STAGE: Ready to Quit

STAGE: Ready to Quit

You are an ob/gyn clinician, and you are seeing Ms. LeClair, a 24- year-old woman who recently found out that she is pregnant. When you inquire about her use of tobacco, she tells you that she is a cigarette smoker and would like advice on how she might quit. She has no medical problems.

KEY POINTS

THIS PATIENT

ƒ is pregnant and is ready to quit

ƒ contemplates options of quitting cold turkey or using the QuitKey computerized gradual reduction method; opts to use the QuitKey method

THE CLINICIAN

ƒ reviews the patient’s previous quit attempt, motivation, and confidence in her ability to quit

ƒ discusses strategies to manage automatic smoking associated with drinking coffee, driving, and the end of meals

ƒ reviews non-drug methods for quitting (cold turkey, gradual tapering); counsels the patient on the use of the QuitKey unit

ƒ reviews preparation for quit attempt (home environment, social support system)

ƒ praises the patient for deciding to quit and arranges follow-up

smoking.

Step 2: ADVISE

This patient has indicated that she wants to quit. The physician should commend her on this decision and emphasize the importance of quitting.

Step 3: ASSESS

Clinician

So, you are considering quitting—would you like to quit sometime within the next month?

Patient

I want to quit as soon as possible—I don’t want to hurt my baby.

Clinician

OK, I’m going to ask you a few questions, so we can choose the most appropriate treatment for you.

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

Step 4: ASSIST

;

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

Patient Just cigarettes.

Step 4: ASSIST (cont’d)

Clinician

How many cigarettes per day do you usually smoke?

Patient

I smoke maybe 15 cigarettes per day…not quite a pack.

;

How long have you been smoking 15 cigarettes a day?

Patient

About 4 years. But since I found out I was pregnant, earlier this week, I started cutting down, to about ten a day or so.

Clinician

At what age did you begin smoking?

Patient

I started when I was 18, about 6 years ago.

Clinician

Have you ever seriously tried to quit before?

Patient

I tried to quit, once, about 8 months ago…when I decided I was ready to start a family.

Clinician

Why did you return to smoking?

Patient

I never really quit that time. I tried to quit cold turkey…didn’t last very long. I guess I didn’t have a big enough reason to quit. But now I do.

;

So it sounds like the main reason you want to quit is because you’re pregnant. Any other reasons why you might want to quit?

Patient

Well, I know smoking is bad for me. And I certainly don’t want to smoke around my baby, because I heard it causes breathing problems.

;

How do you feel about your chances of quitting for good this time? How difficult do you think it will be for you?

Patient

I’m determined to quit. But I know it’ll be hard, because I like smoking. I’ve thought about using the nicotine patch or some other drug…but I don’t know if I should do that while I’m pregnant.

Clinician

Well you have already experienced some success, in being able to cut back on your smoking since finding out that you are pregnant. That is a big step in the right direction. We’ll talk about nicotine patch a little later.

;

Have you spoken with your family or friends about your quitting?

Step 4: ASSIST (cont’d)

Patient

My family knows I’m pregnant. Everyone’s encouraging me to quit smoking. My husband smokes a little, but not every day. He smokes cigars and cigarettes with friends, sometimes. I haven’t told my friends I’m pregnant, yet. I want to wait ‘til I’m into the second trimester.

;

I usually discuss concerns about weight gain at this point, but because you are pregnant we know that weight gain is inevitable. During this time it is very important for you to eat a healthy diet and follow an exercise plan, which we will outline for you. Do you have any concerns about this?

Patient

No. My sister gained 50 pounds when she had her first baby, and she’s already warned me about

“eating for two.” I’m trying hard to eat healthy right now.

;

I’d like to give you an information sheet that describes the different withdrawal symptoms that can occur while quitting. It also explains the duration of the symptoms and what you can do to help alleviate the symptoms, should they occur. You mentioned using the nicotine patch, but because you’re pregnant, it’s best not to use medications to assist with the symptoms, so we’ll want to go with the strategies listed in the information sheet.

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

;

For some people, stress can be a powerful trigger to smoke. Do you think that job stress, the stress of being pregnant, or other situations might make it harder for you to quit?

Patient

It’s hard for me to predict if I’ll have a harder time quitting, now that I’m under more stress from the pregnancy. I’m a nurse, though, and I tend not to smoke while I’m at work. I don’t want my patients to smell the smoke on me.

Clinician

Well, then let’s try to keep this in mind and see how it goes. If you feel that stress is making you want to go back to smoking, then please call me as soon as possible, so we can discuss it.

;

Are there any specific situations that might make it more difficult for you to quit? Any routines that you have, such as smoking after meals, with coffee, or when you’re in the car?

Patient

I usually smoke in the morning, with my first cup of coffee. I also like to smoke after meals, particularly after work. And I almost always smoke while driving.

;

There are several different methods of quitting, but because you’re pregnant, it’s best not to use medications to help you quit. Two options are to quit cold turkey or to try to taper your smoking over time.

Patient

I want to quit; the sooner the better. I don’t want to be smoking too far into my pregnancy. But I don’t think I can do it cold turkey. It didn’t work the last time. Can you tell me more about how I could taper my use?

Step 4: ASSIST (cont’d)

Clinician

True, you want to be able to quit as soon as possible to minimize risk to the baby. But it’s most important that you do quit, successfully. There is a nondrug product called QuitKey, which costs about

$40. It’s a small, hand-held computer device that “schedules” your smoking for you. It tapers your smoking over time in a way that helps to minimize withdrawal effects. It takes about 4–5 weeks to taper down to zero cigarettes a day. Although this may be longer than you’d like, it’s better than not quitting at all! What’s important is that we choose the best method we can to ensure success. Does this sound like a reasonable way for you to quit?

Patient

OK. It sounds like a great idea, but is this device complicated or difficult to use?

Clinician

No, it’s very simple to use, and I’ll be happy to help you get started. The instruction manual is very user friendly, and if you need it, there is a toll-free hotline support service to call if you do have any questions. I also like the fact that a QuitKey unit has been developed especially for pregnant women.

Patient

Wow…sounds like the perfect method for me.

Clinician

OK, we’ll get you set up with one of the units.

The physician should describe use of the QuitKey unit and give an appropriate demonstration.

Clinician

We’ll also need to work hard on preparing your environment to make it conducive to quitting; getting support from your friends and family; and preparing you, mentally, to be ready to quit for good.

;

First, let’s talk about some methods that will help you with situations when you typically smoke. The idea here is to disrupt, or change, the routines that you normally associate with smoking.

In morning with coffee:

ƒ As soon as you get up each day, remind yourself that you are a nonsmoker. You can make it 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 drinking fruit juice, decaffeinated tea, or a different flavored coffee for a few weeks (e.g., a decaffeinated nonfat latte or cappuccino). Also, 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 excessive weight gain, plus it’s healthy, and the fresh air will help you to wake up.

In the car:

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

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

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

ƒ Keep a bottle of water, a pack of gum, or hard candies in the car.

After meals:

ƒ Before you sit down to eat, remind yourself that you will not smoke after the meal.

ƒ Get up from the table as soon as you finish your meal, and do something that occupies your mind and your hands…this could be as simple as doing dishes or other household chores. Some people like to leave the house and go for a walk, surf the Web, or call a friend who is supportive of their quitting and give him or her a progress report.

What’s important is that you alter your routine and try to keep your mind off of smoking. Do you have any ideas for how you might do this?

At this point the physician should explore options with the patient.

Step 4: ASSIST (cont’d)

Clinician

Next, let’s talk about how to prepare your environment for quitting.

ƒ The night before you are ready to quit, remove all cigarettes from your home, your car, and your workplace. When you discard them, tell yourself (out loud) that you no longer want to be a smoker.

ƒ Get rid of ashtrays…you will not need them anymore!

ƒ Tell your friends, family, and co-workers that you have decided to quit smoking for good. Ask for their support. Tell them to be patient with you if you are irritable or seem distracted. You do not need to tell them that you are doing this because you are pregnant, if you don’t want others to know about the pregnancy yet.

ƒ Ask your husband to quit with you. If he chooses not to quit at this time, then ask him not to smoke around you and to make sure that all tobacco is removed from the house and his car. If he chooses to quit, and if he needs some assistance or guidance in choosing a medication, have him call me.

;

The last step is to set a firm quit date…sometime within the next 2 weeks. With the QuitKey program your quit date is 1 week after you start using the unit. This will give you a couple of days to prepare yourself, your environment, and others for the big day. Some of my patients write the quit date on note paper and stick them throughout the house—on the bathroom mirror, for example, so they see it first thing in the morning, and on the refrigerator, the front door, and the dashboard of the car. When would you like to quit?

Patient

Let’s shoot for a week from now. I’ll start using the QuitKey computer tomorrow.

;

OK, that sounds like an excellent plan. I want to remind you that quitting smoking is a process—it may take weeks or months until you feel that you are free from tobacco. I want to help you through the quitting process. And we should work together, to be sure that you don’t go back to smoking after you have your baby.

Step 5: ARRANGE

Clinician

Congratulations on making a difficult, but important, decision that definitely will improve your health and protect your baby’s health! The next time you come in for an appointment, I’d like you to bring your husband so we can talk about how he can help you quit, and maybe even quit smoking himself. We also can review the situations that might cause you trouble. In the meantime, please call me if you have any questions.