Promoting Smoking Cessation Among Cancer Patients: A Behavioral Model

From Action to Progress; From Talking to Technology for Smoking Cessation and Health Promotion

The article, Promoting Smoking Cessation Among Cancer Patients, is an excellent complement to the clinical practice guideline on smoking cessation recently published by the Agency for Health Care Policy and Research (AHCPR).[1] The guideline presented considerable detail for clinicians on how to help smokers who are prepared to quit. For the approximately 80% of smokers who are not prepared, the guideline included only a few paragraphs. The approach of Prokhorov, Hudman, and Gritz, seasoned clinicians and scientists, can help clinicians become much more confident when counseling all smokers, including those in the precontemplation and contemplation stages.

The authors' approach to cancer patients who smoke is clear, concise, and relatively comprehensive. Part of its comprehensiveness derives from the fact that this same sensitive system can be applied to all patients, not only those with cancer.

Changing the Behavior of Both Patients and Health Professionals

One of the important pros of this stage-matched method that is not emphasized enough is that it can help change the behavior of health professionals, as well as patients. The number one barrier to the practice of behavioral medicine is that two-thirds of physicians believe that their patients either cannot or will not change their behavior.[2] These professionals have probably become demoralized by the application of action-oriented interventions. “Quit smoking, change your diet, start to exercise” are interventions intended to be helpful, but since the vast majority of patients aren’t prepared to take immediate action, the physician’s disbelief becomes a self-fulfilling prophecy:“Patients don’t change in spite of my help, so why waste my valuable time on such treatments?”

The AHCPR guideline reports that if physicians practice an action-oriented approach, they can double the rate of quitting, from 3% to 6% over 12 months. While such results are certainly helpful on a population basis, the concern is, can the individual physician see the difference between 3% and 6% cessation rates? Or will the physician see a 94% failure rate and conclude that patients don’t change and therefore counseling is a waste of time.

With a stage-matched approach, physicians have the potential to produce progress in a large majority of patients, not just the minority in the preparation stage. Seeing the majority of patients progress can be similar to seeing blood pressure or cholesterol decreasing with the properly matched medicine. Such progress can serve to reinforce the physician’s health preparation promotion practices, as well as those of patients.

Technology to Aid Physicians' Counseling Efforts

What I would add to the authors’ approach is stage-matched expert system technology that can help physicians counsel patients.[3; and W. F. Velicer, R. J. Botelho, and J. O. Prochaska, unpublished data] By completing a 10- to 15-minute assessment in the waiting room, patients (and physicians) can receive a computer-generated, individualized report on the stage, decisional balance, self-efficacy, temptations, and processes of change relevant for progressing at each stage. These interactive, individualized reports can guide patients and physicians to optimize their efforts.

The use of such stage-matched technology can complement the efforts of physicians who are increasingly stressed by too many demands and too little time. Solving major health behavioral problems, such as smoking, should be seen as the responsibility of the total health care system, not just the individual physician. Providing such technologies to implement behavioral change counseling can also bring the practice of behavioral medicine into the postinformation age. It is long past the time when behavioral medicine should rely almost entirely on talking. Imagine if biological medicine could rely only on talking to patients, and there were no laboratory reports, scientific assessments, or modern technologies.

Physicians can start to practice more modern behavioral medicine by learning the excellent approach of these experts from M.D. Anderson Cancer Center. Hopefully, our health-care systems will soon see the wisdom of complementing effective talking techniques for smoking cessation with state-of-the science information technologies that can help entire populations of patients and physicians to practice more comprehensive health promotion.

References:

1. Fiore MC, Bailey WC, Cohen SJ, et al: Smoking Cessation: Clinical Practice Guideline No. 18. Rockville, Maryland, US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCR Publication no. 96-0692, April 1996.

2. Orleans CT, Schoenbach VJ, Wagner EH, et al: Self-help quit smoking intervention: Effects of self-help materials, social support intervention, and telephone counseling. J Consult Clin Psych 59:439-448, 1991.

3. Prochaska JO, DiClemente CC, Velicer WF, et al: Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psych 12:399-405, 1993.