What Explains Provider-Delivered Smoking Cessation Counseling to Rural Medicaid Patients?

Special Article - Tobacco and Smoking Cessation

J Fam Med. 2015; 2(5): 1036.

What Explains Provider-Delivered Smoking Cessation Counseling to Rural Medicaid Patients?

Wang L¹, Wewers ME², Seiber EE³ and Ferketich AK¹*

¹Nationwide Children’s Hospital, Planning & Business Development, USA

²Division of Health Behavior and Health Promotion, College of Public Health, the Ohio State University, USA

³Division of Health Services Management and Policy, College of Public Health, the Ohio State University, USA

*Corresponding author: Ferketich AK, Division of Epidemiology, College of Public Health, the Ohio State University, 1841 Neil Avenue, Columbus, USA

Received: August 29, 2015; Accepted: October 07, 2015; Published: October 10, 2015


Tobacco use among the Medicaid population is almost double that in the general population. Health care providers are key in promoting smoking cessation. This study explored the influence of providers’ attitudes, normative beliefs, and perceived behavior control on provider-delivered brief cessation counseling to rural Medicaid-enrolled smokers. Interviews were conducted with health care providers who regularly see Medicaid patients. The interview questions addressed three constructs of the Theory of Planned Behavior: 1) attitudes (towards Medicaid-enrolled smokers and the behavior of cessation counseling); 2) normative beliefs (perceptions of Medicaid administrators’ interests in adopting a cessation program); and 3) perceived behavioral control (perceived ability to deliver cessation counseling). All providers delivered some cessation counseling to their patients despite not receiving reimbursement for counseling. Overall, attitudes appeared to be a major determinant of providers’ delivery of cessation counseling. Providers perceived that a large proportion of smokers had no desire to quit, and they recognized that advising smokers to quit may be ineffective among smokers not ready to quit. However, they did not indicate that they were following the Clinical Practice Guideline Treating Tobacco Use and Dependence recommendations to encourage smokers to move towards getting ready to quit smoking by providing motivational interventions. Normative beliefs and perceived behavioral control did not appear to influence provider behavior. Training for providers on how to conduct brief motivational interventions to unmotivated smokers may be beneficial to promote compliance with the Guideline.

Keywords: Tobacco use; Smoking Cessation; Medicaid; Health care provider; Theory of Planned Behavior


Medicaid enrollees have higher smoking prevalence than the general population [1]. In Ohio Appalachia, a rural area characterized by increased unemployment, poverty, and poor health, the smoking prevalence is 48% among working-age Medicaid enrollees [1], which is far higher than the general population (25.5%) in Ohio. Medicaid patients represent a priority population for tobacco control efforts [2]. Health care providers can play an important role in helping patients to quit smoking [3]. Even brief advice given in a five-minutes session by health care providers can improve smoking quit rates [3,4]. The U.S. Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence encourages all providers to employ the 5 A’s: Ask about tobacco use, Advise users to quit, Assess willingness to quit, Assist in the quit attempt by writing a prescription for pharmacotherapy and referring to counseling, and Arrange for follow-up [4]. In the general population, while ‘ask’ and ‘advise’ are delivered fairly regularly by providers [2,5] the remaining three A’s are not commonly included in discussions with smokers [5]. The same appears to hold true in the Medicaid population. In a national sample of Medicaid current and former smokers, 87% reported being asked about smoking, 65% received advice to quit, 51% were assessed for their willingness to quit, 24% received assistance, and 13% had a follow-up visit arranged [2].

Given the significant role that providers can play and their modest performance of the 5A’s, it is critical to better understand factors associated with delivering brief cessation counseling to patients. One theory that has been used to understand various provider behaviors is the Theory of Planned Behavior (TPB), a model that predicts behavioral intentions, which, according to the model, ultimately leads to behavior [6]. The three constructs of the model include behavioral beliefs (i.e., attitudes towards the behavior), normative beliefs (i.e., how others perceive the behavior), and perceived behavioral control (i.e., confidence in performing the behavior). In previous studies that used the TPB to explain the behavior of providing brief counseling messages to quit smoking, behavioral beliefs and perceived behavioral control explained much of the variance in the outcomes intention to give advice to quit smoking in the next 3 months [7] and actually delivering cessation advice [8]. The TPB framework has not been specifically examined for its relevance to provider behavior with Medicaid patients. By using qualitative research methods, our study thoroughly explored the TPB constructs as a way to understand what influences physician behavior when interacting with Medicaid patients. Our goal was to characterize the influence of attitudes, normative beliefs, and perceived behavior control on the provision of tobacco cessation counseling to rural Medicaid smokers.



This study was conducted with providers who work with Medicaid patients in the Appalachian region of Ohio. According to data from the 2012 Ohio Medicaid Assessment Survey, a statewide household survey of health and insurance, the Appalachian region experiences high rates of uninsured adults of working age (19.4% versus 17.3% in Ohio) and families in poverty (26.4% live below the poverty line versus 23.9% in Ohio) [1]. Medicaid coverage among working age adults is more prevalent in this region as well (17.0% versus 13.8% in Ohio) and, as indicated above, over half of Medicaid-enrolled adults in the Appalachia region are current smokers [1].

Qualitative interview methods

Health care providers were recruited for this study at two major medical centers that serve a large population of Medicaid patients in various counties in the region. Our contacts in the research department and tobacco dependence treatment program at these two medical centers actively recruited providers who regularly see patients with Medicaid. The qualitative interviews were performed by trained staff using a semi-structured interview instrument. All interviewers were trained by the Principal Investigator in interviewing and probing skills. The interviews were audio-taped and discussions lasted approximately 20 minutes. All providers received $20. The interview questions addressed the constructs of the TPB. The topics included: 1) attitudes towards the behavior (perceptions of Medicaidenrolled smokers’ interest in receiving physician delivered cessation counseling, perceptions of how smokers enrolled in Medicaid would embrace a smoking cessation program); 2) subjective norms (perceptions of Medicaid managed care plan leaders’ interest in adopting a comprehensive cessation program); 3) perceived behavioral control (knowledge of effective tobacco dependence treatments and attitudes towards those treatments and perceived ability to deliver cessation counseling).

Coding and analysis

All interviews were transcribed by a trained transcriptionist. The investigators developed an initial coding frame based on questions asked in the interview guide as well as model constructs. The text from each interview was reviewed and coded independently by two of the investigators. Following an independent review, the two investigators met and discussed all of the coding assignments. Investigators developed new codes as new themes emerged from the interview data. When there was disagreement on a particular code, the investigators discussed the point until agreement was reached. All of the data were entered into Excel and the topics and codes were sorted to facilitate the analysis. The textual data were analyzed to identify recurrent patterns and themes related to the research questions. Quotations associated with each code were reviewed and analyzed and select quotes were chosen to illustrate the themes identified.


A total of 10 qualitative interviews (with 9 physicians and 1 nurse practitioner) were conducted. However, one audiotape was lost; therefore, the analysis was performed with data from the remaining 9 providers. Detailed notes taken during the interview indicated that the responses by this provider were consistent with those given by the other 9 providers. The time to complete the interview ranged from 20 to 30 minutes. The providers represented multiple disciplines: primary care, cardiology, endocrinology, oncology, gynecology, and surgery. The number of Medicaid patients the providers reported seeing each week ranged from 5 to 90. The providers estimated that 10-90% of their Medicaid patients are current smokers with the average being 54%.

Behavioral beliefs

The behavioral beliefs that were discussed during the interviews included attitudes about providing unsolicited counseling to smokers, attitudes about smokers themselves, and attitudes about smoking cessation pharmacotherapy. (Table 1) includes relevant quotes that were made by the providers during the interviews. With respect to beliefs about providing unprompted counseling to smokers and how it may interfere with the provider-patient relationship, most providers were not concerned that unsolicited counseling would harm their relationship with patients. However, providers gave some examples of patients who responded negatively to smoking cessation discussions. One physician stated, “I have had one guy who came in and before I even asked him if he smokes or wanted to quit, he like got hostile. Said don’t even talk to me about quitting smoking”. Attitudes toward smoking cessation pharmacotherapy were also discussed with the providers. All providers had prescribed cessation pharmacotherapy to smokers in the past. However, many of the providers indicated that they believed that pharmacotherapy, in general, is not very effective in promoting smoking cessation. Chantix® was frequently mentioned by providers as a medication that is more effective than others.