Approaching smokers in healthcare. We want your opinion

[Dr_Hays]

Stopping smoking for even a short time before surgery significantly improves surgical outcomes and increases the likelihood that a patient will survive surgery.  Because of this, and because surgery can provide a good opportunity to effectively connect with smokers, the Society for Vascular Surgery and the Society for Vascular Nursing this week issued a joint statement encouraging vascular surgery teams to provide treatment for tobacco dependence for all smokers who are considering surgery.

Unfortunately, too often the manner in which smokers are approached within health care is ineffective, or even detrimental.  Sometimes patients are lectured about the health risks they face if they don’t stop.  If the person being lectured has tried to stop and ‘failed’ or if they feel stopping smoking is too difficult, this can cause shame, discouragement, or even unconscious discounting of the message.  None of which are helpful.

Other times people are given a limited ‘yes or no’ choice. ‘Do you want help to stop smoking?’  Unfortunately the lack of accurate information about treatment, or the fear that treatment means more lectures about smoking and health, too often results in a ‘no’, or ‘not at this time’.  Also, people usually think, incorrectly, that tobacco dependence counseling means they must be already committed to stopping or a 'quit date'.

We are looking at more proactive ways to make referrals within surgical groups, or other medical areas in which stopping smoking can be of enormous benefit.  We are piloting projects in which we automatically provide treatment as usual care, or ‘opt-out’ rather than ‘opt-in’ approaches.  For example, prior to surgery a patient who smokes will automatically have scheduled a visit with a Tobacco Treatment Specialist (TTS).  The TTS is trained to connect with patients, engender hope, provide education and options, respect a patient’s personal choice, and provide treatment as indicated.  A trained TTS doesn’t admonish a person for smoking, instead the TTS uses an empathic strength based approach to inform and build confidence.

Here we would like your opinion.  What are your thoughts about ‘opt-out’ rather than ‘opt-in’?  Should patients automatically be referred to treatment and support for stopping smoking? Or should we first ask if they ‘want help’ with the ‘yes or no’ as a final answer? Or, should we just give them a brochure or contact information and encourge them to call a tobacco quitline?  

We would also like to hear from you about any good and bad experiences you have had in health care encounters when tobacco use was broached.

Thanks as always!

[YoungAtHeart]

When I needed vascular surgery for an arterial blockage to my leg, my surgeon said to me, "I can make your artery 40 years old with this surgery, but I guarantee if you continue to smoke, you will need this surgery again and you wil most likely not be healthy enough for me to do it."  What he didn't have to say was that at that point I might just lose my leg.  THAT got my attention. 

I immediately found a doctor who specialized in smoking cessation. I was quit for four weeks at the time of my surgery. 

Have you ever CONTACTED a State quit smoking program?  My experence with the one in Maryland was most unhelpful.  They actually suggested I keep a pack of cigarettes in my freezer - the idea being that if I had a major crave, I could take one out and, by the time it thawed, the crave would be over.  HELLO?  There is no liquid in a cigarette - it doesn't FREEZE.  We all know that keeping any cigarettes in your house is a bad idea.  I gave them another chance and calledf with a question and could actually hear this person turning pages to find the answer - and then reading it in a monotone. Luckily, I found the EX site - and THIS is where I would hope surgeons refer people. I read all the materials suggested, got involved and I am now 4 1/2 years quit.....on my first and only attempt.

Nancy

[TerrieQuit]

Hello, Dr. Hays,

The state program here in Ohio called it cessation counseling. The lady asked me how much I smoked, she then prepared a bag of patches, lozenges, and gum and without instruction told me to come back in a month. 2 years later when I was fed up with smoking I found Zonnic gum. Inside the box was a link to becomeanex.org (I never chewed the gum) I came to Ex and followed every suggestion and had a 519 day quit. Unfortunately, I lost that quit, came back the very next day and now have 44 days!

EX offers wallet cards, here is a link to the blog to order some.

https://excommunity.becomeanex.org/blogs/Mark-blog/2016/02/29/do-you-find-yourself-referring-people-...

I find them effective, I have passed them out to several, 5 have joined. I hear them talking about quitting, I ask them if they are serious and then I give them a card. I don't push! As a former smoker, I know that pushing it is not helpful.

I hope I have helped!

~Terrie~   44  DOF  I Won't Quit on my Quit on my Quit! (ever again) 

[Giulia]

  That's a tough call.  As a former smoker I would be immediately put on guard and turned off by automatically being "opted in" to a quit smoking program or worse, scheduled to visit with a  TTS.   How DARE you, would be immediate reaction.  First of all there's something psychologically uncomfortable about someone, without my telling them that I smoke, assume I want to quit or admonish me that I should.   When I smoked, I was extremely hostile to anyone trying to suggest, advise, badger or in any way confront me about the "habit" of which I was already long aware as being detrimental to my health.  Even if it was "out of love."   Most smokers are put immediately on the defensive when their "habit" is mentioned.

  Of course when we fill out certain forms the "do you smoke" box is there for the checking.  But that doesn't mean I want someone telling me I should stop.  I doubt there's a smoker alive who doesn't already know they should stop.  So the way it is presented is an extremely delicate psychological maneuver. 

  I'm trying to imagine an  approach that would have worked the best for me.  I think if the doctor/surgeon said something to the effect -  "I notice from your chart you're a smoker.   I just want to inform you that  smoking can seriously hamper the surgical outcome.  If you'd like, I can provide a source of help for stopping prior to the surgery......"  Or something of that ilk.  But then I also think that a much more blunt approach would, as Nancy said above,  have a greater impact, one that might actually shake up the addict's  mind enough to  seek help in that area for themselves.  When I was contemplating a dental implant my dentist told me point blank there would be no point in doing it if I continued to smoke.  As a matter of fact he said he   wouldn't do the implant if I smoked. 

  I think a  brochure would be thrown in the trash as soon as the person got out of the doctor's office. 

  I doubt  an effective approach would be a one-size fits all.  Some need the blunt truth, some need the gentle, kindly-but-serious doctor talk.  Some doctors don't mince words, some work their magic by the caring urging.  Ultimately I think it should be the doctor's call as they know the best approach for their individual patients and themselves.

Of the three choices you gave above, I'd have to say - "first ask if they ‘want help’ with the ‘yes or no’ as a final answer."

[indingrl]

thanks for asking keep it simple just send in a RECOVERING NICOTINE ADDICT WHOS EXPERINCE WILL HELP CUZ THEY BEEN WHERE YOUR USING NICOTINE VICTIM HAD BEEN in Jesus name and HOORAY FOR JESUS! thanks for letting ME be ME and share MY EXPERIENCE STRENGTH AN HOPE!

[crazymama_Lori]

My biggest turn off before I quit was all the information about the detriments of smoking, everyone telling me what smoking is doing to my lungs and this, that and the other.  I already knew that.  My response always was I'll quit when I want to.  I think if it was approached as if you continue to smoke healing will take longer......... blah, blah.  If you choose to stop smoking for 2 weeks prior to surgery, the benefits would be........  Information and optional patch, gum, lozenge, prescription will be given if you choose this option and a suggested support group.  I think if it's approached that way, it gives the smoker just the short term option.  I think once they get beyond the 2 weeks, the recovery, find out how much better they feel, I feel the long-term option will be followed 

[stAn3]

I think opting in is a good idea. Most encounters I've had with healthcare workers have been more hands off. They told me to quit smoking and offered resource to help, but left it up to me. Still smoking at the time, of course, I always chose to keep smoking until a health crisis arose.

Automatic measures, in my opinion, change the default from doing nothing to considering doing something. This might push more people who are in the contemplation stage of quitting to the planning/preparation stage by removing a barrier for reaching out for help.

I need to mention that I have tried to intervene with many clients to try to help them quit smoking during my career as mental health professional. This colors my thinking about the issue.

[Lauralives]

The smoker needs to be ready to HEAR the information.  That can make it difficult.  I have used other quit sites and I must say EX is the best.  Interactive, supportive and with a plethora of data, facts, stories and short anecdotes to help you "get over yourself!"  I didn't even know this site existed and it was my missing piece.  With technology as it is today, ex-smokers have so much more at their finger tips. 

[elvan]

I think if EX had been available to me or I had KNOWN it was available a long time ago, I certainly would have done the reading and I would have embraced the education.  I WANTED to quit for a long time but I kept falling into the same traps.  I have told all of my doctor's since I quit, about becomeanex.org and they have been very receptive.  I have no idea about the impact it has had on patients.  I had lung volume reduction surgery in November of 2015 and I was told that I would not be considered as a candidate unless I had been smoke free for at least a year.  That was pretty sobering since they showed me the difference it COULD make for me in the quality of my life.  

[Mike.n.Atlanta]

I feel that inquiring of a patient as to whether they smoke or not & then going at them about quitting or even curtailing their use is not the way to go. The slow healing process of smokers should be included in the beginning when discussing any surgical procedure. If the patient gets that information feeling that they're not being talked down to maybe they would be a little more curious about quitting.

Make em think it's their idea.

Keep on keepin on,

M n @

[CrimsonQueen]

I think that you should ask if a patient even wants help. I've been through five surgeries and was always offended by doctors who lectured me like my mother used to. I had no intention of quitting and didn't want help. At the time, I thought that I'd smoke until the day I died. Smokers already know the reasons that they should quit, after all. I like the out-in/-out option.

[Thomas3.20.2010]

I was offended just Thursday when the technician asked if I had quit smoking yet. It seems to me that were she to mention the difference between a smoker and a quitter I would have been more receptive but yes, I felt blamed for having smoked at all. The information is very important but the blame game doesn't work!

[Christine616]

Thankfully, I've not had to have any major surgery, but I have tried quitting in the past and have been approached and lectured and asked, etc. I believe that I was not in the right mental frame of mind at the times I tried to quit (basically, on my own). Of course doctors and nurses would give me advice that I've heard over and over again, stuff I already knew, but it didn't matter, cause I just wasn't ready to give them up.  It was only annoying to be harped on about it - from any and everyone.

It took me the last several years to begin changing my habits, partly due to society (not being able to smoke in restaurants, etc.), and partly because so many around me were quitting that I began to be the odd man out (woman, thank you).  I started to feel like a closet smoker, of which I never was before. My son even pitched some awful fits over my smoking in the house, and knowing he was right, how could I keep doing it?  My long time smoking habit/s began to change, and because of that I began to cut down on the amount of cigarettes I smoked each day. This was over the course of a few or several years, which I believe, made it easier to quit when I finally decided to do it.

So, for days, weeks, and months I thought about quitting and the fact that I just HAVE to do it! Somehow, someway.

I told my doctor I wanted to be on the meds and get the patch, and whatever else it took. The difference this time though was that my doctor had a psychologist (TTS?) in the office for me to see once a week while I was quitting. I think that made a big difference for me. It was great to have someone to talk to about it who would be understanding, etc. She began my treatment with me and got me all lined up on a several weeks program with the patch and gum and meds. Then on the night I quit, I chose to also not take the patch or gum. I figured if I'm not going to have anymore cigarettes, then why would I keep putting more nicotine in me. That great line of thinking came from the whyquit.com website and from reading Allen Carr's book - and of course EX 😃  I have also been diving into the self-help material, which also helps a ton. I was happy that I had the psychologist to go back to and report that I had quit earlier that she expected and with NO nicotine help. 

[elvan]

This is a tough question, I have been hospitalized for pneumonia and for a few different surgeries.  The most recent one was Lung Volume Reduction Surgery and I was told that if I had not been quit for a year that they would not be able to do the surgery. I am not sure if it was that surgeon's policy or the hospital's. I had not smoked in 22 months so I was okay.  I think that patients should receive some sort of counseling and their smoking addiction should be approached as just that, an addiction.  I think making all of the information available and having a support person there to go over it could dramatically reduce post-operative complications.  I was an RN for many years and I knew the consequences of smoking, I just thought I was somehow immune...quitting was the best thing I have ever done for myself and I would offer as much support as possible to any patient preoperatively.