Too many doctors and other healthcare professionals fail to properly support nicotine addicts and fall short of their immediate duty of care – let alone help avoid a host of associated long-term health conditions – according to tobacco harm reduction experts from around the world, writes Chris Bateman for MedicalBrief.
This was the message from the 3rd Scientific Summit on Harm Reduction: Novel products, research & policy, a virtual event organised in Greece and held on 24 and 25 September 2020. The benefits of harm reduction were debated along with risks associated with the use of alternative tobacco products such as e-cigarettes, heat-not-burn products and snus.
Addressing Best Practice in Smoking Cessation Professor Georgios Goumas, director of the Cardiology Clinic in Athens and former head of the Cardiology Department at Athens General Clinic-Bioclinic, said: “It takes only a few minutes extra [with a patient] to triple the possibilities for successful smoking cessation.”
“There’s this perception that smoking cessation attempts don’t work, aggravated by most doctors lacking the knowledge and skills to help patients stop. We have to concentrate on achieving high rates of quitting or we’ll continue to face high cholesterol and raised blood pressures and all the associated, often-fatal conditions,” he said.
Goumas said that intervening effectively and early achieved far more with less money than later associated healthcare interventions.
Indeed, dramatically better healthcare outcomes would be possible if physicians, cardiologists, internal medicine specialists and other consultants were trained to help patients quit and-or encouraged to refer patients appropriately. Web-based monitoring and adherence tools were also under-used.
The professor “couldn’t agree more” with the American guidelines on quitting smoking, which state in the preamble that it’s difficult to identify any other condition “that presents such a mix of lethality, prevalence and neglect – despite readily available interventions”.
He pleaded: “They want to give-up; we have to help them. The problem is not tobacco addiction, but nicotine addiction. Surveys of long-time smokers show that over 80% say that if they had their lives over again, they would not smoke.”
Data expose addicts’ struggle
The summit was aimed at the international scientific community, health professionals, regulatory authorities and policy-makers. It was organised by the University of Thessaly and the University of Patras, in collaboration with the University of West Attica in Athens and the National and Kapodistrian University of Athens.
Another speaker was pulmonologist Professor Paraskevi Katsaounou, of the Division of Respiratory Diseases in the School of Medicine at the National and Kapodistrian University of Athens, said up to 70% of smokers wanted to quit while 40% made attempts. Only 3% to 5% managed long-term abstinence without medical help.
With the global trend being away from smoking, harm reduction alternatives were rapidly gaining market space. But which ones are most effective?
With only one exception that Katsaounou knew of, studies of the use of e-cigarettes in quitting smoking revealed a success rate of between 5% and 7%.
“It’s important to note that between 40% and 80% of smokers who tried to quit smoking using nicotine-containing e-cigarettes, continued to use ordinary cigarettes after six months. A metanalysis showed that the odds of quitting smoking using e-cigarettes are about 32% lower than nicotine replacement therapies,” he added.
Nicotine dependence is a disease
Guidelines worldwide agree that behaviour modification combined with pharmacotherapy is the most effective method of quitting smoking.
Katsaounou was at pains to emphasise that nicotine dependence is a disease.
Somatic (bodily) addictiveness on a scale of one to three stood at 1.8 – lower than cocaine but with withdrawal symptoms like cravings, headaches, irritation, decreased heart rate, weight gain, anxiety, restlessness, concentration difficulties, dysphoria (a state of unease or generalised dissatisfaction with life) or even clinical depression.
He said anyone analysing trials comparing nicotine replacement therapy or NRT (nicotine replacement therapy) with e-cigarettes or other heat-not-burn devices containing nicotine, should remember the way nicotine was delivered when smoking.
“When inhaling nicotine, it goes to the arterial blood stream and the left-hand side of heart, reaching the brain in less than 10 seconds. This is not case with NRT patches or other forms of NRTs; here it takes 10 to 20 minutes, using the venous stream and left-hand side of the heart and, importantly, with far lower concentrations of nicotine.
“With straight nicotine inhalation, blood concentrations rise quickly and after one or two hours decrease – so if you don’t smoke again, you quickly feel withdrawal symptoms,” Katsaounou emphasised.
Clinical trials showed higher short-term abstinence from cigarette smoking (18%) in those using e-cigarettes versus those using NRTs (10%). However, with NRTs almost all those who tried to quit all tobacco succeeded after a year (and quit NRTs), while only 3.6% of those using e-cigarettes and other heat-not-burn devices quit using tobacco product after a year.
Katsaounou said most doctors tended to underdose NRTs. He advised them to continue prescribing these for three months after the target-quit day, to suppress withdrawal symptoms.
Hospitals provide captive audience
Goumas said hospitals were the “ideal place” – satirically adding, “not gyms!” – to help nicotine addicts because they were often admitted after a cardiovascular event or a stroke and were therefore likely to be highly motivated.
“The risk becomes personal. Hospitals are also smoke-free zones. If we can get them to give up, there is a 36% reduction in crude relative risk. If we fail and they continue smoking after the admitting event, it’s the strongest independent predictor of future cardiac events,” he said.
Appealing to medical aid schemes or governments to subsidise NRTs, Goumas said this would vastly improve access to treatment.
He recommended the 2017 guidelines for treating myocardial infarction patients, which began by identifying smokers, gauging their willingness to quit, and advising what was available and why it was necessary before offering to help. This was followed by prescribing highly effective first-line pharmacotherapy and monitoring progress.
“You need to encourage if they fail at first,” he added.
Stressing the relative efficacy of NRTs, he said more than 30% of individuals who used alternative novel nicotine products were dual users, which increased the excess risk by 40% to 50%. Only 2% of current users of novel nicotine products were not smokers before, with many being children or adolescents.
The smoking industry advertised reduced risk “not because they care, but because they know that a nicotine dependency will do the job”, he added.
Research bias and smoker doctors
Katsaounou said that contrasting findings by authors of scientific publications supported one widely held notion – that where they had a conflict of interest with e-cigarette companies, scientists found less harm inflicted than autonomous authors who had no relationship with the tobacco industry.
Goumas highlighted another serious problem – smoker doctors. Research had shown that smoker doctors feel awkward and guilty when advising smokers. “They also present the benefits of giving up or harm reduction as lower and are less likely to help,” he added.
* The 3rd Scientific Summit on Harm Reduction was organised by the University of Thessaly’s Department of Biochemistry-Biotechnology and the University of Patras’s Laboratory of Molecular Biology and Immunology, in collaboration with the Department of Public and Community Health at the University of West Attica in Athens and the Medical School at National and Kapodistrian University of Athens.
[link url="https://www.nosmokesummit.org"]Click here to visit the 3rd Scientific Summit on Harm Reduction: Novel products, research & policy[/link]