“I’ll give up smoking when you get me better”: patients’ resistance to attempts to problematise smoking in general practice (GP) consultations

Abstract

This paper focuses on general practice consultations where the issue of patients’ smoking is raised and problematised by general practitioners (GPs) by linking it to their presenting or ongoing medical conditions. The data are taken from a larger study in one country of the UK, of the factors influencing discussion of smoking between GPs and patients who smoke. Consultations have been examined informed by the conversation analysis literature, with a focus on patients’ resistance to doctors’ problematisation of smoking. It is argued that, despite evidence from other areas of health care that advice is most effective when it is personalised, and despite GPs’ expressed views that a preferred way of topicalising smoking is to make links to a patient's current medical problems, this is not generally the case in these consultations. Linking smoking to current problems commonly results in explicit resistance from patients of a kind that is rarely seen in other medical consultations. It is postulated that this results from the moral implications of linking a person's health status with their own behaviour, thereby undermining their claim to legitimate illness and to medical help.

Introduction

Smoking remains a major public health problem in the UK (HEA, 1993) and as a result, over recent years there has been increased emphasis placed on the role of health care professionals such as general practitioners (GPs) and pharmacists in encouraging smokers to quit. Previous research suggests that GPs’ advice against smoking does have a beneficial effect, though quitting is likely to be seen in only 1–2% of patients so advised by their GPs (Ashenden, Silagy, & Weller, 1997). The Royal College of General Practitioners has called on its members to maximise their role in smoking cessation, and to give advice repeatedly to as many patients as possible in this respect (RGCP, 1981). Recent guidelines for health professionals emphasise the importance and effectiveness of advice, and recommend that GPs should advise current smokers to stop during routine consultations at least once a year (West, McNeill, & Raw, 2000).

Whilst the rationale behind this call is self-evident, what is less immediately apparent is how GPs might best give anti-smoking advice in order to maximise its uptake. As Coleman, Murphy, and Cheater (2000) have noted, recommendations often ignore the context in which advice is given, and population-based approaches may be at odds with the problem-based approaches that GPs report to find preferable. With the notable exception of some qualitative work in this area (e.g. Stott & Pill, 1990; Butler, Pill, & Stott, 1998), the question of how anti-smoking advice should practically be incorporated into routine general practice (GP) consultations has largely been ignored. Patient perception of advice is a key factor in addressing this question, and Butler et al. (1998) stress the importance that patients attach to an individualised approach, as opposed to the kind of routinised and repeated message that guidelines focusing on frequency may appear to promote. More detailed issues of how advice may best be delivered to maximise interactional uptake (i.e. positive response from clients) have, however, been central to the conversation analytic (CA) work which examines interaction in health care settings. This body of work includes studies of HIV counselling (Kinnell & Maynard, 1996; Silverman, 1997), health visiting (Heritage & Sefi, 1992) and patient counselling by pharmacists (Pilnick, 1999). These studies have focused on examining the ways in which interactional sequences of advising and informing are set up by health care professionals, and the ways in which clients respond. The analysis presented here is set in the context of this literature, drawing on findings as to the interactional features of advice giving that can be seen to have an effect on uptake, and exploring the implications of these for this particular setting.