Over 400,000 individuals die each year in the United States from cigarette use: one out of every five deaths nationwide. Approximately 40% of smokers will die prematurely unless they are able to quit; major diseases caused by cigarette smoking are listed in Table 217-1.
TABLE 217-1RELATIVE RISKS FOR CURRENT SMOKERS OF CIGARETTES |Favorite Table|Download (.pdf) TABLE 217-1RELATIVE RISKS FOR CURRENT SMOKERS OF CIGARETTES
| ||Current Smokers |
|Disease or Condition ||Males ||Females |
|Coronary heart disease |
| Age 35–64 ||2.8 ||3.1 |
| Age ≥65 ||1.5 ||1.6 |
|Cerebrovascular disease |
| Age 35–64 ||3.3 ||4 |
| Age ≥65 ||1.6 ||1.5 |
|Aortic aneurysm ||6.2 ||7.1 |
|Chronic airway obstruction ||10.6 ||13.1 |
| Lung ||23.3 ||12.7 |
| Larynx ||14.6 ||13 |
| Lip, oral cavity, pharynx ||10.9 ||5.1 |
| Esophagus ||6.8 ||7.8 |
| Bladder, other urinary organs ||3.3 ||2.2 |
| Kidney ||2.7 ||1.3 |
| Pancreas ||2.3 ||2.3 |
| Stomach ||2 ||1.4 |
| Cervix || ||1.6 |
| Acute myeloid leukemia ||1.4 ||1.4 |
|Sudden infant death syndrome || ||2.3 |
|Infant respiratory distress syndrome || ||1.3 |
|Low birth weight at delivery || ||1.8 |
APPROACH TO THE PATIENT Nicotine Addiction
All pts should be asked whether they smoke, their past experience with quitting, and whether they are currently interested in quitting; those who are not interested should be encouraged and motivated to quit. Provide a clear, strong, and personalized physician message that smoking is an important health concern. A quit date should be negotiated within a few weeks of the visit, and a follow-up contact by office staff around the time of the quit date should be provided. Incorporation of cessation assistance into a practice requires a change of the care delivery infrastructure. Simple changes include:
Adding questions about smoking and interest in cessation on pt-intake questionnaires
Asking pts whether they smoke as part of the initial vital sign measurements made by office staff
Listing smoking as a problem in the medical record
Automating follow-up contact with the pt on the quit date
TREATMENT Nicotine Addiction
Clinical practice guidelines suggest a variety of pharmacologic and nonpharmacologic interventions to aid in smoking cessation (Table 217-2).
Numerous nicotine-replacement products exist, including over-the-counter nicotine patches, gum, and lozenges, as well as nicotine nasal and oral inhalers available by prescription; these products can be used for 3–6 months with a gradual step-down in dosage with increasing duration of abstinence.
Prescription medications that have been shown to be effective include antidepressants such as bupropion (300 mg/d in divided doses for up to 6 months) and varenicline, a partial agonist for the nicotinic acetylcholine receptor (initial dose 0.5 mg daily increasing to 1 mg twice daily at day 8; treatment duration up to 6 months). Antidepressants are more effective in pts with a history of depressive symptoms.
Clonidine or nortriptyline may be useful for pts who have failed first-line therapies.
Current recommendations are to offer pharmacologic treatment, usually with nicotine replacement therapy or varenicline, to all who will accept it and to provide counseling and other ...