Physician Harm Reduction
During his postgraduate training as a primary care physician, Sudhanshu Patwardhan became increasingly concerned about the ineffectiveness of counseling and treatment given to patients who smoked combustible cigarettes. Since then, he has focused his clinical and research career on harm reduction for addicted smokers. He is currently based in Britain, where he is director of the Center for Health Research and Education.
Patwardhan has researched doctors and nicotine in the UK, Sweden, Greece and India. Over the past year, he and I have spoken about the clinical and public policy challenges that come with moving to a harm reduction approach to smoking cessation.
“Constantly, between 65 [percent and] 80% of doctors surveyed in all these countries have misconceptions about nicotine,” he said. “It’s no wonder that, universally, ‘Why replace one addiction with another?’ is one of the most common attitudes [among physicians] for nicotine replacement therapy for smoking cessation using a harm reduction approach.
“Doctors forget that in addition to its long-term effects, inhaling the smoke of burning tobacco induces the degradation of many drugs, thus rendering these treatments ineffective. Many psychiatrists I interact with simply admit to increasing the dose of medications given to compensate for the loss of effectiveness due to smoke-induced depression, but do not simultaneously offer withdrawal support. This, of course, leads to greater side effects and poorer patient outcomes, all because physicians are not educated and empowered about smoking cessation and harm reduction.
“Most newly trained physicians would recognize the most esoteric heart murmur, but have no practical experience of the basics of behavioral intervention or the role of medications in smoking cessation. Pharmacology and clinical medicine barely touch on nicotine replacement therapy and give trainee physicians no clues about what prescribe, for How long and how to manage cravings and withdrawal symptoms effectively. Most non-communicable diseases have smoking as a risk factor. Yet doctors simply do not approach it with the presented complaint.
“Our center’s strategy focuses on getting to the root of the problem: we develop and conduct peer-to-peer training for healthcare providers in a safe, non-judgmental environment. Our approach and our materials are specific to each country. For example, in the UK, e-cigarettes are part of the suite of potential harm reduction tools offered by the National Health Service. In India, however, e-cigarettes are currently banned and not allowed for smoking cessation. Here we focus on proven approaches, such as nicotine replacement therapy, bupropion, and varenicline.
“We need to start revamping the medical training curriculum in this area. We are running pilot programs in some medical schools with exciting results and will publish this data. Practicing physicians also need training to increase their effectiveness. Finally, scaling up nicotine education for healthcare providers can be a daunting challenge, especially for countries as large as the United States or as populous as India. Digital technology tools, such as weaning apps, short media presentations including online videos, and smart print campaigns designed for social media can all help. »–CKO