Guideline on smoking cessation: what works in practice

Smoking remains the leading cause of preventable disease and death in Canada. A new clinical practice guideline published in CMAJ on tobacco smoking cessation outlines evidence-based behavioural and pharmacological interventions to help patients quit. On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham speak with Dr. Eddy Lang, co-author of the guideline, and Dr. Andrew Pipe, a pioneer in smoking cessation research and practice, about how clinicians can better support patients ready to stop smoking.

Dr. Eddy Lang, an emergency physician and professor at the Cumming School of Medicine, describes how the Canadian Task Force on Preventive Health  assessed a wide range of interventions to make sense of a complex evidence base. He outlines the strong recommendations in favour of pharmacological therapies such as nicotine replacement therapy, bupropion, varenicline, and cytosine, as well as behavioural interventions including counselling, group therapy, and quit lines. He also explains the conditional recommendation against e-cigarettes, citing limited long-term safety data and concerns about normalizing their use among youth.

Dr. Andrew Pipe, professor of medicine at the Ottawa Heart Institute and co-creator of the Ottawa Model of Smoking Cessation, offers practical guidance for everyday practice. He highlights how a state-of-the-art smoking cessation intervention can be delivered in as little as 26 seconds. This brief approach is non-judgemental, empathetic, and emphasizes that help is available whenever the patient is ready.

He also stresses that clinicians should treat cessation pharmacotherapy like any other chronic disease medication—titrated to patient response and continued as long as needed. Pipe emphasizes that nicotine replacement therapy is often underdosed, which undermines its effectiveness. He encourages physicians to combine long-acting patches with rapid-acting forms such as gum or lozenges, and to adjust dosing based on patient comfort, allowing individuals to guide their own titration.

This episode underscores that even brief encounters can open the door to meaningful change for patients ready to stop smoking. Asking about smoking status, offering practical, evidence-based assistance, and prescribing cessation therapies in sufficient doses can effectively help patients quit.

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Transcript

Dr. Mojola Omole

Hi, this is Mojola Omole. 

Dr. Blair Bigham

I'm Blair Bigham. This is a CMAJ podcast.

Dr. Mojola Omole

So, well, no, I want to just prime this episode with the fact that I'm struggling to say the word cessation. 

Dr. Blair Bigham

Cessation, not sensation. Cessation. Smoking is not sensational.

Dr. Mojola Omole

So if you hear, you think you hear a sensation, you didn't. I'm just struggling today.

Dr. Blair Bigham

Cessation, cessation. Anyways, we are going to talk about something that should cease, and that is smoking, a bane of all of our existences as physicians. For me, definitely in the emergency department, Jola, I'm sure you see sequelae of smoking every time you go to the operating room.

Dr. Mojola Omole

Well, yes, and oftentimes part of a good history taking is to ask patients about their smoking, if they smoke, if they're former smokers. And this is actually something that I struggle with in being able to tell patients what the next step is. Oftentimes, I'm like, OK, well, you shouldn't smoke.

You should go to your family doctor if you're thinking about quitting smoking.

Dr. Blair Bigham

And today, we're going to try to answer the question of what we do next to maybe change how that question is answered. There are new guidelines out in CMAJ titled Recommendations on behavioral and pharmacological interventions for tobacco smoking cessation. Today, we'll be talking to Dr. Eddy Lang, one of the expert methodologists of this guideline, and then somebody who has spent his entire life trying to help Canadians quit, Dr. Andrew Pipe. That's coming up next on the CMAJ Podcast.

Dr. Mojola Omole

Dr. Eddy Lang is the co-author of the guidelines article in CMAJ titled “Recommendations and interventions for tobacco smoking cessation in adults in Canada". Dr. Lang is the past academic department head and a professor in the Department of Emergency Medicine at the Cummings School of Medicine. Eddy, thank you so much for joining us today.

Dr. Eddy Lang

Thank you so much for having me. 

Dr. Mojola Omole

So let's just start with your own connection to this work. You're an emerg doc.

How did you become involved in developing national smoking cessation guidelines?

Dr. Eddy Lang

One of my big interests is in evidence-based medicine. And if you are interested in evidence-based medicine, you're naturally drawn to guidelines. Guidelines are often considered the top of the evidence pyramid, if you will, because it includes analysis of the evidence and input from all stakeholders.

So that's what took me to the Task Force. Now, once on the Task Force, there's a whole process involved around selecting topics. I'm an emergency physician.

The Task Force does preventative health care topics. Smoking cessation was the perfect intersect for me because we see the ravages of smoking in the emergency department every day, be it patients who have exacerbations of COPD or advanced lung cancer or just a nasty pneumonia that would never have occurred had they not been smoking in the first place. So I did suggest the topic and after a number of vetting processes, it ended up as one of the ones we worked on.

Dr. Mojola Omole

Were there specific gaps that you were interested in the Task Force wanting to address?

Dr. Eddy Lang

I think it's really such an important topic that it was clear as one of the most preventable things in health care, preventable causes of morbidity and mortality, that it might be worth pursuing. So once we started scoping the topic, what we realized was there was just a plethora of options, some of them well studied, some of them not well studied. And we imagined it would be pretty confusing for primary care providers and the general public to decide what would be the best approach.

So it was from that vantage point that we said someone needs to sort out this evidence and clarify what works, what doesn't work, get input from the relevant stakeholders as to what's practical, which one has acceptable side effects. And that kind of gave birth to the idea that we needed a guideline that made sense of this very complex literature.

Dr. Mojola Omole

Before we get into the recommendations, what does it look like in terms of smoking rates in Canada today?

Dr. Eddy Lang

Well, fortunately, they have been steadily coming down. But they still sit at around 11 percent of the population, more so for men than for women. And you don't need to check with any health care provider to see that although the rates are relatively small and improving, the downstream consequences are incredible.

Smoking and the carcinogens that you find in tobacco are going to be a major cause of preventable illness, including cardiovascular disease, vascular disease, lung problems and cancers. So if you think about all of the bad things that smoking does and the incredible benefits of stopping, if you can, it just made a lot of sense to go in that direction.

Dr. Mojola Omole

OK, so let's walk through some of the main recommendations and what the guidelines highlight about each one. So can we talk about pharmacological therapies? What are your guideline recommendations for those?

Dr. Eddy Lang

Well, we were pleasantly surprised to see that pharmacological interventions, primarily varenicline and bupropion and nicotine replacement therapy, all of them work. And there have been hundreds of randomized controlled trials looking at the outcome of stopping smoking at six months. And the synthesis of the evidence was beneficial.

The side effects were fairly minimal or manageable. And the benefit's enormous because you do end up stopping smoking. So we are in favor of those.

So those are the pharmacological ones that are well known that are beneficial. But there is one other one that's characterized as a health supplement. It's called cytosine.

And there's actually been a number of randomized control trials on this particular substance. You can get it at health food stores. And it also is effective at reducing the urges of nicotine in people who are motivated to stop smoking.

Dr. Mojola Omole

So what about psychological interventions?

Dr. Eddy Lang

There again, they work really well. Whether it be individual counseling, advice from a physician, group therapy, or even those 1-800 quit lines, all of them have been studied pretty well. And they are beneficial.

So we did find that they are effective and they are amongst our strong recommendations that people should go for them.

Dr. Blair Bigham

Talk to me a little about those behavioral interventions. It seems like everybody who smokes knows they shouldn't smoke. Everyone knows smoking is bad for you.

How do behavioral interventions even work in this?

Dr. Eddy Lang

I'm not a psychologist. But from what we glean from the literature, a lot of these techniques bring in peer support, coaching, motivational approaches. And those things actually tend to make a difference.

I mean, you always have to start with a motivated individual. But sometimes just knowing that your group is following you and your coach is there for you, just those things alone can make a huge difference, it seems.

Dr. Blair Bigham

We've heard of some plans that sort of, or employers that sort of incentivize quitting smoking. Is there any data on, like, gamifying or paying people to quit?

Dr. Eddy Lang

We didn't include those kinds of studies in our review. But in the ones that we do recommend and favor are those that are text message-based. On the flip side, though, when you look only at the online versions of quitting programs, those are not as effective.

So we have made a conditional recommendation against online counseling or the ones that are purely virtual in nature. At least that's the current state of the evidence. Maybe in the future, when we revise or update the guideline or other people do, that equation might change.

Dr. Mojola Omole

I think for me, intuitively, it makes sense because the things that work are the ones that rely on community and on each other, the peer support, versus other methods that are more like online that are less targeted towards you. I can see how that makes that difference.

Dr. Eddy Lang

For sure, Joel, I see that every day in the emergency department. The patients who we meet who have been able to break free of alcohol use disorder or other substance use disorder rarely can do it on their own. They rely on 12-step programs or other kinds of intensive support, whether it be coaches or people with lived experience navigating them through the system.

So for sure.

Dr. Mojola Omole

What about e-cigarettes?

Dr. Blair Bigham

Because that's a pretty controversial one. Like we've seen sort of policy footlock happening for it.

Dr. Mojola Omole

Well, because also patients also come in saying, well, I don't smoke. I just, I vape. And I'm like, I think we're close to the same things.

Dr. Eddy Lang

Yeah. Well, just to take a step back, our strongest recommendation, and it might seem self-evident, but we just want to remind health care providers wherever they might encounter patients is that you should always be aware of your patient's smoking status, even if you're seeing them for an abdominal pain problem in the emergency department. And then you should always, if you can, encourage that they quit.

It's amazing how just that little message from a physician can make a difference. And that's one of the things we looked at. But back to your question, e-cigarettes, oh my gosh, we had so many meetings about this topic because there was such differing literature and so much controversy in the literature.

At the end of the day, what we decided was that we're going to make a conditional recommendation against e-cigarettes as a method for smoking cessation. So I gave you the bottom line right away. But behind that decision making was a number of things.

First of all, we thought that the evidence showed that it could stop smoking, but it was not as convincing as some of the other data we had seen for other conditions. The other thing was that we lacked the long-term safety data. If you were going to use e-cigarettes as a means of stopping tobacco, we didn't know where you would be at, even though it may have helped you stop by six months, we didn't know what the long-term would look like, especially if you were to continue to use e-cigarettes. And then we had a longer-range picture or analysis of the whole situation. We know e-cigarettes are being used more and more, especially amongst youth.

And by giving it a green light or a thumbs up, we felt it might contribute to normalizing its use and embedding it into society as a reasonable thing to do. So here's what we say. We say, in general, it should not be your first choice.

However, if your patient in front of you, and if you're using a shared decision-making approach, says, you know what, I think e-cigarettes will work well for me, or you're in a situation where everything else has failed, then we do say it's OK to do this and give it a try. So that's where we're walking that fine line. But it overall has a thumbs down because the evidence as it exists now lacks the long-term safety data and the convincing evidence that it will help you stop, as opposed to just replacing one addiction for another.

Dr. Mojola Omole

So just to summarize, rapid-fire, pharmacological?

Dr. Eddy Lang

Beneficial. The four with the thumbs up are nicotine replacement therapy, like patches, lozenges, gum, inhalers. It's bupropion, varenicline, and that surprise supplement, health care supplement, cytosine.

Dr. Mojola Omole

OK, psychological intervention.

Dr. Eddy Lang

So there we have the counseling approaches and the behavioral therapy ones, especially even ones that use some of the electronic tools like text tools. And importantly, you can use the pharmacological and the behavioral ones in combination. We specifically looked at reviews where these were put together and there was some additive benefit.

So it's not necessarily just a one-only. If you have a really motivated patient who likes both the pharmacological approaches and the behavioral, there's absolutely no problem with combining them.

Dr. Mojola Omole

All right, and e-cigarettes?

Dr. Eddy Lang

We are saying thumbs down, but not a double thumbs down as in a strong recommendation against. That would make it almost forbidden to use. There are some things that we did find were really not ready for prime time.

So that's hypnotherapy, laser therapy. There's a couple of other supplements that don't work. Acupuncture just doesn't seem to work.

So there's a list of things that we've identified as don't waste your time here. Even if you think one of those sounds attractive to you, it's not likely to work. So you're much better because these are time-consuming interventions,  you're much better to put your time and in the case of something that you may need to buy, put your financial resources in what works.

Dr. Mojola Omole

All right, so the reality of what we live in Canada is like not everyone has access to a family physician. So how does that account for this reality? For the general public who doesn't have a family doctor, they want to start their journey in to stop smoking.

Dr. Eddy Lang

That's exactly what we've been discussing on the task force for the last several years. We realized that in some jurisdictions, you just cannot get access to a primary care physician or a nurse practitioner for this kind of issue or topic in a timely way. So it's for those reasons in particular that we've designed our educational materials to be accessible and publicly facing and designed to be at a reading level that anyone can understand.

So the tools can be used either in a shared decision-making model with a primary care physician or they can be taken directly off the website, which is all going to be free access, wide open, and allow people to begin that journey. Having said that, remember that most provinces do have a 1-800 line. So they usually have 1-800 quit lines and those can be used at least as a launch point in conjunction with the materials that people can download to get them started on that journey.

Dr. Mojola Omole

Amazing. Thank you so much for joining us today.

Dr. Eddy Lang

Well, thank you so much for having me. It's such a pleasure to do this podcast.

Dr. Mojola Omole

Dr. Eddy Lang is the co-author of the new guidelines on smoking cessation published in CMAJ. Thank you. Thanks so much, Eddy.

Dr. Blair Bigham

To help us go from evidence to implementation, we're going to turn to someone who spent decades helping people quit smoking. Dr. Andrew Pipe is a professor of medicine and former chief of prevention and rehabilitation at the Ottawa Heart Institute, and he's one of Canada's leading experts on smoking cessation. He was instrumental in developing the Ottawa Model that has been adopted in hundreds of clinical settings across the country.

Andrew, thank you so much for joining us today.

Dr. Andrew Pipe

It's a real pleasure to be with you. Thank you for the invitation.

Dr. Blair Bigham

What does the CMAJ review mean to you?

Dr. Andrew Pipe

Well, I think it's once again an endorsation of the importance of smoking cessation as being a fundamental responsibility of clinicians. It's a review of reviews, if I can use that term, so it doesn't really provide us with anything startlingly new. I think perhaps the most important element is that it underscores that the evidence of using vaping devices or e-cigarettes to help with smoking cessation is not there.

Dr. Blair Bigham

What do clinicians need to take away? Where's the self-reflection that can come out of this review that involves practice at the bedside?

Dr. Andrew Pipe

I think it's all about asking oneself, what can I be doing? What can I establish in my clinical environment, in my setting, in my hospital, in my department, in my outpatient clinic? What mechanisms, what processes can I put in place that make it so much easier for me to offer assistance and so much more effective in terms of the assistance that I provide?

And so, one could make the case that you can deliver a state-of-the-art smoking cessation intervention in 26 seconds or less. 

Dr. Blair Bigham

26 seconds? 

Dr. Andrew Pipe

Simply by saying, Blair, I see that you're a smoker, and I'll bet you've struggled with that in the past.

I know how difficult that can be. But you know, here in our clinic, we've got an approach that will offer a much greater chance of your stopping smoking. Be pleased to offer you that assistance.

Don't ever hesitate to ask for my help. And this is just so important, given the lung disease that we're treating, that I'm going to ask you about this every time I see you from now on. Now, if you're prepared to do something today, we can do that.

But otherwise, let's proceed. And that simple kind of message is, A, personally relevant to the patient, the lung disease we're treating. It's non-judgmental.

It's none of this, let me give you reason number 227 why you should stop smoking. And it's a very clear, unambiguous offer of assistance. And I think most clinicians will be very pleasantly surprised at the response they get to that kind of messaging.

Dr. Blair Bigham

So it's not an education issue.

Dr. Andrew Pipe

It's not an education issue. It's an offer of realistic, practical, clinical assistance with smoking cessation.

Dr. Blair Bigham

So why, if they want to quit, if they know the harms, they're just scared to try? They think it'll be hard? What's the barrier?

Dr. Andrew Pipe

A majority of smokers will make one or two personal, private quit attempts every year, 95 percent of which will fail. And so they've learned failure, if you will. And many smokers are profoundly embarrassed in clinical environments about revealing their smoking status or raising the question.

I mean, one of the most typical responses you get to the kind of message that I modeled a few seconds ago is that that's the first time any doctor has ever spoken to me in a way that reveals that they understand something about what smoking cessation might be like. Most clinicians today have never, ever smoked. And it's important to underscore that unless you've been a smoker who has successfully stopped smoking, it's unlikely that you in your lifetime will ever experience a challenge that can be as complex or as frustrating or as difficult.

Now, having said that, one should not conclude, oh, geez, this is a really difficult task. We know that we can do things that will dramatically enhance the likelihood of smoking cessation. And as this article notes, there are a number of pharmacotherapies that can be profoundly helpful in that respect.

The challenge here is to transform the way in which clinicians, A, use those therapies. Typically, those therapies were introduced as, use this therapy for X number of weeks. And if you haven't stopped smoking at the end of this number of weeks, according to the schema we've described, then go away and think more seriously about when you want to make a smoking cessation.

Dr. Blair Bigham

It means you're not serious yet.

Dr. Andrew Pipe

Well, rather than understanding that in every other clinical situation, we use medications, we titrate them according to their response, and we continue their use for as long as is necessary.

Dr. Blair Bigham

Let's get into the pharmacotherapy. How should clinicians approach nicotine replacement and other pharmacologic therapy when someone says, I'm ready to quit?

Dr. Andrew Pipe

Well, here, I think it's important to follow the precepts in the article that we're basing our discussion on, a shared decision-making approach. What is most likely to be most helpful for you? I can, from my perspective, say, I know that the most effective approach to smoking cessation is the use of combination nicotine replacement therapy.

That is the use of a nicotine patch at a dose level appropriate to your level of smoking, in combination with a more rapid form of nicotine delivery, which you can use during the course of the day if stressful or other situations occur that really prompt your urge to smoke. I want to underscore that we're going to use this therapy in doses that are appropriate for as long as is necessary. And it's far more important to me that you stop smoking, and it's also important that I help you understand that you are infinitely safer receiving any form of cessation pharmacotherapy than you would be to continue smoking.

So the other thing that I would highlight in my discussion, if someone chose to use nicotine replacement therapy, is that smokers have an exquisite ability to precisely titrate their nicotine intake. And they know when nicotine levels fall and they start to experience the discomfort that is the incipient symptoms of withdrawal and so on. And so I would say, gee, I see you're smoking two packs of cigarettes a day.

We're going to start you on two 21-milligram nicotine patches as on the basis of what you're normally daily—

Dr. Blair Bigham

I don't think I've ever seen anyone prescribe two nicotine — two 21s

Dr. Andrew Pipe

Yeah. You make the point. Clinicians are blissfully unaware of how to practically and effectively and helpfully assist with smoking cessation.

Dr. Blair Bigham

Is this why people kind of poo-poo nicotine replacement? Because we're underdosing it already.

Dr. Andrew Pipe

Exactly. It doesn't work, right? So the standard schema that we use at the Heart Institute with cardiac patients who present with a recent infarct or whatever, they are immediately offered nicotine replacement therapy and it's titrated according to their needs.

So if you're a one-pack-a-day smoker, you get a single patch of NRT plus a more rapid form. If you're a two-pack-a-day smoker, you get two patches plus a more rapid form. If you're a three-pack-a-day smoker, you can do the math.

And I think it's important for clinicians to understand that irrespective of the dosing that you use of nicotine replacement therapy, you're still providing minuscule levels of nicotine in contrast to what would be taken up by an individual smoking. It's being delivered via the venous system slowly, not via the arterial system in huge amounts, which are immediately distributed via the left ventricle to every tissue in the body. And the whole rationale is to provide a level of nicotine which approaches that personal idiosyncratic comfort level.

And once nicotine levels fall below that level, that's when an individual smoker has the urge to smoke. So it's all about making people feel comfortable while they go about acquiring a whole new repertoire of non-smoking behaviors. And we can even perhaps complicate this a little bit further because most clinicians have no idea that there are various factors that influence the rate at which you metabolize nicotine.

So if you are a rapid nicotine metabolizer, the standard dose of nicotine replacement therapy will be metabolized very quickly, and therefore you won't derive that same sort of benefit. And most clinicians are completely unaware that if a woman is on a birth control pill, her rate of nicotine metabolism may double. If a woman is pregnant, her rate of nicotine metabolism may triple or quadruple.

Which explains why all the nicotine replacement therapy clinical trials in pregnant women were unsuccessful. Because the moment individuals in those trials, in any smoking cessation trial, experience the fact that what they're using isn't helping them, they discontinue the medication.

So, you know, we're just talking now about nicotine replacement therapy.

Dr. Blair Bigham

Yeah, what about varenicline or bupropion or other medications that are often used?

Dr. Andrew Pipe

So varenicline is the agent, when used singly, is the most effective agent. And it very specifically and very precisely stimulates the nicotinic receptors in the brainstem. And it blocks those receptors.

Now, when it stimulates those receptors, that causes the release of dopamine in the forebrain. And in a sense, the desire of a smoker to have a cigarette comes in the face of declining levels of nicotine receptor stimulation and falling levels of dopamine. So varenicline stimulates the nicotine receptor, occupies it and blocks it, and at the same time causes a release of dopamine.

And the story of varenicline immediately causes us to think about cytosine. Because varenicline and its properties and its approach was based on the recognition that during the Second World War, when tobacco wasn't available, people smoked the leaves of something called the golden chain shrub. The active ingredient of which is cytosine.

And cytosine does exactly what varenicline does. And here there's a very unique Canadian success story. Because pharmacists at the University of Waterloo recognized that cytosine is a natural product.

And so they sought and got permission to produce cytosine. And so cytosine is available without prescription and has been proven to be a highly effective smoking cessation aid. But most clinicians in Canada are completely unaware of its existence, probably because it hasn't received the same kind of marketing attention as other medications might have been.

And also because the original Eastern European schemas of using cytosine employed a rather arcane daily dosing schedule. Whereas we now know that using cytosine in appropriate doses a couple of three times a day can be just as effective and remarkably inexpensive and available over the counter, but unfortunately not widely available. So that's a subtle element of the pharmacotherapeutic approaches to smoking cessation that I think more clinicians and especially more pharmacists perhaps should be much more aware of.

But varenicline, to come back to that product, that substance, is a highly effective smoking cessation aid.

Dr. Mojola Omole

What advice or clinical direction would you give to specialists where we're seeing them for something else, but, you know, the smoking comes up, that goes beyond telling them, just go to your family doctor to quit smoking?

Dr. Andrew Pipe

Yeah, thank you. A very insightful question, because it would be my view that any clinician who regularly sees smokers should be as comfortable and as confident in providing a simple, straightforward approach to smoking assistance with smoking cessation. And that is all about providing advice, being familiar with the use of smoking cessation medications, the use of which is very straightforward.

So, for instance, in the oncology setting, we know that irrespective of the stage of your diagnosis, that the likelihood of reducing the toxicity of chemotherapy or radiotherapy, the ability to enhance quality of life, and in many tumour states and in many cancer states to enhance life expectancy, comes about as a part of smoking cessation, which is why smoking cessation is now in the clinical pathways, if you will, in major cancer centers, not only in Canada, but elsewhere around the world. And, you know, I think, unfortunately, there has developed this tendency on the part of clinicians to think of smoking cessation as being this incredibly complex, oh, it's an addiction, it's incredibly complex, it's going to take me lots and lots of time, I don't... Whereas I think the message I would like to impart is that smoking cessation can be, A, it can be made much more effective, B, we can help you be much more efficient in the use of your time, and we want to be reassuring that the provision of smoking cessation pharmacotherapy is far more straightforward than is the case of prescribing so many of the other medications that individuals prescribe as part and parcel of their daily practice.

Dr. Mojola Omole

So what would you say is the best way for physicians to update their practice around smoking cessation, both primary and specialists alike?

Dr. Andrew Pipe

Well, you know, at the risk of me being totally self-referential, becoming familiar with the Ottawa model of smoking cessation, we know that as this has been introduced into primary care clinics, into specialty clinics, into plaster rooms in orthopedic settings, we know that the province of Nova Scotia, within their health system, their two health systems, the Francophone and the Anglophone system, the Ottawa model is now part and parcel of clinical protocols in every clinical setting in that province, with dramatic and distinct benefits in overall rates of smoking cessation.

So, being familiar with these simple techniques, also, I think, understanding that smoking is a very tenacious addiction. And when approaches and initiatives fail, that's not a reflection of the failure of a clinician, but unfortunately, as clinicians, we often see it as that. It's a reflection of just the nature of this addiction.

And yeah, individuals may require several attempts before they're ultimately able to stop smoking, but that should not get in the way of our,   A, understanding that reality and being in a position to be able to offer them with ongoing assistance.

Dr. Blair Bigham

Andrew, thank you so much. This is amazing. Thank you so much for joining us.

That was terrific.

Dr. Andrew Pipe

Well, I appreciate the opportunity and thank you for your interest in what, as you can tell, is something I view of unbelievable importance, given the impact that successful cessation can represent. Thank you.

Dr. Blair Bigham

Dr. Andrew Pipe is a professor of medicine at the Ottawa Heart Institute and the University of Ottawa.

Dr. Mojola Omole

So, for me, the key takeaway is that I feel a little bit more equipped when I talk to patients who are smoking. Oftentimes, I'm taking a history related to cancer, and I want to talk to them about, and they say, OK, yes, this is something that has made me want to stop. I now feel a little bit ready, a bit better, to be able to say, well, what have you thought about?

Here are some of the guidelines. Any of this resonate with you? I always see them again.

When I see you again, maybe that'll be the time for us to take the next step in helping you to stop smoking. 

Dr. Blair Bigham

I love that tip of just saying, when you're ready, I'm here for you. 

Dr. Mojola Omole

Always.

Dr. Blair Bigham

Which is one of Andrew's tips.

It also is, I don't know, I would have said that this is, again, in the wheelhouse of family medicine and people with longitudinal relationships, but maybe there is more room for this type of thing in episodic care as well, either as an internist or as a hospitalist, or, I hate to say it, as an emergency doctor. Maybe there's just, again, those 26 seconds that we need to just recognize that people just need to hear that this is hard and that there is help when they're ready.

Dr. Mojola Omole

Yeah, 100%. And maybe you won't be the person that writes the prescription for nicotine replacement, but you'll be the person that spurs the conversation. And that's the first step.

Dr. Blair Bigham

One of the things that was really interesting in terms of how we support people, Andrew mentioned that when you smoke cigarettes, you can smoke two or three if you're having a particularly stressful time. You can go outside and smoke whenever you want. And so making sure that if you're going to suggest or support people with nicotine replacement, that they have enough nicotine.

You know, people can figure out how much nicotine they need if they're not feeling good, if they feel like they need a cigarette. Make sure they have that option of popping another piece of gum, a lozenge, slapping on another patch. I was surprised when he was talking about doses.

I don't think I've—I use this rough estimate in my head of how much nicotine people need when they're in the ICU, but I don't think I really understand the literature around that. And I'm probably underdosing nicotine to some degree.

Dr. Mojola Omole

I think a lot of us probably are.

Dr. Blair Bigham

It sounds like all of us are. That's it for this episode of the CMAJ Podcast.

Thank you so much for listening. The link to the guideline is in the show notes. Please subscribe to our podcast so that you don't miss any new episodes.

And of course, always feel free to share our podcast far and wide. This podcast is produced for CMAJ by Neil Morrison at PodCraft Productions. Catherine Varner is our deputy editor of the CMAJ and senior editor on the podcast.

I'm Blair Bigham.

Dr. Mojola Omole

I'm Mojola Omole. Until next time, be well.