Transcript

Russell [00:00:02] Let's get stronger. 

Gates [00:00:04] Healthier. 

Prickett [00:00:04] Calmer. 

Russell [00:00:05] Smarter. 

Gates [00:00:06] Better. 

Russell [00:00:07] Living a healthier life is a journey, not a destination. 

Gates [00:00:10] You can always get better. 

Prickett [00:00:12] Let's get better together. 

Gates [00:00:20] Tobacco use is the leading preventable cause of death in the United States. But even though we know this and the other dangers of smoking, it can still be extremely hard to quit because of the developed addiction. Hi, I'm Dr. Khalilah Gates. 

Russell [00:00:35] I'm Dr. Susan Russell. 

Prickett [00:00:36] And I'm Dr. Michelle Pickett. 

Gates [00:00:38] The good news is that, even for long-term smokers, quitting smoking carries major and immediate health benefits.  As highly specialized lung and chest care experts, we treat all types of respiratory conditions. So, today, we're going to explore what happens when you put anything other than air into your lungs, as well as how to take steps to kick your smoking habit for good. So, with that, I think we should just dive in with some very basic health information. What are some short-term and long-term benefits after quitting? And how immediately do these benefits occur? 

Russell [00:01:15] Well, your breath smells better (laughs).

Gates [00:01:19] Your clothes, your hair. 

Prickett [00:01:21] Well, and your cough improves. So, I see a lot of patients for chronic cough. And so, the one thing is when, when you're smoking or having tobacco or other vaping products, it will stun that normal cleaning process. So, cilia, those hair cells, they actually get stunted, so they stop moving and you get a lot of secretions in your lungs. So, one of the very immediate, other than better breath, is actually improvement in cough. And so, people may actually have a purge. They might get all that stuff that has been sitting, those hair cells start to work again, they cough it out. But chronic cough can improve very short-term after you stop smoking. 

Gates [00:01:53] Absolutely. And additionally, I think as lung doctors, we always think of the, the lung benefits of smoking and stopping smoking, I should say. 

Prickett [00:02:02] Of course we do. It's the only part of smoking that it affects. 

Russell [00:02:07] Most important organ. 

Gates [00:02:10] Absolutely. But it actually affects a lot of other things as well, right? So, we know that there's a link between cardiovascular disease and smoking. So, hypertension, heart disease, we can see decreases in blood pressure in patients who stop smoking. There are risks of various cancers, not just lung cancer, associated with smoking. So, quitting reduces the risk of lung cancer, but also other cancers as well. Although it's very hard, stopping smoking and more importantly, not starting smoking is very important from a global health standpoint. 

Russell [00:02:46] And I've had patients tell me that they can taste things better. In terms of cancer risk, it depends on how long you smoked, as to how long it takes for your cancer risk to go back down to normal. So, it's different for every person, because it's based on how much you smoked and for how long. That's kind of a longer-term effect over the periods of years. But, some of those things you could see within just a couple of days. No matter what's going on with your life, I think it's especially important to highlight life changes as being a really good time to quit smoking. Like, pregnancy is one of the big ones. Smoking cessation is so important for pregnancy and neonatal health that it’s the perfect time to consider quitting if you have not already, and it’s the perfect time to quit as a family. 

Prickett [00:03:31] Or prior to surgery. There’s a lot of data showing that preoperative quitting of smoking helps you through surgical outcomes, but also maintaining that in the post-surgical recovery period is going to be important. So, I think looking for opportunities with life events is a good first step to move toward that long-term goal. 

Russell [00:03:52] Yeah, there’s some really strong data looking at people who have vascular surgeries, and quitting smoking even as late as just two weeks before your surgery can lead to benefits in terms of surgical complications and outcomes. So, it's never too late to quit smoking before a surgery. 

Prickett [00:04:09] I think my answer is — when is the best time? I said the best time is today. The best time is now. And if you're asking the question, today is a good day. I think it's also, it's hard to quit smoking. I think you ladies are smart as well. I mean, people know that they should quit smoking, but it's hard. So, what is your experience with quitting smoking? What do we know about some of the data there? And why is it so hard for people? Once they start smoking, why is it so hard to quit? 

Gates [00:04:34] So, I think what you said highlights why it's so hard. As you said, people know they shouldn't smoke, but it's hard to quit. And that, by definition, is an addiction. And what we know is that nicotine is an addictive substance. Nicotine binds to different receptors in the brain, creates this dopamine release that gives you this euphoric, happy, calm feeling, and that in and of itself has addictive properties. Like other substances, nicotine is an addictive substance. And so once we start to really understand and explain that, we can then offer our patients the understanding that, this is not just you, this is something that we're going to have to work together to get you through. 

Russell [00:05:23] I think there are a lot of social barriers to quitting smoking, too, even aside from the biological ones, because a lot of people who've been smoking for a long time have built their daily life to include cigarettes. Whether that's smoking with their partner at home, whether that's, that kind of routine, if you get up in the morning, you have a cigarette with your coffee. Or, this is how I take a break at work in non-COVID times, where, like, this is how I get away from my desk for like 15 or 20 minutes. And so, I think it's really hard for people also to think about, like, what do I replace that time with? How do I take that out of my normal routine, something that's kind of ingrained in what I do every day? That can be really difficult. 

Prickett [00:06:07] I always share with patients because I feel like patients feel like it's a moral failing, right? Like, “Oh, I can't do this because it's on me.” And it's really not on them. It's on their brain. And most patients started, you know, most people that smoked started when they were young and their brain gets addicted. And we see this now where we saw this with vaping, right? So, that was still nicotine not coming in the form of a cigarette per se, but still had all that addictive capacity, if not greater, especially to young brains. And then, what I like to share with patients is, you know, the old school training was the average number of “quits” for most patients that do end up quitting is eight attempts. I actually looked it up in preparation for this, that's, the “old school.” There's actually newer data saying it can take up to 30 attempts. So, if you fail, get right back on the horse, like, don't worry about it, you are normal. There are very few people that can quit cold turkey or just have a quit date and stay quit for prolonged periods of time. So, relapses are common and they should be expected, embraced and moved forward from. I think is, is my coaching to patients when we talk about time to quit, how we can stay off the cigarettes. It's, it's not a moral failing, it's a brain signal. If you go back into those environments where there's social context toward that and exposures, and secondhand smoke has the nicotine and you get the high, and then it triggers you right back to wanting to do that behavior. So, it is highly addictive, and people just need that support and understanding. 

Gates [00:07:33] I want to highlight that idea that it is addictive, an addictive substance, because I think that the fact that we don't highlight that as much puts a huge burden on our patients and they feel like, "Oh, I just can't do this, is something wrong with me?" when in fact it is a biochemical process. And so, you pointed out, "Oh, you don't want to go to the bars, you don't want to be around other people who smoke." Those are the similar things that we say to people recovering from other substance addictions. And so, it is a lifestyle modification that has to occur when we are attempting to help our patients quit smoking. And we recognize, as it was pointed out, that this is very difficult, and it's usually not a one-and-done decision. And we have to keep all of those factors in mind as we're working with our patients. 

Russell [00:08:25] Yeah. And especially if you have somebody else in the home who is also a smoker, if the other person does not quit, then that temptation, that stimulus, that kind of "come hither" (laughs) dopamine will always be in the air. 

Prickett [00:08:40] Is that how dopamine works? Come hither-ing? Is that? 

Gates [00:08:43] Dopamine is a good drug, a good natural drug. 

Russell [00:08:46] It is. So, quitting together. Quitting as a family is helpful, but it does not make it impossible for, you know, some, a patient, to quit. But having that stuff even in the house, even around it can be really hard to overcome. 

Prickett [00:09:01] And some people need additional help. So, I think I look at the social factors of it, like you want to kind of minimize any elements that could lead you to go back to cigarettes or kind of trigger those cravings, if you will. I think I also bring up the pharmaceutical options that may help the brain not need that nicotine hit. And so, thinking about some of our medications that we prescribe in clinic, in talking about these as options. I think for some patients, they are really great options, and they work really well. But you have to be, you have to be committed. Like, you can't just prescribe a drug and expect it to work. You have to do all the things. And so, the pharmaceutical interventions that we use in pulmonary clinic and general medicine clinics, I mean basically any clinic, any doctor can prescribe these, that smoking, as we mentioned, it's not just the lungs. It's all the organ systems. And so, if someone is willing to smoke, I really feel like a physician should be able to help support them mentally as well as pharmacologically. If that is an option, that would be helpful for them and would work for them and support them through that. 

Russell [00:10:04] So when a patient comes to you and says, “I'm ready to quit smoking,” what's your advice? 

Prickett [00:10:09] Yay! That's my inner monologue. Just let that out. (laughs)

Gates [00:10:12] It comes out like, “Yes, you do this!” 

Russell [00:10:16] Usually it is like, “Finally,” no. (laughs)

Prickett [00:10:18] I try to keep my cool because I know that's a big thing. But part of me just kind of bubbles up inside going, okay, great. Because when a patient comes to me saying, “I want to do this,” it means that they have the will. Like, they have the motivation. And that's really the biggest first step. It's not about me or you wanting that for them. It's about them wanting it for them. And so, part of me is just, like, overjoyed, but I try to keep my professional cool. 

Gates [00:10:42] I'm like, “Yeah,” right. This is wonderful. 

Russell [00:10:45] I like, clap my hands, do the happy dance (laughs). 

Prickett [00:10:50] And I personally like to explore what, like, what made the change? Like with smokers, you don't just smoke for a day or two and then decide to quit, like, there's usually something and try to latch on to that and hang on to that because I know that there's going to be ups and downs. And say, "What's your motivation? What led to this? What was the impetus?" And acknowledge that and how important it will be for the process of recovery from smoking. And then lay out, you know, what their plan is. I think most patients will have a plan and you want to build on that, or at least I'd like to build on that plan and think about different options that might support them. 

Russell [00:11:27] I try to get a sense from the patient of what their intentions are and how they would like to go about quitting, and then try to support them with options that would go with that plan. Some patients tell me they want to quit cold turkey. I try to make sure they know that usually success is better with some sort of adjunct on top of just quitting straight up. But some people do prefer to do it that way. There are a lot of, kind of, nonpharmacologic options, so a lot of medical communities and providers offer group classes or individual counseling to help somebody quit. We do that here at Northwestern Medicine, and it's easy for people to be certified to become people who are tobacco cessation counselors. As Michelle mentioned, there is a lot of medications out there that can help, and they come in all various forms. Now, you can get a patch, you can get a pill, you can get a gum, you can get an inhaler, although not all of them are covered by insurance. So, it's important to kind of cover whether, you know, if the patient's interested, what things are covered, what is the cost to them? And then kind of come up with a plan together, I guess this is, at the end of the day, what's important. And just like you guys said, like saying, "It may not be successful, that's OK. Try again because the biggest chance of success is as having tried to quit before."

Gates [00:12:46] So, I want to play devil's advocate. I might be a patient. I'm going to say, you know, “You tell me the health problems is from nicotine. That's why you want me to stop smoking. And then you're going to do it by giving me nicotine replacement therapies. So, that doesn't make sense. I should just keep smoking.” So, what is our thought process behind the pharmacologic therapies that we're often prescribing to our patients? Like, why does — why are we taking that approach? 

Prickett [00:13:11] I think it's actually a really good question, and that's one of the main issues that leads to exposures, and a lot of the problems with cigarettes per se are all the other things that come with the cigarette itself. So, it's the inhalation of smoke, inhalation of heat that comes with vaping or, depending, or oils that can come with vaping. And it's all the byproducts with it. The nicotine itself has some components that are problematic, but the biggest leader of all the other inflammatory cascades that can lead to things like heart disease, lung health malignancies or cancers are related to the other byproducts. So, in the short term, we know that what links you to the cigarettes is the nicotine, because that's the addictive component. And so, we're going to give you just that one element, knowing that's the most addictive, so that we can get rid of the other elements. Over time, though, some patients can come off of the nicotine, but that can take longer. And so, we'd rather have the replacement of the lowest risk factor and get rid of the higher risk factor. But I certainly, we have patients that over time can come off of all of those. Once they, we can wean them down from their nicotine addiction and help with some of the social issues. Change in habits take a year to develop. So, when you're going to start really getting to talking about habitual change, integration of exercise, changes in diet, we're talking about something it takes a year to get into your daily to-do. So, it's not unreasonable to think that if we do this substitution or substitute cigarettes out of your life, that having a long-term gain can take a year to implement so that it becomes habit and part of your day-to-day routine. 

Gates [00:14:48] You threw in vaping. So now I'm like, "Hey, I might as well just go get a vape pen and I can get that tactile stimulation as well." So, how are we feeling about vaping? And its bridge to smoking or tobacco cessation?

Russell [00:15:02] There has been a little bit of data looking at vaping and helping people who are long-term habitual smokers, kind of heavier smokers, so greater than a pack per day, and how this could be helpful in helping them to quit smoking. However, I do not think that should be the first thing in your arsenal, especially in these times. It's less common for people to be at that level where we should think about that right off the bat. And also it kind of continues to perpetuate those social habits that are associated with the cigarettes. And so, I think the chance of what we call recidivism, or kind of sliding back into cigarettes themselves, is much greater with vaping. And for that reason, most of the guidelines from the bigger respiratory societies, like the American Thoracic Society, have recommended against using that as, kind of, your primary smoking cessation tool, because it just doesn't break all those habits that you'd need time and kind of, really, thought to wean yourself off of. 

Prickett [00:16:07] I think there's a role for everything. I do think there is a role for vaping, just like you said. And I think we've seen that. Really heavy smokers, multiple pack-a-day-smokers, vaping can help reduce some of that. You can help with it. What we've seen in the United States, though, vaping is not occurring in these heavy smokers that are switching to vaping. We're seeing it in our teens who are instead of, you know, cigarettes are kind of out for teens, but vaping pens that they could do were highly — you know — that was the “in thing” several years ago. It was a really big problem. And so, I think, you know, everything has its place and I think we need to be honest about that. There are roles that vaping, I think, is better for some. If you're a four-pack-a-day smoker, would I prefer vaping over four packs a day? Yeah, I would. But if you're a teenager and you're like, “Vaping is fine.” It's very, very addictive, and it has other issues. And we've seen those in our pulmonary clinic as well. Vaping can have its own set of lung issues, not exactly like cigarettes, but a lot of hypersensitivity issues. We've seen several, many people get admitted to the hospital in the “before times” and needing treatments. And so, I think we need to be honest about, “Does it have a role?” Yeah, I think it has a role, but it's a really, a limited role in how we use it. For the teenagers out there, this is no, this is not good. 

Gates [00:17:21] Any other advice you would give your patients who come in to say, “Hey,” you know, “I want to stop smoking? What else can I do?” 

Russell [00:17:30] Well, first I would just plug to any health care provider who's listening is that it doesn't matter who you are, what setting, asking somebody about smoking and if they're ready to quit in a health care setting is always helpful at helping people think about it and start thinking about quitting itself. Having people who are influencers close to you and your family or your health care provider asking you about quitting smoking definitely helps people in preparing themselves to quit. There's a reason those recommendations are out there. 

Gates [00:18:04] I think we all ask every patient, “Are you smoking? And if you are, are you ready to quit?” We advise you to quit. But one thing I definitely make sure of is, I ask all my patients and if they tell me they're not ready to quit, I'll say, “Okay, let’s talk about why I want you to quit, and then I want you to think about it. And when you’re ready to quit, let me know.” And we address that on a regular basis. And, but I think the data also suggests that pursuing a cessation program does not work until the patient has made up, in their minds that they are ready to quit. And so, we can't strong-arm patients into quitting, but we can continue to address it and ask and encourage. 

Russell [00:18:47] Yeah, I always ask the patient. If they tell me, no, I'm like, “Okay, we're going to talk about it again next time.”

Gates [00:18:55] You're not off the hook. Just off the hook today. 

Russell [00:18:58] Yeah. 

Russell [00:18:59] Sometimes patients will come back at me with "Well, I already got diagnosed with X lung disease, COPD, cancer, what have you. What's the point in quitting now?" What do you say to those guys? 

Gates [00:19:11] So, as an asthma COPD doctor, I always say to those folks, “Yes, there is damage that has been done, currently, but if we can stop smoking now, we can prevent further damage. If we stop smoking now, we can improve quality of lung function status. We can prevent that decline that we know we see with COPD patients who continue to smoke. We can prevent the recurrent exacerbations in patients with asthma when their exacerbations are associated with smoking.” So, there's always a reason to quit. There's always a hope for improved respiratory status in the patients that I see. And then additionally reminding my patients that the long-term effects of smoking, like high blood pressure, cardiovascular disease, and how we can impact that if we stop smoking as well. And then I always throw in the little extra, “You can save a lot of money as well if you stopped smoking.” 

Russell [00:20:12] I believe there's an app out there where you can put in how much you are smoking on a daily basis and then how, like, your quit date. And then it will tell you how much money you're saving every single day. 

Gates [00:20:23] I think I heard like a pack of cigarettes is $13. 

Russell [00:20:27] And more in some states. 

Gates [00:20:28] So there are multiple benefits, including financial. 

Prickett [00:20:32] I think looking proactively in taking control of your health and saying there's things that we can help you feel better, and knowing that it's going to take some work on both of our parts and that we're there to partner with patients and understanding them as individuals. And this is one element in the context of their health, in their life, and that we can make them better with this, I think, is how I approach it. I'm glad to hear what you all — what you ladies do. I'm going to come see you as my pulmonologist, if I ever need one. 

Gates [00:21:00] We would gladly take you (laughs). So, as we wrap up, what's one thing that we would each want to leave with our audience when it comes to smoking cessation? 

Russell [00:21:12] If at first you don't succeed, try, try again. Because the next time you have a higher chance of making it there. 

Prickett [00:21:20] I would say there's never a wrong day to quit. And to pick a day, pick a plan, and find a support system, and know that your medical team is also part of that support system. And there are multiple avenues out there to help you quit. If it is your time and if you fall off the wagon, get right back on. 

Gates [00:21:38] Just to piggyback on that, we, as your physicians, are here to help you through this. We are in your corner. We are one of your biggest cheerleaders, and we're going to get through this with you, together. So, with that, I would like to say thank you, ladies, for a great conversation. And as always, it's been a pleasure to talk to you about topics that we don't typically cover. So, until next time, we'll end here. 

Russell [00:22:08] Thanks for listening to Get Better. 

Gates [00:22:10] We hope you leave this podcast better than when you started. 

Prickett [00:22:13] For more information, visit nm.org/healthbeat.