ASSISTING PATIENTS
with QUITTING
Released June 2000
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)
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.
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 (cont’d)
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 (cont’d)
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 (cont’d)
Assess readiness to make a quit attempt ASSESS
Assist with the quit attempt ASSIST
Arrange follow-up care ARRANGE
The 5 A’s (cont’d)
Number of sessions Estimated quit rate*
0 to 1 12.4%
2 to 3 16.3%
4 to 8 20.9%
More than 8 24.7%
* 5 months (or more) postcessation
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 DECISION TO 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):
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
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 (cont’d)
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
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
Established a relationship
Established yourself as a resource
Planted a seed to move patient forward
Opened a door to facilitate further counseling
COUNSELING SCENARIO:
SUMMATION
The STAGES of CHANGE (cont’d)
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
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 and why they use tobacco.
Identifies activities or situations that trigger tobacco use.
Information can be used to develop coping strategies to
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
DOs
Discuss and develop coping strategies
Cognitive
Behavioral
STRATEGIES for COUNSELING
DURING PREPARATION
COPING with QUITTING (cont’d)
Cognitive strategies
Review of commitment to quitting
Distractive thinking
Positive self-talks
Relaxation through imagery
Mental rehearsal and visualization
COPING with QUITTING (cont’d)
Examples:
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 (cont’d)
Behavioral strategies
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
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 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
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
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
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 weeks after quitting
Cravings can last longer, up to several months or years
Often can be ameliorated with cognitive or behavioral coping strategies
Refer to Withdrawal Symptoms Information Sheet
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 (cont’d)
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
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
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
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 (cont’d)
Tobacco-free for 6 months
Patients remain vulnerable to relapse.
STAGE 5: Maintenance
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
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
CESSATION COUNSELING:
SUMMARY
WHAT IF…
a patient asks you
about your use of
tobacco?
Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.
