Treatment Strategy ebooksclub.org Tobacco or Health Physiological and Social Damages Caused by Tobacco Smoking Second Edition

The฀smoker’s฀own฀determination฀to฀quit฀is฀the฀crucial฀prerequisite฀for฀success฀in฀smok- ing฀cessation฀therapy.฀Discordant฀smokers฀are฀more฀suitable฀as฀patients.฀In฀principle,฀given฀ the฀many฀and฀well-known฀harmful฀effects฀of฀smoking,฀any฀intervention฀to฀achieve฀smoking฀ cessation฀is฀to฀be฀recommended฀for฀details฀of฀indications,฀see฀Sect.฀ 10.1 ฀in฀ Chap.฀10 .

15.2 The Counselling Process

During฀the฀initial฀consultation,฀the฀patient’s฀history฀is฀taken฀and฀information฀is฀elicited฀ concerning฀any฀concurrent฀illnesses฀that฀might฀be฀relevant฀in฀terms฀of฀smoking฀cessation.฀ The฀ Fagerström฀ Test฀ is฀ administered฀ to฀ determine฀ the฀ degree฀ of฀ nicotine฀ dependence฀ Table฀4.5฀in฀ Chap.฀4 .฀Smokers฀undergo฀a฀situational฀analysis฀to฀determine฀how฀easily฀ they฀can฀be฀provoked฀to฀smoke,฀and฀the฀CO฀content฀in฀expired฀air฀and฀forced฀expiratory฀ volume฀in฀1฀s฀FEV 1 ฀are฀measured.฀They฀are฀informed฀in฀detail฀about฀the฀harmful฀effects฀ of฀smoking,฀and฀the฀effects฀of฀nicotine฀and฀those฀of฀tobacco฀smoke฀and฀its฀constituents฀are฀ discussed฀separately.฀The฀mode฀of฀action฀of฀the฀various฀nicotine฀products฀is฀then฀explained.฀ Once฀ smokers฀ have฀ consented฀ to฀ NRT,฀ one฀ or฀ perhaps฀ two฀ nicotine฀ products฀ are฀ pre- scribed,฀depending฀on฀the฀extent฀of฀smoking,฀the฀Fagerström฀Test฀score฀and฀CO฀levels฀in฀ expired฀air. Future฀ex-smokers฀are฀issued฀with฀an฀information฀booklet฀written฀in฀the฀Institute฀and฀are฀ referred฀to฀the฀nearest฀pharmacist฀with฀a฀private฀prescription฀and฀precise฀instructions฀on฀ how฀the฀nicotine฀products฀are฀to฀be฀used.฀Patients฀are฀told฀to฀start฀using฀the฀nicotine฀prod- ucts฀that฀same฀day฀in฀the฀form฀supplied.฀A฀date฀is฀also฀ixed฀for฀the฀next฀appointment.฀The฀ initial฀consultation฀lasts฀for฀1-h,฀giving฀smokers฀the฀opportunity฀to฀outline฀their฀motives฀for฀ smoking.฀Information฀sessions฀in฀dialogue฀format฀have฀been฀assessed฀positively. The฀appointment฀schedule฀for฀individual฀smokers฀who฀wish฀to฀quit฀depends฀on฀the฀ progress฀made.฀Weekly฀appointments฀are฀made฀initially,฀followed฀later฀by฀appointments฀ every฀2฀weeks฀and฀then฀every฀4฀weeks.฀Interim฀telephone฀counselling฀is฀often฀considered฀ helpful.฀In฀all฀cases,฀the฀target฀is฀for฀the฀ex-smoker฀to฀report฀an฀outcome฀of฀tobacco฀absti- nence฀after฀6฀months.฀The฀number฀n฀=฀6–12฀and฀duration฀of฀subsequent฀counselling฀ses- sions฀will฀depend฀upon฀the฀success฀of฀therapy. Contrary฀to฀what฀is฀stated฀in฀the฀prescribing฀information,฀nicotine฀products฀are฀used฀in฀ double฀ or฀ triple฀ combinations,฀ depending฀ on฀ the฀ assessed฀ severity฀ of฀ dependence฀ see฀ Table฀11.3฀in฀ Chap.฀11 .฀Additional฀individual฀counselling฀for฀smokers฀is฀essential฀and฀ boosts฀the฀success฀rate.฀The฀duration฀of฀treatment฀is฀guided฀by฀the฀active฀and฀successful฀ cooperation฀of฀the฀ex-smoker฀and฀may฀range฀from฀4฀to฀12฀weeks.฀The฀nicotine฀dose฀admin- istered฀initially฀is฀reduced฀as฀rapidly฀as฀possible:฀this฀means฀that฀the฀patient’s฀cravings฀ should฀be฀extremely฀minimal฀or฀abolished฀altogether.฀Nicotine฀patches฀with฀a฀nicotine฀ release฀rate฀of฀1.5฀mgh฀are฀prescribed฀to฀be฀worn฀only฀for฀16฀h฀during฀the฀day.฀The฀patch฀ dose฀is฀reduced฀by฀halving฀the฀patch฀–฀though฀this฀is฀only฀possible฀with฀Nicorette฀patches.฀ Nicotine฀ chewing฀ gum฀ andor฀ nasal฀ spray฀ are฀ used฀ in฀ addition,฀ with฀ treatment฀ supple- mented฀by฀both฀products฀together฀in฀exceptional฀cases฀only฀see฀Table฀11.3฀in฀ Chap.฀11 . If฀smokers฀who฀wish฀to฀quit฀do฀not฀receive฀NRT฀with฀nicotine฀doses฀that฀are฀similar฀to฀ those฀obtained฀from฀cigarette฀smoking,฀they฀relapse฀at฀once.฀Naturally,฀these฀high฀initial฀ doses฀must฀be฀reduced฀as฀rapidly฀as฀possible,฀but฀in฀a฀way฀that฀reliably฀prevents฀relapses.฀ The฀risk฀of฀adverse฀effects฀through฀to฀intoxication฀exists฀only฀if฀ex-smokers฀additionally฀ smoke฀larger฀quantities฀of฀cigarettes฀during฀this฀period.

15.3 Experiences with Outpatient Smoker Counselling

In฀the฀2.5฀years฀since฀the฀Centre฀has฀been฀in฀existence,฀a฀total฀of฀1,000฀smokers,฀primar- ily฀ from฀ Thuringia฀ but฀ also฀ from฀ other฀ regions฀ of฀ Germany,฀ have฀ enrolled฀ with฀ the฀ intention฀of฀quitting฀smoking.฀History-taking฀revealed฀that฀these฀patients฀were฀highly฀dis- satisied฀with฀their฀smoker฀status,฀and฀many฀of฀them฀admitted฀that฀for฀years฀they฀had฀ wanted฀to฀quit฀the฀habit,฀but฀had฀been฀prevented฀from฀doing฀so฀by฀their฀degree฀of฀depen- dence.฀Over฀the฀intervening฀period,฀smokers฀for฀whom฀smoking฀cessation฀is฀an฀urgent฀ necessity฀on฀medical฀grounds฀have฀also฀been฀referred฀to฀the฀Centre฀by฀their฀doctors.฀After฀ an฀ initial฀ consultation,฀ patients฀ from฀ other฀ German฀ regions฀ have฀ then฀ undergone฀ tele- phone฀counselling฀and฀successfully฀achieved฀smoking฀cessation.฀Among฀the฀patients฀at฀ the฀Centre,฀ive฀had฀already฀withdrawn฀from฀alcohol฀and฀successfully฀remained฀tobacco- abstinent฀for฀6฀months. On฀average,฀female฀smokers฀have฀smoked฀20฀cigarettesday฀for฀17฀years,฀while฀male฀ smokers฀have฀smoked฀25฀cigarettesday฀for฀20–25฀years.฀The฀very฀heaviest฀smokers฀consume฀ 80–100฀cigarettesday.฀Attempts฀at฀smoking฀cessation฀initiated฀by฀the฀smokers฀themselves฀ have฀lasted฀for฀a฀maximum฀4฀weeks฀in฀women฀and฀generally฀for฀only฀1฀week฀in฀men. The฀Fagerström฀Test฀in฀women฀has฀revealed฀scores฀of฀4–6฀for฀the฀most฀part,฀with฀scores฀ of฀7–10฀in฀isolated฀cases฀only,฀whereas฀in฀men฀scores฀of฀4–6฀or฀7–10฀were฀recorded฀with฀ equal฀frequency.฀At฀the฀start฀of฀treatment,฀the฀smokers฀had฀an฀average฀CO฀level฀in฀expired฀ air฀of฀21฀ppm.฀On฀the฀completion฀of฀successful฀treatment,฀levels฀of฀5฀ppm฀were฀recorded.฀ CO฀levels฀of฀80฀ppm฀were฀measured฀initially฀in฀four฀cases.฀For฀ex-smokers,฀the฀measure- ment฀of฀this฀variable฀was฀an฀important฀marker฀of฀success฀in฀cases฀where฀smoking฀cessation฀ was฀achieved. Further฀ appointments฀ with฀ ex-smokers฀ at฀ weekly฀ or฀ fortnightly฀ intervals฀ are฀ useful,฀ particularly฀at฀the฀start฀of฀treatment.฀Approximately฀25฀of฀smokers฀who฀attend฀a฀irst฀ appointment฀fail฀to฀return฀subsequently.฀A฀further฀25฀give฀up฀the฀treatment฀after฀4–8฀ weeks฀because฀they฀have฀relapsed.฀Also฀of฀importance฀is฀the฀patients’฀experience฀of฀leav- ing฀the฀irst฀consultation฀–฀supplied฀with฀NRT฀products฀–฀without฀having฀the฀craving฀to฀ smoke.฀ This฀ abstinence฀ from฀ smoking฀ was฀ also฀ conirmed฀ by฀ virtually฀ all฀ ex-smokers฀ 97฀during฀the฀following฀week฀and฀should฀be฀interpreted฀as฀a฀key฀experience:฀“The฀feel- ing฀that฀it฀is฀not฀necessary฀to฀smoke.”฀In฀this฀context,฀it฀is฀important฀that฀smokers฀obtain฀ their฀nicotine฀products฀immediately฀from฀a฀nearby฀pharmacy.฀If฀the฀continuous฀supply฀of฀ nicotine฀is฀not฀guaranteed฀immediately฀after฀the฀irst฀consultation,฀patients฀turn฀back฀to฀ cigarettes฀and฀thus,฀start฀to฀smoke฀again.