Brief Intervention for Smoking Cessation
National Training Programme
National Tobacco Control Office
Health Service Executive Oak House, Millennium Park
Naas, Co. Kildare
Telephone: 045 880400 www.hse.ie
PART
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The development of an accredited National Training Programme is one of the key priorities of the HSE cross service group responsible for implementation of the HSE’s Tobacco Control Framework. The course is recognised for CPD by The Irish College of General Practitioners (5.5 CPD credits and 2 GMS study leave sessions for registered doctors) and has been awarded Category 1 Approval from An Bord Altranais (6 CEUs for registered nurses and midwives). This resource was delivered in collaboration between Health Promotion, the Irish Health Promoting Health Services’ Network and the National Tobacco Control Office.
Available online at www.hse.ie/bitobacco.
September 2012
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCETable of Contents
1. Introduction 2
2. Understanding Tobacco Use 4
What’sInaCigarette? 4
What’sinCigaretteSmoke? 4
WhyDoPeopleSmoke? 5
TheStoryofSmoking 7
TobaccoQuiz 8
3. Brief Intervention for Smoking Cessation 11
FrameworkforBriefInterventionforSmokingCessation–The5As 12
4. Stages of Change 13
Prochaska&DiClemente’sCycleofChange 13
5. Effecting Change 15
ClientCentredApproach 15
MotivationalInterviewing 15
ResponsesforChallengingStatements 18
6. Tools and Techniques to Support Quitting 20
Top10TipsforSuccessfulQuitting 20
WithdrawalSymptoms 22
MedicationsfortheTreatmentofTobaccoDependence 24
ComparisonofNicotineDeliveryDevices 28
DrugInteractionswithSmoking 29
7. Benefits of Quitting 31
8. Bibliography 32
Appendices
WHOCodeofPracticeonTobaccoControl 35
TFUCharter 36
FiveKeyToolsforSuccessfulInterventions 37
UsefulResources 42
TableofContents
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Intr
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ThisresourcehasbeendevelopedaspartoftheHSEBriefInterventionforSmokingCessationNationalTrainingProgramme.Itisapracticalguidetosupportprofessionalswhohaveundertakenthetrainingprogrammeandwillassistinintegratingbriefinterventionsintodailypractice.
Theresource(www.hse.ie/bitobacco)includesinformationandreferencematerialsonthekeytopicspresentedduringthecourseincluding:
• latesttobaccostatisticsforIreland
• smokingbehaviourandaddiction
• 5AsFrameworkforBriefInterventionforSmokingCessation
• Prochaska&DiClemente’sstagesofchangemodel
• motivationalapproachwhenraisingtheissueofsmoking
• OARS:communicationsforeffectiveinterventions
• toolsandsupportstohelpsmokersquit.
Tobacco or Health
Smokingplacesanenormousburdenofillnessandmortalityonoursociety.Itaffectsthealmost1millionpeoplewhosmokeinIreland,andtheirfamilies,whilecreatinganenormouscostforourhealthserviceeachyear.
1inevery2smokerswilldiefromatobaccorelateddisease,andmostsmokerslosebetween10to15qualitylifeyears.Tobaccouseisthesinglebiggestcauseofcancerandchronicrespiratorydiseasesandisasignificantcauseofcardiovasculardisease.Thismajorcauseofdeath,illness,chronicdisabilityandinequalityispreventable,yetaccountsforsome5,500deathsinIrelandeachyear.
DepartmentofHealthestimatesthattobaccousecoststheexchequersomewhereintheregionof€1-2bnperannum.Arecentstudyofhospitaldischargesshowsthatsmokingrelateddiseasesaccountedfor3.7%oftotaldischarges,butaccountedfor9.4%oftotalcosts,totalling€280min2008.ThesecostsdonottakeaccountofthecostsforOPD,GP,communitybasedservicesandsocialservicesfromsmoking.Thestudyalsohighlightedthatdespitea25%declineinoverallmortalityrates(fromallcausesofdeath)inIrelandfromtheyear2000,thedeclineindeathsattributabletotobaccoisonly10%.
Reducingthenumberofsmokersinoursocietyisthesinglemostsignificantstepthatcanbetakentoimprovepopulationhealthandreducepressureonthehealthsystem–thisrequiresasustainedmulti-facetedapproach.
In2010,theHSEadoptedtheTobaccoControlFrameworktoinformHSEpolicyandprovideacoherentresponsetotobaccouseinIreland.AnumberofactionsfromtheFrameworkareprioritisedintheHSE’sNationalServicePlans,includingtrainingallhealthcareworkerstohavethenecessaryskillstoaddresssmokingasacareissue.Healthcareprofessionalsareideallyplacedtoraisetheissueofsmokingwithserviceusers–andwiththerightmixofknowledge,skillsandattitudecanreally“makeeverycontactcount”byencouragingandsupportingsmokerstoquit.
1. Introduction
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEIntroduction
Brief Interventions
BriefInterventionsarearangeofeffectivebehaviourchangeinterventionsthatareclient-centred,shortindurationandusedinavarietyofsettingsbyhealthandotherprofessionals.Theyuseanempathicapproach,emphasisingselfefficacy,personalresponsibilityforchange,informationgivinganddetailsofresourcesavailabletosupportchange.
Forsmokingcessation,briefinterventionsinvolveopportunisticadvice,discussion,negotiationandencouragementthattypicallytakebetween5and10minutes.Theinterventionmayinvolvereferraltoamoreintensivetreatmentifappropriate.Interventionsshouldberecordedandfollowedupasappropriate.
BriefInterventionsforsmokingcessationaremoresuccessfulwhenusedwithclientswho:
• areunlikelytoneed/seekorattendspecialisttreatment
• areunsure/ambivalentaboutquitting
• mayrequireaccesstootherappropriateservices.
Framework for Brief Intervention for Smoking Cessation
The5AsThefivecomponentsoftheFrameworkare:
1. Ask: systematicallyidentifyallsmokersateveryvisit.Recordsmokingstatus,no.ofcigarettessmokedperday/weekandyearstartedsmoking.
2. Advise: urgeallsmokerstoquit.Adviceshouldbeclearandpersonalised.
3. Assess: determinewillingnessandconfidencetomakeaquitattempt;notethestageofchange.
4. Assist: aidthesmokerinquitting.Providebehaviouralsupport.Recommend/prescribepharmacologicalaids.Ifnotreadytoquitpromotemotivationforfutureattempt.
5. Arrange: follow-upappointmentwithin1weekorifappropriaterefertospecialistcessationserviceforintensivesupport.Documenttheintervention.
AdaptedfromFioreMC,JaénCR,BakerTB,etal.TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.April2009.
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What’s in a Cigarette?
Acigaretteisaveryefficientandhighlyengineereddrug-deliverysystem.Theprimaryingredientincigarettesistobacco(includingreconstitutedtobaccoandgeneticallymodifiedtobacco)towhichhundredsofchemicaladditivesareintroducedduringthemanufacturingprocess.600differentaddictivesarecurrentlyapprovedforuseinthemanufactureofcigarettesandtheseincludehumectants(moisturisers)toprolongshelflife,sugarstomakethesmokeseemmilderandeasiertoinhale;andflavouringssuchaschocolate,cinnamonandvanilla.Whilesomeadditivesmayappearquiteharmless,othersaretoxicoraddictiveintheirownright,orincombination.Whenadditivesareburned,newproductsareformedandthesetoomaybetoxicorpharmacologicallyactive.
What’s in Cigarette Smoke?
Tobaccosmokeismadeupofsidestreamsmokefromtheburningtipofthecigaretteandmainstreamsmokethatisinhaledbythesmoker.Manytoxinsarepresentinhigherconcentrationsinsidestreamsmokethaninmainstreamsmokeduetothelowertemperatureatwhichthecigaretteburnswhennotbeingsmoked.
Cigarettesmokecontainsmorethan7,000chemicalsandcompoundswhicharereleasedintotheairasparticlesandgases.Hundredsaretoxicandatleast69causecancer.Tobaccosmokeisaknownhumancarcinogen.Thechemicalsintobaccosmokereachthelungsveryquicklywhenasmokerinhales,andthengoquicklyfromthelungsintothebloodwhichcarriesthesechemicalstotissuesallaroundthebody.
Theparticulatephaseincludesnicotine,tar,benzeneandbenzo(a)pyrene.Thegasphaseincludescarbonmonoxide,ammonia,dimethylnitrosamine,formaldehydeandhydrogencyanide.
Nicotineisadeadlypoison–asmallamountinjectedintotheblood-streamcankillapersoninlessthananhour.Tobaccosmokecontainsverytinyamountsofnicotineandinthedosesobtainedfromsmokedtobaccoisnotasignificantcontributortodisease.Itishoweverhighlyaddictive–accordingtotheWHOitismoreaddictivethanheroinandcocaine.
Nicotineisastimulantwhichaffectsmanybodysystems,includingthebrain,theheartandthenervoussystem.Nicotineisabsorbedbythebodyveryquickly,reachingthebrainwithin10-20seconds.Itactivatestherewardpathwaysinthebrainandincreaseslevelsofdopamineintherewardcircuits,creatingfeelingsofpleasureforthesmoker.Theacuteeffectsofnicotineandthefeelingsofrewarddonotlastmorethanafewminutes.Asnicotinelevelsfallinthebody,smokersfeelanurgentdesiretosmoke(atintervalsof20-45minutesdependingonconsumptionrates)inordertorestorethesepleasurablefeelingsandavoidwithdrawal.
Chronicexposuretonicotinecausesstructuralchangesinthebrainbydesensitisingnicotinereceptorsandincreasingthenumberofnicotinicreceptorsthusincreasingtheurgeforthenextcigaretteandresultinginaddiction.
Nicotineincreasestheheartrateandbloodpressure,leadingtotheheartneedingmoreoxygen.
Tar isthecollectionofsolidparticlesthatsmokersinhalewhentheylightacigarette.Itisamixtureoflotsofchemicals,manyofwhichcausecancer.Tarcanstainsmokers’fingersandteethanditgathersinthelungsasastickybrownsubstanceincreasingasmoker’sriskoflungcancer,emphysema,andbronchialdisorders.
Carbon Monoxide isacolourlessgaswithnosmellwhichisreleasedfromburningtobaccoandstickstoredbloodcellsinplaceofoxygen.Thislowerstheblood’sabilitytocarryoxygenaroundthebodytovitaltissuesandorganssuchastheheartandbrain.Carbonmonoxidealsokillscilia(hairsliningthelungs)andreducesthelungs’abilitytocleartoxinsmakingiteasierforotherchemicalstoattackthem.Upto15%ofasmoker’sbloodcanbecarryingcarbonmonoxideinsteadofoxygen.
2. UnderstandingTobaccoUse
Cancer-causing Chemicals
Toxic Metals
Poison Gases
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEU
nderstanding Tobacco Use
Why Do People Smoke?
Tobaccouseisacomplexbehaviourinfluencedbyarangeofphysiological,behaviouralandcognitivefactorswhichiswhypeoplecontinuetosmoke,despitewidelypublicisedevidenceofthehealth,socialandfinancialburdenitcauses.
Physical addiction
TheWHOdefinesaddictionas‘repeateduseofapsychoactivesubstanceorsubstances,totheextentthattheuser(referredtoasanaddict)isperiodicallyorchronicallyintoxicated,showsacompulsiontotakethepreferredsubstance(orsubstances),hasgreatdifficultyinvoluntarilyceasingormodifyingsubstanceuse,andexhibitsdeterminationtoobtainpsychoactivesubstancesbyalmostanymeans’.
Thetermdependenceasappliedtoalcoholandotherdrugs,isdefinedbytheWHOas‘aneedforrepeateddosesofthedrugtofeelgoodortoavoidfeelingbad’.InDSM-IIIR(DiagnosticandStatisticalManualofMentalDisorders),dependenceisdefinedas‘aclusterofcognitive,behaviouralandphysiologicsymptomsthatindicateapersonhasimpairedcontrolofpsychoactivesubstanceuseandcontinuesuseofthesubstancedespiteadverseconsequences’.
Otherchemicalsinclude:
Cancer-Causing Chemicals
• Formaldehyde:Usedtoembalmdeadbodies
• Benzene:Foundingasoline
• Polonium210:Radioactiveandverytoxic
• Vinylchloride:Usedtomakepipes
Toxic Metals
• Chromium:Usedtomakesteel
• Arsenic:Usedinpesticides
• Lead:Onceusedinpaint
• Cadmium:Usedtomakebatteries
Poison Gases
• Hydrogencyanide:Usedinchemicalweapons
• Ammonia:Usedinhouseholdcleaners
• Butane:Usedinlighterfluid
• Toluene:Foundinpaintthinners
USDepartmentofHealthandHumanServices,CDC,OfficeonSmokingandHealth,2010.AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease:WhatitMeanstoUs.
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ClassificationofDependence
• Strongdesiretotakeasubstance,takingmorethanintendedforlonger
• Difficultyquittingorcontrollinguse
• Considerabletimespentobtaining,usingand/orrecoveringfromuse
• Higherprioritygiventothedrugthanothersocialactivities
• Continuedusedespiteknowledgeofharm
• Tolerancedevelops
• Withdrawalsyndrome
Tobaccodependenceexhibitsclassiccharacteristicsofdrugdependence.Nicotineispsychoactive,toleranceproducing,andcausesphysicalandpsychologicaldependencecharacterisedbywithdrawalsymptomsandcravings.
Automatic habit
Smokingisoftenassociatedwithandreinforcedbyroutineactivities,peopleandsituations–attheendofameal,drivingthecar,chattingonthephone,socialisingwithcertainfriends,drinkingtea/coffee/alcohol.Forsomepeople,thefeel,smellandsightofacigaretteandtheritualofhandling,lightingandsmokingthecigaretteareallpartoftheenjoymentandpleasureofsmoking.Withinashorttime,smokingbecomesanchoredindailylife,andoftenbecomesanunconscioushabitwhereapackof20canbesmokedwithoutthepersonrememberingmanyoftheindividualcigarettes.
Psychological dependence
Emotionaldependenceisafeatureoftobaccouseandcanmanifestitselfinmanyways.
Smokingisoftenusedasanaidtoreduceand/orcontrolnegativefeelingsofanxiety,frustrationoranger.Cigarettesareoftenusedtocopewithstressandthelevelofconsumptionmayincreasewhenapersonfeelsunderpressure.However,becausenicotineisastimulantitdoesn’tactuallyhelpapersonrelax–asmokerwill“feelbetter”becausehavingacigarettewillrestorenicotinelevelsinthebodypreventingwithdrawal.
Manysmokersusecigarettestogivestructuretotheirdailyroutinebyprovidingbreaks–forsomethismaybewhentheymeetupwithfellowsmokers,forothersitmaybetimetobealone.Thisbehaviourcanbetriggeredbyboredom,lonelinessorexcitement.
Smokingissometimesusedtoconveyconfidenceandcreateanimpressionthatapersonisincontrol;itcanbeanice-breakerinsocialsituationsformanyindividuals.
Tobacco dependence shows many features of a chronic disease
Sevenoutoftensmokerswanttoquitandfouroutoftensmokersmakeaquitattempteveryyear.However,onlyasmallminorityofsmokerswillquitsuccessfullyinaninitialquitattempt.Themajorityofuserscontinuetosmokeformanyyearsandtypicallycyclethroughmultipleperiodsofrelapseandremission.
Tobaccodependenceisadiseasethatdeservestreatmentinthesamewayasotherchronicdiseases.Effectivetreatmentshavebeenidentifiedandshouldbeusedwitheverysmoker.
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nderstanding Tobacco Use
The Story of Smoking
First try
Experimentation
‘Social’ smoker
Adult non-smoker
Regular smoker
Adult smoker
Cessation
Resumption of smoking
Tobacco environment
Family influences Personal beliefs and values
ENVIRONMENT
EXT
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TR
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Psychosocial influences
Personal physiological factors
Comm
unity norms
Exposureto •tobaccomarketing
Imagesofsmoking •inpopularmedia
Tobaccoindustry •
Access •
Price •
Parentalsmoking •
Siblingsmoking •
Parentalvaluesand •attitudesresmoking
Socio-economic •status
• Noriskintrying
• Itwon’thappentome
• Curiosity
• Individualchoice
• Adulthoodaspirations
• Perceptionsofsmokingnorms
• Risk-takingpropensity
• Self-esteem/self-image
Peeraffiliations •andfriendships
Connectednessto •schooland/orhome
Senseofalienation •
• Genetics
• Inuteroexposure
• Pubertyandadolescence
• Adultsmokingprevalence
• Restrictionsonsmoking
• Attitudestoyouthandyouthculture
• Socio-economicandculturalcontext
ScolloMM,WinstanleyMHTobaccoinAustralia:FactsandIssues.Thirdedition.InfluencesonUptakeofSmoking2008.
What support does a person need to increase their chances of making a successful quit attempt?
• Supportiveenvironment
• Supportfromhealthprofessionals
• Easyaccesstosmokingcessationsupport
• Personalcopingstrategies
• Familysupport
• Supportofpharmacologicalaidsinsomecases
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Tobacco Quiz
1. Howmanychemicalsintobaccosmoke?
a) 2,000+ b) 4,000+ c) 7,000+
2. Howmanyofthesechemicalsareknowntobecancercausing?
a) None b) 35 c) 69
3. Onaverage,byhowmanyminutesdoeseverycigaretteshortenasmoker’slife?
a) 30minutes b) 11 minutes c) Notatall
4. WhatpercentageofmeninIrelandsmoke?
a) 16% b) 25% c) 31%
5. WhatpercentageofwomeninIrelandsmoke?
a) 14% b) 21% c) 27%
6. HowmanypeopledieinIreland,onaverageeachyear,fromtobaccorelateddiseases?
a) 3,000 b) 5,500 c) 7,000
7. HowmanypeoplearediagnosedwithlungcancerinIrelandeachyear?
a) 700 b) 900 c) 1,910
8. WhichtypeofcancerhasthehighestdeathratesamongwomeninIreland?
a) Breast b) Lung c) Cervical
9. Womenwhosmokeinpregnancyincreasetheriskof?(chooseoneormore)
a) Ectopic pregnancy
b) Low birth weight babies
c) Babies which are slower to develop
10. Smokinghasnoeffectonfertility?
a) True b) False
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nderstanding Tobacco Use
11. Childrenaremorelikelytosmokeiftheirparentsand/orfriendssmoke?
a) True b) False
12. Youngpeoplewhosmokecanexperiencethesamelevelofwithdrawalasadultsmokers?
a) True b) False
13. Itisillegalforunder18stobuytobaccoproducts?
a) True b) False
14. Second-handsmokecancauseincreasedriskof?(chooseoneormore)
a) Heart disease b) Cancer c) Asthma and Bronchitis
15. Smokersinhale85%oftobaccosmoke?
a) True b) False
16. Childrenexposedtosecond-handsmokehaveanincreasedriskof(chooseoneormore)
a) Asthma and bronchitis b) Lower respiratory infections c) Middle ear disease
d) Bacterial meningitis e) Sudden Infant Death Syndrome
17. Whatdoesnicotinedo?(chooseoneormore)
a) Causes addiction b) Nothing c) Causes increase in heart rate
18. Howquicklydoesnicotinereachthebrain?
a) 10-20 seconds b) 30seconds c) 60seconds
19. Whatdoescarbonmonoxidedo?(chooseoneormore)
a) Displaces oxygen when you inhale
b) Nothing
c) Aids hardening of the arteries (Atherosclerosis)
20. QuittingsmokingraisesthelevelofHDL(thegoodcholesterol)inthebody?
a) True b) False
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21. Whatdoestardo?(chooseoneormore)
a) Nothing b) Causes cancer c) Causes smoker’s cough
22. Light/Lowtarcigarettesarelessharmfulthanregularcigarettes?
a) True b) False
23. Whichofthefollowingchemicalsareintobaccosmoke?
Nicotine Formaldehyde Ammonia Nickel
Arsenic Butane DDT Hydrogen Cyanide
Lead methanol Polonium 210 Radon Acetone
24. In2006,thetotalcostofrespiratorydiseasestotheIrishhealthservicewasestimatedat?
a) €65million b) €250million c) €437 million
25. In2008,whatwastheaveragecostofahospitaladmissionfortobaccorelatedillness?
a) €3,700 b) €5,700 c) €7,700
26. WhatpercentageofdeathsinIrelandiscausedbytobaccouse?
a) 5% b) 19% c) 38%
27. Oneineverytwosmokerswilldiefromatobaccorelateddisease?
a) True b) False
28. Peoplewithmentalhealthissuesaremorelikelytousetobacco?
a) True b) False
29. Cardiovasculardiseaseisthemostcommoncauseofdeathinschizophrenicpatients?
a) True b) False
30. HowmanyIrishchildrendoestheTobaccoIndustryneedtorecruiteachday,tomaintainprofits?
a) 25 b) 50 c) 75
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBrief Intervention
Brief Intervention Definition
BriefInterventionsinvolveopportunisticadvice,discussion,negotiationorencouragement…Forsmokingcessation,briefinterventionstypicallytakebetween5and10minutes
(NICE Guidelines, Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings, 2006)
• Unassistedquitrate=2-3%
• Briefadviceinterventionincreasesquitrateby1to3percentagepoints
(Cochrane Review, Physician Advice for Smoking Cessation, 2008)
Brief Intervention – The Evidence
• Interventionfromhealthprofessionalshasbeenshownrepeatedly,inrandomisedcontrolledtrials,toincreasethepercentageofsmokerswhostopandremainabstinentfor6monthsormore
• Itisahighlycosteffectiveintervention
(West et al, Smoking Cessation Guidelines for Health Professionals: An Update, 2000)
Missed Opportunities
• Only38%ofcurrentsmokerswhoattendedaGPorotherhealthprofessionalinthelastyearreportedthatthehealthprofessionalhaddiscussedquittingsmokingwiththemduringtheirconsultation.
(Brugha et al, SLÁN 2007 Survey of Lifestyle, Attitudes and Nutrition in Ireland: Implications for Policy and Services, 2009)
3. BriefInterventionforSmokingCessation
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Framework for Brief Intervention for Smoking Cessation
The5As
systematically identify all smokers at every visit. Record smoking status, no. of cigarettes smoked per day/week and year started smoking.
ASK �
urge all smokers to quit. Advice should be clear and personalised.
ADVISE �
determine willingness and confidence to make a quit attempt; note the stage of change.
ASSESS �
aid the smoker in quitting. Provide behavioural support. Recommend/prescribe pharmacological aids. If not ready to quit promote motivation for future attempt.
ASSIST �
follow-up appointment within 1 week or if appropriate refer to specialist cessation service for intensive support. Document the intervention.
ARRANGE �
AdaptedfromFioreMC,JaénCR,BakerTB,etal.TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.April2009.
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEStages of C
hange
ProchaskaandDiClemente(1983)describedaseriesofstagesthroughwhichpeoplepasswhenmakingbehaviourchange.Ateachstageapersonisthinkingandfeelingdifferentlyabouttheproblembehaviourandwillfinddifferentprocessesandinterventionshelpfulinmovingon.Thismodelismostoftenpictureddiagrammaticallyasacircle.
The Wheel of Change (Trans-Theoretical Model of Behaviour Change)
E s t a b l i s h ed Change
MAINTENANCE
ACT ION
PR
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CON T E M P L AT I ON
P R E - CON T E M P L AT I ON
REL
AP
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MAINTENANC
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ACT ION
PR
EPA
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CON T E M P L AT I ON
REL
AP
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4. StagesofChange
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Stag
es o
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hang
e
Pre-contemplation Stage• Nointerestatallinchangingbehaviour
• Seesmanypersonaladvantagesinit• Hasmostlypositivethoughtsaboutthebehaviour
Contemplation Stage• Awareofsomepersonaldisadvantages
• Hasthoughtaboutchangingsomeaspectsofthebehaviour• Stillhasmanyreasonsforcontinuing
Preparation Stage• Intendingtomakeachange
• Knowswhytheywanttochange• Planningwhenandhowtodoit
Action• Believingthatchangeispossible• Actuallymakingaquitattempt
Maintenance• Thebehaviourchangeisongoing• Abletocopewithoutrelapsing
• Supportandencouragementneeded
Relapse• Thisattemptunsuccessful
• Returnstooneoftheabovestages
Itiscommontogoaroundthemodel3-4timesbeforereachingthemaintenancestage,henceitsname–thecycleofchange/wheelofchange.Passingthroughthiscyclewilltaketime,whichcanbemonthsoryearsdependingonindividualcircumstances.
E s t a b l i s h ed Change
MAINTENANCE
ACT ION
PR
EPA
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CON T E M P L AT I ON
P R E - CON T E M P L AT I ON
REL
AP
SE
MAINTENANC
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ACT ION
PR
EPA
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CON T E M P L AT I ON
REL
AP
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEEffecting C
hange
Client Centred Approach
Theclient-centredapproachconsiderstheclientholistically.Itisanon-directivebehaviourchangeapproachwhichenhancesrapportbuilding.Thisapproachallowstheclienttoacceptresponsibilityfortheirownhealthandthereforetosettheirowngoals.Thehealthprofessional’sroleismorefocussedonlisteningwithemphasisonhowtosaythingsratherthanwhattosay.
Core conditions of client-centred approach
• Acceptance
• Empathy
• Genuineness
While using the client-centred approach, the client:
• Istheexpertaboutthemselvesandtheirsituation
• Isthedecisionmaker
• Hastherightnottochange
• Hasthecapacitytofindtheirownanswers,withpossibleassistancefromthehealthprofessional
Motivational Interviewing
MotivationalInterviewing(MI)isanevidencebasedclinicalmethodforhelpingpeopletomakechange,firstproposedin1983byWilliamMillerandfurtherdevelopedinthe1990sbyMillerandRollnick.Itisaclient-centred,directive,behaviourchangeapproachwhichresolvesambivalenceandresistance.Ambivalenceisacknowledgedasasignificantfactorinthechangeprocess.Readinesstochangeisalsoacentralconceptasreadinesscanvaryconstantlythroughoutthecycleofchange.Recognisingwheretheclientisatisthestartingpointinanyconsultationandiskeytoaneffectiveoutcome.
TheunderlyingspiritofMIisthatchangecomesfromwithintheindividual,notfromsomeoutsideforce.Itistheclient’splace(notthehealthprofessional’s)tostateandresolvetheirambivalence.Thehealthprofessional’sroleistodrawonandenhancetheclient’sinternalmotivationtomakechanges,basedontheirowndecisionsandchoice.Theclientisallowedtodotheirownselfpersuadingandproblemsolvingandisencouragedtostatetheiruncertaintyinaclearandcompleteway.Selfmotivationalstatements(changetalk)areelicited;thisiswheretheclientbeginstotalkabouttheirneedforchange,advantagesofchanging,theirabilityandintentiontochange.‘Changetalk’leadstocommitmentandanincreasedprobabilityofbehaviourchange.
5. EffectingChange
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Effe
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Five general principles of Motivational Interviewing:
1. Express Empathy –seetheworldthroughclient’seyes.Benon-judgemental;leaveasideone’sownviewsandvalues.
2. Develop Discrepancy –facilitateclienttoidentifythediscrepancybetweencurrentbehaviourandfuturegoals.
3. Avoid Argumentation –it’scounterproductive.Lookforinconsistenciesandconsequencesthatconflictwithimportantgoals.
4. Roll with Resistance –defusetheresistance.Beempatheticandnon-judgementalandencourageclienttodeveloptheirownsolutionsandexaminenewperspectives.
5. Support Self-Efficacy –clientisresponsibleforchoosingandcarryingoutpersonalchange.Beliefinthepossibilityofchangeisagoodmotivatorandpreviouseffortsandsuccessescanbeelicitedtobuildself-confidence.
EffectivemotivationalinterviewingencompassesthefollowingcommunicationtechniquescommonlyreferencedbytheacronymOARS:
• Openendedquestions–allowsclienttoexpresstheirperspectiveandprovidesinsightsfortheconsultation.
• Affirmations–showsappreciationandsupportfortheclient’sstatements.Theycanbeverbalornon-verbal.
• Reflectivelistening–addsdirectiontotheconsultationandhelpsfocusonchangestatements.
• Summarising–drawsanumberofstrandstogetherandclarifiesandreflectstheclient’sownthoughtsbacktothem.
Asking permission hasalsobeenshowntobeapowerfultool.Itcommunicatesrespectfortheclientandresultsinincreasedlikelihoodofdiscussingchange.
Inmotivationalinterviewingthefocusshiftsfromgivinginformationandadvice,tohelpingclientsexploreconcerns,uncertainties,reasonsforchange,andideasandstrategiestomakechangehappen.
Examples of how to raise the issue of smoking using non-threatening language
What questions could you ask someone who would like to quit?
• Tellmealittlebitaboutyoursmoking?
• You’vetoldmeyouareasmoker.Whatdoyoumostenjoyaboutsmoking?
• What’snotsogoodaboutyoursmoking?
• Whatdoyourememberaboutyourpreviousquitattempts?
• Whydoyouwanttostopsmokingnow?
• Haveyouthoughtaboutitbefore?Yes–howlonghaveyoubeenthinkingaboutquitting?
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• Whatisyourunderstandingofthebenefitsofquitting?
• Whatsupportsdoyouhaveinhelpingyouquit?
• Howimportantisthistoyou(onascaleof1-10)?
• Howconfidentdoyoufeelthatyoucanquit?(onascaleof1-10)?
• Ifyouweretosetaquitdate,whenwouldbeagoodtimetoquit?
• Howdoyouthinkyoucanbesupported?
• Whatwouldyouliketodowiththemoneyyousave?
What questions can you ask someone who tried to quit before but didn’t succeed?
• Whatisitthatmakesyouthinkyoucouldn’tmanagethistime?
• Whydoyouwanttostopagain?
• Whatdidyouusetohelpyoulasttime?
• Howlongdidyoustopfor?
• Whatdidyoufinddifficult?
• Whatdoyoumeanbytried?
• Whatsupportdidyouhave?
• Whatdoyouthinkyouwouldorcoulddodifferentlythistime?
• Howimportantisitforyoutotryandstopagain(onascaleof1-10)?
• Whatstrategiesdoyouthinkyoucouldusetobemorepreparedthistime?
• Howconfidentdoyoufeelthistime(onascaleof1-10)?
What questions can you ask someone who says “I’ve cut down”?
• Whatpromptedyoutocutdown?
• Whatdifferenceshaveyounoticedsincecuttingdown?
• Howmanyhaveyoucutdownfrom–to?
• Howareyoucopingwiththereduction?
• Areyourfamilysupportive?–Inwhatway?
• Whatfurtherchangesdoyoufeelyoucouldmake?
• Howhaveyouchangedyourlifestyle/socialcircle?
• Whatisthenextstepforyou?Wheredoyouwanttogofromhere?
• Whatrewardswouldhelptokeepyoumotivatedwhileyouarequitting?
• Let’stalkabouthowtobaccodependencetreatmentscouldhelpyoutoquitcompletely.
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What questions can you ask someone who says they have stopped?
• Welldone.Howdidyoudoit?
• Whatisthenextstepforyou?
• Howareyoucopingwithit?
• Whatstrategiesdoyouuse?
• Whatsupportdoyouhave?
• Doyoufeelbetternow?Inwhatway?
• Howhaveyoumanagedaroundothersmokers?
Responses for Challenging Statements
Statement 1
“Mygrannysmoked40adayandshelivedwellintohereighties.”
Response:
Soundslikeyourgrannywasoneoftheluckyones!
Whatwasherhealthlikeforthelatterpartofherlife?
Didsheevertrytostop?Whydoyouthinkthatwas?
Statement 2
“Well,Ihavecutdownandchangedtoa‘lighter’brand.”
Response:
Whatmadeyoudecidetodothat?
Howdoyoufeelnowthatyouhavedonethat?
Wheredoyouwanttogofromhere?
Whydoyoufeelthatsmoking‘light’cigaretteswillprotectyou?
Statement 3
“I’vetriedtostopsomanytimesinthepastanditjustdoesn’twork”.
Response:
Whydoyouthinkithasn’tworkedbefore?
Whatdoyouthinkyoucoulddodifferentlythistime?
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Statement 4
“Ihavealmostmanagedtostop,butmypartnersmokesandIkeephavingtheoddonewithhim.”
Response:
Howdoesthatmakeyoufeel?
Whatwouldyouliketodo?
Howdoesyourpartnerfeelaboutyousmoking?
Whatsupportwouldyouneedtomakethatfinalefforttoquit?
Statement 5
“What’sthepoint–thedamageisdonealready.”
Response:
Whatdoyouthinkwillhappennowifyoucontinuetosmoke?
Howdoyouthinkyouwouldfeelifyoudidstop?
Didyoueverstopbefore?Howdidyoufeelthen?
Statement 6
“It’snotlikeI’mhurtinganyoneelsebysmoking.”
Response:
Haveyoueverheardaboutrisks/harmfromsecondhandsmoke?
Tellmewhyyoubelieveyoursmokingdoesn’taffectanyoneelse.
Inwhatwaydoyouthinkyoursmokingmightbeaffectingyourself?
Statement 7
“SureI’monlysmoking,itcouldbeworse,Icouldbedoingdrugsorsomethingelse.”
Response:
Itsoundslikeyouthinksmokingissaferthandoingdrugs?
Youseemtobelievethat‘onlysmoking’isokayforyourhealth–isthatright?
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Top 10 Tips for Successful Quitting
1. Prepare to Quit Smoking
Writedownyourreasonsforstoppingandkeepthemcloseathand.Weighuptheprosandcons.
2. Make a Date to Quit
Somesmokerscutdowngraduallywithaplanforaquitdate.However,mostpeoplewhosuccessfullyquitsmokingdosobystoppingaltogetherandnotbygraduallycuttingdown.Pickyourdaytoquitandsticktoit.
3. Support
Seekthesupportoffamilyorfriends.
4. Change Your Routine and Plan Ahead
Smokingisoftenlinkedtocertaintimesandsituationssuchasthefirstsmokeinthemorning,drinkingcoffeeoralcohol.Thesearecalledyourtriggers.Replacetriggerswithnewactivitiesthatyoudon’tassociatewithsmoking.Forexample,ifyoualwayshadacigarettewithacupofcoffee,switchtoteaforawhile;orfortwoweeksbeforeyourquitdatehaveyourcoffeebutpracticedelayingbyfiveminutesoneday,sixminutesthenextdayandsoonuntilyoubreaktheassociationbetweencoffeeandsmoking.
5. Exercise Regularly
Regularexercisecontributestogoodhealth;helpstomanageyourweightandcanalsoimprovethebody’sabilitytomeetthedemandsandstressesofdailyliving.
6. Think Positive
Youmayfindyouexperiencewithdrawalsymptomsonceyoustopsmoking.Theseareverypositivesignsthatyourbodyisrecoveringfromtheeffectsoftobacco.Coughing,irritabilityandsleepdisturbancearesomecommonsymptoms.Don’tworry,theyareallperfectlynormalandshoulddisappearwithinafewweeks.
6. ToolsandTechniquestoSupportQuitting
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7. Learn to Deal with Cravings
Cravingscanoccurfrequentlyduringthefirstfewdaysafterstopping.Acravingincreasesinintensityoveraperiodof3-5minutesandthenbeginstosubside.
Tips for dealing with cravings – The 4 Ds:
• Delay atleast3minutesandtheurgewillpass.
• Drink aglassofwaterorfruitjuice.
• Distract yourself.Moveawayfromthesituation.
• Deep breaths.Breatheslowlyanddeeply.
8. Save Money
Startsavingthemoneyyouwouldnormallyspendontobacco.Workouthowmuchyouspendoncigarettesperweek,monthandyear.Thenwatchyoursavingsgrow.
9. Watch What You Eat
Ifyouareworriedaboutgainingweight,beextracarefulwithyourdiet.Avoidsnackingonchocolatebarsandbiscuits,trysomefruitorchewsugarfreeguminstead.
10. Take One Day at a Time
Remember,everydaywithoutacigaretteisgoodnewsforyourhealth,yourfamilyandyourpocket.
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Withdrawal Symptoms
Quittingsmokingbringsaboutavarietyofphysicalandpsychologicalwithdrawalsymptoms.Forsomepeople,copingwithwithdrawalsymptomsislikeridingarollercoaster–theremaybesharpturns,slowclimbs,andunexpectedplunges.Mostphysicalsymptomsmanifestwithinthefirstonetotwodays,peakwithinthefirstweek,andsubsidewithintwotofourweeks.Anynewsymptomsshouldbenotifiedtoahealthprofessional,especiallyifsevere.Recentmedicationchangesandcaffeineintakecanhaveanimpactonsymptoms.Itmaytakelongertobreakthepsychologicaldependencecausedbyconstanttriggersandsocialcuesassociatedwithsmoking.
SYMPTOM CAUSE DURATION RELIEF
Craving for a cigarette
Nicotineisastronglyaddictivedrug,andwithdrawalcausescravings
Acravingforacigarettecanlastforbetween3-5minutesfrequentlyfor2-3days;canhappenformonthsoryears
Waitouttheurge,whichlastsonlyafewminutes
Distractyourself
Exercise(takewalks)
Drinkaglassofwaterorfruitjuice
Breatheslowlyanddeeply
Useofanicotinemedicationmayhelp
Irritability Thebody’scravingfornicotinecanproduceirritability
2-4weeks Takewalks
Tryhotbaths
Userelaxationtechniques
Dizziness Thebodyisgettingextraoxygen 1-2days Useextracaution
Changepositionsslowly
Chest tightness Tightnessislikelyduetotensioncreatedbythebody’sneedfornicotineormaybecausedbysoremusclesfromcoughing
Afewdays Userelaxationtechniques
Trydeepbreathing
UseofNRTmayhelp
Constipation, stomach pain, gas
Intestinalmovementdecreasesforabriefperiod
1-2weeks Drinkplentyoffluids
Addfruit,vegetables,andwhole-graincerealstodiet
Cough, dry throat, nasal drip
Thebodyisgettingridofmucus,whichhasblockedairwaysandrestrictedbreathing
Afewdays Drinkplentyoffluids
Avoidadditionalstressduringfirstfewweeks
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SYMPTOM CAUSE DURATION RELIEF
Depressed mood
Itisnormaltofeelsadforaperiodoftimeafteryoufirstquitsmoking.Manypeoplehaveastrongurgetosmokewhentheyfeeldepressed
1-2weeks Increasepleasurableactivities
Talkwithyourclinicianaboutchangesinyourmoodwhenquitting
Getextrasupportfromfriendsandfamily
Difficulty concentrating
Thebodyneedstimetoadjusttonothavingconstantstimulationfromnicotine
Afewweeks Planworkloadaccordingly
Avoidadditionalstressduringfirstfewweeks
Fatigue Nicotineisastimulant 2-4weeks Takenaps
Donotpushyourself
Useofanicotinemedicationmayhelp
Hunger Cravingsforacigarettecanbeconfusedwithhungerpangs;sensationmayresultfromoralcravingsorthedesireforsomethinginthemouth
Uptoseveralweeks
Drinkwaterorlow-calorieliquids
Bepreparedwithlow-caloriesnacks
Insomnia Nicotineaffectsbrainwavefunctionandinfluencessleeppatterns;coughinganddreamsaboutsmokingarecommon
2-4weeks Limitcaffeineintakebecauseitseffectswillincreasewithquittingsmoking
Userelaxationtechniques
AdaptedfromMaterialsfromtheNationalCancerInstitute,U.S.NationalInstitutesofHealth.
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Medications for the Treatment of Tobacco Dependence
Long Acting Medications
PRODUCT USE ADVANTAGES DISADVANTAGES PRECAUTIONS SIDE EFFECTS EST COST (AUG 2012)
Nicotine Patch* Applyeachdaytoclean,dryhairlessskin
Ifusing24hrpatch,startwith21mgpatchdailyifsmokesmorethan10cigs/day;cantaperto14mgatweek6to8;then7mgforweek9,10ifnocravings
Ifusingthe16hrpatch,startwith25mgpatchdailyifsmokesmorethan15-20cigs/dayuntilweek8completed,taperto15mgforweek9,10andthen10mgforweek11,12ifnocravings
Placeandforget
Overthecounter,candecreasemorningcravingsifwornatnight(24hrpatchonly)
Passive–noactiontotakewhencravingoccurs
Notrecommendedtousewhilesmoking.Useonlywithdoctor’sprescriptionwithin4weeksofheartattack,inpatientswithseriousunderlyingarrhythmiasandworseningangina
Notrecommendedinpregnancyandbreastfeeding–useshortactingmedicationwithGPprescription
Skinreaction–50%ofpatients,usuallymild.*Rotatesites
Canexperiencevividdreamsorsleepdisturbanceatnightwith24hrpatch
Nic CQ
€27for1/52of21mg,14mg,and7mg.
€47for2/52of21mg.
Nicotinell
For1/52=€26/21mg,€25/14mgand€24/7mg.
3/52of21mg=€61
Nicorette
€24for1/52of25mg,15mgand10mg.
Champix/Varenicline*
0.5mgoncedailydays1-3
0.5mgtwicedailydays4-7
Then1mgtwicedaily.
Useupto12weeks.Extra12weeksifrequired
Reduceswithdrawalandmaypreventrelapse
Passive–noactiontotakewithcravings.Prescriptionrequired
Donotuseifyouhaveseverekidneydisease
Notlicensedinpregnancyorbreastfeeding
AcuteDepressiveDisease
Blackboxedwarningforneuropsychiatricsymptoms
Nausea(30%)usuallymild–canreduceto0.5mglevel.Takewithfood.Insomnia
€132onDPSper1monthsupply
4/52starterpack€131
4/521mgbdpack€131
Zyban*
Wellbutrin SR
Wellbutrin XL
Bupropion
150mgeachmorningfor3-7days,then300mg/day
Startpriortoquitdate
Dosesmustbeatleast8hoursapart;takesecondpillinearlyeveningtoreduceinsomnia
Lessweightgainwhileusing
Safetosmokewhiletaking
Sideeffectscommon
Passive–noactiontotakewithcravings.Prescriptionrequired
DoNotUsewith:Seizuredisorders;currentuseofWellbutrinorMAOinhibitors;electrolyteabnormalities;eatingdisorders
Monitorbloodpressure
Notlicensedinpregnancyorbreastfeeding
Insomnia(40%)DrymouthHeadacheAnxietyRash
Flexibledosing(keepingat150mg/day)helpfulwithsideeffects
€110onDPSper1monthsupply
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Medications for the Treatment of Tobacco Dependence
Long Acting Medications
PRODUCT USE ADVANTAGES DISADVANTAGES PRECAUTIONS SIDE EFFECTS EST COST (AUG 2012)
Nicotine Patch* Applyeachdaytoclean,dryhairlessskin
Ifusing24hrpatch,startwith21mgpatchdailyifsmokesmorethan10cigs/day;cantaperto14mgatweek6to8;then7mgforweek9,10ifnocravings
Ifusingthe16hrpatch,startwith25mgpatchdailyifsmokesmorethan15-20cigs/dayuntilweek8completed,taperto15mgforweek9,10andthen10mgforweek11,12ifnocravings
Placeandforget
Overthecounter,candecreasemorningcravingsifwornatnight(24hrpatchonly)
Passive–noactiontotakewhencravingoccurs
Notrecommendedtousewhilesmoking.Useonlywithdoctor’sprescriptionwithin4weeksofheartattack,inpatientswithseriousunderlyingarrhythmiasandworseningangina
Notrecommendedinpregnancyandbreastfeeding–useshortactingmedicationwithGPprescription
Skinreaction–50%ofpatients,usuallymild.*Rotatesites
Canexperiencevividdreamsorsleepdisturbanceatnightwith24hrpatch
Nic CQ
€27for1/52of21mg,14mg,and7mg.
€47for2/52of21mg.
Nicotinell
For1/52=€26/21mg,€25/14mgand€24/7mg.
3/52of21mg=€61
Nicorette
€24for1/52of25mg,15mgand10mg.
Champix/Varenicline*
0.5mgoncedailydays1-3
0.5mgtwicedailydays4-7
Then1mgtwicedaily.
Useupto12weeks.Extra12weeksifrequired
Reduceswithdrawalandmaypreventrelapse
Passive–noactiontotakewithcravings.Prescriptionrequired
Donotuseifyouhaveseverekidneydisease
Notlicensedinpregnancyorbreastfeeding
AcuteDepressiveDisease
Blackboxedwarningforneuropsychiatricsymptoms
Nausea(30%)usuallymild–canreduceto0.5mglevel.Takewithfood.Insomnia
€132onDPSper1monthsupply
4/52starterpack€131
4/521mgbdpack€131
Zyban*
Wellbutrin SR
Wellbutrin XL
Bupropion
150mgeachmorningfor3-7days,then300mg/day
Startpriortoquitdate
Dosesmustbeatleast8hoursapart;takesecondpillinearlyeveningtoreduceinsomnia
Lessweightgainwhileusing
Safetosmokewhiletaking
Sideeffectscommon
Passive–noactiontotakewithcravings.Prescriptionrequired
DoNotUsewith:Seizuredisorders;currentuseofWellbutrinorMAOinhibitors;electrolyteabnormalities;eatingdisorders
Monitorbloodpressure
Notlicensedinpregnancyorbreastfeeding
Insomnia(40%)DrymouthHeadacheAnxietyRash
Flexibledosing(keepingat150mg/day)helpfulwithsideeffects
€110onDPSper1monthsupply
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Short Acting Medications
PRODUCT USE ADVANTAGES DISADVANTAGES PRECAUTIONS SIDE EFFECTS EST COST (AUG 2012)
Nicotine Gum* 2mg and 4mg
2mgand4mg(4mgifsmokesmorethan20cigs/day)
Takeevery1-2hrsasneeded.Chewandpark
Useasneeded
Canselfdose
Availableoverthecounter
Difficulttochew Avoidfoodandacidicdrinks15minutesbeforeandwhileusing*(decreasedabsorption–reducedeffect)
Jawpain
Nausea/heartburnifswallowingsaliva
2mg€9/30;€28/105;€44/210
4mg€11/30;€34/105;€55/210
Nicotine Inhaler* 15mg
Puffasneeded.Useupto6cartridges/day,lessneededifusingcombinationtherapy.Oralabsorbed–noneedtoinhaledeeply.Eachcartridgelastsfor20-40minutesofinhaling
Useasneeded
Mimicshandtomouthactionofsmoking
Advisetousenonsmokinghandtohold.
Visibleinhand Avoidfoodandacidicdrinksbeforeandwhileusing.Cautionuseinasthmaticclients
Cough;throatirritation(usuallymild)
€12for18cartridges
€29for42cartridges
Nicotine Lozenge* 2mg and 4mg
2and4mg(4mgifsmokeswithin30minsofwaking)
Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow.Useapprox9perdayforfirst6weeksthentaper.
Easeofuse
Overthecounter
Flexibledosing
Avoidfoodandacidicdrinksbeforeandwhileusing
Hiccups
Nausea/heartburnifswallowingsaliva
2mg€14/36€26/72
4mg€14/36€26/72
Nicotine Microtab* 2mg
Placeunderthetongueandleavetodissolve.Donotchew.Useevery1-2hoursifsmokesmorethan20cigs/day
Useasneeded
Overthecounter
Flexibledosing
Discrete
Avoidfoodandacidicdrinksbeforeandwhileusing
Nausea/heartburnifswallowingsaliva
€11for30
€25for100
Nicotine Mini Lozenge 1.5mg and 4mg
1.5and4mg(4mgifsmokeswithin30minsofwaking)Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow
Useasneeded
Overthecounter
Flexibledosing
Discrete
Avoidfoodandacidicdrinksbeforeandwhileusing
Hiccups
Nausea/heartburnifswallowingsaliva
1.5mg€7/20€20/60
4mg€7/20€20/60
*AvailableonGMS.AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.Disclaimer–Theabovelistismeantasaguideonlyandthemanufacturers’instructionsshouldalwaysbeadheredto
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Short Acting Medications
PRODUCT USE ADVANTAGES DISADVANTAGES PRECAUTIONS SIDE EFFECTS EST COST (AUG 2012)
Nicotine Gum* 2mg and 4mg
2mgand4mg(4mgifsmokesmorethan20cigs/day)
Takeevery1-2hrsasneeded.Chewandpark
Useasneeded
Canselfdose
Availableoverthecounter
Difficulttochew Avoidfoodandacidicdrinks15minutesbeforeandwhileusing*(decreasedabsorption–reducedeffect)
Jawpain
Nausea/heartburnifswallowingsaliva
2mg€9/30;€28/105;€44/210
4mg€11/30;€34/105;€55/210
Nicotine Inhaler* 15mg
Puffasneeded.Useupto6cartridges/day,lessneededifusingcombinationtherapy.Oralabsorbed–noneedtoinhaledeeply.Eachcartridgelastsfor20-40minutesofinhaling
Useasneeded
Mimicshandtomouthactionofsmoking
Advisetousenonsmokinghandtohold.
Visibleinhand Avoidfoodandacidicdrinksbeforeandwhileusing.Cautionuseinasthmaticclients
Cough;throatirritation(usuallymild)
€12for18cartridges
€29for42cartridges
Nicotine Lozenge* 2mg and 4mg
2and4mg(4mgifsmokeswithin30minsofwaking)
Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow.Useapprox9perdayforfirst6weeksthentaper.
Easeofuse
Overthecounter
Flexibledosing
Avoidfoodandacidicdrinksbeforeandwhileusing
Hiccups
Nausea/heartburnifswallowingsaliva
2mg€14/36€26/72
4mg€14/36€26/72
Nicotine Microtab* 2mg
Placeunderthetongueandleavetodissolve.Donotchew.Useevery1-2hoursifsmokesmorethan20cigs/day
Useasneeded
Overthecounter
Flexibledosing
Discrete
Avoidfoodandacidicdrinksbeforeandwhileusing
Nausea/heartburnifswallowingsaliva
€11for30
€25for100
Nicotine Mini Lozenge 1.5mg and 4mg
1.5and4mg(4mgifsmokeswithin30minsofwaking)Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow
Useasneeded
Overthecounter
Flexibledosing
Discrete
Avoidfoodandacidicdrinksbeforeandwhileusing
Hiccups
Nausea/heartburnifswallowingsaliva
1.5mg€7/20€20/60
4mg€7/20€20/60
*AvailableonGMS.AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.Disclaimer–Theabovelistismeantasaguideonlyandthemanufacturers’instructionsshouldalwaysbeadheredto
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Comparison of Nicotine Delivery Devices
TOBACCO PRODUCTS
NICOTINE DELIVERY DEVICE
NICOTINE IN PRODUCT
APPROX AMOUNT OF NICOTINE DELIVERED
COMMENTS
Marlboro Gold 13mg 1-3mg AlsodeliversawiderangeofcarcinogensandothertoxinsMarlboro Red 13mg 1-3mg
Cigars 10-40mg Highlyvariable
Moist Snuff 3-12mg Variesdependingonphandothercharacteristics
NICOTINE REPLACEMENT PRODUCTS
NICOTINE DELIVERY DEVICE
NICOTINE IN PRODUCT
APPROX AMOUNT OF NICOTINE DELIVERED
COMMENTS
Nicotine Gum 2mgpiece Upto0.8mg Onlydeliversnicotinetouser
Nicotine Gum 4mgpiece Upto1.5mg
Nicotine Patch
Step 1
Step 2
Step 3
10mg/16hours
15mg/16hours
25mg/16hours
Nicotine Patch
Step 1
Step 2
Step 3
7mg/24hours
14mg/24hours
21mg/24hours
Nicotine Inhaler 15mg/cartridge Upto3mg/cartridge
Nicotine Microtabs 2mg Approx1mg
Nicotine Lozenge 2mg Approx1mg
Nicotine Lozenge 4mg Approx2mg
Nicotine Mini Lozenge 1.5mg Upto0.8mg
Nicotine Mini Lozenge 4mg Approx2mg
AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.
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Drug Interactions with Smoking
Manyinteractionsbetweentobaccosmokeandmedicationshavebeenidentified.Tobaccosmokemayinteractwithmedicationsthroughpharmacokineticorpharmacodynamicmechanisms.Pharmacokineticinteractionsaffecttheabsorption,distribution,metabolism,oreliminationofotherdrugs,potentiallycausinganalteredpharmacologicresponse.ThemajorityofpharmacokineticinteractionsaretheresultofinductionofhepaticcytochromeP450enzymes(primarilyCYP1A2).Pharmacodynamicinteractionsaltertheexpectedresponseoractionsofotherdrugs.Themostclinicallysignificantinteractionsaredepictedintheshadedareasofthetable.
DRUG/CLASS MECHANISM OF INTERACTION AND EFFECTS
Benzodiazepines(diazepam,chlordiazepoxide
• Pharmacodynamicinteraction:decreasedsedationanddrowsiness.• Maybecausedbycentralnervoussystemstimulationbynicotine.
Beta-blockers • Pharmacodynamicinteraction:lesseffectiveantihypertensiveandratecontroleffects.
• Maybecausedbynicotine-mediatedsympatheticactivation.
Caffeine • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby56%.• Caffeinelevelsmayincreaseaftercessation.
Chlorpromazine(Thorazine) • Decreasedareaunderthecurve(AUC)(36%)andserumconcentrations(24%).
• Smokersmayexperiencelesssedationandhypotensionandrequirehigherdosagesthannonsmokers.
Clozapine(Clozaril) • Increasedmetabolism(inductionofCYP1A2);plasmaconcentrationsdecreasedby28%.
Flecainide(Tambocor) • Clearanceincreasedby61%;troughserumconcentrationsdecreasedby25%.
• Smokersmayrequirehigherdosages.
Fluvoxamine(Luvox) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby25%;decreasedplasmaconcentrations(47%).
• Dosagemodificationsnotroutinelyrecommendedbutsmokersmayrequirehigherdosages.
Haloperidol(Haldol) • Clearanceincreasedby44%;serumconcentrationsdecreasedby70%.
Heparin • Mechanismunknownbutincreasedclearanceanddecreasedhalf-lifeareobserved.
• Smokersmayrequirehigherdosages.
Insulin • Insulinabsorptionmaybedecreasedsecondarytoperipheralvasoconstriction;smokingmaycausereleaseofendogenoussubstancesthatantagonisetheeffectsofinsulin.
• Smokersmayrequirehigherdosages.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
30
Tool
s an
d Te
chni
ques
to
Supp
ort
Qui
ttin
g
DRUG/CLASS MECHANISM OF INTERACTION AND EFFECTS
Mexiletine(Mexitil) • Clearance(viaoxidationandglucuronidation)increasedby25%;half-lifedecreasedby36%.
Olanzapine(Zyprexa) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby40-98%.
•Dosagemodificationsnotroutinelyrecommendedbutsmokersmayrequirehigherdosages.
Opioids(propoxyphene,pentazocine)
• Pharmacodynamicinteraction:decreasedanalgesiceffect;higherdosagesnecessaryinsmokers.
• Mechanismunknown.
Propranolol(Inderal) • Clearance(viasidechainoxidationandglucuronidation)increasedby77%.
Oralcontraceptives • Pharmacodynamicinteraction:increasedriskofcardiovascularadverseeffects(e.g.,stroke,myocardialinfarction,thromboembolism)inwomenwhosmokeanduseoralcontraceptives.
• Riskincreaseswithageandwithheavysmoking(15ormorecigarettesperday)andisquitemarkedinwomenoverage35years.
Tacrine(Cognex) • Increasedmetabolism(inductionofCYP1A2);half-lifedecreasedby50%;serumconcentrationsthreefoldlower.
• Smokersmayrequirehigherdosages.
Theophylline(TheoDur,etc) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby58-100%;half-lifedecreasedby63%.
•Theophyllinelevelsshouldbemonitoredifsmokingisinitiated,discontinued,orchanged.
•Maintenancedosesareconsiderablyhigherinsmokers.
RxforchangeUCSF,adaptedfromZevinS,BenowitzNL.Druginteractionswithtobaccosmoking.ClinPharmacokinet1999;36:425-438.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
30 31
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBenefits of Q
uitting
Within 20 minutes Bloodpressuredrops,pulseratesdropstonormal,bodytemperatureofhandsandfeetreturntonormal
Within 8-12 hours Carbonmonoxidelevelsinthebloodstartreturningtonormalandwithinafewdaysarethesameasnonsmokers
Within 24-48 hours Riskofheartattackbeginstodecrease
Within 48 hours Abilitytosmellandtasteimproves
Within 72 hours Breathinggetseasierasbronchialtubesrelax,lungcapacityincreases
Within 3 weeks Mucusinthelungsloosen,lungfunctionandcirculationimproves
Within 2-3 months Bloodflowsmoreeasilytoarmsandlegs,lungfunctionbeginstoincrease
After 1 year Riskofsuddendeathfromheartattackisalmostcutinhalf
After 5 years Theriskofsmokingrelatedcancersandstrokeisgreatlyreduced.
Within 10-15 years Riskofheartattackfallstothesameassomeonewhohasneversmoked.Riskoflungcancerfallstohalfthatofanonsmokerandtheriskofcancerofthemouth,throat,esophagus,bladder,cervixandpancreasdecreases.
AdaptedfromBurnside,G.Spiers,A.,Winckles,W.HelpSmokersQuitKit.UlsterCancerFoundation,NorthernIreland;WHOFactSheetAboutHealthBenefitsofSmokingCessation;NHSSmokeFree‘WhyQuitTimeline’;AmericanCancerSocietyWhenSmokersQuit–WhatAreTheBenefitsOverTime?
What is Smoking Costing You?
NUMBER OF CIGARETTES
SMOKED EACH DAY
NUMBER OF CIGARETTES SMOKED IN
A YEAR
WASTED HOURS
COST PER DAY
€
COST PER WEEK
€
COST PER MONTH
€
COST PER YEAR
€
5 1,825 122 2.28 15.93 69.20 830.38
10 3,650 243 4.55 31.85 138.40 1,660.75
15 5,475 365 6.83 47.78 207.59 2,491.13
20 7,300 487 9.10 63.70 276.79 3,321.50
40 14,600 973 18.20 127.40 553.58 6,643.00
60 21,900 1,460 27.30 191.10 830.38 9,964.56
Packof20cigarettescosts€9.10@May2012.
7. BenefitsofQuitting
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
32
Bibl
iogr
aphy
AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease:WhatitMeanstoYou(2010).Availableathttp://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf
AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease2010–TheBiologyandBehavioralBasisforSmoking-AttributableDiseaseFactSheet.Availableathttp://www.surgeongeneral.gov/library/reports/tobaccosmoke/factsheet.html
BaborTF,Higgins-BiddleJC(2001)BriefInterventionforHazardousandHarmfulDrinking,AManualforUseinPrimaryCare.Geneva:WorldHealthOrganisation.
BrughaR,TullyN,DickerP,ShelleyE,WardM,McGeeH(2009)SLÁN2007SurveyofLifestyle,AttitudesandNutritioninIreland.SmokingPatternsinIreland:ImplicationsforPolicyandServices.DepartmentofHealthandChildren.Dublin:TheStationeryOffice.
ButtonTMM,ThaparA,McGuffinP(2005)RelationshipbetweenAntisocialBehaviour,Attention-DeficitHyperactivityDisorderandMaternalPrenatalSmoking.BritishJournalofPsychiatry.Vol.187:155-60.
CampaignforTobacco-FreeKids(2012).Availableathttp://www.tobaccofreekids.org/research/factsheets/pdf/0001.pdf
CancerinIreland2011:AnnualReportoftheNationalCancerRegistry(2011).Availableathttp://www.ncri.ie/pubs/pubfiles/AnnualReport2011.pdf
FioreMC,JaénCR,BakerTB,etal.(April2009)TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.
GrantBF,HasinDS,ChouSP,StinsonFS,DawsonDA(2004)NicotineDependenceandPsychiatricDisordersintheUnitedStates:ResultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedConditions.ArchivesofGeneralPsychiatry.Vol.61(11):1107-15.Availableathttp://archpsyc.jamanetwork.com/article.aspx?articleid=482090
HealthServiceExecutiveQUITCampaign(2011).Availableathttp://www.quit.ie/en/1_in_every_2_smokers
HoweG,WesthoffC,VesseyM,andYeatesD(1985)EffectsofAge,CigaretteSmokingandOtherFactorsonFertility:FindingsinaLargeProspectiveStudy.BritishMedicalJournal(ClinResEd).Vol.290:1697-700.
HowellF(2011)SmokingRelatedDischarges,BedDaysandCostsintheAcuteHospitalSector,ProceedingsoftheFacultyofPublicHealthMedicineRCPISummerMeeting,page21.Dublin.Availableathttp://www.rcpi.ie/Documents/SSM%20final%20programme%20for%20web%20170511.pdf
InternationalAgencyforResearchonCancer(2004)IARCMonographsontheEvaluationofCarcinogenicRiskstoHumans:TobaccoSmokeandInvoluntarySmoking.Vol.83.Lyon(France):InternationalAgencyforResearchonCancer.
IrishThoracicSociety(2008)INHALEReport,2ndEd.Dublin:IrishThoracicSociety.
8. Bibliography
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
32 33
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBibliography
LeHouezecJ(2003)RoleofNicotinePharmacokineticsinNicotineAddictionandNicotineReplacementTherapy:AReview.TheInternationalJournalofTuberculosisandLungDiseaseVol.7(9):811–9.Availableathttp://www.ncbi.nlm.nih.gov/pubmed/12971663
MillerBJ,PaschallCB3rd,SvendsenDP(2006)MortalityandMedicalCo-MorbidityamongPatientswithSeriousMentalIllness.PsychiatrisServicesVol.57(10):1482-7.Availableathttp://www.ncbi.nlm.nih.gov/pubmed/17035569
MillerWR,RollnickS(1991)MotivationalInterviewing:PreparingPeopletoChangeAddictiveBehaviour.NewYork:GuilfordPress.
MillerWR,RollnickS(2002)MotivationalInterviewing,PreparingPeopleforChange(2nded).NewYork:TheGuilfordPress.
NationalInstituteforHealthandClinicalExcellence(2006)BriefInterventionsforSmokingCessationinPrimaryCareandOtherSettings,PublicHealthInterventionGuidance1:QuickReferenceGuide.London:NationalInstituteforHealthandClinicalExcellence.
NilsenP,KanerE,BarborTF(2008)BriefInterventionThreeDecadesOn:AnOverviewofResearchFindingsandStrategiesforMoreWidespreadImplementation.NordicStudiesonAlcoholandDrugsVol.25:453-67.
OfficeofTobaccoControl(2004)SecondHandSmoke–theFacts.Availableathttp://www.ntco.ie/uploads/final.pdf
OfficeofTobaccoControl(2012).Availableathttp://www.otc.ie/research.asp#section1
PassiveSmokingandChildren(2010).Availableathttp://old.rcplondon.ac.uk/professional-Issues/Public-Health/Documents/Preface-to-passive-smoking-and-children-March-2010.pdf
ProchaskaJO,andDiClementeCC(1983)StagesandProcessesofSelfChangeofSmoking:TowardanIntegrativeModelofChange.JournalofConsultingandClinicalPsychology.Vol.51(3):390-5.
PublicHealth(Tobacco)Act,2002.Availableathttp://www.irishstatutebook.ie/2002/en/act/pub/0006/sec0045.html
RisksAssociatedwithSmokingCigaretteswithLowMachine-MeasuredYieldsofTarandNicotine.SmokingandTobaccoControlMonograph13(2001).Availableathttp://cancercontrol.cancer.gov/tcrb/monographs/13/m13_complete.pdf
RogersCR(1951)Client-CenteredTherapy:ItsCurrentPractice,ImplicationsandTheory.Oxford,England:HoughtonMifflin.
RollnickS,MasonP,ButlerC(1991)HealthBehaviourChange:AGuideforPractitioners.Edinburgh:ChurchillLivingstone.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
34
Bibl
iogr
aphy
ScolloMM,WinstanleyMH(2008)TobaccoinAustralia:FactsandIssues.ThirdEdition.InfluencesonUptakeofSmoking.Availableathttp://www.tobaccoinaustralia.org.au/downloads/chapters/Ch5_Uptake.pdf
SeltzerV(2003)SmokingasaRiskFactorintheHealthofWomen.InternationalJournalofGynecology&Obstetrics.Vol.82:393-7.Availableathttp://www.ijgo.org/article/S0020-7292(03)00227-3/fulltext
ShawM,MitchellR,DorlingD(2000)TimeforaSmoke?OneCigaretteReducesyourLifeby11minutes.BMJ.Vol.320:53.Availableathttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117323/
Smoking’sImmediateEffectsontheBody(2009).Availableathttp://www.tobaccofreekids.org/research/factsheets/pdf/0264.pdf
SteadLF,BergsonG,Lancaster,T(2008)PhysicianAdviceforSmokingCessation(Review).TheCochraneCollaboration:JohnWiley&SonsLtd.
TheHealthConsequencesofInvoluntaryExposuretoTobaccoSmoke:AReportoftheSurgeonGeneral–ChildrenareHurtbySecondhandSmoke(2007).Availableathttp://www.surgeongeneral.gov/library/reports/secondhandsmoke/factsheet2.html
TsuangMT,StoneWS,LyonsMJ(2007)RecognitionandPreventionofMajorMentalandSubstanceUseDisorders.Washington,DC:AmericanPsychiatricPublishing.
WarnerKE(2007)InSearchoftheElusive‘ReplacementSmoker’:WhytheTobaccoIndustryHasn’tGivenUponIreland’sKids…andWhyYouShouldn’tEither.Availableathttp://www.otc.ie/article.asp?article=366
WestR,McNeillM,RawM(2000)SmokingCessationGuidelinesforHealthProfessionals;AnUpdate.Thorax.Vol.55:987-99.
What’sinaCigaretteFactSheet,(2009).Availableathttp://ash.org.uk/files/documents/ASH_117.pdf
WorldHealthOrganisation(1993)TheICD-10ClassificationofMentalandBehaviouralDisorders–DiagnosticCriteriaforResearch.Geneva:WorldHealthOrganisation.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEA
ppendices
Preamble:Inordertocontributeactivelytothereductionoftobaccoconsumptionandincludetobaccocontrolinthepublichealthagendaatnational,regionalandgloballevels,itisherebyagreedthathealthprofessionalorganisationswill:
1. Encourageandsupporttheirmemberstoberolemodelsbynotusingtobaccoandbypromotingatobacco-freeculture.
2. Assessandaddressthetobaccoconsumptionpatternsandtobacco-controlattitudesoftheirmembersthroughsurveysandtheintroductionofappropriatepolicies.
3. Maketheirownorganisations’premisesandeventstobaccofreeandencouragetheirmemberstodothesame.
4. Includetobaccocontrolintheagendaofallrelevanthealth-relatedcongressesandconferences.
5. Advisetheirmemberstoroutinelyaskpatientsandclientsabouttobaccoconsumptionandexposuretotobaccosmoke–usingevidence-basedapproachesandbestpractices–giveadviceonhowtoquitsmokingandensureappropriatefollow-upoftheircessationgoals.
6. Influencehealthinstitutionsandeducationalcentrestoincludetobaccocontrolintheirhealthprofessionals’curricula,throughcontinuededucationandothertrainingprogrammes.
7. ActivelyparticipateinWorldNoTobaccoDayevery31May.
8. Refrainfromacceptinganykindoftobaccoindustrysupport–financialorotherwise–andfrominvestinginthetobaccoindustry,andencouragetheirmemberstodothesame.
9. Ensurethattheirorganisationhasastatedpolicyonanycommercialorotherkindofrelationshipwithpartnerswhointeractwithorhaveinterestsinthetobaccoindustrythroughadeclarationofinterest.
10. Prohibitthesaleorpromotionoftobaccoproductsontheirpremises,andencouragetheirmemberstodothesame.
11. Activelysupportgovernmentsintheprocessleadingtosignature,ratificationandimplementationoftheWHOFrameworkConventiononTobaccoControl.
12. Dedicatefinancialand/orotherresourcestotobaccocontrol–includingdedicatingresourcestotheimplementationofthiscodeofpractice.
13. Participateinthetobacco-controlactivitiesofhealthprofessionalnetworks.
14. Supportcampaignsfortobaccofreepublicplaces.
AdoptedandsignedbytheparticipantsoftheWHOInformalMeetingonHealthProfessionalsandTobaccoControl;28-30January2004;Geneva,Switzerland.
Appendices
WHOCodeofPracticeonTobaccoControlforHealthProfessionalOrganisations
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
36
App
endi
ces
TFUCharter
HPH & ENSH Collaborative Taskforce on Tobacco Tobacco Free United – (TFU)
As Health Personnel (Doctor, Nurse or other):
1. I am conscious of the harmful effects of tobacco• toeachsmoker/tobaccouser• toeachpersonwholiveswithasmoker• tosociety
2. I know that exposure to environmental tobacco smoke also called “second hand smoke” and “passive smoking” is a widespread source of morbidity and mortality that imposes a significant cost on society.
3. I am conscious that tobacco is a drug that causes psychological and pharmacological dependence
4. I am ready to motivate tobacco user to quit
5. I am willing to discourage tobacco use of any kind:• bypresentingmyselfasagoodrolemodelbynotsmokingorusingtobacco• bypromotingthedesignationandmaintenanceofhealthcareserviceastobaccofree• bydevelopingskillstoclarifytobaccoaddictionandmotivatetobaccousersandrelativestoquit• bypromotingtobaccocessationinmysociallife
6. I realise that I have a great responsibility, not only towards patients but also to colleagues and to the general public and, in particular, towards the young generations• Iincitemanagerstoapproveandtakeappropriatepreventivemeasures
We – as Health Personnel (Doctors, Nurses and other) – join our efforts and strength to reduce tobacco consumption in the knowledge that it is the single most important voluntary risk factor and the cause of many early deaths in our communities.
Name&Surname
Profession
Hospital/Service
City Country
Date / /
Signature
IgivepermissiontopublishmynameintheCharterRegisteronpaper&web(pleasetick):
This Charter is based on the TFU Pact on Tobacco for Hospitals and Health Services and can be found online http://www.ensh.eu/tfu-form.php
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEA
ppendices
FiveKeyToolsforSuccessfulInterventions
1. Framework for Brief Intervention for Smoking Cessation
The5As
systematically identify all smokers at every visit. Record smoking status, no. of cigarettes smoked per day/week and year started smoking.
ASK �
urge all smokers to quit. Advice should be clear and personalised.
ADVISE �
determine willingness and confidence to make a quit attempt; note the stage of change.
ASSESS �
aid the smoker in quitting. Provide behavioural support. Recommend/prescribe pharmacological aids. If not ready to quit promote motivation for future attempt.
ASSIST �
follow-up appointment within 1 week or if appropriate refer to specialist cessation service for intensive support. Document the intervention.
ARRANGE �
AdaptedfromFioreMC,JaénCR,BakerTB,etal.TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.April2009.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
38
App
endi
ces
2. Referral Pathways to National & Local Smoking Cessation Support Services
Thereisawiderangeofsupportsavailabletohelpsmokerstoquit.Theseinclude:
1. QUIT.ie isaHSEhealtheducationwebsiteaimedatencouragingsmokerstoquit.Ithasinformationonthehealthimpactsofsmoking,benefitsofquitting,usefultipsonhowtomeasurelevelofaddictionandacostcalculator.ThereisalsoanoptiontosignuptoaQUITplanandreceiveongoingemailsupportduringthefirstsixweeks.
2. ‘You can QUIT’ facebookpagewww.facebook.com/HSEquitisanonlinecommunitysupportingquittersthroughtheirquitjourney.
3. HSE’sNational Smokers’ QUITline 1850 201 203 offersaconfidentialcounsellingservicetoanyoneseekingsupportorinformationaboutquittingsmoking.Theserviceisavailable8am-10pmMondaytoSaturday.
4. HSESmoking Cessation Services providespecialistsupporttoclientseitherincommunityorhealthservicesettings(seelist).Servicesvarybetweenareasandcanincludeone-to-one,grouportelephonesupport.Servicesareavailablefreeofcharge.
HSE DUBLIN MID-LEINSTERDublinSouthEast 012744297DublinSouthCentral 014632800DublinSouthWest 014632800DublinWest 014632800Kildare 014632800Longford 1800242505Laois 1800242505Offaly 1800242505Westmeath 1800242505WicklowEast 012744297WicklowWest 014632800
HSE DUBLIN NORTH EASTCavan 0416850671DublinNorthCity 018976184DublinNorthCounty 018976184Louth 0416850671Meath 0416850671Monaghan 0416850671
HSE SOUTHCarlow 0567761400CorkCity 0214921641CorkNorth 02258634CorkWest 02840418Kerry 0667195617Kilkenny 0567761400TipperarySouth 0526177037Waterford 051846712Wexford 1850201203
HSE WESTClare 0656865841Donegal 1850200687LetterkennyGeneralHospital 0749123678GalwayUniversityHospital 091542103Leitrim 1850200687Limerick 061301111Mayo 1850201203Roscommon 1850201203Sligo 1850200687SligoGeneralHospital 0719174548TipperaryNorth 1850201203
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEA
ppendices
3. Fagerstrom Test for Nicotine Dependence
Score 8+ = high dependence
Score 5-7 = moderate dependence
Score 3-4 = low to moderate dependence
Score 0-2 = low dependence
QUESTION RESPONSE SCORE
1. Howsoonafteryouwakeupdoyousmokeyourfirstcigarette?
After60minutes
31-60minutes
6-30minutes
Within5minutes
0
1
2
3
2. Doyoufinditdifficulttorefrainfromsmokinginplaceswhereitisforbidden?
No
Yes
0
1
3. Whichcigarettewouldyouhatemosttogiveup? Thefirstinthemorning
Anyother
1
0
4. Howmanycigarettesdoyousmokeperday? 10orless
11-20
21-30
31ormore
0
1
2
3
5. Doyousmokemorefrequentlyduringthefirsthoursafterwaking,thanduringtherestoftheday?
No
Yes
0
1
6. Doyousmokeevenifyouaresoillthatyouareinbedmostoftheday?
No
Yes
0
1
AdaptedfromHeathertonTF,KozlowskiLT,FreckerRC,FagerstromKO.TheFagerstromTestforNicotineDependence:ArevisionoftheFagerstromToleranceQuestionnaire.BritishJournalofAddictions1991;86:1119-27.
Themostdistinctiveindicatorsofnicotinedependenceare:
• Timetofirstcigaretteafterwaking
• Thenumberofcigarettessmokedperday
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
40
App
endi
ces
4. Decisional Balance Tool
REASONS TO STAY THE SAME REASONS TO CHANGE
Benefits:
Whatdoyoulikeaboutsmoking?
•
•
•
•
•
•
Concerns:
Whatconcernsyouaboutsmoking?
•
•
•
•
•
•
Concerns:
Whatconcernswouldyouhaveifyouweretoquit?
•
•
•
•
•
•
Benefits:
Whatarethebenefitsofquitting?
•
•
•
•
•
•
On a scale of 1-10, how ready are you to quit smoking?
(1 = not ready; 10 = ready)
� 1 2 3 4 5 6 7 8 9 10 �
On a scale of 1-10, how confident are you that, if you tried, you could quit for good?
(1 = not at all confident; 10 = very confident)
� 1 2 3 4 5 6 7 8 9 10 �
On a scale of 1-10, how important is quitting smoking to you?
(1 = not at all important; 10 = very important)
� 1 2 3 4 5 6 7 8 9 10 �
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEA
ppendices
5. Smoking Diary
1. Number of cigarettes smoked
DAY MORNING AFTERNOON EVENING TOTAL
1
2
3
4
5
6
7
2. Other things to consider
WhyIneededtosmoke?
WheredidIsmokemost?
Whowith?
Desiretosmoke*
HowmuchdidIenjoyit?**
HowdidIfeelafter?
*10isaverystrongdesiretosmoke,1isnodesireatall.**10isreallyenjoyedcigarette,1isdidn’tenjoyatall.
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
42
App
endi
ces
UsefulResources
HSEQuitSmokingWebsite www.quit.ie
HSETobaccoFreeCampusPolicy www.hse.ie/tobaccofreecampus
HSENationalTobaccoControlOffice www.ntco.ie
CochraneReviews www.cochrane.co.uk
TreatTobacco www.treatobacco.net
WorldHealthOrganisation www.who.int/tobacco/mpower
USSurgeonGeneral http://www.surgeongeneral.gov/initiatives/tobacco/index.html
NationalInstituteforClinicalExcellence www.nice.org.uk
SocietyforResearchonNicotineandTobacco www.srnt.org
SocietyfortheStudyofAddiction www.addiction-ssa.org
AgencyforHealthcareQualityResearch www.ahrq.gov
Motivational Interviewing: Preparing People to Change Addictive Behaviour
WilliamRMiller&StephenRollnick(1991)
GuilfordPress:NewYork
Motivational Interviewing: Preparing People for Change
WilliamRMiller&StephenRollnick(2002)
GuilfordPress:NewYork
Health Behaviour Change: A Guide for Practitioners
StephenRollnick,PipMason&ChrisButler(1991)
ChurchillLivingstone:Edinburgh
Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual
MaryMardenVelasquez,GaylynGaddyMaurer,CathyCrouch,CarloC.DiClemente
GuilfordPress:NewYork
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
42 43
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
UsefulResources
HSEQuitSmokingWebsite www.quit.ie
HSETobaccoFreeCampusPolicy www.hse.ie/tobaccofreecampus
HSENationalTobaccoControlOffice www.ntco.ie
CochraneReviews www.cochrane.co.uk
TreatTobacco www.treatobacco.net
WorldHealthOrganisation www.who.int/tobacco/mpower
USSurgeonGeneral http://www.surgeongeneral.gov/initiatives/tobacco/index.html
NationalInstituteforClinicalExcellence www.nice.org.uk
SocietyforResearchonNicotineandTobacco www.srnt.org
SocietyfortheStudyofAddiction www.addiction-ssa.org
AgencyforHealthcareQualityResearch www.ahrq.gov
Motivational Interviewing: Preparing People to Change Addictive Behaviour
WilliamRMiller&StephenRollnick(1991)
GuilfordPress:NewYork
Motivational Interviewing: Preparing People for Change
WilliamRMiller&StephenRollnick(2002)
GuilfordPress:NewYork
Health Behaviour Change: A Guide for Practitioners
StephenRollnick,PipMason&ChrisButler(1991)
ChurchillLivingstone:Edinburgh
Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual
MaryMardenVelasquez,GaylynGaddyMaurer,CathyCrouch,CarloC.DiClemente
GuilfordPress:NewYork
Notes
BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE
44
Notes
National Tobacco Control Office
Health Service Executive Oak House, Millennium Park
Naas, Co. Kildare
Telephone: 045 880400 www.hse.ie