smoking cessation OSCE module

1. Smoking Cessation
Kishore SR
Oman Medical College

2. Objective
To learn how to help your patient to quit smoking
using 5As counselling technique.

3. Why stop smoking?
According to WHO Tobacco fact
sheet October 2014
• Tobacco kills up to half of its
users.
• Tobacco kills nearly six million
people each year
• The annual death could rise to
more than eight million by 2030.
• Nearly 80% of the world's one
billion smokers live in low- and
middle-income countries.

4. 5As
1. Ask about smoking .
2. Advise every smoker to stop smoking .
3. Assess readiness to quit .
4. Assist the smoker in stopping smoking .
5. Arrange for follow up and monitor the progress of the
smoker .

5. ASK
• Ask about tobacco use every single time
• Implement a system that ensures that, for every
patient at every clinic visit, tobacco-use status is
queried and documented.
• Repeated assessment is not necessary in the
case of the adult who has never used tobacco or
has not used tobacco for many years, and for
whom this information is clearly documented in
the medical record.

6. ARE YOU A
SMOKER ?
No Yes

7. • Since how long are you a smoker ?
• What type of smoke you are using ?
• Why you are smoking ?
• How many cigarettes per day ?
• What is your frequency of smoking ?
• What are your preferred times for smoking ?
• What are your behaviors associated with smoking ?
• How long do you take after waking in the morning to
smoke?
YES, Smoker

8. • Any attempt to stop before ?( take details about this
attempt).
• Do you have any medical problem due to smoking?
• Is there any smoker around you ( home , work ) ?
• Is there any family member or friend who had any
medical problem due to smoking ?
• Are you married ? Do you have children ?
• Are you convinced about the risk of smoking?
• Are you willing to quit ?

9. No! Non smoker
• Congratulate him .
• Encourage him to continue as non-smoker .
• Advice to avoid indirect smoking ( second –
hand smoker ) .
• Encourage him to participate in smoking
cessation .

10. ADVISE
Advice should be:
1. Clear - "I think it is important for you to quit smoking
now and I can help you." "Cutting down while you are ill
is not enough.“
2. Strong - "As your clinician, I need you to know that
quitting smoking is the most important thing you can do
to protect your health now and in the future. The clinic
staff and I will help you.“
3. Personalized - Tie tobacco use to current
health/illness, and/or its social and economic costs,
motivation level/readiness to quit, and/or the impact of
tobacco use on children and others in the household.

11. ASSESS
• Determine the patient's willingness to quit smoking
within the next 30 days:
• If the patient is willing to make a quit attempt at this
time, provide assistance.
• If the patient will participate in an intensive treatment,
deliver such a treatment or refer to an intensive
intervention.
• If the patient clearly states he or she is unwilling to make
a quit attempt at this time, provide a motivational
intervention.
• If the patient is a member of a special population (e.g.,
adolescent, pregnant smoker), provide additional
information specific to that population.

12. ASSIST
 Set a quit date. Ideally, the quit date should be within 2
weeks. He can select a special date in his life or in the
year .
 Tell family, friends, and coworkers about quitting and
request understanding and support.
 Anticipate challenges or triggers to planned quit
attempt, particularly during the critical first few weeks.
These include nicotine withdrawal symptoms.
 Prior to quitting avoid places where you spend a lot of
time smoking (e.g., work, home, car) .

13.  Remove tobacco products and smell from your
environment the day before quitting.
 Total abstinence is essential. "Not even a single puff
after the quit date."
 Review past quit attempts including identification of
what helped during the quit attempt and what factors
contributed to relapse.
 Alcohol can cause relapse, the patient should consider
limiting/abstaining from alcohol while quitting.
 Quitting is more difficult when there is another smoker in
the household. Patients should encourage housemates
or his colleagues to quit with them or not smoke in their
presence.

14.  Provide a supportive clinical environment while
encouraging the patient in his or her quit attempt. "My
office staff and I are available to assist you.“
 Help the patient develop social support for his or her
quit attempt in his or her environments outside of
treatment. "Ask his/her spouse/partner, friends, and
coworkers to support you in your quit attempt.“
 Assess behaviors associated with smoking (you can
use smoker diary) to concentrate on them in the quitting
process.
 Recommend the use of pharmacotherapies found to be
effective. Give him the options, details and what is
suitable for his condition

15.  Explain how these medications increase smoking
cessation success and reduce withdrawal
symptoms.
 Always remind him about quitting rewards and keep
encouraging him.
 Tell him that relapse can happen. So, he can know
the weaknesses and try again and again until he
succeeds.
 Determination and Will power are the cornerstone
in the quitting process.

16. Pharmacotherapies
• Nicotine replacement therapy (NRT)
▫ Increase the chance of stopping by 1.5X
▫ Start with higher doses for dependent people
▫ Continue for 3mo, reduce gradually over 2 wks.
before stopping
▫ Contraindicated in Immediate Post MI, stroke, TIA,
arrhythmias

17. • Bupropion (ZYBAN)
▫ Smokers >18y, tablets 1-2 wks. before the
intended quit date.
▫ Increase cessation by 2x
▫ Contraindications- epilepsy , eating disorders,
bipolar disorders
• Varenicline (CLAMPIX)
 Smokers >18y, tabs one week before intended
date
 Increase cessation by >2x
 Contraindications in psychiatric illness

18. ARRANGE
• Schedule follow-up contact, either in person or by telephone.
• Follow-up contact should occur soon after the quit date,
preferably during the first week.
• A second follow-up contact is recommended within the first
month.
• Schedule further follow-up contacts as indicated.
• Congratulate success during each follow-up and encourage
him to remain abstinent.
• Remind the patient that a relapse can be used as a learning
experience.
• Consider use or referral to more intensive treatment if needed

19. Summary (how to approach)
Meets greets and introduces. Demography
Started in non judgmental way /assess current symptoms
Current smoking status/ ever tried to stop before/ if yes than
what method used and causes to restart / if motivated and
confidence in stopping now
Discuss benefits and value of stopping and risk if continue to
smoke
Set a date/stop completely on the date/ tell your friends /
throw away all gadgets related to smoking e.g. ash tray etc.
Nicotine Withdrawal effects: increase appetite, depression,
poor concentration, irritability, insomnia, constipation
Advice drugs/ NRT / bupropion. Assess for depression
Arrange follow up 1-2 weeks or smoking cessation clinic
Offer motivational leaflets/ literature
Advice appropriate management(diet, exercise, drug)

20. For not smoking…