Posts Tagged ‘nicotine addiction’

Why the nicotine patch fails, and what to do about it.

December 17, 2017

The smoker should take part of a straw

Through which, when breathing, should draw

For the smoking cessation

It bring relaxation

And that, with the patch, is the flaw.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.


I hate tobacco with a passion which I restrain to as to not alienate patients. I ask people, on a scale of 1 to 10, how ready they are to quit.  If they say 1 or 10 I move to another topic.  If they say anything else, I ask them to tell me why they aren’t LESS ready to quit, and to name the best three things about smoking.

Smokers most commonly say “stress relief” as the best thing about smoking. I used to argue, pointing out that smokers smoking have the same level of stress as non-smokers at baseline; the stress the patient felt, I would say, comes down to nicotine withdrawal.

That approach didn’t help anyone quit; if anything it hardened the person’s commitment to death by tobacco.

Recently, I have started to point out that if a person wants stress relief, the deep breathing exercise that every smoker has mastered brings half the stress relief of smoking. Inhale like you’re getting the best drag of the day, I say, and your stress level will go down.

(Recently the FDA approved a device to treat high blood pressure.   Really an app, it gets people to slow their breathing.)

I think the nicotine patch fails so often because the people don’t get the stress relief of deep breathing.

Today, a patient who had already figured out that strategy announced he planned to get some straws and to breathe through, to give him something to do with his hands.

And, just like that, within an hour I had two more patients intending to quit smoking.

I advised both to get a soda straw, cut it in half and carry the half where they carry their cigarettes. And to breathe through the straw as if smoking a cigarette.

This simple, brilliant technique will answer the habit strength question, help with stress management, give the person something to do with their hands which also includes the mouth, and give the person much the same velocity of air as breathing in through a lighted cigarette.



How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.


Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.


About ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.