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Clinicians can play a key role in the identification and management of medical, social, and psychiatric problems. Counseling skills include building a supportive therapeutic relationship with the patient and family. A patient's family is often helpful in confirming the diagnosis and developing the treatment plan. Health maintenance consists of three main areas: disease detection, disease prevention, and health promotion.

Ask patients whether they have regular doctors and routine medical checkups. When was their last dental examination? Do they get their eyes checked periodically? Are they aware of their cholesterol levels? Do they do anything for exercise? If the patient is a woman, does she see a gynecologist regularly? Does she perform breast self-examination? When were her last mammogram and her last Pap smear obtained? If the patient is a man, does he perform routine testicular self-examination?

Tobacco use is probably the main avoidable cause of morbidity and mortality in the world. It is responsible for more than 450,000 deaths each year from cancer, heart disease, stroke, and chronic obstructive lung disease in the United States alone. Despite this fact, however, tobacco use is still prevalent. The Centers for Disease Control and Prevention estimates that 25% of all Americans still smoke and that more than 3000 children and adolescents become regular users every day. It is estimated that the cost of medical care for tobacco-related illness in the United States is more than $50 billion annually, and the cost of lost productivity and forfeited wages due to disability is an additional $50 billion per year. Despite these staggering statistics, health-care providers often fail to treat tobacco use effectively. Health-care providers have unique access to patients who use tobacco, and yet studies show that fewer than half of individuals who use tobacco reported being urged to quit by their physicians.

Health-care providers must determine and document the tobacco use status of all patients. If patients use tobacco, they should be offered smoking cessation treatment at every office visit. It has been shown that a discussion of only 3 minutes per visit can be effective. More intensive treatment with other medical therapies, social support, and other specific skills is more effective in producing long-term results. At the time of this writing, in addition to nicotine replacement products (i.e., nicotine patches, nicotine gum, nicotine lozenge, nicotine nasal spray, and nicotine inhaler), another drug has been introduced to help someone quit smoking.

Varenicline (Chantix) is non-nicotine prescription medicine specifically developed to help adults quit smoking. Varenicline, approved by the U.S. Food and Drug Administration (FDA) in 2006, contains no nicotine, but it targets the same receptors that nicotine does. It is believed to block nicotine from these receptors. It is the only prescription treatment of its kind at this time. Studies have demonstrated that at the end of 12 weeks of varenicline therapy, 44% of patients were able to quit smoking. It also helped reduce the urge to smoke.

It has been also been demonstrated, however, that there are times when patients are unreceptive or even resentful if the issue is broached. According to the ''stages of change'' model, success is most likely when the health-care provider is sensitive to the patient's stage. Stage 1 is the precontemplation stage in which the smoker is in denial about the hazards of smoking and is not willing to stop. Stage 2 is the contemplation stage, when the patient acknowledges a willingness to quit but has not determined when that will occur. Stage 3 is the action stage during which the patient has prepared for a change, is engaged in changing behavior, and has a plan for smoking cessation. Stage 4 is the maintenance stage during which the health-care provider needs to encourage the patient about the experience of quitting. Stage 5 is the relapse. Smokers generally make three or more attempts to quit smoking before permanent success is achieved.

Patients should be told in clear, strong language that it is in their best interest to quit smoking. Say, ''I think that it is important for you to quit smoking, and I will help you. I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.''

Also remember to ask the questions about alcohol consumption discussed in the previous section.

Counseling is very important, but interviewers must remember that a patient must want to change his or her behavior. If he or she does not, interviewers should indicate to the patient that they will provide support when the patient is ready.

Finally, do not forget to ask all patients whether they wear seat belts in cars or use helmets if they ride bicycles or motorcycles.

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