TOBACCO TRIGGER TAPE SYNOPSES
Filename Dialogue EPIDEMIOLOGY OF TOBACCO USE MODULE TT‐EPI1 Hey, we’re all gonna die at some point. So what if I lose a couple of years at the end of my life because I smoke….
Scenario
Problem
Solution
Man is lying on a patient examination table, talking with his clinician.
Smokers who make this statement think that they will simply fall over one day and die in an instant. They forget that smoking‐related illness can create years of miserable pain and suffering. Many smokers are switching to spit tobacco under the mistaken impression that it is a safe alternative to smoking.
● Shift the focus from dying, as this is not about dying. Rather, it is about living with the very real long‐term effects of smoking. Ask the patient, “What would it be like to lie in bed for years as a result of a stroke or to not be able to walk up two or three steps because of emphysema?” Say, “If you continue to smoke, you significantly increase the chances of something like this happening. I would hate to see that happen.” ● Educate the patient about years of life lost due to smoking, such as by saying, “The average smoker loses about 7 years of life because of smoking. What do you get from smoking that is so important that you are willing to give up that much of your life?” ● Help the patient understand that he is being manipulated by the spit tobacco companies. The companies disseminate this information as a way to get smokers to use their products. ● Smokeless tobacco products are likely less harmful than combustible forms of tobacco, but they can cause cancer of the mouth, esophagus and pancreas. Smokeless tobacco use contributes to oral disease (leukoplakia, gum disease, tooth decay and tooth loss). ● Explain that there is no safe form of tobacco. All tobacco naturally contains many toxins, including significant numbers of cancer‐causing substances. ● Inform the patient that smoke can stay on clothes and hair for hours after smoking. Consider saying, “If you pick up or hug your child, this smoke could still irritate her lungs and bring on an asthma attack.” ● Advise the patient, “If you smoke outside but near an open window or door, the smoke can still enter your home, and although you aren’t smoking near your child, it can still cause harm. I wanted you to be aware of this—it’s obvious that you care a great deal about your daughter.” ● Advise the patient that it is never too late to quit smoking. Explain that many of the positive physical changes that occur as a result of quitting happen within weeks or months and, further, research shows that even people in their 70s and 80s benefit from quitting. ● Remind the patient that even if someone has a smoking‐related illness, quitting can reduce the rate of disease exacerbation. ● Advise the patient that smoking negatively impacts the success of surgery, chemotherapy, and radiation treatment. Likewise, continuing to expose the body to the cancer causing chemicals in tobacco significantly increases the chances of secondary tumors occurring. ● Many patients who make this statement are focusing on dying. Help refocus these patients on quality of life and how continued smoking can negatively impact their ability to engage in everyday activities. Remind these patients that a cancer diagnosis is not necessarily a death sentence.
TT‐EPI2
But I thought snuff was safe. That’s why I switched!
Man is lying on a patient examination table, talking with his clinician, who is wearing a mask and is looking in his mouth.
TT‐EPI3
Oh, but I don’t smoke around her. I always smoke outside at home…because of her asthma.
Mother and child are in a patient examination room, talking to the child’s clinician.
Smokers often do not realize the lingering effects of the smoke on clothing, hair, etc.
TT‐EPI4
I’d like to quit smoking, but it’s probably too late for me. I’m sure the damage has already been done.
Man is sitting on a patient examination table, talking with his clinician.
TT‐EPI5
I already have cancer. What’s the point in quitting?
Hospital room
Many individuals over age 40 think that the damage done to the body from smoking is beyond repair. They think, What’s the point of quitting? Many cancer patients think that they are near the end of their lives so “why not enjoy myself.” They see no point in quitting smoking.
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Filename TT‐EPI6
TT‐EPI7
TOBACCO TRIGGER TAPE SYNOPSES Dialogue Scenario So, I’m going to be miserable N/A enough recovering from this surgery. Why would I want to make it worse by quitting now? I’m only 27…it’s not like I’ve N/A been smoking that long. Besides, I only smoke when I drink.
TT‐EPI8
What do you mean, you won’t do my surgery unless I quit?
Clinician’s office
TT‐EPI9
I really don’t know what one has to do with the other. I get so tired of dealing with this diabetes and people nagging me about my smoking!
Examination room
TT‐EPI10
I heard that vaping is way safer than smoking, so shouldn’t I switch?
Clinician’s office
Problem These patients feel that they will inevitably go through significant physical withdrawal when quitting. Many youth and young adults believe that non‐ daily, intermittent smoking is not dangerous. Furthermore, they believe that they can easily maintain this level of smoking and never become daily smokers. Many surgeons are becoming increasingly reluctant to conduct surgical procedures on current smokers as evidence mounts about the negative impact continued smoking has on surgical outcomes. Patients do not always attribute their illnesses (or exacerbation of their illnesses) to their tobacco use.
Patient mistakenly believe that vaping is much safer than smoking regular cigarettes.
Solution ● Advise the patient, “There are seven effective medications for quitting that will significantly reduce your withdrawal symptoms from nicotine, and these can make you more comfortable while you are quitting.” ● Reframe surgery as an ideal time to quit. Hospitalized patients cannot smoke as inpatients, and surgical outcomes can be significantly improved in smokers who quit. ● Explain to the patient that there is no safe level of smoking. There are cases of people in their teens and twenties developing smoking‐related illnesses even though they have only smoked for a few years or on an intermittent basis. ● Very few people can “control” their smoking. Almost all individuals start out as intermittent smokers and quickly become everyday smokers as a result of the addictive nature of nicotine.
● Surgical outcomes can be significantly compromised if an individual continues to smoke. Many physicians are reluctant to perform surgical procedures on individuals who continue to smoke due to the mounting evidence that smoking can: ● Result in the need for increased anesthesia ● Reduce wound healing ● Interfere with immune response ● Negate surgical outcomes ● Reframe surgery as the ideal time to quit and review available quitting options at your institution. ● Inform the patient that some of the chemicals in cigarettes can affect how the body uses insulin so there is a direct connection between diabetes and smoking. ● Remind the individual that quitting will give them the best chance of staying as healthy as possible and minimizing the effects of their diabetes. ● Many diabetes are quite naturally in a negative state of mind, feeling that they have already given up so many things they love (certain foods) that they cannot bear to give up anything else. Therefore, focus on what the person will be getting by not having cigarettes in their life. ● Inform the patient that while smoking is much worse, vaping is not necessarily safe because the aerosol that the users breathe from the device and exhale can contain harmful and potentially harmful substances. ● Remind the patient that smoking cessation is the most important thing she can do to protect her health now and in the future. ● It is difficult for consumers to know what e‐cigarette products contain. For example, some e‐cigarettes marketed as containing zero percent nicotine have been found to contain nicotine.
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TOBACCO TRIGGER TAPE SYNOPSES
Filename Dialogue Scenario ASSISTING PATIENTS WITH QUITTING MODULE TT‐ASSIST1 Yes, I smoke. Why do you N/A ask?
Problem
Solution
Patient appears to be surprised that he’s asked about smoking, and is not aware of the importance of quitting.
● Consider saying, “I take time to ask all of my patients about tobacco use because it is one of the most important and preventable cause of multiple health issues, and I care about your health.” ● Consider asking, “Have you given any thoughts to quitting? ” or “May I tell you what concerns me?” to assess patient’s readiness for smoking cessation ● Try to figure out the patient’s rationale behind tobacco use by asking, “What do you think cigarettes provide you?” Clarify any misunderstandings of tobacco use. ● Ask the patient for his opinion on health and help him understand the health consequences related to tobacco‐use. ● Remember to mention, “We have a smoking cessation program and I can connect you to this service.” ● Explain that the quitline is staffed by highly trained specialists, and she can receive up to 4–6 personalized sessions. ● Introduce the patient to the services provided by the quitline, which includes individualized telephone counseling, quitting literature mailed within 24 hrs, and referral to local programs. ● Free service, call pretty much at any time, do fax referral ● Ask the patient about his tobacco use to determine whether he needs a nicotine replacement therapy. ● “You certainly can try to quit on your way, but pts who use medications are more comfortable while they are quitting.” ● Smoking cessation regimens cost less than cigarettes. ● Strongly encourage him to enroll in a behavioral program, which will help with coping strategy that last for lifetime ● If the patient insists on quitting without assistance, recommend several non‐ pharmacological options to assist smoking cessation, such as web‐based/telephone counseling and self‐help programs. ● Encourage the patient to think of quitting smoking as a learning process, similar to learning to ride a bicycle. Consider saying, “When you learned to ride a bike, you fell off, figured out what worked and what didn't, and then got back on. You did this until you were able to ride without falling. Some people even used training wheels.” ● Discuss the quitting process and how the patient can learn from past quit attempts. Consider saying, “Those past experiences were your ‘training wheels.’ What did you learn about yourself during those attempts? Apply those lessons now to make this quit successful. Don’t let those past ‘falls’ be a reason never to try again.” ● Also, this time they can get more help, e.g. help from 2 professionals, which is proven to increase the chances of success. ● Acknowledge and reflect the patients concern first, “This sounds like a challenge for you, would you like to hear about different options for weight management?” ● Encourage healthy diet and meal planning
TT‐ASSIST2
I don’t understand. How will a quitline help me stop smoking? How does it work?
Woman is at a pharmacy counter.
Patient needs information about the tobacco quitline.
TT‐ASSIST3
Nah, I think I’d rather quit cold turkey and do it on my own. I don’t need no help.
Man is sitting on the end of a patient examination table.
Many smokers try to quit without assistance, despite the proven positive impact of behavioral counseling and pharmacotherapy.
TT‐ASSIST4
I’ve quit at least a hundred times. I just don’t know that I can stay off cigarettes once I get home.
Man is in a hospital bed, receiving bedside counseling.
Many individuals who have had multiple relapses convince themselves that they can never quit.
TT‐ASSIST5
Here's the thing. Every time I try to quit…I gain a ton of weight!
Community Pharmacy
Many individuals who smoke, particularly women,
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Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
TT‐ASSIST6
But I’m really worried I might gain weight when I quit!
Woman is in a patient examination room, talking with her clinician.
TT‐ASSIST7
I can’t live without cigarettes. I just can’t!
Patient with psychiatric illness reacts to the notion of quitting.
Problem Solution are concerned about weight ● Suggest increasing water intake or chewing sugarless gum gain after quitting. ● When fear of weight gain becomes a barrier to smoking cessation, ask the patient whether she would like to be on pharmacotherapy with evidence of delayed weight gain, (bupropion SR or 4 mg nicotine gum or lozenge); can also refer patient to specialist or weight control programs. ● Acknowledge patient’s concerns. Advise patient to try to put his or her concerns Some smokers think that nicotine burns thousands of about weight on the back burner temporarily. Patients are most likely to be calories and that without it successful if they first try to quit smoking, and then later take steps to reduce weight. they will have significant Offer to assist with quitting as well as subsequent weight maintenance or reduction. ● Advise the patient that nicotine increases the metabolism only slightly and that the weight gain. average weight gain as a direct result of quitting is 5–7 pounds. Anything over that is due to the individual eating more. Tell the patient, “Simply walking for about 20 minutes a day will make up for this when you quit.” Encourage the patient to consider that the average smoker is used to putting something into his or her mouth 300–400 times a day, and that many tobacco users miss that when they quit, so they substitute food for the cigarettes. They end up snacking on junk food all day long. ● Explain to the patient that many smokers’ taste buds are “asleep” as a result of the chemicals in cigarettes. When they quit, these taste buds “wake up” and everything tastes incredible. Because fat gives food the most taste, these individuals start eating much more fatty food. This contributes to weight gain. Many patients with ● Generally speaking, you will approach patients with psychiatric illness in a slightly psychiatric illness believe different manner than patients in the general population. Because smoking is viewed they cannot function by the vast majority of these individuals as a central part of their life, quitting without smoking and are altogether on a specific day may be untenable and overwhelming. Therefore, it is extremely fearful of possible that a tapering schedule, with an eventual quit day, may be more efficacious quitting. with some individuals within this population. However, thoroughly discuss the options with the patient before making a decision about methods for quitting. ● Individuals with psychiatric or substance abuse problems can quit smoking as well as the general population, as long as the quitting plan meets their specific needs. ● Because many psychiatric medications interact with cigarette smoke, be aware of the need to monitor drug dosing with anyone in this population who is quitting. Consider discussing the situation with the patient’s physician prior to their quit date. ● Many individuals who say they cannot live without cigarettes literally do believe it. Therefore, be especially empathic and understanding, and do not push. However, make it clear that cigarettes cannot help anyone live a better life, and that the vast majority of the population lives just fine as nonsmokers. In fact, patients with mental illness who smoke are 2‐3 times at higher risk for cardiovascular diseases compared to the general population and lose a decade of life on average as a result of smoking.
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Filename TT‐ASSIST8
TOBACCO TRIGGER TAPE SYNOPSES Dialogue I just have too much stress in my life to even think about quitting.
Scenario Patient examination room
Problem The pervasive belief that smoking either gets rid of stress or helps the smoker deal with stress prevents many smokers from attempting to quit or prompts them to relapse back to smoking once they have quit. Many patients who smoke think that only an ex‐ smoker can be an effective cessation counselor.
TT‐ASSIST9
You don’t know what it’s like…you’ve never smoked.
Clinician’s office
TT‐ASSIST10
What do you mean I can’t go outside and smoke?
TT‐ASSIST11
I get up every morning at 5AM and work out. So what’s the big deal if I smoke a few cigarettes a day?
Patient with IV pole, in hospital hallway, attempting to go outside to smoke N/A
Many hospitalized patients think that they have the “right” to smoke and that they can leave the hospital at any time to do so. There is a belief that exercise, especially aerobic type workouts, will mitigate the negative effects of smoking.
TT‐ASSIST12
How am I supposed to quit…everybody I know smokes!
N/A
Smokers generally have many friends who smoke. This can be a significant impediment to quitting successfully.
Solution ● Help the patient understand that smoking does not get rid of stress, it causes it. ● Because there is no drug in cigarettes that magically gets rid of stress, remind the patient that they have actually been the one to deal with their stress for their entire life. Advise the patient to give themselves credit, not the cigarette, for successful stress management. ● Refer patients to local stress management programs, advise them to begin to exercise, or suggest that they take a meditation class, all ways to effectively learn to deal with stress. ● Inform the patient that you do not have the disease/condition you are treating them for but that you are still able to help them. ● Remind the patient that helping someone deal with a particular condition is a matter of education and skill, not about having had that condition yourself. ● Although you may not have had to quit smoking, you have made some type of behavior change in your lifetime (e.g., weight loss, exercise, medication adherence). Relay that experience to the patient and use the similarities between that and quitting to help the patient understand that you empathize with what they are going through. ● Calmly remind this patient that they are in the hospital to get well, not to continue to harm himself by smoking. Reframe the hospitalization as the ideal time to quit and review the options available at your institution to help them do so. ● Help this patient to understand how smoking has contributed to his hospitalization and that permitting him to smoke would be unethical. ● Exercise, no matter what type, does not negate the effects of smoking. In fact, remind this individual that continued smoking will negatively impact their ability to exercise by damaging the lungs and reducing available oxygen. ● Also remind the patient that they have taken an excellent step towards staying healthy by exercising daily, however, research shows that the best thing to do for health is quitting smoking. ● Very few people can “control” their smoking. Almost all individuals start out as intermittent smokers and quickly become everyday smokers as a result of the addictive nature of nicotine. ● Remind this patient that many people have quit smoking even though they have friends, relatives, or spouses who smoke. Quitting in this circumstance is a matter of addressing the situation at the beginning of the quit by creating a coping plan. ● Some suggestions for coping with this situation: ● Speak to other smokers and inform them that you are quitting. ● Ask friends not to smoke in front of you or to limit their smoking around you for at least the first few weeks after you quit.
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Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐ASSIST13
I’m doing good…I only had one cigarette last week to reward myself for being quit a whole month!
N/A
A most popular misconception that ex‐ smokers have is that they can smoke an occasional cigarette and not return to regular daily smoking. They think that they can “control” their smoking.
TT‐ASSIST14
The last time I quit, my depression got worse. I’m just starting to feel good now…I don’t want to backslide.
Clinician’s office
Patients often understand the link between smoking and depression and fear that quitting will impact their depression.
TT‐ASSIST15
Hey don’t hassle me about my smoking, doc! Everyone keeps asking me if I smoke – why can’t everyone just leave me alone?! Look…my life’s a mess right now, and I just need my cigarettes!
Clinician’s office
Many patients believe they cannot function without smoking and are extremely fearful of quitting.
TT‐ASSIST16
But won’t the stress of quitting increase my chances of drinking again?
Counselor’s office
Because smoking and drinking (alcohol) are closely associated for many patients, they commonly
Solution ● Visualize yourself socializing with your friends, having a good time, all without a cigarette. Then see one of them offer you a cigarette and you turn it down by saying, “No thanks, I don’t smoke.” ● Remind yourself that just because you see someone doing something, that does not mean you have to do it. ● Very few people can “control” their smoking. Almost all individuals start out as intermittent smokers and quickly become everyday smokers as a result of the addictive nature of nicotine. Have them review the beginning of their own smoking history. They almost certainly started out smoking a few a day but eventually began smoking on a daily basis. ● Inform the patient that, generally speaking, if a smoker can excuse one or two cigarettes a day, they can create an excuse to have three or four. This inevitably leads to a return to regular daily smoking. ● Use the relationship analogy. “You can’t break up with someone and still date them once or twice a week and think nothing is going to happen. It’s always best to make a clean break and be done with it!” ● Inform the patient that the effects of nicotine on the brain mimic those of an antidepressant. As such, depression can be a very real withdrawal symptom. Therefore, anyone with a history of depression should quit smoking under a doctor’s care or with help from a psychiatry pharmacist so that medication levels can be monitored. ● However, be sure to emphasize that they can quit successfully without a recurrence of their depression. ● From the start, coordinate your quitting program with the individual’s psychiatrist/psychologist. Pay special attention to the patient’s symptoms/mood the first week of the quit and at points where the patient is stepping down on nicotine replacement therapy as these are likely the times of the greatest metabolic shifts. ● Consider saying, “I’m asking because I’m concerned about your health and I want you to be as healthy as possible. I’m not telling you that you have to quit.” ● Understand that many individuals who make these types of statements literally do believe that they “need” cigarettes to survive. Therefore, be especially empathic and understanding, and do not push. However, make it clear that cigarettes cannot help anyone live a better life and that the vast majority of the population lives just fine as nonsmokers. ● Ask the patient, “How is smoking making your life better?” or “What benefit do you think you are getting from your cigarettes?” Then point out the reality behind the myth of the positive impact they think the cigarette is providing them. ● Inform the patient that there simply is no scientific evidence to show that people who quit smoking relapse back to drinking. In fact, research shows the exact opposite. Individuals with substance abuse problems who quit smoking are more likely to stay sober than those who continue to use.
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Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem assume that quitting smoking will lead to an increase or return (for those who are abstinent) to drinking. Most patients who live in group homes perceive it will be very difficult to quit when others are smoking around them.
TT‐ASSIST17
I have so many problems anyway another one’s not gonna make any difference. Besides how can I quit when everyone in my group home smokes?
Clinician’s office
TT‐ASSIST18
Smoking helps me deal with stress.
N/A
Patients mistakenly attribute relief of withdrawal symptoms
TT‐ASSIST19
Well, my doctor didn’t say anything about my smoking, so…it can’t be that bad, right?
Examination room
Failure to address tobacco use with a patient tacitly implies that continued smoking is acceptable.
TT‐ASSIST20
What are you talking about…my grandfather, he lived to be 95 years old. Smoked cigarettes from 1925 until he died. That’s over 70 years that he lived, smoking cigarettes – at least 2 packs, every day – get outta here…!
Examination room
Many smokers under‐ estimate their risk of tobacco‐related disease.
Solution ● “In any case, we will certainly address your concerns as we create your quitting plan by focusing on stress management strategies.” ● Encourage this patient to maintain their attendance at (or return to) AA during the quitting process so that they have a ready forum to discuss any concerns as they arise. ● Consider saying, “Hundreds of people who live with other smokers quit every day. I will work with you to create a plan so that you will be able to deal with this situation and be comfortable in your home.” ● Some suggestions for dealing with this situation: Have a meeting with the housemates to discuss where they will/will not smoke. Ask the housemates not to leave cigarettes or dirty ashtrays where the quitter can find them. Because this likely is a psychiatric setting, contact the health professional in charge of the home and discuss possible strategies to help the quitter cope while in this setting. Strongly encourage the entity in charge of the group home to make it smoke‐free. ● Help the patient understand that smoking does not get rid of stress, it causes it. ● Because there is no drug in cigarettes that magically gets rid of stress, remind the patient that they have actually been the one to deal with their stress for their entire life. Advise the patient to give themselves credit for successful stress management, not the cigarette. ● Provide patients with handouts that explain the real relationship between smoking and stress. ● Refer patients to local stress management programs, advise them to begin to exercise, or suggest that they take a meditation class, all ways to effectively learn to deal with stress. ● “Unfortunately, many physicians do not address tobacco use for a variety of reasons. However, don’t take that as an endorsement to continue to smoke. The scientific evidence is very clear…smoking is the leading cause of disease and death.” ● Clearly link the presenting diagnosis with smoking. Remind the patient that smoking is causing their condition, exacerbating symptoms or interfering with healing. ● Point out to the patient that for every person in their 70s or 80s who smokes and does not have any apparent ill health effects, there is someone in their 20s or 30s who already suffers from emphysema, has been diagnosed with cancer, or has had their first heart attack. ● Use personal stories of young patients you have encountered who have had smoking‐ related illnesses to illustrate this point. ● Help the patient understand that there is no scientific way to know which group they will fall into. Remind them that smoking is very risky, and the vast majority of smokers develop serious health problems as a result of their smoking.
Page 7 of 11 Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐ASSIST21
I just smoke with my friends. It’s not like I’m addicted…like my mom! I can quit any time I want.
Adolescent girl is talking with her clinician in an office setting.
TT‐ASSIST22
So why are you asking me if I smoke, if you sell cigarettes at the front of the store? Isn’t that a little hypocritical?
Community pharmacy (probably located in a grocery store)
Many adolescent smokers Educate the patient on the nature of nicotine and dependence. Nicotine is a very believe mistakenly that addictive drug. Consider saying, “Although you may start out smoking just they can “control” their occasionally, the body begins to demand more and more nicotine until you are smoking. They clearly smoking 20–30 cigarettes a day in order to feel comfortable. This happens to almost underestimate the every smoker.” addictive nature of nicotine. ● Research conducted with high school smokers shows that in spite of saying that they Evidence shows that, in could quit any time they wanted to, more than 85% of 9th graders who smoked were some youth, the still smoking in their first year of college, with most of them smoking much more than establishment of they did in 9th grade. dependence can occur rapidly. ● Use reflective listening skills and consider saying, “I understand the irony in this Many smokers do not understand why they are situation.” Explain to the patient that the pharmacy itself does not provide tobacco asked about tobacco use at products. State your opinion. the pharmacy when there ● There are efforts made to take the tobacco products off the shelves. However, I are tobacco products sold personally don’t have the power to control that now. In the meantime, I would try to in the front of the grocery provide the best health to you. store. ● Help the patient understand that questions are being asked because we care about her health. ● Consider having a conversation with the store representatives about taking tobacco products off the shelves. ● Remind the patient that you have a lot of experience with smoking cessation and would be able to help her if she has thought about quitting. Assess patient’s readiness for smoking cessation. Let her know that if she changes her mind, we would be available to help her. Many smokers mistakenly ● Explain to the patient that she is putting lots of chemicals in her body every time she view the cessation products smokes. Each cigarette contains over 4,000 substances, many of which are known or negatively while not suspected human carcinogens. Any smoking cessation medication contains only one understanding the real drug that has been shown to be an effective way to help smokers quit for good. negative consequences of ● Ensure that the patient understands that although nicotine is the addictive drug the chemicals found in found in cigarettes, it is not what causes the majority of negative health cigarettes. consequences of smoking. These health consequences occur from ingesting carbon monoxide, acetone, and tar, for example, as well as a multitude of cancer‐causing substances. Thousands of chemicals are found in each and every cigarette. ● Say to the patient, “You will only use a smoking cessation medication for a short period of time. These medications have been proven to be safe and effective through dozens of clinical trials. They help you slowly reduce your dependence on nicotine while immediately eliminating all the other toxic substances found in cigarettes.”
Filename
MEDICATIONS FOR CESSATION MODULE TT‐MED1 Why do I need drugs to quit? Woman is sitting I don’t like putting drugs in on a patient my body. examination table, talking with her clinician.
Solution ● Focus the patient on how these potential health effects could negatively impact their ability to engage in favorite activities.
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Filename TT‐MED2
TOBACCO TRIGGER TAPE SYNOPSES Dialogue All those smoking medications cost way too much.
Scenario N/A
Problem Many patients who smoke feel that they cannot afford cessation medications, so they continue to smoke.
TT‐MED3
Aren’t I just trading one addiction for another if I use the gum or the patch?
Clinician’s office
Many smokers think that NRT products are as addicting as smoking.
TT‐MED4
Wow. Nicotine patches cost that much? That’s more than cigarettes! You know, I just don’t have that kind of money.
Community Pharmacy
Many smokers believe that they cannot afford smoking cessation products.
TT‐MED5
Hmm. Is it safe to use the patch and the gum at the same time?
Community pharmacy
TT‐MED6
But I’ve tried everything…none of these quit smoking medicines ever worked for me.
Clinician’s office
Many smokers are not aware of the fact that cessation products can be used concurrently. Some smokers believe that cessation products are not effective.
Solution ● Point out that all of the cessation products cost between $3.50 ‐ $5.00 a day, generally the same as a pack of cigarettes. ● Do the math. Determine how much the smoker spends in a year on cigarettes and show them how much they will save if they quit. ● Remind the patient that although they perceive the products as being expensive, use is only for a short period of time, unlike continued smoking. ● Help the patient understand that the nicotine in all forms of nicotine replacement therapy is delivered to the body in a much different way than it is from smoking. Nicotine from smoking reaches the brain in 11 seconds. All forms of NRT take between five minutes to six hours to reach peak concentrations. It is the speed at which the nicotine from smoking reaches the brain that promotes addiction. Additionally, NRT provides much lower levels of nicotine than does smoking. Because the NRT products deliver much lower amounts of nicotine at a much slower rate than smoking, they have very low addictive potential. ● Remind the patient that using NRT doubles ones chances of quitting successfully and that it is only to be used for a short period to time. ● Remind the patient that cessation products actually cost less than smoking a pack per day. ● Help the patient understand that smoking continuously would potentially cost more than short‐term use of cessation products. Go ahead and calculate the estimated cost of smoking and show the patient how much money she can save by quitting. Remind the patient that she will be saving a lot of money in the long run. ● Consider saying. “If it is too much for you to pay initially, what is your thought on asking your family and friends to donate a few dollars?” ● Explain to the patient that both products can be used at the same time and is more effective when used in combination. Nicotine gum can help relieve situational cravings for patients who are using patches for smoking cessation. ● Explore how the medications were used—what medication(s), what strengths, how used, and duration of use. ● Ask the patient what he has tried in the past and clarify any misunderstandings. Some patients could be using the cessation products incorrectly or less frequently than needed. ● Reflect on the fact that “You’ve been frustrated with the fact that they haven’t worked for you in the past. If you don’t mind me asking, what have you tried in the past and how have you used them? ● Make sure that the patient understands how to use each of these cessation products. ● Consider asking, “What are your expectations for these products you have tried?” These medications are used to prevent withdrawal rather than treat it when it happens because they don’t work as fast.
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Filename TT‐MED7
TOBACCO TRIGGER TAPE SYNOPSES Dialogue So…what do you think about e‐cigarettes for quitting?
Scenario Community pharmacy
Problem Many smokers believe that e‐cigarettes are less harmful than cigarettes and consider them as an option for smoking cessation.
TT‐MED8
Chantix? Isn’t that the drug with all the horrible side effects?
Clinician’s office
Many smokers feel nervous about the side effects associated with Chantix.
TT‐MED9
Doing great…haven’t smoked in a week. But I’m having a hard time sleeping. Do you think that’s the Chantix?
Could be anywhere, pt is calling to clinician’s office
Patient suspects his difficulty sleeping is due to use of Chantix.
TT‐MED10
First I hear that Chantix is bad. Now you’re saying it’s OK. What gives?
Clinician’s office
Patient is hearing different information on Chantix, and asks for clarification.
Solution ● Although traditional cigarettes are much more harmful, explain to the patient that e‐ cigarettes are not necessarily less harmful than other tobacco products because they also contain harmful products that can negatively impact health. We also don’t know about the long term effects. It is less harmful, but not safe. ● Ask patient what her goal is. Is it to get off of tobacco? Or nicotine altogether? Discuss the risks associated with dual use. ● Consider saying, “I am glad that you have given some thought to quitting smoking. E‐ cigarettes are not proven for quitting, however, there are seven FDA approved cessation products available that can help smoothen the process for you. Would you like to learn more about these options?” ● Talk about non‐pharmacological options that can also be very helpful in the process of quitting. ● Try to figure out what the patient knows about Chantix. Admit that there are side effects associated with Chantix such as treatment‐related nausea and insomnia. However, these side effects are usually temporary. ● “Which side effects are you referring to?” ● Address black box warning. There was a very large research study conducted showing that those side effects are not due to the drug itself. A similar number of people on the placebo experienced similar effects. That quite possibly is the side effect of quitting smoking. ● Remind the patient that there are different options available. Involve the patient in the decision‐making process and help him choose a product that suits him well. Introduce non‐pharmacological approaches to the patient. ● Compliment the patient on his success, and encourage him to maintain the good behaviors. ● Ask the patient to provide more information on his sleeping problem. e.g. “How long have you been experiencing this? When have you started to take Chantix? What are the s/sx? ‐ insomnia, abnormal dreams?” ● Offer to review his medication therapy to exclude other factors that could contribute to his sleeping problem. ● Inform the patient that sleep disturbances are one of the common side effects from Chantix. However, the insomnia is usually temporary. If symptoms persist, he should notify his health care provider. ● Talk about caffeine intake, excess caffeine and smoking has an interaction, reduce intake to half and not drink any after lunch time if they sleep at normal time. ● Counsel on lifestyle changes, consider taking the second dose earlier or even skip the last dose if none of the above worked. ● Ask about the patient’s concerns, why he thinks Chantix is bad, and would go from there. ● If the patient is concerned about neuropsychiatric symptoms/suicide risk, ask about his medical history; Advise to use with caution or adjust current medication therapy.
Page 10 of 11 Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐MED11
The patient in room 207 has Hospital a nicotine patch ordered. But they were admitted for a heart attack. Isn’t the patch contraindicated in a patient with a recent MI?
Physician questions the use of nicotine patch in a patient with recent MI.
TT‐MED12
Is it really OK to use the patch and the nicotine lozenge at the same time? That doesn’t sound safe.
Clinician’s office
Patient doubts the safety of using two forms of NRT at the same time.
TT‐MED13
Two of my friends quit by vaping. Why won’t you recommend it?
Clinician’s office
Patient thinks vaping is a good smoking cessation tool since her friends quit by vaping.
TT‐MED14
Hi. This is Veronica Ward. I was in last week, and you helped me with the nicotine patch. I’ve been wondering…ever since I started using it, I’ve been having a hard time sleeping at night. Do you think it’s the patch or something else? Now…why would I want to put nicotine in my body if I wanted to quit smoking?
Woman calls her clinician from her office phone.
A side effect of the nicotine patch is difficulty sleeping.
Community Pharmacy
Customer wants to know the rationale behind using NRT during the quitting process.
TT‐MED15
Solution ● If the patient still seems to be hesitant trying Chantix, ask what his expectations are towards pharmacotherapy, and involve the patient in selecting the right product. ● Tell the physician that underlying cardiovascular disease is not an absolute contraindication to NRT, but he is right that we should use it with precaution. ● Inform the physician that NRT products may be appropriate for patients under medical supervision. ● Review the patient case or conduct a patient interview and see how patient is doing with the nicotine patch. Can assess whether to continue the patch afterwards. ● Also confirm the strength the patch is matched with the previous cigarette use. ● Assure that the combination pharmacotherapies are regimens with enough evidence to be recommended first line. Recent studies even showed pts on combination therapy has a higher success rate. ● The product consists of a long‐acting (patch) and a short acting (lozenge) formulation. ● The patch produces relatively constant levels of nicotine, while the lozenge allows for acute dose titration as needed for situational cravings. ● Let her know that she can certainly try on her own way; I am not recommending it from safety and efficacy standpoint ● Educate the pt that there are many unknowns about vaping, including what chemicals make up the vapor and how they affect physical health over the long term. ● While vaping might help promote short‐term smoking cessation, new study suggests it is an ineffective long‐term therapy, might end up to be a dual‐user. ● Ask her what her goal is, get off nicotine or tobacco? If tobacco, this might help, but would not recommend to her, less harmful, but not harmless ● Confirm that the patch is being worn for 24 hours. ● If the patient is wearing the patch for 24 hours, it might be contributing to the sleep disturbance. Recommend that she remove it before bedtime only if cutting caffeine didn’t help. ● Assess for symptoms of nicotine excess. If such symptoms are present, select a lower‐ dose patch. Ask the patient about concurrent tobacco use while on treatment. ● Assess the patient's use of caffeine late in the day. Smoking cessation leads to an estimated 56% increase in caffeine levels. ● Ask the patient to contact you again if she experiences further difficulties sleeping. ● NRT reduces physical withdrawal symptoms, and eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco ● It allows her to focus on behavioral and psychological aspects of tobacco cessation. ● Makes you more comfortable while quitting ● Let the patient know that NRT is not the only option to aid in the process. There are always non‐pharmacologic methods (counseling groups, quitline…) and other types of drugs (varenicline, bupropion SR) if she would like to try.
Page 11 of 11 Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
