Empowering tobacco users for improving outcomes: The transformative potential of shared decision making in tobacco cessation

Despite commendable efforts to reduce tobacco use over the last half-century, around 1.3 billion people still continue to consume tobacco products annually, resulting in more than 8 million fatalities worldwide.1 Tobacco usage and exposure cause premature death and illness globally.2 While there are several methods to help people stop smoking and get the health benefits that come with doing so, most smokers either relapse or needed sustained intervention for maintaining quit status.3 Current smoking cessation methods overlook patients' active participation in decision-making and rely only on medical or behavioural approaches directed by physician.4 A paradigm change toward shared decision making (SDM), on the other hand, has the potential to impact tobacco cessation efforts, empower patients, and provide better results.5 The SDM model is a healthcare approach that prioritizes patient involvement in medical decision-making processes, ultimately leading to patient-centred care.6 This model empowers individuals to actively participate in decisions that impact their health outcomes. The system functions on two fundamental principles. Firstly, well-informed consumers possess the ability and willingness to engage in the process of medical decision-making by posing informed inquiries and articulating their personal values and perspectives regarding their medical conditions and available treatment alternatives. Secondly, healthcare providers will acknowledge and prioritize the objectives and choices of their patients, utilizing them as a framework for advising and administering medical interventions. Overall, SDM supports autonomy by fostering strong connections, recognizing individual competence and interdependence underpinning self-determination and relational autonomy.7 SDM is a separate concept from informed decision making, in which the physician imparts information to the patient and subsequently the patient makes a decision.8 The later approach is a relevant approach to involve patients in the decision-making process regarding diagnosis, treatment, or follow-up, particularly when there are multiple medically viable options to consider.8 Compared to typical care or informed decision making, SDM programs: (1) enhanced knowledge; (2) provided more realistic expectations; (3) lessened decisional conflict; (4) raised the percentage of persons involved in decision-making; (5) reduced the number of indecisive; and (6) boosted value-choice agreement.9 Various models of SDM have been tried in multiple health conditions, such as a case-based approach using the Design A Case authoring template, for prostate cancer screening,10 interprofessional SDM model in primary health care,11 a conversation approach for practice nurses in primary care to make shared decisions about goals and actions with chronically ill patients,12 5-step framework in SDM for proceeding with pelvic assessment in asymptomatic, nonpregnant patients,13 SDM 3-Circle Conceptual Model and multistep SDM pathway for improving quality and patient safety through in hospital settings,14 SDM model to treatment planning for youth psychotherapy,15 dual-layer: SDM approach to address the challenges of managing multimorbidity in primary care,16 and 4-step SDM in addressing inappropriate polypharmacy in older adults.17 Most of these SDM, models have demonstrated success in helping in patient satisfaction, treatment adherence and health Status.18 However, the studies have documented SDM can be improved by implementing patient tools or decision aids, providing training for healthcare providers, utilizing other members of the clinical team as "decision coaches," modifying reimbursement policies for patient encounters, and restructuring healthcare practices to facilitate patient engagement in healthcare decision-making.19 SDM models is relatively novel in tobacco cessation but have been widely used in physical healthcare, cancer, ulcer disease, ischemic heart disease, hormone replacement therapy, benign prostatic hypertrophy conditions.20 A systematic review done by Bomhof-Roordink et al.21 in 2019 identified 40 unique SDM models, but none specifically focused on tobacco cessation nor did they provide a specific SDM model for tobacco cessation. SDM and decision aids has a potential to promote physician engagement and patient knowledge of smoking cessation therapy, thus will enhance collaborative decision-making for preference-sensitive therapy like smoking cessation, improving treatment utilization and results.5 Decision aids has also offered promise for promoting increased education and access to tobacco use treatment,22 along with the potential to improve the effectiveness of nonpharmacological interventions during clinical encounters, especially for patients who exhibit lower levels of motivation (i.e., pre-contemplative or contemplative) towards modifying their behaviour.23 The utilization of in-visit decision aids has served as a pragmatic approach to promote SDM between clinicians and patients regarding tobacco use.24-26 These aids have demonstrated a significant enhancement in patient engagement during the decision-making process.27, 28 Hence, we propose a model of SDM for tobacco cessation based on the most commonly used and cited three-talk model, i.e., (1) choice talk, which involves informing patients about the availability of reasonable options, (2) option talk, which entails providing more comprehensive information about the available options, and (3) decision talk, which involves taking into account patient preferences and making the best decision. (Box 1), given by Elwyn et al.,29 The model incorporated in conjunction with a decision aid in the form of a flip chart containing information about willingness to quit tobacco; rewards of quitting tobacco on health; side effects of tobacco consumption; information about previous efforts to quit tobacco; withdrawal symptoms of quitting tobacco; coping mechanisms; therapies available for quitting tobacco and their advantages, side effects, direction of use and finally asking the patients their choice of drug which should be delivered by health care physician. Communicate the need to decide as a team Communicate the decision objectives, why is it required (the individual tobacco user risk factors), and the available treatment options Patient could have time to decide on the treatment and could take the support of family members Respond appropriately to the body language and reactions of the tobacco user Support the user through the decision process so that they feel confident to make a decision. Communicate information about the benefits and side effects of each drug Investigate the concerns, values, anticipations, and initial priorities (based on previous knowledge or preconceived notions about tobacco cessation) In-depth risks and benefits of each drug should be explained and discussed with the user Discuss the pharmacotherapy options they have and which would be the best drug for tobacco cessation Emphasize that enough time would be provided for reflections on personal preferences and they would support the user's decision. Try to identify barriers in case a user is not concerned with the pharmacotherapy use. In summary, despite commendable efforts in tobacco control, the significant annual prevalence of tobacco use leading to a substantial worldwide mortality rate emphasizes the need for innovative approaches. Conventional smoking cessation methods, often relying on medical or behavioural interventions facilitated by healthcare professionals, exhibit challenges in terms of long-term effectiveness. The adoption of SDM as a paradigm shift has the potential to enhance the autonomy of individuals seeking to stop tobacco use. The promotion of patient involvement in medical decision-making is essential to fostering autonomy and patient-centred therapy under the SDM paradigm. SDM programs exhibit superior attributes compared to conventional care, including enhanced information acquisition, the cultivation of realistic expectations, reduced decisional conflict, increased involvement in decision-making processes, less indecisiveness, and improved value and choice agreement. The use of this paradigm has the potential to enhance physician engagement, increase patient knowledge, promote treatment utilization, and facilitate collaborative decision-making in preference-sensitive interventions such as smoking cessation. This work is supported by the Science and Engineering Research Board, Government funding agency of India, 3rd & 4th Floor, Block II Technology Bhavan, New Mehrauli Road New Delhi-110016. (File No.: CRG/2021/008371) (Sanction Order No. & date SERB/F/2494/22-23). Open access funding provided by IReL. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.