1. Tobacco cessation techniques Session 2
If the version of participant manuals you have to give out do not have the new information about NRT medication and prescription medication bring the handouts available from the AlbertaQuits online catalogue for each NRT and prescription cessation medication.
Consider providing Decision to Change handout if you would like participants to fill out vs using the version in their participant manual.

2. What we will talk about in this session…
My smoking/tobacco use patterns
Nicotine Replacement Therapy (NRT) and prescription medication
My Decision to change tobacco use
More Quitting Support Techniques
Triggers

3. Homework Review Changed brands of tobacco.
Bought only one package at a time
Read my handbook – Participants Manual
Tobacco Tracker/Tobacco Use Patterns
Listed reasons to quit or change using tobacco in “My Tobacco Change Plan”.
When asking people about the results of their self-monitoring ask them to go to page 35 of their participant manual to look at the summary of daily tobacco use patterns
If you are holding an optional support person session concurrent with session three ask if people have given their invitations and have someone coming

4. Nicotine Addiction Pg 16 and 17 of participant manual
Optional video – plain language video from My.Health. Alberta – doubleclick link to bring up video and then click to play

5. Nicotine Withdrawal and NRT
What have your personally experienced as withdrawal symptoms?
Carbon Monoxide and the 69 carcinogens in tobacco smoke cause the harms – not nicotine
Nicotine replacement therapy (NRT) is a safe and clean source of nicotine
NRT helps to reduce or minimize your withdrawal symptoms or cravings.
Pg 18 to 25 of participant manual covers the different NRT products

6. Health Canada license update
NRT products can be used after stopping smoking to maintain a quit or for a “reduce to quit” approach.
If using a NRT product to quit and you have a “slip” continue using.
If still experiencing withdrawal talk to provider about an increase or combination
In 2016 Health Canada issued an update to the licenses for the Nicoderm® and Nicorette® lines of NRT products. Contraindications and warnings about using more than one form of NRT concurrently and warnings about concurrent smoking while using NRT were removed as part of these updates. (Health Canada, 2016)
With the license updates, each NRT product can be used to quit immediately or for pre-cessation treatment, which may include a reduce to quit or a pre-quit approach, whereby NRT is started prior to smoking cessation. (Health Canada, 2016)
The “reduce to quit” strategy involves gradually reducing the cigarette intake while using a fast acting NRT, such as gum, to help manage nicotine cravings and withdrawal symptoms until the person who smokes reaches a point where complete smoking cessation can be achieved. Nicoderm patches can be use with a “pre-quit” approach where a quit date is set and the patch is started two weeks prior to this time. The number of cigarettes smoked is then gradually reduced over the two weeks leading up to the quit date. (Health Canada, 2016)
Additional wording changes encompasses the following statements: (Health Canada, 2016)
If the amount of NRT product the individual is taking does not help them quit smoking it is suggested that they should talk to their health-care provider about using more than one type of nicotine replacement therapy at the same time.
If the individual is using a NRT product to quit smoking, but slips up and has a cigarette they should not stop using the product and they should keep trying to quit.
Specifically for the NRT gum, a statement is made that it can be used in cases in which the individual temporarily refrains from smoking, for example, in smoke-free areas or in other situations where the person who smokes wishes to avoid smoking.
Notes on Reduce: individuals with no immediate plans to set a quit date can utilize NRT with behavioral support to reduce smoking. Providing this support can increase motivation to quit in the future.

7. Too Much Nicotine Cold sweat
Nausea, vomiting , abdominal pain, diarrhea
Salivation
Headache
Dizziness
Disturbed hearing and vision
Tremor
Mental confusion

8. Contraindications and Precautions
Previous acute hypersensitivity reaction
Immediate post-myocardial infarction period
Life-threatening arrhythmias
Severe or worsening angina pectoris
Recent cerebral vascular accident
Precautions
Pregnancy and Nursing mothers

9. NRT Patch
When reviewing proper use remember to cover possible side effects – the printable versions of each NRT and prescription cessation medication can be found at
Or handouts can be ordered through the online order catalogue at

10. NRT Gum

11. Nicotine Lozenge

12. Nicotine Mouth spray

13. Nicotine Inhaler

14. Prescription medications
Reduce Nicotine Withdrawal
Do not contain Nicotine
Varenicline – Champix
Bupropion - Zyban

15. Varenicline - Champix
Pg 27 and 28

16. Bupropion SR
Pg 25 and 26

17. Tobacco Smoke and Caffeine
General recommendation: individuals who were smoking, or using other forms of tobacco, on a daily basis should reduce their caffeine intake by at least a half when they stop smoking. If you are on prescription medication talk to your physician, pharmacist, or other prescribers when you plan to reduce or stop smoking. Some of these medications will also be processed differently and may need to be adjusted.

18. Preparation for Quit/Change Plan
Try to eliminate stress- causing events from your calendar over the couple weeks prior to your quit/change date
Make a plan with your support person/people to help with everyday stress.
When creating your tobacco change plan it is often recommended that you pick a date for each planned change i.e. if you plan to significantly reduce or quit/stop

19. Quitting Support Technique #4 Decision to Change my tobacco use.
The Good Things About Tobacco Use
The Not So Good Things About Tobacco Use
The Not So Good Things About Stopping or Changing Tobacco Use
The Good Things About Stopping or Changing Tobacco Use
Print and Handout the Decision to Change Table from the downloadable tobacco cessation toolkit – or online QuitCore facilitator handouts folder
Working through the Decision Balance exercise is helpful to explore ambivalence if people are still contemplating change. When used this way start with the Good Things About Tobacco Use, Than the Not So Good Things about Tobacco Use, The Not So Good Things About Stopping or Changing Tobacco use – End with The Good Things About Stopping or Changing Tobacco Use. This approach supports the client in being the expert in themselves as they hear themselves articulate their own reasons for change.
If people have committed to making a change and/are in the preparation stage you can use the questions to identify the roles tobacco has in their lives that should be replaced so they do not see stopping as a loss. i.e. the Good Things about tobacco use could be asked as How does tobacco/smoking fit into your typical day? What role does it have in your live?
The Not So Good Things About Stopping or Changing Tobacco Use could be replaced with – what are the barriers you have run into when attempting to quit before – what things do you see getting in the way we can help you plan for?
The Good Things About Stopping or Changing Tobacco Use – could be turned into – When you think of yourself no longer smoking/using tobacco what does life look like? What has changed for the better?

20. Behaviour Modification
TECHNIQUE
Change my behaviour:
Give up tobacco use in one difficult place.
Separate smoking materials.
Isolate tobacco use from anything enjoyable
Buy nutritious and low-calorie snacks.
Increase your physical activity level.
This approach is all about changing or breaking behavioral associations – replacing one behavior with another.
Breaking associations can involve: (1)If you are going to have a cigarette don’t do anything else at the same time i.e don’t visit, use your phone, have a coffee, or do anything else while having the cigarette (2) change your brand of cigarettes (3) completely finish one package before buying another (4) keep your lighter and ash trap separate from your cigarettes i.e leave them in your car at night.
Add positive behaviors i.e. purchase low, calorie healthy high crunch, snacks to have on hand when reducing/quitting if worried about hand/mouth snacking with cravings
Start Eating Breakfast, Become more physically active – these ideas are explored in Session 5 of your manual.
Suggest playing Mindful smoking video from the AlbertaQuits play list on AHS YouTube channel. Currently available to look at through Dropbox

21. The 4 Ds TECHNIQUE When you have an urge to use tobacco:
Delay: a few minutes and the urge will pass
Drink Water: sip it slowly
Deep Breathe: take three slow, deep breaths
Do Something Else: Take your mind off smoking
Cravings will usually only last 3 to 5 minutes. The 4 Ds is a classic technique originally published by the American Lung Association which helps distract people till the craving passes. Delay, hydrate (which is good to clear toxins), slow relaxed deep breaths, and do something else. If time permits you could practice the deep breathing relaxation exercise with class

22. Quitting Support Technique #7 Quitting buddy
GOAL To get social support from someone who is committed to helping you. 24

23. Quitting Support Technique #8 Rewarding myself
GOAL
Enhance the ‘payoff’ for not using tobacco:
Use immediate and tangible rewards
These are often “internal” ones you experience with success and accomplishment
Plan short and long term awards
Discuss ideas as a group

24. Quitting Support Technique #9 Avoiding tobacco cues/triggers
GOAL
To reduce the number and intensity of urges to use tobacco
What did tracker sheet give for list of situations where the craving level for tobacco was 4 or 5

25. Quitting Support Technique #10 Deep relaxation
GOAL
To use healthy alternatives to reduce stress instead of “using tobacco to relax”
What techniques do you use to relax and reduce stress?
If time permits pick an exercise and practice with the class i.e. deep breathing or progressive muscle relaxation. Find out if participants have a preferred exercise they do.

26. Quitting Support Technique #11 Internet support
AlbertaQuits: Canadian Cancer Society: Health Canada: Lung Association:

27. Homework Stop using tobacco in at least one place.
Separate smoking materials or make tobacco difficult to access.
Prepare your grocery list with nutrition in mind.
4. Discuss with your support person how they can provide support as you quit using tobacco.
5. Review “Participant’s Manual”