Helping Patients Take Their Medication: Lessons from Helping Patients Quit Smoking
[This article first appeared in the Journal of Patient Compliance, the only peer-reviewed journal devoted to patient adherence.]
Smokers are not patients — or, at least, that’s the view that most people have of smokers. Like most “self-inflicted” health risks, like drinking too much alcohol and sharing needles, the stigma attached to smoking and smokers is pervasive.[1]
Unfortunately, not treating smokers as “patients” and seeing smoking as a “disease” can lead us to fail to apply valuable lessons from quit smoking programmes to helping patients take their medication.
The interesting thing about smoking cessation is that we as a society often treat this as a social problem. For example, to get dad to quit, we solicit the help of his family (wife, kids) and friends. We suggest aids that may help, like exercise and diet. We recommend that he see his doctor and try nicotine replacement therapy. Surrounding the patient with the necessary support that he needs to quit (and not what we want) is critical.
With that in mind, I, together with the Vietnamese American Cancer Foundation (VACF) and GlaxoSmithKline (GSK) developed a programme directed towards the Vietnamese American community targeting “Little Saigon” in Orange County, California. Little Saigon has the largest number of Vietnamese outside of Vietnam. Unfortunately, this community was facing a number of enormous challenges. It had one of the US market’s highest smoking rates (36 per cent)[2] and had therefore been deeply impacted by the scars of this addiction – death, disease and their consequences on family wellbeing and livelihood. Moreover, entrenched cultural and social acceptance of smoking made it an even more difficult task, with smoking for example still occurring in restaurants and offices with social impunity.
We purposely engaged the entire community in the programme (doctors, a community patient advocate, and a pharmaceutical company). Local doctors were asked to actively speak with their smoking patients about the need to quit. As Dr Loc D. Bui (a Little Saigon doctor) urged his colleagues at the start of the campaign, “As physicians, we know the danger of smoking. I would like to see all the physicians in our community talk to their patients about smoking and strongly encourage them to quit.”
The pharmaceutical GSK, although a manufacturer of nicotine replacement products, was content to fund these activities without active product promotion. For example, in a survey of local physicians, doctors’ attitudes and beliefs about nicotine replacement therapies involving gums, patches and lozenges were explored along with “cold turkey”, herbal supplements, diet, exercise, or anything else they might recommend to their patients.
These patients were made aware of the cadre of healthcare experts, quit lines, and volunteers at the VACF that stood ready to assist them. “People don’t realise that it is not just their health, it is the health and welfare of their whole family that the smoker puts at risk,” said Leonard Tran (then Executive Director of VACF). “Men who develop smoking-related diseases often leave their families without means for support. By quitting smoking, men can give themselves their best chance of being able to be there for their families in the long term.”
The community responded to VACF’s message. A young widow, for example, spoke on community radio to tell her heart-wrenching story of not getting her husband to quit soon enough. Sadly, he had then recently died, leaving his wife and kids to deal with bills and payments, and continuing to live their lives without him.
The results? Activity on the quit lines and at VACF increased dramatically. As one doctor observed, epitomising the programme results, “Since the programme started, I have had 4-5 patients per month quit smoking which is 4-5 times more than I usually have.”
However, what the programme had really done is motivational counselling at its best — doctors intervened as the medical authority, the community provided stories and emotional support, and the local cancer foundation (VACF) gave individualised and group counselling and advice.
More importantly, we applied techniques that we knew would work. We were not encumbered with the need and desire to wait for clinical trial data, or to have confirmed and documented returns on investments from other smoking cessation programmes before starting the Little Saigon programme.
Waiting for this data before acting is truly regrettable. Recently, for example, the Archives of Internal Medicine reported on the results of a study to examine whether a telephone-based counselling programme rooted in motivational interviewing would improve adherence to osteoporosis medication.
For this study, more than 1000 Medicare patients who had been newly prescribed osteoporosis medication were divided into a control group who were mailed educational materials and an intervention group who received telephone-based counselling.
Median medication adherence was 49% in the telephone group and 41% in the control group. In short, as the osteoporosis researchers concluded, “In this randomized controlled trial, we did not find a statistically significant improvement in adherence to an osteoporosis medication regimen using a telephonic motivational interviewing intervention.”
Unfortunately, the results of studies like these may result in programmes like these never starting. As Dr Jon Ebbert (Professor of Medicine at Mayo Clinic) emailed me:
Tragically, this may mean that stakeholders may not pay attention to what may be a very promising and innovative strategy to improve medication adherence. Behavioral strategies have been used very successfully in getting patients to quit smoking and can be a great tool in getting patients to take their physician-prescribed medication.
So, the next time you start to think about an adherence programme, take a page from smoking cessation — make sure it listens to patients and responds to their individual needs in improving medication adherence.
This patient-centric approach should be a part of each and every strategic decision.
Why? Because the old marketing adage that the customer is always right applies even to the healthcare industry. Don’t discount such things as complaints of side-effects, lifestyle inconveniences, and forgetfulness — listening and responding may be the difference between an adherent patient and a non-adherent
[1] Stuber J et al., “Smoking and the emergence of a stigmatized social status” Social Science and Medicine (May 2008) http://deepblue.lib.umich.edu/bitstream/2027.42/60953/1/stuber_smoking%20and%20stigma_2008.pdf (accessed April 8, 2012).
[2] A Provider’s Handbook on Culturally Competent Care, Smoking Among Asian Americans: A National Tobacco Survey
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