New York City endodontist recently interviewed Dr. Mary O’Sullivan of Mount Sinai Hospital about smoking cessation. Dr. O’Sullivan specializes in pulmonary medicine and is a smoking cessation specialist.
The Doctor wanted to not only dig into the effects of smoking and why some people just can’t seem to quit cigarettes, but also what smoking cessation entails and how it works for those people with extreme addictions.
Read on to learn how and why people start smoking, why it’s so difficult to quit smoking, and what doctors, dentrists and specialists like Dr. O’Sullivan are doing to help.
The Doctor: Do you ever have information sessions for the general public?
Dr. Mary O’Sullivan: It’s hard to get people to show up. People don’t show up for smoking cessation discussions as much as you would think, which is why I think doing it in the office while they’re there for their visit, getting providers more comfortable with speaking about it directly is a very efficient way to go. Trying to get people to show up for a smoking cessation discussion is difficult. People are very private about it. They don’t like to talk about it in groups. We had a group and people didn’t want to do the group. The patients that I see mainly have disease; they have COPD, cancer or coronary disease. There is so much stigma and shame associated with smoking, it’s really quite remarkable. I think it holds people back a little bit in terms of being open. The one-on-one with the dentist and the hygienist, that’s very powerful.
TD: You’re a smoking cessation specialist. What extra training do you get from, let’s say, an internist or family doctor, that makes you a specialist?
MO: I’ve done it for 17 years now. I went to Mayo Clinic and spent up to a week training and I’ve been doing it ever since. I’ve spent a lot of time with the literature and patients. I’ve developed a sort of expertise in doing it. Again, it’s not something that’s rocket science. It’s not something that requires tremendously complex knowledge. It does require an ability to talk and to listen to folks and to help them move along in their behavior. That concept was very new to me. I have no training as a psychiatrist or psychologist and yet behavioral modification is what we do when we’re taking care of patients all the time. This was a golden opportunity to learn how to change people’s motivation and being able to move them along in a process that’s incredibly difficult. At Mayo, they had one of the sessions with a psychologist and psychiatrist on how to do that and so I utilize all that in the clinic and in teaching that I do. I spend a lot of time teaching other people how to do it. The use of the medication, that’s pretty straight forward. I think people may be hesitant to do it because they haven’t used these medications as much. I think the biggest learning part is how to speak, how to listen, how to move people forward, how to get them to engage without getting them annoyed and angry, how to open the subject. These are skills that over the last 17 years I’ve been working on.
TD: By training you are a pulmonologist, when you focus of smoking cessation do you have to have a training in pulmonology?
MO: Absolutely not. Internists, a social worker, psychologists, dentists, oral surgeons, anybody. You have to have a certain knowledge on how to speak and listen to a patient. Only certain providers can write prescriptions, but anyone with straightforward training can learn how to move a person forward in this process. There are people who are certified and that’s something relatively recent that they put in certification for smoking cessation. The closest one is in Rutgers and you can go for training for a week and become a certified tobacco cessation specialist. But you don’t have to do that in order to do smoking cessation.
TD: So it’s not a recognized specialty as of now?
MO: I think it’s in process. It’s not something that you have to have certification to do it. I would love it if every center had a certified smoking cessation person there. It’s not just about knowing how to do it, it’s having the energy to move it forward and to change the culture of the institution is what you’re talking about. Have everybody thinking it’s their second nature, of course they’re going to give priority to smoking cessation. You need a point person to do that, somebody who’s had a certain amount of training and enthusiasm for it.
TD: Besides Mt. Sinai West, are there hospitals in the city that have smoking cessation programs?
MO: The VA system has programs. The program that I run is different. When you come to see us, you’re going to see a physician. It’s not a class. It’s really a one on one visit where we sit down and we talk about what your medical conditions are, including the teeth, and how it relates to your smoking. We talk about your risk factors for disease and the interaction between the genetics of your nicotine receptors determine how addicted you are. That’s such a big issue for patients because they don’t realize that so much of smoking is biologically and genetically determined, because of their nicotine receptor. I’m sure you’ve been looking in the mouth of someone who has terrible teeth and issues with their mouth and you can’t understand why they’re still smoking. And they can’t understand why they’re still smoking. Part of the education there is to communicate that it’s dictated in large part by the kind of nicotine receptors you have. And that then determines how addicted you are and how hard it is for you to quit.
TD: Are there behavioral, physiological or genetic risk factors that increase the likelihood of an individual developing an addiction to smoking? How are the treatment modalities targeting these elements? You must have a repertoire of treatments available. How do you decide as a doctor which one to utilize and how do you profile a patient?
MO: Right now we do know that 50 percent of the starting of smoking is genetically determined; 60-70 percent of the continuance of smoking is genetically determined. This is hugely important for the patient to understand. When I’m talking to somebody with lung cancer and they can’t figure out why they can’t quit and I tell them it’s their biology, it’s not that you’re a weak, lazy person with no strong moral fiber. I usually bring up a picture of President Obama because he’s such an ideal, highly motivated, disciplined, good person and he has this nicotine addiction. Who knew? There’s such a stigma associated with smoking that they don’t realize it’s biologically determined. And people who are smoking nowadays are what I call the [inaudible]. Anybody who could quit easily did. In New York City they’re surrounded by information, they’re surrounded by scorn. Anybody who smokes, they’re a pariah. They’re surrounded by all sorts of reasons why they would quit and yet they haven’t. The reason is the nicotine receptors they have. So how does that translate into how we treat them? First, we try to get rid of the guilt because that really holds you back. It also says that I, as a provider, understand how hard it is for you to quit and that’s a huge thing. Most providers can have a little bit of an attitude of, Ugh! They’re not going to quit! And that’s totally destructive. That ends the game right there. What we have to do is understand how addicted they are and convince them that we believe that they will succeed. And try and get them to believe that they will succeed because they’ve tried 52 times and it was overwhelming and they couldn’t do it. Then we look at a couple of things: medication and behavior. If you’re a person with a higher level of addiction, you need medication to succeed. The success rate of quitting cold turkey is 4-6 percent. Folks who are smoking now need to use the medication whether they’re going to use nicotine replacement, Wellbutrin or Chantix. Those are the three medications that are approved for this program. They double your chances of success, for some people it’s more than that. We use combination treatment to assist with that or combining different forms of nicotine replacement. There are studies combining Chantix with nicotine replacement to get a little bit further along. Initially Chantix was only used alone, but now we have data to say it can be used in combination with nicotine replacement. There are studies to look at who’s going respond best to nicotine replacement versus who is going to respond best to Chantix and Wellbutrin, but those aren’t commercially available yet but I’m sure it’s coming. We do know that some people are fast or slow metabolizers so they respond differently to these drugs. And even different races have different rates of metabolism, pregnancy has a different rate, teenagers have a different rate. The biology depending on all this is in progress. We don’t yet have clinically available tools to determine who’s going to do best with what medication, so we do have to use clinical judgment.
TD: When you prescribe the medications, how are they used? Are they to wean off the addiction or are they life-long medications like insulin?
MO: Nicotine addiction is a permanent addiction and this is a very important point for people to recognize. They’re always going to be vulnerable to the relapse. The relapses are common and frequent. I think the literature is reflecting that. Yes, let’s use longer term nicotine replacement. Let’s use Wellbutrin for relapse prevention. Let’s use longer courses of Chantix. That’s definitely the direction the literature is going. Lifetime we don’t have data. We know people relapse repeatedly. If I have a patient who has lung cancer, throat cancer or coronary disease who relapses frequently, I’m going to keep them on their medication longer than I would somebody who wasn’t looking at that terrible diseases that are going along with it. There’s a spectrum. But no, people don’t stay on lifetime medication.
TD: How long is a typical course of a treatment?
MO: A couple of months; it’s individual. A good deal of it is determined by the kind of biology you have, but also your behavioral situation. If you’re living with a smoker, if you have a problem with alcohol, if you have other addictions or you’re living with tremendous stress it’s harder to quit. Nicotine makes a person able to cope better. So there’s the biological part and then there’s the sociological and psychological part. It’s very difficult for people in certain life circumstances to even think about quitting when they’re under so much stress. It’s a combo thing and very individual.
TD: When a patient is undergoing treatment in a smoking cessation program like yours, is the approach a team approach (e.g. a physician and psychologist or psychiatrist) or does one practitioner typically manage it? I know some addictions require a team approach, but how is it with smoking?
MO: I think every place is different. We write the prescriptions and do the behavioral modification ourselves. If a person has a serious mental illness and has a psychiatrist, we certainly work with the psychiatrist. People with serious mental illness are a big component of the smoking community because it helps them cope with their mental illness. It works as an antidepressant and helps with hampering stress, so there’s a lot of psychiatric interaction. We work with the psychiatrist to get there thoughts, input and support in the process. But every program is different. Programs like the Quitline are very effective and they have very good counselors. That’s one of the things, that’s a really simple thing, you can do in the dentist office is to make a referral to the Quitline.
TD: Some addictions are very refractory. There are different types addictions, there’s of course substance abuse all the way to an eating disorder, for example. There’s components of addiction to that. Treatment of certain types of addictions, typically there could be a healthcare team from a psychologist or psychiatrist, and in the case of an eating disorder, sometimes a dentist gets involved. In terms of dealing with smoking addictions, a typical program in this day and age, does it involve a physician managing it? Or are there typically a group of people helping them? Since you mentioned that the relapse rate of high and the cases that you say in an environment like New York City where everyone is opposed to smoking, compliments of Michael Bloomberg, there seems to be the more difficult cases. Are the teams involved typically a general practitioner or does a smoking cessation specialist manage the patient?
MO: It’s absolutely appropriate for a primary care physician to be handling the smoking cessation if they feel comfortable with it. The training for smoking cessation was not the standard part of medical school for many years. Lots of practitioners may not feel as comfortable as they might, but I think that’s changing as the culture of the times change. Having the luxury of the whole team is a wonderful thing. I don’t know if having a psychiatrist/psychologist, and a provider and social worker, that sounds great, but that would be a very special set up. Paying for this is also how you do it. How do you pay for a smoking cessation program if you have multiple professionals involved? It’s a costly thing.
TD: It’s certainly costly, but is it more costly than a lung or heart transplant? Is smoking a disease?
MO: Absolutely. It’s a chronic illness and it should be viewed as that. Nicotine receptors change with exposure to nicotine. You develop more of them and they become more demanding. The whole physiology of your brain is affected. It’s definitely a disease.
TD: What percent of smokers during their lifetime develop other ailments from that?
MO: Oh I can’t tell you a number. It’s very very high though. Smokers die earlier. What percentage develops heart disease? What percentage develop mouth cancer? I couldn’t quote numbers, but those numbers are certainly available. Smokers are 5 to 10 times more likely to develop oral cancer. In terms of lung cancer, I can’t give you the numbers.
TD: The treatments that are available to smokers these days, how would you characterize their effectiveness? If you were to have an outcome assessment these days versus 10 to 20 years ago, would you say the effectiveness has changed?
MO: We have a little bit more understanding how to use them and we have more understanding of how difficult the addiction is. For example, when you used to use nicotine replacement for a short period of time, we wouldn’t do that with heroin. We wouldn’t give people methadone for six weeks or two months or three months we’d obviously give it a much longer period of time. And this addiction every bit of severe as a heroin addiction. Our understanding of the [ ] of the disease has changed. Our understanding of how it affects our mind, how there’s a plasticity of the brain, that you actually develop physical pathways that tell your brain it’s time to smoke. The neurobiology here is incredible. It’s a physical thing like Pavlov’s dogs; they sit and you give them a biscuit. You walk into a place where you usually smoke and the brain, just like Pavlov’s dogs, says it’s time to smoke. We didn’t understand that before that it was biology that was driving all this. That changed our understanding of the use of medication, how we need to interfere with the biology to get a person through it. The only thing is, and this is the more recent change, is that we always talk about a quit day, going for zero, throwing out the ashtrays and letting everybody know. And, you know, put on your patch and away you go and that’s really changed because again. We’re dealing with people who are terribly addicted. A lot of those people can’t even begin to think about quitting. It’s just a total impossibility for them. In the past year or two we’ve realized we can reach a lot more people if we talk about cutting down. Just cut down, then we can go the next step, but don’t not start. That’s a very important concept; it’s new.
TD: From your experience as a doctor, what are the common excuses people give to themselves that prevents them from going and seeing a smoking cessation specialist to get help?
MO: The number one thing is they believe they can’t do it. They believe it’s impossible for them to quit. Here’s an example I like to us. Let’s say it’s the morning and the children are late for the school bus. You really want your cigarette really badly, then someone spills the milk and the usual craziness of the morning happens. You’re really really stressed and you know if you have just one puff, you’ll feel a million times better. The stress gives you craving, the craving gives you excess acetylcholine, you become agitated, angry, upset, irritable. You can’t handle it. Then you know that if you take a couple of puffs, because of the delivery system, the relief is so fast that you feel better and that you can cope. It’s a really tough addiction.
TD: For those who don’t smoke and wonder why they can’t stop, what does smoking deliver to them in that difficult circumstance that you described?
MO: It’s a variety of neurotransmitters. The one most referred to is dopamine, which is released by the nicotine receptors when they get nicotine. You feel better, you think better The list of neurotransmitters that are listed is a really long list; there are a number of them. It really affects how your brain is able to function. One of the things that I think providers are helped by if they understand, the nicotine receptor, we have acetylcholine in our brain and it’s a lot of how we think and operate. It’s a big factor in how we operate. There are two kinds of receptors: nicotinic and muscarinic. Nicotine is binding to the nicotinic acetylcholine receptor, so it’s in charge of cognition and mood. It regulates so many components of thinking and our ability to operate. And when nicotine gets in there? Wonderful! Off you go. When there’s no nicotine there and you’re in withdrawal, what the brain does to respond to that is put out excess acetylcholine. And so what does that do? It makes you irritable, anxious and really agitated.
TD: So the absence of it has a positive feedback towards the deterioration of your mood? (positive feed back, means the increased sense of agitation, makes the patient even more agitated. The keeps going through an increasingly more violent loopback, which with each loop the intensity gets stronger).
MO: Absolutely! They compare it to a person with psychiatric illness becoming agitated. It’s physically unpleasant, some people says it’s like walking on glass. But the problem with the cigarette is that if you just have a puff, it goes away. That’s really tough addiction. That doesn’t happen to the people who quit easily. They don’t understand why a person who is smoking with gum disease or oral cancer or heart disease. They don’t understand what they’re going through. And the people who have that addiction, they really believe that they can’t do it. The one thing you can do to convince them is to say I know you can do it. It’s a tough road and I understand the addiction, but I know you can succeed.
TD: The reason you’re saying you know they can succeed, when you’re a doctor you’ve seen a million cases like that. But the reason is the pharmacological agents that you prescribe, will that substitute the relief they get from the nicotine spike?
MO: Right. It blocks a lot of that. Nicotine makes nicotine withdrawal go away. And when I say to patients, their face relaxes. You can take care of that part if you get the right dose of nicotine for what you’re used to. People will say they used it before and that didn’t work, but it will work if you get the right dose. That agitation is nicotine withdrawal, so nicotine replacement really works.
TD: What else are you trying to treat with Wellbutrin and Chantix?
MO: Wellbutrin also affects the nicotine receptors. It works in a different way. We don’t know the details of how Wellbutrin works, but we know if you take it between10 days and two weeks, you don’t think about smoking so much, you don’t feel like smoking, it doesn’t taste so good.
TD: So empirically it works?
MO: Yes, with time. Chantix is an amazing drug because it was developed to bind specifically to the nicotine receptor. It gets off about 60 percent of the dopamine that a cigarette would do. But on top of that, if you smoke, you get no pleasure. So it blocks the receptor as well as giving you some of the dopamine. So by blocking the receptor everytime you smoke, you get no please, so it undoes that cycle of needing pleasure and relief. It works very very well.
TD: You have mentioned a few things that I would assume may sound frightening to a patient who hears this for the first time. One of the comments that you said was that if you were to profile genetically the individuals who have a refractory case of tobacco addiction, they seem to have a more genetic predisposition to that. Does that mean to a lay person who has no medical understanding that they are destined to be smokers and that there isn’t much you can do for them?
MO: No, it means just like with alcohol you have to recognize that you have an illness and then you go forward prepared. The person who doesn’t have those genes is probably able to smoke on a Tuesday and not think about it again until two weeks from now. Whereas the person who has the addiction and has those genes, they can’t do that. They have to get to zero.
TD: So you satisfy their urges pharmacologically in that case, not just simply telling them you can do this?
MO: Right. Oh definitely. The two things have to go together. You have to do both. For people who are smoking nowadays, they would have quit if it was easy. They need the behavioral part and the medication.
TD: Is there any data on how effective treatment for smoking cessation is for someone who you do not profile as a refractory case versus a refractory patient?
MO: I didn’t quite understand. The person who has a milder addiction?
TD: If a person who has a milder addiction, you’re saying it’s easier for them to quit smoking. When a person who has a refractory case of addiction, where they’ve tried it and they’ve tried nicotine and it didn’t work. Do you have any data on how many rounds of treatment it typically takes for a more difficult case to be successfully treated and they abstain from smoking going forward?
MO: It’s a refractory illness, so they relapse and relapse and relapse. I don’t have data on how many relapsed 20 times, but they’re not rate. What we do by combining the behavioral modification with the medication is that you have to deal with the behavioral part. So it’s not just the medication. How do you handle stress? One of the things we do is say what are your triggers? What are the things that make you get that craving? Coffee, alcohol, teenage children, mortgages, etc. We make an actual list and try to concretely say how can we handle that? What can we do for pleasure? What other pleasures can we put in our life? How do we handle stress? How can we handle stress? Can we go to the gym, can we do deep breathing, can we do yoga, can we pray, can we meditate? We try all of those things. Every once in awhile you’ll hit just the thing that will help that person.
TD: [inaudible] coping mechanisms.
MO: Coping mechanisms and the void that is left by what the nicotine did. That has to be taken care of. They need other pleasures. They need ways to relax. What do you do when you’re bored? What do you do when you’re angry? You’ve got to have a plan because in that moment, the first thing that’s going to come to your mind is have a cigarette. That’s part of the lifetime skills. We sort of reprogram the brain on how to handle those situations that you’ve used the cigarette to handle. That’s a vital part of it. I didn’t mean to emphasize the medication to the exclusion of the behavioral. The behavioral part is really important to put in place along with the medication.
TD: Why did you dedicate your life or focus your life on helping individuals with smoking as opposed to other ailments?
MO: Oh I do a ton of things, this is only one of the things I do. So much of pulmonary medicine is caused by smoking. So much of health and disease is caused by smoking. I watched my father, he had throat cancer, he had leukemia. You see this unnecessary death, and wow, that’s really an unnecessary suffering. You say, gee, this is… You have to take care of so many lung cancers, that you say oh my god. I used to give the talk on lung cancer to the fellows of the year and I’d say smoking cessation is really important. Then I realized they didn’t know [inaudible] how to really do it. And then I decided I better change this. This is a basic premise of pulmonary medicine. Somebody else will do it or I’ll send it to somebody. But you can’t. That’s another thing to think about actually. The show rate of smoking cessation programs is 20 percent.
TD: By patients or by doctors who are trying to educate themselves?
MO: By patients. Any barrier, the difficulty of showing up is so overwhelming to patients in this circumstance. That’s why, to me, the approach has always been we have to train every provider that sees a person who is a smoker to take it on themselves and move that person forward. People don’t want to go to another program. If you look at people who have bladder cancer, for instance, or people who have throat cancer, those are the two cancers where they’ve looked at how many people who come to a cancer center will say that they’re a smoker. If they’ve looked at that bladder and throat, 50 percent of the people say they’re not smokers.
TD: Even though they’re smokers?
MO: Even though they’re smokers, right. It’s that hard to deal with it, the stigma of being a smoker, especially a smoker who’s got cancer. That’s a huge stigma. The stigma of it all is so impossible to cope with. So if you’re sitting there in the chair and your dentist, endodontist or hygienist is working with you, and you say Is it OK if we talk about your smoking? It’s a good question to say because it doesn’t get them angry. What do you think about your smoking? What do you think would happen if you quit? Open ended questions; let them talk about it. Then follow their lead in terms of what they worry about most with their smoking. It may be their teeth, heart, wrinkles or cost. Follow what they worry about and then come back to Your gums are really really in bad shape. They’ll get better when you quit. Why don’t we work on that? Why don’t we think about that? It’s a two second conversation. Find out what they worry about, convince them they can succeed, look at the triggers, provide substitutes. Just be able to have that open conversation where you’re transmitting I know you can do it.
TD: When you are successful in coaching and treating a smoker, and I’m sure you must have plenty of them, what are the common pluses that come with a life without smoking? When they do kick the habit, do you ever get comments or notes sent to you that. Look this is what I have in my life that I didn’t have before?
MO: Their breathing gets better, their mood. They come back beaming. It’s like a nightmare is over even though there’s ongoing jeopardy from relapse. It’s an incredible thing when they come back and they say they’re down to half a pack from smoking two packs for forty years. And now my heart is going to get better and my lungs. My breathing has improved. So many things improve so quickly. A good deal of it is the nightmare of why am I doing this to myself and I can’t get out of it? That’s the real tough part of it.