Smoking Cessation

Advair is one of the most sought out medications through the Patient Assistance Program at the health centers through Philadelphia Department of Public Health (PDPH).  Advair is used for severe asthma and COPD. According to GlaxoSmithKline (GSK), the pharmaceutical company who provides this medication, "once asthma control is achieved and maintained, assess the patient at regular intervals and step down therapy." My instincts say that GSK is on to something, but why is this not happening? Are the pharmaceutical companies guilty or are the physicians to blame? Aside from my personal frustrations with the pharmaceutical world, I try to err on the side of caution when interacting with our patients at the health center. A commonly used expression in our office: "I NEED my medicine." I'd like to believe this need is earnest, but I'm not convinced that patients haven't been brainwashed by the medical world, a world notorious for pushing meds and ingraining a false "need" in their heads.

What really interests me is why these patients remain on these medications, year after year.  It doesn't seem like the patients' symptoms are subsiding, and if they're not, they expect more intervention, with more, more, more MEDICATIONS (and of course this is the radical perspective. I agree that sometimes certain medical interventions are necessary). Are patients really getting the support they need, to make the lifestyle choices, to actually understand the repercussions of their actions? Or are we (as a culture) way too trusting of our medical professionals, lacking the courage to ask questions?

Let's talk about some of the problems, in the chapter of persistent asthma.

First off, environmental conditions.
air quality, cockroaches, asbestos.
Second, smoking.

My personal experience speaks to the last issue, smoking, and my big mouth (for better or for worse) has had a difficult time letting the patients secondhand smoke go unnoticed - one truly systemic issue connected to excessive medication use and abuse.

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Let me relay a true story.
A patient walked into our office at Health Center 6, on Girard Ave, one day.
Reeking of cigarette smoke. She handed me her prescription for Advair.
history: COPD, diabetes, hypertension.
and she's a smoker.
I'm not the doc, no. I don't have the authority, power, nor educational training to try to convince this patient to make lifestyle changes, but my mouth thinks otherwise (how about a person-to-person conversation, with voiced concern? Is that so wrong?)

"so, are you a smoker?"
"for decades..."
"hmmm, how does this affect the asthma?"

The conversation continues, and she opens up. I learn about the "smokeful" life she has lived and how it has always been a part of her daily routine. She laments about her endless struggle. She wants to quit. She claims to have tried, using the patch.I bring up a statistic I learned in the smoking cessation training at the Health Federation. "Did you know that 80% of cigarette use is rooted in habit, socialization, routine? Only 20% is based on addiction." So, nicotine replacement is addressing this 20%. How will you ever cut this addiction from your life if you only address the 20%, the physiological problem? Nicotine is known to be harder to kick than cocaine and heroine. Providing support for individuals whom are dedicated to quitting, with the quit line or the smoking cessation classes (that have been offered for years with genuinely empathetic and engaged counselors, that continue to have low turnout rates), are the best option - coupled with nicotine replacement, of course. The patient came to the conclusion she was ready to try again, fight this addiction, and recognized that this addiction is keeping her on a handful of medications - expensive and often superfluous. I didn't have to say much. She just needed a safe space to talk about it and someone to listen, supporting her decision. And maybe just a little push.

Seeing her at the center since has been heart-warming and exciting, especially to see her attend the class at the health center (it's one thing to get a patient to say they are going to do something...). Her quit day is approaching, and she is taking positive steps to be well on her way to a smoke-free life. Since our first interaction, she has consulted me with countless other issues, and it is clear that this is not going to be an easy battle for her...

Of course, like any of these other problems, this is just the tip of the iceberg. However, addressing an issue, although scary, can be an empowering experience that is much more exhilarating than kicking any symptom with a lifelong drug regimen.