Canadian Medical Association Journal 1996; 154: 1827-1834
However, were I the patient labelled as a smoker, contemplating a confrontation with either my concerned physician or his or her committed staff members at my every visit, I fear that I would be inclined to change physicians.
Thus, I am led to believe that physicians should support prevention and health promotion (such as the Participaction program) aimed at school children and the public at large, rather than seriously consider confrontation and "intervention" in their offices.
William D. Panton, MD
Retired from family practice
and from smoking
Burnaby, BC
Regarding the approach: if you were a smoking patient, I hope that your physician would offer you clinical tobacco intervention in a way that would leave you feeling supported rather than stigmatized. Stigmatizing approaches would likely reinforce your smoking by reducing your sense of control over it. Instead, I hope that your physician would listen for 45 seconds to how you feel about smoking and stopping smoking. I hope that you would get what Willms and colleagues[1] have described as a "personalistic," not a paternalistic, approach to smoking. A "personalistic" approach implies caring, concern, support and empathy. In the words of two British Columbia smokers,
Stopping smoking was, for me, a very individual, long, lonely road. It was a very personal matter. . . . I stopped on my own. . . . Later, when I saw my GP, I hoped that I would get support and reinforcement or at least a how-do-you-feel-now response. But it didn't come. Doctors and nurses have to tune in.[2]
Doctors and nurses have repeatedly wagged their fingers at me. They have patronized me. I know I should quit smoking. But no one has laid out the options for me on how I could.[2]
Smokers desperately want their doctors to understand how they feel. They want support for their efforts to stop smoking. They want good information on how to make another serious attempt to stop smoking. Since 80% to 85% of smokers are not ready to stop now, this implies, for most, a minute of "How are you feeling about stopping smoking?" and then reflective listening. With such support, most smokers will eventually stop smoking on their own and will likely be very appreciative of their physician's help.
Far fewer patients die from allergy to penicillin than from smoking. I believe that every patient's chart should indicate the patient's current smoking behaviour. The purpose of labelling is to cue the physician and office staff to address smoking systematically, not to harass the patient. Randomized, controlled studies on improving physician performance have shown that chart reminders are simple and effective. Given this level of evidence, labelling charts with the patient's smoking status may soon become standard.[3,4] I agree with Panton that we need to educate children and the public at large. One of the most effective places to do this is in the physician's office. The original meaning of "to doctor" was "to teach." That still holds true.
Frederic Bass, MD, DSc
Director
BC Doctors' Stop-Smoking Program
Vancouver, BC