TOBACCO TRIGGER TAPE SYNOPSES - Rxforchange

TOBACCO TRIGGER TAPE SYNOPSES
Tape Dialogue Scenario Problem Solution
1
2
3
“WHAT!! More than a
hundred dollars for
Zyban I’d rather
continue to smoke!”
“I was recently watching
TV and I saw an ad for
an all-natural medication
for quitting smoking. Do
these things really
work”
“No, I think I’d rather
quit cold turkey and do
it on my own. I don’t
need no help.”
Man is holding and
examining a
prescription bottle.
Woman approaches a
counter to ask the
clinician a question.
Man is sitting on the
end of a patient
examination table.
The initial financial outlay for
cessation medications might
surprise many patients. This could
be a barrier to use of
pharmacotherapy.
Several herbal aids for cessation
are available. Although it is
possible that these products are
effective, their safety and efficacy
have not been established with
scientific rigor.
Many smokers try to quit without
assistance, despite the proven
positive impact of behavioral
counseling and pharmacotherapy.
• Consider advising the patient that the daily cost of pharmacotherapy is
comparable to that of cigarettes. The difference is the amount of cash
outlay at a given time (e.g., approximately $4–$7 per pack of cigarettes
versus approximately $50 for a box of nicotine replacement therapy).
• Remind the patient that although pharmacotherapy is expensive, it is for
a finite period, unlike the cost of continued smoking.
• Have the patient calculate what he spends on cigarettes each year and
compare that with the potential cost of therapy.
• Consider splitting the prescription into partial fills.
• Ask the patient whether she knows the name of the product and its
active ingredients.
• Explain to the patient that numerous studies have proven that nicotine
replacement therapy products and bupropion SR double the likelihood of
quitting. In comparison, the effectiveness of herbal treatments has not
been established.
• Encourage the patient to consider using one of the first-line FDAapproved
agents for quitting in addition to behavioral counseling, but
respect the patient’s decision. If she is reluctant to use an approved
medication, despite the information you provide, be sure to facilitate the
quit attempt through behavioral counseling.
• Ask the patient, “What would not using a medication accomplish”
• Remind the patient that quitting smoking is like learning a new behavior:
not smoking. Then explain that most people go through significant
withdrawal when they quit. Ask, “Could you learn anything if you are
irritable, anxious, and restless all day long”
• Consider advising the patient that quitting is not something he can just
make happen. Explain that having a plan and a good teacher increases
his chances of being successful.
• Educate the patient about the impact of behavioral counseling and
cessation medications. Consider saying, “Research clearly shows that
combining a smoking cessation medication with a behavior modification
program doubles or triples your chances of quitting for good. Do you
want to give yourself the best chance of being successful”
Page 1 of 5
Copyright © 1999-2007 The Regents of the University of California, University of Southern California, and Western University of Health Sciences. All rights reserved.

TOBACCO TRIGGER TAPE SYNOPSES (CONT’D)
Tape Dialogue Scenario Problem Solution
4
5
6
“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”
“I’ve quit at least a
hundred times. I just
don’t know that I can
stay off cigarettes once
I get home.”
“Well, we all have to die
of something! So what if
I lose a couple of years
at the end of my life
from smoking”
Woman calls her
clinician from her office
phone.
Man is in a hospital bed,
receiving bedside
counseling.
Man is lying on a
patient examination
table, talking with his
clinician.
A side effect of the nicotine patch
is difficulty sleeping.
Many individuals who have had
multiple relapses convince
themselves that they can never
quit.
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.
• Confirm that the patch is being worn for 24 hours.
• If the patient is wearing the patch for 24 hours, it is likely contributing to
the sleep disturbance. Recommend that she remove it before bedtime.
• 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.
• Instruct 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.”
• Educate the patient about the quitting process and how he can learn
from his 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 the excuse to never try again.”
• 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 Could
you live this way” Say, “If you continue to smoke, you significantly
increase the chances of something like this happening to you!”
• 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”
Page 2 of 5
Copyright © 1999-2007 The Regents of the University of California, University of Southern California, and Western University of Health Sciences. All rights reserved.

TOBACCO TRIGGER TAPE SYNOPSES (CONT’D)
Tape Dialogue Scenario Problem Solution
7
8
9
“But I thought snuff was
safe. That’s why I
switched!”
“Why do I need drugs to
quit I don’t like putting
drugs in my body.”
“I just smoke with my
friends. It’s not like I’m
addicted…like my mom!
I can quit any time I
want.”
Man is lying on a
patient examination
table, talking with his
clinician, who is wearing
a mask and is looking in
his mouth.
Woman is sitting on a
patient examination
table, talking with her
clinician.
Adolescent girl is talking
with her clinician in an
office setting.
Many smokers are switching to spit
tobacco under the mistaken
impression that it is a safe
alternative to smoking.
Many smokers mistakenly view the
cessation products negatively while
not understanding the real
negative consequences of the
chemicals found in cigarettes.
Many adolescent smokers believe
mistakenly that they can “control”
their smoking. They clearly
underestimate the addictive nature
of nicotine. Evidence shows that, in
some youth, the establishment of
dependence can occur rapidly.
• 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.
• Inform the patient that, by using spit tobacco, all he is doing is
exchanging one set of risk factors for another. Although he reduces his
chances of developing lung problems, he significantly increases his
chances of getting head and neck cancers.
• Explain that there is no safe form of tobacco. All tobacco naturally
contains many toxins, including significant numbers of cancer-causing
substances.
• 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 negative
health 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.”
• 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.”
• Advise the patient that research done with high school smokers shows
that in spite of saying that they could quit any time they wanted to, over
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.
Page 3 of 5
Copyright © 1999-2007 The Regents of the University of California, University of Southern California, and Western University of Health Sciences. All rights reserved.

TOBACCO TRIGGER TAPE SYNOPSES (CONT’D)
Tape Dialogue Scenario Problem Solution
10
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12
“But I really…really don’t
want to gain any weight
when I quit!!”
“Oh, but I don’t smoke
around her. I always
smoke outside at
home…because of her
asthma.”
“I’d like to quit smoking,
but it’s probably too late
for me. I’m sure the
damage has already
been done.”
Woman is in a patient
examination room,
talking with her
clinician.
Mother and child are in
a patient examination
room, talking to the
child’s clinician.
Man is sitting on a
patient examination
table, talking with his
clinician.
Some smokers think that nicotine
burns thousands of calories and
that without it they will have
significant weight gain.
Smokers often do not realize the
lingering effects of the smoke on
clothing, hair, etc.
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
• 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.
• 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 is still entering your home,” and “You may not be
smoking near your child, but that doesn’t mean you’re not having a
negative impact. You are a role model for your child. Your smoking
sends the message that smoking is okay. Is this a message you want
your child to get”
• 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.
Page 4 of 5
Copyright © 1999-2007 The Regents of the University of California, University of Southern California, and Western University of Health Sciences. All rights reserved.

TOBACCO TRIGGER TAPE SYNOPSES (CONT’D)
Tape Dialogue Scenario Problem Solution
13
14
15
“I don’t think I can quit
without something to
help me, but I’m afraid
to use drugs while I’m
pregnant.”
“I need a quick refill on
my birth control pills.”
“Since when did
pharmacists start asking
patients whether they
smoke”
Pregnant woman is
sitting on a patient
examination table,
talking with her
clinician.
Woman, approximately
45 years old,
approaches the
pharmacy counter to
ask for a refill on her
oral contraceptives. As
she opens her briefcase
to reach for her pills, a
pack of cigarettes
becomes visible.
Man finishes completing
his new-patient intake
form at the pharmacy
and hands it over to the
pharmacist.
Smoking cessation medications are
not indicated for use during
pregnancy. The Clinical Practice
Guideline recommends using
medications in pregnant individuals
who are otherwise unable to quit.
Smoking does not decrease the
effectiveness of oral
contraceptives. However, women
who are at least 35 years and
smoke heavily (at least 15
cigarettes per day) are at a
markedly elevated risk for the
development of serious
cardiovascular complications,
including stroke, myocardial
infarction, and thromboembolism.
For this reason, experts generally
consider oral contraceptive use to
be contraindicated in this patient
population.
Historically, pharmacists have not
been active in screening for
tobacco use. This might be
surprising to some patients.
• Advise the patient that many chemicals found in cigarettes, including
nicotine, can cross the placental barrier. Therefore, nicotine replacement
therapy should only be used with caution during pregnancy, and while
under the direct supervision of a physician.
• Discuss with the patient that the amount of nicotine that reaches the
fetus from any nicotine replacement product is small and, in any case, is
much less than the amount reaching the fetus from smoking. The
resulting medical consequences to the fetus would be negligible and
certainly less harmful than those associated with the other chemicals
found in cigarettes. The patient should be aware that another option
would be bupropion SR, which is designated as a pregnancy category B
medication and therefore is not contraindicated for use during
pregnancy.
• Assess the patient’s tobacco use status.
• If the patient is a current smoker, assess her level of tobacco use. If she
smokes at least 15 cigarettes per day, she is at significant cardiovascular
risk because she is at least 35 years. Express concern about possible
drug interactions between smoking and oral contraceptives.
• Strongly advise the patient to quit smoking.
• If the patient is not interested in quitting now, encourage her to consider
alternative options for birth control; offer to arrange this with the
patient’s health care provider.
• Explain that it is important for you, as a health care provider, to know
the patient's tobacco use status.
• Advise the patient that many drugs interact with tobacco smoke and
that, by assessing whether he smokes, you will be able to screen more
effectively for these drug interactions. Additionally, you can monitor and
discuss the implications of tobacco use on the patient’s health status
(current diseases as well as diseases for which the patient is at risk) and
assist him with quitting when he is ready.
Page 5 of 5
Copyright © 1999-2007 The Regents of the University of California, University of Southern California, and Western University of Health Sciences. All rights reserved.