Transcript Guidelines for the Instruction of Tobacco Cessation Programs

Tobacco Cessation Competency
Class
Section 2: Assessment Tools &
Types of Counseling
Objectives
• The participant will be able to discuss the
assessment tools commonly used to
screen and assess patients prior to
enrollment in a tobacco cessation
program.
• The participant will be able to identify the
stages of change a patient is in and
provide the appropriate counseling to
assist the patient in tobacco cessation.
Objectives con’t
• The participant will be able to follow the 4
as as described by the American cancer
society when counseling patients who use
tobacco.
• The participant will be able to screen the
patient with tobacco dependence for
depression and provide the proper referral
and/or enrollment in a tobacco cessation
program.
Assessment Tools
• Nicotine Dependence
• Stages of Change
• Depression Screening
Nicotine Dependence
• Nicotine is a highly addictive drug
naturally found in tobacco
• Body becomes physically and
psychologically dependent upon
nicotine
• Cutting back or quitting leads to
withdrawal symptoms
Nicotine Dependence and
Nicotine Withdrawal
• The “gold standard’ for diagnosis comes
from the DSM IV
• The key features for the diagnosis of
Nicotine Dependence (305.1)
– Continued use despite wanting to quit
– Prior quit attempts
– Persistent use in the face of physical
illness,
– Tolerance
– Presence of withdrawal symptoms
Nicotine Withdrawal
(292.00)
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Dysphoric or depressed mood
Insomnia
Irritability, frustration, or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Measurement of Nicotine
Dependence
• Fagerstrom Tolerance Questionnaire
– The nicotine rating item and the inhalation
item were unrelated to biochemical
measures
• Fagerstrom Test for Nicotine
dependence
– At present, how long after waking up do
you wait before having your first cigarette?
– How many cigarettes do you smoke in a
typical day?
The Fagerstrom score is a
quicker approach
adaptable to busy clinical
settings
Patients who answer affirmatively to
both questions are highly dependent
on nicotine:
•Do you smoke more than 25
cigarettes per day?
•Do you smoke within 5 Minutes of
awakening?
(Prochazka, 2000)
Withdrawal Symptoms
• Occur within a few hours after the last
cigarette and peak about 48 – 72 hours
later
• Can last for a few days to several
weeks
• Symptoms include:
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Depression
Frustration & Anger
Irritability
Difficulty concentrating; Trouble sleeping
Headache and increased appetite
Dealing with Withdrawal
• Do not rationalize
• Avoid people/places where you are
tempted
• Alter habits associated with smoking
• Deep breathing
• Visual imagery
• Stay active
• Remind yourself why you’ve quit
Behavior Change Research
• Health Belief Model
• Stages of Change
Health Belief Model
You will be more likely to stop tobacco use if
you:
– Believe that you could get a tobacco-related
disease and this worries you
– Believe that you can make an honest attempt
at quitting
– Believe that the benefits of quitting outweigh
the benefits of continuing tobacco use
– Know of someone who has had health
problems as a result of their tobacco use
Transtheoretical Model of
Change
• Developed by Prochaska and others
• Identifies the stages a person goes
through in making a change in behavior
• Help the provider tailor counseling and
therapy: Provide stage-appropriate advice
and therapy
• Demonstrates the benefits of identifying
the smoker’s readiness to change before
attempting to intervene
(Kottke, 1999)
Stages of Change
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Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Pre-contemplation
• No intention to change behavior in the
immediate future
• Unaware or under-aware of their problems
• Not ready to change
• Best Strategy: Offer general awareness
information and counseling regarding their
problem with tobacco dependence
Interventions for the
Pre-contemplator
• Assess awareness and knowledge
• Discuss pros and cons
– Benefits of quitting
– Identify reasons for usage “triggers”
• Acknowledge their concerns
• Advise of need to quit and personalize the
message
• Give self-help materials
Contemplation
• Aware that a problem exists and are
seriously thinking about overcoming it
• Have not yet made a commitment to
change or take any action
• Best Strategy: Motivate! Offer additional
information regarding tobacco usage
Interventions for the
Contemplator
• Discuss reasons for wanting to quit
• Review barriers to quitting
• Review resources and support for
quitting
• Review coping skills
• Discuss strategies for quitting
• Give self-help materials
Preparation
• Combines both an intention and
behavior to change
• Individual is intending to take action in
the next month
• Best Strategy – offer an intervention
program….they are
ready to address their
tobacco addiction
Interventions for the Patient
in the Preparation Phase
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Review reasons for quitting
Resolve ambivalence
Develop a QUIT PLAN
Set a quit date
Provide encouragement and provide support
Give direct and positive message for quitting
Have patient practice saying “No thank you, I
don’t smoke”
• Give self-help materials/Refer to support
group
Action
• Individuals modify their behavior,
experiences a/o environment
in order to overcome their problems
• Overt behavioral changes which require
a considerable commitment of time and
energy
• Best Strategy: Offer continued support
and reinforcement for positive changes.
Assess and address relapse potential
Interventions for the Patient
in the Action Phase
• Review reasons for
quitting
• Explore relationship
with tobacco
• Select a quit date
• Review relapse
triggers
• Discuss obstacles to
quitting
• Encourage cessation
efforts
• Focus on progress
• Offer referral to
support group
• Be sure to follow-up
• Review coping
strategies
• Explore support
system
On Quit Day
• Do not smoke; Do not use any tobacco products
• Get rid of all tobacco products and
paraphernalia (lighters, ashtrays, etc…)
• Stay active
• Drink lots of water
• Avoid high-risk situations where the urge to
smoke is strong
• Avoid coffee and alcohol
• Avoid being around individuals who are smoking
Maintenance
• Individual works to prevent
relapse
• Consolidates the gains attained
during action
• This stage lasts from six months
to an indeterminate period
• Best Strategy: Offer reinforcement and
praise
Relapse
“Stopping smoking is easy to
do…..
I have done it thousands of
times…..”
-Mark Twain
Relapse and Smoking
Cessation
• Relapse is the norm with nicotine
dependence
• Tobacco users seem to benefit from prior
quit attempts
– Tobacco cessation is a process
• Motivate relapsers to try again
• Most tobacco users make several
serious quit attempts before they are
successful
Who is likely to Relapse?
• Unable to cope with withdrawal and
cravings
• Highly dependent on nicotine
• Copes poorly with stress and moods
• Non-adherent
• Ambivalence
• Mental health issues
Treatment strategies for the
patient in Relapse
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Identify barriers to success
Review and explore negative feelings
Explore successful quitting strategies
Review relapse events and triggers
Encourage and motivate patient to try
again
Depression and Nicotine
Dependence
• Complex association between depression
and addiction to nicotine and tobacco
• Persons with a vulnerability to depression
are more likely to become regular smokers
and to become dependent smokers
• Level of nicotine dependence and number
of cigarettes smoked are directly
associated with the prevalence of major
depression
(Covey, 1999)
Depression Screening Tools
• The Beck Depression Inventory
– BDI is a good instrument for screening
depressive disorders in community surveys
– BDI cut-off score: greater than or equal to
13
– BDI when compared to SCAN (Schedules
for Clinical Assessment in
Neuropsychiatry) yielded 100% sensitivity;
99%specificity, and 98% diagnostic value
(Lasa, et.al., 2000)
Depression-Prone Smokers
and Cessation
• Depression-Prone smokers have a lower
quit rate
• Depression-prone smokers experience
more severe nicotine withdrawal
• Smoking cessation can provoke severe
depression in depression-prone smokers
• Use the Beck Depression Inventory to
screen patients for depression: consider
concurrent therapy- referral to psychiatry
(Covey, 1999)
Counseling
• Individual provider counseling
– Physicians have contact with 70% of smokers
annually
– Smoking cessation provided by a physician is
MORE cost-effective than screening PAP’s,
mammograms, treating HTN or
hyperlipidemia
• Group counseling
• Proactive telephone counseling
• Motivational counseling
Brief interventions during
medical visits are costeffective and could potentially
reach most smokers
•Unfortunately, brief interventions
are not consistently delivered!
(Ockene, et.al., 2000)
National Patterns in the Treatment
of Smokers by Physicians
• Smoking counseling by physicians
– 1991 – 16% of smokers’ visits
– 1993 – 29% of smokers’ visits
– 1995 – 21% of smokers’ visits
• Physicians identified patients’ smoking status
at 67% of all visits in 1991 and this
percentage did not increase over time
• Nicotine Replacement Therapy
– 0.4% of smokers’ visits in 1991 to 2.2% in 1993
and decreased to 1.3% in 1995
(Thorndike, et.al., 1998)
Physician Interventions
• Primary care physicians were more likely
to provide treatment to smokers than were
specialists
• All physicians were more likely to treat
patients with smoking-related diagnoses
• Physician practices for smoking
intervention falls far short of national
health objectives and practice guidelines
(Thorndike, et.al., 1998)
Individual Counseling: Four A’s
NCI Guidelines
• ASK: ask about tobacco use at every
visit and document in the patient record
- the fifth vital sign
• ADVISE: strongly!
• ASSIST: plan, provide information,
treatment, diary, routines, habit change
• ARRANGE: referrals and follow-up
Provider Advice
• “As your physician, I must advise you
to stop smoking.”
• “I need you to know that quitting
smoking is the most important thing
you can do to protect your current and
future health.”
• “I think it is important for you to quit
smoking (smokeless tobacco) now and
I will help you. Cutting down when you
are ill is not enough.”
Advise
• Personalize the message
• “Teachable moment”
• Encourage the positive aspects of quitting
– Focusing on the negative effects of tobacco
use and scare tactics are not effective
strategies for motivating tobacco users to quit
• Motivational Counseling is helpful to
individuals who are ambivalent or resistant
to change
Advise
• Focus on the 4 R’s
–Relevance of quitting
–Risks of Tobacco
–Rewards of quitting
–Repeat the message
Assist
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Review quitting strategies
Discuss potential problems
Listen to concerns
Provide stage based self-help materials
Establish a plan
Set a quit date
Refer to specialist or program is needed
Assist/Pharmacotherapy
• Zyban
• Nicotine Replacement Therapy (NRT)
– Gum
– Transdermal patches
– Nasal Spray
– Nicotine inhaler
Smoking Cessation with
Assistance
• Use of assistance for smoking cessation has
increased over recent years, from 7.9% in 1986
to 19.9% in 1996.
• Types of assistance: self-help, counseling, a/o
NRT
• Patients most likely to use assistance
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Heavy smokers
Women
Usage increases with age
Whites were more likely to use NRT than were other
ethnic groups
Smokers’ preferences for
assistance with cessation
• Given the several different options for
assistance…………..
46% of current smokers stated they were
interested in none of the options
Of those interested in assistance:
67% preferred help from a medical
professional
12.4% a stop smoking group
23% a book, pamphlet or quit kit
2.9% mail or telephone services
(owen & Davies, 1990)
Overall, those who used
assistance had a higher
success rate than those
who did not: the 12-month
abstinence rates were 15.2%
and 7.0% respectively
(Zhu, et.al, 2000)
Arrange
• Follow-up
• Ask:
–Did you stop?
–Are you tobacco free?
–Any problems?
• Provide encouragement!
Motivational Interviewing
• Developed and introduced in 1991 by Miller and
Rollnick
• HCP remains positive during counseling and
praises all attempts to decrease or cease
tobacco use
• HCP shows empathy towards
problems/withdrawals the patient is experiencing
• HCP helps patient clarify his goals and provides
the patient with treatment options
Group Counseling
Behavioral Therapy
• Cessation rates average 20% for those willing to
participate
• American Lung Association “Freedom from
Smoking” 1 year quit rate is 16%
• American Cancer Society “Fresh Start Program”
1 year quit rate is 22%
• Social support increases the smoker’s desire to
quit, helps the smoker acquire the skills to
become and remain abstinent and reinforces
actions that have been taken to quit smoking
(Kottke, 1999)
Key Components for an
Effective Behavioral
Program
• Assessment of stages of change
• Identification of barrier to quitting
• Development of cessation and relapse
prevention plans
(Prochazka, 2000)
Proactive Telephone
Counseling
• The follow-up of all patients who have
been counseled by their HCP to cease
tobacco usage
• Empower staff to become involved in
the cessation process……this means
delegate the phone call to someone
else
• Follow-up can double cessation rates
Any Last Questions?