So now it's my privilege to introduce Dr. Matthew Everson from the UK, who is a respiratory specialist based in Manchester at the Manchester University NHS Foundation Trust, and he has many hats, including a member of the British Thoracic Oncology Group Steering Committee and the NHS England Lung Cancer Expert Group. Thank you very much. Thank you very much. It's a pleasure to be here and to share the stage with my colleagues and the talks that have happened already have been superb. So we've heard about why it's so important that we treat the disease of tobacco dependency. We've heard about some of the tools that we have to allow us to do that. So my talk was about building trust, supporting quitting, what not to do. So I don't have slides of Kaplan-Meier curves or studies to present. These are reflections of what we should do in our culture, what we should do in our language, in how we talk to a patient that's in front of us. And a personal reflection is that maybe eight, 10 years ago, before getting into this field, it could feel quite apprehensive to approach the topic of smoking with a patient and have nervousness about how that's going to be received. And looking back, I think that was built on not having the knowledge, the skills, and the competence to be able to discuss this disease and approach it in the right way to create a rapport and create a way forward. So these slides are very much some reflections on that. So I'm going to start just with some ground truths, because I think these are important. This is what we build our conversations on. So there would be no smoking without nicotine. We all know this. Nicotine is the addictive component of cigarettes. And a cigarette is simply a nicotine delivery device. It just happens to be a highly effective one. And the vehicle for that delivery is the smoke produced from the combustion of tobacco. That smoke, tiny particles of nicotine, very rapidly get into the deep sections of the lung. They're rapidly absorbed. They cross the blood-brain barrier and enter that person's brain very quickly at a speed and an intensity that is very difficult to match in any other way. And nicotine is a psychoactive chemical. So it has effects within the brain. And they create feelings of reward. And with repeated use, and once dependency is formed, those effects are strongly rewarding, because you've developed dependency, and you create withdrawal without it. And therefore, relieving that withdrawal is a strongly rewarding effect. And over many years, that creates very longstanding, deeply ingrained behaviors that are associated with smoking. So tobacco dependency, I agree entirely with Magdalena's comments that this is a disease. It is a disease of addiction, of withdrawal, of cravings, that is intertwined with a complex set of deeply ingrained behaviors. So it is exceptionally difficult to stop. And it creates the fears, the fears of having to face those withdrawal symptoms, to face those cravings, to face the routines and the behaviors that are associated with smoking, to face life without cigarettes. Patients once told me it was like mourning losing a part of themselves when they no longer smoked. That's how deeply ingrained it is. And the fear of failure, this whole, right, I am now going to try and stop, that you acknowledge publicly to people around you, which something is so challenging. And if you don't achieve that, the sense of failure that surrounds that. And on the other side, underneath all of that, the real horror that nicotine is not a hazardous chemical, that stuff that they crave, that develops that dependency, that develops the deeply ingrained behaviors, is not the thing that's causing the harms. And for us, the ongoing delivery of nicotine from non-tobacco sources is a central component of treating tobacco dependency. Whether that's from nicotine replacement, whether it's medications that are nicotine analogs within the brain, whatever it is, our treatments are the provision of nicotine and its effects without tobacco. In a way, that's a way we can conceptualize this to patients, that rewarding the psychoactive effects of nicotine can still be experienced in a tobacco-free way. And that's a reassurance that we can mitigate some of those fears that we've just described. So the optimal model for treating tobacco dependency, we've heard, we screen all patients, we provide information. And for me, that has to center around the truth about nicotine. We've heard that in the environment that we work in, in lung cancer, there are very specific benefits to treatment and outcomes, and that the best way of treating this disease is to recognize the disease and also recognize the deeply ingrained behaviors, and both of those elements require interventions, and for which we refer on to specialists. We give the treatments that allow the effects of nicotine without tobacco, and we refer to specialists that provide the behavioral change support. And ourselves, as the person in front of the clinician, has to equip ourselves with the confidence and the competence to implement that intervention. And there's some examples. It's that the apprehension about approaching somebody that smokes, I think, is built on years of saying to someone, do you smoke? I think you should stop. It's very harmful. Why? I can't stop. And if we don't have anything behind that to engage that conversation, it can stop and it can feel very, a poor experience on both sides of things. People say to us, I've tried patches, they don't work. Simply knowing about nicotine replacement therapy, knowing that the intensity and the rapidity that cigarettes deliver nicotine into the brain, how do you try and match that? It's very difficult for nicotine replacement to do that, but if we appreciate that, we can engage in a conversation of it. So the best way to do it is to combine long-acting and short-acting products. You have to have a patch, a slow drip of nicotine into the bloodstream to mitigate withdrawal, and you need a short-acting product to reach for at the time of cravings. And so this is, the British Thoracic Society are about to release some guidance on managing tobacco dependency, and it's about creating easy-to-implement protocols at your fingertips. So a simple NRT prescribing protocol, there's lots of different products out there. You have to use high doses, all the Cochrane Review evidence suggests use high doses. So go for the strongest patch, 25mg over 16 hours, the highest nicotine strength patch that there is, so go for that for everybody, add in a short-acting product, and just use a few of them. There are lots of products out there, but if you're familiar with a couple of them, and you can go into the detail of how to use them with that patient, you have a few options and you have some knowledge to back that up. So the conversation becomes, I'm discussing the pros and cons of different types of treatment, not, I think you should stop smoking. This is how we're going to help support you. And there are phrases like, on the hour, every hour, using short-acting nicotine so regularly to try and keep that blood level of nicotine in a place that will stop withdrawal and stop cravings. Just understanding simple things about the inhalator, it's a terrible name, you don't inhale the nicotine down deep into the lungs, it's absorbed through the buccal membranes. The enemy of short-acting nicotine is swallowing it, because it won't get absorbed. You have to know that that nicotine needs to stay in the mouth and be absorbed there. These become medical, technical conversations, not trying to undertake complex behaviour change or simply informing someone that they need to stop smoking. So what not to do. First has to be not addressing it at all. I hear this myth a lot of the time, it's too much, we've just told somebody that they have lung cancer, we don't have the time to be able to address tobacco dependency. We've already heard the great benefits that come with it, or the fear of damaging that relationship. But it can be done, when it is done in an empathetic, when it's done in a positive way. We've again heard already, the cancer diagnosis, the time of that diagnosis is a loss of control. That person has no control over the diagnosis, no control over the effectiveness of treatment. The way they can take control back is preparation for treatment, and that plays out in the prehab literature as well. So these are things that become positive interventions about preparing for treatment. Without long-term abstinence, we are going to prepare for treatment by being tobacco-free, being active and nutritionally supported. Error two, focusing on the harms. Everybody knows smoking is harmful, and if we say to them, this is harmful, you should stop. Everybody is aware of the harms, and that for me doesn't show an appreciation of the challenges of stopping. If it was so easy as to say, it's harmful for you, no one turns around and says, I had no idea. Thanks so much for telling me, I am going to stop now. It's the challenge of stopping, and it implies that it's a simple choice based on those harms rather than a deeply ingrained dependence, and they could feel judged if it was all just about the harms. Motivation to quit, I hear this term a lot, and it comes out of, in the UK, we developed a model when there was a very high smoking prevalence, and we had to identify those that were most likely to stop smoking, and this motivation to quit, setting a quit date, all this terminology came out of that process, and we're in a very, very different place now. If we're the people that judge motivation, then that is a very variable factor. We know the vast majority of smokers wish to stop, but the apprehension about the difficulty of stopping, those fears that I talked about, can be misinterpreted as a lack of motivation. If we would simply say, do you want to stop, someone might say, no, I don't, I can't, and the conversation goes no further. We offer treatment and support to every tobacco-dependent person. I think language matters. Quit, I think this is a little controversial, but quit I don't think is a good term. It implies this choice of, right, I am now going to quit. My choice is now to stop. The responsibility is on the patient, driven by willpower, where actually they have a disease and a very, very powerful dependency. We can help them to be free of tobacco. Stop, stopping smoking, this immediate binary outcome, yes or no, can lead to this apprehension of success and failure. We have effective treatments and we can start on a journey towards becoming free of tobacco. I think those words matter that help develop the rapport and trust between a clinician and a patient. I think we need to change our approach to what clinicians do. We diagnose diseases. We discuss management options. We initiate management, and we refer to someone who is a specialist in that area if we can't do it ourselves. So we diagnose tobacco dependency, provide information about it, commence treatment, prescribe NRT, and refer on to a specialist team for ongoing management. And wouldn't it be great, the day comes, if we looked at medical records of a new patient in a cancer clinic who has stage 3 lung cancer, and what I would see in a diagnostic clinic is a list of tests of how we're going to investigate that patient. If we got to the day where we diagnosed tobacco dependency, we diagnosed lung cancer and a plan for staging, but we initiate their management and referral on to a specialist team, that's our medical records, and that's how we conceptualize this disease. Thank you very much.

Dr. Matthew Everson

respiratory specialist

tobacco dependency

nicotine replacement therapy

behavioral change support