The patient, a smoker for 50 years, told her doctor she was afraid quitting would kill her.
Her mother had smoked her entire life, the patient explained, finally quit, then died of a heart attack three months later. Quitting cigarettes had killed her mother, the patient believed, and she was sure the same thing would happen to her.
Her doctor, Richard Bryce, DO, could have given up in the face of that illogical stubborness, but he persisted. And, after a year of treatment and encouragement, the patient quit.
“You’ve got to plant that seed,” says Bryce, chief medical officer at Community Health and Social Services Center in Detroit. “If you allow the frustration to change the way you practice as a doctor, that’s a problem.”
Treating the compulsion
Smoking is no longer as severe a health crisis it once was. Smoking rates have been declining for decades and those who do smoke are smoking less. Smoking bans in public and private places means smoking has become less of an annoyance for non-smokers. The opioid crisis gets more headlines and congressional hearings than smoking does.
But it’s still one of the most serious health problems in the nation.
According to the Centers for Disease Control (CDC), cigarette smoking is responsible for more than 480,000 deaths a year in the United States, more than 10 times the number of opioid deaths in 2017. Nearly 38 million American adults, or 15.5 percent, smoked in 2016 and the CDC reports tobacco use is on the rise among middle and high school students, largely due to vaping.
For decades, physicians have been scolding, educating, pleading and more in an effort to get their smoking patients to quit, but it doesn’t always work. So, what should a doctor do? Frank Leone, MD, MS, thinks physicians who try to scare patients into quitting are going about it the wrong way.
“The message has been to turn up the heat on the patient. Constantly reiterating the negative effects of smoking—no one should expect it to make a difference,” says the director of the University of Pennsylvania’s Comprehensive Smoking Treatment Program.
Most smokers know smoking is bad for them and want to quit, Leone says, but they’re unable to because the compulsion to smoke, which is largely due to nicotine addiction, is simply too strong. The solution, he says, is to separate the compulsion from the smoking and treat the compulsion as an addiction.
“The motivation bucket is already full. It’s what’s on the other side of the scale that’s the problem,” he says.
Doctors should treat smoking the same as they would any other addiction, which means anticipating incremental progress with inevitable setbacks and sporadic improvement, he says. Too often, Leone says, smoking cessation is treated as an all-or-nothing proposition, rather than a treatment program like those designed for chronic conditions like asthma or diabetes.
“It’s not an event; it’s a process,” Leone says. “There is no such thing as failure in this system.”
Ideally, he says, there would be three levels of care for smokers: primary care physicians, community- and health system-based programs and intervention specialists who understand the chemistry of addiction.
Scold or encourage?
Most smokers want to quit. According to a 2015 report in Morbidity and Mortality Weekly, 68 percent of adult smokers wanted to stop smoking and 55.4 percent had attempted to quit in the past year.
For years, pictures of smoke-blackened lungs and warnings of lung cancer were standard scare tactics for doctors trying to get smokers to quit. However, that approach largely has been abandoned in favor of gentler means.
“Nagging never works. It just makes people mad,” says Windel Stracener, MD, a family practitioner in Richmond, Ind. “I think our job is to encourage them in quitting. Reassure them that they’re not the only ones to relapse and then help them get back on track.”
Doctors say they try to understand why patients smoke and address those reasons, if possible. Stracener says he will not nag a smoker who’s not ready to quit, but will keep revisiting the subject. “One of those times you go to the well you might get what you’re looking for,” he says. “When I’ve had success, it’s been when I’ve used a positive approach.”
Bryce says the key to success is to not be discouraged by the patient’s inevitable relapse, but to keep providing encouragement and never abandon a smoker as a lost cause. “Even if the (success rate) is only one percent, it’s worth my time,” he says.
And patients do listen, says Steve Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. While smokers probably have been told numerous times to stop smoking, research shows they are twice as likely to do so if they hear it from their doctor, he says. “People trust physicians,” he says. “We carry a lot more impact than their mothers-in-law.”
Doctors differ on whether to wait until patients say they want to quit to begin treating them. Stracener says a smoker will not quit until ready, but Leone says anti-smoking medication can within weeks bring patients to the point where they’re ready to stop. “The idea of ‘Are you ready to quit?’ is a big obstacle,” he says. “Create the readiness.”
Getting outside help
Helping patients stop smoking can be a long, frustrating and time-consuming process for physicians, not all of whom have the time to manage it or the patience for the inevitable relapses and setbacks. However, that doesn’t excuse inaction on the part of physicians. “To do nothing is malpractice,” says Schroeder.
Some physicians use office staff to check in with patients who are in the process of quitting. Others refer them to the numerous online cessation programs and organizations like the American Cancer Society and American Lung Association. Stracener has referred patients to social workers in the Federally Qualified Health Center where he works.
Busy physicians often advise smokers to call 1-800-QUIT-NOW. Available in all 50 states, the quit lines are staffed by National Cancer Institute-trained counselors who take patient histories, create personalized cessation programs and offer ongoing counseling.
The days of having to rely solely on patient willpower to stop smoking are long gone. A variety of effective medications are available.
There are two types of anti-smoking medications: controllers that prevent cravings, such as varenicline tartrate (Chantix), bupropion (Zyban) and nicotine patches (Nicoderm); and relievers that fight immediate urges by delivering nicotine through less harmful methods than smoking. These include gum (Nicorette) and lozenges, as well as prescription inhalers and nasal sprays.
Doctors should not give up hope if a single medication doesn’t work, Leone says, adding that it often takes a combination of medicines or medicines and therapy to succeed.
E-cigarettes and vaping devices have not been around long enough to generate the body of research that smoking has, but those in the field say there is reason to worry about their addictive properties.
Like regular cigarettes, e-cigarettes deliver doses of nicotine but, unlike cigarettes, their use is increasing dramatically. A 2016 study found that 10.8 million adults in the U.S. are vaping and more than half also were smoking tobacco cigarettes. Use among teens also is increasing.
According to the CDC, vaping went up among middle and high school students from 2011 to 2018. Nearly one of every 20 middle school students (4.9 percent) reported in 2018 that they had used electronic cigarettes in the past 30 days. That figure was 20.8 percent for high school students.
Vaping also could make it more likely that users graduate to tobacco cigarettes. A 2017 study from the University of Southern California found that 40 percent of teens who vaped started smoking tobacco cigarettes, compared to 10 percent of the youth who did not smoke at all.
Vaping is hard to quit, Leone says, because the devices are good at delivering nicotine. His treatment center has just started seeing high school students who want to quit vaping and who are surprised they are unable to.