The Diplomacy of Smoking Cessation “Advice”
Many of us see smokers who want to quit but are not quite ready (about 80% of smokers). The USPHS recommends using the 5 A’s algorithm with such clients: i.e. “Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in quit attempt and Arrange followup.” If a smoker is not ready to quit, it recommends the 5 R’s: discuss their Relevant reason to quit, their Risks of smoking, their Rewards from quitting, their Roadblocks to quitting, and Repeat. When I teach medical students, residents and doctors I vary from these 10 strategies in two ways. First, the USPHS guidelines recommends discussing treatment options only if the smoker states he/she is willing to quit in the next few weeks. In contrast, I think its best to first educate a smoker about treatment options: e.g., tell them about the state quitline, OTC meds, Rx meds, groups and individual counseling. And, most importantly, that I am willing to help them access these. Second, I do not advise to quit. Many experts believe it’s very important to have a clear and explicit statement such as “I strongly advise you to stop smoking.” On the other hand, motivational interviewing sees such proscriptive advise as counterproductive. I compromise by asking if the smoker has ever tried to quit or thought about quitting. Over 90% say yes and then I ask why they wanted to quit. I then reinforce this reason and only then, ask if they are interested in quitting in the next few weeks. At this point, I do not specifically advise quitting because it’s obvious that I think they need to quit. And this way I avoid embarrassing or shaming the smoker. So is there any data on different methods of proactively approaching smokers about quitting? Well, Paul Aveyard in an in press paper in Addiction, did a meta-analysis comparing studies in which only advice was given with studies in which only offering assistance was given. Advising increased quit attempts1.2 fold whereas offering assistance increased attempts 1.7 fold, and this difference was statistically significant. I think this paper is important because it suggests one does not have to take a “wag the finger” proscriptive approach but can, instead take a “how can I help” supportive approach. The later is more consistent with what therapists want to do and is more respectful of the patient, plus it’s just more fun to do. I would enjoy hearing thoughts of others on this.