Garis Panduan Program Farmakoterapi Berhenti Merokok

GARIS PANDUAN
PROGRAM FARMAKOTERAPI
BERHENTI MEROKOK (FBM)

Edisi Pertama 2012

Bahagian Perkhidmatan Farmasi
Kementerian Kesihatan Malaysia



Penghargaan

• Dato’ Eisah bt A. Rahman
Pengarah Kanan Perkhidmatan Farmasi, Kementerian Kesihatan Malaysia

• Dr Ismail bin Abu Taat
Pengarah Jabatan Kesihatan Wilayah Persekutuan Kuala Lumpur & Putrajaya

• Pn Hajjah Rosnaini bt Kamaruddin
Timbalan Pengarah Kesihatan Negeri (Farmasi) JKWPKL & Putrajaya

• Dr Salmah bt Bahri
Pengarah Amalan & Perkembangan Farmasi, Kementerian Kesihatan Malaysia

• Pn Abida Haq bt Syed M Haq
Timbalan Pengarah Farmasi Klinikal & Teknikal, Bahagian Perkhidmatan Farmasi

• Jawatankuasa Kerja Program Farmakoterapi Berhenti Merokok:

• Pn Muslisah bt Musa
• En Kobu a/l Thiruvanackan
• Pn Najwa bt Ahmad Hamdi
• En Zenson Yong Chee How
• En Mohd Dziehan b Mustapha
• Pn Nursahjohana bt Md Sahak
• Pn Sharon Ong Chin Wen
• Cik Soo Gian Wan

• Unit Farmasi Ambulatori, Cawangan Farmasi Klinikal & Teknikal, BPF KKM



Kandungan Mukasurat

Pendahuluan 1

Objektif 1

Definisi 2

Skop 2

Tanggungjawab 2

TPKN (F) 3

Pegawai Farmasi 3

Penolong Pegawai Farmasi 3

Perlaksanaan FBM 4

Modul Farmakoterapi Berhenti Merokok 5

Carta Aliran Pengendalian Khidmat
Berhenti Merokok (KBM) 10

Carta Aliran FBM Bagi Lawatan Pertama 11
Carta Aliran FBM Bagi Lawatan Susulan 12
Rujukan 13
Lampiran 1(a) - Borang Lawatan Pertama FBM 17
Lampiran 1(b) - Borang Lawatan Susulan FBM 23
Lampiran 1(c) - Rekod Jadual dan Carta Pesakit 27
Lampiran 2 - Panduan Kaunseling FBM 33
Lampiran 3 - Master Rekod FBM 43
Lampiran 4 - Assessment of Motivation To Stop Smoking 47

Lampiran 5 - Hospital Anxiety and Depression (HAD) Scale 51



GARIS PANDUAN PROGRAM
FARMAKOTERAPI BERHENTI MEROKOK (FBM)

PENDAHULUAN
Merokok merupakan salah satu faktor utama penyebab penyakit yang boleh
membawa maut seperti penyakit jantung dan kanser. Namun begitu, tabiat
merokok masih menjadi kebiasaan kebanyakkan orang dan ianya amat sukar
untuk dihentikan. Berdasarkan Kajian Morbiditi dan Kesihatan Kebangsaan
Ke-3 yang dijalankan oleh Kementerian Kesihatan Malaysia pada tahun 2006,
tabiat merokok telah menyumbang kepada lebih kurang 35% daripada jumlah
keseluruhan kematian di hospital.

Sehubungan dengan itu, membantu masyarakat dalam menghentikan tabiat
buruk ini merupakan usaha preventive medicine yang sama pentingnya
dengan usaha memperbaiki nutrisi masyarakat. Menyedari kepentingan usaha
ini, Bahagian Kawalan Penyakit KKM telah melaksanakan Program Berhenti
Merokok” atau Quit Smoking Program (Smoking Cessation Program) semenjak
tahun 1998 bagi membantu masyarakat mengatasi tabiat merokok ini.

Kajian meta-analisis yang diterbitkan pada tahun 20002 telah menunjukkan,
penglibatan pelbagai disiplin termasuk pegawai farmasi dalam menangani
tabiat buruk ini dapat meningkatkan keberkesanan dan estimated abstinence
rate. Rentetan daripada itu, Bahagian Perkhidmatan Farmasi (BPF) telah
mengeluarkan garis panduan FBM sebagai panduan kepada pegawai farmasi
dalam memantapkan pelaksanaan Program Berhenti Merokok.

1

OBJEKTIF

1. Meningkatkan kualiti perkhidmatan Program Berhenti Merokok di semua
OBfaJsEiKlitTi IKFementerian Kesihatan Malaysia melalui penglibatan pegawai farmasi
secara aktif dan dinamik.

1. Meningkatkan kualiti perkhidmatan Program Berhenti Merokok di semua fasiliti

2. MeKneymeedntiearkiaannKersuihjuatkaannmeblaalugiippenegllaibkastaannpaeaganwaFiafarrmmaaski osetecarraapaiktBif edarhnednintaimMik.erokok
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oleh pegawai farmasi.

3. Menyeragamkan perkhidmatan Farmakoterapi Berhenti Merokok yang
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Mapleagyaswiaai.farmasi di fasiliti kesihatan Kementerian Kesihatan Malaysia.

DDEEFFIINNIISSI I Bebas rokok selama 6 bulan.

• ABSTINENCE Pensijilan yang diiktiraf oleh BPF untuk melayakkan
pegawai farmasi mengendalikan program FBM.
• CERTIFIED SMOKING Pensijilan ini boleh diambil melalui peperiksaan
CESSATION SERVICE secara online dalam laman web Academy of
PROVIDER Pharmacy.
(CSCSP)
Fasa di mana pesakit sedar terhadap kepentingan
• FASA MINAT berhenti merokok tetapi masih belum menunjukkan
sebarang usaha untuk berhenti merokok.

• FASA PERCAYA DAN YAKIN Fasa di mana pesakit mempunyai niat yang
• FASILITI KKM bersungguh-sungguh dan mempunyai usaha sendiri
• PARAMEDIK untuk berhenti merokok.

Hospital, Klinik Kesihatan dan Institut Kesihatan
KKM.

Penolong Pegawai Perubatan dan Jururawat.

• PENYELARAS PROGRAM Pegawai yang dilantik mengikut kesesuaian fasiliti
• PRA- LAWATAN masing-masing.

Sesi temujanji pesakit sebelum didaftarkan dalam
program FBM. Bilangan sesi bergantung kepada
kesediaan pesakit untuk berhenti merokok.

SKOP

PSroKsOePdur ini boleh digunapakai oleh semua fasiliti farmasi yang menjalankan FBM di klinik
kPersoihseadtaunr idnai nbohleohspditigaul nKaKpMak.ai oleh semua fasiliti farmasi yang menjalankan FBM di klinik

kesihatan dan hospital KKM.

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 4

2

TANGGUNGJAWAB
Bahagian Perkhidmatan Farmasi

1. Rancang dan pantau pelaksanaan FBM peringkat kebangsaan.
2. Sediakan dan kemaskini Garis panduan FBM mengikut keperluan semasa.
3. Kumpul dan analisa data dan maklumat pelaksanaan FBM.
4. Bentangkan pencapaian dan mencadangkan tindakan penambahbaikan

kepada pihak pengurusan atasan.

TPKN (F)

1. Rancang dan pantau pelaksanaan FBM peringkat negeri.
2. Pastikan setiap klinik kesihatan menjalankan aktiviti promosi FBM.
3. Kumpul dan analisa data dan maklumat pelaksanaan FBM di peringkat

negeri.
4. Pantau dan selesaikan masalah-masalah berkaitan kelancaran pelaksanaan

FBM di peringkat negeri.
5. Membentangkan pencapaian dan mencadangkan tindakan penambahbaikan

kepada pihak pengurusan atasan.
6. Rancang dan mengagihkan sumber manusia mengikut keperluan di fasiliti

yang menjalankan FBM.

Pegawai Farmasi

1. Pegawai farmasi yang terlatih perlu melaksanakan FBM bagi memastikan
penggunaan ubat-ubatan secara selamat dan meningkatkan komplians
pesakit yang menjalani terapi.

2. Memberi maklumbalas berkenaan program Berhenti Merokok kepada
Bahagian Perkhidmatan Farmasi, KKM setiap 6 bulan atau apabila
diperlukan oleh BPF.

Penolong Pegawai Farmasi

1. Membantu dalam menjalankan aktiviti promosi FBM.

3

PELAKSANAAN FBM

1. Pelaksanaan FBM di klinik kesihatan mesti selaras dengan Garis
Panduan Perkhidmatan Berhenti Merokok di Klinik Kesihatan (Julai 2011)
oleh Bahagian Pembangunan Kesihatan Keluarga, KKM sementara
pelaksanaannya di peringkat hospital perlu selari dengan Manual Latihan
Kebangsaan dalam membantu perokok berhenti merokok pada tahun 2005
oleh Bahagian Pendidikan Kesihatan, KKM.

2. lPuelugsawCaeirtiffaierdmSasmi oykainngg CteerslastaihtiodnaSlaemrvicmeePngroevniddearlik(CanSCFSBPM) serta sudah
sahaja boleh
melaksanakan FBM.

3. Pengurusan rawatan bagi pesakit FBM dijalankan mengikut modul
farmakoterapi berhenti merokok yang disyorkan dalam garis panduan ini.
Panduan Kaunseling Farmakoterapi Berhenti Merokok disertakan sebagai
rujukan dalam melaksanakan perkhidmatan FBM (rujuk Lampiran 2).

4. Perlaksanaan FBM perlu didokumentasikan dan dilaporkan ke Bahagian
Perkhidmatan Farmasi bagi tujuan pemantauan. Penghantaran laporan
maklumbalas perlu dilakukan setiap 6 bulan atau apabila diperlukan ke
BPF melalui emel: [email protected]

5. Pesanan/ Preskripsi bagi ubat FBM perlu dibuat oleh Pakar Perubatan/
Pakar Kesihatan Keluarga atau pegawai perubatan yang diberi kuasa.

6. Kaunseling modifikasi tingkah laku (behavioral therapy) dilaksanakan oleh
pegawai kaunselor.

7. Pkeasriahmateadnikdamnekmabuenrsikealinngsobkeohnagvaionradlathlaemrapmye.njalankan prosedur saringan
8. tPaerinkyhelkaaruanssPerloinggrabme/hAapvpioorinatletdheSrtaapffybedratnanmggeumnagkjlauwmakbaunnktuekpamdeanepteaspakkaint/

klien untuk datang ke temujanji berjumpa doktor/pegawai farmasi.

4

MODUL FARMAKOTERAPI BERHENTI MEROKOK

MODUL FARMAKOTERAPI BERHENTI MEROKOK

Lawatan Aliran Tugas Tanggungjawab
Pesakit Kerja
Fasa Minat: Pegawai Perubatan
Pra Lawatan 1 Mempromosi program FBM dan menjalankan / Pegawai Farmasi /
(1-2 kali saringan bagi pesakit yang layak mengikuti Paramedik /
lawatan) program ini. Penyelaras
Program

Pra Lawatan 2 Fasa Yakin dan Percaya:
(1-2 kali Membuat pendaftaran hanya bagi pesakit yang
lawatan) layak mengikuti program ini dan bersetuju dengan
kriteria yang ditetapkan. Pesakit yang ingin
menyertai program ini perlu dipastikan mempunyai
tahap motivasi dan kemahuan yang tinggi. Rujuk
Lampiran 4 untuk penilaian.

a. Tetapkan tarikh temujanji (dalam tempoh 2 Pegawai Perubatan
minggu). / Pegawai Farmasi /
Paramedik /
b. Penyelaras Program perlu memaklumkan tarikh Penyelaras
temujanji pesakit baru kepada Pegawai Program
Perubatan dan Pegawai Farmasi.

Lawatan 1 Penyaringan
Pertama (Bagi perokok yang bersetuju untuk
mendapatkan rawatan).

a. Mendapatkan keizinan pesakit (Borang Pegawai Farmasi /
Keizinan- Lampiran 1a). Paramedik

b. Ambil dan catatkan tanda- tanda vital: Tekanan Paramedik
Darah (BP), Berat Badan & CO (Lampiran 1a
& 1c) .

c. Terangkan tahap CO dengan bantuan carta Pegawai Farmasi /
yang sedia ada (Lampiran 1c). Paramedik

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 7

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Lawatan Aliran Tugas Tanggungjawab
Pesakit Kerja
Konsultasi oleh Pegawai Perubatan.
Lawatan 2
Pertama

a. Tetapkan tarikh berhenti merokok. Pegawai Perubatan
/ Pegawai Farmasi
b. Bincangkan rintangan-rintangan yang bakal
dihadapi oleh pesakit dan cara-cara mengatasi.

c. Bincangkan dan tentukan farmakoterapi yang
sesuai bersama Pegawai Farmasi.

d. Tetapkan tarikh temujanji yang sesuai dengan Penyelaras

Pegawai Perubatan (Lampiran 1c). Program

Lawatan 3 Sesi Kaunseling
Pertama

a. Dispen ubat mengikut kriteria yang ditetapkan Pegawai Farmasi
dalam rekod pesakit FBM untuk tempoh masa 2
minggu.

b. Berikan kaunseling mengikut Panduan
Kaunseling FBM (Lampiran 2).

c. Isikan maklumat Quit Smoking Clinic-Initial Visit
dalam borang rekod pesakit FBM (Lampiran
1a).

d. Tetapkan tarikh temujanji dengan Pegawai Penyelaras
Farmasi dalam masa 2 minggu (Lampiran 1c). Program

e. Penyelaras Program merancangkan tarikh
kaunseling modifikasi tingkahlaku (behaviour
therapy) dengan Kaunselor.

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 8

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Lawatan Aliran Tugas Tanggungjawab
Pesakit Kerja
Penilaian Awal.
Lawatan 1
Susulan
(minggu ke-2, a. Pendaftaran.
4, 8, 12)

b. Ambil dan catatkan tanda-tanda vital: BP, Berat Pegawai Farmasi /

Badan, CO (Lampiran 1b & 1c). Paramedik

c. Terangkan tahap CO dengan bantuan carta
yang sedia ada (Lampiran 1c).

d. Isikan maklumat Quit Smoking Clinic - Follow
up Visits dalam borang rekod pesakit FBM
(Lampiran 1b)

Lawatan 1 Penilaian / Sesi Kaunseling.

Susulan

(minggu ke-2) a. SMS atau telefon pesakit sebelum tarikh Pegawai Farmasi /

susulan minggu ke-2 untuk mengingatkan tarikh Penyelaras

temujanji. Program

b. Cadangkan isu-isu penjagaan farmaseutikal Pegawai Farmasi
kepada Pegawai Perubatan (sekiranya ada).

c. Rujuk pesakit kepada Pegawai Perubatan
(sekiranya perlu).

d. Dispen ubat dan jalankan kaunseling mengikut
modul yang ditetapkan dalam Panduan
Kaunseling FBM (Lampiran 2) untuk tempoh
masa 2 minggu.

e. Isikan maklumat farmakoterapi kaunseling
dalam borang rekod pesakit FBM (Lampiran
1b).

Lawatan 1 Konsultasi oleh Pegawai Perubatan dan

Susulan kaunseling oleh Pegawai Farmasi.

(minggu ke-4,

8 & 12) a. SMS atau telefon pesakit sebelum tarikh Pegawai Farmasi /

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 9

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Lawatan Aliran Tugas Tanggungjawab
Pesakit Kerja
susulan minggu ke-4, 8 & 12 untuk Penyelaras
mengingatkan tarikh temujanji. Program

b. Bincangkan rintangan-rintangan yang bakal Pegawai Perubatan

dihadapi oleh pesakit dan cara-cara mengatasi. / Pegawai Farmasi

c. Tetapkan tarikh temujanji seterusnya pada Pegawai Farmasi /

setiap bulan yang akan datang ( Lampiran 1c). Penyelaras

Program

d. Kaunseling susulan dengan Pegawai Farmasi Pegawai Farmasi
tentang ubat-ubatan (Lampiran 2).

e. Isikan maklumat farmakoterapi kaunseling
dalam borang rekod pesakit FBM (Lampiran
1b).

f. Sesi kaunseling modifikasi tingkahlaku Pegawai Farmasi /
(behaviour therapy) sekiranya ada. Kaunselor

Susulan 1 Pemantauan keadaan pesakit.

Melalui

Telefon a. Berikan kaunseling Pegawai Farmasi

(minggu ke- 6 mengikut Panduan Kaunseling FBM (Lampiran

dan 10) 2)

b. Isikan maklumat farmakoterapi
kaunseling dalam borang rekod pesakit FBM
(Lampiran 1b).

Lawatan 1 Sesi Kaunseling
susulan
setelah a. SMS atau telefon pesakit sebelum tarikh Pegawai Farmasi /
berhenti susulan minggu ke -16 & 24 untuk Penyelaras
merokok mengingatkan tarikh temujanji. Program
(minggu ke-
16 & 24) b. Kaunseling bersama Pegawai Perubatan dan Pegawai Perubatan
Pegawai Farmasi (Lampiran 2). / Pegawai Farmasi

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 10

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Lawatan Aliran Tugas Tanggungjawab
Pesakit Kerja
c. Tetapkan satu sesi testimoni pesakit yang Kaunselor/
berjaya (sekiranya perlu). Paramediks/
Penyelaras
d. Tetapkan tarikh temujanji dengan pesakit Program
(Lampiran 1c) untuk membuat penilaian
abstinence pada bulan ke - 6 dan ke -12. Pegawai Farmasi /
Penyelaras
e. Sesi kaunseling behavioral therapy. Program

Pegawai Farmasi /
Kaunselor

REKOD-REKOD KUALITI

REKO1.DB-RoraEnKg ROeDkodKPUesAakLit FITarImakoterapi Berhenti Merokok ( Lampiran 1a,b,c).

2. Master rekod klinik FBM (Lampiran 3)

1. Borang Rekod Pesakit Farmakoterapi Berhenti Merokok ( Lampiran 1a,b,c).
2. Master rekod klinik FBM (Lampiran 3)

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 11

9

CaCrtaartaAAlilirraannPPenegnegndeanlidanalKiahindmKaht BidermheanttiBMeerrohkeonk t(Ki BMMe)rdoakriopakda(KBBhgM. )
daripada BhgP.ePrkehridkmhaidtamn KaetsaihnatKanesKiehluaatragan(BKPeKlKu)arga (BPKK)

Pendaftaran GUNA BUKU
Klien DAFTAR KBM

Penilaian Dan GUNA BUKU
Penentuan Tahap Ketagihan Nikotin REKOD

(FAGERSTROM) KESIHATAN KBM

Pemeriksaan Fizikal
Dan Ujian Klinikal Klien

Rawatan Klien**

Non-Farmakologi Farmakologi
(NRT/CHAMPIX)

Rawatan Susulan

Rujukan

Aktiviti Pengekalan
Status Berhenti Merokok

Pemantauan

** Di mana peranan pegawai farmasi bermula

** Di mana peranan pegawai farmasi bermula

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 12

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CARTA ALIRAN FBM BAGI LAWATAN PERTAMA

CARTA ALIRAN FBM BAGI LAWATAN PERTAMA

Tanggungjawab Carta Aliran

Pegawai Perubatan/ Mula
Paramedik/
Penyelaras Program Saringan dan pemilihan
pesakit yang sesuai

Paramedik Penilaian awal

Pegawai Perubatan/ Berikan rawatan yang sesuai
Pegawai Farmasi kepada pesakit

Pegawai Farmasi Beri kaunseling
farmakoterapi
Pegawai Farmasi/ kepada pesakit
Penyelaras Program
Tetapkan temujanji
susulan

Tamat

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 13

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CARTA ALIRAN FBM BAGI LAWATAN SUSULAN

CARTA ALIRAN FBM BAGI LAWATAN SUSULAN

Tanggungjawab Carta Aliran

Mula

Paramedik

Penilaian awal

Pegawai Perubatan/ Beri kaunseling kepada
Pegawai Farmasi/ pesakit
Kaunselor/ Paramedik

Pegawai Farmasi/ Tetapkan tarikh kauseling
Penyelaras Program susulan/ kaunseling

berkumpulan/ kaunseling
selepas berhenti rokok

Tamat

Garis Panduan Program Farmakoterapi Berhenti Merokok (FBM) 14

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LAMPIRAN
1. Borang Rekod Pesakit FBM

a. Quit smoking clinic- Initial visit
b. Quit smoking clinic- Follow up visits
c. Tables and charts for recording
2. Panduan Kaunseling FBM
3. Master rekod klinik FBM
4. Assessment of motivation to stop smoking
5. HAD assessment form.
RUJUKAN
1. Clinical Practice Guidelines on Treatment of Tobacco Use and Dependence,
2003.
2. United States of America: Clinical Practice Guidelines on Treating Tobacco
Use and Dependence, 2008
3. Manual Latihan Kebangsaan dalam Membantu perokok berhenti
merokok,Bahagian Pendidikan Pesakit KKM Edisi, 2005.
4. Active Approach Smoking Cessation Program (AASCEP). Jabatan
Kesihatan Wilayah Persekutuan Kuala Lumpur & Putrajaya, 2011.

13



LAMPIRAN 1(a)



LAMPIRAN 1(a)

BORANG KEIZINAN RAWATAN
KLINIK BERHENTI MEROKOK

Saya, ______________________________ No. K/P: _________________________

bersetuju untuk menyertai Program Berhenti Merokok. Saya juga memberi keizinan
untuk sebarang langkah atau ujian sebagaimana yang didapati perlu untuk tujuan ini.

Tarikh: _____________ Tandatangan:

________________

Saya mengaku bahawa saya telah menerangkan tujuan dan kebaikan rawatan
serta kesan sampingan rawatan yang mungkin berlaku kepada penama.

Tarikh: _____________ Tandatangan:
___________________

Nama:
Cop:

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

17

LAMPIRAN 1(a)
FBM ver. 1/2012

BORANG REKOD PESAKIT
PROGRAM FARMAKOTERAPI BERHENTI MEROKOK

BAHAGIAN PERKHIDMATAN FARMASI, KKM

QUIT SMOKING CLINIC - INITIAL VISIT Date: _______________

A) PATIENT’S BIODATA SOCIO DEMOGRAPHY INFORMATION

PERSONAL INFORMATION Date of Birth:
Name:
Age:
I.C Number (New):
I.C Number (Old): Gender: ○ Male ○ Female
Tel. No (Mobile):
Tel. No (Office): Religion:
Tel. No (Home):
Email : Nationality:
Home Address:
Race:
NEXT OF KIN INFORMATION
Name: Marital Status: ○ Single ○ Married
Relationship:
Address: Occupation:

Tel. No (Mobile): Level of Education:
Tel. No (Home):
Household Income/month (RM):

B) PARAMETERS

BP (mmHg) BMI (kg/m2)
HR (bpm) CO level (ppm)
Weight (kg) Height (m)
SrCr (µmol/l) CrCl (ml/min)
Fagerstrom score
□ Pre-contemplative stage
Readiness to quit □ Contemplative stage
□ Preparation stage
□ Action stage

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

18

LAMPIRAN 1(a)

C) MEDICAL HISTORY

i) DIAGNOSIS (Please √)

Yes No Yes No

Asthma/ COPD Heart Disease - Myocardiac Infarction /
Angina/ Left Ventrical Hypertrophy/
Atrial Fibrillation

Diabetes Mellitus Psychosis

Hypertension Dyslipidemia

Others :

ii) DRUG ALLERGY

Bil Generic Name / Brand Bil Generic Name / Brand

13

24

iii) CURRENT MEDICATION(S)

Bil Generic Name Dose Bil Generic Name Dose

16

27

38
49

5 10

iv) CONSUMPTION OF ALCOHOL / ILLICIT DRUGS
Alcohol use: Yes / No (if yes how many pints/week)

Illicit drugs: Yes/No (If yes, please state what drug)

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 1(a)

D) SMOKING HISTORY RM
1 Duration of smoking history After meal
2 Reason of smoking During festive season
3 Average no. of cigarette/day When feeling bored or sleepy
4 Average cost spent on cigarette/day Stress
5 Trigger factors Friends/ Colleague
(Can √ more than 1) Watching television
In the Bathroom/ toilet
6 Is it a relapse? Do you live with smokers
Others:
7 No. of quit attempt/s (and method/s used)
□ Yes □ No

Reason/s:

□ Craving □ Lack of support to stop

□ Peer pressure

□ Others:___________________

No of Attempt/s :
Date of Last
Attempt :
Method :

Additional Comment/s: (E.g. Deep Inhalation)

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 1(b)



LAMPIRAN 1(b)

QUIT SMOKING CLINIC - FOLLOW UP VISITS

Date: ____________ No. of visit: ______ No. ______ Week / month of treatment

i) Parameters

BP (mmHg)
HR (bpm)
Weight (kg)
Height (m)
BMI (kg/m)
PEFR (l/min)
CO level (ppm)
Total Score of Fagerstrom

ii) New medical problem (if any)

___________________________________________________________________________
___________________________________________________________________________

iii) Smoking History

• Current smoking status: Yes/ No

• No. of cigarettes: ______

• Cost spent on cigarettes/day: ________

• Attitude towards smoking: □ Positive □ Negative □ Uncertain

iv) Withdrawal symptoms (Please tick √)

a) Physical dependence Anger/ frustration
Headache
Irritability, restlessness Change in bowel movement
Impatience Change in appetite
Poor concentration Dizziness
Fatigue Tremors
Change in sleep pattern
Palpitation
Others:

b) Behavioural dependence

Habitual -hand-to-mouth action
Habitual- situational triggers (eg. After meal, relax, stress)
Psychological dependence (eg. Convinced cigarette as source of comfort)
Others:

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23

LAMPIRAN 1(b)
v) Management of Withdrawal Symptoms (Refer to FBM Counselling Guide)

__________________________________________________________________________
__________________________________________________________________________

vi) Side Effects (Please tick √)

Nicotine Gum Nicotine Patch Varenicline
Nausea
Headache Headache Increased appetite
Dizziness Dizziness Abnormal dreams
GI discomfort Nausea Insomnia
Hiccups Vomiting Dizziness
Nausea Irritation at site of patch Vomiting
Vomiting Erythema at site of patch Constipation
Throat irritation Palpitations Diarrhoea
Jaw ache Abdominal distension
Palpitations Flatulence
Erythema Stomach discomfort
Atrial flutter Dry mouth
Allergy reaction Fatigue
Others:
Suicidal ideation

vii) Management of Side-effects (Refer to FBM Counselling Guide)

_________________________________________________________________________
viii) Remarks/ Comment

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 1(c)



LAMPIRAN 1(c)

TABLES & CHARTS FOR RECORDING

A) FAGERSTROM SCORE (FS)

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

□ within 5 minutes (3)

□ 6 – 30 minutes (2)

□ 31 – 60 minutes (1)

□ After 60 minutes (0)

2. Do you find it difficult to not smoke in places where it is forbidden? E.g. work, cinema

□ Yes (1)

□ No (0)

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

□ The first one in the morning (1)

□ All others (0)

4. How many cigarettes do you smoke per day?

□ 10 or less (0)

□ 11 – 12 (1)

□ 21 – 30 (2)

□ 31 or more (3)

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

□ Yes (1)

□ No (0)

6. Do you smoke if you are so ill that you are in bed most of the day?

□ Yes (1)

□ No (0)

B) FS SCORE TABLE

1st Visit Tel. 2nd 3rd Tel. 4th Tel. 5th Visit
(wk 0) Counsel. Visit Visit Counsel. Visit Counsel. (wk 12)
(the 3rd (wk 2) (wk 4) (wk 6) (wk 8) (wk 10)
Dr/PF
APPOINTMENT day) PF Dr/PF PF Dr/PF PF Dr/PF
WITH
DATE PF
Q1
Q2
Q3
Q4
Q5
Q6
Total Score

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C) TRENDING CHART FOR FAGERSTROM SCORE (FS) LAMPIRAN 1(c)
(Please tick (x) in the appropriate score box)
ADDICTION
Date LEVEL
FS
VERY HIGH
10
9 HIGH
8 MODERATE
7
6 LOW
5
4
3
2
1

D) TRENDING CHART FOR CO LEVEL (Please tick (x) in the appropriate score box)

Date CO ADDICTION
(%CO HB) LEVEL
CO Heavy
(PPM) >3.2 smoker

>20 Smoker

18 Light
Smoker
16 3.2 -
14 1.76 Non Smoker

12

10 1.6 –
8 1.12

6

4 0.96 –
0.16

<2

E) TRENDING CHART FOR PEAK EXPIRATORY FLOW RATE (PEFR*)
Please fill in the score box with best reading for 3 attempts

*Formula (L/min): [Height (cm)-80] x 5

Date

PEFR

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 1(c)

F) QUIT SMOKING CLINIC- TREATMENT CHART

Target quit date:_____________ Actual Quit Date:_____________
Date Treatment (Dosage & Duration) Next TCA Medication Cost

According to protocol, patient’s appointments fall on week 0, 2, 4, 8 & 12. Week 16 & 24 are optional
appointment.

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 1(c)

• DOCUMENTATION CHECKLIST

Date Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7 Visit 8

Visit

1. CONSENT
FORM
2. INITIAL VISIT
FORM
3. FAGERSTROM
SCORE
4. FOLLOW UP
VISIT FORM
5. TREATMENT
FORM
6. COUNSELING
GUIDE
7.
APPOINTMENT
DATE

• IMPORTANT DATES

1st Tel. 2nd 3rd Tel. 4th Tel. 5th
Visit Counsel. Visit Visit Counsel. Visit Counsel. Visit
(wk 0) (the 3rd (wk 2) (wk 4) (wk 6) (wk 8) (wk 10) (wk 12)
day)
APPOINTMENT Dr/PF PF Dr/PF PF Dr/PF PF Dr/PF
WITH PF
APPOINTMENT
DATE (SET)
APPOINTMENT
DATE (ACTUAL
CAME)
REMINDER
DATE (SET)

REKOD PESAKIT FARMAKOTERAPI BERHENTI MEROKOK, BPF KKM

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LAMPIRAN 2



LAMPIRAN 2

FBM (PHARMACY) COUNSELLING GUIDE

A) PHARMACOTHERAPY COUNSELLING

1. Nicotine Replacement Therapy (Nicotine Gum)

DATE
COUNSELLING POINTS
Dosing

• Use at least one piece every 1 to 2 hours for at least 1-
3 months

• Use not more than 24 pieces per day

Chewing technique
• Gum should be chewed slowly until a “peppery “or
“flavored” taste emerges, then “parked” between cheek
& gum to facilitate nicotine absorption.
• Gum should be slowly and intermittently “chewed and
parked” for about 30 minutes or until the taste
dissipates.

Side effects
• Mouth soreness, hiccups, dyspepsia, and jaw ache -
generally mild and transient and often can be alleviated
by correcting the patient’s chewing technique

Interaction
• Acidic beverages (e.g., coffee, juices, soft drinks)
interfere with the buccal absorption of nicotine, it should
be avoided for 15 minutes before or during use of orally
NRT.
• Antipsychotic drugs, opioid, antihypertensive, insulin,
blood thinning drugs and theophyline : Increased level
or effect
• Cimetidine: Increased level of nicotine

Contraindication/Precaution
• Cardiac problems such as immediate (within 2 weeks)
post myocardial infarction period, serious arrhythmias,
unstable angina pectoris or pregnancy

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PANDUAN KAUNSELING FBM

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LAMPIRAN 2

2. Nicotine Replacement Therapy (Nicotine patch)

DATE
COUNSELLING POINTS
Dosing

• 8 weeks : 15mg/16 hours
• Then 2 weeks :10mg/16 hours
• Then 2 weeks: 5mg/16 hours

Technique of administration
• Patch should be applied as patient wakes up each day
to avoid sleep disruption
• Apply on relatively hairless location (e.g. hip, upper
arm or chest)
• Rotate sites (each week) to avoid skin irritation

• When the patch is removed, fold patch and place it in
its pouch before discarding

Side effects
• Skin reaction – Rotate patch sites or treat with
steroidal creams
• Headache, dizziness, nausea, vomiting

• Insomnia and/or vivid dreams- may be related to

Interaction
• Antipsychotic drugs, opioid, antihypertensive, insulin,
blood thinning drugs and theophyline : Increased level
or effect of drug
• Cimetidine: Increased level of nicotine

Contraindication/Precaution
• Cardiac problems such as immediate (within 2 weeks)
post myocardial infarction period, serious arrhythmias,
unstable angina pectoris or pregnancy

PANDUAN KAUNSELING FARMAKOTERAPI BERHENTI MEROKOK PANDUAN KAUNSELING FBM

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LAMPIRAN 2

3. Varenicline

DATE
COUNSELLING POINTS
Dosing

• Day 1-3: 0.5mg od
• Day 4-7: 0.5mg bd
• Day 8 to end of treatment: 1mg bd
• Patient to quit smoking on Day 8
Technique of administration

• Take with food (non-oily food)
• Take a full glass of water
• Take at the same time everyday
Side effects
• May impair the ability to drive or operate heavy

machinery
• Nausea- Take on a full stomach
• Insomia- Take second pill at supper time or after dinner
• Trouble sleeping, abnormal/vivid/strange dreams,

abdominal pain, flatulence, headache.
Interaction

• Antipsychotic drugs, opioid, antihypertensive, insulin,
blood thinning drugs and theophyline : Increased level or
effect of drug

• Cimetidine: Increased level of nicotine
Contraindication/Precaution

• Pregnancy, kidney disease, history of psychiatric illness,
change in mood- Inform doctor or pharmacist

• Patients with significant kidney disease (creatinine
clearance < 30mL/min) or who are on dialysis. – Reduce
dose

Note: All patients intended to be started on Varenicline should be assessed using Hospital
Anxiety & Depression (HAD) Scale in Lampiran 5

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PANDUAN KAUNSELING FBM

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LAMPIRAN 2

B) ADDITIONAL COUNSELLING POINTS

Using 5Ds strategy to cope with nicotine Date

withdrawal symptoms

Delay Reaching for cigarettes until urges pass
Distract Yourself- call a friend to go for a walk, take after
meal walks, fruits after meal, shower, exercise,
yoga or take sweets

Drink water To fight off cravings
Deep Relax- close your eyes and take 10 deep
breaths breaths
Discuss
your With someone close to you or at a support forum
feelings

Using DEAD strategy to cope with nicotine Date

withdrawal symptoms

Delay Delay reaching for cigarettes

Escape E.g.: Reject offers for cigarettes, throw away
cigarettes / lighters / ashtrays

Avoid Triggers factors like smoking zones, food /
beverage that will trigger urge to smoke (hot &
spicy food, strong caffeinated drinks)

Distract After meal walks, take fruits after meal, shower,
exercise, yoga, sweets

Remarks/Comments:

PANDUAN KAUNSELING FARMAKOTERAPI BERHENTI MEROKOK PANDUAN KAUNSELING FBM

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LAMPIRAN 2

C) Addressing withdrawal symptoms/side effects

Withdrawal symptoms/ Date
side effects

Symptoms Coping strategies

Constant cravings  Follow 5Ds strategy

Feeling irritable  Do relaxation exercises

 Listen to soothing music

 Watch a movie

 Warn family and friends of potential
irritability

 Do light exercises e.g. brisk walking
to release endorphins in the body

Headaches  Get enough sleep
Feeling tired
 Stay in quiet, relaxed surroundings
Coughing
Tingling hands  Don’t stress the eyes. Read and
and feet watch television with the lights on

 Get enough sleep

 Don’t tire yourself out

 Do light exercises e.g. brisk walking

 Take small regular meals to regulate
your blood sugar level and boost
energy level

 Replace coffee with ginger or herbal
tea to perk up

 Suck on sugar-free cough drops

 Sip warm water

 Distract yourself with a book or a
walk

 Go for stretching exercises such as
yoga

 Go for foot or hand massages

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PANDUAN KAUNSELING FBM

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D) Others LAMPIRAN 2
Date
Problems encountered by smokers
PANDUAN KAUNSELING FBM
Problems Responses
 Schedule follow-up visits or telephone
Lack of calls with the patient.
support for
cessation  Urge the patient to call the national quit
line network or other local quit line.

 Help the patient identify sources of
support within his or her environment.

 Refer the patient to an appropriate
organization or support.

Negative mood  If significant, provide counseling,
or depression prescribe appropriate medication, or
refer the patient to a specialist.

Strong or  Consider extending the use of an
prolonged approved medication or
withdrawal adding/combining medications to
symptoms reduce strong withdrawal symptoms.

Weight gain  Use 5Ds strategy

 Recommend starting or increasing
physical activity- 30 minutes 5 times a
week or more

 Emphasize the importance of a healthy
diet and active lifestyle

 Reassure the patient that some weight
gain after quitting is common and
usually is self-limiting.

 Emphasize the health benefits of quitting
relative to the health risks of modest
weight gain.

 Low-calorie substitutes such as
sugarless chewing gum, vegetables,
mints, fresh fruits or crunchy vegetables.

 Drink at least 8 glasses or water daily.

PANDUAN KAUNSELING FARMAKOTERAPI BERHENTI MEROKOK

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Problems encountered by smokers (Cont.) LAMPIRAN 2
Date

Problems Responses
Weight gain
 Maintain the patient on medication
known to delay weight gain (e.g. NRTs—
particularly 4-mg nicotine gum and
lozenge).

 Refer the patient to a nutritional
counselor or program.

Smoking  Suggest continued use of medications,
lapses which can reduce the likelihood that a
lapse will lead to a full relapse.

 Encourage another quit attempt or a
recommitment to total abstinence.

 Reassure that quitting may take multiple
attempts, and use the lapse as a
learning experience.

 Provide or refer for intensive counseling.

 Reassure the patient that these feelings
are common.

 Recommend rewarding activities.

 Probe to ensure that patient is not
engaged periodic tobacco use.

 Emphasize that beginning to smoke
(even a puff) will increase urges and
make quitting more difficult.

Source: Fiore et al. 2008

Remarks/ Comments:

PANDUAN KAUNSELING FARMAKOTERAPI BERHENTI MEROKOK

PANDUAN KAUNSELING FBM

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LAMPIRAN 3



Data FBM Fasiliti

LAMPIRAN 3(a)

Program Farmakoterapi Berhenti Merokok Lawatan Pertama Lawatan Ke-2
Master rekod Hospital/Klinik: ____________________________

Data Demografi

Umur Tarikh
Jantina berhenti
Bangsa merokok
Tinggi (cm)
Pekerjaan
Penggunaan
dadah, Alkohol

dsb)
Purata
perbelanjaan utk
rokok/ sehari
(RM)
Purata
perbelanjaan utk
rokok /sehari (RM)
Bil. IC/MRN Nama Tempoh Tahap Berat Tahap Markah Rawatan Berat Tahap Markah Rawatan
merokok pendidikan Tarikh badan CO Fager digunakan Tarikh badan CO Fager digunakan
(Tahun) strom strom
(kg) (kg)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

43