STAGE: Not Ready to Quit (Ready to cut back)

STAGE: Not Ready to Quit (Ready to cut back)

You have been approached by Mr. Faulk, a healthy young male, aged 28, who has applied to become a fireman and has a good chance of being offered the job. His training will be rigorous, but he is young and healthy and has been smoking for only 5 years. He figures that he can cut down to half a pack a day, once training starts, from the current pack and a half he is now smoking. His buddies want him to quit totally and have encouraged him to talk with his pharmacist.

KEY POINTS

THIS PATIENT

ƒ is ready to cut down but not ready to quit completely

ƒ wants to cut down to half a pack of cigarettes per day before starting a new job

ƒ is considering quitting completely in 3–4 months

THE PHARMACIST

ƒ discusses the difficulties associated with smoking reduction but respects the patient’s choice not to quit now

ƒ advises the patient on methods for tapering smoking levels

ƒ addresses key issues, including the patient’s reasons and motivation for wanting to quit, confidence in ability to quit, and social support for quitting

ƒ discusses coping strategies for routines and situations associated with tobacco use

ƒ arranges follow-up counseling

Step 1: ASK

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

Patient

Hi. I wanted to talk with you about cutting back on my smoking, maybe using the nicotine patch. Looks like I’m going to be starting a new job as a firefighter, and the station just went smoke-free. My buddies thought I should talk to a pharmacist about the patch.

Step 2: ADVISE

Pharmacist

So your goal is to cut back, not quit completely?

Patient

Yeah, for now. I want to quit eventually, but I thought it would be easier if I just cut back first. I’m smoking about a pack and a half a day, and I’d like to get down to about a half a pack. I’ll see how that goes and then maybe quit for good in 3 or 4 months.

It is difficult for heavier smokers to reduce their smoking to a lower level. Most who cut back for a short time eventually return to previous smoking levels. Thus, it is helpful to talk with the patient about the nature of addiction and explain to him that the odds are against him if he hopes to cut back to less than 10 cigarettes per day in the long term.

Pharmacist

Sure, I can help you. But I must warn you that it’s difficult to cut back, for a few reasons. Many smokers are able to reduce the overall number of cigarettes per day, but what typically happens is that they begin to smoke more of each cigarette, they inhale more deeply, and they keep the smoke in their lungs longer than usual. So in essence, they really haven’t cut back much at all. And often, even if you are able to truly cut back, there’s a high probability that you’ll eventually go back to your normal smoking level. But reducing your level of smoking certainly can be a step in the right direction, if it’s a first step toward quitting completely. I’m happy to help you—whether you choose to cut back or quit entirely. The choice is yours. But I also must tell you that most of the medications for helping people quit, such as the nicotine patch, are recommended for use only if you’ve quit smoking completely.

Patient

Hmm…I didn’t realize that I wouldn’t be able to use the patch if I don’t quit completely.

Step 3: ASSESS

Pharmacist

How soon do you want to start cutting back, and what is your target date for quitting completely?

Patient

I’d like to cut back right now. And maybe in the next 3 or 4 months, I hope to quit completely.

This patient is ready to cut down but not ready to quit completely.

Step 4: ASSIST

;

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

Patient Just cigarettes.

;

You said that you’re smoking about 30 cigarettes a day. How long have you been smoking at this level, and at what age did you begin smoking?

Patient

Oh, I’d say I’ve been smoking that much for about 4 years now. I started smoking when I was about 23.

Step 4: ASSIST (cont’d)

Pharmacist

And have you ever seriously tried to quit or cut back?

Patient

Nope. But I’ve thought about it a bunch.

;

So, it sounds like the main reason that you want to cut back is because of the new job. Any other reasons why you might want to cut back? Any reasons why you might want to quit completely?

Patient

Well, my girlfriend’s a nonsmoker. She’d rather I quit. And I’m getting more concerned about the fact that I’ve been smoking for 5 years now. It’s hard to believe.

;

You’ve never tried to cut back or quit before. How do you feel about this? Do you think it’ll be difficult?

Patient

I don’t know. I figured that cutting back wouldn’t be too hard. But quitting completely—that’s a different story. I’m not sure how hard it’s going to be. I think I’d have a better chance at quitting if I used the patch or the gum. Maybe I’ll use that later, when I quit completely.

;

You mentioned that your buddies and your girlfriend would like for you to quit smoking completely.

Have you told them about your plans for trying to cut back?

Step 4: ASSIST (cont’d)

Patient

No, I haven’t told anyone yet. I don’t want them to know about it yet. Too much pressure.

Pharmacist

I understand your concern; however, friends often can be very helpful during your quit attempt, particularly if they are supportive of your quitting. You might consider picking at least one person to confide in…to be your buddy during the quitting process.

Patient

I guess I’ll tell my girlfriend. I spend the most time with her.

;

While you’re cutting back, you may experience withdrawal symptoms that might make you more easily distracted and irritable. Given that you might be starting a new job, it would be best if you were over the main hurdle of withdrawal before you start the new job. When would the new job start?

Patient In 2 months.

Pharmacist

Most withdrawal symptoms generally subside within 2–4 weeks. I can give you an information sheet that describes the different withdrawal symptoms that occur while weaning off of tobacco. It also explains the duration of the symptoms and what you can do to manage them, should they occur.

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

Step 4: ASSIST (cont’d)

;

For some people, new jobs can be stressful. Do you think that job stress might make it harder for you, or do you think it will make you more likely to go back to your usual levels of smoking once you’ve started the new job?

Patient

I think the opposite’s true for me. Right now, most of my co-workers smoke during their breaks. At the fire station, hardly anyone smokes.

;

Are there any specific situations that might make it more difficult for you to cut back? Any routines that you have, such as smoking after meals, smoking in the car, or lighting up when you’re having a drink with friends?

Patient

I usually have my first cigarette with my morning coffee, while I’m reading the newspaper. I also smoke after meals.

;

OK. What I’d like to do is put you on a schedule for smoking reduction. You’re trying to cut back from 30 cigarettes a day to 10, so that’s 20 total that you need to reduce. What do you think about reducing by 1 cigarette each day for 20 days? That way, you’d be at your target level a few weeks before you’d start the new job. Then later we can discuss how we can get you off of cigarettes completely. Think of cutting back as your first step—a big step—toward becoming a nonsmoker.

Step 4: ASSIST (cont’d)

Patient

That sounds good to me. I’ll start tomorrow morning.

Pharmacist

OK. Let’s mark a calendar with the number of cigarettes you’ll be smoking each day.

The pharmacist should mark each day on a calendar with the appropriate number of cigarettes.

Pharmacist

Each evening, I want you to count out your cigarettes for the next day. Set them aside and remind yourself that you cannot have any more! Keep your calendar in the same place each day, where you will see it first thing in the morning—on your nightstand, on the kitchen table, or wherever works best for you.

Carry with you only the cigarettes you counted out the night before. Before you light up each cigarette, ask yourself how badly you need or want that cigarette—if it isn’t very badly, then you probably should try to skip it, or at least wait another half hour or so. If you’ve waited 5 or 10 minutes and you still are having a very strong urge to smoke, go ahead.

Patient

OK, one cigarette a day seems doable to me! Should I change to a low-tar, low-nicotine brand of cigarette?

Pharmacist

It’s fine for you to do that. Some patients find that changing the brand of cigarette they smoke is a good first step in changing their smoking behavior. Just keep in mind we still want you to cut back by one cigarette a day for the next 20 days. I will warn you that most people who switch to light or ultra- light cigarettes find they smoke differently. They inhale more deeply, smoke the cigarette all the way to the end, or either consciously or subconsciously cover the special vents on the filter as a means of getting more nicotine into the body. I’m not trying to discourage you for switching brands. I just want you to be aware that switching to a low-nicotine cigarette is not always a safer or easier alternative.

Step 4: ASSIST (cont’d)

;

Let’s talk about some specific strategies to deal with situations where you are likely to smoke. I’m going to suggest a few alternatives for you.

Behavioral Coping Strategies:

In the morning, with coffee while reading the newspaper:

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. Because nicotine speeds up the metabolism of caffeine, your body will need less caffeine while you are cutting back. If you continue to drink the same amount of caffeine, you likely will feel jittery—and this will make your nicotine withdrawal symptoms seem worse.

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.

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. You might like to leave the house and go for a walk, surf the Web, or call your girlfriend to give her a progress report.

ƒ Use a smoking replacement, such as a mint, sugarless gum, toothpick, straw, or a swizzle stick.

Cognitive Coping Strategies:

ƒ As soon as you get up in the morning say to yourself, “Today I’m going to smoke one less cigarette than yesterday!”

ƒ Remind yourself throughout the day how important it is for you to be able to work at your new job without needing to sneak outside for a smoke break.

ƒ When you have a thought about a cigarette step back for a moment. Examine what you are 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)

Pharmacist

Any questions or other thoughts?

Patient

No. It seems pretty straightforward.

;

Congratulations on making a very difficult but important decision! I’d like to continue to help you throughout the process. If you have any questions, please call me here at the pharmacy.

Step 5: ARRANGE

Pharmacist

If it’s OK, I’d like to give you a call in the middle of next week, to see how you’re doing.

Patient

Sounds great. Thanks so much for your help.

The pharmacist should obtain contact information and make a note to call the patient in 1 week.