Integrating smoking cessation in a clinical setting

Read an interview with Dr. Andrew Pipe at the University of Ottawa about the importance of bringing programs to help people quit smoking into the clinical setting

Andrew PipeDr. Andrew Pipe, Former Chief of the Division of Prevention and Rehabilitation at the University of Ottawa Heart Institute and Professor in the Faculty of Medicine at the University of Ottawa, talks about the importance of integrating smoking cessation into clinical settings.

Over the last 40 years, thanks to cancer control policies in Canada, the percentage of Canadians who smoke has gone from roughly 50 per cent to roughly 16 per cent. Can we do better?

Yes we can. That is still too many Canadians who are smokers. It translates into roughly 5,200 hospital admissions a day that can be directly attributed to smoking. We need to push those numbers lower.

Tell me about the smoking cessation work you do at the University of Ottawa?

We’ve developed the Ottawa Model for Smoking Cessation, which is universally applied to all patients who are admitted to the Ottawa Heart Institute and has been implemented in more than 150 health-care facilities across Canada. A modification of this model has been developed for family health teams and primary care practices in Canada. The model mandates that the smoking status of any patient in any health-care setting must be identified and documented. That patient is then offered help with smoking cessation from a clinician who is trained in pharmacotherapy, and the patient is followed-up with in the weeks after the cessation attempt.

We also conduct ongoing research programs to improve our ability to help our patients stop smoking. Finally, we do a significant amount of professional and public education around smoking cessation, with an emphasis on professional education to improve the skills of clinicians.

Can you talk about the most promising clinical approaches to smoking cessation you’re looking at?

We know that most of the people who remain smokers these days are really addicted to nicotine, so our focus is on the symptoms of withdrawal. Just as we treat the physiology of hypertension with medication, we can treat the physiology of nicotine withdrawal with medications that can alleviate those symptoms, such as nicotine replacement therapy. But probably the most important approach we take is helping clinicians identify smokers, offer assistance with smoking cessation and then follow up. We’re trying to change the language and the attitudes of clinicians.

What are the top things physicians should know about smoking cessation that they might not already know?

Smoking is not a habit.

  1. I continue to be amazed that many clinicians still view smoking as a habit. Smoking is not a habit. Nicotine is the most tenaciously addictive drug we deal with in our community.
  2. Most clinicians feel they have a responsibility to educate smokers about the hazards of smoking. The overwhelming majority of smokers know why they shouldn’t smoke, the overwhelming majority of smokers don’t want to be smokers and they don’t need more education. They need help quitting.
  3. There are many misconceptions –I term them “zombie concepts”–about the use of pharmacotherapy in smoking cessation. Perhaps the classic and most enduring is that you can’t use nicotine replacement therapy in people with cardiac disease. There’s absolutely no reason you can’t. Smokers are remarkably tolerant of the cardiovascular effects of nicotine. Regardless of how much nicotine replacement therapy you give them, they’re going to get far less nicotine in them than if they continue to smoke.
  4. Just as we need to adjust medications to manage hypertension or high levels of cholesterol, in some smokers we need to adjust the amount of nicotine replacement therapy they receive to effectively address the symptoms of withdrawal that accompany a cessation attempt. Somebody who is smoking two packs of cigarettes a day is not going to be helped by the standard dose of nicotine replacement therapy.
  5. Concerns about the psychiatric side effects of smoking cessation from pharmacotherapy have been greatly exaggerated in the public and the professional media, and evidence continues to accumulate that pharmacotherapy for smoking cessation is safe and effective in those with psychiatric illness. It’s very important to realize that smokers are constantly administering small doses of antidepressants as they smoke, so the emergence of depression at the time of smoking cessation can be very common in certain patients.
  6. It’s all about being systematic and doing it in a way that ensures you can spend minimal amounts of time most effectively. It’s another great myth that smoking cessation requires inordinate amounts of time.

How can clinicians integrate smoking cessation into their primary care practices?

We can dramatically improve the efficiency and effectiveness of smoking cessation interventions in the primary care setting by integrating the smoking cessation protocol into the pattern of practice. That can be done particularly seamlessly in settings with electronic medical records. It also involves ensuring that all staff in a particular clinical practice setting assist with smoking cessation in ways that are appropriate and consistent with their other areas of responsibility.

What is the role of policy in smoking cessation?

Policy is very important. We know that the development of smoke-free environments, for instance, can have a dramatic impact on increasing the interest of smokers in quitting, and it can provide very explicit support for those who are in the process of quitting or who have recently quit smoking. We also know that increasing the price of tobacco products impels smokers to make quit attempts. We know that attempts to minimize the attractiveness of the product by, say, adopting a plain packaging technique also can be important in tempering the urge to smoke.

How do you implement a tobacco control strategy while taking into account the wide range of clinical health-care settings in Canada?

One of the important elements is to move toward a uniform smoking cessation approach, such that people can access the skills of smoking cessation clinicians and experts in a variety of ways—through hospitals, family physicians, public health units or quit lines. That way, there’s a seamless cessation system that’s established across our communities.

Can you talk about the link between smoking cessation and lung cancer screening?

Understandably, many individuals with a long history of smoking are very concerned about lung cancer, so they are likely to take advantage of lung cancer screening programs. That’s a perfect opportunity to provide—in a very sensitive and strategic way—assistance with smoking cessation. Even in individuals with lung cancer, we know the response to treatment is dramatically improved if they quit smoking.

How does mental health play into smoking cessation?

It’s very important to understand that individuals in Canada with significant psychiatric issues have a life expectancy that is almost 25 years less than that of other Canadians. A large proportion of that discrepancy is accounted for by tobacco-related diseases. Individuals with psychiatric illness have very high rates of smoking for a number of reasons. They derive partial relief of their symptoms from smoking. For example, those with depression will feel better because hundreds of times a day, each time they smoke, they’re self-administering smoke agents which have antidepressant properties. The myth exists that it’s almost impossible to help these patients quit smoking. That’s not true. We should be moving quickly to ensure that all psychiatric facilities in Canada are smoke free because that will act as a stimulus to smoking cessation in this very vulnerable population.