1. Rocky Mountain Tobacco Treatment Specialist Certification (RMTTS-C) Program

2. Cognitive & Behavioral Interventions
Module 6:
Cognitive & Behavioral
Interventions
Training Notes:
In this module, we will discuss and review cognitive and behavioral intervention strategies for tobacco cessation.

3. Module 6: Cognitive & Behavioral Interventions Objectives
Review counseling interventions for tobacco cessation best practices as recommended by the Public Health Service in their Clinical Practice Guideline
Learn processes and practices for cognitive and behavioral interventions
Learn processes and practices for group interventions
Training Notes:
This module provides information about:
Models of behavior change including motivational interviewing, cognitive behavior change and supportive counseling;
Strategies to enhance motivation and encourage commitment to change;
Group counseling.

4. Tobacco Cessation Treatment Strategies
Treatment Format
Abstinence Rate
Unaided
4-7%
Self-help
11-14%
Quitline
11-15%
Individual counseling
15-19%
Group counseling
12-16%
Medication alone
22%
Medication + counseling
25-30%
Training Notes:
In the previous module, we discussed how tobacco cessation medications assist individuals in coping with their physical addiction. In this module, we’ll focus on counseling skills that assist individuals in changing their behaviors and addressing the habit of using tobacco.
As you can see, research shows that these approaches work (Fiore et al., 2008).

5. Everyone who uses tobacco should be offered an opportunity to make the decision to stop.
Training Notes:
This message is important because this module focuses on the best practices for cognitive and behavioral intervention strategies for tobacco cessation. While best practices are important, we know that not all organizations will have the resources to provide intensive treatment at the best practices level. We do know that spending even less than 3 minutes with an individual talking about tobacco cessation can significantly increase overall abstinence rates (Fiore et al., 2008).

6. Clinical Practice Guideline Recommendations
Best practices:
Session length of 10 minutes or more
4 or more sessions
Intervention formats – proactive telephone counseling, group counseling and individual counseling
Treatment in multiple formats (telephone, group and individual)
Training Notes:
Review the Public Health Service (PHS) Clinical Practice Guideline for Treating Tobacco Use and Dependence recommendations for best practices regarding counseling interventions for tobacco cessation.
With regard to session length, research shows a strong relationship between the length of time spent in a person-to-person contact and successful treatment outcomes. If there is no contact, the abstinence rate is at 10.9%, while with minimal counseling (<3 minutes), low-intensity counseling (3-10 minutes) and high intensity counseling (>10 minutes), the abstinence rates increase to 13.4%, 16% and 22.1%, respectively.
Multiple treatment sessions increase tobacco abstinence rates over one or no sessions. Although more intensive treatment may produce greater abstinence rates, it is more narrow in its reach, is less feasible in certain settings such as primary care, and certain individuals may not have access to or resources to pay for services. Estimated abstinence rates for 0-1 sessions is 12.4%, 2-3 sessions is 16.3%, 4-8 sessions is 20.9% and >8 sessions is 24.7%.
Proactive telephone counseling, group counseling and individual counseling are all effective treatments for tobacco cessation. Estimated abstinence rates for the different formats are 10.8% for no format, 12.3% for self-help, 13.1% for proactive telephone counseling, 13.9% for group counseling, and 16.8% for individual counseling.
Treatment provided in multiple formats (telephone, group and individual) increases abstinence rates. As compared to no format (10.8% abstinence rate), one format (15.1%), two formats (18.5%) and 3 or 4 formats (23.2%) provide increasing abstinence rates with each additional treatment format. Tailored materials, both print and Web-based, also appear to be effective in helping people quit.
Reference for this slide: Fiore et al., 2008.

7. Clinical Practice Guideline Recommendations
Best practices:
Cognitive and behavioral interventions with highest abstinence rates
Skills-Building/Problem-Solving
Support and Encouragement
Training Notes:
According to the Clinical Practice Guideline recommendations, the cognitive and behavioral interventions with the highest abstinence rates are (Fiore et al., 2008):
Skills-building/problem-solving
Support and encouragement
Details of these best practices will be covered in the next several slides.

8. Cognitive & Behavioral Interventions
Skills-Building/Problem-Solving:
Learn to identify high-risk situations
Daily activities (driving, eating a meal)
Internal states (stress, craving)
External events (being around other tobacco users)
Training Notes:
One Skills-Building/Problem-Solving strategy is to learn to identify high risk situations (Fiore et al., 2008).
These situations span daily activities, such as driving or eating a meal; internal states, such as feelings of stress and cravings; as well as external events, such as being around other tobacco users.
As individuals learn to identify these high-risk situations, they can identify creative strategies to adapt, avoid or cope with these situations that meet their unique needs.

9. Cognitive & Behavioral Interventions
Skills-Building/Problem-Solving:
Identify and practice coping skills
Learn to anticipate and avoid trigger situations
Lifestyle changes to improve overall health and wellness
Cognitive and behavioral strategies to cope with cravings
Training Notes:
Another Skills-Building/Problem-Solving strategy is to identify and practice coping skills or other strategies to handle high-risk situations (Fiore et al., 2008).
Typical strategies include (with examples):
Learn to anticipate and avoid trigger situations – Avoid certain environmental triggers, develop relationships with tobacco-free individuals, drink tea instead of coffee
Lifestyle changes to improve overall health and wellness – Regular medical check-up, increased physical activity, set healthy boundaries
Cognitive and behavioral strategies to cope with cravings – Distracting attention, mindfulness training, deep breathing

10. Cognitive & Behavioral Interventions
Skills-Building/Problem-Solving:
Gain knowledge about tobacco and successful strategies for tobacco cessation
Tobacco addiction
Symptoms and duration of withdrawal
Health benefits to stopping tobacco use
Training Notes:
The last Skills-Building/Problem-Solving strategy is to gain knowledge about tobacco and successful strategies for tobacco cessation (Fiore et al., 2008).
Knowledge about tobacco and tobacco cessation strategies include:
Tobacco addiction – Information about the neurobiological aspects of tobacco addiction
Withdrawal symptoms and duration – In general, withdrawal symptoms manifest within the first 1-2 days, peak within the first week, and gradually dissipate over the next 2-4 weeks (Hughes, 2007). Withdrawal symptoms include irritability/frustration/anger, anxiety and depression, difficulty with concentration, restlessness and impatience, insomnia, and increased appetite.
Health benefits of stopping tobacco use – Oxygen levels return to normal after 12 hours and carbon monoxide levels drop significantly, increased lung function, improved breathing, increase in overall energy (USDHHS, 2004).

11. Cognitive & Behavioral Interventions
Support and Encouragement:
Advocate for stopping tobacco use
Effective tobacco cessation strategies (Counseling and tobacco cessation medications)
Statistics about tobacco cessation (Successful quit rates)
Communicate belief that the individual can successfully stop their tobacco use
Training Notes:
One strategy to Support and Encourage is to advocate for stopping tobacco use (Fiore et al., 2008).
This may be providing talking about:
Effective tobacco cessation strategies – Counseling and tobacco cessation medications
Statistics about tobacco cessation – One-half of all people who have ever smoked have now quit
Communicate belief that the person can successfully stop their tobacco use – Use information that is personal and specific to the individual upon which the belief is based.

12. Cognitive & Behavioral Interventions
Support and Encouragement:
Communicate care and concern
Ask about how the person feels about stopping their tobacco use
Explore their ambivalence and fears
Offer support and assistance
Training Notes:
Another strategy to Support and Encourage is to communicate care and concern (Fiore et al., 2008).
Care and concern can be communicated by:
Asking how an individual feels about stopping their tobacco use – “How do you feel about stopping your tobacco use?”
Exploring their ambivalence and fears – “It sounds like you are uncertain about whether you want to stop your tobacco use. Will you talk with me further about this?”
Offering support and assistance – “How can I assist you?”

13. Cognitive & Behavioral Interventions
Support and Encouragement:
Talk about the process of stopping tobacco use
Explore motivation to stop using tobacco
Examine potential challenges and barriers
Discuss concerns or worries
Celebrate successes
Training Notes:
The last strategy to Support and Encourage is to talk about the process of stopping tobacco use (Fiore et al., 2008).
Talk about the process of stopping tobacco use by:
Exploring the individual’s motivation to stop – “Talk with me about the reasons you would like to stop using tobacco.”
Examining potential challenges and barriers – “What could get in the way of your successfully stopping your tobacco use?”
Discussing concerns or worries – “Tell me what your concerns are…”
Celebrating successes – Focus on the small successes, such as any change in tobacco use behavior or increased change talk.

14. Cognitive & Behavioral Therapy Process and Practice Training Notes:
This section will discuss cognitive and behavioral therapy model and strategies.
This section is not intended to teach a comprehensive course on cognitive and behavioral therapy. We will be reviewing some key information and strategies that can be helpful when working with individuals who are interested in stopping their tobacco use.

15. How do cognitive & behavioral therapies work?
Change beliefs and behaviors
Learn coping skills
How do cognitive & behavioral therapies work?
Solve problems
Experience a collaborative relationship
Training Notes:
Generally, cognitive & behavioral therapies contain several different components (Beck, 1995).
Therapy is focused on:
Changing beliefs and behaviors
Learning new coping skills
Solving problems
Experiencing a collaborative relationship

16. What do cognitive & behavioral therapies look like?
Structured
Goal-Oriented
What do cognitive & behavioral therapies look like?
Homework
Practicing new skills
Training Notes:
Generally, cognitive & behavioral therapies are:
Structured
Goal-oriented
Activities may include:
Homework
Practicing new skills

17. Cognitive Model
People’s emotions and behavior are influenced by their perception of events. — Judith Beck
Training Notes:
This is a quote from Judith Beck in her book, Cognitive Therapy: Basics and Beyond, a key Cognitive Behavioral Therapy text (Beck, 1995).

18. Thoughts
Behaviors
Feelings
Training Notes:
Cognitive and behavioral approaches are based on interplay between thoughts, feelings and behaviors.
Although different strategies may directly focus on changing one aspect at a time, adjustments in any one component can change the other components. For instance, stopping tobacco use (a behavior) can increase confidence (a feeling), changing a person’s belief that they are not powerful (a thought).
Depending upon a person’s presentation, the counselor may focus on any one of these areas as an entry point to change.

19. Cognitive Model Definition of Terms: Core Beliefs – Fundamental truths
Intermediate Beliefs – Rules, attitudes and assumptions based on a person’s core beliefs
Automatic Thoughts – Words or images that go through a person’s mind
Training Notes:
Core beliefs are the most fundamental level of belief. They tend to be global, rigid and overgeneralized.
Intermediate beliefs are rules, attitudes and assumptions based on a person’s core beliefs and reside between core beliefs and automatic thoughts.
Automatic thoughts are words or images that go through a person’s mind. They tend to be situation specific and may be considered the most superficial level of cognition.
Reference for this slide: Beck, 1995.

20. Cognitive Model Core Belief “Life is overwhelming” Intermediate Belief
“Cigarettes reduce my stress”
Emotional Reaction Anxiety
Situation
“Stressful Event”
Automatic Thoughts
“I can’t handle my stress”
Training Notes:
Review the cognitive model, including the example to illustrate what the model looks like in real-life situations.
In a specific situation, a person’s underlying beliefs influence their perception. This perception is expressed in a situation-specific automatic thought. The automatic thought, in turn, influences a person’s emotional, behavioral and physiological reaction.
Behavioral Reaction Smoke a cigarette
Physiological Reaction Tightness in chest

21. Cognitive Strategies Goals: Develop new core beliefs
Increase rational thinking
Training Notes:
Review the goals of cognitive strategies.

22. Cognitive Strategies Cognitive Distortions Description
All-or-nothing thinking
Looking at something from only two categories
Catastrophizing
Prediction of a negative future
Discounting the positive
Negating positive experiences
Emotional reasoning
Believing something is true because it “feels” true
Labeling
Place a fixed or global label on self or others
Magnification/ Minimization
Magnify the negative, minimize the positive
Mental filter
Focused attention on one negative detail
Mind reading
Assuming knowledge about what others are thinking
Overgeneralization
Making a sweeping negative conclusion
Personalization
Taking responsibility for others’ negative behaviors
“Should” or “Must” statements
Fixed idea or expectations about behaviors
Tunnel vision
Focus on only negative aspects
Training Notes:
Review this list of cognitive distortions and provide examples.

23. ABC’s of Identifying Core Beliefs
Cognitive Strategies
ABC’s of Identifying Core Beliefs
Situation
Core Belief
Feelings/Actions
Activating Event
Belief
Consequence
Training Notes:
For many people, their core beliefs are outside of their conscious awareness. In order to increase an individual’s awareness of their core beliefs, it can be helpful to explore specific situations that can activate a particular core belief.
The typical process includes discussion of:
An activating event or a specific situation that generates a fairly strong emotional response
The consequences of the event, including feelings and behaviors
Potential core beliefs that are activated by this event

24. Identifying Core Beliefs
ABC’s Group Activity
Training Notes:
Ask trainees to generate an example ABC for themselves. Have them pair up for a short discussion with another trainee, role playing a discussion to identify core beliefs.
Once the role play is complete, ask trainees to discuss their experience and process.

25. Cognitive Strategies Changing Irrational Beliefs
Step 1
Step 5
Step 4
Step 3
Step 2
Practice the new behaviors
Act as if the rational belief is true
Identify a rational belief to replace the irrational one
Training Notes:
A cognitive strategy that assists in changing irrational beliefs includes 5 steps:
Recognize the irrational belief
Decide to change the irrational belief
Identify a rational belief to replace the irrational one
Act as if the rational belief is true
Practice new behaviors
Discuss the importance of practicing new behaviors and its impact on a person’s belief system.
It is important to note that you may choose to use different phrasing than “rational” and “irrational” when working with clients since those words can carry negative connotations. For instance, you may use “helpful” and “unhelpful” beliefs instead.
Decide to change the irrational belief
Recognize the irrational belief

26. Behavioral Strategies
Goal:
Increase participation in positive activities
Decrease participation in behaviors identified for change
Training Notes:
Review the goals of behavioral strategies.

27. Behavioral Strategies
Self-Monitoring
(Time, activity, trigger, feeling, people, environment)
Role Play
(Practice new behaviors, such as saying no to tobacco)
Skills Building
(Deep breathing, boundary setting, physical activity)
Training Notes:
There are many different behavioral strategies for tobacco cessation. These are some that can be used to facilitate tobacco cessation.
Engage trainees in a discussion of other effective behavioral strategies they have used.

28. Group Interventions Process and Practice Training Notes:
Group interventions are another important counseling modality to help motivate individuals to change.

29. How does group facilitate change?
Altruism
Instill Hope
Guidance
Self-Awareness
Social Support
Social Skills
Psycho-Education
Universality
How does group facilitate change?
Training Notes:
According to Yalom (1995), in his seminal text on group therapy, The Theory and Practice of Group Psychotherapy, he outlines several factors that facilitate therapeutic change in a group setting. Group participants change through:
Altruism – Receiving through giving to others
Instill Hope – Communication and reinforcement of positive expectations, observation of improvement in group members, and peer support
Guidance – Direct advice, modeling positive behaviors
Self-Awareness – Learning about oneself through interactions with others
Social Skills – Implicit and explicit learning of social skills through group process (e.g. role play, feedback from others, relationship development)
Psycho-Education – Didactic instruction
Universality – Through an exchange of shared experience, group members learn they are not alone

30. Starting a Tobacco Free Group
Tips for a successful group:
Open – Participants can join at any time
Flexible – Setting a quit date is not required
Focused – Participants learn about healthy living, including living tobacco-free
Training Notes:
Review this list of tips for a successful group.
Discuss any personal experiences in starting and running a Tobacco Free group.
Explore strategies that worked for you in different settings.

31. Starting a Tobacco Free Group
Intake Assessment – Assess tobacco history, determine readiness to change, orient to group process, increase motivation to change
Facilitation – Groups run by providers and/or peers living tobacco-free
Training Notes:
Prior to an individual attending group, it can be helpful to conduct an intake assessment. In this meeting, it is important to use the motivational interviewing skills learned in this training to assess the individual’s tobacco history, determine their readiness to change, and enhance their motivation to quit. You will also use this time to orient the individual to the group process, explaining to them what to expect when they attend their first group.
Groups run by former tobacco users who are now living tobacco-free can be very motivating and supportive for group members. By sharing their lived experience, peers have personal experience that can help to enhance motivation and assist group members to explore effective solutions to their barriers to quitting.

32. Setting Group Rules
Group rules encourage a safe and supportive group environment
Develop group rules in collaboration with group participants
Training Notes:
During the initial stage of a group, group rules create a safe and trusting environment (Corey & Corey, 1987).
It is important that the development of group rules is a collaborative process between the group facilitator and group participants.
Since the group participants help to develop the group rules, it is often up to them to enforce them. It is useful to empower group participants and decrease the sense of a hierarchy between counselor and group member.

33. Setting Group Rules Show up on time Tobacco-free space
Treat others with respect
Silence cell phones
Training Notes:
Review these group rules. Share ideas about other group rules any trainees have used.
Confidentiality

34. Group Facilitation Group process can be facilitated by:
Creating a climate of safety and acceptance
Inviting participation of all group members
Providing encouragement and support
Training Notes:
Review this list of ways in which to facilitate group process.
Group process is the interpersonal component of a group session, in contrast to the content like decisions or information that have been generated during the group.

35. Group Facilitation Group process can be facilitated by:
Encouraging open expression of feelings
Increasing open communication
Decreasing dependence on the group leader
Training Notes:
Review this list of ways in which to facilitate group process.

36. Standards of group behavior
Regular attendance
Show up on time
Active participation
Provide feedback
Express emotions
Focus on the “here and now”
Training Notes:
Talk about group norms.
What are the typical standards for group behavior?
What do trainees believe are important group norms to set? Why?
Reference for this slide: Yalom, 1995.

37. Group participants are the “experts” on their lived experience.
Training Notes:
It is important to create a group environment in which group members are active and empowered participants. Through group participants’ sharing of experience and expertise, others can learn and be inspired by their story.

38. Alternative Therapies
Acupuncture – Evidence does not support acupuncture as an effective treatment for tobacco cessation. Results may be produced by positive expectation.
Hypnosis – Insufficient evidence to support hypnosis as a tobacco cessation treatment.
Training Notes:
Through a meta-analysis conducted in 2000 to evaluate the effectiveness of acupuncture, the Clinical Practice Guideline (Fiore et al., 2008) report that the evidence does not support acupuncture as a tobacco use treatment. There was no difference between the “control” and “active” acupuncture. These results suggest that any effect of acupuncture might be produced by other factors such as positive expectations about the procedure. Additionally, the Guideline Panel did not identify scientific literature to support the effectiveness of electrostimulation or laser acupuncture treatments for tobacco use.
According to the Guideline, the effectiveness of hypnosis as a treatment for tobacco cessation is difficult to evaluate. The few studies that have been performed use very heterogeneous procedures. There was no common standard intervention technique to analyze. As such, there is insufficient evidence to support hypnosis as a treatment for tobacco cessation.
For some people, these alternative therapies may work for them. As a treatment provider or peer, it is important to support steps that individuals want to take towards living tobacco-free.

39. Creating Successful Interventions
Discussion
Discussion
Training Notes:
The trainer will facilitate a discussion about successful cognitive and behavioral interventions as well as group interventions trainees have used. Explore aspects and strategies that made these interventions particularly effective.