The majority of COPD is caused by smoking. Cigarette smoking has been shown to be as addictive as alcohol or narcotic agents (15). This addictive power of tobacco explains the tendency of individuals to continue to smoke, even in the face of pulmonary disease. Because of this, it is crucial for interventions aimed at smoking cessation to be initiated and maintained. Quitting smoking is clearly in the patient's interest, and performing surgery or other therapeutic interventions in the face of continued smoking is self-defeating—the patient must actively participate in his or her care by not smoking. Direct confrontation and insistence on the cessation of smoking by the entire staff are critical components in the management of individuals with COPD in pulmonary rehabilitation. The involvement of the referring physician is important, as the physician's counseling and warning are important predictors of compliance with the program (16,17). The individuals who are to start a program of pulmonary rehabilitation should either have stopped smoking or commit to cessation during the rehabilitation program. The focus of the rehabilitation program then becomes one of support and education for the patient and the family. There are several roles that the rehabilitation program can play:
1. Support the initiation of smoking cessation.
2. Support the continuation of smoking cessation.
3. Integrate smoking cessation with the rehabilitation program.
4. Educate the patient and family in the maintainence of a smoke free environment (18).
Table 2 outlines the components of the smoking cessation program that should be associated with or incorporated into the rehabilitation program.
Table 2 Smoking Cessation Program
Establish quit date and form a "contract" Arrange participation in a treatment program—either self-standing or part of a pulmonary rehabilitation program Continuous contact with individual after quit date, weekly for a month, then biweekly—provide supportive counseling as needed. Have medical Follow up within 2 mo of cessation. Assess compliance with testing as needed—carbon monoxide, cotinine levels. Reward compliance, provide strict guidelines, support for failure of abstinance. For failure of abstinance, consider nicotine replacements and/or pharmacological measures. Use support group as available worker, psychology Ongoing follow-up after abstinence achieved with support and occasional screening testing, as required
Physician, program coordinator, physical therapists Treating physician and program coordinator Treating physician Coordinator, physician, physical therapist
Coordinator, physical therapist, physician
Physician with assistance of the rehabilitation team
Rehabilitation team, social Team and physician
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