Case Study: Adult with Chronic Disease

Phyllis is a 53 y.o. African-American female who works as a hospital telephone operator. She is married to a non-smoker and has two adult children, aged 27 and 24, who live nearby. Her younger child, a daughter, smokes. Phyllis was admitted from the Emergency Department to the hospital for acute respiratory distress.  Upon admission to the institution, Phyllis was seen by the hospital’s smoking cessation counselor, a nurse, who obtained a smoking history and administered the Fagerstrom Test for Nicotine Dependence.  

Based on this information, Phyllis was diagnosed as nicotine dependent and offered nicotine replacement therapy to manage abrupt nicotine deprivation while hospitalized.  She wore a 21 mg transdermal patch each day throughout hospitalization  ( in Clinical Practice Guidelines (pdf) – see hospitalized smoker recommendations Chapter 7 Special Populations).  Phyllis was discharged after 4 days, with a diagnosis of acute respiratory infection and a new diagnosis of Chronic Obstructive Pulmonary Disease.  

Her discharge planning included continued smoking cessation treatment, antibiotics and bronchodilator metered dose inhalers, and follow-up in the pulmonary disease clinic for pulmonary function studies.  The smoking counselor was scheduled to call Phyllis 24 hours after discharge and arranged to see her at the one week follow-up appointment in pulmonary clinic.

Smoking History

Started smoking at age 23

• Smokes about a pack a day of Newport 100’s
• Tried to quit in the past many times
• Most recent quit attempt was 6 months ago – used nicotine patch for 4 days but resumed smoking during argument with her daughter.
• Last cigarette was 16 hours ago and carbon monoxide (CO) was 6 ppm when seen by counselor
• Half her friends are non-smokers, along with husband and son
• Work environment is smoke-free

Phyllis’ Fagerstrom Test for Nicotine Dependence

1.        How soon after you wake up do you smoke your first cigarette? 

 __x_ within 5 minutes (3 points)

___ 6-30 minutes (2 points)

___ 31-60 minutes (1 point)

___ > 60 minutes (0 points)

2.        Do you find it difficult to refrain from smoking or using tobacco products in places where it is forbidden, e.g. church, at the library, in the cinema, etc.?

__x_ Yes (1 point)                     ___  No (0 points)

3.        Which cigarette would you hate most to give up?

_x__ First one in the morning (1 point)                ___ All others(0 points)

4.        How many cigarettes/day do you smoke?

___ 10 or less (0 points)

                _x__ 11-20 (1 point)

                ___ 21-30 (2 points)

                ___ 31 or more (3 points)

5.        Do you smoke more frequently during the first hours of waking than during the rest of the day? 

_x__ Yes (1 point)                     ___  No (0 points)

6.        Do you smoke if you are so ill that you are in bed all day?

__x_ Yes (1 point)                     ___  No (0 points)

Phyllis’ score was 8 –

Total score of greater than 7 indicates high nicotine dependence.         

Heatherton, T.F., Kozlowski, L.T., Frecker, R.C., Fagerstrom, K.O. (1991). The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addictions, 86: 1119-1127 .

Treatment Plan: AHRQ guideline recommendations

1. Combination Nicotine Replacement Therapy (NRT) p. 77 of guideline

• Patch 14 mg/day – 8 weeks
• 4 mg gum administered ad libitum for cravings – 8 weeks and not to exceed 20 pieces/day
• See Tables 34 and 37 for clinical use of these products

2. Practical counseling strategies

·        Total abstinence from tobacco is essential

·        Avoid drinking alcohol – it increases the risk for relapse

·        Try to avoid your triggers temporarily – ask your daughter to not smoke around you

·        Keep nicotine gum available and use with “urges” or cravings

3. Intra-treatment social support

·        Nurse counselor to phone at periodic intervals to offer support and encouragement

·        Pulmonary physician to endorse treatment plan and verbalize support to Phyllis

4. Extra-treatment social support

·        Have Phyllis ask her spouse/family, co-workers, and friends to support her in her quit attempt

Questions for further consideration:

1. What is the rationale for recommending combination NRT?

2. What is the explanation for Phyllis’ CO level of 6 ppm?

Answer:  A CO of < 8 ppm is considered non-smoker status.  It has been sixteen hours since Phyllis’ last cigarette.  The half-life of carbon monoxide is relatively short, at 4 hours.  The time since last cigarette is an important consideration when assessing smoking status via CO.  It is recommended that time of last cigarette be recorded along with the actual value.  Also, it is recommended that CO assessment be performed later in the day to give CO the opportunity to accumulate.

3. What are subsequent treatment options, if Phyllis fails this form of treatment?

Answer:  Another form of pharmacotherapy, such as bupropion SR should be considered, if no contraindications to the drug exist.  (See Table 33 in Chapter 6 in Clinical Practice Guidelines (pdf)) .  Combination bupropion and nicotine replacement therapy may also be appropriate.

4. How should the nurse counselor proceed on phone follow-up, if Phyllis isn’t interested in quitting after all?

Answer:  The nurse might say “I know quitting is difficult and I’d like to keep working on this with you”.  At this point, the nurse could ask Phyllis to address what Roadblocks (Five R’s – see Brief Strategy B in Chapter 3 in Clinical Practice Guidelines (pdf)) occurred and then spend time over the phone addressing strategies to deal with the roadblocks.  It is important for the nurse to convey a continued interest in working with Phyllis and to be sure that Phyllis has a contact phone number as well as a return appointment to the health care institution for continued assessment of her readiness to attempt cessation in the future.