CLINICAL PRACTICE GUIDELINES - Ministry of Health Desa and was officiatedby Duli Yang Teramat Mulia...

CLINICAL PRACTICE GUIDELINESSmoking Cessation Guideline2014

CLINICAL PRACTICE GUIDELINESSmoking Cessation Guideline2014

Ministry of HealthBrunei Darussalam

I love smoke free B

runei!

Contents Pages

ForewordbyPermanentSecretary,MinistryofHealth

ForewordbyHeadofHealthPromotionCentre

Acknowledgements

BruneiDarussalam’sTobaccoControlInitiatives

CodeofPractice

INTRODUCTION

Introduction 1-2

HarmfulEffectsofTobacco 3-4

BenefitsofQuitting 5-6

COUNSELLING

ABCApproach 7

5‘A’sApproach 8-15

5‘R’sApproach 16-17

PHARMACOTHERAPY 19-23

REFERENCES 25-26

APPENDIX 27

APPENDIX1:ABCOFTOBACCOCESSATION 27

APPENDIIX2:5‘A’sAND5‘R’s 28

APPENDIX3:RESPONSESTOPATIENTSDIFFICULTIES 29-31

APPENDIX4:FLOWCHARTOFSMOKINGCESSATIONSERVICES 32-34

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4

5

Globallynon-communicablediseases(NCDs)aretheleadingcauseofprematuredeathsandchronicdisabilities.NCDscomprisemainlyofcancers,diabetes,cardiovascularandchronic lung diseases, which account for 60% of all deaths worldwide, and kill anastounding36millionpeopleeachyear.Thevastmajority(86%)ofprematuredeathsfromNCDsoccurindevelopingcountries.

InBruneiDarussalam,NCDswereestimatedtoaccountfor82%ofalldeathsin2011.ThetopfourcausesofdeathinBruneiDarussalamwerecancer,cardiovasculardiseases,diabetesandcerebrovasculardiseases.Tobaccouseisoneofthebiggestcontributingagents as it increases the risk of diseases such as lung cancer, chronic obstructiveairway disease and cardiovascular disease. Furthermore, the secondNational Healthand Nutritional Status Survey (NHANSS) in 2011 reported that the overall smokingprevalence amongst Bruneianswas 17%with the prevalence of adultmale smokersincreasing slightly from 31.1% in 1997 to 32.8%.While prevalence of adult femalesmokersdecreasedfrom5.3%to3.7%.

Inthelastdecade,majorachievementshavebeenmadeinrelationtotobaccocontrol,startingwithratificationoftheFrameworkConventiononTobaccoControlinJune2004followedby theenactmentofTobaccoOrder2005, its subsequent amendmentsandimplementationaswellasestablishmentofsmokingcessationclinicsinthecommunity.However,sincetobaccoconsumptioncontinuestobetheleadingcauseofpreventabledeath,tobaccocontrolmustcontinuetobegiventhehighpriorityitdeserves.

To address this, the Brunei Darussalam National Multisectoral Action Plan for thePreventionandControlofNon-communicableDiseases2013-2018(BruMAP-NCD)whichwaslaunchedinSeptember2013,hasput“reducingtobaccouse”asitsfirstobjectivewithatargetofa30%reductioninprevalenceofcurrenttobaccouseinpersonsaged

Foreword By: Permanent Secretary

15+yearsby2018.Variousrecommendedactionshavealsobeenoutlinedinordertoachievethistarget,oneofwhichistostrengthensmokingcessationservices.

The first ‘Klinik Berhenti Merokok’ was first launched at Berakas ‘A’ Health Centre,AnggerekDesaandwasofficiatedbyDuliYangTeramatMuliaPadukaSeriPengiranMudaMahkotaPengiranMudaHajiAlMuhtadeeBillahIbniKebawahDuliYangMahaMuliaPadukaSeriBagindaSultanHajiHassanalBolkiahMu’izzadinWaddaulah,SeniorMinisteratthePrimeMinister’soffice,on4June2005.Inordertoexpandthesmokingcessationservicestoallhealthcentresandhospitalsinthecountry,theMinistryofHealth,BruneiDarussalam,namelytheHealthPromotionCentrehasorganizedanumberofsmokingcessationcounselingworkshopsforallhealthprofessionalsincludingdoctors,dentists,nurses,psychologists,dietitians,healtheducationofficersandpharmaciststobecomesmokingcessationcounsellors,sothattheycanprovidesmokingcessationservicesattheirrespectivehealthcentresandhospitals.

It is hoped that this clinical practice guideline will help to equip and assist healthprofessionalstodelivereffectiveinterventionstohelptobaccousersbecometobacco-free.IthereforewishtocongratulatemembersoftheCoreTeamfortheirsuccess inproducing thisguideline,whichwill surelyputus in the right track forachieving thetargetset inBruMAP-NCD, leadingustowardsagenerationfreefromTobacco inthefuture.

DATINPADUKADRHJHNORLILABTEDATOPADUKAHJABDULJALILPermanentSecretary

Foreword By: Permanent Secretary

Foreword by Head of Health Promotion Centre

Treatingtobaccouseanddependenceisanimportantandcomplimentaryaspectofanynational tobaccocontrolprogrammes.Theprovisionof smokingcessation services isessentialinhelpingsmokersandtheirfamiliesbecometobacco-freeandinthelongruncontributetoimprovingthequalityoflifeandhealthofallBruneiansgenerally.

The primary aim of this Smoking Cessation Clinical Practice Guidelines is to reducetheprevalenceoftobaccouseanddependencethroughcessationadvice,counsellingand treatment. This current Clinical Practice Guidelines is based on the first editionof the guidelines that was produced in 2005 and has been revised and updated toincludeinformationonharmfuleffectsoftobacco,benefitsofquitting,5‘A’scounsellingapproach,5‘R’smotivationalinterventionsandalsopharmacotherapythatarecurrentlyavailableinsmokingcessationservices.Ihopethatthisrevisededitionwillcontinuetobeausefulresourceandwillhelpguiderelevanthealthprofessionalsinidentifyingandscreeningfortobaccousersaswellasindeliveringevidence-basedtobacco-usecessationadviceandtreatmentforpatientswhousetobaccointheirdailypractice.

ThedevelopmentofthisguidelinesisalsoinlinewiththeactionsidentifiedunderObjective4(ToidentifypeopleatriskofNCDsandmanageeffectively)intheBruneiDarussalamNationalMultisectoralActionPlanforthePreventionandControlofNoncommunicableDiseases(BruMAP-NCD)2013–2018.

Lastly, I would like to take this opportunity to thank the Smoking Cessation ClinicalPractice Guidelines Working Group for their tireless efforts, commitment as well asvaluable contribution in revising and helping to develop this second edition of theSmokingCessationClinicalPracticeGuidelines.

Letusallworktogetherindeliveringqualitycessationservicestohelpreducethenumberofsmokersinourpopulationandultimately,towardsatobacco-freeBruneiinthefuture.

DRHJHNORHAYATIHJMDKASSIMHeadofHealthPromotionCentre

The committee of this Clinical Practice Guideline would like to express theirgratitudeandappreciationtothefollowingforprovidingexpertiseandsupportinthedevelopmentandpublicationofthisguideline:

DatinPadukaDrHjhNorlilabintiDatoPadukaHjAbdulJalil,Permanent Secretary,MinistryofHealth Dr.HjhMaslinabintiHjMohsin,DirectorofHealthServices,MinistryofHealth Dr.HjhNorhayatibintiHjKassim,HeadofHealthPromotionCentre, MinistryofHealth

MatronHjh.FatimahbintiAbdullah,DirectorofNursingServices, MinistryofHealth

Allthosewhohaveprovidedvaluableinputandfeedback

Coreteammembers:

Dr.ErninaNisdzarinahbintiHjAbdulRani,SeniorMedicalOfficer,Smoking CessationServices,HealthPromotionCentre

NurliyanabintiHjMdNoor,Psychologist,HealthPromotionCentre

SuffianbinAwangJulidy,StaffNurse,Berakas‘A’HealthCentre

NoorizanbintiHjIdris,StaffNurse,HealthPromotionCentre

AsnirahbintiApelah,StaffNurse,BelaitSchoolHealth

Pg.AnuarHusainibinPgRambli,HealthEducationOfficer, HealthPromotionCentre

Acknowledgements:

Brunei Darussalam’s Tobacco Control InitiativesDate Actions2013 IncreasecompoundtoBND$300for1stoffencefor

smokingatprohibitedplaces2012 •Tobacco(ProhibitionincertainPlaces)

(Amendment)Notification,2012-Extensionofno-smokingzonesinmorepublicareasinafollowuptotheenforcementofTobaccoAct.•Tobacco(Labeling)(Amendment)Regulation,2012-Increaseinthesizeofhealthwarningimagesfrom50percentto75percentoncigarettepacks.

2011 Nolicenseforsalesoftobaccogivenforretailerswithin1kmanyschoolorinstitution

2010 Newtobaccotaxandprice•CustomsImportDutyOrder(Amendments)2010andExciseDutyOrder(Amendments)2010

2009 NationalCommitteeonTobaccoControlestablished2007 TobaccoRegulations:

-Tobacco(Prohibitionincertainplaces)Notification2007-Tobacco(Licensingofimporters,wholesalers&retailers)-Tobacco(Compositionofoffences)-Tobacco(Labeling)

2005 TobaccoOrder2005March2005 TheMunicipalBoardissuedanotificationletter

foralllicensedholders(restaurants,retailoutlets)prohibitingthesaleofcigarettestominors(under18)

Date Actions4thJuly2005 Smokingcessationclinicsestablished3rdJune2004 BruneiDarussalamsigned&ratifiedtheWorldHealth

OrganizationFrameworkConventiononTobaccoControl

July2002 AdministrativeprohibitionsofsmokingonbusinesspremisesbytheMunicipalBoard&DistrictOffices.

1stJanuary2002 Declarationofallschools(includingprivateschools)ascigarette&smoke-freeareas

1999 ProhibitiontosmokeattheBruneiInternationalAirport

1stApril1998 ProhibitiontosmokebytheRoyalBruneiAirlineonallflight

1stDecember1994 Increaseontobaccotaxationby200%1stSeptember1994

AdministrativeprohibitiontosmokeinallgovernmentBuildings

CustomsAct1991 Prohibitionforcigarettestoenterthecountrywithouthealthwarnings

15August1990 AdministrativeprohibitiontosmokeinallbuildingsundertheMinistryofHealth,BruneiDarussalam

1976 BanontobaccoadvertsbytheRadio&TelevisionBrunei&incinema

Brunei Darussalam’s Tobacco Control Initiatives

Code of practice (adapted from the World Health Organization):

Inordertocontributeactivelytothereductionoftobaccoconsumptionaswellastoincludetobaccocontrolinthepublichealthagendaatnational,regionalandgloballevels,itisherebyagreedthatanyhealthprofessionalorganizationsinBruneiwill:

1.Encourageandsupporttheirmemberstoberolemodelsbynotusingtobaccoandbypromotingatobacco-freeculture.

2.Assesandaddressthetobaccoconsumptionpatternsandtobacco-controlattitudesoftheirmembersthroughsurveysandtheintroductionofappropriatepolicies.

3.Maketheirownorganizations’premisesandeventstobacco-freeandencouragetheirmemberstodothesame.

4.Includetobaccocontrolintheagendaofallrelevanthealth-relatedcongressandconferences.

5.Advisetheirmemberstoroutinelyaskpatientsandclientsabouttobaccoconsumptionandexposuretotobaccosmoke–usingevidence-basedapproachesandbestpractices,giveadviceonhowtoquitsmokingandensureappropriatefollow-upoftheircessationgoals.

6.Influencehealthinstitutionsandeducationalcenterstoincludetobaccocontrolintheirhealthprofessional’scurricula,throughcontinuededucationandothertrainingprograms.

7.ActivelyparticipateinWorldNoTobaccoDayevery31May.8.Refrainfromacceptinganykindoftobaccoindustrysupport–financialorotherwise, and from investing in the tobacco industry, and encourage theirmemberstodothesame.

9.Ensurethattheirorganizationhasastatedpolicyonanycommercialorothertobaccoindustrythroughadeclarationofinterest.

10.Prohibitthesaleorpromotionoftobaccoproductsontheirpremises,andencouragetheirmemberstodothesame.

11.ActivelysupportthegovernmentsintheimplementationoftheWHOFrameworkConvention on Tobacco Controls as well as the Brunei Darussalam TobaccoOrder2005.

12.Dedicatefinancialand/orotherresourcestotobaccocontrol,includingdedicatingresourcestotheimplementationofthiscodeofpractice.

13.Participateinthetobaccocontrolactivitiesofhealthprofessionalnetwork.14.Supportcampaignsfortobacco-freepublicplaces.

1 Introduction

IntroductionHarmful Effects of TobaccoBenefits of Quitting

1 IN

TROD

UCTION

TheClinicalPracticeGuidelinesonSmokingCessationareanupdateoftheClinicalPracticeGuidelines ‘AGuideToAssistSmokersQuit ‘developedby theMinistryofHealth in2005.The revised guidelines provide updated evidence-based recommendations to support theeffectivenessofinterventionstotreattobaccouseanddependence.Tobaccodependenceisachronicconditionthatrequiresrepeatedinterventionsandmultipleattemptstoquit.

Objectivesofguidelines Theaimistoassistallhealthprofessionalstoidentifyandassessthetobaccouse statusofeverypatientandtodeliverevidence-basedeffectivetobaccouseand dependencetreatments.

Targetusers Theguidelinesareintendedforallhealthprofessionals,includingdoctors, dentists,psychologists,pharmacists,dieticians,socialworkers,occupational therapists,physiotherapistsandnursestoassistthemintheirtobaccousecessation initiatives.

Emergingtrendsoftobaccouse Tobaccoconsumptionisincreasingworldwide(1.3billionsmokers)andhasgrown substantiallyinlow-andmiddle-incomenations(82%oftheworld’ssmokers) includingintheASEANregion.Thishighlyaddictiveproductiscommonlyusedby allsegmentsofthepopulationincludingwomen,youthandchildren. Atpresent,thereare127millionadultssmokers(30%ofadultASEANpopulation) livinginASEANcountries.Tobaccouseremainsthesinglebiggestpreventable causeofdisease,disability,andprematuredeathsintheworld.TheWorldHealth Organizationestimatesthatabout5millionpeopledieprematurelyeachyearfrom tobacco—relateddiseases.Tobaccosmokersarenotonlyputtingthemselvesatrisk butalso1.8billionnon-smokersworldwide.In2004,itwasestimatedthat40% ofchildren,33%ofmaleand35%offemalenon-smokerswereexposedto environmentaltobaccosmoke(ETS).

Introduction

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SmokingCessation Cigarettesmokingisanaddiction.Nicotineincigarettescausesbothphysicaland psychologicaldependence.Mosttobaccouserswhounderstandthefullrangeof harmscausedbytobaccousewanttoquit,butitisdifficultformanytodoso unaidedbecauseoftheextremeaddictivenessofnicotine.Mostsmokerswhoquit areabletodosowithoutassistance,butcessationinterventionsgreatlyincrease quitrates.Peoplewhoquittobaccouseexperienceimmediateandsignificanthealth benefits,andreducemostoftheirexcesshealthriskwithinafewyears.

Article14oftheWorldHealthOrganization(WHO)FrameworkConventionon TobaccoControl(FCTC)states“Eachpartyshalltakeeffectivemeasurestopromote cessationoftobaccouseandadequatetreatmentfortobaccodependence.Each partyshalldesignandimplementeffectiveprogrammesaimedatpromotingthe cessationoftobaccouse.”

Clinicalcessationinterventionsareeffective,andalsoextremelycost-effective.It hasbeenshownthatbriefadvicefromdoctorsandhealthcareworkersincreases quitratesandpharmacologicaltherapywithnicotinereplacementtherapy(NRT) aloneorincombinationwithotherprescriptioncessationmedicationscandoubleor triplequitrates.

Theprimarygoaloftheclinicalpracticeguidelinesistoreducetheprevalenceof tobaccouseanddependencethroughcessationtreatments.ThisupdatedClinical PracticeGuidelinesonSmokingCessationaredevelopedbasedoncomprehensive literaturereviewsonevidenceontobaccouseanddependencetreatments. Asuggestedframeworkfortreatingtobaccouseanddependencehasalsobeen developedtoprovideasimplestep-by-stepapproachthatallhealthprofessionals canuse.Theimportantmessagetoeveryhealthprofessionalistomaketreating tobaccouseanddependenceapriorityduringthepatient’svisit.

Introduction

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Harmful Effects of Tobacco

Tobacco use is a major risk factor for many diseases and is also the number onepreventablecauseofdeathintheworld.Onaverage,asmokerdies14yearsprematurelyduetotobacco-relateddiseasescomparedtoanon-smoker.Theharmfuleffectsoftobaccousearewelldocumentedinnumerousstudies.

Ifonesmokes20cigarettesaday,theriskofcontractinglungcancerisabout10-15timesthatofanon-smoker.Onaveragetheriskofdevelopinglungcanceris1%fornon-smokersandupto30%forheavysmokers.

Smokingcausesdiseasesrelatedtotheheartanditsarteriesaswellasbloodvessels.Smokingincreasesthelikelihoodofcontractingcoronaryheartdiseasesby3-4times.Asmokeristwiceaslikelytosufferastrokeascomparedwithapersonwhohasneversmoked.

Nicotinealterstheacid-alkalinebalance,disturbsstomachacidcontractionsandcausestheflowofstomachacidbackuptheoesophagus.Smokersaretwiceas likelytohavepepticulcer.OtherhealtheffectsfromtobaccouseareshowninFigure1.

FIGURE1:EFFECTSOFSMOKINGONHEALTH 3

Harmful Effects of Tobacco

Second-handtobaccosmoke,alsoknownasenvironmentaltobaccosmoke(ETS),isacombinationofsidestreamsmoke(thesmokethat isgivenoutbytheburningof tobaccoproduct)andmainstreamsmoke(thesmokeexhaledbythesmoker).

Globally,exposuretosecondhandtobaccosmokehasbeenestimatedtohavecaused379,000deathsfromischaemicheartdisease,165,000fromlowerrespiratorytractinfections,36,900fromasthmaand21,400fromlungcancer.Itwasestimatedthatlivingwithatobaccouserincreasesthenon-smokersriskofdevelopinglungcancerby20-30%.

OtherharmfuleffectsfromexposuretosecondhandsmokeareshowninFigure2.

FIGURE2:EFFECTSOFSECONDHANDSMOKEONHEALTH

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Benefits of Quitting

Quittingtobaccousehasmajorandimmediatehealthbenefitsforbothmenandwomenofallages.Itiswellestablishedthroughnumerousstudiesthatquittingtobaccouseimproveshealthandqualityoflifealmostimmediately.

TIMEAFTERQUITTING HEALTHBENEFITS

20MINUTES •Bloodpressurereturnstonormal•Pulseratereturnstonormal•Circulationimprovesinhandsandfeet

8HOURS •Carbonmonoxidelevelinblooddropstonormal•Oxygenlevelinbloodincreasestonormal

24HOURS •Carbonmonoxideiseliminatedfromthebody•Lungsstarttoclearoutmucusandotherdebris

48HOURS •Nerveendingsstarttore-grow•Sensesoftasteandsmellaregreatlyimproved

72HOURS •Breathingbecomeseasierasbronchialtubesrelax•Lungcapacityincreasesmakingiteasiertodophysicalactivities

3MONTHS •Naggingcoughdisappears•Riskoffurthergumdiseasereducedsignificantly•Tobaccorelatedmouthulcersdisappear•Circulationimproves•Walkingbecomeseasier•Lungfunctionincreasesupto30%

UPTO9MONTHS •Coughing,sinuscongestion,fatigue,shortnessofbreathdecrease

•Overallenergylevelincreases

1YEAR •Riskofcoronaryheartdiseaseishalfthatofasmoker

5-10YEARS •Riskoflungcancerreducesbyalmosthalf•Riskofstrokeandheartdiseasedecreasetothatofanon-smoker

TABLE1:BENEFITSOFQUITTINGSMOKING

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Tobaccouseisachronicconditionthatoftenrequiresrepeatedcessationinterventionsindifferentforms.Thereareeffectivetreatmentsfortobaccouseanddependencethatcansignificantly increase rates of long-term abstinence. Behavioural support and counselingremains themainstay of treatment andmay be effective alone. Howevermany patientsrequire additional pharmacotherapy to ameliorate physical withdrawal symptoms. Thehighestabstinenceratesareusuallyachievedwithacombinationofbehaviouralsupportandmedications.

Tobaccouseanddependencetreatmentinterventionscanbecarriedoutat2levels,dependingontheamountoftimeavailableandthecompetencylevelofthehealthprofessionals.

LEVEL1 TheABCapproach(BasicLevelIntervention)

LEVEL2 The5‘A’sapproach(IntensiveLevelInterventionforclientwhoisreadytoquit)

The5‘R’sapproach(MotivationalInterviewingforclientwhoisnotreadytoquit)

TABLE2:FRAMEWORKFORTOBACCODEPENDENCETREATMENT

Framework for Treating Tobacco Use and Dependence

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2 Counselling

ABC Approach5 ‘A’s Approach 5 ‘R’s Approach

2 ABC APPRO

ACH

TheABCapproach isasimpleandeasy-to-rememberaidforbusyhealthprofessionalssuchasgeneralpractitioners,specialistsandwardnurseswhohaveonly1to3minutestoinitiatethesubjectoftobaccousecessationduringtheirconsultationsessions.Theaimof theABCapproach is to incorporate tobaccousecessationadviceasaroutineopportunisticfirst-lineinterventionwhenprovidingconsultationtopatients.

Ask Askanddocumentstatusoftobaccouseforeverypatient.“Doyousmokeoruseanyotherformsoftobacco?”Forpatientswhosmokeorhaverecentlystoppedusingtobacco,thetobaccousestatusshouldbecheckedandupdatedonaregularbasis.Systemsshouldbeputinplacetoensuretobaccousestatusisdocumentedateachvisit.Forhealthfacilities:toincludetobaccouseasa“vitalsign”Tobaccouse(circleone):CurrentFormerNeverPassiveSmokerPatientswhohaveneverusedtobaccoorhavenotusedformanyyearsneednotbeaskedrepeatedly.

BriefAdvice Briefadvicetostoptobaccouseforeverypatientwhousestobaccoregardlessofintentiontoquit.Briefadviceappearstoworkbytriggeringaquitattempt.Advicecanbestrengthenedbylinkingittothesmoker’sexistingtobacco-relatedmedicalcondition.Asthmasufferersmayneedtohearabouttheeffectofsmokingonrespiratoryfunction.Womenmaybemorelikelytobeinterestedintheeffectsofsmokingonfertility.Peoplewithyoungchildrenmaybemotivatedbyinformationontheeffectsofsecondhandsmoke.Documenttheadvicethatwasgiven.

Cessationreferral Cessationsupportforeverypatientwhoexpressestheintentiontoquit.Fortobaccouserswhoarewillingtoquit:•RefertoaSmokingCessationCounselor(SCC)atyourclinic/hospitalorthenearestKlinikBerhentiMerokok(KBM)

Fortobaccouserswhoarenotwillingtoquit:•Askfortheirreasonsfornotwantingtoquit•Reinforcetheadvantagesandacknowledgethedisadvantages•Provideinformationonsmokingleafletsandsmokingcessationservicesiftheyareagreeable,incasetheychangetheirmindaboutquittinginthefuture

TABLE3:THEABCAPPROACH

LEVEL 1 – The ABC Approach (Basic Level Intervention)

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The5 ‘A’sapproach (Ask,Advise,Assess,AssistandArrange) isaneasy-to-implementinterventionforhealthprofessionalsinsettingsthatallowthemtospendalittlemoretimeon tobacco use cessation with their patients. This approach is recommended specificallyfor smoking cessation counselors (SCC) and other health professionals such as generalpractitioners,nurseeducatorswhohaveattendedsmokingcessationcounselingworkshop,tospend15-20minutestoinitiateassessmentandcessationinterventionswithpatientswhousetobacco.

1.ASKPATIENTABOUTSMOKINGSTATUS

Askanddocumentstatusoftobaccouseforeverypatient.Thisshouldbearoutinepracticeateveryconsultation.

“Doyousmokeoruseanyotherformsoftobacco?”

For patientswho smoke or have recently stopped using tobacco, the tobacco use statusshouldbecheckedandupdatedonaregularbasis.Systemsshouldbeputinplacetoensuretobaccousestatusisdocumentedateachvisit.

Forhealthfacilities:toincludetobaccouseasa“vitalsign”Tobaccouse(circleone):CurrentFormerNeverPassiveSmoker

Smokingstatusshouldbeupdatedregularlyanddocumentedinthefile.

Patientswhohaveneverusedtobaccoorhavenotusedformanyyearsneednotbeaskedrepeatedly.Non-smokers(especiallyyouthsandyoungadults)andex-smokersneedpositivereinforcementoftheirsmoke-freelifestyle.

Forsmokers,aroutinesmokinghistoryisessentialforallpatients,andshouldinclude:•Numberofcigarettessmokedperday•Durationofsmoking(years)

LEVEL 2 – THE 5 ‘A’s Approach(Intensive Level Interventions for patient who is ready to quit)

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•Previousquitattempts:◊Methoduse◊Duration◊Whathelpedandwhatdidnot◊Reasonforrelapse•Medicalconditionssuchashighbloodpressure,heartattack,stroke,diabetesmellitus,hypercholesterolemia,chroniclungdiseasese.g.asthma,emphysema,recurrentlunginfections,pepticulcers.•Familyhistoryofhighbloodpressure,heartattack,stroke,diabetes,lungcancerandothercancer.

Assesslevelofaddiction:

•Thesmoker’sdegreeofnicotineaddictionwillinfluenceyourcounselingandcessation

strategies

•UsetheFagerstrom’sQuestionnairetoassessthelevelofaddiction

THEFAGERSTORMQUESTIONAIRRE

1.Howsoonafteryouwakeupdoyousmokeyourfirstcigarette?i.Within5minutes (3points)ii.5to30minutes (2points)iii.31to60minutes (1point)iv.After60minutes (0point)

2.Doyoufinditdifficultnottosmokeinplaceswhereyoushouldnot,suchasinmosque,inahospitalorinanairplane?i.Yes (1point)ii.No (0point)

3.Whichcigarettewouldyoumosthategive-up;theonewhichyoutreasurethemost?i.Thefirstoneinthemorning (1point)ii.Anyotherone (0point)


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THEFAGERSTORMQUESTIONAIRRE

4.Howmanycigarettesdoyousmokeeachday?i.10fewer (3points)ii.11to20 (2points)iii.21to30 (1point)iv.31ormore (0point)

5.Doyousmokemoreduringthefirstfewhoursafterwakingupthanduringtherestoftheday?i.Yes (1point)ii.No (0point)

6.Doyoustillsmokeifyouaresickthatyouareinbedmostofthedayorifyouhaveacoldorthefluandhavetroublebreathing?i.Yes (1point)ii.No (0point)

Noofpoint(s)(_____)

Scoring:7–10points Highlydependent 4–6points Moderatelydependent 0–3points Minimallydependent

TABLE4:FAGERSTROMSCORE

2.ADVICEPATIENTTOSTOPSMOKING

Somereasonsforpatient’sreluctancetoquitare:•Lackofinformationontheharmfuleffectsoftobacco•Demoralisedbecauseofpreviousrelapse•Fearsorconcernsaboutquitting

Convincethepatienttoquitsmokingwithaclearadviceandstrongmanner.

•“Ireallythinkyoushouldstopsmokingnow”•“Stoppingsmokingisoneofthemostimportanthealthdecisionsyoucanmakeforyourself/yourchild”

Bearinmindyourpatient’sageintailoringyourmessagetohim/her:a.Demographics:Forexample,womenmaybemorelikelytobeinterestedintheeffectsofsmokingonfertilitythanmen.

b.Health:Asthmasufferersmayneedtohearabouttheeffectofsmokingonrespiratoryfunction,whilethosewithgumdiseasemaybe interested intheeffectsofsmokingonoralhealth.

c.SocialFactors:Peoplewithyoungchildrenmaybemotivatedbyinformationontheeffectsofsecondhandsmoke,whileapersonstrugglingwithmoneymaywanttoconsiderthefinancialcostsofsmoking.

Examplesoftailoredadviceinclude:•“Yourcoughwillsubsidemorequicklyandyourairpassageswillreturntonormal”

•“Youwillstopfurtherdamagetoyourlungwhichcausesyourcough/breathingdifficulty”

•“Yourriskofheartattackwilldropimmediately”•“Yourbloodpressurewilldropandyourriskofstrokewillbereducedimmediately”

•“Youwillincreaseyourchancesofhavingnormal,healthybaby”•“Youarelikelytohaveahealthierbaby/childbecauseyouarereducinghis/herriskofsufferingfromchestinfection”

•“Yourstaminawillimprove”


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3.ASSESSPATIENT’SREADINESSTOSTOPSMOKING.

Whenwecounselpatientstoquitsmoking,itisimportanttorecognizethatdifferentpatientsareatdifferentstagesofreadinesstoquit.ThesestageswereidentifiedbyProchaskaanddiClementeandadaptedforuseinsmokingcessationasshownbelow:

FIGURE3:TRANSTHEORETICALMODELOFCHANGE


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Pre-contemplationThepatienthasnointentiontoquitsmoking

PreparationThepatientpreparestoquitsmokinginthecomingmonth,orisreadytostartquitting

ContemplationThepatientconsidersquittingsmokinginthecoming6months

RelapseThepatientregressesintothesmokinghabit

ActionThepatientisinthecourseofquitting

MaintenanceThepatientremainssmoke-freeforatleast6months

4.ASSISTPATIENTINPREPARATIONFORQUITTING

Workoutwiththepatientonthesmokingcessationplan:

•Setaquitdate–preferablywithinthesubsequenttwoweeks.Makesurethatyourpatientselectsaperiodinhislifewhichisrelativelylowinstress.

•Encouragethepatienttotellfamilymembers,colleaguesandfriendsabouthis/herdecisiontoquitsmokingsoastoenlisttheirsupportandencouragement.Ifaprivatecommitmenttostopsmokingisthenmadepublic,itcreatessocialpressurestosupportthechange.

•Smokersshouldencouragefamily/friends/colleaguestoquitwiththemornotsmokeintheirpresencetominimizeriskoftreatmentfailureandexposuretosecondhandsmoking.

Provideappropriatetechniquesonproblemsolving:

•Identifyreasonsforquittingandbenefitsofquitting•Reviewpastquitattempts–whathelpedandwhatledtorelapse•Reducethenumberofcigarettessmokedgraduallybeforethesetdate.Youmaysuggesttoyourpatientthesetips:◊Trytodelaysmokingthefirstcigaretteforaslongaspossible◊Onlysmokehalfofacigaretteandthrowawaytheremainder◊Ifthereisacravingtosmoke,advisetodelaysmokingingraduation(e.g.15/20/30minutes)

◊Whensmoking,placethecigaretteontheashtrayanddonotholditallthetime◊Smoketheirowncigaretteandsay“no”offeredbyothers◊Changethebrandofcigarettetoaleastfavouredone

•Priortoquitting,avoidsmokinginplaceswherealotofsmoker’stimeisspent(e.g.work,home,car).Makeafewkeyareasas“nosmoking”zone(e.g.inthecar, infrontofthechildren,inthehouse)andputupremindersifnecessary.

•Discardcigarettes,lightersandallothersmoking-relateditemsonthequitdate.


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•Anticipatechallengestoplanquitattempt,particularlyduringthecriticalfirstfewweeks.Theseincludenicotinewithdrawalsymptoms.Discusschallenges/triggersandhowsmokerwillsuccessfullyovercomethem.

•Thesmokershouldconsiderlimiting/abstainingfromalcoholwhilequittingasitcancauserelapses.

•Recommendtheuseofnicotinereplacementtherapyormedicationifindicated.•Remindyourpatientthattotalabstinenceisessential.Notevenasinglepuffafterthequitdate.

•Providerelevantsmokingcessationinformationsuchasquitdiarypack,pamphletsetc.•Assistbymakingreferraltoasmokingcessationcounseloratyourclinic/hospitalorthenearestsmokingcessationservicesavailable.

5.ARRANGEFOLLOW-UPFORTHEPATIENT

Workoutwiththeclientonthefollow-upscheduleandapproaches.

•Itispreferabletoconductthefirstfollow-upwithinthefirstweekafterthequitdayandthensubsequentencountersregularly.

•Providecounselingandencouragementduringeachfollow-up.•Recognizetheeffortsofthosewhohavesuccessfullyremainedsmoke-free,andremindthosewhoarestillunabletokickthehabittoregardoccasional‘slips’asanalert.

•Ifarelapseoccurs,encouragetheclienttorepeatquitattempt.

IftheclientisintheActionstage,andhasstoppedsmokingforlessthanamonth,heislikelytobeexperiencingwithdrawalsymptoms.Supportclientby:

•Reinforcethesmoker’sdecisiontoquit.•Praisehim/herforremainingsmokefreesofar.•Encouragethesmokertoactivelydiscussthebenefitsalreadyderivedfromcessation.•Encouragethesmokertoreportanydifficultiespromptlywhilecontinuingeffortstoremainabstinent.

•Stronglyencouragetothesmokertoremainabstinent.


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Belowaresomeofbehavioraltechniquesthatpatientcantrytostaysmoke-free:

Delay •Setaquitdate–preferablywithinthesubsequenttwoweeks.Makesurethatyourpatientselectsaperiodinhislifewhichisrelativelylowinstress.

Escape •Escapesituationthatinducesmokinge.g.negativeemotionalstate(suchasdisagreementwithemployer,spouse)

Avoid •Avoidusualsmokingsocialgrouptemporarilye.g.tocoffeeshops.•Avoidsituationassociatedwithsmokinge.g.sittinginafavoritechair.•Avoidplaceswheresmokingiscommon.•Avoidalcoholwhichmaytriggertosmoke.

Distract •Distractsmokingbydrinkingwater,chewingonsugar-freegums,keepinghandbusybyfiddling(e.g.‘bertasbih’).

•Keepbusywithactivityyouenjoy.•Spendfreetimeinplaceswheresmokingisnotallowed.

TABLE5:D.E.A.Dpointersasbehaviouraltechniques


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Often,thepatientwillnotbereadytoquit.Theymaynotwanttobeanon-smoker,orbecertainthattheycouldnotquit.Inthesecases,itisadvisedtodeliverabriefmotivationalinterventionbeforeendingtheconsultation.Theinterventioniscalledthe5R’s(Relevance,Risks,Rewards,RoadblocksandRepetition).Thiswill occurafter theAssess stage.Oncecompleted,tryre-assessreadinesstoquitandcompletethe5A’sifappropriate.

RELEVANCE Encouragethesmokertoindicatewhyquittingispersonallyrelevant.

Ifthesmokerisconsultingaboutamedicalcomplaint,usetheopportunitytorelatethehealthconditionwithhis/hersmokinghabit,forexample:•Colds,fluandrespiratoryproblems•Chroniclungdisease•Cardiovasculardisease•Highbloodpressure•Pregnancyandthepill•InvoluntarysmokingandthechildrenYoucouldalsorelatethepossibleinteractionofsmokingwiththedrugsthatthepatientmightbetakingforexistingconditions.

RISKS Askthesmokertoidentifypotentialnegativeconsequencesoftobaccosmoking.Suggestandhighlightthosethatseemmostrelevanttothesmoker.Emphasisethatswitchingtolow-tar/lownicotinecigarettesorotherformsoftobaccowillstillcarrysimilarrisks.Examplesofrisksare:

•Short-termrisks:Shortnessofbreath,exacerbationofasthma,harmtopregnancy,impotence,infertility,increasedserumcarbonmonoxide.

•Long-termrisks:Heartattacksandstrokes,cancers(oralcavity,larynx,pharynx,lung,oesophagus,pancreas,bladder,cervix),chronicobstructivepulmonarydisease(chronicbronchitisandemphysema),long-termdisabilityandneedforextendedcare.

•Environmentalriskoflungcancer.

LEVEL 2 – The 5 ‘R’s MOTIVATIONAL INTERVENTIONS(Intensive Level Interventions for patient who is not ready to quit)

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REWARDS Askthesmokertoidentifypotentialbenefitsofquittingsmoking.Suggestandhighlightthosethatseemmostrelevanttothesmoker.Examplesofrewardsare:

•“Itwillreduceyourasthmaattacksinayear”•“Sinceyoualreadyhavehighbloodpressure,quittingsmokingwillreduceyourbloodpressureandwillreduceyourriskofheartattacksandstrokes”.

ROADBLOCKS

Askthesmokertoidentifybarriersofquittingandsuggestpossiblesolutionstothosebarriers.Examplesofroadblocks:cravings,withdrawalsymptoms,environmentaletc.

REPETITION Repeatthemotivationalinterventioneverytimeasmokervisitstheclinic.Remindthemthatmostex-smokersmakerepeatedquitattemptsbeforetheyaresuccessful.

Ifthepatientstillrefusestostopsmoking:•Followthemupabouttheirsmokingatanotherappointment(andmakesurethatyoudoit).Thiswillletthepatientknowthatyouareseriousabouthimstoppingsmoking.

•Provideinformationleafletstoreinforcetheadvicethatyouhadalreadygiven.

•Documentinthefilewhatwasdiscussedduringtheconsultationtofacilitatefurtherfollow-upofthepatient.

Table5:MotivationalIntervention:The5R’sApproach

LEVEL 2 – The 5 ‘R’s MOTIVATIONAL INTERVENTIONS(Intensive Level Interventions for patient who is not ready to quit)

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3 Pharmacotherapy

3 PH

ARMACO

THERAPY

Allpatientsattemptingtoquitshouldbeencouragedtouseeffectivepharmacotherapiesforsmokingcessationexceptinthepresenceofspecialcircumstances.Onceasmokerrefrainsfromsmoking,thenicotinelevelinsidehis/herbodywillstarttodropgradually.Someofthewithdrawalsymptomsinclude:

Studiesshowedthatpharmacotherapiescanalleviatewithdrawalsymptomsandincreasethesuccessrateeffectively.Besides,themedicationcanalsobecomeanincentiveforthequittertoattendfollow-upconsultationonschedule.Commonfirstlinesupplementarymedicineforsmokingcessationnowadayscanbebroadlydividedintotwocategories:•Nicotinereplacementtherapy•Non-nicotinereplacementtherapy

Pharmacotherapy

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Figure4:WITHDRAWALSYNDROME

SleepdisturbanceIrritability

IncreaseappetiteorweightgainAnxiety

DepressorlowmoodRestlessness

Tinglingsensationinhandandfeet

Difficultyconcentrating

FluorcoughCravings

Nicotine replacement therapy (NRT) help to relieve withdrawal symtoms and allowsmokertoconcentrateonbehavioralandpsychologicalfactorsduringquitattempt.Italsoeliminatesthereinforcingeffectofnicotineachievedthroughsmoking.Itisusefulforsmokerswhoaremoderately tohighlydependentonnicotine. It is vital to remindpatient to stopsmokingwhileundergoingtreatment.InBrunei,nicotinereplacementtherapiesthatareavailableinclude:•Nicotinepatch•NicotineLozenges

1.NICOTINEPATCH

Thenicotinepatchisusedasatemporaryaidtotreatnicotinedependenceamongmoderatelyto highly addicted smoker. It should be used in conjunction with behavioral counselingfor better success rate. They are used in gradual strengths to help reduce the smoker’sdependencyonnicotine,graduallyweaninghimoffnicotine.

PRODUCT NICOTINELL(24HRPATCH) NICORETTE(16HRPATCH)

Strengths 7mg(10”)14mg(20”)21mg(30”)

5mg10mg15mg

Durationofuse 24hr 16hr

Instruction PutonAM,changenextday PutonAM,removebedtime

Dosage1cigarette≈1mgnicotine

No.ofcigarettessmoked=doseofnicotinerequired

10-20cigarettes/day21mgfor6-8weeks14mgfor2-4weeks7mgfor2weeks

10-20cigarettes/day15mgfor6-8weeks10mgfor2-4weeks5mgfor2weeks

Dosage <10cigarettes/day14mgfor6weeks7mgfor4weeks

<10cigarettes/day10mgfor6weeks5mgfor4weeks

TABLE6:NICOTINEPATCHREGIMEN

NICOTINE REPLACEMENT THERAPY (NRT)

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ADVERSEREACTIONS:•Skinirritationatapplicationsitee.g.Erythema,pruritis,oedema,burningsensation,blister,rash,pinchingsensation.

•Headache•Cold,flu-likesymptoms•Dysmenorrhoea•Insomnia•Nausea•Myalgia•Dizziness

PRECAUTIONFORUSE:•Severehypertension•Severecardiovasculardisease

•Diabetesrequiringinsulin•Skindisorders•Kidneyorliverproblems•Pregnancyorlactation•Uncontrolledhyperthyroidism

CONTRAINDICATIONSFORUSE:•*Under18yearsold•Non-smoker•Occasionalsmoker•*Pregnancyorbreastfeeding

•Recentheartattactorstroke

•Unstableorworseninganginapectoris

•Severecardiacarrythmias•Recentcerebrovascularaccident

•Generalizedskindisorder.•Brokenorinflamedskin.•Hypersensitivitytonicotineorcomponentofthetherapeuticsystem.

TABLE7:NICOTINEPATCHUSE

2.NICOTINELOZENGES

Devicestodelivernicotineintothebloodstreamtoreducemotivationtosmokeby:•reducingcravingsandwithdrawalsymptoms•reducingtherewardingeffectofsmoking

Nicotine absorption is intermediate absorption so it is used when there are cravings forimmediatereliefofwithdrawalsymptoms.Nicotinelozengescandeliver25%morenicotinethanequivalentdoseofnicotinegum,asyoumustchewgumtoreleasenicotine.Canbeusedascombinedtherapywithnicotinepatches.


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Heavysmoker>20cigarettesperday:4mglozenges

Moderatesmoker<20cigarettesperday:

2mglozenges

Weeks1to6:useonelozengeevery1to2hoursWeeks7to9:useonelozengeevery2to4hoursWeeks10to12:useonelozengeevery4to8hoursDonotusemorethan20lozengesperday.

TABLE8:NICOTINELOZENGESREGIMEN

HOWTOUSE:•Suckslowlyuntilthetastebecomestrong.

•Restlozengebetweengumandcheek.

•Suckagainwhenthetastehasfaded.

•EachLozengecanlastabout30minutes.

SIDEEFFECTS:•Hiccups•Throatirritation•Palpitations•Rapidheartbeat•Dizziness•Headacheandnausea•Vomitingordiarrhea•Weaknessinthebody

CONTRAINDICATIONS:•*Under18yearsold•Recentanginaorheartattack

•Stroke•*Pregnancyorbreastfeeding

PRECAUTIONS:•Diabetes•Hyperthyroidism•Stomachulcerorstomachproblems

•Highbloodpressure•Anyformofcardiovascularandcirculatorydisease

•Liverorkidneydisease•Phenylketonuria•Pregnancyorbreast-feeding•Toothorgumdisease•Sorethroatsorirritations

TABLE9:NICOTINELOZENGEUSE


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Highaffinityandselectivityatalpha4–beta2neuronalnicotinicacytycholinereceptors.Workbyitslow-levelagonistactivityatthereceptorsitecombinedwithcompetitiveinhibitionofnicotinebinding.

Actionsby:•Partiallyblockingnicotine:◊Toreducethepleasurableeffectsofnicotine◊Toreducetheriskoffullrelapse

•Partiallystimulatingthereceptors:◊Torelievecravingandwithdrawalsymptoms

DOSSAGE:Therapystartsoneweekbeforethequitdate

Day1-3:0.5mg(1tab)dailyDay4-7:0.5mg(1tab)twicedailyWeek2(quitdate)–endofweek12:1mg(1tab)twicedailyMaybeextendedforanother12weeks.

Excretedsubstantiallybykidneys,dosereductionto0.5mg/day(upto0.5mgbdmax)insevererenalimpairment.

SIDEEFFECTSANDWARNINGS:Nausea,sleepdisturbances(insomnia,abnormaldreams),constipation,flatulence,vomiting

Therehavebeenreportsofdepressedmood,agitation,changesinbehaviour,suicidalideationandsuicideinVareniclineusers

WHOCANUSE:Alladultsmokersexceptthose;

•Withsevererenalimpairment•Pregnantorbreastfeeding

TABLE10:VARENICLINEUSE

VARENICLINE TARTRATE (CHAMPIX)

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4 References

4 REFEREN

CES

REFERENCES:

1.BuildingcapacityforTobaccocontrol/trainingpackage2013.WorldHealthOrganization,Switzerland

2.CertificationforQuitSmokingConsultants2005.HealthPromotionBoard,Singapore

3.ClinicalPracticeGuidelineaGuidetoAssistSmokerQuit2005.MinistryofHealth,BruneiDarussalam

4.Clinicalpracticeguidelines.Treatmentoftobaccosmoking&dependence2003.DiseaseControlDivision,MinistryofhealthMalaysia.Academyofmedicine,September2003.

5.FioreMC,BaileyWC,CohenSJ,etal.TreatingTobaccouseandDependence.ClinicalPracticeGuideline.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService,June2000

6.FroomP.MelamedS,BenbassatJ.Smokingcessationandweightgain.[Review][61refs].JFamilyPractice1998;46(6):460-4

7.HelgasonA&LundK.Generalpractitioners’perceivedbarrierstosmokingcessation’ –results from four Nordic countries. Scand J Public Health2002;30(2):141-7

8.McEwenA,WestR.Smokingcessationactivitiesbygeneralpractitionersandpracticenurses.Tobaccocontrol2001:10:27-32.

9.TheNationalNutritionalStatusSurvey1998,MinistryofHealth,BruneiDarussalam

10.MasonP.HelpingsmokersChange.Aresourcepackfortraininghealthprofessionals.WorldHealthOrganization.

REFERENCES:

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11.ProschaskaJ,GoldsteinMG.Processofsmokingcessation.Implicationforclinicians.ClinicalChestMedicine1991;12(4):727-35

12.Talktoyourpatientsaboutsmoking.Aguideforthebusyhealthprofessional.NationalhealthEducationaldepartment,MinistryofHealth,Singapore.

13.TreatingTobaccoUseandDependence.HPB-MOHClinicalPracticeGuidelines1/2013.HealthPromotionBoard,Singapore.

14.SmokingCessationInformationKit2009.TobaccoControlOffice,DepartmentofHealth,HongKong.

REFERENCES:

HEALTHLINE 145MINISTRY OF HEALTHBRUNEI DARUSSALAM

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5 Appendix

APPENDIX 1: ABC OF TOBACCO CESSATION

APPENDIIX 2: 5 ‘A’s AND 5 ‘R’s

APPENDIX 3: RESPONSES TO PATIENTS DIFFICULTIES

APPENDIX 4: FLOWCHART OF SMOKING CESSATION SERVICES

5 APPEN

DIX

APPENDIX 1:

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APPENDIX1:ABCOFTOBACCOCESSATIONAttriageorconsultation(3mins)

APPENDIX 2:

APPENDIX2:5‘A’sAND5‘R’s(IntensiveCounselling)

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PATIENT’SREASON YOURRESPONSE

It’stoohardtoquit.Idon’thaveenoughwillpower.

Quittingandstayingawayfromcigaretteswillnotbeeasy,butmillionsofpeoplehavesucceeded,andIamsureyoucantoo.Youmayneedtotrydifferentmethodsofquitting.IwillgiveyouallthesupportIcan.

I’munderalotofstressandsmokingrelaxesme

Ifasmokerfeelsedgyduetofallingnicotinelevels,thenacigarettewillreducethisperceived“stress”whichisactuallythebeginningofwithdrawalfromsmoking.Nicotineisastimulant.Infactsmokersasawholetendtohaveslightlyhigheranxietylevelsthannon-smokersorex-smokers.

I’llbeimpossibletolivewith. Yourfamilyandfriendswillunderstandandbegladthatyouarestopping,evenifitmeansputtingupwithyouforashortwhile.Mostsmokersfindthattheyarenotasirritableastheyexpectedtobe.You’dbehardertolivewithifyouhadastrokeoremphysema.

Ican’tconcentrate/performwell/create/produceetc.

Thesearenormalsymptomsofnicotinewithdrawal.Youfeelmorealertbecausethenicotineraisesyourheartrateandbloodpressure.Butsmokingalsodeprivesyourbrainofoxygen.Thesesymptomsaremostacuteinthefirst3to4daysafterstopping,buttheywilldisappearafterafewweeks.Makesureyougetenoughresteverydaytoimproveyourconcentrationwithoutneedingtodependonsmoking.Youhavealsolearnttoassociatecertainactivitieswithsmoking.Thesubstancesintobaccosmokeactuallyinhibitperformance;soinfact,youshouldbeabletodoabetterjobwithoutsmoking.



IfeelsoirritablewheneverItrynottosmoke.

Thisispartofthewithdrawalsymptoms.It’sharderforsomepeoplethanothers.Justrememberitisalsotemporary.Trytotakeyourmindoffsmokingwhenthathappense.g.takeawalk,chatwithafriend,playsomesport,orgosomewhereyoucan’tsmoke(likethecinema).

I’mconcernaboutgainingweight. Itiscommonforpeopletoputonfewkilogramswhentheyfirststopsmoking.Thiscanbemadeworsebysnackingonsweetandfattyfoodsasareplacementforsmoking.However,thisdoesnothappentoeveryoneandbeingslightlyoverweightislessofhealthriskthanbeingasmoker.

SometimesIhaveoverwhelmingstrongdesiretohaveacigarette.

Somepeoplerelievecravingsbychewingsugar-freegum,suckingonacinnamonstick,oreatingacarrot.Cravingforcigarettesareanormalpartofwithdrawal.Mostcravingslastforonlyafewminutesandthensubside.Cravingsbecomerareafterafewweeks.UseNRTifprescribed.

Idon’tknowwhattodowithmyhands. That’sacommoncomplaintamongex-smokers.Keepyourhandsoccupiedinotherways.Tryholdingsomethinglikeapencil,paperclip,keychainormarbleoreven‘tasbih’.

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Iblewit.Ismokedacigarette. Smokingoneoreven10cigarettesdoesn’tmeanthatyouhaveblownit.You’vegottenthroughseveraldayswithoutsmoking.Don’tletthisonecigarettebecomeanexcusetostartsmokingagain.Youareex-smokerandcancontinuetobeex-smoker.Keeptrying.

IforgetallaboutmydeterminationtoquiteverytimeIseecigarette

Writedownallyourreasonsforwantingtoquit,andallthepositivethingsthatyouhavenoticesincequitting.Keepthislistinyourpocketoronyourofficetableanduseittoremindyourselftostayawayfromcigarettes.

I’vetriedtoquitmanytimesbutIjustcan’tseemtoquitforgood.

That’strueforalotofpeople.Mostex-smokershavetoquitafewtimesbeforetheyfinallysucceed.Welearnbytrying.Themoreoftenyoutry,themorelikelyyouaretosucceed.Don’tgiveup.


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REGISTRATIONDAY

aPatienttofill-intheregistrationform.aDoctorsandnursestoassessreadinesstoquit:

(stageofchange:PRECONTEMPLATION/CONTEMPLATION/PREPARATION/ACTION/MAINTENANCE/RELAPSE)

aDoctorsandnursestoassessthepatient’swill,determinationandconfidencetoquitsmoking.

aSetaquitdateandchooseappropriatequittingmethods:(COLDTURKEY/SLOWREDUCTIONTOQUIT)

aSetappointmentforagroupintroductorylecture

FOLLOW-UPFORTHEFIRSTMONTH(PreparationStage)

aAdvisepatienttoannouncethequitdatetofamilymembers,friendsandcolleagues.aDiscardallcigarettes,ashtraysandlighters.aPointoutpossiblewithdrawalsymptomsandreliefmeasures.aAdviseonrefusalskillstowardsothersmokers’offers.aWhenindicated,recommendnicotinereplacementtherapy(NRT)inadditionto

counselingtherapy.HelpthepatienttomakeappropriatechoiceonthetypeanddosageofNRTandprovidesdetailedinformationonthetreatmentplanandusagesforvariousmedications.


FOLLOW-UPFORTHESECONDANDTHIRDMONTH(ActionStage:aftertheQUITDATE)

aMakeanoteontheQUITDATE.aCheckcarbonmonoxidelevelonthesmokerlyzers.aCheckurine/salivarycotininetest.aAssessthepatient'sprogress;assistthemtohandledifficultiesencounteredaccordingly.aAssessthemode,dosageandeffectivenessofNRT.aCoachandstrengthenpatient'sconfidenceandskillstoovercomedifficultiesandbarriers.aDiscusstheimportanceofbalanceddietandhealthylifestyles.Encourageregularexercise

anddecenthobbies.

FOLLOW-UPFORTHEFOURTH,FIFTHANDSIXTHMONTH(MaintenanceStage)

aMakeanoteonSmokingStatusat3monthsafterQuitdateaCheckcarbonmonoxidelevelonthesmokerlyzers.aAssessthepatient'sprogress;assistthemtohandledifficultiesencounteredaccordingly.aAssessthemode,dosageandeffectivenessofNRT.aCoachandstrengthenclients’confidenceandskillstoovercomedifficultiesandbarriers.aGuidethepatienttoidentifythesourceofpressureandfigureourappropriatestress

copingstrategies.aSharingofrefusalskillsandencouragethepatienttourgefamilymembers,friendsor

colleaguestoquitsmoking.

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FOLLOW-UPAFTERSIXMONTHS(MaintenanceStage)

aDischargepatientat6thmonth,makenoteonthesmokingstatus.aCheckcarbonmonoxidelevelonthesmokerlyzers.aCheckurine/salivarycotininetestaGivepatientcertificateof‘successfulquitter’andinviteassupportgrouporspokepersonaOffernecessarycounselingandarrangementstounsuccessfulquitters,andpointoutthat

manysmokersneedseveralattemptstosucceed.aEncouragethepatienttocalltheHealthline145whennecessary.aEncouragesuccessfulquitterstourgefamilymembers,friendsorcolleaguestoquit

smokingaswell.aToremindclientthatafollow-upcallat1yearwillbemadetocheckpatient’sstatus.

Ministry of HealthBrunei Darussalam

CLINICAL PRACTICE GUIDELINES - Ministry of Health Desa and was officiatedby Duli Yang Teramat Mulia...

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