We all dismiss patients who are noncompliant with treatment. The threshold varies between us, but all of us have fired (for example) an epilepsy patient who won’t take the meds and is in and out of the emergency department.

What about smokers? Do they count?

A recent article in Anesthesiology News (2014 September) featured a surgical group that won’t do elective hernia repairs on patients who don’t quit smoking. I can see their point. Smoking increases the risk of complications, which hurt the patient. So, having a good patient outcome depends on their condition, too. And, honestly, I don’t blame the surgeons for refusing to do nonurgent cases under these circumstances.

What about neurologists, though?

Smoking is a big one. The literature has no shortage of data on it worsening migraines and multiple sclerosis, increasing the risk of stroke and peripheral vascular disease, contributing to vascular dementia … and many other things.

I always tell smokers that they should quit, but should I be going beyond that? Refuse to treat migraines until someone quits smoking? The other conditions I mentioned have enough serious health risks that I don’t think it’s ethical to withhold care over smoking.

At my first job, I had a partner who took this approach. She routinely told migraineurs who smoked that they couldn’t return to her until they’d quit. Her view was that then she could treat them to her best ability without tobacco as a confounding factor, or they’d simply not come back.

I can understand this approach, and, in a perfect world, would do it myself. I certainly don’t support tobacco use and wish I had a magic bullet to help them quit. But I don’t. I can preach it, explain why they should quit, review the risks, send them to their internist for cessation … but I’m still not sure I’d flat out turn them away.

I’m trying to help them. Refusing to provide care, even in the name of quitting smoking, is only going to alienate them. They may get turned off to seeing doctors altogether and consequently develop other issues. I don’t want them to smoke, but none of us is without our vices, either.

I’m also not them, and don’t know what’s going on in their lives. Maybe they are taking care of a parent with a terminal condition, going through a divorce, have a terrible job, or a million other stressors and just don’t have the will right now to quit tobacco.

Migraines, in the grand scheme of medicine, are certainly a lower-risk issue than surgical complications. So, while I disapprove of tobacco and encourage smokers to stop, my door remains open to them. Part of caring for my patients is accepting them as they are and trying to work with them inside that framework.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.


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