Smoking Cessation Options

In the United States, an estimated 25.9 million men (23.9 percent) and 20.7 million women (18.1 percent) are smokers. These people are at higher risk of heart attack and stroke among other illnesses. With such consequences, people are seeking ways for smoking cessation, but with so many options out there, how do physicians help their patients choose the right one?

Introduction and Questions
What are you opinions of providing traditional treatments for smoking cessation (i.e. nicotine replacement) to teenagers, especially those who aren't old enough to be smoking legally. How do we help this population quit?

For many smokers (and especially teens), smoking is an issue much like some of the dietary issues in obesity that deal as much with psychological dependence as it does with a physiological need. '''How do we address that dependence? In a I wonder how effective Smoking Cessation Pharmaceutical options could possibly be in teenagers?'''

Discussion
Teens often view themselves as immortal and may not have a very deep understanding of the health risks of smoking. Death and terminal illnesses are just such a far away concept for these youngsters. Instead of hitting them with facts and figures about cancer rates, COPD, etc, use motivators that are more relevant to their present life. E.g. mention to the teen boy that girls are turned off by the smell of cigarettes on their breath and clothes and that smoking can turn their teeth yellow. Emphasize to teens that smoking can hurt their performance in sports. I help my doc on Tuesdays & Thursday afternoons at the Woodberry Forest (private boys school) infirmary, and saw a poster that warned that smoking is one of the risk factors for male impotence. Back in the day there were a lot more advertisements for smoking, and these ads portrayed smokers as cool, sexy, strong, and youthful. These ads were an important factor in getting a lot of teens hooked on cigarettes. I propose using the same kind of logic for anti-smoking --> portraying the smoker as smelly, ugly, and weak Though these factors are certainly not as important to us as doctors as the cancer risk and the COPD, etc, it may be what teens will listen to more.

In this case, Alexander's smoking habits could be explained as a trigger for his asthma. The EPA states "it is well known that secondhand smoke can trigger asthma episodes and increase the severity of attacks. Secondhand smoke is also a risk factor for new cases of asthma in preschool aged children who have not already exhibited asthma symptoms. Scientists believe that secondhand smoke irritates the chronically inflamed bronchial passages of people with asthma. Secondhand smoke is linked to other health problems, including lung cancer, ear infections and other chronic respiratory illnesses, such as bronchitis and pneumonia." http://www.epa.gov/asthma/shs.html

We had an interesting situation arise at my preceptor’s office. A 5 y/o came in for recurrent exacerbations of her asthma. The patient presented with her mother who smelled “like a chimney.” When questioned she explained that both parents smoke at home, but the mom claimed that they never smoke around the child. With smoke being a common trigger of asthma, we found ourselves in a situation where the parent’s bad habits were adversely affecting the child’s health. Screening questions made it clear that the mom had no intent of quitting although her habit could be a cause of the child’s asthma.

A conversation in the office got started as to when child protective services should be called in such a situation and how to handle the mother in general. How would you handle this situation where a patient (pediatric/elderly) is being affected by secondhand smoke? What role should the physician play?

One thing I've read in the past is that on average people quit smoking 7 times before they finally are able to kick the habit. That's just something to keep in mind when you're talking with a patient who has had one or several relapses. The better we get to know our patients, the better able we will be to help understand their particular motivational factor at that stage in their lives. For the young it may be short-term consequences such as the ones I mentioned in the previous post. Some male patients I've encountered wanted to quit smoking because they knew they were just about to father a child and didn't want to be a smoker & a dad. Some women plan to quit smoking for their pregnancy -- that's an excellent time to get them thinking about quitting smoking for life! Some middle aged patients want to quit smoking after their parent or aunt/uncle gets lung cancer. And some middle-aged / elderly patients want to quit smoking so they'll be around to see their grandkids graduate grow old / graduate from college. Whatever the motivational factor, if you are in tune with your patient and his/her life changes you'll be better able to help them through the PROCESS of kicking the coffin nails.

People know smoking is bad and that they should quit, yet they just cant seem to do it. They try and try repeatedly with no success. I think this is because we tend to focus on why they should quit and when they should quit(asap) without taking other factors into consideration. For example, perhaps the patient has finally chosen a quit date but some life altering event just so happened to get in the way-perhaps now we should focus on stress reduction so that the patient can successfully get rid of the habit. We need to provide them with enough information on behavioral modification and give them outside resources. The more counseling someone gets, the better the chances that they will actually quit. Here is an excellent evidence based resource. http://www.ahrq.gov/consumer/tobacco/quits.htm

I agree with what everyone has said above. It is important to modify your treatment plan based on the situation. You can't just give a generic speech about smoking cessation because it may not apply to everyone. As stated above, getting teenagers to quit smoking is tricky. They are probably not interested in the long-term consequences of smoking, such as cancer or COPD. So, you should scare them with more immediate consequences. You can talk about bad breath, dental problems, smelling bad, or discoloration of fingers. This may hit home. In addition, counseling parents who smoke around their children is another tricky situation. You have two parties to be concerned about, the patient and their children. To reiterate the points above, EDUCATION is extremely important. Patients may not know how they are effecting their children. While it may not be easy to motivate patients, we can simply give them the resources for change. If we feel like we have given patients plently of reasons to quit and have shown them the way, then we can only sit back and wait for the patient to change. As a part of this process, we should make ourselves available to help patients get over the road bumps. We can help the person with a back-up plan and schedule follow-up visits.

Getting through to teenagers is the difficult part. Like the previous post, teenagers think they are immortal and invincible or that they can quit any time they want. Smoking may look cool and appealing to many. And a lot of celebs on tv kids look up to do smoke and they think it's ok or it's cool. There's certainly peer pressure issue as well. To combat that there's been poster contests and what not. One short anti-smoking commercial that I remember seeing on tv is where a guy has two cigarettes sticking out of his ears. And he says, "what's funnier than cigarettes in your ears? In your mouth." Maybe keeping it simple like that may help teenagers rather than scaring them with cancer. I think it was the guy from will and grace.

Any thoughts on the best way of dealing with potential judgments on the part of the care giver when talking with patients about smoking? I find that I have a hard time with this topic especially when talking to a mom or dad about smoking when they have a child - particularly if it's a newborn that spends a lot of time nuzzled up against mom's sweater that smells like lit cigarette. I hear doctors emphasizing the importance of smoking outside and wearing a designated smoking jacket that they take off as soon as they are done smoking but I still have a hard time not judging. My boyfriend has pretty bad asthma and we are often times restricted in places we can go for dinner or drinks because of that, but at least we can choose to avoid a smokey situation unlike a little baby in house of smoking parents.

In response to an observation above that parental smoking when the patient has asthma amounts to child abuse, I agree to a point. Smoking parents love their children just like nonsmoking parents. It may seem like character weaknees not to quit, but a low opinion of the parent will come through loud and clear and most likely not be motivating for them.

Also, what about other situations in which parenting skills may seem suboptimal? For instance, are parents abusing obese kids by overfeeding them?

One thing that I have noticed which is unique about family medicine is that by treating the entire family, the doctor has the ability to see how one family member’s illness or habits affects the health of the rest of the family. Having insight into the family dynamic can provide an advantage when trying to motivate a smoker to quit and when preparing for potential obstacles. We recently saw a patient who decided to quit smoking because his 8 year old son kept asking him to quit. He felt ready to quit, however his wife is also a smoker and is not really thinking about quitting. Knowing this, we were able to discuss what some of the potential set backs may be as he attempts to quit.

As mentioned above, children do not have the option of avoiding a parent who smokes. This can be frustrating since we know that second hand smoke has so many negative health effects. Yet I wouldn’t consider smoking around children child abuse since the intention of the parent’s smoking is not to hurt or belittle the child. I agree with the points made above that education is extremely important. Drawing connections between a child’s illness and a parent’s smoking can be a strong motivational tool.

I also wanted to point out that some states are taking legal action to protect kids from second hand smoke. Starting in 2008, California will outlaw smoking in all vehicles containing children under 18 years old to limit kid’s exposure to second hand smoke. http://www.californiachronicle.com/articles/viewArticle.asp?articleID=39943

The important issue here is to warn the patients about the consequences of smoking and making sure that the patients understand it. According to American Heart Association “About 46 million American adults smoke cigarettes, but most smokers are either actively trying to quit or want to quit. Since 1965, more than 49 percent of all adults who have ever smoked have quit.” This number will hopefully increase since the emergence of the new drugs. In my family practice, many patients love the new drug called chantix, a great drug which decrease the craving sensation for smoking in patients. Another important issue here is smoking in pregnant women. It is important to make sure that these patients know about the consequences of smoking to the health of their babies. A doctor should try to educate the patients as much as possible for the sake of the baby and the mother.

My preceptor challenges his patients to join him in the game of bettering their own healthcare. It's very interesting and psychological. Yesterday we saw a teenager who drinks and has uncontrolled diabetes (HgbA1C = 8.7)present with horrible thrush and a sore throat. My preceptor did not use a physician-centered approach in that he did not say "Do not drink. Control your diet. Your Diabetes will kill you." Instead, he engaged the teen and his mom in a conversation when the mom asked what they should do about her son's alcohol drinking. My preceptor said comething to the effect of "Now, ______ knows alcohol is a fermented sugar that worsens his diabetes. After this episode (with the thrush), he knows better. I dont think he wants that again." Then he looks at the teen, and the teen emphaticly agrees with the doctor. My preceptor then goes on and says "Besides, if ______ continues down this road, he's going to lose this game and I dont think he wants to lose. Alot of times teens think they are young and can recover but in this case, losing can mean going blind or amputating a leg." Again, the teen agrees with the doctor. At the end of the visit, the teen told my preceptor he liked him alot more than his last doctor because my preceptor treated him like an adult and let him decide. In terms of teen smoking and obesity, I believe that challenging the patient to participate, just like how my preceptor did in the above situation, can engage them to attempt to stop smoking/ start dieting. It seems very psychological and can be effective because most people like games and do not like to lose. When many of them are alerted time and time and time again about their smoking, obesity, HTN, DM, or other chronic problem, at some point they may realize the importance of managing the issue and "winning this health game." My preceptor tries to engage every patient and told me that the ones who respond usually do well. However, there are also the ones who no not respond and either continue needing more meds/leave his practice. I know this is somewhat of a tangent, but when we're practicing, we are going to meet the patients who are morbidly obese, smokers, hypertensive, with DM, CHF. At first, we may try to continually counsel and engage them on weight management/nutrition/managing chronic illnesses. However, realistically, that is frustrating and we may end up seeing the counseling as futile and just increase their medications. For some reason, my preceptor continues to counsel and challenge the patients (and increasing medication as necessary)even though often it is like hitting a brick wall. He always emphasizes to me that the more times the patient hears something the more it is emphasized as an importannt issue. What kind of mind set do you think we need to be in as we see these types of patients again and again?

As a response to the question about what mindset we need to be in when repeatedly encountering patients with chronic, lifestyle-modifiable diseases is one that can be summed up by the word "limits". What I mean is that just like the limits physicians often place on the do's and do not's for patients, the limits of what's acceptable for bloodwork and limits as to how long they prefer to spend per patient so must they limit the amount that they feel personally invested in the patient's health. Physicians must realize that if we truly give our best shot each time we interact with the patient through motivational and educational counseling that is sincere and supported with medical interventions at the physicians disposal such as medications and/or referrals to specialists/counselors than that is honorable attempt. Rather than feeling as if one has failed a patient, it must be emphasized that it all boils down to patient's autonomy. Patients are free to decline smoking cessation pleas, weight loss advice and diet restrictions just like they can decline taking their medications or receiving blood transfusions. I could not imagine being in the mindset where you continuously ponder the question of "Why won't they just listen to me?". Inevitable a mindset like that would be cause for concern of my own health.

This discussion also fits nicely with a patient encounter I had today. A young lady 22 weeks pregnant came in the office. Previously she had been a heavy drinker and smoker, but due to the consistent efforts of my preceptor she has given up alcohol. Unfortunately she was not willing (even on that day) to give up smoking. Neither I nor my preceptor judged or scolded her. Nor did we take that responsibility upon our shoulders once we walked out that door.

I would agree with everyone’s comments that educating our patients and making sure they have the information that they need to make informed choices.

However, I would challenge all of us to begin a lifelong pursuit of continuously improving our ability to help to motivate and encourage our patients to begin any incremental change that they possibly can. I kind of feel like there are many issues in which many physicians say to themselves, to colleagues, to students… well, all you can really do is…

And I certainly agree that this is often the case… I guess my comment is more of a… “let’s be sure that we really have in fact done all that we can.” Do we really know if maybe in searching for a different way to approach the topic, we might not be able to find SOME way to reach that patient?

I recently did a physical for a gentleman who was a smoker… and he said, “Yeah, I know I need to quit, but I’m not ready yet.” And I smiled and said, “Well, I’m very glad you are aware of the need to quit… I truly hope that you will come to a point when you are ready to quit, because I think your kids would really love to be able to spend as much time with you as possible and I know they would want that time to be good quality time with you… and I’m pretty sure you would want the same.” This gentleman with a 15 year 1 pack a day habit, started tearing up and crying… we sat down for a while and he talked about being short of breath playing with his 7 year old. We started looking for a date for him to quit. We talked about triggers. He walked out with a prescription for Chantix.

I don’t know if this is going to take hold. I don’t know if he is going to make his change permanent. But it’s a start. And I am so glad that I kept looking for a way to reach him.

I don’t know that this is going to work every time. I am certain that there will be people that this will NOT work for. I guess my point is… I hope that none of us loses that fire within us that wants to genuinely help every single person that walks in through our doors. I hope that none of us ever gives up on any of our patients and their chronic unhealthy habits without really truly giving it everything that we have… not out of judgement… but out of genuine concern for their well-being.

Interestingly, almost all of the patients that I have really sat down and talked to about smoking have expressed a desire to quit, and a suprising (to me at least) number of them have been really receptive to considering chantix or bupropion perscriptions. In fact, the major argument that i have heard against trying one of the drugs isnt that the patient wants to keep on smoking but that the medications (particularly chantix) can be expensive, especially for patients without insurance or patients whose insurance dosent cover it. I think the case made the point as well, that physicians simply asking about smoking cessation was shown to increase quit rates. Given the return on a pretty small investment of time, it seems like something that should be brought up at every visit with smoking patients (at least as long as it isnt an inappropriate time). Still, it seems that it could easily fall through the cracks, people get busy and patients often bring a lot of problems to the office visit. Do you guys have a feel for how often your preceptors bring this up with smoking patients?

I guess it depends on each preceptor, some are take-charge, challenging type, others pick up from patients' attitude or general sense of readiness from years of following the patient, and maybe pick the right moment to bring up the subject. As you see the patient continuously over the years, we may be able to track how they progress in their readiness to kick the habit. Some may take offense at your bringing up the subject each time they come, some may eventually show up with reason for visit "smoking cessation." But, as far as bringing up the issue goes, I think it's a judgment call. We've all sorta talked about our job as someone who educates, who challenges, who cheerleaders, who really tries our best to help our patients, etc... How about someone who participates? In a rather light situation, when we were with this patient, my preceptor joked "Mr.____ and I both tried this diet a few years ago, lost some pounds and gained right back up." Obviously this won't really apply to smoking, I guess, but if you can find some common grounds with your patient, it could produce positive experience.

One particular preceptor, a recent graduate, asks about patient smoking 80 percent of the time. In fact, 10/12 of his patients have quit smoking through the help of chantix. He first asks about their smoking history. Next, he asks them if they ready to quit. Even if they aren't ready to take action, he will note that 10/12 of his patients have quit smoking, with his most outrageous case being a patient who smoked 4ppd for over 30 years. Even though they aren't fully ready to take that next step in quitting, he is planting the seed in their subconscious for a plan to stop smoking. I haven't seen it work yet, in terms of having the patients take chantix for those unwilling patients, but I'm sure it makes a big difference sometime down the road. Another time, he gave a patient (who was willing, but hadn't begun to stop smoking) a chantix coupon. I'm not sure if he ended up buying chantix, but it showed the patient that the physician had cared a lot for him. The caring gesture meant a lot to me. If some smokes can actually quit smoking, despite the high prices of chantix, can save a lot of money, in addition to improving their health.

So, a few things. In relation to the smoking topic, something that I have seen as a common theme among the preceptors that I have worked with up here, is nothing more than good old fashioned persistence. I have had more than one doctor say to me before we go into a patient's room, "Now, I'm going to ask so and so if they are ready to think about changing (insert behavior/habit here). I ask them this every time they come in and they always say no. But they know I am going to ask so they are at least thinking about the change, whether or not they want to do it." On more than one of these occasion the patient has surprised both of use by saying that "yes" they are indeed ready to start a change. What I think is important from this (and this may have been mentioned above) is that change takes a long time and we have to be willing to accept that. As students everything for us is accelerated and it is hard sometimes to realize that if they don't change this week or even this year, there is still plenty of time. Our preceptors have the luxury of time and they know that they will have many other chances to reach that patient over the course of their relationship.

In response to a question above. While I won't go so far as to say that it is outright child abuse I do think that parent's should be held accountable for their children's weight just like they are for many other aspects of their child's health. I have one encounter that has stuck with me from my first year preceptor. A 10year old boy was in for a physical and check up on his asthma and his weight. He had indeed gained more weight since his last visit. When we were in the room talking we were asking him how he felt and if he was getting exercise. He was playing little league baseball and brought up that he was getting short of breath running around the bases. At this point his dad jumped in and said, "yeah, but if you hit it far like babe ruth, you don't have to run, you can jog." Needles to say I was surprised that the dad was basically saying to his son, don't worry about getting in shape, just hit the ball further.

A comment to the post above - "I just took a course in Motivational Interviewing that was really intriguing. It is a process of exploring a patient's ambivalence about changing a behavior to help them move toward being prepared to attempt to change it. Has anyone ever read or heard about it?"

I think this is a really cool concept and should be implemented more in outpatient settings. Especially in illnesses such as substance abuse, pain management, obesity and depression this could be of much benefit. I think the four principles of the motivational interview (expressing empathy, developing discrepancy, rolling with resistance, supporting self efficacy) helps the patient to think differently about their behavior and ultimately to consider what might be gained through change. When they understand the positive gain themselves it is as if a light bulb goes off. You’ve not only helped create change but you’ve inspired them to be the greatest gate keepers of their own health.

Recommended Resources
http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=66721
 * Below is a link to some interesting facts about teen smoking from the American Lung Association:

http://www.epa.gov/asthma/shs.html
 * Link to information on Second Hand Smoke

http://www.ahrq.gov/consumer/tobacco/quits.htm
 * Evidence based resource on quitting smoking

http://www.californiachronicle.com/articles/viewArticle.asp?articleID=39943
 * Starting in 2008, California will outlaw smoking in all vehicles containing children under 18 years old to limit kid’s exposure to second hand smoke.

Links for smoking education topics:

Specifically the section: "Finally, cultural competency for tobacco intervention training has not been developed to any significant degree in US medical schools, despite the high prevalence of tobacco use among many minority populations5 and the finding that tobacco intervention is best accomplished among these groups through culturally relevant approaches."
 * 1) Why quit: A Source on helping your patients find reasons to stop smoking www.whyquit.com
 * 2) AAFP Ask and Act power point presentation: excellent resource on providing clinicians with information about approaching smoking cessation among their patients. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/askact/ppt-physicians.Par.0001.File.tmp/askandact-presentation-clinicians.ppt
 * 3) Tobacco Intervention Training,Current Efforts and Gaps in US Medical Schools  John G. Spangler, MD, MPH, et.al. JAMA. 2002;288:1102-1109.

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