Chronic Obstructive Pulmonary Disease
Key Feature 4: Encourage smoking cessation in all patients diagnosed with COPD
Skill: Clinical Reasoning, Patient Centered
Key Feature 5: Offer appropriate vaccinations to patients diagnosed with COPD (ex: influenza/pneumococcal vaccination).
Key Feature 1: In all patients, regularly evaluate and document smoking status, recognizing that people may stop or start at any time.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Follow-up
Key Feature 2: In smokers: Discuss the benefits of quitting or reducing smoking.
Skill: Clinical Reasoning, Patient Centered
Working as a Resident in Vancouver's Downtown East Side, I am constantly reminded of the realities of the opioid crisis. More than 1420 people died of illicit opioid overdose in 2017 (CBC News). However, at risk of downplaying this very real crisis, the rate of deaths from lung cancer in 2015 well surpassed this, by 1000 people (BC Cancer), and that's not including the thousands of people living with COPD with significant detriment on their quality of life by this chronic disease. Although not as sensational due to its prolonged delay in negative consequences compared to death secondary to acute drug overdose, cigarettes are a MAJOR source of morbidity and mortality. When patients are diagnosed with COPD or lung cancer, it's as important as ever to reinforce this - it's never too late to quit. This graph from the Lung Foundation of Australia demonstrates why:
By the above statistics, it would seem all reasonable people would give up their cancer sticks. But life is not so simple: we are dopaminergic hedonistic creatures. That being said, many people want and manage to quit smoking despite how challenging this can be, and despite the many barriers that people may need to overcome. Likewise, many people relapse, as with all other addictive disease processes. It is always important to re-evaluate someone's smoking status, creating space to assess motivation to reduce or quit smoking in someone who has already been afflicted by this addiction, and to reassess for relapse (and possibly new motivation) in those who had previously gained ground in this lifelong battle. It's also important to practice harm reduction (such as ensuring influenza and pneumococcal vaccines are up to date in someone with diagnosed chronic obstructive lung disease) and perhaps above all else, building a relationship of trust whereby patients will able to be honest because they believe the care they are receiving is nonjudgmental and centered on their well-being.
As with all addictions, it needs to be the person who is addicted to cigarettes who needs to feel motivated enough to be successful in quitting, and no degree of patient counselling can make someone who doesn't want to quit, quit smoking. There is, however, evidence to show that brief interventions in the office visit can make a difference, which essentially means asking where patients are at with smoking. If the patient turns out to be precontemplative, meaning they think there is no way in hell they would quit smoking, the health provider should not "waste any more breath." It is best to just mention that if they ever want to quit in the future and want help, that they would be happy to support them at that time. In order to promote a shift from a precontemplative mindset to a contemplative mindset, it can sometimes help to be inquisitive, by asking about why it is that patients smoke, as in what benefits it provides for them, and then to follow that with inquiry into what negative consequences it may have in their lives. It is really about the patient deciding if the benefits or the risks outweigh the other to have any motivation or lack thereof to quit smoking. And honestly, like all behaviours we choose, that is just the way it is, and it is not necessarily a bad thing. However, it is also doing one's due diligence as a patient's family doctor, in my opinion, to help patients be aware of how behaviours may be influencing their health status. It's hard to imagine the patient who isn't aware that smoking increases the risk of lung cancer, but this negative consequence can seem so far into the future that patients, especially young ones likely to live a long time prior to this repercussion, may not be motivated to quit given the benefits they may be getting from the behaviour in the here and now. So being aware of other negative effects from this addiction can be useful to drop as well, such as the detrimental effect of COPD, or the hit to the wallet. And the above graph is again useful for this purpose if patients are open enough to be in the contemplative stage where they are considering quitting and are open to appreciate the severity of the burden it has on lung function. I refer patients who are in the contemplative stage of motivation for smoking cessation, as well as those who are preparing more seriously for quitting, to quitnow.ca to amplify the impact I can have in reducing the burden of harm from tobacco.