Albert Rizzo, MD: Smoking Cessation Struggles & E-Cigarettes

Although more formers smokers than smokers now reside in the US, the American Lung Association (ALA) is not letting up on its smoking cessation efforts. In a recent interview with MD Magazine^®, Albert Rizzo, MD, pulmonologist and senior medical advisor at the ALA, highlighted the necessary steps of smoking cessation practices as well as the unknown surrounding e-cigarettes.

MD Mag: Why is it so important for physicians to ask patients about their smoking history?

Rizzo: In the overall scheme of things, smoking is the number 1 preventable cause of death. If we can get people off of tobacco products, it would improve mortality from cardiac disease, lung disease, and several forms of cancer. As a preventive measure—getting people off of cigarettes—it is the most important thing we can do. Hopefully it will prevent individuals from getting any diseases that we would then need to treat later on.

The other big reason [for physicians to ask patients about their smoking history] is that unless it’s brought up by them, it’s not going to be top-of-mind for patients themselves to see about quitting even though they may understand it’s important to do. They may feel if they’re doctor is not asking them about it, they should not worry about it.

Exactly what other types of diseases can smoking lead to?

The ALA has recently recorded that about 438,000 deaths related to smoking occur each year. Many of them are because of premature heart attacks, so coronary artery disease is high on the list of smoking-related issues. The development and worsening of COPD and asthma or flareups of asthma and COPD are also significantly related to continued smoking if you have those diseases.

The other big ones [diseases] have to do with the development of cancers. The number 1 cancer killer of both men and women is lung cancer, which is caused by cigarettes in 90% of the cases. In COPD, 80% of the deaths are related to a previous diagnosis of smoking and the development of emphysema and bronchitis.

Those are just United States numbers, but worldwide, it’s even worse.

Do different types of smoking—such as cigarettes versus cigars—have different effects? Are some more toxic than others?

There has been some controversy over the years of people saying when they smoke a cigar they’re not inhaling as much. That may or may not be the case, but the trouble is cigars are associated with cancers of the tongue and lips. There are carcinogens that the body is still exposed to even with cigars.

For many years, there was also thinking that if you had a low-tar nicotine, a more mild cigarette, it would be better. Well, those cigarettes were never really shown to be any less harmful than normal cigarettes. Tobacco and its ingredients in the cigarette have been shown to be disease-causing—from heart disease, lung disease, and cancers.

What is your opinion on vaping and e-cigarettes?

The big thing about vaping is that we just don’t know enough about it because it comes in multiple sizes, brands, and different temperatures that they are heated to. There are also all kinds of different vaping instruments out there.

There’s a push in the public health sphere about saying, ‘Well maybe vaping is safer than cigarettes because you’re really just using nicotine and you’re not getting all the other ingredients that are in tobacco smoke.’

The problem is we don’t know what’s in the vaping. We know some e-cigarettes have ethylene glycol components and carcinogens in them, so e-cigarettes are just a non-regulated produc, and we just don’t know what the acute and or long-term effects will be.

There is a part of the health community that feels if you can get people off of cigarettes and onto e-cigarettes as a smoking cessation device, that would be a safer way to go.

But again, we have no evidence that e-cigarettes are helpful as a smoking cessation device. They have never been studied, and there are very few articles that show that changing to e-cigarettes helps a person quit cigarettes. There are a lot of unknowns in that realm.

Part of the concern of e-cigarettes is that that may be used by—and they are being used by— individuals who would have never picked up a regular cigarette. We are in the middle-school-age range of people who are using e-cigarettes as an addiction and as a device that is socially acceptable and peer-pressured.

What we have to do is make sure these products—whether they’re ultimately found out to be safe or not—don’t end up in the hands of young people whose brains are very sensitive to the addiction of nicotine.

How do you suggest physicians bring up how to quit smoking with their patients?

Once a physician knows a patient is still smoking, the first step is to gage the patient’s willingness and readiness to quit. We know that quitting is much more successful if there is a commitment from the patients to make the effort at that time.

Patients who may be in the midst of financial issues, family discord, work implications—these are just some of reasons people who smoke use smoking as a way to help get through stressful situations.

I often ask the patient—especially one who has quite before—what do you think? Is this a time in your life when you want to take on the effort to quit smoking?

The more smokers you ask, 70% to 80% want to quit smoking. They understand it’s bad for their health, and it’s something they’ve enjoyed doing for many years. They have to be at a point in time where they have an understanding of the importance of quitting and the ability to make a commitment.

Sometimes it’s the birth of a grandchild, and the parents don’t want to have grandparents around if they are still smoking or have secondhand smoke on them. They may just have lost a loved one to cancer, and this is the light that goes off where they realize they should quit smoking.

There are many triggers that make someone switch from being a chronic smoker to being someone who quits. It has to be the right time for that patient thought.

If I don’t bring smoking cessation up at all when a patient comes to see me, then I’m never giving them the opportunity to think that this might be the right time. Asking if they smoke and assessing whether they’re at a time and place where they might be able to make that commitment is important.

How do you narrow down on choosing an FDA-approved medication to assist patients in smoking cessation?

The best success for smoking cessation usually involves having a plan, having a support system with friends and family around you, but also using some type of counseling and 1 of the 7 FDA-approved smoking cessation drugs.

Five [of the FDA-approved therapies] are nicotine replacement therapies, and the other 2 are the medications bupropion or varenicline.

Many times, patients will have had experience with 1 or more of those drugs in the past if they tried to quit before, so they will tell you what their experience was. Sometimes they’ll say, ‘I did a great job with the patch. I got off and was off for a year or 2, but then something happened and I went back to cigarettes.’

I’ll often say that’s not a failure on your part. You did quit for a time, so you can quit again. In fact, there are more former smokers than there are smokers in this country right now, so people can quit. That usually gives them encouragement to try again.

So, if they used a device before and it was successful, I often recommend we go back to that. I then explain to them the role of a drug like the nicotine replacement. Sometimes people will say, ‘The patch worked for a while, but I just had cravings throughout the day, and I just had to go back to cigarettes.’

Sometimes the combination of a patch along with using a nicotine lozenge or a nicotine gum can help get those peeks of craving under control. Sometimes you just have to make them realize that the craving will only last a few minutes, and then thet can get back to doing what they were doing before and try to find some other way to get though that craving.

Then there are people who have been on the other drugs before and may or may not have had good experiences, and they may also relate to experiences they heard from others. They may have heard someone say, ‘Oh I tried that drug, and I just had bad side effects.’ So they don’t even want to try the drug.

That’s when the role of physicians can come into play though. They can ask, ‘Well, what were the things you heard, and what are some of the realistic benefits and side effects of the medication?’

We go over that with any medication we give to a patient. We have to talk about the risks and benefits. Sometimes they’ll say, ‘That’s not for me.’ Then we move onto another mode of cessation if they’re ready to quit.

Are counseling and medications equally important in helping a patient quit, or does 1 outweigh the other?

I think the best [approach] is to have both counseling and a chemical of some type, whether it be a nicotine replacement or bupropion or varenicline.

The counseling can take many forms though. Sometimes it’s a quit line, a telephonic help line, internet-related smoking cessation tools like Freedom from Smoking by the ALA program, and face-to-face programs. Primary care and pulmonary offices have wellness coaches who can help with smoking cessation. Sometimes, counseling can just come from loved ones who are going to be supportive and helpful and may have been former smokers themselves.

The worst situation is where someone really wants to quit but there are other people at home who are still smoking and don’t buy into the person trying to quit. You really need that support, and that’s what works the best.

If you look at people who try to quit cold turkey, usually 4% to 5% are successful.

What do you feel needs to be done to close the gap of existing challenges surrounding smoking cessation in the US?

The 1 thing to realize is that smoking is a very difficult addiction. The ALA has realized it’s a physical, mental, and social addiction.

The physical addiction has to do with the nicotine, which is a very potent drug that releases chemicals in the pleasure centers of the brain. The brain is very susceptible to that, especially in young people and adolescents.

Patients then develop the mental association of having a cigarette with their coffee and meals, and when they’re stressed—that becomes an addiction. The social addiction is the peer pressure. ‘I’m going out for a few drinks and everyone is smoking.’

Having people realize that there are those forms of addiction and trying to address all of them with medications, which address the physical addiction, and counseling, which helps with the social and mental addiction, is important. That’s why I think counseling and FDA-approved drugs work the best.