Should doctors stop prescribing inhalers for smokers?

I’ve always had a tough relationship with cigarettes and the people who love them. As a lung doctor I hate cigarettes, and I hate that patients I see everyday continue to use them. But I also understand that vilifying smokers seems to be in vogue right now. I figure that if someone does something that is not considered socially palatable, and that does them harm, even as they strive to take treatment for it … well it must be a pretty powerful addiction.

Recently I was hanging out with a few physician friends, when the topic of conversation came to treating patients who are smokers. Some contemplated whether patients who smoke should even be prescribed inhalers for breathing disorders. Furthermore, we wondered about whether such patients should be followed up for breathing problems unless and until they quit smoking.

This made me wonder about my current approach. As I mentioned above, I have always been accommodating to smokers, particularly considering how little is done to help them quit or prevent them from starting. So is treating smokers a practice I should continue? I do discuss smoking at every visit, as well as the  importance of quitting. I use my usual analogies of using inhalers while continuing to smoke;  “you’re hitting the accelerator and the brake at the same time” or “you’re pouring gas and water on the flame at the same time.” Sometimes I even tell them they would not need the inhalers and probably wouldn’t need to see me anymore if they quit smoking. Unfortunately these approaches rarely work.

Perhaps I’m even acting as an enabler and tacitly endorsing their behavior by inviting them back for another appointment. One could even say that I’m benefiting by continuing to see a patient who is smoker, profiting from their continued behavior.

However, while I said that smokers rarely quit, some actually do respond to my constant pestering. It would be interesting to know whether refusing to see a smoker is a better cessation tool than a cessation intervention itself. However, as it stands now, the questionable ethics of conducting such a study would make it highly unlikely that it would be conducted in the U.S., or anywhere, for that matter. Those same ethics would make some physicians somewhat uncertain about  using such an approach in their own practices. Could I reasonably withhold an inhaler  which may benefit someone? Can I also withhold a cessation intervention (which in this case would be the smoking cessation discussion)  when I know it might help some people, albeit very few?

We must also remember also that we can only have this discussion because of the current negative view of smoking by society. For example, would it be acceptable for my doctor to tell me that they are not going to prescribe me Lipitor because I’m fat and I need to lose weight, first? Certainly not! If they did, would it make me lose weight? Maybe.  Yet still it would not be considered ethical to do such a thing. Should we deny insulin to chocoholics? Tell people with GERD to come back for Nexium post fried chicken cessation? Explain that we prescribe STD treatments only after people stop practicing unsafe sex? No, we don’t do that, at least not that I’ve heard of.

And so I guess I’ll keep seeing smokers, and keep talking about smoking cessation until I’m blue. But maybe I’ll push back a little harder when they ask what I can prescribe that will help their breathing.

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.

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