Correspondence
Treatment of Tobacco Use and Dependence
N Engl J Med 2002; 347:294-295July 25, 2002
- Article
To the Editor:
In her article on tobacco use (Feb. 14 issue),1 Rigotti recommends that at every visit, clinicians routinely assess and record patients' smoking status and advise them to quit before assessing their readiness to change and offering stage-appropriate interventions. However well intentioned, this approach may have important adverse effects.
In a qualitative study, we found that patients were already well aware that they should quit smoking.2 Being told that they should quit each time they went for health care was often counterproductive. For example, a 30-year-old woman said, “I found that when I've gone [to the doctor's office] for a bad ankle, he's said, `You shouldn't smoke.' I think, `Well, I haven't come about that.' There is a certain doctor I won't see . . . because of smoking. It's annoying when you go [to the doctor] for something and have a lecture.” Some of our subjects avoided seeking health care at times in order to avoid anticipated interventions against their smoking. Asking patients' permission to raise the subject of smoking and establishing rapport are essential first steps. Telling patients what they already know takes time away from responding most effectively to each smoker's unique situation.3
3 ReferencesChristopher C. Butler, M.D.
McMaster University, Hamilton, ON L8N 3Z5, Canada
cbutler@mcmaster.ca Stephen Rollnick, Ph.D.
Llanedeyrn Health Centre, Cardiff CF3 7PN, United Kingdom1
Rigotti NA . Treatment of tobacco use and dependence. N Engl J Med 2002;346:506-512
Full Text | Web of Science | Medline2
Butler CC ,Pill RM ,Stott NCH . Qualitative study of patients' perceptions of doctors' advice to quit smoking: implications for opportunistic health promotion. BMJ 1998;316:1878-1881
CrossRef | Web of Science | Medline3
Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. Edinburgh, Scotland: Churchill Livingstone, 1999.
To the Editor:
Rigotti does not address the question of smoking cessation immediately after an acute coronary event. The initiation of nicotine-replacement therapy is not advised after acute events. Although bupropion, with or without the use of nicotine patches, is recommended in the guidelines of the American College of Cardiology and the American Heart Association as a treatment option for patients with stable cardiovascular disease,1 its safety among patients who have had an acute coronary event has not been established, and its dopaminergic and noradrenergic effects warrant concern. A recent case report suggests that bupropion treatment may induce acute coronary syndromes and notes that the British Committee on the Safety of Medicines has received many reports of chest pain or tightness among patients for whom this medication was prescribed.2 Only 20 to 60 percent of smokers who have had a myocardial infarction cease smoking without any pharmacologic intervention.3 More data are therefore needed to facilitate smoking cessation among these and other patients at high risk.
3 ReferencesMoshe E. Gatt, M.D.
Samuel N. Heyman, M.D.
Hadassah University Hospital Mount Scopus, Jerusalem 91240, Israel
mooshie@netvision.net. il 1
ACC/AHA guidelines for the management of patients with acute myocardial infarction. IV. Preparation for discharge from the hospital. Dallas: American Heart Association, 2002. (Accessed July 3, 2002, at http://www.americanheart.org/presenter.jhtml?identifier=1854.)
2
Patterson RN ,Herity NA . Acute myocardial infarction following bupropion (Zyban). QJM 2002;95:58-59
CrossRef | Medline3
Schwartz JL . Methods of smoking cessation. Med Clin North Am 1992;76:451-476
Web of Science | Medline
Author/Editor Response
Dr. Rigotti replies:
To the Editor: The concern raised by Drs. Butler and Rollnick is often expressed by clinicians. In contrast to their qualitative report, two quantitative studies provide reassurance that, in the aggregate, clinicians do not alienate smokers — even those who are not interested in quitting — by routinely addressing tobacco use at office visits.1,2 In both studies, smokers who recalled being asked about smoking and being advised to quit at their most recent office visit reported higher levels of satisfaction with their physicians and with the visit than smokers who did not recall receiving this advice. This was true even among smokers who were not interested in quitting smoking. It may be that patients have come to expect that an office visit will include an assessment of smoking status, just as they expect that their blood pressure will be measured. If there is no such assessment, they may wonder whether other important health issues are also being neglected. Nonetheless, Butler and Rollnick correctly point out that the way in which a physician addresses smoking matters. An abrupt or judgmental tone certainly alienates a smoker. Their own work suggests that physicians should take an empathic stance when delivering the message and avoid arguments, promote the patient's autonomy, and boost the patient's self-confidence.3
Drs. Gatt and Heyman correctly note that the safety of sustained-release bupropion in patients who have an acute coronary syndrome or who have recently had a myocardial infarction has not been established. This point is noted in the Food and Drug Administration's product information for the drug, which states that “care should be exercised if it is used in these groups” of patients.4 It is my impression that the drug is commonly used in such patients, but as Gatt and Heyman note, data from smokers with an acute coronary syndrome or a recent myocardial infarction are lacking. Studies to address this gap are currently in progress.
4 ReferencesNancy Rigotti, M.D.
Massachusetts General Hospital, Boston, MA 02114
nrigotti@partners.org 1
Solberg LI ,Boyle RG ,Davidson G ,Magnan SJ ,Carlson CL . Patient satisfaction and discussion of smoking cessation during clinical visits. Mayo Clin Proc 2001;76:138-143
CrossRef | Web of Science | Medline2
Hollis JF ,Bills R ,Whitlock E ,Stevens VJ ,Mullooly J ,Lichtenstein E . Implementing tobacco interventions in the real world of managed care. Tob Control 2000;9:Suppl 1:I-18
CrossRef3
Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991.
4
Zyban (bupropion hydrochloride) sustained-release tablets: Food and Drug Administration product information. Rockville, Md.: Food and Drug Administration, April 2002.
