Dealing with our heart patients who are smokers has always been a major dilemma, ever since I started my clinical practice in internal medicine and cardiology.

Doctors like me have persuaded, motivated, even threatened patients to make them stop smoking. We’re only successful in around three out of 10 cases.

We reach exasperation point with recalcitrant smokers such that if they’re not able to quit smoking in six months, we advise them to see another physician.

Occasionally, a few eventually succeed in quitting smoking, and we welcome them back. However, a few who have already licked the vice slide back and voluntarily go somewhere else for a followup. Some just maintain the initial drugs they’re given, and simply stop seeing a specialist for their heart issues.

This has been the standard policy in our practice until the start of the pandemic last year, when we realized we might have been too harsh on our recalcitrant smoker-patients.

Killer team

Smoking and COVID-19 definitely make a killer team. Smoking is a major risk factor for developing severe COVID, even in younger individuals.

In a pooled meta-analysis of seven separate studies comprised of a total of 1,726 patients by Q. Zhao et al. published in the American Journal of Medical Virology, a statistically significant association between smoking and severity of COVID-19 outcomes was shown.

Other researchers have shown that the risk in smokers increases several times if they have other risk factors like high blood pressure, diabetes, chronic kidney disease, obesity and chronic obstructive lung disease due to the smoking.

So, COVID-19 was really tragic news for those who continued smoking. It always pained us to hear of a former patient whom we’ve “expelled” from the clinic being hospitalized for severe COVID-19 or succumbing to it. Some of them get admitted to the inensive care unit or die, either because of complications in the lungs or cardiovascular complications like heart attack, heart failure and stroke, which may all be COVID-related also.

Somehow, it got us to think—would the few who died have remained alive if we didn’t give up on them?

So, since last year, we eased up on our strict policy on smokers, and made a firm resolve to double our efforts to get them to quit smoking. The threat of more severe COVID-19 if they continued to smoke has increased our success rate to around 50 percent. It’s quite perplexing, though, that half of our smoker-patients still keep smoking. But most smokers are simply helpless against their nicotine addiction.

Our main goal is still to make them quit permanently. But at least half of smokers, or more than half pre-COVID era, simply can’t quit.

Middle ground

Rather than “expel” them as we used to do, we’re now trying all other options that can at least reduce their risk. We’re trying to look for the best middle ground, hoping that, eventually, we could push them up to the real safe, high ground of completely not smoking.

I still have my serious concerns on vaping or e-cigarettes, since the reports on e-cigarette- or vaping-product-use-associated lung injury (Evali) came out. More than 60 deaths due to Evali have so far been reported.

A patient told us about heated tobacco products (HTPs), so we also started looking at the published data on it. HTPs produce aerosols containing nicotine and other chemicals, which are inhaled by users through the mouth, like the conventional cigarette, but the stick is not lit; it’s just heated using a battery-powered heating system device. No burning, so no ashes.

The inhaled substance still contains nicotine (from the heated tobacco), which makes it still addictive. But based on some studies, the amount of toxic substances a smoker gets is up to 95 percent less, compared to traditional tobacco smoking.

There are also short-term studies showing it leads to a reduction in the substances released by the body that cause inflammation, compared to traditional smoking. Any form of inflammation in the body, no matter how little, is always bad news, as it slowly causes damage to the vital organs such as the heart, brain and kidneys.

So based on these preliminary less harmful effects of HTPs, we’re allowing our smoker-patients to shift to this alternative, but always reminding them that quitting smoking is the ultimate goal. We don’t know yet if these less harmful effects of HTPs could really translate to long-term beneficial outcomes. It’s a middle ground that appears to be relatively safer than traditional smoking.

Insufficient data

There are several fairly recent published comprehensive reviews that have suggested that HTPs may be less harmful than conventional cigarettes. However, in 2016, a Cochrane review, which was a comprehensive study, found it inconclusive.The jury is still out on its long-term benefit or harm.

In the now frequently quoted line in treatment guidelines, there is still “insufficient data” to either recommend or advise against HTPs. According to the World Health Organization (WHO), “There is no available evidence to conclude whether HTP use is associated with any long-term clinical outcome—positive or negative—from exposure to the mainstream or secondhand emission.”

In 2019, the WHO stated that “the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products (HTPs) may be lower relative to cigarettes.”

In their policy statement on tobacco smoking alternatives, the American Heart Association cited epidemiological studies on smokeless tobacco use coming from Scandinavia, where a large percentage of men use snus, a smokeless tobacco product that contains nicotine, but has relatively low levels of carcinogens and other toxins.

With current data, it does look relatively clear that HTPs are less harmful than traditional smoking, but are still more harmful than not smoking.

We don’t wish to start another debate on HTPs, as we accidentally did with our ivermectin commentaries. But it’s something that the medical community, legislators and regulators should discuss. After all, the lives of our 16 million Filipino smokers may hinge on the options we offer them if they really cannot quit smoking.

Less harmful alternatives to traditional smoking like HTPs seem to be a pragmatic middle ground. Our previous attitude was to give them up and allow them to suffer from the unhealthy state they’ve chosen. But with the smoker-patients we’ve lost to COVID-19 in the past 14 months, our attitude has somewhat changed.

Legislation and regulation

Smokers who can’t quit remain part of the health equation, as much as the healthy nonsmokers, the youth and others who may be affected by this killer vice. They actually need more attention, more understanding and more care from their physicians to at least partially protect them from the uncontrollable addiction.

The downside of HTPs is that the youth and nonsmokers might be “seduced” into trying them. This is where legislation and regulation come in.

A strict but balanced regulation is important, but it should not be more restrictive than regulation for cigarettes. There must be control measures to prohibit sales of HTPs to nonsmokers and the youth, but current smokers must be given the free choice to shift to it, if they wish to, and especially those with the guidance of their physician.

Though HTPs are supposed to be smoke-free, we don’t think they should be allowed in public. The harmful particulate pollution they cause is relatively less, but the potential harm to secondhand smokers is still there.

If more scientific data is generated showing that HTPs really have a potential to improve long-term outcomes in smokers and possibly save lives, then it may be worthwhile to encourage switching for smokers who would otherwise continue to smoke.