Factors Associated with Erectile Dysfunction Among Older Gay Men.

Erectile dysfunction (ED) is a common issue that aging men encounter, but whether internalized gay ageism (i.e., the internalization of ageist messages within the context of aging as a gay man) is related to ED among older gay men is unknown. A cross-sectional web-based survey explored the relationship between internalized gay ageism, health-related and social factors, and ED among older gay men who resided in the Midwest United States (N = 181). Internalized gay ageism was not significantly associated with ED. However, hierarchical regression analysis found that age (ß = .224, t = 2.70, p = .008) and overall health (ß = -.247, t = -3.05, p = .003) were significantly associated with ED among older gay men, suggesting that older gay men share similar risk factors for ED as the general male population. Future research should continue to explore other factors that are unique to gay men that may be associated with ED.

Social and Mental Health Factors Associated with Sexual Satisfaction Among Older Gay Men.

The internalization of ageist stereotypes or messages based on the framework of an aging gay man is known as internalized gay ageism. Internalized gay ageism may influence an older gay man's sexual satisfaction. The aim of this study was to examine the relationship between internalized gay ageism and sexual satisfaction and determine if body image was a potential mediator. A cross-sectional online survey collected data on sexual satisfaction and other variables related to sexual health and well-being among older gay men. Inclusion criteria included: aged 50 or older, identified as gay, identified as male, assigned male at birth, and resided in the Midwestern region of the United States. Descriptive, bivariate, and mediation analyses were conducted. A complete mediation effect was found between internalized gay ageism and sexual satisfaction when mediated by body image. Older gay men who were in open relationships were more sexually satisfied than single/widowed older gay men. Future research should continue to explore internalized gay ageism, relationship status, body image, and sexual satisfaction among older gay men.

Differences Between Transgender and Gender Diverse Adults in Michigan Currently Using Gender-Affirming Hormone Therapy and Nonusers Reporting Interest in Future Use.

Purpose: This study explores the sociodemographic, insurance coverage, and substance use differences among transgender and gender diverse (TGD) individuals currently using hormone therapy (HT) and those who have an interest in future HT use. Methods: We surveyed TGD individuals in Michigan in 2018 to examine sociodemographic, health insurance, and substance use differences between those who had used HT and those who were interested but had never accessed HT using logistic regression models. Results: Respondents (N = 536) were 80.1% White and 18.0% nonbinary. About two-thirds of the participants had ever used HT (65.7%). In multivariate analyses, nonbinary participants were much more likely to be interested in future HT use than transmasculine individuals (odds ratio [OR] = 6.91), yet no significant difference between transmasculine and transfeminine individuals was found. Black participants also had higher odds of interest in future HT use (OR = 8.79). Those who did not know if they had trans-specific insurance coverage (OR = 42.39) and those who had no trans-specific insurance coverage (OR = 4.50) were more likely to be in the future interest group compared with those who reported full trans care coverage. Those with a bachelor's degree were less likely to be in the future interest group than those with some college education or an associate's degree, as were heavy marijuana users. Conclusion: Nonbinary individuals may be interested in HT but lack access, and known health care disparities around race and socioeconomic status may also impact HT access. Standard and transparent insurance coverage for gender-affirming care is sorely needed.

Prescription Pain Reliever Misuse Among Transgender and Gender Diverse Adults.

Purpose: Little is known about the prevalence and risks associated with transgender and gender diverse (TGD) persons' misuse of prescription pain relievers (PPRs). This study explores the relationship between PPR misuse and various sociodemographic identities and experiences of discrimination in health care among TGD adults. Methods: TGD participants (n=595) were recruited in 2018 to participate in a cross-sectional statewide trans health survey through convenience sampling. Chi-square tests of independence and logistic regressions were conducted to explore associations between sociodemographics and experiences of discrimination among persons who had ever misused PPRs, or who had misused PPRs in the past year. Results: Sociodemographics such as gender identity (odds ratio [OR]=0.44, p=0.01), race/ethnicity (OR=0.14, p<0.001), and sexual orientation influence TGD individuals likeliness of misusing PPRs (OR=0.40, p<0.001). Notably, those who were ever diagnosed with anxiety had a higher likeliness of having lifetime PPR misuse compared with those who were never diagnosed (OR=2.05, p=0.05), and those reporting past-year discrimination within the mental health care setting because of their gender identity were more than twice as likely to report past-year misuse than those who reported not experiencing it (OR=2.43, p=0.004). Conclusion: Certain subpopulations of TGD individuals may be at elevated risk of PPR misuse. It is imperative to acknowledge the impact of multimarginalized identities as well as differences across various identities and experiences within the TGD community while working to address non-PPR misuse.

Healthcare experiences among Black and White sexual and gender minority cancer survivors: a qualitative study.

PURPOSE: The purpose of this study was to explore healthcare experiences of Black and White sexual and gender minority (SGM) cancer survivors across the cancer care continuum. METHODS: This was a qualitative analysis of two focus groups and eight individual interviews completed as part of a larger initiative using a community-engaged research approach to reduce cancer disparities in marginalized communities. There was a total of 16 participants in the study (9 were White, 7 were Black) and data were collected between 2019 and 2020. RESULTS: Three main themes emerged from the thematic analysis: strategically coming out, provider preferences, and health system challenges. Participants noted that they often came out through their support system, decided to come out based on the relevance of their SGM identity that they perceived, and expressed a desire for privacy. Lack of an accessible and competent PCP was tied to delayed cancer diagnosis and many participants voiced a preference for consistency when they found a provider they liked. CONCLUSIONS: Providers across specialties can address barriers for SGM patients by not making assumptions about patient sexual orientation or gender identity. Institutions should systematically collect sexual orientation and gender identity information. Primary care providers should be aware that due to resistance to switching from trusted providers, they may need to take greater initiative to facilitate cancer screenings for their patients when appropriate or take special care when making referrals to ensure they are using SGM-affirming providers. IMPLICATIONS FOR CANCER SURVIVORS: SGM cancer survivors often benefit from a cultivating relationship with a trusted PCP or other provider.

Emergency Clinicians' Comfort Levels in Caring for Transgender Patients.

Objective: Transgender individuals report negative experiences in emergency department settings, but little is known about emergency clinicians' barriers to treating transgender patients. The purpose of this study was to explore emergency clinicians' experiences with transgender patients to better understand their comfort with caring for this population. Methods: We conducted a cross-sectional survey of emergency clinicians in an integrated health system in the Midwest. To assess the relationship between each independent variable and the outcome variables (i.e., comfort level generally and comfort level asking transgender patients about their body parts specifically), Mann-Whitney U test or Kruskal-Wallis analysis of variance was conducted for categorical independent variables and Pearson correlations were conducted for continuous independent variables. Results: Most participants (90.1%) were comfortable caring for transgender patients, whereas two-thirds (67.9%) were comfortable asking transgender patients about body parts. Although none of the independent variables was associated with increased clinician comfort level caring for transgender patients in general, White clinicians and those who were unsure how to ask patients about their gender identity or transgender-specific care they had received were less comfortable asking about body parts. Conclusion: Having skills to communicate with transgender patients was associated with emergency clinicians' comfort levels. In addition to offering traditional classroom-based didactics about transgender health care, providing opportunities for clinical rotations that allow clinicians-in-training to treat, and perhaps more importantly, learn from transgender patients will likely be higher yield in bolstering clinician confidence in serving this patient population.

Gynecological Providers' Willingness to Prescribe Gender-Affirming Hormone Therapy for Transgender Patients.

Purpose: Transgender individuals face barriers to accessing gender-affirming hormone therapy, yet little is known about gynecological providers' willingness to provide such care. Methods: We surveyed gynecological providers in one healthcare system to determine their willingness to prescribe hormone therapy (HT) for transgender patients and factors associated with willingness to both initiate and refill HT. Results: Among respondents (N = 60), 60.3% and 27.6% were willing to refill and initiate HT for transgender patients, respectively. Willingness to refill HT was associated with having met a transgender person and lower transphobia. Unwillingness was associated with lack of transgender health training, lack of staff knowledge about transgender health, and unfamiliarity with transition guidelines. Willingness to initiate HT was associated with younger age and resident status. Unwillingness was associated with unfamiliarity with transition guidelines. Conclusion: While gynecological providers are qualified to prescribe HT for transgender patients, willingness to do so may be influenced by both personal and educational/training factors. Encouraging and training gynecological providers to provide gender-affirming HT will help to increase access for transgender individuals.

Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial.

BACKGROUND: Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening. DESIGN: Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention's effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients. RESULTS: A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material. CONCLUSIONS: By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective. IMPLICATIONS: Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population. HIGHLIGHTS: Electronic health record tools can be used to facilitate practice-embedded pragmatic trial and patient-facing intervention processes, including patient identification, study arm allocation, and intervention delivery.The online portal-embedded intervention did not improve colorectal cancer (CRC) screening uptake following a physician recommendation, likely in part because portal users tend to be already highly engaged with healthcare.Relying on patient portals alone for CRC screening interventions may not alter screening use and could exacerbate well-known care disparities.

Suicide Attempts Among a Cohort of Transgender and Gender Diverse People.

INTRODUCTION: Transgender and gender diverse people often face discrimination and may experience disproportionate emotional distress that leads to suicide attempts. Therefore, it is essential to estimate the frequency and potential determinants of suicide attempts among transgender and gender diverse individuals. METHODS: Longitudinal data on 6,327 transgender and gender diverse individuals enrolled in 3 integrated healthcare systems were analyzed to assess suicide attempt rates. Incidence was compared between transmasculine and transfeminine people by age and race/ethnicity and according to mental health status at baseline. Cox proportional hazards models examined rates and predictors of suicide attempts during follow-up. Data were collected in 2016, and analyses were conducted in 2019. RESULTS: During follow-up, 4.8% of transmasculine and 3.0% of transfeminine patients had at least 1 suicide attempt. Suicide attempt rates were more than 7 times higher among patients aged <18 years than among those aged >45 years, more than 3 times higher among patients with previous history of suicide ideation or suicide attempts than among those with no such history, and 2-5 times higher among those with 1-2 mental health diagnoses and more than 2 mental health diagnoses at baseline than among those with none. CONCLUSIONS: Among transgender and gender diverse individuals, younger people, people with previous suicidal ideation or attempts, and people with multiple mental health diagnoses are at a higher risk for suicide attempts. Future research should examine the impact of gender-affirming healthcare use on the risk of suicide attempts and identify targets for suicide prevention interventions among transgender and gender diverse people in clinical settings.

Challenges and opportunities using online portals to recruit diverse patients to behavioral trials.

We describe the use of an online patient portal to recruit and enroll primary care patients in a randomized trial testing the effectiveness of a colorectal cancer (CRC) screening decision support program. We use multiple logistic regression to identify patient characteristics associated with trial recruitment, enrollment, and engagement. We found that compared to Whites, Blacks had lower odds of viewing the portal message (OR = 0.46, 95% CI = 0.37-0.57), opening the attached link containing the study material (OR = 0.75, 95% CI = 0.62-0.92), and consenting to participate in the trial (OR = 0.85, 95% CI = 0.67-0.93). We also found that compared to Whites, Asians had lower odds of viewing the portal message (OR = 0.53, 95% CI = 0.33-0.64), opening the attached link containing the study material (OR = 0.76, 95% CI = 0.54-0.97), consenting to participate in the trial (OR = 0.68, 95% CI = 0.53-0.95), and completing the trial's baseline questionnaire (OR = 0.59, 95% CI = 0.36-0.90). While portals offer an opportunity to mitigate human bias in trial invitations, because of racial disparities-not only in who has a portal account, but in how they interact with trial recruitment and enrollment material within the portal-using portals alone for trial recruitment may generate study samples that are not racially diverse.

Gynecologic Health Care Providers' Willingness to Provide Routine Care and Papanicolaou Tests for Transmasculine Individuals.

Background: Transmasculine individuals who have a cervix may be at risk of cervical cancer, but they face a number of barriers to accessing care, including difficulty finding knowledgable and culturally sensitive providers who are willing to care for transgender patients. We examined gynecologic health care providers' willingness to provide routine care and Papanicolaou tests (Pap tests) to transmasculine individuals, including the role of personal, clinical, and professional factors. Materials and Methods: We surveyed attending physicians, advanced practitioners, and residents in the Women's Health department of a large, integrated Midwest health system (n = 60, 74.1% response rate). Results: A majority of participants were female (68.3%) and white (73.3%). Most had met a transgender person before (79.7%), and 40.7% had cared for a transgender patient in the past 5 years. Most reported willingness to provide routine care (74.6%) and Pap tests (85.0%) to transmasculine people. Bivariate analysis suggests that having met a transgender person (p = 0.028), higher empathy scores (p = 0.015), political views (p = 0.0130), and lower transphobia (p = 0.012) were associated with willingness to provide routine care to transmasculine individuals. Lower transphobia (p = 0.034) and political views (p < 0.001) were also associated with willingness to provide Pap tests to transmasculine people. Conclusions: Providers' willingness was not associated with barriers related to training or knowledge-only with personal biases and experiences. Transgender-inclusive health care training that addresses personal attitudes should be a routine part of training for all health professionals.

Randomised trial to evaluate the effectiveness and impact of offering postvisit decision support and assistance in obtaining physician-recommended colorectal cancer screening: the e-assist: Colon Health study-a protocol study.

INTRODUCTION: How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening. METHODS AND ANALYSIS: In partnership with healthcare teams, we developed 'e-assist: Colon Health', a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient-physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50-75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians. ETHICS AND DISSEMINATION: All trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action. TRIAL REGISTRATION NUMBER: NCT02798224; Pre-results.

Transphobia rather than education predicts provider knowledge of transgender health care.

PURPOSE: Transgender and gender diverse (TGD) patients face significant hurdles in accessing affirming, knowledgeable care. Lack of provider knowledge presents a substantial barrier to both primary and transition-related care and may deter patients from seeking health care. Little is known about factors that affect provider knowledge or whether exposure to TGD health content during training is associated with improved knowledge among providers. Using the TGD Healthcare Knowledge Scale, this study aimed to determine whether prior education on TGD health predicts clinicians' current knowledge regarding health care for TGD patients. METHODS: An online survey examining exposure to TGD content and knowledge of TGD health care was distributed to all primary care providers in an integrated health care system in the Midwestern United States. Multivariable linear regression was used to predict provider knowledge, controlling for demographics, transphobia and other potential confounders. RESULTS: The response rate was 57.3% (n = 223). The mean knowledge score was 7.41 (SD = 1.31) on a 10-point scale. Almost half (48.4%, n = 108) had no formal education on TGD health care, yet half (49.7%, n = 111) of providers reported previously caring for at least one transgender patient. In regression analysis, provider knowledge of TGD health care was associated with transphobia (ß = -0.377, 95% CI = -0.559 to -0.194, p < 0.001), but not with hours of formal education (ß = -0.027, 95% CI = -0.077 to 0.023, p = 0.292) or informal education (ß = -0.012, 95% CI = -0.033 to 0.009, p = 0.259). CONCLUSIONS: Increasing hours of education related to TGD health care may not be sufficient to improve providers' competence in care for TGD individuals. Transphobia may be a barrier to learning that needs to be addressed. Broader efforts to address transphobia in society in general, and in medical education in particular, may be required to improve the quality of medical care for TGD patients.

Patient-Reported Needs Following a Referral for Colorectal Cancer Screening.

INTRODUCTION: Patient-physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support. METHODS: Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016. RESULTS: Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician. CONCLUSIONS: Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Patients' adoption of and feature access within electronic patient portals.

OBJECTIVES: We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs. STUDY DESIGN: Retrospective cohort study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system. METHODS: Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated "clicks." Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters. RESULTS: One-third of patients were portal adopters, with African Americans (odds ratio [OR], 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters. CONCLUSIONS: The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities-even among those with an activated portal account.

Primary Care Clinicians' Willingness to Care for Transgender Patients.

Transgender patients report negative experiences in health care settings, but little is known about clinicians' willingness to see transgender patients. We surveyed 308 primary care clinicians in an integrated Midwest health system and 53% responded. Most respondents were willing to provide routine care to transgender patients (85.7%) and Papanicolaou (Pap) tests (78.6%) to transgender men. Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia. Medical education should address professional and personal factors related to caring for the transgender population to increase access.

Primary care providers' willingness to continue gender-affirming hormone therapy for transgender patients.

Background: Most transgender individuals either use or are interested in using gender-affirming hormone therapy (HT). Making gender-affirming HT available in primary care is critical for quality care to this vulnerable population. The barriers that transgender patients experience to accessing this treatment may be exacerbated if primary care providers (PCPs) will not provide it. Little is known about PCPs' willingness to administer HT to transgender patients. Objective: To examine whether PCPs are willing to continue prescribing HT for transgender patients and the factors that predict such willingness. Methods: An online survey of internal and family medicine physicians and residents practising in a large integrated Midwest health system (n = 308); 158 responded to the relevant questions (51.3%). Results: Approximately 50% of respondents were willing to continue HT for transgender patients. Most participants had previously met a transgender person (77%), and approximately half of them had cared for a transgender patient in the past 5 years. Multivariate logistic regression results indicate that attending physicians had lower odds of willingness to continue HT compared with medical residents, and those who reported perceived capability of providing routine care to transgender patients had higher odds of willingness. Conclusions: Only about half of PCPs surveyed were willing to continue HT for transgender patients. Our study indicates that both personal and clinical factors play a role. Future research should address ways to increase PCPs' willingness and comfort related to continuing HT for transgender patients.

To Refer or Not to Refer: General Pediatricians' Perspectives on Their Role in Caring for Transgender Youth.

Little is known about general pediatricians' experience and knowledge regarding the care of transgender youth. We surveyed N=50 general pediatricians practicing in an integrated Midwest health system. Few respondents had participated in medical management care for transgender patients, but one-third were willing to do so if training opportunities were made available. Notably, <60% of respondents were comfortable providing routine care for transgender youth. At a minimum, pediatricians need the training to feel capable of providing routine care for transgender pediatric patients. In addition, opportunities for training should be offered to those who are willing to learn about medical management of transgender youth.

Discrimination and Delayed Health Care Among Transgender Women and Men: Implications for Improving Medical Education and Health Care Delivery.

BACKGROUND: The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of the many factors significantly associated with health care utilization and delayed care. OBJECTIVES: We assessed factors associated with delayed medical care due to discrimination among transgender patients, and evaluated the relationship between perceived provider knowledge and delayed care using Anderson's behavioral model of health services utilization. RESEARCH DESIGN: Multivariable logistic regression analysis was used to test whether predisposing, enabling, and health system factors were associated with delaying needed care for transgender women and transgender men. SUBJECTS: A sample of 3486 transgender participants who took part in the National Transgender Discrimination Survey in 2008 and 2009. MEASURES: Predisposing, enabling, and health system environment factors, and delayed needed health care. RESULTS: Overall, 30.8% of transgender participants delayed or did not seek needed health care due to discrimination. Respondents who had to teach health care providers about transgender people were 4 times more likely to delay needed health care due to discrimination. CONCLUSIONS: Transgender patients who need to teach their providers about transgender people are significantly more likely to postpone or not seek needed care. Systemic changes in provider education and training, along with health care system adaptations to ensure appropriate, safe, and respectful care, are necessary to close the knowledge and treatment gaps and prevent delayed care with its ensuing long-term health implications.

Assessment of the Efficiency of Tobacco Cessation Counseling in Primary Care.

Clinical Practice Guidelines for Treating Tobacco Use and Dependence advocate for using counseling targeted at tobacco users' motivation to quit during each office visit. We evaluate tobacco use screening and counseling interventions delivered during routine periodic health examinations by 44 adult primary care physicians practicing in 22 clinics of a large health system in southeast Michigan. 484 office visits were audio-recorded and transcribed. For this study, current tobacco users (N = 91) were identified using pre-visit surveys and audio-recordings. Transcripts were coded for the delivery of tobacco-related counseling interventions. The extent to which counseling interventions were used and/or targeted to the patients' readiness to quit was the main outcome measure. The majority of tobacco users (n = 77) had their tobacco use status assessed, and most received some sort of tobacco-related counseling (n = 74). However, only 15% received the recommended counseling targeted to their readiness to quit. On the other hand, 19% received less counseling than recommended given their readiness to quit, 7% received only nonindicated counseling, and 59% received nonindicated counseling in addition to indicated counseling. Results illustrate physicians' commitment to cessation counseling and also identify potential opportunities to improve the efficiency of tobacco-related counseling in primary care.