HEALTH SYSTEM PROCESSES, CLINICIAN ATTITUDES, AND REFERRALS TO TOBACCO TREATMENT PROGRAMS

Assisting smokers to quit and stay quit is the most important intervention clinicians can undertake to improve the length and quality of life of patients who use tobacco. The chronic, relapsing nature of tobacco dependence complicates tobacco treatment. Tobacco treatment counseling programs provide on-going support to help patients avoid relapse. Assistance with a referral increases the likelihood that patients will participate in counseling, but few clinicians regularly assist with referrals to tobacco treatment programs. This dissertation examined health system processes and clinician attitudes that influence the likelihood that clinicians will refer their patients for tobacco treatment counseling. Three papers examined health system processes, clinician attitudes, and frequency of referrals. A systematic review of the literature was conducted to evaluate strategies to increase the frequency of clinician referrals and effects on quit rates in primary care. The most effective strategies were those that combined clinician education with integrated referral systems. Integrated referral systems include non-clinician staff and clinician and staff prompts with algorithms or protocols for referrals. The second paper reports the findings of a pilot study using qualitative methods to explore experiences and strategies used for tobacco treatment by clinician champions practicing in independent primary care practices. Tobacco champions (N = 11) described experiences counseling patients but not assistance with referrals. Themes identified were: sources of knowledge and experience, understanding dependence, role perception, and treatment strategies. The final paper reports the findings of a cross- sectional, non-experimental study to examine clinician attitudes toward counseling, health system processes that facilitate referrals, and referrals to tobacco treatment counseling. Attitudes about the efficacy of tobacco counseling and the presence of processes that facilitate referrals predicted referrals. Clinicians sampled in these studies held favorable attitudes toward tobacco treatment but lacked confidence in the efficacy of community-based counseling for tobacco treatment. These findings have implications for health care policies to improve integration of processes that facilitate referrals and clinician education that includes information about counseling resources to improve chronic care for the treatment of tobacco dependence