Q&A: How PCPs can identify, help patients who smoke
May 31 is World No Tobacco Day, a WHO-sponsored event to draw attention to the health risks linked to tobacco use and encourage governments to adopt policies that can lower smoking and other tobacco use.
Tobacco use is started and established primarily during adolescence, according to the CDC, with almost nine out of every 10 cigarette smokers in the United States having tried smoking for the first time by age 18. In addition, CDC data show that if smoking continues at the current rate among youth, about one of every 13 Americans aged 17 and younger alive today will die prematurely from a smoking-related illness.
According to the CDC, the rate of adult current smokers in the United States has declined from 20.9% in 2005 to 15.1% in 2015. However, cigarette smoking remains the leading cause of preventable disease and death in the United States, accounting for more than 480,000 deaths every year, or one of every five deaths.
In recognition of World No Tobacco Day, Healio Family Medicine spoke with Harold J. Farber, MD, pediatric pulmonologist at Texas Children’s Hospital, member of the American Thoracic Society Tobacco Action Committee and associate medical director for Texas Children’s Health Plan, about ways primary care physicians (PCPs) can discuss smoking with their younger patients, these patients’ parents and more.
Question: How should PCPs broach the subject of smoking with their patients who are not legally allowed to do so?
I usually start by asking about tobacco product use by family, then friends, then ask if they have tried any tobacco or nicotine products (cigarettes, e-cigarettes/vapes, cigars, hookahs, chewing tobacco/dip/snus) themselves, and if so, when the last time was that they used. If they reply yes, I discuss personally relevant reasons why they should stop, including how fast dependence develops. If they are moderately or severely dependent and want to stop, we can discuss treatment options. If they reply no, then I ask them why not and provide reasons that they would want to stay tobacco- and nicotine-free. I will congratulate them on their decision and then provide even more reasons why their decision was the right one, using reasons that would be relevant to them. I will discuss how the industry manipulates them, how easy it is to get addicted, impact on sports performance, smell (both their own sense of taste and smell, and how it makes them smell to others) and how it ages them faster. I will talk about toxins and contaminants in the products — flavors that are not safe to inhale, to metallic nanoparticles in ENDS emissions, etc. The goal I have is — by telling the truth - to reinforce an unappealing and undesirable image of these tobacco and nicotine products.
Q: How should PCPs broach the subject of smoking with these patients’ parents?
A: Parents should start by setting an example for their children. Children learn much more from the example their parents set. It is hard for a parent to tell their child not to smoke if they are smokers themselves.
Parents should start talking to their children about tobacco and nicotine use as early as their children can understand it and in terms that their children can understand and relate to. When they are young, refer to it as “yuck” and expand on it as they get older and are able to understand more.
The tobacco and nicotine industry markets their highly addictive and toxic products in ways that appeal to children — from product design, celebrity role models, movies, video games, internet and social media. There is point-of-sale advertising at most grocery stores, convenience stores and gas stations. The inexpensive candy and fruit-flavored products that appeal to children are often displayed on lower shelves closer to a young child’s eye level. Parents can’t ignore the issue. If the parent does not tell their child the truth, the industry is ready to feed them lies.
Finally, children’s health care providers need to be politically active. They need to tell their representatives at the local, state and federal levels that they want their children protected from tobacco and nicotine.
Q: How should PCPs broach the subject of smoking with their patients who are old enough to smoke??
A: Health care providers should start by asking permission to discuss their tobacco dependence. Place treatment of their tobacco dependence in the context of treatment needed for their health and the health of their child in terms that are personally relevant. For a young adult, it may be attractiveness, sports performance and reproductive health. For a parent, it may be the health of their child.
Q: What is the best advice PCPs can give patients to get the patient to stop smoking?
A: Frame tobacco dependence as a severe chronic illness that impacts not just the individual, but everyone close to them. Assess the severity of their tobacco dependence and prior experience with stopping tobacco use. Treatment recommendations can then be based on the severity of their chronic disease. Those with severe tobacco dependence are likely to need a combination of medications for a long time. Those with mild tobacco dependence may be able to stop tobacco use without medications, but will do better with medications. Medications can be considered as controller or reliever medications. Long-acting controller medications would include the nicotine patch, bupropion (Zyban, Wellbutrin) and varenicline (Chantix). Shorter acting reliever medications include nicotine gum, nicotine lozenges, nicotine nasal spray and nicotine oral inhalers. Health care professionals should not recommend electronic nicotine delivery systems (e-cigarettes, etc.), as these unregulated products have not been shown to be safe or effective for tobacco dependence treatment. Many of the chemicals (including flavoring agents, metallic nanoparticles and other toxins and carcinogens) commonly found in the emissions from these devices can be harmful to the lungs.
Q: What ways won’t work to get kids to stop smoking?
A: Guilt does not work. Probably the least helpful thing I have ever said to a parent is ‘Don’t you know what a bad thing it is that you are doing to your child?’ Tobacco dependence is not simply a bad habit. Nicotine changes brain structure and chemistry so that the brain does not work normally without nicotine on board.
By re-framing tobacco dependence as a severe chronic disease, assessing severity of disease, readiness to change and recommending effective treatments based on the severity of the tobacco dependence, you can enter into a productive discussion. Maybe the parent is not ready to stop tobacco use, but is willing to keep the home and car smoke-free. Maybe they are willing to consider use of the nicotine patch to help them cut down on smoking and get ready to consider stopping. Or maybe they are not ready to make a change right now, but by keeping lines of communication open, you can be there for when they are ready in the future.
•American College of Chest Physician’s Tobacco Dependence Treatment Toolkit provides treatment algorithms, tools, and patient education materials: http://tobaccodependence.chestnet.org/
•The National Smoker’s HelpLine offers free telephonic support for stopping smoking: 1 800 QUIT NOW.
•The Campaign for Tobacco Free Kids advocates for effective Tobacco Control policies: http://www.tobaccofreekids.org/
Disclosure: Farber reports no relevant financial disclosures.