Smoking Cessation in Clinical Practice CACUSS Annual Meeting June 11-13, 2007 Saskatoon, Saskatchewan Owen Moran MSc, RN Health Educator Concordia University Health Services Montreal, Quebec Note: This powerpoint is a summary of the activities that are part of an algorithm that clinicians can use to help clients quit smoking. If you wish to receive the algorithm and the associated clinician and client materials contact Owen Moran at

Objectives of Presentation  To present notable results from a smoking cessation survey of Concordia Health Services practitioners.  To introduce a theory-based algorithm designed to guide a clinician’s efforts to help a client quit using tobacco.  To review activities and “clinician guides” related to the activities that are included in the algorithm.

Tobacco and Health “Cigarette smoking remains the number one preventable cause of death in Canada and its impact on the health of Canadians continues to be an unacceptable burden.” Makomaski Illing, EM and Kaiserman, MJ (2004). Mortality attributable to tobacco use in Canada and its regions, Canadian Journal of Public Health, 95(1):38-44.

Origins of this Presentation  CACUSS 2005, Kingston Ontario  Smoking Cessation Interventions By Primary Care Professionals on Ontario University/College Campuses given by: Kelli-an Lawrance, PhD Associate Professor, Brock University PI & Co-Director Leave The Pack Behind Melodie Shick-Porter, RN, BA Director of Clinical Services, Brock University Co-Director Leave The Pack Behind Sharon Lawler, RN, MEd Manager & Co-Director Leave The Pack Behind Amy Sherman, BA Student, Brock University

Survey of Practitioners in Ontario ( Lawrance et al) Participants:  334 nurses, physicians and counselors from 19 Ontario colleges & universities Measures:  Estimates of percentages of non-, occasional, and regular smokers among their patients/clients  How many patients/clients they typically ask about smoking  How often they address smoking at specific types of visits  Percent of patients/clients they talk to about smoking once it has been established that patient smokes  What actions they take when a smoker is identified  Where in clinic smoking-related patient materials are located  What barriers prevent them from addressing smoking

Concordia Census of Health Professionals 1. Are you a: Physician/Nurse 2. Of all the clients you see in a typical day, what percentage do you ask about their tobacco use? ______% 3. What are barriers to asking all the clients you see about tobacco use? (Indicate all that apply) 4. Of all the clients you see who use tobacco, what percent do you advise to quit? ______%

Concordia Census of Health Professionals 5. How do you assist a client to quit? (Indicate all that apply) 6. What barriers do you encounter in assisting a client to quit? (Indicate all that apply) 7. What could help overcome these barriers? (Indicate all that apply) 8. Other comments and feedback about smoking cessation in clinical practice:

What the Census Revealed  Most MD’s and about half of nurses ask clients about their tobacco use  About half of MD’s and nurses who don’t ask say it is because they don’t believe it is relevant to the client’s reason for visit  All MD’s and most of the nurses advise their tobacco- using patients to quit  The greatest barrier to helping a client quit is being “too busy”  Other reasons include lack of confidence and lack of knowledge about effective smoking cessation strategies  An in-service by health educators, a smoking cessation guidebook for clinical practice and smoking cessation materials in each office were listed as ways to overcome barriers to helping clients quit smoking

Smoking Cessation Algorithm  Developed in response to smoking cessation census of clinicians at Concordia Health Services  Theoretically based: Stages of Change model Motivational Interviewing Ask, Advise, Assess, Assist, Arrange model Brief Intervention

Smoking Cessation Algorithm  Is accompanied by over 20 activities, each of which includes: Objective of activity Rationale How to use activity Practice points Brief intervention

Smoking Cessation in a Nutshell 1. You are addicted to nicotine and when you don’t get it you experience negative emotions. 2. Identify, develop, rehearse and refine effective ways to manage these negative emotions (coping strategies). 3. Develop an attitude where you will implement the coping strategies you develop (see it as a gift rather than a deprivation).

Ask “Do you use tobacco?”  “Every healthcare provider should ask each patient/client about their smoking status when appropriate and document it.”  Position Statement: The Role of Health Professionals in Smoking Cessation. Joint Statement. Canadian Nurses Association,  “Nurses implement minimal smoking cessation intervention using the “Ask, Advise, Assist, Arrange” protocol with clients.”  Integrating Smoking Cessation into Daily Nursing Practice, Registered Nurses Association of Ontario (October 2003)

Ask “Do you use tobacco?”  “It is essential that clinicians and health care delivery systems (including administrators, insurers and purchasers) institutionalize the consistent identification, documentation and treatment of every tobacco user seen in a health care setting”  U.S. Department of Health and Human Services, Clinical Practice Guidelines for Treating Tobacco Use and Dependence  “Identify and document every adult’s smoking status”  National Health Committee,  “All patients should be asked about their smoking status and assessed for their willingness to quit”  University of Michigan Health System (evidence based), Smoking Cessation Guideline, February 2001

Advise Client to Quit  Example of what you can say: “Quitting smoking is the best thing you can do for your health. As your health professional, I strongly advise you to quit smoking, and we at _____ can help you.”  Must have resources available to help person quit  Online resources (e.g. Health Canada’s E-Quit, Canadian Cancer Society etc.)  Local/community resources  In-house resources

Assess Client’s Interest in Quitting  Stage the client  Precontemplation  Contemplation  Preparation  Action  Maintenance

Precontemplation  Emotional Arousal Future oriented question Personalize factors by linking smoking to chief complaint  Health Effects of Smoking - A Systems Approach (clinician guide only)

Precontemplation  Changing Attitude Awareness raising  Benefits of quitting Nicotine Addiction  Understanding nicotine addiction  How addictive is nicotine  (Nicotine and me) Bibliotherapy  For smokers who don’t want to quit (from the Canadian Cancer Society)

Contemplation  Immersion in Smoking Cessation Talk with others about smoking cessation Read about others’ experience  Testimonials from ex-smokers Read about smoking cessation  Smoking cessation resources Visualize life as a non-smoker

Contemplation  Changing Attitudes Develop discrepancy  My values  My goals Awareness raising (see precontemplation)  + The cost of smoking Understanding nicotine addiction (see precontemplation) Challenge myths  Exploring the myths about smoking Develop discrepancy  My reasons to quit/My reasons to continue

Preparation  Set the Goal Set Quit Date  Guidelines to setting goals Instruct client to cut down  Calendar to quit Instruct client to inform family and friends

Preparation  Immersion in Smoking Cessation (see contemplation)  Changing Attitude (see contemplation)  Build Coping Strategies Identify coping strategies for high risk situations  1 st Cigarette monitoring  2 nd Smoke-free planning sheet

Preparation  Build Coping Strategies (con’t) Identify coping strategies for barriers  1 st Reason to quit/Reason to continue  2 nd Overcoming the barriers to becoming smoke-free Identify coping strategies related to nicotine withdrawal  Symptoms of recovery Identify other coping strategies  What makes me happy  Strengths

Preparation Build Coping Strategies (con’t)  List coping strategies Wallet Card (List of coping strategies) Disassociate tobacco from activities Discuss pharmacotherapy  Identify rewards  Rewards

Action  Staying on Track Monitor Progress  Calendar with stickers What to do in case of a slip  In case of a slip  Reinforcement Management Review benefits to date Review and support coping strategies Remind client to implement rewards

Action  Smoke-free Healthy Living Nutrition Physical activity Stress management Assertiveness Healthy weight  If a slip happens (or there is relapse) Review coping strategies and attitude (see preparation) In case of a slip

Maintenance  Staying on Track What to do in case of a slip  In case of a slip  Reinforcement Management Review benefits to date Focus on client’s success Encourage client to remain smoke-free  Smoke-free Healthy Living (See action)

Maintenance  If a slip happens (or there is relapse) Review coping strategies and attitude (see preparation) In case of a slip

Arrange Follow-up  Assess if client requires follow-up and schedule as needed

Conclusion  Tobacco use is the greatest preventable threat to the health of Canadians  Addressing tobacco use with ALL clients should be integrated into health care delivery  Smoking cessation interventions should be theory and evidence-based. These include motivational interviewing, brief intervention and on-going counseling.