Results
To help readers to assess the influence of video-recording on the interview study, we present brief, numerical data on this topic first. Of the 42 video-recorded GPs, two had no smokers attend their surgeries and one declined to be interviewed, so we base our findings on 39 interviews. Ninety-nine per cent of attending patients gave their smoking status on the pre-consultation ques- tionnaire, and 86% consented to video-recording.16 Self-reported smokers were not more likely to withhold consent to recording, but younger patients and those with overt mental health problems were.16 Of the 86 video-recordings shown to GPs, 33 involved talk about smoking and in 25 of these the doctor thought a smok- ing-related problem was present.17
We report our interpretation of GPs’ accounts below. Quotes from GPs appear in italics and are attributed to individual GPs by code numbers (eg DR124). Non-italic quotes from GPs with these code numbers appear in Box 3 or 4 illustrating points made.
Factors influencing GPs’ awareness of patients’ smoking status
Clinical cues, such as the smell of smoke or tar-stained hands, as well as medical records (where accurate), alerted doctors to patients’ smoking status. In consultations where GPs perceived patients to be well, with no medical problems (eg oral contracep- tive check or blood pressure check), doctors felt less time pres- sure and were more likely to enquire about smoking. Additionally, the requirement to make registration health checks or collect health promotion data prompted occasional enquiry about smoking. However, GPs expressed doubts about its useful- ness:
‘We’re supposed to get a record [of patients’ smoking sta- tus] for health promotion purposes so that’s why we do it. Whether we act on it of course is a different matter...’ (DR209.)
General practitioners’ accounts illustrated that, even when they are aware of patients’ smoking status, they do not routinely discuss this further. Different factors influence whether GPs try to encourage smokers to stop and the most important of these are discussed below.
Doctor–patient relationship (Box 3)
Maintaining good relationships with patients was of paramount importance to GPs. A frequently-cited barrier to discussing smok- ing was a fear of harming the doctor–patient relationship. This fear seemed to explain the problem-based approach that GPs employed
1. Both authors independently read the first 13 interview transcripts to identify ‘themes’: the principal factors that appear to influence discussion about smoking .
2. TC codes transcripts for themes. Data relating to each theme assembled. TC and EM independently read this and identify ‘categories’: variations in GPs’ thinking within themes.
3. TC and EM agree working definitions for emerging categories and themes. TC codes the 13 transcripts using these.
4. TC and EM discuss and refine definitions of themes and categories.
5. TC begins re-coding all available and subsequent transcripts using definitions in 4. above. During this process some definitions are altered after discussion between researchers.