STAGE: Not Ready to Quit

STAGE: Not Ready to Quit

Mr. Cassell, 45 years old, has been a customer of your pharmacy for many years. Today (January 15th) he presents with a new

prescription for “Zyban 150mg b.i.d. for smoking cessation, #60.”

KEY POINTS

THIS PATIENT

ƒ presents at the pharmacy with a prescription for Zyban

ƒ has been coerced into quitting by his wife; he is not serious about quitting yet

ƒ is not ready to quit in the next 30 days

THE PHARMACIST

ƒ stages the patient’s readiness to quit

ƒ discusses the importance of being mentally ready to quit and of enlisting social support

ƒ briefly addresses psychosocial factors related to quitting

ƒ congratulates the patient on his interest in quitting

ƒ schedules follow-up counseling

Step 1: ASK

Not applicable. The pharmacist knows the patient is a tobacco user.

Step 2: ADVISE

Step 3: ASSESS

This patient has a prescription for Zyban. However, it is inappropriate to assume that patients who have a prescription for a cessation medication are ready to quit; their readiness to quit still must be determined.

Pharmacist

Mr. Cassell, I see you have a prescription for Zyban. Are you intending to quit smoking in the next month?

Patient

I’m gonna quit but not just yet. My wife’s been nagging me to quit, so when I saw my doctor for my usual check-up, he gave me this prescription. I was gonna get it filled so she’d quit nagging me about it.

Pharmacist

Are you intending to quit smoking in the next 6 months?

Patient

I’ll quit when tax season is over [4–5 months from now]—I’m an accountant.

This patient is not ready to quit in the next 30 days.

Pharmacist

Great, I’m pleased that you’re giving some serious thought to quitting! It sounds like you’d be ready to quit in about 4–5 months. Although that’s a ways off, there are some things that we can do now, to help us prepare for designing a course of therapy for you later. If you have a minute, I’d like to ask you a few questions.

Step 4: ASSIST

;

Are you currently smoking cigarettes only, or do you also smoke cigars or use other types of tobacco?

Patient

I smoke mostly cigarettes and a few cigars every now and then with my neighbor. About one every other week or so.

Pharmacist

How many cigarettes per day do you currently smoke?

Patient

I smoke about a pack a day—sometimes a little more, sometimes less. At tax time, I seem to smoke a lot more, about two packs a day.

;

How long have you been smoking about a pack a day?

Patient

Geez. I’ve been smoking that much for 25 years, I guess.

Pharmacist

At what age did you begin smoking?

Patient

I was about 20…maybe 19…when I started smoking. Somewhere around that.

Step 4: ASSIST (cont’d)

Pharmacist

Have you ever seriously tried to quit before?

Patient

I tried to quit once, about 8 years ago, when my uncle had a stroke.

Pharmacist

How long were you off of cigarettes?

Patient

I stayed off about 3 weeks, then I had a bunch of stress at work and went out with some co-workers to a bar and was drinking and ended up smoking a cigarette. After that I eventually ended up smoking a pack a day again.

Pharmacist

What methods did you use to quit smoking?

Patient

I used that nicotine gum. It was on prescription back then.

Pharmacist

How did you use the gum?

Patient

I chewed it only when I needed it—that stuff tasted terrible! But I hear they have new flavors now.

Pharmacist

Yes, they have orange and mint flavors now. My patients don’t seem to complain about the taste as much nowadays.

Step 4: ASSIST (cont’d)

;

So, it sounds like you want to quit smoking to stop your wife’s nagging. Are there other reasons why you’d like to quit?

Patient

Some of my friends have quit smoking. Plus, they made my workplace smoke-free, so it’s become harder to smoke at work. I know smoking isn’t good for me. I’m starting to cough more than I used to, and my allergies seem to have gotten worse. I don’t know if that’s caused by smoking, but who knows?

;

You tried to quit once before and were smoke-free for 3 weeks. Do you think you can do it again?

Patient

Yeah, eventually. I just need to be able to focus on it. I can’t try to quit smoking and have clients to deal with at the same time. I think that this summer I’ll be less busy and could deal with it.

;

Not applicable. The patient is not in the preparation or action stage. However, because has a prescription for Zyban, it is important to address this issue. Also, it would be helpful to recommend that he complete a Tobacco Use Log, which will at least partially engage him in the quitting process.

Pharmacist

I know you don’t have immediate plans to quit, but I’m encouraged that you’re giving thought to it. I’d like you to share these thoughts with your wife, and explain to her that you are not ready to quit right now but would like to quit after the tax season. Certainly she’ll understand this, and hopefully she’ll view your getting a written prescription as a step in the right direction. Your wife can be an important source of support when you quit. But I’d also like you to view me as a source of support for you.

Step 4: ASSIST (cont’d)

Pharmacist

You quit once before, and that shows that you’re able to do it. Your return to smoking could have been triggered by stress, but also you might not have been using the nicotine gum properly. With the gum, it’s best to chew it on a regular schedule to prevent cravings rather than only chewing the gum when you feel you need it.

There are many benefits of quitting. It’s very likely that your cough is related to smoking, and your allergy symptoms may improve if you quit. I think it’s also important for you to know that you’re at an age where if you quit smoking now, you can substantially decrease your chances of developing lung cancer, and other tobacco-related diseases, later. But only you can decide when you are ready to quit—not your doctor, and not your wife. If you are not psychologically ready to quit now, because of work or other stress, you most likely will not be successful. It’s better to try to quit when you are ready and when you think circumstances will improve your chances for success…such as after tax time.

Step 5: ARRANGE

Pharmacist

It’s important that you continue to think about quitting. I’d like you to spend some time thinking about why you keep smoking and ask yourself, “What is the worst thing that would happen to me if I had to quit tomorrow?” This might help you to feel more comfortable about your decision to quit.

In late May or early June I’d like to see you so we can get you set up with a Tobacco Use Log—this is a tool to help you better understand your smoking behavior, which then will help you with quitting. At that time we’ll also fill your prescription and discuss your treatment regimen. In the meantime, if it’s OK with you, I’d like to give your doctor a call to let him know that we’re going to postpone your quit attempt for a few months, until your work environment is less stressful.

Patient

That sounds OK with me…if you call my doctor. But tell him that I really do want to quit—just not yet.

Pharmacist

Will do. And I’ll make a note to call you toward the end of May. I’ll go ahead and enter the prescription into the computer, so you don’t have to keep up with it over the next few months, but we won’t fill it until you’re ready.