Federally Qualified Health Center (FQHC) Case Study: 18 year old annual visit prescribing Varenicline

Background

Patient Information

18 y/o Caucasian female in for a follow up visit

Initial Vitals:RR =16; BP=120/80 mm Hg, Temp= 98.6

Meds:

• Albuterol

ROS (pertinent positives):

• Patient was admitted to hospital 4 months ago for asthma exacerbation.
• It has been 1 month since their last follow up visit.
• Review of their chronic asthma symptoms, Admits to becoming short of breath more frequently; has had more asthma attacks recently. Their family is aware of tobacco use.

Other Info:

• Non-binary; pronouns: they/them
• They live with their mother.
• They have two older siblings who also live at home.

Ask

Screen for Tobacco Use With Every Youth Age 11+ at Every Clinical Encounter

* Products used may vary between communities. Visit the Considerations for Clinicians page to view illustrations of common products.

Create a Space for Confidentiality & Trust

Sample Dialogue Part 1 of 3

Clinician: Do you use any tobacco or vaping products, like cigarettes, e-cigarettes, pod, vapes or dip?

Patient: Yes, I smoke menthols.

Clinician: Thank you for sharing that with me. How often are you smoking?

Patient: Ummm, probably 4-5 cigarettes a day.

Clinician: Do your friends or family use tobacco or vaping products?

Patient: My family and I like to go to hookah bars on the weekend.

Clinician: Thank you for sharing that with me. Are there any other products you’ve tried?

Patient: No just the menthols since they’re not as bad.

Counsel

Counsel All Patients Who Use Tobacco About Quitting, Regardless of Amount or Frequency of Use.

Sample Dialogue Part 2 of 3

Clinician: Thank you for sharing that with me. I do want to make sure you know that menthol cigarettes are just as unhealthy as other types of cigarettes and may actually lead to greater addiction to tobacco. "Menthol is a chemical that creates a cooling effect on your throat, reducing the harshness of cigarette smoke and suppressing coughing.

Patient: Oh wow-I didn’t know that.

Clinician: You also mentioned using hookah on the weekend. Hookah use can affect your heart by increasing your heart rate and blood pressure and it can affect how well your lungs work. Hookah can also make you have more asthma symptoms such as shortness of breath or wheezing and can lead to further asthma attacks.*

Patient: I didn’t know that, either.

Clinician: Quitting will protect your health, save your money, and increase your independence. Is that something you’re interested in trying?

Patient: I guess so, I’m willing to try.

*Effects of hookah/waterpipe smoking on general health and the cardiovascular system

Treat

Link Youth to Appropriate Behavioral Supports

Cessation Support & Additional Follow Up

**AAP Recommendations for NRT Prescription can be found at aap.org/NRT

Sample Dialogue Part 3 of 4

Clinician: If it's ok with you, I'd like to have you complete this quick form to help us understand how dependent your body is on nicotine.

Patient: Sure.

*Patient is determined to be moderately dependent*

Clinician: Based on your assessment, I think using a medication combined with some quit coaching will help you the most. The medication can help with withdrawal symptoms as your body gets used to not having nicotine around. The quit coaching can help you learn how to manage cravings and triggers. Would you be interested in these treatments?

Patient: Yes

Clinician: Let’s set a quit date 2 weeks from now. What day would you like to start?

Patient: I would like to start this Monday

Clinician: Awesome! Let's also set up a quit coach. Would you like support through text, call or web-based program?

Patient: Call.

Clinician: Okay. If you have your phone with you save this number. 1-800-QUIT-NOW.

Patient: Thank you.

*Additional behavioral support options can be found in “Youth Tobacco Cessation: Considerations for Clinicians”

Cessation Medication and Patients >18

Sample Dialogue Part 4 of 4

Clinician: I’m also going to prescribe you some medication to help you quit smoking too. This medication is called varenicline.

Patient: How does it work?

Clinician: Varenicline works by blocking nicotine's effects in the brain that make you want to smoke.

Patient: Okay.

Clinician: You can fill the prescription and begin taking varenicline today. You will take 1 pill once a day for three days, then increase to 1 pill twice a day for 4 days. The dose is slowly increased to lessen the chance of side effects, which can include nausea and unusual dreams. It will help if you take the medication with food. It's okay to smoke during this time, but make sure you stop on your quit date. After your quit date, keep taking 1 pill twice a day for 12 weeks total.

Patient: Okay that makes sense.

Clinician: I’m proud of you for making the decision to try again. Quitting can be difficult, but I know you can do it. I or someone from the clinic will follow up with you in 2 weeks to see how things are going.

Patient: Thank you.

Download Full Case Study View Full Youth Clinical Considerations

Additional case studies were developed to show the variations in clinical settings, common products, screening techniques, motivational interviewing, patient response, and clinician considerations. Please return to the home page to see additional case studies.