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Case One "Barbara": 32-year old legal assistant who has been smoking for 15 years and is being seen for acute bronchitis. She reports smoking about 10-15 cigarettes per day but has cut back to less than 10/day during her illness. Her first cigarette of the day is while driving to work, about an hour after she gets up. Her husband, a non-smoker, has been nagging her to quit. She has no other health problems, but her 5-year old son has asthma. Her favorite cigarette is during her regular coffee break mid-morning with 4 co-workers, two of whom also smoke.
Q: What other info. would you want? How motivated is she to quit? Has she tried to quit in the past? How, how long did she stay quit, and what caused her to go back to smoking? Does she have any other drug, alcohol, or psychiatric problems?
Q: What treatment would you suggest? Behavioral counseling with nicotine replacement, even though she doesn't seem that dependent.
Case Two “Bill" is a 52-year old mechanic with a history of heart disease. He has smoked since he was 14 and now smokes 20-30 cigs/day. He first tried to quit 5 years ago after experiencing an MI. He stopped during the week he was in the hospital but started again a few days after getting home. A year later, his doctor told him to quit and suggested he try nicotine gum. Bill said he bought a box of the gum and tried it, but said it didn't work. His wife smokes and is not interested in quitting right now. Bill wants to quit because his daughter, who does not smoke, does not want her parents to smoke around their grandchildren.
Q: What other info. would you want? In previous quit attempt, did he understand how to use gum and what to expect? Did physician or anyone else give him specific suggestions on how to control urges, etc., and did they follow up after a few weeks? What is his current health status? Does he drink alcohol or use other drugs? Is his wife willing to help him quit by not smoking in front of him, etc.? Is he allowed to smoke at work, do his coworkers smoke around him? When does he most enjoy smoking?
What treatment would you suggest? Nicotine patch with clear instructions on how to use it. Zyban is a possibility if Bill is not at risk for seizure (e.g. history of alcohol abuse). Heighten motivation by providing information about how smoking cessation is particularly beneficial for those with heart disease, and how second hand smoke harms children’s health. Counseling to control urges and avoid relapse situations, ask wife and daughter to help. Set quit date and schedule follow-up.
Case Three "Rob" is a 24-year old, unmarried student receiving a routine physical exam. He says he has smoked since high school and smokes about a pack per day. He has no serious health problems. He says he smokes his first cigarette as soon as he wakes up and that his favorite cigarette is his first one. He also enjoys smoking with morning coffee and smokes more heavily while studying. He hasn't tried to quit before and hasn't thought much about it. He has a lot of friends who smoke, and he enjoys socializing with them. When told he should quit, Rob says he thinks he can quit whenever he wants to but that he's not interested right now.
Q: What other info. would you want? Did a doctor ever advise him to quit before? Have any of his friends quit? What about parents or other family members? (Role model for quitting) Does he have concerns about quitting smoking (e.g. feeling he needs smoking to study effectively)?
What treatment would you suggest? No formal treatment unless he is willing to try. He should be encouraged to think about his smoking, health risks, and to talk with others who have quit to see what it's like. Leave door open for future consideration of quitting; don't push a quit attempt if he's not willing to work at it. Raise the issue at next visit to see if he may be ready then.
