Healthcare provider smoking cessation advice among US
David J Lee, Lora E Fleming, Kathryn E McCollister, Alberto J Caban, Kristopher L Arheart, William
G LeBlanc, Katherine Chung-Bridges, Sharon L Christ, Noella Dietz, John D Clark III
............................................................... ............................................................... .....
See end of article for
David J Lee, PhD, University
of Miami School of
Medicine, Department of
Epidemiology and Public
Health, PO Box 016069 (R-
669), Miami, FL 33101,
Received 29 October 2006
Accepted 11 May 2007
Tobacco Control 2007;16:325–328. doi: 10.1136/tc.2006.019117
Objective: Among workers in dusty occupations, tobacco use is particularly detrimental to health because of
the potential synergistic effects of occupational exposures (for example, asbestos) in causing disease. This
study explored the prevalence of smoking and the reported smoking cessation discussion with a primary
healthcare provider (HCP) among a representative sample of currently employed US worker groups.
Methods: Pooled data from the 1997–2003 National Health Interview Survey (NHIS) were used to estimate
occupation specific smoking rates (n=135 412). The 2000 NHIS Cancer Control Module was used to
determine (among employed smokers with HCP visits) the prevalence of being advised to quit smoking by
Results: The average annual prevalence of current smoking was 25% in all workers. In 2000, 84% of smokers
reported visiting an HCP during the past 12 months; 53% reported being advised by their physician to quit
smoking (range 42%–66% among 30 occupations). However, an estimated 10.5 million smokers were not
advised to quit smoking by their HCP. Workers with potentially increased occupational exposure to dusty
work environments (including asbestos, silica, particulates, etc), at high risk for occupational lung disease and
with high smoking prevalence, had relatively low reported discussions with an HCP about smoking cessation,
including farm workers (30% overall smoking prevalence; 42% told to quit), construction and extractive trades
(39%; 46%), and machine operators/tenderers (34%; 44%).
Conclusion: The relatively low reported prevalence of HCP initiated smoking cessation discussion, particularly
among currently employed workers with potentially synergistic occupational exposures and high current
smoking prevalence, needs to be addressed through educational campaigns targeting physicians and other
leading cause of preventable mortality in the United States.2
Among workers in dusty occupations (for example, construc-
tion, farming), tobacco use is particularly hazardous because of
the potential synergistic effects of occupational exposures in
causing lung disease.3–7
One of the most obvious and low cost forms of smoking
prevention is for healthcare providers (HCPs) to recommend
smoking cessation to their patients.8Despite calls from the
public health and medical care communities for greater
participation of HCPs in encouraging smoking cessation,9and
the availability of evidence based treatment guidelines and
smoking cessation products,10 11HCP participation in such
activities is relatively low.12
It is currently unknown if HCP smoking cessation advice
varies for patients from different occupational groups. This
study explored the prevalence of smoking and the reported
prevalence of smoking cessation discussion with an HCP across
41 occupational categories in a nationally representative sample
of US worker groups.
t has been over 40 years since the publication of the first
Surgeon General Report linking smoking to cancer and other
adverse health outcomes,1yet tobacco use remains the
The National Health Interview Survey (NHIS) is a household
survey of the US civilian non-institutionalised population
conducted yearly since 1957 by the National Center for
Health Statistics (NCHS).13Annual response rates have ranged
from 70% to 80%.14–21Forty-one standardised occupational
codes derived from more detailed US census occupational codes
were provided in the NHIS database.22Participants who
reported smoking at least 100 cigarettes in their lifetime were
asked if they now smoked every day, some days, or not at all.
Those responding that they smoked every day or some days
were considered current smokers.
The 2000 NHIS Cancer Control Module was used to
determine if smokers were advised to quit smoking by a
physician or other HCPs (for example, primary care physicians,
specialists, nurse practitioners, etc). The number of smokers
with at least one HCP contact in the previous 12 months who
reported receiving advice to quit smoking was divided by the
total number of smokers with at least one HCP contact in the
previous 12 months.
A subset analysis examined participants who reported only
HCP contacts with primary care physicians and/or obstetrics/
gynaecologists to examine the hypothesis that these particular
primary HCPs would be more likely to provide smoking
cessation advice than the broader array of HCPs who, in some
cases, would have limited repeat patient encounters (for
All analyses were completed with adjustments for the
complex sample survey design and the pooling of annual
smoking prevalence estimates.24 25Logistic regression analysis
was used to determine if the occupation specific prevalence of
receipt of smoking cessation advice differed from the pre-
valence for all workers after adjustment for education
Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; HCP,
healthcare provider; JCAHO, Joint Commission on Accreditation of
Healthcare Organizations; NCHS, National Center for Health Statistics;
NCQA, National Committee for Quality Assurance; NHIS, National Health
(classified as less than high school, high school graduate, and
more than high school). This study was approved by the
University of Miami human subjects committee.
The study population represented an estimated 126.4 million
US workers annually between 1997–2003. The average annual
prevalence of current smoking was 25% in all workers over
years 1997–2003 (table 1). Smoking rates ranged from 39% in
forestry and fishing occupations to 5% in health diagnosing
Among all US workers in the 2000 NHIS, 84% reported
visiting an HCP during the past 12 months with substantial
variability across occupations (for example, 68% in workers
employed in the constructive and extractive trades to 95% in
those employed in the health assessment/treating occupations).
Among workers who were current smokers at the time of the
2000 NHIS interview, 53% were told by their HCP to stop
smoking (range 42%–66% across occupations). This translates
to an estimated 10.5 million US workers who smoked cigarettes
and saw an HCP in 2000, but did not report being advised to
quit during any provider contact in the previous 12 months.
Worker groups with an expected increased occupational
exposure to dusty work environments (including asbestos,
silica, bio-aerosols, etc),7and high reported smoking prevalence
often reported below average rates of smoking cessation
discussions with their HCPs. Examples included farm workers
(30% overall smoking prevalence; 42% told to quit), construc-
tion and extractive trades (39%; 46%), and machine operators/
tenderers (34%; 44%). In fact, of the 41 occupations listed in
table 1, 13 are known to have a higher risk of occupational dust
exposures and subsequent lung disease.7Notably, all but one of
these high risk occupations (that is, farmer operators and
managers) were among the top 13 occupations with the highest
reported smoking rates.
Workers with more than a high school education were
significantly more likely to report receiving smoking cessation
advice relative toworkers
ratio=1.30; (95% confidence interval 1.03 to 1.62)); there
were no differences in workers with a high school education
quit, and the estimated number not advised to quit by their healthcare provider (HCP) in year
2000: the National Health Interview Survey
1997–2003 pooled current smoking rates, the percentage of smokers advised to
Advised to quit
by HCP? (%)
of smokers in year
2000 not advised
to quit by HCP`
Forestry and fishing occupations?
Construction and extractive trades?
Material moving equipment operators?
Machine operators/tenderers, except precision?
Motor vehicle operators?
Freight, stock, material handlers?
Fabricators, assemblers, inspectors, samplers?
Precision production occupations?
Mechanics and repairers?
Cleaning and building service?
Farm workers and other agricultural workers?
Other protective service occupations
Other transportation, except motor vehicles
Supervisors and proprietors
Mail and message distributing
Other administrative support
Managers administrators, except public administration
Financial records processing occupations
Sales representatives, commodities and finance
Secretaries, stenographers and typists
Technologists, technicians except health
Private household occupations
Computer equipment operators
Police and fire fighters
Management related occupations
Writers, artists, entertainers, athletes
Farm operators and managers?
Officials and administrators public administration
Natural mathematical/computer scientists
Health assessment/treating occupations
Architects and surveyors
Other professional specialty occupations
Teachers, librarians, counsellors
Health diagnosing occupations
10 544 011
*Based on pooled rates from the 1997–2003 NHIS (n=135 412). ?Based on the 2000 NHIS employed smokers who
reported a healthcare visit in the previous 12 months (n=3454). `Calculated by applying NHIS sampling weights to the
number of smokers with healthcare encounters who reported not being told to quit by their healthcare provider(s).
?Occupations with high risk of dust exposure and lung disease.
71Estimate not reported because of small sample size.
326 Lee, Fleming, McCollister, et al
versus less than a high school education. With education
controlled for in the model, food service workers were
significantly less likely to report receipt of quit smoking advice
(0.68 (0.49 to 0.94)) relative to all other workers. Conversely,
after control for education, health service workers and other
administrative support workers were more likely to report
receiving smoking cessation advice (1.78 (1.17 to 2.71); 1.42
(1.07 to 1.88)).
Fifty-three per cent of smokers reporting only primary care
physician and/or obstetrics/gynaecologist contacts in the pre-
vious 12 months indicated that their physician had advised
them to quit smoking (worker group range: 41%–66%) (data
We found a relatively low reported prevalence of physician
initiated smoking cessation discussion, particularly among
currently employed workers with potentially synergistic occu-
pational 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.27Therefore, 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%).28Despite 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.10Based 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 monthsreported being
Furthermore, there was no increase in this prevalence when
only the primary care physician and/or obstetrician/gynaecol-
ogist 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.29It 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 30indicating that
the increasing availability of anti-smoking educational materi-
als and programmes have been insufficient to motivate more
HCPs to communicate smoking cessation messages to their
advisedto quit smoking.
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 stan-
dards that include the monitoring and delivery of smoking
cessation services.31Continued development and implementa-
tion of these standards, along with more favourable reimburse-
ment 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
Online clinical practice guidelines on smoking cessation
advice and treatment are available (http://www.surgeongener-
al.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 11While intensive clinical interventions are more
efficacious, there is strong evidence that brief clinical interven-
tions are cost effective.10All HCPs should, at minimum, know if
their patients use tobacco and provide information to their
smoking patients on the new national quitline launched in
Telephone counselling is a proven, relatively low cost, and
barrier free method for smoking cessation,33 34and 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.37–39There are limited
online resources available for HCPs who seek additional
What this paper adds
Among workers in dusty occupations (for example, construc-
tion, 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.
Healthcare provider smoking cessation advice among US worker groups327
information on the unique occupational risks of their smoking Download full-text
patients.40 41Educational 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.37Knowledge 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 43Widespread 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
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 44–46
This study was funded in part through the National Institute of
Occupational Safety and Health (grant No R01 OH03915) and the Flight
Attendant Medical Research Institute.
David J Lee, Lora E Fleming, Noella Dietz, John D Clark III, Sylvester
Comprehensive Cancer, University of Miami, Miller School of Medicine,
PO Box 016069 (R-669), Miami, FL 33143, USA
David J Lee, Lora E Fleming, Kathryn E McCollister, Alberto J Caban,
Kristopher L Arheart, William G LeBlanc, Katherine Chung-Bridges,
Department of Epidemiology and Public Health, University of Miami, Miller
School of Medicine, PO Box 016069 (R-669), Miami, FL 33143, USA
Sharon L Christ, University of North Carolina at Chapel Hill, Odum Institute
for Research in Social Science, Manning Hall, CB#3355, Chapel Hill, NC
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328Lee, Fleming, McCollister, et al