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, which was transferred from her prior physician’s office, 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 in the preparation stage for quitting

ƒ previously failed trying to quit when using the nicotine gum

THE CLINICIAN

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

ƒ assesses psychological and other factors

associated with the patient’s ability to quit; assists the patient with appropriate coping mechanisms

ƒ counsels the patient on appropriate use of the nicotine patch and

ƒ arranges follow-up counseling

problems, including myocardial infarction, heart failure, and stroke. Smoking can accelerate and worsen these conditions. Clinicians 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 tobacco dependence 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.

Clinician

Ms. Warner, I see that your blood pressure has been elevated for quite a while. Please tell me how you are taking your blood pressure medication.

Patient

I take one blood pressure pill every morning, with a glass of orange juice.

Clinician

And do you smoke cigarettes or use any other form of tobacco?

Patient

I smoke cigarettes.

Step 2: ADVISE

Clinician

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

Clinician

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.

Clinician

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 best method?

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

Step 4: ASSIST

;

Well, there are many different methods—and we can try to pick the one best suited for 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.

Clinician

How long have you been smoking?

Patient

About 25 years now.

Clinician

Have you ever tried to quit?

Patient

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

Clinician

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.

Step 4: ASSIST (cont’d)

Clinician

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. I chewed 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.

Clinician

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

Patient

The gum reduced my cravings a little, but I’d never use it again. I threw out half of a starter pack.

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.

Clinician

It sounds like the gum is out of the question for you. The taste of the gum was so bad you were only about to tolerate one fourth to one half of the recommended dose. That’s a common complaint, although there are new flavors available. Do you think you will need some form of nicotine replacement to help you quit?

Patient

I’d like something to help with the cravings.

Clinician

Okay, there are other options besides nicotine gum. We can talk about those a little later. I have a few more questions.

;

First…it seems like you are 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 5 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?

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.

;

You said you have two children at home. Do you have any other family members or friends who can assist or support you during this time period?

Patient

I’m divorced and haven’t met many people outside of work since we moved. Being in a new place will actually help, because my old friends and co-workers were all big smokers. My children have wanted me to quit for years.

Step 4: ASSIST (cont’d)

;

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?

Clinician

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.

;

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

Also, using a form of nicotine as your therapy, such as the nicotine patch, nasal spray, or inhaler, will help with cravings quite a bit.

The clinician should give the patient the Withdrawal Symptoms Information Sheet.

Patient

Yes, I’ve read and seen TV commercials about the nicotine patch. I think the patch might help.

;

Do you find you smoke when you’re stressed?

Patient

No…I mostly smoke because I enjoy it. Usually not because I’m stressed.

;

Are there certain situations when you’re more likely to smoke than others? For example, are there any routines that you associate with smoking?

Patient

Well, I smoke in the morning with coffee, while driving, and while talking on the phone. I used to smoke in bars and restaurants with friends, but not anymore.

;

Let’s review the different methods you can use to stop smoking. You’ve already expressed interest in using the nicotine patch to help with your cravings for cigarettes. I think this is a good idea. There are also prescription nicotine replacement products available. These include the nasal spray and 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 approximately double your chances of quitting.

Nicotine replacement products help many of my patients deal with the symptoms of nicotine withdrawal while they implement changes in their lifestyle to become nonsmokers. We’ll also need to talk about coping techniques to help you handle situations where you may be tempted to smoke. This includes anticipating situations that trigger your smoking and developing strategies to avoid these situations or substitute different behaviors for smoking.

Any of the nicotine replacement products or Zyban would be reasonable for you to consider. Does any one particularly appeal to you?

Step 4: ASSIST (cont’d)

Patient

I guess I’m leaning toward the patch. I kind of like the idea of once-a-day dosing and the fact that the patch can lessen the withdrawal symptoms.

;

Let’s develop some strategies to deal with situations that you associate with smoking. I’m going to suggest a few alternatives to smoking for you.

While talking on the phone:

ƒ Speak while standing instead of sitting.

ƒ Substitute gum, toothpicks, swizzle sticks, or straws for cigarettes.

ƒ Doodle to keep your hands occupied.

ƒ Use a timer to limit the length of your telephone calls.

While driving:

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

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

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

In morning, while drinking coffee:

ƒ As soon as you get up each day, remind yourself that you are a nonsmoker. You can go through another day without cigarettes.

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 changing your brand of coffee, or drink a different flavored coffee for a few weeks (e.g., nonfat latte or cappuccino).

ƒ Try drinking tea or fruit juice instead of coffee.

ƒ 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 weight gain, plus it’s healthy, and the fresh air will help you to wake up.

;

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. I just hope I won’t be too cranky that day.

Clinician

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

On the night before your quit date, throw away all cigarettes and ashtrays. You might also consider removing any high-fat, high-calorie snacks that you’d be tempted to eat while you are quitting. Restock your kitchen with low-calorie foods: vegetables (e.g., carrots, celery, frozen peas), fruits (e.g., apples, oranges, strawberries), sugarless gum, and hard candies.

;

Before you actually quit smoking for good, I would like you to keep a diary of your current smoking patterns using a Tobacco Use Log. This will help us to 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 6 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.

Step 4: ASSIST (cont’d)

Clinician

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 the Tobacco Use Log. At that time we’ll develop some coping strategies to help you overcome the temptation to use tobacco.

After you have 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.

;

You said that in the past you had difficulty quitting because you were craving cigarettes and were hungry all the time. Although the nicotine patch should help with the cravings, you might experience these symptoms again. I’d like you to call me if you experience troublesome withdrawal symptoms while on the nicotine patch.

;

The following information is for discussion at the follow-up session, just prior to quitting.

(Note: The products indicated by an asterisk are recommended to be tapered in the following manner: 14 mg for 2 weeks, then 7 mg for 2 weeks.)

Clinician

Let’s discuss the use of the nicotine patch. I know you’ve used nicotine gum in the past, and the principles with the patch are the same. The only difference is the nicotine patch provides a steady, controlled amount of nicotine throughout the day to reduce withdrawal symptoms and cravings for cigarettes.

Given that you smoke half to a full pack per day, I would start with (select one):

* Nicoderm CQ Step 1 (21 mg) patch daily for 6 weeks (worn 16 or 24 hours/day) Generic nicotine patch (21 mg) patch daily for 4 weeks (worn 16 or 24 hours/day)

Some information that you’ll need to know about the patch:

ƒ Rotate application sites (do not use same site for at least 1 week).

ƒ Do not smoke while wearing the patch.

ƒ If the patch falls off, put on a new one, in a different skin area.

ƒ Water (showering, bathing, swimming) will not affect the patch if applied correctly.

ƒ Normal side effects include mild itching, burning, or tingling in the first hour.

ƒ Skin may appear red after removing the patch, but this should subside during the day.

ƒ If skin becomes swollen or a rash appears, do not put on a new patch. This may be a reaction to the adhesive.

ƒ It’s important to follow the dosing instructions exactly, and to stay on the therapy for the entire course of treatment—even when you think you may be OK without using a patch. This will increase your likelihood of quitting.

;

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. As part of your routine care through this clinic, I’m going to help you with quitting.

Step 5: ARRANGE

Clinician

These next few weeks are going to be a challenge, but remember this is something that you can do.

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. 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 patch. Is that date good for you?

Patient

Yes, that works for me. It’s best to page me because I’m not reliably in one place.

Clinician

Great. Do you have any other questions or concerns?

Patient

No, not that I can think of right now.

Clinician

OK, we will talk again on Wednesday.