The authors 1 address an extremely important question; namely, how can we engage more smokers in smoking treatment during their health-care visits? Clearly, too few smokers leave their clinics with strong evidence-based treatment arranged or in place 2. The authors suggest a bold strategy to achieve higher rates of engagement in smoking treatment, i.e. using the ‘opt-out’ principle to provide treatment to smokers making health-care visits. In essence, this would seem to mean that clinicians offer counseling and/or medication to all smokers without gaining smokers’ buy-in or agreement. This strategy seems consistent with data showing that smokers’ willingness to quit (i.e. ‘willingness’) is labile; thus, it may be unwise to set much store in it 3. While the opt-out approach is innovative, and we are highly supportive of seizing every health-care visit to intervene with patients who smoke, questions remain regarding how best to do that. The authors juxtapose the opt-out approach to guideline-based treatment. Most guidelines recommend that all smokers be encouraged strongly to make a quit attempt using evidence-based treatment; i.e. smokers should be given strong, clear and personalized advice to quit (e.g. 4). If the smoker is unwilling to try to quit, s/he would then be given motivational treatment to encourage entry into cessation treatment. This conflicts with the authors’ statement that: ‘Guidelines in many countries recommend that health care providers a) ask patients if they are ‘ready’ to quit using tobacco and b) provide treatment only to those who state they are ready to quit’. Virtually all guidelines call for all smokers to receive treatment: motivational or cessation. Under the opt-out approach, it seems that the clinician would try to encourage smokers to agree to cessation treatment regardless of the patient's stated willingness. This may pressure smokers to assent to treatment despite their having low motivation to quit. While the authors express doubt about the relation between motivation and cessation success, there is evidence that unwilling, unmotivated smokers (e.g. 5) are relatively unlikely to even make quit attempts 6, 7, and low intrinsic motivation to quit may reduce quitting success 8, 9. Indeed, when we tried to provide cessation treatment to ‘unwilling’ smokers at a health-care visit, few accepted such treatment and there was little evidence of clinical benefit 10. It may be that patient ‘buy-in’ is needed for optimal behavior change 11. An alternative 12, 13 is to assess each smoker's quitting goal; if a smoker is willing to make a quit attempt, he or she would receive evidence-based cessation treatment. ‘Unwilling’ smokers, however, would be urged to enter a ‘motivation’ treatment (which differs from the ‘motivational counseling’ mentioned by the authors) that is designed to reduce smoking and prepare them to quit. Such treatment appears to be reliably efficacious 4, 12-15 and differs markedly from cessation treatment; (1) consistent with chronic care, the expectation is that treatment is prolonged and there is no failure marker to encourage attrition, (2) it uses a different pharmacotherapy than does cessation treatment (nicotine gum or mini-lozenge versus combination nicotine replacement therapy 14, 15) and (3) it focuses upon smoking reduction. We believe that there are at least three important reasons to adopt such an approach. (1) Offering a smoking reduction goal to ‘unwilling’ smokers may significantly increase the proportion of smokers who enter treatment 16. (2) Such motivation treatments 12, 13 encourage treatment continuation, promoting chronic care, and they ultimately boost cessation success 14, 15, 17. (3) There is evidence that the different phases of smoking treatment (e.g. motivation, preparation, cessation) offer different challenges and opportunities, which have treatment implications 12. Thus, while the nicotine patch works well as a cessation aid, we find that it works poorly as a motivation intervention 14, 15. Therefore, rather than funneling smokers into cessation treatment, it might be better to engage in some assessment in order to provide them with treatment that is congruent with both their intrinsic goals (for which there is ‘buy-in’) and the phase-related challenges they face 13. At present, it is too early to tell which sort of approach will yield the greatest benefits to smokers. Multiple strategies (e.g. 18) should be explored in an effort to take greater advantage of the health-care visit as an opportunity to engage smokers in evidence-based treatment. T.B.B has not served as a paid consultant to any for-profit interests related to this work; he has served as a paid and non-paid consultant to governmental and non-profit interests related to this work. M.C.F. has not served as a paid consultant to any for-profit interests related to this work; he has served as a paid and non-paid consultant to governmental and non-profit interests related to this work. This work was supported by NCI award 1 P01 CA180945-01.
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Jul 1, 2015
H Bowers + 11
