Family Practice Vol. 20, No. 5, 520-523
© Oxford University Press 2003
The consultation |
Comparison of the smoking behaviour and attitudes of smokers who believe they have smoking-related problems with those who do not
Division of General Practice, University of Nottingham, The Medical School, Queen’s Medical Centre, Nottingham NG7 2UH and
a Department of General Practice and Primary Health Care, Leicester Warwick Medical School, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK.
Correspondence to Tim Coleman; E-mail: tim.coleman{at}nottingham.ac.uk
Coleman T, Barrett S, Wynn A and Wilson A. Comparison of the smoking behaviour and attitudes of smokers who believe they have smoking-related problems with those who do not. Family Practice 2003; 20: 520–523.
Received 26 November 2002; Revised 14 April 2003; Accepted 19 May 2003.
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Abstract |
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Background. Motivation to stop smoking is associated with smokers’ possessing substantial smoking-related morbidity or believing that they have symptoms caused by smoking, but it is not clear if this holds for smokers attending general practice consultations.
Objective. Our aim was to compare the attitudes and behaviour of smokers attending their GP with symptoms that they believe are smoking related with those who do not.
Method. A cross-sectional, pre-consultation survey of patients attending GPs in Leicester, UK was carried out.
Results. A total of 83.8% (2955/3525) of people attending GPs completed the questionnaire and 34.7% were smokers. Multiple logistic regression showed that where smokers perceived that their problems were smoking related they were more likely to have tried stopping in the past [odds ratio (OR) 1.78, 95% confidence interval (CI) 1.26–2.67], to want to stop smoking (OR 1.83, CI 1.15–2.9) or to intend to stop in the near future (OR 1.58, CI 1.03–2.43).
Conclusion. Smokers who attend GPs’ routine consultations and believe that they have smoking-related problems are more motivated to stop than others. This suggests that it is important for GPs to ascertain patients’ views about the aetiology of their symptoms before discussing smoking with them.
Keywords. Behaviour, GPs, smokers, smoking-related problems.
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Introduction |
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Smoking remains a huge public health problem and a great cause of morbidity and mortality.1 As most smokers cite health improvement as a reason for stopping,2 it might be expected that suffering from smoking-related illnesses would motivate people who smoke to try stopping. The evidence to support this is conflicting, however. Population surveys show a similar prevalence of smoking in asthmatics and non-asthmatics3,4 and similar attitudes towards smoking in these two groups, including comparable levels of ‘readiness’ to stop.4 One possible explanation for this is that smokers often hold self-exempting beliefs,4,5 i.e. whilst they accept that smoking is generally harmful, they cite illogical justifications to explain why they are not personally at risk from their own smoking. For example, many smokers do not believe that their smoking puts them at any higher risk of myocardial infarction or cancer than other people.6 Other populations of smokers may have differing views, however, and one study found that smokers selected from general practice chronic disease registers who have substantial smoking-related morbidity (e.g. diabetes or ischaemic heart disease) are more motivated about stopping smoking than others.7
Although evidence for a straightforward relationship between smoking-related illnesses and smokers’ attitudes to their habit is inconclusive, there is more consistent information from studies investigating the link between smokers’ attitudes and their beliefs about the aetiology of illnesses or symptoms from which they suffer. A study of older smokers found that those who attributed symptoms to smoking rather than ageing were more motivated to try stopping8 and, amongst smokers with established respiratory symptoms, those who attributed these to smoking were also more motivated.9 Interestingly, in this latter study, having respiratory symptoms was not associated with motivation to stop, whereas believing symptoms were caused by smoking was. It is uncertain, however, how applicable these research findings are to smokers attending GPs’ routine consultations who are unlikely to suffer from such severe smoking-related illnesses. To investigate this issue further, we compared the beliefs and attitudes of smokers attending routine general practice consultations who believed they had smoking-related problems with those who did not.
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Method |
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Data used in this analysis were collected as part of a study which has been reported elsewhere.10,11 Thirty-five GPs (out of 62 approached) from 13 general practices (out of 28 approached) were recruited and 31 participated in the study, representing 56% of practices based in the Leicester City West Primary Care Trust area. Over 21 months, a researcher attended a random selection of GPs’ surgeries. All patients (parents or guardians of those aged <16 years) attending these surgeries were asked to complete questionnaires before their consultations. These sought demographic details, identified regular smokers (those smoking on at least most days) and asked about smoking behaviour and attitudes to smoking, whether the smoker was the patient or accompanying someone else and whether the smoker was seeing the GP about a problem that he/she perceived to be smoking related. The Heaviness of Smoking Index, a biologically validated measure of nicotine addiction,12 quantified current smoking habit, and smokers also indicated whether or not they had attempted to quit smoking in the past year. Smokers rated their confidence of being able to stop smoking on a 5-point Likert scale (ranging from ‘very certain’ to ‘very uncertain’) and their desire to do so (on a 5-point scale from ‘I would like to stop smoking’ to ‘I would like to keep on smoking’). Additionally, respondents indicated whether or not they intended to stop smoking in the next 4 weeks (again a 5-point scale from ‘yes, definitely’ to ‘definitely not’). Finally, respondents were also asked to indicate which of five statements relating to thinking about or trying to stop smoking that they most strongly agreed with. This latter item was derived from an American questionnaire item13 and aimed to measure low levels of readiness to stop smoking. All items had been piloted and used in previous studies.10,14 Patients who could not complete the questionnaire were excluded.
We compared the researcher’s records with those of receptionists to estimate the number of missed patients. We compared demographic details, attitudes towards smoking, and past and present smoking behaviour between smokers who were patients (i.e. not accompanying children or others) and who perceived their presenting problem(s) to be smoking related with those who did not. t-tests and chi-square tests were used for continuous and categorical data, and the Mantel–Haenszel chi-square test was used for ordinal variables. Next we used forward, logistic regression (with SPSS version 10) to determine the characteristics of smokers who were patients (i.e. not accompanying children or anyone else) that were independently associated with their belief that their problems were smoking related (dependent variable). We entered variables with a P-value of <0.1 from the univariate analysis into the model as explanatory variables. Smokers who were not patients were not included in this analysis, as they had no medical problems on which they could give an opinion.
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Results |
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A total of 3525 patients attended surgery sessions, 16 were excluded, 97 refused to participate, 457 were missed by the researcher and 83.8% (2955/3525) answered the questionnaire, of which 34.7% (1026/2955) were smokers. Of the smokers, 79.1% (811/1026) reported attending to see the doctor about their own problems (i.e. they were the patient), with 19.1% (155/811) of these patients believing that their problems were definitely smoking related and 80.3% not (data missing for five patients).
Perceiving that their presenting problems were smoking related was not associated with gender: 19.8% (61/308) of men and 18.7% (94/503) of women believed they had smoking-related problems [odds ratio (OR) = 1.07, 95% confidence interval (CI) 0.75–1.54]. Similarly, the mean ages of those who believed their problems to be smoking related were not significantly different from those who did not [mean age of those believing problems were smoking related = 41.6 years, not believing = 42.4 years (95% CI for difference between means = –7.5 to 5.70)] and neither the number of cigarettes smoked daily (P = 0.134, by Mantel– Haenszel) nor the time from waking to smokers’ first cigarettes (P = 0.492, by Mantel–Haenszel) was associated with smokers’ beliefs about their presenting problems.
Table 1
compares the remaining characteristics of smokers who believed they had smoking-related problems with those who did not, and Table 2 reports findings of the multiple logistic regression. On univariate analysis, smokers who believed their problems were smoking related were significantly more likely to report a quit attempt in the last year, to intend to quit in the next 4 weeks, to desire to quit and to have thought about quitting smoking. After multivariate analysis, having tried to stop smoking in the past year, intending to try stopping in the next 4 weeks and desiring to stop smoking were all independently associated with believing problems to be smoking related.
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Discussion |
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This study found that patients who attend their GP with problems that they believe are smoking related are more likely to have tried stopping in the past and want to or intend to do so in the future. Previous studies have shown that past quit attempts14–16 and an intention14,15,17 or desire15,18 to quit in the near future are associated with making quit attempts and achieving future smoking cessation, so smokers who believe their problems are smoking related might also be more likely to stop smoking in the future than others.
By employing research assistants to distribute questionnaires, we ensured a high response rate, and by including standard questionnaire items that had been used in previous research studies, we ensured low rates of missing data. Additionally, any correlation between explanatory variables in the multivariate analysis will have been taken into account by the stepwise approach to the logistic regression. Therefore, it is worth considering the meaning of our results.
We have conducted a cross-sectional survey rather than a longitudinal, cohort study. Consequently, we cannot tell whether: (i) being motivated to stop results in patients accepting that any symptoms or problems are contributed to by smoking; or (ii) motivation to stop smoking increases when patients believe that their problem is smoking related. There is evidence to support both of these possibilities. If one accepts the first explanation, then other factors that we have not measured and are associated with motivation may have influenced smokers, resulting in them overcoming any self-exempting beliefs4,5 and accepting that smoking actually does cause them problems. One such unmeasured factor is self-efficacy,19 or the strength of smokers’ beliefs in their expectations of success in quitting. In this study, self-efficacy was not formally measured because only limited time was available for subjects to complete pre-consultation questionnaires before seeing physicians. Instead, a single-item measure of smokers’ confidence/certainty concerning their ability to stop smoking was used. Although confidence in stopping smoking is a related concept to self-efficacy, confidence was not associated with believing symptoms or problems to be smoking related. This suggests, therefore, that the apparently higher motivation of smokers who believed their symptoms to be smoking related would not be explained by them having greater self-efficacy. Further studies investigating the link between the health beliefs and motivation in primary care should consider measuring self-efficacy more formally.
Evidence for the second hypothesis (ii above) was first provided by a large, longitudinal population survey which investigated the link between health beliefs and motivation to stop smoking.15 This found that a change in beliefs and attitudes regarding the health consequences of smoking preceded the intention to try to stop and attempts at doing so. The findings of the current study help to contextualize this work15 and also the findings of other studies which have demonstrated that substantial smoking-related morbidity7 or a belief that respiratory symptoms measured by a standard postal questionnaire are caused by smoking9 are both associated with motivation to stop.
We have demonstrated that smokers who present to primary care doctors and who believe that they have symptoms or problems related to smoking show greater interest or motivation in stopping smoking. This finding is similar to that demonstrated by a postal survey of smokers,9 but the utility of this work lies in its relevance to routine general practice consultations in which patients often suffer from minimal symptoms or very minor illness. Findings suggest that, where smokers present to their GP and have symptoms which are related to their smoking, it is important to ascertain what the smokers themselves believe causes these symptoms. Those who accept that smoking has a role in causing their symptoms may be more receptive to support with stopping smoking. Where patients do not believe they have smoking-related problems, the appropriate actions of the GP are less clear, however. Some of these smokers may be motivated to stop smoking, but many will not. It is possible that some of these smokers might become more motivated to stop if they are persuaded (perhaps by countering any self-exempting beliefs) that their symptoms are smoking related. Alternatively, a different approach such as, for example, increasing the self-efficacy of non-motivated smokers might be needed to increase their motivation to stop. Whilst this study provides further evidence of how health professionals can judge smokers’ motivation to stop smoking, it provides only hypotheses about how they can increase motivation to stop amongst those who are ambivalent or not motivated. Further empirical research into this complex area20 is required.
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Acknowledgments |
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The authors would like to thank Miss Laura Jones for her secretarial assistance and an anonymous peer reviewer for useful comments. The Trent NHS Executive funded the data collection for this analysis.
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References |
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1 Callum C. The Smoking Epidemic. London: Health Education Authority; 1998.
2 Duncan CL, Cummings SR, Hudes ES, Zahnd E, Coates TJ. Quitting smoking: reasons for quitting and predictors of cessation among medical patients. J Gen Intern Med 1992; 7: 398–404.[ISI][Medline]
3 Althuis MD, Sexton M, Prybylski D. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma 1999; 36: 257–264.[ISI][Medline]
4 Wakefield M, Ruffin R, Campbell D, Roberts L, Wilson D. Smoking-related beliefs and behaviour among adults with asthma in a representative population sample. Aust NZ J Med 1995; 25: 12–17.[ISI][Medline]
5 Chapman S, Wong WL, Smith W. Self-exempting beliefs about smoking and health: differences between smokers and ex-smokers. Am J Public Health 1993; 83: 215–219.
6 Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. J Am Med Assoc 1999; 281: 1019–1021.
7 Wilkes S, Evans A. A cross-sectional study comparing the motivation for smoking cessation in apparently healthy patients who smoke to those who smoke and have ischaemic heart disease, hypertension or diabetes. Fam Pract 1999; 16: 608–610.
8 Clark MA, Hogan JW, Kviz FJ, Prohaska TR. Age and the role of symptomatology in readiness to quit smoking. Addictive Behav 1999; 24: 1–16.[CrossRef][ISI][Medline]
9 Walters N, Coleman T. Comparison of the smoking behaviour and attitudes of smokers who attribute respiratory symptoms to smoking with those who do not. Br J Gen Pract 2002; 52: 132–134.[Medline]
10 Coleman T, Wynn AT, Barrett S, Wilson A, Adams S. Intervention study to evaluate pilot health promotion payment aimed at increasing general practitioners’ antismoking advice to smokers. Br Med J 2001; 323: 435–436.
11 Coleman T, Wynn AT, Stevenson K, Cheater F. Qualitative study of pilot payment aimed at increasing general practitioners’ antismoking advice to smokers. Br Med J 2001; 323: 432–435.
12 Heatherton TF, Kozlowski LT, Frecker RC, Rickert W, Robinson J. Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Br J Addiction 1989; 84: 791–799.[CrossRef][ISI][Medline]
13 Biener L, Abrams DB. The contemplation ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol 1991; 10: 360–365.[CrossRef][ISI][Medline]
14 Coleman T. Anti-smoking advice in general practice consultations: a description of factors influencing provision of advice and the developement of a method for describing smokers’ responses. MD thesis, University of Leicester; 1998.
15 Marsh A, Matheson J. Smoking Attitudes and Behaviour. London: HMSO; 1983.
16 DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991; 59: 295–304.[CrossRef][ISI][Medline]
17 Russell MA, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. Br Med J 1979; 2: 231–235.[ISI][Medline]
18 Sanders D, Peveler R, Mant D, Fowler G. Predictors of successful smoking cessation following advice from nurses in general practice. Addiction 1993; 88: 1699–1705.[CrossRef][ISI][Medline]
19 Strecher VJ, McEvoy B, Becker MH, Rosenstock IM. The role of self-efficacy in acheiving health behaviour change. Health Educ Q 1986; 13: 73–91.[ISI][Medline]
20 Rollnick SR, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners. London: Churchill Livingstone; 1999.
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