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Association of Primary Care Physician Relationship and Insurance Status With Reduced Rates of Tobacco Smoking FREE TO VIEW

Zachary DePew, MD; William Gossman, MD; Lee E. Morrow, MD, FCCP
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From the Department of Internal Medicine(Dr DePew), the Department of Emergency Medicine (Dr Gossman), and the Department of Pulmonary, Critical Care, and Sleep Medicine (Dr Morrow), Creighton University Medical Center.

Correspondence to: Lee E. Morrow, MD, FCCP, 601 N 30th St, Ste 3820, Omaha, NE 68131; e-mail: lmorrow@creighton.edu

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

© 2010 American College of Chest Physicians

Chest. 2010;138(5):1278-1279. doi:10.1378/chest.10-1316
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To the Editor:

In order to determine whether an existing primary care provider (PCP) relationship was associated with reduced rates of tobacco smoking, we carried out an anonymous self-reporting survey of all noncritically ill adults seen in the Creighton University Medical Center ED during March and April of 2008. This nonvalidated, institutional review board-approved survey assessed tobacco smoking history, PCP relationship status, and third-party payer status. The survey was completed by 501 of approximately 2,500 patients, for a participation rate of approximately 20% during the study period.

Of patients with a PCP relationship, 26.5% were current tobacco smokers compared with 62.3% of patients without a PCP. A total of 54.8% of patients without insurance reported current smoking compared with 55.4%, 25.9%, and 21.4% of Medicaid, private insurance, and Medicare patients, respectively (Table 1). Although lack of an established PCP relationship and the absence of a third-party payer source were correlated (r2=0.71, P=.001), both variables were independent predictors of current tobacco use using multivariate logistic regression modeling (absence of a third-party payer adjusted OR =1.3 [P = .002] and lack of a PCP relationship adjusted OR =5.2 [P < .001]). This finding implies that insurance status does not serve as a simple proxy for access to health care by a PCP and that the relationship among tobacco smoking, an established PCP relationship, and the availability of a third-party payer are more nuanced.

Table Graphic Jump Location
Table 1 —Comparisons of Primary Care Provider Relationship Status, Tobacco Use, and Smoking Cessation Methods by Insurance Status

PCP = primary care physician.


Values given are No. or No. (%).

An interesting observation in this cohort was that a significant portion of the between-group difference in the rate of current tobacco smoking was increased cessation among those with a PCP relationship and/or a third-party payer. Rates of never smokers were consistent across groups when stratified by PCP or insurance status. The exception to this generalization was the Medicaid group, which had a significantly lower percentage of never smokers (16.2%) compared with other groups (34.7%-40.5%). Unmeasured socioeconomic variables may contribute to this finding.

Tobacco smoking cessation rates were drastically improved in the groups with a PCP and/or a third-party payer, and these patients used a more robust complement of cessation modalities. These observations suggest that access to a PCP increases the likelihood of individualized, multimodality prescription medications and that a third-party payer provides financial assistance for access to additional modalities of cessation. The implication that the deleterious effects of tobacco smoking can be mitigated by increasing access to a PCP and ensuring a third-party payer source to subsidize preventative therapies is significant when determining how to best deliver cost-effective health care in the United States.



Table Graphic Jump Location
Table 1 —Comparisons of Primary Care Provider Relationship Status, Tobacco Use, and Smoking Cessation Methods by Insurance Status

PCP = primary care physician.


Values given are No. or No. (%).


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