For a long time, Black people have battled skin conditions
ranging
from excessively dry skin to persistent acne. In
the past, the drugs
associated with the treatment of these ailments
have not been
completely effective. But recent breakthroughs in
treatment have
produced a wide array of safer medications; thus,
we don't have to
live with skin problems.
"We tend to face a variety of skin problems that
many other ethnic groups don't have to deal
with," says Dr. Toni Stockton, a board certified
dermatologist since 1987. At the Skin and
Cancer Center of Arizona, Dr. Stockton treats
patients daily who suffer from a variety of skin
conditions. "With all of the new developments
going on, it is no longer impossible to find a
product for our skin."
False Nails
One problem that seems to be on the rise is fungal
nail infections.
While it took two years to treat this infection
in the past, there are
new drugs that can completely clear the nail in
six months. "The
problem often arises from artificial nails," Stockton
says. "Water
gets under the nails and then fungus and mold starts
to grow
causing an infection." Precautions should be taken
when getting a
manicure, she suggests. "Make sure the nail technician
uses sterile
equipment or, bring your own nail kit, especially
if it's your first time
there."
A growing trend in the world of skin care is the
use of alpha-hydroxy
acids. These acids exfoliate the skin. They are
also used to help
other products work more effectively and are available
over the
counter or in prescription strength. "Alpha-hydroxy
acids can be
helpful in treating aging skin, dark spots, dry
skin and acne,"
Stockton says. It is safer to start with a lower
concentration and
work your way up, she advises.
Chemical peels
Chemical peels can be used safely on people of color
as long as
they are superficial peels and you have an experienced
provider,
according to Dr. Stockton. "The superficial peels
are safe for our
skin. Medium and deep peels are more risky and they
can actually
shut off our color or produce more dark spots. They
may be used
under special conditions."
To perform a chemical peel, the face is cleaned,
the chemical agent
is applied to the face for a short period of time
and then wiped off.
According to Dr. Stockton, the procedure is not
painful and there is
little recovery time. "It tingles and it's only
slightly uncomfortable,"
she says. "Some people call it a lunch-time peel
because it doesn't
take much time to do and you can return to work
when it's done." A
chemical peel costs a little more than a regular
facial; it is a
cosmetic procedure and not covered by insurance
companies.
Bleaching agents
Another skin problem many African-Americans face
is dark spots
caused by acne, scratches or scrapes. "What happens
is the cells
get irritated and produce more pigment. Exposure
to the sun can
make the dark spots darker," Stockton says. To solve
this problem,
many people turn to bleaching agents. When applied,
these products
attempt to stop the pigment from producing more
pigment. "It is
important only to use them on the dark spots and
not all over
because they can lighten other areas of the skin
as well," Stockton
warns.
The active ingredient in most over-the-counter products
is
hydroquinone, which also is available
in stronger form by
prescription. "There are other bleaching agents
used in patients who
don't respond to hydroquinone," Stockton says. "It
usually takes four
to six weeks before you notice fading, but, when
used in conjunction
with a peel, that may occur sooner."
Skin cancer
One myth many people tend to believe is Black people
don't have to
worry about skin cancer. "Everyone should take steps
to protect
themselves from the sun by always wearing a sunscreen."
Stockton
says. When shopping for a sunscreen, be mindful
of the SPF
number. "The SPF number represents the amount of
time it would
take for you to burn if you were out in the sun
with the sunscreen.
For example, if you burn after one hour of exposure,
SPF 15 would
protect you for 15 hours." She recommends that people
with oily
skin use a gel-based sunscreen while people with
dry skin use a
moisturizing sunscreen. "People with sensitive skin
also should avoid
products which contain aloe vera, cocoa butter or
topical Vitamin E
because they may cause allergic reactions."
Most importantly, Stockton says cleaning the skin
daily and wearing
a sunscreen can help keep existing skin problems
from getting
worse. "These days there is a product out there
for everyone --
whether you have dry skin, oily skin, need a bleaching
agent or a
chemical peel -- so you don't have to suffer with
skin problems any
longer."
Viagra
Offers Little Benefit To Women, Say
Researchers
NEW YORK, NY -- March 5, 1999 -- In the first evaluation of the effects
of
Pfizer Inc.’s Viagra(R) (sildenafil) on women, investigators at Columbia
Presbyterian Center of New York Presbyterian Hospital found that, unlike
in
men, the drug offers little relief of sexual dysfunction.
The results of the nonrandomised study, published in this month’s issue
of
Urology, examined the safety and efficacy of Viagra in 33 postmenopausal
women with self-described sexual dysfunction of at least six months'
duration.
Each of the study participants took 50 mg of Viagra (the same dose prescribed
for men) approximately one hour prior to planned sexual activity,
but not more
than once daily. All of the women were in stable, monogamous relationships
with male partners that had begun at least six months earlier. Thirty women
completed the study. The mean use of Viagra was about three times
per week
for the duration of the study.
The most common symptoms of sexual dysfunction reported by the study
participants included decreased arousal, decreased lubrication,
diminished
orgasm and inability to achieve orgasm.
Therapy effectiveness was evaluated at four, eight and 12 weeks using a
newly-developed nine-item self-administered Index of Female Sexual Function
(IFSF). The IFSF uses a numbered scale (1 = almost never; 5 = almost always
or always) to measure overall satisfaction with sexual function, orgasm,
lubrication and clitoral sensation, as well as degree of lubrication and
clitoral
sensation and ability to achieve orgasm. In addition, women were asked
to
assess whether treatment improved overall sexual function. Blood pressure
also
was measured at each assessment visit and patients were questioned about
any adverse reactions to Viagra.
The IFSF is patterned after the International Index of Erectile Function
(IIEF), a
15-question, validated, multidimensional, self-administered questionnaire
that is
used for assessing erectile dysfunction in men. Currently, there is no
validated,
widely accepted assessment tool for sexual function in women.
"We
found that there was no significant change either in intercourse satisfaction
or in the degree of sexual desire after the patients had taken Viagra for
12 weeks," said Steven Kaplan, M.D., professor of urology
at the Columbia
University College of Physicians & Surgeons and the director of the
Prostate
Center at the Squier Urologic Clinic at the Columbia Presbyterian Center.
Dr. Kaplan is also vice chairman and administrator of the department of
urology
and director of neurourology at the Columbia Presbyterian Center.
"Even though about 25 percent of the patients had some improvement
in overall
sexual function, that's equal to the placebo response in men receiving
Viagra.
So that response might be a placebo effect rather than a true improvement
in
sexual function due to the drug, although that remains to be determined,"
Dr.
Kaplan said. "Men and women have fairly equivalent placebo responses to
other medications, so there is little reason to think that the placebo
response
rate would be different for Viagra."
Overall, only 21 percent of patients had a significant (greater than 60
percent
improvement in IFSF) response. Although the mean scores for the questions
dealing with lubrication and clitoral sensation improved by 23 and 31 percent,
respectively, those changes were not statistically significant. The mean
score
for the question regarding orgasm improved by only seven percent.
Furthermore, the changes in overall scores for lubrication, clitoral sensation
and
orgasm were not significantly different for women who were on hormone
replacement therapy [PREMARIN]versus
those who were not. Only 20 percent of patients
wished to continue drug therapy after 12 weeks. While the neurovascular
events that accompany and result in erectile dysfunction in men have been
well
described, the corollary mechanisms in women have not. Unpublished
preliminary data suggest that changes in both clitoral and vaginal
blood flow are
related to aging and may be involved with sexual dysfunction in women.
"Viagra did appear to increase blood flow to the clitoris but this didn't
seem to
translate to increased sexual satisfaction,” Dr. Kaplan said. “Neither
increased
clitoral sensation or lubrication would be expected to be of benefit to
women
with diminished desire to either initiate or respond to sexual activity."
In fact, clitoral discomfort and hypersensitivity occurred in seven of
the patients,
three of whom withdrew from the study. Other side effects were minor
(dizziness and headache) and did not cause withdrawal from the study.
Dr. Kaplan cautions that while the Columbia Presbyterian Center study shows
little to support the use of Viagra for postmenopausal women with sexual
dysfunction, it must be noted that only a small number of women were
evaluated and the follow-up was relatively short. In addition, the entry
criteria
were completely subjective.
"Our study does, however, point out the need for a validated instrument
to
assess efficacy and sexual function in women, as there is for men," he
said.
“Larger, long-term studies in both post- and premenopausal women that look
at
different dosages and combinations with other drugs are necessary to fully
assess Viagra's safety and efficacy regarding female sexual dysfunction."
Pharmacologic and
Behavioral Approaches to
Smoking Cessation
Lily Kaye, PharmD
[Hospital Medicine 34(8):41-44, 47-50, 1998, 1998 Quadrant HealthCom, Inc.]
Abstract
Although the health hazards of smoking are well known,
many physicians do not play
an active role in helping their patients quit. To
combat their addiction, you can arm
them with one or more of the numerous drug therapies
available and with various
coping strategies.
Introduction
Despite the well-publicized risks of tobacco use, cigarette smoking
remains the most
prevalent modifiable risk factor for increased morbidity and mortality.
Approximately
55% of Americans have smoked at some point in their lives: 25% are
ex-smokers and
30% currently smoke. In addition, 4% use pipes or cigars and 3% use
smokeless
tobacco.[1] For the US population as a whole, the incidence of smoking
has declined
substantially since 1965, when approximately 40% of adults smoked.
This decline has
not been equal across population subgroups: A relatively higher proportion
of
African-Americans, blue-collar workers, and less well-educated persons
smoke.[2,3]
Males are slightly more likely than females to smoke.
Most smokers are introduced to tobacco during the early teenage years.
Among those
who continue to "indulge" through age 20, 95% become regular daily
smokers. Of
those who quit successfully, fewer than 25% do so on the first attempt.
Most fail 3 or 4
times before stopping permanently; overall, about 45% succeed in this
regard. A major
challenge in the effort to reduce the prevalence of nicotine addiction,
then, is to prevent
adolescents from starting to smoke. For every 2 million smokers who
quit or die each
year, more than 1 million persons start smoking.[4,5]
Surprisingly, many primary care physicians do not routinely educate
their patients
about the consequences of smoking or help them to quit; sometimes,
minimal advice is
all that is needed.[6] This article reviews the latest information
regarding pharmacologic
and behavioral interventions to help your patients stop smoking.
Nicotine Addiction
The progression from occasional smoking (five or fewer cigarettes per
day) to nicotine
addiction involves an interplay among physical, psychological, and
social factors, all of
which should be considered in a comprehensive treatment plan. Among
occasional
smokers, one-third to one-half progress to maladaptive use and to physical
dependence on nicotine.[7] The transition from experimentation to intermittent
smoking
to nicotine dependence commonly takes 2 years or less, but some smokers
are
"hooked" in months or even weeks.[8]
Cigarette smokers inhale nicotine both directly and indirectly (via
the smoke released
from the burning cigarette). Nicotine stimulates, relaxes, relieves
boredom, and
improves performance in a manner similar to that of other cholinergic
agonists. Rapid
tolerance develops to many nicotine effects, even with one cigarette.
The nicotine withdrawal syndrome[1] begins within a few hours of smoking
cessation
and peaks 24 to 48 hours later. It usually lasts about 4 weeks. The
signs and
symptoms of nicotine withdrawal syndrome include anxiety; decreased
heart rate;
difficulty concentrating; dysphoric or depressed mood; increased appetite
or weight
gain; irritability, impatience, and hostility; and restlessness. Smoking
cessation can
lead to reductions in cortisol and catecholamine levels, sleep, and
basal metabolic rate,
and can elicit electroencephalographic changes.[9] Also, the drop in
nicotine level may
provoke a relapse of major depression, bipolar disorder, or alcohol
and/or drug
problems in vulnerable persons.
Health Consequences Of Smoking
The exact mechanism by which smoking causes or accelerates disease remains
poorly
understood. Some of the components of cigarette smoke may damage vascular
endothelium and accelerate atherosclerosis. Cigarette smoke lowers
high-density
lipoprotein cholesterol levels, causes coronary vasospasm, and indirectly
increases
platelet aggregation, blood viscosity, and fibrinogen levels.[5] Of
the more than 4,000
substances in cigarette smoke, 43 are known carcinogens.[10]
The overall death rate from cancer is twice as high in smokers as in
nonsmokers;
heavy smokers -- those who smoke 40 or more cigarettes per day-have
4 times the
risk.[10] Compared with nonsmokers, smokers have higher rates of respiratory
disease[3] (Figure 1, P 48), cardiovascular disease, and peripheral
vascular disease
(Table 1, p 48). They also have an increased risk of developing peptic
ulcer disease,
cataracts, osteoporosis, reduced fertility, and complications during
pregnancy.
Nicotine alters the metabolism of many different drugs. Smokers may
need to adjust
the dosages of their other medications because of these pharmacokinetic
effects
(Table 2, above).[11]
The health costs of tobacco use are staggering. The average lifetime
medical cost is
about $6,000 higher for smokers than for nonsmokers.[5] This figure
does not include
the indirect costs of morbidity and lost productivity. The total economic
health cost of
smoking may exceed $100 billion per year.
Pharmacotherapy For Nicotine Addiction
Pharmacologic treatment can be divided into two main categories: nicotine
replacement therapy and non-nicotine therapy. The former provides an
alternate
source of nicotine, which helps to decrease nicotine withdrawal symptoms.
The latter
includes nicotine antagonists (eg, mecamylamine) and medications that
attenuate
withdrawal (eg, antidepressants, anxiolytics, clonidine).[12]
Nicotine Replacement Therapy
These treatments, which relieve or prevent withdrawal symptoms, allow
patients to
focus on habit and environmental cues during the quitting process.
The nicotine in these
products does not produce the positive effects some people associate
with smoking
cigarettes because it is absorbed relatively more slowly. Because many
of these
products are heavily promoted in the media and are available over the
counter, more
and more smokers have contemplated quitting, bought the products, used
them
(sometimes over and over again), and ultimately succeeded in quitting.
This therapy
should be considered in patients who smoke more than one pack per day
or who
smoke the first cigarette within 30 minutes of awakening.
Nicotine gum (nicotine polacrilex; Nicorette) -- available by prescription
since 1985 --
was approved for over-the-counter use in 1996. The gum, which contains
nicotine 2 or
4 mg bound to an ion-exchange resin, is designed to be chewed briefly
and then
"parked" in the mouth. Patients may chew up to 30 pieces of the 2-mg
gum or 20
pieces of the 4-mg gum per day. A fixed dosing regimen (eg, 2 mg/h;
4 mg/h in highly
addicted patients) is recommended; treatment should last at least 3
months.
Manufacturers recommend using the gum for 4 to 6 months, but the optimal
duration is
not known. Drinking coffee or carbonated beverages decreases the pH
of saliva and
may therefore interfere with nicotine absorption.[13]
This treatment produces high rates of long-term abstinence when it is
combined with
behavioral therapy. Patient education maximizes the usefulness of the
gum (Table 3,
above). Side effects of nicotine gum include flatulence, indigestion,
nausea, dysgeusia,
hiccups, and a sore mouth, throat, or jaw. Some patients who smoke
while using the
gum or who chew the gum too fast may experience symptoms of nicotine
overdose
(eg, nausea, vomiting, headache, palpitations). Mild withdrawal symptoms
may occur
after the nicotine gum is discontinued.
This device diffuses nicotine through the skin and into the bloodstream
at
a constant
rate. It is available in four formulations that vary in strength and
duration of action
(Table 4, p 59). Three of the patches are worn for 24 hours and one
is worn for 16
(waking) hours. An advantage of the 24-hour patches over the 16-hour
patch is that
they produce relatively higher blood nicotine levels on awakening and
may help control
smoking urges in the morning. A drawback of the 24-hour patches is
that they, unlike
the 16-hour patch, have been associated with sleep disturbances.
The starting doses are 21 to 22 mg for the 24-hour patches and 15 mg
for the 16-hour
patch. Patients apply a new patch each morning. After 4 to 6 weeks,
the dose is
usually tapered to an intermediate level -- 14 mg for the 24-hour patches
and 10 mg
for the 16-hour patch. After 2 to 4 more weeks, the lowest dose is
applied -- 7 mg for
the 24-hour patches and 5 mg for the 16-hour patch. The duration of
therapy ranges
from 6 to 12 weeks, depending on patient comfort and your clinical
judgment. Absolute
abstinence rates increase in a linear fashion with the intensity of
accompanying
behavioral intervention.
The nicotine patch causes few side effects. The most common is minor
skin irritation --
characterized by erythema, itching, or burning under the patch -- which
occurs in 35%
to 54% of users. This can be minimized by rotating the application
site. Less common
adverse events include generalized rash, headache, nausea, vertigo,
and dyspepsia.
Overdose, dependence, and abuse have not been reported with the patch.
The nicotine nasal spray (Nicotrol[®] NS) was approved in March
1996 for prescription
use. Patients administer one spray per nostril (total nicotine dose,
1 mg) when they
feel the urge to smoke. The resulting blood nicotine level is higher
than that produced
by the gum or patch and lower than that produced by cigarettes. The
nasal spray may
be more effective than the other nicotine delivery systems in highly
dependent
smokers, but it may also sustain or cause dependence. Smokers are instructed
to use
the nasal spray as needed, up to 30 times daily, for 12 weeks, including
a tapering
period. Although the nasal spray may cause adverse reactions (eg, headache,
a
burning sensation, watering eyes, nasal or throat irritation, sneezing)
during the first
few days, this tendency diminishes within the first week.[14] More
research is needed to
draw conclusions about this method.
The nicotine vapor inhaler (Nicotrol[® ]Inhaler) was approved by
the FDA for
prescription use in May 1997 and has just recently (September 1998)
been released in
this country. (It became available for over-the-counter use in Europe
in 1996.) It has a
unique role in that it fulfills the need for the "hand-to-mouth" ritual
of smoking. Plugs of
nicotine are placed inside hollow cigarette-like rods. The plugs produce
a nicotine
vapor when warm air is passed through them. Each puff of the inhaler
delivers nicotine
13 ng; nearly 80 puffs are required to achieve nicotine doses equivalent
to those
obtained from most cigarettes. Very little nicotine actually reaches
the lower
respiratory tract; absorption occurs primarily from the oral and pharyngeal
mucosa
and, after swallowing, from the gastrointestinal tract. Blood nicotine
levels are lower
with the inhaler than with the nasal spray, gum, or patch. The nicotine
inhaler can
cause cough or throat irritation and should not be prescribed for patients
with
bronchospastic disease. The usefulness of this method cannot be ascertained
at this
time because of the paucity of research data.
The use of non-nicotine medications for smoking cessation has long been
of interest to
clinicians. A number of such medications have been evaluated as potential
smoking-cessation aids.
Mecamylamine
Mecamylamine (Inversine), a nicotine antagonist, is an antihypertensive
agent that
blocks nicotinic receptors and may attenuate the reinforcing or pleasurable
effects of
nicotine.[12] Sufficient evidence is lacking at this time to recommend
this treatment, but
it is considered promising.[9]
Antidepressants
Smokers are more likely than nonsmokers to have a history of major depression;
nicotine may act as an antidepressant in some of them.[15] Researchers
have studied
the use of doxepin, fluoxetine, and bupropion in facilitating smoking
cessation. Although
the results of clinical trials of doxepin (Sinequan) -- a tricyclic
antidepressant -- have
been encouraging, none of the trials has been large enough to offer
conclusive results.
Likewise, no conclusions have been drawn regarding the efficacy of
fluoxetine
(Prozac), a selective serotonin reuptake inhibitor.[12]
In contrast, bupropion (Zyban) -- an antidepressant
of the aminoketone class -- was
approved in May 1997 by the Food and Drug Administration as an aid
to smoking
cessation. Sustained-release bupropion was shown to be safe and effective
for this
indication in a randomized, double-blind, placebo-controlled study.[15]
At the end of
treatment, smoking cessation rates were 17% with placebo and 22%, 27%,
and 36%
with daily bupropion doses of 100, 150, and 300 mg, respectively. The
efficacy of
bupropion may be related to its effect on dopaminergic and noradrenergic
receptors.
The dopaminergic activity affects areas of the brain that are involved
with the
reinforcing properties of addictive drugs, and the noradrenergic activity
affects nicotine
withdrawal.[16]
The recommended dosage is bupropion 150 mg once daily for 3 days and
then twice
daily for 7 to 12 weeks, alone or with nicotine replacement. Patients
should set a quit
date 1 week after starting the drug. Side effects include insomnia
and dry mouth.
Bupropion can also decrease the seizure threshold. Patients with a
history of anorexia
nervosa, bulimia, or alcohol withdrawal should not take bupropion.
Anxiolytics
Some patients experience increased anxiety when they stop smoking; thus,
benzodiazepines and buspirone have been evaluated in this setting.
Although the
results from benzodiazepine studies have not been promising, buspirone
was found to
ameliorate most short-term withdrawal symptoms associated with smoking
cessation.[17] No recommendations can be made at this time, though;
additional
controlled studies of buspirone are needed.
Clonidine
This antihypertensive agent, which may help combat alcohol and opioid
addictions, has
also been tried in patients addicted to nicotine. However, a panel
from the Agency for
Health Care Policy and Research concluded that little evidence from
clinical trials exists
to support the use of clonidine as primary or adjunctive pharmacotherapy
for smoking
cessation.[12,18]
Gamma vinyl-gamma aminobutyric acid. This agent, also known as GVG,
is expected
to be approved shortly for treating seizures. It has also been shown
to block the
effects of cocaine in the brains of rats and primates, as well as the
processes that
cause euphoria in humans. Preliminary studies suggest that this compound
may
counteract the addictive effects of nicotine. Additional research is
needed to assess
the clinical utility of GVG in this setting.[19]
Although pharmacotherapy has been emphasized in this article, behavior
modification is
the mainstay of smoking-cessation therapy offered by specialized clinics
and formal
programs. No optimal behavioral approach exists; the therapy selected
should depend
on patient preference and your clinical judgment.
Before embarking on any program, it is useful to assess patients' degree
of tobacco
dependence. You can administer the Fagerstrom Tolerance Questionnaire
-- the most
commonly used instrument to measure such dependence. This 8-item questionnaire
yields a score ranging from 0 to 11; a score of 6 or greater indicates
a significant
degree of dependence.[15] The degree of nicotine dependence can also
be deduced
from the number of cigarettes smoked per day or the time to the first
cigarette of the
day.
Behavioral strategies include nonspecific methods such as relaxation,
contingency
management (a reward and punishment system), visualization (patients
imagine the
unpleasant consequences of smoking), and emphasis on the positive reasons
for
stopping smoking.[20] Hypnosis, accupuncture, and biofeedback are some
other
techniques used in smoking cessation. However, the efficacy of these
therapies has
not been clinically established; thus, none of these therapies can
be recommended at
this time.[9] Other, more formalized, methods are described below.
Self-management
With this commonly used program, smokers try to become aware of smoking
patterns
and cues. They start with self-monitoring, wherein they record the
cues that precede
the smoking response. This will make them aware of how often they smoke
and what
motivates them to light up. Once patients learn self-management, other
behavioral
modalities can be tried.
Stimulus Control
With this popular technique, patients try to limit the number of cues
to smoking. For
example, if a right-handed patient typically has a cigarette with the
morning cup of
coffee, he or she should switch to the left hand and drink tea. This
will reduce the
intensity of smoking cues and allow the patient to quit with greater
ease.[5]
Aversive conditioning
This less commonly used strategy involves either rapid smoking or satiation.
With the
former, smokers puff cigarettes every 6 to 8 seconds until nausea occurs.
With the
latter, smokers double or triple their daily cigarette consumption
for a brief period. The
rationale for both these methods is to make smoking more aversive and
less
reinforcing by inducing mild nicotine intoxication symptoms such as
nausea and
dizziness. Safety concerns have limited the use of these two techniques
in smoking
cessation clinics.
Relapse prevention
With this technique, patients who have quit smoking try to anticipate
the circumstances
or cues that would be likely to prompt them to resume smoking.[9] These
include
stress, social influences, withdrawal symptoms, weight gain, and depressed
mood.
Initially, patients try to avoid exposure to any of these situations.
Later on, they devise
strategies to cope with these situations. Interestingly, the specific
coping strategy
utilized (eg, deep breathing, use of relaxation tapes) is less important
than simply
having a plan to follow.[5]
Nicotine Fading
This strategy involves gradual decrements in the nicotine yield from
cigarettes.
Smokers either cut back on the daily number of cigarettes or switch
from a
high-nicotine cigarette to a low-nicotine cigarette. Nicotine fading
has not been proven
to be consistently effective and is not recommended.[5,9]
The Four Stages Of Smoking Cessation
Smoking cessation is a dynamic process that requires behavioral changes.
Although
the ultimate goal is abstinence, a more realistic plan of action is
to move from one
stage to the next. Interventions are selected on the basis of the stage
of smoking
cessation.
Precontemplation
During the first stage, smokers are not seriously considering smoking
cessation, but
they may be getting ready to think about it, perhaps because of prodding
by loved
ones or by you.
Contemplation
During the second stage, smokers are seriously considering quitting;
they are ready to
formulate a specific smoking cessation strategy.
Action
During the third stage, smokers try to quit by taking medication, undergoing
behavior
modification, exerting will power, instituting an informal quitting
strategy, or using a
combination of some or all of these processes.
Maintenance
During the fourth stage, patients have succeeded in quitting and are
trying to avoid
relapse.[5,10] In fact, relapse occurs so often that some smoking cessation
experts
recommend labeling it a fifth stage.[5]
The "Four A's" Intervention
The most widely used initial intervention is the National Cancer Institute's
"Four A's"
program, which was based on observations of smokers under the care
of general
medical practitioners.[21] This program can be used in almost any outpatient
setting.
Figure 2 (p 61) outlines the general guidelines of this program as
used at our center in
Santa Monica. The four components are "ask," "advise," "assist," and
"arrange," as
described below.[9,21]
Ask about smoking status at each visit. Record smoking status on patients' charts.
Advise smokers to stop: Give a strong, clear, personal message. For
example,
describe how smoking adversely affects their own health or their family's
health.
Assist patients in approaching smoking cessation. Set a quit date within
1 to 4 weeks.
Help them abstain from smoking; you might devise a smoking contract
to legitimize the
process. This document, signed by patients and their physicians, states
the desire to
quit and indicates the stop date. In addition, encourage patients to
begin nicotine
replacement therapy if indicated.
Arrange a follow-up visit shortly after the quit date, preferably during
the first week.
Waiting 7 to 10 days after the quit date is usually too long, since
many patients relapse
during the first few days.[8] A telephone follow-up at this time can
bolster patients'
attempts at abstinence or can serve as an opportunity to review reasons
for a relapse
that might have occurred. View relapses as educational experiences;
use them as a
springboard to discuss more effective coping skills.
Author's disclosure statement
The author has indicated no significant financial interest in or other
relationship with the
manufacturer of any commercial product discussed in this article.
References
1.Substance-related disorders, in Diagnostic and Statistical Manual
of Mental
Disorders (4th ed). Washington, DC, American Psychiatric
Institute, 1994, pp
243-247.
2.Fiore MC, Novotny TE, Pierce JP, et al: Trends in cigarette
smoking in the United
States. The changing influence of gender and race.
JAMA 261:49, 1989.
3.Lee EW, D'Alonzo GE: Cigarette smoking, nicotine addiction,
and its
pharmacologic treatment. Arch Intern Med 153:34,
1993.
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Breastfed Infants Have Lower Incidence Of Illness
Than Formula-Fed Children
TUSCON,
AZ -- May 13, 1999 -- Babies fed infant formula are more likely to
need doctor
visits and prescription drugs than babies who are breastfed,
according
to a study by The University of Arizona department of pediatrics,
which
was published in the April issue of the Journal of the Ambulatory
Pediatric
Society.
Thomas
Ball, M.D., MPH, assistant professor of clinical pediatrics, and Anne
Wright,
Ph.D., research professor, led the study, which was designed to
determine
the excess cost of health care services among babies who are
formula-fed.
"These
findings are significant because they quantify the cost of not
breastfeeding,"
Dr. Wright said. "Our work at The University of Arizona, as well
as that
of other researchers, has shown that breastfed infants have lower
incidence
of illness. This may be the first to attach a price tag to not
breastfeeding."
Researchers
analysed data from more than 1,500 healthy newborns from the
Tucson
Children's Respiratory Study at the UA and the Dundee Community
Study
from Scotland. The study focused on three illnesses common to babies:
otitis
media (ear infections), lower respiratory infections and diarrhoeal
illnesses.
Drs. Ball and Wright gathered information about doctor visits,
prescription
drug use and hospitalisation for these three illnesses among this
group
of newborns.
When they
compared 1,000 never-breastfed babies to 1,000 babies who had
been exclusively
breastfed for three or more months, they found 2,033 excess
office
visits, 212 excess days of hospitalisation and 609 excess prescriptions
for these
three illnesses. Researchers estimate the additional health care costs
of exclusive
formula feeding between $331 US and $475 US per infant in the
first
year of life.
"We know
that managed health care plans make medical decisions based on
cost and
health outcomes," Dr. Ball said. "We hope this study will convince
health
plans across the country to promote breastfeeding the way they promote
smoking
cessation, exercise and low-fat diets. It's clear that in this period of
cost-containment
in health care, encouraging breastfeeding improves infant
health
and the bottom line."