STAGE: Ready to Quit

STAGE: Ready to Quit

You are a community pharmacist and have been approached by a 16-year-old girl, Nicole Green, who would like your advice on how she can quit smoking. She says, “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.”

KEY POINTS

THIS PATIENT

ƒ is ready to quit in the next 30 days

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

ƒ wants to quit but doesn’t know how

THE PHARMACIST

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 recommends use of Tobacco Use Log

ƒ schedules follow-up counseling

Step 2: ADVISE

Not applicable. The patient has asked the pharmacist for assistance with quitting.

Step 3: ASSESS

Pharmacist

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.

Pharmacist

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.

Step 4: ASSIST

;

What type of tobacco do you use, and how much?

Patient

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

Step 4: ASSIST (cont’d)

;

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.

Pharmacist

And have you ever seriously tried to quit before?

Patient

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

;

What I’m hearing is that you’re uncomfortable with the thought of being hooked on cigarettes. 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.

Pharmacist

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.

Pharmacist

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

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.

Pharmacist

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?

Step 4: ASSIST (cont’d)

Patient

Huh? Are you serious? I didn’t think I smoked that much. Of course I don’t want to gain any weight!!

Pharmacist

You don’t smoke much, so I wouldn’t expect much weight gain, if at all. Especially given that you are physically active, being on the swim team. But it’s something we’ll want to monitor.

;

Let’s talk about the reasons why you smoke. And the situations where you are most likely to smoke.

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 us to be more prepared for the quit attempt and will help you to succeed. I’d like you to spend the next several days filling out a Tobacco Use Log for me – if you can do this for a week, that would be great. But no fewer than 3 days. It will help us to learn more about the activities and situations that trigger your smoking.

When you’re using the log, you should continue to smoke normally. Don’t attempt to change your smoking. 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)

Pharmacist

After you’ve done this, I’d like to meet 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?

Pharmacist

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?

Pharmacist How old are you?

Patient Sixteen.

Step 5: ARRANGE

Pharmacist

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 call your doctor and ask for his or her guidance in helping to treat you. I think our best option will be to taper you off of cigarettes over a period of a few weeks.

Patient

OK. So do you want me to come back in here next week? What time?

Pharmacist

How about the same day, same time? And if you have any questions, please call me here at the pharmacy. Because your parents don’t know we’re working on this together, I won’t call your home.

Patient

Sounds great. See you next week. Thanks!