Case Answers:

Case answers will be presented after review of the HPI.

Answer 1
As this patient describes, one of the frequent reasons that adolescent girls begin to smoke is their view that it will keep them thin. They also begin to smoke due to peer role modeling in that those whose peer group members smoke are more likely to use tobacco than those whose peers are non-users.

Answer 2
Public policy areas that would help include a smoking ban in all work areas and a ban on cigarette smoking advertisements for all ages in all areas including billboards and magazines. Restriction of the sale of cigarettes to minors with much more rigorous enforcement and punishment would probably be of benefit.

Answer 3
The counterarguments for weight gain with cessation of smoking are:

• Some people do gain weight, but others do not.
• The smoker's metabolic rate may slow down as the body returns to a normal, non- smoking state. Usual gain, however, is about five pounds and can be lost as the body adjusts.
• Only a huge weight gain would be as unhealthy as smoking.
• Sweets definitely need to be avoided as a substitute for cigarettes. Suggest lots of vegetables and low calorie snacks like air-popped popcorn.
• Increasing exercise will soothe cravings and keep the pounds off as well.

Answer 4
Nicotine replacement therapy in pregnancy is controversial. It should only be used if the benefit outweigh the risks, and obviously close followup is necessary. Ideally, behavioral approaches alone will work, though nicotine replacement can be considered.

Answer 5

1. Ask each patient you see each day about smoking. It should be the 5th vital sign.
2. Advise those who do smoke to stop. Set up a quit date.
3. Assist in getting the patient connected with the proper support (eg., American Lung Association, American Heart Association, etc.).
4. Arrange followup. Remember that the initial three months after quitting smoking is when a person is at their greatest risk for returning to smoking.