Issue 44 / 12 November 2012

SMOKERS are weak-willed individuals making a bad lifestyle choice. Why should we waste time on recalcitrant smokers who refuse to quit? Surely resources should be allocated to motivated patients with medical illnesses.

Unfortunately many doctors hold this outdated view of tobacco smoking and do not give smokers the level of support they need to quit.

Smoking (nicotine dependence) is now recognised as a substance abuse disorder. Eighty per cent of smokers want to quit but fail repeatedly because they are addicted to nicotine and have lost control of their smoking behaviour. In fact, 40% of Australian smokers try to quit each year, mostly unsuccessfully.

Most smokers begin in adolescence when they are unable to make a rational and balanced decision. The rapid delivery of nicotine to the reward centre in the midbrain creates powerful drug-seeking behaviour often within several days of the first cigarette. Genetic predisposition augments the addiction further in many cases.

Nicotine dependence is now also conceptualised as a chronic medical disease, with multiple cycles of relapse and remission. Doctors often use an acute treatment model for smoking patients but it is not applicable.

Relapse is the hallmark of this chronic illness and smokers need to be re-engaged repeatedly until they quit. Few clinicians would initiate a blood pressure medication and then give up if the initial treatment was unsuccessful.

Smoking is a serious life-threatening disease that kills half of all long-term sufferers. Continuing smokers will lose 10 years of life on average. In spite of this, smoking remains the elephant in the consulting room and is often neglected.

However, there has been an exponential growth in research into evidence-based strategies to help smokers quit. Effective smoking cessation treatments are now available and are among the most cost-effective interventions in modern medicine.

Although smoking rates in Australia are falling, this is not true in all subpopulations. In particular, disadvantaged groups form an increasing proportion of the smoking population. Smoking contributes to a very large part of the health and financial gap between these groups and the rest of the community.

In 2008, the smoking rate of Indigenous Australians was 47%, compared to 17% for non-Indigenous Australians. People with mental health disorders have twice the smoking rate of the general population and also smoke more heavily. Twice as many people in the lowest socioeconomic group smoke as those in the highest socioeconomic group. Seventy-four per cent of prisoners smoke daily.

What we can do?

Doctors or nurses who want to learn more can join the Australian Association of Smoking Cessation Professionals (AASCP).

AASCP was officially launched in 2012 to help train and support health professionals in smoking cessation. Members include GPs, psychiatrists, psychologists and nurses.

A Smoking Cessation Update Day for health professionals will be held in Sydney on 27 November, conducted by the Smoking Research Unit at the University of Sydney, in collaboration with AASCP.

The 1-day conference boasts an impressive list of international and local speakers who will provide a practical update for clinicians. Areas covered will include postcessation weight gain, smoking and mental health, smoking in prisons, smoking cessation in patients with HIV/AIDS and Indigenous smoking.

It may be time to confront that smoking elephant in the consulting room.

Dr Colin Mendelsohn is a tobacco treatment specialist at the Brain and Mind Research Institute, University of Sydney. He is a member of the executive committee of AASCP.

Posted 12 November 2012

2 thoughts on “Colin Mendelsohn: The smoking elephant

  1. Mark Quittner says:

    Very interesting article. As a physiotherapist I take every opportunity to educate my smoking patients. Unfortunately, my dealing with some doctors and the Australian (Victorian) legal system has been less successful. A close relative (cannot be identified for legal reasons) was encouraged to recommence smoking after a 10-year abstinence via a spouse carer, despite my relative having 5 smoking-related diseases (including quadruple CABG) and Alzheimer’s disease. As the medical power of attorney I was not supported by the LMO, despite the cardiologist stating that smoking was not a good idea. VCAT and the Office of the Public Advocate were useless in addressing the issue. A Victorian politician commented that the situation amounted to elder abuse by the spouse carer, yet nothing was done.
    My questions – how serious are government and some doctors in implementing protection for the human rights of those without capacity to protect themselves? How can the situation be improved to protect others?

  2. Modern Paradigms says:

    Thank you Dr Mendelsohn.
    Scientific evaluation and non judgemental willingness to adopt new paradigms will surely help to advance our understanding of substance use disorders including smoking, and to detect confounding and underlying aetiological factors. Perhaps there are yet other elephants to be confronted, in order that more adequate and effective care in this area can be provided:
    The Intersection of Attention-deficit/Hyperactivity Disorder and Substance Abuse

    Can we prevent smoking in children with ADHD: a review of the literature.

    ADHD as a Serious Risk Factor for Early Smoking and Nicotine Dependence in Adulthood.

    Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review

    Treatment Strategies for Co-Occurring ADHD and Substance Use Disorders

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