Help Patients Stop Smoking

Podcast Transcript

Announcer:

Hello, and welcome to the Respiratory Exchange podcast. I am your host, Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timeless and timely topics in the areas of pulmonary, critical care, allergy, sleep, and infectious disease. I hope you enjoy today's episode.

Peter Mazzone, MD:

Hello everyone. Welcome to today's episode of Respiratory Exchange. I'm your host, Peter Mazzone, the section head of the thoracic oncology program for the Respiratory Institute at the Cleveland Clinic. My guest today is Dr. Humberto Choi, MD. Dr. Choi established and currently directs our smoking cessation program in the Respiratory Institute and across the Cleveland Clinic health system. He's also the leader of operations for the thoracic oncology program at main campus. We're very fortunate to have Dr. Choi to talk to us today about smoking cessation. Welcome Humberto.

Humberto Choi, MD:

All right. Thanks so much.

Peter Mazzone, MD:

Humberto, I wonder maybe if you could just start by updating our listeners about the epidemiology of cigarette smoking in the United States.

Humberto Choi, MD:

So, it's actually good news. You know, the prevalence of smoking among adults has been declining over the last 50 to 60 years. Right now, we are, you know, at our lowest numbers. The numbers are around 12.5 percent more or less among adults, meaning people who are 18 or older; it does vary from state to state. We do live right here in Ohio, in a state with a high prevalence, which is around 20 percent, but overall among the states, one of the highest prevalence is in West Virginia that is around 23, 24 percent. And one of the lowest is in Utah, which is around five point six percent.

Peter Mazzone, MD:

Are there any particular groups that are maybe more vulnerable or more likely to smoke than others?

Humberto Choi, MD:

Yeah. There's several groups that have a higher prevalence than say the average nationwide or locally. For example, groups in lower income, people who had a lower level of academic education, minorities, LGBT groups. Those are groups that tend to have a higher average prevalence of smoking, compared to others.

Peter Mazzone, MD:

I see. Well, it's great news that the percentage of individual smoking is down, but it's still obvious that more work needs to be done with all that's already been known about the downsides of cigarette smoking and we still have people who smoke. What would you say to your patients about the benefits of smoking cessation?

Humberto Choi, MD:

Well, over several years, we learned so much about the potential harms from smoking. And I think those are the things that I would probably discuss with my patients, just looking at the most common reason of death in the United States. Six of them are related to smoking, for example, heart disease, cancer, stroke, COPD, and infections like influenza or having a pneumonia, they're all related to smoking.

And over the last two years, you know, we had the COVID-19 pandemic and we know that the risk of having a severe form of infection leading to hospitalization or even death is actually higher when someone smokes. So I would probably go over those problems that are related, associated with smoking.

And that's the benefit of touching on tobacco treatment, you know, and advising someone to quit and offering the resources that someone can have available at their site to motivate someone to quit and offer tobacco treatment because their risk of having heart disease, the risk of having cancer, cardiovascular disease or lung disease is gonna be lower when we help them quit.

Peter Mazzone, MD:

You probably had patients who are currently smoking and you described these benefits and maybe they say to you that, "Doc, I've smoked long enough. You know, it is what it is now." Can you reassure them that quitting will still impact their health?

Humberto Choi, MD:

Yes. You know, and I think my mantra is that really is it's never too late to quit, and the sooner the better. And even when someone already has an established heart disease or lung disease, they'll still benefit from quitting. So there's a lot of reasons to help someone to quit. And the treatment is really a combination of things. There is no one thing that will benefit everyone. There's no one size fits all.

And it's important to try to individualize the treatment as much as possible. The word is really combination, from offering pharmacotherapy, combined with behavioral therapy and auto therapies that can help someone go through the process the best way they can. So that's the key word, try to combine things, combine counseling. It's very strong counseling combined with pharmacotherapy that may include nicotine replacement therapy or medications like Varenicline combined with behavioral therapy and other therapies that someone may have available at their site. Here at the Cleveland Clinic, something that we try to promote is having a visit with a clinician to go over medical problems and go over medications when it comes to that and explain very carefully how those medications or a nicotine replacement can be used. And we have a group of health coaches that help motivate patients and troubleshoot problems that come along the way. We try to combine that with wellness programs that help with stress management, with weight management, along other problems that someone can face while trying to quit smoking.

Peter Mazzone, MD:

Oh, that sounds like a great program for sure. With all these tools available, we still have individuals who have a very difficult time quitting. What are some of the challenges that you've found in trying to treat an individual who's tobacco or nicotine dependent?

Humberto Choi, MD:

Well, we can talk about challenges in smoking cessation the entire day. But I'll just go over a few. First of all, you know, nicotine dependence is a very strong form of addiction and is very difficult to treat meaning that there will be relapses. Often the first attempt is not successful and may require someone to try multiple times.

So that can be frustrating for clinicians. It can be frustrating for patients. So just the process itself is very difficult. So one of the guidelines that has been very popular from the early 2000s talked about asking if someone smokes and then providing advice and assessing if they are ready or not. And that kind of translated into a somewhat passive behavior. When a clinician is trying to approach someone and something, what we would like to see more and more is trying to be more proactive, you know, regardless if someone feels that they're ready or not, if they're motivated or not, we should be very proactive and offer treatment.

And, you know, the first attempt that we offer may not be successful, but being proactive and going over, over and over, you know, at some point we will be. And another challenge is that there aren’t many clinicians out there with training for tobacco treatment. So there is some understanding of what should be done. But talking to many healthcare professionals, you know, I know that a lot of them did not have a formal training in addiction medicine or in nicotine dependence.

So I think that's one of the things that will be very helpful to see more of in the future. And on the patient side something that we'll see often in our program, and in any program, the no-show rates are high, patients will resist. That's why on our end, it's our objective to make it as easy as possible, as accessible as possible, and try to address misconceptions about treatments at any point when they come up.

I'll say there are so many challenges in, I think, any program. Any professional dealing with tobacco treatment just needs to be very flexible, be very open to trying to come up with solutions for many challenges that they can come up from a program structure, from the patient and or any other challenge that they may face.

Peter Mazzone, MD:

That's fabulous. Now, it's hard to talk about smoking cessation and nicotine dependence nowadays without talking about vaping. Where do we stand with vaping? You know, is it a safer alternative to combustible cigarettes?

Humberto Choi, MD:

Good question. This is something that we have been dealing with over the last few years. Vaping is one word that includes different devices and methods of using nicotine. Typically it refers to the use of an electronic device. And, in general, they have the same thing as a power source, that tends to be a battery, and the use of a liquid that people call illiquid or juice, that often contains nicotine.

But vaping and these electronic cigarettes, they are very different and there are several different types and different generations of them. And most of them do contain nicotine, but they also may contain cannabinoids, synthetic cannabinoids, CBD, THC and now synthetic nicotine as well. So they include different kinds of devices and different methods of using them.

The companies that manufacture them, they're using the same strategy that they used, that tobacco companies used, back in the '50s and '60s, trying to promote that this is something that could be a safe thing to do, or now it's a safer alternative to smoking. I think it's very early for us to say something like that; it is a very strong statement to promote electronic cigarettes and vaping as a safe alternative.

It's something that we saw back in 2019 before COVID-19 pandemic. A lot of our attention was directed to vaping because there was an outbreak of acute lung injury and ARDS that was associated with vaping, among many other things, that we saw that were connected to the use of electronic cigarettes and vaping.

Vaping and electronic cigarettes contain nicotine. They can help some people to quit, but it's not by any means right now a tobacco treatment alternative to the other forms of treatment that we already have well established. And we don't call it a safer alternative to smoking.

Peter Mazzone, MD:

That's very interesting. So we hear a lot of different opinions on that topic. Even in different parts of the world, they seem to accept these products as aids to help quit smoking, more than we do here in the United States at this time. What are the potential harms of vaping that keep it perhaps from being the alternative we're looking for?

Humberto Choi, MD:

I think what you mentioned is really some of the challenges that we see that are associated with vaping. One is that it is very socially well accepted, you know, in different parts of the world. And in the community, people just accept a lot more that someone will vape compared to someone who is smoking. And there's a lot of misconception, that means misinformation, around vaping.

In terms of potential harms, addiction itself is probably the most common one and often underestimated. These products that they're developed with nicotine, especially, they're always trying to come up with new product that has a very high content of nicotine and finding a way that they can, that the high level of nicotine can go to the brain as fast as possible, as quick as possible. And this is what would determine how addictive a product can be.

Some of these electronic cigarettes might have the same content of nicotine as a full pack of cigarettes, and that massive amount of nicotine can go to the brain very quickly. So that's how we see someone very young, like a teenager whose brain is still developing, can get hooked very quickly to these products, because of the dose of nicotine that they may contain and how fast that can achieve the brain.

Something that we touched on before in terms of the other potential harms was really what we saw in 2019, when we had this outbreak of acute lung injury and ARDS. There were more than 2000 mostly young people hospitalized and several deaths related to electronic cigarettes. So their potential harms for that can be very mild, like someone having a cough, having just some abnormal X-rays or CT scans without any symptoms, all the way to someone having acute lung injury, respiratory failure, ARDS and even death coming from that.

Peter Mazzone, MD:

Well, lots to think about. Tell me, where do you see this going? What's the next step in research treatments, policies? How are we going to get to the no cigarette smoking status that we'd all love to see?

Humberto Choi, MD:

Yeah. So this is a very interesting field to be in right now. There is so much going on, especially in terms of policy.

On the clinical side, I think we are craving for new breakthrough treatments and a lot of things we don't know, especially when it comes to young adults and teenagers. We are seeing so many young people who are highly addicted to nicotine. Some of the pharmacotherapy that we have available are actually not effective in that age group. I think we need to explore more how we can treat, especially teenagers, who are addicted to nicotine through vaping. And as we touched on before, vaping includes the use of other products, not only nicotine, like THC, CBD, and synthetic cannabinoids and synthetic nicotine.

So this opened, you know, a higher need to investigate how we can treat disorders related to all these substances as well. On the other side, in terms of policies and legislations, there have been several advances over the last few years. Something that happened two years ago was the banning of some flavoring on electronic cigarettes and on some products.

This was not a very comprehensive legislation, but I'll say it's a good start. It's a good recognition that flavoring, especially, can be very harmful. So I was glad to see that there was a push for that, but hopefully we can see a little bit more in the next few months and years. And something that happened, that was lot of push for a long time was really tobacco 21. Now, in over 50 states and US territories, it's illegal to sell tobacco products for anyone who is younger than 21 years of age.

So I think this was a big win for everyone when that was passed. But whenever we see a win, we see loopholes. So something that we saw happening was that the companies that were making, especially electronic cigarettes, they found that loophole that, and the term was really a “tobacco” product. So you can't sell tobacco products to anyone who is younger than 21. You can sell something that you don't call a tobacco product. So that opened the field for the synthetic nicotine products, because what they advertise is that it's not a tobacco product; so it would not be under that legislation. Now synthetic nicotine products are under the FDA oversight. So I'm excited to see what happens next with that.

Peter Mazzone, MD:

That's really fascinating. I've seen other countries as well with policies and goals of less than five percent, and they seem really to be getting there. And as much as all these additional treatments will be helpful, it seems without these really lifesaving policies in place, we're just not gonna get where you want to be.

Humberto Choi, MD:

Right and, you know, there are so many things that have happened over the last few years, it is very early to say how much impact they will have in the prevalence of smoking and vaping use. But, you know, I'm hopeful that they will be impactful and we'll see some good results in the next few years.

Peter Mazzone, MD:

Oh, fabulous. Well, if I had to summarize, if I had to say here's a few takeaways for the audience, maybe unlike most smoking cessation conversations that you've had, one would be, there is good news that the cigarette smoking rate is down and has continued to decline over time; but there are still some groups that are a little underrepresented in that benefit and still smoke more than the average across the country.

The second I took away is that we have lots of tools to help these folks. None of them are great. None of them are home runs, but they are proven helpful in making them as accessible and convenient to engage in smoking cessation programs as possible really should be one of our major goals. And the final is that vaping is a potential benefit, but also potential harm of which the magnitude is really not known. And so it maybe a little too soon to have it in a place in a smoking cessation algorithm. Lots of hope for the future. Anything I may have missed there, anything you would like to add as a final takeaway?

Humberto Choi, MD:

I think that's exactly it, tobacco is something that we learned a lot over the last 50 and 60 years. I think what we're seeing now compared to, you know, 50 years ago is just a lot of good news, but there's still a lot of work to do. There are a lot of new things like vaping that will be a new challenge, but we are up to that. And, you know, we are very optimistic that hopefully as we continue to do this work, hopefully these smoking rates will continue to decline over the next few years.

Peter Mazzone, MD:

That's great. Well, I just want to thank you again, Dr. Choi for joining us on the podcast today. This information's been extremely helpful for our listeners, I'm sure. Have a good day, everyone.

Announcer:

Thank you for listening to this episode of the Respiratory Exchange. For more stories and information from Cleveland Clinic Reparatory Institute, you can follow us on Twitter @CleClinicLungs or follow me @RaedDweikMD. Thank you.