Quitting is hard, and your patients need YOUR help
Quitting is hard, and your patients need YOUR help
DISCLOSURE: I am NOT an expert in tobacco cessation, but you don't have to be either. You simply have to recognize the negative impact of combustible tobacco in your patients lives, and work at it to make cessation efforts a part of your practice. You don't have to be a professional golfer to enjoy a round of golf, or a world class triathlete to get the benefits of training and exercise.
Start at the top to read some quick tips about prescribing and monitoring FDA approved tobacco cessation pharmacotherapy. Scroll down a bit to read up (THOUGHTS ON MOTIVATIONAL INTERVIEWING...") on how to help motivate ambivalent patients to make a serious quit attempt
Varenicline (1 mg twice daily) Start with 0.5 mg daily. Increase gradually to target dose of 1 mg twice daily. This drug can be prescribed as a "Starting month pack" which comes with instructions on gradually increasing the dose, and a "continuing month pack" which is 1 mg twice daily. When I start a patient on varenicline, I prescribe a "Starting month pack", and instruct our clinic to call the patient in three or four weeks to provide refill for the "Continuing month pack".
Nausea (29%), Vivid dreams (10%)
MYTH!! Despite common belief, there is no increase in adverse psychiatric events or cardiovascular events noted in large well done clinical trials. So many of the adverse side effects attributed to tobacco cessation medications are simply the symptoms of nicotine withdrawal.
TIPS: Take with meals to reduce/prevent nausea (the most common complaint), and take afternoon dose earlier (rather than at bedtime) to reduce dream symptoms. Reduced dose in severe renal insufficiency
(7, 14, 21 mg) Change daily, remove at night (to prevent bizarre dreams), place on a different body part every day. In general, if you smoke a pack or more per day, you need the 21 mg patch. Very heavy smokers can actually use more than one patch at time. The cardiovascular safety of these medications is very well established, in spite of many misconceptions.
Side effects: Skin irritation
MYTH! Its not contraindicated in people with stable angina and is probably safer than nicotine withdrawal symptoms in someone with unstable angina who cannot smoke because they are in the hospital (https://www.ncbi.nlm.nih.gov/pubmed/30371184 ).
Works best when combined with ‘on demand’ nicotine products (*see below)
*Nicotine Lozenges (2 mg or 4 mg) Dissolve 1 lozenge inside cheek q 4 hours as needed. I almost always prescribe 4 mg for smokers of 1 pack or more daily.
Side effects: Throat irritation (rare)
*Gum (2 mg, 4 mg)
Chew one piece every 4 hours as needed to manage cravings. This is not to be chewed like regular gum. Proper use is to place it in the mouth, bite, and leave in the cheek until the tingling is gone. aka 'Bite and ‘park’ in cheek until the tingling is gone, then start chewing as with any gum.
Side effects: Throat irritation (rare)
*Nasal spray (10 mg/ml). This is one of my favorite on-demand products, based on feedback from patients. Smokers with cravings can use 1-2 sprays in each nostril every hour as needed.
Side effects: Nasal or throat irritation (rare)
*Inhaler (10 mg cartridge). Take ~4 puff/minute over ~20 minutes; New cartridge every two to four hours as needed.
Side effects: Throat irritation. Its probably best to avoid this delivery mechanism in people with bronchospasm or asthmatic tendencies.
Bupropion (150 mg twice daily) Start with one dose daily and begin two weeks before proposed quit date (the smoking cessation benefits are derived from metabolites that accumulate over weeks).
Side effects: Insomnia, agitation, dry mouth, headache.
Contraindicated in patients with seizure disorder or predisposition
Cytisine (1.5 mg every 2 hr) tapered over 25 days*
NOT Currently available in US
Side effects: Stomach ache, dry mouth, dyspepsia, and nausea
Six tablets per day (q 2 hr) for 3 days (days 1-3), 5 per for days 4-12, 4 per day for days 13-16, 3 per day for days 17-20, 2 per day for days 21-25
“Motivational interviewing” is in an effort to bring out intrinsic motivation to change behavior. This is a goal-oriented, patient-centered counseling style aimed at eliciting behavior change. In tobacco treatment, it specifically refers to overcoming individual smokers’ ambivalence toward making cessation efforts, and when done well it can significantly increase the number of quit attempts made by people with a tobacco addiction.
Motivational interviewing is fundamentally counter-intuitive for physicians. We spent a lot of time instructing, cajoling, and trying to get our patients to do what we want them to do, take your medicine, avoid this food, exercise more, etc. Trying to get people to stop smoking is trying to change their behavior. What works in other areas of medicine does not work well in tobacco cessation. In motivational interviewing you are asking questions and offering information to help people recognize THEIR REASON TO QUIT. You cannot give them that reason, but you can help them see it.
Below are several commonly encountered patient responses that present barriers to discussing or promoting cessation attempts. For each patient reported barrier, we discuss several strategies to help motivate patients to set a goal for tobacco cessation. Since addiction to tobacco is a chronic relapsing disorder, expect that you will need to repeat discussions with patients as one conversation will not likely be enough. I welcome suggestions for additions, or disagreements with these. Please e-mail me (dougarenberg at gmail.com) with your input.
“I don’t want to quit smoking”
The majority of smokers do want to quit, but may lack the confidence to make a quit attempt. Many cancer patients do quit shortly before or after a cancer diagnosis, although many will relapse back to smoking again. Smokers are often defensive about their tobacco use and are aware of the need to stop, even while fighting to preserve their addiction. They often feel guilt over their smoking and this guilt may be a barrier to discussing cessation strategies. Overcoming this guilt may make your patients open to discussing how they can "get to zero".
One successful method to encourage willingness to talk about cessation is to create an ‘us versus them’ awareness around tobacco. Specifically, I like to talk about how tobacco companies have generated enormous wealth by knowingly creating, manipulating, marketing, mass-producing and selling a product that is known to cause addiction and several deadly diseases. Worse yet, they systematically lied about the addictive potential while covering up its lethal nature. This deceit was one of the major justifications of a $200,000,000,000 (TWO HUNDRED BILLION) settlement against tobacco companies in 1998. Tobacco companies seek to create “replacement smokers” out of teenagers to replace older smokers who quit or die from tobacco use . People may may gain motivation from knowing that that they have been manipulated and this can prompt internally motivated action. try to imaginr any other product that, when used as directed, killed half of its users.
Nicotine can modulate mood, anxiety, relaxation, motivation, and stress, so addiction may be particularly difficult to overcome in the face of 'stress'. Nicotine withdrawal can exacerbate feelings of stress and fear. In effect, nicotine can provide a false sense of security to patients, particularly during times of stress. Talk with patients frankly about this false sense of security or safety. Refer to the feelings of anxiety and danger provoked by nicotine withdrawal and the sense of recognition by the patient is often palpable when they realize that their doctor may understand why it is so difficult for them to stop smoking. Empathy on the part of the treating physician opens doors. Promoting openness to discuss cessation attempts is the first step towards success, and carefully selected words have a powerful impact on this interaction.
“I quit for a while but I started smoking again after <Fill in the blank>”
Mark Twain said “giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.” Relapse is the norm, so many of patients who have stopped smoking will end up smoking again. Reassure the patient who has relapsed that this is not a “failure”, that in fact the vast majority of former smokers “quit” multiple times before they quit for good. People who feel that they are not alone in this struggle are more likely to make repeat attempts, knowing that success may be just around the corner, after their next attempt. People who have relapsed after a quit attempt should be encouraged, not criticized. Make them aware of the facts about quit attempts, and guide them back towards the original reason(s) they attempted to quit. If patients have reduced smoking but not quit altogether, congratulate them on their progress and encourage continued progression toward abstinence.
MOST RELAPSES ARE IN REACTION TO STRESS! You have to help your patient acknowledge that stress is a natural part of life, and that waiting for life to be stress-free may contribute to relapses. Stress comes in many forms. For some, it is the inability to put food on the table. For some, stress is an unfriendly boss or a bad commute, and for some stress is a life-threatening illness. In any form, stress prompts a natural retreat to familiarity and a comfort zone. However, tobacco provides a false sense of comfort. Helping patients understand that nicotine induced ‘comfort’ is both fleeting and false might prevent them from seeking that sensation through tobacco. Make clear that the next cessation attempt should include strategies to deal with unexpected stresses BEFORE they happen. Stress is inevitable.
I don’t want to use <Fill in the blank with FDA approved cessation pharmacotherapy>
While the words we choose can be very effective if chosen properly, every effort should be made to overcome the word “No” if it comes to pharmacotherapy to support a quit attempt (See above table for suggestions). Tobacco cessation pharmacotherapy safely and effectively increases the success rates for a quit attempt. In particular, the safety of formerly controversial medications, such as varenicline (Chantix™), have been clearly established in recent meta-analyses and clinical trials. There are many objections that patients may offer, but the proven safety and efficacy of tobacco cessation drugs is such that their proper use has to be encouraged. Would you try to climb a mountain without proper climbing tools? Build a house without proper carpenter’s tools? Fix a car without mechanic’s tools? Expect me as your doctor to treat your cancer without proper medicines, surgery or radiotherapy? Of course not. These jobs require proper tools, and successfully treating nicotine dependence is no different.
Cessation is a difficult task and the odds of success are increased by using the proper medicines. Ask patients to remember that they are already using an addictive drug – nicotine - delivered in a dirty package (cigarette) with harmful side effects. For some patients, it is hard to understand why in treating nicotine dependence we sometimes recommend that they use a nicotine medication. It is helpful to explain that nicotine medications reduce withdrawal symptoms, making it easier for them to stop smoking, thus eliminating the dirty chemicals that are found in cigarette smoke. This is also true when patients, or other clinicians, cite the risk of nicotine on health, surgery, or healing: smoking delivers equivalent or higher doses of nicotine in combination with countless other toxic compounds that are eliminated with the use of pharmacotherapy. The cost of cessation medications may also be an excuse not to make a quit attempt, but the cost of medications is less than that of sustaining a smoking habit or dealing with the health consequences of continued smoking.
Referral to the country/state or province toll-free quit line might be appropriate, where many have resources for free medications (e.g., in the United States doctors can advise patients to call: 1800-QUIT NOW). At the University of Michigan we encourage use of our own Michigan Medicine Tobacco Treatment Service ( 734-998-6222 or email email@example.com )
WHAT ABOUT E_CIGARETTES? or “I am using electronic cigarettes to quit smoking”
This is a controversial subject that triggers debate among tobacco cessation experts and frankly a lot of confusion as to the benefits and potential risks of e-cigarettes. While the UK has advocated e-cigarettes to quit smoking, there are no approved uses in the United States and leading organizations, such as the American Association for Cancer Research, American Society for Clinical Oncology, the International Association for the Study of Lung Cancer , and National Comprehensive Cancer Network do not advocate for the use of e-cigarettes as cessation devices at this time.
While there is some evidence showing that e-cigarettes can help people stop smoking, the data are mixed and unlike government approved cessation pharmacotherapy, there is a lack of data to clearly demonstrate e-cigarettes are an effective stop-smoking treatment. Also, while it may seem obvious that e-cigarettes are safer to use than using tobacco cigarettes, the short and long term health effects of e-cigarettes are unknown at this time, particularly for those with conditions such as cancer and heart disease. In the midst of this uncertainty, the best approach in the exam room is to first encourage cessation attempts aided by medications that are proven safe and effective.
Current medications for treating nicotine dependence may not be effective for all patients. ALL people addicted to cigarettes need to be supported in their efforts to quit. I recommend we caution people that e-cigarettes are not well regulated and their safety profile is not established. However, we should encourage all reasonable efforts to STOP COMBUSTIBLE TOBACCO USE. There will be patients unable to use medications approved by the FDA. In the face of inability or unwillingness to use approved drugs, patients should be advised that quitting smoking is of paramount importance. Those who can successfully use e-cigarettes to avoid smoking can and should be supported by their doctors to do so. There is concern over the promotion of "dual use". That is, concurrent use of combustible nicotine (cigarettes), supplemented by e-cigarettes. This is probably the worst possible outcome as this dual use does not reduce the total level of carcinogen or toxic compounds from combustible tobacco use, and preserves/promotes continued dependence without evidence that it helps in long term cessation. The ONLY current data that supports e-cigarettes as a cessation tool comes from clinical trials in which subjects were exclusively using e-cigarettes AND simultaneously receiving tobacco cessation counselling. E-cigarettes used outside of a clinical trial setting are probably not effective cessation aids if not also combined with expert level tobacco cessation counseling.
Though the utility of e-cigarettes as an evidence-based cessation method are ambiguous at this time, patients who report using e-cigarettes rather than smoking should be congratulated and encouraged to keep refraining from the use of combustible tobacco and to try to wean from the e-cigarettes if at all possible. This remains a controversial area at this time, and future data will hopefully provide evidence upon which more sound recommendations can be made.
“My spouse/partner/co-worker still smokes around me.“
This creates a difficult situation for the smoker looking to quit, as having a spouse or significant other in the home or work setting who is still smoking reduces the success rate of quit attempts. If the other smoker is present in the exam room this can be addressed by pointing this fact out to both the patient and their smoking partner. The solutions to a live-in smoking spouse or significant other are limited by the bounds of the physician patient encounter (many physicians do not provide prescriptions to someone who is not their patient), but rather they encourage partners interested in tobacco cessation to both think of this as a means of supporting their loved one and to call their doctor or state/country quit-line to specifically discuss their tobacco cessation plans and get pharmacotherapy. Offer printed tobacco cessation information to both the patient and their family members, friends, and caregivers who require support.
“I already have cancer, why quit now” or “I want to quit smoking after cancer treatment is over”
While it might be tempting to hear such an objection to tobacco cessation as reasonable, that instinct ignores the overwhelming evidence demonstrating that outcomes of cancer treatment are worse in those who continue to smoke. Smoking increases overall mortality, cancer specific mortality, risk for second primary cancer, or increased cancer treatment toxicity across all cancer disease sites and treatments. The mantra that it is “never too late to stop smoking” might be more readily accepted if accompanied by encouraging words, tailored to the patient’s treatment situation about how smoking cessation is one of the things they can control that will favorably impact not only their quality of life, but the success of their cancer therapy. A recent report using phone-based smoking cessation support demonstrated a 44% reduction in mortality in lung cancer patients who were able to quit smoking as compared with patients who continued smoking. It is particularly important that nicotine withdrawal symptoms be effectively managed in cancer patients so as not to add to their symptom burden. Emphasis on the notion of giving back some measure of control to the patient can be very effective since many cancer patients lament that their disease has brought about a loss of a sense of being in control of their future.
“I tried _______ before and it didn’t work”
Nicotine addiction is a chronic relapsing disorder characterized by multiple failed quit attempts. Even among motivated patients, most quit attempts result in relapse, and smokers need to be encouraged to make repeated quit attempts. The problem is we often tell patients to use the same failed method that they might have tried in the past, so it is not surprising for some patients simply give up and tell us that they’ve tried in the past and it hasn’t worked. It is helpful to explore with patients what they’ve done in the past to try to quit. Identifying stressors, routines, environments, triggers, and reasons for prior failed attempts can be used to guide repeated attempts at cessation. Many patients may report they want to quit “cold turkey”, incorrectly assuming that it is "...only matter of willpower" that is needed to quit. However cold-turkey is the least effective method to quit smoking. Previously successful cessation attempts can be repeated with a strategy to avoid those events that triggered a relapse, or alternative pharmacotherapy agents can be offered (see above). An emphasis on experimenting with different treatment options e.g., combining different stop smoking medications) can help, starting medications before the patient sets a quit date, etc, and on preparing ahead of time to avoid smoking triggers can make a big difference.
Words for the doctor
Finally, some words of encouragement not for the patient, but for the provider. Smoking now carries a burden of stigma. Stigmatizing smoking behavior has been an effective public health strategy in reducing overall smoking rates. However, in the exam room, the patient who carries this stigma with them can be defensive and resistant to discussing tobacco cessation. This is especially true if they feel they are being judged, condescended to or patronized for continued smoking in the face of tobacco related illness. Older patients who smoke stated in surveys that younger healthcare providers in particular “…don’t know the culture we grew up in” (e.g., when smoking was common, socially acceptable and the risks weren’t as widely recognized). In such an environment it may have been easier to start than to avoid smoking. Patients who have experienced smoking-related stigma from a doctor in the past may expect to experience it again, making them resistant to discussing cessation attempts. Rather than using words that perpetuate stigma, hopelessness and despair, choose words that establish a sense of solidarity, convey encouragement and hopefulness. A simple “I believe in you” can turn an adversarial dialog into a collaborative discussion.
Congratulate patients for reducing tobacco consumption even when they have not achieved abstinence, and encourage continued reductions in tobacco use. All providers need to respect the social and cultural context in which smoking behavior is initiated, acknowledge the skill and aggression with which these products were marketed, and the respect immense power of nicotine addiction. While stigma is a powerful public health tool, we must bar it from the exam room.