School-Based Health Center Case Study: 17 year old annual visit, NRT prescription

Background

Patient Information

17 y/o Hispanic male in for a general visit

Initial Vitals:RR =16; BP=110/70 mm Hg, Temp= 98.6

Meds:

• None

HPI:

• He lives with both parents who are not present for the appointment.
• He has 2 younger siblings.
• Patient is generally well appearing with no major health concerns.

Other Info:

• Homosexual; pronouns: he/him

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 4

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

Patient: Yeah, I smoke. I know I shouldn't, but I've tried stopping a few times and it never sticks. Plus, it helps me keep my weight down.

Clinician: What happens when you try to stop?

Patient: Well, I have these really strong cravings to smoke, and my appetite increases. Also, I get headaches, and feel irritated all the time.

Clinician: I appreciate you being honest and sharing that with me.

Counsel

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

Sample Dialogue Part 2 of 4

Clinician: It takes courage to share something personal. You’ve mentioned symptoms that happen when you haven’t smoked in a while. These are symptoms of withdrawal, and they tell us that the nicotine is starting to change your brain, and you’re developing an addiction.

Patient: Yeah I would like to stop all together, it’s just hard. Plus I don’t want to gain weight.

Clinician: I get it. Quitting can be challenging and, I hear your concern about weight gain. It sounds though like you know how important quitting is, and I'm here to help you. On a scale of 1-10, how important is it for you to quit smoking?

Patient: 8, I guess?

Clinician: I’m so glad that you’re interested in trying again. Can we talk about some ideas I have about resources that can help you be successful?

Patient: Sure.

Treat

Link Youth to Appropriate Behavioral Supports

Behavioral Support & Additional Followup

Sample Dialogue Part 3 of 4

Clinician: I’m so glad you’re interested in quitting. 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. Is that something you'd be interested in?

Patient: Yes

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

Patient: Can I start tomorrow?

Clinician: Tomorrow is a great day to start. First I’m going to connect you to behavioral cessation support. A coach can talk with your through text, call or web-based chat program. Do you have a preference?

Patient: Web-chat.

Clinician: My Life, My Quit™is the free and confidential way to quit smoking or vaping. Text "Start My Quit" to 36072 or go to their website mylifemyquit.com

Additional behavioral supports can be found at www.aap.org/help2quit

Nicotine Replacement Therapy(NRT) and Adolescent Patients

* A full fact sheet for NRT and Adolescent Patients can be found at www.aap.org/NRT

Nicotine Replacement Therapy(NRT) and Adolescent Patients

* Dosing guideline can be found in NRT and Adolescent Patients at www.aap.org/NRT

Sample Dialogue Part 4 of 4

Clinician: I’m also going to prescribe nicotine patches to help you reduce the urge to smoke and to help control those withdrawal symptoms -the headaches and the irritability -that you had last time

Patient: How does it work?

Clinician: The patch will give you a controlled amount of nicotine without all the harmful chemicals in cigarettes.

Patient: How do I use it?

Clinician: You’ll apply the patch to clean skin and then change it every 24 hours. In 6 weeks, we’ll lower the dose in the path. You’ll wear that patch for 2 weeks, changing every 24 hours.

Patient: Okay, that makes sense.

Clinician: Its important you change your patch every 24 hours. Your skin may feel a little irritated and your might experience changes to your sleep. If any of those side effects start to become a problem give me a call and we’ll figure out another solution.

Patient: Okay, thank you.

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 will follow up with you in a week to see how it’s going. If you want to check in before then, you can call me.

Patient: I would like that. Thanks.

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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.