Tobacco cessation counseling among underserved patients: a report from CaReNet

OBJECTIVES: The purpose of our study was to determine the frequency of smoking cessation counseling in relation to insurance status in a practice-based research network. STUDY DESIGN: We administered a modified National Ambulatory Medical Care Survey (NAMCS), with an additional payment category to identify uninsured patients, quarterly to 100 random patients at each practice site for 1 year. POPULATION: The study population included the patients at the 7 practices within the Colorado Research Network (CaReNet), associated with the Department of Family Medicine, University of Colorado Health Science Center. OUTCOMES MEASURED: We measured the prevalence of smoking and the frequency of cessation counseling. RESULTS: Of 2773 visits analyzed, 1443 were made by adults who were either was uninsured (39%), had Medicaid (22%), or had private or a health maintenance organization insurance (private/HMO; 40%). Smoking prevalence was significantly greater in uninsured patients (30%) and Medicaid patients (31%), compared with private/HMO patients (22%) (P =.008). However, those smokers with private/HMO insurance were more likely to receive tobacco counseling (50%) than Medicaid (41%) and uninsured (25%) patients (P <.001). After controlling for potential confounders, this difference remained significant. CONCLUSIONS: Although smoking is more common among Medicaid and uninsured patients, these smokers are less likely to receive counseling. Possible explanations for this disparity include lack of access to cessation interventions or lower quality of care for underserved patients. This finding may have implications for achieving national public health goals on smoking cessation.