stop smoking by tarmadi12


                                                                                                                                                            IPCRG OPINION 3

Helping patients quit smoking: brief
interventions for healthcare professionals
                                                             How to help smokers quit: flowchart
              Ask about tobacco use (smoking and smokeless tobacco) for all patients and reassess users at every clinic call/at least once a year.
                           This alone doubles the rate of success. Document smoking status/stage of motivation/tobacco burden.

ASK                                                              Have you used tobacco in the last 12 months?

 No – never: Congratulate.                                         Yes - Quit in the last 12 months:                                    Yes – Current smoker: Take brief smoking
 Reinforce non-use. Patients who have smoked                       Congratulate.                                                        history including number of cigarettes smoked
 in the past should be asked about smoking for                     Ask if they need help to remain smoke free.                          a day, year started smoking, presence of
 some years after quitting. Relapse is unlikely                    Advise them to contact you or to seek other                          smoking-related disease, previous quit attempts
 after 5 years abstinence.                                         counselling if they have any difficulty (quit line,                  and what happened?
                                                                   smoking cessation clinic, other …)                                   Use non-judgmental questions such as “How
                                                                                                                                        do you feel about your smoking at the moment?
ASSESS:         Motivation to stop:                                                                                                     Express concern/interest and not criticism.
On a scale from 1-10 how interested are you in trying to quit?

         1                     2                      3             4                  5                  6                  7                    8                    9                   10

                                                                 Are you planning to QUIT in the next 6 months?
                   Not planning to QUIT                             Planning to QUIT within the next 6 months                                    Planning to QUIT within a month

                  NO                                                        YES, but not yet...                                                                YES
               NOT READY                                                UNSURE (CONTEMPLATION)                                                            READY TO QUIT
                                                                 ADVISE                                                                    ASSIST
 • Focus on motivation.                                          • Focus on their ambivalence, help them                                   • Provide assistance in developing a quit
 • Advise the patient on the benefits of quitting                  motivate themselves.                                                      plan.
   without criticism/confrontation.                              • Offer help by asking:                                                   • Help patient to set a quit date. Discuss
 • Respect the patient’s decision.                                 “What are the things you like and don’t like about your                   abstinence and suggest coping
 • Ask if you may tell the patient about the                       smoking?”                                                                 strategies. Encourage social support.
   dangers of smoking.                                             “Have you tried to quit before?”                                        • Assist in dealing with barriers such as fear
                                                                   “How did you get on when you last quit?”                                  of failure, stress coping, weight gain, social
 ADVISE                                                            “What would have to happen for your motivation score                      pressure.
 • Ask, “Is there anything that might help you                     to increase?”                                                           • Give nutritional advice: sleep well, avoid
   consider quitting?” or “Can you imagine any                     “How can I help you increase your confidence in quitting?”                caffeine and alcohol.
   benefits of quitting?”                                                                                                                    Physical activity may help.
 • Offer help if the patient should change                                                                                                 • Assist in giving advice on
                                                                 • Explore barriers to cessation.
   his/her mind.                                                                                                                             pharmacotherapy for smoking cessation:
                                                                 • Offer help quitting.
 ARRANGE                                                         • Refer to quit line or other counselling, refer                            NRT (adequate dosage during sufficient
 • Follow up – ask patient if you should                           to smoking cessation unit if patient prefers.                             time, help through the first 4-7 weeks).
   discuss smoking again at next consultation.                   • Hand out written material/contact numbers.                                Withdrawal symptoms occur mostly
                                                                 • Follow up consultation or telephone contact                               during the first 2 weeks and are fading
                                                                   within 6 months OR remember to ask when                                   after 4-7 weeks.
                                                                   you next see the patient.                                               • Assist with a prescription for varenicline
                                                                                                                                             or bupropion when indicated.
                                                                                                                                           • Follow-up consultations/phone calls
                                                                                                                                             - ideally weekly first weeks, then monthly.

                                        5 As of smoking cessation: ASK, ASSESS, ADVISE, ASSIST, ARRANGE1

                                                                      Writer: Dr Svein Hoegh Henrichsen Reviewer: Dr Nicholas Zwar Editor: Hilary Pinnock
                                                                      Supported by an unrestricted educational grant from Pfizer.
                                                                      The views expressed in this sheet are not necessarily those of the IPCRG.

                                                                      The IPCRG is a registered charity (SC No 035056) and a company limited by guarantee (Company No 256268)
                                                                      Registered offices: Department of General Practice and Primary Care, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY
THE BENEFITS OF QUITTING                          Adverse effects: Skin rash, allergy,
• If you quit before the age of 30 your           insomnia, wild dreams.
                                                  Gum: (chew and park); inhalers,
  health risk is near the risk of a non-smoker.
                                                  lozenges, sublingual tablets:     To be
• The risk of having a low birthweight baby
                                                  administered every 1-2 hours for relief of
  drops to normal if you quit before                                                                                              Unless current smokers quit,
                                                  symptoms while awake.
  pregnancy or during your first trimester.                                                                                       deaths will rise dramatically
                                                  Adverse effects: Include sore dry mouth,                                        over the next 50 years
• Fertility increases.
                                                  dyspepsia, nausea, headache, jaw ache.                                          (millions)
• Within 72 hours: blood pressure                                                                                                                                            520
                                                  Often dose dependent.                                                                                                        500
  decreases, pulse rate drops, the risk of a                                                                                       500      If proportion of young
  heart attack decreases, and the ability to                                                                                                adults taking up smoking
  smell and taste increases.                      OTHER MEDICATIONS                                                                         is halved by 2020
• Within a couple of weeks: lung function         Varenicline                                                                      300
  increases, circulation improves and             Varenicline is a new nicotinic receptor
                                                                                                                                   200          Baseline
  walking becomes easier.                         agonist/antagonist. It is the first drug                                                                             190
• Within a year: shortness of breath and          designed for smoking cessation. Results                                          100             70       If adult consumption
  fatigue improves, coughing decreases            are promising with quit rates up to 44%.                                                                  is halved by 2020
  and the excessive risk of coronary heart        Dosage: A week before the quit date take
                                                                                                                                     1975          2000         2025         2050
  disease becomes half that of a smoker.          0.5 mg for 3 days, 0.5 mg b.i.d. for 4
• Within 5 years: risk of ulcers decrease.        days, then from the quit date take 1 mg
                                                                                                                        Source: Peto and Lopez 2001. First appeared: Finance &
  The risk of cancer of the bladder, kidney,      b.i.d. for 12 weeks.                                                  Development, 1999, Vol. 36, No. 4, published and copyrighted
  mouth, oesophagus, pancreas, and throat         Adverse effects: nausea and headache.                                 by the International Monetary Fund.

  decreases.                                      Seizure has not been seen as an adverse
• Within 5-15 years: the risk of having a         event.
  stroke and the risk of coronary heart           Pregnancy: Should not be used during
  disease is reduced to that of a never           pregnancy.                                                            PRACTICAL HINTS FOR
  smoker. The risk of lung cancer is half                                                                               PATIENTS
  that of a continuing smoker.                    Bupropion                                                             These are suggestions for coping with
                                                  Bupropion is the first medication proven to                           cravings to smoke and ways to reduce the
MEDICATION                                        reduce craving.                                                       risk of relapse. Cravings are most frequent
Any patient smoking more than 10 cigarettes       Dosage: It is taken twice daily starting                              in the first few days after quitting. If you
a day will suffer from withdrawal symptoms        with one tablet a day for a week two                                  use nicotine replacements, varenicline or
                                                  weeks prior to the quit date, then regularly                          bupropion you will reduce your symptoms
and should be offered pharmacologic
                                                  150 mg b.i.d. for 7-12 weeks.                                         of nicotine withdrawal.
support once they set a quit date.
                                                  Adverse effects: insomnia, headache, dry
                                                  mouth, dizziness, anxiety.                                            Remember the 4 Ds:
Nicotine Replacement therapy (NRT)
NRT should not be combined with                   Contraindications: Seizures, major                                    • Delay acting on the urge to smoke. After
smoking. Its main effect is to help the           depression, schizophrenia.                                              5 minutes the urge to smoke weakens
patient through the first couple of months of     Pregnancy: Should not be used during                                    and your resolve to quit will come back.
craving. Most patients use too low doses          pregnancy.                                                            • Deep breathe. Take a long slow breath in
for too short a time. They should use a                                                                                   and slowly release it out again. Repeat 3
dose that takes away most craving                 Nortriptyline                                                           times.
symptoms. Most people need a full dose            Nortriptyline is a tricyclic antidepressant                           • Drink water slowly holding it in your
for 2-3 months, then they might gradually         which has been shown to increase                                        mouth a little longer to savour the taste.
reduce dose over a number of months.              cessation rates from 7% to 17% compared                               • Do something else to take your mind off
Dosage: It is often wise to combine two           to placebo (NNT=10). It is not licensed for                             smoking. Doing some exercise is a good
different NRTs - a patch to cover most of the     use in smoking cessation, but may be an                                 alternative.
day and gum or other types of NRT for             option in countries where the cost of
craving situations during daytime.                licensed smoking cessation drugs is                                   Avoid major triggers for smoking early in
Patch: Comes in 14 mg/24 hours or 10              prohibitive. Recognised side-effects include                          your quit attempt. Common triggers are
mg/16 hours for light smokers (<10 cig/day)       sedation, dry mouth, and cardiac                                      alcohol, coffee and friends who smoke.
or in 21 mg/24 hours - 15 mg /16 hours for        arrhythmia: recent myocardial infarction is
more heavy smokers. Some patients need            a contra-indication. Treatment, at a dose of                          Remember: Just one will hurt. Thinking “I
more than one patch a day to keep the             75mg daily (less in elderly) is usually                               can have just one” is the way most people
craving low.                                      maintained for seven to twelve weeks.                                 go back to regular smoking.

                                                  Source: Coping Strategies for Smoking Cessation. Copyright Commonwealth of Australia. Reproduced with permission.

                                                  1. Fiore MC, et al.”Clinical Practice GuidelineTreating Tobacco Use and Dependence”. U.S. Department of Health and
                                                     Human Services Public Health Service June 2000

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