacts on smoking behaviors. One 7-year cohort study [9] found a significantly higher smoking cessation rate among young adults with a regular source of health care. Another study [10] found that having a regular source of health care did not lead to a significant increase in smoking cessation. These studies included few African Americans and did not examine the receipt of physician advice to quit smoking. The effect of a regular source of health care on smoking outcomes among African American smokers has not been thoroughly examined. We undertook this analysis to more fully characterize the relationship between having a regular source of health care and its effect on smoking-related behaviors among African American smokers. METHODS
Setting The study is a secondary analysis of data gathered from an intervention conducted to evaluate the effects on a smoking status stamp on physicians advising patients to quit smoking. The original intervention study
393
0091-7435/02 $35.00 © 2002 American Health Foundation and Elsevier Science (USA) All rights reserved.
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AHLUWALIA ET AL.
TABLE 1 Smoking Characteristics of African American Smokers by Status of Regular Source of Health Care (N ⫽ 879) Smoking behavior/characteristics
% with regular source of care (N ⫽ 202)
% without regular source of care (N ⫽ 677)
P value
History of diabetes History of hypertension Quit attempts in past year Plan to quit in next 30 days Plan to quit in next 6 months Doctor ever advise to quit Light smoker (ⱕ10 cigs/day)
19.3 51.5 65.8 53.0 75.2 68.3 71.8
7.2 35.0 59.8 40.9 71.5 52.1 62.5
⬍0.001 ⬍0.001 0.123 0.002 0.295 ⬍0.001 0.015
was reviewed and approved by the human subjects review committee at Emory University in Atlanta, Georgia. The stamp appeared on patient charts and prompted the provider to circle current, former, or never smoker. A total of 2,595 African American patients were seen by a housestaff physician. There were 1,229 patients whose charts were stamped and 1,366 control patients whose charts remained unchanged. Patients were surveyed immediately after their clinic visit. The study design and results are detailed elsewhere [11]. Measures Research assistants administered a 33-item questionnaire that asked about demographic characteristics and smoking-related behaviors, including amount smoked, smoking status, smoking patterns, and quit attempts. Participants’ readiness to quit was assessed by asking, “Are you seriously considering quitting cigarettes within the next 6 months,” as well as “Are you planning to quit in the next 30 days?” Physician advice to quit was evaluated by asking, “Not including today’s visit, has any doctor ever told you to quit smoking?” Insurance status was abstracted from patients’ medical records. The dependent variable, regular source of health care, was assessed by asking subjects “Do you have a regular source of care, the same doctor that you regularly see for problems?” (see Table 1). Sample Selection We initially selected 882 African American patients who identified themselves as current smokers by reporting smoking at least 100 cigarettes in their lifetime and having a cigarette in the past 30 days. Three subjects were subsequently omitted due to a lack of cigarette consumption data, resulting in our final sample size of 879 African American smokers. There was no significant difference related to the presence of a regular source of health care between participants assigned to the two arms of the study. Therefore, current smokers from both the intervention and the control arms of the original study were combined to increase the power of the analyses.
Statistical Analyses We categorized the variables age (ⱕ35, 36 –50, 51– 64, and 65⫹), years smoked (1–10, 11–20, 21–30, and 31⫹), and cigarettes per day (1–10, 11–19, and 20⫹) to ensure adequate numbers for each level of comparison against regular source of care and performed univariate analyses. We entered all significant variables at the univariate level, as determined by P ⱕ 0.20, into a forward stepwise logistic regression model. We conducted five separate logistic regressions using the variables in Table 2 as the dependent variable, to determine the effect of having a regular source of health care. For each logistic regression, those without a regular source of care was the reference group. We examined two-way interactions between years smoked and age as well as other covariates in the model. The variable years smoked was excluded in our final model because it was found to be collinear with age. We controlled for the following variables by retaining them in the model regardless of their significance level: experimental group, hypertension, diabetes, gender, and age group. TABLE 2 Multivariate Analysis of the Effect of Regular Source of Health Care on Smoking-Related Behaviors among African American Current Smokers Smoking behaviors/characteristics (dependent variable)
Odds ratio
95% confidence interval
P value
Quit attempts in past year Plan to quit in next 30 days Plan to quit in next 6 months Doctor ever advise to quit Light smoker (ⱕ10 cigs/day)
0.98 1.46 0.90 1.46 1.42
(0.69–1.41) (1.04–2.05) (0.61–1.32) (1.02–2.10) (1.00–2.03)
0.94 0.03 0.59 0.04 0.05
Note. Adjusted for history of diabetes, hypertension, age group, gender, experimental group. We conducted five separate logistic regressions using the variables in the table as the dependent variable, to determine the effect of having a regular source of health care. For each logistic regression, those without a regular source of care was the reference group.
SMOKING BEHAVIORS AND REGULAR SOURCE OF CARE RESULTS
A significantly higher percentage of older individuals and females had a regular source of health care (data not presented). Having insurance, history of diabetes, and hypertension were all related to having a regular source of health care. Table 1 shows the smoking related behaviors, characteristics, and comorbidities by regular source of health care. Of those with regular source of care, 53% of the smokers planned to quit in the next 30 days, compared to 41% for those without regular source of care. Similarly, more smokers were advised to quit by their doctors if they had a regular source of health care compared to those without regular source of care, 68 and 52%, respectively (Table 1). Finally, a greater proportion of those with regular source of care were light smokers (72%). Table 2 shows the adjusted odds ratios for the effect of having regular source of health care on smoking related behaviors. Among the smoking related variables, the following were associated with a regular source of health care: planning to quit within the next 30 days, ever receiving physician advice to quit, and smoking ⱕ10 cigarettes a day (borderline significance). Having a regular source of health care was associated with planning to quit within the next 30 days, ever receiving physician advice to quit, and light smoking. DISCUSSION
The findings from our study emphasize the importance of having a regular source of health care on smoking behaviors of African Americans. Our study, relating regular source of health care and smoking differs from previous research, which has largely focused on general preventive outcomes or use of medical services. We found that respondents with a regular source of health care were more likely to plan to quit within the next 30 days, to have a physician advise them to quit smoking, and to smoke fewer cigarettes. No evidence was found that having a regular source of health care was associated with history of quit attempts in the past year. Previous work suggests that physicians are able to ask and advise about smoking, but do little to assist, such as providing pharmacotherapy, counsel, or help patients set a quit date [11]. It may be that physicians are helpful in initiating the cessation process by raising awareness and offering advice to quit, but that smokers seek methods to quit on their own. Researchers have speculated that one reason for low physician smoking cessation advice rates might be a lack of access to a regular source of health care [7,12]. Our findings seem to support that having a regular source of health care is related to smoking fewer ciga-
395
rettes. However, we cannot directly conclude from our data that African American smokers are acting on physician advice to quit by tapering their cigarette use. To our knowledge, there are only two other studies that examine the relationship between a regular source of health care and smoking characteristics [9,10]. Kiefe et al. examined a cohort of 4,086 healthy young adults over 7 years [9]. Having a regular source of care, as well as health insurance, was associated with a lower prevalence of smoking, increased cessation, and less initiation. The second study was a cross-sectional survey which found no correlation between a regular source of care and having had quit smoking [10]. The latter study measured quit smoking in those who had ever smoked over their lifetime. Since we only looked at current smokers, we were not able to assess cessation. Nonetheless, our findings of intention to quit, receipt of physician advice to quit, and smoking fewer cigarettes are potential precursors to increased cessation and a lower prevalence of smoking, as found by Kiefe et al. While we were unable to examine the rate of smoking cessation, we did have data to explore African American smokers readiness to quit [13]. We did not find any significant difference in planning to quit within the next 6 months between African American smokers with or without a regular source of care, only for planning to quit within the next 30 days. This implies that short-term commitment to quit may be affected more by a regular source of care, and thereby also physician advice to quit, compared to long-term commitment or intentions to quit smoking. In addition, African American current smokers with a regular source of health care were found to have a higher likelihood of being light smokers. This finding suggests they may be acting on physician advice to quit by tapering their cigarette use. In the age group of African Americans we studied, a number of those who smoke ⱕ10 cigarettes a day may be doing so as part of the quitting process or as a strategy to minimize the harmful health effects of smoking. However, we do not know if patients’ lower cigarette use was a direct result of increased physician advice or as a result of having a regular source of health care. A limitation to this study is the generalizability of the results. Since it is a clinic-based study, it is not generalizable to the general African American population. Also, because the results of this study were based on a cross-sectional analysis, the directionality of the relationships should be interpreted with caution. Since patients were surveyed immediately after seeing their provider, both groups may have overstated their desire to quit. Our findings could also be due partly to selection bias. It may be that patients who are more health conscious see a provider regularly, and therefore are motivated to quit smoking within the next 30 days.
396
AHLUWALIA ET AL.
Finally, we did not have information on other confounders such as tobacco-related diseases like emphysema or asthma that may confound the relationship between having a regular source of health care and advice to quit. Our results suggest that African American smokers with exposure to a regular source of health care may be further along the quitting process than those without a regular source of health care. Ensuring consistency of health care providers is another promising approach to reducing tobacco-related mortality and morbidity among African Americans. REFERENCES 1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–12. 2. CDC. Cigarette smoking among adults. MMWR 1999;48:993– 6. 3. USDHHS. Reducing the health consequences of smoking; 25 years of progress. A report of the Surgeon General. CDC, 1989. 4. Harris RE, Zang EA, Anderson J. Race and sex differences in lung cancer risk associated with cigarette smoking. Int J Epidemiol 1993;22:592–9.
5. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549 –53. 6. Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1– 8. 7. CDC. Physicians and other health care professional counseling of smokers to quit United States 1991. MMWR 1993;42:854 –7. 8. Ward J, Sanson-Fisher R. Accuracy of patient recall of opportunistic smoking cessation advice in general practice. Tob Control 1996;5:110 –3. 9. Kiefe CI, Williams O, Greenlumd KJ, Ulene V, Gardin JM, Raczynski JM. Health care access and seven-year change in cigarette smoking. Am J Prev Med 1998;15:146 –54. 10. Ettner SL. The relationship between continuity of care and the health behaviors of patients. Med Care 1999;37:547–55. 11. Ahluwalia JS, Gibson CA, RKE, Wallace DD, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14:402– 8. 12. USDHHS. Tobacco use among U.S. racial ethnic minority groups African Americans, American Indians, and Alaskan Natives, Asian Americans, and Pacific Islanders and Hispanics: a report of the surgeon general. Washington, DC: Government Printing Office, 1998. 13. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38 – 48.
Smoking Behaviors and Regular Source of Health Care among African Americans 1 Jasjit S. Ahluwalia, M.D., M.P.H., M.S.,* ,† ,‡ ,2 Kulmeet S. Dang, B.S.,* Won S. Choi, Ph.D., M.P.H.,* ,‡ and Kari Jo Harris, Ph.D., M.P.H.* ,‡ *Department of Preventive Medicine, †Department of Medicine, and ‡Kansas Cancer Institute, University of Kansas School of Medicine
Objectives. The purpose of the study was to determine associations between having a regular source of health care, advice from a physician to quit smoking, and smoking-related behaviors among African American smokers. Methods. A secondary analysis was conducted on data obtained from an intervention study with a posttest assessment of the effectiveness of smoking status as a vital sign. The setting was an adult walk-in clinic at a large inner-city hospital and 879 African American adult current smokers were examined. Results. Among African American smokers, there was an association between having a regular source of health care and planning to quit smoking within the next 30 days (OR ⴝ 1.46; 95% CI: 1.04 –2.05), receiving physician advice to quit (OR ⴝ 1.46; 95% CI: 1.02–2.10), and smoking <10 cigarettes a day (OR ⴝ 1.42; 95% CI: 1.00 –2.03). Conclusions. African American current smokers with a regular source of health care were further along the quitting process than those without a regular source of health care. Our findings indicate a potential benefit of complementing programs that increase physician cessation advice rates with policies that increase rates of health insurance and the likelihood that individuals have a regular source of health care. © 2002 American Health Foundation and Elsevier Science (USA) Key Words: smoking; smoking cessation; primary health care; Blacks; urban health. INTRODUCTION
Cigarette smoking leads to over 430,000 deaths annually through cancer, cardiovascular disease, and re1 Supported in part by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholars award to Dr. Ahluwalia (No. 032586) and the National Cancer Institute (RO1 CA77856 and K07CA87714). 2 To whom correspondence and reprint requests should be addressed at Department of Preventive Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KA 66160. Fax: 913-588-2759. E-mail: [email protected].
spiratory disease [1–3]. Among the population of smokers, African Americans experience a disproportionate amount of tobacco-related morbidity and mortality [4]. Physicians have an opportunity to intervene early and the physician–patient relationship affords a setting for promoting smoking cessation. Smokers who were advised to quit at their last physician visit have been found to be more likely to make a quit attempt over smokers who did not receive advice [5]. Furthermore, coupling pharmacotherapy with physician counseling increases cessation rates among smokers [6]. Unfortunately, only 37% of smokers report ever receiving any advice to quit from a physician [7]. This low figure probably represents recall bias with the true value lying somewhere between 37% and the 55% that is reported by physicians themselves [8]. There is limited evidence that a regular source of health care impacts on smoking behaviors. One 7-year cohort study [9] found a significantly higher smoking cessation rate among young adults with a regular source of health care. Another study [10] found that having a regular source of health care did not lead to a significant increase in smoking cessation. These studies included few African Americans and did not examine the receipt of physician advice to quit smoking. The effect of a regular source of health care on smoking outcomes among African American smokers has not been thoroughly examined. We undertook this analysis to more fully characterize the relationship between having a regular source of health care and its effect on smoking-related behaviors among African American smokers. METHODS
Setting The study is a secondary analysis of data gathered from an intervention conducted to evaluate the effects on a smoking status stamp on physicians advising patients to quit smoking. The original intervention study
393
0091-7435/02 $35.00 © 2002 American Health Foundation and Elsevier Science (USA) All rights reserved.
394
AHLUWALIA ET AL.
TABLE 1 Smoking Characteristics of African American Smokers by Status of Regular Source of Health Care (N ⫽ 879) Smoking behavior/characteristics
% with regular source of care (N ⫽ 202)
% without regular source of care (N ⫽ 677)
P value
History of diabetes History of hypertension Quit attempts in past year Plan to quit in next 30 days Plan to quit in next 6 months Doctor ever advise to quit Light smoker (ⱕ10 cigs/day)
19.3 51.5 65.8 53.0 75.2 68.3 71.8
7.2 35.0 59.8 40.9 71.5 52.1 62.5
⬍0.001 ⬍0.001 0.123 0.002 0.295 ⬍0.001 0.015
was reviewed and approved by the human subjects review committee at Emory University in Atlanta, Georgia. The stamp appeared on patient charts and prompted the provider to circle current, former, or never smoker. A total of 2,595 African American patients were seen by a housestaff physician. There were 1,229 patients whose charts were stamped and 1,366 control patients whose charts remained unchanged. Patients were surveyed immediately after their clinic visit. The study design and results are detailed elsewhere [11]. Measures Research assistants administered a 33-item questionnaire that asked about demographic characteristics and smoking-related behaviors, including amount smoked, smoking status, smoking patterns, and quit attempts. Participants’ readiness to quit was assessed by asking, “Are you seriously considering quitting cigarettes within the next 6 months,” as well as “Are you planning to quit in the next 30 days?” Physician advice to quit was evaluated by asking, “Not including today’s visit, has any doctor ever told you to quit smoking?” Insurance status was abstracted from patients’ medical records. The dependent variable, regular source of health care, was assessed by asking subjects “Do you have a regular source of care, the same doctor that you regularly see for problems?” (see Table 1). Sample Selection We initially selected 882 African American patients who identified themselves as current smokers by reporting smoking at least 100 cigarettes in their lifetime and having a cigarette in the past 30 days. Three subjects were subsequently omitted due to a lack of cigarette consumption data, resulting in our final sample size of 879 African American smokers. There was no significant difference related to the presence of a regular source of health care between participants assigned to the two arms of the study. Therefore, current smokers from both the intervention and the control arms of the original study were combined to increase the power of the analyses.
Statistical Analyses We categorized the variables age (ⱕ35, 36 –50, 51– 64, and 65⫹), years smoked (1–10, 11–20, 21–30, and 31⫹), and cigarettes per day (1–10, 11–19, and 20⫹) to ensure adequate numbers for each level of comparison against regular source of care and performed univariate analyses. We entered all significant variables at the univariate level, as determined by P ⱕ 0.20, into a forward stepwise logistic regression model. We conducted five separate logistic regressions using the variables in Table 2 as the dependent variable, to determine the effect of having a regular source of health care. For each logistic regression, those without a regular source of care was the reference group. We examined two-way interactions between years smoked and age as well as other covariates in the model. The variable years smoked was excluded in our final model because it was found to be collinear with age. We controlled for the following variables by retaining them in the model regardless of their significance level: experimental group, hypertension, diabetes, gender, and age group. TABLE 2 Multivariate Analysis of the Effect of Regular Source of Health Care on Smoking-Related Behaviors among African American Current Smokers Smoking behaviors/characteristics (dependent variable)
Odds ratio
95% confidence interval
P value
Quit attempts in past year Plan to quit in next 30 days Plan to quit in next 6 months Doctor ever advise to quit Light smoker (ⱕ10 cigs/day)
0.98 1.46 0.90 1.46 1.42
(0.69–1.41) (1.04–2.05) (0.61–1.32) (1.02–2.10) (1.00–2.03)
0.94 0.03 0.59 0.04 0.05
Note. Adjusted for history of diabetes, hypertension, age group, gender, experimental group. We conducted five separate logistic regressions using the variables in the table as the dependent variable, to determine the effect of having a regular source of health care. For each logistic regression, those without a regular source of care was the reference group.
SMOKING BEHAVIORS AND REGULAR SOURCE OF CARE RESULTS
A significantly higher percentage of older individuals and females had a regular source of health care (data not presented). Having insurance, history of diabetes, and hypertension were all related to having a regular source of health care. Table 1 shows the smoking related behaviors, characteristics, and comorbidities by regular source of health care. Of those with regular source of care, 53% of the smokers planned to quit in the next 30 days, compared to 41% for those without regular source of care. Similarly, more smokers were advised to quit by their doctors if they had a regular source of health care compared to those without regular source of care, 68 and 52%, respectively (Table 1). Finally, a greater proportion of those with regular source of care were light smokers (72%). Table 2 shows the adjusted odds ratios for the effect of having regular source of health care on smoking related behaviors. Among the smoking related variables, the following were associated with a regular source of health care: planning to quit within the next 30 days, ever receiving physician advice to quit, and smoking ⱕ10 cigarettes a day (borderline significance). Having a regular source of health care was associated with planning to quit within the next 30 days, ever receiving physician advice to quit, and light smoking. DISCUSSION
The findings from our study emphasize the importance of having a regular source of health care on smoking behaviors of African Americans. Our study, relating regular source of health care and smoking differs from previous research, which has largely focused on general preventive outcomes or use of medical services. We found that respondents with a regular source of health care were more likely to plan to quit within the next 30 days, to have a physician advise them to quit smoking, and to smoke fewer cigarettes. No evidence was found that having a regular source of health care was associated with history of quit attempts in the past year. Previous work suggests that physicians are able to ask and advise about smoking, but do little to assist, such as providing pharmacotherapy, counsel, or help patients set a quit date [11]. It may be that physicians are helpful in initiating the cessation process by raising awareness and offering advice to quit, but that smokers seek methods to quit on their own. Researchers have speculated that one reason for low physician smoking cessation advice rates might be a lack of access to a regular source of health care [7,12]. Our findings seem to support that having a regular source of health care is related to smoking fewer ciga-
395
rettes. However, we cannot directly conclude from our data that African American smokers are acting on physician advice to quit by tapering their cigarette use. To our knowledge, there are only two other studies that examine the relationship between a regular source of health care and smoking characteristics [9,10]. Kiefe et al. examined a cohort of 4,086 healthy young adults over 7 years [9]. Having a regular source of care, as well as health insurance, was associated with a lower prevalence of smoking, increased cessation, and less initiation. The second study was a cross-sectional survey which found no correlation between a regular source of care and having had quit smoking [10]. The latter study measured quit smoking in those who had ever smoked over their lifetime. Since we only looked at current smokers, we were not able to assess cessation. Nonetheless, our findings of intention to quit, receipt of physician advice to quit, and smoking fewer cigarettes are potential precursors to increased cessation and a lower prevalence of smoking, as found by Kiefe et al. While we were unable to examine the rate of smoking cessation, we did have data to explore African American smokers readiness to quit [13]. We did not find any significant difference in planning to quit within the next 6 months between African American smokers with or without a regular source of care, only for planning to quit within the next 30 days. This implies that short-term commitment to quit may be affected more by a regular source of care, and thereby also physician advice to quit, compared to long-term commitment or intentions to quit smoking. In addition, African American current smokers with a regular source of health care were found to have a higher likelihood of being light smokers. This finding suggests they may be acting on physician advice to quit by tapering their cigarette use. In the age group of African Americans we studied, a number of those who smoke ⱕ10 cigarettes a day may be doing so as part of the quitting process or as a strategy to minimize the harmful health effects of smoking. However, we do not know if patients’ lower cigarette use was a direct result of increased physician advice or as a result of having a regular source of health care. A limitation to this study is the generalizability of the results. Since it is a clinic-based study, it is not generalizable to the general African American population. Also, because the results of this study were based on a cross-sectional analysis, the directionality of the relationships should be interpreted with caution. Since patients were surveyed immediately after seeing their provider, both groups may have overstated their desire to quit. Our findings could also be due partly to selection bias. It may be that patients who are more health conscious see a provider regularly, and therefore are motivated to quit smoking within the next 30 days.
396
AHLUWALIA ET AL.
Finally, we did not have information on other confounders such as tobacco-related diseases like emphysema or asthma that may confound the relationship between having a regular source of health care and advice to quit. Our results suggest that African American smokers with exposure to a regular source of health care may be further along the quitting process than those without a regular source of health care. Ensuring consistency of health care providers is another promising approach to reducing tobacco-related mortality and morbidity among African Americans. REFERENCES 1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–12. 2. CDC. Cigarette smoking among adults. MMWR 1999;48:993– 6. 3. USDHHS. Reducing the health consequences of smoking; 25 years of progress. A report of the Surgeon General. CDC, 1989. 4. Harris RE, Zang EA, Anderson J. Race and sex differences in lung cancer risk associated with cigarette smoking. Int J Epidemiol 1993;22:592–9.
5. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549 –53. 6. Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6:1– 8. 7. CDC. Physicians and other health care professional counseling of smokers to quit United States 1991. MMWR 1993;42:854 –7. 8. Ward J, Sanson-Fisher R. Accuracy of patient recall of opportunistic smoking cessation advice in general practice. Tob Control 1996;5:110 –3. 9. Kiefe CI, Williams O, Greenlumd KJ, Ulene V, Gardin JM, Raczynski JM. Health care access and seven-year change in cigarette smoking. Am J Prev Med 1998;15:146 –54. 10. Ettner SL. The relationship between continuity of care and the health behaviors of patients. Med Care 1999;37:547–55. 11. Ahluwalia JS, Gibson CA, RKE, Wallace DD, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14:402– 8. 12. USDHHS. Tobacco use among U.S. racial ethnic minority groups African Americans, American Indians, and Alaskan Natives, Asian Americans, and Pacific Islanders and Hispanics: a report of the surgeon general. Washington, DC: Government Printing Office, 1998. 13. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38 – 48.