Should interventions for helping patients stop smoking be tailored to their stage of readiness to quit?
Although providing stage-based smoking cessation interventions for those trying to quit appears to be more effective than not intervening at all, the evidence does not support tailoring interventions to a patient's perceived motivational stage of change. (Strength of Recommendation = B, based on inconsistent or limited-quality patient-oriented evidence)
Tobacco use is the cause of more than 400,000 deaths in the United States each year.1 Studies show that interventional counseling by primary care physicians has a modest but measurable impact on cessation rates.2 Some advocate tailoring motivational counseling to a patient's perceived readiness to quit. One stage-based model of behavioral analysis suggests that smokers begin in the precontemplation stage, from which they progress through the stages of contemplation, preparation, action, and finally to maintenance as they quit smoking.
The authors of this Cochrane Review searched for studies evaluating the effectiveness of stage-based intervention strategies compared with non–stage-based interventions or usual care. Trials that did not include a minimum of six months' follow-up after start of treatment were excluded, as were those in which assessment of patients' stage of change did not alter the intervention. Forty-one trials met inclusion criteria. Four trials involving 3,255 patients directly compared stage-based with non–stage-based interventions. Of these, two trials compared the use of these strategies in self-help materials and two compared these strategies during individual counseling. For stage-based versus standard self-help materials, the combined relative risk (RR) was 0.93 (95% confidence interval [CI], 0.62 to 1.39). For stage-based versus counseling, the RR was 1.0 (95% CI, 0.82 to 1.22). Thus, there was no clear difference between patient outcomes when the intervention was determined by stage of change.
In the remainder of trials, which compared stage-based interventions with usual care or no intervention in a variety of settings (e.g., telephone, lay, or physician interviewing; computer games), there was a small but clear benefit to the intervention. For example, in six trials comparing stage-based self-help versus usual care or assessment, the RR was 1.32 (95% CI, 1.01 to 1.59). In 13 trials comparing individual counseling with any control, the RR was 1.24 (95% CI, 1.08 to 1.42).
These data support the use of interventional counseling to help patients stop smoking. Smoking cessation counseling strategies should be used regardless of the patient's perceived readiness to quit.