STAGE: Ready to Quit

STAGE: Ready to Quit

You are working at a community pharmacy and are taking a

prescription for prenatal vitamins (Natalins RX) from Ms. LeClair, a 24-year-old woman who has just found out that she is pregnant. She approaches you with questions about smoking during pregnancy and wants advice on how she might quit. She has no medical problems.

KEY POINTS

THIS PATIENT

ƒ is pregnant and ready to quit

ƒ contemplates options of quitting cold turkey or using the QuitKey computerized gradual reduction

method; opts to use the QuitKey method

THE PHARMACIST

ƒ reviews the patient’s previous quit attempt, motivation, and confidence in her ability to quit

ƒ discusses strategies to manage automatic smoking associated with drinking coffee, driving, and the end of meals

ƒ reviews nondrug methods for quitting (cold turkey, gradual tapering); counsels the patient on the use of the QuitKey unit

ƒ reviews preparation for quit attempt (home

environment, social support system); counsels the patient on the use of the Tobacco Use Log

Step 1: ASK

Not applicable. The patient approached the pharmacist for information about quitting smoking.

Step 2: ADVISE

This patient has indicated that she wants to quit. The pharmacist should commend her on this decision and emphasize the importance of quitting.

Step 3: ASSESS

Pharmacist

Have you talked with your obstetrician about quitting smoking?

Patient

Yes. She says I need to quit smoking while I’m pregnant.

Pharmacist

And did she talk with you about different methods for quitting?

Patient

She didn’t tell me how I should quit. She just told me to come to this pharmacy for help.

Pharmacist

Great. I’m glad to hear you’re wanting to quit. Do you think you’ll quit sometime within the next month?

Patient

Yes, for sure! I want to quit as soon as possible. I'm worried about my baby.

This patient is ready to quit.

Step 4: ASSIST

;

I will need to ask you a few questions, before we can design a treatment plan. Are you currently smoking cigarettes only, or do you also smoke cigars or use other types of tobacco?

Patient Just cigarettes.

Pharmacist

How many cigarettes per day do you usually smoke?

Patient

I was smoking maybe 15 cigarettes a day…not quite a pack. But since I found out I was pregnant, earlier this week, I started cutting down, to about ten a day or so.

;

How long had you been smoking 15 cigarettes a day? And when did you start smoking?

Patient

About 4 years – and I started when I was 18, about 6 years ago.

Pharmacist

Have you ever seriously tried to quit before?

Patient

I tried to quit, once, about 8 months ago…when I decided I was ready to start a family.

Step 4: ASSIST (cont’d)

Pharmacist

Do you remember why you returned to smoking at that time?

Patient

Well, I never really quit that time. I tried to quit cold turkey…didn’t last very long. I guess I didn’t have a big enough reason to quit. But now I do.

;

So it sounds like the main reason you want to quit is because you’re pregnant. Any other reasons?

Patient

It’s bad for me. And I certainly don’t want to smoke around my baby.

;

How do you feel about your chances of quitting for good this time?

Patient

I’m determined. But I know it’ll be hard, because I like smoking. I’ve thought about using the nicotine patch or some other drug…but I don’t know if I should do that while I’m pregnant.

Pharmacist

Well, you’ve already had some success, in being able to cut down on your smoking since finding out that you are pregnant. That’s a big step in the right direction!

;

Pharmacist

Have you spoken with your family or friends about your quitting?

Step 4: ASSIST (cont’d)

Patient

My family knows I’m pregnant. Everyone’s encouraging me to quit. My husband smokes a little, but not every day. He smokes cigars and cigarettes with friends, sometimes. I haven’t told my friends I’m pregnant, yet. I want to wait ‘til I’m into my second trimester.

;

I usually discuss concerns about weight gain at this point, but because you’re pregnant we know that weight gain is inevitable. During this time it is very important for you to eat a healthy diet and follow an exercise plan recommended by your doctor. Do you have any concerns about this?

Patient

Well, I’m trying hard to eat healthier. My doctor talked to me about the types of food I should be eating.

;

Are there any specific situations that might make it more difficult for you to quit? Any routines that you have when you typically smoke?

Patient

I always smoke in the morning, with my first cup of coffee. And after meals. And almost always when I’m driving.

;

Step 4: ASSIST (cont’d)

Patient

I want to quit; the sooner the better. I don’t want to be smoking too far into my pregnancy. But I don’t think I can do it cold turkey. It didn’t work the last time. Can you tell me more about how I could taper my use?

Pharmacist

Well, there is a nondrug product called QuitKey. It costs about $40. It’s a small, hand-held computer device that “schedules” your smoking for you. It tapers your smoking over time in a way that helps to minimize withdrawal effects. It takes a few weeks to taper down to zero cigarettes a day. Although this may be longer than you’d like, it’s better than not quitting at all! What’s important is that we choose the best method we can to ensure success. Does this sound like a reasonable way for you to quit?

Patient

OK. It sounds like a great idea, but is it hard to use?

Pharmacist

No, it’s very simple, and I’ll be happy to help you get started. The instruction manual is user friendly and if you need it, there’s a toll-free support service to call if you have any questions. I also like the fact that a QuitKey unit has been developed especially for pregnant women.

Patient

Wow…sounds great.

The pharmacist should describe use of the QuitKey unit and give an appropriate demonstration.

Pharmacist

We’ll also need to work hard on preparing your environment to make it conducive to quitting; getting support from your friends and family; and preparing you, mentally, to be ready to quit for good.

Step 4: ASSIST (cont’d)

;

First, let’s talk about some methods that will help you with situations when you typically smoke. The idea here is to disrupt, or change, the routines that you normally associate with smoking.

Behavioral Coping Strategies:

In morning with coffee:

ƒ Change the order of your morning routine. If you usually have your coffee before you shower, shower first.

ƒ Change what you do. Listen to the radio instead of the television. Eat a smaller breakfast, or try new breakfast foods.

ƒ Change where you do things. Read the paper in a different part of the house. Get dressed in a different room.

ƒ Try drinking fruit juice, decaffeinated tea, or a different flavored coffee for a few weeks (e.g., a decaffeinated nonfat latte or cappuccino). Also, instead of sitting at the table and reading the paper with your coffee, use the time to go for a short, brisk walk before you shower. This also will help you to combat excessive weight gain, plus it’s healthy, and the fresh air will help you to wake up.

After meals:

ƒ Consider sitting at a different side of the dinner table. Or eat in a different room of the house.

ƒ Get up from the table as soon as you finish your meal, and do something that occupies your mind and your hands…this could be as simple as doing dishes or other household chores. Some people like to leave the house and go for a walk, surf the Web, or call a friend who is supportive of their quitting and give him or her a progress report.

In the car:

ƒ Remove cigarettes from your car, and clean out the ashtrays. Consider having the interior detailed to remove tobacco smell.

ƒ If you feel the urge to smoke, take a deep breath instead. Do some self-massage; this has been shown in a research study to reduce the cravings to smoke.

ƒ Listen to a talk radio station or a book-on-tape to keep your mind occupied.

ƒ Keep a bottle of water, a pack of gum, or hard candies in the car.

Step 4: ASSIST (cont’d)

Pharmacist

We also need to discuss how to prepare your environment for quitting.

ƒ The night before you are ready to quit, remove all cigarettes from your home, your car, and your workplace. When you discard them, tell yourself (out loud) that you no longer want to be a smoker.

ƒ Get rid of ashtrays…you will not need them anymore!

ƒ Tell your friends, family, and co-workers that you have decided to quit smoking for good. Ask for their support. Tell them to be patient with you if you are irritable or seem distracted. You do not need to tell them that you are doing this because you are pregnant, if you don’t want others to know about the pregnancy yet.

ƒ Ask your husband to quit with you. If he chooses not to quit at this time, then ask him not to smoke around you and to make sure that all tobacco is removed from the house and his car. If he chooses to quit, and if he needs some assistance or guidance in choosing a medication, have him call me.

Cognitive Coping Strategies:

ƒ As soon as you get up in the morning, look in the mirror and say to yourself, “I’m doing the best thing that I can for me and my baby by quitting smoking.” Then, at night do the same thing but say out loud, “I’m proud that I made it through another day without smoking.”

ƒ Visualize yourself sitting at a table after a wonderful meal with friends. See yourself laughing, having a great time, and really enjoying the taste of the food, all without a cigarette. Do this several times a day. Make the scene as clear and vivid as you can.

;

The last step is to set a firm quit date. With the QuitKey program you’ll start reducing the number of cigarettes you smoke 1 week after you start using the unit. This will give you a few days to prepare yourself, your environment, and others for the big day. Some of my patients write the quit date on note paper and stick them throughout the house—on the bathroom mirror, for example, so they see it first thing in the morning; and on the refrigerator, front door, and dashboard of the car. When would you like to start?

Patient

I want to start tomorrow.

Step 4: ASSIST (cont’d)

;

Sounds like a plan! Over the next week, while you’re beginning your program, I’d also like you to complete a Tobacco Use Log. This is a simple task that will help you to understand your smoking behavior, which will help you while quitting.

The pharmacist should give the patient a copy of the Tobacco Use Log and explain how to use it.

Pharmacist

I want to remind you that quitting smoking is a process—it may take months until you feel that you are free from tobacco. I will help you through the quitting process. And we should work together, to be sure that you don’t go back to smoking after you have your baby.

Step 5: ARRANGE

Congratulations on making a difficult, but important, decision that will improve your health and protect your baby’s health! I’d like to meet with you a day or two before you start the tapering portion of the QuitKey program. I’d also like you to bring your husband. We’ll review your Tobacco Use Logs and talk about the withdrawal symptoms you can expect and how to cope with them. We also can review the situations that might cause you trouble. In the meantime, please call me if you have any questions.

The pharmacist should obtain the patient’s contact information.