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, (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 sessionsEstimated quit rate* 0 to 112.4% 2 to 316.3% 4 to 820.9% More than 824.7% * 5 months (or more) postcessation Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 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): 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 No Did the patient once use tobacco? Prevent relapse* Encourage continued abstinence Yes 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 PrecontemplationActionContemplationMaintenance Quit date Preparation - 30 days- 6 months+ 6 months

Maintenance Contemplation Action Preparation Pre- contemplation 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? PreparationPrecontemplation - or - Contemplation Yes No Did the patient once use tobacco? Action - or - Maintenance Never smoker Yes 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 (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 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, 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 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 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 Develop coping strategies to prevent relapse

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 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

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

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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 for relapse 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 (cont’d) Tobacco-free for 6 months Patients remain vulnerable to relapse. STAGE 5: Maintenance GOAL: Remain tobacco-free for life.

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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 PrecontemplationActionContemplationMaintenance 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 about your use of tobacco?

Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

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.