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In the 20 June 1998 issue of the “BMJ”, Butler et al published a study “to determine the effectiveness and acceptability of general practitioners’ opportunistic antismoking interventions by examining detailed accounts of smokers’ experiences of these.” Based on interviews with 42 current smokers and recent quitters, these investigators, from the University of Wales College of Medicine, concluded that “Doctor–patient relationships can be damaged if doctors routinely advise all smokers to quit.” The abstract from their article is reproduced in the box.
Because the conclusions reached by Butler et alchallenge the conventional wisdom espoused in the tobacco control community, we solicited commentaries on their paper from several experts in the role of physicians in smoking cessation. Two commentaries—one by Solberg and Kottke, and the other by Fiore and colleagues—appear below. Another reply to the article by Butleret al—from Hong Kong—appeared in the 5 December 1998 issue of the “BMJ” (1998; 317:1588).—ED
BMJ 1998;316 :1878–81 (20 June)
Qualitative study of patients’ perceptions of doctors’ advice to quit smoking: implications for opportunistic health promotion
Christopher C Butler,lecturer; Roisin Pill, professor; Nigel C H Stott, professor;
Department of General Practice, University of Wales College of Medicine, Cardiff CF3 7PN, UK
Objectives—To determine the effectiveness and acceptability of general practitioners’ opportunistic antismoking interventions by examining detailed accounts of smokers’ experiences of these.
Design—Qualitative semistructured interview study.
Subjects—42 participants in the Welsh smoking intervention study were asked about initial smoking, attempts to quit, thoughts about future smoking, past experiences with the health services, and the most appropriate way for health services to help them and other smokers.
Results—Main emerging themes were that subjects already made their own evaluations about smoking, did not believe doctors’ words could influence their smoking, believed that quitting was down to the individual, and felt that doctors who took the opportunity to talk about smoking should focus on the individual patient. Smokers anticipated that they would be given antismoking advice by doctors when attending for health care; they reacted by shrugging this off, feeling guilty, or becoming annoyed. These reactions affected the help seeking behaviour of some respondents. Smokers were categorised as “contrary,” “matter of fact,” and “self blaming,” depending on their reported reaction to antismoking advice.
Conclusions—Doctor–patient relationships can be damaged if doctors routinely advise all smokers to quit. Where doctors intervene, a patient centred approach—one that considers how individual patients view themselves as smokers and how they are likely to react to different styles of intervention is the most acceptable.
Patient perceptions: an important contributor to how physicians approach tobacco cessation
The interviews conducted by Butler et al 1-1 with current and former smokers make several important contributions to tobacco control strategies. We entirely agree with their report that most smokers already are aware that smoking is dangerous, and that many will resent physician advice when it is provided in a preaching manner. Moreover, a patient-centred approach that is respectful and individualised, which they recommend, is not only necessary but the only one likely to achieve the desired result.
The National Cancer Institute in the United States suggests an unforgettable series of 4 As as a guideline for desired physician behavior (Ask, Advise, Assist,Arrange).1-2 Unfortunately, there is a tendency for many physicians to emphasise advice—warnings about the dangers of smoking and efforts to convince a patient to quit—without first asking about interest in quitting. If there is already interest in quitting (as is usually the case in the United States), then suggestions and assistance are more appropriate. The patients reported by Butler et al corroborate our opinion that attempts to convince the patient to take action are neither helpful nor appropriate most of the time.1-3
Prochaska’s stages of readiness to change are an even more elegant and evidence-based model for this approach.1-4 1-5 The tobacco cessation guideline developed by the Minnesota-based Institute for Clinical Systems Integration is built on these principles and on the need for supportive systems.1-6 1-7
Unfortunately, Butler et al have carried this important report from smokers to an unnecessary extreme by emphasising the potential for damage to the doctor–patient relationship and the need to reconsider advising cessation at every opportunity.1-1Physicians are already doing poorly in raising the smoking issue at patient encounters.1-8 1-9 If the patient-centred approach suggested by the study by Butler et al is followed, it is not only possible to discuss smoking at nearly every encounter, but such discussions will produce far greater quit rates than the article notes. Regardless of what smokers may report, there is very strong evidence that physician support for cessation is effective and more effective the more frequently it occurs.1-10 1-11
Fear in physicians and nurses of a negative reaction from patients may be one of the reasons for their dismal record of cessation support. Because there is an effective way to intervene that does not risk damage to the patient–doctor relationship, avoiding discussions of smoking cessation to avoid the possibility of offending patients is an unhealthy form of collusion between physicians and patients. Brett and McCullough have written convincingly about the limits to the physician’s obligation to respond to requests by the patient.1-12 They note that physicians may legitimately deny requests by their patients for useless or dangerous care. In the case of smoking cessation, agreeing to an unspoken or assumed request to refrain from discussing smoking is tantamount to agreeing to dangerous care.
Therefore, let us emphasise and repeat the important message in the study by Butler et al—that most smokers neither want nor benefit from prolonged attempts to convince and warn. Instead, they will welcome a consistent, friendly assessment of their interest in quitting and individualised, respectful provision of cessation support for whatever that assessment reveals.
Quality in quantity: in support of consistent, physician-delivered smoking intervention
The conclusions generated by Butler et al 2-1 are troublesome in light of recent literature. The authors are critical of the consistent delivery of smoking intervention by physicians during routine office visits. However, a body of research suggests that brief and repeated smoking cessation treatment can indeed be efficacious in a clinical setting.2-2-2-5 Physicians by nature are responsible for educating their patients about health risks and appropriate preventive measures. Therefore, unless there is a compelling, countervailing reason, physicians should provide their smoking patients with a brief, effective cessation or motivational intervention at each clinical visit.2-2
The authors advocate that physicians take a “patient-centred” approach to smoking intervention. That is, they suggest that physicians focus their intervention on patients who appear interested in cessation. Such a strategy could deny a majority of smokers effective cessation treatment. A central problem with the authors’ approach is that a physician’s objective assessment of a smoker’s interest in quitting may be a poor index of the likelihood that that smoker would benefit from intervention. Because of this, any time that physicians withhold smoking treatment, they may be denying the patient the opportunity to avoid premature death or disability. Therefore, before physicians withhold treatment for some patients, especially treatment for a potentially life-threatening condition, they should be certain that such a policy would result in a net improvement in public health. No such evidence is currently available.
The authors suggest that physicians abandon consistent and repeated smoking intervention because they believe that such intervention may introduce “barriers” in the doctor–patient relationship. Why would smoking intervention produce more barriers than intervention for hypercholesterolaemia, sexually transmitted disease, or hypertension? Although maintaining a positive doctor–patient relationship is of importance in a clinical setting, a patient’s health is of primary concern. Worry about occasional strain in the relationship isnot sufficient for denying the patient available health-enhancing information. The fallaciousness of their argument is apparent when considering other common health issues. For example, should a physician neglect to monitor cholesterol and to offer motivational advice to an individual at risk of heart disease, simply because of the chance of an adverse patient reaction? When physicians prioritise healthcare issues, smoking intervention should assume a role commensurate with the impact of smoking on public health.
The article by Butler et al does bring up the fact that more needs to be learned about physician style in smoking intervention. How the physician addresses the patient is obviously of extreme importance in terms of patient compliance. The authors imply that the physician-delivered intervention must be negative in tone. This is not the case. Although physicians must be lucid and straightforward in their delivery, they should not appear uncaring or judgmental. Warmth and empathy may not only reduce strain in the doctor–patient relationship, but enhance the efficacy of the cessation intervention as well.
Approximately half of all smokers will die prematurely of a disease that results directly from their tobacco addiction.2-6 To ignore this extraordinary health threat because of potential damage to doctor–patient relationships would be an inappropriate standard of care in 1999.
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