An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.

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U.S. Public Health Service (USPHS) clinical guidelines for tobacco treatment recommend that providers routinely counsel smokers using a five-step algorithm (5A's): ask about tobacco use, advise smokers to quit, assess interest in quitting, assist with treatment, and arrange follow-up. A potential barrier to compliance is providers' concern that addressing smoking might alienate smokers, especially those not ready to quit. A survey was mailed to 1,985 patients seen at one of eight Boston-area primary care practices from January 1 to March 31, 2003, and identified as smokers by chart review. The survey assessed respondents' receipt of the 5A's at their visit and their satisfaction with the provider's tobacco treatment and with their overall health care. We used multivariable logistic regression models to assess the association between satisfaction with care and patient-reported receipt of each 5A step, adjusted for age, sex, education, race, health status, smoking intensity, readiness to quit, and length of relationship with provider. Of 1,160 respondents (58% response rate), 765 reported that they smoked at the time of the visit. They reported high levels of satisfaction with their tobacco-related care and overall care. Patient-reported receipt of each 5A step was significantly associated with greater patient satisfaction with tobacco-related care and with overall health care, even after adjusting for a smoker's readiness to quit smoking. Satisfaction with overall health care increased as counseling intensity increased. Patient reports of smoking cessation interventions delivered during primary care practice are associated with greater patient satisfaction with their health care, even among smokers not ready to quit. Providers can follow USPHS guidelines with smokers without fear of alienating those not yet considering quitting.