Sarah Evers-Casey

Developing a Rational Approach to Tobacco Use Treatment in Pulmonary Practice: A Review of the Biological Basis of Nicotine Addiction.

The toll of tobacco use on a pulmonary practice is severe. Physicians, patients, and their families experience frustration, hopelessness, and even anger when confronted with a seemingly irrational decision to keep smoking despite morbid lung disease. This paper examines the biological basis of this behavior and seeks to integrate this insight into a rational approach to the problem in practice. Smoking is reexamined within the framework of an irrational compulsion to seek nicotine, despite a rational desire to stop. Control over the compulsion to smoke is established as an important clinical outcome, and the rationale for treating tobacco dependence as a chronic illness is examined. Finally, practical insights into managing ambivalence, including an aggressive pharmacotherapeutic approach based on the neurobiology, are presented.

Medical Symptoms Associated with Tobacco Smoking with and without Marijuana Abuse among Crack Cocaine‐dependent Patients

Despite the widespread use of tobacco and marijuana by cocaine abusers, it remains unclear whether combined tobacco and marijuana smoking is more harmful than tobacco smoking alone in cocaine abusers. We investigated the differences in medical symptoms reported among 34 crack cocaine abusers who did not smoke tobacco or marijuana (C), 86 crack cocaine abusers who also smoked tobacco (C + T), and 48 crack abusers who smoked both tobacco and marijuana (C + T + M). Medical symptoms were recorded using a 134-item self-report instrument (MILCOM), and drug use was assessed using the Addiction Severity Index (ASI). After controlling for clinical and demographic differences, the C + T + M group reported significantly more total symptoms on the MILCOM as well as on the respiratory, digestive, general, and nose/throat subscales than the C + T or C groups. The C + T group reported higher total and respiratory and nose/throat symptoms than the C group. HOwever, the C group had the highest number of mood symptoms among the three groups. The C + T and C + T + M groups were comparable in number of cigarettes smoked and ASI scores. Although tobacco smoking is associated with higher reports of medical problems in crack abusers, smoking both marijuana and tobacco seems to be associated with greater medical problems than smoking tobacco alone. Tobacco smoking was not related to changes in cocaine use. Also, marijuana smoking does not appear to be associated with a reduction in tobacco or cocaine use.

Behavioral Interventions in Tobacco Dependence

Patients who smoke represent a frustrating social paradox. The harmful effects of tobacco use have been well publicized in the past 50 years, yet more than one in five adults in the United States continue to smoke. A better understanding of the nature of nicotine addiction, of behavioral learning, and of common misconceptions regarding tobacco use treatment, can create new opportunities to impact smoking by offering clinicians novel methods of influence that have otherwise not be available within the traditional cessation approach. Understanding and dealing with the paradox can provide more productive and meaningful ways of improving not only health, but potentially also improving well-being.

Examining the Role of the Health Care Professional in Controlling the Tobacco Epidemic: Individual, Organizational and Institutional Responsibilities

Despite a historical inclination to view tobacco use as a defect in character or reason, advances in the neurobiological understanding of human behavior and the associated disturbances in behavior pat

Integrating Tobacco Use Treatment Into Practice: Billing and Documentation

Balancing population-based efforts to modify the social and environmental factors that promote tobacco dependence with efforts to improve the delivery of case-based treatments is necessary for realizing maximum reductions in the cost and consequences of the disease. Public health antismoking campaigns following the 1964 Surgeon Generals report on the health risks of smoking have changed social norms, prevented initiation among youth, and promoted abstinence among the addicted. However, the rate of progress enjoyed to date is unlikely to continue into the coming decades, given that current annual unassisted cessation rates among prevalent smokers remains fairly low. With more than 1 billion patient interactions annually, there is an enormous unrealized capacity for health-care systems to have an effect on this problem. Clinicians report a perceived lack of reimbursement as a significant barrier to full integration of tobacco dependence into health care. A more complete understanding of the coding and documentation requirements for successful practice in this critically important area is a prerequisite to increasing engagement. This paper presents several case-based scenarios illustrating important practice management issues related to the treatment of tobacco dependence in health care.