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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  • Greg Friese

    A related or parallel conversation is should employers continue to insure smokers or other employees that continue behaviors that worsen chronic health problems – diabetes, hypertension, etc.

    I definitely think doctors and other healthcare providers should talk to patients about the connection between behavior and problem, recommend actions to change the behavior, and pester as needed.

  • Deep Ramachandran MD

    That’s interesting, I heard of a medical system recently that is not going to hire new smokers. I suspect this will become more common and perhaps spread to other bad habits as medical costs continue to increase.

  • Kenneth Berger

    My company, which does not permit smoking in our building, has announced that smoking will be prohibited anywhere on company property. The prohibition will extend even to the inside of automobiles of employee smokers, as long as the automobile is on company property. Perhaps when it becomes too inconvenient to smoke, some folks will seriously consider quitting. The company will also assist smokers in the quitting process.

  • Bradley Evans

    I think we are talking about doctors denying medical care to patients based on the doctor’s determination that the patient in some way caused the illness.
    Do doctors want to be in this position of not only diagnosing and treating, but also measuring how much they think the patient caused his own illness? As a patient, would you want your doctor denying you medical care because s/he thinks you caused your illness? To me, this reminds me of the firemen in Fahrenheit 451, who had switched from fighting fires to starting them. You go to see a doctor to be denied medical care.
    Doesn’t this violate the Hippocratic Oath?

  • Alan Turley

    If you have a chance to counsel someone more than once about a numbskulled behavior that should’ve killed ‘em by now but for your gentle ministration, count yourself lucky and keep at it. That’s another chance for the message to get through. Some take longer to convince than others — particularly those facing competing messages from addiction and alternative marketing.

    If one’s duty is to care for the health of patients, to ameliorate their hurt and ills, then wouldn’t it be wrong to withhold needed service from those obviously in need? Or, perhaps one should stop prescribing antiretrovirals to AIDS patients whose choices put them at undue risk; stop treating the wounds of those wounded in the course of criminal acts — or those of law enforcement officers who’ve assumed the risk of standing in harm’s way; stop treating… Draw the line where you will.

    Alternatively, you might concentrate on splinting it where it lies and counseling those who’ll listen as to how they might avoid landing in the same ditch repeatedly. You can only be an “enabler and tacitly endorsing their behavior” where you remains tacit. You’re not doing that, right?

  • Betsy Murphy

    Perhaps inserting a simple 5-letter word would help, as in :”We will discuss interventions to help your breathing after you become smoke-free”. It’s not as punitive sounding as ‘unless’ but it gets the point across that there is an order you intend to follow. To do otherwise is enabling not only the patient to injure him or herself, but also enabling them to injure their children, family members, and friends.

  • Payne Hertz

    Sadly, this illustrates perfectly the authoritarian nature of our medical system. The only solution to problems many doctors can come up with is to punish patients by denying them medical care. Allowing people to suffer and maybe even die because they don’t adhere to the lifestyle some doctor insists they maintain is morally depraved.

    Doctors like this perceive themselves as perfect judges of their patients’ morals and feel comfortable acting in the role of moral gatekeeper. It is truly disturbing how common this attitude is, as judged by many blog posts and comments I’ve seen by doctors. This is why citizens need to be given greater control and autonomy over their own medical care. No one should ever have the right to tell you that you are going to suffer because they don’t approve of your lifestyle.

    I don’t think many doctors would be comfortable working in a system where if you accused of misconduct or malpractice, you will be denied the right to practice medicine without due process. But that is precisely the kind of system many doctors want for their patients with themselves playing judge, jury and executioner.

  • Rachel Wasson

    What happened to “do no harm?”
    I honestly don’t understand why you would want your patient, or any human being for that matter, to be in intermittent or chronic respiratory distress! Would you prescribe only patients with juvevile onset diabetes their insulin, or would you also treat patients with DM2? Would you check an A1C before you prescribe their limb saving Novalog (just incase they were induldging in the chocolate cake you told them that you do not approve of?)

    I can go on and on with examples ad nauseum.
    Get off your damn pedestal, because you sir, are not God.

    I suggest you have a PDoc friend prescribe you some Ambien to prevent your late night musings because your argument is borderline ludacris!
    On second thought, it almost seems as if you can use a healthy dose of Geodon 20mg IM in one cheek and Ativan 2mg IM in the other…..hmmmmmmm…..

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