TOBACCO TRIGGER TAPE SYNOPSES
Filename Dialogue Scenario Trigger Tapes for use with the Epidemiology of Tobacco Use module TT‐EPI1 Hey, we’re all gonna die at Man is lying on a some point. So what if I lose patient a couple of years at the end examination table, of my life because I smoke…. talking with his clinician.
Solution
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.
● First, say, “You enjoy smoking and at this point you’re thinking if you lose a couple of years, it’s no big deal.” ● Next (after patient says, “Right”), say the following, “I want you to know the decision to smoke or quit is really yours. What I worry about is that oftentimes, smokers don’t just die a few years early. They often suffer from lung disease, heart disease, kidney disease and the like. Often it is very painful. I don’t want to see that happen to you. What are your thoughts?” ● Quitting smoking has immediate as well as long‐term benefits to health. It is never too late to quit and incur benefits, but sooner is better. Smoking reduces lifespan but also significantly reduces quality of life. It also is expensive to smoke, and the cost of treating tobacco‐related diseases can be significant. ● First, say, “You’re surprised to find out that snuff is actually harmful, too.” ● Next, after the patient responds, say, “Snuff and other smokeless products can cause cancer of the mouth, throat, esophagus and pancreas, along with gum disease, tooth decay, and tooth loss. What are your thoughts about not using any tobacco product? I would like to help you quit.” ● There is no safe form of tobacco. All tobacco naturally contains many toxins, including significant numbers of cancer‐causing substances. ● Smokeless tobacco products are likely less harmful than combustible forms of tobacco, but they are not harmless and do lead to cancer. Smokeless tobacco use also contributes to oral disease (leukoplakia, gum disease, tooth decay and tooth loss). ● First, say, “You care about your daughter and you don’t want to see her asthma flare up, so you smoke outside and not in the house.” ● Next, after the patient responds, say, “Would you mind if I share a few thoughts with you and you tell me what you think?” ● If the patient says, “Yes, but I’m not ready to quit” or “OK,” say the following, “I know that the decision to smoke or quit is yours. I like that you want to do what’s best for your daughter. Even though you smoke outside, the smoke from the cigarette can get on your clothes and skin. If you hold or hug your daughter, this residue can irritate her lungs and trigger an asthma attack. Her lungs are just so much more sensitive than ours. What do you think of all of this?” ● Smoke can stay on clothes and hair for hours after smoking. This smoke can irritate a child’s lungs and induce an asthma attack.
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.
Many smokers are switching to spit tobacco under the mistaken impression that it is a safe alternative to smoking.
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.
Page 1 of 19
Problem
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
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.
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?
TT‐EPI5
I already have cancer. What’s the point in quitting?
Hospital room
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.
TT‐EPI6
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?
Page 2 of 19
These patients feel that they will inevitably go through significant physical withdrawal when quitting.
Solution ● If an individual smokes outside but near an open window or door, the smoke can still enter their home. Although they aren’t smoking near their child, it can still cause harm. ● First, say, “Actually, I have some good news. It’s never too late to quit. Quitting and staying quit can allow your body to begin to make positive physical changes to improve your health. What do you think about that? ● It is never too late to quit smoking. Many of the positive physical changes that occur as a result of quitting happen within weeks or months, and research shows that even people in their 70s and 80s benefit from quitting. Furthermore, even if someone has a smoking‐related illness, quitting can reduce the rate of disease exacerbation. ● First, say, “Things seem pretty bad (hopeless) because you already have cancer, so why give up smoking at this point?” ● Next, after the patient responds, say, “You raise an important question. We know that even though you already have cancer, if you quit smoking, it can help your treatment (chemo, radiation) work more effectively. Smoking also interferes with and can impact the success of surgery if it is needed. Finally, smoking exposes your body to cancer causing chemicals which can increase the chances of additional tumors. I know this is a lot. What are your thoughts?” ● 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. ● First, say, “You’re thinking that smoking will help you feel less miserable after surgery. You worry about going through withdrawal.” ● Next, after the patient responds, say, “I sure don’t want you to go through withdrawal symptoms on top of surgery. Your doctor is going to want you to stop smoking before surgery, because smoking can make surgery riskier…and you can’t smoke in the hospital. I have a number of medications that are effective for quitting that will really reduce withdrawal symptoms. What are your thoughts?” ● There are seven effective medications for quitting that will significantly reduce withdrawal symptoms from nicotine, and these make patients more comfortable while quitting (or while abstaining during the surgical period, if the patient has no desire to quit long‐term).
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐EPI7
I’m only 27…it’s not like I’ve been smoking that long. Besides, I only smoke when I drink.
N/A
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.
TT‐EPI8
What do you mean, you won’t do my surgery unless I quit?
Clinician’s office
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.
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
Patients do not always attribute their illnesses (or exacerbation of their illnesses) to their tobacco use.
Page 3 of 19
Solution ● 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. ● First, say, “You’re fairly young and don’t smoke that often so you’re wondering, what’s the problem?” ● Next, after the patient responds, say, “Unfortunately there is no safe level of smoking. Even people who smoke very little can develop serious illnesses from smoking. It’s really an interaction between the harmful chemicals in cigarette smoke and how your body reacts to them. That’s the part that’s not predictable. Plus, nicotine is addicting. Eventually, if you keep smoking even though it is only when you drink, your body will want more. I’d like to hear your thoughts about all of this.” ● 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. ● First, say, “You’re surprised that I would refuse to do your surgery if you don’t quit.” ● Next, after the patient responds, say, “Smoking can create all sorts of problems regarding surgery. Often, more anesthesia is needed, wounds don’t heal as well after surgery, smoking reduces your body’s immune response or healing process, and can, in general interfere with surgical outcomes. This might be a good time to consider quitting for good. I’d like to help. What are your thoughts?” ● 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: (a) result in the need for increased anesthesia, (b) reduce wound healing, (c) interfere with immune response, and (d) negate surgical outcomes ● Reframe surgery as the ideal time to quit and review available quitting options at your institution. ● First, say, “It’s annoying to you that people keep bugging you about your smoking. It’s enough that you have to deal with your diabetes and you just don’t see how one affects the other.” ● Next, after the patient responds, say, “Some of the chemicals in cigarettes actually interfere with your body’s ability to use insulin. Increasing your insulin use is the whole point of the medication you’re taking. So, smoking really makes it harder to control your diabetes and increases your chances
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TT‐EPI10
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
I heard that vaping is way safer than smoking, so shouldn’t I switch?
Scenario
Problem
Clinician’s office
Patient mistakenly believe that vaping is much safer than smoking regular cigarettes.
Trigger Tapes for use with the Assisting Patients with Quitting module TT‐ASSIST1 Yes, I smoke. Why do you N/A Patient appears to be surprised ask? that he’s asked about smoking, and is not aware of the importance of quitting.
TT‐ASSIST2
Page 4 of 19
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.
Solution for complications from both your diabetes and your smoking. What are your thoughts?” ● Some of the chemicals in cigarettes can affect how the body uses insulin so there is a direct connection between diabetes and smoking. ● Quitting will give patients the best chance of staying as healthy as possible and minimizing the effects of their diabetes. ● Many patients with 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. ● First, say, “While smoking is much worse than vaping, vaping is not really safe because the aerosol that people breathe from the device and exhale contains harmful substances.” ● Next, after the patient responds, say, “What would it take for you to quit altogether? I can’t think of anything more important to protect your health. I’d like to help.” ● Inform the patient that while smoking is likely worse, vaping is not safe because the aerosol that the users breathe from the device and exhale contains 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. ● First, say, “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. I would hate to see you become ill or cause harm to yourself as a result of smoking. What are your thoughts about quitting?” ● 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.” ● First, say, “You want to make sure that if you use the quitline that it will actually work.” ● Next, after the patient responds, explains what the quitline can do that directly addresses the patient’s issues.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
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, are
Page 5 of 19
Solution ● The quitline is staffed by highly trained specialists, and individuals who enroll can receive up to 4–6 personalized sessions. ● Services provided by the quitline includes individualized telephone counseling, quitting literature mailed within 24 hrs, and referral to local programs. ● It is a free service. ● First, say, “The decision to choose a way to quit really is your decision. While some people can quit cold turkey, they often have a difficult time without help from medication. Would you mind if I ask you a few questions about your tobacco use? This will help determine whether cold turkey is likely to be successful for you. People who use medications are more successful and more comfortable while they are quitting.” ● Ask the patient about his tobacco use to determine whether he needs a nicotine replacement therapy. ● 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. ● First, say, “You worry that if you try to quit again, you’ll fail again and go back to smoking after you get home. It’s been a vicious cycle.” ● Next, after the patient responds, say, “Quitting is a process. In fact, we can learn from your past quit attempts…what worked for a while and then what made it difficult to sustain that. I could work with you and refer you to professionals who can really work with you and increase the chance you will quit for good. What do you think?” ● 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. ● First, say, “Sounds like you understand the importance of quitting to your health. You just don’t want to gain a lot of weight after quitting.”
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem concerned about weight gain after quitting.
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.
Some smokers think that nicotine burns thousands of calories and that without it they will have significant weight gain.
TT‐ASSIST7
I can’t live without cigarettes. I just can’t!
Patient with psychiatric illness reacts to the notion of quitting.
Many patients with psychiatric illness believe they cannot function without smoking and are extremely fearful of quitting.
Page 6 of 19
Solution ● Next, after the patient responds, say, “We can work together to help you keep your weight off after quitting. I have a number of suggestions that have been successful for other patients and you can tell me which ones you would be willing to try.” ● Encourage healthy diet and meal planning; suggest increasing water intake or chewing sugarless gum. ● 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. ● First, say, “You know that quitting would be really good for your health. You’re just worried about gaining weight when you quit.” ● Next, after the patient responds, say, “We can work together to help you keep your weight off after quitting. I have a number of suggestions that have been successful for other patients and you can tell me which ones you would be willing to try.” ● Acknowledge patient’s concerns. Advise patient to try to put his or her concerns about weight on the back burner temporarily. Patients are most likely to be successful if they first try to quit smoking, and then later take steps to reduce weight. 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 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. ● First, say, “You can’t imagine your life without cigarettes. Quitting seems impossible.” ● Next, after the patient responds, say, “I really believe I can help you with a number of approaches that could help you quit successfully...and improve your health. Would you be willing to let me talk with you about some approaches? After we’re doing, if you don’t want to quit, I promise I won’t bug you. What do you think?”
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐ASSIST8
I just have too much stress in my life to even think about quitting.
Patient examination room
TT‐ASSIST9
You don’t know what it’s like…you’ve never smoked.
Clinician’s office
Page 7 of 19
Solution ● Generally speaking, you will approach patients with psychiatric illness in a slightly different manner than patients in the general population. Because smoking is viewed by the vast majority of these individuals as a central part of their life, quitting altogether on a specific day may be untenable and overwhelming. Therefore, it is possible that a tapering schedule, with an eventual quit day, may be more efficacious 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. The pervasive belief that ● First, say, “You’ve learned to rely on a cigarette when you feel stressed. You smoking either gets rid of stress wonder how you would deal with the stress if you quit.” or helps the smoker deal with ● Next, after the patient responds, say, “I want you to know that smoking stress prevents many smokers cigarettes actually can increase stress. I suspect that when you smoke, at from attempting to quit or least temporarily, you remove yourself from the stress and feel a bit better. prompts them to relapse back It’s not the cigarette that’s reducing the stress, it’s YOUR action that helps. I to smoking once they have believe I can help you with things you can do to reduce your stress without quit. putting your health at risk. You’ve already learned one…removing yourself from the situation temporarily. What do you think?” ● 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. Many patients who smoke ● First, say, “You wonder how someone who doesn’t or hasn’t smoked can think that only an ex‐smoker help you. How can I possibly know what it’s like?”
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem can be an effective cessation counselor.
TT‐ASSIST10
What do you mean I can’t go outside and smoke?
Patient with IV pole, in hospital hallway, attempting to go outside to smoke
Many hospitalized patients think that they have the “right” to smoke and that they can leave the hospital at any time to do so.
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?
N/A
There is a belief that exercise, especially aerobic type workouts, will mitigate the negative effects of smoking.
Page 8 of 19
Solution ● Next, after the patient responds, say, “I have worked with a lot of patients in helping them quit. I needed their help to do that because each person who smokes is different. I need your help so I can better understand your smoking habits so we can work together on a quit plan. How does that sound?” ● 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. ● First, say, “You’re upset because we won’t let you go outside and smoke.” ● Next, after the patient responds, say, “Smoking has contributed to the reason you’re in the hospital. I care about the health of my patients. It’s not ok with me to allow you to do anything that may harm your health while you’re here. Given that you can’t smoke while you here, what do you think about looking at this as a great time to consider quitting and improving your health outlook?” ● 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. ● First, say, “I think it’s great that you’re so committed to working out. You’re wondering what’s the big deal if you smoke a few cigarettes?” ● Next, after the patient responds, say, “You raise a good question. What we know is that no amount of exercise can counteract the negative effects of cigarettes…even a few cigarettes. Your lungs, heart, and other organs can still be damaged by the toxic chemicals in cigarette smoke. You’re committed to exercise because it sounds like health is important to you. I hate to see you undue that with smoking. What are your thoughts?” ● 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.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
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.
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.
Page 9 of 19
Solution ● 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. ● First, say, “It’s hard to imagine quitting when so many people you are around smoke.” ● Next, after the patient responds, say, “While it seems daunting to quit given that many people you know smoke, I know many people who have quit even though they have friends and family who smoke. I have several suggestions for handling this. I would really like to see you quit. Would you be willing to hear my suggestions and then decide what you want to do?” ● 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 specific 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. – 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. ● First, say, “Wow…you have been quit a whole month. That’s terrific! How have you done it? I would love to share your success story with other patients.” ● Next, after the patient responds, say, “I’m wondering if you would consider finding a healthier way of rewarding yourself for the hard work you have put it? I know, it’s just one cigarette. I do worry that one can lead to two…and so on. Nicotine is addicting. An any inhaled smoke is harmful. What do you think?” ● 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!”
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename TT‐ASSIST14
TOBACCO TRIGGER TAPE SYNOPSES Dialogue The last time I quit, my depression got worse. I’m just starting to feel good now…I don’t want to backslide.
Scenario Clinician’s office
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
TT‐ASSIST16
But won’t the stress of quitting increase my chances of drinking again?
Counselor’s office
Page 10 of 19
Problem Patients often understand the link between smoking and depression and fear that quitting will impact their depression.
Solution ● First, say, “You’re feeling good right now…you’ve taken steps to start feeling better and you don’t want that to change by quitting.” ● Next, after the patient responds, say, “I don’t want you to backslide either. I really believe I can work with you and coordinate with your doctor and a psychiatry pharmacist to develop a quit method specifically for you so you don’t backslide. What do you think of that?” ● 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. Many patients believe they ● First, say, “I sure don’t mean to hassle you. I do know that the decision to cannot function without smoke or quit is yours. I do care about the health of my patients. I have smoking and are extremely helped several patients quit who could not imagine their lives without fearful of quitting. cigarettes. Would you be willing to talk with me about your smoking?” ● Impress upon the patient that you are concerned about her health and you want her to be as healthy as possible. Also stress that you are not telling her that she has 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. Because smoking and drinking ● First, say, “You worry that if you quit smoking the stress will cause you to (alcohol) are closely associated relapse back into drinking. That scares you.” ● Next, after the patient responds, say, “I have good news. There is no for many patients, they commonly assume that quitting evidence that quitting causes people to relapse into drinking. The research smoking will lead to an increase shows the opposite…that is people who quit smoking are more likely to stay or return (for those who are sober. Cigarette smoke actually INCREASES anxiety. What are your abstinent) to drinking. thoughts?”
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
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
Page 11 of 19
Solution ● 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. ● 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. Most patients who live in group ● First, say, “It’s hard to imagine quitting when so many people you are homes perceive it will be very around smoke.” difficult to quit when others are ● Next, after the patient responds, say, “While it seems daunting to quit given smoking around them. that many people you know smoke, I know many people who have quit even though they have friends and family who smoke. I have several suggestions for handling this. I would really like to see you quit. Would you be willing to hear my suggestions and then decide what you want to do?” ● Consider telling the patient that you will work with her to create a plan so that she will be able to deal with this situation and be comfortable in her group 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. Patients mistakenly attribute ● First, say, “You’ve learned to really on a cigarette when you feel stressed. relief of withdrawal symptoms You wonder how you would deal with the stress if you quit.” ● Next, after the patient responds, say, “I want you to know that smoking cigarettes actually can increase stress. I suspect that when you smoke, at least temporarily, you remove yourself from the stress and feel a bit better. It’s not the cigarette that’s reducing the stress, it’s YOUR action that helps. I believe I can help you with things you can do to reduce your stress without putting your health at risk. You’ve already learned one…removing yourself from the situation temporarily. What do you think?” ● 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.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
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.
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.
Many adolescent smokers believe mistakenly that they can “control” their smoking. They clearly underestimate the addictive nature of nicotine. Evidence shows that, in some
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Solution ● 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. ● First, say, “You’re thinking that if the doctor didn’t mention quitting, it can’t be that serious.” ● Next, after the patient responds, say, “I’m not sure why your doctor didn’t mention anything about your smoking. She may have been very focused on your heart disease. I do know that smoking can make your condition much worse. There’s a good chance that smoking was a cause of your heart disease. Would you be willing to talk with me about quitting?” ● Unfortunately, many physicians do not address tobacco use for a variety of reasons (often due to time constraints). However, that is not meant as an endorsement to continue to smoke. The scientific evidence is very clear…smoking is the leading known preventable 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. ● First, say, “Given how long and how much your grandfather smoked, you’re thinking, what’s the problem if you smoke?” ● Next, after the patient responds, say, “You raise a good question. I hope you live and long and HEALTHY life. I worry that anyone who smokes puts themselves at risk of heart disease, lung disease, kidney disease, etc. While you are related to your grandfather, people within families vary…different eye color, hair color, height…you have to decide do you want to hope you can live as long as your grandfather or do you want to take steps now to reduce your risks of poor health through smoking. I have met many patients who started smoking at your age who now have emphysema, asthma, and high blood pressure, etc. I don’t want to see that happen to you. What are your thoughts?” ● 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. ● Focus the patient on how these potential health effects could negatively impact their ability to engage in favorite activities.
First, say, “You limit your smoking to time with your friends so right now
you’re not worried about your smoking.” Next, after the patient responds, say, “Unfortunately there is no safe level of smoking. Even people who smoke very little can develop serious illnesses from smoking. It’s really an interaction between the harmful chemicals in
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TT‐ASSIST22
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
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?
Scenario
Problem youth, the establishment of dependence can occur rapidly.
Solution cigarette smoke and how your body reacts to them. That’s the part that’s not predictable. Plus, nicotine is very addicting. Eventually, if you keep smoking even though it is only when are with your friends, your body will want more. I’d like to hear your thoughts about all of this.” Educate the patient on the nature of nicotine and dependence. Nicotine is a very addictive drug. Consider saying, “Although you may start out smoking just occasionally, the body begins to demand more and more nicotine until you are smoking 20–30 cigarettes a day in order to feel comfortable. This happens to almost every smoker.” Research conducted with high school smokers shows that in spite of saying that they could quit any time they wanted to, more than 85% of 9th graders who smoked were still smoking in their first year of college, with most of them smoking much more than they did in 9th grade.
Community pharmacy (probably located in a grocery store)
Many smokers do not understand why they are asked about tobacco use at the pharmacy when there are tobacco products sold in the front of the grocery store.
First, say, “Seems very hypocritical that I would ask you about smoking and
Trigger Tapes for use with the 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.
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this store sells cigarettes.” OR “It is hypocritical. I don’t like that we sell cigarettes. We don’t sell cigarettes in the pharmacy itself and I make every effort to talk to my patients who smoke about quitting. Does that help?” 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.
● First, say, “You don’t like taking any drugs if you don’t have to…” ● Next, after the patient responds, say, “I wouldn’t want you to take any medicines that aren’t necessary. Nicotine in cigarettes is an addictive drug that is going into your body, along with 4000 substances contained in each cigarette. Hard to believe, isn’t it? I’m asking you to consider taking one drug for a short period of time so that your body no longer needs all those other harmful substances. How does that sound?” ● Explain to the patient that she is putting lots of chemicals in her body every time she smokes. Each cigarette contains over 4,000 substances, many of which are known or suspected human carcinogens. Any smoking cessation medication contains only one drug that has been shown to be an effective way to help smokers quit for good. ● Ensure that the patient understands that although nicotine is the addictive drug found in cigarettes, it is not what causes the majority of negative health Copyright © 1999‐2019 The Regents of the University of California. All rights reserved. Many smokers mistakenly view the cessation products negatively while not understanding the real negative consequences of the chemicals found in cigarettes.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐MED2
All those smoking medications cost way too much.
N/A
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
Community Pharmacy
Many smokers believe that they cannot afford smoking cessation products.
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Solution 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. ● The vast majority of patients use smoking cessation medications for a short period of time. These medications have been proven to be safe and effective through dozens of clinical trials. They help to slowly reduce dependence on nicotine while immediately eliminating all the other toxic substances found in cigarettes. ● First, say, “You’re worried about the what it will cost you to take medication to stop smoking.” ● Next, after the patient responds, say, “Most of the smoking cessation products cost between $3.50 and $5.00 a day. This is the same as one pack of cigarettes. In a short time, you will no longer need to smoke, and you won’t have to spend money on either cigarettes or medicine to quit. And this doesn’t even include the long‐term costs of illnesses that are caused by smoking. Where does this leave you now regarding the cost of quitting?” ● Do the math with the patient. 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. ● First, say, “That’s a really good question. Nicotine from smoking reaches the brain in 11 seconds. Nicotine from all the gums and patches, for example, take five minutes to six hours to reach their peak levels. It’s the SPEED that nicotine reaches the brain through smoking that causes the addiction. The medicines provide much lower levels of nicotine at a much slower rate. These products greatly improve the chances of quitting successfully. And, they are only used for a short time. What do you think of all this?” ● 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. 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. ● First, say, “You’re worried about how much patches cost.” ● Next, after the patient responds, say. “Most of the smoking cessation products cost between $3.50 and $5.00 a day. This is the same as one pack of cigarettes. In a short time, you will no longer need to smoke, and you
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue just don’t have that kind of money.
Scenario
Problem
TT‐MED5
Hmm. Is it safe to use the patch and the gum at the same time?
Community pharmacy
Many smokers are not aware of the fact that cessation products can be used concurrently.
TT‐MED6
But I’ve tried everything…none of these quit smoking medicines ever worked for me.
Clinician’s office
Some smokers believe that cessation products are not effective.
TT‐MED7
So…what do you think about e‐cigarettes for quitting?
Community pharmacy
Many smokers believe that e‐ cigarettes are less harmful than cigarettes and consider them as
Page 15 of 19
Solution won’t have to spend money on either cigarettes or medicine to quit. And this doesn’t even include the long‐term costs of illnesses that are caused by smoking. Where does this leave you now regarding the cost of quitting?” ● 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?” ● First, say, “Yes it is. I want to assure you that taking the two together is very safe. In fact, recent studies show that combining medicines has a higher success rate. The patch is long acting, and the gum helps with cravings that may come up. They work together. How does that sound to you?” ● 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. ● First, say, “Seems like you’ve tried everything, and nothing has worked. You’re not sure if you want to try again.” ● Next, after the patient responds, say, “I want to help make sure that anything that you try really works for YOU. In order to do that and understand better why these medicines didn’t work for you, I need to ask you some questions. Would that be ok?” Then see below. ● 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. ● This is straight forward information provision, a motivational interviewing response is not needed.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem 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.
Page 16 of 19
Solution ● Although traditional cigarettes are likely much more harmful, explain to the patient that e‐cigarettes also contain harmful products that can negatively impact health. We also don’t know about the long term effects. These products are likely 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. ● First, say, “Sounds like you’re worried about using Chantix." ● NEXT – see below. Find out what the patient has heard specifically. ● “Which side effects are you referring to?” ● Address the FDA’s removal of the black boxed warning. There was a very large research study conducted showing that the neuropsychiatric 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. ● First, say, “First of all, that’s great about not having smoked for a week! Sorry to hear you’re having trouble sleeping. Let’s see if we can figure out what’s going on. In order to do that I need to ask you a few questions. Is that ok?” Then see below. ● 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.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename TT‐MED10
TOBACCO TRIGGER TAPE SYNOPSES Dialogue First I hear that Chantix is bad. Now you’re saying it’s OK. What gives?
Scenario Clinician’s office
Problem Patient is hearing different information on Chantix, and asks for clarification.
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, because,e her friends quit by vaping.
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Solution ● First, say, “You’re hearing conflicting information about Chantix and that has you worried about whether you should use it.” ● Next, after the patient responds, say, “Please tell me a bit more about what you have heard so that I can address specific issues for you.” ● 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. ● If the patient still seems to be hesitant trying Chantix, ask what his expectations are towards pharmacotherapy, and involve the patient in selecting the product. ● First say to the physician, “You’re concerned about the use of a patch with a patient with a recent MI.” Wait for a response then simply provide the information below. ● 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. ● First, say, “You’re worried about getting too much nicotine by using the patch and lozenge together.” ● Next, after the patient responds, say, “I want to assure you that taking the two together is very safe. In fact, recent studies show that combination therapy has a higher success rate. The patch is long acting, and the lozenge is short acting. They work together. How does that sound to you? ● 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. ● First, say, “Vaping seems like a good idea, because a few of your friends quit that way.” ● Next, simply provide the information below.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
Filename
TOBACCO TRIGGER TAPE SYNOPSES Dialogue
Scenario
Problem
TT‐MED14
Hi. This is Veronica Ward. I Woman calls her was in last week, and you clinician from her helped me with the nicotine office phone. 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?
A side effect of the nicotine patch is difficulty sleeping.
TT‐MED15
Now…why would I want to put nicotine in my body if I wanted to quit smoking?
Customer wants to know the rationale behind using NRT during the quitting process.
Page 18 of 19
Community Pharmacy
Solution ● Let her know that she can certainly try on her own way; however, vaping is not FDA‐approved for cessation so it is not recommended for quitting at this time. ● Educate the patient that there are many unknowns about vaping, including what chemicals make up the vapor and how they affect physical health over the long term. ● Ask her what her goal is—to get off of nicotine or tobacco? If tobacco, this might help, but it is not harmless. And she might become a life‐long vaper as a result. ● This one is straightforward regarding the questions and information below. You might start with, “Sorry you’re having a hard time sleeping. Let’s see if we can figure out what’s going on. In order to do that I’d like to ask you a few questions. Is that ok?” ● 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. ● First, say, “That’s a great question. Nicotine from smoking reaches the brain in 11 seconds. Nicotine from all smoking cessation products take five minutes to six hours to reach their peak levels. It’s the SPEED that nicotine reaches the brain through smoking that causes the addiction. The nicotine products provide much lower levels of nicotine and at a much slower rate. They reduce physical withdrawal symptoms and make you more comfortable while you are quitting. These products greatly improve the chances of quitting successfully. And, they are only used for a short time. What do you think of all this?” ● 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 patients feel 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.
Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
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Copyright © 1999‐2019 The Regents of the University of California. All rights reserved.
