Responsible for more than 75,000 deaths per year, smoking remains a major public health problem in France. Every year, thousands of people attempt to embark on a “tobacco-free” life. But very often, the urge to smoke is irresistible and the relapse inevitable: it is estimated that only 7.4% of people who quit manage to abstain for more than a year. This is why it is urgent to put in place more effective aid strategies. For several decades, doctors have been keen on “precision medicine”, which consists of adapting treatment to each patient. Because when it comes to tobacco, there is no consensus on how to act, and each patient is different. It is with this in mind that a team of researchers from the University of Paris-Cité has identified individual criteria to be taken into account in withdrawal intervention plans, more or less adapted to the specificities of each.
“The whole issue is based on the current observation that personalized interventions are often defined according to the biological variability of people. But we often ignore the experience, the personality, the resources, the culture of the patient, in short everything that makes his subjectivity”, explains Dr. Viet-Thi Tran, doctor researcher, lecturer at the University of Paris Cité and co-author of the study published in the Journal of Clinical Epidemiology. The team thus reviewed the scientific literature to identify 36 markers likely to optimize the effectiveness of withdrawal, such as the patient’s psychosocial situation or their smoking habits. Then, they asked 795 physicians and 793 patients from the ComPaRe cohort (Community of Patients for AP-HP Research) to prioritize these markers according to their relevance.
Unsurprisingly, both patients and physicians rated motivation to quit smoking as the most important factor in choosing the best treatment. However, the order of priorities diverged more or less for the rest of the indicators. After motivation, physicians considered that personalized interventions should first be based on patients’ preferences for support, on smoking-related beliefs, such as the fear of weight gain when quitting smoking, but also behavior, for example whether the patient smokes more at home and/or at work, and finally previous attempts at quitting. The patients consider for their part that after the motivation, the actions should better take into account the smoking behavior, the level of tobacco dependence which makes it more or less difficult to quit, the preferences and expectations on the proposed treatments , and finally knowledge of the side effects associated with these treatments.
How can this doctor-patient difference be explained? “We noticed that the doctors were more categorical in their answers, ie they tended to judge an important criterion or not, whereas the answers of the patients were more qualified”, notes Dr Tran. For Dr Catherine De Bournonville, tobacco specialist at the University Hospital of Rennes, it is however more difficult to move forward. “It’s quite funny because being a tobacco specialist I agree more with the classification of patients, she explains. It would be interesting to compare the responses of tobacco specialists and those of general practitioners to see if this ranking was not influenced by their level of specialization.”
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These results finally raise the full extent of the problem: standardized approaches neglecting certain individual aspects in care could have their share of responsibility in the weaning failure rate, in the same way as preconceived ideas. However, each smoker is unique and so is their relationship with tobacco. For this reason, it is essential to recognize that one-size-fits-all approaches are not for everyone.
While it is possible that tobacco specialists are better informed about the importance of individual criteria, the improvement of their assessment, reconciling the priorities of patients and doctors, is still strongly expected in the design of better adapted care. “A personalized intervention begins with getting to know the patient and their habits. On this basis, it is possible to define a framework that can include, if necessary, multidisciplinary support, such as cognitive-behavioral therapies and drug treatments,” says Catherine De Bournonville. But this also presupposes the possibility for the patient to make informed choices, so that he has in hand all the information relating to the offers of help. Finally, regular monitoring but also support groups and dedicated mobile applications, such as SmockCheck, are very important to improve the chances of success.
