Clinical practice. Treating smokers in the health care setting.

A 45 year-old overweight woman with a history of asthma and depression presents to her primary care physician with her third episode of acute bronchitis in the last 24 months. She began smoking at age 15 and now smokes 10 to 15 cigarettes per day, but every day she starts smoking immediately upon awakening, an indication of severe nicotine dependence. She has made multiple unsuccessful attempts to quit, once briefly using the nicotine patch, but relapsed due to strong urges to smoke and weight gain. She has not used cessation counseling or other medications. She is bothered by the cost of cigarettes, and is worried about smoking’s health effects on her two children and on herself. Importantly, she is reluctant to make a quit attempt now, in part, because she fears she won’t succeed. What would you advise?