Tobacco Cessation Competency Class

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Tobacco Cessation Competency Class

• Section 2 Assessment Tools
• Types of Counseling

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Objectives

• The participant will be able to discuss the
  assessment tools commonly used to screen and
  assess patients prior to enrollment in a tobacco
  cessation program.
• The participant will be able to identify the
  stages of change a patient is in and provide the
  appropriate counseling to assist the patient in
  tobacco cessation.

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Objectives cont

• The participant will be able to follow the 4 as
  as described by the American cancer society when
  counseling patients who use tobacco.
• The participant will be able to screen the
  patient with tobacco dependence for depression
  and provide the proper referral and/or enrollment
  in a tobacco cessation program.

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Assessment Tools

• Nicotine Dependence
• Stages of Change
• Depression Screening

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Nicotine Dependence

• Nicotine is a highly addictive drug naturally
  found in tobacco
• Body becomes physically and psychologically
  dependent upon nicotine
• Cutting back or quitting leads to withdrawal
  symptoms

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Nicotine Dependence and Nicotine Withdrawal

• The gold standard for diagnosis comes from the
  DSM IV
• The key features for the diagnosis of Nicotine
  Dependence (305.1)
• Continued use despite wanting to quit
• Prior quit attempts
• Persistent use in the face of physical illness,
• Tolerance
• Presence of withdrawal symptoms

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Nicotine Withdrawal(292.00)

• Dysphoric or depressed mood
• Insomnia
• Irritability, frustration, or anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite or weight gain

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Measurement of Nicotine Dependence

• Fagerstrom Tolerance Questionnaire
• The nicotine rating item and the inhalation item
  were unrelated to biochemical measures
• Fagerstrom Test for Nicotine dependence
• At present, how long after waking up do you wait
  before having your first cigarette?
• How many cigarettes do you smoke in a typical day?

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The Fagerstrom score is a quicker approach
adaptable to busy clinical settings

• Patients who answer affirmatively to both
  questions are highly dependent on nicotine
• Do you smoke more than 25 cigarettes per day?
• Do you smoke within 5 Minutes of awakening?

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Withdrawal Symptoms

• Occur within a few hours after the last cigarette
  and peak about 48 72 hours later
• Can last for a few days to several weeks
• Symptoms include
• Depression
• Frustration Anger
• Irritability
• Difficulty concentrating Trouble sleeping
• Headache and increased appetite

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Dealing with Withdrawal

• Do not rationalize
• Avoid people/places where you are tempted
• Alter habits associated with smoking
• Deep breathing
• Visual imagery
• Stay active
• Remind yourself why youve quit

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Behavior Change Research

• Health Belief Model
• Stages of Change

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Health Belief Model

• You will be more likely to stop tobacco use if
  you
• Believe that you could get a tobacco-related
  disease and this worries you
• Believe that you can make an honest attempt at
  quitting
• Believe that the benefits of quitting outweigh
  the benefits of continuing tobacco use
• Know of someone who has had health problems as a
  result of their tobacco use

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Transtheoretical Model of Change

• Developed by Prochaska and others
• Identifies the stages a person goes through in
  making a change in behavior
• Help the provider tailor counseling and therapy
  Provide stage-appropriate advice and therapy
• Demonstrates the benefits of identifying the
  smokers readiness to change before attempting to
  intervene

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Stages of Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse

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Pre-contemplation

• No intention to change behavior in the immediate
  future
• Unaware or under-aware of their problems
• Not ready to change
• Best Strategy Offer general awareness
  information and counseling regarding their
  problem with tobacco dependence

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Interventions for the Pre-contemplator

• Assess awareness and knowledge
• Discuss pros and cons
• Benefits of quitting
• Identify reasons for usage triggers
• Acknowledge their concerns
• Advise of need to quit and personalize the
  message
• Give self-help materials

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Contemplation

• Aware that a problem exists and are seriously
  thinking about overcoming it
• Have not yet made a commitment to change or take
  any action
• Best Strategy Motivate! Offer additional
  information regarding tobacco usage

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Interventions for the Contemplator

• Discuss reasons for wanting to quit
• Review barriers to quitting
• Review resources and support for quitting
• Review coping skills
• Discuss strategies for quitting
• Give self-help materials

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Preparation

• Combines both an intention and behavior to change
• Individual is intending to take action in the
  next month
• Best Strategy offer an intervention
  program.they are
  ready to address their
  tobacco addiction

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Interventions for the Patient in the Preparation
Phase

• Review reasons for quitting
• Resolve ambivalence
• Develop a QUIT PLAN
• Set a quit date
• Provide encouragement and provide support
• Give direct and positive message for quitting
• Have patient practice saying No thank you, I
  dont smoke
• Give self-help materials/Refer to support group

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Action

• Individuals modify their behavior, experiences
  a/o environment in order to
  overcome their problems
• Overt behavioral changes which require a
  considerable commitment of time and energy
• Best Strategy Offer continued support and
  reinforcement for positive changes. Assess and
  address relapse potential

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Interventions for the Patient in the Action Phase

• Review reasons for quitting
• Explore relationship with tobacco
• Select a quit date
• Review relapse triggers
• Discuss obstacles to quitting

• Encourage cessation efforts
• Focus on progress
• Offer referral to support group
• Be sure to follow-up
• Review coping strategies
• Explore support system

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On Quit Day

• Do not smoke Do not use any tobacco products
• Get rid of all tobacco products and paraphernalia
  (lighters, ashtrays, etc)
• Stay active
• Drink lots of water
• Avoid high-risk situations where the urge to
  smoke is strong
• Avoid coffee and alcohol
• Avoid being around individuals who are smoking

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Maintenance

• Individual works to prevent
  relapse
• Consolidates the gains attained during
  action
• This stage lasts from six months
  to an indeterminate period
• Best Strategy Offer reinforcement and praise

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Relapse

• Stopping smoking is easy to do..
• I have done it thousands of
• times..
• -Mark Twain

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Relapse and Smoking Cessation

• Relapse is the norm with nicotine dependence
• Tobacco users seem to benefit from prior quit
  attempts
• Tobacco cessation is a process
• Motivate relapsers to try again
• Most tobacco users make several
• serious quit attempts before they are
  successful

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Who is likely to Relapse?

• Unable to cope with withdrawal and cravings
• Highly dependent on nicotine
• Copes poorly with stress and moods
• Non-adherent
• Ambivalence
• Mental health issues

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Treatment strategies for the patient in Relapse

• Identify barriers to success
• Review and explore negative feelings
• Explore successful quitting strategies
• Review relapse events and triggers
• Encourage and motivate patient to try again

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Depression and Nicotine Dependence

• Complex association between depression and
  addiction to nicotine and tobacco
• Persons with a vulnerability to depression are
  more likely to become regular smokers and to
  become dependent smokers
• Level of nicotine dependence and number of
  cigarettes smoked are directly associated with
  the prevalence of major depression

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Depression Screening Tools

• The Beck Depression Inventory
• BDI is a good instrument for screening depressive
  disorders in community surveys
• BDI cut-off score greater than or equal to 13
• BDI when compared to SCAN (Schedules for Clinical
  Assessment in Neuropsychiatry) yielded 100
  sensitivity 99specificity, and 98 diagnostic
  value

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Depression-Prone Smokers and Cessation

• Depression-Prone smokers have a lower quit rate
• Depression-prone smokers experience more severe
  nicotine withdrawal
• Smoking cessation can provoke severe depression
  in depression-prone smokers
• Use the Beck Depression Inventory to screen
  patients for depression consider concurrent
  therapy- referral to psychiatry

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Counseling

• Individual provider counseling
• Physicians have contact with 70 of smokers
  annually
• Smoking cessation provided by a physician is MORE
  cost-effective than screening PAPs, mammograms,
  treating HTN or hyperlipidemia
• Group counseling
• Proactive telephone counseling
• Motivational counseling

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Brief interventions during medical visits are
cost-effective and could potentially reach most
smokers

• Unfortunately, brief interventions are not
  consistently delivered!

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National Patterns in the Treatment of Smokers by
Physicians

• Smoking counseling by physicians
• 1991 16 of smokers visits
• 1993 29 of smokers visits
• 1995 21 of smokers visits
• Physicians identified patients smoking status at
  67 of all visits in 1991 and this percentage did
  not increase over time
• Nicotine Replacement Therapy
• 0.4 of smokers visits in 1991 to 2.2 in 1993
  and decreased to 1.3 in 1995

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Physician Interventions

• Primary care physicians were more likely to
  provide treatment to smokers than were
  specialists
• All physicians were more likely to treat patients
  with smoking-related diagnoses
• Physician practices for smoking intervention
  falls far short of national health objectives and
  practice guidelines

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Individual Counseling Four AsNCI Guidelines

• ASK ask about tobacco use at every visit
  and document in the patient record - the fifth
  vital sign
• ADVISE strongly!
• ASSIST plan, provide information, treatment,
  diary, routines, habit change
• ARRANGE referrals and follow-up

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Provider Advice

• As your physician, I must advise you to stop
  smoking.
• I need you to know that quitting smoking is the
  most important thing you can do to protect your
  current and future health.
• I think it is important for you to quit smoking
  (smokeless tobacco) now and I will help you.
  Cutting down when you are ill is not enough.

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Advise

• Personalize the message
• Teachable moment
• Encourage the positive aspects of quitting
• Focusing on the negative effects of tobacco use
  and scare tactics are not effective strategies
  for motivating tobacco users to quit
• Motivational Counseling is helpful to individuals
  who are ambivalent or resistant to change

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Advise

• Focus on the 4 Rs
• Relevance of quitting
• Risks of Tobacco
• Rewards of quitting
• Repeat the message

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Assist

• Review quitting strategies
• Discuss potential problems
• Listen to concerns
• Provide stage based self-help materials
• Establish a plan
• Set a quit date
• Refer to specialist or program is needed

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Assist/Pharmacotherapy

• Zyban
• Nicotine Replacement Therapy (NRT)
• Gum
• Transdermal patches
• Nasal Spray
• Nicotine inhaler

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Smoking Cessation with Assistance

• Use of assistance for smoking cessation has
  increased over recent years, from 7.9 in 1986 to
  19.9 in 1996.
• Types of assistance self-help, counseling, a/o
  NRT
• Patients most likely to use assistance
• Heavy smokers
• Women
• Usage increases with age
• Whites were more likely to use NRT than were
  other ethnic groups

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Smokers preferences for assistance with cessation

• Given the several different options for
  assistance..
• 46 of current smokers stated they were
  interested in none of the options
• Of those interested in assistance
• 67 preferred help from a medical professional
• 12.4 a stop smoking group
• 23 a book, pamphlet or quit kit
• 2.9 mail or telephone services

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Overall, those who used assistance had a higher
success rate than those who did not the 12-month
abstinence rates were 15.2 and 7.0 respectively
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Arrange

• Follow-up
• Ask
• Did you stop?
• Are you tobacco free?
• Any problems?
• Provide encouragement!

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Motivational Interviewing

• Developed and introduced in 1991 by Miller and
  Rollnick
• HCP remains positive during counseling and
  praises all attempts to decrease or cease tobacco
  use
• HCP shows empathy towards problems/withdrawals
  the patient is experiencing
• HCP helps patient clarify his goals and provides
  the patient with treatment options

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Group CounselingBehavioral Therapy

• Cessation rates average 20 for those willing to
  participate
• American Lung Association Freedom from Smoking
  1 year quit rate is 16
• American Cancer Society Fresh Start Program 1
  year quit rate is 22
• Social support increases the smokers desire to
  quit, helps the smoker acquire the skills to
  become and remain abstinent and reinforces
  actions that have been taken to quit smoking

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Key Components for an Effective Behavioral Program

• Assessment of stages of change
• Identification of barrier to quitting
• Development of cessation and relapse prevention
  plans

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Proactive Telephone Counseling

• The follow-up of all patients who have been
  counseled by their HCP to cease tobacco usage
• Empower staff to become involved in the cessation
  processthis means delegate the phone call to
  someone else
• Follow-up can double cessation rates

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• Any Last Questions?