with QUITTING

ASSISTING PATIENTS

with QUITTING

„ Sponsored by the AHRQ (Agency for Healthcare Research and Quality) of the USPHS (US Public Heath Service) with:

„ CDC (Centers for Disease Control)

„ NCI (National Cancer Institute)

„ NIDA (National Institute for Drug Addiction)

„ NHLBI (National Heart Lung & Blood Institute)

„ RWJF (Robert Wood Johnson Foundation)

http://www.surgeongeneral.gov/tobacco/

CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE

EFFECTS OF CLINICIAN INTERVENTIONS

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS, 2000.

0 10 20 30

No clinician Self-help material

Nonphysician clinician

Physician clinician Type of Clinician

Estimated abstinence at 5+ months

1.0 1.1

(0.9,1.3)

1.7

(1.3,2.1)

2.2

(1.5,3.2)

n = 29 studies ASK

ADVISE ASSESS ASSIST ARRANGE

The 5 A’s

The 5 A’s

„ Ask about tobacco use

„ “Do you ever smoke or use any type of tobacco?”

„“I take time to ask all of my patients about tobacco use—because it’s important.”

ASK

The 5 A’s

„ tobacco users to quit (clear, strong, personalized, sensitive)

„ “It’s important that you quit as soon as possible, and I can help you.”

„ “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”

ADVISE

The 5 A’s

„ Assess readiness to make a quit attemptASSESS

„ Assist with the quit attemptASSIST

„ Arrange followARRANGE - up care

The 5 A’s

20.9%

4 to 8

24.7%

More than 8

16.3%

2 to 3

12.4%

0 to 1

Estimated quit rate*

Number of sessions

* 5 months (or more) postcessation

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS, 2000.

PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT

5 A’s: REVIEW

ASK about tobacco USE

ADVISE tobacco users to QUIT

ASSESS readiness to make a QUIT attempt

ASSIST with the QUIT ATTEMPT

ARRANGE FOLLOW-UP care

„Faced with change, most people are not ready to act.

„Change is not a single step, but a process.

„Typically, it takes multiple attempts.

HOW CAN I LIVE WITHOUT TOBACCO?

The (DIFFICULT) DECISION to QUIT

HELPING SMOKERS QUIT IS a CLINICIAN’S RESPONSIBILITY

„Clinicians have a professional obligation to help their patients quit using tobacco.

THE DECISIONTO QUIT LIES IN THE HANDS OF EACH PATIENT.

PATIENTS DIFFER IN THEIR READINESS TO COMMIT TO QUITTING

PATIENTS DIFFER IN THEIR READINESS TO COMMIT TO QUITTING

TAILORING the INTERVENTION to MEET the PATIENT’S NEEDS

„Persons NOT READY TO QUIT (in the next 30 days):

„Motivational interventions

„Persons READY TO QUIT(in next 30 days):

„Behavioral counseling

„Pharmacotherapy

„Persons who RECENTLY QUIT(in past 6 months):

„Relapse prevention interventions

IS a PATIENT READY to QUIT?

Does the patient now use tobacco?

Is the patient now ready to quit?

Provide treatment

The 5 A’s Promote

motivation

Yes

Yes No

Did the patient once use tobacco?

Prevent

relapse* Encourage

continued abstinence Yes

No

No

*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation.

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS, 2000.

FIVE STAGES THAT DESCRIBE a PERSON’S READINESS to CHANGE

STAGE 1: Not thinking about changing anytime soon STAGE 2: Considering changing, but not yet

STAGE 3: Getting ready to change soon STAGE 4: In the process of changing

STAGE 5: Changed a while ago

FIVE STAGES THAT DESCRIBE a PERSON’S READINESS to CHANGE

STAGE 1: Precontemplation STAGE 2: Contemplation

STAGE 3: Preparation STAGE 4: Action STAGE 5: Maintenance

STAGES of CHANGE:

A LINEAR VIEW

Precontemplation Contemplation Action Maintenance Quit

date

Preparation - 30 days

- 6 months + 6 months

Maintenance

Contemplation Action

Preparation contemplationPre- Termination

Relapse*

* Patients can relapse out of the maintenance or action stages, reverting to earlier stages.

ASSESS READINESS TO QUIT:

STAGES of CHANGE, CYCLICAL VIEW

Not ready to quit

STAGES of CHANGE for TOBACCO CESSATION

Does the patient now use tobacco?

Is the patient ready to quit now?

Preparation Precontemplation

- or - Contemplation

Yes

Yes No

Did the patient once use tobacco?

Action - or - Maintenance

Never smoker Yes

No

No

The STAGES of CHANGE

STAGE 1: Precontemplation Not thinking about quitting in the next 6 months

„Patients might not be aware of the need to quit.

„They might be aware of the need but resist quitting.

„Pros of smoking outweigh the cons.

GOAL:Move the patient into the contemplation stage.

STRATEGIES for COUNSELING during PRECONTEMPLATION

DON’Ts

„ Persuade

„ “Cheerlead”

„ Tell patient how bad smoking is, in a judgmental manner DOs

„ Strongly advise to quit

„ Ask noninvasive questions

„ “Envelope”

„ Raise awareness of health consequences/concerns

„ Demonstrate empathy, foster communication

„ Leave decision up to patient

Considering quitting in the next 6 months but not in the next 30 days

„ Patients are aware of the need to quit.

„ They are aware of the benefits of quitting.

„ But they struggle with ambivalence about change.

STAGE 2: Contemplation

The STAGES of CHANGE

GOAL:Move the patient into the preparation stage.

STRATEGIES for COUNSELING during CONTEMPLATION

DON’Ts

„ Apply action- oriented interventions DOs

„ Strongly advise to quit

„ Provide information

„ Identify reasons for tobacco use

„ Demonstrate empathy; increase motivation

„ Encourage self-reevaluation of concerns

„ Offer encouragement

METHODS for INCREASING MOTIVATION—5 R’s

For patients who are not yet ready to quit:

„Relevance

„Risks

„Rewards

„Roadblocks

„Repetition

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Rockville, MD: USDHHS, PHS, 2000.

TAILORED INTERVENTION

MESSAGES

A DEMONSTRATION: COUNSELING a PATIENT who is NOT READY TO QUIT

CASE SCENARIO:

MS. STEWART

You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema.

She uses two different inhalers for her emphysema.

COUNSELING SCENARIO:

KEY POINTS

„Ask about tobacco use

„Link inquiry to knowledge of disease

„Assess readiness to quit

„Aware of need to quit; not ready yet

„Advise to quit

„Discuss implications for disease progression

„“I will help you, when you are ready”

The clinician has

9Established a relationship

9Established yourself as a resource

9Planted a seed to move patient forward

9Opened a door to facilitate further counseling

COUNSELING SCENARIO:

SUMMATION

The STAGES of CHANGE

Ready to quit in the next 30 days

„Patients are aware of the need to, and the benefits of, making the behavioral change.

„Getting ready to take action.

Goal: Move the patient to the action stage.

STAGE 3: Preparation

STRATEGIES for COUNSELING DURING PREPARATION

DOs

„Praise the patient’s readiness

„Assess tobacco use history

„ Current use:

„Type(s) of tobacco, brand, amount

„ Past use: duration, recent changes

„ Past quit attempts:

„Number, date, length

„Methods used, compliance, duration

„Reasons for relapse

DOs

„Discuss key issues

„ Reasons/motivation to quit

„ Confidence in ability to quit

„ Triggers for tobacco use

„ Routines/situations associated with tobacco use

„ Stress-related smoking

„ Social support for quitting

„ Concerns about post-cessation weight gain

„ Concerns about withdrawal symptoms

STRATEGIES for COUNSELING DURING PREPARATION

DOs

„Facilitate quitting process

„ Discuss methods for quitting (pros, cons)

„ Pharmacotherapy: a treatment, not a crutch!

„ Behavioral counseling

„ Set a quit date!

„ Recommend Tobacco Use Log (see handout)

STRATEGIES for COUNSELING

DURING PREPARATION

TOBACCO USE LOG

„The Tobacco Use Log is most appropriate for patients who are getting ready to quit.

„Documenting tobacco use helps patients to understand when andwhy they use tobacco.

„Identifies activities or situations that triggertobacco use.

„Information can be used to develop coping strategiesto overcome the temptation to use tobacco.

TOBACCO USE LOG:

INSTRUCTIONS for USE

„Patient should continue regular tobacco use for a period of 3 or more days

„Each time any form of tobacco is used, the following information should be recorded on the log:

„Time of day

„Brief description of activity or situation during use

„“Importance” rating (scale of 1–3)

„Review log sheets to identify situations that trigger tobacco use

„Develop coping strategies to prevent relapse

DOs

„Discuss and develop coping strategies

„Cognitive

„Behavioral

STRATEGIES for COUNSELING

DURING PREPARATION COPING with QUITTING

„Review of commitment to quitting

„Distractive thinking

„Positive self-talks

„Relaxation through imagery

„Mental rehearsal and visualization

COPING with QUITTING

„Thinking about cigarettes doesn’t mean you have to smoke one.

„“Just because you think about something doesn’t mean you have to do it!”

„Tell yourself “It’s just a thought,” or “I am in control.”

„Say the word STOP! out loud, or visualize a stop sign.

„When you have a craving, remind yourself that:

„ “The urge for a cigarette will only go away if I don’t smoke.”

„As soon as you get up in the morning, look in the mirror and say to yourself

„“I am proud that I made it through another day without smoking.”

COPING with QUITTING

„Control your environment

„Smoke-free home and workplace

„Alter or remove cues to tobacco use

„Modify behaviors that you associate with tobacco: when, what, where, how, with whom

„Actively avoid trigger situations

„Substitutes for smoking

„Water, chewing gum or hard candies (oral substitute)

„Take a walk, diaphragmatic breathing, self-massage

„Rely on social support

„Actively work to alleviate withdrawal symptoms

STRESS MANAGEMENT

„ Smoking gets rid of all my stress

„ I can’t relax without a cigarette

„ There will always be stress in one’s life

„ There are many ways to relax without a cigarette

The Myths The Facts

STRESS MANAGEMENT SUGGESTIONS:

Deep breathing, shifting focus, taking a break.

Smokers confuse the relief of withdrawal with the feeling of relaxation

SOCIAL SUPPORT for QUITTING

„ Key ingredients for successful quitting:

„ Social support as part of treatment (intra-treatment)

„ Social support outside of treatment (extra-treatment)

Patients who receive social support and encouragement are more successful in quitting PATIENTS SHOULD BE ADVISED TO:

„ Ask family, friends, and coworkers for support – ask them not to smoke around you, and not to leave cigarettes out

„ Talk with your health-care provider

„ Get individual, group, or telephone counseling

ADDRESSING CONCERNS about POSTCESSATION WEIGHT GAIN

„Most quitters gain weight

„Most gain < 10 pounds, but there is a wide range

„Discourage strict dieting while quitting

„Recommend physical activity

„Encourage healthy diet, plan meals, eat fruits

„Increase water intake

„Chew sugarless gum

„Select nonfood rewards

„Maintain patient on pharmacotherapy shown to delay weight gain

„Refer patient to specialist or program

„Restlessness

„Drowsiness

„Fatigue

„Impaired task performance

„Nervousness

„Sleep disturbances

„Anger/irritability

„Anxiety

„Cravings

„Difficulty concentrating

„Hunger/weight gain

„Impatience

ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS

Hughes et al. Arch Gen Psychiatry 1991;48:52–59.

„Most pass within 2 to 4 weeksafter quitting

„Cravingscan last longer, up to several months or years

„Often can be ameliorated with cognitive or behavioral coping strategies

„Refer to Withdrawal Symptoms Information Sheet

„Symptom, cause, duration, relief

ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS (cont’d)

DOs

„ Discuss concept of slip versus relapse

„“Let a slip slide”

„ Medication counseling

„Proper use, with demonstration

„Promote compliance

„ Arrange follow-up

„Offer to assist throughout quit attempt

„Provide resources and referrals

„Congratulate the patient!

STRATEGIES for COUNSELING

DURING PREPARATION

The STAGES of CHANGE

Actively trying to quit for good

„Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success.

„Withdrawal symptoms occur.

„At high risk for relapse.

STAGE 4: Action

GOAL:Remain tobacco- free for at least 6 months.

STRATEGIES for COUNSELING during ACTION

DOs

„Praise progress - solicit commitment to quit for good

„Evaluate current quit attempt:

„ Status of attempt

„ “Slips” or relapse

„ Medication use, plans for termination

„Ask about social support

„Identify temptations and triggers for relapse

„ Negative affect, smokers, eating, alcohol, cravings, stress

„Encourage healthful alternative behaviors to replace tobacco use

„Offer tips forrelapse prevention

RELAPSE PREVENTION

„Congratulate success!

„Encourage continued abstinence

„Promote smoke-free environments

„Discuss benefits of quitting and successes achieved

„Discuss problems encountered and potential barriers to continued abstinence

„Strong or prolonged withdrawal symptoms?

„Add, combine, or extend use of pharmacotherapy agents

„Social support

„Discuss ongoing sources of support

„Schedule follow-up visits or calls; refer to support groups

The STAGES of CHANGE

Tobacco- free for 6 months

„Patients remain vulnerable to relapse.

STAGE 5: Maintenance

GOAL:Remain tobacco- free for life.

STRATEGIES for COUNSELING DURING MAINTENANCE

DOs

„Congratulate continued success

„Continue to offer tips for relapse prevention

„ Assess temptations and triggers

„ Discuss and suggest coping strategies

„Encourage alternative behaviors

„Provide positive reinforcement

STAGES of CHANGE: A REVIEW

Precontemplation Contemplation Action Maintenance Quit

date

Preparation - 30 days

- 6 months + 6 months

„Routinely identify tobacco users (ASK)

„Strongly ADVISE patients to quit

„ASSESS stage at each contact

„Tailor intervention messages (ASSIST)

„Be a good listener

„Minimal intervention in absence of time for more intensive intervention

„ARRANGE follow-up

„Use the referral process, if needed

CESSATION COUNSELING:

SUMMARY WHAT IF…

a patient asks

you

The RESPONSIBILITY of HEALTH PROFESSIONALS

It is inconsistent to provide health care and

—at the same time—

remain silent (or inactive) about a major health risk.

TOBACCO CESSATION is an important component of

THERAPY.

DR. GRO HARLEM BRUNTLAND, DIRECTOR-GENERAL of the WHO:

“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”

US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Washington, DC: Public Health Service, 2001.