Cigarette smoking is a dominant, preventable cause of morbidity and mortality in the United States, accounting for more than 419,000 deaths each year. More than 150,000 of these deaths occur as a result of neoplasms. In 1993, an estimated 25% of adults in the United States were current smokers, and smoking-attributable costs for medical care were estimated to be $50 billion.
Effective and timely administration of smoking cessation interventions can significantly reduce the risk of smoking-related disease. Physicians in general and oncologists in particular can play an important role in providing this type of intervention. Since 70% of smokers see a physician annually,[6,7] there is considerable opportunity for smoking cessation counseling by health-care providers. Even a very brief intervention provided by a health care professional appears to increase smoking cessation, and a physicians strong advice to quit increases positive outcomes in a remarkably cost-effective way.
The National Cancer Institute (NCI) projects that if 100,000 physicians were to help 10% of their patients who smoke to stop each year, the number of smokers in the United States would decrease by an additional 2 million people annually. Unfortunately, many physicians still underutilize or neglect smoking cessation treatment. The modifiable barriers to delivery of smoking cessation intervention by many health-care providers include absence of necessary skills, limited knowledge of the effectiveness of their own counseling, lack of organizational support in the office environment, and limited availability of materials to aid them and their patients in smoking cessation efforts.[10-12]
In addition, some physicians may have reservations about the relevance of smoking cessation intervention for patients who have types of neoplasms that have not been firmly attributed to smoking (eg, breast cancer). However, the potential benefits of smoking cessation for the majority of cancer patients can be assumed on the basis of compelling evidence obtained from disease-free populations. First, tobacco use may lead to a second primary malignancy, such as lung cancer, for which cancer survivors may be at high risk. Second, smoking can increase the incidence of comorbidity (eg, cardiovascular and/or pulmonary disease) by worsening the course of the disease[13,14] and by reducing the effectiveness of commonly prescribed medications (eg, beta-blockers, bronchodilators, analgesics, benzodiazepines, and phenothiazines). Third, cigarette use may reduce or negatively impact on the patients overall quality of life by reducing physical fitness and affecting financial well-being.
Smoking cessation has been shown to improve self-control, self-esteem, and other characteristics of well-being.[5,16] Hence, effective smoking cessation counseling should be incorporated into the cancer treatment plan.
The smoking cessation clinical practice guideline recently published by the Agency for Health Care Policy and Research (AHCPR)[17,18] summarizes current progress in smoking cessation treatment and recommends specific methods to be utilized by health-care providers when counseling and treating patients who smoke. The AHCPR guideline delineates recommendations for: (1) primary-care physicians; (2) tobacco cessation specialists and programs; and (3) health-care administrators, insurers, and purchasers. In the clinicians section of the guideline, the five steps involved in promoting cessation are outlined: step I entails systematically identifying all smokers; step II, strongly advising all smokers to quit; step III, determining patients willingness to make a quit attempt; step IV, motivating patients who are not willing to quit in the immediate future and assisting those who are willing to quit smoking by setting a quit date, offering nicotine replacement therapy, and providing self-help materials and skill training; and step V, scheduling a follow-up contact.
The behavioral aspects of smoking cessation treatment are not as relevant to the typical physicians training as are the pharmacologic aspects (eg, nicotine replacement therapy). Therefore, while fully recognizing the value of the guideline in enhancing outcomes from smoking cessation treatments delivered by health-care providers, this paper focuses on a specific method of behavioral counseling based on the transtheoretical model of change (TTM),[19-21] a promising theoretical approach to helping patients quit smoking. We believe that this approach represents a feasible, effective method that can easily be applied by physicians in a clinical setting.
A wide range of social-behavioral theories are available to help explain, predict, and alter human behavior. Typically, health-care providers apply aspects of multiple theories simultaneously when promoting behavioral change.
The TTM, which was developed by combining common theoretical elements identified through the analysis of multiple therapeutic approaches, provides a practical, effective approach to promoting positive health behaviors. Although studied primarily within the context of smoking behavior, the model has demonstrated robustness across various other health behaviors, including weight control, skin cancer prevention, psychological distress, alcohol use, exercise, and psychiatric disorders. In the sections below, we describe the model and how it may be applied by physicians to promote smoking cessation among patients with cancer.
The TTM classifies smoking behavior as a function of five stages of change: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance. Generally speaking, the stages reflect an individuals current disposition about his or her smoking behavior and intent to quit. Movement through the stages is associated with changes in the use of coping activities and shifts in attitudes about smoking, motivation, decision-making, and confidence in quitting. Assessing the stage of change over time enables health-care providers to determine when changes in smoking behavior occur. The model also provides a practical framework for designing interventions and enables providers to select the most appropriate intervention strategies.
Because patients dispositions toward quitting vary, action-oriented or just do it approaches are not appropriate for all patients. Unlike most smoking intervention approaches, TTM-based interventions do not assume that all patients are ready to quit smoking. Instead, the intervention messages and strategies are stage-specific and correspond to the smokers readiness to quit. This stage-based approach represents a significant step forward in smoking cessation methods.
Assessing Smoking Status and Stage of Cessation
To effectively reduce smoking among patient populations, smokers first must be identified accurately. Typically, smoking status is assessed using a simple dichotomous-response question, such as Do you smoke? Research has shown, however, that altering the way this question is asked can improve disclosure of smoking status, regardless of whether the question is asked orally or is administered as part of a written survey. Specifically, by expanding the response options to enable patients to report on cutting down, Mullen et al improved smoking disclosure by 40% in a population of pregnant women.
Modifying the item suggested by Mullen et al to make it more amenable to use of the TTM among cancer patients, we suggest that physicians assess smoking status using the question, Which of the following statements best describes your cigarette smoking? As shown in Figure 1, this questions can have multiple answers. The item has a fourth-grade readability level, as measured by the Flesch-Kincaid Readability Test. The question can be included as part of patient registration forms, or the information can be assessed through an interview conducted by the physician or other support staff.
After smoking status is determined, all current and former smokers then should be targeted for a stage-specific smoking intervention, where stage of smoking cessation is assessed as depicted in Figure 1.
- Precontemplation StageIn the earliest stage, precontemplation, people are likely to be unaware of the harmful effects of smoking or are unwilling or too discouraged to quit. Being in the precontemplation stage, however, does not necessarily mean that the individuals do not want to quit. Rather, they may have tried to quit, failed, and currently feel frustrated and disappointed about the results.
Individuals in this stage commonly have experienced few negative consequences associated with smoking; may be defensive about their behavior; and often are not convinced that the negative aspects of smoking outweigh the positive. They are not seriously considering quitting smoking in the next 6 months and, when compared with persons at other stages of change, precontemplators will be the least receptive to cessation interventions. Again, being a precontemplator does not imply that a smoker does not want to quit; rather, it means that the person has no intention of quitting in the foreseeable future.
- Contemplation StageThis stage includes current smokers who are seriously considering quitting in the next 6 months and yet have not made a commitment to quit. This group tends to perceive the pros and cons of smoking as approximately equal. It is common for patients to remain in this stage for extended periods, often for years at a time.
- Preparation StageIndividuals in the preparation stage are defined as current smokers who are ready to quit smoking in the immediate future (next 30 days) and have made at least one 24-hour quit attempt within the past year. They are taking small but significant steps toward another quit attempt and may have thought about methods for quitting and set a quit date. In general, these smokers are more prepared to take action than are contemplators.
- Action StageThis stage encompasses the 6-month period following smoking cessation. During this time, recent quitters are struggling to prevent relapse; thus, they continue to actively modify their habits and environment. This stage requires the most lifestyle changes, and patients may be faced with particularly challenging temptations to smoke in a variety of situations, such as periods of extensive workload or stress, when with others who are smoking, while at social gatherings, and after meals.
- Maintenance StageThis stage encompasses the period from 6 months following cessation through the point of termination, where termination is characterized by zero temptation to smoke across all problem situations and maximum confidence in ones ability to resist relapse. Importantly, individuals in the maintenance stage remain susceptible to relapse and must be continuously aware of environmental and internal stimuli that can cue a return to smoking.
Cyclical Nature of the ModelIt is a well-known fact that quitting smoking is not necessarily a smooth or easy process. More often than not, long-term change is reached only after repeated attempts,[24,25] with the average smoker making three to four quit attempts before actually becoming a former smoker. When patients relapse, they revert to an earlier stage. Although progression through the stages is required to achieve long-term smoking cessation, the inclusion of the concept of relapse requires the model to take on a cyclical property.
By combining the notion of linear progression with the prospect of recycling through the stages, one obtains a more accurate picture of the process of change. This concept is demonstrated pictorially in Figure 2.
1. Bartecchi C, Mackenzie T, Schrier R: The human costs of tobacco use (part I). N Engl J Med 330:907-912, 1994.
2. Centers for Disease Control: Mortality trends for selected smoking-related cancers and breast cancerUnited States, 1950-1990. Morbid Mortal Weekly Rep 42:857-866, 1993.
3. Centers for Disease Control: Cigarette smoking among adultsUnited States, 1993. Morbid Mortal Weekly Rep 43:925-930, 1994.
4. Centers for Disease Control: Medical-care expenditures attributable to cigarette smokingUnited States, 1993. Morbid Mortal Weekly Rep 43:469-472, 1994.
5. US Department of Health and Human Services: The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Atlanta, US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. DHHS publication no. (CDC) 90-8416, 1990.
6. National Cancer Institute: Tobacco and the Clinician: Interventions for Medical and Dental Practice. Bethesda, Maryland, US Department of Health and Human Services, Public Health Services, National Institutes of Health. Smoking and Tobacco Control monograph no. 5, NIH publication no. 94-3693, 1994.
7. Gilpin EA, Pierce JP, Johnson M, et al: Physician advice to quit smoking: Results from the 1990 California Tobacco Survey. J Gen Intern Med 8:549-553, 1993.
8. Cummings SR, Rubin SM, Oster G: The cost-effectiveness of counseling smokers to quit. JAMA 261:75-79, 1989.
9. Fiore MC, Pierce JP, Remington PL, et al: Cigarette smoking: The clinicians role in cessation, prevention, and public health. Dis Month 36(4):181-242, 1990.
10. Ockene JK, Aney J, Goldberg RJ, et al: A survey of Massachusetts physicians smoking intervention practices. Am J Prev Med 4:14-20, 1988.
11. Battista RN, Williams JI, MacFarlane LA: Determinants of primary medical practice in adult cancer prevention. Med Care 24:216-224, 1986.
12. Kottke TE, Blackburn H, Brekke ML, Solberg LI: The systematic practice of preventive cardiology. Am J Cardiol 59:690-694, 1987.
13. US Department of Health and Human Services: The Health Consequences of Smoking: Chronic Obstructive Lung Disease: A Report of the Surgeon General. Rockville, Maryland, US Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS publication no. (PHS) 84-50205, 1984.
14. Gritz ER, Kristeller JL, Burns DM: Treating nicotine dependence in high-risk groups and patients with medical co-morbidity, in Orleans CT, Slade J (eds): Nicotine Addiction: Principles and Management, pp 279-309. New York, Oxford University Press, 1993.
15. Lipman AG: How smoking interferes with drug therapy. Mod Med 8:141-142, 1985.
16. Knudsen N, Schulman S, Fowler R, van den Hoek J: Why bother with stop-smoking education for lung cancer patients? Oncol Nurs Forum 11:30-33, 1984.
17. 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. AHCPR publication no. 96-0692, April 1996.
18. The Smoking Cessation Clinical Practice Guideline Panel and Staff: The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 275:1270-1280, 1996.
19. Prochaska JO: Systems of Psychotherapy: A Transtheoretical Approach. Homewood, Illinois, Dorsey Press, 1979.
20. Prochaska JO, DiClemente CC: Transtheoretical therapy: Toward a more integrative model of change. Psychother Res Prac 19:276-288, 1982.
21. Prochaska JO, DiClemente CC: The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Homewood, Illinois, Dow Jones-Irwin, 1984.
22. Prochaska JO, Velicer WF, Rossi JS, et al: Stages of change and decisional balance for 12 problem behaviors. Health Psychol 13:1-8, 1994.
23. Mullen PD, Carbonari JP, Tabak ER, Glenday MC: Improving disclosure of smoking by pregnant women. Am J Obstet Gynecol 165:409-413, 1991.
24. Prochaska JO, DiClemente CC: Stages of change in the modification of problem behaviors, in Hersen M, Eisler RM, Miller PM (eds): Progress in Behaviors Modification, Newbury Park, Sage, pp 183-218. 1992.
25. Prochaska JO, DiClemente CC, Norcross JC: Changing: Process approaches to initiation and maintenance of changes, in Klar Y, Fisher JD, Chinsky JM, et al (eds): Self Change: Social Psychological and Clinical Perspectives, pp 87-114. New York, Springer-Verlag, 1992.
26. Schacter S: Recidivism and self-cure of smoking and obesity. Am Psychol 37:436-444, 1982.