An otherwise useful review by Okuyemi, Ahluwalia, and Wadland1 of the evaluation and treatment of tobacco use disorder promotes asking every patient about tobacco use at every visit. We conducted a qualitative interview study with smokers. Several found being asked about smoking at visits for non-smoking–related conditions intrusive and offensive.2
A 53-year-old woman commented, “If I went down there [to the doctor] with a broken finger, they would say, ‘Do you smoke?’ They blame smoking for everything. It aggravates me.” A 30-year-old woman said, “I found that when I’ve gone up for a bad ankle, he said, ‘You shouldn’t smoke.’ I think, ‘Well, I have not come about that.’ There is a certain doctor . . . that I won’t see . . . because of smoking.” We obtained accounts of individuals who altered their help-seeking behavior in ways that could seriously harm their health to avoid ritualized interventions about smoking.
There appears to be an assumption that the 5As approach (ask, advise, assess, assist, and arrange) is free of adverse effects. But as with any intervention, it has potential disadvantages. Our study provided evidence that giving brief advice regarding smoking cessation may damage patient–physician rapport, increase resistance to change, and result in patients’ failure to consult physicians for serious symptoms. Studies evaluating interventions, such as the 5As approach, have not adequately evaluated adverse effects. Until the potential harm is better studied, clinicians should remain cautious about implementation.
Christopher C. Butler, MD
Faculty of Health Sciences
McMaster University
Hamilton, Ontario, Canada
Dr Okuyemi responded as follows:
The purpose of our article was to summarize the best evidence on the evaluation and treatment of tobacco use disorder in a format useful to practicing physicians. Our review promotes the assessment of tobacco use status at every visit, as recommended by the US Public Health Service Clinical Practice Guideline panel.
The issue raised by Dr Butler is not new or unique to smoking cessation. For various chronic medical conditions, patients may not appreciate physicians’ advice on treatment adherence. Many physicians encounter patients who are offended at first by medical advice, only to express gratitude for it later. The clinical practice guideline recommends that tobacco use be treated like other chronic medical conditions and be considered a fifth vital sign. Since more than 400,000 deaths a year are attributable to smoking and approximately $100 billion in direct medical and indirect nonmedical costs is incurred, smoking cessation advice should be provided often and repeatedly.
The qualitative study by Butler and colleagues2 of 42 patients found that patients did not believe physicians’ words could influence their smoking, but this is contrary to consistent findings by a vast majority of studies. Some have suggested that advice to quit should be given only during “smoking-related” visits or “teachable moments.”3 Following this precept violates principles of primary prevention: to intervene before medical consequences have occurred.
Physicians should not badger patients. A patient with a sprained ankle could be told, however, “I noticed that the nurse recorded that you were a current smoker. It is in your best interest to quit. If you would like to talk about it now, we can do so. Otherwise, we can discuss it at another visit. Here is a handout.” Rather than suggesting reasons for physicians not to advise patients to quit smoking at every opportunity, discussions in the literature should focus on training physicians to tailor their advice to each patient’s readiness to change.
Kola Okuyemi, MD, MPH
Kansas City, Kansas