1. Nurses’ Role with Clients/Patients Who Use Tobacco Created by the Registered Nurses’ Association of Ontario

2. RNAO BPG “Integrating Smoking Cessation into Daily Nursing Practice” Practice Recommendations: 1.Nurses implement minimal smoking cessation intervention (4As) with all clients. 2.Nurses introduce intensive smoking cessation intervention (more than 10 minutes duration) when possible. 3.Nurses recognize possibility of relapse and need to re- engage clients in the smoking cessation process. 4.Nurses should be knowledgeable about community smoking cessation resources, for referral and follow-up. 5.Nurses implement smoking cessation interventions and tailor strategies to the diverse needs of populations. 6.Nurses implement, wherever possible, intensive intervention with women who are pregnant and postpartum. 7.Nurses encourage people to make their homes smoke- free, to protect from exposure to second-hand smoke.

3. Role of Nurses & Nursing Students with clients/patients who use tobacco Key intervention: ◦Introduce topic with a question  Comfortable, non-judgmental, not coercive ◦Use reflective practice with answers ◦Offer assistance when the smoker is ready to quit ◦Offer advice and guidance in choosing cessation method ◦Support the quitting process Nursing students can act as peer-to-peer counselors Provide self-help material

4. 4As vs. 5As protocol 4As Protocol: Minimal Tobacco Intervention  1-3 minutes in duration AskAsk every client/patient if they use tobacco. “Have you used any form of tobacco in the past six months?” Document tobacco use status (ie. Non-smoker, smoker, ex-smoker) AdviseAdvise every tobacco user of the importance of quitting. “I am concerned about how smoking is affecting your health. Have you thought about quitting?” AssistAssist the smoker to quit by providing appropriate self- help materials and referrals. ArrangeArrange a follow-up or referral appointment to discuss quitting.

5. 4As vs. 5As protocol 5As Protocol: Intensive Tobacco Intervention  Over 10 minutes in duration Ask Advise Same protocol as for 4As AssessAssess nicotine dependence level and readiness to quit. Review the client/patient’s quitting history. AssistAssist the smoker with the choice of: - quit date - cessation method - general quitting plan This can involve providing self-help material and possibly prescriptions. ArrangeArrange for follow-up visit(s) - on quit day & afterwards

6. Stages of Change Theory Originally developed in the late 1970's & early 1980's by James Prochaska and Carlo DiClemente at the University of Rhode Island Views behaviour change as a dynamic process Applied to a broad range of behaviours smoking cessation weight loss injury prevention etc.

7. Basic Premise of Stages of Change Theory People quit smoking by progressing through a series of five successive stages People in each stage differ from those in other stages in important ways (dynamic) Stages reflect how we plan, deliver and evaluate smoking cessation interventions.

8. Stages of Change Model

9. Pre-Contemplation  Unaware or unwilling to change  Not thinking of quitting in the next 6 months  Spend little time thinking about smoking  May not see it as a problem Goal: To help the client/patient begin to think seriously about quitting  What to do: ◦Ask regarding feelings about smoking ◦Ask about pros and possible cons of smoking ◦Advise by offering quitting information & assistance at any time

10. Contemplation  Thinking about smoking  May be thinking about quitting within 6 months  Feel ambivalent about taking the next step Goal: To help smoker move towards a decision to stop smoking To help the client/patient feel more confident  What to do: Ask about pros and possible cons of smoking (decision balance) Acknowledge ambivalent feelings Assist by reinforcing reasons for change & exploring new ones Suggest they cut back or stop for a day Assist by offering a future visit and information

11. Preparation  Getting ready to stop within the next 30 days  Have set a stop smoking date  Have made a 24-hour quit attempt in the last 12 months Goal: To help the smoker prepare for an anticipate positively a quit date  What to do: Ask about concerns, preparations and lessons learned from previous attempts Advise by identifying barriers to stopping and elicit solutions Assist by Booklet, Action Plan, Nicotine Replacement, Date for quitting (BAND)

12. Action  Have quit smoking within the past 6 months  May try several different techniques  Are at greatest risk of relapse Goal: To help client/patient stay off tobacco products and recover from relapses  What to do: Ask how the client is doing: relapses, temptations, successes, NRT use Advise re: relapse prevention, weight gain, triggers Assist by focusing on successes, encourage self rewards and increase support, elicit solutions for problems

13. Maintenance Have quit for more than 6 months Integrating smoke-free living into their routine Goal: To help the client/patient remain smoke-free for a life time What to do: Ask how the client is doing: risk situations, relapses Assist by offering suggestions for difficult times, support, encouragement Congratulate!

14. The Cycle of Change Most smokers will cycle through the stages 3-4 times before quitting for life Each attempt offers new learning opportunities Relapse is a normal event in the process of making behavioural change

15. Motivational Interviewing for health behaviour change Designed to take 3 – 5 minutes per session Psychosocial or socio-behavioural approach (rather than biomedical) Focused, goal directed, client-centred councelling style Aimed at eliciting behaviour change by helping clients explore and resolve ambivalence

16. 5 Principles (Counselling Techniques) 1. Express Empathy 2. Avoid Arguments 3. Develop Discrepancy (Dissonance) 4. Roll with Resistance 5. Support Self-efficacy

17. 6 General Skills for Motivational Interviewing 1. Asking Open-ended Questions 2. Reflective Listening 3. Affirmations 4. Summarizing or Reframing 5. Self-motivational Statements 6. Personalized Feedback  See the guideline Appendix G for a detailed description of the motivational interviewing process

18. Referrals to Community for Cessation Support Communities vary in the amount of cessation support resources they have based on size, location, etc. ◦Most communities offer cessation support through their local public health department Other resources are more consistently available for clients/patients who are trying to quit smoking Self help booklets & resources Online resources