Tobacco Use

Case Scenario: Tobacco Use

CB is a 55-year-old woman who periodically visits Your-Rx-Done-Right Pharmacy for her medications. Today she comes to see the pharmacist after recently losing her sister to lung cancer. CB has been smoking 1? packs of cigarettes per day for 40 years. She tells the pharmacist, "I have always wanted to quit. I think it just took something like this to open my eyes. I don't want what happened to my sister to happen to <?XML:NAMESPACE PREFIX = ST1 />

me.

" She is visibly concerned, so the pharmacist decides to take a few minutes to talk to her about smoking cessation.

Before stepping into the counseling area, the pharmacist takes a moment to review CB's prescription profile so that he is aware of all her medications and medical conditions. CB is an overweight woman in no apparent distress. She has a history of hypertension, depression, gastroesophageal reflux disease, and asthma. She is currently taking omeprazole 20 mg once daily, hydrochlorothiazide 25 mg each morning, and escitalopram 10 mg once daily, and she uses an albuterol inhaler, 2 puffs every 4 to 6 hours as needed. The pharmacist also notes that CB is allergic to bupropion.

The pharmacist decides to start by assessing CB's barriers to smoking cessation. CB reports that she has tried to quit many times in the past unsuccessfully. "I quit for a few days and then start up again when something sets me off. Sometimes life is just too difficult to take on another challenge," she says.

The pharmacist is familiar with CB and her family. He knows that CB works long hours as an emergency room nurse. She also has raised 3 children as a single mom while working full-time, but now all the children are grown and out of the house. This is the first time that CB has sought help for smoking cessation. Her other attempts were done without help.

The pharmacist informs her that every attempt to quit is another attempt at success and that there are many options to help her quit. The pharmacist can see that now is a good time to reinforce some of the risks associated with long-term smoking.

While discussing the risks associated with smoking, the pharmacist decides to take a few minutes to explain to CB some of the pharmacologic treatment options available for smoking cessation. The pharmacist informs her that pharmacologic therapy is useful in all patients who smoke more than 10 cigarettes per day who are not pregnant or who have other confounding medical conditions. The pharmacist recommends that she talk to her doctor before making any decision, but he wants to make sure that she has all the available information to help her choose a therapy.

The pharmacist starts by informing her of the various nicotine replacement therapy options, including the patch, gum, lozenge, inhaler, and nasal spray. He explains that these agents work to replace the nicotine lost when smoking is stopped, thereby reducing the intensity of withdrawal symptoms. CB jokes that she would need more than 1 of those options. The pharmacist explains that evidence does support the combining of nicotine replacement therapies, such as wearing a patch and chewing a piece of nicotine gum during a bad craving.

CB asks, "Can't I just pop a pill? That would be easier than some of these other options." The pharmacist tells her that a product called Zyban (bupropion) also is marketed as an antidepressant and may work to treat depression and nicotine addiction simultaneously. This drug should be avoided in patients with a history of seizures, because it will increase the risk that a patient will have a seizure. Finally, the pharmacist tells her about Chantix (varenicline), which stimulates the nicotine receptor and has been found to be effective in smoking cessation.