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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Explain the adverse effects of secondhand smoke exposure.

  • Interpret the stage of change exhibited by a specific patient, and prepare an action plan to promote smoking cessation and nicotine abstinence based on the 5A plan.

  • Design patient-specific recommendations for initiating lifestyle modifications and pharmacologic treatment to encourage reduction or elimination of cigarette smoke exposure.

  • Recommend alternative treatments for nicotine dependence if an initial plan fails.

  • Develop patient counseling on the use of pharmacotherapeutic agents used to treat nicotine dependence for a specific patient.

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PATIENT PRESENTATION

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Chief Complaint

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“I don’t know why I’m feeling so bad, but giving up these coffin sticks might be a good thing to do. The one time I tried to quit using nicotine gum for two days, it made me sick to my stomach, my jaw really hurt and I really craved a cigarette.”

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HPI

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Phil Morris is a 32-year-old man who presents to the primary care clinic complaining of extreme thirst, excessive urination, and generally feeling unwell for the past 2 weeks. “I have missed 2–3 days of work each week in the last month so there is less money to stretch for our expenses. My insurance premiums are high and I struggle to pay for the coverage. My wife and three kids are hungry and I can only afford to buy one cigarette at a time. And one more thing, it is so hard for me to remember to take that medication that was prescribed to control my sugar. Can you help me get right so I can get back to work?”

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PMH

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Type 2 diabetes mellitus (diagnosed at age 29)

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FH

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Mother (age 52) has history of type 2 diabetes and ovarian cancer. Father (age 57) has history of hypertension, myocardial infarction, and obesity. Patient is the oldest child of six siblings. All siblings have smoked cigarettes, but in the last 5 years, two of the siblings have quit smoking. Wife is a nonsmoker and son has asthma; one daughter has ADHD, and one daughter has no identified health problems.

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SH

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Works at a local convenience store. Smokes a pack of cigarettes daily, when he can afford to buy them, and has smoked for the past 18 years. Drinks 10 cans of Mountain Dew a day when he is working. States that he only drinks a six pack of beer on Friday nights after he gets paid. Lives with his wife of 14 years and their three children who are 12, 9, and 3 years old. Wife is a stay-at-home mother. The family has insurance coverage through a state program which they signed up for through the Health Insurance Marketplace Web site.

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