Qualitative study of patients' perceptions of doctors' advice to quit smoking: implications for opportunistic health promotionBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7148.1878 (Published 20 June 1998) Cite this as: BMJ 1998;316:1878
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The paper by Butler et al1 challenges current practice regarding unsolicited antismoking advice from GPs. It potentially provides a basis for the development of patient centred approaches. Before this can be done the suggested typologies need to be reliably reproducible in a practical setting. Observers independent of the study have not as yet attempted to place the study’s subjects into the specified categories. To do so would reduce concerns that classification could vary between practitioners. We also need to demonstrate that this typology can be reliably applied to the wider population, including people from social class V and the unemployed (who were not included in the study).
The idea of typologies raises the important issue that the same intervention may not be suitable for all patients. Current practice relies on the insight of GPs to give acceptable antismoking advice. Typologies would provide GPs with guidance, enabling them to tailor advice to individual patients more effectively, making the advice more acceptable. However the authors’ assumption that that this advice would therefore be more effective in terms of smoking cessation is an hypothesis that requires further investigation. It has been estimated that GP advice to stop smoking costs £270 per QALY2. The use of this more complex, new intervention would increase the associated cost. Thus we need to be sure that the intervention will be of sufficient benefit to maintain cost-effectiveness.
This study does not address the effectiveness of opportunistic antismoking advice but it does provide important information about the acceptability of this intervention to different patients. If the effectiveness of more acceptable antismoking advice is proven in the future this will be of mutual benefit to patients and doctors.
Malcolm Lawson Third year medical student
Linda Waddilove Third year medical student
Jacqui Mascall Third year medical student
Department of Epidemiology and public Health, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, NE2 4HH.
1. Butler CC, Pill R, Stott NCH. Qualitative study of patients’ perceptions of doctors’ advice to quit smoking: implications for opportunistic health promotion. BMJ 1998; 316:1878-81 (20 June)
2. Maynard A. Developing the Health Care Market. The Economic Journal 1991; 101:1277-86 (September)
Competing interests: No competing interests
After 5 years of developing and utilising a programme of advice about smoking I concur with many of the findings of Butler, Pill and Stott. I am acutely aware of the criticism that many General Practitioners are dictatorial, and demanding of immediate smoking cessation. I adopt a sympathetic and supportive stance, helping patients understand more about the addictive nature of nicotine, the importance of support from family and friends, and the need for long-term effort. Increasing a smoker’s awareness and changing their attitude are of paramount importance.
Smokers may be aware of the dangers of smoking, but has anybody explained why smoking causes hardening of the arteries, why it causes babies to be born small. It’s no wonder that denial and under-reporting of smoking is a problem. If smoking-related diseases are to be treated effectively accurate information about smoking is required. Laboratory tests to verify and quantify smoking are available, and a near-patient test to measure nicotine and its breakdown products is currently being developed1. This correctly identifies smokers, and quickly assesses nicotine intake. The medical profession, as well as the general public, need to be educated about the variability of smoking behaviour, which includs the range of cigarettes available, the manner of smoking - the number, duration and frequency of puffs from a cigarette, and the variability of nicotine metabolism.
Smokers often cite their enjoyment of smoking, and its ability to induce relaxation as the reason for continuing to smoke. Attitudes quickly change if it is explained that nicotine, and the craving for it during periods of deprivation, is the cause of the anxiety and enjoyment is simply a relief of the yearning. To achieve smoking cessation a person, must progress through a series of psychological stages. Their ‘readiness’ to quit can be manipulated with an understanding, individualistic approach with long-term support. Complete cessation is too demanding for many patients, but a gradual concerted effort to cut down, with a view to cessation when the time is right is more acceptable. Also taking into account ‘life factors’ which may be impeding change, and delaying action until the time is right, shows compassion and understanding.
As the paper in question highlights current advice to smokers is inadequate and new approaches are needed. The message to quit smoking needs modification, moving away from the negative effects of smoking on health, towards a positive attitude that behaviour can be changed to the benefit of health and general well-being. The patient should be set achievable targets, which will encourage progress towards the goal of smoking cessation.
1. Cope G, Nayyar P, Holder R, Gibbons J, Bunce R. A simple near-patient test for nicotine and its metabolites in urine to assess smoking habit. Clin Chim Acta 1996; 256: 135-49.
Competing interests: No competing interests