Paradigm change: Readiness to quit does not always predict success

Some evidence suggests ALL smokers can benefit from being offered treatment

Both Canadian and US smoking cessation guidelines recommend that if a patient is not ready to quit, motivational interviewing should be used to encourage a future quit attempt.1,2 Nearly 2/3 of smokers were seriously considering quitting in the next 6 months, but few are ready within the next month.2 So, asking patients about their readiness to quit and offering treatment to only those who say they are ready to quit excludes the vast majority of smokers from receiving treatment.

Numerous studies show that NRT significantly increased smoking cessation in those not ready to quit

Study Design Results

Systematic review of 10 RCTs3

  • Restricted to patients not ready to quit

Smoking reduction interventions that included pharmacotherapy like NRT significantly increased long-term abstinence.3


(n=750; 10+ cigarettes/day)

Smokers not ready to quit actually quit at the same rate as those who were ready to quit, when offered pharmacotherapy.4

Population-based study5


Motivation to quit did not predict abstinence, and only half of those who ultimately quit initially said they were planning to.5,6

Randomized trial using telephone-based interventions (n=3006)

Intervention increased uptake of smoking cessation therapy and 1-year abstinence in those planning to quit and those not. Nearly half of those who did quit initially stated they were not ready to.7

Smokers’ intentions change rapidly, as may their readiness to quit on any given day

A new treatment strategy: The opt-out approach

Recent work by Richter and colleagues suggests an intriguing new approach to smoking cessation: an “opt-out” (vs. opt-in) strategy. Rather than asking patients if they are ready to quit before offering treatment – offer all patients treatment that they must choose to opt out of.8

Then, determine past quit attempts to identify the right format and dose of treatment.

New Treatment Paradigm: Opt-In vs. Opt-Out6
Opt-In Opt-Out
Tobacco User?
Brief Advice
Ready or Willing?
Motivational Intervention
Tobacco User?
Brief Advice

Data suggest that HCPs will treat tobacco dependence more effectively by providing opt-out care:9

  • Advising all patients to quit, compared to giving no advice, significantly increased long-term abstinence (RR=1.47, 95% CI: 1.24-1.75).
  • Compared to counselling alone, smokers offered NRT were twice as likely to quit (RR=1.49, 95% CI: 1.17-1.89)

HCPs may choose the traditional screening or an “opt-in” approach because of fear of damaging patient relationships by pressuring them to quit. However, the evidence indicates the opposite. Smokers report higher satisfaction when receiving intervention, even amongst those not ready to quit.10

“When there is strong evidence that supports an appropriate therapy, therapy should be presented as the default.”8

- Richter et al., 2015

A shift to treating smoking as a chronic condition

Current evidence suggests the need to move beyond the traditional emphasis on convincing smokers to quit before offering treatment. This approach may underestimate smokers’ motivation to quit, as the overwhelming majority want to quit but may not express a willingness to.11 HCPs may be more effective by treating tobacco dependence the same way they treat high blood pressure and other chronic medical conditions and proactively recommending evidence-based treatment, such as NRT, regardless of whether the patient has opted in to therapy. For example: Have you used tobacco products in the past 30 days? The best way to stop smoking is a combination of support and medication, like NRT. Here is the dose I’d recommend for you...

The likelihood of quitting may be related to nicotine dependence rather than the intention to quit.

-- Ontario Tobacco Research Unit Report, 2016

“Providing treatment only to smokers who are already prepared to quit further limits the reach of current smoking cessation interventions.”4

- Ellerbeck EF, et al. Ann Intern Med. 2009