Worldwide, one-billion people smoke cigarettes. Physicians, educators, health advocates, and governments have attempted to increase cessation and reduce cigarette uptake through taxation, labeling changes, marketing campaigns, and innumerable other efforts, all with very little impact. Yearly, less than 1% of smokers quit.

I completed my medical training in rural Indiana where 22% of the county’s population smoked cigarettes. I know a tremendous amount about Chantix, Nicoderm, nicotine gum, bupropion, hypnosis, counseling, free resources … I have done handstands (metaphorically) trying to unlock the box that would help me help people quit. In my thirteen years as a primary care physician and forty-three years as a daughter of a smoker, I have had minimal to no success in aiding my patients and loved ones in cessation. This is not for a lack of trying, a lack of training nor a lack of time. The vast majority of people who I care for who smoke state they have no desire to quit.

In the United States, the dialogue around cigarette smoking has largely been distilled to: “Cigarettes are bad for you. Quit.” Or “Smoking will kill you … Quit.” The majority of physician groups discuss prevention and cessation, but none discuss transition.

Our modern approach to smoking cessation is akin to telling a person who is one-hundred pounds overweight that they must lose one hundred pounds. This all-or-nothing approach, while academically correct, does not accommodate gradual modifications in human behavior that may ultimately lead to sustained behavioral change. It also flies in the face of accepted practices of motivational interviewing. Motivational interviewing is a strategy utilized by physicians, counselors, and even parents to help people work through uncertainty and commit to change (Miller, 1983).

Offering two behavioral options: continue or quit, leaves little room for transition.

Four years ago, one of my lovely patients with a long-term smoking habit looked at me and said – “Dr. G, I don’t think I’ll ever quit. Asking me to give this up is like asking me to walk away from a best friend. Through my life the only thing that’s always been there for me is a cigarette.” While I reminded this patient that, generally, best friends don’t kill us slowly, her statement struck a chord. I really, truly, had no understanding of just how important, and addictive, cigarettes are.

If I could bottle nicotine and safely prescribe it, I would. As a biochemical substance it works like the best combination of medications we have for anxiety, ADHD, panic attacks, depression, and movement disorders all at the same time. It is a brilliant chemical. In today’s crazy, uncertain, unsettled, insanely busy, and aggravating times I understand how nicotine can feel like a best friend. Unfortunately, for all that it ‘improves’, nicotine dramatically impacts the human cardiovascular system and increases the risk of early death from stroke and heart attack. In the balance of benefits vs. harms, nicotine has a lot of harms.

Nicotine is not the whole story of cigarettes, however. The products of combustion from a traditional cigarette are divided into gas and particulate phases. Biochemistry was never my favorite subject, but let me summarize the US Surgeon General’s Report: “Chemistry and Toxicology of Cigarette Smoke and Biomarkers of Exposure and Harm”:

The result of burning a cigarette means inhaling nail polish remover, Mr. Clean, Vics Vaporub, some of my old trainer’s hand wax parrafin, and a whole lot of stuff that is basically like pesticide mixed with embalming fluid.

The products of combustion of a cigarette are horribly harmful.

Incremental change – as with the weight loss metaphor encouraging that even a reduction of 25 pounds is a marked health improvement – until recently did not exist as part of our dialogue about smoking cessation. E-cigarettes, vaping devices, nicotine substitutes, and new nicotine delivery systems such as heat-not-burn tobacco products offer the possibility of a gradual reduction in the health impact of smoking while a person works toward full cessation. They offer the option for the US health care system, and the physicians within it, to rethink our dialogue around motivational change for our smokers.

The United Kingdom’s National Health Service states, “[e-cigarettes] … aren't completely risk free, but they carry a small fraction of the risk of cigarettes… While nicotine is the addictive substance in cigarettes… [a]lmost all of the harm from smoking comes from the thousands of chemicals contained in tobacco smoke, many of which are toxic. Nicotine replacement therapy has been widely used for many years to help people to stop smoking and is a safe form of treatment.” The UK is a potentially powerful model for U.S.-based health professionals in expanding the range and efficacy of tools for people who want to stop smoking -- and, at least as powerful, for potentially increasing the number of people who are willing to try.

US physicians and health organizations may struggle with a dialogue around nicotine alternatives. When I first considered thinking about smoking not as one thing but as nicotine plus products of combustion, the absolutist in me wanted to call ‘BS’.

People must quit smoking. Period.

Endorsing alternative nicotine sources as a path to cessation gets rid of the clear all-or-nothing “smoking is bad” messaging. The pragmatist in me, however, the day-to-day, do-the-very-best-I-can family physician, the physician who in 13 years has maybe had 1% of my smoking population quit smoking, sees tremendous brilliance in this frameshift. If I can’t help people quit all of the way…can I help them quit part way? Does shifting towards the road of cessation move people through the hardest first part of change?

Leading a conversation that looks towards cessation as a matter of incremental change differs from the long-held culture of saying that smoking is deleterious for health and quitting is the only option. The absolutism of that strategy towards cessation has been and remains woefully ineffective. For patients who can’t or won’t quit, is a dialogue of “if you can’t or won’t quit, will you switch” a transition toward improved health? Is continuing a harmful habit that can be modified to be less harmful, better than no change at all? As a physician and daughter of a smoker, I think it is.

Julie K. Gunther, MD, FAAFP is a member of Clinicians for Tobacco Control – an informal, physician-led group of health professionals dedicated to giving the patients we treat the tools they need to stop smoking