1. Tobacco Cessation Interventions Lunch and Learn Seminar Series for Physicians, Family Health Teams, and other Health/Allied Health Practitioners Session 3: Brief Cessation Counselling: The 4- Point Plan Faculty: Stephanie Cohen, MSW, RSW

2. 2 Housekeeping Please sign-in Please ensure you have completed Learning Assessment 1 http://www.surveymonkey.com/s/fhtjune2011la1 http://www.surveymonkey.com/s/fhtjune2011la1 A link to Learning Assessment 2 will be sent by e-mail Both Learning Assessments are required for the Letter of Completion If you cannot hear audio on your computer, please dial-in via audioconference. You will be automatically muted. Conference #: 1-800-669-6180 Participant Code: 925619 The Adobe Connect webinar will remain ON until 1:00 pm

3. 3 Stephanie Cohen, MSW, RSW Stephanie_cohen@camh.net (416) 535-8501 ext. 7415 Stephanie Cohen received her Masters of Social Work Degree from the University of Toronto in 1997. Since that time, Stephanie has been working in the field of addictions and mental health at the Centre for Addiction and Mental Health (formerly the Addiction Research Foundation). Initially she worked as a clinician in the Opiate Clinic, with pregnant women in the methadone program. However, for the past 11 years she has been working in a variety of roles in the Nicotine Dependence Clinic; clinical, educational and managerial. She has been a member of the TEACH faculty since the initial pilot program in 2006. In addition, she has had the opportunity travel across the province and across the country working with a diverse array of health care practitioners in the field of nicotine dependence. Presently, her role is a blend of clinical and educational duties. In 2009, she became a member of the Motivational Interviewing Network of Trainers (M.I.N.T.)

4. 4 Stephanie Cohen Disclosures No Disclosures

5. 5 The recipient of the funding is in compliance with the CMA and the CPA guidelines / recommendations for interaction with the pharmaceutical industry.

6. 6 These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions, but do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances. Disclaimer

7. 7 Disclaimer: TEACH Curriculum Development The TEACH Curriculum and slides were developed and compiled with funding from the Government of Ontario, Ministry of Health Promotion. Content of slides are primarily based on evidence based guidelines including: US Guidelines Treating Tobacco Use and Dependence: clinical Practice Guideline 2008 Update. US Department of Health and Human Services, Public Health Service Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper, January 2008. The development or delivery of the TEACH curriculum was not influenced or funded in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. TEACH project did receive a $10 000 unrestricted grant from Pfizer, to develop video vignettes that are used in our training. Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the US guidelines. An algorithm is provided to help practitioners determine if and which pharmacotherapy is appropriate for a smoker.

8. 8 Session 3: Learning Objectives 1. Review the EBB (Environment/Behaviour/Biology) framework for treatment planning and intervention 2. Review 4 key strategies for behaviour change: 1. Strategize 2. Take action 3. Optimize 4. Prevent relapse (persevere) 3. Apply a structured set of tools for psychosocial cessation counselling

9. 9 EBB Model for Smoking Cessation: Environment, Behaviour and Biology

10. 10 EBB: Environment, Behaviour, Biology A three domain adaptive model Dr. Peter Selby, 2010 Addresses behavioural, environmental, & biological determinants Individual and population level; expands the current bio-psycho-social model.

11. 11 Environment Environmental determinants either promote or protect against substance use Interventions should address these deficits Dr. Peter Selby, 2010 home, work, social, dealer, financial

12. 12 Behaviour Interventions address attitudes, knowledge and skills necessary to recover regardless of treatment philosophy Dr. Peter Selby, 2010 Behavioural dimensions, including the level of motivation to change, are assessed to develop an individualized treatment plan.

13. 13 Biology Other co-morbid medical and psychiatric disorders that complicate addictions may also be treated concurrently. Dr. Peter Selby, 2010 Medications may be prescribed for withdrawal management, relapse prevention and or maintenance.

14. 14 Behaviour Change Roadmap: THE 4 POINT PLAN

15. 15 Important Aspects to Consider Quitting is a process = 110,000 hand to mouth repetitions/year

16. 16 Important aspects to consider

17. 17 4 steps to stopping destructive behaviours and leading a healthier life: 1. S 1. STRATEGIZE 2. T 2. TAKE ACTION 3. O 3. OPTIMIZE 4. P P 4. PREVENT RELAPSE (PERSEVERE)

18. 18 Step 1: STRATEGIZE

19. 19 1. Strategize –# of sessions? –Developing a quit plan in conjunction with the client –Use EBB framework

20. 20 Strategize - Environment Smoke-free environment – Home, areas of the home – Work – Car – Social events – Paraphernalia – Social Circle

21. 21 Positive supports: –Partner, family, friends, colleagues –Professionals : physician, pharmacist, nurse, etc. –Other supports: helpline, groups, websites, etc. Strategize: Support Systems

22. 22 Negative influences: – Other smokers (partner, family) – People who don’t want client to quit smoking – Unhelpful “encouragement” to quit Strategize: Support Systems

23. 23 Strategize – Set a Goal Quit Date Prevents delay Time to reduce, practice Refine quit plan

24. 24 Goal Statement The behaviour I want to/need to change is: What is your goal now? START DATE: ACHIEVEMENT DATE:

25. 25 Readiness Ruler People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following three questions with respect to the goal you have set. How important is it to change this behaviour? How confident are you that you could make this change? How ready are you to make this change? 0 1 2 3 4 5 6 7 8 9 10

26. 26 For Reflection: “Readiness Ruler” What are 3 reasons you are at ______ and not zero? 1. 2. 3.

27. 27 Reasons for Change Making a commitment to meeting your goal is important to your success. Sometimes, it’s easy to forget why you’re making the change, so write down your reasons and use this as a reminder to yourself when things seem tough! The most important reasons why I want to change are: 1 ____________________________________________________________ 2 ____________________________________________________________ 3 ____________________________________________________________

28. 28 Decision to Change Worksheet Changing my current behaviour Continuing the behaviour in the same way Benefits Costs

29. 29 Daily Diary Keeping a diary is a key part of any behaviour change program. It gives you accurate details about the behaviour you want to change, and can also help you to identify high risk situations. This diary can also help you to see when you aren’t likely to engage in this behaviour, and to identify what was different about those days. Keeping a diary takes time and commitment, but research has shown that simply keeping track of a behaviour can lead to change! What is your goal for this week? __________________________________________________________________ © CAMH/TEACH Project

30. 30 Daily Diary - Baseline Think back to the last week starting today and make a note when you engaged in the current behaviour(s). Increase awareness of smoking behaviour Helps identify triggers and challenges Identifies easy/difficult cigarettes to quit Breaks automaticity of smoking behaviour Possibly reduces number of cigarettes

31. 31 Identifying Barriers and Solutions to Change Possible Barriers:Proposed Solutions: © CAMH/TEACH Project

32. 32 Step 2: TAKE ACTION

33. 33 Triggers and Consequences Identify and describe high-risk situations Describe types of triggers usually associated with the situation Describe the types of consequences associated with the situation How often does this type of situation occur?

34. 34 Sample Plan Triggers Smoke with colleague every day at breaks Coping Skills Tell colleague I am quitting After meals Chew gum after meals, get up from table right away Stress at work gets too much on some days Plan to take walks when stress is high

35. 35 Triggers and Consequences Worksheet High-risk situation: _______________________ 1. Briefly describe one of your most serious high-risk situations. 2. Describe as specifically as possible the types of triggers usually associated with this situation. 3. Describe as specifically as possible the types of consequences usually associated with this situation (immediate and delayed consequences, and positive and negative consequences). 4.How often did this type of situation occur in the past year? What percentage of your total behaviour over the past year occurred in this type of situation? _____________%

36. 36 Step 3: OPTIMIZE YOUR STRATEGY

37. 37 O ptimize Strategy Identify problems ? Changes in mood ? Withdrawal symptoms ? Low motivation ? Weight gain ? Lapses/slips Potential Solutions  Referral  Adjust meds  Decisional Balance  Nutrition, Exercise  Review

38. 38 Continue identifying triggers, stressful situations Continue self-monitoring Maintain smoke-free environments Reset quit/reduce date if needed Congratulate your client for coming back O ptimize Strategy

39. 39 Doing a 360 : Asking for Feedback Social supports (family members, friends colleagues) Professionals ( MD, RN, Pharmacists, others) Feedback on my plan? Things missing? Watch for saboteurs and enlist supporters

40. 40 Notes and Important Numbers Smokers’ Helpline: 1-877-513-5333 Ontario Lung Association: 1-888-344-5864 My Quit Buddy: (416) 555-5555 Other personal and professional supports ___ ___________________________________

41. 41 Step 4: PREVENT RELAPSE (Persevere) “ A Slip is Not a Fall ”

42. 42 Also helps clinicians understand that continued use and relapse is not exclusively a lack of personal motivation or ability but multi-factorial in nature. EBB and Relapse The three domains can help identify which areas need further optimization

43. 43 Prevent Relapse (2) Were there any slips/relapses? What happened? What can be done in those situations again so things are different? Which options worked and what more needs to be done?

44. 44 Prevent Relapse (3) Pharmacotherapy – long term use for those that would benefit Staying engaged in treatment / counselling / groups when possible What other supports will remain available beyond treatment? Planning for relapse – What situations/triggers might lead to a slip or relapse? – Is there a plan on how to deal with those situations?

45. 45 Preventing Relapse - The Health Care Provider Follow-up calls: – Support/Counselling – Evaluation – Re-engaging client if needed

46. 46 Questions?

47. 47 Applying the Skills: Practice Exercise: Consider a behaviour you would like to change – something that you are ambivalent about or have been meaning to change for awhile. Complete the tools on the following slides…

48. 48 Readiness Ruler People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following three questions with respect to the goal you have set. How important is it to change this behaviour? How confident are you that you could make this change? How ready are you to make this change? 0 1 2 3 4 5 6 7 8 9 10

49. 49 For Reflection: “Readiness Ruler” What are 3 reasons you are at ______ and not zero? 1. 2. 3.

50. 50 Reasons for Change Making a commitment to meeting your goal is important to your success. Sometimes, it’s easy to forget why you’re making the change, so write down your reasons and use this as a reminder to yourself when things seem tough! The most important reasons why I want to change are: 1 ____________________________________________________________ 2 ____________________________________________________________ 3 ____________________________________________________________

51. 51 Decision to Change Worksheet Changing my current behaviour Continuing the behaviour in the same way Benefits Costs

52. 52 Discussion and Debrief 1. What was it like writing down your responses using these tools? 2. How did using these tools impact your confidence, readiness or importance of change? 3. How might you use this learning in your application of the tools with your patients?

53. 53 For reflection/discussion… What will you take away from this session? How will your learning impact your clinical practice? What is one thing you will commit to trying with patients in the coming week?

54. Resources

55. 55 Available for PDF download http://www.teachproject.ca/publicdownloads/SOR_Booklet.pdf

56. 56 Remember … A link to the Online Course Evaluation will be sent by e-mail. A link to Learning Assessment 2 will also be sent by e-mail. This must be completed by June 29 th in order to receive your Letter of Completion Next session: July 20 th 2011: Motivational Interviewing Part 1: How to ask patients about tobacco use and using FRAMES **Application period is now open**

57. Thank you!

58. 58 Copyright Copying or distribution of these materials is permitted providing the following is noted on all electronic or print versions: © CAMH/TEACH No modification of these materials can be made without prior written permission of CAMH/TEACH.