Physician advice for smoking cessation in primary care: time for a paradigm shift?

Abstract

General practitioners are often exhorted to routinely counsel patients who smoke about quitting in light of current evidence-based medicine (EBM) guidelines suggesting that such brief interventions provide an easy and effective way of increasing quit rates. Drawing on semi-structured interviews conducted with 25 smokers and 10 general practitioners (GPs) in British Columbia, Canada, this article explores smokers’ and GPs’ perspectives on smoking cessation interventions in primary care settings. Study findings indicate that both patients and GPs believe smoking is best broached when it is patient-initiated or raised in the context of smoking-related health issues, and there was a broader consensus that the role of doctors is to provide education and information rather than coercing smokers to quit. However, smokers wanted further recognition of the difficulties of quitting smoking and many questioned the competence of GPs to deal with addiction-related issues. Similar barriers to smoking cessation were raised by smokers and GPs – primarily inadequate time and resources. Based on these findings, we argue that the assumption that primary care consultations provide an important venue for encouraging smokers to quit deserves reconsideration based on the complexity of this issue, the circumstances in which most GPs practice, and the danger of alienating smokers. Questions are raised about whether current EBM guidelines are an adequate tool for guiding individual clinical interactions between GPs and smokers.

Keywords:

• health promotion
• population health
• primary care

Acknowledgements

This research was funded by a seed grant from the Ethics Office of the Canadian Institutes of Health Research titled ‘Rights, risks and smoking: How denormalisation mediates patient-provider interactions in primary care settings’. We would like to acknowledge the contribution of our fellow co-investigator on this study, Amy Salmon, in helping to develop the coding framework for the smoker/ex-smoker interview material, and the two anonymous CPH reviewers, who provided invaluable feedback on the initial draft of this manuscript. Ethical approval was obtained from the University of British Columbia Research Ethics Board (H08-01170-A003) prior to commencing this study.

Notes

Notes

1. This growing emphasis on health promotion and lifestyle counselling in primary care represents part of a broader ideological shift from targeting high risk or symptomatic individuals to a population-level, preventive approach to healthcare (Lawlor et al. 2000) that reflects public health policy interests in finding low-cost, non-institutional solutions to healthcare (Bunton 1992).

2. This resistance amongst primary care physicians to a population-level approach to the provision of smoking cessation advice has been documented for lifestyle advice more broadly (Lawlor et al. 2000, Yarnall et al. 2003).

3. Initially, the study advertisements targeted all smokers/recent ex-smokers. A spreadsheet was kept of the sex, age and smoking status of all participants so that we could keep track of the basic demographic characteristics of participants. As the study progressed, advertisements became more targeted in order to focus on those groups underrepresented in our sample.

4. In the interests of equity, we originally decided upon a $25 honorarium for both groups. However, given the difficulties with recruiting GPs, a consultant GP on the project advised us to raise the GP honoraria to $50. We recognise the resulting irony that those participants who would have most benefited from the honorarium got the smallest one. That said, we would likely have had difficulty in getting ethics approval for a higher honorarium for smokers, because of concerns about the ‘coercive’ dimensions of high payments for low-income participants. This speaks to the ongoing debates about the use of honoraria in research studies and whether they should be seen as incentives, reimbursements or payments equivalent to hourly wages (Dickert and Grady 1999).

5. Following the identification of the manifest content (the visible, surface themes), the latent themes were inferred through close readings of the coded material in order to examine the relationships between the statements proffered and draw broader conclusions regarding their underlying meanings (see Kondracki et al. 2002, Graneheim and Lundman 2004, for further discussion of latent/manifest content analysis).

6. However, this particular GP had received training in delivering brief tobacco interventions, which likely informed his views on the need to regularly broach the topic of smoking with patients.

7. Canada's doctor–patient ratio is amongst the worst of any industrialised nation: with just 2.2 physicians per thousand people (Gulli and Lunau 2008).

8. Potential areas of difference include the higher levels of tobacco denormalisation in Canada than the UK (Hammond et al. 2006, Bell et al. 2010a), which we have previously suggested contributes to the charged nature of smoking cessation discussions in primary care settings (Bell et al. 2010b). Other differences may be related to the local specificities of British Columbia's ‘west coast’ lifestyle’, where a high moral valence is attached to the pursuit of health and ‘natural’ means of pursuing it (e.g. yoga, ‘nutriceuticals’, etc.).