K. Address Reasons for Unwillingness to Quit. Determine Medical/Psychological Risks of Continued Use

OBJECTIVE

To determine the existence of any medical or psychological conditions that may have predictable adverse outcomes if the person does not stop using tobacco products.

ANNOTATION

There are special target populations of smokers who need to be identified and referred for intervention because of the high likelihood of adverse outcomes that accompany continued tobacco use. These include:

1. Pregnancy¾ Due to increased risk to the mother and potential fetal prematurity, all pregnant patients should be encouraged to stop smoking as early in pregnancy as possible. (See the discussion about use of medications during pregnancy in Annotation H).
   
   
2. Chronic tobacco related disease¾ Smokers who have developed a progressive, chronic tobacco related disease (Emphysema, coronary artery disease, peripheral vascular disease) that will continue to deteriorate should be urged to make an attempt to quit tobacco during routine primary care for those disorders.
   
   
3. Complications of surgical anesthesia¾Smoking cessation should be addressed with all pre-operative patients. If tobacco users will quit smoking 4 to 6 weeks prior to anesthesia, complications and post-operative recovery (infections, wound healing, cardiac procedures) can be reduced.

L. Promote Motivation to Quit

OBJECTIVE

To provide guidance and encouragement to heighten the motivation to quit tobacco use.

ANNOTATION

The PCM/PCP should use a motivational technique characterized by the "four Rs:" relevance, risks, rewards, and repetition.

1. Relevance¾ Motivational information given to a person has the greatest impact if it is relevant to a person's disease status, family life or social situation.
   
   
2. Risks¾ Ask the person to identify the potential negative consequences of smoking; then discuss the most relevant risks for the person in detail.
   
   
3. Rewards¾ Ask the person to identify the potential benefits of quitting smoking. Highlight and elaborate on the benefits that are most relevant to the person.
   
   
4. Repetition¾ The motivational intervention should be repeated when an unmotivated person visits the PCM/PCP in a primary care setting.

DISCUSSION

The PCM/PCP should highlight the risks most relevant to the person. It should be emphasized that switching to smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (smokeless tobacco, cigars, pipes, etc.) will not eliminate these risks. Examples of specific risks to discuss with the person include:

1. Acute health risks:
   
   
   1. Shortness of breath.
   2. Exacerbation of asthma.
   3. Chronic cough or acute bronchitis.
   4. Reproductive risks: infertility, low birth weight, infant death.
   5. Increased serum carbon monoxide level.
   6. Loss of smell and taste.
      
      
2. Long-term health risks:
   
   
   1. Heart attack, stroke and vascular disease.
      
      
   2. Lung and other cancers¾ larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix, leukemia.
      
      
   3. Chronic obstructive pulmonary diseases (chronic bronchitis and emphysema).
      
      
   4. Impotence.
      
      
3. Environmental risks:
   
   
   1. Increased risk of lung cancer in spouse and children.
      
      
   2. Higher rates of tobacco use by children of tobacco users.
      
      
   3. Increased risk for sudden infant death syndrome, asthma, middle ear disease, and respiratory infections in children of tobacco users.
      
      
   4. Fires.

The PCM/PCP may also highlight the benefits that seem most relevant to the person. Examples of these benefits include:^{44, 45}

1. Breathe more easily.
   
   
2. Improved overall health for the person and family.
   
   
3. Having healthier babies and children.
   
   
4. Feeling better about themselves, their clothes, car, home.
   
   
5. Won't need to worry about exposing others to tobacco use (and often receiving criticism as a result).
   
   
6. Food tastes better.
   
   
7. Breath smells better.
   
   
8. Improved sense of smell.
   
   
9. Feeling better physically.
   
   
10. Knowing one's self is free from the slavery of addiction.
    
    
11. Being able to stop worrying about quitting.
    
    
12. Setting a good example for kids.
    
    
13. Improved performance at work and in sports.
    
    
14. Significant money savings.

EVIDENCE

LE = C, SR = I Fiore 1996

REFERENCES

⁴⁴ Brandon et al. 1986; ⁴⁵ Fiore 1996