So the week started with me picking up my dear wife and kids at the airport after returning from a family visit in California. The day after, my sister came to Boston for a visit.

Her trip started in New York, followed by a train ride to Boston. It seems that she enjoyed New York, the same as she did during her previous visits to the city. A bonus was the Thanksgiving parade and the selling events of Thanksgiving. So you can add this information to my experience of New York City, as I described in issue #9 of this newsletter. My kids had an opportunity to spend time with their aunt (who also gave them a well-needed haircut 💇‍♂️ 💇), and we all had the chance to do a little catching up.

Firstborn had his first boy scouts winter camp this weekend, which also included spending the night in a cabin with his boy scouts friends. This is the first time he has had the opportunity of being away from his family and comfortable surroundings, and we are glad that our Boston journey has enabled him to have this experience. We believe that this adventure, and similar ones in the future, will prove to be meaningful for his growth as a young individual.

So after driving my sister back to the airport, we are back again to our core-of-four family. Our next family-related event will be a visit to Israel of my dear wife and kids in a few weeks. I will have to sit this one out and spend the Christmas season in Boston without them. As I mentioned last week, the fellowship schedule comes with substantial obligations, and the holiday season is no different.

In today’s newsletter, I will take a different angle and share my clinical experience in supporting my patients through their process of quitting smoking.

Enjoy number 16!

“The difference between winning and losing is most often not quitting.” - Walt Disney

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Table of contents

1. Main Article - How to Help Your Patients Quit Smoking (a Cancer Surgeon Perspective)

2. OMFS World

3. Stuff (App, Gear)

Main Article - How to Help Your Patients Quit Smoking (a Cancer Surgeon Perspective)

🚬 Smoking is an unhealthy habit that can lead to significant health risks. Quitting smoking can be a difficult process, but there are many steps one can take to make the transition easier. Understanding the challenges of quitting and developing an appropriate plan can increase the chances of your patients for success.

👨‍⚕️ As a cancer surgeon, meeting people interested in quitting smoking is a daily routine. In my practice, I see an association between the diagnosis and the motivation for quitting smoking, which can be divided into three groups: Cancer, pre-malignant conditions (i.e., may transform into cancer in the future), and benign.

💊 With cancer patients, many had their last cigarette before hearing their diagnosis for the first time, and it is pretty rare for them to restart smoking afterward. In other words, getting them to quit smoking is usually no issue.

🏹On the other end of the spectrum are patients with benign conditions. Since their diagnosis is not related to smoking and usually doesn’t require long-term follow-up, their journey with me is relatively short.

👤That leaves us with the pre-malignant group, and this is where smoking habits get interesting. Initially, many patients are worried that they have cancer, so they seriously consider quitting smoking altogether. But then they get their non-cancer diagnosis (such as dysplasia), and the fear factor that initially pushed them to quit smoking wears off. In my experience, it usually happens around one month afterward. So how do I preserve the motivation after the fear factor has disappeared? This article will look at the techniques I found most effective with my patients to stay motivated throughout the process.

Intermission - a classic. Love the Rat Pack!

📝 First, let’s understand the five stages every person undergoes on the way to change: pre-contemplation, contemplation, preparation, action, and maintenance.

🥽Pre-contemplation is the stage in which a person is not even aware that they have a problem in the first place. For example, when people are addicted to smoking, they do not know it because they don’t consider “smoking” a problem. The second stage is contemplation. This is when one becomes aware of problems but doesn’t want to change. The third stage is preparation. The individual begins to make a plan for change, but still has not taken action. In the fourth stage, action, one acts on a plan of change and starts to change behavior. In the fifth stage, maintenance, one is aware that they have changed and integrates the new behavior into their life. As medical professionals, we should identify our patient’s stages and act accordingly. With my pre-malignant patients, we reach the action stage pretty quickly, but then the hard work begins.

💪So, what do I do to keep them motivated? First and foremost, we discuss smoking during EVERY SINGLE VISIT. Yes, even when the clinic is running behind, and we are pressed for time. I use the 5 A’s: Ask about smoking at every office visit; Assess readiness to quit; Advise patients to quit; Assist with medications and behavioral therapy; Arrange a quit date and follow up. I find it helpful to discuss the things they miss the most about smoking, and from there, we discuss how to move forward.

“If you want to master a habit, the key is to start with repetition, not perfection. You don’t need to map out every feature of a new habit. You just need to practice it.” - James Clear, Atomic Habits

😷So, how do we move forward? First, I ask them to schedule an appointment with their primary care provider to discuss ways to quit smoking. (“Just schedule the appointment, and that will be a huge step forward!”). Second, I introduce them to the various pharmacologic options available to help them quit smoking: nicotine replacement therapy (nicotine patches, nicotine gum), Varenicline, and Bupropion. If they are on board, I prescribe nicotine replacement therapy, and I leave the other options to the discretion of their primary care provider.

➕➖Then we discuss how to progress from the action stage (#4) to the maintenance stage (#5), and for that, I like to focus on coupling of behaviors: Positive coupling and negative coupling.

🍾When you couple a positive act with smoking cessation, you reward yourself with something pleasant, and when you couple a negative action with smoking, you punish your undesired behavior with a negative act. For example, if you quit smoking and managed to get through the first 24 hours, you can treat yourself to having dinner in your favorite restaurant; if you went a whole week without smoking, you take the weekend off for a vacation; if you went an entire month, then you can buy that thing you always wanted but never did.

🫙And there’s the negative coupling. In this case, every cigarette you smoke has a price tag: put 20$ in a jar for every cigarette you smoke. You can later give this money to someone else (donate to a cancer organization, for example). This will lead you to question every cigarette: “Is it worth the 20$?” If the answer is yes, go ahead and smoke. With time, when you’ll notice that you spent 400$ for every pack of cigarettes you smoked, you will start feeling uncomfortable about smoking.

🕰️So this is how I do it. Remember that the essential part of helping your patients quit smoking is that you take the time to discuss it every time you see them. Just ask them about their smoking habits and whether they are willing to consider quitting. You’ll be surprised by how meaningful it will be for them and you.

OMFS World

🥼For the OMFS resident - Install the NCCN app on your phone. The National Comprehensive Cancer Network (NCCN) is an important organization for cancer care providers, and its guidance documents provide evidence-based recommendations for managing various cancers. The application of NCCN guidelines is essential for oncology teams to ensure that patients receive the highest quality evidence-based care. As an OMFS resident, it is sometimes difficult to keep track of the updates in the guidelines. Having the (free) NCCN app on your phone will ensure that you always have the most updated data at hand.

🩺For the non-MD medical professional - All women are recommended to begin cervical cancer screenings at the age of 21 and continue to do so until age 65. For women ages 21-29, a PAP test (cytology) is recommended every three years. Between ages 30 and 65, they can continue with a PAP test every three years or a test for human papillomavirus (HPV) every five years (with or without cytology). After age 65, women who had previous negative screening tests and are at low risk can stop screening altogether.

Stuff

📱 Application I use(d) - My Fitness Pal is an online resource and app that helps track your calorie intake. Whenever I wanted to lose weight, this app helped me to be mindful of everything I eat and make deliberate choices. Using this app is very simple: 1. Download the app for free on your phone. 2. Enter your current weight, height, and age. 3. Define your goal weight and how fast you want to lose it, and you’re all set! Every time you have a meal, you log it into the app, which will calculate how many calories are in that meal and how many calories are left for you to consume until the end of the day. I highly recommend that you log each meal BEFORE having it so you can change your mind once you see how many calories are in it. There are many weight loss programs, but the best one is the one you can keep. The method of My Fitness Pal is simple and easy to follow.

💡Gear I use - Lowepro Adventura SH 160 II camera bag. Got it for 25$ through the Amazon marketplace in a “like new” condition. Considering I carry it to the OR, I don’t mind some wear and tear, but it turned out to be in mint condition. It holds my camera, macro lens, ring flash, extra camera battery, camera battery charger, and Eneloop fast charger (check out this newsletter about photography for more details about my camera gear). I also place my surgical loupes and phone charger in it, with room to spare.

Epilogue

That’s it for this issue.

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Have a great weekend!

Shay