Smoking, Alcohol, and Drugs: What to Ask

By Fady Akladios

“Do you smoke, Mrs. Z?” I asked my patient. She was recently diagnosed with small cell lung cancer.

“No,” she replied without hesitation. Her answer sounded very unlikely though.

“Well, have you ever smoked?”

“I quit after they saw the cancer in my lung.”

Asking about personal indulgences in the form of alcohol, smoking, and drugs can be one of the initially challenging parts of taking a proper history for any medical student. The questions are challenging for two main reasons:

  1. You are tapping into very personal parts of the patient’s life. Since most people know that overindulging in these habits can lead to serious consequences, they often feel reluctant to give that full history sometimes.
  2. What you perceive as abuse may not seem that way to the patient. This is particularly true for alcoholics. You will almost definitely stumble on an alcoholic patient who thinks eight beers a day is “not much.”

Below I will give a few pointers on how to extract these important elements of history from personal experience and other resources as well.

  1. Always ask, and be nice: make it an absolutely regular part of your history taking to ask about smoking, alcohol, and drugs. It is best to ask and help the patient quit before the barrage of complications knocks on the door. Also, be nice and not judgemental. Your job is to simply gather data and help the patient accordingly.
  2. Smoking history: There is evidence that regular questioning and counselling about smoking habits can increase quitting rates. Ask each patient if she smokes. If the answer is no, ask her if she ever smoked. Asking “when was the last time you smoked?” is a great way to cover all the bases (gets you current and previous smoking history in one question). Also, remember to quantify your patient’s smoking habits (packs per day, years of smoking). Remember that previous smokers are still prone to complications years later (lung and bladder cancer, AAA’s, etc.)
  3. Alcohol history: Questioning an alcoholic about his drinking habits is possibly one of the most difficult tasks. From personal experience, an alcoholic patient can hide his habits very well; he has learned to pretend to act well even when he is intoxicated. Specifically, ask each patient if he drinks alcohol. If the answer is no, but you are still suspicious, get specific (i.e. “so no beer, whiskey or anything of that sort?”). Quantify how much your patient drinks on a weekly or daily basis, and don’t forget your CAGE questionnaire. Finally, always ask when the last drink was in alcoholic patients (important to be aware of withdrawal symptoms).
  1. Illicit drug abuse: Ask each patient if he uses any illicit or street drugs and give examples of those drugs (marijuana, cocaine, heroin, etc.) Realize that many patients do not think of marijuana as an illicit drug (political debate aside), and therefore it is important to mention it in your examples. With any history of serious illicit drug abuse, ask about the frequency of use, quantity, and most recent use.

Do you have a way to navigate the sensitive area of asking about smoking, drugs, and alcohol? Share your tips below.


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