It's important to make sure that the responsibility for addressing tobacco dependence is placed on the shoulders of clinicians, and off of the shoulders of the afflicted.
My patient in clinic grew uneasy. It was clear he wanted to respond to my question on smoking with an answer that would “satisfy the doctor.” I leaned forward and reminded him that I was neither his mother or his priest – there would be no judgment. He chuckled. And then he took in a deep breath and began, I smoke. I smoke a lot. When he wakes up, he reaches first for a cigarette. After breakfast, he’s on to his second cigarette. Before getting into his car, the walk down the driveway, he finishes his third cigarette. Then two more as he drives to work.
During my residency, bringing up smoking status was not enjoyable. Right before the end of a clinic visit, I would simply refer my patient to a quitline for more information. Now, years later, remembering how I talked with former patients about smoking makes me uncomfortable. There isn’t a single other disease I’ve shifted the entire responsibility of treating off of my shoulders and solely onto my patient’s shoulders alone.
Today, I’ve made a complete 180 to my approach to a person who smokes. When I give a talk on smoking to trainees, I often start by reviewing the anatomy of a cigarette. Watching medical students, residents, and lay health community persons be horrified in learning the diabolical nature of a cigarette reaffirms to me how little the general public knows of this enemy. When I finish speaking, there are two points the audience always appreciates: chronicity and consistency, just like any other chronic illness, are warranted when managing a person with tobacco dependence.
Now, my mission is to assure that the responsibility for addressing tobacco dependence is placed on the shoulders of healthcare professionals, and off of the shoulders of the afflicted. I’m still happy to refer to a quitline, just as long as I’m still 100% managing the patient’s tobacco dependence. But more than anything, I remind my patient that I’m “pro-smoker, but anti-smoking.”
I review with my patients all of the things that define their tobacco dependence, from what they smoke, to the mechanics of smoking, to their triggers to smoke, in order to characterize their smoking phenotype. Then I tell my patient what to expect for the first month, the second, the third, and so on, as they take this journey with me to become smoke free. It’s not an easy journey, there are no shortcuts, and the reality is, it may take 6-12 months before they fully stop using the cigarette. I promise my patients that each step along the way, I’ll be there to support them.
As for my patient I saw in clinic recently, he sent me a text earlier today that motivated me to write this reflection. I’ve been his “smoking doctor” for 9 months. He officially went 24 hours without a cigarette. It’s his first 24 hours since he was 11 years old not smoking a cigarette. After reading his text, I called him. He was flooded with emotion and began to cry. I stayed on the phone and just listened.
Our patients who smoke have one of the most challenging chronic illnesses known to medicine. Supporting a patient who smokes in an attempt to help them become tobacco independent is challenging, as it takes a considerable amount of time without much objective data (if any) to monitor, coupled with the high rate of relapse.
Of course I support the work towards curing cardiopulmonary and oncological diseases, and I applaud those efforts. But we also need to apply to persons who smoke the same sophisticated scientific knowledge to help them stop smoking. We must instill the treatment of tobacco dependence with the same standards of professionalism and quality improvement inherent to other medical disciplines. If we don’t, then, to use a great quotation from Dr. Osler, “the greater the ignorance [towards smoking], the greater the dogmatism.”