Thank you for filling out this questionnaire regarding cigarette usage. Our goal is not to scold you or hassle you, it is to help you.

1. How many cigarettes do you smoke per day? _____ Per week?_____

2. How many years have you been smoking?

3. Did your parents smoke?

4. Do you ever feel ill when you smoke, or have you ever considered quitting because of the affects?

5. If you decided to quit, would you need help?

6. Do you know there are medications to help you quit such as Zyban(Bupropion) and Chantix,? Yes No

·         Are you interested in any of these? Yes No

7. Would you be willing to discuss the Nicotine patch, gum, or inhaler with the physician?  (50% increase in successive quitting with these agents).

8. Do you have any other concerns or questions regarding smoking?

Cigarette smoking is the single greatest cause of preventable morbidity and mortality in American women. It is responsible for 55% of cardiovascular deaths in women ages less than 65 years, and women smokers are 12 times more likely to die of lung cancer than women who have never smoked. Lung cancer has now surpassed breast cancer as the number one cause of cancer deaths in women. Smoking increases the risk of oral cancer, laryngeal cancer, bladder cancer, pancreatic cancer, and probably cervical cancer, as well as chronic obstructive pulmonary disease (COPD).

Approximately 30% of American women smoke cigarettes, and 19-30% continue to smoke during pregnancy. The prevalence is higher among older, less educated, and African-American women. Women are more likely than men to have never tried to quit smoking. Physicians and other health care professional can have a dramatic effect on influencing smokers to reduce or quit smoking with counseling and smoking cessation guidance.

In addition to learning about the general ill health effects of smoking, patients can be informed of the effects of smoking on childbearing:

Decreased fertility

  • Twice the rate of ectopic pregnancy
  • Increased rate of spontaneous abortions (1.2 - 1.8 times higher)
  • Greater likelihood (39%) of aborting a chromosomally normal fetus
  • Increased rates of abruptio placentae(sudden premature detachment of the placenta from a normal uterine site of implantation), placenta previa (the condition where the placenta has grown to completely cover the cervix), and premature rupture of membranes
  • Increased relative risk of preterm births compared with nonsmokers (1.2 - 1.5 times higher)
  • Decreased mean birth weight of infants

Women smokers have other risks in addition to those effects of smoking in the childbearing years:

  • Early menopause (an average of 1.7 years earlier than nonsmokers)
  • Higher risk of osteoporosis
  • Greater risk of myocardial infarction and stroke if over age 35 years and oral contraceptives are used.

Smoking cessation can reverse many of the risks associated with smoking. By 10 years after smoking cessation, a former smoker's risk of lung cancer returns to that of a nonsmoker. Smoking reduction in pregnancy improves the birth weight of the infant, especially if cessation occurs before 16 weeks of gestation. It is estimated that if all pregnant women stopped smoking a 10% reduction in fetal and infant deaths would be observed.

Please note that nicotine withdrawal symptoms may occur in some patients who are heavy smokers. These will last less than a week and may include tobacco craving, irritability, anxiety, insomnia, fatigue, difficulty with concentration, dizziness, drowsiness, depression, stomach upset, and headache. There may be weight gain of 5 to 10 pounds over the first few months, due to changes in metabolism and eating behaviors. We suggest that you go to the gym immediately. Not only will this help you burn calories, but will reinforce your smoke free life. You will be able to work harder, run faster, and feel better once you are not smoking.

Please feel free to discuss any of the above with the physician. Other self help manuals are available from the National Cancer Institute, American Cancer Society, and the American Lung Association. Many of these booklets are available in the office.











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