John R. Polito

Physicians will exhaust their knowledge base, energy and skills to stop bleeding and save the patient's life. But when the smoking patient arrives, a patient whose circulatory and respiratory systems are being gradually devastated by chemical addiction to smoking nicotine, the patient's self-destruction and slow suicide are either ignored, or they are reminded of the obvious, "you need to quit smoking."

On February 7, the World Health Organization released a 342-page report entitled "WHO Report on the Global Tobacco Epidemic 2008." It opens with a full page reminder that, "in the 20th century, the tobacco epidemic killed 100 million people worldwide." It then predicts that, "during the 21^st century, it could kill one billion."

If true, how much culpability should be attributed to medical haste, apathy regarding smoking related disease processes, or ignorance of such elementary yet critical nicotine dependency recovery concepts as the "Law of Addiction," a principle backed by the fact that 93.5% of quitters who "taste" one cigarette during the first three months of quitting will experience relapse to smoking?

In June, my daughter graduated from medical school without receiving any formal instruction in how to counsel patients regarding our nation's leading cause of premature demise. Other than watching doctors advise patients during clinical rotations, primarily in use of pharmaceutical products, nearly all medical students graduate lost when it comes to substantive smoking cessation counseling. Regarding cessation pharmacology, once away from the hospital clinic environment, follow-up empirical evidence will quickly pound home the reality that these products perform dismally in real-world use. The new doctor will soon join an army of veteran physicians left feeling frustrated, defeated and betrayed.

As evidenced by the U.S. Tobacco Cessation June 2000 Clinical Practice Guideline, whose near worthless 2008 revision is nearing release, pharmaceutical influence has done its utmost to destroy effective competition by actually declaring all attempts to quit without pharmacology as being in violation of official U.S. cessation policy ("Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.").

Imagine a policy that actually denounces nicotine cessation in favor of three months of nicotine replacement, or use of other dopamine enhancing chemicals. In February 2007, the Wall Street Journal attacked the ethics of the revision panel's chairman, in having substantial financial ties to the quitting product industry. Defiantly, he has refused to step aside.

In providing a pharmacological solution to what's primarily a behavioral problem having roots in true dependency, both the quitting aid industry and the U.S. Guideline hide the reality that 80 to 90% of all long-term successful ex-smokers continue to be cold turkey quitters, that industry consultants have found that the over-the-counter nicotine patch and gum have a 93% six-month relapse rate, and that outside of formal clinical trials, that pharmacology has failed to prevail over those quitting without it in nearly every head-to-head quitting survey conducted to date. But why?

While the double-blind format has served as the gold standard in pharmacology study, in drug addiction studies it has been a license to steal. In what other study area are those randomly assigned to the placebo group made dramatically worse by being thrown into full-blown drug withdrawal? None. Studies show that drug addicts with any quitting history know what it feels like to experience full withdrawal. For far too many, it wasn't a matter of guessing group assignment, they knew. Drug addiction clinical study efficacy findings do not document performance but rather expectations that were either frustrated within the placebo group or, to some degree, fulfilled by active group assignment with enhanced dopamine flow.

The only honest means of conducting drug addiction studies is to openly service each group's unique cessation needs following randomization. Abrupt cessation quitters benefit greatly by daily counseling and support during the first three days, the period during which the body is purged of nicotine and peak withdrawal achieved. Almost daily provider telephone contact during the next ten days will transport the majority of smoking patients to a point where their now arrested dependency is no longer doing the talking, where they can again sample and taste the flavor of a nicotine-free life.

Those engaged in gradual stepped-down nicotine withdrawal via NRT, or a significant period of dopamine enhancement via bupropion or varenicline, would be best served with initial counseling designed to support successful transfer to the dopamine enhancement product, followed by ongoing periodic support during product use (usually 10 to 12 weeks). Additional counseling and follow-up should intensify slightly at the point when the patient ends product use and makes that final adjustment to natural dopamine levels.

Historically, smoking cessation counseling has rarely been taught in medical schools. A 2007 study found that only 18.3% of Jordanian physicians surveyed had received training, either in medical school or thereafter, on counseling patients about smoking. In the U.S., according to a 2006 review of 2001-2004 National Ambulatory Medical Care Survey, 81% of smokers did not receive physician cessation assistance.

I just completed presenting two-hour nicotine dependency recovery seminars to thousands of inmates in 28 state prisons that recently went tobacco-free. In a number of prisons attendance was mandatory for those with a recent history of purchasing cigarettes or oral tobacco. It was impossible to ignore their hostility upon arriving, as it was communicated in their faces, gestures and comments. But by program's end, most were applauding and expressing thanks. But why?

For the first time ever, they understood the purpose and function of brain dopamine and fight-or-flight pathways, and how they combine to produce nicotine's chemical high, a stimulated "aaah" sensation. The PowerPoint presentation they viewed showed how the super-toxin nicotine, via acetylcholine pathways, hijacked and tricked the limbic mind into believing that arriving nicotine was a species survival event, every bit as real as eating.

You could see mental light bulbs going off as they realized that dopamine pathway "aaah" sensations experienced when anticipating eating food, or actually eating, were no different than the "aaah"s experienced when anticipating smoking or actually doing so. On the punishment side, they couldn't help but notice parallels between eating and nicotine, in how the limbic mind gained compliance via insula generated urges, anxieties and craves.

They watched the brain attempt to defend against the presence of nicotine and too much dopamine flow by up-regulation and down-regulation of nicotinic-type acetylcholine receptor counts in at least thirteen brain regions. Most departed with a crude understanding of tolerance, de-sensitization and why they gradually increased their nicotine intake over the years.

Imagine standing in a gym in front of 300 inmates in a maximum security prison where about one-third face life sentences. Imagine, within 30 minutes of arrival repeatedly pounding home the message that they are true drug addicts in every sense, with a dependency every bit as real and permanent as alcoholism.

Getting nicotine addicts to fully accept dependency provides two immediate benefits. It simplifies the rules to quitting. Like alcoholism, it's all or nothing. There is no having your cake and eating it too, no figuring it out, no in-between. Full acceptance also destroys the need for their long laundry list of smoking rationalizations. They were taught that, if un-replenished, the amount of nicotine in their bloodstream would fall by half every two hours. Nicotine's half-life compelled replenishment, as a rising tide of anxieties would begin to hurt if they didn't.

Physicians can and should aid patients in destroying smoking rationalizations. Smoke for taste? How many taste buds inside human lungs? Relaxation? Nicotine is a powerful stimulant that makes the heart pound 20 beats per minute faster. Choice? There are only two choices, either replace declining nicotine reserves or endure the onset of withdrawal.

Like, love? What basis remains for honest comparison? None. Their addicted limbic mind long ago buried nearly all remaining memory of the calm and quiet pre-addiction mind they once called home. Ask them what it was like going months and years without ever once thinking about wanting to smoke nicotine. It isn't that they like smoking but that they don't like what happens when they don't smoke.

Regarding recovery, physicians need to teach patients how nicotine, via their fight or flight pathways, had instantly fed them stored fats and sugars, allowing them to skip breakfast (and in my case lunch) without ever feeling hunger pains. It is critically important that they understand what will happen if they continue to skip meals during early nicotine cessation.

Keeping blood sugar stable aids in avoiding adding hyperglycemic-type symptoms to nicotine withdrawal, including hunger pains, anxieties and an inability to concentrate. Encourage them to purchase and drink natural fruit juices for the first three days. Cranberry is excellent.

They should be taught the basic relationships between nicotine and stress, alcohol, and caffeine. They need a recovery roadmap and realistic expectations regarding the phases of recovery: (1) physical withdrawal and re-sensitization; (2) crave trigger cue extinguishment; and (3) and moving beyond conscious thought fixation and at times what can seem like a sea of pesky smoking related thoughts.

What would it say if prison inmates were better trained in helping their loves ones quit than physicians in connecting with patients? I wish this were simply some idle, uninformed comment. But, part of my life has been spent reading and condensing medical records in social security disability claims. Although the majority of claims are heavily infected by smoking related disease, rarely do I encounter physician records that do more than recite the amount or number of years the patient has smoked.

Truth is, most physicians do a horrible job at providing smoking patients the basic knowledge needed to understand the seriousness and gravity of their own gradual self destruction. Although I expect many physicians know that roughly 42% of smokers claimed by smoking will die of smoking related circulatory disease, try to locate any smoking patient who is able to explain how nicotine and carbon monoxide combine to destroy circulation.

Likewise, most doctors would be challenged to locate any smoking patient without emphysema, who can explain what it would feel like to try and breathe with it, or who can name even one of the four major types of lung cancer, it's characteristics or warning signs. If not the physician's responsibility to use education to motivate improved health, then whose?

Inmates at all 28 prisons were provided a comprehensive list of nicotine cessation tips. Although the Internet is loaded with free, high quality nicotine cessation tip sheets that can be downloaded, printed and shared with smoking patients, try to locate any physician who has actually handed a patient quitting tips. They're rather rare.

Inmates also now have prison library access to copies of "Never Take Another Puff" by Joel Spitzer. Spitzer is one of America's most studied nicotine cessation counselors and more than a million copies of his free book have been downloaded via the Internet. Physicians are free to print and distribute his book so long as patients are never charged for the book itself.

Sadly, far too many physicians callously expose waiting patients to magazines filled with tobacco advertising instead of making quality quitting guides standard fare in waiting areas. Imagine the subliminal message sent when the reading material selected and supplied by the doctor encourages the patient to smoke or use oral tobacco. Imagine the seriousness attached to a physician's quitting admonition when their waiting room shouts a contrary message.

What physicians need to ask is, what dependency recovery learning takes place by slapping on a patch, swallowing a pill, chewing nicotine gum, being hypnotized or when stuck with needles? None, absolutely none. Knowledge truly is a quitting method, but it cannot be shared unless and until physicians are willing to themselves admit that their understanding of nicotine dependency recovery is seriously lacking.

Although physician-patient contact time will always be at a premium, a smoking patient waiting in an examination room to see the doctor reflects both a captive audience (almost like prison inmates) and a golden opportunity to dim the lights and treat the patient with a healthy dose of education.

Imagine a short 15 minute video clip or a physician recorded automated PowerPoint presentation playing upon an exposed exam room wall, a wall teaching patients: (1) the price their body is paying, (2) how and why their mind became nicotine's slave (3) how to arrest their dependency, including crave coping techniques, or (4) relapse prevention.

If the billion smoking related deaths predicted by WHO are to be avoided, the standard of care must quickly evolve so that ignoring nicotine dependency recovery is a clear and recognized deviation from it. Unless physicians fully embrace their patient health education responsibilities, then all patients will learn is what pharmaceutical industry direct marketing continues to teach them.

Every physician encountering nicotine dependent patients must have some means of instructing them regarding the time needed to rid the mind of all nicotine and achieve peak withdrawal, and the law of addiction, the fact that they are not fighting a whole pack or even a whole cigarette but just that one powerful puff of nicotine that would, within 8-10 seconds, cause roughly 40% of their brain's nicotinic-type acetylcholine receptors to be occupied, creating a powerful dopamine explosion that their mind's priorities teacher would find nearly impossible, in the short term, to ignore.

Increasingly, both health insurance and government programs are showing greater willingness to compensate physicians for nicotine dependency recovery counseling. Just one or two wires running from an existing office computer to a less than $1,000 examining room LCD or DLP projector and a less than $50 speaker could instantly deliver your personalized counseling message to smoking patients. PowerPoint presentations can be made to sequence automatically with your voice on recorded audio clips, explaining exactly what the patient is seeing and why it's important.

The only limitations on a physician's ability to successfully counsel smoking cessation is dedication, imagination and a willingness to have either themselves or a staff member master the basics. Joel's Library is an excellent starting point.

---

---