SMOKING CESSATION   63A

A 33-year-old man visits his primary care clinician for advice about how to quit cigarette smoking. He started smoking a half pack daily at age 16 years but gradually increased over the next 6 years to 1 pack daily. He had one previous quit attempt at age 30 years but resumed smoking within several days. He has never used nicotine replacement or other medications to help quit. Currently, he smokes within a half hour of awakening, and when forced to go without cigarettes for more than a few hours (e.g., on coast-to-coast airplane flights), he begins to crave them, with restlessness and irritability. He says that smoking relaxes him, and he likes to smoke with coffee or alcohol and after meals. Over the past year, he has had several respiratory infections with prolonged cough. He and his wife have recently had their first child, and his wife and their pediatrician have asked him to avoid smoking around the infant and to try to quit.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: ≥15 pack-year smoking history; previous quit attempt; no use of adjuvant therapies; addiction and withdrawal symptoms; using smoking to relax; cough as an adverse effect of smoking

How to think through: Tobacco is the most important of all modifiable disease risk factors. Although the approach must be a tailored to each patient, smoking should be addressed by the clinician at every opportunity. The transtheoretical stages of change model provides a means of positioning a patient on the continuum of readiness to quit smoking. If this patient reports he is ready to quit, the clinician can facilitate development of a cessation plan. What are the elements of an effective, multidimensional plan? (Jointly choosing a quit date. Beginning preparation. Discussing risks and benefits of nicotine replacement, bupropion, and varenicline. Enlisting support from family, peers, groups, telephone quit lines, and behavioral medicine specialists. Avoiding activities associated with smoking and identifying smoking replacement rituals.) At the other end of the spectrum, are “precontemplators” with limited interest in quitting. What is an appropriate strategy in such cases? (Motivational interviewing. The birth of this patient’s first child and the patient’s respiratory infections are ideal anchors for such a discussion.)

SMOKING CESSATION   63B

What are the essentials of diagnosis and general considerations regarding smoking cessation?

Essentials of Diagnosis

Tobacco use; dependence and withdrawal symptoms

Assessment of willingness to quit and previous quit attempts

History of use of nicotine replacement and other medications

General Considerations

Smoking is the most important cause of preventable morbidity and mortality; responsible for one in four deaths in the United States; 4.8 million premature deaths worldwide attributed to smoking in 2000 alone.

Smoking is the major cause of the leading causes of death: cardiovascular disease, chronic obstructive pulmonary disease (COPD), and lung cancer.

It also increases risk of other cancers, stroke, peptic ulcers, pneumonia, and bone fractures.

Second-hand smoke also has adverse effects on the cardiovascular and pulmonary systems.

Smoking cessation reduces the risks of death and disease and increases life expectancy.

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