Transcript TOBACCO CONTROL STRATEGIES for PHARMACISTS

ASSISTING PATIENTS
with QUITTING
CLINICAL PRACTICE GUIDELINE for
TREATING TOBACCO USE and DEPENDENCE


Released June 2000
Sponsored by the AHRQ (Agency for Healthcare
Research and Quality) of the USPHS (US Public
Heath Service) with:
 CDC (Centers for Disease Control)
 NCI (National Cancer Institute)
 NIDA (National Institute for Drug Addiction)
 NHLBI (National Heart Lung & Blood Institute)
 RWJF (Robert Wood Johnson Foundation)
http://www.surgeongeneral.gov/tobacco/
Estimated abstinence at
5+ months
EFFECTS OF CLINICIAN
INTERVENTIONS
30
n = 29 studies
20
10
1.0
2.2
1.7
(1.5,3.2)
1.1
(1.3,2.1)
Self-help
material
Nonphysician
clinician
Physician
clinician
(0.9,1.3)
0
No clinician
Type of Clinician
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS, 2000.
The 5 A’s
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
The 5 A’s

(cont’d)
ASK about tobacco use
Ask

“Do you ever smoke or use any type of tobacco?”

“I take time to ask all of my patients about tobacco
use—because it’s important.”
The 5 A’s

(cont’d)
ADVISE tobacco users to quit (clear, strong,
personalized, sensitive)


“It’s important that you quit as soon as possible, and I
can help you.”
“I realize that quitting is difficult. It is the most
important thing you can do to protect your health now
and in the future. I have training to help my patients
quit, and when you are ready, I will work with you to
design a specialized treatment plan.”
The 5 A’s
(cont’d)

ASSESS readiness to make a quit attempt
Assess

Assist
ASSIST with the quit attempt
The 5 A’s

(cont’d)
Arrange
ARRANGE follow-up care
Number of sessions
Estimated quit rate*
0 to 1
12.4%
2 to 3
16.3%
4 to 8
More than 8
20.9%
24.7%
* 5 months (or more) postcessation
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS, 2000.
5 A’s: REVIEW
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
ASSESS
readiness to make a QUIT attempt
ASSIST
with the QUIT ATTEMPT
ARRANGE
FOLLOW-UP care
The (DIFFICULT) DECISION
to QUIT

Faced with change, most people are not ready to act.

Change is not a single step, but a process.

Typically, it takes multiple attempts.
HOW CAN I LIVE
WITHOUT TOBACCO?
HELPING SMOKERS QUIT IS a
CLINICIAN’S RESPONSIBILITY

Clinicians have a professional obligation to help
their patients quit using tobacco.
THE DECISION TO QUIT LIES IN THE
HANDS OF EACH PATIENT.
TAILORING the INTERVENTION to
MEET the PATIENT’S NEEDS
PATIENTS DIFFER IN THEIR
READINESS TO COMMIT TO QUITTING

Persons NOT READY TO QUIT (in the next 30 days):


Persons READY TO QUIT (in next 30 days):



Motivational interventions
Behavioral counseling
Pharmacotherapy
Persons who RECENTLY QUIT (in past 6 months):

Relapse prevention interventions
IS a PATIENT READY to QUIT?
Does the patient now use tobacco?
Yes
Is the patient now
ready to quit?
No
Promote
motivation
No
Did the patient once
use tobacco?
Yes
Yes
Provide
treatment
The 5 A’s
Prevent
relapse*
No
Encourage
continued
abstinence
*Relapse prevention interventions not necessary
if patient has not used tobacco for many years
and is not at risk for re-initiation.
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS, 2000.
FIVE STAGES THAT DESCRIBE a
PERSON’S READINESS to CHANGE
STAGE 1: Not thinking about changing anytime soon
STAGE 2: Considering changing, but not yet
STAGE 3: Getting ready to change soon
STAGE 4: In the process of changing
STAGE 5: Changed a while ago
FIVE STAGES THAT DESCRIBE a
PERSON’S READINESS to CHANGE
STAGE 1: Precontemplation
STAGE 2: Contemplation
STAGE 3: Preparation
STAGE 4: Action
STAGE 5: Maintenance
STAGES of CHANGE:
A LINEAR VIEW
Quit
date
- 6 months
Precontemplation
- 30 days
Contemplation
Preparation
+ 6 months
Action
Maintenance
ASSESS READINESS TO QUIT:
STAGES of CHANGE, CYCLICAL VIEW
Termination
Relapse*
Maintenance
Action
Precontemplation
Not ready
to quit
Contemplation
Preparation
* Patients can relapse out of the maintenance or action stages, reverting to earlier stages.
STAGES of CHANGE for
TOBACCO CESSATION
Does the patient now use tobacco?
Yes
Is the patient ready
to quit now?
No
Precontemplation
- or Contemplation
No
Did the patient once
use tobacco?
Yes
Yes
Preparation
Action
- or Maintenance
No
Never smoker
The STAGES of CHANGE
STAGE 1: Precontemplation
Not thinking about quitting in the next 6
months



Patients might not be aware of the need to quit.
They might be aware of the need but resist quitting.
Pros of smoking outweigh the cons.
GOAL: Move the patient into the contemplation stage.
STRATEGIES for COUNSELING
during PRECONTEMPLATION
DOs
DON’Ts

Strongly advise to quit

Ask noninvasive questions




“Envelope”
Raise awareness of health
consequences/concerns
Demonstrate empathy, foster
communication
Leave decision up to patient

Persuade

“Cheerlead”

Tell patient how
bad smoking is,
in a judgmental
manner
The STAGES of CHANGE
(cont’d)
STAGE 2: Contemplation
Considering quitting in the next 6 months
but not in the next 30 days

Patients are aware of the need to quit.

They are aware of the benefits of quitting.

But they struggle with ambivalence about change.
GOAL: Move the patient into the preparation stage.
STRATEGIES for COUNSELING
during CONTEMPLATION
DOs

Strongly advise to quit

Provide information

Identify reasons for tobacco use



Demonstrate empathy; increase
motivation
Encourage self-reevaluation of
concerns
Offer encouragement
DON’Ts

Apply actionoriented
interventions
METHODS for INCREASING
MOTIVATION—5 R’s
For patients who are not yet
ready to quit:
 Relevance

Risks

Rewards

Roadblocks

Repetition
TAILORED
INTERVENTION
MESSAGES
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS, 2000.
A DEMONSTRATION: COUNSELING a
PATIENT who is NOT READY TO QUIT
CASE SCENARIO:
MS. STEWART
You are a clinician providing care to
Ms. Stewart, a 55-year-old patient
with emphysema.
She uses two different inhalers for
her emphysema.
COUNSELING SCENARIO:
KEY POINTS

Ask about tobacco use


Assess readiness to quit


Aware of need to quit; not ready yet
Advise to quit


Link inquiry to knowledge of disease
Discuss implications for disease progression
“I will help you, when you are ready”
COUNSELING SCENARIO:
SUMMATION
The clinician has
 Established
a relationship
 Established
yourself as a resource
 Planted
a seed to move patient forward
 Opened
a door to facilitate further counseling
The STAGES of CHANGE
(cont’d)
STAGE 3: Preparation
Ready to quit in the next 30 days


Patients are aware of the need to, and the benefits of,
making the behavioral change.
Getting ready to take action.
Goal: Move the patient to the action stage.
STRATEGIES for COUNSELING
DURING PREPARATION
DOs

Praise the patient’s readiness

Assess tobacco use history

Current use:



Type(s) of tobacco, brand, amount
Past use: duration, recent changes
Past quit attempts:



Number, date, length
Methods used, compliance, duration
Reasons for relapse
STRATEGIES for COUNSELING
DURING PREPARATION
DOs
 Discuss key issues








Reasons/motivation to quit
Confidence in ability to quit
Triggers for tobacco use
Routines/situations associated with tobacco use
Stress-related smoking
Social support for quitting
Concerns about post-cessation weight gain
Concerns about withdrawal symptoms
STRATEGIES for COUNSELING
DURING PREPARATION
DOs

Facilitate quitting process

Discuss methods for quitting (pros, cons)

Pharmacotherapy: a treatment, not a crutch!

Behavioral counseling

Set a quit date!

Recommend Tobacco Use Log (see handout)
TOBACCO USE LOG




The Tobacco Use Log is most appropriate for patients
who are getting ready to quit.
Documenting tobacco use helps patients to understand
when and why they use tobacco.
Identifies activities or situations that trigger tobacco use.
Information can be used to develop coping strategies to
overcome the temptation to use tobacco.
TOBACCO USE LOG:
INSTRUCTIONS for USE


Patient should continue regular tobacco
use for a period of 3 or more days
Each time any form of tobacco is used,
the following information should be
recorded on the log:



Time of day
Brief description of activity or situation
during use
“Importance” rating (scale of 1–3)

Review log sheets to identify situations that trigger tobacco use

Develop coping strategies to prevent relapse
STRATEGIES for COUNSELING
DURING PREPARATION
DOs

Discuss and develop coping strategies

Cognitive

Behavioral
COPING with QUITTING
Cognitive strategies

Review of commitment to quitting

Distractive thinking

Positive self-talks

Relaxation through imagery

Mental rehearsal and visualization
(cont’d)
COPING with QUITTING
(cont’d)
Examples:

Thinking about cigarettes doesn’t mean you have to
smoke one.




When you have a craving, remind yourself that:


“Just because you think about something doesn’t mean you have
to do it!”
Tell yourself “It’s just a thought,” or “I am in control.”
Say the word STOP! out loud, or visualize a stop sign.
“The urge for a cigarette will only go away if I don’t smoke.”
As soon as you get up in the morning, look in the mirror
and say to yourself

“I am proud that I made it through another day without smoking.”
COPING with QUITTING
(cont’d)
Behavioral strategies

Control your environment





Substitutes for smoking




Smoke-free home and workplace
Alter or remove cues to tobacco use
Modify behaviors that you associate with tobacco: when, what,
where, how, with whom
Actively avoid trigger situations
Water, chewing gum or hard candies (oral substitute)
Take a walk, diaphragmatic breathing, self-massage
Rely on social support
Actively work to alleviate withdrawal symptoms
STRESS MANAGEMENT
The Facts
The Myths


Smoking gets rid of all
my stress
I can’t relax without a
cigarette


There will always be stress
in one’s life
There are many ways to
relax without a cigarette
Smokers confuse the relief of withdrawal
with the feeling of relaxation
STRESS MANAGEMENT SUGGESTIONS:
Deep breathing, shifting focus, taking a break.
SOCIAL SUPPORT
for QUITTING

Key ingredients for successful quitting:


Social support as part of treatment (intra-treatment)
Social support outside of treatment (extra-treatment)
PATIENTS SHOULD BE ADVISED TO:

Ask family, friends, and coworkers for support – ask them
not to smoke around you, and not to leave cigarettes out

Talk with your health-care provider

Get individual, group, or telephone counseling
Patients who receive social support and
encouragement are more successful in quitting
HERMAN ® is reprinted with permission from
LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
ADDRESSING CONCERNS about
POSTCESSATION WEIGHT GAIN

Most quitters gain weight


Discourage strict dieting while quitting







Most gain < 10 pounds, but there is a wide range
Recommend physical activity
Encourage healthy diet, plan meals, eat fruits
Increase water intake
Chew sugarless gum
Select nonfood rewards
Maintain patient on pharmacotherapy shown to
delay weight gain
Refer patient to specialist or program
ADDRESS CONCERNS about
WITHDRAWAL SYMPTOMS

Anger/irritability

Restlessness

Anxiety

Drowsiness

Cravings

Fatigue

Difficulty concentrating

Impaired task
performance

Hunger/weight gain

Nervousness

Impatience

Sleep disturbances
Hughes et al. Arch Gen Psychiatry 1991;48:52–59.
ADDRESS CONCERNS about
WITHDRAWAL SYMPTOMS (cont’d)


Most pass within 2 to 4 weeks after quitting
Cravings can last longer, up to several months or
years


Often can be ameliorated with cognitive or behavioral coping
strategies
Refer to Withdrawal Symptoms Information
Sheet

Symptom, cause, duration, relief
STRATEGIES for COUNSELING
DURING PREPARATION
DOs

Discuss concept of slip versus relapse



“Let a slip slide”
Medication counseling

Proper use, with demonstration

Promote compliance
Arrange follow-up

Offer to assist throughout quit attempt

Provide resources and referrals

Congratulate the patient!
The STAGES of CHANGE
(cont’d)
STAGE 4: Action
Actively trying to quit for good

Patients have quit using tobacco sometime in the past
6 months and are taking steps to increase their
success.

Withdrawal symptoms occur.

At high risk for relapse.
GOAL: Remain tobacco-free for at least 6 months.
HERMAN ® is reprinted with permission from
LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
STRATEGIES for COUNSELING
during ACTION
DOs




Praise progress - solicit commitment to quit for good
Evaluate current quit attempt:
 Status of attempt
 “Slips” or relapse
 Medication use, plans for termination
Ask about social support
Identify temptations and triggers for relapse
 Negative affect, smokers, eating, alcohol, cravings, stress

Encourage healthful alternative behaviors to replace tobacco use

Offer tips for relapse prevention
RELAPSE PREVENTION

Congratulate success!

Encourage continued abstinence

Promote smoke-free environments

Discuss benefits of quitting and successes achieved


Discuss problems encountered and potential barriers to
continued abstinence
Strong or prolonged withdrawal symptoms?


Add, combine, or extend use of pharmacotherapy agents
Social support

Discuss ongoing sources of support

Schedule follow-up visits or calls; refer to support groups
The STAGES of CHANGE
STAGE 5: Maintenance
Tobacco-free for 6 months

Patients remain vulnerable to relapse.
GOAL: Remain tobacco-free for life.
(cont’d)
HERMAN ® is reprinted with permission from
LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
STRATEGIES for COUNSELING
DURING MAINTENANCE
DOs


Congratulate continued success
Continue to offer tips for relapse
prevention

Assess temptations and triggers

Discuss and suggest coping strategies

Encourage alternative behaviors

Provide positive reinforcement
STAGES of CHANGE: A REVIEW
Quit
date
- 6 months
Precontemplation
- 30 days
Contemplation
Preparation
+ 6 months
Action
Maintenance
CESSATION COUNSELING:
SUMMARY
Routinely identify tobacco users (ASK)
 Strongly ADVISE patients to quit
 ASSESS stage at each contact
 Tailor intervention messages (ASSIST)
 Be a good listener
 Minimal intervention in absence of time for
more intensive intervention
 ARRANGE follow-up
 Use the referral process, if needed

WHAT IF…
a patient asks you
about your use of
tobacco?
Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.
The RESPONSIBILITY of
HEALTH PROFESSIONALS
It is inconsistent
to provide health care and
—at the same time—
remain silent (or inactive)
about a major health risk.
TOBACCO CESSATION
is an important component of
THERAPY.
DR. GRO HARLEM BRUNTLAND,
DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred
years from now our grandchildren and
their children will look back and seriously
question how people claiming to be
committed to public health and social
justice allowed the tobacco epidemic to
unfold unchecked.”
US Department of Health and Human Services. Women and Smoking: A Report of
the Surgeon General. Washington, DC: Public Health Service, 2001.