Dr. Allan Goldstein, pulmonary physician with Pulmonary Associates of the Southeast, is passionate about smoking cessation, and he wants other physicians to be passionate about it as well. And he doesn't stop there…he wants insurance companies to pay for smoking cessation counseling, and he is a proponent of efforts to stop people from smoking before they start. "The people who are paying for healthcare need to tell the insurers that they want [smoking cessation] paid for, and they need to put money into prevention," Goldstein says. "We talk a lot about prevention, but I can tell you that there aren't a lot of people that want to pay for prevention, which doesn't make sense to me. It costs a whole lot more to remove somebody's lung cancer than it does to get them off cigarettes. Goldstein continues, "I think sometimes we've got things a little bit backwards as to where the priorities should be. We're looking for ways to reward doctors for appropriate and better care, for taking care of sick patients. Why not reward them for preventing the patient from becoming sick?" Goldstein equates smoking cessation to drug addiction, obesity or alcoholism. "You're talking about behavior modification. If you or I do not want to quit, it doesn't make any difference what anybody tells us, because we're not going to do it. Even in the individuals that do quit, we're talking about success rates over a long period of time in the range of 20 percent or so, and that's not a great percentage," he points out. Goldstein says that cold turkey has proven to work better than tapering off more slowly for most people. "The abrupt cessation needs a definite quit day," he cautions. He notes what some smokers tell themselves: "'Whatever cigarettes are left in my pocket, they get thrown away, and I'm off of the cigarettes.' Now there are some people who can do the tapering method, but they have to have a strong willpower, because as you go down, you're getting some nicotine withdrawal. And you don't want to have that nicotine withdrawal lead to the fact that you're going to take another cigarette." There are many support therapies for easing the nicotine withdrawal, including patches, nicotine gum, nasal spray, inhalers, and anti-depressants. Goldstein says one therapy is not significantly more successful than another, but each smoker may find one suits his or her individual needs better. The key, he stresses, is adding counseling with it. "You have to do some type of counseling. Doctors must talk to every patient who's smoking. You ask them are they smoking. If the answer is yes, encourage them to quit, because most of the programs that work, work because either a nurse or physician or a counselor have spent time encouraging the patient and being there to support the patient." "The duration of therapy is important," Goldstein continues. "I think people think the longer you use the therapy, the better chance you're going to quit. And the answer is, 'no, not really.' Because the longer you're using it, the less effective it is, and then you find that people become hooked on whatever their therapy is. There are some studies that say seven weeks is long enough. If you give somebody 10, 12, at most 16 weeks and they aren't off cigarettes and/or the aids to get them off cigarettes, the likelihood is that person is not going to have a successful smoking cessation program." It's important to raise the question with every patient during every visit, Goldstein says. "Every patient needs to be asked do they smoke, and if they do they shouldn't, and they need to be given the reasons why. And they need to be asked that every visit. Those who really need help getting off cigarettes ought to be able to get that help. That's just as important as treating their diabetes or treating their ulcer disease or their heart disease. And if they're going to try to quit, they're going to need a lot of support, because it is not easy." Many patients have to try several times before they're successful, but they'll need their doctor's support with every attempt. "You don't tell your children don't drink alcohol and then forget about telling them the rest of their life," he says. "You have to reinforce certain things, and smoking cigarettes is a habit that can become an addiction. If you keep smoking every day and nobody is counseling about it, then you never think about the negatives until it's too late." He admits that many doctors don't have time for counseling, especially those in rural areas who see high numbers of patients daily. And when there's no insurance reimbursement for that hard-to-find time, the problem is exacerbated. It's a problem he believes needs to be addressed. "I don't have to put my stethoscope on somebody's chest every time I see them just to say I did something good. I might see them and hold their hand and talk about cigarette smoking, and that may be more valuable than anything else I do. And I think those are things we need to work on." More than anything, he wants to see more emphasis on stopping people from smoking. "Just trace what happened to the money that was obtained from the cigarette suits that the states got. Very little of it went to smoking cessation. It went to other projects. And so we talk a good game, but we don't walk it," he maintains. "We know smoking cessation reduces disease, and therefore, we ought to pay for the prevention." In the meantime, he continues to talk to his own patients about this critical issue, and when he finds a patient who is willing to try quitting, he gives him or her all the support he can. "I can't make you do anything you don't want to do," he says, "but I can sure encourage you. And that's what I plan to do with my patients."