29 SMOKING CESSATION PRACTICES OF RURAL AND URBAN HEALTH CARE PROVIDERS Linda D. Scott, DNS, BC-FNP1 Kathleen B. LaSala, PhD, RN, CS, PNP2 Carolyn Z. Lyndaker, PhD, RN, CCE3 Sherry Neil-Urban, PhD, RN4 1 Family Nurse Practioner, Spectrum Healthcare Resources, Fort Bragg, NC, sweetpea7095@aol.com 2 Associate Professor, Beth El College of Nursing, University of Colorado at Colorado Springs, klasala@uccs.edu 3 Associate Professor (retired), James Madison University 4 Instructor, Nursing and Allied Health Division, Western Nevada College, neilurba@wncc.edu Keywords: Smoking Cessation, Enhancement Factors, Barriers, Interventions, Rural Health Care Providers, Urban Health Care Providers ABSTRACT The purpose of this descriptive research was to identify the similarities and differences of demographic characteristics, specific intervention practices, perceived barriers, and enhancement factors associated with smoking cessation interventions of rural and urban primary health care providers. A convenience sample consisted of 342 physicians, registered nurses, and advanced practice nurses with the majority of urban health care providers being younger aged physicians and advanced practice nurses compared to older, registered nurses in rural areas. Findings revealed minimal basic educational preparation of health care providers for smoking cessation interventions. Rural health care providers reported diverse, multiple practice settings with a generalist view, estimated that more of their clients smoked, and were less likely to assess clients’ smoking practices and initiate smoking interventions. Consistent, strong curricula education at all health provider levels and continuing education for new and more effective strategies is essential to empower health care providers to address smoking cessation interventions consistently and effectively. INTRODUCTION An estimated 47 million or 25% of adult Americans currently smoke. Tobacco dependence is a chronic condition that causes disease and death in America with a societal cost of $100 billion annually even though tobacco dependence is a preventable disease. It is estimated that more than 70% of all smokers want to quit smoking completely and need the assistance of their health care providers. Approximately 46% of smokers attempt to quit smoking each year and more than 70% of smokers visit a health care setting each year. Provider-delivered interventions are effective in promoting smoking cessation, especially with treatment intensity or minutes of contact (Centers of Disease Control and Prevention, 2002; Fiore et al. 2000; Satcher, 2001; U.S. Department of Health and Human Services [USDHHS], 2000b). The national health objective of Healthy People 2010 requests that 75% of health care providers offer tobacco cessation Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 http://www.shrusa.com/ mailto:lscott@fau.edu http://web.uccs.edu/bethel/ mailto:klasala@uccs.edu http://www.wnc.edu/academics/division/nalh/ mailto:neilurba@wncc.edu 30 assistance to adult smokers (U.S. Department of Health and Human Services [USDHHS], 2000a). All health care providers need to be more cognizant and consistent in the identification, documentation, and treatment of every tobacco user encountered in a health care setting as smoking cessation promotes the client’s health and quality of life. BACKGROUND Numerous studies have documented the similarities and differences of smoking cessation practices, attitudes, and interventions among various health care providers. Secker-Walker et al. (1994) compared the tobacco cessation practices of primary care physicians, dentists, dental hygienists, family planning counselors, community mental health counselors, and Women, Infants, and Children (WIC) counselors in four New England counties. Physicians and counselors were most likely to identify patients who used tobacco and counsel them about tobacco use. Kviz et al. (1995) compared physicians, nurse practitioners, and nurses to find that smoking cessation attitudes did not vary between groups; however, physicians and nurse practitioners were more likely to implement smoking cessation activities than nurses. Zapka et al. (2000) reported that nurse practitioners and midwives were significantly more likely to counsel pregnant women about smoking cessation than physicians, nurses, and nutritionists. Consistency in monitoring tobacco usage and providing tobacco counseling at follow-up visits were low for all providers. Moody, Smith, and Glenn (1999) described the practice patterns of nurse practitioners (NP) in primary care in Tennessee and compared the findings with a national survey of office- based physicians. Findings revealed similar health care practices by both groups with the NP providing more health care to women, caring for a younger population, and implementing health education and counseling more frequently than physicians. The NP and physicians reported similar types of health education and counseling, such as nutrition counseling (19% compared to 15%), exercise counseling (12% compared to 7%), smoking cessation (7% compared to 2.5%), weight reduction (5% compared to 4%), and family planning (5% compared to 0.1%). The NP provided smoking cessation education three times more frequently than physicians. Only one study addressed the smoking cessation practices, attitudes, and interventions of rural health care providers. Block, Hutton, and Johnson (2000) surveyed 614 rural dentists, chiropractors, primary care physicians, physician specialists, nurse practitioners, physician assistants, and public health nurses in 16 upper Midwestern counties about tobacco assessment practices of clients, intervention practices, attitudes, skills, barriers, and desire for tobacco education. Findings showed that 58.5% of all providers consistently assessed tobacco use; however, fewer providers (10%) offered consistent pharmacological interventions or referrals to community resources. Providers reported supportive attitudes toward interventions, awareness of community resources, and sufficient tobacco counseling skills. Low patient priority and lack of time for counseling were the common barriers to tobacco counseling. Approximately two-thirds of the providers desired further tobacco education. Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 31 There were no documented studies in the literature that addressed the similarities and differences in the smoking cessation practices, attitudes, and interventions of rural and urban health care providers. It was estimated that 20% of the American population lived in rural or non-metropolitan areas. Rural areas reported more elderly, mostly Caucasian, native-born residents with few minority residents. Rural residents were more likely to attain a high school education, experience lower incomes with higher levels of poverty, encounter lower levels of insurance coverage, perceive lower levels of health (fair to poor), sustain higher trauma mortality rates, specifically in motor vehicle accidents and gun-related incidences, experience higher rates of chronic diseases, report higher infant mortality rates, demonstrate less utilization of hospitals and health care providers, and use less preventive health screening than urban residents (Coburn & Bolda, 1999; National Center for Health Statistics [NCHS], 2001; Rural Information Center Health Services [RICHS], 2001a; Ricketts, Johnson-Webb, & Randolph, 1999). Adults living in rural areas were more likely to smoke (27% in women and 31% in men) than adults living in urban areas (20% in women and 25% in men). Similarly, rural adolescents were more likely to smoke than urban adolescents (19% and 11% respectively). Two factors associated with higher rates of smoking in rural residents were lower educational attainment and limited access to medical and media resources for lifestyle changes. Rural areas reported less available health care providers (10% physicians, 25% of physician assistants, and 24% of nurse practitioners) than urban areas (Coburn & Bolda, 1999; NCHS, 2001; RICHS, 2001a; Ricketts, Johnson-Webb, & Randolph, 1999). Research is needed to determine if similarities and differences among rural and urban health care providers exist. The research questions were as follows: 1. What are the demographic characteristics (type health care provider, age, gender, personal tobacco use, family or significant other tobacco use, and educational preparation of smoking cessation interventions) of rural and urban health care providers? 2. What are the characteristics of the work environment (type of practice setting, practice location, and perceived percentage of clients who smoke) in rural and urban health care providers? 3. What are the smoking assessment patterns, smoking cessation interventions, and prescribed pharmaceutical methods of rural and urban health care providers? 4. What are the perceived enhancement factors to implementing smoking cessation interventions of rural and urban health care providers? 5. What are the perceived barriers to implementing smoking cessation interventions of rural and urban health care providers? METHODS The purpose of this descriptive research was to identify the similarities and differences of demographic characteristics, specific intervention practices, perceived Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 32 barriers, and enhancement factors associated with smoking cessation interventions of rural and urban primary health care providers. The study was approved by four universities’ institutional review boards. Primary health care providers were surveyed in three Regional Tobacco Use Prevention and Control Networks: Southeastern (Alabama and Virginia), Rocky Mountain (Colorado), and Western (Nevada). Diverse definitions and characteristics of rural and urban areas have been documented in the literature. For this study, rural was defined as territories, populations, and housing units not classified as urban generally located 15 to 30 miles from a community with a population no larger than 10,000 residents. Urban was defined as a community with a combined population of at least 50,000 from a central city and contiguous closely settled territory (Rural Information Center Health Service, 2001b; U.S. Census Bureau, 2001; U. S. Office of Management and Budget, 1994). A convenience sample of 342 subjects was obtained from a population of primary health care providers listed in their professional society directories (medical and nursing). The selection of subjects was equitable. Each subject was contacted by telephone to explain the purpose of the study, confirm name and address, and obtain willingness to participate in the study. Each subject was mailed a cover letter that explained the purpose of the study, confidentiality of information, informed consent, names of principal and co- investigators, and institutional associations along with a questionnaire, and a self- addressed, stamped envelope. The return of a completed questionnaire served as consent of voluntary participation. A follow up letter and second copy of the questionnaire were mailed to subjects who did not respond in three weeks. Data were collected over eight weeks with a return rate of 46% (342 subjects). Sample The convenience sample consisted of physicians (MD), registered nurses (RN), and advanced practice nurses (APN), such as nurse practitioners and certified nurse midwives. The 230 rural health care providers were from a four-county continuum or contiguously close areas with a population range of 1,500 to 20,000 located in the eastern and southern regions of the United States. The rural areas were less populated with greater distances between towns or incorporated areas and consisted of fewer shopping opportunities and minimal health care services and providers than the urban areas. The 112 urban health care providers were from a two-county continuum or contiguously close areas with a population range of 40,000 to 80,0000 located in the mid-western and western regions. Measures The Primary Care Health Provider Survey: Influences on Implementation of Smoking Cessation Practices is a 38-item, 5-point Likert scale that measured the demographic characteristics, specific smoking cessation intervention practices, perceived enhancement factors, and barriers associated with smoking cessation interventions. LaSala, the primary investigator, developed content items from the smoking cessation Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 33 concepts identified in the literature. Content validity was determined in a pilot study of 10 expert primary health care providers that were not subjects in the study. A content validity index was used to quantify the extent of agreement, assure clarity of items, and confirm the readability of items. Minor revisions of five items were based on the findings of the pilot study. A Cronbach alpha of .7740 confirmed reliability. Data Analysis Data were analyzed using the SPSS 11.0 for Windows for descriptive statistics and Pearson’s product-moment correlation. Descriptive statistics were performed on all study variables. Means and standard deviations were calculated; means were in expected ranges and sufficient variation was present. Pearson’s product-moment correlation of all items was obtained with the significant level of p < .05. RESULTS The first research question asked: What are the demographic characteristics (type health care provider, age, gender, personal tobacco use, family or significant other tobacco use, and educational preparation of smoking cessation interventions) of rural and urban health care providers? The major rural health care providers were registered nurses and the major urban health care providers were physicians. The majority of health care of providers was aged 30.1 to 50 years, female, never smoked, no family members or significant others who smoked, and educational preparation about smoking cessation from combined resources for both rural and urban areas (Table 1). There was a significant difference in types of professional rural and urban health care providers (chi- square = 13.506, p = .009). There was a significant difference in the ages of the rural and urban health care providers (chi-square = 9.251, p = .055). The second research question asked: What are the characteristics of the work environment (type of practice setting, practice location, and perceived percentage of clients who smoke) in rural and urban health care providers? The most commonly reported practice setting was family practice located in private clinics (Table 2). There was a significant difference in the primary focus of the practice setting of rural and urban health care providers (chi-square = 44.935, p = .000), type of practice setting of rural and urban health care providers (chi-square = 30.924, p = .000), and estimation of the percentage of clients that currently smoke by rural and urban health care providers (chi- square = 10.705, p = .058). The third research question asked: What is the smoking assessment patterns, smoking cessation interventions, and prescribed pharmaceutical methods of rural and urban health care providers? Urban health care providers assessed clients’ smoking practices more frequently than rural health care providers (70.7% and 68.7%, respectively) (Table 3). Rural health care providers were less likely to assess clients’ smoking practices once or never (8.6% and 1.8% respectively) than urban health care providers. There was a significant difference in the frequency of initiating smoking interventions (chi-square = 9.728, p = .045), types of smoking cessation interventions most frequently recommended Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 34 Table 1 Demographic Characteristics of Rural and Urban Health Care Providers Rural (n = 230) Urban (n = 112) Variable n % n % Health care provider Physicians 75 32.6 51 45.9 Registered nurses 84 36.5 20 18.0 Advanced practice nurses 71 30.9 40 36.0 Age 20-30 years 21 9.1 2 1.8 30.1-40 years 74 32.2 36 32.1 40.1-50 years 78 33.9 44 39.3 50.1-60 years 48 20.9 21 18.8 60.1 or more years 9 3.9 9 8.0 Gender Male 69 30.0 35 31.2 Female 161 70.0 77 68.8 Personal tobacco use Never smoked 145 63.0 74 66.0 Life-time (1-2 times) 29 12.6 12 10.7 Past smoker (>2 for some time) 48 20.9 20 17.9 Current “light” smoker (occasional) 5 2.2 6 5.4 Current “heavy” smoker (>2 daily) 3 1.3 0 0 Smoker in family or significant other Yes 92 40 37 33 No 138 60 75 67 Educational preparation Formal academia curriculum 20 9.1 4 3.6 Formal continuing education programs 10 4.3 5 4.5 Professional literature 22 9.6 10 8.9 Pharmaceutical literature or salesperson 4 1.7 3 2.7 Informal professional networking 30 13.0 10 8.9 Other (combinations of above) 143 62.2 80 71.4 N = 342 (chi-square = 15.744, p = .072), and pharmaceutical methods prescribed (chi-square = 22.905, p = .011). The fourth research question asked: What are the perceived enhancement factors to implementing smoking cessation interventions of rural and urban health care providers? Both rural and urban heath care providers strongly reported that a client’s request for Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 35 Table 2 Characteristics of Work Environments Rural (n = 230) Urban (n = 112) Variable n % n % Primary focus of practice setting Pediatric 27 11.7 22 19.6 Family 77 33.5 45 40.2 Women 30 13.0 32 28.6 Adult 42 18.3 11 9.8 Other 54 23.5 2 1.8 Type practice setting Private clinic 101 43.9 72 64.2 Public clinic 30 13.0 15 13.4 Hospital 47 20.4 3 2.7 School 26 11.3 19 17.0 Other 26 11.3 3 2.7 Estimation of clients who currently smoke 0 5 2.2 4 3.6 1-25% 97 42.2 63 56.3 25.1-50% 88 38.3 37 33.0 50.1-75% 28 12.2 7 6.3 75.1-100% 12 5.2 1 0.9 N = 342 smoking cessation intervention to be a strong enhancement factor and all other factors as having moderate enhancement to smoking cessation interventions (Table 4). There were no significant differences between rural and urban health care providers in relation to the 10 perceived enhancements for smoking cessation practices. The fifth research question asked: What are the perceived barriers to implementing smoking cessation interventions of rural and urban health care providers? Both rural and urban health care providers strongly reported that lack of client commitment or compliance and the addictive mechanism of nicotine were perceived barriers to cessation interventions and moderately rated the other perceived barriers, i.e., time constraints, cost factors, community resources (Table 5). However, several health care providers expressed lack of clinical intervention skills (33.6% of rural and 21.4% of urban, respectively). The only significant barrier to implementation of smoking interventions between the rural and urban health care providers was the lack of perceived effectiveness of smoking cessation (chi-square = 8.188, p = .085). Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 36 Table 3 Assessment and Intervention Practices of Health Care Providers Rural (n = 230) Urban (n = 112) Variable n % n % Assessment of client smoking practices Never 10 4.3 2 1.8 Once 10 4.3 0 0 Several times (2-49%) 52 22.6 31 27.7 Frequently (50-99%) 113 49.1 58 51.8 Always (100%, every visit) 45 19.6 21 18.9 Initiation of smoking interventions Never 23 10.0 4 3.6 Once 13 5.7 2 1.8 Several times (2-49%) 100 43.5 44 39.3 Frequently (50-99%) 82 35.6 53 47.3 Always (100%, every visit) 12 5.2 9 8 Follow-up on smoking interventions Never 36 15.7 11 9.8 Once 13 5.7 4 3.6 Several times (2-49%) 107 46.5 51 45.5 Frequently (50-99%) 62 26.9 41 36.6 Always (100%, every visit) 12 5.2 5 4.5 Smoking cessation interventions None 26 11.3 4 3.6 Self-help materials 34 14.8 13 11.6 Individual counseling 33 14.3 12 10.7 Group counseling 4 1.7 3 2.7 Combination of above methods 133 57.8 80 71.4 Pharmaceutical methods prescribed None 39 16.9 24 21.4 Nicotine gum 3 1.3 2 1.8 Nicotine replacement patches 26 11.3 4 3.6 Nicotine inhalers or sprays 13 5.7 13 11.6 Zyban 36 15.6 17 15.2 Other (combinations of above) 113 49.1 52 46.4 N = 342 Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 37 Table 4 Perceived Enhancements to Implement Smoking Cessation Interventions Rural (n = 223) Urban (n = 112) Variable n % n % Health risks of smoking behaviors None 5 2.2 5 4.5 Mild 25 11.2 11 9.8 Neutral 25 11.2 12 10.7 Moderate 92 41.3 45 40.2 Strong 76 34.1 39 34.8 Long-term costs for client None 18 8.1 6 5.4 Mild 51 22.7 25 22.3 Neutral 53 23.8 26 23.2 Moderate 66 29.6 40 35.7 Strong 35 15.7 15 13.4 Client request for cessation intervention None 8 3.6 2 1.8 Mild 17 7.6 6 5.4 Neutral 30 13.5 15 13.4 Moderate 55 24.6 26 23.2 Strong 113 50.7 63 56.3 Reimbursement for intervention None 30 13.5 20 17.9 Mild 31 13.9 15 13.4 Neutral 58 26.0 30 26.8 Moderate 65 29.1 30 26.8 Strong 39 17.5 17 15.2 Personal skill and knowledge of interventions None 7 3.1 2 1.8 Mild 17 7.6 10 8.9 Neutral 45 20.2 26 23.2 Moderate 112 50.2 49 43.8 Strong 42 18.8 25 22.3 Availability of community resources for referral None 18 8.1 5 4.5 Mild 33 14.8 16 14.3 Neutral 67 30.0 27 24.1 Moderate 75 33.6 52 46.4 Strong 30 13.5 12 10.7 Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 38 Personal peer support and encouragement None 13 5.8 5 4.5 Mild 24 10.8 14 12.5 Neutral 65 29.1 38 33.9 Moderate 96 43.0 46 41.1 Strong 25 11.2 9 8.0 Media-tobacco campaigns None 25 11.2 6 5.4 Mild 54 24.2 34 30.3 Neutral 74 33.2 27 24.1 Moderate 56 25.1 38 33.9 Strong 14 6.3 7 6.3 Law & public policy restrict smoking in public places None 22 9.9 13 11.6 Mild 44 19.7 22 19.6 Neutral 58 26.0 24 21.4 Moderate 70 31.4 34 31.3 Strong 29 13.0 18 16.1 Personal commitment to implement interventions None 3 1.3 1 0.9 Mild 13 5.8 7 6.3 Neutral 35 15.7 16 14.3 Moderate 101 45.3 42 37.5 Strong 71 31.8 46 41.0 N = 335 DISCUSSION AND RECOMMENDATIONS This research provides the first comparative view of demographic characteristics, work environment characteristics, smoking assessment patterns, smoking cessation interventions, prescribed pharmaceutical methods, and perceived enhancement factors and barriers to implementing interventions of rural and urban health care providers across four geographical areas. The results of this study must be interpreted with caution because of the nonrandomized, convenience sample and the inequity of numbers of the two groups’ participants. There are a greater number of rural health care providers (67.3%) than urban health care providers (32.7%) that participated in this study. The majority of the urban health care providers consisted of younger aged physicians and advanced practice nurses compared to rural health care providers (81.9% and 63.5% respectively) who used prescriptive authority and possibly viewed the questions from a different perspective than RNs. The rural health care providers consisted of more registered nurses (36.5% and 18% respectively) than the urban health care providers. Findings revealed that the majority of the sample consisted of older women who had Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 39 never smoked and reported combined resources for educational preparation for smoking cessation interventions. Block, Hutton, and Johnson (2000), Kviz et al. (1995) and Zapka et al. (2000) reported similar findings of providers related to age, gender, and educational preparation. Table 5 Health Care Providers Perceived Barriers to Implementation of Smoking Interventions Rural (n = 223) Urban (n = 112) Variable n % n % Time constraints of practice setting None 12 5.4 4 3.6 Mild 42 18.8 19 17.0 Neutral 38 17.0 18 16.1 Moderate 78 35.0 51 45.5 Strong 52 23.8 20 17.8 Cost factors for client None 19 18.5 5 4.5 Mild 30 13.5 8 7.1 Neutral 36 16.1 21 18.8 Moderate 84 37.7 52 46.4 Strong 54 24.2 26 23.2 Lack of clinical intervention skills or knowledge of interventions None 37 16.6 28 25.0 Mild 50 22.4 32 28.6 Neutral 61 27.4 28 25.0 Moderate 54 24.2 15 13.4 Strong 21 9.4 9 8.0 Lack of perceived effectiveness of interventions None 19 8.5 16 14.3 Mild 37 16.6 26 23.2 Neutral 57 25.6 32 28.6 Moderate 89 39.9 28 25.0 Strong 21 9.4 10 8.9 Lack of reimbursement None 31 13.9 15 13.4 Mild 29 13.0 15 13.4 Neutral 47 21.1 33 29.5 Moderate 74 33.2 29 25.9 Strong 42 18.8 20 17.9 Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 40 Lack of community resources for referral None 21 9.4 11 9.8 Mild 43 19.1 28 25.0 Neutral 58 26.0 27 24.1 Moderate 70 31.4 35 31.3 Strong 31 13.9 11 9.8 Lack of client interest None 4 1.8 2 1.8 Mild 8 3.6 4 3.6 Neutral 17 7.6 8 7.1 Moderate 76 34.1 30 26.8 Strong 118 52.9 68 60.7 Lack of client commitment or compliance None 4 1.8 2 1.8 Mild 8 3.6 4 3.6 Neutral 15 6.7 8 7.3 Moderate 66 29.6 31 28.2 Strong 130 58.3 67 59.8 Addictive mechanisms of nicotine None 6 2.7 3 2.7 Mild 10 4.5 5 4.5 Neutral 26 11.7 9 8.0 Moderate 76 34.0 33 29.5 Strong 105 47.0 62 55.4 Media or advertisement influence None 22 9.9 6 5.4 Mild 34 15.2 21 18.8 Neutral 58 26.0 27 24.1 Moderate 77 34.5 34 32.1 Strong 32 14.3 22 19.6 Personal beliefs associated with smoking None 125 56.1 72 64.0 Mild 27 12.1 8 7.1 Neutral 39 17.5 22 19.6 Moderate 19 8.5 3 2.7 Strong 13 5.8 7 6.3 N = 335 The rural health care providers reported diverse, multiple practice settings with a generalist view compared to urban heath care providers who reported private practice settings in family or specialty areas. Rural health care providers estimated that more of their clients smoked than the clients of urban health care providers. These findings are congruent with the known characteristics of rural residents (Cobrun & Bolda, 1999; NCHS, 2001; RICHS, 2001a; Ricketts, Johnson-Webb, & Randolph, 1999). Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 41 The health care providers of this study indicated the need for more knowledge, skills, and confidence to assess, initiate, and follow up on smoking interventions. This finding was supported by Block, Hutton, and Johnson (2000). Consistent and strong curricula education at all health provider levels about tobacco use, nicotine dependence, and cessation interventions is critical to empower health care providers to address smoking cessation interventions effectively. Rural health care providers were less likely to assess clients’ smoking practices and to initiate smoking interventions. Urban health care providers were more likely to initiate smoking interventions that consisted of combined methods, i.e. counseling, self- help materials, group counseling, and pharmaceutical methods of nicotine patches, sprays, or Zyaban. These findings were comparable to the study by Kviz et al. (1995). Continuing education of all health care providers is essential for learning new and more effective strategies for smoking cessation. Possibly more continuing education programs need to be available to rural health care providers or they should focus on other accessible resources, such as journals or Internet resources (Table 6). Table 6 Tobacco Resources for Clinicians Website URL Agency for Healthcare Research and Quality http://www.ahrq.gov American Heart Association http://www.americanheart.org American Lung Association http://www.lungusa.org Center for Disease Control http://www.cdc.gov/tobacco National Cancer Institute http://www.mci.nih.gov Nicotine Anonymous http://www.nicotine-anonymous.org Nursing Spectrum (continuing education) http://www.nursingspectrum.com Quick Reference Guide for Clinicians http://www.surgeongeneral.gov/tobacco/tobaqrg Quit Net http://www.quitnet.com It is critical that health care providers implement smoking cessation interventions. The U.S. Public Health Service provided specific evidenced-based recommendations for brief, intensive, or system-level changes for tobacco cessation interventions. The five step plan consisted of the 5 A’s: 1. Ask-systematically identify all tobacco users at every visit, 2. Advise-strongly urge all tobacco users to quit, 3. Assess - determine willingness to make a quit attempt, 4. Assist - aid the client in quitting, and 5. Arrange - common elements of practical counseling (problem solving, skills training, intratreatment supportive and extratreatment supportive interventions (Centers of Disease Control and Prevention, 2000; Fiore et al. 2000; Spoljoric, 2000; USDHHS, 2000b). Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 http://www.ahrq.gov/ http://www.americanheart.org/ http://www.lungusa.org/ http://www.cdc.gov/tobacco http://www.mci.nih.gov/ http://www.nicotine-anonymous.org/ http://www.nursingspectrum.com/ http://www.surgeongeneral.gov/tobacco/tobaqrg http://www.quitnet.com/ 42 Health care providers have multiple client opportunities to address smoking cessation. Health care providers armed with enhanced knowledge, confidence, and an intervention plan will achieve the Healthy People 2010 goal to consistently assess and initiate smoking cessation interventions of clients (USDHHS, 2000a). Further research is required about rural and urban health care providers’ practice patterns of clients’ smoking cessation to determine if this study’s results are comparable to other regions of the United States. A larger, more equitable randomized sample of similar health care providers is essential to determine significant similarities and differences between and among groups. The characteristics and needs of rural and urban residents are different; therefore, further research is needed to determine if smoking cessation interventions for each area’s residents should be the same or different. ACKNOWLEDGMENTS We would like to thank Jenenne Nelson, RN, PhD, CNS, at the University of Colorado at Colorado Springs for her assistance with statistical analysis. REFERENCES Block, D.E., Hutton, K.H., & Johnson, K.M. (2000). Differences in tobacco assessment and intervention practices: A regional snapshot. Preventive Medicine, 30, 282-287. [MEDLINE] Centers of Disease Control and Prevention. (2000). New guidelines challenge all clinicians to help smokers quit. Retrieved March 30, 2002, from http://www.cdc.gov/tobacco/quit/guidelines.htm Centers of Disease Control and Prevention. (2002). Annual smoking-attributable mortality, years of potential lives lost, and economic costs—United Sates, 1995- 1999. Mortality Morbidity Weekly Report, 15: 300-3. Coburn, A.F., & Bolda, E.J. (1999). The rural elderly and long-term care. In T.C. Ricketts (Ed.), Rural health in the United States (pp. 179-189). New York: Oxford University Press. Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz, E.R., et al. (2000). A clinical practice guideline for treating tobacco use and dependence: A U.S. Public Health Service report. [Consensus Statement]. Journal of the American Medical Association, 283, 3244-3254 Kviz, F.J., Clark, M.A., Prohaska, T.R., Slezka, J.A., Crittenden, K.S., Freels, S., & Campbell, R.T. (1995). Attitudes and practices for smoking cessation counseling by provider type and patient age. Preventive Medicine, 24, 201-212. [MEDLINE] Moody, N.B., Smith, P.L., & Glenn, L.L. (1999). Client characteristics and practice patterns of nurse practitioners and physicians. Nurse Practitioner, 24(3), 94-104. [MEDLINE] National Center for Health Statistics. (2001). Health, United States, 2001: Urban and rural chartbook. Retrieved January 15, 2002, from http://www.cdc.gov/nchs/data/hus01.pdf Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10731456&dopt=Abstract http://www.cdc.gov/tobacco/quit/guidelines.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7597023&dopt=Abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10100243 http://www.cdc.gov/nchs/data/hus01.pdf 43 Ricketts, T.C., Johnson-Webb, K.D., & Randolph, R.K. (1999). Populations and places in rural America. In T.C. Ricketts (Ed.), Rural health in the United States (pp. 7-24). New York: Oxford University Press. Rural Information Center Health Service. (2001a). Rural health statistics. Retrieved March 30, 2002, from http://www.nal.usda.gov/ric/richs/stats/htm Rural Information Center Health Service. (2001b). What is rural? Retrieved March 30, 2002, from http://www.nal.usda.gov/ric/faqs/ruralfaq.htm Satcher, D. (2001). Targeting tobacco use: The nation’s leading cause of death. Retrieved March 30, 2002, from http://www.cdc.gov/tobacco/overviewg/oshang.html Secker-Walker, R.H., Chir, B., Solomon, L.J., Flynn, B.S., & Dana, G.S. (1994). Comparisons of the smoking cessation counseling activities of six types of health professionals. Preventive Medicine, 23, 800-808. [MEDLINE] Sheahan, S.L. (2000). Documentation of health risks and health promotion counseling by emergency department nurse practitioners and physicians. Journal of Nursing Scholarship, 32, 245-250. [MEDLINE] Spoljoric, D. (2000). How to implement an effective smoking cessation plan. Patient Care for the Nurse Practitioner, 3(7), 59-61, 65-68. U.S. Census Bureau. (2001). Urban and rural criteria. Retrieved March 30, 2002, from http://www.census.gov/geo/www/ua/ua_2k.html U.S. Department of Health and Human Services. (2000a). Healthy people 2010. Retrieved March 30, 2002, from http://www.health.gov/healthypeople/document U.S. Department of Health and Human Services. (2000b) Treating tobacco use and dependence: Quick reference guide for clinicians. Retrieved March 30, 2002, from http://www.surgeongeneral.gov/tobbacco/tobaqrg.htm U.S. Office of Management and Budget. (1994). Metropolitan areas: Changes in Metropolitan areas: 1950-1994. Washington, DC: Statistical Policy Office, Office of Information and Regulatory Affairs. Zapka, J.G., Phert, L., Stoddard, A.M., Ockene, J.K., Goins, K.V., & Bonollo, D. (2000). Smoking cessation counseling with pregnant and postpartum women: A survey of community health center providers. American Journal of Public Health, 90(1), 78-84. [MEDLINE]. Online Journal of Rural Nursing and Health Care, vol. 3, no. 2, Fall 2003 http://www.nal.usda.gov/ric/richs/stats/htm http://www.nal.usda.gov/ric/faqs/ruralfaq.htm http://www.cdc.gov/tobacco/overviewg/oshang.html http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7855113&dopt=Abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12462818&dopt=Abstract http://www.census.gov/geo/www/ua/ua_2k.html http://www.health.gov/healthypeople/document http://www.surgeongeneral.gov/tobbacco/tobaqrg.htm http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10630141&dopt=Abstract SMOKING CESSATION PRACTICES OF RURAL AND URBAN HEALTH CARE PROVIDERS