Damian Sendler: Patients’ smoking habits and willingness to quit are often unknown to primary care providers (PCPs) as they go about their daily clinical practice. The purpose of this metasynthesis is to examine the views of PCPs and patients who are smokers on the issue of quitting smoking in primary care. Meta-ethnography is used, and thematic synthesis is used to synthesize the data. Included are twenty-two studies with a total of 580 participants. There are three major themes that emerge: There are I some expectations but no requests, (ii) and (iv) ways to address the issue and compel patients to take part. Despite the fact that PCPs have developed innovative strategies based on the core values of their practice, such as proximity, continuity, long-term relationships, and trust, our findings reveal a widespread lack of legitimacy among PCPs when it comes to addressing the issue of tobacco use and smoking cessation with their patients.
Damian Jacob Sendler: Most smokers (1.1 billion of them) are unaware that tobacco use kills half of those who use it (more than 8 million people a year). A person’s insatiable need to smoke to regulate their mood and arousal and alleviate the symptoms of nicotine withdrawal is caused by a complex interplay of factors (pharmacological, genetic, social, environmental, psychological, and behavioral). Tobacco use has dropped by about 60 million people globally in the last two decades (from 1.397 billion in 2000 to 1.337 billion in 2018)1. These measures and actions have taken place at both the national and international levels, resulting in this reduction.
Dr. Sendler: Smoking cessation intervention programs, such as the 5A approach to quitting, the motivational interviews, and brief advice, have been shown to be effective only among specific populations or in specialized clinical settings. More than 95% of attempts to quit smoking will fail if you don’t have any kind of professional support.
WHO claims that primary health care is the best health setting for providing advice and support on smoking cessation because it provides frequent and important opportunities to identify tobacco use, provide advice, and help people to quit9,10. Even though primary care providers (PCPs) are trusted and opportunistic11,12, many smokers do not receive support from their PCPs13, because only a few of them have received training in delivering specific interventions14, and most of the patients come to daily clinical practice without an explicit demand of quitting.
National guidelines tend to focus on “smokers who want to stop”15 or the 5A-approach supposedly covering all stages of the process16,17. Clinicians can use a variety of methods to help their patients quit smoking in primary care settings: clinical practice guidelines, national recommendations, and public health policies all address the issue of identifying smokers and providing behavioral change interventions as well as counseling and medication. It’s important to point out the following inconsistencies and gaps in the guidelines: Among the guidelines from 22 countries, only a few involved PCPs directly in their development21, and only two included recommendations for “a person who smokes [and] is not ready to quit.” Taking into account the patient’s own time frame and personal needs and goals22, based on the main lines of prevention campaigns (understanding the risk and encouragement to seek help to stop)
The quantitative literature mainly focuses on the cessation phase24–28, the obstacles professionals face when starting smoking cessation treatment29,30 and the question of prevention31–33 in the quantitative literature.. Increasing patient and public involvement in qualitative research is critical in the field of addiction generally and tobacco addiction specifically. Detailed descriptions of PCPs and patients’ daily lives are critical to understanding complex issues like tobacco use and developing new strategies to improve smoking cessation outcomes in primary care settings. The generalizability of qualitative studies is often questioned due to the small sample sizes and specific contexts in which they are conducted. Analyzing and synthesizing qualitative study data can be useful in formulating health policy and clinical practice guidelines. However, there has never been a systematic review of this qualitative literature.
Some patients had zero expectations of their primary care physicians, meaning they didn’t want any advice or discussion of the subject during appointments39,41,46. They argued that they were solely responsible for their own tobacco use problem43 and that quitting was a matter of their own will to begin the process47. The topic of smoking cessation should be initiated by patients themselves, not by their primary care physicians (PCPs), unless it is directly related to the medical issue they are seeking help for. Some of the PCPs in these studies agreed with this sentiment. As a result of these studies, many patients and PCPs alike felt that physicians were doing their “duty” when they systematically inquired about smoking status and habits. Some patients felt that the topic of tobacco use should be brought up frequently and routinely during consultations41. PCPs were expected to show encouragement and support to their patients as soon as they requested it.41 Patients who explicitly state they want to quit smoking are more likely to receive proactive and supportive care from their primary care physicians, which is consistent with the PCPs’ common attitude in these studies43.
Patients expected their PCPs to respect their own sense of timing and pacing.48 A non-moralist and non-judgmental approach was valued by both patients and PCPs, according to some authors, so that patients could freely discuss anything.
Patients also expected PCPs to take an active role in their care49,50, such as providing smoking cessation counseling and information to all patients.
In some cases, patients explained that they were too embarrassed or embarrassed to bring up the subject of smoking on their own49. Patients said that general practitioners (GPs) were the best place to begin the process, since they were familiar with the patients and had a long-term relationship with them.
Patients’ primary care physicians (PCPs) are aware that they have a role to play in the cessation process of those they treat. However, they couldn’t agree on what their roles and responsibilities should be.
Some PCPs had only one goal in mind: to sow a seed that would bear fruit in the long run40,53. GPs viewed their role as advising and referring patients to the nurses for further assistance, rather than trying to persuade everyone to quit smoking43. After advising43, they felt the weight had been lifted from their shoulders.
PCPs, as previously mentioned, had a tendency to hold off on treating patients until they made a specific request. Only if patients initiated the conversation did physicians address smoking concerns41,54. These PCPs were able to meet the needs of their patients by responding promptly to their requests for assistance and doing so in a manner that was respectful of their individual rhythms and schedules48.
Finally, many primary care physicians (PCPs) and general practitioners (GPs) believed that they owed it to their patients who used tobacco to educate them about the dangers of smoking. It wasn’t about whether or not they should support smoking cessation, but rather how they should do it42: as part of a routine intake or annual physical41, providing advice and options43, educating people about the smoking health outcomes41, but also inducing a desire to quit.
Damian Sendler
Finding the right time to talk to a patient about quitting smoking can have a significant impact, both for the patient and for the physician.
In cases where the patient has a health condition that could be made worse by smoking, like asthma, cardiovascular disease, diabetes, or periodontal disease, it may be appropriate to bring up the topic of smoking cessation during a visit.
Damian Jacob Markiewicz Sendler: What emerged most clearly was the importance of the relationship between patients and their primary care physician (PCP). Many patients emphasized the special bond of confidence they shared with their primary care physicians (PCPs)51,52. Key factors and therapeutic levers for enhancing smoking cessation were a long-term relationship based on long-term acquaintance and familiarity42 and a genuine dialogue between professionals and patients. As a means of reinforcing success or suggesting alternate solutions to overcome failures and to take the advice given acceptable and “hearable”46, authors have mentioned “ongoing, longitudinal relationships with patients”57. The therapeutic relationship was the most important outcome for several authors40,49. It was even thought by some nurses who smoked that their habit could aid in the therapeutic process.
Respect and understanding are critical for patient-centered care providers (PCPs), according to both studies. As a way to build a relationship built on mutual respect and trust, PCPs used this strategy to help their patients change their behavior (40,46,48,58). Even more importantly, both argued that there should be a greater emphasis on face-to-face communication. As a starting point, PCPs could tell the patient that they were aware that the patient had previously stated “no” and that they were just curious if the patient had changed his/her mind.
Few patients suggested that PCPs use frightening images depicting the dangers of smoking to frighten them into quitting. Despite this, the same patients said they wouldn’t give up smoking even if faced with a major personal health shock47. “More direct” and “more forceful” were some of the terms used by PCPs to describe this confrontation strategy, which was also criticized as “nagging”58. There were those who advocated for rigor and direct communication while others used “scare tactics” to highlight the dangers of smoking
Damian Jacob Sendler
Numerous obstacles have been addressed in the literature, including lack of clinician engagement, a lack of clarity in policies and guidelines, insufficient time, insufficient resources, and lack of management support59–66. PCPs are frequently forced to shorten their scheduled appointments due to the increased demands of their patients and the resulting increase in their workload67. There is no requirement for physicians to learn about addiction medicine during their training, and when it is included, only a small amount of time is devoted to substance abuse and addiction. The 5As and 5Rs—to assist smokers willing to quit (5As) and implement interventions to increase future attempts with patients unwilling to quit at the time of their visit (5Rs)69, for example, or the transtheoretical model by Prochaska and DiClemente70, the label “teachable moment”2,71 and “opportunistic smo”72—are just a few examples of models, tools, and theories that can be applied in PCP daily practice. In addition, some national public health policies, such as the UK’s “Making Every Contact Count”74 campaign, target and compel healthcare professionals to deliver opportunistic health behavior change interventions to patients during routine medical consultations. Even so, only 31% of PCPs had heard about this new policy. Research shows that PCPs adhere to smoking cessation guidelines less than 50% of the time78 and that even when they are informed, only 50% of them offer adjunct support to patients73,76,79. As a matter of fact, rates of tobacco treatment delivery in primary care are quite low77.
All of these issues, in addition to the fact that some PCPs are smokers, add to the sense of untrustworthiness.
Damien Sendler: Our metasynthesis has brought up a novel and unexpected issue that requires further investigation. Primary care encounters between a PCP who feels unwelcome and a smoker with no request or desire to quit could explain why, despite all the guidelines, tools, and policies that are in place, many opportunities presented by the primary care setting are missed73,80–82. Our findings, on the other hand, show that smokers regard PCPs as legitimate and appropriate for dealing with their tobacco problem. A few quantitative studies73,83 have been bolstered by this. Tobacco addiction is a problem that many patients seek help with from their primary care physicians. For this reason, it is not the specific knowledge or skills in addiction, psychology, or psychotherapies that make PCPs qualified to help their patients who smoke; it is the core of PCP practice, which is proximity, continuity and long-term relationships based on trust that make PCPs qualified to help their patients who smoke. PCPs should be trained in addiction medicine, but their role is not to be a reduced version of a tobacco specialist or a therapist. This means that instead of focusing on what needs to be improved, we should concentrate on PCPs’ specific knowledge and skills. Because of their expertise and personal connection to their patients, primary care physicians (PCPs) can help their patients kick the habit. As a primary care physician (PCP), you need to be aware of your role and devote more time to it. They must overcome their feelings of illegitimacy and the absence of patients’ requests84 and focus on how to induce a patient’s desire to quit.
While it is possible to apply these findings to a variety of different cultural contexts, caution must be taken when doing so. Implementation research and transcultural studies would be required to ensure the relevance of these programs in their respective communities.
PCPs’ sense of illegitimacy must be further explored qualitatively and quantitatively, and their specific skills and competencies must be better integrated into guidelines so that they can truly be at the forefront of effectively preventing tobacco addiction and its harmful effects.
More than 325 people participated in this metasynthesis. In medical research85, the method we used was rigorous and met the ENTREQ guidelines86.
This metasynthesis has some shortcomings that prevent it from being universally applicable. Data from the participants and their interpretations by the researchers are only collected in a qualitative metasynthesis. Furthermore, despite the fact that the review included articles from a wide range of cultural backgrounds, the number of articles from English-speaking countries is disproportionately high. As a result, the study’s findings may be limited to this particular cultural context.
This meta-findings analysis’s were also redundant from a methodological standpoint. To get more original and relevant results, more participatory research methods need to be used by professionals and patients.
