Smoking Cessation

Question 1

Approach

Answer 1

Compliment + encourage this man on his readiness to change, and approach this in a non-judgmental manner. I would use the 5-A’s framework + opportunistic GP screening

• Ask
• Assess
• Advice
• Assist
• Arrange

Question 2

Ask

Answer 2

• Smoking history:
  ¬ Pack years, products used, previous quit attempts (+ why did they fail)

¬ Degree of dependence (withdrawal symptoms) \
o High: waking at night to smoke, smoking <5 min after waking, ≥30 cigarettes/day
o Moderate: smoking <30 min after waking, 20-30 cigarettes/day
o Low-moderate: smoking <1 hour after waking, 10-20 cigarettes/day
o Low: no need to smoke in >1 hour after waking, ≤10 cigarettes/day

• Contributing: stress, social pressure,
• Consequences: smoking-related disease, Cardiovascular, Respiratory, GIT, Other: impotence, infertility, impact on children (asthma, child smoking)
  Screen general health – SHX (smoking, alcohol, drugs, diet, physical activity)

Question 3

Assess

Answer 3

• Stage of change (likely ‘contemplation’ or ‘preparation-action’) Pre-contemplation, contemplation, action, maintenance.
  • How do you feel about your smoking atm? Are you ready to stop smoking right now? Next 30 days?
  Assess reasons for quitting – physical health, social issues (issues with partner)

Question 4

Advice

Answer 4

• Non-judgmental, empathetic advice, compliment – The best thing you can do for your health is to quit smoking

Pros and cons of quitting (e.g. costs, health impact), common barriers/reasons for failure (e.g. withdrawal, weight gain, depression, other smokers around), counter measures (coping techniques)

Question 5

Assist

Answer 5

Non-pharmacological

• Motivational interviewing based on stage of change. For preparation-action:
  1. Remind them of their reasons to change, , relapse will not disrupt patient-clinician relationship
  2. Realistic plan + set goals (quit date in 2 weeks)
  3. Stop smoking strategies
• Limit/abstain alcohol , proper nutrition (SNAPs)
• Tell family/friends/co-workers about quitting
  4. Prior to quitting, avoid smoking in places you spend lots of time (work, car, home)
  5. Review past quit attempts, what helped and what contributed to relapse. Anticipate future triggers and challenges
• Referral to Quitline, social support , psychologist (coping skills, CBT), patient education.

Pharmacological

• [1] Nicotine replacement therapy (NRT) – OTC (one patch/day, one gum/hour, one lozenge/1-2 hours)
• [1] Varenicline – most effective, 12-week course, start 1-4 weeks before quitting
• [1] Bupropion – ≈12-week course, start 2 weeks before quitting, inhibits NA and DA uptake

[2] Dual therapy with NRT/varenicline/bupropion

Question 6

Arrange

Answer 6

• Arrange F/U, 2 weeks after varenicline or bupropion

- If relapse, review circumstances and elicit recommitment to total abstinence. Anticipate further challenges in future.