Although millions of Americans have kicked the habit, the effects of cigarette smoking likely will be around for a long time. What was once regarded as a glamorous habit is now recognized as a health threat and an economic burden. But what headway has been made in the reduction of related morbidity and mortality? The authors of this article review the current epidemiologic data on smoking-related diseases and make an indisputable case for smoking cessation.
A 53-yr-old active man with angina but no angiographically significant obstructive coronary artery disease developed refractory spasm following ergonovine provocation. This resulted in thrombus formation and myocardial infarction. As such, this is the first case in which thrombosis developed at the site of intense coronary artery spasm induced by ergonovine, all of which were documented angiographically. Despite the notable safety of this test, this case re-emphasizes the potential of ergonovine to produce intractable myocardial ischemia and infarction.
The arsenal of pharmacologic agents available for smoking cessation has expanded in the last few years, and it is likely to continue to do so. It is important that practicing physicians keep abreast of new methods as they become available and encourage patients who smoke to undertake cessation measures. Nicotine-replacement therapy is available in gum, patch, nasal spray, or inhaler form, and bupropion therapy aids in smoking cessation through dopaminergic activity. The foundation of effective intervention is likely to remain unchanged: an individualized plan addressing behavioral, addictive, pharmacologic, and relapse-prevention components. In addition to the necessary information about treatment choices, physicians should offer motivation, support, and follow-up to their patients who wish to quit smoking.
Alcoholism, more than any other illness, requires the integration of social and family history, physical symptoms and signs, and laboratory data in order to make a firm diagnosis. Common in alcoholism is the patient's minimization or denial of the disease and its symptoms, thwarting efforts at early diagnosis and intervention. If early diagnosis is to be made, several points should be remembered: 1. Life problems associated with alcohol use are the earliest signs of the disease. 2. There are few reliable early physical symptoms and signs. 3. Laboratory markers of alcoholism are neither sensitive nor specific when used alone as screening tools. 4. Alcoholism questionnaires, e.g., the MAST or the CAGE, should be a part of routine office practice in screening for alcoholism. Effective therapy is available, but early diagnosis is necessary for the best outcome. Gallant has reminded us of the "tragedy of delayed treatment." Early recognition of alcoholism puts the internist, as well as other primary care providers, in the best position to begin the process of healing the patients and their families.
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