Don't scold! How doctors can take the shame out of smoking cessation counseling

By Alistair Gardiner
Published November 2, 2021

Key Takeaways

November is Lung Cancer Awareness Month, and smoking cigarettes is by far the biggest risk factor for developing the disease. Yet, many current and former smokers fail to get lung cancer screening, partially due to the stigma around smoking, according to some studies.

While detection is simple, lung cancer tends to have a poor prognosis, with an overall 5-year survival rate of 20.5%, according to recommendations published this year in JAMA Network. If it’s found early enough, however, survival rates can be much higher. Many doctors and health experts recommend that people aged 50-80 who have a smoking history of 20 pack-years or longer, or have quit within the past 15 years, get an annual screening for lung cancer.

But, according to the JAMA article, just 14.4% of the US population eligible for lung cancer screening actually goes for a check-up. Why? According to health experts, this may in part be due to the stigma attached to heavy smoking, which can lead patients to experience negative feelings like guilt. Therefore, a doctor's bedside manner and communication style around smoking cessation conversations with patients really does matter.

So how can you counsel your patients to quit smoking without turning them off to your advice and making them feel ashamed? We’ll take a look at that here and cover some of the latest research on the links between smoking and lung cancer.

The latest on lung cancer

According to data provided by the CDC, smoking is not only the leading cause of preventable disease and death in the United States—killing more than 480,000 Americans a year—it’s also the cause of up to 90% of lung cancer deaths. Here are a few other key stats:

  • In 2018, 218,520 new lung cancers were diagnosed and 142,080 Americans died from lung cancer

  • Cigarette smoking can increase the risk of lung cancer by 15-30 times

  • Secondhand smoke contributes to an estimated 7,300 of the 10-20% of lung cancers diagnosed every year in patients who never smoked

  • This situation has slowly improved over the years: In 2019, 14% of US adults were current cigarette smokers, compared with 21% in 2005

  • The best way to avoid lung cancer is to quit smoking, which will reduce your risk of developing the disease by 50% after 10 years of cessation

  • And if you’ve ever been a smoker, the best way to improve your lung cancer survival chances is to get regular screenings

The stigma around smoking  

Evidence shows that shame and stigma can prevent smokers from taking actions to address their habit, or even from getting check-ups to monitor their health. For example, a study published by Wiley Online in 2019 found that tobacco users who were exposed to negative stereotypes commonly associated with smoking felt more eager to have a cigarette than those who weren’t. Researchers concluded that shaming essentially acted as a "smoking-promoting message" for tobacco users. 

Another study, published in Women and Birth in 2020, looked at the impacts of “moral judgments” directed toward pregnant women who smoked. Researchers found that stigmatization was akin to victim-blaming and often led to hidden smoking. They concluded that this kind of scolding represented a “barrier to women obtaining evidence-based stop smoking support.”  

What physicians can do

As noted by the authors of an article published in the AMA Journal of Ethics, research has linked stigma with lung cancer patients’ avoidance or delay of seeking medical care. But there are ways to combat this.

Physicians can try bringing up “counter-stigma themes,” such as reminding a patient how predatory the tobacco industry is and how much money it spends keeping people addicted. 

It’s also useful to speak in terms of self-affirmation regarding quitting, rather than pointing out how damaging smoking is, during consultations. Research indicates that patients are more likely to dismiss a message if it’s perceived as threatening; on the other hand, highlighting the benefits of quitting is a way of showing compassion and a nonjudgmental stance.

Finally, communicating empathically with patients can help build their resilience. This is particularly important if the patient has been diagnosed with lung cancer or another disease. According to information provided by the US Department of Health and Human Services, a good way to do this is through “shared decision-making.” This is characterized by “a collaborative patient-centered process,” whereby the physician helps the patient to explore the possible benefits and harms of screening or treatment options. Two important aspects of this are: Assessing the patient’s values regarding lung cancer screening and evaluating the patients’ feelings about the final decision made.

A note about vaping

According to the FDA, while different tobacco products pose varying levels of health risk, no tobacco products are considered safe. That includes vaping, which may be less harmful than cigarettes, but could still cause damage to your lungs. 

While Electronic Nicotine Delivery Systems are still being evaluated for their impacts, e-cigarettes contain chemicals that can be harmful when inhaled. This includes flavoring chemicals and in some cases acrolein, acrylonitrile, and formaldehyde.

And evidence also shows that these products will likely not help you quit smoking. For example, a study published in JAMA Network Open in October examined whether switching to e-cigs is associated with the prevention of a cigarette smoking relapse. 

Researchers followed the progress of a cohort of 13,604 participants who smoked cigarettes at baseline, over a period of 12 months. Of the group, 9.4% had recently quit cigarette smoking, and 22.8% of those who quit had swapped out their cigarettes for e-cigs. By the end of the study period, researchers found switching to vaping did not help smokers abstain from cigarettes.

“Indeed, the evidence suggested that switching to alternate tobacco products by recent former smokers may be associated with increased risk of a relapse to cigarette smoking,” the authors wrote.

It’s worth bearing this in mind the next time you’re chatting to a patient who’s considering vaping as a way to quit; the evidence simply doesn’t support this notion.

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