Behavior-based means of cutting the risks of tobacco

Three researchers who study behavior-based means of cutting the risks of tobacco use have made a case for counseling patients about the health risks of exposure to secondhand smoke when they're asked about direct tobacco use.

Their statement appeared in the Fall (September/October) issue of Families, Systems & Health, a peer-reviewed journal published by the American Psychological Association (APA).

Authors Geoffrey Williams, MD, PhD and Roy Korn Jr., MD, both members of the Medical Society of the State of New York Task Force on Tobacco, join Stephen Williams, MD in outlining the known health risks of secondhand smoke (SHS), which kills an estimated 50,000 in the United States alone every year – about as many as die from colon cancer. They explain that, "Although certain populations are particularly vulnerable (e.g., children and patients with coronary artery disease or asthma), everyone who is exposed has increased risk for heart and other diseases."

In light of emerging evidence of the broad risks of SHS, the authors propose incorporating new clinical counseling guidelines into the existing 5As model recommended by the U.S. Preventive Services Task Force, a branch of the federal Public Health Service.

Williams et al. propose combined counseling for several reasons. First, given the time pressures on doctors, discussing direct and indirect tobacco exposure at the same time, following the same model, would be more efficient and realistic than following two separate and distinct models. Second, it could exploit the smoker-patient (often a family member) dynamic: Patients who insist on smoke-free home could only lower their own health risks but also make it more probable that the smoker will quit.

As of now, the authors report that pediatricians and family practitioners ask less than half of parents about SHS exposure in the home, and counsel only about one third of smoking parents about how SHS might hurt their children. Yet more people are affected by second-hand smoke than directly use tobacco: The authors estimate that a broader counseling could apply to 60% to 70% of the U.S. population, whereas about 22% of the population actually smokes.

The 5As of the current counseling guidelines include Ask (whether they use or have used tobacco), Advise (urge patients to avoid all exposure to SHS for themselves and their family members and explain the risks), Assess (see how willing patients are to change behavior to avoid SHS exposure, including whether they can successfully negotiate with the smoker), Assist (help patients make changes if they want – role play, invite the patient to bring in the smoker, provide resources) and Arrange Follow-up (provide additional support in future visits, especially because smoking is a chronic relapsing problem).

The authors also discuss psychological research into family dynamics that may help doctors to help patients quit smoking or minimize their SHS exposure.