Frank T. Leone, MD
University of Pennsylvania
Leone FT. Smoking cessation: when and how to have the conversation with your patients [published online February 28, 2019]. Pulmonology Consultant.
This commentary is based on a podcast with Dr Leone. You can listen to the full audio here.
For the most part, people who are dependent on tobacco do not really understand why. A lot of people who are dependent on tobacco come in to my clinic with their main question being, “Why can’t I just stop?” That is by far the most common question I receive. In essence, what they are asking is, “Why is the nature of dependence to nicotine/tobacco really so much more complicated than anyone has told me about before? What is it that I am not really understanding about the nature of addiction, and how can I proceed in an effective way?”
Having the Cessation Conversation
The best way to actually have a conversation about tobacco is to begin by divorcing the idea of quitting from the idea of having a conversation about tobacco dependence. Doing so allows clinicians to speak knowledgably about the concept of tobacco dependence—how it works, what it does, how it makes a person feel, what the treatment options are—without really focusing on the goal of quitting. Of course, not using tobacco is always the therapeutic end goal, but the first step in engaging in a conversation is actually talking about the process without a lot of pressure to quit.
All tobacco dependence treatment is prevention, but not all prevention treats tobacco dependence. In other words, the more we understand and speak about smoking behavior as the cardinal sign of a dependence syndrome that is the result of profound changes in biology in the instinct part of the brain, the more we begin to recognize that the behavior is not simply a function of willpower or commitment to change. People cannot just simply change. So, if we talk about the problem as an influence on the process of memory learning and decision making, that actually forms a viable foundation for talking legitimately about prevention.
This strategy can also be used when talking to young people about not starting—do not start smoking only because you are likely to get chronic obstructive pulmonary disease (COPD) 40 years in the future, but also because it is going to affect your brain, your ability to make decisions, and your autonomy.
Also keep in mind that marginalizing the behavior or talking about it as though it is unpleasant or something that cannot be understood logically actually keeps people out of the clinic. It keeps people who are already dependent away from treatment resources that they will need in order to get out from under it.
It is never too early to start talking about quitting smoking; it is never too early to start talking about the nature of dependence. It also never too late. So even if a young person has already started using tobacco or tobacco-related products, if they are beginning to show signs of dependence, it is worth a conversation early on—even if the conversation does not include the future risk of lung cancer or COPD.
What If the Patient Is Not Ready?
Most practitioners have been taught that there is very little we can do to help a person stop smoking until they are ready to stop smoking. Our philosophy at the Comprehensive Smoking Treatment Programs is that it is our job to help patients develop that readiness to stop smoking.
Addiction is really about changes in the instinctive parts of the brain. That is where nicotine is doing its work. You can imagine that those parts of the brain are functioning autonomously, pushing a person closer to smoking; at the same time, the cognitive part of the brain is saying, “This is no good for me, I do not like the fact that I cannot breathe, my doctor has told me 1000 times I need to stop, it is very expensive, my family does not like it.” That conflict that is going on inside smokers’ heads leads to a situation of ambivalence where patients simultaneously want to and do not want to stop smoking.
And so, the strategy that is most underutilized in practice is to actually begin treating someone who does not want to stop smoking, to really have a conversation about the nature of dependence and what the obstacles are for them moving forward. By beginning treatment in advance of readiness, the treatment itself helps facilitate readiness.
A Multidisciplinary Treatment Plan
Generally speaking, a multidisciplinary and coordinated approach to tobacco dependence is the correct approach. Just like any other chronic illness of any other organ system, we all have a role based on our background and discipline, and the better we are at coordinating those roles to meet the patient’s underlying needs, the better the outcome.
While it might not be necessary for a pulmonologist to have a psychiatrist by their side at all times, having one as a referral to ask for advice about how to manage the emotional aspects of quitting smoking is always beneficial. The cooccurrence of mental illness and tobacco dependency is quite high, so if you had a psychiatric colleague you could consult regarding depression when one of your patients is suffering end-stage COPD, that patient is going to be better off.
Treating tobacco dependency should have a solid treatment plan—it is important to not allow the problem to continue to fall through the cracks.
Frank T. Leone, MD, is director of the Comprehensive Smoking Treatment Programs at Penn Medicine and a professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia.