STAGE: Ready to Quit

STAGE: Ready to Quit

You are a clinician in a family practice group and are seeing 16-year- old Nicole Green, one of your existing patients. She has asthma and has come to the office today for her yearly physical examination.

KEY POINTS

THIS PATIENT

ƒ is ready to quit (in the preparation stage)

ƒ is a teenager who is beginning to feel like she is addicted to smoking

ƒ has asthma and is worried about her breathing

ƒ wants to quit but doesn’t know how

THE CLINICIAN

ƒ assesses the patient’s tobacco use history

ƒ discusses the patient’s reasons and motivation for wanting to quit, confidence in ability to quit, social support for quitting, concerns about weight gain, and routines and situations associated with smoking

ƒ schedules follow-up counseling

Step 1: ASK

Clinician

Well, Nicole, it’s good to see you again. How have you been doing?

Patient

I’ve been doing OK. I’ve been having a hard time breathing.

Clinician

Hmm. It’s not a peak allergy season for you yet…what kind of symptoms are you having?

Patient

Just some coughing in my chest. I don’t have a cold or anything. But I’ve been wanting to ask you—

but I’ve been kind of afraid to—because I know you’ll yell at me. I’ve been smoking, and I’m feeling like I need to quit. I never thought it would happen to me, but I’m hooked. The first thing I think about in the morning is how fast I can get out of the house so I can light up a cigarette. My parents don’t know, so please don’t say anything.

Step 2: ADVISE

Clinician

I won’t say anything to your parents. And, of course, I won’t yell at you. But I strongly encourage you to quit, especially given that you have asthma.

Step 3: ASSESS

Clinician

It sounds like you’re considering quitting. Any thoughts on when you might like to do this? In the next month, maybe?

Patient

Actually, I was thinking more about starting right away. I just don’t know how to do it.

Step 3: ASSESS (cont’d)

Clinician

That sounds good. Let’s spend some time talking about how to quit, then we’ll pick a quit date. I’m going to need to ask you a few questions first, so we can select the most appropriate treatment plan for you.

This patient is ready to quit (in the preparation stage).

Step 4: ASSIST

;

What type of tobacco are you using, and how much?

Patient

I smoke cigarettes—about half a pack a day now.

;

How long have you been smoking?

Patient

I had my first cigarette when I was in 7th grade. But I really didn’t start smoking much until last year, in 10th grade.

Clinician

And have you ever seriously tried to quit before?

Patient

No...I never thought I had a problem before. Until recently.

Step 4: ASSIST (cont’d)

;

What I’m hearing is that you’re uncomfortable with the thought of being hooked on cigarettes and you’re worried about your breathing. Is this correct, and are there any other reasons why you want to quit?

Patient

Yes. It scares me to think that I need to smoke. My mother smelled smoke on my clothes last week, and I told her I was around some smokers. That wasn’t really lying—I was around smokers! They would ground me for the rest of my life if they ever found out! Plus, I hate the way it makes me smell.

;

Sounds like you have a lot of great reasons to quit. How confident are you that you’ll be able to do it?

Patient

I have to quit. I just have to do it.

Clinician

Well, we can work together on this, to increase your chances of succeeding. The most important thing is that you’re committed to doing it. And it sounds like you are.

;

A key risk factor for smoking in teens is having close friends who smoke. It is imperative to address social support with all adolescent smokers who are interested in quitting.

Clinician

Tell me about your closest friends. Do they smoke too?

Step 4: ASSIST (cont’d)

Patient

One does, one doesn’t. My friend who smokes works with me at the movie theater and drives me to school every day. We usually smoke 2 or 3 cigarettes on the way to school, and at work we take our breaks together and usually smoke outside of the theater. The other one, who doesn’t smoke, has been harassing me to quit. We’re both on the swim team.

Clinician

So, do you think your friend who smokes would be supportive of your quitting, or maybe would consider quitting at the same time?

Patient

I don’t know…she’s kind of hard core. Her parents and her older brothers smoke too.

;

Are you concerned about weight gain as a result of quitting?

Patient

Huh? Are you serious? I never thought that I’d gain weight if I stopped smoking. Of course I don’t want to gain any weight!!

Clinician

Well, since you don’t smoke much, and because you are physically active on the swim team, I wouldn’t expect that you’d gain much weight, if at all. But it is a possibility. It’s something we’ll want to monitor.

;

Let’s talk about the reasons why you smoke and the situations in which you’re most likely to feel a need to smoke.

Step 4: ASSIST (cont’d)

Patient

Hmm…I never really thought about it. I just sort of smoke when I’m with my friend and in the mornings on the way to school.

;

OK. I think we need to do a little bit of work before you actually quit. This will help you to be more prepared for the quit attempt and will help you to succeed. I’d like you to spend the next 3 days filling out a Tobacco Use Log. This will help us to learn more about the activities and situations that trigger your smoking. Let me review the log with you now.

Continue to smoke normally for the next 3 days. Don’t attempt to reduce your smoking during this time. The goal is to learn more about your current smoking habits and patterns.

Use a separate log sheet each 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 light 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) Clinician

After you’ve done this, I’d like to talk with you again. We can review your log, and at that time we’ll help you to change your routines and develop some coping strategies to help you overcome temptations to smoke. Does this sound like a reasonable plan to you?

;

Yes, but what do I do about my friend who smokes? Should I try to stay away from her?

Step 4: ASSIST (cont’d)

Clinician

No, not yet. Just go about doing everything as normal. Be sure to make notes on your log describing how you feel in situations when you’re with her and you’re smoking. Think about how badly you want those cigarettes that you have while you’re on your break, and think about whether you could still take a break with her and not smoke. If you don’t feel strong about this, we might try to alter your routines to have you spend your breaks doing something else. But let’s not jump to that conclusion until you’ve spent some time thinking about it. The idea is not to have you lose your friends, but we might need to protect you from their smoking influence for a while until you’re feeling comfortable in your ability to resist smoking while you’re around them.

;

OK, I see where you’re coming from. What about that nicotine gum stuff? Can I use that?

Clinician

I don’t like to prescribe nicotine gum for my patients who are under 18, because it hasn’t been adequately tested in this age group. But, if you have a very difficult time quitting, despite giving it an honest effort, then we might consider it. I think our best option will be to taper you off of cigarettes over a period of a few weeks.

Step 5: ARRANGE

Patient

OK. So you want to talk in a few days? When?

Clinician

On your way out of the office today, schedule a time with Rhonda, my receptionist. Tell her I need her to schedule 15 minutes with you. She will give you my direct phone number, to my office, and we can talk at that time. And if you have any questions in the meantime, please call. Because your parents don’t know we’re working on this together, I won’t call your home.

Patient