Treating more smokers, more of the time, more successfully.

The authors [1] address an extremely important question; viz. how can we engage more smokers in smoking treatment during their healthcare 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 healthcare visits. In essence this would seem to mean that clinicians offer counseling and/or medication to all smokers without getting 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 healthcare visit to intervene with patients who smoke, questions remain regarding how to do that best. The authors juxtapose the opt-out approach to guideline based treatment. Most guidelines recommend that all smokers be strongly encouraged 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: i.e., “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 get 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 healthcare 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, 13, 14, 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 vs. combination NRT: [14, 15], and 3) it focuses on 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]. Therefore, rather than funneling smokers into cessation treatment, it might be better to engage in some assessment in order to provide them 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 healthcare visit as an opportunity to engage smokers in evidence based treatment.