Commentary on Stepankova et al. : Try, try, try again—smoking cessation clinics and their role in the cessation journey

Field: Health Professions (Health Sciences)

Stepankova and colleagues demonstrate that the second round of treatment for smoking cessation can be as effective as the first round. It is important to recognize that, in a clinical context, most smokers will have already made multiple quit attempts and have learned the nature of their addiction. However, learning that quitting can be difficult can act as increased motivation to try to quit again. Clinicians should be willing to treat cessation as a long- term progress and not fear repeated clinical interventions. This important paper by Stepankova et al. [1] demonstrates that the second round of treatment for smoking cessation can be as effective as the first round. Their work suggests that clinicians should be emboldened to continue providing long-term care. Only a small proportion of smokers seek treatment in specialized smoking cessation programs. While this group is comprised of individuals with mixed levels of dependence, smoking patterns and other characteristics, smokers seeking help differ substantially from smokers in general population [2]. Those who have been successful at quitting unassisted or without specialized assistance would not seek help at smoking cessation programs [2]. Thus, the subpopulation of smokers seeking help in smoking cessation programs may include larger numbers of smokers who unsuccessfully tried to quit before admission and are likely to possess features associated with smoking cessation failure in the past and, theoretically, in the future. There is a consensus across the literature that treatment programs should be matched to their respective clientele in order to provide support adequate to their needs [3-5]. The heavier smoking and higher dependence levels observed in Stepankova et al.’s sample are associated with significantly lower cessation rates and higher chances of relapse [6]. Clients seeking help in smoking cessation clinic demonstrate high prevalence of cardiovascular and respiratory disorders, mood and anxiety disorders and other addictive behaviors. In addition, socio-economic features of the smokers who attend specialized treatment, such as low income and education level, might pose additional barriers to treatment due to the cost of medications or nicotine replacement therapy products (if they are not covered by health insurance), transportation costs, and so on. In sum, the difficulty of achieving success can discourage clinicians to continue supporting a seemingly ever more difficult population to treat [7]. Generally, quitting smoking is recognized as being difficult, and most now agree that quitting should be regarded as a chronic process. While clinical success rates can be improved, it is important to recognize the context: these are probably not the only quit attempts that have been undertaken by this population. By the time people are seen in specialized clinics most will have already tried to quit multiple times, perhaps tried even hundreds of times. On average, smokers attempt to quit about once a year, every year [8]. Quitting attempts are very common, and the vast majority of these attempts are failures. Even among those who are able to attain 1 year smoke-free, a commonly accepted indicator of success, we would expect that more than 25% of these people will go on to relapse into regular smoking. Overall, our best estimates of the number of quit attempts before success is greater than 30 times [9]. It is not surprising, then, that repeated attempts to treat smoking at a clinic has so little effect on the success rate. Those who attend smokers’ clinics are already more likely to have difficulty quitting smoking in the first place, and these quit attempts are only one of many of a life-time of attempts. The learning—the expectations—that develop in a clinical quit attempt are part of a process that is affected by many factors before patients enter the clinic. The important learning from this is that clinicians should not be afraid of initiating quit attempts in fear of quitting ‘failures’. Tobacco treatment has many barriers, including the lack of belief that health professionals are even responsible for treating tobacco use and fear of offending patients, but we need to make tobacco treatment as routine and effective as possible to make an impact on a population level, even if it feels insurmountable to the individual clinician. The efficacy of interventions to support cessation are well supported by clinical trials [10-13]. The effectiveness of physician advice, particularly when combined with concrete help (i.e. effective pharmacotherapies)[14] unquestionably helps the individual who smokes to help quit. Stepankova and colleagues’ study shows us that clinicians must continue to support and encourage repeated quit attempts for the benefit of their clients [1]. While clinical smoking cessation treatment may only be a small portion of the overall smoking cessation journey for many smokers, clinicians should feel empowered to continue to provide assistance if a client is not successful on their first, or rather first observed, attempt. None.