Because of the remarkable similarity in the accounts of those who had quit and those who continued to smoke, data from interviews with both these groups were pooled. Interviews conducted by the general practitioner and the social scientist contained a similar proportion of accounts that were critical of the health services. Thus, the suggestion that subjects would be less frank when interviewed by the general practitioner was not supported. The main themes relevant to subjects’ interactions with the health services are given in the box.
- Subjects had already made their own evaluations about their smoking
- Subjects were sceptical about the power of doctors’ words to influence their smoking
- Most believed that quitting smoking was down to the individual
- Subjects felt that doctors should be sensitive to the individual patient when talking about smoking
Subjects did not need to be told what to do about smoking since they had already made their own evaluations about their habit. A typical response was that of a 40 year old woman: “Well I’m telling myself the ... same thing. I mean it’s a waste of money, you are ruining your health, it’s obviously so many years off your life, things like before you could walk for miles and miles ... and now you are out of breath. ... I’m telling myself all these things, the problems like the smell of it, the expense and things like that. ... I know it all.”
Doctors’ powers of persuasion
Most subjects were sceptical about the power of doctors to influence smoking behaviour, especially since smokers already knew the risks they were taking with their health. Half stated that quitting is “down to the individual.” A 40 year old man stated that: “Everyone knows the dangers of smoking now. It’s not like it’s a top secret. ... If that smoker don’t want to stop smoking, the doctor could be three hours talking to him and he’ll walk out of the surgery and have a fag and thank God for that. I think everyone has heard of the consequences of what smoking does to you ... so I can’t see there is any good in going into great detail about it, because a smoker already knows it causes heart, cancer, whatever.”
Centring on the patient
If doctors are to raise the topic of smoking opportunistically, most subjects stated that good practice involves using a respectful tone, sensitivity to the patient’s receptivity, understanding the patient as an individual, being supportive, and, most frequently, not “preaching.” Approaching the subject in any of these ways was taken as support for the view that doctors should adopt a patient centred approach to talking about smoking in the consultation.
The response of a 51 year old woman is typical. “It depends on the person and the doctor. As long as they don’t lecture. They could ask perhaps, would you like to give up smoking? Would you like literature on smoking, do you know the pitfalls? But this ‘you will or you should give up’ attitude doesn’t, as far as I’m concerned—it’s very difficult because a lot of people, once you’ve asked the question, are you a smoker, they go on the defensive. I find now that I do. ... If doctors are going to talk, don’t patronise and don’t treat them like they are a different type of person. I think if they try and understand what people are going through, and its not always easy to give up. There are many reasons why people smoke. ... You’re half way there if you find that people understand how you are and what you feel.”
A few subjects suggested that doctors should try to scare patients into quitting, with visual images illustrating the health consequences of smoking. Paradoxically, none of these subjects volunteered that they themselves would quit if confronted by a major personal smoking health shock.
Anticipating antismoking advice
Over half the subjects anticipated that they would receive advice about smoking when attending for health care. Some shrugged this off, while others experienced irritation and guilt and saw these interventions as an inappropriate invasion of their privacy. Some modified their help seeking behaviour as a consequence of anticipated medical responses to their smoking, generally by changing their usual doctor. Two subjects, however, gave accounts of repercussions that were potentially dangerous.
A 30 year old man told the interviewer that “Everything was being blamed on smoking.... We weren’t going down any other avenues like diet or anything else, and I felt that it was pretty unfair, it made me feel pretty low ... it made me go out and have five or six cigarettes just to calm down and make me feel a little bit better about it, although that then had a backward effect because having had those cigarettes you would feel even worse.... He was pounding over and over.... I felt I had a knot in my stomach every time I had to go to see him, and to be perfectly honest, on two occasions I phoned up and cancelled the appointment ... because I was too wound up.... The day I was meant to go and see him next was the day I was admitted to hospital by ambulance.”
A 40 year old woman was also reluctant to seek help. “Also, like I say, I’ve been getting a few pains in my chest and I think perhaps I should go to the doctor and then you think the first thing they’re going to say to you is do you smoke, and you feel because you smoke and you go there they’re going to say its your fault, you shouldn’t smoke. ... Well I feel guilty then. I think, Oh my God, its my fault, nobody else’s and now I’m going expecting help. ... My sister, she was quite a heavy smoker. ... She died of hardening of the arteries. Now weeks she wasn’t well: she was having chest pains and then she had a bad stomach and she just went to bed one night and never woke up. So that frightened me as well because I was thinking obviously hardening of the arteries, that’s what causes chest pains in the beginning but I kept on at her that week to go to your doctor, go to your doctor, and she said oh no he’ll only tell me about my smoking.”
Types of smokers
Three broad types of smoker were identified, primarily according to how they reacted to advice from doctors to quit smoking. A “contrary” group tended to be less convinced of the merits of giving up, smoked more in response to being told to quit, and anticipated “ritualistic” advice from health professionals. They were sceptical about the power of doctors’ words to influence them and reported that they were already saturated with antismoking information. They were more likely to recount negative experiences of interacting with doctors about smoking, to change help seeking behaviour because of these negative experiences, and were more likely to assert that quitting smoking was down to the individual.
The “matter of fact” group tended to see smoking as a somewhat inexplicable and unfortunate lacuna in an otherwise balanced and worthy life. They thought it quite reasonable for doctors to discuss smoking with them. They were least likely to express a desire for a magic bullet cure, and they tended not to see themselves as social outcasts because of smoking. They were also least likely to be sceptical about the power of doctors’ words to influence smokers and least likely to report an overload of antismoking information.
The “self blaming” group spoke about their smoking with disgust and self loathing and reported shame at their smoking causing ill health in themselves and possibly others (through passive smoking). In fact, they more commonly had close personal experience of the negative health effects of smoking. They more often felt that smoking was a habit rather than an addiction, emphasising the personal failure of the smoker. They felt that doctors ought to speak to everyone about smoking, and they experienced guilt when this happened during their visits to the doctor.