STAGE: Ready to Quit

STAGE: Ready to Quit

About 2 weeks ago, you filled prescriptions for bupropion (Zyban) and the nicotine patch for Mr. Lynn, a 42-year-old patient in your community pharmacy. His physician has recommended that he use the patch in conjunction with bupropion to increase his chances of quitting. Today, Mr. Lynn and his wife have stopped by the pharmacy to ask you some questions about the patch, which you previously advised him to begin using on his quit date.

KEY POINTS

THIS PATIENT

ƒ has been on bupropion for 10 days and is ready to start using the nicotine patch

ƒ has strong social temptations to smoke

ƒ has a wife who is very supportive of his quitting

THE PHARMACIST

ƒ assesses the patient’s progress on bupropion and reviews his use of the nicotine patch

ƒ assesses the patient’s reasons and motivation for quitting, confidence in ability to quit, and routines and situations associated with tobacco use

ƒ discusses withdrawal symptoms and coping strategies

ƒ arranges follow-up counseling

Step 1: ASK

Not applicable. The pharmacist has been assisting the patient with quitting.

Step 2: ADVISE

Not applicable. The pharmacist has been assisting the patient with quitting.

Step 3: ASSESS

This patient has been on bupropion for 10 days and is ready to stop smoking and initiate the nicotine patch. Thus, he currently is ready to quit.

Step 4: ASSIST

;

Not applicable. This was done at a previous assessment. It is important to address the patient’s use of bupropion and his preparedness for stopping smoking.

;

Hi, Mr. Lynn. It’s good to see you again. Tell me, how are things going?

Patient

Seems to be going well. I’m ready for the patch now, right? You said I should use the pills for 10 days, then stop by to pick up the patch. Oh, and this is my wife, Helen. I wanted you to meet her because she’s my main reason for quitting.

Pharmacist

Very nice to meet you! I’m glad you came, because we’re going to need your help, too.

Step 4: ASSIST (cont’d)

Patient’s wife

I really appreciate you helping my husband.

Pharmacist

No problem. I’m happy he stopped by to ask for help. So, Mr. Lynn, you’ve been on Zyban for 10 days, and now it’s time for the patch. Last time, you said you were smoking 30 cigarettes a day, so we decided we’d start you on the 21 mg Nicoderm patch for 6 weeks. This is a patch that is typically worn around the clock.

Patient

Yeah, that’s what we talked about. You thought that if I have any trouble sleeping, because I’m taking Zyban too, I could take the patch off at bedtime. I haven’t had any trouble sleeping since I started taking Zyban, though.

Pharmacist

That’s good to know. Tell me how you are taking your Zyban.

Patient

Well I take one in the morning when I wake up, with my breakfast, and then I take one right after dinner.

Pharmacist

Perfect. Any problems? Any side effects?

Patient

No, not really. My mouth seems to be a little dry, but that’s all. I drink more water now. And I don’t seem to crave my cigarettes as badly. But that’s a good thing! Maybe it’s working already.

Pharmacist

Step 4: ASSIST (cont’d)

;

We set your quit date for tomorrow. How are you feeling about this? Any second thoughts, or are you feeling pretty confident?

Patient

I feel pretty good about it. I think this time will be different. Using two drugs, having Helen in on the plan, and having you to guide me—if I can’t do it this time, I guess I’ll never be able to do it!

;

Helen is your main reason for quitting. Any other reasons?

Patient

Yeah, Helen quit last year, and I hate that she’s not smoking and I still am. I don’t like her having to be around my smoke, I know it’s bad for her. But I also want to quit because I know that it’s bad for me.

I’m 42 now. It might already be too late.

Pharmacist

No, it’s not too late. You’d be surprised how many health benefits can occur with quitting, no matter what age you are. Within the first 3 months, your circulation will improve and your lung function should increase up to 30%! Also, your lungs will feel “healthier.” Less coughing. Less shortness of breath. And over time, you’ll decrease your chances for heart disease, stroke, and cancer.

Patient’s wife

That’s good. I’d like to keep him around for a while!

;

Pharmacist

I see that you have big-time support from your wife. Last time we talked, you said that you have a bunch of friends who smoke. Have you told them you’re quitting?

Step 4: ASSIST (cont’d)

Yes…I told them last week at our poker night. Most of them laughed and said, “Again?”

Pharmacist

But did they seem to be supportive?

Patient

I guess, but I kind of doubt they will give up smoking during poker night. Guess I’ll need to be extra strong those nights. Or not go at all. I hate to give it up, though.

Pharmacist

Our goal isn’t to make you give up your social life. But we might need to make a few changes, at least until you’re feeling strong about being a nonsmoker.

;

Other than your poker nights, are there any other specific times that you smoke?

Patient

I mostly smoke in the morning, with my coffee, and in the car to and from work. My office is smoke- free, so it’s harder to smoke while I’m at work.

;

Patient

I was really irritable. But I was in a different job then. Much more stressful. I’m hoping it won’t be as bad this time.

Step 4: ASSIST (cont’d)

;

I hope the combination of the Zyban and the patch will help decrease your withdrawal symptoms and cravings for cigarettes. But here’s an information sheet that describes the different withdrawal symptoms, how long they last, and ways to lessen them. Most patients find that these symptoms disappear within the first month. Cravings tend to last longer, but that’s because cravings are more

“mentally induced”…because you’re thinking about cigarettes…as opposed to being “physiologically induced,” when your body is going through chemical withdrawal from nicotine. Helen, he’s probably going to be a bit grumpy for a month or so. Do think you can help him with this?

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

Patient’s wife

Oh, I think I can manage. I’ll read over that sheet and see what I can do to help. And I’ll do my best to be patient and tolerant. I’ve only quit for a year myself—I know exactly what he’s going through.

;

Great. Now let’s do a bit of brainstorming together to see what we can do about those poker nights and other times when you are most likely to smoke.

Patient’s wife

I have an idea! What if we host it at our house for the next few weeks and ask everyone to smoke outside if they need to smoke? Roger and I have decided that, as of tomorrow, our house will be smoke-free.

Pharmacist

That’s a great idea. Roger, do you think it will work?

Patient

Well, I’m sure the guys won’t mind not having to harass their wives to let them host it. Plus, they love Helen’s cooking. That will be an incentive! I guess I can ask them. If Helen doesn’t mind, I surely don’t.

Step 4: ASSIST (cont’d)

Sounds good. I also recommend that you skip the first 3–4 weeks—just to be safe—before tempting yourself. After that, you’ll need to prepare yourself for the temptation to smoke when you’re around your friends. Think about how you will respond when they tease you, offer you cigarettes, or blow smoke in your face. Have a plan in advance, and you’ll be in a better position to handle these situations. If you don’t feel ready to deal with this, don’t go. Wait until you are ready.

Patient

Sounds reasonable.

Pharmacist

What about other situations in which you are likely to smoke—in the morning with coffee and in the car? Any ideas for how to deal with these?

The pharmacist should have the patient and his wife reflect on this and develop their own unique coping strategies. The pharmacist can help the patient to think about plans to change the way he thinks (cognitive strategies) and the things he does (behavioral strategies) in response to his temptations to smoke.

If the patient can’t think of coping strategies, the pharmacist could suggest the following:

Pharmacist

Behavioral Coping Strategies:

While driving:

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

ƒ Put a note in your car, on the dash, to remind you not to smoke.

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.

Step 4: ASSIST (cont’d)

In the morning, with coffee:

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 tea or a different flavored coffee for a few weeks (e.g., nonfat latte or cappuccino).

ƒ Try drinking tea or fruit juice instead of coffee. When you stop smoking, your metabolism of caffeine may change. It’s possible you’ll need less coffee now. A general recommendation is to decrease the consumption of caffeinated beverages once you’ve quit smoking (by half for example to avoid caffeine overload).

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.

While at work:

ƒ Let your co-workers know that you are quitting and that you will not be participating in smoke breaks with them anymore.

ƒ Instead of going outside to take a smoke break, spend a few minutes walking the stairs at work.

This will increase your circulation, burn a few calories, and also keep you away from the temptation to smoke.

ƒ Stand, stretch, and walk around the office. Visit some of your nonsmoking friends and tell them that you’re skipping your smoke break.

ƒ Drink plenty of water, all day long. And keep a pack of sugarless gum or hard candies in your desk.

Cognitive Coping Strategies:

ƒ As soon as you get up in the morning say to yourself, “It’s great to be a nonsmoker!”

ƒ Remind yourself throughout the day that your wife is there to help you if you need her.

ƒ When you have a thought about a cigarette, step back for a moment. Examine what you’re doing and feeling. Then decide what else you could do in that situation that would not be associated with smoking. By the time you do this, the urge should pass.

Step 4: ASSIST (cont’d)

;

Now…you’ll be stopping smoking tomorrow. That means that tonight you’ll have your last cigarette.

Tomorrow morning, you’ll put on your first patch. Put it on a hairless part of your upper body. Leave it on all day, and take it off when you get into bed at night. You’ll want to change application sites every day, to decrease the chances for skin irritation. If your skin appears a little red after you take off the patch, this is normal. But if it turns into more of a rash that doesn’t seem to go away within a day or two, then we should talk.

Patient

Oh, yeah…I nearly forgot to ask you…what if I need to shower? Do I take it off before my shower and then put it back on after I dry off?

Pharmacist

No. Just shower with it on—as long as you apply it correctly, there should be no problem. To apply it, just take it out of the wrapper and peel off half the backing. Try not to touch the sticky area with the nicotine, because if you get it in your eyes, it will sting! Then you just place the adhesive side on your skin, peel off the backing on the other side, and press firmly with the palm of your hand for about 10 seconds, being sure to get all of the edges attached securely.

I think I mentioned this last time, but just in case I didn’t, it’s important to know that as soon as you start using the patch, you can’t smoke anymore. Not even a puff! And you also can’t use any smokeless forms of tobacco—like chewing tobacco or snuff. It might give you too much nicotine and increase your chances for nicotine-related side effects. Any questions?

Patient

No, I don’t think so.

;

If you do decide that you have any questions, be sure to call me. My goal is to help you throughout your quit attempt, which might mean several months or even longer, until you are very comfortable in

Step 5: ARRANGE

Pharmacist

It sounds like you’re set. Tomorrow is the big day. If it’s OK with you, I’d like to call and check in with you in 2–3 days.

Patient Great!

Patient’s wife

Thank you so much. I feel really good about it working this time! We’ll keep you posted!