Smoking or Tobacco Abuse

Tobacco abuse is the leading preventable cause of much more rapidly; the excess risk of a second MI is death and disability in the United States. Each year in cut in half within 1 to 2 years of quitting. the United States, approximately 400,000 deaths are attributable to tobacco use. Although the percentage of smokers in the United States has declined to about 25%, millions of Americans continue to smoke, and the incidence of adolescent smoking has fallen very little since its peak in the 1970s. Smoking among teenage girls has even increased.

PATHOGENESIS OF SMOKING OR TOBACCO ABUSE

Smoking is a complex behavior that is still not completely understood. Pharmacologic and psychological models have been proposed. The psychological and behavioral models propose that smoking is a learned behavior that continues because the individual receives gratification from it. Smoking also becomes a habit, triggered by situations such as stress or alcohol. There also appears to be a link between depression and smoking.
The pharmacologic model emphasizes physical addiction to smoking. There is abundant evidence that nicotine is an addictive drug capable of creating tolerance and physical dependence as well as causing withdrawal symptoms. According to this model, smokers use tobacco to maintain their nicotine levels and avoid withdrawal. Withdrawal symptoms include craving for cigarettes, restlessness, irritability, poor concentration, headache, and nausea. Withdrawal varies greatly among smokers. Clinically, those who need to smoke shortly after rising, smoke at least one pack a day, or have difficulty abstaining for even a few hours are at greatest risk for withdrawal symptoms. Although withdrawal symptoms explain why many smokers fail to quit during the first week, they do not explain why many smokers have trouble abstaining for long periods of time.
Epidemiologic data clearly identify multiple benefits for smoking cessation. Box 54-1 lists some health consequences of smoking. Even older individuals benefit from stopping tobacco use after years of smoking or from quitting after a smoking-related illness. Lung cancer risk drops significantly 10 years after a smoker quits. Coronary risk reduction occurs 182much more rapidly; the excess risk of a second MI is cut in half within I to 2 years of quitting.

CLINICAL MANIFESTATIONS OF SMOKING OR TOBACCO ABUSE

Smokers may present with symptoms of one of the Smoking related illnesses. More commonly, smokers complain of cough, sore throat, sortness of breath, and frequent infections. The history should focus on when and why the patient began to smoke. Smoking can be quantified in pack years by multiplying the average number of packs smoked per day by the number of years of smoking. Asking whether the patient has thought about quitting, tried to quit, or intends to quit helps assess readiness and motivation to quit. By under-.standing and accepting the patient's past failures or fears about quitting, the physician can help address carriers to smoking cessation.

PHYSICAL EXAMINATION FOR PATIENT WITH SMOKING OR TOBACCO ABUSE

The physical examination may show signs of underlying smoking-related disease. The mouth and oral cavity should be examined for lesions that may represent cancer. The tongue in smokers often has a brownish discoloration due to exposure to the tar in smoke. Wheezing and diminished breath sounds may indicate CO PD. Peripheral pulses maybe diminished, suggesting vascular disease.
DIFFERENTIAL DIAGNOSIS
In general, laboratory tests are not helpful for the diagnosis but may be indicated to evaluate the consequences of smoking. Pulmonary function tests may help quantify pulmonary damage and provide evidence of the .importance of smoking cessation. If the tests are normal, it is important to stress the importance of stopping smoking now to prevent future damage.

CLINICAL EVALUATION

By providing all smokers seen in the office with even brief advice, the physician can help to increase the proportion of smokers who quit. The National Cancer Institute lists four "A's for office-based intervention:
Ask about smoking at every opportunity. Ask those who smoke whether they are interested in stopping.
Advise every smoker with a clear, unambiguous direct message. Tailor the advice to the patient's individual situation.
Assist patients in their efforts to stop. If a smoker is ready to quit, ask him or her to set a quit date. Provide self-help material and offer pharmacologic therapy, such as nicotine replacement. Consider a referral to a formal smoking cessation program.
If the individual is not ready to quit, discuss the benefits and barriers to smoking cessation. Make the information as relevant to the individual as possible. Advise the smoker to avoid exposing family members to secondhand smoke. Indicate a willingness to help in the future, when the smoker is ready, and continue to ask about quitting in follow-up visits.
Arrange a follow-up appointment, generally within I to 2 weeks after the quit date. Make sure you congratulate those who have quit and reinforce the benefits of giving up smoking. Discuss high-risk situations for relapse and review coping mechanisms. For those who fail to quit, provide positive reinforcement for taking the first steps toward quitting. Ask about what obstacles the patient encountered and discuss strategies to overcome these problems in the future. Encourage the smoker to set another quit date.

Treatment of Smoking or Tobacco Abuse

The most effective approaches address nicotine addiction and behavioral dependence. Nicotine replacement mitigates some of the symptoms of withdrawal by continuing nicotine exposure, although at reduced and tapered doses. Nicotine dehvery can be achieved with transdermal patches, nicotine-containing chewing gum, lozenges, or nicotine inhalers. All are ideally used for 2 to 3 months and then discontinued. They may be utilized for more extended periods of time if needed to ensure continued abstinence from smoking.
Nicotine replacement is not a panacea but does improve the quit rate. For example, nicotine patches double quit rates- They should be offered to smokers willing to set a quit date, who will not smoke while on the patch, and who ideally will follow a behavioral program either individually or in a group setting. The side effects of the patch are mild, generally being limited to skin irritation. Nicotine gum was the original form of nicotine replacement. Side effects of the gum are mostly related to vigorous chewing and the release of excess nicotine. These symptoms include sore jaw, mouth irritation, hiccups, nausea, dizziness, and headache. Data suggest that combined use of patches, to provide a continuous release of nicotine, along with rapid-release forms of nicotine (inhalers, gum, lozenges) is more effective in addressing vulnerable periods of increased desire for nicotine.
Bupropion, originally marketed as an antidepressant, also enhances quit rates. It is contraindicated with seizures. It is useful for people who do not want or have been unable to quit with nicotine replacement. It is generally started I week before the target quit date. Bupropion has been used in conjunction with nicotine replacement, and some evidence suggests that the combination of the two is more effective than either one alone. Varenicline is an agonist acting on a nicotinic receptor and has been shown to be an effective oral therapy. Varenicline is started at an escalating dose for I week while the patient is still smoking and the patient stops smoking during the second week of use. Nausea is the most common adverse effect.
The behavioral model has also stimulated a host of strategies to help manipulate the environment. The physician can work with the patients to develop strategies like spending time in places where smoking is not permitted or rewarding themselves with the money saved by not smoking. Organized group programs such as those sponsored by the American Cancer Society or the American Lung Association may also be of benefit. These societies sponsor telephone services that provide education, encouragement,advice, and referral.

KEY POINTS of Tobacco abuse

  • Tobacco abuse is the leading preventable cause of death and disability in the United States.
  • There are benefits even for older individuals who stop smoking after many years or quit after a smoking-related illness.
  • By providing all smokers seen in the office with even brief advice, the physician can help to increase the proportion of smokers who quit.
  • Bupropion, varenicline, and nicotine replacement are medication options.