Building Blocks for Tobacco Dependency

The British Thoracic Society recently published a ten-author Clinical Statement with the promising title, Medical management of in-patients with tobacco dependency. It’s supposed to be a guide for doctors to help smokers give up the evil weed if they have the misfortune to be admitted to hospital, though if they’re addicted to vaping presumably it doesn’t apply to them.

The article sets out a ‘Summary of key clinical practice points’ consisting of five ‘Building Blocks’. It’s not clear why they don’t simply call them five steps or stages, but let’s work through them anyway.

Building Block 1: screen for tobacco dependencey
This merely consists in the advice to ‘Ask every patient if they smoke.’ Well, I’d never have thought of that. Medical students are taught, or used to be, when taking a patient’s history to ask if they smoke, and write the answer down. But let’s get up to date. We now need to ‘record “tobacco dependency” as an active disease in the medical history.’

Hang on a minute! Is smoking, or what they call tobacco dependency, not only a disease but an active (!) disease? I thought it was a voluntary activity, though one that may be hard to resist.

But there’s more! We are adjured to ‘Ensure any electronic systems for recording smoking status and supporting referral to the specialist tobacco dependency team are completed.’ Wow, this is really getting complicated. We must ensure, not just to make a referral, but to support (!) referral, and not just to any old tobacco dependency team, but to the specialist (!) tobacco dependency team.

Building Block 2: advise on the role of nicotine
I suppose a smoker, ill enough to be confined to a hospital bed, may put on a show of compliance to listen to the following advice: ‘Nicotine drives the dependency to tobacco but is NOT [sic] the cause of the harms of smoking.’ What a relief to know that! But this relief is short-lived because another piece of advice in Building Block 2 is ‘nicotine withdrawal can be very unpleasant.’ Oh dear. However, fortunately, ‘being smoke-free does not have to mean being nicotine-free during a hospital admission or after discharge from hospital.’

Building Block 3: initiate combination nicotine replacement therapy (NRT) as soon as possible
Quick – there’s not a moment to lose! This is true, but it assumes our poor sick in-patient smokers want to quit poisoning themselves with tobacco fumes and are glad of the opportunity to be offered, not just any old NRT but combination (!) NRT. But suppose they don’t want this? Maybe they’ve already tried it and failed to stop smoking. Are they going to be prohibited from smoking while in hospital and be forced to use NRT instead? Not to worry. All will be fine if the doctor ‘adequately addresses the patient’s withdrawal symptoms and urges to smoke.’ All right then: Oh withdrawal symptoms! Oh urges! (Is that adequately enough?)

Building Block 4: complete a referral to an on-site Tobacco Dependency Advisor (TDA)
‘Refer all patients with tobacco dependence to the TDA team unless they opt out. Advise on the benefits of working with specialist tobacco dependency advisors.’ You can imagine the patient thinking, ‘Well, should I go to an ordinary tobacco dependency advisor or a specialist (!) tobacco dependency advisor?’ And what is the advisor, specialist or otherwise, going to advise me to do? Presumably, to stop smoking. Oh great.

Now we come to the climax of the piece:

Building Block 5: provide accurate and consistent information on Vaping
I should hope they wouldn’t provide inaccurate and inconsistent information on Vaping, but here we go:

  • Nicotine vapes deliver high dose fast-acting nicotine which can help to alleviate withdrawal and urges to smoke

Only help to alleviate the dreaded withdrawal and urges? Thanks a lot.

  • Vaping is an effective tool in the treatment for tobacco dependency and can be used to support patients during a hospital admission and to help achieve long term abstinence

This dubious claim could be shortened to: ‘Vaping is an effective treatment for tobacco dependency and can help to achieve abstinence.’

Gesture of despair
One almost despairs of this kind of advice. It amounts to offering smokers who are admitted to hospital to consider vaping instead of smoking. This is discouraging and almost an insult because it implies it may be too difficult simply to quit, and smokers will need a supposedly safer alternative.

The total lack of understanding of the smoking problem by our ten authors is also shown in their phraseology, ‘tobacco dependency’. Smokers are not dependent on tobacco but on the nicotine in tobacco. And how can they call smoking a disease? Clearly, it’s not a disease in the normal sense of the word: it’s nicotine addiction.

A further reason for despairing is that the smoking problem will never be solved while cigarettes are available on largely unrestricted sale in every corner shop and supermarket throughout the land.

Text © Gabriel Symonds

Picture credit: Karl Abuid on Unsplash

Gabriel Symonds

Dr Gabriel Symonds is a British medical doctor living in Japan who has developed a unique interactive stop smoking method. It involves no nicotine, drugs, hypnosis, or gimmicks but consists in helping smokers to demonstrate to themselves why they really smoke and why it seems so hard to stop doing it. Then most people find they can quit straightaway and without a struggle. He has used this approach successfully with hundreds of smokers; it works equally well for vapers. Dr Symonds also writes about transgenderism and other controversial medical matters. See

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