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Background: Despite years of intervention, few studies describe the extent to which recommended tobacco use prevention and cessation activities occur in community-based family practices. This study was designed to discover current practice patterns in these areas and to describe physician outcome and efficacy expectations., Methods: An exploratory comparative case study of 11 family practices used direct observation of practices and clinical encounters, chart reviews, and in-depth interviews. Qualitative and quantitative information was gathered on (1) intensity of tobacco use prevention and cessation; (2) physicians' attitudes and beliefs regarding outcome expectations; and (3) physicians' perceptions of their ability to counsel. Qualitative content analysis and descriptive statistics were used to construct case studies for comparisons., Results: Themes common to most practices included the "provision of little prevention" and "a lack of perceived need to address smokeless tobacco." Responsibility for tobacco activities fell almost solely to physicians. Although physicians felt confident in their counseling skills, the skills they identified were fairly basic. Most physicians were pessimistic about the positive effects of these activities. None of the practices was using any specifically developed "package," and pharmaceutical companies provided almost all patient education material. There was considerable variation in intensity of activities because of differences in attitudes, expectation, and background., Conclusions: To increase tobacco control activities, practice systems need to be individually evaluated to identify what is needed, how it will fit within the practice culture, and how it can best be implemented in this specific practice. One-size-fits-all interventions probably will not be widely implemented.