I discuss cases with nurse coaches from a couple of organizations at least once a week and we are finding gaps in care all the time. Today we discussed a man who works in healthcare and had a stroke in their early 40s. This individual is reasonably knowledgeable about healthcare issues. He understood that his smoking habit is the biggest reason he had the stroke, and he asked their doctor for help in stopping smoking. His response: “It is a habit. You just need to quit.” That proves a complete misunderstanding of this situation by the clinician, and he failed this patient. The man recognized the need to stop smoking and the physician did not help. It was a missed opportunity, and he left the patient in danger.
Smoking is not a habit. It is an addiction. Nicotine is the most highly addictive substance found in tobacco products. Nicotine is the most common addiction in America. More than two-thirds of Americans who tried cigarettes or chewing tobacco report being addicted at some point during their lifetime. Some knowledgeable medical leaders say that nicotine is the third most addictive substance on earth. Only heroin or cocaine are more addictive.
It is not the nicotine in a patch that causes a stroke. Smoking is the most common preventable cause of premature cardiovascular disease and cancer in the developed world. Smoking cessation interventions, including nicotine replacement therapy like the patch, are among the most cost-effective interventions available in practice. Guidelines from most developed countries recommend that these interventions are made available to all smokers. Some worry that nicotine may actually cause heart attack and stroke. Clinical trials have not confirmed this risk. A review of over 30,000 patients showed that nicotine replacement alone does not cause heart attack, stroke, or death. That said, all nicotine replacement therapies are not equal. Vaping exposes users to increased oxidant exposure in the lungs but it seems to be less dangerous than cigarette smoke. I would use a pure nicotine replacement like the patch to maximize safety.
Smoking directly causes vascular disease and it is extremely dangerous. I have only seen two women in my decades of practice who had recognized artery disease before the age of 40, and they were both heavy smokers. A single puff of cigarette smoke contains ten to the fifteenth oxidative particles. That is a quadrillion particles. I can’t even get my arms around that number. That, and other chemicals in cigarette smoke, cause all the damage. Those oxidants activate growth factors and inflammation to cause cardiovascular disease and cancer. These pathways are understood in great detail today.
Stopping smoking is a critical part of best practice medical treatment of vascular disease. It is one of the five elements of best practice medical care for diabetes and one of four elements of best practice treatment of artery disease. Patients on optimal medical therapy (OMT) for diabetes have one fifth as many strokes as those in usual care. Patients on OMT after a heart attack are ten times more likely to be alive in five years compared with those receiving usual care. The effect on stroke should be in the same ballpark. This is a life or death issue.
Using the nicotine patch as a substitute for the addictive nicotine in the cigarette is a great answer to this man’s problem. It would immediately reduce his risk. Stopping smoking is not a matter of habit and willpower. It is a matter of addiction and addictions are extremely difficult to overcome. This patient had sense enough to ask for help. His doctor did not have sense enough to provide it. I would find another doctor.
Both of my parents smoked and died from diseases caused by the smoking. Even as a youngster, it was something I was not going to do - and never did. I think that decision served me well.
Great post and should help physicians appreciate better there’s more onus on them to more aggressive in bringing solutions