tobacco flower
The Case of Shelly Storm
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Shelly is a 55 year-old woman who is a patient of your family practice with type II diabetes, for which she takes metformin. She also smokes 30 cigarettes daily, does not exercise, and her diet is poor.
She rarely comes in to your clinic, and has been resistant to your previous efforts to improve her health choices.
introduction
You are concerned about her risk of developing the numerous diseases that accompany poor lifestyle, and know that her smoking is very unhealthy. You decide to speak with her about this during her upcoming annual health exam.
How do you raise the topic with Shelly?
Shelly knows, as everyone does, that smoking is damaging her body, and simply telling her this is not the most effective way of proceeding. Instead, it would be prudent to start by assessing her readiness to quit. The stages of change provide a good breakdown for this:
- precontemplation
- contemplation
- preparation
- action
- maintenance
- relapse
Shelly states she's actually been thinking about quitting, but that her life is 'way too stressful right now.'
How do you respond to Shelly?
If patients are resistant to quitting, share with them the five R's:
- Relevance to health
- Risk of smoking: SOB, asthma, impotence, infertility, pregnancy complications, heartburn, URTI
- Rewards of quitting: health, money, food tastes better, good example to children
- Roadblocks to quitting: fear of withdrawal or failure, weight gain, lack of support
- Repetition of discussion at each visit
section 2
A few days before your next appointment, you receive a call that Shelly is unfortunately admitted to the hospital with a myocardial infarction. You visit her and are glad to find her stable.
She says "I really want to quit smoking now, doctor."
What are the pharmacologic options for Shelly?
There is much evidence that smoking cessation is more successful with pharmacologic support. Options include:
nicotine replacement therapy
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medications
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What are some of the adverse effects of these products?
While all treatments are safe, there are adverse effects to be considered and monitored:
- nicotine gum: nausea, hiccups, and a sore jaw
- nicotine patch: headache, nausea, dizziness, and poor sleep
- inhalers: throat and nasal irritation, runny nose, sneezing, and coughing
- bupoprion and varenicline: depressed mood, hostility, and suicidal thoughts
- buproprion: dry mouth and insomnia. risk of seizure is 1:1000 (higher in those with seizure disorders or eating disorders)
- varenicline: nausea, insomnia, nightmares. use with caution in patients with renal dysfunction.
What counseling should be offered her?
Intensive counseling, started in the hospital and carried on after discharge, has been considered best practice for many years.
Effective counselling strategies include cognitive behavioural therapy, aimed at influencing thoughts and choices, as well as motivational interviewing, which guides patients to identify and develop approaches that work for themselves.
Other options include group counseling, telephone counseling, and online self-directed tools.
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