STAGE: Ready to Quit

STAGE: Ready to Quit

Ms. Warner has a history of essential hypertension. She is a 52- year-old woman who recently moved from out of state for a job promotion. She has been taking hydrochlorothiazide (a diuretic) for the past year. You review the medical record from her prior physician and note that her blood pressure has remained elevated (137/94) for over a year. She is mildly overweight (about 10 pounds) for her

height and has no other medical problems.

KEY POINTS

THIS PATIENT

ƒ has high blood pressure that has been uncontrolled for over a year

ƒ is ready to quit

ƒ previously failed trying to quit when using the nicotine gum

THE PHARMACIST

ƒ informs the patient of the effects of smoking on cardiovascular disease

ƒ advises the patient to quit

ƒ assesses the patient’s compliance with the nicotine gum regimen (used during previous quit attempt)

ƒ assists the patient in selecting a course of therapy (nicotine lozenge)

ƒ assesses reasons/motivations for quitting,

confidence in quitting, and concerns about weight gain and withdrawal symptoms

ƒ asks patient to complete a Tobacco Use Log

ƒ arranges follow-up counseling to review Tobacco Use Log and discuss use of nicotine lozenge

Step 1: ASK

Patients with elevated blood pressure are at risk for numerous cardiovascular problems, including myocardial infarction, heart failure, and stroke. Smoking can accelerate and worsen these conditions. Pharmacists practicing in primary care clinics should routinely review their patients’ smoking status and provide stage- appropriate smoking cessation interventions at each opportunity. Addressing and treating nicotine addiction is an essential component in the overall prevention and treatment of cardiovascular disease. As part of the medical history taken to determine other cardiovascular risk factors, it is important for the provider to determine whether the patient smokes.

After appropriate dialogue addressing the patient’s compliance with the medication and her exercise and diet plans…

Pharmacist

Do you smoke cigarettes or ever use any other form of tobacco?

Patient

I smoke cigarettes.

Step 2: ADVISE

Pharmacist

You may already know this, but smoking worsens blood pressure control and can lead to serious cardiovascular disease. I strongly encourage you to quit.

Step 3: ASSESS

Pharmacist

Have you given any thought to quitting?

Patient

Yes, I’ve been thinking about quitting, a lot recently. I’ve just started a new position, bought a new house, and my family is starting over in a different area of the country. I think I’m ready to finally quit smoking.

Step 3: ASSESS (cont’d)

Pharmacist

That’s excellent. Would you consider quitting sometime within the next month?

Patient

I haven’t really decided when I’ll quit. But there’s no sense putting it off. I think I could be ready to quit in the next month. What’s the easiest way to quit?

This patient is ready to quit.

Step 4: ASSIST

;

Well, there’s no easy way to quit—but we can try to pick the method that’s best suited to you. But I’ll need to get some information from you first. About how much do you currently smoke per day?

Patient

Right now I smoke between one half and a full pack each day.

;

Has the number of cigarettes that you smoke per day changed recently?

Patient

I smoke less during the week at work because nobody else smokes at work. I used to smoke a pack a day, but now I’m down to half a pack on work days.

Pharmacist

And how long have you been smoking?

Step 4: ASSIST (cont’d)

Patient

About 25 years now.

Pharmacist

Have you ever tried to quit?

Patient

Several times. The last time was years ago…when nicotine gum became available without a prescription. I quit for about a week, but I hated the taste of the gum and didn’t think it worked very well. Finally, I went back to smoking.

Pharmacist

What about the other times you tried to quit?

Patient

I tried hypnotherapy with a friend about 10 years ago. It seemed to work for a couple of weeks, but I still craved cigarettes. I was hungry all the time, too. And I started snacking a lot. I worried about gaining weight, so I went back to smoking.

Pharmacist

Ms. Warner, you tried nicotine gum on your last attempt. Can you tell me how you used the gum? How many pieces did you use each day?

Patient

I chewed the gum whenever my cravings were out of control. About six pieces a day. I was using the dose for light smokers. I’m glad I didn’t get the stronger gum. I couldn’t stand the taste, and it was hard for me to keep the gum in my mouth longer than 5–10 minutes.

Pharmacist

Did you think the gum helped to alleviate your cravings for cigarettes?

Step 4: ASSIST (cont’d)

Patient

The gum reduced my cravings a little, but I’d never use it again. I threw out half of a starter pack. I’d like something to help with the cravings.

Although this patient did not receive an adequate trial with nicotine gum, she should not be challenged with a more aggressive administration schedule. The recommended initial dose for this patient should have been 2 mg every 1–2 hours (12–24 pieces/day).

This patient has made it clear that the gum delivery system is not a reasonable option for her. Any attempts to get her to reconsider the gum could compromise the pharmacist’s credibility.

Pharmacist

There are newer, more tolerable flavors of the gum, but it sounds like we should go with a different option. We can talk about those a little later. I have a few more questions.

;

First…it seems like you’re motivated to quit now because you want to start over, given your recent move and job change. Are there any other reasons you want to quit smoking?

Patient

I have two children, a 17-year-old daughter and a 15-year-old son. Thankfully, neither of them smokes.

I hate that I’m setting a bad example. Also, I watched my former mother-in-law die of lung cancer 8 years ago. She smoked two packs a day for 50 years. I don’t want to go through that myself.

;

You’ve got a lot of things going on in your life right now. A new job, new home, teenagers adjusting to new schools. Do you think this a good time to quit smoking?

Step 4: ASSIST (cont’d)

Patient

We’ve been here 6 weeks now, and I think we’re finally getting settled. I’d like to quit smoking before I get too set in my ways. I’ve already cut down on my use at work. I really want to quit completely. I think I can handle it.

;

Are you concerned about gaining weight when you quit?

Patient

I’m already overweight. I certainly don’t want to gain any more. I started smoking again the last time I tried to quit because of the weight issue. Is there anything I can take to prevent weight gain?

Pharmacist

I understand, based on your previous quit attempts, that weight gain is an issue for you. Unfortunately many people who try to diet while trying to quit smoking end up not being able to quit. They’re trying to do too many things all at once, and it’s hard. In general I don’t recommend that my patients worry about weight gain when they’re in the early stages of quitting smoking. I try to help them get through the rough parts, then work on any weight gain. Keep in mind that, on average, patients gain between 5 and 10 pounds after quitting smoking. I am not trying to minimize your concerns about weight. And, of course, it’s up to you whether you want to work on both simultaneously. There are some strategies that can help you to minimize weight gain while you quit, and we can discuss those.

Patient

I suppose I could wait and see what happens. I’ll just be careful in what I eat. Keep the junk food out of the house.

;

You’ve already told me that you’re concerned about withdrawal. I’m going to give you an information sheet that describes the different withdrawal symptoms that you can expect and how to alleviate them.

Step 4: ASSIST (cont’d)

;

Ms. Warner, let’s review the different methods you can use to stop smoking. You’ve already expressed that you are not keen on giving the gum another try. There also is the nonprescription nicotine patch, which is used just once a day, and the nicotine lozenge. On prescription, we have the nicotine nasal spray and the nicotine oral inhaler. If you’re interested in a nonnicotine medication, there’s a product called Zyban that’s also quite effective. Although none of these products is a cure for smoking, they all approximately double your chances of quitting. Any of these would be reasonable for you to consider. Does any one particularly appeal to you?

Patient

Hmmm. I guess I’m leaning toward the lozenge. Although I kind of like the idea of once-a-day dosing with the patch, I have a bit of eczema that I’d be afraid to irritate. And I’d rather not have to get a prescription. If they all work about the same, then I guess I’ll go with the lozenge.

Pharmacist

That sounds like a reasonable choice.

;

We’ll need to set a quit date…sometime within the next 2 weeks. Give yourself a couple of days to prepare yourself for the big day.

Patient

How about a week from today? It’s my son’s 16th birthday. That’ll be another reason to celebrate.

Pharmacist

Great idea. Make sure your family knows you’re quitting. You’ll need their help and understanding for the next several months. Quitting smoking is a wonderful gift for your son!

Step 4: ASSIST (cont’d)

;

Before you actually quit smoking for good, I need you to keep a diary of your current smoking patterns.

For the next 5 days I’d like you to fill out a Tobacco Use Log. This will help us identify activities and situations that trigger your smoking. Determining your smoking habits and patterns will help us to develop strategies to maximize your chances of quitting. Let me review the Tobacco Use Log with you now.

Continue your regular tobacco use for the next 5 days. Do not attempt to reduce your tobacco use during this time. The intent is to document current tobacco use habits and patterns. I normally suggest a full week of documentation (to account for fluctuations in smoking patterns as a function of the day of the week), but because you plan to quit on your son’s birthday, we’ll have only 6 days; this will be fine.

Use a separate log sheet each day. Because you smoke 10–20 cigarettes per day, you’ll need only one sheet per day. Record the following information in the Tobacco Use Log each time you smoke:

ƒ Cigarette number

ƒ Time of day

ƒ Brief description of the activity or situation just before you lit up, and the situation while using the tobacco

ƒ Rating of the importance of that cigarette, at that time, using the following scale:

1 = Not very important (would not have missed it) 2 = Moderately important

3 = Very important (would have missed it a great deal)

I’ll call you next Wednesday afternoon—that’s 6 days from now—to review your logs. At that time we’ll develop some coping strategies to help you overcome the temptation to use tobacco. After you’ve carefully monitored when, where, and why you have smoked for several days, you’ll list the top three situations where you found you wanted to smoke.

Remember, to successfully quit smoking, you must be aware of the situations where you are most likely to smoke. You must be ready to change your routines to avoid situations that may trigger your smoking. When you find yourself in one of those situations, you must be prepared to change what you do and how you think so that you do not reach for a cigarette.

Anticipate trouble situations and develop avoidance or substitute plans for smoking. We can discuss this further next Wednesday after you’ve determined your major triggers for smoking. Do you think this sounds like a reasonable approach?

Patient

I’ve never quit smoking like this before. I just “did it” without any planning. No wonder I failed!

Step 4: ASSIST (cont’d)

;

Congratulations on your decision to quit smoking. Quitting smoking is a process that may take weeks or months until you feel that you have truly become a nonsmoker.

Quitting smoking is every bit as important for your overall health as controlling your high blood pressure. I’m looking forward to having you as a patient in my clinic and am impressed with the steps you are already making to improve your health. These next few weeks are going to be a challenge, but remember that this is something you can do. I want to help you through the quitting process.

Step 5: ARRANGE

Pharmacist

I’ll call you next Wednesday afternoon to check in with you just before your quit date. We can review your Tobacco Use Log, develop coping strategies, and review the proper use of the nicotine lozenge.

Is that date good for you?

Patient

Yes, that works for me.

Pharmacist

Great. And after you quit, I’d like to see you again in 2 weeks. At that time we can recheck your blood pressure and see how you are doing off cigarettes. Do you have any other questions or concerns?

Patient

No, not that I can think of right now.

Pharmacist

OK. We’ll talk again on Wednesday.