- Email: [email protected]
Patients’ Perspectives of a Physician-Delivered Smoking Cessation Intervention
Patients' Perspectives of a Physician-Delivered Smoking Cessation Intervention Dennis G. Willms, PhD ]. Allan Best, PhD Douglas M. C. Wilson, MD ]. Raymond Gilbert, MD
D. Wayne Taylor, MA Elizabeth Lindsay, PhD Joel Singer, PhD Nancy Arbuthnot Johnson, MA
Forty-three patients-recipients of a highly structured, physician-delivered smoking cessation intervention-were interviewed using ethnographic (anthropological) research methods. We conducted interviews with patients after visits with the physician, then audiotaped and transcribed them. Discourse analysis of interview texts identified features and components of the physician manuever most effective from the patients' point of view. Patients discussed two general areas of physicians' preventive activities: an interventionistic component (in which professional, diagnostic, and authoritative features were emphasized) and a personalistic component (in which physicians were experienced as equals, supportive, caring, empower-
ing, and challenging). From the perspective of patients, the personalistic component of the physician-delivered smoking cessation maneuver appeared most effective. We conclude that, in clinical preventive medicine generally, patients (1) evaluate the kind of support they receive from their physician (e.g., degree of empathy, encouragement, and sincerity), (2) respond favorably to positive imagery in the challenge to alter their lifestyle, (3) look for a balance in the relationship established with their physician (negotiation, respect, mutual understanding, and rapport), and (4) remember the consistency and regularity of their physician's health promotion messages. [Am J Prev Med 1991;7:95-100]
Increasingly, family physicians are recognizing that engaging in health promotion work in their practice is rewarded. Despite professional, economic, and educational barriers to the practice of clinical preventive medicine, 1 both physicians and patients benefit from health promotion interventions delivered effectively.2 Yet, what are the ingredients of an effective clinical preventive or health promotive intervention? In particular, which components are the most critical from the patients' point of view? Using a smoking cessation intervention as an example, we examine these clinical concerns in this study.
Designed to provide insights into the process of behavior change, this ethnographic research project was conducted as one of two side studies to the Family Practice Smoking Cessation Project, a large clinical trial; the main trial was conducted through the Department of Family Medicine and the Department of Clinical Epidemiology and Biostatistics of McMaster University, Hamilton, Ontario, Canada.3,4 Ethnography, a qualitative method in anthropology, uses an open-ended, relatively unstructured interview style. Ethnography aims to "understand" the social construction of cultural meanings; moreover, it attempts to preserve the richness, complexity, and uniqueness of cultural meanings, while noting social and situational determinants.5,6 From practical science? and action sciences perspectives, ethnographic research can be characterized as fundamental or basic research. It is a form of hypothesis-generating, phase 1 research; in phase 2 research, these hypotheses and problems are subsequently tested in survey and controlled trial studies. 9 In this study-in which we attempt to identify specific features of a smoking cessation intervention effective from the patients' point of view-we thought an ethnographic design would be useful in identifying emergent problems associated with the burgeoning work of clinical preventive medicine. Five family practice physicians, based in Kitchener-Waterloo (Ontario, Canada), attended a four-hour workshop to learn
Research Design We base this paper on data from an ethnographic research study conducted through the Department of Health Studies of the University of Waterloo, Waterloo, Ontario, Canada.
From the Departments of Clinical Epidemiology and Biostatistics (Willms, Gilbert, Taylor, and Johnson), Family Medicine (Wilson, Gilbert, and Singer), and Continuing Medical Education (Lindsay), McMaster University, Hamilton, Ontario, Canada; and the Department of Health Studies, University of Waterloo (Best), Waterloo, Ontario, Canada. Address reprint requests to Dr. Willms, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON L85 4L8, Canada.
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how to deliver a highly structured smoking cessation intervention. The session included demonstration and practice of the key elements of the intervention, which entailed challenging smokers to quit, negotiating a contract for a cessation date, prescribing nicotine gum appropriately (2 mg), and offering supportive follow-up visits.10,11 Sixty patients were recruited as participants in two process side studies; 15 participated in a physiological side study,12 and two dropped out, leaving 43 participants for the ethnographic study. Of these 43, 23 were women and 20 were men. These participants were patients who arrived for regular office visits and were invited by office receptionists to participate in the study. Subsequently, they were randomized into a Nicorette and non-Nicorette condition. Self-reported cessation rates at one year showed 12 out of the 43 participants quitting, or 27.9%: six women and six men. All successful quitters, except one person, were in the non-Nicorette condition. A member of the ethnographic research team interviewed these 43 participants in their homes or place of work. Interviews were scheduled (a) twice before the participants' "quit date" -the date agreed upon between physician and patient when the patient would quit smoking, (b) once a week for four weeks following their quit date, (c) monthly up to six months, (d) by telephone for five months, and (e) in participants' homes one year afterward. Participants were recruited to the study in April and May 1985.
METHODS
Combining methodological and interpretive procedures, our ethnographic research was divided into four stages or levels of work: (1) interviews and the writing of fieldnotes; (2) the construction of a standardized set of codes; (3) the writing of individual case studies; and (4) the interpretation of cultural idioms of smoking cessation.13 In the first level, we used probe questions to initiate a dialogue between the researcher and the participants about what their physician did during the visit, what was said, and how the patient felt about it. Yet, given the open-ended and unstructured nature of the interviewing style,14 the discussion would usually follow the participants' own agenda of personal relevances. ls Using this tack, we were able to elicit participants' "explanatory models" 16 of their smoking and cessation experience. Each interview was audiotaped and transcribed directly onto the mainframe computer at the University of Waterloo. The result of this fieldwork is an estimated 3,500 pages of transcribed texts of participant interviews; additionally, fieldnotes written by the research assistants after each participant interview were entered into the computer database. The discourse generated through these series of interviews between researcher and participant, together with the fieldnotes, provided the text used in our interpretation and analysis. This interpretive approach assumes (1) that personal experience and meaning is mediated through language-a symbolic, metaphoric, and literal vehicle for communicating relevant and significant meanings and (2) that if these encounters between the participant and the researcher are mutually supportive, reflective, and collaborative, participants will be permitted to characterize their experience richly according to their own rules of personal, social, and cultural relevance.
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The second level of work was the coding stage. Each page of transcribed text was read and reread in the work of identifying emergent issues and themes. 17 Through a process of consensus (i.e., eventual agreement between researchers), we constructed a coding system that reflected the shared experience of participants. Specifically, research assistants, who were each familiar with 8-10 participants' experiences from having conducted the in-home interviews, were required to agree on the relevance (based on relative frequency of certain issues) of emergent themes (codes) in the participants' texts. The codes were subsequently applied to the texts and then crosschecked by "blind readers" as a reliability measure. In the database, passages that related in some way to the physician's intervention were coded as follows: 30400 Doctor (clinical, professional mediation, and participant's perception of mediation) 30401 Doctor's view of health, disease, and illness 30402 Doctor's view of smoking and risk 30403 Doctor's actual intervention 30404 Participant's perception of doctor 30405 Participant's questions for the doctor 30406 Participant's perceptions of the doctor's intervention For example, if participants mentioned during the interview that they asked their physician a question regarding their smoking (for example, a question about withdrawal symptoms), the paragraph in the transcribed text would be coded 30405. The third level of interpretation involved the writing of individual case studies. In the format of a life history, each participant's smoking experience and cessation attempt were rendered into prose (5-10 pages of written text). The research objective at this level of analysis was to provide a configurational interpretation of each individual's situation, which preserved elements of the individual's social-cultural context, the uniqueness of individual experience, and the authenticity of the individual's "story." The fourth level of analysis involved the interpretation of cultural idioms of smoking experience and cessation identified in Levels 1, 2, and 3. To illustrate our findings, we have extracted "discrete units of text" that bear directly on patients' perceptions of the physician-delivered smoking cessation intervention. A "discrete unit of text" (DUT) encompasses both the interviewer's question [I] and the participant's response [P]. For example: I: What did your doctor tell you when you saw him yesterday? P: He told me that he was very proud of me for quitting. He said ... what was it ... yes, he said, I was his success story. Isn't that great? These "texts" are verbatim comments of patients-often accentuated by pauses and comments on mood and tone-and are organized in our analysis into clusters of patient relevance and significance. This process was facilitated by a computerized software package designed for this purpose, called Ethnographic Theme Search. Ethnographic Observations In a physician-delivered smoking cessation intervention, which component is the most important from the patient's point of view: the communication of potential risks, the explanation of
withdrawal symptoms, perceived support, or some other component of professional care? Our process research suggests that the most significant component of the physicians' intervention was the kind of support given. Patients frequently forgot the details of the physician's message (for example, strategies and methods of quitting, negative aspects of smoking), but selectively remembered (1) the kind of support the physician provided (e.g., a pat on the back, congratulations, or encouragement); (2) the positive images used by the physicians to communicate what it is like becoming an ex-smoker (e.g., getting back to normal, feeling better/healthier); and (3) a relationship of equality, care, and moral accountability established between physician and patient (e.g., not wanting to let the doctor down, or, "he i.s doing his best so I need to do mine"). In presenting these findings, we divide our ethnographic observations into two general domains of clinical experience: interventionistic and personalistic. Keeping in mind that these comments of patients relate to the health promotion activities of their physician, we prefer to think of these organizing labels in the following way. Activities of the physician defined as interventionistic are those components of the physicians' work that generally refer to traditional, biomedical models. This component of work characterizes the doctor as (1) medical professional; (2) diagnostician; and (3) biomedical spokesperson-an authority on the scientific explanation of physiological processes, including knowledge of the disease-related risks of continued smoking.1 s Given this biomedical orientation, the relationship established between physicians and patient is often asymmetrical; thus, it is often nonequivocal, authoritarian, and interventionistic. Those activities of the physician we label as personalistic are components of the physicians' work that are characteristically nurturing, caring, and mutually communicative. These statements refer to the physician as (1) concerned friend; (2) support-giver; (3) empathizer; and (4) facilitator. The relationship established in this kind of clinical orientation is egalitarian; the physician and patient experience a balanced, mutually respectful, moral relationship. Although this breakdown of perceptions of physician work may appear unnaturally dualistic or dichotomous, the text itself points to this structural interpretation in patient experience. A structural interpretation posits that human experience and cognition are characteristically dialectical and binary in nature. t 9 In the interpretation of physician work and clinical processes, herefore, we could divide the components of the health promojon visit as follows: personalistic interventionistic personal biomedical intervener in illness process care provider understanding explanation symmetrical relationship asymmetrical relationship heals20 cures popular language professional language extended clinical time limited clinical time wellness model disease model communication/ dialogue documentation (historytaking) We do not mean to suggest that physicians display only one or the other form of clinical work; in fact, they often display both interventionistic and personalistic strategies in the clinical
visit. Rather, we suggest that the personalistic component is the one remembered; it is experienced to be the most effective form of support in the clinical preventive or health promotive visit. Interventionistic qualities. In this section, we present patient comments that refer to the interventionistic qualities of the physician's work. The import of patients' comments suggests that this aspect of the physicians' health promotion activity is less appreciated, and in some instances, even considered obtrusive. Research questions and record-keeping. The following patient comments refer to the problems associated with record-keeping (documentation of forms, history-taking) and the research requirements of the study itself. Each quotation from patients is appended with (1) a participant number; (2) an interview number; and (3) the page number from which the quotation was taken in the transcribed text. For example, [02:02:3] refers to participant number 2, interview number 2, page 3. Consider the following quotations: He asked me a bunch of questions that were on a sheet. How did I feel about quitting? How was my willpower? [02:02:3] Well, he just filled out a questionnaire about: the commitment is high and how much weight did you gain .... [02:06:8] He didn't really say too much. He just asked me if I wanted to [quit]. Then he wrote some things and gave me some sheets [34:01:90]. All he says when you go in is: How much are you smoking? ... when are you going to quit? ... that is all he ever says ... he has ... to keep a record of, hasn't he? Don't they ... that goes with this course? ... that is all he ever did was ask questions out of the course [25:05:92]. Time. Time seems to be a frequent complaint of both patient and physician. In this instance, however, the meaning seems to be that of time taken at the patients' expense: He gave me a quick little pep talk about what it was about ... who it was funded by, and what it was for. And he wanted to see me again ... on my quit day, my first day ... we sort of rushed into this pretty quickly [30:01:66]. I think he was rather rushed at the time, you know. I just went into the office ... he had a lot of patients there and he asked me how I was feeling f42:02:93].
It was a pretty brief visit. We didn't really talk about that much [03:04:15]. With the case-loads they've got nowadays, they're just too damn busy to ... if you didn't really want to quit, I don't think they're going to help much f44:01:00]. Not understanding patient experience. Patients seemed less concerned about time, however, than about not being understood by their physician. In this respect, patients seem troubled with physicians who did not understand the life of a smoker (what it is like to smoke) or the difficulty they would have trying to quit ("it's not easy to do!"). These are sample remarks: [My doctor] says you don't have to [gain weight], but I haven't met anybody yet that didn't [02:06:8].
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[He] feels you have extra time on your hands when you don 't smoke. I haven't found that either [02:06:9 ]. Oh, I think he certainly believes anybody could quit smoking. I don't think he believes me when I say a cigarette tasted good. I think that is only an opinion that a nonsmoker, somebody who has never smoked, could have. I think anybody that ever did smoke would understand that phrase [03 :03:12]. It's just that he can't tell me nothing. I don't know about smoking . . . you have to be smoking to explain that to somebody. Like I don't know if [my doctor] ever smoked in his life, I don't know that. But I can't see how he can explain to me and tell me the feeling of smoking if he never smoked in his life. You almost have to smoke for somebody to know how it feels [27:02 :100]. [My doctor said] I wish you would find friends that don't smoke . . . get somebody who's a nonsmoker . . . the doctor wants me to just hang around nonsmoking people . .. he doesn't want me to be around a smoker, you know. And I don't plan to give John up [25 :02,02:05:88, 89:92].
Explanation of physical complaints. Patients remembered a few pieces of physician advice. Most of them said their doctor told them to "change hands and change brands" [12:01:34; 17:01:43] when preparing to quit, or to "put their cigarettes in an unusual spot" [12:01 :34]. A surprising few (given that physician training had explicitly encouraged personalization of risks ) commented before they quit that their physicians made a connection between existing physical symptoms and their smoking habit. For example: He said that smoking irritates [my sinuses] [04:01:16]. This connection is usually admitted, however, after the patient quits smoking. As one participant said: Had I not quit he would be concerned that I was on the road to hardening of the arteries, and whatever goes along with that [30:04:71 ]. Another patient said: We talked about cancers and stuff [40:02:105].
Explanatory models of smoking. Regarding the health promotion intervention itself, patients said that the physician discussed and compared two theories for smoking cessation (as they had in fact been trained to do ): physical withdrawal (an addiction to nicotine) as opposed to overcoming the habit of smoking (a behavioral explanation ): [My doctor] is saying a week to a couple of weeks, they should be all over, physically. The habit of not reaching for a cigarette is probably going to take a lot longer than that [02:03:5]. He said, you know, the physical withdrawal is something that you have to conquer, and once that's conquered that's great. But your next hurdle is going to be . .. [08:04:47]. So he went through that, and explained to me that, you know, it's not only just pure habit, but it's an addiction to the nicotine [04:01: 17].
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Personalistic. The great majority of patients' comments on their doctor's interventions were of a personal and relational nature. That is, they commented on the relationship they had with their doctor. The doctor, in these instances (1) communicated lifestyle and medical information to the patient in a straightforward and easily understood manner; (2) communicated in a convincing way the need to be healthy and feel good; and (3) showed concern, care, and support. Instead of discussing the negative aspects of the patient's life as a smoker, the doctor is remembered for helping the patient start again (a lifestyle change), giving hope ("your body will return to normal" ), and understanding the difficulty of attempting to quit smoking. Images of regeneration. The images of "getting clean" and of "lungs coming back to life" are symbolically rich (new birth, purification ); these are the messages remembered in these physician-patient encounters. Here are a few examples: The doctor told me it takes up to three months before you actually clear your lungs [50:02:111]. And he said something about your cells coming back to life, or something like this [15:01:73] . He said it's just that your chest, something with your smoking that's happened to your chest, that cleans it out. It kind of deadens it now or something. So not that there's no smoke there, it's starting to come back, like trying to get rid of that stuff you got in there [19:03:55]. Smoking kills something in your lungs, or did, whatever; when you stop, it revives and starts to clean out [19 :03 :55]. [My doctor] said that in 10 years your lungs would be back to nearly as good as they were ... [30:01:75]. He said, don't let anyone tell you that you can't reverse the effects, that you can ... improving my chances . .. that's something else he did bring up [56:01:129].
Promises of better health. The end result of quitting smoking, some doctors say, is the feeling and experience of being healthy. Patients remembered this inspirational message and want to feel better, change for the better, and even consider a lifestyle change if that is what it takes to quit smoking. The physicians promise of feeling better is evident in the following examples: The doctor says it's going to take a while, but one day you're going to wake up, and you're going to be puttering around for a couple of hours, and suddenly realize, hey, I didn't cough [30:02:68]. He just said, someday, it's going to make you feel great [02:06:8 ]. Reinforcement about ... being healthier [04:02:19]. He told me how my life's going to change, and how much better I'm going to feel [05:03:24]. You're going to feel like a different person when you completely stop. Your head's going to clear up again ... he told me my color is different already ... looks better [05 :04:27].
Recommending a change in lifestyle. Physicians' advice to
patients to change their whole lifestyle and to adopt healthier liabits is mentioned in the following comments: I plan to change my whole-like the doctor and I talked about that. If you are going to quit smoking, you have to change your lifestyle [51: 03: 116]. [My doctor] said I'm at a new stage in my life [08:04:45]. He says, in six years you'll be off cigarettes for six years, your lungs and heart will be back to normal. Like that of a nonsmoker ... it has to be a change of lifestyle. You cannot just quit smoking, and continue doing what you're doing, because you are leading a life of a smoker [08:03:43].
A contract with the doctor. Another aspect of .this personalistic orientation is the feeling of being morally responsible to the doctor (not letting the doctor down, not lying to him or her). The relationship of trust that these statements are based on is experienced as a form of support in the quitting process. Here are some examples:
A lot of the time, I think if I have a cigarette, I'll have to tell ... the doctor (02:05:7]. Not letting them people down, you know ... knowing that I've got to face [my doctor] and different people. And it's just a little bit more of a deterrent [03:04:15].
I was thinking that this may be a good way to quit smoking, because I don't dare lie to the doctor [17:01:43]. Physician support. The following comments are explicit statements from patients about being supported by their doctor. These statements are also tempered with their feeling of not being pressured or hurried and of being supported as a friend. Here are some examples: He didn't hurry me or anything [02:02:3].
I made up my mind that I was going to do it, and I think with the support that I've had too, it's a big thing ... [04:0:21].
If I did it all by myself, I don't know if I would have lasted [06:05 :29]. He's got a very nonchalant attitude. Like, here's hoping you can do it kid, but if you don't, you tried. He's good [30:02:69]. He is very supportive; he always has been. And every time I go, he asks me if I am smoking (50:02:111]. I just figure in life there's help you should take, and not try to do things yourself, because there's a lot of things you can't do yourself [19:01:51]. I just wouldn't do it on my own. Because I wouldn't make it, not now [19:02:54]. I'm glad [my doctor] is taking time out to help .... I need someone to help discipline me [17:01 :44]. Moral support, I mean, he's not pushing me ... with me, I got to come half way, and the doctor is going to come half way [07:01:31].
Encouragement and Congratulations. Lastly, patients frequently mentioned the importance of being encouraged and congratulated by their physician. This too is experienced as a form of moral support. Consider the following quotations: How did he put it-he was going to put me down as his success story [02:07:11]. It's always good to hear some encouraging words [03:03:14]. You have to have a belief in your doctor, like a trust or something. And I am impressed ... if anyone cares about me like I am impressed ... when a doctor who is a professional and has his own life, his own family, will actually come out and say I'm going to come out and help you quit smoking you kind of think, wow! [10:02:56]. It is hard to remember what the heck we talked about. He was very encouraging [04:03:21]. He seems to care a lot about people [33:01:81]. He just said that he was happy to see that I was going well. That is about it. He just said congratulations, hope it keeps going well for you [22:05:63]. He seemed pretty confident that I had things well in hand [30:02:67]. It's just the way he says it [19:03:54]. I feel good about the fact that it was only through [my doctor], you know, through his encouragement, I see that someone is willing to help ... and that's encouraging (31:01:75].
CONCLUSIONS These comments from patients alert us to a number of problems associated with physician-delivered smoking cessation imerventions. The fact that patients emphasize the helpfulness of the personalistic component of physician work over and above the interventionistic component is telling. However, for physicians to speak with biomedical authority, to communicate the problem of disease-related risks, or even to use scientific jargon in their encounters with patients is not inappropriate at times. In fact, our evidence suggests that patients expect a certain amount of biomedicine-what physicians normally do and are trained to do-in both critical care and preventive/promotive visits with their physician. As one patient complained: "Is that all it is, verbal support?" In other words, an intervention done well would presumably contain both biomedical and care components. The surprising frequency of relational and personalistic concerns mentioned, however, leads us to believe that more emphasis should be placed on the creation, organization, and management of clinically-based supports. We suggest that these supports are not only appropriate for physician-delivered smoking cessation interventions, but more generally for physician work in health promotion and clinical preventive medicine. To summarize, we categorize the support component of physician-delivered smoking cessation interventions into the
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following conclusions. This list of characteristics can be read as recommendations for a "patient-centered" approach to clinical preventive medicine: 1. Patients evaluate the kind of support they receive from their physician, whether empathy, encouragement, or sincere understanding. Is the doctor really interested in me as a person, does he or she believe that I can do it, does he or she really understand my dilemma? 2. Patients seem to respond favorably to positive imagery in the challenge to quit smoking: a clean life, a healthier life, and a life (and lungs) that is being regenerated day-by-day. Undue emphasis on the negative aspects of smoking, which is, indirectly, a negative statement about the patient's personal life, is either not heard by the patient, selectively not remembered, or ignored. 3. Patients seem to look for a balance in the relationship established with their doctor, where, for example, the method of quitting smoking is open to negotiation, the discourse between them is mutually understandable, and there is mutual respect and rapport. If the relationship is unduly one-sided, there is the possibility that the patient will not comply with the physician's recommendations. If, on the other hand, the patient feels that "we are doing this together," the patient is supported in his or her efforts to change. 4. Patients remember the consistency and regularity of their physician's health promotion messages. Is the issue of a "healthier life" mentioned every time the patient sees the doctor, is the physician actually interested and concerned about the patient's well-being, or is the message sporadic and unexpected? A health promotive message given often and consistently (ideally where the individuals and their family have been patients of the physician for a number of years) symbolizes and communicates committed and personal support.
This research was supported by the National Institutes of Health (U.S.A.) through the auspices of the National Cancer Institute [ROl CA 38334]. In the ethnographic process study, we acknowledge the important contribution of our research assistants: Kenneth Friesen, Alan Harkness, Marie Sternberg, and Diana Tuttleman.
3. Wilson DMC, Taylor DW, Gilbert JR, et al. A randomized trial of a family physician intervention for smoking cessation. JAMA 1988;260: 1570-4. 4. Lindsay EA, Wilson DM, Best JA, et al. A randomized trial of physician training for smoking cessation. Am J Health Prom 1989;3(3):1 l-8. 5. Glaser B, Strauss A. The discovery of grounded theory. Chicago: Aldine, 1967. 6. Rabinow P, Sullivan WM, eds. Interpretive social science: a reader. Berkeley: Universiry of California Press, 1979. 7. Bellah RN. Social science as practical reason. The Hastings Center Report. October 1982:32-9. 8. Argyris C, Putnam R, Smith DM. Action science. San Francisco: Jossey-Bass, 1985. 9. Best JA. Program development for smoking prevention and cessation. In: Craig KD, Weiss SM, eds. Health enhancement, disease prevention, and early intervention: biobehavioral perspectives. New York: Springer, 1990. 10. Best JA, Gilbert JR, Taylor DW, Wilson DMC. Compliance with Nicorette-bearing chewing gum. Grant Application, National Institutes of Health, National Institute [ROl CA 38334]; 1983. 11. Wilson DMC, Lindsay EA, Best JA, et al. A smoking cessation intervention program for family physicians. Can Med J 1987;138: 613-9. 12. Kirkland SA. Physiological correlates of smoking cessation in habitual smokers. M.Sc. thesis, Department of Health Studies: Universiry of Waterloo, 1987. 13. Willms DG, Best JA, Taylor DW, et al. A systematic approach for using qualitative methods in primary prevention research: a focus on smoking. Med Anthropol Q 1990;4:391-409. 14. Agar M. The professional stranger. New York: Academic Press, 1980. 15. Ricouer P. The model of the text: meaningful action considered as a text. Soc Res 1971; 38(3):529-62. 16. Kleinman A. Patients and healers in the context of culture. Berkeley: Universiry of California Press, 1980. 17. Fabian J. Language, history and anthropology. Philos the Soc Sci 1971;1:19-47.
REFERENCES 1. Wechsler H, Levine S, Idelson RK, et al. The physician's role in health promotion-a survey of primary care practitioners. N Engl J Med 1983;308:97-100. 2. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practices: a metaanalysis of 40 controlled trials. Paper prepared for the United States Preventive Services Task Force.
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18. Hahn RA, Kleinman AM. Biomedical practice and anthropological theory: frameworks and directions. In: Annual Review of Anthropology. Palo Alto California: Annual Review Press, 1983. 19. Levi-Strauss C. Structural anthropology. New York: Basic Books, 1960. 20. Eisenberg L. Disease and illness. Distinctions between professional and popular ideas of sickness. Culture, Med, Psychiatry 1977; 1(1):923.
D. Wayne Taylor, MA Elizabeth Lindsay, PhD Joel Singer, PhD Nancy Arbuthnot Johnson, MA
Forty-three patients-recipients of a highly structured, physician-delivered smoking cessation intervention-were interviewed using ethnographic (anthropological) research methods. We conducted interviews with patients after visits with the physician, then audiotaped and transcribed them. Discourse analysis of interview texts identified features and components of the physician manuever most effective from the patients' point of view. Patients discussed two general areas of physicians' preventive activities: an interventionistic component (in which professional, diagnostic, and authoritative features were emphasized) and a personalistic component (in which physicians were experienced as equals, supportive, caring, empower-
ing, and challenging). From the perspective of patients, the personalistic component of the physician-delivered smoking cessation maneuver appeared most effective. We conclude that, in clinical preventive medicine generally, patients (1) evaluate the kind of support they receive from their physician (e.g., degree of empathy, encouragement, and sincerity), (2) respond favorably to positive imagery in the challenge to alter their lifestyle, (3) look for a balance in the relationship established with their physician (negotiation, respect, mutual understanding, and rapport), and (4) remember the consistency and regularity of their physician's health promotion messages. [Am J Prev Med 1991;7:95-100]
Increasingly, family physicians are recognizing that engaging in health promotion work in their practice is rewarded. Despite professional, economic, and educational barriers to the practice of clinical preventive medicine, 1 both physicians and patients benefit from health promotion interventions delivered effectively.2 Yet, what are the ingredients of an effective clinical preventive or health promotive intervention? In particular, which components are the most critical from the patients' point of view? Using a smoking cessation intervention as an example, we examine these clinical concerns in this study.
Designed to provide insights into the process of behavior change, this ethnographic research project was conducted as one of two side studies to the Family Practice Smoking Cessation Project, a large clinical trial; the main trial was conducted through the Department of Family Medicine and the Department of Clinical Epidemiology and Biostatistics of McMaster University, Hamilton, Ontario, Canada.3,4 Ethnography, a qualitative method in anthropology, uses an open-ended, relatively unstructured interview style. Ethnography aims to "understand" the social construction of cultural meanings; moreover, it attempts to preserve the richness, complexity, and uniqueness of cultural meanings, while noting social and situational determinants.5,6 From practical science? and action sciences perspectives, ethnographic research can be characterized as fundamental or basic research. It is a form of hypothesis-generating, phase 1 research; in phase 2 research, these hypotheses and problems are subsequently tested in survey and controlled trial studies. 9 In this study-in which we attempt to identify specific features of a smoking cessation intervention effective from the patients' point of view-we thought an ethnographic design would be useful in identifying emergent problems associated with the burgeoning work of clinical preventive medicine. Five family practice physicians, based in Kitchener-Waterloo (Ontario, Canada), attended a four-hour workshop to learn
Research Design We base this paper on data from an ethnographic research study conducted through the Department of Health Studies of the University of Waterloo, Waterloo, Ontario, Canada.
From the Departments of Clinical Epidemiology and Biostatistics (Willms, Gilbert, Taylor, and Johnson), Family Medicine (Wilson, Gilbert, and Singer), and Continuing Medical Education (Lindsay), McMaster University, Hamilton, Ontario, Canada; and the Department of Health Studies, University of Waterloo (Best), Waterloo, Ontario, Canada. Address reprint requests to Dr. Willms, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON L85 4L8, Canada.
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how to deliver a highly structured smoking cessation intervention. The session included demonstration and practice of the key elements of the intervention, which entailed challenging smokers to quit, negotiating a contract for a cessation date, prescribing nicotine gum appropriately (2 mg), and offering supportive follow-up visits.10,11 Sixty patients were recruited as participants in two process side studies; 15 participated in a physiological side study,12 and two dropped out, leaving 43 participants for the ethnographic study. Of these 43, 23 were women and 20 were men. These participants were patients who arrived for regular office visits and were invited by office receptionists to participate in the study. Subsequently, they were randomized into a Nicorette and non-Nicorette condition. Self-reported cessation rates at one year showed 12 out of the 43 participants quitting, or 27.9%: six women and six men. All successful quitters, except one person, were in the non-Nicorette condition. A member of the ethnographic research team interviewed these 43 participants in their homes or place of work. Interviews were scheduled (a) twice before the participants' "quit date" -the date agreed upon between physician and patient when the patient would quit smoking, (b) once a week for four weeks following their quit date, (c) monthly up to six months, (d) by telephone for five months, and (e) in participants' homes one year afterward. Participants were recruited to the study in April and May 1985.
METHODS
Combining methodological and interpretive procedures, our ethnographic research was divided into four stages or levels of work: (1) interviews and the writing of fieldnotes; (2) the construction of a standardized set of codes; (3) the writing of individual case studies; and (4) the interpretation of cultural idioms of smoking cessation.13 In the first level, we used probe questions to initiate a dialogue between the researcher and the participants about what their physician did during the visit, what was said, and how the patient felt about it. Yet, given the open-ended and unstructured nature of the interviewing style,14 the discussion would usually follow the participants' own agenda of personal relevances. ls Using this tack, we were able to elicit participants' "explanatory models" 16 of their smoking and cessation experience. Each interview was audiotaped and transcribed directly onto the mainframe computer at the University of Waterloo. The result of this fieldwork is an estimated 3,500 pages of transcribed texts of participant interviews; additionally, fieldnotes written by the research assistants after each participant interview were entered into the computer database. The discourse generated through these series of interviews between researcher and participant, together with the fieldnotes, provided the text used in our interpretation and analysis. This interpretive approach assumes (1) that personal experience and meaning is mediated through language-a symbolic, metaphoric, and literal vehicle for communicating relevant and significant meanings and (2) that if these encounters between the participant and the researcher are mutually supportive, reflective, and collaborative, participants will be permitted to characterize their experience richly according to their own rules of personal, social, and cultural relevance.
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The second level of work was the coding stage. Each page of transcribed text was read and reread in the work of identifying emergent issues and themes. 17 Through a process of consensus (i.e., eventual agreement between researchers), we constructed a coding system that reflected the shared experience of participants. Specifically, research assistants, who were each familiar with 8-10 participants' experiences from having conducted the in-home interviews, were required to agree on the relevance (based on relative frequency of certain issues) of emergent themes (codes) in the participants' texts. The codes were subsequently applied to the texts and then crosschecked by "blind readers" as a reliability measure. In the database, passages that related in some way to the physician's intervention were coded as follows: 30400 Doctor (clinical, professional mediation, and participant's perception of mediation) 30401 Doctor's view of health, disease, and illness 30402 Doctor's view of smoking and risk 30403 Doctor's actual intervention 30404 Participant's perception of doctor 30405 Participant's questions for the doctor 30406 Participant's perceptions of the doctor's intervention For example, if participants mentioned during the interview that they asked their physician a question regarding their smoking (for example, a question about withdrawal symptoms), the paragraph in the transcribed text would be coded 30405. The third level of interpretation involved the writing of individual case studies. In the format of a life history, each participant's smoking experience and cessation attempt were rendered into prose (5-10 pages of written text). The research objective at this level of analysis was to provide a configurational interpretation of each individual's situation, which preserved elements of the individual's social-cultural context, the uniqueness of individual experience, and the authenticity of the individual's "story." The fourth level of analysis involved the interpretation of cultural idioms of smoking experience and cessation identified in Levels 1, 2, and 3. To illustrate our findings, we have extracted "discrete units of text" that bear directly on patients' perceptions of the physician-delivered smoking cessation intervention. A "discrete unit of text" (DUT) encompasses both the interviewer's question [I] and the participant's response [P]. For example: I: What did your doctor tell you when you saw him yesterday? P: He told me that he was very proud of me for quitting. He said ... what was it ... yes, he said, I was his success story. Isn't that great? These "texts" are verbatim comments of patients-often accentuated by pauses and comments on mood and tone-and are organized in our analysis into clusters of patient relevance and significance. This process was facilitated by a computerized software package designed for this purpose, called Ethnographic Theme Search. Ethnographic Observations In a physician-delivered smoking cessation intervention, which component is the most important from the patient's point of view: the communication of potential risks, the explanation of
withdrawal symptoms, perceived support, or some other component of professional care? Our process research suggests that the most significant component of the physicians' intervention was the kind of support given. Patients frequently forgot the details of the physician's message (for example, strategies and methods of quitting, negative aspects of smoking), but selectively remembered (1) the kind of support the physician provided (e.g., a pat on the back, congratulations, or encouragement); (2) the positive images used by the physicians to communicate what it is like becoming an ex-smoker (e.g., getting back to normal, feeling better/healthier); and (3) a relationship of equality, care, and moral accountability established between physician and patient (e.g., not wanting to let the doctor down, or, "he i.s doing his best so I need to do mine"). In presenting these findings, we divide our ethnographic observations into two general domains of clinical experience: interventionistic and personalistic. Keeping in mind that these comments of patients relate to the health promotion activities of their physician, we prefer to think of these organizing labels in the following way. Activities of the physician defined as interventionistic are those components of the physicians' work that generally refer to traditional, biomedical models. This component of work characterizes the doctor as (1) medical professional; (2) diagnostician; and (3) biomedical spokesperson-an authority on the scientific explanation of physiological processes, including knowledge of the disease-related risks of continued smoking.1 s Given this biomedical orientation, the relationship established between physicians and patient is often asymmetrical; thus, it is often nonequivocal, authoritarian, and interventionistic. Those activities of the physician we label as personalistic are components of the physicians' work that are characteristically nurturing, caring, and mutually communicative. These statements refer to the physician as (1) concerned friend; (2) support-giver; (3) empathizer; and (4) facilitator. The relationship established in this kind of clinical orientation is egalitarian; the physician and patient experience a balanced, mutually respectful, moral relationship. Although this breakdown of perceptions of physician work may appear unnaturally dualistic or dichotomous, the text itself points to this structural interpretation in patient experience. A structural interpretation posits that human experience and cognition are characteristically dialectical and binary in nature. t 9 In the interpretation of physician work and clinical processes, herefore, we could divide the components of the health promojon visit as follows: personalistic interventionistic personal biomedical intervener in illness process care provider understanding explanation symmetrical relationship asymmetrical relationship heals20 cures popular language professional language extended clinical time limited clinical time wellness model disease model communication/ dialogue documentation (historytaking) We do not mean to suggest that physicians display only one or the other form of clinical work; in fact, they often display both interventionistic and personalistic strategies in the clinical
visit. Rather, we suggest that the personalistic component is the one remembered; it is experienced to be the most effective form of support in the clinical preventive or health promotive visit. Interventionistic qualities. In this section, we present patient comments that refer to the interventionistic qualities of the physician's work. The import of patients' comments suggests that this aspect of the physicians' health promotion activity is less appreciated, and in some instances, even considered obtrusive. Research questions and record-keeping. The following patient comments refer to the problems associated with record-keeping (documentation of forms, history-taking) and the research requirements of the study itself. Each quotation from patients is appended with (1) a participant number; (2) an interview number; and (3) the page number from which the quotation was taken in the transcribed text. For example, [02:02:3] refers to participant number 2, interview number 2, page 3. Consider the following quotations: He asked me a bunch of questions that were on a sheet. How did I feel about quitting? How was my willpower? [02:02:3] Well, he just filled out a questionnaire about: the commitment is high and how much weight did you gain .... [02:06:8] He didn't really say too much. He just asked me if I wanted to [quit]. Then he wrote some things and gave me some sheets [34:01:90]. All he says when you go in is: How much are you smoking? ... when are you going to quit? ... that is all he ever says ... he has ... to keep a record of, hasn't he? Don't they ... that goes with this course? ... that is all he ever did was ask questions out of the course [25:05:92]. Time. Time seems to be a frequent complaint of both patient and physician. In this instance, however, the meaning seems to be that of time taken at the patients' expense: He gave me a quick little pep talk about what it was about ... who it was funded by, and what it was for. And he wanted to see me again ... on my quit day, my first day ... we sort of rushed into this pretty quickly [30:01:66]. I think he was rather rushed at the time, you know. I just went into the office ... he had a lot of patients there and he asked me how I was feeling f42:02:93].
It was a pretty brief visit. We didn't really talk about that much [03:04:15]. With the case-loads they've got nowadays, they're just too damn busy to ... if you didn't really want to quit, I don't think they're going to help much f44:01:00]. Not understanding patient experience. Patients seemed less concerned about time, however, than about not being understood by their physician. In this respect, patients seem troubled with physicians who did not understand the life of a smoker (what it is like to smoke) or the difficulty they would have trying to quit ("it's not easy to do!"). These are sample remarks: [My doctor] says you don't have to [gain weight], but I haven't met anybody yet that didn't [02:06:8].
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[He] feels you have extra time on your hands when you don 't smoke. I haven't found that either [02:06:9 ]. Oh, I think he certainly believes anybody could quit smoking. I don't think he believes me when I say a cigarette tasted good. I think that is only an opinion that a nonsmoker, somebody who has never smoked, could have. I think anybody that ever did smoke would understand that phrase [03 :03:12]. It's just that he can't tell me nothing. I don't know about smoking . . . you have to be smoking to explain that to somebody. Like I don't know if [my doctor] ever smoked in his life, I don't know that. But I can't see how he can explain to me and tell me the feeling of smoking if he never smoked in his life. You almost have to smoke for somebody to know how it feels [27:02 :100]. [My doctor said] I wish you would find friends that don't smoke . . . get somebody who's a nonsmoker . . . the doctor wants me to just hang around nonsmoking people . .. he doesn't want me to be around a smoker, you know. And I don't plan to give John up [25 :02,02:05:88, 89:92].
Explanation of physical complaints. Patients remembered a few pieces of physician advice. Most of them said their doctor told them to "change hands and change brands" [12:01:34; 17:01:43] when preparing to quit, or to "put their cigarettes in an unusual spot" [12:01 :34]. A surprising few (given that physician training had explicitly encouraged personalization of risks ) commented before they quit that their physicians made a connection between existing physical symptoms and their smoking habit. For example: He said that smoking irritates [my sinuses] [04:01:16]. This connection is usually admitted, however, after the patient quits smoking. As one participant said: Had I not quit he would be concerned that I was on the road to hardening of the arteries, and whatever goes along with that [30:04:71 ]. Another patient said: We talked about cancers and stuff [40:02:105].
Explanatory models of smoking. Regarding the health promotion intervention itself, patients said that the physician discussed and compared two theories for smoking cessation (as they had in fact been trained to do ): physical withdrawal (an addiction to nicotine) as opposed to overcoming the habit of smoking (a behavioral explanation ): [My doctor] is saying a week to a couple of weeks, they should be all over, physically. The habit of not reaching for a cigarette is probably going to take a lot longer than that [02:03:5]. He said, you know, the physical withdrawal is something that you have to conquer, and once that's conquered that's great. But your next hurdle is going to be . .. [08:04:47]. So he went through that, and explained to me that, you know, it's not only just pure habit, but it's an addiction to the nicotine [04:01: 17].
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Personalistic. The great majority of patients' comments on their doctor's interventions were of a personal and relational nature. That is, they commented on the relationship they had with their doctor. The doctor, in these instances (1) communicated lifestyle and medical information to the patient in a straightforward and easily understood manner; (2) communicated in a convincing way the need to be healthy and feel good; and (3) showed concern, care, and support. Instead of discussing the negative aspects of the patient's life as a smoker, the doctor is remembered for helping the patient start again (a lifestyle change), giving hope ("your body will return to normal" ), and understanding the difficulty of attempting to quit smoking. Images of regeneration. The images of "getting clean" and of "lungs coming back to life" are symbolically rich (new birth, purification ); these are the messages remembered in these physician-patient encounters. Here are a few examples: The doctor told me it takes up to three months before you actually clear your lungs [50:02:111]. And he said something about your cells coming back to life, or something like this [15:01:73] . He said it's just that your chest, something with your smoking that's happened to your chest, that cleans it out. It kind of deadens it now or something. So not that there's no smoke there, it's starting to come back, like trying to get rid of that stuff you got in there [19:03:55]. Smoking kills something in your lungs, or did, whatever; when you stop, it revives and starts to clean out [19 :03 :55]. [My doctor] said that in 10 years your lungs would be back to nearly as good as they were ... [30:01:75]. He said, don't let anyone tell you that you can't reverse the effects, that you can ... improving my chances . .. that's something else he did bring up [56:01:129].
Promises of better health. The end result of quitting smoking, some doctors say, is the feeling and experience of being healthy. Patients remembered this inspirational message and want to feel better, change for the better, and even consider a lifestyle change if that is what it takes to quit smoking. The physicians promise of feeling better is evident in the following examples: The doctor says it's going to take a while, but one day you're going to wake up, and you're going to be puttering around for a couple of hours, and suddenly realize, hey, I didn't cough [30:02:68]. He just said, someday, it's going to make you feel great [02:06:8 ]. Reinforcement about ... being healthier [04:02:19]. He told me how my life's going to change, and how much better I'm going to feel [05:03:24]. You're going to feel like a different person when you completely stop. Your head's going to clear up again ... he told me my color is different already ... looks better [05 :04:27].
Recommending a change in lifestyle. Physicians' advice to
patients to change their whole lifestyle and to adopt healthier liabits is mentioned in the following comments: I plan to change my whole-like the doctor and I talked about that. If you are going to quit smoking, you have to change your lifestyle [51: 03: 116]. [My doctor] said I'm at a new stage in my life [08:04:45]. He says, in six years you'll be off cigarettes for six years, your lungs and heart will be back to normal. Like that of a nonsmoker ... it has to be a change of lifestyle. You cannot just quit smoking, and continue doing what you're doing, because you are leading a life of a smoker [08:03:43].
A contract with the doctor. Another aspect of .this personalistic orientation is the feeling of being morally responsible to the doctor (not letting the doctor down, not lying to him or her). The relationship of trust that these statements are based on is experienced as a form of support in the quitting process. Here are some examples:
A lot of the time, I think if I have a cigarette, I'll have to tell ... the doctor (02:05:7]. Not letting them people down, you know ... knowing that I've got to face [my doctor] and different people. And it's just a little bit more of a deterrent [03:04:15].
I was thinking that this may be a good way to quit smoking, because I don't dare lie to the doctor [17:01:43]. Physician support. The following comments are explicit statements from patients about being supported by their doctor. These statements are also tempered with their feeling of not being pressured or hurried and of being supported as a friend. Here are some examples: He didn't hurry me or anything [02:02:3].
I made up my mind that I was going to do it, and I think with the support that I've had too, it's a big thing ... [04:0:21].
If I did it all by myself, I don't know if I would have lasted [06:05 :29]. He's got a very nonchalant attitude. Like, here's hoping you can do it kid, but if you don't, you tried. He's good [30:02:69]. He is very supportive; he always has been. And every time I go, he asks me if I am smoking (50:02:111]. I just figure in life there's help you should take, and not try to do things yourself, because there's a lot of things you can't do yourself [19:01:51]. I just wouldn't do it on my own. Because I wouldn't make it, not now [19:02:54]. I'm glad [my doctor] is taking time out to help .... I need someone to help discipline me [17:01 :44]. Moral support, I mean, he's not pushing me ... with me, I got to come half way, and the doctor is going to come half way [07:01:31].
Encouragement and Congratulations. Lastly, patients frequently mentioned the importance of being encouraged and congratulated by their physician. This too is experienced as a form of moral support. Consider the following quotations: How did he put it-he was going to put me down as his success story [02:07:11]. It's always good to hear some encouraging words [03:03:14]. You have to have a belief in your doctor, like a trust or something. And I am impressed ... if anyone cares about me like I am impressed ... when a doctor who is a professional and has his own life, his own family, will actually come out and say I'm going to come out and help you quit smoking you kind of think, wow! [10:02:56]. It is hard to remember what the heck we talked about. He was very encouraging [04:03:21]. He seems to care a lot about people [33:01:81]. He just said that he was happy to see that I was going well. That is about it. He just said congratulations, hope it keeps going well for you [22:05:63]. He seemed pretty confident that I had things well in hand [30:02:67]. It's just the way he says it [19:03:54]. I feel good about the fact that it was only through [my doctor], you know, through his encouragement, I see that someone is willing to help ... and that's encouraging (31:01:75].
CONCLUSIONS These comments from patients alert us to a number of problems associated with physician-delivered smoking cessation imerventions. The fact that patients emphasize the helpfulness of the personalistic component of physician work over and above the interventionistic component is telling. However, for physicians to speak with biomedical authority, to communicate the problem of disease-related risks, or even to use scientific jargon in their encounters with patients is not inappropriate at times. In fact, our evidence suggests that patients expect a certain amount of biomedicine-what physicians normally do and are trained to do-in both critical care and preventive/promotive visits with their physician. As one patient complained: "Is that all it is, verbal support?" In other words, an intervention done well would presumably contain both biomedical and care components. The surprising frequency of relational and personalistic concerns mentioned, however, leads us to believe that more emphasis should be placed on the creation, organization, and management of clinically-based supports. We suggest that these supports are not only appropriate for physician-delivered smoking cessation interventions, but more generally for physician work in health promotion and clinical preventive medicine. To summarize, we categorize the support component of physician-delivered smoking cessation interventions into the
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following conclusions. This list of characteristics can be read as recommendations for a "patient-centered" approach to clinical preventive medicine: 1. Patients evaluate the kind of support they receive from their physician, whether empathy, encouragement, or sincere understanding. Is the doctor really interested in me as a person, does he or she believe that I can do it, does he or she really understand my dilemma? 2. Patients seem to respond favorably to positive imagery in the challenge to quit smoking: a clean life, a healthier life, and a life (and lungs) that is being regenerated day-by-day. Undue emphasis on the negative aspects of smoking, which is, indirectly, a negative statement about the patient's personal life, is either not heard by the patient, selectively not remembered, or ignored. 3. Patients seem to look for a balance in the relationship established with their doctor, where, for example, the method of quitting smoking is open to negotiation, the discourse between them is mutually understandable, and there is mutual respect and rapport. If the relationship is unduly one-sided, there is the possibility that the patient will not comply with the physician's recommendations. If, on the other hand, the patient feels that "we are doing this together," the patient is supported in his or her efforts to change. 4. Patients remember the consistency and regularity of their physician's health promotion messages. Is the issue of a "healthier life" mentioned every time the patient sees the doctor, is the physician actually interested and concerned about the patient's well-being, or is the message sporadic and unexpected? A health promotive message given often and consistently (ideally where the individuals and their family have been patients of the physician for a number of years) symbolizes and communicates committed and personal support.
This research was supported by the National Institutes of Health (U.S.A.) through the auspices of the National Cancer Institute [ROl CA 38334]. In the ethnographic process study, we acknowledge the important contribution of our research assistants: Kenneth Friesen, Alan Harkness, Marie Sternberg, and Diana Tuttleman.
3. Wilson DMC, Taylor DW, Gilbert JR, et al. A randomized trial of a family physician intervention for smoking cessation. JAMA 1988;260: 1570-4. 4. Lindsay EA, Wilson DM, Best JA, et al. A randomized trial of physician training for smoking cessation. Am J Health Prom 1989;3(3):1 l-8. 5. Glaser B, Strauss A. The discovery of grounded theory. Chicago: Aldine, 1967. 6. Rabinow P, Sullivan WM, eds. Interpretive social science: a reader. Berkeley: Universiry of California Press, 1979. 7. Bellah RN. Social science as practical reason. The Hastings Center Report. October 1982:32-9. 8. Argyris C, Putnam R, Smith DM. Action science. San Francisco: Jossey-Bass, 1985. 9. Best JA. Program development for smoking prevention and cessation. In: Craig KD, Weiss SM, eds. Health enhancement, disease prevention, and early intervention: biobehavioral perspectives. New York: Springer, 1990. 10. Best JA, Gilbert JR, Taylor DW, Wilson DMC. Compliance with Nicorette-bearing chewing gum. Grant Application, National Institutes of Health, National Institute [ROl CA 38334]; 1983. 11. Wilson DMC, Lindsay EA, Best JA, et al. A smoking cessation intervention program for family physicians. Can Med J 1987;138: 613-9. 12. Kirkland SA. Physiological correlates of smoking cessation in habitual smokers. M.Sc. thesis, Department of Health Studies: Universiry of Waterloo, 1987. 13. Willms DG, Best JA, Taylor DW, et al. A systematic approach for using qualitative methods in primary prevention research: a focus on smoking. Med Anthropol Q 1990;4:391-409. 14. Agar M. The professional stranger. New York: Academic Press, 1980. 15. Ricouer P. The model of the text: meaningful action considered as a text. Soc Res 1971; 38(3):529-62. 16. Kleinman A. Patients and healers in the context of culture. Berkeley: Universiry of California Press, 1980. 17. Fabian J. Language, history and anthropology. Philos the Soc Sci 1971;1:19-47.
REFERENCES 1. Wechsler H, Levine S, Idelson RK, et al. The physician's role in health promotion-a survey of primary care practitioners. N Engl J Med 1983;308:97-100. 2. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practices: a metaanalysis of 40 controlled trials. Paper prepared for the United States Preventive Services Task Force.
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18. Hahn RA, Kleinman AM. Biomedical practice and anthropological theory: frameworks and directions. In: Annual Review of Anthropology. Palo Alto California: Annual Review Press, 1983. 19. Levi-Strauss C. Structural anthropology. New York: Basic Books, 1960. 20. Eisenberg L. Disease and illness. Distinctions between professional and popular ideas of sickness. Culture, Med, Psychiatry 1977; 1(1):923.