Study: Wisconsin Adults Who Smoke Receive Primary Care Less, Visit the Hospital More


Wisconsin adults who smoke are receiving primary care less and visiting emergency departments more than their non-smoking counterparts, highlighting a need for change in the way the healthcare community reaches out to the most vulnerable individuals.

In this new study— published in the Wisconsin Medical Journal—researchers analyzed 1,726 survey responses collected between 2014 and 2016, comparing how people who currently, formerly, or never smoked utilized healthcare services differently.

Dr. Margaret Nolan
Dr. Margaret Nolan

“I had always focused on smoking cessation as part of a healthcare visit,” said Dr. Margaret Nolan, lead author on the project, “but, during my time at UW-CTRI, I was involved in the primary-care outreach project at GHC, where we were proactively reaching out to patients who had not been in to see a doctor in the past year. Many of these patients were interested in quitting smoking. This got me thinking more about the patients who do not use primary care, and how we might reach them in other ways.”

Nolan led a team that analyzed data from 1,726 respondents to the Survey of the Health of Wisconsin. She found that people who reported current smoking (about 15 percent of the respondents) had more emergency-service visits than did people who formerly or never smoked, and they were less likely to access primary care.

Sixteen percent of people who reported current smoking said they had no place to go when sick, 18 percent said they needed healthcare but didn’t get it in the past year, 16 percent reported a delay in getting care, and 12 percent said the emergency room was their usual place to go when sick. These rates were at least twice as high as those in people who don’t smoke.

Only 58 percent of people who smoke said they had received a general health checkup in the past year, compared to 70 percent of those who don’t smoke.

“Patients who do not receive primary care may miss out on smoking cessation interventions that we at UW-CTRI train and assist primary care teams to deliver,” said Dr. Danielle McCarthy, UW-CTRI researcher on the project. “Sadly, it is not surprising to see that smoking is associated with proxies for socioeconomic disadvantage, including limited access to health care. This is consistent with the overall trend that we have seen: smoking hits those with the least means the hardest.

Danielle McCarthy Headshot
Dr. Danielle McCarthy

“Patients who smoked had one more visit to an emergency department per year, on average, than did patients who did not smoke. Perhaps receiving more outpatient care could have reduced the need for these emergency visits. Even with insurance, an emergency department visit can be expensive. Without insurance, this can be quite costly. As such, the differences in access to care observed in this study may be consequential for individuals and families.

“The findings from this study reinforce the importance of finding new, effective ways to bring smoking cessation treatment to socioeconomically disadvantaged people who smoke in ways that do not rely exclusively on primary care. Integrating smoking-treatment screening and referral in emergency-department care could help address gaps in access to primary care. One of our UW-CTRI collaborators, Steven Bernstein, MD has evaluated strategies to achieve this.”

“We see that people who smoke are also more likely to report poor health and lower perceived quality of health care,” said Nolan.

“These could all be areas of further research in order to better address these inequities. Most importantly, we need to better understand the motivations for healthcare utilization patterns. Are people using the ED for primary care because they are uninsured? Because they can’t get time off from work to schedule a primary care visit? Because they are sicker? We don’t know this from the current data, but it would be important to know in order to better meet the needs of patients who smoke (both to offer smoking cessation services and offer other preventive care services).”

Nolan M, Spicer A, Remington P, Malecki K, McCarthy D. (2022) Missing Out: Underutilization of Primary Care by Wisconsin Patients Who Smoke and Its Implications for Tobacco Treatment Access. Wisconsin Medical Journal. Online December 20, 2022.