COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 14
Recommended best practices for working with patients who smoke to reduce the risk of chronic obstructive pulmonary disease progression.
Neil Minkoff, MD: I want to go back to some old-school things for a minute here now that we’ve been talking about the technology. One of the things that’s come up repeatedly is smoking cessation. A smaller proportion of the population smokes than ever before—or at least for the last 50 or so years—yet smoking cessation is still an integral part of treating heart disease, lung disease, etc. Obviously, it’s something you’re stressing, but how do you get the patients to really engage? How do you bolster the use of smoking cessation in your practice? Dr Drummond?
M. Bradley Drummond, MD, MHS: This is 1 of the most important things we do poorly in medical care. The reality is that you’re trying to get someone to change a highly addictive behavior, which they may have done for 30 or 40 years, in an 8-minute encounter. That is probably not going to be successful. Our approach is to reiterate at every clinical encounter the importance of smoking cessation. We have taken advantage of some automated electronic health record prompts that we can put into their visit summaries that review the importance, even if they’ve been smoking all their life, with some of the patient-level data about how we can still improve their health.
We engage them at every visit about understanding and trying to get them from a precontemplative state about cessation to a contemplative state. Once they do reach a point where they understand that they want to quit, we then try to deploy every resource we have. We have dedicated tobacco dependence clinics here. We take advantage of our state programs to try to offer free nicotine replacement therapy. We discuss the benefits of the different pharmacotherapies for nicotine replacement therapy.
As Michael alluded to, we always do this in a nonjudgmental way. We want to maintain that therapeutic alliance with the patient. This is an addiction that has consumed them for 30, 40, or 50 years. I often tell patients that the secret to quitting is that it’s every small battle to win the war. It’s the next cigarettes. It’s knowing that 20 times a day you’re going to have this stress point that’s going to trigger something, and so we have to get you through all 20 of those each day. You have to maximize the effect of pharmacotherapies, help assist the patient to get them from a precontemplative to a contemplative state, and do this iteratively because it is a chronic disease.
Michael Hess, MPH, RRT, RPFT: This is where in my practice we use a lot of motivational interviewing. As Dr Drummond was just saying, a lot of these people have been doing this for 30 or 40 years, and for at least that long, they’ve had somebody telling them that they shouldn’t. That tends to reinforce that guilt or even that stubbornness in some cases. “Nobody is going to tell me what to do” or, “Now here’s yet another person telling me I need to quit, and I wish it were just that easy.”
I love that phrase “therapeutic alliance.” If we’re able to engage a little better and find their motivation or soft spot, then we can maybe put a little gentle, supportive pressure so that we can move people along each of those battles. That has been very effective in reducing consumption. I won’t say it’s been a magic bullet or anything for getting people to completely quit, but we have had significant results in getting people to at least reduce their tobacco use. I suspect that as we get more into the electronic nicotine delivery devices and start looking at those strategies, it’s going to be very similar there too.
Donald A. Mahler, MD:In my practice, after I get history about how much they smoke and for how long, I try to ask in a very simple way, “Why do you smoke? What benefits do you get? What pleasures do you have?” At least 80% of patients look at me like, “Do you have 2 heads on?” They can’t give me an answer. It’s taken me a long time to realize that as an addiction, people don’t necessarily smoke because the nicotine gives them a buzz or they feel good. It’s to avoid feeling bad as associated with opioid addiction. Then we try to talk about that a little. Once the patient opens up, stress reduction is clearly 1 of the key factors for people smoking. Whether it’s nicotine or just the habit of doing something when they have their coffee in the morning, or when they have family problems or financial problems. It’s obviously very complicated, but most people I see recognize they shouldn’t smoke but have difficulty actually stopping.
Maria Lopes, MD, MS: I agree. For a behavioral problem, we need more behavioral solutions. We’re just starting to also see areas like Click Therapeutics and others where devices don’t judge you, but they can offer some degree of personalization and help with triggers and hopefully create greater success around abstinence and how that can be achieved for each individual. There are also other things like computerized cognitive behavioral therapy that hopefully can provide this degree of support. It’s 1 day at a time, just like with the other addictive disorders. It’s 1 day at a time with the right support and personalization.
This activity is supported by an educational grant from Boehringer Ingelheim.