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)