Peter is a 55-year-old Class 1 truck driver who comes into your office for his annual driver’s medical exam. You’re concerned about his health: he’s overweight, has documented hypertension, dyslipidemia, and leads a sedentary lifestyle. And to top things off, he continues to smoke a pack a day, even though you reviewed with him the staggering statistics of smoking-related health hazards during your last appointment together. So, where do you start today, to address his nicotine addiction and help reduce his substantial risk of cardiovascular disease? Or should you simply fill out his motor vehicle form and get on with more promising patients?
Despite the fact that smoking prevalence in Canada has decreased over the past decade, cigarette smoking remains our leading cause of preventable death.1 Legislation may have banished smokers to doorways and parking lots, but over 4.9 million Canadian adults continue to smoke, exposing themselves — and all those within a whiff of their fumes — to detrimental effects.2 Oddly, smoking cessation receives scant attention from clinicians, although there are numerous effective interventions to help smokers quit. Even in the face of life-threatening, smoking-related illnesses, busy practitioners often neglect to identify the smokers in their practice, let alone counsel them to quit.3 Many physicians falsely assume that smokers don’t want to quit or be asked about their addiction, and many more doubt the effectiveness of smoking cessation interventions. However, considering that smoking kills half of those who use cigarettes, and adds significantly to our escalating healthcare costs, it’s a problem worthy of our undivided attention.
Nicotine addiction is best understood as a chronic illness involving a complex mix of physiology, psychology and behavioural issues. Similar to patients with other chronic illnesses like diabetes mellitus or congestive heart failure, patients who smoke benefit from vigilant follow-up and repeated encouragement. As such, family physicians are uniquely positioned to influence and assist their smoking patients in quitting. Contrary to popular misperceptions, 60% of smokers actually want to quit, and hold a positive view of healthcare providers who inquire about their smoking status.4 Advocating for smoking cessation is the most effective intervention family physicians can offer their patients to improve quality of life and survival.5 As patients can reap the benefits of quitting regardless of their age, or the presence of established vascular disease, tobacco use should be addressed at every patient visit.
The most successful smoking cessation efforts involve a combination of supportive patient-centred counselling, and individualized pharmacotherapy. Since there’s little to be gained in either hammering out the hazards of smoking for patients who have already decided that they want to quit, or trying to initiate a pharmacological intervention for those who defiantly refuse to quit, it’s important to determine your patient’s level of motivation. For the motivated patient who’s preparing to quit, or at least thinking about it, physicians have an open door to take direct and immediate action (see Table 1). Practical suggestions that can assist the patient in their early efforts to quit include: refraining from smoking in the home or vehicle, delaying the time of the first cigarette in the morning, reducing the number of cigarettes smoked over the course of the day, and eliminating the “favourite” cigarette of the day.
Smoking cessation literature is available from Health Canada for patient distribution, and computer-savvy people can be directed to the Canadian Council for Tobacco Control website (www.cctc.ca), which offers an extensive array of excellent resources for quitting. To help build some smoking cessation momentum, patients should be encouraged to establish a “quit date,” and share this date with family and friends for support and accountability. Because of the high smoking relapse rate, it’s important to offer some motivational counselling, ideally in the form of a community-based smoking cessation program or support group. The Canadian Council for Tobacco Control also has a list of local support programs and resources from 27 addiction services across the country (www.cctc.ca/cctc/EN/cessation/quitlines).
Pharmacotherapy is efficacious
The provision of appropriate pharmacotherapy has been shown to double quit rates, and unless contraindicated (e.g. by pregnancy), medical therapy should be considered for everyone attempting to quit smoking.6 Efficacious therapies recommended for first-line treatment for smoking cessation include nicotine replacement therapy (NRT), sustained-release buproprion, and varenicline. Nicotine replacement therapy, in the form of patch, gum, inhaler, nasal spray, lozenge, or slow-release tablets, allows the patient to separate the behaviour of smoking from the nicotine addiction. To counter the heavy smoker’s complaint that “the patch doesn’t work,” doctors need to titrate NRT doses to meet the patient’s personalized nicotine needs, and consider combining therapies, such as adding an inhaler or gum to the daily nicotine patch, or using two patches. Many fear nicotine; but while nicotine isn’t devoid of problems for the CV system, these effects are minor in adults, especially by comparison to those of the 4,000-odd chemicals found in cigarette smoke.
For the recalcitrant smoker, like Peter, who doesn’t want to quit any time soon, an indirect approach with the hopes of opening up health dialogue may prove more fruitful than attacking the smoking behaviour head-on (see Table 2). Direct argument and confrontation makes patients defensive and shuts down communication lines for health dialogue. People who smoke are at a higher risk for CVD and require intensified support, not condemnation. While it’s essential to acknowledge the detrimental health effects of smoking, it’s also important for us to roll with resistance and let our patients know that they’ll still receive unconditional medical care, even if they continue to smoke. For non-motivated smokers, rather than demanding they quit, a more effective strategy is to gently highlight the discrepancy between their current state of health (as a smoker), and the improved state of health they might expect (as a non-smoker). Patients are often surprised and delighted to learn that the health benefits of smoking cessation are immediate and are independent of age, duration of the smoking habit, or of the number of cigarettes smoked. Relaying the fact that CV risk can fall by 50% within the first year of smoking abstinence may plant the seed for future smoking cessation.
It’s also useful to address the many tobacco industry-generated myths. Physicians need
to matter-of-factly underscore that smoking isn’t relaxing, nor is it a concentration aid, a viable weight control method, a tasty treat or attractive; but rather, stress that this
activity is an ingeniously designed nicotine addiction trap, a chemical minefield, a death sentence, and a major waste of money.
While smoking is the most important major modifiable risk factor for CVD, it isn’t the only one. Discussions focussing on other risk factors, like hypertension and dyslipidemia, can lead the way to risk reduction dialogue in a less threatening fashion. Clinicians should also keep in mind that they can enhance patient quit rates by encouraging them to adopt a healthy lifestyle. Daily exercise, eating greater quantities of fruits and vegetables, limiting processed food consumption, improving dental hygiene, and optimizing restorative sleep patterns can all reduce CV risk and help mitigate the detrimental effects of smoking, while patients are in the process of quitting — or working up the courage to quit.
Theodore K. Fenske, MD, FRCPC is a cardiologist and clinical professor at the Alberta Heart Institute in Edmonton. He has a keen interest in preventative medicine and has recently published a book entitled, While You Quit, with Dundurn Press.