STAGE: Ready to Quit

STAGE: Ready to Quit

Ms. Crosby is a 32-year-old woman who recently began attending a worksite group program for smoking cessation. Her group has set a quit date for one week from today, and she would like to purchase a nonprescription medication to assist with her quit attempt. She has asked for your advice.

KEY POINTS

THIS PATIENT

ƒ smokes one pack (20 cigarettes) per day

ƒ is currently participating in a worksite group program for smoking cessation

ƒ chooses to use the nicotine gum

THE PHARMACIST

ƒ congratulates the patient for deciding to quit

ƒ provides counseling for proper use of the nicotine gum

ƒ encourages the patient to continue her participation in the group program

ƒ arranges additional follow-up medication counseling

Step 1: ASK

Not applicable. The patient has approached the pharmacist for assistance.

Step 2: ADVISE

Not applicable. The patient has approached the pharmacist for assistance.

Step 3: ASSESS

Not applicable. The patient has informed the pharmacist that her quit date is set for one week from today.

Step 4: ASSIST

;

That’s terrific that you’ve decided to quit! And I’d be happy to help you choose an appropriate

medication for quitting. We have three nonprescription options – the nicotine gum, lozenge, and patch.

Each of these approximately double patients’ chances of quitting, and chances for success are increased even further for patients who get behavioral counseling, such as with your group program.

Just a few questions first. Have you ever tried to quit before, and how much do you currently smoke?

Patient

No, this is my first time. But I’ve been smoking for more than 10 years now. About a pack a day.

Pharmacist

Have you had any changes in your level of smoking recently?

Step 4: ASSIST (cont’d)

;

And tell me how your group program is going – are you feeling like you are getting sufficient support?

Patient

I like the facilitator – she’s been terrific. Very encouraging.

;

And how is your confidence…are you feeling good about your ability to stay off of cigarettes after your quit date?

Patient

I guess I feel pretty confident. Time will tell!

;

And do you have any initial thoughts about which of the three medications you’d like to use? A benefit of the patch is that you apply it only once a day. The gum and lozenge require frequent dosing throughout the day, but unlike the patch, you are able to titrate the dose a bit, depending on how much nicotine you feel that you need. It really is just a matter of preference.

Patient

I was thinking that I’d try the gum – I tasted my friend’s once, that FreshMint flavor.

Pharmacist

That’s an excellent choice.

Pharmacist

Given that you are smoking about 20 cigarettes per day, we’ll start you on the 2mg gum. During the first 6 weeks, you’ll chew one piece every 1-2 hours; during weeks 7-9, you’ll decrease to one piece every 2-4 hours, and during weeks 10-12, you’ll decrease further, to one piece every 4-8 hours. During any 24 hour period, be sure not to use more than 24 pieces.

The chewing technique is different than normal chewing gum. You’ll want to chew each piece slowly.

After about 15-30 chews, you’ll get a minty taste and tingling sensation. This is your sign that the nicotine is being released from the gum, and you should then “park” the gum in an undisturbed area of your mouth. Once the tingling has faded, you should chew again until the tingling returns. Park the gum again, in a different area of your mouth. You’ll continue to do this until the tingling does not return upon chewing. This means that the nicotine is depleted. Generally, a single piece of gum is good for about 30 minutes.

Patient

That sounds reasonable.

Pharmacist

Once you start your treatment with the gum, it’s important that you not smoke or use any form of tobacco. Also, be sure to dose it according to the recommended schedule, because if you wait until you feel that you need a piece, it will be too late. The nicotine in medications is absorbed much more slowly than the nicotine in cigarettes, so it’s important to keep the drug ‘on board’ at all times. Also, because it’s absorbed in the mouth, you’ll want to be sure not to eat or drink anything acidic at least 15 minutes before or while using the gum.

And if you drink caffeinated beverages, you’ll want to cut your consumption in about half, and try not to drink caffeine after 12 noon. When you quit smoking, your metabolism of caffeine will decrease substantially. Here’s a handout describing many of the withdrawal symptoms that are associated with quitting, and some methods for trying to alleviate them. If you are having severe withdrawal, please let me know and we might consider adjusting your dose. Generally, most of these symptoms peak within just a few days and subside over 2 to 4 weeks.

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

Step 4: ASSIST (cont’d)

;

I know that you are getting behavioral support through your group program, and I encourage you to continue attending the group meetings. If you need any further assistance – with your medications or otherwise – please let me know. I’m happy to help throughout your quit attempt.

Step 5: ARRANGE

Pharmacist

Let’s touch base again in about 6 weeks, so we can evaluate the next step of your nicotine gum regimen. Here’s my business card.