Professional training in motivational interviewing as a strategy to overcome the therapeutic nihilism in smoking

Dear Editor,

Only 58% of healthcare professionals in Spain consider nicotine addiction to be a chronic disease. In spite of this, in our country these professionals are generally becoming increasingly involved in controlling and preventing nicotinism.¹ In our surgeries we see one of the population segments with the highest rates of prevalence and for whom smoking is, if possible, more harmful² (smoking more cigarettes per day, with higher plasma levels of nicotine and greater dependency than the general population, among other factors). I carefully read and reflected on the recent editorial in this journal, “Smoking cessation programs for individuals with schizophrenia: an urgent and unmet need”.² We are able to use the whole pharmacological therapeutic arsenal now that the European Medicine Agency (EMA) has withdrawn its warning about the possible risk of suicide with varenicline. This is due to the results of the EAGLES³ study (a fact that now has to consolidate among professionals, as the warning given by the highest authority in clinical safety may be foreseen to be hard to revert). Studies are now available which accredit the efficacy and feasibility of intervening, especially in this population.⁴ The authors raised the challenge of asking what more would have to be done to motivate managers and doctors to cease old habits (along the lines of the always correct ethical reflections of Lolas-Stepke in this journal⁵). Smoking cessation should be included as a care objective at the level it deserves in terms of health and ethics (and efficiency for managers). However, among the barriers cited in this relevant editorial, we missed one that may be of key importance in overcoming these prejudices in care: training in motivational interviews, an approach that has proven its usefulness in many areas to encourage healthy behavior. Empirically it is a highly effective way of giving medical advice and improving compliance with therapy.⁶ We know how effective advice or short interventions are, as well as cessation rates using nicotine replacement therapy, bupropion and varenicline⁷ (always in combination with psychological and social support). Thanks to initiatives such as the Socidrogalcohol “Autumn School”, which runs workshops for beginners and more advanced levels in this field, healthcare professionals in different fields are developing the motivational spirit. Working on nicotine abuse means working on an addiction, and therefore involves working on a chronic condition. It is necessary to increase training in the field of addiction from university onwards, to overcome the stigma of care. It is also necessary to give professionals the tools they need to overcome the frustration of dealing with patients who have often been smoking for years and have never attempted cessation. They often seem (and in fact, are) impermeable or completely unreceptive to cessation advice,⁸ and there is an urgent need for the system to accept the need to attain the care goals proposed.

Regarding the cost of pharmaceutical therapies, we would like to add that there should be public and ideally universal coverage, although in these times of necessary spending controls it would seem to be common sense to concentrate on those patients for whom smoking is especially harmful; those with serious mental disorders, but without forgetting those at high cardiovascular risk (diabetics, those with ischemic cardiopathy or metabolic syndrome).