MKSAP Quiz: management of tobacco use
A 59-year-old man is evaluated during a follow-up examination. He has COPD and hypertension. He has an 80-pack-year history of cigarette use, but has recently decreased his smoking to a half pack of cigarettes daily. Medications are ipratropium and amlodipine. He is barrel-chested with diffuse wheezing on lung examination. What is the most appropriate management of this patient's tobacco use?
A 59-year-old man is evaluated during a follow-up examination. He has COPD and hypertension. He has an 80-pack-year history of cigarette use, but has recently decreased his smoking to a half pack of cigarettes daily. Medications are ipratropium and amlodipine.
On physical examination, temperature is 37.3 °C (99.2 °F), blood pressure is 138/92 mm Hg, pulse rate is 96/min, and respiration rate is 22/min. BMI is 29. He is barrel-chested with diffuse wheezing on lung examination. The remainder of the physical examination is normal.
Which of the following is the most appropriate management regarding this patient's tobacco use?
A. Assess his interest in smoking cessation
B. Prescribe bupropion
C. Prescribe nicotine replacement therapy
D. Refer for smoking cessation counseling
MKSAP Answer and Critique
The correct answer is A: Assess his interest in smoking cessation. This item is available to MKSAP 16 subscribers as item 27 in the General Internal Medicine section. More information is available online.
Current recommendations are that all clinicians assess tobacco use at every visit, encourage every patient to make a quit attempt, and counsel patients appropriately. Patients who exhibit medical illnesses related to smoking present an opportunity for clinicians to increase the patient's awareness of the connection between the unhealthy behavior and its negative consequences. Even if time does not allow for an in-depth counseling session, all patients should be asked about their smoking at every visit, and a brief, clear message about quitting should be provided to all patients. A recommended strategy for counseling is to follow the “five A's”: Ask every patient at every visit about their smoking; Advise all smokers to quit; Assess their current interest in quitting; Assist by offering resources and/or medications, and Arrange for follow-up.
It is not clear yet whether this patient is truly interested in quitting. Thus it would be inappropriate to prescribe either smoking cessation aids or counseling until the physician has determined that the patient is indeed ready to quit.
Key Point
- Tobacco use should be assessed at every visit, and patients who smoke should be encouraged to make a quit attempt and counseled appropriately.