How are you
going to stop this patient smoking?
Thank you
for asking, briefly I will;
1)
Assess
smoking dependence
2)
Assess
willingness to quit
3)
Treat
by using a behavioural, psychological and pharmacological interventions.
In more
detail,
I would
assess their willingness to quit by asking;
“Which of
the following best describes your smoking?
1)“Not
ready to quit in the next 6 months”
2)“Thinking
about quitting within 6 months”
3)“Ready to
quit within the next month”
Subsequently,
if the answer was (1) I would strongly advise the patient to stop and help the
patient identify personal benefits of quitting. The 4Rs model is useful here
i.e. I would make the advice relevant, stress the risks, identify
the rewards, and repeat these often
If the
answer was (2) I would strongly advise the patient to stop, help the patient
identify personal benefits of quitting and discuss barriers to quitting
If the
answer was (3) I would prepare the patient of quitting by helping to set a quit
date and inform family and friends as appropriate (to provide social support),
review any past attempts, give the patient tips on how to quit and discuss high
risk situations and relapse prevention (if necessary providing skills and
problem-solving technique training or put in contact with a support group). I
would also assess smoking dependence by asking,
1)
Do you
smoke after waking?
2)
Do you
smoke in forbidden areas?
3)
Would
you hate to give up your morning cigarette?
4)
How
many cigarettes per day do you smoke?
5)
Do you
smoke more cigarettes in the morning?
6)
Do you
smoke when sick?
The number
of positive responses would influence by prescription of nicotine replacement
(usually 21mg patch +/- gum. This can then be weaned to lower dose patches over
the next 6 weeks. The dose of the gum is usually varies but as a rough guide if
they are smoking over 25 cigarettes per day use the 4mg gum) +/- bupropion
(this is a noradrenaline/ dopamine reuptake inhibitor if anyone asks. It is
contraindicated in seizure disorders and hypertension). If there is only a low
dose of nicotine dependence e.g. less than 10 cigs per day you may not need to
use nicotine replacement. Remember that the combination of NRT and bupropion
was not statistically better for tobacco cessation than bupropion alone but did
have a trend to significance in the NEJM review. Bupropion is given before the
quit date by several weeks then set the date and keep it going for 3 months
subsequently.
In the
post-quitting phase I would ensure there is regular follow-up and provide
positive reinforcement and would maintain the patient off cigarettes by liasing
with their local doctor and encouraging their attendance at support groups.
(Remember
that you wont prescribe a patch within 4 weeks of and AMI, UAP or arthymias.
50% get a local skin reaction with the patch, 5% do npt tolerate it. Treatment
for 8 weeks of less is as efficacious as a longer period. The gum is not meant
to be chewed but placed between the cheek and the gum. Do not exceed 80mg in a
day)