7 minute read
By John J. Seidenfeld, MD and Neal Meritz, MD
By John J. Seidenfeld, MD and Neal Meritz, MD
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In high school, I smoked with friends down in a ravine near my home. The Seidenfeld home was near Lake Michigan in a Northern Illinois town with ravines memorialized in Ray Bradbury’s “Dandelion Wine.” These were quiet, dark, but sun-speckled places under the shade of large leafy trees where we could be alone and discuss the critical issues of teens. Through high school and then college, smoking continued up to two packages of cigarettes per day and many were unfiltered so that I inhaled burning paper and tobacco deep into the lungs. Attempts at quitting were often met with failure, as the lure of the cigarette and the nicotine drew me back. Just before medical school started, I found a boarding house near campus which was wonderfully clean and quiet. The landlady, Mrs. Bishop, was an elderly woman who climbed the stairs backward to the second floor each day to change towels and clean. Why did she do this? I probably should have done a history and joint exam, but did not know how and why to do either at the time. Her only request was that I not smoke. Her request was a great excuse to quit “cold turkey.” No matter how many times you quit, the last time is “cold turkey.” I imagine there were withdrawal symptoms, but they were lost in the first few weeks and then months and years of medical studies. Each day the desire became less until today, many years later, when I fantasize that I will start again at age 90 (as there are so few studies of the effects of smoking or vaping on nonagenarians). Such is the strength of this disorder.
Smoking tobacco products is the leading cause of preventable deaths throughout the world. The smoke contains thousands of chemicals, and many have been identified as carcinogenic. People who smoke the equivalent of more than 20 cigarettes per day for over 20 years account for approximately $300 billion per year of hospital and health care resources as well as lost productivity. Tobacco executives have testified that they know their products are addictive, and have marketed to young people for years by making the smoker look attractive and sophisticated in movies, commercials and other media advertisements. Many of the large cigarette producers now own companies that sell tobacco vaping products to increase their market share. Currently, many pulmonologists feel that vaping and smoking are equally damaging to the body so that all references to cigarette smoking apply to vaping also in this article. Nicotine in tobacco smoke is one of the most addictive substances known to man. While it is common for many teens to become addicted to tobacco and begin a lifelong habit, quitting is extremely difficult, and few effective resources have been available to help in this effort.
Who wants to quit? The motivated smoker who has just had a myocardial infarction (MI) or a pregnant patient have a quit rate near 50% with doctors’ advice and some guidance. Quit rates are usually gauged at six to 12 months after cessation and recidivism is common. Multimodal therapy with long-term counseling support and medications
may improve the quit rate by more than 20%. Most doctors are not trained in motivational interviewing or in behavioral approaches to assist in quitting, and medications alone are less likely to help improve chances of remaining tobacco-free long-term. Some physicians also have misperceptions about the harmful effects of nicotine and are unwilling to use nicotine replacement therapy. It has been reported that 68% of adult smokers have voiced a desire to quit.
What are the benefits of quitting smoking? In the first 20 minutes tobacco-free, blood pressure and pulse begin to drop. In 12 hours, carbon monoxide levels drop to normal, allowing blood to carry more oxygen. Within two to three weeks, circulation and lung function improve, and risk for MI is lower. Cough is reduced by nine months, and at one year, the risk for coronary artery disease (CAD) drops in half. Between two and five years off, risk for many cancers decreases by 50%, risk for CAD is reduced by two thirds, and risk for stroke equals that of non-smokers. At 10 years, the risk for lung cancer drops to 50%. After 15 years of abstinence, the risk for CAD equals that of non-smokers.
What are the barriers to quitting? Nicotine enters the bloodstream quickly by inhalation. It reaches the brain within seconds and acts on the pleasure pathways of the meso-cortico-limbic system. There, it causes the release of dopamine which produces a mood-elevating effect that becomes highly addictive. If nicotine is withdrawn, the smoker may become irritable, depressed, anxious, insomniac, hungry and restless. Often these withdrawal symptoms begin within a few hours after last tobacco use and can continue for longer than a month. Number of cigarettes smoked and time of day of first use are correlated with severity of dependence. Since cigarette smoking becomes a habit, behavioral change is needed to reduce dependence. Frequent daily use, social situations, and certain environments lead to rituals with cues and triggers that perpetuate habitual use. Since most patients begin smoking before age 18, adding this question to the vital signs for pediatrics, family medicine and internal medicine practices is a promising idea. Those who are not smoking should be encouraged to maintain their healthy habits. For smokers, the US (United States) Public Health Service recommends a Five A approach or 1) ask about smoking status, 2) advise cessation, 3) assess readiness to quit, 4) assist people to quit and 5) arrange follow-up visits and discussions. Listen to your patients and do not judge them to learn cues to readiness, desire for help, and ability and need to quit. Do not give up. Quitting may only occur after many attempts.1
The Canadian working group under Thabane et al. on smoking cessation in 2012 noted from the literature of randomized controlled trials in COPD (chronic obstructive pulmonary disease) patients, 1) “compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counseling or a combination of intensive counseling and NRT (Nicotine Replacement Therapy), 2) abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo 3) and abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.”2 Intensive counseling is not standardized, and studies have looked at cognitive behavioral therapy, facilitated group therapy, online resources and telehealth resources with many showing similar usefulness. Many of these programs are run by nonprofit organizations at no or minimal cost to recipients, but some are offered for-profit.
Lang noted that smoking cessation face-to-face could be continued with telehealth during COVID-19 and remain effective. Since smoking is one of the few readily modifiable risk factors for COVID-19, the group was able to run a successful telehealth to-
bacco treatment program adapted to the pandemic. The authors described adaptation of their program to telehealth, described the process and lessons learned from this initiative, and suggested that the model is applicable and scalable to government and civilian health centers.3
The National Institutes of Health, the American Cancer Society and the American Lung Association are a few of the organizations that offer nicotine users web-based support for smoking counseling and cessation resources. Telehealth resources for counseling, and specifically nicotine cessation, are becoming more available through nonprofit organizations, apps and physician practices. If your patient is ready to quit, let them know about the available resources shown below. Cessation is most likely to be successful in those who want to quit, have reason to quit, can quit and need to quit. Intensive counseling in-person or by telehealth and medications will have a synergistic effect in helping achieve permanent cessation.
When questioned about his experiences advising patients regarding smoking cessation, another former smoker, Dr. Neal Meritz, noted, “That as a longtime practicing Family Physician, I always felt that assisting a patient in smoking cessation was one of my most valuable medical interventions. Almost all smokers want to stop; my emphasis was mostly concerning how to quit, not why. I encouraged patients to utilize nicotine replacement therapies and bupropion. I advised the smoker that many of the pathophysiologic effects of nicotine addiction last only for a few days, and that many less-emotionally strong people than them had quit smoking successfully. I used tactics like ‘Find a new distraction such as exercise. When you want a cigarette, go for a walk.’ I advised adolescent male smokers that they were unlikely to attract a female partner who did not smoke, thus severely diminishing the pool of available potential girlfriends. Often these approaches were ineffective initially, but I kept trying, and the occasional successes were well worth it.”
References 1. Manish S. Patel, MD, Sheetal B. Patel, MD,Michael B. Steinberg,
MD, MPH. Annals of Internal Medicine, Volume 174, Issue 12, In the Clinic, December 2021 Smoking Cessation https://doi.org/10.7326/AITC202112210 2. Thabane M; COPD Working Group. Smoking cessation for patients with chronic obstructive pulmonary disease (COPD): an evidencebased analysis. Ont Health Technol Assess Ser. 2012;12(4):1-50.
Epub 2012 Mar 1. PMID: 23074432; PMCID: PMC3384371. 3. Lang AE, Yakhkind A. Coronavirus Disease 2019 and
Smoking: How and Why We Implemented a Tobacco Treatment
Campaign. Chest. 2020 Oct;158(4):1770-1776. doi: 10.1016/j.chest.2020.06.013. Epub 2020 Jun 17. PMID: 32561438; PMCID: PMC7297684. Support on the web https://medlineplus.gov/quittingsmoking.html www.cancer.org/search.html?q=smoking+cessation www.lung.org/help-support/lung-helpline-and-tobacco-quitline https://smokefree.gov/ https://www.uptodate.com The Microsoft Store, Apple Store and Google Play Store for smoking cessation apps (available but not researched for this article). There are many of these and if anyone knows of objective ratings of the apps, please write a letter to the Editor with a comparison or review.
John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee.
Neal Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee.
