Circuit 2, station 6

To understand the patient’s perspective on smoking and their motivations for change, it’s essential to explore their current ideas, concerns, and expectations (ICE) regarding smoking cessation. This consultation aims to foster a collaborative and non-confrontational dialogue with the patient.

Begin by asking open-ended questions to elicit the patient’s thoughts on smoking:
a) “How do you feel about smoking?”

1. b) “Are there any specific concerns you have about smoking or quitting?”
2. c) “What do you hope to achieve during our discussion today?”

Note: The purpose of this discussion is not to judge but to gain insight into the patient’s views and motivations for behaviour change.

Establishing Common Ground:

Establishing ICE helps create a common understanding between you and the patient, facilitating tailored advice and ensuring the patient feels heard.

Taking a Comprehensive Smoking History:

Before offering smoking cessation counselling, it’s crucial to gather a comprehensive smoking history. In some scenarios, you may receive this information in the patient’s brief and proceed directly to counselling.

Inquire about the patient’s smoking history, covering the following aspects:

1. Duration of smoking habit
2. Daily consumption (calculate pack-years if needed)
3. Types of tobacco or nicotine products used
4. Situations or triggers for smoking
5. Emotional and physical effects of smoking
6. Impact of smoking on daily life and relationships
7. Financial aspects related to smoking
8. Potential savings if the patient quits
9. Past attempts at quitting and reasons for relapse
10. Experience of withdrawal symptoms (e.g. cravings, irritability, mood changes)

Exploring Past Medical History:

Investigate the patient’s past medical history, specifically focusing on conditions   relevant to smoking:

1. a) Pre-existing lung diseases (e.g. COPD, asthma, pulmonary fibrosis)
2. b) Cardiovascular diseases and risk factors (e.g. coronary artery disease, hypertension, diabetes, hyperlipidemia)
3. c) Previous hospitalisations and surgeries
4. d) Medications, including any prior nicotine replacement therapies and their effectiveness

Family History Assessment:

Explore the patient’s family history to identify any malignancy cases, as this may indicate an elevated baseline risk for the patient.

Understanding Social Factors:

Evaluate the patient’s social history:

1. a) Quantify the patient’s weekly alcohol intake
2. b) Inquire about recreational drug use
3. c) Address psychosocial aspects, including stressors at home and work, and their potential impact on smoking habits
4. d) Investigate the patient’s employment and its relation to smoking behaviour

The 5 A’s Approach to Smoking Cessation

The 5 A’s approach involves a structured method for assisting patients in quitting smoking:

Ask: Begin by asking about and documenting the patient’s current smoking status.

Advise: Commend the patient for seeking help and provide advice on the health risks associated with smoking, emphasising its long-term effects (e.g. cardiovascular disease, lung cancer, stroke, peripheral vascular disease). Reassure the patient of the healthcare team’s support.

Even if the patient is not ready to quit entirely, advise them to consider reducing the frequency and quantity of smoking, as complete cessation is the ultimate goal.

Assess: Assess the patient’s understanding of the consequences of smoking in relation to their specific health conditions.

Explore the patient’s motivation to quit by asking them to rate their readiness on a scale of 1 to 10, with 1 being the least motivated and 10 being the most motivated. Utilise the Stages of Change model to gauge their readiness for behaviour modification.

Assist: Implement the STAR approach:

• Set a quit date within 2-4 weeks, aligning with the patient’s willingness and motivation.
• Encourage the patient to inform family and friends about their quitting journey for added support.
• Identify potential challenges and develop strategies to overcome them.
• Recommend the removal of all tobacco products and consider counselling programs and pharmacological therapies as appropriate.

Pharmacological Therapies for Smoking Cessation

Pharmacological options can significantly aid in smoking cessation:

Nicotine replacement therapy (NRT):

• Utilised as a first-line therapy and available in various forms (e.g. patches, sprays).
• Increases the likelihood of successful cessation.
• Caution advised for patients with cardiovascular disease or acute coronary syndrome.

Bupropion:

• Enhances the chances of successful cessation.
• Suggest starting medication 1-2 weeks before the quit date and completing a 12-week course.
• Contraindications include hypersensitivity reactions, seizure disorders, and eating disorders.

Varenicline:

• Functions as a nicotine receptor partial agonist.
• The most effective pharmacological therapy, significantly increasing the likelihood of successful cessation.
• Recommend initiating medication 1 week before the quit date and completing a 12-week course.
• Contraindicated in cases of hypersensitivity reactions.

Non-Pharmacological Therapies

Non-pharmacological interventions involve behavioural counselling programs tailored to patient preferences and beliefs:

Discuss various options with the patient, allowing them to choose the method they find most effective. Some patients may benefit from a combination of methods.

Follow-up and Support

• Arrange a follow-up appointment within 1-2 weeks to assess the patient’s progress.High relapse rates occur in the first three months; reassure the patient that relapses are common but part of the process.
• Multiple attempts may be needed for permanent cessation.

During follow-up visits:

• Assess the patient’s motivation level.
• Congratulate and encourage the patient to remain smoke-free.
• Monitor progress and evaluate the response to therapies.
• Identify current and anticipated challenges.
• Provide ongoing support and collaborate on strategies to overcome challenges.

Current recommendations for follow-up visits:

• Schedule follow-up appointments within 1-2 weeks after the quit date, at 4 weeks, at 3 months, and at 1 year.

During follow-ups, assess new side effects, smoking status, and any relapses