STAGE: Not Ready to Quit
Ms. Liska, a 35-year-old mother of a child with asthma, asks for your help in quitting smoking. Her daughter's pediatrician told her she needs to quit smoking and suggested she come to your pharmacy for help.
KEY POINTS
THIS PATIENT
was told by her daughter’s physician to quit smoking because it exacerbates her child's asthma
approached the pharmacist for assistance
recognizes the need to quit but is not ready THE PHARMACIST
reinforces the physician's recommendation to quit smoking
asks the patient about tobacco use, reasons for quitting, and confidence in quitting
provides general information about new pharmacologic aids for cessation but defers the decision to select methods for quitting until later, when the patient is ready to quit
offers to assist the patient, should she decide to quit
Rev 07.08.06 CASE 22 Page 1 of 6
Step 1: ASK
Not applicable. The patient approached the pharmacist for information about quitting.
The children of parents who smoke have an increased frequency of asthma, bronchitis, pneumonia, ear infections, and other respiratory illnesses compared with the children of nonsmoking parents and are more likely to be hospitalized with these conditions. Pharmacists should routinely ask parents of children with asthma or other respiratory diseases whether the children are exposed to tobacco smoke.
Step 2: ADVISE
This patient has indicated that she wants to quit. The pharmacist should commend her on this decision and emphasize the importance of quitting.
Pharmacist
Ms. Liska, your daughter’s medications are ready.
Patient
Great. I also need to talk with you about quitting smoking. Dr. Vera read me the riot act this morning about my smoking. She said you would be able to help me.
Pharmacist
I’ve worked with many of Dr. Vera’s patients who were trying to quit tobacco. I'm pleased that you’re thinking seriously about quitting. This is a difficult decision but an important one.
Step 3: ASSESS
Pharmacist
I would be happy to help you quit smoking. Are you considering trying to quit in the next month?
Patient
Well, I’m not ready to quit just yet. I’ve got too many other things on my plate at the moment. I’d like to quit after this semester of school is over. I’m training to become a dental hygienist.
Although this patient approached the pharmacist for assistance, she is not yet ready to quit in the next month. Thus, prescribing a treatment plan would be inappropriate.
Rev 07.08.06 CASE 22 Page 3 of 6
Step 4: ASSIST
; Assess tobacco use history: current use Pharmacist
Are you currently smoking cigarettes only, or do you also smoke cigars or use other types of tobacco?
Patient
I only smoke cigarettes.
Pharmacist
How many cigarettes per day do you currently smoke?
Patient
On average, I smoke a pack a day. During final exams I sometimes get up two packs a day.
; Assess tobacco use history: past use Pharmacist
How long have you been smoking a pack a day?
Patient
Gosh…I’ve smoked that much for about 15 years now, ever since I was a senior in high school.
Pharmacist
Have you ever seriously tried to quit before?
Patient
Umm…I’ve tried to quit twice. Both times I was pregnant.
Pharmacist
When did you last try to quit?
Step 4: ASSIST (cont’d)
Patient
The first time I tried to quit was about 7 years ago, when I was pregnant with my daughter. More recently…I tried to quit about 3 years ago, during my second pregnancy.
Pharmacist
How long were you off cigarettes?
Patient
With my daughter, I didn’t have any cigarettes for 4 months. During my first and second trimesters I gradually cut back my use. By the third trimester I was smoke-free. But I started smoking a month after giving birth.
During my second pregnancy I had cut down to half a pack a day, but then I miscarried in the first trimester.
Pharmacist
I’m sorry about your miscarriage. Why do you think you relapsed?
Patient
I wasn’t really prepared for the stress of having a new baby. She cried a lot, and I didn’t get much sleep. It got to be too much to handle. I had a cigarette one night, to try to calm myself down. Of course, I planned to have just one cigarette…but one became two…and before I knew it, I was back to smoking again.
Then, after the miscarriage, I was so depressed…I jumped right back up to smoking a pack a day.
Pharmacist
What methods did you use to quit smoking during your pregnancies?
Patient
I quit, before, by tapering to five cigarettes a day…then going cold turkey.
Rev 07.08.06 CASE 22 Page 5 of 6
Step 4: ASSIST (cont’d)
; Discuss key issues: reasons/motivation for wanting to quit Pharmacist
It sounds like your primary reason for wanting to quit smoking is your daughter's health? Are there any other reasons why you might want to quit?
Patient
My mom’s a smoker. She has a chronic cough and lots of wrinkles on her face. I don’t want that happening to me.
I’m also in school, training to be a dental hygienist. I’m embarrassed to be a smoker. I don’t want my patients to smell the cigarette smoke on my clothes. Besides, I know it’s unhealthy. Problem is… I’m afraid I’m hooked.
; Discuss key issues: confidence in ability to quit Pharmacist
You were able to quit for several months before. Do you think you can do it again?
Patient
Eventually, I’ll quit. It’s just that right now I’ve got enough on my mind…juggling the responsibilities of family and school.
Not all psychosocial issues are addressed in this counseling session (most would be addressed when the patient is ready to quit). However, the pharmacist can gain sufficient insight into the patient's situation to make some general recommendations (see below, under Arrange).
Step 5: ARRANGE
Pharmacist
I know you don’t have immediate plans to quit smoking, but I’m encouraged that you’re giving some thought to it. The fact that you were able to quit for 4 months indicates that you can quit. Women who quit smoking during their pregnancy are at high risk for relapse after giving birth. This is a very stressful time period, and many women who were able to quit smoking while pregnant start smoking again when faced with the additional responsibilities of a new baby.
When you previously quit you didn’t use any medications to help with the withdrawal symptoms. You probably already know about the nicotine gum, patch, and lozenge that are available without a prescription. There are also several other medications available with a prescription that may be appropriate for you.
But, only you can decide when you’re ready to quit. I'd like to remind you that if you continue to smoke, your daughter's asthma may become worse and require more medications (including higher steroid dosages) to keep it under control. Cigarette smoke is one of the strongest triggers for asthma attacks.
Even if your daughter's asthma appears to be in control, constant exposure to cigarette smoke causes her lungs to be inflamed and more susceptible to other asthma triggers (e.g., colds, exercise, and allergies). Your quitting smoking is an important aspect of her asthma treatment. Plus, it's important for your health as well.
Patient
Oh, I don’t smoke around my daughter. I only smoke outside, when I’m at home.
Pharmacist
It's good that you don't smoke inside the house, but keep in mind that the cigarette smoke is in your clothes, hair, and car. Even these small exposures can be very irritating to an asthmatic's lungs. The best recommendation is to quit smoking entirely.
But before you attempt to quit, it’s important for you to be ready. Dr. Vera has told you to quit, and I think that’s an excellent recommendation. You've suggested you might be able to quit after this semester is over. Why don't you give me a call about a month before then? Or if you'd like, I can make a note to call you instead. In the meantime, try to spend some time thinking about the reasons why you want to continue being a smoker but also ask yourself, “What is the worst thing that would happen to me, if I had to quit tomorrow?” This might help you to make your decision. When you’re ready, I’ll work with you to design the most effective treatment plan that we can.
