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DISCUSSION PAPER
TIM COLEMAN
ANDREW WILSON
SUMMARY
General practitioners’ (GPs’) advice against smoking has a
small, beneficial effect on patients’ smoking. Consequently,
GPs have been urged to adopt a population-based
approach to advice-giving that involves discussing smoking
repeatedly with the maximum possible number of smokers.
This discussion paper assesses how far GPs’ current clini-
cal practice is from a population-based approach to advice-
giving and finds that GPs prefer a problem-orientated
approach to advising those who present with smoking-relat-
ed problems. Discussion focuses on the feasibility of sug-
gesting that GPs adopt a population-based approach
instead.
Keywords: smoking cessation; health promotion, general
practitioner.
Introduction
BRIEF advice against smoking is the simplest anti-smoking
intervention primary care physicians can provide and it is the
most frequently studied.1Trials have been completed in many
different primary care settings and these have been collated in
systematic reviews2-5 which conclude that general practitioners’
(GPs’) brief advice against smoking causes 2–3% of those
advised to stop smoking, that supportive follow-up increases quit
rates, and intensive advice is more effective than less intensive
advice. One analysis of the literature also concludes that provid-
ing a consistent, repeated anti-smoking message maximises the
efficacy of anti-smoking advice.5This message has recently been
emphasised by evidence-based guidelines for the management of
smoking cessation that have been published in the United
Kingdom6and in the United States of America.7Additionally,
the UK government published a White Paper8explaining how
policy can best address the smoking epidemic. These documents
argue, correctly, that anti-smoking interventions delivered by
doctors are effective and that the widespread delivery of these
interventions in primary care could reduce smoking prevalence.
They also propose that GPs should take a population-based
approach to advice-giving that involves discussing smoking
repeatedly with the maximum possible number of smokers to
have the greatest possible effect on population smoking rates.
Both the guidelines6,7 and the White Paper8acknowledge that a
population-based approach to advice-giving is far from general
practitioners’ current clinical practice, but neither suggests how
this could be achieved (at the time of writing this discussion
paper, the UK smoking cessation guidelines6were in the process
of being updated — see Postscript on page 1003).
This article assesses how far current practice is from a popula-
tion-based approach and whether or not it is feasible or desirable
to suggest that GPs adopt this approach. This is done by review-
ing literature on (a) how often UK general practitioners advise
patients against smoking and (b) what influences this aspect of
UK GPs’ clinical behaviour. The structures of primary care differ
greatly between countries, so it is likely that different factors will
influence family physicians’ clinical behaviour in these different
contexts. Consequently, we restrict our review and discussion
mainly to GP advice-giving in the context of UK general prac-
tice. Searches of the Medline, PsychLIT and Assia databases,
with reference checking, identified papers that describe the fre-
quency of and help explain GPs’ advice-giving behaviour. Some
papers that are known to the authors were also used where these
were not identified by searching. Identified papers had a variety
of keywords and it is possible that others remained unidentified.
This review must therefore be viewed as selective rather than
exhaustive, though we have tried to be as representative of the
available literature as possible.
How often do GPs discuss smoking with patients?
Knowing how often GPs currently discuss smoking with patients
helps us to assess the likelihood of them adopting a population-
based approach. Ideally, to answer this question accurately, we
need information from studies where GPs’ behaviour with
patients is observed. Few UK studies have actually done this, so
we also report those that used patient recall and GPs’ self-report
of their behaviour to quantify rates of advice-giving.
Up to 60% of smokers have no recollection of discussing
smoking with their GP at any time.9This increases to 70–73% if
smokers are asked whether they recall advice within the last
year10,11 and in a study of individual consultations 76% of smok-
ers reported that smoking was not discussed. Sixty-four per cent
of Oxford GPs12 and 49% of Scottish GPs13 reported discussing
smoking routinely in all or nearly all consultations with smokers.
The validity of the Oxford survey is questionable though since,
as a concomitant survey of smokers in the region10 found, only
36% recalled ever discussing smoking with their GP. Finally,
estimates from a 1994 Leicestershire survey suggested that GPs
advise fewer than 35% of smokers attending their surgeries to
stop.14
Observing GPs’ consulting behaviour should give the most
accurate estimates of how frequently they discuss smoking with
patients. In 1983, Boulton and Williams audiotaped a large num-
ber of consultations from 16 GPs. General practitioners discussed
smoking in 16% of smokers’ consultations but gave clear advice
to stop in only 10%.15 In 1995, a study of 42 Leicestershire GPs
using video-recorded surgeries found that GPs discussed smok-
ing in 29% of smokers’ consultations.16,17
These studies reveal a low level of anti-smoking advice-giv-
ing. General practitioners do not advise against smoking in the
Anti-smoking advice from general practitioners:
is a population-based approach to advice-giving
feasible?
T Coleman, MD, MRCGP, senior lecturer in general practice; and A
Wilson, MD, MRCGP, senior lecturer in general practice, Department of
General Practice and Primary Health Care, University of Leicester,
Leicester General Hospital.
Submitted 14 January 2000; Editor’s response: 17 April 2000; final
acceptance: 21 June 2000.
© British Journal of General Practice, 2000, 50, 1001-1004.
British Journal of General Practice, December 2000 1001
majority of consultations with smokers but probably cover the
topic in only 20% to 30%. Findings are fairly consistent between
studies using patient recall and observation of GPs’ consulting
behaviour; however, these methods may overestimate advice-
giving activity. Patients tend to report advice when it has not
been given18 and GPs’ awareness of video-recording or audiotap-
ing could result in them giving more advice than usual. Also,
GPs agreeing to video-recording19 (and possibly other observa-
tion methods) differ qualitatively from others. This may intro-
duce recruitment bias where doctors who are more enthusiastic
about advice-giving participate in studies. Surveys of GPs report
more frequent advice-giving activity, but self-report is likely to
overestimate this by favourable response bias.20 It is also possible
that GPs and patients differ in their perceptions of what consti-
tutes ‘anti-smoking advice’ and this could help explain the
observed discrepancies between GPs’ self-report and patients’
recall of anti-smoking advice. However, we are not aware of any
research investigating this topic.
The next section considers the influences on GPs’ advice-
giving and assesses the feasibility of encouraging movement
from the current low levels of anti-smoking advice-giving to a
population-based approach.
Explaining GPs’ practice
Understanding why GPs discuss smoking with only a minority of
smokers could help to suggest ways in which their advice-giving
can be increased. As both doctors and patients are likely to influ-
ence this aspect of clinical behaviour, studies exploring the issue
from the perspectives of both are considered. There have been
few studies that exclusively investigate GPs’ attitudes towards
discussing smoking in general practice consultations.13,14
However, GPs cite giving advice against smoking as one of their
most important preventive activities21,22 so studies that explore
GPs’ and patients’ attitudes towards preventive medicine in gen-
eral are also used. We acknowledge that understanding clinical
behaviour is difficult, or perhaps impossible, but the research
summarised below provides us with some insight into this.
General practitioners acknowledge that advising patients
against smoking is part of their job and they have a responsibility
to advise smokers to stop.12-14,23-27 They are consistently positive
about the need to address patients’ smoking during their routine
consultations.12-14,23 There is evidence, however, that GPs are
more likely to discuss smoking with patients who have smoking-
related problems. In the GP surveys cited above,12-14 larger pro-
portions of GPs (over 90%) reported that they were likely to dis-
cuss smoking when patients had ‘relevant symptoms’ than rou-
tinely in every consultation. General practitioners also report
their preferred mode of discussing smoking as linking advice to
patients’ smoking-related problems,14 with 97% feeling that their
advice was likely to be more effective in this context. Smokers’
consulting patterns differ from non-smokers. Overall rates are
lower for smokers of both sexes aged over 45, especially for pre-
ventive care where perhaps smoking is likely to be an issue.
However, at all ages smokers are significantly more likely to
consult for mental health problems28 and in these types of consul-
tations GPs may find it more difficult to discuss smoking.
Additionally, some GPs report time constraints as a disincen-
tive against raising the topic of smoking with patients.12-14,27,29
For GPs, preventive medicine mainly constitutes giving lifestyle
(or ‘stop smoking’) advice during routine consultations and they
prefer to discuss lifestyle issues in the context of relevant prob-
lems.14,27 Qualitative studies indicate that although GPs feel their
anti-smoking advice is important, few feel that it is relevant in all
consultations12-14 as the time required for this would detract from
the curative workload.25 To avoid confrontation with patients,
GPs tend to restrict advice-giving to situations where patients
present with smoking-related problems.30 This helps explain why
GPs prefer a problem-based approach towards discussing smok-
ing with patients and also why they report time constraints: GPs
simply do not appear to perceive that there is an appropriate
opportunity to discuss smoking in many of their consultations.
General practitioners’ reports of preferring this problem-orien-
tated approach towards advice-giving are corroborated by infor-
mation from patients.11 Those suffering from hypertension,
ischaemic heart disease or diabetes are all more likely to recall
GPs’ advice against smoking, suggesting that GPs are indeed
more likely to discuss smoking when patients have smoking-
related morbidity.11 Finally, in both studies that involved obser-
vation of consultations,15-17 GPs were more likely to discuss
smoking when patients presented with smoking-related prob-
lems.
Although GPs’ lack of time is an important issue it is not the
only barrier to the provision of anti-smoking advice. Increasing
consultation time results in only a modest increase in the number
of discussions about smoking that take place.31 Surveys and
interview studies with GPs highlight other problems that they
feel hinder discussion of smoking. General practitioners find giv-
ing anti-smoking advice challenging. They find it difficult to per-
suade resistant patients to adopt ‘correct’ ideas about unhealthy
attitudes and behaviours,12,13,26 Consequently, GPs prefer giving
lifestyle advice when smokers have already decided to stop.12-
14,25,26 and avoid discussing smoking in detail with smokers who
give negative reactions when the topic is mentioned.30 Doctors
also find it hard to advise smokers who are stressed or whose
social environment militates against cessation.25,27 Accordingly,
some GPs are ambivalent about the effectiveness of their
advice,12,13,25-27 calling for more training12,13,26 to improve their
communication of health promotion messages.12,13,26 Few doctors
appear to blame patients for their inability to change unhealthy
behaviour and one study reported a minority of GPs who consid-
ered patients were not intelligent enough to understand health
promotion messages.26
Influence of smokers’ views
Surveys of patients9,32 suggest that people believe GPs should be
interested in ‘smoking problems’ but only 40–50% of smokers
actually consider they have a smoking problem.9,32 Although the
vast majority of smokers are happy for their doctor to raise the
topic of smoking, many of those with little motivation to stop do
not welcome advice about how they should stop.33 Stott and Pill
explored working class women’s views,34 and some women in
their study found lifestyle (smoking) advice unacceptable if it
was not directly linked to either their health or a current smok-
ing-related problem. Some even rejected outright the notion that
GPs should advise them about their lifestyle. They felt that
advice should be given sensitively: they were more likely to lis-
ten to a GP with whom they had a good relationship and who
respected their autonomy in decisions about lifestyle issues.
These findings were reiterated in a broader population by a later
study concerned purely with smokers’ views of GPs’ anti-smok-
ing advice.35 Smokers felt it was up to them to decide when they
are ready to stop and disliked repeated, ritualistic anti-smoking
advice. Again, smokers who were not ready to stop were more
likely to react negatively towards GPs’ advice. It appears, there-
fore, that if GPs are to raise and discuss the issue of smoking
without provoking negative reactions then they must tailor their
discussion to the patient’s readiness to stop smoking.
1002 British Journal of General Practice, December 2000
T Coleman and A Wilson Discussion papers
British Journal of General Practice, December 2000 1003
T Coleman and A Wilson Discussion papers
How feasible is a population-based approach?
General practitioners’ and patients’ views appear to be comple-
mentary. For example, GPs report problems in getting patients
motivated to stop and some smokers report irritation about being
advised to stop when they are not ready to do so. Also, both GPs
and patients seem more comfortable discussing smoking in the
context of smoking-related problems. To achieve a population-
based approach to advice-giving, GPs need to change from advis-
ing only 20–30% of patients who smoke to advising almost all
smokers who consult with them to stop. This is a daunting
prospect as there appear to be many and varied barriers towards
advice-giving rather than a few easily modifiable ones.
Furthermore, the culture of general practice as defined by doc-
tors’ and patients’ views seems to encourage a problem-orientat-
ed approach to advice-giving. It is not clear how these views, and
in particular GPs’ fears of upsetting patients, could be overcome:
unless a way is found it is unlikely that GPs will ever discuss
smoking repeatedly with the majority of their patients.
An alternative approach towards increasing the rates of advice-
giving GPs would be to encourage them to make more use of
problem-orientated opportunities. Exhorting doctors to discuss
smoking whenever patients present for preventive care or with
smoking-related problems is likely to be a more acceptable mes-
sage to GPs and perhaps is more likely to be heeded. This
approach could result in GPs advising greater numbers of smok-
ers but is inconsistent with current guidelines6and so needs to be
examined in more detail.
The systematic review finding that providing a consistent,
repeated anti-smoking message maximises the efficacy of
advice5has been used to suggest that GPs should advise all
smokers to stop and to repeat this at every opportunity.6,8 This
finding is based on the observation that smokers who are advised
more frequently to stop are more likely to do so. However, most
trials of primary care doctors’ anti-smoking advice have involved
short follow-up periods. Although participating doctors have dis-
cussed smoking with all presenting smokers this has usually only
been for brief periods: less than a year in most studies. The
majority of smokers will have been advised only once and
repeated advice will not have been given. Where primary care
studies have involved doctors providing follow-up and repeated
advice, only motivated smokers will have repeatedly attended for
this. Smokers who are motivated to stop are more likely to do so
and they differ from unselected ones attending their GP who will,
on average, be less motivated. It is impossible to say whether the
increased quit rates among smokers who are repeatedly advised
is owing to doctors giving more advice or to the smokers being
more motivated to stop. As one cannot predict which smokers
will respond positively to GPs’ anti-smoking advice (by stop-
ping), any method of increasing GPs’ rates of advice-giving is
likely to promote smoking cessation among their patients.
Consequently, advising a problem-orientated advice-giving strat-
egy is not inconsistent with current evidence. It should be noted,
though that using this approach to the issue may result in more
patients developing symptoms before any effective anti-smoking
intervention is delivered. This could diminish the potential health
gain from anti-smoking advice.
We know that GPs’ brief advice against smoking is effective
but we have no idea which smokers will quit in response to being
advised. General practitioners need objective ways of identifying
how ready smokers are to try to stop smoking as they consult
with them. Smokers who are motivated to try to stop appear to
behave differently during primary care consultations than non-
motivated ones,36 but further work is needed to confirm whether
or not these behaviours can predict future smoking behaviour.
This could help GPs to concentrate their advice most effectively
on those smokers who are most likely to change their behaviour.
In answer to the question posed by the title of this article, a popu-
lation-based approach towards advice-giving is untested and does
not appear feasible in the UK at this present time. Given the con-
cerns of clinicians and patients about this approach, perhaps we
should reconsider whether this is a desirable aim.
Postscript
An update to the UK smoking cessation guidelines6has now
been published.37 These revised guidelines pay particular atten-
tion to how GPs and other primary health care workers might
implement an evidence-based approach to smoking cessation.
Significantly, the problems for GPs in implementing a popula-
tion-based approach to advice-giving are acknowledged and dis-
cussed. A new recommendation that GPs aim to discuss smoking
with patients and to document this at least annually is made.
Additionally, the revised guidelines make constructive sugges-
tions about how the primary health care team can be organised to
support smokers who are motivated to stop. We recommend that
GPs read the revised guidelines and evaluate their clinical prac-
tice in the light of these.
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