Physicians should treat smoking the way they treat other chronic addictions and expect incremental and sporadic improvements, according to Frank Leone, MD, director of comprehensive smoking treatment programs at the University of Pennsylvania in Philadelphia.
This means that physicians must change their own minds about smoking before patients will change theirs, he said here at the American College of Physicians Internal Medicine Meeting 2019. They need to let go of some of the hardline antismoking approaches they learned in medical school.
During his presentation, Leone described Mary, a hypothetical patient in her 60s who has smoked for 4 decades and continues to smoke, even though she has emphysema and hypertension and is dependent on oxygen.
Taking time out of every appointment to encourage a patient like Mary to quit smoking is not productive, he said.
"You treat her tobacco dependence," he said. "You evaluate and manage the nature of her chronic tobacco dependence — her brain biology that leads her to these behaviors."
Treating Dependence
It is important to understand that smoking patients are fighting, on a daily basis, a very real biologic battle between the rational thought that smoking can kill them and a powerful survival force telling them not to let cigarettes go, he explained.
And persuading patients to end one addiction at a time is not a helpful strategy.
"When you help people control their tobacco dependence at the same time as you control their addiction to other substances, the likelihood of sobriety from the other substances goes up by a relative 25%," he reported. "These are interrelated phenomena — about the biology of dependence — and there are a lot of different manifestations, including overeating, gambling, and depression."
If you use nicotine, you are 16 times more likely than a nonsmoker to use heroin and 14 times more likely to use crack. "That's not random; that's a biological phenomenon," said Leone.
It is also time to dispel the myth that people start smoking as teenagers and stop as adults, and that the goal is to get them to stop earlier. "Just forget that," he added.
"What's more likely to happen is that patients will start and stop throughout their lives and spend a lot of time in the 'gray' area," he explained. "Our job is to minimize the time in gray."
Smoking is not about a deficit of motivation to quit, but about an excess of motivation not to quit.
Ask About Smoking, Not Quitting
To change the conversation, Leone recommends asking patients about smoking instead of quitting: "Tell me what you get out of smoking. Tell me about what you feel when you think of putting the cigarettes down. What was the situation that led you to return to smoking?"
When patients begin to think about their instincts in a conscious manner, they can start to resolve their issues, eliminating escape hatches one by one, he said.
He encouraged physicians in the audience to change the conversation with a system of "validate, reframe, repeat."
First validate what the patient says about the smoking experience by acknowledging that the struggles are real.
Then reframe the ask: Instead of telling patients to stop, ask them to add nicotine replacement therapy. Check back in a few months to see if that has changed the smoking experience for them. The next time the patient comes in for a visit, he or she might be more willing to talk about their smoking.
Then be prepared to repeat. "This is a chronic problem that's going to take a good, long time," Leone said.
When prescribing a nicotine replacement patch, he recommends starting with the 21 mg dose.
Start With High-Dose Patch
"Most people who don't do well on the patch are underdosed," he said. At the same time, tell patients that it is okay to pick up a cigarette when they're on the patch, just don't take the patch off.
"The odds ratio of controlling the compulsion to smoke doubles with a patch," compared with placebo, Leone reported. "You can double the likelihood of control just by giving her permission to try a patch."
In addition, nicotine gum gives patients an active way to turn off the signal that tells them to smoke, he said.
Above all, "recommend two forms of nicotine replacement at the same time," he said. "It's an easy way to change the probability of control in your practice."
A member of the audience asked about potential nicotine toxicity if patients smoke when they're on the patch.
What About Nicotine Poisoning?
The US Food and Drug Administration changed package inserts that advised against smoking while on the patch in 2013, Leone replied. "That kept more people smoking than wearing patches," he said.
The way people smoke — the size, depth, and number of puffs — changes when they're wearing the patch, he explained, and their health won't suffer if they smoke while the patch is on.
Another person asked whether the gum dose should be lower — 2 mg — when used in combination with the patch.
To that, Leone gave what he acknowledged is anecdotal rather than data-driven advice: use the 21 mg patch and 4 mg gum.
"You're way more likely to face someone who says I tried the gum and I still had the urge to smoke than to face someone who says they tried it and it was overwhelming and it made me quit smoking too fast," he said. "You can always take the 4 mg gum out of your mouth sooner, but you can't double-chew 2 mg gum."
Leone's messages resonated with Chinelo Okoye, MD, an internist in private practice in Katy, Texas.
"This is new for a lot of us, because it's not what we learned in medical school," she told Medscape Medical News.
She said she is particularly optimistic that restructuring questions about smoking can help patients and physicians move forward.
It is easy for doctors who treat long-term smokers to lose hope, and "it's hard to feel that there's nothing you can do, especially when you get a patient who says they've tried to quit a million times," she said.
Leone and Okoye have disclosed no relevant financial relationships.
American College of Physicians Internal Medicine (IM) Meeting 2019. Presented April 11, 2019.
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