4 INSTRUCTOR GUIDELINES

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1 STAGE: Recent Quitter You are a clinician working on the vascular surgery service and are about to discharge Mr. McCray, a 58-year-old patient who recently underwent a femoral artery bypass graft for peripheral vascular disease. During the hospitalization he was unable to smoke, and the attending surgeon prescribed the nicotine patch (Nicoderm CQ 21 mg worn for 24 hours) on postoperative day 3 to minimize his withdrawal symptoms. Now the patient is ready to be discharged, and because he hasn t smoked for the past week, he would like to continue to be smoke-free as part of his rehabilitation program. He states, My smoking has caused this, and I don t ever want to go through this again. He wants to continue to use some kind of nicotine replacement therapy. KEY POINTS THIS PATIENT has just undergone surgery for a smoking-related condition is in the action stage; has been smoke-free for several days, as a result of his hospitalization was prescribed the nicotine patch and has been using it with no problems for 4 days THE CLINICIAN suggests that the patient continue with his course of therapy counsels the patient on the appropriate use of the medication addresses psychosocial and other factors related to quitting arranges follow-up counseling Rev CASE 4 Page 1 of 8

2 Step 1: ASK Not applicable. The patient asked for assistance in remaining smoke-free. Step 2: ADVISE Not applicable. The patient is in the process of quitting. Step 3: ASSESS The patient is in the process of quitting and therefore is in the action stage. Step 4: ASSIST Assess tobacco use history: current use Mr. McCray, how much were you smoking, just before you were admitted to the hospital? Before this operation I was smoking one and a half packs per day. Assess tobacco use history: past use As stated above, the patient had no nicotine until postoperative day 3, when the nicotine patch was prescribed. How long have you been smoking 30 cigarettes per day? I ve been smoking that much for close to 40 years. Rev CASE 4 Page 2 of 8

3 Have you ever made a serious attempt to quit before? A loooong time ago, I tried to quit. Tell me a little about the last time you tried to quit. Thirty years ago I went cold turkey. But I had horrible withdrawal symptoms, so it lasted only 2 days. I was anxious, couldn t concentrate, and was irritable. No one wanted to be around me. My wife also smoked back then, and she was actually glad I started smoking again because I was in such a bad mood while I was quitting. Discuss key issues: reasons/motivation for wanting to quit It seems like you re motivated to quit at this time because you want to avoid smoking-related surgeries in the future. Any other reasons that are motivating you to quit smoking for good? I m tired of feeling terrible all the time. I want to be able to go for long walks and enjoy hunting again. Because I ve got such poor circulation through my legs, I haven t been able to hunt or fish in over a year. Plus, my wife quit smoking last year. She just up and quit one day. Said she wanted to see our grandson grow up he s three now. Rev CASE 4 Page 3 of 8

4 Discuss key issues: confidence in ability to quit It s been a long time since you tried to quit smoking. You previously tried to quit cold turkey but are now using the nicotine patch. How difficult do you think this will be for you? Do you think this method will help you? This surgery really scared me. Scared my wife, too. I don t ever want to go through it again. Now I guess I think that not quitting isn t an option. The nicotine patches definitely seem to take the edge off my cravings for a cigarette, which will help. Discuss key issues: social support for quitting You said your wife recently quit smoking. Would she, or other members of your family, be able to assist or support you while you re quitting? Yeah, both my wife and children are supportive. The trouble is work most of the office staff smokes at work. No one bothers to enforce the smoke-free policy at my law firm because all five of us who work there smoke. Discuss key issues: concerns about weight gain Are you concerned about gaining weight when you quit? Yeah, who isn t? But I ll have to deal with that after my legs heal from the surgery. Rev CASE 4 Page 4 of 8

5 Discuss key issues: concerns about withdrawal symptoms You mentioned that the nicotine patches have helped to take the edge off your withdrawal symptoms. You ve already gone almost a week without smoking. Do you think the nicotine patches will continue to help you manage your nicotine withdrawal symptoms? I m worried a bit about withdrawal symptoms. I don t like the idea of quitting cold turkey, so the patch seems like a good choice, from what I ve heard. I can give you some information about withdrawal symptoms and how you can help them subside the nicotine patch will help with these, but there will be times when you experience some pretty intolerable withdrawal symptoms. What s important is for you to focus on not smoking, realizing that the symptoms will pass. Discuss key issues: stress-related smoking You say you work in a law firm. I m assuming this is a stressful position. Do you find that you smoke more when your work environment becomes stressful? Oh, yes. I smoke like a chimney a week or two before we go to trial. Discuss key issues: routines and situations associated with tobacco use Are there certain situations where you are more likely to smoke than others? Are there any routines that you associate with smoking such as talking on the telephone, drinking alcohol, or driving? Rev CASE 4 Page 5 of 8

6 I smoke at the office and after meals. Facilitate quitting process: discuss methods for quitting Not particularly relevant. The patient is doing well on the patch. The clinician might consider mentioning that other methods can be used, but he or she should recommend that the patient continue on his current course of therapy. Facilitate quitting process: discuss coping strategies You ve just had major surgery and will be recovering at home for the next 4 6 weeks. This may be the ideal time to begin your lifestyle changes. It sounds like you smoke a great deal at work. Let s talk about some of the challenges you ll have to face when you return to work. Have you considered enforcing the smoke-free workplace ban? This may reduce the temptation to smoke when you return to work. I ve been thinking about designating some outside space for employees to smoke on their breaks. I didn t have incentive before to enforce the smoke-free policy because all of us smoke. Now I think it s time to enforce the policy. I don t want my staff to have these types of problems either. You can bet I m going to encourage them to quit, too. You may want to have your staff remove all ashtrays and cigarettes from your work place. It might also be a good time to have the office thoroughly cleaned (carpets, blinds, walls, and windows) to remove the smell of tobacco. I d also like to suggest some stress management techniques; these also will help you when you feel an urge to smoke, such as after meals and while at work: Do some deep breathing or self-massage. Take a break. Stretch or go for a walk. Use meditation or imagery. Rev CASE 4 Page 6 of 8

7 Facilitate quitting process: offer to assist throughout the quit attempt Quitting smoking is a process. It may take weeks or months until you feel that you are free from tobacco. I can help you through the quitting process. Facilitate quitting process: discuss concept of slips versus relapse While you are on the nicotine patch, it s important that you not smoke or use any form of tobacco, because you may experience more nicotine-related side effects by combining the nicotine in the patch with the nicotine in the tobacco. Also, it s important not to smoke because even one cigarette could lead you back to smoking regularly. However, if you do smoke a cigarette, please contact me as soon as possible. It s important that you view this as a slip and not a complete reversal of your quit attempt. We ll work together to get you back on track right away. Facilitate quitting process: discuss withdrawal symptoms You said that you had difficulty quitting in the past because you were nervous and irritable and couldn t concentrate. You may experience these symptoms again. It will help to continue to focus on recovering from your surgery and remembering how important quitting smoking is to your overall health. The nicotine patch should help alleviate your withdrawal symptoms. Here s an information sheet that describes the different withdrawal symptoms that occur while quitting. It also explains the duration of the symptoms and what you can do to help manage them, should they occur. The clinician should give the patient the Withdrawal Symptoms Information Sheet. Facilitate quitting process: provide medication counseling Let s review proper use of the nicotine patch. Considering your smoking history of one and a half packs a day, I d recommend that you continue the Nicoderm CQ 21 mg patch, as you ve been doing in the hospital, for the next 6 weeks. You can then taper down to the 14 mg patch for 2 weeks, then the 7 mg patch for an additional 2 weeks. After that you can stop using the patch altogether. Rev CASE 4 Page 7 of 8

8 The clinician may recommend any patch (with appropriate dosing), but because the patient is tolerating the Nicoderm CQ in the hospital, it may be preferable to continue using that formulation. How are you tolerating the patches so far? I haven t had any problems with the patch yet. That s good; just remember to rotate the patch application sites daily. It s best not to apply the patch to the same skin site for at least 1 week. This will minimize the possibility of skin irritation. Apply the patch to a nonhairy, dry area of skin such as the shoulder blade, side, or upper arm. Press the patch firmly to your skin for at least 10 seconds. Make sure it sticks well to your skin, especially around the edges. I haven t had a proper shower since I was admitted; just sponge bathes. Is it OK to shower with the patch on? It s fine to shower or bathe with the nicotine patch on. Water won t harm the patch if you apply it correctly. Step 5: ARRANGE Congratulations on taking this important step toward improving your health. Feel free to call me at the hospital if I can be of further assistance while you are quitting. Alternatively, I know several pharmacists in the community who provide follow-up smoking cessation counseling. I d be happy to provide you with referrals if you d like. Rev CASE 4 Page 8 of 8

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