1. Smoking Cessation: Counseling and Resources Catherine A. Powers, EdD, LSW Boston University School of Medicine

2. The 5 A’s Ask about tobacco use. Implement an office-wide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented. Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit. Assess willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at the time (e.g., within the next 30 days). Assist in quit attempt. Help the patient with a quit plan Arrange follow up. Schedule follow-up contact, either in person or via telephone.

3. Effective Counseling and Behavioral Therapies for Smokers Research found three types of counseling and behavioral therapies to be especially effective, and all patients attempting tobacco cessation should use them -Provision of practical counseling (problem solving/skills training) -Provision of social support as part of treatment (intra-treatment social support) -Help in securing social support outside of treatment (extra-treatment social support) (Treating tobacco use and dependence. A clinical practice guideline 2000)

4. Common Elements of Practical Counseling Practical counseling (problem solving/skills training) Treatment component Teach patient to recognize danger situations—Identify events, internal states, or activities that increase the risk of smoking or relapse. Examples Negative affect. Being around other smokers. Drinking alcohol. Experiencing urges. Being under time pressure.

5. Coping Skills Develop coping skills—Identify and practice coping or problem-solving skills. Typically, these skills are intended to cope with danger situations. Examples Learning to anticipate and avoid temptation Learning cognitive strategies that will reduce negative moods Accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure. Learning cognitive and behavioral activities to cope with smoking urges (e.g. distracting attention)

6. Provide basic information about smoking and successful quitting Provide basic information—Provide basic information about smoking and successful quitting Examples Any smoking (even a single puff) increases the likelihood of full relapse Withdrawal typically peaks within 1-3 weeks after quitting Withdrawal symptoms include negative mood, urges to smoke, and difficulty concentrating The addictive nature of smoking

7. Intra-treatment Supportive Interventions Elements of Intra-treatment Supportive Interventions (within treatment setting) Treatment provider offers encouragement and belief in user's ability to quit Provider communicates caring and concern, is open to individual's expression of fears of quitting and ambivalent feelings Tobacco user is encouraged to talk about the quitting process (reasons to quit, previous successes, difficulties encountered) The use of intra-treatment social support yields a 14.4% abstinence rate (Fiore et al., 2000)Fiore et al., 2000)

8. Extra-treatment Supportive Interventions Elements of Extra-treatment Supportive Interventions (outside treatment setting) Tobacco user is offered skills training in soliciting support from others (family, friends, co-workers), is helped in establishing a smoke-free home Information on community resources (helplines) is provided Tobacco user establishes a buddy system (letters, contracts, tip sheets) (www.lungusa.org) (www.lungusa.org) Extra-treatment social support shows a 16.2% abstinence rate (Fiore et al., 2000)Fiore et al., 2000

9. Does Counseling Work? There is a strong dose- response relationship between the intensity of tobacco dependence counseling and it is effectiveness. Treatments involving person- to-person contact (via individual, group, or proactive telephone counseling) are consistently effective Effectiveness increases with treatment intensity (minutes of contact)

10. Telephone Counseling Community Preventive Services recommend multicomponent cessation interventions that include telephone support Used to increase the motivation of the smoker Can include trained counselors, healthcare providers or a taped message in single or multiple sessions Usually combined with other interventions –Client education materials –Individual or group cessation counseling –Nicotine replacement therapies

11. Telephone Counseling in Community Settings May provide access to self-help materials List of local resources (for example schedule of group sessions) May provide counseling and motivation cessations

12. Telephone Counseling in the Clinical Setting Follow-up calls usually support other clinical cessation interventions Including: Provider counseling Group cessation sessions Nicotine replacement and other therapies

13. Smoking Cessation Groups There are two types of smoking cessation groups that are discussed in the literature Support groups (also labeled self-help) and group counseling with a trained facilitator

14. Support/Self-Help Groups vs. Group Counseling Support groups are more informal and require the client to be motivated to attend the meetings on her own According to the Public Health Service Clinical Practice Guidelines, Treating Tobacco Use and Dependence, self-help does not appear to have a significant impact on reducing rates of smoking among the general population Group counseling may be done in a more structured environment, or even in a prenatal care setting It is organized by a health care professional with knowledge of evidence-based tobacco treatment approaches Facilitated group counseling improves people's ability to quit 14% abstinence rate versus 10.8% abstinence rate for no intervention

15. Web-based Interventions Reaches a wide audience Readily available Inexpensive to operate Easy to update and collect data Limited number of health-based web programs have been evaluated Limited empirical support for web- based smoking cessation Maybe used in conjunction with counseling and other treatment options

16. Don’t Miss Opportunities to make a Difference Prenatal – up to 12 provider visits Post-partum – follow-up visit Well baby visits Patient may be motivated by her pregnancy Motivated by new baby Motivated by concern for newborn

17. Pediatric Providers on the Frontline The American Academy of Pediatrics recommends a well care visits at the following ages: birth; 1 week; 1, 2, 4, 6, 9, 12, 15, and 18 months Annual visits from age 2 and up. Visits to the pediatric provider that include counseling, medication, and collaborative support can help parents stop smoking Each well-child visit provides an opportunity for a brief tobacco counseling intervention

18. Intervention with Parents The American Academy of Pediatrics and the American Academy of Family Physicians have policies supporting parental smoking cessation in order to end children's ETS exposure. Policies include counseling pregnant women, women with infants, and other parents who smoke. Pediatric clinicians are well positioned to address parental smoking because of interactions with parents during health visits that occur frequently during a child's early years. The evidence base regarding the positive effect of clinicians counseling adults during their own health visits is clear The evidence base regarding the effectiveness of pediatric clinicians counseling parents during their child's health visits is beginning to accumulate. ( National Conference on Tobacco or Health )

19. Parents Want Referrals In a survey of parents who smoke conducted at Children's Hospital Boston, all believed that pediatricians should offer parents the chance to participate in a smoking cessation program 56% of parents enrolled in a smoking cessation program when asked by a motivational counselor. (Jonathan Winickoff, MD, MPH Massachusetts General Hospital,Center for Child and Adolescent Health Policy)

20. Teachable Moment "Harnessing the pediatric visit sets up a teachable moment for smoking parents, because they are concerned about the health of their child. Many physicians think that parents would refuse smoking cessation services, but we had 80 percent saying they wanted it, which is similar to what we saw in the hospitalization study.“ Jonathan Winickoff, MD, MPH Massachusetts General Hospital Center for Child and Adolescent Health Policy 2003

21. The Role of the Pediatric Providers There are several steps pediatric providers can take 1. Communicating with the parent's primary care physician 2. Referring the patient to phone counseling 3. Steering the parent toward such community resources as local health plans, hospitals, or smoking cessation support groups

22. Take Home Message for Your Students Provider Counseling is effective intra-treatment social support yields a 14.4% abstinence rate Extra-treatment social support shows a 16.2% abstinence rate Community and web-based resources help patients stay smoke-free Information on local and national quit lines and cessation groups are available on the web