How Not to Counsel Smokers

I just read an article in a recent edition of Medical Economics that, frankly, annoyed the crap out of me. Seems there was this doctor who went up to a guy at an airport and tried to stage a tobacco intervention (from his original article in the Seattle Times):

… I saw a man smoking under a large “NO SMOKING” sign. I stopped and asked him if he could read the sign.

He looked at it, and he said to me, “It says, ‘Mind your own G-damn business.’ ”

“No,” I told him. “It says there are people who love you and care about you, so please stop smoking.”

He swore at me — but then he put the cigarette out. Did what I say make him a nonsmoker? Probably not, but if it moved him one step forward along the path of becoming tobacco-free, it was worth it.

Granted he begins the Seattle Times piece by pointing out that he’d had a particularly bad week in terms of patients with tobacco-related illnesses. But then in his Medical Economics article, he goes on to bemoan the negative feedback he received, and tries to justify his actions with this:

 I believe it is my obligation to my patients and to all members of society to use the knowledge and experience I have to give people the opportunity to live more healthful and safer lives.

I know more about the overwhelmingly proven dangers and complications of smoking than the man at the airport does, and I believe he might be more willing to consider cessation if he knew what I know.

Hoo boy, where to start?

He is wrong for three separate reasons. Number one:

“I know more about the overwhelmingly proven dangers and complications of smoking than the man at the airport does”

No sir, you do not know that. He is a stranger. You have no idea what he knows or doesn’t know. He could be a cardiologist, or a pulmonologist, or an environmental engineer, or have any number of advanced degrees. He could be, and more than likely is, entirely aware of all of the same deleterious effects of tobacco as you are. Which leads me to the second reason you are wrong:

You are making the flawed assumption that the only reason anyone would choose to smoke is because of a knowledge deficit. They must not know about the dangers and complications of tobacco use, because no one who did would make the rational decision to use tobacco. Trust me: the vast majority of smokers are well aware of everything bad about smoking. The reasons for continuing their nasty, nasty habit are far more complex, mainly emotional in nature. You claim to be an experienced clinician. I find it hard to believe don’t understand this dynamic.

Finally, there’s this:

I believe it is my obligation to my patients and to all members of society [emphasis mine] to use the knowledge and experience I have to give people the opportunity to live more healthful and safer lives.

No, it’s not. At least not uninvited. You’re welcome to appear on television and radio broadcasts, give newspaper and magazine interviews in your quest to benefit “society” with your vast knowledge and experience. But you do not have the right to accost a stranger in a public place with an impromptu tobacco intervention. Yes, he was under a No Smoking sign. Yes, you can point out that specific transgression. But beyond that, you’re out of line.

Your main obligation is to your patients. In order to become your patient, a person has to walk in your door, (probably fill out a bunch of paperwork), and sit down with you. You have neither the right nor the obligation to go around spreading your “knowledge and experience” willy-nilly to the general public, and your arrogance in doing so gives the rest of us doctors a bad rap.

Furthermore, tobacco counseling is not — or shouldn’t be — the first thing you do in a patient encounter. You begin by taking a history, don’t you? Then you do a physical exam. You get to know your patient; all about their health, hopefully including why they smoke. Then and only then does it make sense to embark on a personalized discussion of smoking cessation.

How do you know the guy at the airport isn’t an addiction specialist who happens to be on his way back east to attend the funeral of a buddy killed in Iraq? How do you know his quit date isn’t tomorrow and this is the last cigarette he’ll ever have, except now you’ve aggravated him to the point of changing his mind? It’s like lambasting someone who’s twenty pounds overweight before finding out they’ve already lost sixty pounds on their own. You have no context. And you have no right to accost a stranger in public, to the extent that he is not doing anything illegal and minding his own business, with whatever holier-than-thou aspirations you may have of dispensing your great “knowledge and experience…to give people the opportunity to live more healthful and safer lives.”

Mind your own G-damn business.