Talk:Alexander

Many of our patients smoke and many of them acknowledge that they understand its negative impact. Yet, I have met only the "I can't quit right now" and "I'm cutting down a lot" folks. I believed we are well prepared to gather the smoking history.

But, are we assessing patient’s dependence (using CAGE or Fagerstrom) effectively?

I have seen physicians prescribing pharmacological agents to help patients quit, but rarely seen recommendation for behavioral therapy when it has been found that combination works best.

Have you seen your physician do “quick therapy” or making referral? How can we coordinate efficiently smoking screening, education, therapy, while providing care for acute illness, chronic diseases such as DM, HTN, and CAD?

In the Commonwealth of Virginia, smoking ban in public places – differently defined in different bills – has been defeated year after year, but making is closer to reality each time it gets introduced. My representative told me that passive smoking is not harmful, and even if it is, the restaurants have advanced ventilation systems that patrons of the eateries in metro Richmond should not be concerned.

Without getting too deep into politics of personal rights and government responsibilities, I wonder how the health care providers can educate not only the public but the law-makers on the danger of smoking. Is it out duty to lobby and influence our elected officials?

In medicine, there sometimes is a conflict between respecting patient autonomy and doing what is best for the patient. We all know that there are hundreds of undesirable long-term effects from smoking that can often be greatly reduced just by quitting, but how hard should one try to effect change. Patients are adults who are free to do what ever they want and very often, that choice is to continue smoking. How hard should a doctor push? My person belief is to simply query for interest and change and offering help if they are interested. Any more and one runs the risk of destroying any trust that they have built. Is this the best way to handle something with major long term health consequences? For better or worse, it very well may be.

Alexander noted that he was, "stressed out at work", as his reason for relapsing after quitting smoking. How many patients have you heard say they smoke to relieve stress or they smoke socially or after meals? I am sure you have heard all reasons that people use to justify why they smoke.

Smoking becomes a part of their lifestyle and their daily routine. This is why I feel that people addicted to cigarettes not only need effective methods to get rid of their cravings, but also lifestyle and behavior modification techniques.

How do we as physicians make a link in patients' minds that not only is it unhealthy to smoke, but they also must avoid situations and even people perhaps that will make them more inclined to partake in bad habits?

How do we effectively provide the multiple modalities (i.e. medications, behavior modification techniques, group therapy...) necessary to help the patient beat addiction?

There are so many ways to approach quitting smoking including behavioral modifications, medications, hypnotic therapy and several others. I have seen several patients who have tried to quit smoking each using a different method or combination of methods. Usually the reason for one method over another is money, what will the insurance company pay for or what is the least expensive. Some patients simply can't afford anything and that is why they haven't tried to quit.

Right now the best medication out there as far as evidence based medicine is concerned is chantix. However, there are few insurance companies that will cover this medication which means the patient ends up paying literally hundreds of dollars out of pocket. This is a huge deterrent for our patients and I wonder what we can do to help push the insurance companies to broaden their coverage.

Also according to evidence based medicine, we have found that smokers can reverse the health risks of smoking within 5 years of quitting. From an insurers prospective, it would make sense to help them quit smoking and therefore defer later costs of medical care. Again how do we get the insurance companies to listen and begin covering the various methods that will enable smokers to quit.

Providing preemptive suggestions about ways to relieve stress isn't a bad idea. Psychologically speaking, having a wholesale change of environment (or as good of a simulation of one as is possible) can be an effective tactic as well. Many successful quit attempts start with a vacation, hospital stay, or other break from normal routine. Giving careful consideration to behaviors that trigger cravings can be essential. http://www.smokefree.gov/ is a good resource to provide to patients for strategies and information.

The cost of quitting strategies can be high, but, cigarettes are hardly cheap either, and are certainly far more costly over time. It is a process where the price of success can be high, and the price of failure higher still.

As we have learned, it is always good to assess what stage the smoking patient is at in terms of quitting: precontemplative, contemplative, etc. For the patient in the precontemplative stage, we are taught to counsel them on the dangers or smoking, the positive effects of quitting, and find out why they smoke, what triggers their smoking, and how they feel about their smoking. I have seen many patients, who according to my preceptors, at check-ups repeatedly acknowledge that smoking is bad for their health and they understand the negative consequences, yet they are never willing to try to quit or move into the contemplative stage (willing to quit) preparation stage (make a plan to quit). For patients like these, do we continue to counsel them over and over, or do you think it would benefit the patient if we were more firm, and pushed them more to get them to the next stage? For example, instead of just telling the patient the different ways doctors can help them quit (medicines, support, etc), that doctors come up with specific plans for the patient, with specific time frames. Ultimately, a patient will do what they want to do, but maybe for some patients a push like this is just what they need to get going. For others, it may turn them off quitting even more. What do you think a doctor should do when patient are aware of the risks to their health, yet do not want to quit smoking?

What role do you think counseling patients who do not smoke plays? People may start smoking at any time in their lives for any reason, be it stress, social pressure, whatever. Do you think it would be beneficial to take a few seconds at a yearly physical to discuss the risks of smoking? I do this at least with my teenage patients when discussing HEADSS. I know that we have limited time to spend with our patients but could it decrease the number of new smokers if we took the time to do this?

As discussed, the Stages of Change Model can be helpful in determining how ready a patient is to quit smoking. Our smoking cessation "guru" at Student Health, Linda Hancock, PhD, a nurse practitioner, has done some studies of her own. She has found that the patients who 1) rate themselves highly (8,9 or 10 on a 1-10 scale,) on WANTING to quit and 2) rate themselves highly on being CONFIDENT that they will be able to quit are the most likely to actually go ahead and quit smoking. Those who do not want to quit yet are still in the precontemplative stage and probably don't warrant much time spent on education. But I will still say something like, "Smoking causes a number of bad diseases. As your doctor, I strongly recommend that you quit smoking.  Let me know if I can help you with medication when you are ready to quit." For those who want to quit, but lack confidence in their ability to quit, we can ask why they think that it will be hard for them to quit. This may provide an opportunity for giving specific advice about smoking cessation techniques or medication.

In response to the post about Chantix, I have had numerous patients come in requesting to try it because they have had friends go on it and successfully quit in a short period of time. In cases like those, it's easy to encourage patients to quit. The issue of insurance coverage has come up with all of them, but my preceptor has argued that if they have a pack to two pack a day habit, the cost of cigarettes will be only slightly less than the daily cost of Chantix (the cost of a chantix 30 day starter pack plus the two month additional supplement costs about $417). Regardless, they would only be paying for the medication for three months, as opposed to spending money on cigarettes for the rest of their lives. The bottom line is that they will be saving money while improving their health.

Check out this article. http://www.nytimes.com/2007/02/15/business/media/15adco.html?n=Top/News/Business/Small%20Business/Marketing%20and%20Advertising

Its about Camel's new line of cigarettes aimed at younger women smokers, Camel No. 9. It is written as a piece of business news but it serves as an example of what the tobacco industry is doing to increase the number of smokers. These people are good at marketing.

"Reynolds American will sponsor promotional events for the new Camel in large markets around the country and promote the brand in a variety of other ways, like giving away packs at nightclubs, distributing cents-off coupons and running ads in magazines, including Cosmopolitan, Flaunt, Glamour, Vogue and W."

Its a little disheartening to think that this is going on and to know that an office visit is one of the only opportunities one has to get someone to stop or never start smoking. It would be nice if we could compete by giving Chantix away or by purchasing equal advertising, but I guess the system does not work that way.

I felt that this case actually had a lot in common with the charlotte case on domestic violence. it only reinforces the fact that there is only so much that can be done as a physician, that each person has their own free will.

I agree that as a physician it is our responsibility to promote patient education and discuss every option that there is to quit, but I have watched 2 out of 3 of my preceptors downplay the efficacy of nicotine replacement therapy (patch, gum, or chantix) and spend the majority of their time promoting behavioral therapy.

I found the following article to be really interesting: http://whyquit.com/pr/123106.html

I am at a very rural family practice and it made me question if it made sense to be promoting drugs as expensive as chantix, especially to patients that really cant afford it.

My parents and I have a good family friend who is dying of lung cancer secondary to smoking right now. He will not live to see Christmas most likely. He tried several times unsuccessfully to quit in the last 40 years. He says he wishes he had never started. He continues to smoke because it is one of his few pleasures now. I hope that new treatments are successful in helping people kick the habit. I think primary care doctors need to be as supportive as possible and let people know it takes a number of tries to stop smoking. Physicians can also direct patients to other resources. Nowadays, many patients research conditions and treatments on the internet so we can direct them to resources like www.smokefree.gov. Maybe this will get more people thinking about smoking.

To me, the area to focus is clear. I would start with the smoke cessation long before urging to get rid of his pet. Of course, I would explain all the risks, but literatures have shown that having pet has so many health benefits (i.e. pet therapy, Center for Human http://www.chai.vcu.edu/). After tackling the risk for #1 killer cancer, I would push hard for the pet. It is POSSIBLE that Alexander will discredit physician’s advice to stop smoking if he was also told to avoid his pet. However, in my opinion, with short discussion, two topics can be separated.

Re: strategies Many of posts here have discussed about different strategies. Though some physicians may down-play the efficacy of pharmacological agents, I agree that smoking is part chemical addiction and part learned behavior. Some people may be “built” to overcome the addiction on their own (cold turkey), some need both modalities to quit successfully. Of course, as one of us pointed out, when suggesting behavior modification, we cannot change their environment completely. I only know few people who is strong enough to say “NO” consistently for long period of time when everyone in the household and everyone in the social network continue to smoke.

Re: trust in recommendations Trust is earned. The relationship the patients have with their primary care physicians is unique and built overtime. I doubt that all the recommendations by the physician at the first visit will be accepted without question by many patients.

As we have discussed, “pushing” the patients to change without assessing the stage that they are in is waste of time, energy, and risk of losing the relationship. Though we learned these stages in the FCM, I think we refine our assessment skills by repeatedly doing it. I suspect most of us will make incorrect assessment first few times (just as we may make incorrect assessment of pneumonia, STDs, etc.). I feel that during the third year, we don’t get enough training on the important but “soft-science” materials. In residency, perhaps?

I believe it is as important for us to praise those who don’t smoke or do other health risk behaviors. I have seen many physicians continue on with simple remark “Good.” With my personality, I would show my emotion and how proud I am and follow up with one line negative consequence to reinforce their behavior. I do the same for those who have been sober, clean, and quit for how many days, months, or years. In my opinion, it doesn’t take much time and builds more solid relationships.

For high risks patients, and those who have expressed the desire to quit, but still in the early stages of change for long period of time (note here that we must have longitudinal relationship), I would inquire more (slowly) of their obstacles to quit and address them.

From the business perspective, I used to think that pharmaceutical companies and tobacco companies are the same. They must invest money to develop new products, to market their products, and to recuperate their investments. Then it hits me recently. Once you are addicted to tobacco, it is much harder to quit. But, we only take medication as needed. So, I guess it is harder for the pharmaceutical companies. But then, there are fancy dinners, elaborate gifts, etc. etc. They should use that money on more samples for underserved population.

As for the insurance companies who have been making unbelievable amount of money over the years, it does make sense to cover Chantix. But, in the world where people change jobs and the insurance frequently, I suspect they are more concerned with the profits now than actual health of the people. I have heard many debates about how impossible “Universal Healthcare” is in the States, but I must say it may be able to fix some of this problem. I hope.

Obviously the sale of cigarettes is extremely profitable. How else could cigarette companies still afford to stay in business and pay the enormous settlements that they were forced to pay in the class action lawsuits made by the states? Because of the large amounts of money involved, they can afford to buy the best in marketing and advertising available. Because they are restricted from advertising on television, they avoid the high cost of TV advertising and have a huge advertising budget to invest elsewhere. That is why they can afford to give away packs and fund promotional events. Sometimes, cigarette promotions are obvious, such as TV advertising and giving away free packs of cigarettes; sometimes promotion efforts are more subtle, such as event sponsorship. (Still, I am glad that TV promotion of cigarettes is prohibited. I can still recall cigarette jingles stuck in my head from decades ago!) As with the Joe Camel cartoon character that they were forced to drop a few years ago, tobacco companies are always trying to target children and young adults as new or future smokers. That is one reason why sporting events are heavily promoted by tobacco companies, because children are exposed to their products at young ages, and the products are associated with health and athleticism. I was happy to see when Winston sponsorship was dropped for the Winston Cup NASCAR competition. (It was changed to the Nextel Cup.) I think that when we recognize what the tobacco companies are doing, we can find ways to fight back too. I once wrote a letter to a cereal company, expressing my disapproval for having the Winston Cup logo prominently displayed on a cereal box, in association with a promotion for the cereal's NASCAR driver. In my residency we were advised to check our office waiting room magazines for smoking ads, since these were/are often placed in prominent places, such as the back cover.

My preceptor and I had a long discussion about the use of Chantix last week. One of the interesting points that he seemed to emphasize was the delicate balance about knowing when the patient is truly ready to make the next step in quitting smoking. As we read about in the case, a patient goes through a complex set of stages before accomplishing their goal. (The 5 levels of change: precontemplation, contemplation, preparation, action, maintenance) As a student, I think the hardest part maybe when to/how hard to push a patient and when to hold off and encourage them. Each patient is different in terms of what they need from the physician to make this dramatic change in their life and thus, the doctor-patient relationship maybe the key element in this process.

The other day we had a pregnant lady inquire about Chantix. It is considered a pregnancy category C drug (Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks). Smoking poses known risks to the fetus and Chantix may also pose risks but this is unclear. Would you be inclined to prescribe Chantix to a pregnant lady who would otherwise continue smoking and put her baby at risk?

As we look at the global health, one cannot deny that many giant American tobacco companies shifting their tobacco market to developing countries where the ad rules are not as strict and the adverse health effects are not well-known. With the tobacco profits, these companies can branch out into other fields such as technology, food, etc. For example, Altria which is a parent name for Philip Morris owns part of Miller, until recently General Foods and Kraft, Nabisco, etc.

At my preceptor office, I would estimate that close to 80% of his patients smoke. I always make a point during my interview to ask questions about smoking (eg. frequency, willingness to quit, etc.) and often times, patients express a recognition that they know they should not smoke and an interest in trying to quit. During my discussion with patients about smoking cessation, I remind them about the health risks of continuing to smoke and offer some psychological advice that was passed to me by one of my earlier preceptors from FCM concerning smoking cessation... You must want to stop smoking permanently and must be mentally prepared to battle the cravings that will inevitably come. (These comments speak to one of the earlier posts concerning pre-contemplation, contemplation, etc.) Along these lines, I remember my preceptor telling me that when attempting to help a person to stop an unhealthy component of their lifestyle, they must be willing to make changes that are permanent.(This advice also applies to diet and exercise interventions.) If the patient is not willing to make changes for the rest of their life, then their chances of successfully stopping the unhealthy practice decrease. Therefore, I ask patients about their willingness to make smoking cessation a permanent part of their new lifestyle. Their response to this question often dictates how aggressively my preceptor will pursue a smoking cessation plan.

Addiction is a powerful force. My wife has worked with drug addicts so I have had some limited opportunities to see just how powerful addiction really is. The fact that patients recognize and understand how harmful smoking is and yet continue to smoke speaks to the control that addiction has over one's mind. While behavioral modification is an important component of stopping any addictive behavior, the ability to offer simultaneous pharmacological intervention is crucial. As is discussed buring Psychiatry within the context of mental illness, either intervention by itself (eg. behavior and pharmacological) is not as effective as both working together.

Besides www.smokefree.gov, there is also www.smokefreevirginia.org  and www.smokefreeVCU.org The Federal quitline is 1-800-QUIT-NOW (1-800-784-8669)

A preceptor pointed out to me many years ago that the people who are most determined to quit are able to quit cold turkey before they even come to see us. The patients who we see for smoking cessation (or those who sign up to be in smoking cessation studies) will therefore tend to be the more difficult cases. I tell my patients who have relapsed that most people try quitting several times before they are successful. They should not be discouraged, but should plan to try quitting again in the near future.

Below is a paper published by MCV family medicine about an interesting idea of using internet based resources to aid in patient education about things like smoking cessation. At the very bottom is the link to the free full manscript. My attending told me that Dr. Rothemich is the doctor responsible for studies showing that asking patients about smoking cessation at each office visit can lead to increased success. Woolf SH, Krist AH, Johnson RE, Wilson DB, Rothemich SF, Norman GJ, Devers KJ. Related Articles, Links Free in PMC    A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study. Ann Fam Med. 2006 Mar-Apr;4(2):148-52.

PURPOSE: We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change. METHODS: In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction. RESULTS: During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health be! haviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians. CONCLUSIONS: Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether info! rmation alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1467008&blobtype=pdf

While the tele-medicine is the present and future of medicine (and I personally love the idea), at this point the disparity between net-savvy and net-naïve is profound. Many chronic diseases such as HTN, DM, and CAD are most prevalent in older population, many of whom are still resistant to technology (my pure observation). Of course, working in Churchill, I wonder how many of our patients can afford computer and net service. Yes, going to the library to use the net may be an option. But, last time when I used the public library, privacy, security, and speed were all issues. (Perhaps more funding for public computers?) I do agree, however, that when a physician is “forced” to see 30 patients a day, he or she can screen those who are wired so that they can be treated via tele-medicine. But then while the physician seems to have lighter patient load on the surface, in reality it would create more working time for the physicians (see patients all day and treat tele-meds folks all night?)

Yesterday the washington post ran an article about a smoking cessation tool for cell phones: http://www.washingtonpost.com/wp-dyn/content/article/2007/10/11/AR2007101101299.html?sub=AR. It's an interesting concept since it takes a lot of support to quit, and you can't count on friends and family (or your doctor) to be with you around the clock. You fill out a survey at the website fixnixer.com to figure out at what times of day you are most vulnerable to smoke (after a meal, when out for drinks, times of stress, etc), then this information is processed and text messages are sent to your phone when you are most likely to get stressed and pick up a cigarette.

Although this also may not be so helpful for the older patient population, it sounds like a great tool for young adults, especially the ones that talk on their phones/hold text message conversations while my preceptor or I are interviewing them (this really happens at my downtown Richmond clinic, ha.)