Low Blood Pressure & Exercise By James Rada, Jr.

, eHow Contributor Exercise and Low Blood Pressure Exercise can cause sudden changes in blood pressure. A change of 20 points in your blood pressure can cause you dizziness or even fainting. This happens because for that moment the brain isn't getting enough blood. Athletes and those who exercise regularly tend to have lower blood pressure and slower heart rate. So a sudden drop of 20 points could easily put an athlete into the realm of low blood pressure. Orthostatic Hypotension The type of low blood pressure that occurs during exercise is called orthostatic hypotension. It typically occurs when there is a sudden change in posture, for instance, when the head rises from below the heart. It can also happen from a supine position when the head is level with the heart. When you change position, circulation isn't forceful enough to continue getting blood to the head and you experience dizziness or worse, faint. When this happens, sit down or lean against something until the dizziness passes. Cautionary Exercises Some of the exercises that place your body in a position where you can experience orthostatic hypotension are: bench press, sit-ups, bent-over rows, reverse flies, aerobic dance, yoga poses, lunges and squats. Also, if you stand still after a cardio exercise like a treadmill, blood pools in the legs. You body needs the assistance of the leg muscles to help pump the blood back to the head after the cardio exercise. Symptoms When working out, you need to be careful about sudden changes in your position. Here are some of the symptoms of low blood pressure: dizziness or lightheadedness, fainting (syncope), lack of concentration, blurred vision, nausea, clammy skin, rapid or shallow breathing, fatigue or thirst. Since some of these symptoms are also experienced during workouts so watch to see if the symptom is more severe than usual.

Home Remedy For Low Blood Pressure The best and the most effective home remedy for treating low blood pressure would be to consume lots of water. This is because dehydration reduces blood volume and leads to a drop in the blood pressure. Beetroot juice is beneficial for those suffering from low blood pressure. So, have a cup of raw beetroot juice two times a day. Prepare a cup of strong black coffee and consume this whenever you feel that your blood pressure is dipping. Put 15-20 gm of Indian Spikenard in 250 ml water and boil it. Now, remove from heat and let it cool down. Have this infusion thrice a day. You can also have 30-40 grains of Indian Spikenard, along with some camphor and cinnamon. Fill your bathtub with lukewarm water and add one kg of Epsom salt to it. Immerse yourself in the bath for 20 minutes, before going to bed. Take caution not to expose the body to a cold area after this. In a bowl of water, soak 7 almonds and keep them overnight. Peel them and prepare a paste. Add this paste to lukewarm milk and drink it. Take a bowl of water and soak 30 raisins in it, overnight. Chew them one by one, on an empty stomach, in the morning and have water. Holy basil works effectively in curing low blood pressure. Take about 15 holy basil leaves and crush them. Filter the mixture with the help of a muslin cloth. Have this filtered mixture, along with a tsp of honey, on an empty stomach. Include salt, asafetida and fruits in your diet. All these are beneficial in restoring the blood pressure level.

Foods rich in proteins, vitamin C and vitamin B are effective in treating low blood pressure. Exercises, light walking, swimming and cycling are beneficial in regulating the blood pressure level.

DIARRHEA Prevent or Treat Dehydration o Give a child or adult plenty of clear fluid, like water, Pedialyte, Ceralyte, or Infalyte (for adults and children), and clear broth. Fruit juices and sports drinks should be watered down to 1/2 strength. Avoid milk or milk-based products, alcohol, apple juice, and caffeine while you have diarrhea and for 3-5 days after you get better. They can make diarrhea worse. Give an infant frequent sips of water, 1/2 strength juice (no apple juice) or a rehydration solution such as Pedialyte, Ceralyte, or Infalyte. Do not add salt tablets to a babys bottle. Make sure the person drinks more fluids than they are losing through diarrhea. If they are unable to keep up with their losses, call a doctor. 2. Rest o Have the person rest as needed and avoid strenuous exercise. Keep a sick child home from school or day care. FEVER 3. Ease Into Eating o o For an infant or child, feed the BRAT diet (bananas, rice, applesauce, and toast) as soon as they can tolerate it. For an adult, add semisolid and low-fiber foods gradually as diarrhea stops. Avoid spicy, greasy, or fatty foods. 3. When to Call a Doctor Treatment Monitor temperature using a thermometer Remove the excess clothing Keep the person in a cool place Give a sponge bath in luke warm water Give plenty of fluids Give prescribed doses of acetaminophen /paracetamol Do not give aspirin to a person with fever Do not wrap the person in blankets / warm clothing o o o o o If you think the person needs over-the-counter diarrhea medication. Some kinds of diarrhea can get worse with anti-diarrheal medications. If you think the person has travelers diarrhea or drank contaminated water and may need special medication If the person is taking an antibiotic that may be causing the diarrhea If there is blood or mucus in the stool If the person is losing more fluid in their stool than they can replace by drinking fluids Follow-Up Seek medical attention if: o o Diarrhea in an adult worsens or doesnt clear up after 2 or 3 days An infant or child doesnt feel better after 24 hours

Heat stroke Overview Heat stroke is the most severe of all heatrelated illness Heat stroke could be life - threatening Causes Cooling mechanism of the body fails due to a. Excessive humidity b. Extreme heat c. Activity in the hot sun

Internal body temperature rises, leading to stroke Risk Factors Dehydration Infants & older people People who work long hours, outdoor Obesity Impairment in sweat gland function Cardiovascular disorder Alcohol usage Medications Symptoms Body temperature, greater than 104 F Treatment
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Head ache Dizziness Confusion Disorientation Fatigue Hot dry skin Skin is moist, if stroke is due to exertion Rapid / shallow breathing Rapid heartbeat Absence of sweating Fluctuating blood pressure Irritability Confusion Lack of consciousness / coma

Remove the person to a shady place Cool the person by sponging with wet towel Apply ice packs in armpits and groin Water with electrolyte, fruit / vegetable juice should be given Victim must be rested Prevention Avoid outdoor activity during excessive heat Drink plenty of fluids when working outdoors During outdoor activity, splash your body frequently with water Avoid alcohol / coffee / soda / alcohol Wear light weight, light- colored, loose-fitting clothes Protect yourself from the sun by wearing sun glasses and hat

1. Lower Body Temperature 3. Rest Get the person out of the heat and into a cool environment. If air-conditioning is not available, fan the person. Spray the person with a garden hose, get him into a cool shower, apply cool compresses, or give the person a sponge bath Have the person avoid physical activity for the rest of the day. Give over the counter acetaminophen if the person has a mild headache.

4. See a Health Care Provider 2. Rehydrate Give cool, nonalcoholic beverages as long as the person is alert. Untreated heat exhaustion can progress to heat stroke. See a doctor that day if: Symptoms get worse or last more than an hour The person is nauseated or vomiting

Stress management Stress management starts with identifying the sources of stress in your life. To identify your true sources of stress, look closely at your habits, attitude, and excuses: Do you explain away stress as temporary (I just have a million things going on right now) even though you cant remember the last time you took a breather? Do you define stress as an integral part of your work or home life (Things are always crazy around here) or as a part of your personality (I have a lot of nervous energy, thats all). Do you blame your stress on other people or outside events, or view it as entirely normal and unexceptional? Until you accept responsibility for the role you play in creating or maintaining it, your stress level will remain outside your control. Start a stress journal A stress journal can help you identify the regular stressors in your life and the way you deal with them. Each time you feel stressed, keep track of it in your journal. As you keep a daily log, you will begin to see patterns and common themes. Write down: What caused your stress (make a guess if youre unsure). How you felt, both physically and emotionally. How you acted in response. What you did to make yourself feel better. Look at how you currently cope with stress Think about the ways you currently manage and cope with stress in your life. Your stress journal can help you identify them. Are your coping strategies healthy or unhealthy, helpful or unproductive? Unfortunately, many people cope with stress in ways that compound the problem. Unhealthy ways of coping with stress These coping strategies may temporarily reduce stress, but they cause more damage in the long run: Smoking Drinking too much Using pills or drugs to relax Sleeping too

Overeating or undereating Zoning out for hours in front of the TV or computer Withdrawing from friends, family, and activities

much Procrastinating Filling up every minute of the day to avoid facing problems Taking out your stress on others (lashing out, angry outbursts, physical violence)

Learning healthier ways to manage stress If your methods of coping with stress arent contributing to your greater emotional and physical health, its time to find healthier ones. There are many healthy ways to manage and cope with stress, but they all require change. You can either change the situation or change your reaction. When deciding which option to choose, its helpful to think of the four As: avoid, alter, adapt, or accept. Since everyone has a unique response to stress, there is no one size fits all solution to managing it. No single method works for everyone or in every situation, so experiment with different techniques and strategies. Focus on what makes you feel calm and in control. Dealing with Stressful Situations: The Four As Change the situation: Change your reaction: Avoid the stressor. Adapt to the Alter the stressor. stressor. Accept the stressor. Stress management strategy #1: Avoid unnecessary stress Not all stress can be avoided, and its not healthy to avoid a situation that needs to be addressed. You may be surprised, however, by the number of stressors in your life that you can eliminate. Learn how to say no Know your limits and stick to them. Whether in your personal or professional life, refuse to accept added responsibilities when youre close to reaching them. Taking on more than you can handle is a surefire recipe for stress.

Avoid people who stress you out If someone consistently causes stress in your life and you cant turn the relationship around, limit the amount of time you spend with that person or end the relationship entirely. Take control of your environment If the evening news makes you anxious, turn the TV off. If traffics got you tense, take a longer but less-traveled route. If going to the market is an unpleasant chore, do your grocery shopping online. Avoid hot-button topics If you get upset over religion or politics, cross them off your conversation list. If you repeatedly argue about the same subject with the same people, stop bringing it up or excuse yourself when its the topic of discussion. Pare down your to-do list Analyze your schedule, responsibilities, and daily tasks. If youve got too much on your plate, distinguish between the shoulds and the musts. Drop tasks that arent truly necessary to the bottom of the list or eliminate them entirely.

Manage your time better. Poor time management can cause a lot of stress. When youre stretched too thin and running behind, its hard to stay calm and focused. But if you plan ahead and make sure you dont overextend yourself, you can alter the amount of stress youre under.

Stress management strategy #3: Adapt to the stressor If you cant change the stressor, change yourself. You can adapt to stressful situations and regain your sense of control by changing your expectations and attitude. Reframe problems. Try to view stressful situations from a more positive perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time. Look at the big picture. Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere. Adjust your standards. Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with good enough. Focus on the positive. When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective. Adjusting Your Attitude How you think can have a profound effect on your emotional and physical well-being. Each time you think a negative thought about yourself, your body reacts as if it were in the throes of a tension-filled situation. If you see good things about yourself, you are more likely to feel good; the reverse is also true. Eliminate words such as "always," "never," "should," and "must." These are telltale marks of self-defeating thoughts.

Stress management strategy #2: Alter the situation If you cant avoid a stressful situation, try to alter it. Figure out what you can do to change things so the problem doesnt present itself in the future. Often, this involves changing the way you communicate and operate in your daily life. Express your feelings instead of bottling them up. If something or someone is bothering you, communicate your concerns in an open and respectful way. If you dont voice your feelings, resentment will build and the situation will likely remain the same. Be willing to compromise. When you ask someone to change their behavior, be willing to do the same. If you both are willing to bend at least a little, youll have a good chance of finding a happy middle ground. Be more assertive. Dont take a backseat in your own life. Deal with problems head on, doing your best to anticipate and prevent them. If youve got an exam to study for and your chatty roommate just got home, say up front that you only have five minutes to talk.

Stress management strategy #4: Accept the things you cant change Some sources of stress are unavoidable. You cant prevent or change stressors such as the death of a loved one, a serious illness, or a national recession. In such cases, the best way to cope with stress is to accept things as they are. Acceptance may be difficult, but in the long run, its easier than railing against a situation you cant change. Dont try to control the uncontrollable. Many things in life are beyond our control particularly the behavior of other people. Rather than stressing out over them, focus on the things you can control such as the way you choose to react to problems. Look for the upside. As the saying goes, What doesnt kill us makes us stronger. When facing major challenges, try to look at them as opportunities for

personal growth. If your own poor choices contributed to a stressful situation, reflect on them and learn from your mistakes. Share your feelings. Talk to a trusted friend or make an appointment with a therapist. Expressing what youre going through can be very cathartic, even if theres nothing you can do to alter the stressful situation. Learn to forgive. Accept the fact that we live in an imperfect world and that people make mistakes. Let go of anger and resentments. Free yourself from negative energy by forgiving and moving on.

Stress management strategy #5: Make time for fun and relaxation Beyond a take-charge approach and a positive attitude, you can reduce stress in your life by nurturing yourself. If you regularly make time for fun and relaxation, youll be in a better place to handle lifes stressors when they inevitably come. Set aside relaxation time. Include rest and relaxation in your daily schedule. Dont allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries. Connect with others. Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress. Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike. Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways. Eat a healthy diet. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day. Reduce caffeine and sugar. The temporary "highs" caffeine and sugar provide often end in with a crash in mood and energy. By reducing the amount of coffee, soft drinks, chocolate, and sugar

Healthy ways to relax and recharge Go for a walk. Savor a warm cup Spend time in of coffee or tea. nature. Play with a pet. Call a good friend. Work in your Sweat out tension garden. with a good Get a massage. workout. Curl up with a good Write in your book. journal. Listen to music. Take a long bath. Watch a comedy. Light scented candles. Dont get so caught up in the hustle and bustle of life that you forget to take care of your own needs. Nurturing yourself is a necessity, not a luxury. Stress management strategy #6: Adopt a healthy lifestyle You can increase your resistance to stress by strengthening your physical health. Exercise regularly. Physical activity plays a key role in reducing and preventing the effects of stress. Make time for at least 30 minutes of exercise, three times per week. Nothing beats aerobic exercise for releasing pent-up stress and tension.

snacks in your diet, youll feel more relaxed and youll sleep better. Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or drugs may provide an easy escape from stress, but the relief is only temporary. Dont avoid or mask the issue at hand;

deal with problems head on and with a clear mind. Get enough sleep. Adequate sleep fuels your mind, as well as your body. Feeling tired will increase your stress because it may cause you to think irrationally.

Practical Steps to Smoking Cessation for Recovering Alcoholics HELEN E. MCILVAIN, PH.D., JANET KAY BOBO, PH.D., AMBER LEED-KELLY, M.A., and MICHAEL A. SITORIUS, M.D., University of Nebraska Medical Center, Omaha, Nebraska Smoking rates among persons with a history of alcohol abuse are triple that of the general public. Strong evidence indicates that the risk of cancer and cardiovascular disease is higher in recovering alcoholics than in peers who smoke, but do not drink alcohol. Yet these persons often receive less than optimal tobacco counseling out of fear that attempts at smoking cessation will jeopardize their sobriety. Recent research, however, does not support this belief; rather, it suggests that smoking cessation may actually enhance alcohol abstinence. A model for more effective counseling of smokers in recovery is presented, including an algorithm for assessing stages of readiness to change, with activities tailored for each stage. Specific motivational counseling techniques may be useful in encouraging recovering alcoholics to progress to the point that they are ready to change their smoking behavior. Smoking remains the chief preventable cause of premature disability and death in the United States. 1 Smoking rates average 25 percent in the general population but increase to 80 to 95 percent in 2 chemically dependent persons. Assessing Readiness to Change In the readiness-to-change model, smoking cessation is viewed as a process of change with five stages: precontemplation, contemplation, preparation, action and maintenance. Research has suggested that the progress patients make following interventions for behavioral change tends to be a function of their 17 pretreatment stage of change. When a smoker's stage of readiness to change is known, messages can be tailored to the appropriate goal for that patient's condition. An algorithm for assessing stage of readiness to change is presented in Figure 1. The question Are you currently using tobacco? is in accordance with the clinical practice guidelines of the AHCPR. According 19 20 to these guidelines and supporting research, every patient's current tobacco-use status should be identified at every office visit, and all smokers should be offered smoking cessation treatment at every visit. It is especially important to use these strategies with recovering alcoholic patients, since these persons have been found to be at increased risk for tobacco-related illnesses. The other questions in the algorithm assess the patient's stage of readiness to change smoking behavior by identifying current intentions and previous actions.
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FIGURE 1. Algorithm for identifying five stages of readiness to change in recovering alcoholic patients who use tobacco. Counseling Strategies REALISTIC GOALS Once the smoker's stage of readiness has been identified, the strategies for that stage can be implemented (Table 1). These activities are designed to facilitate patient movement from his or her

current stage to the next stage, with the eventual goal being long-term smoking cessation. The activities themselves are a mix of proven smoking cessation techniques and Alcoholics Anonymous' 12-step activities with which the patient is likely to be familiar. Drawing a parallel between the patient's successful alcohol recovery and his or her tobacco addiction allows smoking cessation to be redefined in a way that 21 is familiar to the patient and may increase the possibility of successful cessation. STRESS MANAGEMENT TABLE 1 Stage-Based Counseling Strategies for Smoking Cessation in Recovering Alcoholic Patients

Precontemplation stage: patient is not considering quitting in the next six months 1. Take a smoking history (if not previously done) that includes the following: the age at which the patient started smoking; the amount smoked per day; the brand of cigarettes smoked; the length of time after awakening before the patient has the first cigarette; the number of past attempts to quit and the length of time off cigarettes each time; the reasons for relapse; concerns about quitting; changes in smoking behavior since the patient has been in recovery; and potential barriers to quitting (family, friends, co-workers, etc.). 2. Assess the patient's knowledge by asking an open-ended question: What do you know about the increased risks to your health from your history of heavy drinking and smoking? 3. Assess the patient's cognitive rationale for smoking, using the positive/negative technique: What is positive about smoking for you? What would be negative about quitting for you? Are you concerned that trying to quit smoking might make it harder to stay off alcohol? What would be positive about quitting for you? What would be negative about continuing to smoke? Do you think of your smoking as an addiction in the same way that your previous alcohol use was an addiction? 4. Give a strong message about the patient's need to stop smoking and your willingness to help when he or she is ready: I encourage all my patients who smoke to quit. This is especially important for those with a history of heavy drinking. I'd like you to stop smoking. If you're unable to do so today, then I'd like you to think about it and let me know how I can help when you're ready. Consider giving patient education materials appropriate to the patient's stage of readiness to change. 5. Update the patient's smoking status and stage

of readiness to change at each office visit. Record the patient's smoking status in the chart at each visit. (Label the charts of current smokers so that all staff members can participate in counseling for smoking cessation.) 6. Document the stage and intervention in the patient's record, including the increased risk because of his or her past alcohol history. Contemplation stage: patient is considering quitting in the near future but has made no commitment, as indicated by action in the past year 1. Take a smoking history, if not previously done (see Precontemplation, item 1). 2. Assess cognitive rationale for smoking, using the positive/negative technique (see Precontemplation, item 2). 3. Identify reasons for not committing to quit by asking the patient the following questions: What is it that keeps you from setting the date and quitting? Do you have any concerns about maintaining your sobriety if you attempt to quit smoking? How did you overcome any similar concerns you had about trying to quit alcohol? 4. Give a strong, nonjudgmental message about the patient's need to stop smoking and your willingness to help when he or she is ready: I'm ready to help you whenever you choose to commit to quit. I consider your smoking to be as serious a threat to your health as your drinking was. You might think about how you were able to successfully lick that problem. 5. Encourage the patient to experiment with quitting: As with drinking, you'll eventually need to go cold turkey in order to successfully quit smoking. In the meantime, you can learn more about your addiction to cigarettes and how to manage the cravings by experimenting. Suggested patient strategies might be stopping smoking for 24 hours and keeping a diary of what it feels like, or cutting out, for one to two weeks, the two or three cigarettes that are

hardest to give up each day and keeping track of effective coping techniques, or reducing the number of cigarettes smoked each day by one half for one week. Consider giving patient education materials that are appropriate to the patient's stage of readiness to change. 6. Document stage, intervention and follow-up in the patient's record. Preparation stage: the patient is planning to quit smoking in the near future and has made a genuine attempt to quit in the past year 1. Take a smoking history, if not done previously (see Precontemplation, item 1). 2. Reinforce the patient's desire to quit and offer support. Define the patient's desire to quit in the same positive framework as his or her decision to get into alcohol recovery: We both know that this won't be easy, but neither was getting sober. It's the best gift you could give yourself and your family. I'll help you all the way. 3. Discuss the patient's past quit attempts, if any, including particular strategies that were helpful, along with situations that led to relapse. Ask if alcohol use was involved in previous returns to smoking. 4. Help the patient develop an explicit plan for quitting, including a quit date, strategies for coping with problem situations and rewards for success. Discuss the patient's experience with getting sober. How did the patient do it? What worked best? How did the patient manage cravings to drink? How does the patient feel about himself or herself for successfully working through the alcohol cessation program? How might the patient apply 12-step concepts to quitting smoking? Consider the possibility of using nicotine replacement therapy (see the guidelines of the Agency for Health Care Policy 19 and Research ). Give patient education materials appropriate to the patient's stage of readiness. 5. Explain the difference between temporary and permanent relapses, and the need to keep working on the plan regardless of slips. Emphasize one day at a time. 6. Schedule follow-up contact in one to two weeks. The contact does not need to be a clinic visit. In fact, telephone contact may be more acceptable to both the patient and the physician. Use of support staff in this role may be more efficient. Discuss sources of outside support, such as getting a sponsor to help with the plan, attending nonsmoking Alcoholics Anonymous meetings, attending a Nicotine Anonymous program (if available) and doing daily

meditations on being smoke-free and coping with cravings. Action stage: the patient successfully implements new behavior 1. Continue positive reinforcement and support as needed until the patient has been abstinent for one year. 2. Encourage the patient to call or come to the office as soon as possible if he or she relapses. Relapse or maintenance stage: patient has either relapsed to smoking or has maintained abstinence from smoking for one year 1. If the patient has relapsed, assess the reason and discuss how the patient thinks he or she might handle smoking cessation differently the next time. 2. Following a relapse, assess the patient's current stage of readiness to quit again. Recycle through the process. 3. If the patient is maintaining abstinence, periodically reinforce behavior. Trying to persuade a patient who is in the precontemplation stage to agree to quit smoking is a frustrating, time-consuming activity that is likely to fail. However, getting the patient to discuss concerns about quitting and presenting information on the risks involved with smoking are accomplishable goals. Thus, setting a quit date is realistically reserved for a patient who is in the preparation stage. In summary, the overall approach of the readiness-to-change model is based on the recognition that smoking is an addictive, complex behavior, and that change takes time. MOTIVATIONAL COUNSELING While many physicians voice concerns about repeatedly nagging patients who have indicated no interest in quitting smoking, they also feel obligated to provide good care. As described in one text, Motivational interviewing is a particular way to help people recognize and do something about their present or potential problems. It is particularly useful with people who are reluctant to change and ambivalent about changing. It is intended to resolve ambivalence and to get a person moving along 18 the path to change. The key components of motivational interviewing, or counseling, are a nonpaternalistic, nonjudgmental attitude on the part of the physician, an orientation that accepts patients as they are, and techniques that encourage and reinforce patient selfresponsibility. A complete description of

motivational counseling is beyond the scope of this article. In brief, the five basic principles of motivational counseling are as follows: Express Empathy. In providing smoking cessation counseling for a patient in recovery from alcoholism, the physician needs to express empathy in order to convey acceptance of the patient's current situation. Acceptance does not mean agreement with, or approval of, the patient's behavior. Rather, it is the respectful desire to understand the patient's frame of reference. It acknowledges that changing behavior is difficult and involves feelings of ambivalence. Respectful listening and reflection of feelings are two key communication skills for this task. For example, the physician might say the following: So, it seems like you think you should stop smoking at some point, but you're afraid that quitting both smoking and drinking would be too hard. I would like to tell you about some facts that have recently come to light on that subject. Develop Discrepancy. This is accomplished by creating and amplifying incongruities between the patient's present behavior and his or her stated personal goals. Using skillful questioning to help the patient clarify goals and explore consequences, the physician can often get the patient to present his or her own reasons for needing to change. This approach can be much more effective than subjecting the patient to another lecture, because it allows the patient to think about his or her behavior without feeling pressured and coerced. The following remarks could accomplish this goal: I know that you are interested in protecting your health and your family's well-being by the fact that you've worked so hard at attaining sobriety. What do you know about the additional risk that smoking holds for people with a past history of heavy alcohol use? Avoid Argumentation. Arguing with a patient tends to evoke resistance. As a result, both the physician and the patient are likely to come away feeling dissatisfied and more entrenched in their own positions. While motivational counseling is confrontational in its goals, it is not confrontational in its style. Resistance by the patient is a signal to the physician to change strategies: I can see that you're just not ready to try quitting right now. I would ask that you give some thought to what we have talked about, and

let me know if and when you're ready. I'd like to help. Roll with Resistance. The physician can also roll with resistance by using the momentum of the patient's resistance to shift his or her perspective. Turning a question or problem over to the patient is an excellent way to do this. This approach encourages the patient to use his or her own resources to solve the problem. For example, the physician might use the following statements: Smoking is the main way that you cope with stress, and you're worried about giving it up. That's understandable. Did you learn any methods in your recovery program that could help you when you decide to tackle this addiction? Support Self-Efficacy. This is the only possible path to change. The concept of self-efficacy can be difficult, because it requires a shift in perception that often seems at odds with professional ethics and values. Most physicians understand that they cannot force patients to change their behavior. However, physicians often feel inadequate or frustrated when they are unable to persuade patients to do what is best for them. As a result, they often avoid the topic of smoking cessation or nag patients about quitting smoking. In the physician training program at the University of Nebraska Medical Center, residents are encouraged to respect the patient's right to make decisions about his or her own behavior. At the same time, residents are encouraged to define for themselves what they need to do in order to feel as if they have fulfilled their professional responsibilities. This letting go of the responsibility for change often frees the physician to listen more empathically and to assume a less authoritarian position. Using this approach, the physician can make statements such as the following: You're not ready to make any plans to quit right now, but I'm glad we've had a chance to talk about it. You've shown good judgment in the past by getting into alcohol recovery, and we both know these things take time. The stage of readiness to change should be identified during every office visit for patients who are in alcohol recovery but continue to smoke. Specific stage-based activities and motivational counseling techniques should also be used with these patients. These interventions

require only three to five minutes, assuming that the tobacco-use history was obtained in a Health effects of smoking among young people

previous visit.

Among young people, the short-term health consequences of smoking include respiratory and non respiratory effects, addiction to nicotine, and the associated risk of other drug use. Long-term health consequences of youth smoking are reinforced by the fact that most young people who smoke regularly continue to smoke throughout adulthood.(1) Cigarette smokers have a lower level of lung function than those persons who have never smoked.(1) Smoking reduces the rate of lung growth.(1) In adults, cigarette smoking causes heart disease and stroke. Studies have shown that early signs of these diseases can be found in adolescents who smoke.(1) Smoking hurts young people's physical fitness in terms of both performance and enduranceeven among young people trained in competitive running.(1) On average, someone who smokes a pack or more of cigarettes each day lives 7 years less than someone who never smoked.(2) The resting heart rates of young adult smokers are two to three beats per minute faster than nonsmokers.(1) Smoking at an early age increases the risk of lung cancer. For most smoking-related cancers, the risk rises as the individual continues to smoke.(1) Teenage smokers suffer from shortness of breath almost three times as often as teens who don't smoke, and produce phlegm more than twice as often as teens who don't smoke.(3) Teenage smokers are more likely to have seen a doctor or other health professionals for an emotional or psychological complaint.(3) Teens who smoke are three times more likely than nonsmokers to use alcohol, eight times more likely to use marijuana, and 22 times more likely to use cocaine. Smoking is associated with a host of other risky behaviors, such as fighting and engaging in unprotected sex.(1) Alcohol and tobacco are among the top causes of preventable deaths in the United States (1). Moreover, these substances often are used together: Studies have found that people who smoke are much more likely to drink, and people who drink are much more likely to smoke (2). Dependence on alcohol and tobacco also is correlated: People who are dependent on alcohol are three times more likely then those in the general population to be smokers, and people who are dependent on tobacco are four times more likely than the general population to be dependent on alcohol (3).
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HEALTH RISKS ASSOCIATED WITH ALCOHOL AND TOBACCO USE Alcohol and tobacco use may lead to major health risks when used alone and together. In addition to contributing to traumatic death and injury (e.g., through car crashes), alcohol is associated with chronic liver disease, cancers, cardiovascular disease, acute alcohol poisoning (i.e., alcohol toxicity), and fetal alcohol syndrome. Smoking is associated with lung disease, cancers, and cardiovascular disease (9). Additionally, a growing body of evidence suggests that these substances might be especially dangerous when they are used together; when combined, alcohol and tobacco dramatically increase the risk of certain cancers (10).

Cardiovascular Disease Cancers of the Mouth and Throat People who drink and smoke are at higher risk for certain types of cancer, particularly those of the mouth and throat (1214). Alcohol and tobacco cause approximately 80 percent of cases of cancer of the mouth and throat in men and about 65 percent in women (11,1618). For people who both smoke and drink, the danger of mouth and throat cancer increases dramaticallyin fact, the combined risk is greater than or equal to the risk associated with alcohol multiplied by the risk associated with tobacco (15). Alcohol and tobacco co-use appears to substantially increase the risk of at least one type of cancer of the esophagus (19). Liver Cancer During the past decade, the incidence of liver cancer has increased dramatically in the United States (20). Although some studies have reported that alcohol and tobacco may work synergistically to increase the risk of liver cancers (21,22), more research is needed to explore this issue. The American Heart Association (23) estimates that more than 34 percent of the United States population has some form of cardiovascular disease. Tobacco use and alcohol consumption both are major risk factors for various forms of cardiovascular disease. However, little evidence exists to suggest that drinking and smoking together raise the risk more than the sum of their independent effects (24). Determining the risk factors for cardiovascular disease is difficult because the issues involved are extremely complex. First, cardiovascular disease encompasses a variety of conditions (such as heart attack, stroke, and hardening or narrowing of the arteries), which result from numerous factors (25). Second, although tobacco has been shown to raise the risk for cardiovascular disease in a dose-dependent mannerthe more a person smokes, the more his or her risk of developing cardiovascular disease increasesalcohols effect on cardiovascular disease depends on many factors, including gender, age, and drinking patterns. Overall, moderate drinking appears to reduce the risk for many forms of cardiovascular disease (26), whereas drinking large amounts of alcohol generally increases the risk (27).