Guidelineitis Strikes Again! Or, How Not to Quit Smoking
I recently came across an interesting guideline for doctors who are trying to help smokers quit. It’s a publication from 2008 by the US Department of Health and Human Services called Treating tobacco use and dependence. The guideline is not just for any old smokers, mind you, but for ‘smokers unwilling to quit’.
Here we go again – the lack of understanding of what smoking is all about. Firstly, what’s the difference between tobacco use and tobacco dependence? Secondly, there’s the curious idea that a group of smokers exists who are unwilling to quit and that these are different in some way from smokers who are willing to quit. It follows that those who are willing presumably will just do it, while those who are unwilling won’t. And where does that get us?
Let’s plunge into the guideline. The doctor is advised to ‘Encourage the patient to indicate why quitting is personally relevant.’ Well, all right. Then ‘Ask the patient to identify potential negative consequences of tobacco use.’ I would think most smokers are already well aware of these, for example, cancer and heart disease. In any case, it’s a way of trying to get smokers to quit through fear – a strategy not noted for its success. Next, ‘Ask the patient to identify potential benefits of stopping tobacco use.’ Here are a few of the suggested benefits or rewards of quitting: ‘Improved health, food will taste better, improved sense of smell, save money, feel better about yourself, can stop worrying about quitting…etc.’
Let me interject a question at this point. Why is it when smokers are perfectly well aware of a) the dangers of smoking, and b) the advantages of quitting, they don’t just do it? This carrot and stick approach likewise is not noted for its success.
The next stage in the process is to look at Roadblocks, which they helpfully explain mean barriers or impediments to quitting. Thank you. Examples follow: ‘Withdrawal symptoms, fear of failure, weight gain, lack of support, depression, enjoyment of tobacco.’ The doctor is exhorted to ‘address [these] barriers’. Oh Barriers! I would have thought it would be more useful to try to remove or overcome them.
It’s interesting that fear of failure is given as an example of an impediment to quitting. Every time a smokers lights another cigarette it’s a demonstration of his or her failure to quit – although I had one smoker tell me it was the fear of success that prevented him quitting. So we’re back to square one and the ‘smokers unwilling to quit’. All smokers are unwilling to quit; that’s why they’re smokers! The idea that smokers who say they want to quit, really want to quit but find it too difficult, reinforces the notion that quitting is difficult, and worse, it infantilises smokers by implying they can’t do it on their own.
As for the unspecified withdrawal symptoms, which presumably include depression, as I have pointed out several times, if one talks with real people who smoke, what do they say about withdrawal symptoms? It’s exceedingly rare for them to mention depression. Indeed, most smokers find it difficult to say anything at all except – usually with some prompting – that all they feel as a result of not smoking is mild anxiety or nervousness – these are psychological symptoms.
In any case, with the balance overwhelmingly in favour of quitting, why do smokers continue to smoke? And what can the poor doctor or smoking cessation counsellor hope to achieve by having this kind of dialogue? Do they think they can persuade these smokers – the ones who are unwilling to quit – nonetheless to do so through logic?
Finally, the counsellor is advised: ‘Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.’
Well, that’s some good news at least. But just one more question. (This is beginning to sound like Lt Columbo.) What is meant by a quit attempt? Is it a smoker saying ‘I’m trying to quit’ or ‘I want to quit but I can’t’? It seems merely to mean the situation of a smoker who, when asked ‘Have you ever attempted to quit?’, answers in the affirmative.
This question is meaningless. One either smokes or one doesn’t. ‘Trying to stop’ is a self-justifying excuse for the smoker to carry on smoking – the Yes-but response. ‘I smoke, but I’m trying to stop.’ So that’s all right then. It brings to mind Mark Twain’s famous remark: ‘Stopping smoking is easy. I know because I’ve done it thousands of times!’
As with so much in the conventional approach to smoking cessation, the concept of ‘trying to quit’ should be abandoned. The counsellor by this insidious question puts himself or herself in a collusive relationship with the smoker: ‘You’re trying to stop – good for you! There’s no such thing as failure when it comes to stopping smoking – you just need to keep trying a bit longer!’ Like for the rest of your life.
How about quitting right now?
Text © Gabriel Symonds