expert tips to stop smoking now january 17, 2011 vicky...

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Expert Tips to Stop Smoking Now Webcast January 17, 2011 Vicky Fang, M.D. Yunyu Cao, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you. Introduction Andrew Schorr: Quitting smoking is certainly easier said than done. You know the risks, so what's the key to success? How can you quit smoking and stay a nonsmoker? Coming up, two UW Medicine physicians will share tips for success and reinforce the benefits of quitting smoking. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by UW Medicine Health System. I'm Andrew Schorr. Well, on our programs we talk about some very serious chronic diseases. We talk about cancer. And all the time when we talk to physicians and we say well, what--what can someone do for themselves to really help them be healthier, number one on the list always seems to be if you smoke, quit. And let's face it, there are millions of people who smoke and most of them have tried to quit, and I've heard some people try to quit as many as 20 times, and why didn't it work the first time or the second or the 10th time or the 15th time? Why is it so hard? Well, you may know that nicotine is one of the most addictive things. You know, some people say and I think some studies say it can be as addictive as heroin, so it is really, really tough. On this program we're going to give you some tips for success. And to help us do that are two UW Medicine internal medicine specialists. One is Dr. Vicky Fang. She is at the UW Medicine neighborhood clinic in Federal Way, and our other guest is Dr. Yunyu Cao, who is an internal medicine physician at the Issaquah clinic of UW Medicine. So let me start with you, Dr. Fang. So it is really tough. I'm right about how addictive it is, isn't it. It's just part of someone's life, and that craving is just so strong. Dr. Fang: Well, Andrew, thank you so much for inviting us to talk about this topic that's so near and dear to our hearts as primary care doctors. Smoking is definitely one of the hardest things we ever ask a patient to do in quitting. For us it's just a passion because, as you know, tobacco use is the number one cause of preventable death in the United States, and most smokers are trying to quit smoking. In many surveys, if you ask have you been trying to quit smoking in the past year, the answer will be yes. Well over 70 percent of smokers will say, yes, I have tried to quit in this past year, so we know it's something that is of great interest to people.


Tips for Success Andrew Schorr: Dr. Cao, so is there something you've seen in your patients that seems to help those people succeed where others have failed? Dr. Cao: Well, family support, that's a very important thing. So I very often heard it from patients, say, I'm trying to quit smoking. However, my husband still smokes, and he doesn't have any intention to quit smoking. What should I do? I tried several times, but every time I quit and then later on with people around me smoking, I smoke again. So that's one important thing to pay attention to. And then also, you know, some people, they need like a group help. So there are some groups can discuss about supportive groups, can talk about, you know, how you do, and deal with those cravings and then any tips people sharing around, that's also important. And then they really need to know that smoking itself is dangerous and then especially for those people who have heart disease or lung disease. And I usually tell people that if they can cut down smoking no matter how long they have been smoking it will be very helpful to cut down the risk of COPD, which is a chronic lung disease, and then also heart disease risk and then also, you know, lung cancer, so on and so forth. No matter how long they've been into it, it's never too late to quit smoking. They need to learn that as well. Andrew Schorr: Well, here we are in 2011. I imagine there are many of our listeners who have made a new year's resolution to stop. I want to tell a story because I understand one of the--one of the strategies is to set a quit date, and Dr. Fang, I'm going to ask you about that in a second. I just want to share a story. Now, I've been married 25 years now, but going back a quarter of a century my mother-in-law said to us, said, well, what would you like as a wedding gift. And we responded we want you to quit smoking. And we worked with her where she set her quit date as our wedding day. Put a lot of pressure on her. But how important is it, Dr. Fang, to set a date, make a decision that you really want to do this for all the reasons like we were just talking about, health reasons, how important it is to do that for your health. How important is it setting a date? Dr. Fang: Oh, I think that is an excellent idea, Andrew. Setting a date really helps us plan almost anything in our lives that is an important and difficult task to do. If you're not ready to set that date yet it's still a good time to be thinking about why you should quit smoking, and so don't be fearful about the idea of setting the date as the first step. The first step is really trying to convince yourself that it is time to think about setting a date. When you do get to that point and it's time to set a date, I agree with you. These stories come along to us in the clinic often, and just like your story, I can share one of a grandmother who told me that she didn't think that she'd ever be able to stop smoking


until her little grandson, who must have been just about at that age when children say such things said, Grandma, I don't think that there is a Santa Claus because if there was he would make you stop smoking. And indeed, she had to convince him that there was, and she stopped smoking for him. So I think setting that date and finding those motivations is very important. Andrew Schorr: One other comment from you, Dr. Fang, is we were just talking about family support, so you need to get that support. Obviously, if your husband smokes that makes it very tough if you're around it. Hopefully you can avoid that, but is it important also to tell others? Say, you know what, I've set a date. I really want to do this. I would really enjoy your support and help me through this because I know it's tough, or I've tried before. Dr. Fang: And I think family, even if they are not able to stop smoking at the same time, can still be supportive in this. I think it's probably a good idea to use the trick that we find helps people in the workplace, where most workplaces you can no longer smoke, you have to step outside. If you make that kind of commitment in your own home you can be helping that spouse who is trying to get away from your cigarette smoking while they're trying to quit. So there are lots of ways you can be supportive even if you as a smoker are not quite ready to help your smoking spouse quit. Andrew Schorr: Dr. Cao, you were talking about support. Now, I know that's important. So there are many facets to this, but you have medications as well, but it doesn't sound like there's a medication that's a magic bullet all by itself. Am I right? You have to have a number of parts to the plan. Am I correct? Dr. Cao: Exactly. So, you know, a study already done that, you know, smokers can quit without, you know, any intervention, meaning if without medication or without, you know, medical supply. They able to quit smoking as long as they have strong, you know, mind, saying, I'm not going to be smoking anymore, or, you know, with some sort of, you know, social help, and that's for most people can be helpful. However, there is a small group of people, yes, it's fairly difficult for them to quit smoke because, as we know, the nicotine is very, very addictive. And also, you know, it's kind of like a behavioral change for lots of smokers. They have been smoking for years, years, years. It's like a part of their routine life, so it's fairly difficult to change a routine life. And then also some people have kind of side effects or complications after they quit smoking, so like people concerned of weight gaining, people concerned about craving. And then people, you know, people have some kind of headaches, nausea. If they do develop those and they're trying, yes, there are medications we can try. But most people probably can do it just with strong mind, set a date, and then go ahead.


Substituting Habits: The Good and the Bad Andrew Schorr: Let's talk about people's fear of gaining weight, Dr. Fang. So somebody says, you know, I like the way I look. I understand there are health risks over time, but I like the way I look, and my friends who quit smoking, some of them have put on some weight. I don't want to put on weight. What do you say to them? Dr. Fang: Well, I've been in that situation many times, and I generally say if I had a diet pill that caused cancer and emphysema you would not want me to prescribe it to you. And I think turning it around and seeing it in that light is helpful for some people. I also let people talk about how smoking is a friend to them and how it has helped them keep their weight trim. If they feel they need to talk about that we talk about it as if, if you had a friend who came to your house and messed up your house you'd still have that friend leave the house. So I think it's important to recognize that, yes, there can be a little bit of weight gain when you attempt to quit smoking, but it pales in comparison to the health benefits of smoking cessation. And there are some things that you can do to try to minimize the amount of weight gain. There is a small effect of the nicotine increasing the metabolism, but most of the weight gain that comes from smoking cessation happens because people are substituting eating for smoking, and trying to strategize about how to quit smoking without substituting other bad habits is a useful approach to that problem. Andrew Schorr: Now, what about substituting good habits, Doctor Cao? What about saying you know what, instead of doing this behavior where I always reach for a cigarette I'm going to take a walk, or I'm going to watch a sitcom on TV something that is enjoyable, substituting? Dr. Cao: So I usually tell people, you know, if you want to nibble on something, if you want something in your hand, you can use a pen to write something, or you can use a candy bar, or you can also have some, you know, handful of nuts in your hands, and we all know those kind of nuts, almonds, all those kind of things, kind of healthy, lower our cholesterol, you know, lots of fibers. Why not doing those healthy habits instead of just, you know, smoking? And then those, you know, fruits, so they can eat more fruit, and then also, you know, they can have those kind of vegetables, celery sticks, you know, those kinds of things. And then instead of high calorie or smoking then they can have more fibers. It's healthy and it will not cause weight gain. So I think that will be helpful. The Delay Method Andrew Schorr: I've got another story. Part two with my mother-in-law. So after the wedding, so she had set the date, the wedding date. So what happened after that is she started chewing


nicotine gum. And, you know, we all have seen people chew gum, but, I mean, her jaw was going all the time. Dr. Fang, what about whether it's a pill or nicotine gum or a patch, but gum, I think, is sort of an oral gratification. Where does that come into play for some people? Dr. Fang: I think that can be very helpful for some people. I think the nicotine replacement systems, one of the nice things about them is they're so readily available. You can buy them without a prescription over the counter. The--they can be tailored to the individual smoker's needs, so if you're a very light smoker and a patch might be too much nicotine replacement for you, you can use the gum. And I think your point is really well taken, Andrew, that that oral need can be met just as Yunyu was saying with healthier things, and chewing gum is certainly one of those things as well. Andrew Schorr: We talked about a quit date. The way my mother did it was a little bit different. She had cigarettes all over the house. And she started to get them out of her environment. She decided she wanted to quit. She had had pneumonia, and the doctor said, you know, you're going to have a really rough go with your lungs if you continue smoking, so she decided she wanted to quit. The way she did it was she said she was going to delay having a cigarette. Normally I'd have a cigarette, you know, at this time of day, but I'm going to wait till later, and she just kept putting it off. So is delaying a way of doing it? Some people say, okay, I'm going to draw a line in the sand, but she did it a different way, Dr. Cao, where she just kept pushing it off. Dr. Cao: Well, as long as in her mind she knows that she needs to quit smoking, I think delaying is okay. Sometimes I tell people, you know, if you are able to cut down from one pack a day to half pack a day, you can do that. And then that's also like tapering down the nicotine level in your body, and then, you know, gradually, gradually, cut down from half to--half pack to five cigarettes a day and then later on to two, three packs--cigarettes a day, and then people, they will not feel that huge rush of nicotine withdrawal, and then maybe they're able to do that just gradually. So I think people, if they have mind saying, I know consciously I'm going to quit smoking but I'm going to do slow, I'm thinking they are on the right way to do it as long as towards the day, no more cigarettes. Dr. Fang: I have had patients successfully use the delay method. I had one patient who took their cigarettes and wound wire around the pack and then put the package in an inaccessible place so that every time she needed to or wanted to take a cigarette she would have that built-in delay to getting at the cigarette so that she had more time to think about whether or not she really wanted that cigarette or whether she could wait. And it worked for her. Andrew Schorr: That's like having to be a safe cracker.


Dr. Fang: Having to be a safe cracker. Sounds unusual and wouldn't work for everyone, but it fit her personality, gave her that extra time that she needed. One thing that people sometimes think is going to help them is to go to a lower-tar cigarette, and that's something, I think, where people may be fooling themselves a little bit because studies have shown that people will smoke those cigarettes a little bit harder and pull in sometimes just as much nicotine as they did on the other cigarettes. So, I think, while it's a good idea to smoke lighter cigarettes, it doesn't actually work for smoking cessation as much as you would think. Support Andrew Schorr: Dr. Cao, so let's talk about support. So there are these free telephone quit lines and things like that in most of the states. I know we have it in Washington State. So there is support there. You can go to in-person support groups, there are small groups that meet, but it can be as close as your phone, too, right? Dr. Cao: Yes, correct. So telephone therapy, it's like a constant support and a reminders, and then to say on the track, and then that helps people to trying to quit. And then individual telephone counseling is a popular way. And then they just give you extra support and then reinforcement that you are doing the right thing. You are feeling--you have the normal feeling after you stop quitting smoke, don't be too nervous, don't be anxious. People sometimes they just need some reassurance, make sure that they are on the right track. So telephone therapy, I think that's a very good way to do, and it's cheap, you know. Dr. Fang: Here in the state of Washington we're really blessed with the 1-800-QUIT-NOW line. I've had several patients use that and be very happy with it. That's a service offered by the state, counselors waiting to talk to you about smoking cessation. And you can also go to their internet site, quitline.com. Dr. Cao: Yes. And then the quit rates are the highest for those who receive more intensive therapy in the form of multiple sessions of call-back counseling. So just back and forth, back and forth, and that just reinforces the therapy and then the successful rate. Andrew Schorr: Well, I know there's something like 40 million former smokers in the US. So, Dr. Fang, I know, really, when somebody is trying to quit smoking it may seem monumental to them, and they have this guilt about probably many failures in the past, but there are a lot of people who want to help, aren't there?


Dr. Fang: There certainly are, and as you point out there are a lot of people who used to smoke who feel very dedicated, and some of those people do work on the 1-800-QUIT-NOW line. As well, I think there are people like us who have taken care of patients who have died of smoking-related illnesses, and so we too feel very strongly about it. I think it's an important thing to know that you can get counseling very easily and for free at a place like 1-800-QUIT-NOW. And if you're coming into your doctor's office for any reason it's always a good time to bring up your questions about smoking cessation. Andrew Schorr: Let's go through that for a minute because our program is called Patient Power. So, Dr. Cao, so coach me a little on what I should say to you if I were your patient and now I really, really decided I wanted to do this and I wanted your help. What do I say to you? Maybe I came for the flu or something else, but what do I say to make this part of our agenda or schedule an appointment so that we work together and develop a plan? Dr. Cao: Well, some people already have their agenda, and then a lot of times they come in and then they say, Doctor, I need to have something to help me to quit smoking. I smoked for so many, many years, and now I have tried several times. I heard it from my friends that there are some things you can help to prescribe for me to help me for quit smoking. And some people come in, they just come in for, you know, some routine checkup, and then they can say, yeah, Doctor, you know, I'm smoking. Do you think smoking can cause some of the illness I'm having? Some people have, you know, asthma, or some people have lung issues. Some people have frequently kind of pneumonia, bronchitis, and they can pose the question that because, you know smoking certainly can be the trigger and then that increased the risk. Also, you know, when people have diabetes, high blood pressure, you know, all those metabolic syndromes they should be aware of smoking can cause, you know, all those kind of strokes, coronary artery disease, and they need to be--cautiously be aware of smoking is a very bad, bad risk. And then when they come in to get those routine checkups they can also ask, you know, Doctor, shall I do something with my smoking? I'm having difficulty to do that. However, on a contrary side, as doctors, we also routinely ask those questions. Are you ready to quit smoking? Do you have a set date? How many cigarettes you are smoking a day? So you know, it's not one side effort. It needs to be both sides. Benefits & Success Andrew Schorr: Dr. Fang, let's talk about that partnership for a minute. It probably makes your day as you have patients maybe you've known for a long time who have been smokers where you and maybe other support have all worked together with them, and they actually have quit.


Dr. Fang: Oh, very much so, Andrew. And one of the things in our line of work is sometimes we're not sure which seeds we plant will finally sprout, and so it can be one of the great pleasures of your day when a patient comes back and says, hey, I saw you last year at my physical, and we talked about smoking cessation, and, guess what? I went through with it and I'm a nonsmoker now. And that is a thrill for us. Part of primary care is what we don't see, and what we enjoy the most is not seeing you when you come in with a cancer or a heart attack, and so it's a quiet, subtle victory but an important one for us. Andrew Schorr: I can imagine. If you were going to sum up, though, in your experience the components that come together, and I know it varies by person, to put them over the hump, if you will, what would those be? What were the factors when you think back generally that have helped your patients quit smoking once and for all? Dr. Fang: I think the number one most important thing is that they want to quit and that that desire to quit is strong enough for them to look for help. That's a number one thing. The help is out there, whether it be the support groups or the family members who want to help, their primary care doctors who want to pitch in. The number one thing is that they make that decision to quit. Once they do I tell them it's going to be hard, but we can help you. And we can help you with some tips. The smoking counselors can help you with some tips, and there are some medications that can sometimes ease the discomfort of smoking cessation. But that number one thing is the desire. Andrew Schorr: And just one other point for you is, when somebody does it, how much of a difference have they made for their health, and maybe emotionally feeling that they have succeeded? Dr. Fang: Enormous. You know, I think to all of your listeners who have quit smoking they can tell you that it's one of the hardest things they've ever done and one of their proudest accomplishments. And as physicians it's one of our proudest accomplishments if we can participate in that success. So very much so. Andrew Schorr: Dr. Cao, so if 2011 is the year, this is the new year's resolution that really gets kept, support, I hear, maybe some medications to ease the way, but you'd agree deciding this is the time, I'm really going to do it. Dr. Cao: Yes. So every time you look at a cigarette you should ask yourself why you need to smoke and then, you know, smoke can cause lots of health issues, make you sick, shorten your life. And just remember if you quit now, no matter when, you will be healthier. Healthier. And, yes, I agree with Dr. Fang, quitting is very, very hard. However there are


many ways to help you, and we are here to help our patients, too. And then if you go to see your doctor, ask your doctor about how important to quit smoking. Anything we can help you to quit, and then, you know, any treatment groups with other smokers, you know, or the medication we can prescribe. So, you know, as doctors we would like to see our patients to be healthier, nonsmoking. Dr. Fang: And I hope your listeners will know that the benefits of stopping smoking will accrue immediately. So we've been talking a little bit about decreasing your risk of cancer and emphysema, but after just 24 hours off of cigarettes your risk of having a heart attack goes down. After just two days you start to have nerve endings that are regrowing if you have had some nerve damage from smoking. Your taste and sense of smell will begin to improve in that first week. Your circulation starts to improve in the first couple of weeks. So there are immediate benefits. They are not delayed. And if you are older and thinking that it's too late to stop smoking the answer is that it's never, never too late. Dr. Cao: Yeah, I totally agree. And there is another important part is it's saving money. Dr. Fang: Good point. Andrew Schorr: Right, right, absolutely. One last thing for you, Dr. Fang, and that is, as I mentioned some people have tried, five, 10, 15, 20 times, and then they started smoking again, and so you feel like a failure. And they can hear this and say, okay, I'll try one more time, but they're carrying that weight of having failed before. How do you get someone past that? Dr. Fang: Well, I think what they need to know is that's the norm. That's what is expected to happen, so I don't think we think anything of having--I don't think of it as a failure. I think attempts to don't end up coming to fruition are part of the process, and most people who stop smoking will have tried and had to try again many times. I liken it to learning how to walk. We don't say that a toddler who is getting up and walking and falls down is never going to walk. It takes a lot of effort, and it's an expected part of the process. Andrew Schorr: Well said, well said. That's a very good analogy, I think. I want to thank both of you. Dr. Cao, from the UW Medicine clinic in Issaquah, thank you for your commitment to patients and hopefully for helping people get on the road to quitting in 2011. Dr. Vicky Fang, from the Federal Way clinic, thank you for being with us. And hopefully we can get back together again and feel that maybe there are fewer smokers in Washington state with a little help from this conversation and some of tactics we've talked about. Ladies, thank you so much for being with us on Patient Power.


Dr. Fang: Thank you, Andrew. Dr. Cao: Thank you to have us. Andrew Schorr: Ladies, this is a great help, and, for our listeners, thank you for being with us, and we wish you better health. If you're a smoker we hope this is the year where you really turned it around and go on to a healthier life. Thanks for listening to Patient Power. And thank you to UW Medicine Health System for being such a long-time sponsor and bringing this education to you. Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.

expert tips to stop smoking now january 17, 2011 vicky...

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