Mr. P. started to be followed at the smoking cessation consultation of the Champalimaud Foundation in mid-2018. He had been a smoker for 33 years, and in 2018, he smoked around one pack of cigarettes a day. His first attempt to quit failed, but Mr. P. never quit the consultation and never gave up on quitting smoking. He finally achieved his goal in mid-2020 through a multidisciplinary approach (including psychology and psychiatry consultations) – and, to this day, has never smoked again. He could have already been discharged from the consultation, but he wants to keep on being followed, to avoid a relapse and also to participate in the lung cancer screening programme.
Susana Simões, pulmonologist at the Lung Unit of the Champalimaud Clinical Centre (CCC), is in charge of its smoking cessation consultation. She thinks this patient is “paradigmatic of how hard it is to quit smoking”. But his case also conveys a crucial message to all those who want to quit: never give up. “Sometimes, you don’t succeed on the first try, but there is nothing to be ashamed of. We know that, on average, five to seven attempts may be needed to quit smoking for good”, she emphasises.
Susana Simões has been doing smoking cessation consultations since 2008, and started working at the CCC in December 2015. At that time, there were no such consultations at the CCC; they were launched the following year, in 2016. “When we deal with lung cancer, it is absolutely necessary to have a smoking cessation consultation”, she says. “It’s part of our training as pulmonologists.”
“Smoking is the main cause of avoidable deaths and the major risk factor for lung cancer in nearly 80 to 90% of the cases”, she adds. In fact, smoking has an extremely strong relationship not only with cancer, but also with disease in general, from diabetes to auto-immune diseases to cardiovascular disease.
Two “bad guys”: nicotine and the rest of the cigarette
What we force into our lungs when we smoke a cigarette may be split the following way, perhaps a little simplistic but forceful: on the one hand, the nicotine present in tobacco; on the other hand, all the other components of cigarette smoke (including the paper with which cigarettes are made).
Cigarette smoke contains about 7,000 chemical constituents that globally are potentially carcinogenic. And among these substances, there is a particularly prominent one, nicotine, which apart from being carcinogenic and able to cause immediate toxic effects (rise in cardiac frequency and blood pressure, and even acute intoxication syndromes), is all by itself responsible for cigarette dependency and the difficulty to quit smoking. “Only nicotine causes dependency and withdrawal symptoms”, explains Susana Simões. A perfect recipe for disaster: cigarettes, one of the most harmful things there is for human health, is a vehicle for nicotine, whose addictive effects make people, at a certain point, smoke more and more, unable to stop. Nicotine dependency is the tobacco industry’s core business.
“Clearly, nicotine is different from other drugs in that its withdrawal symptoms are not as strong”, points out Susana Simões. “But its mechanism of action is similar.” Cigarette smoke carries nicotine to the brain in just a few seconds, where it activates regions of the so-called pleasure centre, releasing substances such as dopamine, which foster relaxation and decrease anxiety. Also, at some brain sites, nicotine stimulates the release of serotonin, known as the “happiness hormone”, increasing the amount of this neurotransmitter in circulation and modulating the smoker’s mood.
But there is more: the continuance of smoking makes the brain respond to nicotine by increasing the number of nicotine receptors on the surface of its cells, an authentic snowball effect that invariably leads to dependency. Quitting cigarettes then becomes harder and harder, because those who try develop withdrawal symptoms resulting from the lack of nicotine in their organism and therefore feel more agitated, anxious, irritated, and can experience insomnia.
But all this is transitory. “The intensity of all those symptoms peaks at 48 to 72 hours after quitting, and the first month of cessation is the hardest. After approximately three months, these complaints become more attenuated”, says Susana Simões. “That is why the duration of the pharmacological treatment of smoking cessation lasts around three months: it corresponds to the ‘acute’ phase of cigarette/nicotine deprivation.”
One of the withdrawal symptoms that do persist is the craving for cigarettes – the desire, perceived as irresistible, to light a cigarette. “It is for this reason that it is so difficult not to start smoking again, and that there is a risk of relapse at every moment, mainly when circumstances make emotions run high”, says Susana Simões. “There is nothing as fast as a smoke to relax; it’s like an injection”, she adds.
Smoking is a disease, she states. And like drinking, it is classified as such by the World Health Organisation (WHO).
“Pity cigarettes packs do not include a patient leaflet!”
Smoking habits are hard to change, simply because any deep-rooted human behaviour is always hard to change. And relapse is, in fact, the greatest danger. “Because of that, the smoking cessation programme lasts two years and starts with a three-month-long ‘acute’ phase (the most critical period, as has already been mentioned), during which medication may be needed to help control withdrawal symptoms”, explains Susana Simões.
After the first three months, maintaining smoking cessation becomes a question of willpower on the part of smokers. To a certain extent, they have already been prepared for this. “To be able not to smoke for three months is a positive indicator, and the more lasting the cessation, the lesser the probability to relapse”, she stresses.
How is the process implemented? At the Champalimaud Foundation, the strategy is essentially the same as that applied by other healthcare institutions, public and private, that have this type of consultation in Portugal. It follows the orientations of the Portuguese health authorities (Direcção-Geral da Saúde).
At the CCC, the goal is “for oncological patients that are followed there to also have smoking cessation consultations, since quitting smoking is always beneficial”, specifies Susana Simões. The consultation applies an intensive, multidisciplinary intervention, in which patients are meticulously evaluated, and in conjunction with them, the ideal moment to quit smoking and the need (or not) for a pharmacological treatment (best adapted to each case) is chosen. The last word on whether to quit smoking is always the patient’s – and medication is chosen by mutual agreement between doctor and patient.
During the acute phase, essentially three types of first-line medication are used: nicotine substitution therapies (patches, jelly gums and chewing gums), nicotine-receptor inhibitors and an antidepressant. The consultations, which take place once a month during the first three months, are carried out by Susana Simões or her colleague Claúdia Matos.
During the first one, a “D day” – that is, the first day without smoking – is chosen. And on that day, the patient will be contacted by a nurse to verify that everything is going according to plan and help the patient overcome this critical moment.
“On the third monthly consultation, patients who succeeded in not smoking for three months are scheduled for a new consultation in three months' time”, explains Susana Simões. “And at the end of six months without smoking, a new consultation is scheduled for six months later.”
“After a year without smoking, patients are considered to be former smokers and will only come back for a consultation a year later. After two years, they are discharged”, she continues. In the meantime, the nurses will always be available by phone in case the patient experiences a high-risk situation or has any doubts – and the patient can always go back for a consultation if needed.
Concerning high-risk for relapse situations, Susana Simões stresses a fact that perhaps many people are not aware of: cigarette craving lasts about four to five minutes each time. In those moments, often triggered by emotional stress, “people need to remember that and to find strategies to distract their attention until the moment passes”, she says. “The important thing is to find solutions that work for each person.”
Although they are not the majority, many patients are referred to the psychology and psychiatry consultations (also at the CCC), where they may be prescribed medication according to their needs, to complement the smoking cessation treatment (for instance, antidepressants). “Curiously, some patients refuse these treatments”, says Susana Simões, “because they have read the drug’s patient leaflet and are afraid of its possible side effects. “Pity cigarette packs do not include a patient leaflet!”, she exclaims.
Multidisciplinarity is one of the core characteristics of smoking cessation interventional consultations. These consultations imply a collaboration between pulmonologists, nurses, psychologists, nutritionists – and the patients themselves. “A doctor advises the patient, nurses provide support and follow-up, there are consultations with psychologists and sometimes with psychiatrists”, says Susana Simões. Furthermore, the appetite increase that comes with quitting smoking (another deprivation symptom that does not disappear) can be approached through nutrition consultations, which help to curb the resulting weight gain.
Two predictive factors of success
Susana Simões does not conceal, however, that the success rate, after a year of smoking cessation consultations, is modest: around 20%. Even so, this rate is several times higher than the rate of success for people who quit smoking without any help. And there is a way to make a pretty accurate prognostic for each patient.
There are two factors that allow the evaluation, for each patient, of the probability for success of the cessation strategy: the motivation of the smoker to quit smoking, on one hand, and the patient’s level of nicotine dependency, on the other. Both are quantifiable using specific questionnaires.
“During the intensive intervention consultations, we have a proper time to talk about tobacco use – about the person’s history, their previous attempts to quit, their social lifestyle. We perform a careful evaluation of the person’s motivation and degree of dependency and establish a plan tailored to that person”, says Susana Simões. Currently, the two pulmonologists who do smoking cessation consultations at the CCC have, on average, five to six of these consultations per week overall.
But even without using questionnaires, any health professional is able to evaluate a person’s motivation to quit smoking from 1 to 10 (1: not at all motivated; 10: extremely motivated). And as to evaluating nicotine dependency, it only takes three simple questions, Susana Simões further explains.
First question: “How many cigarettes do you smoke per day?” If the answer is 20 cigarettes or more, the dependency is considered significant. Second question: “How long after waking up do you smoke?” Those who smoke during the first five minutes are more dependent. Third question: “What is the cigarette that is the hardest to go without?” If it’s the first cigarette of the day, that is a sign of strong nicotine dependency. A low motivation combined with a strong dependency corresponds to a negative prognosis in terms of the capacity to quit smoking.
What Susana Simões would really like to see implemented in every first-line health center, and more generally by all health professionals, in every medical consultation, is what she calls the “3A strategy”.
The 3A strategy, that can be repeated by the doctor during every appointment with a given patient consists of: Asking about the the patient’s smoking habits; if the patient is a smoker, Advising the patient to quit smoking and telling the patient about the benefits vs the risks of smoking; Assessing the two determinant factors of the prognosis for smoking cessation: motivation and dependency.
By repeating this strategy occasionally, at every appointment, doctors could help motivated, weakly dependent people to “dwell on the idea of abandoning cigarettes”, says Susana Simões. “At the Champalimaud Foundation, every time we are asked to, we perform this type of brief intervention with hospitalised patients from other units. These are people who spend days without smoking, and that represents a one-off opportunity to do it.”
“Brief interventions help between 2 and 3% of smokers to quit smoking on their own”, she adds. “It’s supposed to be mandatory for all health professionals to implement them, but we know this is not being met. In Portugal, cigarettes are still condoned, courses in health sciences (pharmacy, nursing, among others) do not include training about smoking. But smoking is a disease!”, she reiterates. According to the WHO, smoking habits should even become part of the list of vital signs, just as blood pressure or cardiac frequency, and they should be measured routinely, systematically, by health professionals.
The smoking cessation consultation is also fundamental for screening for lung cancer, intended for smokers with high-risk criteria and consisting of a yearly low dose thoracic CT-scan. “There can be no screening for lung cancer that does not include a smoking cessation consultation”, says Susana Simões, who believes that a programme joining the two may soon be available at the Champalimaud Foundation.
Text by Ana Gerschenfeld, Health & Science Writer of the Champalimaud Foundation.