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Keep Our University Free From Smoking. Submitted To King Saud University Program:. Ata Ulhaq, MD, FACEP, MPH. Smoke - Free Environment. Smoking Cessation [stopping smoking]. Represents the single most important step to enhance length and quality of life - PowerPoint PPT Presentation
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2009 Atwood & Clark Consultants
Keep Our University Free From Smoking
Ata Ulhaq, MD, FACEP, MPH
Submitted To King Saud University Program:
Smoke - Free Environment
2009 Atwood & Clark Consultants
Smoking Cessation [stopping smoking]
Represents the single most important step to enhance length and quality of life
Quitting smoking is not easy, but you can do it To have the best chance of success in quitting, you
need to know: what you're up against what your options are where to go for help
2009 Atwood & Clark Consultants
Pathology of Smoking
Acute myeloid leukemia
Alzheimer’s Lupus SIDS Colic in babies Impotence Various cancers
Macular degeneration
Rheumatoid arthritis
Acid reflux Breast cancer Depression Thyroid disease
2009 Atwood & Clark Consultants
Cardiovascular Pathology • Firmly established risk factor for
coronary heart disease and peripheral vascular disease
• Twofold or greater risk of coronary heart disease among smokers
• Severe atherosclerosis of the abdominal aorta
much greater risk of aortic aneurysm peripheral vascular disease
2009 Atwood & Clark Consultants
Atherosclerosis
development of
atherosclerosis in
an artery
2009 Atwood & Clark Consultants
Physiologic Responses• Accelerating atherogenesis or increasing the
probability of thrombosis reduction in plasma high-density lipoprotein cholesterol concentration elevation in plasma fibrinogen concentration
elevation in white blood cell count
2009 Atwood & Clark Consultants
Smoker vs. Non Smoker
31 year old non-smoker
30 year old smoker
2009 Atwood & Clark Consultants
Reversible
The rapid amelioration of the risk of cardiovascular disease after cessation of smoking suggests that these processes are readily reversible
2009 Atwood & Clark Consultants
Cancers
Aside from the obvious lung cancer, smoking contributes to many other cancers of the body
2009 Atwood & Clark Consultants
Cancer of the Oral Cavity
2009 Atwood & Clark Consultants
Pharynx
2009 Atwood & Clark Consultants
Esophagus
2009 Atwood & Clark Consultants
Stomach
2009 Atwood & Clark Consultants
Bladder
2009 Atwood & Clark Consultants
Cervix
2009 Atwood & Clark Consultants
Kidney Cancer
Advanced renal carcinoma
Papillary renal carcinoma
2009 Atwood & Clark Consultants
Pancreas
2009 Atwood & Clark Consultants
Carbon Monoxide - CO What Carbon
Monoxide is: CO is a poisonous,
colorless, odorless gas produced as a result of incomplete burning of carbon-containing fuels
2009 Atwood & Clark Consultants
CO
What Happens When CO is Inhaled: When inhaled, CO quickly binds with
hemoglobin in red blood cells in the lungs, creating COHb
This can affect the amount of hemoglobin available for the transport of oxygen throughout the body
May in turn lead to symptoms of CO poisoning
2009 Atwood & Clark Consultants
Carbon Monoxide in Cigarette Smoke
Cigarette smoke can contain high levels of carbon monoxide
Smokers generally have COHb levels in the blood that are many times greater than those who do not smoke
2009 Atwood & Clark Consultants
CO and Secondhand Smoke
Because secondhand smoke may also contain high levels of CO, nonsmokers who breathe in ETS (Environmental Tobacco Smoke) have increased levels of CO in their blood as well
2009 Atwood & Clark Consultants
CO and Secondhand Smoke
Secondhand smoke is a toxic cocktail of: over 4,000 chemical compounds 200 of which are known to be poisonous upwards of 60 that have been identified as
carcinogens
2009 Atwood & Clark Consultants
Smoking During Pregnancy
When a pregnant woman smokes, her baby does too Poisons like carbon monoxide and nicotine travel to
the growing baby Prevents as much as 25 % of oxygen from reaching
the placenta Keeps baby from getting enough food More likely to deliver early or baby of low birth
weight
2009 Atwood & Clark Consultants
Smoking and Pregnancy
Mothers can pass nicotine through breast milk
Nicotine can be found in mucus from the cervix of a female smoker
Nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants
2009 Atwood & Clark Consultants
Smoking During Pregnancy, cont’d.
Children born to women who smoked during pregnancy are more likely to develop asthma and other lung problems as they grow older
May learn more slowly Infants are more likely to develop colds,
bronchitis, and other respiratory diseases if secondhand smoke is present in the home
2009 Atwood & Clark Consultants
Smoking and Women
Female smokers are nearly 13 times more likely to die from COPD
Smoking is directly responsible for more than 90% of chronic obstructive pulmonary disease (COPD), or emphysema and chronic bronchitis deaths each year
Women who smoke also have an increased risk for developing cancers of the oral cavity, pharynx, larynx (voice box), esophagus, pancreas, kidney, bladder, and uterine cervix
2009 Atwood & Clark Consultants
Smoking and Women Women who smoke double their risk for developing
coronary heart disease Postmenopausal women who smoke have lower
bone density Women who smoke have an increased risk for hip
fracture Cigarette smoking also causes skin wrinkling that
could make smokers appear less attractive and prematurely old
2009 Atwood & Clark Consultants
Smoking and Women
Women who quit smoking relapse for different reasons than men Stress Weight control Negative emotions
2009 Atwood & Clark Consultants
Smoking Among Seniors
Seniors face increased risks associated with smoking
hip fractures (both men and women)CataractsCOPDSmoking reduces bone density among menopausal
womennuclear cataracts of the lens of the eye (2-3 times the
risk of nonsmokers)
2009 Atwood & Clark Consultants
Thank YouThank You
2009 Atwood & Clark Consultants
Nicotine and Addiction
Part II
2009 Atwood & Clark Consultants
Nicotine & Addiction
Why is quitting and staying quit hard for so many people?
Answer = Nicotine
2009 Atwood & Clark Consultants
Addiction
Compulsive physiological/psychological need for a habit-forming substance
Dependence on a behavior or substance that one is powerless to stop
One of the most costly public health problems
2009 Atwood & Clark Consultants
Addiction
A progressive syndrome; increases in severity over time unless treated
Characterized by frequent relapse, or return to the abused substance
Abusers often make repeated attempts to quit before they are successful
2009 Atwood & Clark Consultants
Nicotine & Addiction
Nicotine: Drug found naturally in tobacco Highly addictive -- as addictive as heroin or cocaine Over time, a person becomes physically/emotionally
addicted to nicotine Studies show smokers must deal with both the
physical and psychological (mental) dependence to quit and stay quit
2009 Atwood & Clark Consultants
Physical Dependence
“the appearance of characteristic withdrawal symptoms when the use of a substance is suddenly discontinued"
Nicotine is considered physically addictive because it physically alters your brain function
It produces withdrawal symptoms when you stop smoking
2009 Atwood & Clark Consultants
Physical Dependence
Physical dependence is defined by the appearance of withdrawal symptoms when use is discontinued
Opiates (such as Herion) Benzodiazepines Barbiturates Alcohol Nicotine
Induce physical dependence
2009 Atwood & Clark Consultants
Physiological Effects
When you inhale, nicotine is carried deep into your lungs
Absorbed quickly into the bloodstream Nicotine inhaled reaches the brain faster
than drugs that enter the body intravenously (IV)
2009 Atwood & Clark Consultants
Physiological Effects
Nicotine affects many parts of the body: heart blood vessels hormones metabolism brain
2009 Atwood & Clark Consultants
Physiological Effects cont’d.
Nicotine produces pleasant feelingsMakes the smoker want to smoke
more
2009 Atwood & Clark Consultants
Physiological Effects cont’d.
Acts as a depressant by interfering with the flow of information between nerve cells
As the nervous system adapts to nicotine, smokers increase the number of cigarettes they smoke
This, in turn, increases the amount of nicotine in the smoker's blood
2009 Atwood & Clark Consultants
Withdrawal Symptoms dizziness (which may
only last 1 to 2 days after quitting)
depression feelings of frustration,
impatience, and anger anxiety irritability increased appetite
sleep disturbances, i.e. trouble falling asleep/staying asleep, bad dreams or even nightmares
trouble concentrating restlessness headaches tiredness
2009 Atwood & Clark Consultants
Psychological Addiction Much more complex than physical addiction Does not involve the nicotine in cigarettes or
the physical effects the nicotine has on your brain
Psychological dependence transpires when a person develops a daily routine and a habit of actually smoking the cigarettes
2009 Atwood & Clark Consultants
Psychological Addiction: Pleasure
Smoking gives pleasure This "pleasure" comes in many ways:
the tactile pleasure of handling the cigarette oral pleasure of drawing on the cigarette "quick fix" in times of anxiety anger and stress social pleasure of smoking in situations of good
feelings such as bars, pubs or sporting events.
2009 Atwood & Clark Consultants
Addiction: Psychological Aspects
To feel good (sensation seeking) To feel better (self-medicating) Move quickly from the voluntary period of
drug use to compulsive behavior motivated by craving
2009 Atwood & Clark Consultants
Loss of control over use Continued use despite negative physical and
social consequences Believed to be strongly associated with
brain’s reward system
Addiction: Psychological Aspects
2009 Atwood & Clark Consultants
Psychological Dependence
Dependency of the mind Leads to psychological withdrawal
symptoms CravingsIrritabilityInsomniaDepressionAnorexia, etc.
Addiction can be derived from any rewarding behavior
2009 Atwood & Clark Consultants
Psychological Triggers
These triggers are usually brought on by stressful situations such as an argument, vehicle accident, not getting enough sleep or other demanding situations
You need to be able to recognize these stressful situations and react to them appropriately
2009 Atwood & Clark Consultants
Psychologically Hooked
Over time, you become used to smoking in these situations
Your mind associates smoking with them and the pleasure that comes with them
You find yourself lighting up even if you aren't physically craving the nicotine...without even thinking about it!
At this point, you are psychologically hooked
2009 Atwood & Clark Consultants
Why People Start & Continue SmokingStart
Desire to look cool Seduced to try tobacco by
glamorization of smoking in movies and advertisements
Peer pressure Rebellion Poor coping skills Social habit became
addiction
Continue Physical addiction Mental addiction Stress Around other
smokers Rely on pills/patches
rather than willpower
2009 Atwood & Clark Consultants
You Generally Start Smoking
in an attempt to… change your self-image appear more attractivemore manlymore femininemore intelligent
2009 Atwood & Clark Consultants
Sometimes You Start Smoking
in a misguided attempt to… calm your nerves cope with stress lose weight
Smoking does not help solve the source of your problems or compensate
for poor eating habits
2009 Atwood & Clark Consultants
Other Reasons for Smoking
On a dare to show you are not timid or afraid To fit with the crowd (all my friends do it) To appear sophisticated or cool To be grown-up To assert your independence As a sign of protest, rebellion, or to defy authority Free samples from friends or advertisers
2009 Atwood & Clark Consultants
Still More Reasons…
Influences from people you respect and admire
Parents or relatives smoked Images of famous actors, movie stars, or
role models
2009 Atwood & Clark Consultants
Still More Reasons… Sports players who use chewing tobacco Famous scientists
(Einstein is the prototype of intellectual smokers; he looks so proud with a pipe in his mouth)
Portrayals by cigarette advertisements As a kind of "air freshener" when using the
toilet
2009 Atwood & Clark Consultants
Reasons for Continuing
No particular reason, but the cigarettes are handy To reduce a feeling of anxiety or nervousness To calm down when upset or angry To socialize with other smokers When feeling restless As relaxation
2009 Atwood & Clark Consultants
Reasons for Continuing Cont’d.
To take a break from work While having coffee or tea When having a drink with friends To satisfy an urge to smoke After a meal
2009 Atwood & Clark Consultants
Reasons for Continuing Cont’d.
To pass the time while waiting for someone
When driving in the car When feeling depressed When drinking beer, wine, or liquor To celebrate something To think about a difficult problem
2009 Atwood & Clark Consultants
You Have Been Smoking for a While
Now you know that smoking has not made youSmarterCoolerSexier
Smoking has not helped you to achieve your goals You are more aware your health suffers
Burning eyesHacking coughPhlegm in your throat So…
2009 Atwood & Clark Consultants
Why Do You Still Smoke?
Out of habitPeople smoke under specific situations
as a kind of ritual Associating activities with smoking
establishes Pavlovian reflexes
2009 Atwood & Clark Consultants
Pavlovian Reflexes
Named after Dr. Ivan Pavlov who was able to make his dogs salivate in the absence of food by just ringing a bell that had been associated with the dog's feeding time
In the same way, activities you associated with smoking (drinking coffee) will act as triggers
The mere sight of a cup of coffee will cause you to reach for your cigarettes without any conscious thought
2009 Atwood & Clark Consultants
Triggers Seeing friends
smoking cigarettes Watching movies
where actors smoke Smell of cigarette
smoke may trigger the psychological desire to smoke
2009 Atwood & Clark Consultants
The Insular Researchers found smokers
with a damaged (due to stroke) insula, a region of the brain linked to emotion and feelings, quit smoking easily and immediately
Provides direct evidence that addiction to nicotine takes control of some of the neural circuits in the brain
2009 Atwood & Clark Consultants
Ventral Tegmental Area
Brain’s reward circuit are located along the medial forebrain bundle (MFB)
Brain’s punishment circuit (the periventricular system, or PVS) enables us to cope with unpleasant situations
Two major systems of motivation in humans
2009 Atwood & Clark Consultants
Ventral Tegmental Area Neurobiological foundations of addiction
traced to the VTA – “reward circuit” Reward system in the brain is activated when
a person performs an action necessary to survival, such as eating
Activation of the reward circuit provides pleasurable feelings, gives positive feedback
2009 Atwood & Clark Consultants
Ventral Tegmental Area Most abused drugs stimulate the reward system Provide greater pleasure than normally the result of
natural stimulation The reward system underlies addiction to tobacco Many drugs cause physical addiction by affecting
the levels of neurotransmitters, specifically dopamine and glutamate, in the reward circuit of the VTA
2009 Atwood & Clark Consultants
Epinephrine
Immediately after exposure to nicotine, there is a "kick" caused by stimulation of the adrenal glands and resulting discharge of epinephrine (adrenaline)
This stimulates the body causing a sudden release of glucose, and an increase in blood pressure, respiration, and heart rate
2009 Atwood & Clark Consultants
Norepinephrine
Nicotine also suppresses insulin output from the pancreas, which means smokers are always slightly hyperglycemic
Nicotine stimulates specific excitatory systems in the brain
These systems excite not only dopamine but a host of other brain chemicals, such as norepinephrine and serotonin
2009 Atwood & Clark Consultants
Acetylcholine Every nerve in your brain and nervous system
communicates with other cells by sending out tiny neurotransmitters (chemical messengers)
These are received by the receptors of the other cell Nicotine acts on the receptors that are normally used by
a main neurotransmitter called acetylcholine Essentially tricking your body into thinking the nicotine
is extra acetylcholine
2009 Atwood & Clark Consultants
AcetylcholineWhen you started smoking, your
body began responding to the nicotine thinking it was extra acetylcholine
2009 Atwood & Clark Consultants
AcetylcholineAs you continued to smoke, your body
began to adapt to this "extra" acetylcholine
How? By growing extra acetylcholine receptors!
This is the way that nicotine physically alters your brain function
2009 Atwood & Clark Consultants
Over the years, your body has become used to what it thinks is a normal level of acetylcholine
If you were to suddenly stop smoking, your body would react, thinking it was being deprived of this neurotransmitter
Seeking equilibrium, subconsciously your body tells you that you must get more acetylcholine
This is where the craving for nicotine comes from
Acetylcholine
2009 Atwood & Clark Consultants
After a day or two of not smoking, cells begin adapting again by decreasing the amount of acetylcholine receptors
Nicotine cravings begin to subside In fact, the physical addiction to nicotine
can be broken in a matter of days
Acetylcholine
2009 Atwood & Clark Consultants
So why is smoking considered so difficult to give up if nicotine addiction is gone in a few days?
Breaking the physical addiction to nicotine is actually half the battle
Acetylcholine
2009 Atwood & Clark Consultants
Treatment
Once the foundations ofunderstanding addiction have
been laid, the next obviousquestion is how to treat it.
2009 Atwood & Clark Consultants
1. Pre-contemplation: smoking isn't a problem
2. Contemplation: smoking has disadvantages, but I'm not yet ready to quit
3. Preparation: you want to quit and you prepare to quit
Seven Phases of Behavior Modification
2009 Atwood & Clark Consultants
Seven Phases of Behavior Modification
4. Action: you stop smoking 5. Maintenance: you are more
comfortable as a non-smoker 6. Termination: you are a non-smoker 7. Relapse: Back to Phase 2
2009 Atwood & Clark Consultants
B. F. Skinner
Behavior modification is based on the principles of operant conditioning
Developed by American behaviorist B. F. Skinner (1904-1990)
Formulated the concept of operant conditioning
2009 Atwood & Clark Consultants
B. F. Skinner
Behavior shaped by reinforcement or lack of it
Considered his concept applicable to a wide range of both human and animal behaviors
Introduced operant conditioning to the general public in his 1938 book, The Behavior of Organisms
2009 Atwood & Clark Consultants
Behavior Modification
Behavior modification is a treatment approach
Based on the principles of operant conditioning
Replaces undesirable behaviors with more desirable ones through positive or negative reinforcement
2009 Atwood & Clark Consultants
Behavior Modification Positive incentives Negative incentives/Aversive techniques Self-monitoring-keeping a “smoking diary” Step-wise decreasing of agent (nicotine) Stimulus control Contingency management-drawing up contract Coping skills Peer pressure
2009 Atwood & Clark Consultants
Successful Behavior Modification
The success of this approach/technique is dependent on the following environments:
PsychosocialEconomicalReligiousPolitical Educational
2009 Atwood & Clark Consultants
Positive Reinforcement Encourages certain behaviors through system of
rewards Draw up a contract with the client establishing
terms of the reward system Small rewards or recognition programs (t-shirt, pin,
certificate) Providing nicotine replacement products at no cost Reducing insurance premium differentials between
smokers and non-smokers
2009 Atwood & Clark Consultants
Additional Incentives Adding cash to a flexible spending account to
pay for enrolling in a tobacco cessation program
Joining program gets reward Anything economically and socially
acceptable Academic reward Different incentives at different stages
2009 Atwood & Clark Consultants
Negative ReinforcementAnother behavior modification technique
is negative reinforcementMethod of training that uses a negative
reinforcer
2009 Atwood & Clark Consultants
Negative ReinforcementCharging smokers higher insurance
premiumsNegative reinforcer is an event or
behavior whose reinforcing properties are associated with its removal
Example: terminating an existing electric shock after a rat presses a bar is a negative reinforcer.
2009 Atwood & Clark Consultants
Aversive/Punishment Use of electric shock as a punishing stimulus as is
done in the Schick program to eliminate smoking behavior has had limited success
In satiation treatment, subjects are required to increase the number of cigarettes smoked and the rate at which they are smoked
Rapid smoking requires the subject inhale from a cigarette once every six seconds for the duration of the cigarette or until nauseated
2009 Atwood & Clark Consultants
Punishment
In addition to rewarding desirable behavior, behavior modification can also discourage unwanted behavior through punishment
Punishment is the application of an aversive or unpleasant stimulus in reaction to a particular behavior
Penalties Financial fines Extreme -- +education
2009 Atwood & Clark Consultants
Extinction
The removal of reinforcement altogether is called extinction
Extinction eliminates the incentive for unwanted behavior by withholding the expected response
2009 Atwood & Clark Consultants
Thank YouThank You
2009 Atwood & Clark Consultants
Day 2: How To Quit
Ata Ulhaq, MD, FACEP, MPH
2009 Atwood & Clark Consultants
4 Key Factors
Making the decision to quit Setting a quit date and choosing a quit plan Dealing with withdrawal Staying quit (maintenance)
2009 Atwood & Clark Consultants
How Do People Change?
Decision only individual can make
2009 Atwood & Clark Consultants
Health Belief Model
More likely to stop if you:Believe you could get smoking related disease
and this worries youBelieve you can make an honest attemptBelieve the benefits of quitting outweigh the
benefits of continuingKnow someone who has had health problems
from smoking
American Cancer Society
2009 Atwood & Clark Consultants
Stages of Change
Pre-contemplation Contemplation Preparation Action Maintenance
American Cancer Society
2009 Atwood & Clark Consultants
Stages of ChangePrecontemplation
Contemplation
Preparation
Action
Maintenance TerminationRelapse
Don’t want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
American Cancer Society
2009 Atwood & Clark Consultants
Preparing to Quit
Pick a Quit Day, mark your calendar Plan for prescriptions (Zyban, Chantix) Tell friends and family about Quit Day
American Cancer Society
2009 Atwood & Clark Consultants
Preparing to Quit
Rid home, car and work of all ashtrays and cigarettes
Stock up on oral substitutes (gum, carrot sticks, hard candy, toothpicks)
Decide on a plan Set up support system (group, class, family,
friend)
American Cancer Society
2009 Atwood & Clark Consultants
On Quit Day
Do not smoke! Keep active Drink water, juices Nicotine replacement Attend class
Avoid situations that trigger urge to smoke
Reduce or avoid alcohol
Change your routine
American Cancer Society
2009 Atwood & Clark Consultants
Realizations
Definition: mistaken thought that makes sense at the time, but is not based on reality I’ll just have one Today is not good, I’ll quit tomorrow It’s my only vice How bad is it, really? Air pollution is probably just as bad
American Cancer Society
2009 Atwood & Clark Consultants
Avoid Temptation
Change your habits Alternatives: hard candy, coffee stirrer, etc. Activities: Exercise, needlework, woodworking Deep Breathing Delay: If you feel you are about to light up,
delay
American Cancer Society
2009 Atwood & Clark Consultants
Get Through Tough Times
Review reasons for quitting Think of benefits: health, finances, family There is no such thing as just one cigarette or
just one puff Ride out the desire Avoid drinking alcohol Avoid weight gain by staying active
American Cancer Society
2009 Atwood & Clark Consultants
Useful Tools
Beck’s Depression Inventory Family and Personal Development Rating
Scale (social history) These can help establish a percentage rating to
determine “State of Readiness”
Atwood and Clark Consultants
2009 Atwood & Clark Consultants
Freedom From Smoking
Highly structured comprehensive behavior modification approach to smoking cessation in a group support setting
American Lung Association
2009 Atwood & Clark Consultants
Freedom From Smoking
Based on premise that smoking is learned behavior
Seven session format provides tracking personal habits developing coping strategies supportive environment with others who are
experiencing the same feelings and challenges
American Lung Association
2009 Atwood & Clark Consultants
Thinking About Quitting
Session 1: Three-Link Chain of Addition. Physical,
mental and social aspects of addiction Benefits of Quitting. Physiological rewards Registration. Time to decide if ready Triggers and Coping. Prompts and effective
ways to change behaviors Medications. Present medications
American Lung Association
2009 Atwood & Clark Consultants
On the Road to Freedom
Session 2 Self-Management. Techniques to help
participants get past triggers Stress management. Discuss ways to
counteract harmful feeling of stress Assessing Nicotine Dependence. Learn about
personal nicotine addiction. Review medications that help smokers quit
American Lung Association
2009 Atwood & Clark Consultants
Wanting to Quit
Session 3 Increasing Motivation. Reinforce “whys”
behind quitting Social Support. Build a buddy system from
within the group Making a Quit Plan. Design a plan to help
succeed Relapse Prevention. Identify high-risk
situations
American Lung Association
2009 Atwood & Clark Consultants
Quit Day
Session 4 (Follow up with Session 5 within 48 hours) Panel of Ex-Smokers. Listen to other’s personal experiences with
quitting Quitting ceremony. A formal way to say goodbye to cigarettes Contracts and Rewards. Sign a 2-day contract not to smoke and
list rewards Recovery Symptoms. Explain the physical and psychological
symptoms of quitting smoking Overcoming Cravings. Special techniques to use when cravings
come
American Lung Association
2009 Atwood & Clark Consultants
Winning Strategies Session 5
48-Hour Report. Assess short-term coping skills The Grief Cycle. Understand the physiological recovery from
nicotine addition Benefits of Quitting. Discuss medical/non-medical benefits Coping Strategies. Review strategies for dealing with physical,
mental and social aspects of quitting Refining the Quit Plan. Fine tune the original plan Stress Management. More exercises to improve relaxation
American Lung Association
2009 Atwood & Clark Consultants
The New You
Session 6 Progress Review. Assess participants’ success to date. Lifestyle changes. Ways to encourage lifetime abstinence. Weight Management. Introduce ways to control weight. Staying Smoke-Free. Overview of program and tips on
long-term abstinence. Social Situations. Learn to handle risky social situations
carefully.
American Lung Association
2009 Atwood & Clark Consultants
Staying Off
Session 7 Physical Activity. A realistic approach to
physical activity. Changing Your Self-Image. Become a non-
smoker. Assertive Communication. Learn to
communicate in ways that help to handle stress.
American Lung Association
2009 Atwood & Clark Consultants
Celebration!
Session 8 Rewarding New Behaviors. Appreciate current
success. Relapse Prevention. Continue with techniques
that support not smoking. Challenge Your Thinking. Learn to think
differently. Completion Ceremony. Recognize and celebrate
completion of the program.
American Lung Association
2009 Atwood & Clark Consultants
Ultimate Goal – Complete Abstinence
Even in instances when complete abstinence from smoking is not achieved, smoking cessation pharmacotherapies may benefit individual health - and ultimately the public’s health if the smoker reduces the number of cigarettes smoked.
2009 Atwood & Clark Consultants
Ultimate Goal – Complete Abstinence
Relationship between cigarette smoking and lung cancer, and other smoking-associated malignancies, is strongly dose-dependent.
Individual smoker who is unable or not motivated to quit may benefit by using pharmacotherapies (or other means) to reduce the number of cigarettes smoked per day.
2009 Atwood & Clark Consultants
Pharmacological Adjuncts
Bupropion HCl is a non-nicotine aid to smoking cessation.
Relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine, and does not inhibit monoamine oxidase.
Exact mechanism by which bupropion HCl enhances ability of patients to abstain from smoking is unknown.
Presumed that this action is mediated by noradrenergic or dopaminergic mechanisms.
2009 Atwood & Clark Consultants
Theoretical Reasons Antidepressants Help
Two theoretical reasons to believe antidepressants might help in smoking cessation: Nicotine withdrawal may produce depressive symptoms or
precipitate a major depressive episode and antidepressants may relieve these.
Nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect.
2009 Atwood & Clark Consultants
More on Antidepressants
Alternatively, some antidepressants may have a specific effect on neural pathways underlying nicotine addiction, (e.g. blocking nicotine receptors) independent of their antidepressant effects.
2009 Atwood & Clark Consultants
Questions?
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How To Quit
Part 2
2009 Atwood & Clark Consultants
Find reasons to quit that are important to you. Think of more than just health reasons. For example, think of: How much money you'll save by not buying cigarettes The time you'll have for yourself instead of taking
cigarette breaks, rushing out to buy a pack, or searching for a light
Not being short of breath or coughing as much Setting a better example for your children
Smokefree.gov
2009 Atwood & Clark Consultants
Write Down Why You Want To Quit
List ways to fight the urge to smoke, too. (You will find tips for coping later in this guide.)
Keep your list where you'll see it often. Good places are: Where you keep your cigarettes In your wallet or purse In the kitchen In your car
Smokefree.gov
2009 Atwood & Clark Consultants
Reasons for Quitting
1. I will feel healthier right away. I will have more energy and better focus. My senses of smell and taste will be better. I will have whiter teeth and fresher breath. I will cough less and breathe better.
Smokefree.gov
2009 Atwood & Clark Consultants
Reasons for Quitting
2. I will be healthier the rest of my life. I will lower my risk for cancer, heart attacks, strokes,
early death, cataracts, and skin wrinkling.
3. I will make my partner, friends, family, kids, grandchildren, and coworkers proud of me.
4. My children will be healthier (fewer ear infections, coughs, and severe asthma attacks).
Smokefree.gov
2009 Atwood & Clark Consultants
Reasons for Quitting
5. I will be proud of myself. I will feel more in control of my life. I will be a better role model for my children.
6. I will have more money to spend. 7. I won't have to worry: "When will I get to
smoke next?" or "What do I do when I'm in a smoke-free place?"
Smokefree.gov
2009 Atwood & Clark Consultants
Overview of the Basic Steps
S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.
Smokefree.gov
2009 Atwood & Clark Consultants
Set a Quit Date
Think about choosing a special day: Your birthday or wedding anniversary New Year's Day Independence Day World No Tobacco Day (May 31) The Great American Smokeout (the third
Thursday of each November)
Smokefree.gov
2009 Atwood & Clark Consultants
Tell Others your Plan to Quit
Ask everyone to understand your change in mood Remind them that this won't last long (The worst
will be over within two weeks.) Tell them this: "The longer I go without cigarettes,
the sooner I'll be my old self." Does someone close to you smoke? Ask them to
quit with you, or at least not to smoke around you
Smokefree.gov
2009 Atwood & Clark Consultants
Tell Others your Plan to Quit
Do you take any medicines? Tell your doctor and pharmacist you are quitting.
Nicotine changes how some drugs work. You may need to change your prescriptions after you quit.
Smokefree.gov
2009 Atwood & Clark Consultants
Tell Others your Plan to Quit
Get support from other people. You can try talking with others one-on-one or in a group.
You can also get support on the phone. You can even try an Internet chat room. This
kind of support helps smokers quit. The more support you get, the better. But
even a little can help.
Smokefree.gov
2009 Atwood & Clark Consultants
Benefits of a Quit-smoking Program
Quit-smoking programs help smokers spot and cope with problems
The programs teach problem-solving and other coping skills
Can help you quit for good by: Helping you better understand why you smoke Teaching you how to handle withdrawal and stress Teaching you tips to help resist the urge to smoke
Smokefree.gov
2009 Atwood & Clark Consultants
Keep Busy
Keep very busy today. Go to a movie. Exercise. Take long walks. Go bike riding
Smokefree.gov
2009 Atwood & Clark Consultants
Keep Busy
Spend as much free time as you can where smoking isn't allowed (malls, libraries, museums, theaters, department stores, and places of worship)
Do you miss having a cigarette in your hand? Hold something else (a pencil, paper clip, marble)
Smokefree.gov
2009 Atwood & Clark Consultants
Stay Away from What Tempts You
Instead of smoking after meals, get up from the table.
Brush your teeth or go for a walk.
Smokefree.gov
2009 Atwood & Clark Consultants
Stay Away from What Tempts You
If you always smoke while driving, try something new: Listen to a new radio station or your favorite music. Take a different route. Or take the train or bus for a while, if you can.
Stay away from things that you connect with smoking. Do it today and for the next few weeks. These may include:
Watching your favorite TV show
Smokefree.gov
2009 Atwood & Clark Consultants
Stay Away from What Tempts You
Sitting in your favorite chair Having a drink before dinner Do things and go places where smoking is not
allowed. Keep this up until you're sure that you can stay smoke-free.
Remember, most people don't smoke. Try to be near nonsmokers if you must be somewhere you'll be tempted to smoke, for example at a party or in a bar.
Smokefree.gov
2009 Atwood & Clark Consultants
Remember the Instant Rewards of Quitting
Your body begins to heal within 20 minutes after your last cigarette
The poison gas and nicotine start to leave your body
Your pulse rate goes back to normal The oxygen in your blood rises to a normal
level
Smokefree.gov
2009 Atwood & Clark Consultants
Remember the Instant Rewards of Quitting
Within a few days you may notice other things: Your senses of taste and smell are better. You can breathe easier. Your "smoker's hack" starts to go away. (You
may keep coughing for a while, though.)
Smokefree.gov
2009 Atwood & Clark Consultants
Remember the Instant Rewards of Quitting
The nicotine leaves your body within three days. Your body starts to repair itself. At first, you may feel worse instead of better. Withdrawal feelings can be hard. But they are a sign that your body is healing.
Smokefree.gov
2009 Atwood & Clark Consultants
Long-term Rewards of Quitting
After you've quit, you've added healthy, full days to each year of your life
You've greatly lowered your risk of death from lung cancer and other diseases including: Heart disease Stroke Chronic bronchitis Emphysema At least 13 other kinds of cancer
Smokefree.gov
2009 Atwood & Clark Consultants
No matter how much or how long you’ve smoked, when you quit smoking, your risk of heart disease and stroke starts to drop.
In time your risk will be about the same as if you’d never smoked!
American Heart Association
2009 Atwood & Clark Consultants
Step One
List your reasons to quit and read them several times a day
Wrap your cigarette pack with paper and rubber bands
Each time you smoke, write down the time of day, how you feel, and how important that cigarette is to you on a scale of 1 to 5
Rewrap the pack
American Heart Association
2009 Atwood & Clark Consultants
Step Two
Keep reading your list of reasons and add to it if you can
Don’t carry matches, and keep your cigarettes out of easy reach
Each day, try to smoke fewer cigarettes, and try not to smoke the ones that aren’t most important.
American Heart Association
2009 Atwood & Clark Consultants
Step Three
Continue with Step Two Set a target date to quit Don’t buy a new pack until you
finish the one you’re smoking Try to stop for 48 hours at one time
American Heart Association
2009 Atwood & Clark Consultants
Step Four
Quit smoking completely Throw out all cigarettes and matches.
Hide lighters and ashtrays Stay busy! Go to the movies, exercise,
take long walks, go bike riding. Avoid situations and “triggers” you relate
with smoking Find healthy substitutes for smoking
American Heart Association
2009 Atwood & Clark Consultants
How Can Physical Activity Help?
Walking and other exercise releases stress and
calms you It can improve your mood It keeps your mind off cigarettes It can help control your appetite
American Heart Association
2009 Atwood & Clark Consultants
How Can Physical Activity Help With the
Stress? It can help you lose weight if you’re
overweight, or stay at a normal weight. It can lower your blood pressure level It can increase your “good” blood lipid level It can help reduce your risk of developing
heart disease and stroke It can help control blood sugar by
improving how your body uses insulin
American Heart Association
2009 Atwood & Clark Consultants
Questions?
2009 Atwood & Clark Consultants
How To Quit
Part 3
2009 Atwood & Clark Consultants
Nicotine Anonymous
12 Step Fellowship of men and women helping each other live nicotine-free lives
Welcomes all those seeking freedom from nicotine addiction, including those using cessation programs and nicotine withdrawal aids
Nicotine Anonymous
2009 Atwood & Clark Consultants
Nicotine Anonymous
Primary purpose is to help all those who would like to cease using tobacco and nicotine products in any form
Offers group support and recovery using the 12 Steps as adapted from Alcoholics Anonymous to achieve abstinence from nicotine
Nicotine Anonymous
2009 Atwood & Clark Consultants
Facing the Fatal Attraction
Smoking tobacco is the most common method of nicotine delivery
Worldwide 47.5% of men and 10.3% of women smoke a total of 6 trillion cigarettes a year (World Health Organization, 2008)
Nicotine Anonymous
2009 Atwood & Clark Consultants
Facing the Fatal Attraction
In 2000, 70% of U.S. adult smokers wanted to quit 41% stopped smoking for at least one day during
the preceding year in an effort to quit (Centers for Disease Control and Prevention)
Since 1965, more than 49% of all adults who have ever smoked have quit
Nicotine Anonymous
2009 Atwood & Clark Consultants
The Twelve Steps of Nicotine Anonymous
1. We admitted we were powerless over nicotine – that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
Nicotine Anonymous
2009 Atwood & Clark Consultants
The Twelve Steps of Nicotine Anonymous
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
Nicotine Anonymous
2009 Atwood & Clark Consultants
The Twelve Steps of Nicotine Anonymous
7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and
became willing to make amends to them all.9. Made direct amends to such people wherever
possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
Nicotine Anonymous
2009 Atwood & Clark Consultants
The Twelve Steps of Nicotine Anonymous
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to nicotine users and to practice these principles in all our affairs.
Nicotine Anonymous
2009 Atwood & Clark Consultants
Tips for Gaining Freedom
It's not as hard as you think Inform yourself about nicotine Understand that you do not need nicotine (it
is not nutritional)
Nicotine Anonymous
2009 Atwood & Clark Consultants
Tips for Gaining Freedom
Understand that addiction is a chemically compelled behavior
Make an honest appraisal of your nicotine use
Don't delay action toward stopping your use of nicotine because you think there are too many pressures in your life
Nicotine Anonymous
2009 Atwood & Clark Consultants
Treat yourself with love and respect rather then by placating yourself with rationalizations
Write down reasons why you want to be nicotine free rather than thinking about reasons why you "can't quit yet"
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Quit for yourself Look at quitting the use of nicotine as giving
yourself a precious gift Make things easier for yourself
Before quitting, plan your activities for the first few days of abstinence
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Consider quitting as a challenging adventure Imagine letting go of nicotine There is no perfect time to start preparing to
quit
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
If you are not going to quit right away, try cutting down
Don't minimize the truth or deny the risks even if you are not quitting today
Set a quit date Look at quitting as an investment.
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Quit nicotine one day at time and think only about the part of the day you are in
If you could have just one, you wouldn't have had the thousands of cigarettes you have smoked A pack a day for ten years is 73,000 cigarettes!
Think about letting go of nicotine as a "choice" rather than something you are doing to deprive yourself
Pray instead of puff
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
When you quit you may experience a sense of loss If you feel an urge to use nicotine think H.A.L.T.
Four basic triggers for using nicotine are when we are Hungry, Angry, Lonely and Tired
Feed your body with nutrition instead of nicotine Drink lots of liquids to help flush the poison out of
your system What and how much you eat is important when you
quit nicotine
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
When you first stop, don't be surprised if you find yourself feeling cranky, grumpy, crabby or downright angry
Take a second look before you react There are better companions than cigarettes Avoid becoming too tired
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Sometimes all we need is a distraction to shift our focus from a craving
Surround yourself with supportive positive people Ask for help from family, friends, and co-workers Plan activities that do not permit tobacco use Keep something handy for your hands
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Boredom is a signal to get busy Suck, bite, or chew Change your routine
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
Give yourself rewards, frequently Avoid the self-pity trap If you have a problem and then use nicotine,
you now have two problems Re-read all the Nicotine Anonymous
literature on a regular basis
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
All you have to do is not have the "next one" and you will avoid smoking thousands
Frequently notice how you are improving Maintain what you have gained If you want to smoke, use all the tools of the
program instead, and Keep Showing Up
Nicotine Anonymous
Tips for Gaining Freedom
2009 Atwood & Clark Consultants
hhs.gov
Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit
Effective treatments exist, however, that can significantly increase rates of long-term abstinence
It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting
2009 Atwood & Clark Consultants
Tobacco dependence treatments are effective across a broad range of populations
Clinicians should encourage every patient willing to make a quit attempt to use the recommended counseling treatments and medications in the Guideline
hhs.gov
2009 Atwood & Clark Consultants
Brief tobacco dependence treatment is effective
Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in the Guideline
hhs.gov
2009 Atwood & Clark Consultants
Individual, group and telephone counseling are effective and their effectiveness increases with treatment intensity
Two components of counseling are especially effective and clinicians should use these when counseling patients making a quit attempt:
Practical counseling (problem-solving/skills training) Social support delivered as part of treatment
hhs.gov
2009 Atwood & Clark Consultants
FDA Approved Medications
Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline
hhs.gov
2009 Atwood & Clark Consultants
Counseling and medication are effective when used by themselves for treating tobacco dependence
The combination of counseling and medication is more effective than either alone
Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication
hhs.gov
2009 Atwood & Clark Consultants
Telephone quitline counseling is effective with diverse populations and has broad reach
Clinicians and healthcare delivery systems should both ensure patient access to quitlines and promote quitline use
If a tobacco user is currently unwilling to make a quit attempt, clinicians should use the motivational treatments shown in the Guideline to be effective in increasing future quit attempts
hhs.gov
2009 Atwood & Clark Consultants
Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders
Providing coverage for these treatments increases quit rates
Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in the Guideline as covered benefits
hhs.gov
2009 Atwood & Clark Consultants
Questions?
2009 Atwood & Clark Consultants
How To Quit
Part 4
2009 Atwood & Clark Consultants
"5 A's" Model for Treating Tobacco Use and Dependence
1. Ask about tobacco usea) Identify and document tobacco use status of
every patient at every visit
2. Advise to quit a) In a clear, strong and personalized manner urge
every tobacco user to quit
Surgeon General
2009 Atwood & Clark Consultants
"5 A's" Model
3. Assessa) For current tobacco user, is the tobacco user
willing to make a quit attempt at this time?b) For the ex-tobacco user, how recent did you
quit and are there any challenges to remaining abstinent?
Surgeon General
2009 Atwood & Clark Consultants
"5 A's" Model
4. Assista) For the patient willing to make a quit attempt,
offer medication and provide or refer for counseling or additional behavioral treatment to help the patient quit
b) For patients unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts
c) For the recent quitter and any with remaining challenges, provide relapse prevention
Surgeon General
2009 Atwood & Clark Consultants
"5 A's" Model
5. Arrangea) All those receiving the previous A's should
receive follow up
Surgeon General
2009 Atwood & Clark Consultants
Advise—Strongly Urge All Tobacco Users to Quit
Action In a clear, strong, and personalized manner, urge
every tobacco user to quit Advice should be:
Clear—"I think it is important for you to quit smoking (or using chewing tobacco) now and I can help you."
"Cutting down while you are ill is not enough." “Occasional or light smoking is still dangerous.”
Surgeon General
2009 Atwood & Clark Consultants
Advice Should Be
Strong—"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future.
The clinic staff and I will help you."
Surgeon General
2009 Atwood & Clark Consultants
Advice Should Be
Personalized Tie tobacco use to current symptoms and health
concerns, and/or its social and economic costs. and/or the impact of tobacco use on children and
others in the household. “Continuing to smoke makes your asthma worse,
and quitting may dramatically improve your health.
Quitting smoking may reduce the number of ear infections your child has.”
Surgeon General
2009 Atwood & Clark Consultants
Public Health Service (PHS) Guideline
Ensure that all smokers are offered effective tobacco-use treatment at all clinical encounters.
Increase access to and participation in effective tobacco-use counseling.
Public Health Service
2009 Atwood & Clark Consultants
Public Health Service (PHS) Guideline
Increase access to and appropriate use of effective tobacco-treatment medications.
Reduce patient out-of-pocket costs for tobacco-use treatment.
Create a social and economic environment that promotes quitting
Public Health Service
2009 Atwood & Clark Consultants
Community Preventive Services
Increase the unit price for tobacco products
Implement sustained mass media campaigns
Public Health Service
2009 Atwood & Clark Consultants
Community Preventive Services
Implement provider reminder systems in health-care settings
Reduce patient out-of-pocket costs for tobacco-use treatment
Initiate multi-component interventions that include patient telephone
Public Health Service
2009 Atwood & Clark Consultants
CDC Goals
Mobilize health insurers, employers, and others to foster evidence-based tobacco-dependence coverage for all covered lives.
Mobilize health systems to implement system-level changes to foster effective utilization of tobacco-dependence treatments.
CDC
2009 Atwood & Clark Consultants
CDC Goals
Mobilize national quality assurance and accreditation organizations, clinicians, health systems, and others to establish and measure the treatment of tobacco dependence as part of the standard of care (www.cdc.gov/tobacco/ICHS).
CDC
2009 Atwood & Clark Consultants
CDC Goals
Mobilize communities to ensure that policies and programs are in place to increase demand for services and to ensure access to such services, especially for underserved populations (Fiore et al., 2004).
CDC
2009 Atwood & Clark Consultants
CDC Strategies
Health insurance that pays the full cost of smoking-cessation treatments can increase quit rates compared to benefit plans that only partially cover cessation treatment or that offer no cessation benefits
Programs to stop smoking delivered during hospitalization that include a 1-month follow-up are most effective
CDC
2009 Atwood & Clark Consultants
CDC Strategies
Proactive telephone counseling can be effective compared to an intervention without personal contact
Successful interventions generally involve multiple contacts timed around a quit attempt
CDC
2009 Atwood & Clark Consultants
CDC Strategies
All of the commercially available forms of nicotine replacement therapy (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/ lozenges) are effective as part of a strategy to promote smoking cessation
Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small
CDC
2009 Atwood & Clark Consultants
Negative Incentives
Focus on the failure of an individual to adopt a desired behavior
Discipline the individual by withdrawing the reward
Believing this will encourage adoption of the desired behavior
2009 Atwood & Clark Consultants
Negative Incentives
The 192 members of WHO unanimously adopted the Framework Convention on Tobacco Control (FCTC)
Aimed at curbing tobacco-related deaths and disease
2009 Atwood & Clark Consultants
WHO Negative Incentives
requires countries to impose restrictions on: tobacco advertising sponsorship and promotion establish new labeling clean indoor air controls strengthen legislation to clamp down on tobacco
smuggling
2009 Atwood & Clark Consultants
Negative Incentives
Taiwan doubled the surcharge on cigarettes to discourage smoking
US: on April 1, 2009, the tax on cigarettes rose from 39 cents to $1.01 per pack
2009 Atwood & Clark Consultants
Negative Incentives
Chile bans smoking in schools, hospitals, government offices, shopping centers, supermarkets, pharmacies, airports, buses, subway networks and other indoor public places. Smoking in universities indoors is banned, however, smoking is allowed outdoors.
2009 Atwood & Clark Consultants
Negative Incentives
Croatian Parliament passed legislation prohibiting smoking in public institutions such as hospitals, clinics, schools and universities with infractions punishable with up to 1000 kuna (140 euros).
A notable exception in the Act are psychiatric wards in Croatia's hospitals.
2009 Atwood & Clark Consultants
On the Flip Side…
The Gong’an County government of Hubei province found itself at the center of public outrage
Demanded local officials to consume up to 23,000 packs of locally produced cigarettes annually, worth 4 million yuan, using public money
Each office under its jurisdiction received a quota and would face a fine if they failed to meet the target, or if found buying cigarettes produced by other provinces
2009 Atwood & Clark Consultants
Of Interest…
www.stickK.com take out a
“commitment contract” By doing so, you
essentially put your money where your mouth is
2009 Atwood & Clark Consultants
More on StickK.com
You commit yourself to quit smoking within a month
If at the end of the month, you’re still smoking, Stickk will keep the money you deposited
To make it even more interesting, whenever you fail, they have the option of giving your money away to a cause (or person) you really hate.
2009 Atwood & Clark Consultants
Put Your Money Where Your Butt Is
CARES (Committed Action to Reduce and End Smoking) is a commitment savings program
Smokers who wish to quit smoking are encouraged to deposit an increasing percentage of the money they ordinarily spend on cigarettes into their CARES accounts for six months
2009 Atwood & Clark Consultants
Put Your Money Where Your Butt Is
Deposits are collected every week by field staff who motivate clients to continue reducing smoking behavior
The client cannot withdraw any money during the deposit period
2009 Atwood & Clark Consultants
Put Your Money Where Your Butt Is
The balance is what is at stake if the client should fail to quit
At the end of six months, the client submits to a urine test to confirm smoking cessation
Only by passing the test can s/he access the money in the CARES account
Otherwise, the account is closed and the money donated to a charity
2009 Atwood & Clark Consultants
Positive Incentives
Providing smokers with financial incentives to stop smoking increases enrollment in smoking-cessation programs
Cessation efforts using monetary incentives have had yielded increased success in abstinence
Receive incentives or prizes for “good” behavior – in this case, not smoking
2009 Atwood & Clark Consultants
Example of Positive Incentive Program
Individuals given chance to win prizes if their breath and urine samples test negative for cigarette smoking.
The number of draws from a prize bowl increases as long as the participant continues to test negative over the 24-week study
2009 Atwood & Clark Consultants
Positive Incentive Program
The prize bowl contains about 500 cards, half of which are winning cards.
Prizes range from small toiletries, snacks, or coffee shop gift certificates, to tool kits, compact disc players, and prepaid telephone cards.
One card in the prize bowl offers a $100 prize such as a DVD player, a television, or a stereo.
The cards are replaced after each drawing so the probabilities remain constant.
2009 Atwood & Clark Consultants
Questions?
2009 Atwood & Clark Consultants
Day 3: Proposed Program
Ata Ulhaq, MD, FACEP, MPH
2009 Atwood & Clark Consultants
3 Year Program
Phase 1: Year 1 University can become flag bearer/pioneer in
beginning a program for other universities, cities and the entire country
Program for students, faculty, contractors (anyone who is on property)
Positive reinforcement with help and rewards
2009 Atwood & Clark Consultants
Phase 1: Year 1 Four week program open for 3 years and beyond Specific brochure/booklet for new students
advising them of smoke free plan Heavy promotion should be done
3 Year Program
2009 Atwood & Clark Consultants
Government Involvement
Support encouraged by governmental organizations
Involvement in public awareness Radio ads TV ads Billboards Public service announcements
2009 Atwood & Clark Consultants
University Involvement
Signs on campus College radio station Publication Full support of student body/student union Visible student involvement
Joining and supporting – not just talk Actively involved on an individual basis
2009 Atwood & Clark Consultants
3 Year Program
Phase 1: Year 1 Funding from University, government, other agencies Support by faculty, student union/student body, all
involved in campus Step wise reduction/cessation Set up restricted smoking areas New students are advised that in three years, campus will
be totally smoke-free Smokers are strongly advised to join program
2009 Atwood & Clark Consultants
3 Year Program
Phase 2: Year 2 Continue 1st year program Controlled, organized continuation of 4-week
program Mostly negative incentives Demand smoking to restricted smoking areas
only
2009 Atwood & Clark Consultants
3 Year Program
Phase 2: Year 2 If found smoking in other than designated areas,
impose fines Monetary, temporary privileges
At the end of Phase 2, remove restricted areas Anonymous reporting system for non-
compliance comprised of student body (optional)
2009 Atwood & Clark Consultants
3 Year Program
Phase 3: Year 3 Continuation of Phases 1 and 2 No smoking Increased negative incentives Increased penalties (monetary) Prospective students who are smokers must join
Program before enrolling in University Students are required to join program for non-
compliance
2009 Atwood & Clark Consultants
Phase 3: Year 3 Expulsion/no admittance for smokers Anonymous reporting system for non-
compliance comprised of student body (optional) In class, student union, dormitories, etc.
If penalties are not paid, registration for next semester could be withheld
Once penalized, they must join 4-week program
3 Year Program
2009 Atwood & Clark Consultants
Faculty follows same rules and regulations as student body
Separate session for faculty Faculty offered the 4-week program
3 Year Program
2009 Atwood & Clark Consultants
Penalties vary Increased monetary value for faculty (double that
of students) Possibly more for repeat offense of non-
compliance Reporting of non-compliance by faculty and
students Once penalized, they must join 4-week program
3 Year Program
2009 Atwood & Clark Consultants
Contractors Follows same regulations Worst penalty – they can lose their contract Can they join the program?
Separate session for contractors onlyContractors must pay fee to join programOnce penalized, they must join 4-week program
3 Year Program
2009 Atwood & Clark Consultants
Year 1: Phase 1
Beginning program kickoff Supportive of individuals who want to quit
2009 Atwood & Clark Consultants
Kickoff
Set day in advance and build up towards it Well publicized and well known When big day arrives, make it a big event! Celebration!
2009 Atwood & Clark Consultants
Principle
“A Healthy Body Resides
a Healthy Mind”
2009 Atwood & Clark Consultants
Before Beginning
Registration Screening to determine motivation
What made them come? Based on motivation, grade is given
+ 75% will succeed in quitting (if life value involvement is present/doing it for their
children) + - 50% possibility of quitting - 75% will not quit
2009 Atwood & Clark Consultants
Who Gets + 75%?
Those who have life value involvement
Who gets + - 50%? Those you are not sure of
Who gets – 75%? Those who do not have life value involvement or
are doing it for someone other than themselves
2009 Atwood & Clark Consultants
Life Value Involvement
Belief you could get smoking related disease and this worries you
Someone close who has had health problems from smoking; cancer
Loved one diedHeart attack (self or loved one)
2009 Atwood & Clark Consultants
Life Value Involvement
Belief and motivation that is self-centered/tragic experience = more likely to quit
2009 Atwood & Clark Consultants
Screening
Physical screening + - (optional) Determine underlying medical condition Individual who has coughed blood Other bleeding (hematuria, melena or
hematochezia, hematemesis) Weight loss/unable to gain weight – weakness These should be referred for further evaluation
2009 Atwood & Clark Consultants
Depression
Depression is associated with an increased frequency of smoking
Addicted smokers are characterized by: preoccupation with smoking abnormal attachment to cigarettes anticipation of brain reward
Attempts to quit smoking often lead to a decreased level of pleasure and undesirable mood swings
2009 Atwood & Clark Consultants
Created by Dr. Aaron T. Beck 21-question multiple-choice self-report
inventory One of the most widely used instruments for
measuring the severity of depression
Beck’s Depression Inventory
2009 Atwood & Clark Consultants
Individuals with underlying or current depressive symptoms are more likely to experience mood disturbances when they attempt to quit
Smoking may mask an underlying depression in some smokers
Smoking, therefore, may be a way for depressed individuals to self-medicate depressive symptoms
Reason for Beck’s?
2009 Atwood & Clark Consultants
Consequently, healthcare professionals who offer smoking cessation programs should offer depression screening
Should be prepared to address underlying mood disorders as part of a comprehensive smoking cessation program
Reason for Beck’s?
2009 Atwood & Clark Consultants
Beck’s Depression Inventory
1. SADNESS (feeling or showing sorrow; unhappy; causing or characterized by sorrow or regret; unfortunate and regrettable)
0 I do not feel sad. 1 I feel sad much of the time. 2 I'm sad all the time. 3 I'm so sad and unhappy that I can't sand it.
2009 Atwood & Clark Consultants
BDI
2. PESSIMISM0 I'm not discouraged about my future. 1 I feel more discouraged about my future than I
used to be. 2 I do not expect things to work out for me. 3 I feel my future is hopeless and will only get
worse.
2009 Atwood & Clark Consultants
BDI
3. PAST FAILURE 0 I do not feel like a failure. 1 I have failed more than I should have. 2 As I look back, I see a lot of failures. 3 I feel I am a total failure as a person.
2009 Atwood & Clark Consultants
BDI
4. LOSS OF PLEASURE 0 I get as much pleasure as I ever did from the
things I enjoy. 1 I don't enjoy things as much as I used to. 2 I get very little pleasure from the things I used
to enjoy it.3 I can't get any pleasure from the things I used
to enjoy.
2009 Atwood & Clark Consultants
BDI
5. GUILTY FEELINGS 0 I don't feel particularly guilty. 1 I feel guilty over many things I have done or
should have done.2 I feel quite guilty most of the time. 3 I feel guilty all of the time.
2009 Atwood & Clark Consultants
BDI
6. PUNISHMENT FEELINGS 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished.
2009 Atwood & Clark Consultants
BDI
7. SELF-DISLIKE 0 I feel the same about myself as ever. 1 I have lost confidence in myself. 2 I am disappointed in myself. 3 I dislike myself.
2009 Atwood & Clark Consultants
BDI
8. SELF-CRITICALNESS 0 I don't criticize or blame myself more than
usual. 1 I am more critical of myself than I used to be. 2 I criticize myself for all of my faults. 3 I blame myself for everything bad that
happens.
2009 Atwood & Clark Consultants
BDI
9. SUICIDAL THOUGHTS OR WISHES 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would
not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance.
2009 Atwood & Clark Consultants
BDI
10. CRYING 0 I don't cry anymore than I used to. 1 I cry more than I used to. 2 I cry over every little things. 3 I feel like crying, but I can't.
2009 Atwood & Clark Consultants
BDI
11. AGITATION(a stirring up or arousing; disturbance of tranquility; disturbance of mind which shows itself by physical excitement)
0 I am no more restless or wound up than usual. 1 I feel more restless or wound up than usual. 2 I am so restless or agitated that it's hard to stay still. 3 I am so restless or agitated that I have to keep moving
or doing something.
2009 Atwood & Clark Consultants
BDI
12. LOSS OF INTEREST 0 I have not lost interest in other people or
activities. 1 I am less interested in other people or things
than before. 2 I have lost most of my interest in other people
or things. 3 It's hard to get interested in anything.
2009 Atwood & Clark Consultants
BDI
13. INDECISIVENESS(not having or showing the ability to make decisions quickly and effectively)
0 I make decisions about as well as ever. 1 I find it more difficult to make decisions than usual. 2 I have much greater difficulty making decisions than I
used to. 3 I have trouble making any decisions.
2009 Atwood & Clark Consultants
BDI
14. WORTHLESSNESS(having no real value or use; having no good qualities; deserving contempt)
0 I do not feel I am worthless. 1 I don't consider myself as worthwhile and useful as I
used to. 2 I feel more worthless as compared to other people. 3 I feel utterly worthless.
2009 Atwood & Clark Consultants
BDI
15. LOSS OF ENERGY 0 I have as much energy as ever. 1 I have less energy than I used to have. 2 I don't have enough energy to do very much. 3 I don't have enough energy to do anything.
2009 Atwood & Clark Consultants
BDI
16. CHANGES IN SLEEPING PATTERN(Changes in either direction are important. Thus tick the appropriate answer either less or more do you sleep.)
0 I have not experienced any change in my sleeping pattern.
1 I sleep somewhat more OR less than usual. 2 I sleep a lot more OR less than usual.3 I sleep most the day. OR I wake up 1-2 hours early and
can't get back to sleep.
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BDI
17. IRRITABLITY(having or showing a tendency to be easily annoyed or made angry)
0 I am no more irritable than usual. 1 I am more irritable than usual.2 I am much more irritable than usual.3 I am irritable all the time.
2009 Atwood & Clark Consultants
BDI
18. CHANGES IN APPETITE(Changes in either direction are important. Thus tick the appropriate answer either less or more do you eat.)
0 I have not experienced any change in my appetite. 1 My appetite is somewhat less than usual. OR My
appetite is somewhat greater than usual.2 My appetite is much less than usual. OR My appetite is
much greater than usual.3 I have no appetite at all. OR I crave food all the time.
2009 Atwood & Clark Consultants
BDI
19. CONCENTRATION DIFFICULTY(the action or power of focusing one's attention or mental effort)
0 I can concentrate as well as ever. 1 I can't concentrate as well as usual. 2 It's hard to keep my mind on anything for long. 3 I find I can't concentrate on anything.
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BDI
20. TIREDNESS OR FATIGUE 0 I am no more tired or fatigued than usual. 1 I am more tired or fatigued more easily than
usual.2 I am too tired or fatigued to do a lot of things I
used to to do.3 I am too tired or fatigued to do most of the
things I used to to do.
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BDI
21. LOSS OF INTEREST IN RELATIONSHIPS
0 I have not noticed any recent change in my interest in relationships.
1 I am less interested in relationships than I used to be.
2 I am much less interested in relationships now.3 I have lost interest in relationships completely.
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Scoring of Beck’s Depression Inventory
Total score of 0-13 is considered minimal range
14-19 is mild 20-28 is moderate 29-63 is severe
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Treatment for Smoking Addiction and Depression
New medicine treatment for smoking addiction that is also an effective antidepressant Bupropion, (Zyban) is a safe and effective Non-nicotine treatment Lessens withdrawal symptoms Prevents weight gain Improves mood in most patients Before Zyban™ was approved for smoking cessation, it
was, and remains, an effective and commonly prescribed antidepressant sold under the trade name Wellbutrin™.
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Other Treatments
Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline
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Makes Sense
The Author notes that if no depression is present, it is reasonable to treat nicotine with nicotine Nicotine patch Gum Inhalant
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Proposed Program
Smokefree.gov American Heart Association American Lung Society
Organized 4-week program
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Overview of the Basic Steps
S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.
Smokefree.gov
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Products to Help
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Week 1
Facilitator will help by presenting ill effects of cigarette smoking
Program should run 2-3 hours for week 1 Have support group in place
Female support for females/male support for males
Write down list of reasons for quitting on an index card
Make several (you can even laminate)
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List of Reasons
Put these lists in places where you frequently smoke Car, purse, wallet, office, fridge Tuck one in your books as a bookmark Wrap one around your cigarette pack with a
rubber band
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Rewards
Reward yourself at the end of each nonsmoking week
Write reward on back of list of reasons to quit Doesn’t have to be expensive
Homemade meal Hot bath
When the urge comes, look at both sides of the card Isn’t it worth coping for 3 minutes?
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When the Urge to Smoke Arises
Remind yourself of why you quit by reading the list!
Place a sticker on the back for each time you resist
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Week 2
Set a quit day Talk to your doctor/obtain prescription Tell family, friends, co-workers Anticipate changes Remove cigarettes, ashtrays, etc.
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Week 2 Plans Have Alternate Plans in Case You are Tempted
Get away from dinner table
Go for a walk Exercise Call a friend Listen to music or talk
radio in the car
Wash the car Knit a scarf Garden Read a book Take up a new hobby Brush/floss your teeth
Anything to avoid smoking!
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Week 2 Plans
Be Prepared for Your Urges! In most cases, something triggers the craving
Certain feelings People Places
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Be Prepared for Your Urges! Divide a blank piece of paper into 2 columns On one side list “triggers”
Stuck in traffic Morning coffee Arguing with colleague
In column 2 write alternative course of action
Week 2 Plans
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Week 2 PlansAlternative Course of Action
Trigger Morning coffee
Heated argument
Action Read morning paper
Walk around the blockor
Write down everything you think about this person and then tear it up and throw it away(this works!)
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Triggers and Alternatives
If riding in the car, make your car an unfriendly place to smoke Clean it out Empty and scrub the ashtrays and the glove
compartment
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Triggers and Alternatives
Do you find yourself wanting a cigarette right after eating? Get busy immediately after your meal Get up and clear the table Do the dishes/pack up the leftovers
Often just getting through the first few minutes is all you need
Just delay that urge
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Week 2 Plans: Distract Yourself
With a quick task (5-10 minutes) Make a call Send a fax Pour yourself a cup of coffee Water a plant Anything! Hint: Find something that makes smoking
impossible
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Week 2 Plans:Remember…
S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.
2009 Atwood & Clark Consultants
Week 3 A
Quit day! Keep busy! Utilize support group already in place Remember coping mechanisms
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Week 3 A
Remember list, read and re-read Do things that make you happy Get involved in other activities Keep away from people, places, things that
remind you of smoking
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Author’s Note
Plan to quit at least one day before using any drugs or nicotine aids
Drugs or nicotine aids more effective when used in this manner
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Week 3 B
Two days after quit day: This is most difficult time Bring individual in again to reinforce Should be seen a total of 5 times See how they are tolerating things Check their list for dots indicating they resisted
the urge to smoke
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Week 4
Successfully complete one week smoke free Re-evaluate support group’s efforts Support group to involve facilitator
Female support for females/male support for males
Not more than 20 people for each facilitator
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Week 4
Compliment and encourage each other Group to be available 24/7 by phone Female support for females/male support for
males Meet weekly for two months
Once monthly thereafter Support as long as individuals desire Open for alumni as well
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Phase 2: Year 2
Ongoing 4-week program Restricted areas are now removed Fines are imposed on smokers
Monetary Other privileges temporarily withheld
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Phase 3: Year 3
Penalties/fines increase Program readily available Increased negative incentives Prospective students who are smokers must
join Program before enrolling in University Expulsion/no admittance for smokers
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Questions? Comments?
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Day 4: Open Forum
Participants will join for an open forum and discussion concerning modification of the proposed program or accepting it as such for the University.
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Day 5: Formulation of a Program for The University
Participants will unite to give their blessing to the accepted program for the University
University now becomes the flag bearer/pioneer in beginning a program for other universities, cities and the entire country
2009 Atwood & Clark Consultants
Thank YouThank You
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