Smoking Status as the New Vital Sign: Effect on Assessment and Intervention in Patients Who Smoke

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Objective

To assess the effect of expanding the vital signs to include smoking status.

Design

We prospectively conducted, exit interviews with patients at a general internal medicine clinic in Madison, Wisconsin, during a 16-month period from 1991 to 1993.

Methods

Patients were surveyed briefly before (N = 870) and after (N = 994) the implementation of a simple institutional change in clinical practice. This change involved training the staff in how to use progress notepaper with a vital sign stamp that included smoking status (current, former, or never) along with the traditional vital signs. Included in the survey were questions about whether the patient smoked, whether the patient was asked that day about smoking status (by a clinician or other staff), and, for smokers, whether they were urged to quit smoking and given specific advice on how to do so.

Results

After expansion of the vital signs, patients were much more likely to report inquiries about their smoking status on the day of a clinic visit (an increase from approximately 58% at baseline to 81 % at intervention; P <0.0001). The vital sign intervention was associated with significant increases in the percentage of smokers who reported that their clinician advised them that day to quit smoking (from approximately 49% at baseline to 70% during the intervention; P<0.01) and in the percentage who reported that their clinician gave them specific advice that day on how to stop smoking (from approximately 24% at baseline to 43% during the intervention; P <0.01).

Conclusion

Expanding the vital signs to include smoking status was associated with a dramatic increase in the rate of identifying patients who smoke and of intervening to encourage and assist with smoking cessation. This simple, low-cost intervention may effectively prompt clinicians to inquire about use of tobacco and offer recommendations to smokers.

Section snippets

METHODS

The research site was the General Internal Medicine Clinic (GIMC) at the University of Wisconsin Hospitals and Clinics. Baseline and intervention (the expansion of the vital signs to include smoking status) data were collected during a 16-month period from 1991 to 1993 by using anonymous inperson surveys of patients as they exited the clinic. During this period, the GIMC was staffed by 47 physicians and 5 nurse-practitioners. Approximately 28,000 patients made 50,000 visits per year to this

RESULTS

The baseline survey was completed by 870 patients, including 80 current smokers (9.2%); 994 patients, including 165 smokers (16.6%), completed surveys during the intervention phase (Table 1). At baseline, about 60% of the sample was female and the mean age was 45 years (SD = 17.7). During the intervention phase, approximately 54% of patients surveyed were female and the mean age was 48 years (SD = 17.9). At the time of these surveys, the overall prevalence rate for smoking in Madison,

DISCUSSION

The survey data reported herein suggest that expanding the vital signs to include smoking status is an extremely potent intervention. This simple change in the operation of a general internal medicine clinic along with brief staff training was associated with a substantial increase in both the rate of assessment of smoking status and the rate of intervention in patients identified as smokers. If these findings are systematically replicated, this easy, low-cost, institutional change will provide

CONCLUSION

In this initial study, expansion of the vital signs to include smoking status was associated with significantly increased rates of identification of patients who smoke and intervention to inquire about and discourage cigarette smoking. If these findings prove generalizable, inclusion of smoking status as a vital sign will provide a simple, effective, and Smokers low-cost method of intervening clinically with the chief avoidable cause of illness and death in our society—use of tobacco.18

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This study was supported in part by Preventive Oncology Research Grant K-07 CA 015441-03 from the National Cancer Institute, National Institutes of Health, Public Health Service.

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