STROKE PREVENTION CLINIC
SMOKING CESSATION CONSULT FORM
Diagnosis:
____TIA ____Stroke _____Other (specify):___________________
Preferred language: ______English ______French _____Neither
Physician Consult
ADVISE
“You probably already know the risks involved with smoking, but I cannot stress
enough how important it is to stop. Your recent TIA/Stroke makes it (or because you
are at increased risk of stroke means its) even more important for you to quit now
and I would advise you to stop as soon as possible.”
“Quitting smoking is not always easy but we can help you with quitting and there are
medications available to make quitting easier.”
‘We are presently running a study which may be able to provide you with a free 4week supply of quit smoking medications. Taking part in the study means you’ll have
a 50% chance of receiving the quit smoking medications. To become involved with
the study you need to be willing to quit in the next month.”
ASSESS
Are you willing to work with me to set a quit date in the next month?
(initial)
 Yes
 No
READY IN NEXT 30 DAYS QUIT PLAN
ASSIST
Patient
Preference
“It’s great to see that you are ready to make a commitment to quitting smoking. It’s important that you have
a plan for quitting smoking. This is the quit smoking plan that we like to complete to set you up with a plan
for quitting.” (provide patient copy of quit smoking plan)
“Quit smoking medications are available and have been shown to double the chance of being successful
with quitting and staying quit. There are three types of medications that we recommend, one is nicotine
replacement therapy, the other is in a new product that is in pill form and there is also Zyban (which has
been around for a while and is also in pill form).”
 Yes
 No
“Do you have a preference?”
Bupropion / Zyban
ASSIST
Identify Contraindications





 Pregnant, breast feeding or planning pregnancy
History of seizure disorder or head trauma
 Under the age of 18 years;
Presently taking Bupropion/ Zyban/ Welllbutrin
 History of renal failure and is taking Cimetidine;
Previous reaction to Bupropion/ Zyban/
 Using NRT in addition to Varenicline;
Wellbutrin
 Previous drug reaction to Varenicline;
Pre-existing or current eating disorder
 Has history of renal failure (check with physician);
Excessive use of alcohol/sedatives present or
 History of nausea and vomiting in past two months (check with
past
 Taking anti-depressants, antipsychotics,




Varenicline / Champix
corticosteroids, MAO inhibitors, theophyline,
cocaine or diet pills
Taking a quinolone antibiotic (eg.
ciprofloxacin,levoflozacin)
Use of oral hypoglycemic products or insulin
Severe hepatic impairment
Central nervous system tumour
physician).
NRT
 Dentures (avoid NRT gum)
 Allergy to adhesive (consider clear patch)
 NRT
ASSIST
Select
Pharmacotherapy
<10 cigs/cigs
10-20 cigs/day
20+ cigs/day
 7 mg patch
 2mg gum
 Inhaler
 14 mg patch
 2mg gum
 inhaler
 21 mg patch
 4 mg gum
 Consider adding inhaler
 Varenicline - Days 1-3: 0.5mg once/day; Days 4-7: 0.5 mg BID; Day 8-12 weeks 1.0 mg twice daily.
Start 1-2 weeks before the quit date.
 Bupropion - Zyban 150 mg daily (in the morning) x 3 days then 150 mg BID for 3 months
ASSIST
Here is a calendar of the next month? I’d like you to pick your quit date.
Set Quit Date
Quit Date:
(dd/mm/yy)
ASSIST
–
Provide Quit
Plan
ARRANGE
Supplemental
Counselling
ARRANGE
IVR
FOLLOW-UP
 Review medications instruction sheet
 Review “Preparing for quit date” sheet
Initial
This patient would benefit from:
 Group Cessation Program (ACESS)
 UOHI Quit Smoking Program
_________
initial
“As part of our quit smoking program we will be getting touch with you by phone to follow-up on your
progress over the next 6-months. We greatly appreciate if you can answer the phone for these calls and let
us know how you are doing. The calls will be placed at a time that is convenient for you. You should
expect to receive a call in the next 5-7 days?”
 Review Follow-up Plan Instructions for Quit Plan
What is the best time of the day to call you? ________________________
What is the best number to reach you at this time?
 Same as above
 Different: (
)___________________
If patient is unable to receive calls, why?
 No telephone
 Unable to speak English or French
 Already receiving calls through hospital-based smoking cessation program
 Refused
 Other: ___________________________________
Review
Signature: _____________________________________
Study Participants:
Randomized to:
 Quit Smoking Program
 Quit Smoking Program + Cost Free Medications
initial