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Smoking cessation: the potential role of risk assessment tools as motivational triggers
  1. Robert P Young1,
  2. Raewyn J Hopkins1,
  3. Melinda Smith1,
  4. D Kyle Hogarth2
  1. 1Department of Medicine and Psychology, University of Auckland, Auckland, New Zealand
  2. 2University of Chicago Medical Centre, University of Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr Robert Young, Department of Medicine, Auckland Hospital, Private Bag 92019, Auckland, New Zealand; roberty{at}adhb.govt.nz

Abstract

Smoking is the most important and preventable cause of morbidity and premature mortality in developed and developing countries. To date, efforts to reduce the burden of smoking have focused on non-personalised strategies. Anxiety about ill health, especially lung cancer and emphysema, is the foremost concern for smokers and a major reason for quitting. Recent efforts in cessation management focus on behaviour change and pharmacotherapy. The ‘3 Ts’ (tension, trigger, treatment) model of behaviour change proposes that at any one time a smoker experiences varying degrees of motivational tension, which in the presence of a trigger may initiate or enhance quitting. Smokers' optimistic bias (ie, denial of one's own vulnerability) sustains continued smoking, while increasing motivational tension (eg, illness) favours quitting. The 1 year quit rates achieved when smokers encounter a life threatening event, such as a heart attack or lung cancer, are as much as 50–60%. Utilising tests of lung function and/or genetic susceptibility personalises the risk and have been reported to achieve 1 year quit rates of 25%. This is comparable to quit rates achieved among healthy motivated smokers using smoking cessation drug therapy. In this paper we review existing evidence and propose that identifying those smokers at increased risk of an adverse smoking related disease may be a useful motivational tool, and enhance existing public health strategies directed at smoking cessation.

  • Public health
  • genetics

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Introduction

Cigarette smoking is a significant public health problem, and the leading cause of preventable premature death and morbidity in developed countries.1 2 In the USA the total number of deaths per year attributed to cigarette smoking between 1997 and 2001 was 438 000, while in 2008 the predicted mortality from lung cancer is 162 000, approximately 85% of which is related to cigarette smoking.3 4 Among the 438 000 deaths, lung cancer, coronary heart disease, and chronic obstructive pulmonary disease (COPD) were among the most common smoking related diseases contributing to these deaths.3 Together with stroke these diseases account for 80% of all smoking related deaths.5 Fifty per cent of smokers die of a smoking related disease, and the life expectancy of one in four smokers is reduced by as much as 15–20 years.6

The potential health benefits of smoking cessation are substantial. Stopping smoking reduces the future risk of tobacco related diseases, slows the progression of existing tobacco related disease, and improves life expectancy by an average of 10 years.1 7 Smoking cessation results in people living with better health for longer and reduces the duration of ill health before death (ie, compression of morbidity).8 Continued public health efforts to reduce cigarette smoking are therefore imperative if we wish to reduce rates of smoking related disease and premature death. Analogous to the benefits of targeting preventive treatment to reduce coronary artery disease mortality (eg, by lowering serum cholesterol), could personalisation of risk help smoking cessation and reduce smoking related morbidity/mortality? Rather than a nebulous generalisation that smoking is bad for health, can we increase rates of sustained abstinence by giving patients their personalised risk profile for disease related to smoking?

Approaches to smoking cessation

The detrimental effects of tobacco smoke exposure are indisputable and account for the bulk of the cost of healthcare interventions.9 It is well recognised that treatment of tobacco use and dependence is an important part of clinical practice.10 Current treatment guidelines recognise that all smokers should be offered advice and assistance to stop smoking by their health providers. This should be viewed as part of standard clinical care.10–13 Inherent in smoke-free guidelines is the view that it is a neglect of duty if smoking assessment and cessation advice is not included in every consultation.11 As a minimum at each health encounter, smoking habit should be documented and updated, and brief advice on the risks of smoking given along with cessation support in the form of pharmacotherapy with or without counselling.11 The simpler the interaction or intervention the more likely it is that it will be implemented. Numerous models for cessation have been proposed and will be discussed further in this paper.13–15

Despite evidence for the effectiveness of different prevention and treatment approaches, motivating smokers to attempt and ultimately quit is challenging. Cigarette smoking is highly addictive as was highlighted in a London survey of drug addiction users who identified cigarettes as their most needed drug and the most difficult to give up.12 Numerous research reports highlight the differences in smokers' readiness and ability to quit smoking. Annually approximately 41% of smokers attempt to quit, but only 10% succeed and sustain abstinence.16 In the early 1980s, Prochaska and DiClemente14 proposed a ‘stages of change’ model describing a series of stages a smoker progresses through to achieve smoking cessation. This stages of change model proposed that successful smoking cessation involved thinking about stopping, through to planning an attempt, to actually making the attempt. Since its conception, the stages of change model has been widely accepted and implemented in cessation programmes.13–15 The appeal of this model lies in its potential to help tailor smoking cessation intervention to a smoker's stage of change with treatments aimed to promote stage progression through to eventual quitting.17

The 2008 US practice guidelines on the treatment of tobacco use and dependence have based their recommendations for helping smokers to quit smoking on two stages of change models.13 The first of these models is the ‘5 A's’ (ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in quit attempt, and arrange follow-up).13 17 18 In this model, ascertaining the smoker's level of motivation to stop enables the clinician to tailor the treatment to achieve maximum effectiveness. For example, if the patient is willing to make a quit attempt, medication may be offered. Alternatively, for the patient unwilling to quit, assistance should focus on motivational interviewing to ensure a stage progression and setting of a quit date. The type of follow-up should be personalised to the appropriate stage of change. The ‘5 R's’ approach (relevance, risks, rewards, roadblocks, repetition) encapsulates the techniques of motivational interviewing.13 17 This model provides suggestions to help personalise and highlight the benefits of stopping versus the potential negative consequences of continuing to smoke. Incorporating these techniques into interventions for smoking cessation enhance success rates.

Recent research indicates that the majority of attempts to stop smoking are made without previous planning, and that unplanned quit attempts are more likely than planned ones to be successful.16–21 With this in mind, West15 20 21 devised an alternative model to the stages of change approach, called the ‘3 Ts’ (tension, trigger, treatment). This model recognises that a smoker's attitudes to smoking and quitting smoking are based on beliefs, past experiences and the balance of benefit over harms from continued smoking (relevance, risk and reward). This creates varying levels of ‘motivational tension’ (fear and/or anxiety) based on an understanding of the adverse effects of smoking and vulnerability to them that favours quitting.21 In the presence of this motivational tension, even relatively small triggers can result in a switch in motivational state. If that switch involves an immediate quit attempt, this can signal a more complete transformation than if it involves a plan to quit at some future point.20 Triggers may alter a smokers' motivational state to not only initiate a quit attempt but to enhance its likelihood of long term success. The latter is of considerable importance as it takes smokers on average 12–14 quit attempts to succeed eventually.22 The value of this ‘3T's’ model lies in its potential to expand existing approaches to smoking cessation. Smoking cessation interventions that incorporate both a trigger for action (eg, engage the smoker in a conversation about the risks of smoking, regardless of whether they say they are ready to stop smoking or not) and the immediate availability of smoking cessation support (eg, medication or referral to counselling) may be most effective for increasing smoking cessation.20 Such an approach underpins the successful prevention strategy to coronary artery disease, where serum cholesterol testing is the basis of engaging patients in lifestyle changes through assessment of personalised risk and targeted treatment. The recent reduction in coronary artery disease mortality has, in part, been attributed to this approach.23

How do smokers quit?

The vast majority of smokers successfully quit smoking using the cold turkey approach,24 but this has an overall low sustained quit rate of roughly 3–7%.25 Research consistently shows significantly improved quit success rates when smokers use assisted methods, including counselling, nicotine replacement therapies (NRTs) or non-nicotine replacement medication (bupropion or varenicline) compared to unassisted attempts.25 26 A cross sectional study which explored cessation methods used among 8333 current and former adult smokers, attending an Australian general practice,27 revealed that cold turkey was not only the most common method used, but was also the method used most often on their last quit attempt—88% in former smokers and 62% in current smokers. In a sub-analysis of quit attempts made after the introduction of government subsidised bupropion, the use of this medication enhanced success rates. These findings suggest that it is important to make a variety of effective treatment options available to assist smokers to stop smoking. In New York city, as it enacted its Indoor Clean Air Law, 425 000 people called in 3 days to the assists lines requesting free nicotine patches. As smokers generally make multiple quit attempts before successfully achieving abstinence,22 exposure to a variety of quit smoking methods to help them may result in greater success rates.

Informing smokers of the availability of smoking cessation treatments may be just as effective as the actual usage of treatments. In a randomised controlled trial of smokers intending to quit within 6 months, participants who were provided with an information kit promoting the use of treatment aids when attempting to quit smoking reported increased confidence about being able to quit, and more quit attempts were made at 6 months as compared to smokers not receiving the information kit.28 However, no difference in actual usage of treatment aids was found between those provided and those not provided with kits.28 This study emphasises the importance of making smokers aware of the different types of treatment available, even if they decide to quit unassisted. Promoting the availability of cessation methods appears in itself to work to empower smokers, either through challenging them to try to quit unassisted or by providing psychological support from the knowledge that effective treatments are available if needed.

Why do smokers quit?

The preceding discussion explored the models underpinning our current understanding of how smokers initiate and maintain a quit attempt, and the strategies they use to do this. Why do smokers quit smoking? Concerns about health, persistent messages from family and friends, repeated advice from healthcare professionals, and the cost of cigarettes are the reasons most often cited by smokers as catalysts for quitting smoking.29 30 Concerns about health are more commonly cited by older smokers, and issues of cost are more commonly cited by younger smokers.31 In a recent study, concerns about future health was the most frequently reported reason for quitting (29%) followed by current health problems (18%).32 This contrasts with only 4–6% attributing their quitting with medical advice or smoking bans.32 This study also found that health concerns or health problems were the most frequent reasons for quitting across all socioeconomic and age based groups. Former smokers state fear of getting lung cancer or emphysema was the key motivator that led to their successful smoking cessation.33 34 Currently the 5 year survival for lung cancer is only 10%. Of the annual deaths in the USA among smokers, 30% can be attributed to lung cancer, 20% to heart attack, and 20% to COPD.3 In smokers, the symptoms of a smoking related disease or being diagnosed with a smoking related disease is a very common reason stated for successful smoking cessation.35–37

Consistent with this, the term ‘teachable moment’ is used to suggest that health events can be powerful motivators of health behaviour changes.34–38 The experience of a health event is a time when the health risks of smoking are made more salient, and prompt smokers to review and modify their lifestyle habits accordingly. Smokers suffering from heart disease, hypertension or diabetes have been shown to be more motivated to quit smoking and more receptive to support than smokers not suffering from ill health.39 Additionally, numerous studies have documented the effect of a cancer diagnosis, cardiovascular event, or pregnancy for motivating smoking cessation.37 Fuller consideration of the increased tension caused by detrimental health related factors may give further insight into how to engage and encourage more smokers to quit.

Triggers in smoking cessation

There is substantial evidence showing the effectiveness of psychosocial support from health providers, along with pharmacotherapy, in helping smokers achieve successful smoking cessation.40 Interventions given by a health provider generally take the form of brief advice to stop smoking, advice on available smoking cessation ‘treatments’, and monitoring cessation efforts.1 40 Research has shown that combining brief advice with a short period of individual counselling (≤3 min), is more effective than the advice alone. Studies also show that both individual counselling and group therapy increase the chances of quitting smoking, yet group therapy is not consistently better than other interventions involving individualised interventions. Smoking counselling methods delivered through self help materials have limited efficacy, but may be more effective when tailored to an individual's specific concerns.1 11 33 What these studies suggest is that the more the patient is engaged in analysing the benefits over harms from their continuing to smoke, the greater their motivation and success.

Pharmacotherapy including both NRT and non-NRT based therapies (bupropion and varenicline) achieve 1 year quit rates in the order of 15–30%.40–44 NRT is available in many forms,40 providing an alternative form of nicotine, and have efficacy in relieving the symptoms associated with withdrawal and urges to smoke for smokers in the quitting phase.42 Bupropion SR, a monocyclic antidepressant, has been shown to improve short and long term cessation rates and postpone relapse to smoking, as well as reduce associated weight gain.41 43 Varenicline, a partial agonist/antagonist of the nicotinic acetylcholine receptor, prevents the positive reinforcement associated with smoking as well as relieving nicotine cravings and withdrawal symptoms.41 44 Few studies provide clear evidence about the effectiveness of nicotine replacement therapy combinations; however, research has revealed that bupropion alone or combined with NRT is more effective than NRT alone.17 44 Treatment with NRT, bupropion and varenicline achieve two- to threefold greater smoking cessation rates as compared with placebo treatment.1 40 Counselling effectively doubles the success rate of medical interventions.25

As discussed above, adverse health events can act as powerful motivators or triggers for smoking cessation, resulting in comparable or higher quit rates to those reported in healthy motivated smokers treated with the therapies outlined above. A 3 year surveillance study in smokers and ex-smokers, using computed tomography (CT) screening for lung cancer, observed a 40% quit rate in those smokers found to have potentially cancerous nodules. This was much greater than in those with negative CT scans.45 In another study exploring quit attempts following CT screening for early detection of lung cancer,46 23% of smokers reported quitting smoking and a further 27% of smokers decreased their smoking patterns at follow-up. In this study a significantly higher percentage of women with nodules detected reported decreased smoking and greater cessation rates than women who did not have a nodule. The CT scan results did not influence the likelihood of self reported changes in smoking behaviour among men. Healthy smokers who have recently undertaken screening tests may be more receptive to receiving smoking cessation treatment. In an ancillary study within the context of two National Cancer Institute randomised lung screening trials, approximately 60% of smokers (n=313) enrolled in lung screening studies reported a strong interest in smoking cessation counselling and in NRT, while 50% reported interest in using bupropion.33

Experiencing a heart attack is also a significant trigger for behaviour change. In studies of smokers who have suffered a myocardial infarction, the proportion of patients who have quit 1 year after their myocardial infarction range from 46–48%.47 48 Coronary heart disease in general prompts motivation for behaviour change. In a meta-analysis of studies addressing the impact of coronary heart disease on smoking cessation, findings revealed that on average 44% of smokers with coronary heart disease quit smoking at follow-up.49 In similar studies of smokers suffering stroke, 41% quit 6–12 months after the event50 and 43% quit smoking 3 months after the event.51 The highest quit rates are found in smokers who were diagnosed with cancer of the bladder (69%), lung (63%) and head and neck (45%).35 Figure 1 compares the reported 1 year smoking cessation rates among healthy smokers and those diagnosed with a smoking related complication or disease.1 30 35–37 39 40 45–47

Figure 1

Approximate smoking cessation 1 year quit rates among smokers according to intervention or disease status.

Biological markers of harm or risk

Providing individualised information of a smoker's biological markers of harm is a useful way to actively engage a smoker to consider quitting. Using personalised biomarker feedback can help to undermine smokers' optimistic bias,52 53 providing greater motivational tension for behaviour change. Spirometric testing of lung function and genetic testing for smoking related diseases are tools that can be utilised in cessation intervention, where these biomarkers of future risk allow an opportunity to advise and assist smokers in quitting.54 More importantly, like measuring serum cholesterol, such tests give the healthcare provider personalised patient data which are central to engaging smoking patients in discussions of risk and risk reduction. In a manner similar to a threatening health event, testing for harm or risk provides a ‘teachable moment’ to prompt behaviour change.55

Spirometry and lung age

Spirometric assessment of lung function is the most common diagnostic method for detecting airflow limitation in those smokers susceptible to smoking related lung disease. Impaired spirometry is an objective measure for the presence of (or predisposition to) COPD and is also a marker of an increased risk of heart attack, stroke and lung cancer.5 The degree to which lung function is impaired is proportionally associated with increased mortality and premature death.5 Use of spirometric testing is gaining popularity as it is a simple non-invasive procedure which provides powerful personal information of lung damage and future risk.54 56 57 Communication of spirometry results, which include ‘lung age’ correlates, improves rates of smoking cessation, even when lung function results are within the normal range value.54 56 57 Where smoking cessation advice was combined with spirometry, by using graphic representation to show the discrepancy between the smoker's actual lung function compared to his or her predicted lung function,56 58 the message was more powerful than using the numerical values alone. The average quit rate for those undergoing spirometry versus those given physician advice only was 14–17% and 6–12%, respectively.56 57 59

Taken together, these studies suggest that spirometric assessment accompanied by information that allows the smoker to appreciate the salience of quitting, whether this be smoking cessation advice or individualised communication of lung age, is a potentially effective way to increase smoking cessation. Importantly, findings from these studies suggest that intervention increases smoking cessation rates, even when a smoker's airway obstruction is mild to moderate.

Genetic testing

Over the past decade, genetic testing for smoking related respiratory disease such as emphysema, COPD and lung cancer have become viable tools to convey personalised information about risk, thereby motivating smoking cessation. As many as 25% of smokers die prematurely from smoking related diseases before, or at, the age of retirement.6 Genetic testing holds particular appeal in its ability to identify early those smokers at highest risk of disease and premature death. Genetic testing offers an opportune moment to the doctor to engage the smoker in a discussion of their personalised risk of smoking and the substantial benefits of quitting—namely, reduced risk of disease.

Early research work in this area has focused on assessing the impact of imparting genetic risk information for lung cancer on subsequent rates of quit attempts and smoking cessation.60 61 Audin et al60 61 randomised smoking volunteers in the various stages of change14 62 to one of three smoking cessation intervention groups: minimal quit smoking counselling; quit counselling plus biomarker; and quit counselling plus biomarker and genetic susceptibility. The aim was to evaluate the effectiveness of increasing levels of smoking risk feedback, raising the tension to trigger quit actions. At the 12 month follow-up, participants in the genetic risk group were two times more likely to make a quit attempt than those in the counselling only group.

More recently in a randomised controlled trial,63 genetic feedback for lung cancer and telephone counselling was compared with enhanced usual care (smoking cessation advice and nicotine patches) in a sample of 557 African American smokers. Results showed that smoking cessation was greater for smokers in the genetic feedback group than for smokers in the enhanced usual care group at 6 months, but this was not sustained to 1 year. In this study, at all time periods for both intention to treat or actual treatment analyses, smoking cessation rates were consistently higher by 1.5–2-fold in the group who underwent genetic testing (figure 2). These differences were consistent regardless of cessation parameter studied (intention vs actual treatment or point prevalence vs continuous abstinence), although failed to achieve traditional levels of significance after adjustment for levels of addiction. Had the study been twofold bigger (better powered), the differences (unadjusted) reported by this study would have achieved significance for all cessation end points. The quit rates from this study63 are comparable to quit rates seen in motivated well smokers using pharmacological therapy (figure 1). Had the genetic test conferred a greater risk of lung cancer than a twofold increase, the effect on quit rates may have been even greater—that is, secondary to greater motivational tension.21 In this setting, personalised risk data based on genetic profiling appear to have helped with compliance to quit. A better understanding of the interactive role of genetic testing of lung cancer risk and the use of pharmacological treatments for smoking cessation requires further study.

Figure 2

Smoking cessation rates among smokers with and without genetic testing for lung cancer risk (AT, actual treatment; IT, intention to treat).

The psychological and behavioural impact of genetic testing for smoking related disease has been explored using a hypothetical genetic test scenario. In a study addressing genetic testing for heart disease susceptibility, 261 smokers were asked to imagine that they had undergone a test for heart disease risk.64 The results revealed that smokers in the genetic based high risk group reported greater intention to stop smoking than smokers in the non-genetic test high risk group. This study suggests that genetic testing for smoking related disease may be a more effective tool for moving smokers to quit. In another study using a hypothetical genetic test scenario to assess smokers' intentions to quit, 152 smokers were randomly assigned to receive either a test result conferring very high genetic risk, high genetic risk, or average genetic risk for lung cancer.65 This analysis shows a greater intention to quit according to the level of risk, no difference in worry between risk level groups, and no reduction in motivation to quit if testing at the lower genetic risk.65 This study also found that perceived risk of lung cancer was unchanged by genetic testing in those with high baseline levels of worry, but directly proportional to perceived risk in those with low baseline worry (figure 3). Specifically, those with lower perceived risk at baseline suffered greater worry after genetic testing identified them at increased risk of lung cancer in a dose dependent manner. This is exactly the effect one would hope for in raising motivation tension and motivating a quit attempt in someone with a perception of low risk (high optimistic bias), given fear is a well recognised stimulus for behaviour change.

Figure 3

Mean perceived risk (scale 1–7 where 7=highest risk) for lung cancer after hypothetical genetic testing for risk of lung cancer according to baseline perception (low or high worry).

Two recently published studies highlight the importance of these conclusions.66 67 In the first study by researchers from the National Institutes of Health (NIH), a high level of interest for and acceptance of genetic testing for lung cancer risk was found with over 90% uptake of smoking cessation material irrespective of test result and no evidence of either fatalism (reduced efficacy in the higher risk group) or demotivation (reduced efficacy in the lower risk group).66 The study also found that such knowledge of ‘increased lung cancer risk may increase uptake of effective smoking cessation services’. In the second study of smokers recently diagnosed with lung cancer,67 it was reported that 56% of them did not perceive they were at increased risk of lung cancer despite knowing smoking is a risk factor. This finding is a clear indication of the extent optimistic bias is operating in the community despite decades of public health messages linking smoking with lung cancer. Together, these studies point to the utility of genetic testing for smoking related disease for all smokers. They suggest that when smokers are informed they are at higher risk than other smokers (or the average smoker), they have greater intentions to quit. More importantly, these studies demonstrate an improvement in intent for smoking cessation, but no evidence of fatalism68 69 and no evidence of a reduced motivation in lower risk people.

Indeed, concerns of fatalism have been raised in critiques of genetic testing of risk in smoking cessation but are not supported by data.68 69 Preliminary results from a telephone survey of smokers showed that following genetic testing for lung cancer susceptibility, 67% and 89% reported to be more likely to quit when their genetic risk was at or above an average smoker's risk for lung cancer, respectively, whereas 1% and 2% were less likely to quit after testing, respectively (unpublished data). However, there are limited data to suggest fatalism occurs in the context of smoking cessation following genetic testing of nicotine addiction (high genetic addiction associated with poor quit rates).68 69 We conclude that there is no evidence to suggest a demotivating or fatalistic effect from genetic testing that identifies those at greatest risk of a smoking related disease. We also conclude that risk information, presented relative to the ‘average smoker’, has utility in behaviour change in smokers. This observation is consistent with the findings of others suggesting that relative risk is more effective than absolute risk in usefully communicating risk.70

In a recent study examining behavioural health change in smokers 3 months following receipt of genetic test results for emphysema (α1-antitrypsin deficiency), findings showed that genetic testing increased quit attempts for those with high risk genotypes compared to low risk genotypes.38 68 Significantly, quit attempts in those testing at the lower genetic risk level were still greater than quit attempts in those where no genetic testing was performed. Such results reinforce those found in the hypothetical studies discussed above,64 65 suggesting that the act of undergoing a genetic test, regardless of the actual result, positively motivates smoking cessation. A result of low risk did not serve to demotivate smoking cessation resolve. In the same clinical setting, healthy carriers of the α1-antitrypsin deficiency genotype (identified through affected relatives) had a smoking prevalence of only 8%, one third that seen in the general adult population.71 Together, these studies suggest that those identified as genetically predisposed to early onset emphysema and who are asymptomatic have lower smoking prevalence and greater motivation to quit.

The utility of using genetic testing in the public health arena has been explored. In a study examining interest in receiving biomarker testing for smoking related cancer susceptibility among 148 smokers recruited from a public dental clinic, 83% were interested in receiving biomarker feedback.72 This is consistent with other studies reporting readiness to take genetic tests of risk.63 In a study of 300 primary care physicians, the greater the importance they placed on genetic testing for disease, the higher their expectations were that patients would engage in risk reducing behaviours upon receiving their genetic test result.73 These studies suggest that patients are seemingly interested in taking genetic tests, and physicians would refer patients for testing as part of their practice, particularly when the physician believes the test results will promote change to more healthy behaviours.

For genetic testing to be used routinely as a tool to improve cancer outcomes, an adequate evaluation of the benefits and harms needs to be conducted.74 Currently, a large genetic testing initiative is being undertaken in the USA in order to progress understanding of the psychological and behavioural impact of genetic testing for a variety of common health conditions. This study will help to further inform the public about the clinical utility of genetic testing and whether individuals will use genetic testing in ways that will benefit their health.75 A genetic test of lung cancer risk that combines several genetic markers of risk with important non-genetic variables (age, family history and presence of COPD) has recently been developed.76 The clinical utility of this test in smoking cessation is undergoing evaluation. Tests incorporating risk assessment for multiple smoking related complications may also be useful but have yet to be developed.

Summary

A new paradigm in smoking cessation has been proposed that highlights the central role of motivational tension—the smoker's view of perceived harms relative to benefits of continuing to smoke. In this paradigm, triggers are events that precipitate a quit attempt because they increase motivational tension to a point where a smoker desires to quit more than he or she wishes to continue to smoke. This paradigm acknowledges that the majority of successful quit attempts are mostly unplanned, often unassisted, but successful nonetheless.

Clinical trial data consistently show that the greater the assistance a smoker has in quitting, the greater the chance of success. Increasing a smoker's motivational tension helps to initiate and maintain quitting. Health concerns are an important factor in motivating smokers to quit, possibly through increasing tension levels in favour of quitting. Smoking cessation rates appear to be greatest where smokers have suffered, or been shown to be at risk of, life threatening complications from their smoking. In this setting, risk assessment tools that identify those at greatest risk, such as spirometry and genetic susceptibility testing, appear to improve smoking cessation rates. In contrast to the majority of currently available genetic tests, where the effects of environmental modification, lifestyle changes or drug treatment on risk reduction is modest at best, smoking cessation (regardless of the motivating trigger) has been shown to be one of the most efficacious and cost effective preventive interventions in clinical medicine today.

We conclude that any personalised data that may enhance a smoker's understanding of his or her personal risk of adverse health effects resulting from smoking will increase the motivational tension in favour of quitting. Such an approach could provide a complementary strategy to existing non-personalised public health approaches aimed at decreasing smoking prevalence. Personalising smoking cessation approaches, through the use of individualised risk tools, would allow a more cost effective approach by targeting individuals at the higher level of risk and with the most to gain from quitting smoking. Such an approach has become the standard of care in reducing deaths from coronary artery disease and could be equally applied to smoking cessation.

Key learning points

  • The 3 Ts is a new and simplified paradigm for smoking cessation that encompasses tension, trigger and treatment, where triggers initiate quit attempts by raising motivational tension.

  • Concerns about poor health is one of the most frequently cited reasons (trigger) older smokers quit, particularly with regard to lung cancer and emphysema.

  • Risk assessment tools such as gene based risks of smoking complications are now available (eg, lung cancer or emphysema) and have been shown in preliminary studies to improve smoking cessation.

  • Personalised risk assessment has been the mainstay of coronary artery disease prevention and has resulted in significant mortality reduction over the last decade. Similar approaches could be adopted for prevention of pulmonary complications of smoking (lung cancer and COPD) that together account for nearly half of all deaths from smoking per annum.

Key references

  • Young RP, Hopkins R, Eaton TE. Forced expiratory volume in one second: Not just lung function test but a marker of premature death from all causes. Eur Respir J 2007;30:16–22.

  • West R, Sohal T. “Catastrophic” pathways to smoking cessation: Findings from national survey. BMJ 2006;332:458–60.

  • Taylor KL, Sanderson Cox L, et al. Lung cancer screening as a teachable moment for smoking cessation. Lung Cancer 2007;56:125–34.

  • Weinstein ND, Marcus SE, Moser RP. Smokers’ unrealistic optimism about their risk. Tob Control 2005;14:55–9.

  • McBride CM, Hensley Alford S, Reid RJ, Larson EB, Baxevanis AD, Brody LC. Putting science over supposition in the arena of personalized genomics. Nat Genet 2008;40:939–42.

Multiple choice questions (True (T)/False (F); Answers after the references)

1. Which one of the following facts about smoking is false?

  1. 80% of smokers die of a smoking related disease

  2. 25% of smokers lose 15-20 years of life

  3. Quitting smoking results in people living longer and in better health

  4. Smoking cessation is one of the most cost effective interventions in healthcare

  5. Cold turkey is the most common method used by smokers to quit smoking

2. Which of the following features is not part of the 3Ts model of smoking cessation?

  1. Tension refers to motivational tension – a sense of fear or anxiety based on perceived vulnerability to the adverse effects of smoking

  2. Based on beliefs, past experiences and the balance of benefits over harms

  3. Trigger refers to events that may alter a smoker's motivational state favouring quitting

  4. Includes the 5Rs of risk, relevance, reward, roadblock and repetition

  5. Treatment – refers to the immediate provision of treatment to assist smoking cessation

3. Which of the following statements about spirometry and smoking cessation are false?

  1. In the context of risk assessment, impaired spirometry (reduced FEV1) is a marker of premature death from COPD, lung cancer, heart attack and stroke

  2. The lung age derived from spirometry has been shown in a randomised trial to assist smoking cessation

  3. Studies show smokers with normal lung function are de-motivated from quitting

  4. Spirometry can be used as a “teachable moment” to assist smoking cessation

  5. Studies suggest spirometry achieves quit rates of about 15% comparable to NRT

4. Which of the following statements about genetic testing and smoking are false?

  1. Smoking rates in those identified as healthy carriers of α1-antitrypsin deficiency is about one third of the general population

  2. Participants undergoing genetic testing as part of a smoking cessation trial were two times more likely to make a quit attempt.

  3. Genetic testing for lung cancer risk reported superior quit rates than those not undergoing genetic testing

  4. One of the advantages of genetic testing for smoking complications is that it can be done before harmful effects of smoking become clinically manifest

  5. Genetic testing has been shown to de-motivate smokers from quitting

5. Which of the following statements about risk personalisation and smoking cessation are false?

  1. Only the minority of smokers report being interested in taking tests assessing their risk of a smoking-related complication

  2. Tests assessing risk of a smoking-related complication appear to increase motivational tension in favour of quitting

  3. It has been reported that over 50% of smokers diagnosed with lung cancer stated that they did not think they were at risk

  4. With respect to concerns about health, the greater the threat to life, the greater the effect it had on smoking cessation rates

  5. Tests assessing risk of a smoking-related complication may act as triggers for quitting

Answers

  1. (A) F; (B) T; (C) T; (D) T; (E) T

  2. (A) T; (B) T; (C) T; (D) F; (E) T

  3. (A) T; (B) T; (C) F; (D) T; (E) T

  4. (A) T; (B) T; (C) T; (D) T; (E) F

  5. (A) F; (B) T; (C) T; (D) T; (E) T

References

Footnotes

  • Competing interests RY is an advisor to Synergenz BioScience Ltd that has funded the development of a test for lung cancer susceptibility.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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