The PRAXIS Nexus The PRAXIS Nexus

Resolving to Improve Tobacco Treatment

Posted on December 16, 2022   |   

This post was written by Michael W. Hess, MPH, RRT, RPFT.

It is once again that magical time of year when everyone gets ready to engage in healthier lifestyles in the new year.  We’ve all heard (and likely made) the resolutions, then felt guilty after a week or two when, despite our best efforts, we came up a bit short. As health care professionals, one of the more common goals we can help the people in our care with is quitting smoking. Of course, it is also one of the trickiest goals to accomplish, for a variety of reasons. However, by resolving to look at tobacco treatment a little differently this new year, we may be able to improve the odds of success.


Historically, as HCPs, we have looked at tobacco smoking as simply a “bad thing” that our patients should stop doing. Even today, many of our strategies focus on establishing distinct quit dates and similar ideas which make it seem like making a major lifestyle change is the equivalent of flipping a light switch. However, experts from places like the Mayo Clinic reinforce that only around five percent of those who attempt a cold turkey quit are successful for more than six months.1 The Centers for Disease Control and Prevention put the annual success rate of quit attempts of any kind at a dismal 10%.2 Clearly, the cold turkey method needs some reassessment.

I would argue that one of the biggest barriers here is the separation of the behavior from the person. People smoke for many reasons, with nicotine dependence surprisingly often being a lesser one. For example, in the mid-1990s, tobacco companies employed a strategy known as Project SCUM (SubCulture Urban Marketing) to specifically target certain demographics, including sexual minority groups and the unhoused, to create new customers. Project SCUM preyed upon the isolation of many LGTBQ+ community members who wanted to become part of a larger community and establish new connections. In an interview with News Center Maine, anti-smoking advocate Shane Diamond (who describes themselves as queer and trans) stated, “They used our daily experiences of homophobia and transphobia and otherness, and they built us a community and culture that drew us in.” Project SCUM continued the legacy of decades of targeted marketing toward minority groups, with the same intent of using community-building as a hook.

Seeking community can extend beyond ethnic or gender identity, of course. I have spoken with many smokers who are concerned they will lose their social outlet if they become the only non-smoker in their peer group. Many others are concerned about losing a part of their own identity, or what they will do to relieve stress, or a dozen other social issues. To me, that is the bigger issue with our current tobacco treatment strategies. I often tell people that the twenty-first century provides great pharmaceuticals that can help manage biochemical dependence on nicotine within weeks. However, changing the daily rituals and social dynamics involved in smoking is far more complex. This is especially true when smoking is used as a coping mechanism for stress or trauma.


How, then, can we clinicians bend this curve? First, we must remember that people already know that smoking is bad for them. If they do not, please feel free to send them to our podcast about the effects of smoking. Usually, the last thing most people need is another lecture about how bad it is for them, which only serves to increase feelings of guilt and shame. Instead, use the “5 As” strategy to start the conversation:

  • ASK for permission to discuss tobacco usage and the desire for behavior change.
  • ASSESS how much they are smoking and the burden of their symptoms.
  • ADVISE on the benefits of quitting (in a respectful manner) and available resources.
  • AGREE on the importance of quitting and reasonable goals.
  • ASSIST by ordering prescriptions, connecting with community resources, and following up.

Setting goals is highly individualized. Some studies have suggested that abrupt cessation can indeed be successful in lighter smokers when still combined with nicotine replacement and counseling.3 Others suggest a more gradual approach may still be appropriate.4 The key is to share the decision-making with your patient so that any goals you set are reasonable and achievable to avoid setting them up for failure. It is this counseling and discussion in conjunction with pharmacological intervention that gives your patient the best environment for success. In some populations, the combination of strategies increased quit rates by up to 35%.5

Ongoing efforts can be supported by a companion to the 5 As known as the 5 Rs:

  • RELEVANCE: Make sure the reasons for quitting are personally impactful (for example: improved health, less spending on tobacco, or less smoke smell on clothes).
  • RISKS: Reinforce the risks involved in continuing to smoke in a gentle, cooperative fashion.
  • REWARDS: Also reinforce the positive things about quitting.
  • ROADBLOCKS: Identify perceived or actual barriers to successfully quitting.
  • REPEAT: Every discussion increases the odds of a successful quit eventually.

Tobacco dependence is one of the trickiest behaviors to change. Cigarette smoking, in particular, embeds itself into many parts of a person’s daily routine. That makes quitting smoking far more complicated than simply kicking a habit. However, by taking a holistic approach to true behavior change, we can help our smoking community reduce their risk and improve their health, in the new year and beyond!

  1. Does Cold Turkey Work Best? - EX Community. Accessed December 12, 2022.
  2. Smoking Cessation: Fast Facts | Smoking & Tobacco Use | CDC. Accessed December 12, 2022.
  3. Smith DK, Miller DE, Mounsey A, Prasad S. PURLs: “Cold turkey” works best for smoking cessation. J Fam Pract. 2017;66(3):174. Accessed December 1, 2022. 
  4. Bohadana A, Rokach A, Wild P, et al. Varenicline for Gradual Versus Abrupt Smoking Cessation in Poorly Motivated Smokers With COPD: A Prematurely Terminated Randomized Controlled Trial. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation. 2022;9(4):486-499. doi:10.15326/JCOPDF.2022.0305
  5. Rahmanian S, Wewers ME, Koletar S, Reynolds N, Ferketich A, Diaz P. Cigarette Smoking in the HIV-Infected Population. Proc Am Thorac Soc. 2011;8(3):313. doi:10.1513/PATS.201009-058WR


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