Cheryl Martin (Host): You know you should, but how do you quit smoking for good? You'll get some tips for beating the urge to use tobacco from Dr. Odai Sinokrot. He's a physician in the Pulmonary and Critical Care Department at Maimonides Medical Center.

This is Maimo Med Talk, a podcast from Maimonides Health. I'm Cheryl Martin. Dr. Sinokrot, so glad you're here to offer help to those who sincerely want to quit smoking.

Dr Odai Sinokrot: Thank you so much for having me. It's a pleasure.

Host: so first, talk about how quitting smoking can improve your health.

Dr Odai Sinokrot: Absolutely. So as you might be aware, becoming a non-smoker is one of the most important steps you can take to improve your health. It's true no matter how old you are or how long you've smoked for. And quitting smoking can reduce your risk of having cardiovascular disease, high blood pressure. We know that smoking is associated with multiple things like lung cancer and cancers of other organs.

So, quitting smoking or becoming a non-smoker, as I like to call it to my patients, is definitely a step in the right direction for reducing your risk of multiple health-related issues.

Host: So, how does one quit smoking?

Dr Odai Sinokrot: Many people who smoke become addicted to nicotine, and I wanted to kind of like touch on that for a little bit. Nicotine is a drug that is found naturally in tobacco. So, this makes it very hard to quit smoking. But the good news is, which we're going to dive into, is that There are proven treatments that can help you quit.

Apart from just the dependence and addiction to nicotine, things that we help people overcome is really the stigma that's attached to smoking. We want to destigmatize smoking, make the patients feel comfortable in sharing and understanding the process of how to become a non-smoker. And as I mentioned, because of the nicotine being the driver of this addiction to smoking, most of what we target in terms of therapies, really targets that nicotine component.

So, we'll dive into the different aspects, whether it be pharmacological or non-pharmacological that your practitioner or doctor really approaches, But in my practice, and a lot of the physicians, your primary care provider, your cardiologist, would generally start the process by really understanding how much you smoke, how long you've smoked, and mostly a lot of times, what you've tried in the past to quit smoking or to become a non-smoker. Your clinician's involvement increases that likelihood that you'll be successful at becoming a non-smoker, as opposed to you trying to do this alone.

Host: So if I get it right, don't go it alone. There's strength in numbers

Dr Odai Sinokrot: Most people, like myself, in the clinical world try to approach this using what we call a five A's steps. So, there are like five steps that we use as a guideline, questions really that starts with the letter A, just to make things easier in general, that help us gauge your dependence and your readiness. So, the first one being like I usually ask about tobacco use, simple. I advise my patients on stopping. I assess your readiness to become a non-smoker. And then, I want to assist smokers who are ready to stop. And the fifth and final A is arranging followup. And then, all your clinicians here at Maimonides and your clinicians anywhere should really have resources that are available to smokers like pamphlets, handouts, resources that I usually consider as like a smoking cessation toolbox really available for you during your journey of stopping smoking that help you stop.

The two big components of how to stop smoking that we use are a combination of behavioral support, and I can dive into that, and also pharmacotherapy. So, the medications that we use that we can prescribe to you that help you quit smoking. And a combination of those two has been shown, so the behavioral aspect component of it and then the pharmacotherapy, is way superior to one or the other used alone.

Host: So, feel free to go into the details of the prescribed options.

Dr Odai Sinokrot: Absolutely. So, there's three major pharmacologic therapies that are available for patients who want to quit smoking. So, let's say you go in to your physician. As I mentioned before, the first thing that your doctor will probably ask you is, see what's worked for you in the past if you've actually tried to quit smoking before has that trial been successful with the medications? How long were you on them? And one thing I really like to mention to my patients that kind of encourages them is that it usually takes about six to seven trials of like smoking cessation with medications or without to really become successful. Some people, and there's some data to this, some people are able to, and everyone's very different, to quit smoking completely cold turkey. Those people who have that ability are generally more successful at staying, abstinent from smoking. But if you're the majority, six to seven trials is a lot. So, I try not to have my patients get discouraged if they've tried two to three times.

So, there's three really major subtypes of pharmacological therapies: what we call long-acting therapies. So, there's the nicotine replacement therapy, and that's in the form of a patch, which a lot of people might be familiar with. And then, there's two medications. One is called varenicline, which is Chantix, and the other is bupropion. And both medications act on the receptors in your body that receive nicotine. So, what they do is they basically reduce the effect of nicotine, reduce the symptoms of withdrawal that a patient would get. So, a lot of people, once they stop smoking, they have this massive withdrawal from smoking. This really helps with that.

What we usually do is that we start these medications or the patch. You can use one or the other. Sometimes, in some cases, like I said, depending on what you've used in the past, how much you're smoking, we can use multiple of these modalities together. But the general practice is you want to use one of them, so either a patch, which you apply to your skin on an area of your body, usually slightly further away from the chest. It's applied for about 24 hours and changed every day. Or one of the medications are usually given once or twice a day in different doses that your doctor will try to figure out based on the number of cigarettes you smoke a day. And those medications or the patch are usually given in combination with a shorter acting nicotine supplement.

So as you can imagine, the nicotine craving that's there happens throughout the day. So by these medications, you're allowing sort of like what we call like a basal, a daily low dose of a nicotine replacement. And then, when someone tries to reach out for a cigarette, we give them modalities that are shorter acting nicotine replacements like a gum or a lozenge or a spray either in the nose or a mouth spray that we try, because smoking is a habit. So if you're reaching out for those cigarettes during the day, slowly, we want you to be reaching out for the gum over a period of 2 to 3 months, more so than an actual cigarette. So, you start off, and these medications are not meant to have you quit smoking on day one. We actually, together, we form or we decide on a quit date. We're ambitious, we say choose that as three to four months from now. Or I usually actually ask my patients to do or choose their birthday if it's coming up. And we don't usually tell them because it's unrealistic to stop right away. So, these medications are meant to really be replacing your nicotine craving or over a two to three month period.

Initially, those were thought of as just like for three months, and then you're unsuccessful. But actually, more and more in practice, we're giving them for longer, as long as the patient is willing, and you see that there are goals achieved over a two to three-month period, then you can really continue them for quite a while before they completely stop smoking.

And then, basically, at every visit, like we discussed in the five A's, that there are followups. So at each follow up, you celebrate the milestones that you've reached. And then if you were unsuccessful at the first trial with these modalities, now combined with the behavioral aspects that we'll discuss shortly, then you try to have a different approach. Do you need two of those medications at the ,same time? Do you need more resources? And I really do want to talk about the resources that we do have at Maimonides, and also that your doctor should have, and expand on what exactly I meant previously by behavioral interventions, because behavioral interventions generally consist of either the brief clinician counseling, so whatever your doctors talk to you in the office, and those generally are brief. As you can imagine, clinic visits sometimes are short and you can't address everything in them. But we do usually try to squeeze in a counseling session for smoking cessation, but also provide our patients with resources.

Host: What are some of these resources?

Dr Odai Sinokrot: On a national level, there's a quitline that's available. It's a toll free number that I provide my patients with. It's both at a national and at a state level. So if you call 1-800-QUIT-NOW. Usually, they defer you to your state level quitline service. And what that does, and what it offers, it offers evidence-based support, so like counseling, referral to local programs. And at a state level, depending on where you are, they can offer you free medications, kits, nicotine replacement therapy and advice. So, they can keep you accountable. They can go on that journey with you to basically make sure that you reach your milestones.

So, most clinics offer these services. Your doctor can give you handouts on different packets on the available resources, just make sure you reach out to your doctor and ask them about what's available.

Host: So, you're saying what's ideal is for a patient to take the medication, but also experiencing the counseling, which will help with the behavioral aspect, and then tap into this 1-800 number. So, it's more holistic, 1-800-QUIT-NOW.

Dr Odai Sinokrot: Exactly. It's more holistic, it's getting it from different angles, it's allowing the patient to maximize however much resources can be provided for them, and that allows them to really engage with the process, gain insight into the different modalities that are available and empowers you to actually like have all the resources and be able to quit in time for whatever goal you have set.

Host: So, you have seen that those patients who do all three, they have been more successful?

Dr Odai Sinokrot: Absolutely. We know that through data and multiple studies that have been done to date, that combining modalities is way more successful. So while we know that from the medications, varenicline or ChantIx, as it's called by brand name, is the most successful initial medication. Second to that would be the nicotine replacement therapy and the bupropion. Your provider really should cater to your background, your medical history, into which one is most adequate for you. But combining those, the short-acting nicotine replacement therapies to allow you to reach out for a gum, a lozenge, a spray whenever you're craving a cigarette with all of the behavioral aspects and the scheduled counseling sessions really is the most successful way to quit smoking.

Host: Now, you mentioned earlier one of the things that you discuss with patients. It's important to overcome stigmas. Can you talk about that and what

you do

there?

Dr Odai Sinokrot: absolutely. So I think that people generally associate smoking and coming into your office thinking that they'll be judged if they're smoking. And a lot of the times, clinic visits are short, they're fast, and like I said, a third of patients do not report that they're smokers even though they are. And during your interaction, you want to humanize the situation. You want to make sure that the patient sees or feels that they're being seen, because interventions can sometimes come off as a little harsh, aggressive, and fast, and not thought out. So, I usually try to really take it down, make the patient understand that we're there to help them. And that it's really a journey with regards to how to stop smoking, that it's not something that happens overnight. And that a lot of people do try multiple times before they're able to fully quit smoking, to fully stop. And that's kind of my approach. And I usually try to do it over several visits, because sometimes it doesn't work on the first. And I usually try for both of us not to actually quit on each other and kind of really re-elaborate all the data, all the knowledge that comes from your clinician over to your patient so they can slowly do some reading, understand that you're somebody who's developed a good rapport with them so they can trust you. And it takes a little bit of time with that.

Host: This has been some great information. In closing, is there anything else you want to add encouraging smokers to really try to become a non-smoker.

Dr Odai Sinokrot: I do want to talk about one thing that I think is important and it's in the news a lot. And it's about e-cigarettes. And that's a little controversial, and it depends on where you are in the world and where you're practicing, whether it's Europe, where they're pushed more, they're more acceptable as a method of quitting, or in the US, where we're still gathering more and more evidence. But we do see a lot of people use e-cigarettes, like vaping either nicotine-containing vapes or non-nicotine-containing vapes as a method to quit smoking.

Now, there is a lot of data if we look at evidence. I have a lot of patients asking me that. I think it's a very big topic in stopping smoking. There's a lot of data that's showing us that there's a high success rate in stopping smoking when people actually use e-cigarettes when compared to nicotine replacement therapy like the patch. So, the data is good. But there are a lot of caveats that I make sure all my patients understand.

E-cigarettes and vapes, both nicotine and non-nicotine-containing products. The studies that looked at them only looked at them for two years. So while at two years, a lot of patients who are followed up have not touched a cigarette, they've only used the vapes. The data looks good for two years, but we don't have more data that is longer than that to expand on the harms that can potentially come out of vaping from long term vaping. People are more likely, especially young people, to continue vaping past that time that they've quit smoking for much longer, so it becomes a habit. So, I would recommend e-cigarettes and vaping with nicotine replacement products as an alternative to smoking tobacco, because we know tobacco is way more harmful. But I always try to tell my patients about the different caveats that are associated with that. So, that's that for e-cigarettes.

And then with regards to your question, I would always encourage my patients to constantly ask me, get all the resources available for smoking cessation, understand that it's a long process, that it's not something that happens overnight, and rehash at every visit about the different victories that they've had with stopping smoking or reducing cigarettes.

Host: And just to clarify, while you may encourage some to use e-cigarettes instead of smoking tobacco, you ultimately say to them it's best not to start that habit or to stop that habit.

Dr Odai Sinokrot: Correct. Yes. So if they've used it successfully to stop them from smoking and they've stopped tobacco use completely, I then start to encourage them to stop e-cigarette use and not form it into a habit, exactly.

Host: Great. Dr. Odai Sinokrot, thanks for providing great incentives and tips for kicking the habit of smoking. Great information.

Dr Odai Sinokrot: Thank you so much.

Host: To make an appointment with Dr. Sinokrot, call 718-283-8380, that's 718-283-8380, or for more information, visit maimo.org. If you found this podcast helpful, please share it on your social media. You can also check out our entire podcast library for other topics of interest to you. This is Maimo Med Talk, a podcast from Maimonides Health. Thanks for listening.