TOBACCO AS A VITAL SIGN

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3 TOBACCO AS A VITAL SIGN The Tobacco Free Futures guidelines provide health care providers and teams with an overview of the knowledge, skills and resources to address a major crippler and killer: tobacco dependency. With the publication of the 2014 Surgeon General s Report: The Health Consequences of Smoking 50 Years of Progress, tobacco reduction efforts mark an important milestone: it has been a half century since the 1964 U.S. Surgeon General s Report on Smoking and Health first warned of the health consequences of tobacco use. Although great gains have been made, the 2014 report reaffirms that tobacco use and exposure continues to take a toll on the population that we care for. Tobacco use and exposure still kills at least one in two of its regular users and is responsible for 30% of all cancer-related deaths in Alberta. It is important that we recognize tobacco use is as important a vital sign as blood pressure or heart rate in assessing someone s health. Creating Tobacco Free Futures: Alberta s Strategy to Prevent and Reduce Tobacco Use clearly identifies tobacco reduction as a priority for our province. The four strategic directions (prevention, protection, cessation and knowledge translation and capacity building) offer a comprehensive approach to reducing tobacco use and exposure. We have seen the provincial prevalence of tobacco use fall from 36% in 1985 to 17.7% in 2011 (as defined by current smokers). Unfortunately, the risk reduction and health improvement has not been shared uniformly across the Alberta population. There are communities and specific populations where the use of tobacco remains over 40%. Tobacco use continues to shorten lives and cause premature disability. In Alberta, the costs of treating tobacco-related illness alone are estimated to be $470.6 million per year. We have the necessary knowledge and tools to help our patients and clients with their tobacco dependency, if we are only prepared to use them. Offering tobacco treatment as a standard of care requires changes to our systems to support all tobacco users. The starting point is having health care providers prepared to ASK every patient/client who presents in a health care setting if they use tobacco, ADVISE all tobacco users to quit, ASSESS their readiness to quit and interest in withdrawal support, ASSIST by providing pharmacotherapy and behavioural support and ARRANGE ongoing support. Funding from the Alberta Cancer Prevention Legacy Fund (ACPLF) for , along with support from the Canadian Cancer Society, has enabled the development of the Tobacco Free Futures guidelines and supplementary resources. These tools have been developed through a collaborative process, with contributions from many individuals and groups from across the province who have shared their time and wisdom to inform and validate the final products. The 2014 guidelines and tools have gone through an extensive revision and new content has been added. New chapters continue to address implementation in a variety of care settings and with specific populations for example, the unique challenges of addressing tobacco with clients who face other addictions and mental health conditions. With the ACPLF funding ending in September 2014, Tobacco Free Futures has been incorporated within the range of services offered by Alberta Health Services (AHS) to Albertans. The Tobacco Reduction Program will work with health care facilities and programs across the province to help join those who have already implemented the innovation. Together we can realize the goal of providing a seamless and integrated system of support for all Albertans who are affected by the use of tobacco products. I hope you will take up the challenge and become a champion for implementing the Tobacco Free Futures model in your health care setting. Sincerely, Brent Friesen MD FRCPC Medical Officer of Health AHS Tobacco Reduction Program Alberta Health Services 2014 i

4 Disclaimer Every effort has been made to ensure the links in this document are up to date; however, we cannot guarantee they will work. Some links will give error messages because of the security settings on the source files. These files are accessible to AHS staff only. AHS staff can access the documents by copying and pasting the link into their browsers. Copyright Copyright Alberta Health Services. All rights reserved. Alberta Health Services cannot guarantee the validity of the information contained in these guidelines. No part of this document may be reproduced, modified or redistributed in any form without the prior written permission of Alberta Health Services. ii Tobacco Free Futures

5 Contents Opening message: Tobacco as a vital sign i Introduction 1. Tobacco Free Futures: A systems change management model Supporting cessation in health care settings Alignment with strategic priorities and policies Site/program implementation of Tobacco Free Futures References The effects of tobacco exposure Tobacco facts References Initial planning 3. Engagement Leadership support References Appendices Tobacco Free Futures site steering committee Forming a multidisciplinary committee Tobacco Free Futures workshop Appendices Policy Tobacco-free environments AHS Tobacco and Smoke Free Environments Policy TSFE policy protocols Use of tobacco-like products on AHS property TSFE policy-supporting resources References Appendices Timelines Purpose of timelines and schedules Creating an implementation timeline Appendices Alberta Health Services 2014 iii

6 Resource and support planning 7. Brief intervention Tobacco cessation support models for health care settings Brief tobacco intervention Brief tobacco intervention staff roles and documentation References Appendices Intensive cessation counselling Guidelines for intensive cessation support Transtheoretical model of change Clients not yet ready to quit Clients ready to quit Clients who have recently quit Staff roles and documentation References Appendices Pharmacotherapy Pharmacotherapy treatments Assessing nicotine withdrawal Pharmacotherapy staff roles and documentation References Appendices Preparing staff 10. Communication Introduction to the Tobacco Free Futures site communications plan Communications for initial engagement Preparing staff for implementation Site-wide awareness of program and supports Appendices Training AHS tobacco treatment training AHS site capacity-building training and education References iv Tobacco Free Futures

7 Final Planning 12. Sustainability Sustaining Tobacco Free Futures References Appendices Continuous improvement Introduction to quality improvement Leadership Performance measurement Quality improvement using the AHS Improvement Way References Appendices Specific care settings 14. Surgical care Addressing tobacco use in surgical care References Emergency and urgent care Addressing tobacco use in emergency and urgent care References Home care Addressing tobacco use in home care settings References Appendices Public health Addressing tobacco use in public health settings References Appendices Transition and community care Implementation of Tobacco Free Futures in transition and continuing care References Alberta Health Services 2014 v

8 Specific Populations 19. Addiction and mental health Introduction Tobacco treatment recommendations Alzheimer s disease and dementia Anxiety disorders Depression Schizophrenia Substance use disorders References Appendices Reproductive years Introduction Women and girls of reproductive age (not pregnant or breastfeeding) Pregnant and postpartum women Pregnant and postpartum adolescents References Appendices Youth and family (under development) vi Tobacco Free Futures

9 Introduction 1. Tobacco Free Futures: A Systems Change Management Model 2. The Effects of Tobacco Exposure AlbertaQuits.ca

10 Introduction The Tobacco Free Futures guidelines describe an integrated health system tobacco cessation model that is based on best practices. These guidelines were developed as a resource for managers, tobacco steering committee members and other health professionals to assist healthcare sites/programs implement the tobacco cessation support model. The resource and accompanying tools (see appendices) have been written and developed based on the organizational context of Alberta Health Services (AHS). This introductory section includes two chapters that will provide the background information for the sections that follow. Chapter 1: Tobacco Free Futures: A Systems Change Management Model Background information about the development of the Tobacco Free Futures initiative. An overview of a systems approach for tobacco cessation treatment. Highlights of the national CAN-ADAPTT smoking cessation guidelines. Alignment with strategic priorities in the Alberta Health Services context. Summary of the phases and processes for implementation of the Tobacco Free Futures initiative. Chapter 2: The Effects of Tobacco Exposure Review of key health consequences related to tobacco exposure. Types of tobacco commonly used in Alberta. Review of the psychological and physiological effects of nicotine. An overview of the impact of environmental exposure to tobacco. The health benefits of tobacco cessation.

11 Chapter 1 Tobacco Free Futures: A Systems Change Management Model Alberta Health Services

12 SUPPORTING CESSATION IN Health care SETTINGS The Tobacco Free Futures initiative Tobacco Free Futures is an integrated health systems tobacco cessation model that was developed for the Alberta Health Services (AHS) context. The initiative is grounded in the available literature, including established national and international guidelines, and offers an integrated level of cessation support for Albertans who use tobacco products. The aim of the model is to help decrease tobacco use and support the Alberta Cancer Prevention Legacy Fund s vision of preventing cancer through innovative research and prevention strategies. The Canadian Cancer Society reports that the use of tobacco products is responsible for about 30% of all cancer deaths in Canada. 1 Tobacco Free Futures was developed to support AHS systems change related to tobacco cessation treatment, providing guidance and standardized resources that can support adopting tobacco treatment as a standard of care. Tobacco interventions can range from brief intervention (the 5 A s model: ASK, ADVISE, ASSESS, ASSIST and ARRANGE) to more intensive treatment and can be delivered across the continuum of care. This Alberta-based initiative was developed through a collaborative process, with contributions from individuals and groups from across the province. It has been heavily informed by the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-Informed Tobacco Treatment (CAN-ADAPTT), led by the Centre for Addiction and Mental Health (CAMH) in Toronto, and by the Ottawa Model for Smoking Cessation from the Ottawa Heart Institute. Tobacco Free Futures was funded for through the Alberta Cancer Prevention Legacy Fund (ACPLF). Targeted funding allowed for the development of provincial standards of care, practice guidelines, documentation standards (paper and electronic), training and supplementary resources. To date, the initiative has been implemented in many care settings across the province, including urban inpatient acute care, rural inpatient acute care, addictions detoxification and residential treatment, public health programs, home care, continuing care and outpatient services. 1.2 Tobacco Free Futures

13 Figure 1.1: Tobacco Cessation Linked System of Support Community Resources Healthy public policy Supportive environments Partnerships Referrals Health care Setting Integrated tobacco support Patient/client self-management Multidisciplinary team to support treatment Evidence-based guidelines and education Information system to support treatment Informed, engaged patient Ask Advise Assess Assist Arrange Prepared, proactive health care team Adapted by Tobacco Free Futures from the Chronic Care Model (Wagner et al., 2002) 12 A systems approach for effective tobacco treatment The framework in Figure 1.1 is an adaptation of Wagner et al. s Chronic Care Model (2002). It illustrates how a linked system of support from community members across the continuum of care can positively impact the treatment of tobacco dependence and nicotine addiction. 2 This framework views the health system as part of a larger community. Effective tobacco dependence and nicotine addiction management requires an appropriately organized health care system that has access to necessary resources available in the broader community. The health system must have in place the leadership, supports and resources required to meet the needs of patients who use tobacco products. 2,4 These factors support the development of informed, engaged Tobacco use is not a lifestyle choice. It is a chronic,relapsing condition grounded in an addiction to nicotine. 3 patients as well as prepared, proactive health care teams. Preparation means having the necessary skills, expertise, information, time and resources to assure effective treatment. 2 Alberta Health Services

14 The middle section of the framework represents the enhancements that contribute to productive interactions between providers and patients. Patient/client self-management: empowering patients with the information and confidence to make the best use of their involvement with their health care team. Multidisciplinary team: meeting the needs of patients who require more time, a broader array of resources and closer follow-up. Evidence-based guidelines: using explicit plans and protocols. Education: providing training and decision support through guidelines and other tools. Information systems: supporting population-based care, including provider reminders and feedback. The 5A s model, used between the health care team (in a variety of settings) and the client, assures the delivery of services that will improve tobacco treatment outcomes. Desired outcomes of tobacco treatment include measures of clinical care, health status, satisfaction, health care usage and cost. 2 CAN-ADAPTT smoking cessation guidelines The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice informed Tobacco Treatment (CAN-ADAPTT) completed a literature review and developed a set of practice-informed and evidence-based smoking cessation practice guidelines that are intended for use by Canadian health care providers in a variety of settings. 4 CAN-ADAPTT guidelines advocate for the 5 A s model as a basis for intervention for all health care providers. They also provide direction for the care of specific populations, including Aboriginal peoples, hospital-based populations, people with mental health or addictions concerns, pregnant and breastfeeding women, and youth (children and adolescents). 4 These guidelines informed the Tobacco Free Futures initiative. For more information about the CAN ADAPTT guidelines, see Table 1.1. CAN-ADAPTT s vision is a Canada where health care providers have access to the tools needed to deliver up to date evidence based smoking cessation interventions to reduce the prevalence of tobacco use and dependence Tobacco Free Futures

15 Table 1.1: CAN-ADAPTT Guidelines for General and Hospital-Based Populations 5 General Health care providers should Hospital-based populations Facilities should have systems in place to ASK ask every patient/client about his or her tobacco use and update that status on a regular basis Grade 1A* identify all tobacco users Grade 1A ADVISE clearly advise all patients/clients who use tobacco to quit Grade 1C provide clear advice to quit make patients/clients aware of hospital tobacco policies Grade 1C Grade 1C ASSESS ASSIST ARRANGE assess the willingness of patients/clients to begin treatment to quit Grade 1C offer assistance to every tobacco user who is willing to begin treatment to quit Grade 1A assist with minimum brief intervention Grade 1A when possible, assist with intensive counselling Grade 1A combine counselling and pharmacotherapy, which are more effective than either one on its own Grade 1A conduct follow-up, provide support and modify treatment as necessary Grade 1C refer patients/clients to relevant resources Grade 1A assess the willingness of patients/clients to begin treatment to quit (or manage withdrawal) Grade 1C link all elective patients who use tobacco to resources to help them quit before admission or surgery Grade 1B manage a client s tobacco withdrawal during hospital stay, including pharmacotherapy Grade 1C promote a client s attempts towards quitting Grade 1A link patients to follow-up support upon discharge Grade 1A arrange continued pharmacotherapy use post hospitalization Grade 1B *Grades of evidence are based on the strength of the recommendation (1 = strong, 2 = weak) and the quality of the evidence (A = high, B = moderate, C = low). Alberta Health Services

16 Alignment with strategic priorities and policies The Tobacco Free Futures initiative aligns with or complements a number of Alberta and AHS strategic documents and policies, including the AHS mission, values, health and business plans, as well as the ACPLF framework. A number of Government of Alberta-led strategic documents, including tobacco, mental health and cancer care frameworks, provide guidance for the development of the initiative. Two key corporate policies are also reflected in the Tobacco Free Futures guidelines. Alberta Health Services strategic documents AHS VALUES AHS has identified seven values to lead our work, actions and decisions. 5 These values have been integrated into the development of the Tobacco Free Futures initiative in the following ways: Respect: understanding and meeting the client where he or she is at in relation to tobacco cessation and recognizing the need for support for nicotine withdrawal when a client is placed in a tobacco-free environment. Accountability: developing guidelines that are practice-informed and based on current evidence. Transparency: providing clearly defined expectations for clients, staff and visitors. Engagement: developing the Tobacco Free Futures guidelines and tools in a collaborative way, involving stakeholders from across the organization. Safety: supporting client safety by treating nicotine withdrawal to prevent unsafe behaviours, including elopement from care, being discharged against medical advice and using tobacco products on site. Learning: supporting and promoting the development of new knowledge through health care provider training and client resources. Performance: providing the best possible care to clients who are affected by exposure to tobacco products. For more information on AHS values, visit: AHS HEALTH PLAN ( ) The health plan outlines the plan of action for the next three years, and focuses on three strategic directions. 6 Implementating the Tobacco Free Futures initiative can directly or indirectly help support the goals and performance measures set out under each of these strategic directions. Table 1.2 outlines the ways in which a system approach to tobacco treatment can support the identified goals, objectives and performance measures for each of the strategic directions. 1.6 Tobacco Free Futures

17 Table 1.2: Tobacco Free Futures: Supporting the AHS Health Plan 6 Strategic direction Bringing appropriate care to communities Partnering for better health outcomes Achieving health system sustainability Tobacco Free Futures supports Strengthens integration and collaboration for tobacco treatment across the continuum of care. Addresses the needs of complex, high-needs populations who are significantly affected by tobacco use, including persons with mental health problems and addictions, as well as those with significant chronic diseases, such as diabetes, congestive heart failure and chronic obstructive pulmonary disease. Reducing tobacco use and exposure can improve a person s overall health and decrease hospital admissions (primary and readmission) as well as lengths of stay. Supporting tobacco cessation for the elderly can also help facilitate placement in continuing care. Tobacco exposure affects all major systems in the body and is a key risk factor in the development of cancer and chronic disease. Identifying and providing treatment for tobacco use can improve overall health outcomes and reduce the incidence of cancer and chronic disease. Supports the work of Strategic Clinical Networks (SCNs). To date there has been engagement with all established SCNs and direct collaboration with the Cancer Care and Addiction and Mental Health SCNs. Reduction in tobacco use and exposure can lead to improved recovery following surgery or illness, reduced hospital stays and therefore decreased wait times. Practice guidelines, training and standardized order sets help ensure that cessation medications available on formulary provide the best therapeutic value. For more information on the AHS health plan, visit: ALBERTA CANCER PREVENTION LEGACY FUND The Alberta Cancer Prevention Legacy Fund: Strategic Framework was developed to guide the annual $25 million investment by the province into the ACPLF over the next three years. The ACPLF s mission statement is to transform cancer prevention for Albertans through innovative population-based initiatives, screening and collaborative, focused research. 7 The vision and mission for the fund are based on the evidence that 50% of cancer cases are related to modifiable factors, including tobacco. The plan includes a coordinated approach to prevention and screening through seven innovation teams. 7 The Tobacco Free Futures initiative falls under the Acute Care Innovation Team, and has been funded by ACPLF to September Sustaining the initiative at the end of the funding cycle will be supported by the AHS Tobacco Reduction Program (TRP). The success of Tobacco Free Futures has led to a number of new projects under the Acute Care Innovation Team that are focused on continued innovation to support data collection and to extend the reach of the initiative. Alberta Health Services

18 Alberta strategies TOBACCO REDUCTION STRATEGY Creating Tobacco Free Futures: Alberta s Strategy to Prevent and Reduce Tobacco Use, is a 10-year strategy that provides guidance and performance targets for the development of initiatives within the province. It outlines the goals and objectives under four strategic directions: prevention, protection, cessation and knowledge translation and capacity building. 8 The Tobacco Free Futures initiative is closely aligned to the goals and objectives of cessation and knowledge translation and capacity building. But it is also supportive of prevention and protection. Table 1.3 identifies the key links between the strategy and this initiative. Table 1.3: Tobacco Free Futures: Supporting the Alberta Tobacco Reduction Strategy 8 Strategic direction Prevention Protection Cessation Knowledge translation and capacity building Goal To prevent youth, young adults, pregnant women and at-risk populations from using tobacco, tobacco-like products, smokeless tobacco and other related products To protect Albertans from the harms of tobacco, tobacco-like products, smokeless tobacco and secondhand smoke. To expand comprehensive cessation initiatives. To support links between prevention, protection and cessation outcomes. Objectives linked to Tobacco Free Futures 1.2: Awareness of the harms associated with tobacco, tobacco like products and smokeless tobacco. 2.1: More Albertans will be protected from tobacco, tobacco-like products, smokeless tobacco and second-hand smoke. 2.2: Awareness of the harms associated with second-hand smoke from tobacco and tobacco-like products. 3.1: Albertans will have increased access to and availability of tobacco cessation supports and resources. 3.2: Enhanced awareness of tobacco cessation services. 3.3: Promoted cessation supports for specific settings and populations and increased uptake. 4.2: Increased awareness of tobacco reduction initiatives. 4.3: Enhanced stakeholder engagement. 4.5: Enhanced training opportunities. 4.7: Improved enforcement of tobacco reduction legislation and improved policies. 4.8: Implemented research and evaluation strategies. For more information on the Alberta Tobacco Reduction Strategy, visit: Tobacco Free Futures

19 ADDICTION AND MENTAL HEALTH STRATEGY The purpose of Creating Connections: Alberta s Addiction and Mental Health Strategy is to provide direction for the transformation of the addiction and mental health system in Alberta. The overall goal is to reduce the prevalence of addiction, mental health problems and mental illness through promotion, prevention, assessment, treatment and support activities. This strategy aligns with or complements other provincial strategies, including the Creating Tobacco Free Futures. 9 The fourth strategic direction in the strategy is focused on addressing the complex needs of this population. 9 The Tobacco Free Futures initiative includes activities and resources that increase understanding of tobacco dependence as a chronic condition based on a nicotine addiction as well as the strong links between and impacts of tobacco use related to other addictions and mental illness. Chapter 19 ( Addictions and Mental Health ) provides health care providers with background information related to tobacco use for this specific population. For more information on Alberta s Addiction and Mental Health Strategy, visit: ALBERTA S CANCER PLAN Changing Our Future: Alberta s Cancer Plan to 2030 provides a long-term strategy for cancer care and prevention for the province. The plan outlines 10 strategies for change, including reduc[ing] the risk of cancer through coordinated and integrated prevention strategies. 10 Tobacco has a high profile in the overall strategy. To realize its vision, it will be necessary to reduce the use of and exposure to tobacco, which accounts for one-third of all cancer cases. 10 The primary actions related to the prevention strategy include the need to implement the Creating Tobacco Free Futures Strategy. 10 For more information on Alberta s cancer plan, visit: Alberta Health Services

20 AHS corporate policies AHS TOBACCO AND SMOKE FREE ENVIRONMENTS POLICY The Alberta Health Services Tobacco and Smoke Free Environments Policy (TSFE) builds upon the protection provided through the provincial Tobacco Reduction Act by prohibiting tobacco use on AHS property. The policy, which came into effect April 1, 2011, prohibits tobacco use in or on all grounds, facilities, property or vehicles in an area owned, operated, leased or funded by Alberta Health Services. 11 The policy outlines the commitment to a smoke- and tobacco-free environment while ensuring the well-being of clients who use tobacco products. It is essential to ensure the comfort of clients who use tobacco while they are receiving care in AHS facilities. 11 Tobacco Free Futures provides support for successful implementation of this policy. For more information, see Chapter 5 ( Policy ). AHS HARM REDUCTION POLICY AHS is committed to harm reduction as an approach to working with clients who use psychoactive substances, including tobacco. Harm reduction is defined in the policy as policies, programs and practices that aim primarily to reduce the adverse health, social or economic consequences of the use of legal and illegal psychoactive substances without necessarily reducing consumption. The policy accepts that abstinence may not be a realistic goal for some people. 12 The support provided through the Tobacco Free Futures initiative recognizes that clients, especially those who are being treated as inpatients or residents, may not be ready to quit tobacco use. However, they still require support for nicotine withdrawal that is associated with admission to a tobacco-free facility. For more information on the AHS Harm Reduction Policy, visit: Tobacco Free Futures

21 SITE/PROGRAM IMPLEMENTATION OF TOBACCO FREE FUTURES Evidence strongly suggests that health care delivery systems institutionalize the consistent identification, documentation and treatment of every tobacco user seen in a health care setting. 3,4 Within the Tobacco Free Futures guidelines are the information, direction and tools to guide the model implementation in a specific health care site or program. Implementation phases and processes Four phases of implementation, along with their associated processes, have been identified based on development and testing of the model. The processes are not intended to be completed in a linear fashion or in isolation from one another; rather, they are interrelated and often overlap during the implementation timeline. Refer to Table 1.4 for a detailed outline of the phases and associated processes that should be considered when planning and implementing the model at health care sites. 13 Table 1.4: Phases and Processes of Tobacco Free Futures Site/Program Implementation Engage the support of senior management and physician leadership. Phase 1 Initial planning Form a multidisciplinary Tobacco Free Futures site steering committee. Complete a Tobacco and Smoke Free Environments Policy assessment. Set a timeline for implementation of all processes, including a go-live date. Phase 2 Resource and support planning Determine staff roles and ensure tobacco treatment will be documented in the client record. Ensure pharmacotherapy is available in formulary, and stocked on site, and adopt standard ordering or referral processes, if applicable. Identify and stock print resources for staff and clients. Phase 3 Preparing staff Implement a communication plan for site leadership, staff, clients and visitors. Arrange and schedule training for staff. Phase 4 Final planning Plan for sustainability and continuous improvement. Alberta Health Services

22 REFERENCES 1. Alberta Cancer Board. (2007). Evidence supporting tobacco control policies (briefing note). Calgary, AB: Author. 2. Wagner, E., Davis, C., Schaefer, J., Von Korff, M., & Austin, B. (2002). A survey of leading chronic disease management programs: Are they consistent with the literature? Journal of Nursing Care Quality, 16, Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 4. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation guideline (version two). Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 5. Alberta Health Services. (n.d.) Leading with values. Retrieved from 6. Alberta Health Services. (2013). Alberta Health Services Health Plan and Business Plan ( ): Better quality, better outcomes, better value. Retrieved from 7. Alberta Health Services & Alberta Innovates Health Solutions. (2013). Alberta Cancer Prevention Legacy Fund: Strategic framework Edmonton, AB: Authors. 8. Government of Alberta. (2012). Creating tobacco-free futures: Alberta s strategy to prevent and reduce tobacco use Retrieved from 9. Government of Alberta. (2011). Creating connections: Alberta s addiction and mental health strategy. Retrieved from Connections-2011-Strategy.pdf 10. Government of Alberta. (2013). Changing our future: Alberta s cancer plan to Retrieved from Alberta Health Services. (2011). Tobacco and Smoke Free Environments Policy. Retrieved from Alberta Health Services. (2013). Harm reduction for psychoactive substance use. Retrieved from University of Ottawa Heart Institute. (2009). Ottawa model for smoking cessation inpatient implementation guidelines. Ottawa, ON: Author Tobacco Free Futures

23 Chapter 2 The Effects of Tobacco Exposure Alberta Health Services

24 TOBACCO FACTS Health consequences of tobacco use and exposure Although there has been great progress in tobacco control in both Canada and the United States, tobacco use is still considered the single greatest preventable cause of chronic disease and premature death. 1 The U.S. government has just released the 2014 Surgeon General s Report: The Health Consequences of Smoking 50 Years of Progress, which is an update 50 years after a 1964 report first alerted the public to the health impacts of tobacco use. Since then, research has continued expanding our knowledge of the impact of tobacco exposure through active and passive smoking, the systems in the body and their relationship to acute and chronic illness. 2 Tobacco smoke contains over 7,000 chemicals, of which at least 172 are toxic substances and 69 are known carcinogens. 3 Tobacco is the only consumer product that will kill at least one of every two regular users when used as intended by the manufacturer. 4 Tobacco exposure affects the health not only of those who use the products, but also of those who experience environmental exposure. In 2012, the Canadian Tobacco Use Monitoring Survey reported that 16.1% of Canadians and 17.4% of Albertans aged 15 and over were smokers, and that the average daily smoker in Canada consumed 15 cigarettes per day. In 2010, 34% of respondents reported being exposed to second-hand smoke at least once per week. 5 Every year more than 37,000 Canadians die from tobacco-related illnesses; this translates to a death about every 11 minutes. Thousands more are diagnosed with illness due to use of the product. Two Canadian teenagers will start smoking cigarettes every 10 minutes, and one of them may die because of that decision. 6 The health consequences of tobacco use and exposure include a wide variety of acute and chronic illnesses. Tobacco use and exposure is estimated to be responsible for about 30% of all cancer-related deaths in the province. 7 Figure 2.1 illustrates the impact tobacco has on many systems of the body. 3 Figure 2.1: Health Risks of Tobacco Use and Exposure 2.2 Tobacco Free Futures

25 In Alberta, as in the rest of Canada, the impact of tobacco-related illness places a huge strain on the health care system. Based on current estimates that Albertans make up approximately 11% of the Canadian population, provincial costs are estimated in the range of $118 million to $179 million per year to treat hospitalized tobacco users. 8 Canadian estimates identify that 20% of patients admitted to hospital are smokers. 9 The risk of hospitalization for current smokers aged is 80% higher than for non-smokers. Smokers aged will stay in hospital on average 1.5 days longer than non-smoking patients; those aged will stay an average of 6 days longer. 8 Types of tobacco All tobacco products are potentially addictive and hazardous to a person s health. There are many forms of tobacco that are commonly used, including the following: Cigarettes contain more than 7,000 chemicals, 69 of which are known carcinogens. Terms such as low tar and light cigarettes are misleading and do not reduce the risk of disease. Cigarettes are highly engineered devices that allow nicotine to be delivered to the brain quickly and efficiently. 3 Cigars/cigarillos, like cigarettes, contain toxic and cancer-causing chemicals that are harmful to smokers and non-smokers. 10 A large cigar can contain as much nicotine as a package of cigarettes. Cigarillos are small, slender cigars about the size of a cigarette. The use of cigarillo products is rising in Alberta, especially among teens and young adults; flavour additives enhance the appeal. Health Canada 11, 12 considers smoking cigarillos as having the same health risks as cigarettes. Spit tobacco (also known as chew, snus and snuff) products are made of tobacco, water and additives, including flavours. They are designed to be chewed, sucked or, in some cases, inhaled through the nose. For chew tobacco (spit or spitless), nicotine and other chemicals are released from the product and absorbed through the blood vessels of the cheek. In Canada, the market trend for using smokeless tobacco has shifted from older males to boys and young men. These products contain over 3,000 chemicals, including 28 known carcinogens. Waterpipes (also known as hookah, narghile and shisha) come in different shapes and sizes, but all have a similar design that involves smoke passing through water before inhalation. The use of waterpipes is increasing in Alberta, especially among youth and young adults. Products smoked in waterpipes are often marketed as having minimal or no tar, nicotine or tobacco, but these claims have often been found to be inaccurate. Whether or not the products contain tobacco, the resulting smoke can have negative impacts on a person s health. A waterpipe user can inhale as much smoke in one hour as someone who has smoked 100 cigarettes. Waterpipe use is not a safe alternative to smoking cigarettes. 16 Electronic smoking products are battery-powered devices that look like cigarettes and vaporize a chemical mixture that may or may not include nicotine. Users puff on the electronic smoking product and inhale the fine, heated mist. Health Canada advises Canadians not to purchase or use e-cigarettes because these products may pose health risks and have not been fully evaluated for safety, quality and efficacy. 17 Alberta Health Services

26 Figure 2.2: Tobacco Products Psychological and physiological effects of nicotine In order to effectively support tobacco users, it is important to recognize the psychological and physiological effects of nicotine. Inhaling or absorbing the toxic substances is the primary cause of many of the health issues related to tobacco use; however, nicotine is the addictive agent. Repeated exposure to nicotine leads to dependence on the substance. Cigarettes and other tobacco products are designed to maximize nicotine s delivery to the brain. 4 Following inhalation or absorption, nicotine travels very quickly via the bloodstream to the brain and binds with nicotinic receptors. Stimulation of these receptors causes the initiation and maintenance of an addiction. These receptors also play a role in stimulating other brain centres, contributing to the release of dopamine, which results in the sensation of pleasure. 4 Traditionally, tobacco use has been viewed as a bad habit or lifestyle choice ; however, more recently tobacco use has been acknowledged as a chronic, relapsing condition Tobacco Free Futures

27 Figure 2.3: Psychological and Physiological Effects of Nicotine 1. When someone uses tobacco, they take in more than 7,000 chemicals, including nicotine. 2. Nicotine moves to the lungs, where it is absorbed into the bloodstream. 3. The heart pumps the nicotine throughout the body, including the brain. 4. It only takes seven seconds for nicotine to reach the brain. 5. The release of dopamine in the brain causes the high and euphoria that enhance nicotine s addictive effect. 6. Repeated exposure results in the development of tolerance, and larger doses of tobacco are required to produce the same stimulating effects. 7. When an adequate dose of nicotine isn t maintained, the tobacco user will experience symptoms of withdrawal. Tobacco users normally use enough tobacco to maintain a constant level of nicotine in their blood. But when that level drops, they will experience withdrawal symptoms. Signs and symptoms of nicotine withdrawal normally appear within two hours of a user s last nicotine use, peak in hours and last from several days to four weeks. The intensity of withdrawal symptoms can impact the success of a quit attempt. 19 A tobacco user who is abstaining or quitting deals not only with physiological withdrawal but also the conditioned response to the behaviours and cues that have accompanied their tobacco use, including the smell of tobacco, ashtrays, lighters, driving in the car, talking on the phone and drinking coffee. 3 Tobacco dependence, and the associated DSM 5 diagnosis of tobacco use disorder, is a chronic, relapsing condition, not just a bad habit or lifestyle choice. 20 Once a user becomes dependent on tobacco, it is rare that they are successful with their first quit attempt. The majority of users go through cycles of relapse and remission, which are typical of chronic conditions. Health care providers must be aware that effective treatment is comprehensive and recognizes the potential for relapse within days, months and even years. They must also recgonize the need to connect clients to ongoing support. 18 Environmental exposure to tobacco Tobacco smoke is classified into three categories: first-hand smoke, which is inhaled by the smoker; second-hand smoke, which is either exhaled by a smoker or released from the end of a burning cigarette; and third-hand smoke, which refers to the tobacco smoke residue and gases that are left behind after a cigarette has been smoked. Alberta Health Services

28 SECOND-HAND SMOKE Second-hand smoke (SHS) consists of sidestream smoke (the smoke released from the burning end of a cigarette) and mainstream smoke (the smoke exhaled by the smoker). 21 Sidestream smoke makes up about 85% of SHS. 22 It has a different chemical composition than mainstream smoke because it is generated at lower burning temperatures, and the combustion (burning) is not as clean or complete. 23 Exposure to SHS causes disease and premature death in children and adults who do not smoke. 21 Traces of carcinogens and other toxins are found in the blood, urine, saliva and breast milk of non-smokers, even after limited exposure to SHS. 21 There are no safe levels of exposure to SHS. 3 Compared to mainstream smoke, SHS contains more carbon monoxide, tar and nicotine. SHS exposure has immediate adverse effects on the adult cardiovascular system and causes coronary heart disease. Adult non-smokers who live with smokers increase their risk of heart disease by about 25%. 21,24 Exposure to SHS is also a cause of lung cancer in non-smokers. 21 Estimates indicate that more than 300 non-smokers die each year in Canada from lung cancer that is related to SHS. 25 Because their bodies are developing, infants and young children are especially vulnerable to the toxins in SHS. 21,26 Infants whose mothers smoke while pregnant and those who are exposed to SHS after birth are at increased risk of death from sudden infant death syndrome (SIDS), are more likely to have a low birth weight and are more likely to have weaker lungs than babies who are not exposed. 21 Infants with low birth weights are at increased risk of dying within the first year of life and are more likely to go on to develop coronary heart disease and type 2 diabetes. 27,28 SHS exposure also causes acute lower respiratory infections, such as bronchitis and pneumonia, and children who already have asthma experience more frequent and severe attacks. SHS also increases a child s risk of ear infections. 21 Opening windows in buildings or vehicles does not provide protection from exposure to SHS. Ventilation may mask some of the odour; however, the technology to remove carcinogens from the air does not exist. Only environments that are completely smoke free provide full protection from exposure to SHS. 2.6 Tobacco Free Futures

29 THIRD-HAND SMOKE Third-hand smoke (THS) is a more recently coined term to describe the residual tobacco smoke pollutants that remain on surfaces and in dust after tobacco has been smoked and are re emitted back into the air in the gas phase or react with oxidants and other compounds in the environment to form secondary pollutants. 29 The smoke residue, which includes many types of particulate matter (including heavy metals such as arsenic, lead and cyanide), builds up on and in many cases is absorbed into surfaces, furnishings, clothing, draperies and carpets. 30,31 Anyone who smokes in a home, car or other enclosed area in which non-smokers later are present is exposing those non-smokers to potent carcinogens. 33 The burning of tobacco also releases nicotine in the form of a vapour that attaches to surfaces such as walls, floors, carpeting, drapes and furniture. 32 Nicotine reacts with nitrous acid (a common air pollutant, one source of which is burning tobacco) and forms carcinogenic tobacco-specific nitrosamines (TSNAs). 32 The nicotine can last for weeks to months on indoor surfaces and results in the continued creation of carcinogens, which are then inhaled, absorbed or ingested. 30,32 The more a person smokes in the home or car, the more TSNAs are formed, resulting in high levels of tobacco toxins that last well beyond the period of active smoking. 33,34 Children are uniquely susceptible to THS exposure because they breathe near, crawl on, play on, touch and even taste contaminated surfaces. 34 Children can also ingest tobacco residue by placing their hands in their mouths after touching surfaces that are contaminated with THS. 30 More research is needed into the health impact of exposure to THS; however, scientific experts on THS recommend 100% smoke-free homes and vehicles and suggest that replacing nicotine-laden furnishings, carpets and wall board can significantly reduce exposure. 32 Alberta Health Services

30 Health benefits of tobacco cessation Quitting is one of the best things a tobacco user can do to improve his or her health and protect the health of his or her families and friends. Within minutes of a person s last substance use, his or her body will start a process of healing that will continue over the following weeks, months and years. Figure 2.4 identifies many of the health benefits of tobacco cessation. 35 Other benefits include 35 being a positive role model for children saving money freedom from addiction no worries about exposing family, friends and coworkers to SHS Figure 2.4: Health Benefits of Tobacco Cessation 2.8 Tobacco Free Futures

31 REFERENCES 1. World Health Organization (WHO). (2000). Global strategy for the prevention and control of non-communicable diseases. Geneva: Author. 2. United States Department of Health and Human Services (USDHHS). (2014). The health consequences of smoking 50 years of progress: A report of the Surgeon General. Rockville, MD: Author. 3. United States Department of Health and Human Services (USDHHS). (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking attributable disease: A report of the Surgeon General. Atlanta, GA: Author. 4. Els, C. (2009). Tobacco addiction: What do we know, and where do we go? Retrieved from 5. Statistics Canada. (2012). Canadian Tobacco Use Monitoring Survey (CTUMS). Retrieved from ctums-esutc_2012/ann-eng.php 6. Health Canada. (n.d.) About tobacco control. Retrieved from tobac-tabac/about-apropos/index-eng.php 7. Alberta Cancer Board (ACB). (2007). Evidence supporting tobacco control policies (briefing note). Calgary, AB: Author. 8. Wilkins, K., Sheilds, M., & Rotermann, M. (2009). Smokers use of acute care hospitals a prospective study. Health Reports 2009, 20(4), University of Ottawa Heart Institute. (2009). Ottawa model for smoking cessation inpatient implementation guideline. Ottawa, ON: Author. 10. National Cancer Institute (NCI). (2010). Cigar smoking and cancer: Fact sheet. Retrieved from Alberta Health Services (AHS). (2009). Flavour additives in tobacco products: A gateway to tobacco addiction. Edmonton, AB: Author. 12. Health Canada. (2010). Little cigars...big concerns. Retrieved from gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/tobac-tabac/little-cig-petits/little-cig-petitseng.pdf 13. Alberta Health Services (AHS).(2009). Marketing flavoured spit tobacco to youth: An industry success story. Edmonton, AB: AHS Tobacco Reduction Program. 14. Health Canada (2010). Smokeless tobacco products: A chemical and toxicity analysis. Retrieved from index-eng.php 15. Hoffman, D., & Djoerdevic, M. (1997). Chemical composition and carcinogenicity of smokeless tobacco. Advances in Dental Research, 3(11), Alberta Health Services (AHS) (2011). Waterpipe tobacco use (strategic brief). Edmonton, AB: AHS Tobacco Reduction Program. 17. Alberta Health Services (AHS). (2012). Electronic smoking products (strategic brief). Edmonton, AB: AHS Tobacco Reduction Program. 18. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Alberta Health Services

32 19. Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti P. (2007). The tobacco dependence treatment handbook: A guide to best practice. New York: Guilford Press. 20. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC : Author. 21. United States Department of Health and Human Services (USDHHS). (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Rockville, MD: Author. 22. Canadian Council for Tobacco Control (CCTC). (2001). What is secondhand smoke? Retrieved from Witschi, H., Joad, J., & Pinkerton, K. (1997). The toxicology of environmental tobacco smoke. Annual Review of Pharmacological Toxicology, 37, Law, M., Morris, J., & Wald, N. (1997). Environmental tobacco smoke exposure and ischemic heart disease: An evaluation of the evidence. British Medical Journal, 315(18), De Groh, M., & Morrison, H. (2002). Environmental tobacco smoke and deaths from coronary heart disease in Canada. Chronic Diseases in Canada, 23(1), Retrieved from Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). CAN-ADAPTT Canadian Smoking Cessation Guideline. Toronto, ON: Centre for Addiction and Mental Health. 27. Human Resources and Skills Development Canada. (n.d.). Indicators of well-being in Canada: Health low birth weight. Retrieved from eng.jsp?iid=4 28. Lumley, J., Chamberlain, C., Dowswell, T., Oliver, S., Oakley, L., & Watson, L. (2009). Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009, 3. Art. No. CD Burton, A. (2011). Does the smoke ever really clear? Thirdhand smoke exposure raises new concerns. Environmental Health Perspectives, 119, a70 a Americans for Nonsmokers Rights. (2011). Thirdhand smoke. Retrieved from Dale, L. (2011). What is third-hand smoke and why is it a concern? Retrieved from Sleiman, M., Gundel, L., Pankow, J., Jacob, P., Singer, B., & Destaillats, H. (2010). Atmospheric chemistry special feature: Formation of carcinogens indoors by surfacemediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards. Proceedings of the National Academy of Sciences, 107(15), Dreyfuss, J. (2010). Thirdhand smoke identified as potent, enduring carcinogen. CA Cancer Journal for Clinicians, 60(4), Winickoff, J., Friebely, J., Tanski, S., Sherrod, C., Matt, G., Hovell, M., & McMillen, R. (2009). Beliefs about the health effects of thirdhand smoke and home smoking bans. Pediatrics, 123, e74 e The Lung Association. (2012). Smoking and tobacco: Benefits of quitting. Retrieved from Tobacco Free Futures

33 Initial Planning 3. Engagement 4. Tobacco Free Futures: Steering Committee 5. Policy 6. Timelines AlbertaQuits.ca

34 INITIAL PLANNING Initial planning involves the formative processes to set the stage for implementation, including engaging site and/or program leadership, forming a Tobacco Free Futures steering committee, completing an assessment of how the site is complying with the AHS Tobacco and Smoke Free Environments Policy and setting initial timelines for implementation of the model. The following four chapters will provide valuable information for senior site leadership and the site committee to consider, as well as tools and resources to support these processes. Chapter 3: Engagement Overview of the importance of site/program senior management and physician leadership support. How to get formal approval to implement the Tobacco Free Futures initiative. Review of tools and techniques available for gaining support of senior site or program management. Chapter 4: Tobacco Free Futures Steering Committee Review of the purpose of a multidisciplinary committee and recommended membership. Overview of a learning opportunity for persons expected to provide leadership and guidance to support a health care setting in implementing the Tobacco Free Futures initiative. Review of tools and resources available to support the committee. Chapter 5: Policy Overview of the AHS Tobacco and Smoke Free Environments Policy and related protocols. Review of staff roles and responsibilities as outlined by the policy. Review of policy enforcement. Review of use of tobacco-like products on AHS property. Identify policy supporting resources available to AHS sites. Chapter 6: Timelines Overview of the purpose of timelines and schedules in planning for implementation. How to create an implementation timeline and plan for your site or program. Identify tools available to support implementation planning.

35 Chapter 3 Engagementx Alberta Health Services

36 LEADERSHIP SUPPORT Implementing a site systems-based approach to tobacco treatment will require the commitment and support of senior management and leadership from physicians to be successful. Once a health care setting has identified an interest in implementing the Tobacco Free Futures initiative, key stakeholders within the setting will need to be engaged. Importance of support from leadership Administrators should ensure that institutional changes promoting tobacco dependence treatment are implemented universally and systematically. 1 Successful change management requires a commitment from executives and senior managers, whether the change is occurring in a department or in the entire organization. Senior leaders can do the following to make sure their change management is successful: Establish a clear vision for the Tobacco Free Futures change management process. Paint a picture of where the site will end up and what the anticipated outcomes are. Appoint a champion who is in charge of the Tobacco Free Futures change management process and who makes sure others are involved, too. Pay attention to the changes as they happen. Ask how things are going. Focus on progress as well as barriers for the initiative. As an involved participant, sponsor portions of the process to increase active involvement and interaction with other site members. Establish a structure that will support the Tobacco Free Futures initiative. This includes forming the committee and presentations to leadership groups. Change the measurement, reward and recognition systems to measure and reward meeting new expectations as they arise. Solicit and act upon feedback from other members of the organization. Recognize the human element in the change. People have different needs and different ways of reacting to change. They need time to adjust to it. Senior leaders must participate in the training that other organization members attend, but even more importantly, they must display what they learned from the sessions, readings, interactions, tapes, books or research. 3.2 Tobacco Free Futures

37 Engagement tools and techniques Obtaining engagement from leadership means gaining its support of the Tobacco Free Futures initiative, including senior leaders understanding, commitment and action. How can you accomplish this? Health organizations base their operations on business plans and sound strategies. Identifying how new initiatives support the goals of AHS is an important first step in gaining the support of leadership. The individual responsible for engaging leadership must create a vision of a future that connects the decision-makers with the goals of the organization. AHS s vision is to become the best-performing publicly funded health system in Canada. Chapter 1 ( Tobacco Free Futures: A Systems Change Management Model ) outlines the ways in which the Tobacco Free Futures initiative aligns with and supports AHS values and a number of AHS and provincial government strategic documents. Any approach must guide the leadership team through the same thought processes and engage them in their decision-making activities. Chapter 10 ( Communication ) outlines various resources available to inform leadership of the Tobacco Free Futures initiative and change management processes. Failing to engage leadership is one of the most frequently cited reasons for problems with the sustainability of improvements and can easily threaten the long-term viability of the initiative. A memorandum of understanding should be used to gain formal approval to implement the Tobacco Free Futures initiative. See appendices: Appendix 3(a) Tobacco Free Futures Memorandum of Understanding Alberta Health Services

38 REFERENCES 1. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 3.4 Tobacco Free Futures

39 APPENDICES Appendix 3(a) Memorandum of Understanding Alberta Health Services

40 Appendix 3(a) Memorandum of Understanding (page 1) Memorandum of Understanding for Tobacco Free Futures between Tobacco Reduction Program and <INSERT SITE> This MEMORANDUM OF UNDERSTANDING is hereby made and entered into by and between the Alberta Health Services Tobacco Reduction Program and <INSERT SITE> steering committee. A) PURPOSE: To outline the roles, responsibilities, expectations and services provided/received through the Tobacco Free Futures program. Provide terms of reference that clearly outline the above components for both parties. B) STATEMENT OF MUTUAL BENEFITS AND INTERESTS: Tobacco Free Futures supports an integrated system approach to tobacco treatment across the continuum of Alberta health care. Current evidence supports the integration of tobacco treatment into routine health care. By participating in Tobacco Free Futures, the site steering committee and/or zone advisory committee will receive information, access to resources and consultative support from the Tobacco Reduction Program team to support implementation the Tobacco Free Futures systems approach to tobacco treatment using outlined processes. Tobacco Free Futures aligns with and supports the strategic directions outlined in the AHS Health Plan and Business Plan and supports the AHS Tobacco and Smoke Free Environments policy. C) TOBACCO REDUCTION PROGRAM SHALL: Coordinate a facilitated process that enables AHS health care settings to integrate the Tobacco Free Futures initiative. Facilitate access to existing resources and materials that support implementation of the Tobacco Free Futures initiative. Offer support and guidance where appropriate throughout the implementation processes 3.6 Tobacco Free Futures

41 Appendix 3(a) Memorandum of Understanding (page 2) D) <INSERT SITE> SHALL: Provide a point of contact to the Tobacco Reduction Program for the duration of the implementation. If the original point of contact changes, <INSERT SITE> will contact the Tobacco Reduction Program with the name of a new point of contact. Obtain approval from senior decision makers with a vested interested in the impact and outcomes of new initiatives at <INSERT SITE>. Adhere to the implementation processes, documentation standards, training standards and resources associated with Tobacco Free Futures. Participate in monitoring and reporting processes in alignment with Tobacco Reduction Program standards. Submit completed copies of all Tobacco Free Futures initiative forms and templates including but not limited to memorandum of understanding, steering committee terms of reference, implementation planning tool, training records, sustainability planning and quality improvement tools. E) IT IS MUTUALLY UNDERSTOOD AND AGREED BY AND BETWEEN ALL PARTIES THAT: Tobacco Free Futures is designed to improve the quality of tobacco dependence and nicotine addiction care of AHS clients; processes and resources may be adapted during implementation to reflect new best-practice evidence and/or evaluation of participating sites. Participating sites will be an integral part of contributing feedback and participating in the evaluation and ongoing monitoring/reporting to ensure that this objective is met. All information collected via Tobacco Free Futures is private and confidential. Any data or sitespecific information will be maintained according to Alberta Health Services privacy and security of information standards including compliance with the Health Information Act ( HIA ) and the Freedom of Information and Protection of Privacy Act ( FOIP ). For reporting purposes, data will be anonymous and aggregated. Participation in Tobacco Free Futures is entirely voluntary, and either party may withdraw or terminate this agreement at any time. Participating Alberta Health Services sites and/or the Tobacco Reduction Program will provide notice (in writing) two weeks in advance of the termination date. Commencement/Expiration: This agreement is effective <INSERT START DATE>, expiring <INSERT END DATE>. F) APPROVAL: NAME POSITION SIGNATURE DATE Alberta Health Services

42

43 Chapter 4 Tobacco Free Futures Steering Committeex Alberta Health Services

44 FORMING A MULTIDISCIPLINARY COMMITTEE Site leadership will appoint at least one individual to act as site champion(s) for the Tobacco Free Futures initiative. Leadership and the site champion(s) will establish a committee to provide vision, leadership and guidance for the implementation of the initiative. The committee will act to make informed decisions regarding the integration of tobacco treatment and support into routine care offered to clients and their families at the site. This Tobacco Free Futures guidelines and associated tools are designed to support committees in implementing the AHS Tobacco and Smoke Free Environments Policy implementing tobacco treatment through systems change management processes identifying and supporting relevant training for frontline staff and tobacco practice leads communicating with stakeholders, staff and clients providing guidance and support to ad hoc working groups planning for sustainability and continuous quality improvement The committee should be as representative of the site services and health professional groups as possible. Recruitment from the following groups is strongly encouraged: senior management unit management physicians nursing pharmacy respiratory therapy workplace health and safety protective services patient registration other (e.g., clinical education, allied health professionals, community supports or professionals working with specific populations) A Tobacco Reduction Program team member may participate in an ex officio capacity. Regular meetings of the committee are important to ensure timely implementation of the initiative. Templates for meeting agendas and meeting notes are available at See appendices: Appendix 4(a) Site Committee Draft Terms of Reference Appendix 4(b) Site Committee Contact Form 4.2 Tobacco Free Futures

45 TOBACCO FREE FUTURES WORKSHOP Integrating tobacco intervention into health care delivery requires the active involvement of clinicians, health care systems, administrators and decision makers. These efforts represent an opportunity to increase rates of treatment delivery, quit attempts and successful tobacco cessation. The Tobacco Free Futures implementation workshop explores the 10 processes important to organizational change management as defined by the Tobacco Free Futures initiative in Chapter 1 ( Tobacco Free Futures: A Systems Change Management Model ). After this workshop, participants will have the foundational knowledge, tools and resources to provide leadership and guidance to support a health care setting in implementing the Tobacco Free Futures initiative. Anyone who will be supporting the implementation is strongly encouraged to attend the workshop. For more information, see Chapter 11 ( Training ). Alberta Health Services

46 APPENDICES Appendix 4(a) Site Committee Draft Terms of Reference Appendix 4(b) Site Committee Contact Form 4.4 Tobacco Free Futures

47 Appendix 4(a) Site Committee Draft Terms of Reference (page 1) Site Steering committee Terms of Reference purpose Reporting to the <INSERT SITE> leadership team, the <INSERT SITE> Tobacco Free Futures site steering committee will provide vision, leadership and guidance for the implementation of the Tobacco Free Futures initiative. The committee will act to make informed decisions regarding the integration of tobacco treatment and support into routine care offered to clients and their families at the <INSERT SITE>. Ad hoc working groups will be formed on an as necessary basis to support the systems change management processes. This may include review of evidence, development of processes, adoption of documentation standards, roll-out of staff education and review of resources. Ad hoc groups will report to the committee. objectives 1. Support the implementation of tobacco treatment through systems change management processes. 2. Provide guidance and support to ad hoc working groups. 3. Identify and support relevant training for front-line staff and tobacco practice leads. 4. Support evaluation of the implementation process. 5. Support the collaboration and integration of all stakeholders and working groups. 6. Support sustainability and continuous quality improvement. 7. Support implementation of AHS Tobacco and Smoke-Free Environments Policy. RElATED policy Make linkages with related polices (e.g., AHS Tobacco and Smoke Free Environments Policy) MEMbERSHIp Representation from the following groups is recommended: Senior management Unit management Physicians Nursing Pharmacy Respiratory Therapy Workplace Health & Safety Protective Services Patient registration Other (e.g., clinical education, allied health professionals, community supports or professionals working with specific populations) A Tobacco Reduction Program team member may participate in an ex officio capacity. Alberta Health Services

48 Appendix 4(a) Site Committee Draft Terms of Reference (page 2) RolES AND RESpoNSIbIlITIES chair/co-chairs Facilitate and provide leadership for the committee and its members Model and ensure a commitment to the project, inter-professional collaborative practice and capacity-building for members Chair meetings efficiently and effectively: o be on time and start on time o be organized and prepared o maintain order and focus o be available as a resource to the committee committee members Attend meetings on a regular basis Identify an alternate when unable to attend Participate in discussion and work of the committee Establish and maintain a mechanism to share information and gather feedback/input from colleagues Share information with key stakeholders MEETINGS Regular meetings of the committee shall be held monthly or at the call of the chair. The chair will be responsible to prepare and distribute the agenda to committee members prior to the meeting. Agenda items will be sent by committee members to the committee chair. Minutes of all meetings shall be recorded and distributed to all members of the committee and working groups following the meetings. Decision-making processes will use a consensus decision-making process whereby members work collaboratively to develop recommendations, provide guidance and support in decision making. Consensus decision making does not imply unanimity. Alternates may be appointed by individual committee members. GuIDING principles Inclusive Transparent Respectful Evidence-informed Accountable Flexible AppRoVAl Date of Approval: Date of Review: Signatures: 4.6 Tobacco Free Futures

49 Appendix 4(b) Site Committee Contact Form Steering committee contact form Site: Date: NAME DEPARTMENT/UNIT POSITION PHONE NUMBER ADDRESS 1/1 Alberta Health Services

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51 CHAPTER 5 Policy Alberta Health Services

52 TOBACCO-FREE ENVIRONMENTS Environments that restrict or prohibit tobacco use are seen as windows of opportunity for initiating tobacco cessation treatment. 9 Evidence suggests that even a brief intervention is effective in promoting tobacco treatment, but support during admission to health care facilities, with follow-up after discharge, is more effective at sustaining quit rates. 9 Alberta s Tobacco Reduction Act (TRA) protects people from exposure to cigarette smoke by prohibiting smoking with five metres (16 feet) of a doorway, open window or air intake in a public place or workplace, including work vehicles. 6 AHS TOBACCO and SMOKE FREE ENVIRONMENTS POLICY The Alberta Health Services Tobacco and Smoke Free Environments Policy (TSFE) builds upon the protection provided through the TRA by prohibiting tobacco use on AHS property. 1 The policy, which came into effect on April 1, 2011, prohibits tobacco use in or on all grounds, facilities, property or vehicles in an area owned, operated, leased or funded by Alberta Health Services. 1 Property includes parking areas, vehicles parked in parking lots, and sidewalks on site. 1 The policy applies to all agencies/facilities that receive 50% or more of their funding from AHS. 1 The policy outlines a commitment to a smoke- and tobacco-free environment while ensuring the well-being of clients who use tobacco products. It is essential to also ensure the comfort of these clients while they are receiving care in AHS facilities. Access AHS Tobacco and Smoke Free Environments Policy at: Staff roles and responsibilities Under the TSFE policy, Alberta Health Services employees and other persons acting on behalf of AHS shall not facilitate any client s use of tobacco products. 1 This means that staff may not purchase tobacco products or take clients outside to smoke or use other forms of tobacco. 1 If the site manager and the client s physician have authorized special considerations for that client, it is the responsibility of families or friends to accompany him or her. 2 It is not appropriate for clinicians to request, either in writing or verbally, that AHS Protective Services and/or the contracted service providers, take patients outside to use tobacco products. Protective Services has been directed not to comply with such requests. Staff who are not compliant with the TSFE policy are subject to the measures outlined in the AHS Progressive Discipline Policy, which include dismissal. 1 THIRD-HAND SMOKE Third-hand smoke is the residual tobacco smoke pollutants that remain on surfaces after tobacco has been smoked, and are then re-emitted back into the gas phase to yield secondary pollutants. 2,3,5 For more information on third-hand smoke, see Chapter 2 ( The Effects of Tobacco Exposure ). Although more research is required to better understand the health impact of third-hand smoke, the smell of third-hand smoke is offensive to many people and can be a trigger for those who use tobacco; thus, staff are encouraged not to expose patients to it by avoiding smoking while at work. 5.2 Tobacco Free Futures

53 CESSATION SUPPORT FOR STAFF Cessation counselling support for AHS staff is available through and the Employee and Family Assistance Program (EFAP). For cessation medication coverage, staff can access their employee health benefits. Staff without coverage for cessation medications through their health benefits can access a fund to have 80% of the cost of nicotine replacement therapy reimbursed. AHS staff can access the cessation medication reimbursement form by visiting: Enforcement Under the TRA, the manager of a facility must not permit smoking in a prohibited area. 6 Managers who permit smoking where it is prohibited are liable for fines ranging from up to $10,000 for a first offence and up to $100,000 for a second or subsequent offence. 6 Many of AHS s Protective Services staff are trained community peace officers and have the authority to fine people who are not complying with the TRA. AHS community peace officers monitor facilities and approach anyone not compliant with the Act to inform and educate them about the legislation and to redirect them to an alternative location. Individuals who are not in compliance with the TRA may be subject to a fine of $ AHS intends to warn patients and visitors prior to issuing fines. Although only Protective Services staff can fine people under the TRA, all AHS staff have the authority and responsibility to ask people to comply with the TSFE policy. 1 Staff are subject to disciplinary actions for non-compliance with all AHS policies, including the TSFE. AHS Progressive Discipline Procedure #EAR commences with a verbal warning and progresses to a written warning, suspension with or without pay, and dismissal. Staff may also be fined under the TRA. For more information, see: TSFE POLICY PROTOCOLS Special considerations protocol The most senior site manager at a site that is not yet tobacco free may provide special considerations to clients. This is only if the tobacco is used in accordance with the TRA, its regulations and any applicable municipal bylaws, if the tobacco use is kept away from public view and if the site manager works with the AHS Population, Public, and Aboriginal Health Division to transition the site into becoming tobacco free in accordance with the AHS Tobacco Reduction Implementation Plan. 2 AHS clients may also qualify for an exemption from the TSFE policy if they are able to use tobacco out of public view, at an outdoor designated tobacco use area, at their site by themselves or with the support of family/friends under the following situations: 2 the patient/resident is considered to be palliative and nicotine replacement threapy (NRT) and/or medications are not effectively managing their nicotine withdrawal the client is not able to use NRT/medications due to medical contraindications (e.g., allergies or adverse reactions) the client is a long-term care resident who refuses to use NRT/medications Alberta Health Services

54 the client is a long-term care resident with dementia or who is unable to understand or comply with policy the client is mandated in a psychiatric unit the client is a person with developmental disabilities who is unable to understand how to use NRT or unable to comply with the policy due to behaviours/mannerisms (e.g., aggressive behaviour, unable to communicate) the client is in an emergency room and refuses to comply with policy If a client is deemed to meet the criteria of one of the situations listed above, the site manager, attending physician and staff may agree to grant special consideration for that individual. 2 The client may then use tobacco in accordance with the TRA and any applicable municipal bylaws. The tobacco use must also be kept away from public view, in an area agreed to by site leadership and protective services. 2 The TSFE special considerations protocol is available at: Ceremonial tobacco use protocol The traditional ceremonial use of tobacco has powerful spiritual meaning to many Aboriginal peoples. The tobacco plant is treated with a great deal of respect: being picked at the right time, cured naturally in sunlight and blended with other plants native to the area (e.g., sage, lavender, sassafras, sweetgrass). Many spiritual ceremonies involve the burning of these substances (e.g., the sacred sweetgrass ceremony). Because this burning may produce smoke, care must be taken in providing a safe setting for these rituals. Spiritual and cultural ceremonies involving traditional tobacco use may be permitted at sites in designated spaces identified by site managers or directors. Due to the spiritual significance of ceremonial tobacco use, it is preferred that the ceremony be held in a chapel, if available. If the patient is in intensive care, the attending physician must be consulted before granting approval for the ceremony. Criteria for granting approval for performing the ceremony in the patient s room includes the well-being of the critically ill patient the safety and well-being of staff and other patients in the area no oxygen or flammable anesthetics being used in the immediate area (turning off all free-flowing oxygen units in the room during the ceremony) substances being lit outside the patient s room in the main area of ICU, in the case of a ventilated patient taking care to keep the burning ceremony as far away as possible from any medical equipment the ceremony taking place in a single or isolation room Protective Services and maintenance staff should be notified in advance of any ceremonies performed in the chapel, any inpatient room or any other area protected by a smoke detector. Site protocol will be followed to bypass, remove and/or disable the smoke detector(s). Once the smoke detector has been disabled, the site manager will be notified and the ceremony can begin. The site manager will ensure the room is continuously monitored while the smoke detector is disabled. Upon completion of the ceremony, the site manager will advise maintenance staff to reactivate the smoke detector. 5.4 Tobacco Free Futures

55 USE OF TOBACCO-LIKE PRODUCTS ON AHS PROPERTY The use of tobacco-like products, including electronic cigarettes and medical marijuana, is restricted on AHS property. Electronic smoking products The category of electronic smoking products (ESPs), also known as electronic cigarettes, e-cigarettes and electronic nicotine delivery systems (ENDS), is described in Chapter 2 ( The Effects of Tobacco Exposure ). ESPs may not be used indoors at AHS sites because there is not enough evidence demonstrating the safe, indoor use of the product for users and those exposed to the vapour emitted from the products. Clients who request ESPs should be informed that ESPs are also not approved as smoking cessation aids by Health Canada. Those clients who require assistance in managing their nicotine dependence or support in quitting smoking should be offered cessation medications that have been clinically tested and approved by Health Canada as outlined in Chapter 9 ( Pharmacotherapy ). For more information on electronic smoking products, visit: Medical marijuana Marijuana (cannabis, referred to in federal legislation as marihuana ) is a tobacco like material consisting of the dried tops and leaves of the cannabis plant, Cannabis sativa. 4 Possession of marijuana in Canada is a criminal offense unless an individual has authorization to possess or a licence to produce marijuana for medical purposes from Health Canada. Marijuana produced, possessed and used legally under Health Canada s regulations is known as medical marijuana. The Authorization to Possess Marihuana for Medical Purposes permits qualified applicants to possess and use dried marijuana, subject to the federal Marihuana Medical Access Regulations. 8 This authorization does not grant the unrestricted public use of medical marijuana. Medical marijuana is also legally available in prescription drug form, which is made with synthetic versions of chemicals naturally occurring in the plant. The medical marijuana products available in Canada are a spray form called Sativex and oral (pill form) products dronabinol (Marinol ) and nabilone (Cesamet ). 4 AHS provides a safe and healthy environment for patients, visitors, staff, physicians and volunteers by implementing the TSFE policy. 1 In keeping with the TSFE policy and the TRA, the smoking of medical marijuana on AHS property is restricted. 6 Any persons that do not have the expressed written permission of AHS, including all outpatients, visitors and staff, are not permitted to smoke marijuana on AHS property, even if they possess an Authorization to Possess Marihuana for Medical Purposes. Alberta Health Services

56 AHS has the sole discretion to permit patients, on a case-by-case basis, to smoke medical marijuana on AHS property. Permission will be granted only if the inpatient s medical practitioner deems that the only effective or medically appropriate treatment of the inpatient s condition(s) and symptom(s) is inhalation of marijuana smoke. To be eligible to receive this permission, inpatients must have a current, valid Authorization to Possess Marihuana for Medical Purposes under Health Canada s Marihuana Medical Access Regulations. The site manager for the AHS facility, in consultation with the inpatient s medical practitioner, will specify an appropriate location and time for treatment that minimizes the risk of others being exposed to second-hand smoke. The inpatient may only smoke medical marijuana in the location and at the times specified by the AHS site manager. This is supported by the recommendation from Heath Canada advising against public use of medical marijuana: Given the nature of marihuana and the fact that the provision of marihuana is for your personal treatment needs, Health Canada recommends not consuming this controlled substance in a public place. Please take note that persons in charge of public or private establishments (e.g., bars and restaurants) can request that you not smoke marihuana on their premises, even if you have authority to possess marihuana for medical purposes. There may also be municipal bylaws that prevent smoking. In addition, others should not be exposed to second-hand marihuana smoke. 7 For more information on medical marijuana use on AHS property, visit: TSFE POLICY-SUPPORTING RESOURCES There are many resources to support the implementation of Tobacco Free Futures and the TSFE policy. Policy assessment Sites are expected to fully implement and comply with the AHS TFSE policy. A policy assessment tool is available to help the site committee identify its successes and challenges with the policy. The assessment will be used to develop goals and objectives for the site s success in achieving a minimum 95% compliance rate. Please note that a 5% window exists to accommodate clients being granted special consideration only. See appendices: Appendix 5(a): Tobacco and Smoke Free Environments Policy Assessment Tool Policy consultation team Alberta Health Services has established the TSFE policy consultation team to support sites that have questions or challenges related to the TSFE policy. The team can be contacted via tru@albertahealthservices.ca. Print resources Print resources are available to health professionals in Alberta through the Tobacco Reduction Program online catalogue: healthcare-providers/tools-and-resources.php. In some cases, quantities may be limited. Some resources are also available to download. 5.6 Tobacco Free Futures

57 Some of the resources that may be most helpful in supporting Tobacco Free Futures and TSFE are highlighted in Table 5.1 below. Table 5.1. Tobacco and Smoke Free Environments Policy Print Resources Double-sided selfadhesive window cling decal that reads, Welcome to our tobacco and smoke free environment. Going without tobacco is hard; we can help. Window cling decal Single-sided cling poster that reads Welcome to our tobacco and smoke free environment. Going without tobacco is hard; we can help. Decal includes QR code and albertaquits.ca address. Cling Poster Tobacco Free Futures modifiable poster Insert your site-specific message to staff. Examples include training dates and information on new resources. Exterior signage This sandwich-style board can be used outdoors on AHS property to promote awareness of the policy and available cessation support. Tobacco Reduction Act exterior sign This exterior sign informs people that they are subject to a fine for violating the Tobacco Reduction Act. No-smoking stencil for sidewalks Some AHS sites have worked with local printers to develop large reusable stencils of the standard no smoking symbol. They use the stencil to paint sidewalks/pavement in strategic locations around facility. Costs vary among local suppliers but have averaged about $200. Alberta Health Services

58 REFERENCES 1. Alberta Health Services. (2011a). Tobacco and Smoke Free Environments Policy. Edmonton, AB: Author. Retrieved from policydocuments/1/clp-ahs-pol-tobacco-and-smoke-free-environments.pdf 2. Alberta Health Services. (2011b). Tobacco and Smoke Free Environments Policy, Guidelines for special considerations. Edmonton, AB: Author. Retrieved from 3. Burton, A. (2011). Does the smoke ever really clear? Thirdhand smoke exposure raises new concerns. Environmental Health Perspectives, 119, a70 a74. Retrieved from 4. Canadian Centre for Substance Abuse. (n.d.). Clearing the smoke on cannabis, medical use of cannabis and cannabinoids. Retrieved from Library/CCSA-Medical-Use-of-Cannabis-2012-en.pdf 5. Dale, L. (2011). What is third-hand smoke and why is it a concern? Rochester, MN: Mayo Clinic. Retrieved from 6. Government of Alberta. (n.d.). AHS compliant with Alberta s Tobacco Reduction Act. Retrieved from 7. Health Canada. (n.d.). Application for autorization to possess dried marihuana. Ottawa, ON: Author. Retrieved from forms_complete-eng.php#form_a-eng 8. Health Canada. (n.d.). Marihuana medical access regulations. Retrieved from 9. Rigotti, N., Munafo, M., & Stead, L. (2012). Interventions for smoking cessation in hospitalised patients. The Cochrane Database of Systematic Reviews, 16(5), CD Tobacco Free Futures

59 APPENDICES Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool Alberta Health Services

60 Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool (page 1) Tobacco Free Futures policy Assessment Tool This tool is intended to help you identify components of the AHS Tobacco and Smoke free Environments policy (referred to in document as Policy) that your site may need for focus on. The completed assessment tool should be retained for site records and a signed copy sent to the Tobacco Reduction Program at tru@albertahealthservices.ca. Site: Date: Person/Group Completing Assessment: Key Contact: Phone: Select the most appropriate answer for each of the following regarding staff awareness of the Policy and availability of cessation supports for staff. All (close to 100%) Most (around 75%) Some (around 50%) Few (around 25%) None (close to 0%) 1. To what extent are clinical staff aware of the policy? 2. To what extent are non-clinical staff aware of the policy? 3. To what extent are clinical staff aware of the cessation support available to them? 4. To what extent are non-clinical staff aware of the cessation support available to them? 5. To what extent are clinical staff compliant with the Policy? 6. To what extent are non-clinical staff compliant with the Policy? 7. Select the medium/media used at your site to ensure staff awareness of the Policy: (check all that apply) Policy is discussed in all new staff orientations. Policy is discussed regularly in meetings. Posters are displayed at the site. Policy is included in zone newsletter communications. Policy is included in staff communications. No media have been used. Other, specify 8. Is there a system in place at your site to address staff non-compliance with the Policy? Yes No 9. Has your site used any of the following communications media to make clients and visitors aware of the Policy: (check all that apply) Indoor Policy posters Outdoor Policy posters Tobacco Free Futures posters Direct personal communications with patients and visitors None Others, specify comments: 5.10 Tobacco Free Futures

61 Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool (page 2) Reflecting on the practices at your site, select the most appropriate answer for each of the following. 10. To what extent are clients who enter your site informed of the Policy by a staff member? All (close to 100%) Most (around 75%) Some (around 50%) Few (around 25%) None (close to 0%) 11. To what extent are clients assessed for tobacco use? 12. To what extent are clients who smoke specifically informed of the Policy by a staff member? 13. To what extent are clients who smoke offered cessation medications? 14. To what extent are clients who smoke offered counselling support? 15. To what extent are clients who smoke offered cessation information and resources on discharge? 16. Overall, to what extent are clients and visitors compliant with the Policy? Clients and visitors are fully compliant with the Policy: clients/visitors do not smoke on the site grounds. Clients and visitors are mostly compliant with the Policy: few clients/visitors are found to smoke on the site grounds. Clients and visitors are somewhat compliant with the Policy: some clients/visitors are found to smoke on the site grounds. Clients and visitors are not compliant with the Policy: clients/visitors continue to smoke on the site grounds. comments: Select the most appropriate answer regarding implementation of and compliance with the Policy. Yes No Unsure 17. Does your site have a Champion for the Policy? 18. Does Protective Services support compliance with the Policy at your site? 19. Have there been any safety incidents related to the Policy? 20. Are you experiencing any tobacco litter issues? 21. Has your site designated a location for client tobacco use under specific considerations? Yes, our site has designated an out of public view outdoor space for special considerations. Specific considerations have been granted but not specifically in an out of public view space. No, clients continue to smoke in their desired location. No, clients at our site do not meet the criteria for specific considerations. Tobacco Free Futures 2 of 3 Alberta Health Services

62 Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool (page 3) 22. Which of the following groups most present a challenge in terms of compliance with the Policy? site staff protective services officers clients visitors none other, specify 23. Select the answer that best summarizes the status of your site with respect to implementation of and compliance with the Policy: The Policy is fully implemented, and there is no tobacco use on this AHS property. The Policy is mostly implemented with some challenges remaining. The Policy is somewhat implemented with challenges remaining. The Policy has not been implemented, and challenges currently impede implementation. comments: GoAlS Upon reviewing the answers and comments in the above sections, identify the priority areas for your site in order to comply with the AHS Tobacco and Smoke Free Environments Policy. Record your priority areas in section below as Policy Compliance Goals. policy compliance GoAlS From the above data, the following policy compliance goals have been identified for our site: planned AcTIVITIES The timelines for accomplishing the identified goals are to begin work on <INSERT START DATE> and complete work on <INSERT END DATE>. The table below outlines the planned activities to accomplish these goals including resources required, and budget implications. # Task comments person Responsible Start Date End Date cost The completed assessment tool should be retained for site records and a signed copy sent to the Tobacco Reduction Program at tru@ablertahealthservices.ca. Tobacco Free Futures 3 of Tobacco Free Futures

63 CHAPTER 6 Timelines Alberta Health Services

64 PURPOSE OF TIMELINES AND SCHEDULES Timelines and schedules are essential planning tools in nearly every step in the planning process. They are extremely helpful in keeping you focused and on track. You can be as specific as you want for every area of implementation. A thought-out schedule of activities guarantees that significant and essential tasks are met in a timely manner. Think of the schedule as an opportunity to double check everything, leaving all questions answered and tasks done. The complexity or simplicity of your timeline will be determined by the size and services of your health care setting. Timelines are useful in your committee meetings, in delegating responsibilities and in following up on tasks. CREATING AN IMPLEMENTATION TIMELINE Baseline assessment A number of factors will influence the length of time needed to implement the Tobacco Free Futures initiative, including site leadership support current tobacco treatment practices other initiatives occurring at the site staff availability for training and supporting the implementation of the initiative the size of the site and the number of units/services number of staff The baseline assessment planning tool, along with the policy compliance assessment tool found in Chapter 5 ( Policy ) will help determine the length of time needed to implement the Tobacco Free Futures initiative at a particular site. See appendices: Appendix 6(a) Tobacco Free Futures Baseline Assessment 6.2 Tobacco Free Futures

65 Creating an implementation plan Timelines are used to meet critical dates. The best time to create an event timeline is during or after the initial meetings of the committee, after the policy assessment and baseline assessment are complete. Remember: the purpose of the timeline is to keep you on track, so set the timeline early and update it as necessary. One way to create a timeline is to start from the go-live date and then work backward. Revise your timeline as often as you need to. The point is to get everything down on paper and give you enough time to complete each task. The committee will need to determine if a complete site or staged implementation timeline will work best for your setting. A complete site rollout could allow for units to support each other throughout the process; however, competing organizational demands might make a staged implementation a better alternative. Setting a realistic go-live date for the site will allow the committee to set timelines to guide the implementation process. The go-live date should also occur after staff training is complete. As a general rule, allow a minimum of 16 months to complete all 10 Tobacco Free Futures processes, as outlined in Chapter 1 ( Tobacco Free Futures: A Systems Change Management Model ). Suggested timelines for activities in each of the four implementation phases are outlined in Tables 6.1, 6.2, 6.3 and 6.4 below. An expanded version of these tables in Appendix 6(b) can be used as a worksheet, along with the information you have gathered through the baseline and policy assessments, to develop an implementation plan for your site. See appendices: Appendix 6(a) Tobacco Free Futures Baseline Assessment Appendix 6(b) Tobacco Free Futures Implementation Plan Alberta Health Services

66 Table 6.1: Implementation Phase One Suggested Timelines Initial Planning Milestones/Tasks 1.0 Establish the support of senior site leadership. 1.1 Establish the support of senior site leadership. 1.2 Establish the support of senior physician leadership. 1.3 Connect with the Tobacco Reduction Program to identify your zone coordinator. 1.4 Complete and sign memorandum of understanding. 1.5 Send signed copy of memorandum to Tobacco Reduction Program. 2.0 Tobacco Free Futures site committee Timeline (months) Appoint chair(s) for committee. 2.2 Send site designates to Tobacco Free Futures workshop. 2.3 Select members for multidisciplinary committee and assign alternate members. 2.4 Complete committee contact list. 2.5 Ensure each committee member has a copy of the guidelines and toolkit. 2.6 Review Tobacco Free Futures initiative and 10 change processes. 2.7 Establish terms of reference for committee. 3.0 Policy assessment planning. 3.1 Review AHS Tobacco and Smoke Free Environments policy and protocols. 3.2 Complete policy assessment. 3.3 Identify policy compliance goals and planned activities. 3.4 Review goals and activities with site senior leadership and gain approval. 3.5 Senior leadership and committee to communicate activities. 3.6 Send copy of completed policy assessment to Tobacco Reduction Program. 3.7 Establish policy compliance working group. 3.8 Working group implements policy compliance planned activities. 4.0 Implementation timelines. 4.1 Complete site baseline assessment. 4.2 Review specific care setting and specific populations information. 4.3 Determine cessation support required by all client populations on site. 4.4 Develop implementation plan and set go-live date. 4.5 Review implementation plan with senior site leadership and gain approval. 4.6 Send copy of approved implementation plan to Tobacco Reduction Program. 6.4 Tobacco Free Futures

67 Table 6.2: Implementation Phase Two Suggested Timelines Resource Development 5.0 Brief intervention planning Milestones/Tasks 5.1 Review brief intervention processes and integrated care pathway. 5.2 Determine clients to receive brief intervention support on site. 5.3 Identify staff responsible for brief tobacco intervention. 5.4 Compare current practice and AHS standards. 5.5 Determine where documentation will reside in client charts. 5.6 Change site client charts or use new form for each affected unit. 5.7 Review referral options and establish site standard. 5.8 Review and adopt site standards for self-help materials. 5.9 Review and adopt site standards for staff print resources Identify how resources will be made accessible to all staff and clients. 6.0 Intensive counselling support planning 6.1 Review AHS standards for intensive tobacco counselling. 6.2 Determine clients to receive intensive counselling support on site. 6.3 Identify staff responsible for each component of intensive counselling. 6.4 Compare current documentation and AHS standards. 6.5 Determine where documentation will reside in client charts. 6.6 Change charts or use new form for each affected unit/service area. 6.7 Review and adopt site standard self-help materials for intensive counselling. 6.8 Identify how resources will be made accessible to all staff and clients. 7.0 Pharmacotherapy planning 7.1 Review AHS standards for cessation pharmacotherapy. 7.2 Determine clients to receive pharmacotherapy support on site. 7.3 Amend and order stock pharmacotherapy based on formulary. 7.4 Identify staff responsible for pharmacotherapy support. 7.5 Compare current documentation and AHS standards. 7.6 Determine where documentation will reside in site client charts. 7.7 Change site client charts or use new form for each affected unit. 7.8 Adopt site standard client self-help materials for pharmacotherapy. 7.9 Identify how resources will be made accessible to all staff and clients. Timeline (months) Alberta Health Services

68 Table 6.3: Implementation Phase Three Suggested Timelines Preparing Staff 8.0 Communication plan Milestones/Tasks Timeline (months) Review communication rationale and tools. 8.2 Arrange presentation to senior site management to engage support. 8.3 Send invitation to join site committee. 8.4 Inform site mangers of established timelines for implementation. 8.5 Inform staff and physicians of established timelines for implementation. 8.6 Inform all managers of training availability and expectations. 8.7 Notify identified tobacco leads of their training and roles. 8.8 Inform frontline health care professionals of training. 8.9 Inform referring health professionals of site plans for implementation Inform prescribers of education opportunities Inform clients / visitors of AHS Tobacco and Smoke Free Environments policy Inform staff of sustainability plans and celebrate successes. 9.0 Training 9.1 Review AHS training options and availability. 9.2 Identify staff to be tobacco practice leads. Determine training needs. 9.3 Identify training for brief intervention, intensive counselling and prescribers. 9.4 Determine format that will be used as site standards for training. 9.5 Add tobacco training attendance to new hire training lists. 9.6 Schedule and deliver orientation to all staff for AHS policy. 9.7 Schedule and deliver training for tobacco practice leads. 9.8 Schedule and deliver training for brief tobacco intervention. 9.9 Schedule and deliver training for intensive counselling Schedule and deliver training for prescribers. 6.6 Tobacco Free Futures

69 Table 6.4: Implementation Phase Four Suggested Timelines Final Planning 10.0 Sustainability Milestones/Tasks Timeline (months) Review information regarding sustainability Develop sustainability plan Review sustainability plan with senior site leadership and gain approval Send copy of approved sustainability plan to Tobacco Reduction Program Continuous improvement 11.1 Review information regarding continuous improvement Complete quality improvement assessment Complete quality improvement plan Review assessment and plan with senior site leadership and gain approval Send copies of assessment and plan to Tobacco Reduction Program. Alberta Health Services

70 APPENDICES Appendix 6(a) Tobacco Free Futures Baseline Assessment Appendix 6(b) Tobacco Free Futures Implementation Plan 6.8 Tobacco Free Futures

71 Appendix 6(a) Tobacco Free Futures IBaseline Assessment (page 1) Tobacco Free Futures baseline Assessment Date: Site/Program: Key Contact: Phone: Using the data and key informants that are available to you, complete the following assessment tool. Responses and improvement goals should be discussed with the committee and all affected stakeholders. SITE DEMoGRApHIc DATA ITEM RESpoNSE/Comments 1. Number of inpatient admissions annually 2. Number of outpatient admissions annually 3. Number of unit managers 4. Number of clinical educators 5. Number of nurse specialists 6. Number of RNs 7. Number of RNAs / LPNs 8. Number of other health care professionals 9. Number of support staff (e.g., administrative) 10. Number of non-professional staff (e.g., housekeeping, maintenance) 11. Number of physicians 12. Number of medical residents 13. Number of students 14. Number of Protective Services staff 15. Names of units and number of beds in each unit Tobacco Free Futures 1/2 Alberta Health Services

72 Appendix 6(a) Tobacco Free Futures IBaseline Assessment (page 2) Completing the following section will help you understand what the current tobacco treatment practice is at your site. For detailed information regarding the current status of compliance with the AHS Tobacco and Smoke Free Environments Policy, complete the Tobacco Free Futures policy assessment tool in Appendix 5(a) of the guidelines. current TobAcco TREATMENT practice ITEM RESpoNSE (YES/No)/Comments 1. Site leadership engaged 2. Integrated care pathways for tobacco treatment 3. Tobacco use identified and documented for all admissions 4. Cessation medications available on site and standard orders in place 5. Training for tobacco dependence and nicotine withdrawal offered to health care providers 6. Intensive cessation support services on site 7. Client self help materials readily available 8. Links to resources in community 9. Process to follow-up with clients after initial treatment 10. Process for communicating with staff 11. Process for monitoring and reporting on progress to staff The completed assessment will assist in the development of your site/program implementation plan. Refer to the Tobacco Free Futures implementation plan in Appendix 6(b) of the guidelines. The completed baseline assessment should be retained for site records and a copy sent to tru@albertahealthservices.ca. Tobacco Free Futures 2/ Tobacco Free Futures

73 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 1) TOBACCO FREE FUTURES IMplEMENTATIoN plan Date: Site/Program: Key Contact: Phone: The Tobacco Free Futures implementation plan will be the primary document used by your committee to integrate tobacco treatment into routine care at your site. The plan should be kept as up-to-date as possible. The completed plan should be retained for site records and a signed copy sent to the Tobacco Reduction Program at tru.albertahealthservices.ca. The following 10 change management processes are the basis for the implementation plan for your site: 1. Engage the support of senior management and physician leadership. 2. Form a multidisciplinary Tobacco Free Futures steering committee. 3. Complete Policy Assessment and implement any identified activities. 4. Set a timeline for implementation of the 10 processes. 5. Determine staff roles and ensure tobacco treatment will be documented in the client record. 6. If applicable, ensure pharmacotherapy is available in formulary, stocked on site, and adopt standard ordering or referral processes. 7. Stock print resources for staff and clients. 8. Implement a communication plan for site leadership, staff, clients and visitors. 9. Arrange and schedule training for all staff. 10. Plan for sustainability and continuous improvement. Using the data and key informants that are available to you, establish baseline activities and timelines for the implementation plan. The plan should be agreed to by the committee and senior site leadership. Tobacco Free Futures 1/7 Alberta Health Services

74 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 2) phase 1 MIlESToNES/TASKS 1.0 leadership engagement 1.1 Establish the support of senior site leadership. Chapter Establish the support of senior physician leadership. Chapter Connect with Tobacco Reduction Program to identify your zone coordinator. 1.4 Complete and sign memorandum of understanding. Appendix 3(a) 1.5 Send signed copy of memorandum to Tobacco Reduction Program. 2.0 Site Tobacco Free Futures steering committee 2.1 Appoint chair(s) for committee. 2.2 Send site designates to Tobacco Free Futures implementation workshop. Chapter Select members for multidisciplinary committee and assign alternate members. Chapter Complete committee contact list. Appendix 4(b) 2.5 Ensure each committee member has a copy of the Tobacco Free Futures guidelines and toolkit. 2.6 Review Tobacco Free Futures initiative and 10 change management processes. Chapters 1& Establish terms of reference for committee. Appendix 4(a) 3.0 policy assessment and planning 3.1 Review AHS Tobacco and Smoke Free Environments Policy and related protocols. Chapter Complete policy assessment. Appendix 5(a) ScHEDulE Start finish person(s) RESpoNSIblE NoTES Tobacco Free Futures 2/7 INITIAl planning 6.12 Tobacco Free Futures

75 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 3) 3.3 Identify policy compliance goals and planned activities. Appendix 5(a) 3.4 Review goals and activities with site senior leadership and gain approval. Appendix 5(a) 3.5 Senior leadership and committee to communicate policy goals and planned activities with all affected stakeholders. 3.6 Send copy of completed policy assessment to Tobacco Reduction Program. Appendix 5(a) 3.7 Establish policy compliance working group. 3.8 Working group implements policy compliance planned activities and reports on progress to committee. 4.0 Implementation timelines 4.1 Complete baseline assessment. Appendix 6(a) 4.2 Review specific care setting and specific population information relevant to your site. Chapters Determine cessation support required by all client populations on site. Chapters Develop implementation plan and set go live date. 4.5 Review implementation plan with senior site leadership and gain approval. 4.6 Send copy of approved implementation plan to Tobacco Reduction Program. Tobacco Free Futures 3/7 Alberta Health Services

76 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 4) phase 2 MIlESToNES/TASKS 5.0 brief intervention planning 5.1 Review AHS standard brief tobacco intervention processes and integrated care pathway. Chapter Determine clients to receive brief tobacco intervention support on site. 5.3 Identify staff responsible for each component of the brief tobacco intervention. 5.4 Identify any discrepancies between current brief tobacco intervention documentation and AHS standards. Appendix 7(a) 5.5 Determine where the brief tobacco intervention documentation will reside in patient/client charts. 5.6 Change existing patient/client chart forms or adopt new form for brief tobacco intervention for each unit/service area. 5.7 Review referral options available locally and provincially. Establish site standard for referral and documentation process. Appendix 7(b) 5.8 Review and adopt site standard self-help materials. What will be given to patients not ready to quit and those who are ready to quit? Review and adopt site standards for staff print resources Identify staff responsible for ordering and how resources will be made accessible to all staff and clients. 6.0 Intensive counselling support planning 6.1 Review AHS standards for intensive tobacco counselling. Chapter Determine clients to receive intensive tobacco counselling support on site. ScHEDulE Start finish person(s) RESpoNSIblE NoTES Tobacco Free Futures 4/7 RESouRcE AND SuppoRT planning 6.14 Tobacco Free Futures

77 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 5) 6.3 Identify staff responsible for each components intensive tobacco counselling. 6.4 Identify any discrepancies between current intensive tobacco counselling documentation and AHS standards. Appendix 8(a) 6.5 Determine where the intensive tobacco counselling documentation will reside in site client charts. 6.6 Change existing patient/client chart forms or adopt new form for intensive tobacco counselling for each affected unit/service area. 6.7 Review and adopt site standard self help materials for intensive tobacco counselling Identify staff responsible for ordering and how resources will be made accessible to staff and clients. 7.0 pharmacotherapy planning 7.1 Review AHS standards for cessation pharmacotherapy. Chapter Determine clients to receive pharmacotherapy support on site. 7.3 Review cessation medications available on AHS formulary and compare to those currently available on site (inpatient/outpatient pharmacies, stocks on wards/units). Amend and order stock if needed. 7.4 Identify staff responsible for each component of pharmacotherapy support. 7.5 Identify any discrepancies between current pharmacotherapy prescribing and documentation and AHS standards. Appendix 9(a) & 9(b) 7.6 Determine where the pharmacotherapy documentation will reside in site client charts. 7.7 Change existing order sets or adopt standard order set for pharmacotherapy for each affected unit/service area. 7.8 Review and adopt site standard client self-help materials for pharmacotherapy Identify staff responsible for ordering and how resources will be made accessible to staff and clients. Tobacco Free Futures 5/7 Alberta Health Services

78 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 6) phase 3 MIlESToNES/TASKS 8.0 communication plan 8.1 Review communication information and tools. Chapter Arrange presentation to senior site management to engage support. Appendix 10(a) 8.3 Send invitation to join site Tobacco Free Futures steering committee to identified members. Appendix 10(b) 8.4 Inform site mangers of established timelines/target dates for implementation. Appendix 10(c) 8.5 Inform staff and physicians of established timelines/ target dates for implementation. Appendix 10(d) 8.6 Create awareness of availability and expectations of staff training to all site managers. Appendix 10(e) 8.7 Notify identified tobacco practice leads of training expectations and supportive role. Appendix 10(f) 8.8 Inform front-line health care professionals of training opportunities and expectations. Appendix 10(g) 8.9 If applicable, inform referring agencies of site plans for implementing Tobacco Free Futures. Appendix 10(i) 8.10 Inform physicians of expected role in support of brief intervention and education opportunities. Appendix 10(h) Inform visitors and patients of tobacco and smoke-free environment and supports available. Appendix 10(j) Inform staff of sustainability plans and celebrate success of implementation. Appendix 10(k). 9.0 Training 9.1 Review AHS training options and availability. Chapter Identify staff to be tobacco practice leads. Determine training needs and expectations. Chapter Determine training needs and expectations for brief intervention staff, intensive counselling staff and prescribers. Chapter 11 ScHEDulE Start finish person(s) RESpoNSIblE NoTES Tobacco Free Futures 6/7 preparing STAff 6.16 Tobacco Free Futures

79 Appendix 6(b) Tobacco Free Futures Implementation Plan (page 7) 9.4 Determine format that will be used as site standards for training. 9.5 Add tobacco training attendance to existing education tracking systems. 9.6 Schedule and deliver orientation to all staff (clinical and non-clinical) for AHS policy and supports available. 9.7 Schedule and deliver training for tobacco practice leads. 9.8 Schedule and deliver training for brief tobacco intervention. 9.9 Schedule and deliver training for intensive counselling Schedule and deliver training for prescribers. phase 4 MIlESToNES/TASKS 10.0 Sustainability 10.1 Review information on sustainability. Chapter Develop sustainability plan. Appendix 12(a) 10.3 Review sustainability plan with senior site leadership and gain approval Send copy of approved sustainability plan to Tobacco Reduction Program continuous improvement 11.1 Review information on continuous improvement. Chapter Complete quality improvement assessment. Appendix 13(a) Complete quality improvement plan. Appendix 13(b) Review assessment and plan with senior site leadership and gain approval Send copies of assessment and quality improvement plans to Tobacco Reduction Program. ScHEDulE Start finish person(s) RESpoNSIblE NoTES Tobacco Free Futures 7/7 final planning Alberta Health Services

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81 Resource and Support Planning 7. Brief Intervention 8. Intensive Cessation Counselling 9. Pharmacotherapy AlbertaQuits.ca

82 TOBACCO INTERVENTION RESOURCE AND SUPPORT PLANNING Every tobacco user who expresses the willingness to begin treatment to quit should be offered assistance. Brief interventions of 1 to 3 minutes are effective and should be offered at every available opportunity. However, because there is a strong dose response relationship between the session length and successful treatment, intensive interventions should be used whenever possible. The following three chapters will provide valuable information to consider when planning which form of tobacco support will be offered as a part of routine care. Important factors to consider are the average length of stay for the client and the staff available within the care setting, as well as the considerations outlined in the Specific Care Settings and Specific Populations sections of these guidelines. Chapter 7: Brief Intervention Importance of integrating tobacco cessation supports into health care treatment. The 5 A s of the brief tobacco intervention. Care pathway for minimal support. Suggested staff roles in providing brief tobacco intervention. Tools available to support brief tobacco intervention. Chapter 8: Intensive Cessation Counselling Guidelines for intensive cessation support. Effective counselling options to support persons who are not ready to quit, who are ready to quit and who have recently quit. Suggested staff roles in providing intensive cessation counselling. Tools to support delivery of intensive cessation counselling. Chapter 9: Pharmacotherapy Use of pharmacotherapy in supporting temporary abstinence and long-term cessation. Overview of special considerations for specific populations. Assessing nicotine withdrawal. Staff roles in relations to delivery of pharmacotherapy. Tools to support pharmacotherapy treatment.

83 Chapter 7 Brief Intervention Alberta Health Services

84 TOBACCO CESSATION SUPPORT MODELS FOR Health care settings Treatment in or admission to a health care facility provides an important opportunity to support temporary and long-term cessation. The majority of smokers report a desire to quit, and many of them will have made a quit attempt in the past 12 months. 1 Patients who are admitted or treated for smoking-related illness are often even more motivated to overcome their addiction. It is essential to recognize that not every tobacco user is ready to attempt cessation; however, a review of the literature has found that even a brief prompt with limited counselling can lead to a quit rate of 3% to 13% and more intensive intervention that includes follow-up sessions can lead to a 13% to 40% quit rate. 2 Benefits of Tobacco Cessation on Health and Recovery of Patients/Clients Receiving Care in a Health Care Setting 3 1. Improved wound and bone healing 2. Reduced risk of wound infections 3. Decreased risk of cardiopulmonary complications 4. Decreased need for postoperative intensive care 5. Improved surgical results 6. Decreased risk of repeat heart attacks 7. Decreased risk for second primary tumors in patients with lung, head and neck cancer Those who are addicted to nicotine require intervention and support to maximize their success for cessation. Reliance on willpower alone is an outdated approach, as only 3% to 5% of those who attempt without treatment will be successful to sustain a quit for 6 12 months. 4 The most effective way to manage this chronic, relapsing condition is by combining behavioural and pharmaceutical cessation interventions. The delivery of clean nicotine in the form of nicotine replacement therapy (NRT) is a safe alternative to manage symptoms of withdrawal. Drugs such as bupropion SR and varenicline also help to manage the cravings Tobacco Free Futures

85 Brief Tobacco Intervention Tobacco dependence treatments are clinically and cost-effective relative to other medical disease prevention interventions. 5 The Tobacco Free Futures initiative has developed care pathways (algorithms), based on the 5 A s approach, for general and specific care settings, as well as specific populations. Supplementary resources are also provided to guide implementation in Alberta health care settings across the continuum of care. Figure 7.1 outlines the recommended general treatment pathway for health care facilities. The 5 A s approach is to ASK every patient who presents to the facility if they use tobacco, ADVISE all tobacco users to quit, ASSESS the user s readiness to quit and interest in withdrawal support, ASSIST by identifying, providing and documenting both pharmacotherapy and behavioural support and ARRANGE follow-up support. Using motivational interviewing with a nonjudgmental approach is foundational to the 5 A s model. 5 Current evidence supports the implementation of the 5 A s approach for health professionals in any setting to identify and provide at least minimal support for every tobacco user. 2,5 Content in Chapters 3 to 6 of the Initial Planning section provides an overview of specific contextual considerations to integrating the model at a health care facility. Motivational interviewing has been taken into consideration in the development of the supporting script outlined in Table 7.1. Treatment models for specific care settings and patient/client populations are discussed further in later related sections. ASK The first step in treating tobacco use and dependence is to identify tobacco users. CAN ADAPTT recommends that all patients be asked if they use tobacco and have their tobacco-use status documented on a regular basis. 5 The consistent identification, documentation, and treatment of every tobacco user seen in a health care setting will affect a large number of tobacco users. In fact, the identification of smokers itself increases rates of clinician intervention. The identification of tobacco users should take into account the use of all forms of tobacco, including cigarettes, cigars/cigarillos, spit/chew, pipes and waterpipes the quantity and duration of use to determine level of tobacco dependence and nicotine addiction the time since last use Research indicates that a high percentage of those who ultimately return to smoking will do so by six months. 2 Based on pattern and history of use, tobacco-use status can be categorized as follows: Never: no history of use of any tobacco products Current: continued use of tobacco products Recent quit: cessation within the last year; currently not using tobacco products Former: no use of tobacco products in the past year Alberta Health Services

86 Exposure to environmental or second-hand smoke (SHS) causes disease and premature death in children and adults. 6 The CAN-ADAPTT guidelines for youth, as well as pregnant and breastfeeding women, provides support for addressing exposure to SHS, which will be addressed in the proposed algorithims for these specific populations. Scientific evidence indicates that there is no risk-free level of exposure to second-hand smoke. 6 ADVISE Evidence shows that a health provider s brief advice to quit tobacco use increases abstinence rates. 2,5,7 All patients who currently use tobacco should be given personalized motivational advice to quit by physicians and other health care professionals. Patients identified as former or never tobacco users should be complimented and advised to continue abstaining. The more personalized the advice, the more effective it is. Consideration should also be given to personalizing the message based on the patient s concerns, as well as potential teachable moments that may be cued by the patient s illness. 2,5,7 Further advice should be given about the facility s Tobacco and Smoke Free Environments Policy. 8 Policies are intended to support the health of all; therefore, all staff members have a role to play. 9 Every patient, regardless of his or her smoking status, should be advised of the Tobacco and Smoke Free Environments Policy. 5 Withdrawal from nicotine begins within hours of a person s last tobacco use, so clinicians have a duty of care to ensure the comfort and safety of their patients and their patients families. 4 Brief advice from a health professional can double the chances of a successful quit attempt. 10 Refer to the AHS Tobacco and Smoke Free Environments Policy at ASSESS Current tobacco users should be assessed for their readiness to make a quit attempt and, in the case of inpatient settings, their readiness to get help managing withdrawal during their hospital stay. Proper assessment of a user s readiness to quit will ensure the most appropriate treatment is provided. 7.4 Tobacco Free Futures

87 ASSIST It is important to assist patients/clients by improving their comfort through the relief of nicotine withdrawal, promoting patient safety, and engaging the patient in their healing process. Both pharmacotherapy and behavioural support are effective tobacco dependence and nicotine addiction treatment options. 2,5 The combination of medication and counselling is more effective than either alone. Whenever feasible and appropriate, both methods should be provided to all patients willing to be supported, except in the presence of contraindications. 2,5 Furthermore, continued assessment of adherence to treatment and the adjustment of pharmacotherapy to ensure withdrawal relief should be considered. Recognition of ongoing withdrawal symptoms may also provide teachable moments to reassess a patient s readiness to change their tobacco use. As many as 30% to 60% of patients who seek tobacco dependence treatment have a past history of depression that may be exacerbated by withdrawal. 4 Nicotine is known to have anti-anxiety, anti-pain and antidepressant effects, and tobacco is commonly used to self-treat during stressful and negative situations. 10 Although most patients with histories of depression are able to stop tobacco use with few adverse effects, health professionals should closely monitor for changes in affect with a brief mood assessment. 2,4 Results from a brief mood assessment may indicate the need for more in-depth assessment and referral. Pharmacotherapy and behavioural patient interventions and supporting documentation are discussed further in the chapters of this section. ARRANGE Follow-up support should be arranged for every patient who is a current tobacco user and for all former tobacco users who are interested. Upon discharge, it is important to arrange follow up for cessation supports and treatments that were initiated in the course of care. It is also important to provide links to available support for any users who did not begin treatment in the course of care but who are now interested. Telephone counselling, face-toface counselling (both group and individual) and tailored self-help materials are all effective formats of treatment. 2,5 Any pharmacotherapy that has been started in the health care setting should also be arranged for upon discharge. See appendices: Appendix 7(b) AlbertaQuits Helpline Referral Form Alberta Health Services

88 Figure 7.1: Tobacco Free Futures: A Health System Tobacco Cessation Model Tobacco use prevention and cessation treatment Ask every patient/client about tobacco use. Document on patient/client chart. ask Have you used any tobacco products in the past year? Yes No Positive reinforcement. Inform of AHS Tobacco and Smoke Free Environments Policy. What type? How much? How often? Last use? Advise Inform of AHS Tobacco and Smoke Free Environments Policy. Advise to quit with personalized message. Document on patient/client chart. Assess Assess interest in pharmacotherapy support for withdrawal. Assess readiness to quit. Assess interest in behavioural support. Document on patient/client chart. Are you interested in support to reduce your withdrawal symptoms or to help you quit? Yes No Support autonomy. Offer information on withdrawal. Leave offer of support open and monitor withdrawal symptoms. Assist Assist with pharmacotherapy for withdrawal, including referral to prescribing authority and/or ordering and ongoing monitoring of withdrawal symptoms and mood assessment. Link to behavioural support. Document on patient/client chart. Arrange Arrange further support by completing appropriate onsite and/or community-linked referral(s). Arrange for continued pharmacotherapy (e.g., on transfer/discharge). Document on patient/client chart. 7.6 Tobacco Free Futures

89 Table 7.1: Suggested General 5 A s Script ASK all patients/clients if they have used tobacco. All patients/clients: Have you used any tobacco products in the past year? ASSIST ASSESS ADVISE ASK For current tobacco users and recent quitters, ask about pattern of use. ADVISE all patients/clients regardless of tobacco-use status of Tobacco and Smoke Free Environments Policy. For current tobacco users, advise the patient/client to stop using tobacco. Personalize message. ASSESS interest in support for relief of withdrawal. For current tobacco users, assess readiness to quit. ASSIST the patient/client who is not interested in support with brief information. For the patient/client who is interested, assist with pharmacotherapy for relief of withdrawal, including ongoing monitoring for withdrawal symptoms and mood assessment. Current use and recent quit: What type of tobacco products do/did you use? How much and how often do/did you use tobacco? When was the last time you used tobacco? Do/did you use any other tobacco products? No current use: That s great! In case you have any visitors, I d like to let you know that this facility is tobacco-free and so are the grounds. Current use: While you are here, you won t be able to use any tobacco products in the hospital or on the grounds. And as your health care provider, I need to let you know that research shows the best thing you can do for your health and the health of those around you is to not use tobacco. Current use and recent quit: Are you interested in medication to help manage your withdrawal symptoms? Are you interested in more information or support to make/ sustain a change in your tobacco use? Not interested: I d like to leave you with some brief information on withdrawal symptoms and support available. Please let me or another health care provider know if you change your mind. Interested: I m going to let your doctor know that you are interested in medication for withdrawal. I d also like to offer you some brief information on withdrawal symptoms and on strategies and supports that can help you quit. Link to behavioural support. ARRANGE ARRANGE for follow up on discharge for any pharmacotherapy started and link to further behavioural support. Interested: I will provide you with an outline of the NRT you were on in hospital so you can continue it on discharge OR Your physician has provided a prescription for you to continue the medication you started while in our facility when you go home. I d also like to offer you some information on other support available in the community. If you are interested, I would like to refer you to a free and confidential cessation service to ensure you re successful with your plan and to offer you more help. Alberta Health Services

90 BRIEF INTERVENTION STAFF ROLES AND DOCUMENTATION Defining staff roles and client care documentation are essential processes that will have a direct impact on the success of the implementation and sustainability of the Tobacco Free Futures initiative. Staff roles The staff who will perform and document the following client-centred activities need to be identified: 1. screening for tobacco use 2. informing visitors, families and clients of the AHS Tobacco and Smoke Free Environments Policy 3. informing clients of the importance of quitting tobacco 4. informing clients of the available cessation resources 5. assessing clients readiness to quit and their interest in resources 6. assisting clients who are not interested in support with brief information 7. assisting clients who are interested in support with pharmacotherapy for relief of withdrawal symptoms, including ongoing monitoring and mood assessment 8. arranging for follow up for any pharmacotherapy started and linking the client to ongoing behavioural support Documentation The AHS Brief Tobacco Intervention Form is intended to facilitate a brief tobacco intervention. It contains the pertinent information as outlined in this chapter. This form has been reviewed by the Cancer Care Strategic Clinical Network and adopted as an Alberta Health Services standardized form. All forms are now available through the provincial Alberta Health Services forms inventory and can be accessed through approved zone forms ordering processes or through the AHS Forms Library on Insite: Edmonton Zone: call (780) (Data Group) or visit the online catalogue North Zone: call (780) (Data Group) or visit the online catalogue Calgary Zone: call (403) (Data Group) or visit the online catalogue Central Zone: call (780) (Wetaskiwin Production Services) South Zone: call (403) (former Chinook) or (403) , extension 1088 (former Palliser) See appendices: Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form 7.8 Tobacco Free Futures

91 References 1. The Lung Association. (2008). Making quit happen: Canada s challenges to smoking cessation. Ottawa, ON: Author. 2. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008).Treating Tobacco Use and Dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 3. Center for Tobacco Research and Innovation. (2000). Treating tobacco use and dependence in hospitalized patients. Madison, WI: University of Wisconsin Medical School. Retrieved from Info.pdf 4. Els, C. (2008). Tobacco addiction: What do we know, and where do we go? Montreal, QC: Snell Medical Communications. 5. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT.) (2011). Canadian smoking cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 6. World Health Organization. (2008). International consultation on environmental tobacco smoke (ETS) and child health. Retrieved from youth/en/ 7. Stead, L., Bergson, G., & Lancaster T. (2008). Physician advice for smoking cessation. Cochrane Database of Systematic Reviews, 2008, 2. Art. No.: CD Schultz, A., Bottorff, J., & Johnson, J. (2006). An ethnographic study of tobacco control in hospital settings. Tobacco Control, 15, Rigotti, N., Munafo, M., & Stead, L. (2007). Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews, 2007, 3. Art. No.: CD Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P. (2007). The tobacco dependence treatment handbook: A guide to best practice. New York: Guilford Press. Alberta Health Services

92 Appendices Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form Appendix 7(b) AlbertaQuits Helpline Referral Form 7.10 Tobacco Free Futures

93 Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form (page 1) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Birthdate (yyyy-mon-dd) Tobacco Dependence and cessation brief Intervention Gender Personal Health Number The AlbertaQuits Helpline Referral (form #09973) may accompany this form. Ask Have you used any tobacco products in the last year? No Yes, complete this information Type of tobacco (check all that apply) Cigarette Cigar/cigarillo Pipe Chew/spit Waterpipe (e.g.hookah) Other (specify) Amount (e.g. cig/day) Years of use Last use Advise currently not using tobacco products Positive reinforcement Advise of AHS policy STop current tobacco use Advise of AHS policy Advice to quit with personalized message Assess On a scale of 1-10 how important is it for you to stop using tobacco right now? (1 = least, 10 = most) Assess interest in medication to manage nicotine withdrawal. No, complete this information Yes, complete this information continue Assist Give information pamphlet Behavioural counselling (if available) Other (specify) Facilitate Pharmacotherapy Order Give information pamphlet Behavioural counselling (if available) Other (specify) Arrange Interest in referral for ongoing support. No, STop Yes, Referral/Information provided AlbertaQuits Helpline Referral (form #09973) AlbertaQuits Groups AlbertaQuits Online Other, specify (e.g. Primary Care Network group) Provider Name (print) Signature Date (yyyy-mon-dd) Time (hh:mm) (Rev ) Alberta Health Services

94 Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form (page 2) Tobacco Dependence and cessation brief Intervention Suggested script to guide the brief intervention Note: Below is a script to help guide the brief tobacco intervention. Modification to fit a specific context may be necessary. Be sure to personalize the advice to the patient/client whenever possible. Ask Advise Have you used any tobacco products in the last year? current tobacco use As this building and the grounds around it are tobacco free areas, we want to help our patients stay tobacco free while they are here. Research has shown that one of the best things you can do to improve your health, is to stop using tobacco. I (we) cannot stress enough how important it is for you to quit. currently not using tobacco products That is great! In case you have any visitors I d like to let you know that this building and its grounds are tobacco-free. Assess Interest in medication to manage withdrawal I can arrange for medication to help make your stay more comfortable. Are you interested in managing nicotine withdrawal? Readiness to quit On a scale of 1-10 how important is it for you to stop using tobacco right now? Arrange I can arrange for someone from a free and confidential service to contact you and provide you with support and information. Would you like me to set this up for you? 7.12 Tobacco Free Futures

95 Appendix 7(b) AlbertaQuits Helpline Referral Form AlbertaQuits Helpline Referral Please complete all sections and fax to the AlbertaQuits Helpline at Client Demographics Last Name First Name Gender o Male o Female Street Address Home Phone City Postal Code Alternate Phone Contact Information When and where would the client like to be contacted? o Home Phone o AM o PM o Alternate Phone o Weekday o Weekend Preferred Date (yyyy-mon-dd) Consent for leaving message on client s voic recieved? o Yes o No Language interpreter required? o Yes, language/dialect (specify) o No Referring Source Physician/PCN/Program/Site Physician Fax Number Address Reason for Referral (main concern) o Help for self o Help for someone else o Help during pregnancy o Information o Relapse prevention o Other (specify) 09973( ) Alberta Health Services

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97 Chapter 8 Intensive Cessation Counselling Alberta Health Services

98 GUIDELINES FOR INTENSIVE CESSATION SUPPORT Beginning smoking cessation interventions during a health care visit, such as hospitalization, has been shown to help people quit. In their review of clinical trials, Rigotti, Munafo and Stead (2008) found that programs designed to stop smoking that begin during a client s hospital stay and that include follow-up support for at least one month after discharge are also effective. 1 Such programs are useful to all hospitalized smokers, regardless of their admitting diagnosis. 1 There is a strong correlation between the intensity of tobacco dependence counselling and its effectiveness. 2 Whenever possible, intensive tobacco cessation programs should consist of four or more sessions, with each session lasting longer than 10 minutes. 2 Clinical guidelines for treatment of tobacco dependence in the U.S. and Canada advocate for both behavioural counselling and pharmacotherapy as effective options. Evidence suggests that a combination of counselling and medication is more effective than either one factor on its own and, whenever feasible and appropriate, both should be provided to all patients. 3,1 It is recommended that senior leadership at AHS health care settings consider how they will offer counselling support to any individuals who are interested. 2 The United States Clinical Practice Guidelines for Treating Tobacco Use and Dependence recommend the following components in an intensive intervention: 2 1. Making an assessment of the client s interest in participating in an intensive treatment program. This can include other information useful in the counselling process, including the client s readiness to quit, the client s confidence in quitting, how important it is to client that he or she quit, the client s levels of stress and nicotine dependence, the state of the client s social network and environment, and the state of the client s psychiatric co morbidity and substance use. 2. Using a team of medical and non-medical professionals to provide intensive counselling and pharmacotherapy support. 3. A minimum of four sessions, with each session lasting 10 minutes or longer. 4. A program format that includes either individual or group counselling. Telephone counselling is also effective and can supplement treatment. Using self-help materials and web-based support is optional. 5. Counselling and behavioural therapies that include practical counselling (problem solving/skills training) and intra-treatment social support. These can include basic information about tobacco use and successful quitting, the development of coping skills, and identifying triggers and high-risk situations that increase the risk of tobacco use or relapse. 6. Offering appropriate medication to all clients. 7. Offering treatment to all tobacco users, regardless of which populations they belong to. 8.2 Tobacco Free Futures

99 The complexity and intensity of tobacco treatment needs to match the needs of the individual client. For instance, some individuals may require only brief intervention from a health care provider; others with more complex or concurrent concerns may require more intensive support. This is consistent with a continuum of care approach for the treatment of nicotine dependence, as recommended by Canada s national clinical practice guidelines. 2 The U.S. guidelines identify three categories of tobacco user: not yet ready to quit (pre-contemplation), ready to quit (contemplation or preparation) and recently quit (action or maintenance). These guidelines recommend tailoring the treatment approach depending on where a person is at in his or her readiness to quit. 2 Implementation planning tool tasks 1. Determine the cessation support required by all patient populations on site. Which populations require more intensive support? 2. Identify staff responsible for providing more intensive cessation support on site. 3. Review and adopt AHS documentation standards for more intensive tobacco cessation treatment (modify for electronic purposes as necessary). 4. Identify how new forms will be made accessible to participating practice areas and persons responsible for ordering them. A variety of supplementary cessation-support resources for clients and health professionals can be found at See appendices: Appendix 8(a) Tobacco Dependence and Cessation Consult Form Alberta Health Services

100 TRANSTHEORETICAL MODEL OF CHANGE Research shows that people tend to go through similar processes when they make changes in their lives, and that this process can be conceptualized in a series of steps or stages. The stages of change model shown in Figure 8.1, part of the transtheoretical model of change (TTM), depicts this process. 4 The stages of change are dynamic: a person may move through them once, or may cycle through them several times before achieving success. 4 Individuals may also move back and forth between stages on any single issue, or be in multiple stages of change at the same time. Figure 8.1: The Transtheoretical Model of Change The transtheoretical model focuses on the decision-making of the individual and is a model of intentional change. It operates on the assumption that people do not change their behaviours quickly or decisively. Rather, change in behaviour, especially habitual behaviour, occurs continuously through a cyclical process. It is important to remember that the transtheoretical model is not a theory, but a model; different behavioural theories and constructs can be applied to various stages of the model where they may be most effective. Some of the limitations of the model include 5,6 the model ignores the social context in which change occurs (e.g., socio-economic status and income) the lines between the stages can be arbitrary, with no set criteria of how to determine a person s actual stage of change there is no clear sense for how much time is needed for each stage, or how long a person can remain in a stage the model assumes that individuals make coherent and logical plans in their decision making process, when this is not always true 8.4 Tobacco Free Futures

101 CLIENTS NOT YET READY TO QUIT Many of the clients who acknowledge their use of tobacco products may not be ready to accept support to quit. Motivational interviewing Motivational interviewing (MI) and stages of change are complementary. Embedded in MI is the need to meet clients where they are. The stages of change help identify where a person is in the change process. A counsellor will use different MI strategies with clients in different stages. MI is most commonly used in the pre-contemplation and contemplation stages. In these stages, it is important for the counsellor to follow the client s lead. Examples work well in the early stages, as concrete thinking may prevail. A client s motivation to continue the change process fluctuates, as does his or her ambivalence. MI can also be used as clients transition through the stages. In the preparation, action and maintenance stages, MI can be woven throughout the skill-building process in order to maintain the client s readiness to change. MI is not a technique but rather a style, a facilitative way of being with people. It is a collaborative, goal-orientated style of communication with particular emphasis on the language of change. MI is designed to strengthen a person s personal motivation for, and commitment to, a specific behaviour by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion. This approach is used when the individual is ambivalent about change. The use of MI techniques have been shown to be effective in conducting brief interventions as outlined in Chapter 7 ( Brief Intervention ). In MI, the relationship the health professional creates with the client is crucial. 7 With the use of a supportive, warm, non-judgmental and collaborative approach, you convey empathy and sensitivity through your words and tone of voice, and you demonstrate genuine concern and an awareness of the client s experiences. The health professional follows the client s lead in the discussion, instead of structuring the discussion according to your own agenda. 7 FOUNDATIONAL PRINCIPLES (THE SPIRIT) OF MOTIVATIONAL INTERVIEWING Four principles underlie all aspects of the MI approach: partnership, acceptance, compassion and evocation. 7 The first principle refers to the partnership between client and clinician. This partnership is central to the spirit of MI 7 and is seen as an active collaboration. The clinician creates a positive interpersonal atmosphere that is conducive to change in which the client does most of the talking. The second principle is acceptance, which is the support of the individual s autonomy. 7 The health professional s role is to recognize and support the client s autonomy to change and make decisions, to use empathy to understand the client s perspective and to affirm the client s strengths and efforts. 7 Compassion refers to the commitment to pursue the welfare and best interests of the client. 7 A clinician working with the spirit of compassion builds rapport and trust within the therapeutic relationship. The fourth and final foundational principle is evocation. This refers to the drawing out of the client s experiences, ideas and goals related to change. 7 The spirit of MI emphasizes the fact that the client already possesses what is needed to make changes in his or her life. The health professional seeks to evoke and strengthen these motivations by gaining Alberta Health Services

102 an understanding of the client s perspective and resources, rather than focusing on deficits. Ambivalent clients are aware of the arguments for making change and those for staying the same. MI is about evoking what is already present, not installing what is missing. A concept of MI that has recently changed is roll with resistance. The concept was that arguing for change with a client will likely trigger the client to argue against change, which can feel like resistance. 7 In MI, resistance is a signal to do something else. Miller and Rollnick (2013) deconstruct the concept of rolling with resistance into its two components: sustain talk and discord. 7 They write that their discomfort with the concept of resistance has continued growing, particularly because it seems to place the responsibility for the phenomenon within the client only as though one were blaming the client for being difficult. Even if it is unintentional and arisies from subconscious defenses, the concept of resistance nevertheless focuses on client pathology, thereby underemphasizing interpersonal factors. So if we delete resistance from our clinical vocabulary and focus instead on sustain talk and discord, we are in a better position to attract a client into recovery than responding to him or her as a resistant, non-compliant person in denial. TECHNIQUES IDENTIFIED IN MOTIVATIONAL INTERVIEWING Engaging. Establish the foundation of a good working relationship where an atmosphere of acceptance and trust allows the client to explore his or her concerns. Engagement is enabled through a person-centred style where listening is a key tool in establishing the relationship. In practice, this means the client should be doing most of the talking. Focusing. Come to an agreement on the target substance behaviour and maintain direction. Focusing in MI is an ongoing process of seeking and maintaining that identified direction and, within it, more specific achievable goals. There are three styles of focusing that a counsellor can draw from while talking to their client. Directing is used when the client requires the professional to provide his or her expertise or knowledge. This style states to the client that the counsellor knows what must be done to solve a problem. It may also be considered the traditional health professional-to-client relationship. Following is useful at the beginning of a consultation, when you are trying to understand the client. This style is predominantly listening, and good listening comes without instructing, agreeing or disagreeing, warning or analyzing. This style states that you are letting the client make decisions in his or her own time and without any pressure to change one way or another. Guiding is used to help the client find his or her way. An effective guide will present what is possible and what options are available, and the client decides what they want to do with the support of the counsellor to get there. In behaviour change, this style indicates to the client that the counsellor will assist them in solving problems themselves. Evoking. Draw out a client s change talk. In MI, it is the counsellor s task to recognize change talk, elicit it and strategically respond to it. Evocation has been described as the heart of MI. Through this process there is a clear change goal that the counsellor and client work towards. Strategic, directional use of the client-centred OARS micro-counselling skills assists the counsellor in attending to change talk. Planning is the collaborative development of a specific change goal and supporting plan, followed by working with the individual to build confidence and self-efficacy. Once the client has identified significant reasons for change, and made a commitment for change, the counsellor s role is to assist in making the change process occur through careful planning. 8.6 Tobacco Free Futures

103 Once the change plan is developed, the client commits to the plan. The counsellor assists the client in implementing and adjusting the plan. During this process, the counsellor will also be aiming to consolidate and strengthen the client s commitment to change. Sustain talk refers to the client s own motivations and statements favouring the status quo. Hearing sustain talk represents and predicts movement away from change. There is nothing inherently oppositional about sustain talk it is simply one side of ambivalence. Miller and Rollnick suggest responding to sustain talk with reflective listening. Discord refers to the working relationship between counsellor and client. Discord may be present if any of the following becomes apparent during the session: defending, seeing the counsellor as an adversary, interrupting or disengagement. Miller and Rollnick suggest reflective listening as a key tool. Alternatives may include apologizing, affirming or shifting focus. Change talk refers to self-motivational statements. Have the client voice personal concerns and intentions, rather than try to persuade the client that change is necessary. Hearing their own arguments for change leads clients to believe in the need for change. Eliciting change talk helps resolve ambivalence and move forward, and as such is a key MI skill. Although a counsellor may want to hear change talk, an MI counsellor avoids imposing it against the client s will. The goal is to elicit it from the client in a collaborative fashion. Miller and Rollnick (2013) have suggested a number of methods to elicit change talk, including 7 asking evocative questions using an importance ruler (see box below) elaborating looking back/forward exploring goals and values (e.g., a decisional balance) Tools for eliciting change talk 8 The importance ruler is used to assess how important it is for the client to change. Importance, confidence and readiness can be explored with the use of this tool. 1. On a scale of 1 to 10 (1 = not important, 10 = very important), how important is it for you right now to change? 2. On a scale of 1 to 10, how confident are you that you could make this change? Follow-up questions may include Why have you put yourself there? Is there anything you can think of that would help you move up a step? Is there anything I can do to help you move up a step? The decisional balance tool can be used to assess barriers to change. It can help clients weigh out their pros and cons in making a change. 3. On a scale of 1 to 10, how ready are you to make this change now? Follow-up questions can be used to elicit motivating statements, help explore or further clarify a client s response and help determine next steps. The good things about tobacco use The not so good things about quitting The not so good things about tobacco use The good things about quitting Alberta Health Services

104 See appendices: Appendix 8(a) Tobacco Dependence and Cessation Consult Form Change talk can occur in several forms that make up the acronym DARN CAT: Desire statements indicate a desire to make a change. Ability statements speak to the client s self-efficacy or belief in the ability to make changes. Reasons statements reflect on the reasons the client gives for considering a change. Need statements indicate a need for change. Commitment language indicates the strength of change talk. Activation statements, such as I am ready to, indicate they are moving towards action. Taking steps indicates the person has taken some form of action towards change (e.g., I have not had a cigarette today ). Change statements are important to recognize and then emphasize through reflecting or directing the client to further elaboration. These statements are avenues to the most important part of change talk: the C in DARN CAT, or commitment language. For example, a person could say, I might change, I could consider changing, I m planning to change or I will change. The last two examples represent authentic commitment. The strength of the verb in the sentence corresponds with the strength of the commitment language. An important counselling skill is addressing a client s commitment to change over the course of the interview by recognizing and responding to change talk. The goal is a strengthening of the client s commitment level. 9 MOTIVATIONAL INTERVIEWING MICROSKILLS The following strategies for MI can be used by health professionals in the counselling process: open-ended questions, affirmations, reflective listening, summaries and informing/ advising. 7 Asking open- versus closed-ended questions helps clients get started talking. 7 An open question is one that does not invite one-word responses. With open-ended questions, a counsellor sets an interested, open and collaborative tone. A client is then more likely to provide more information, explore issues of concern and reveal what is most important to him or her. Affirmations are genuine, direct statements of support during the counselling sessions that are usually directed at something specific and change oriented that the client has done. 7 These statements demonstrate that the counsellor understands and appreciates at least part of what the client is dealing with and is supportive of the client as a person. Another microskill is listening reflectively, and doing so is one way of demonstrating empathy. 7 Listening reflectively is about being quiet and actively listening to the client, then responding with a statement that reflects the essence of what the client said or what you think the client meant. There are several levels of reflection, ranging from simple to more complex. The counsellor is strategic in what is reflected in order to guide the client towards resolving ambivalence and the positives of making change. 8.8 Tobacco Free Futures

105 The microskill of summaries serves several purposes. Summaries communicate that you have an understanding of what the client has said and help structure a session to stay on important topics. Most importantly, they provide an opportunity to emphasize the positive statements a client has made about change. This gives the client another opportunity to hear what he or she has said in the context provided by the counsellor. Summaries should represent change talk statements. An important aspect of the counsellor role in MI is providing clients with information on a range of facts, diagnoses and treatment recommendations. The main means of conveying this type of information is by informing and advising the client. Before offering the information, it is necessary to ask the client s permission to do so. This is in keeping with the spirit of motivational interviewing and honouring client autonomy. When providing information or advice to the client, it is important to acknowledge directly that the client is free to decide what he or she wants to do with it. CLIENTS READY TO QUIT The Clinical Practice Guidelines for Treating Tobacco Use and Dependence developed in the United States have found three types of counselling and behavioural therapies to be effective: problem-solving/skills training, intra-treatment social support and extra-treatment social support. The guidelines recommend these therapies be used with all patients attempting tobacco cessation. 2 Practical counselling: Problem solving and skills development People most likely to benefit from intensive counselling interventions are those people who also have a more difficult time quitting, including people who are more heavily addicted to tobacco, people with concurrent disorders, people from deprived socio-economic groups and those who live with others who smoke. See appendices: Appendix 8(a) Tobacco Dependence and Cessation Consult Form COGNITIVE BEHAVIOURAL THERAPY A cognitive-behavioural model provides many useful strategies that can be incorporated into an intensive counselling approach. Cognitive behavioural therapy (CBT) focuses on changing the thoughts, feelings and behaviours that accompany tobacco use and addiction. These approaches are guided by the principles of social learning theory and as such can facilitate skill building, problem solving and relapse prevention strategies. In order to increase the chances of a successful quit attempt, an individual should be supported in planning and preparation in advance. 10 The first sessions of intensive counselling typically incorporate many of the following strategies: self-monitoring, increasing awareness of smoking triggers, developing coping strategies, increasing support, setting a quit date and discussing initiation of pharmacotherapy, when applicable. The counsellor should schedule regular follow up to assess responses, provide support and modify treatments as necessary. 10 Alberta Health Services

106 SOCIAL COGNITIVE THEORY Bandura s social cognitive theory (SCT) is well regarded as a comprehensive theory of behaviour change that is grounded in considerable research. 10 Group cessation programs that achieved the highest cessation rates typically incorporated the major concepts of SCT. 10 Specifically, the programs with the highest cessation rates addressed outcome expectations by providing educational information about smoking and its effect on a person s health (e.g., that smoking increases health risks, and that quitting lowers those risks). 10 These programs enhanced behavioural capacity by promoting learning through behavioural skills training focused on smoking cessation. The top programs built self-control through self monitoring, goal setting, problem solving, and self-reward. They also addressed emotional coping responses through training in problem solving, coping with withdrawal, stress management and practicing skills in emotional situations. Finally, these programs helped create a supportive environment through social support such as buddy systems. 10 The following is a summary of components found in cessation programs that achieved the highest cessation rates: Identify situations, thoughts and feelings that trigger and maintain smoking. 2. Set personal target dates to quit smoking. Plan and practice in advance. 3. Provide efficient ways of learning new ways of thinking and behaving to support non smoking. 4. Ensure participants experiment with behaviour changes between sessions and review these experiences with the group. 5. Build participants confidence so that they can make the changes required to quit permanently. 6. Provide training in problem solving and stress management to deal with the emotional pressure of smoking cessation. 7. Ensure rewards for quit efforts. 8. Help participants redefine how they think about their efforts to quit. 9. Correct misperceptions about smoking and non-smoking. 10. Build social support for the participants efforts to quit and to remain a non-smoker. 11. Create physical environments that are conducive to cessation efforts for at least six months. Each of these principles, and the program components that address them, need to be tailored to each individual s need. Group cessation programs that incorporate a range of SCT concepts can help a wider variety of people, who learn in different ways and who exist in different environments. Individual intensive cessation counselling will customize these approaches to each client. Table 8.1 outlines suggested activities for each of the 11 counselling components Tobacco Free Futures

107 Table 8.1: Suggested Activities for Intensive Counselling Components 10,11 Counselling Component Identify situations, thoughts and feelings that trigger and maintain smoking. Set personal target dates to quit smoking. Plan and practice in advance. Provide efficient ways of learning new ways of thinking and behaving to support non smoking. Ensure participants experiment with behaviour changes between sessions and review these experiences with the group. Build participants confidence so that they can make the changes required to quit permanently. Provide training in problem solving and stress management to deal with the emotional pressure of smoking cessation. Ensure rewards for quit efforts. Help participants redefine how they think about their efforts to quit. Correct misperceptions about smoking and non-smoking. Build social support for the participant s efforts to quit and to remain a non smoker. Create physical environments that are conducive to cessation efforts for at least six months. Suggested Activities Clients should record their tobacco use patterns for at least one weekday and one weekend day prior to quitting. This will provide precise information on where and when they smoke, what the situations in which they smoke are, how they think about smoking and how strong a craving they had for each cigarette. Use a tobacco use journal. Clients should choose a quit date that will present the fewest challenges based on their record of tobacco use patterns. Clients may reduce their number of daily cigarettes in preparation but quit completely on their target date. Observing the behaviour and practicing it with feedback are the best ways for a person to learn. Roleplay a difficult situation (e.g., counsellor and client, facilitator and group members). Show participants appropriate behaviours (e.g., with a video). Review and ask participants to evaluate their own practice. Have clients record their smoking or feelings about smoking. Practice difficult situations. Enlist support or help. Have participants rehearse how to handle difficult situations and receive feedback on their performance. Have them try out new actions in a safe setting, progressing to more difficult situations. This increases confidence and self-efficacy. Have them monitor how they think and feel about their performance. Practice with relaxation exercises or mindfulness techniques. Suggest increased physical activity to counter stress. Incorporate relaxation in daily routines as alternatives to smoking. Clients should define small and large rewards for performaning their desired behaviours (e.g., resisting urges to smoke). Use money saved from buying tobacco products to make special purchases (selfidentified rewards). Notice the sense of accomplishment they feel from taking control of these aspects of their lives. Reframe strong urges as recovery symptoms. The body is healing itself. Instead of seeing slips as failures, redefine them as opportunities to learn resilience and better responses to similar situations in the future. Provide information about immediate benefits from quitting tobacco in terms of health, finances and social situations. Provide information to significant others on what to expect of the client s tobacco cessation journey. Coach them on what is helpful support and what is not. Ensure support continues for at least six months. Provide tobacco free signs for participants to use in their homes or vehicles. Suggest clients get their car interiors professionally cleaned as an incentive to avoid further smoking in their cars. Alberta Health Services

108 Clients who have recently quit Tobacco users who have recently quit are at high risk of relapse and may need ongoing support from health professionals. Although research suggests that the majority of former tobacco users will relapse within six months, some may not until years later. Any former tobacco user should be commended for his or her success and strongly encouraged to remain tobacco free. Health professionals should be ready to discuss issues such as 2 the benefits of cessation and remaining tobacco free any successes experienced (e.g., length of quit, decreased withdrawal symptoms, improved overall health) any threats to continued cessation (e.g., ongoing withdrawal symptoms, weight gain, depression, significant stress) and ways to manage them the ongoing use and effectiveness of pharmacotherapy the stress associated with recovery from concurrent issues and ways clients can minimize their risk of relapse encouraging clients to seek out support from their family and friends for quitting (if the client does not have support people in his or her life, discuss the possibility of support through the AlbertaQuits helpline or website) Tobacco dependence is a chronic, relapsing condition similar to other addictive substances such as alcohol, cocaine and heroin. Clients may need frequent reminders about the possibility of relapse and the need to develop relapse prevention plans. Counsellors must continually assess their clients tobacco status and adjust services and techniques to match each client s needs. Prescriptive relapse prevention A central element of all clinical approaches to relapse prevention is anticipating problems that are likely to arise, identifying them and helping clients develop effective strategies to cope with them without having a lapse. For patients in the preparation and action stages of change, providing practical problem solving skills training results in higher abstinence rates. 2 It is important that clients are prepared to see the experience of a lapse as an opportunity to learn and fine-tune approaches, rather than as a failure. Common high-risk situations and suggested coping strategies are outlined in Table Tobacco Free Futures

109 Table 8.2: Suggested Relapse Prevention Strategies 10,12,13 Commonly Reported High Risk Situation Lack of support for cessation Negative mood or depression Strong or prolonged withdrawal symptoms Weight gain Flagging motivation/ feeling deprived Suggested Strategy Schedule follow-up visits or telephone calls with the client. Help the client identify sources of support within his or her environment, such as family, friends or their church. Refer the client to an appropriate program or organization that offers cessation counselling or support, if you or your agency is not able to offer the necessary services. Provide counselling. Prescribe appropriate medications. Refer the client to a specialist. Consider extending the use of an approved pharmacotherapy or adding/ combining medications to reduce strong withdrawal symptoms. Use behavioural techniques to reduce cravings. Discourage strict dieting. Emphasize the importance of a healthy diet. Recommend starting or increasing physical activity. Reassure the client that some weight gain after quitting is common and appears to be self-limiting. Refer client to a specialist, dietitian or weight management program. Reassure client that these feelings are common. Recommend rewarding activities. Follow up to ensure that the client is not engaged in periodic tobacco use. Emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult. See appendices: Appendix 8(a) Tobacco Dependence and Cessation Consult Form Alberta Health Services

110 STAFF ROLES AND DOCUMENTATION Defining staff roles and client care documentation are essential processes that will have a direct impact on the success of the initial implementation and sustainability of the Tobacco Free Futures initiative. Staff roles The staff who will perform and document the following client-centred activities need to be identified: 1. providing more intensive cessation support, such as one-on-one intensive counselling or group cessation counselling Documentation The Tobacco Dependence and Cessation Consult Form is intended to facilitate an intensive counselling session or sessions. It outlines the pertinent information as outlined in this chapter. This form has been reviewed by the Cancer Care Strategic Clinical Network and adopted as Alberta Health Services clinical policy. All forms are now available through the provincial Alberta Health Services forms inventory and can be accessed through approved zone forms ordering processes or through the AHS Forms Library on Insite: Edmonton Zone: call (780) (Data Group) or visit the online catalogue North Zone: call (780) (Data Group) or visit the online catalogue Calgary Zone: call (403) (Data Group) or visit the online catalogue Central Zone: call (780) (Wetaskiwin Production Services) South Zone: call (403) (former Chinook) or (403) , extension 1088 (former Palliser) See appendices: Appendix 8(a) Tobacco Dependence and Cessation Consult Form 8.14 Tobacco Free Futures

111 REFERENCES 1. Rigotti, N., Munafo, M., & Stead, L. (2008). Interventions for smoking cessation in hospitalised patients (Review). The Cochrane Library, 4, Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 3. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPPT). (2011). Canadian smoking cessation clinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 4. Prochaska, J., Diclemente, C., & Norcross, J. (1993). In search of how people change: Applications to addictive behaviors. Journal of Addictions Nursing, 5(1), Whitelaw, S., Baldwin, S., Bunton, R., & Flynn, D. (2000). The status of evidence and outcomes in stages of change research. Health Education Research, 15(6), Behaviour Works Australia. (2012). Stage theories and behaviour change. Melbourne, Australia: Monash University, Monash Sustainability Institute. Retrieved from Miller, W., & Rollnick, S. (2013). Motivational interviewing: Helping people change (applications of motivational interviewing) (3rd ed.). New York: Guilford Press. 8. Miller, W., & Rollnick, S. (2002). Motivational interviewing preparing people for change (2nd ed.). New York: Guilford Press. 9. InSight: Alcohol and Other Drug Education and Training Unit, Metro North Mental Health Alcohol and Drug Service. (2013). Induction module 5: Motivational inteviewing. Brisbane, Australia: Queensland Government. Retrieved from insight/modules/module%205%20motivational%20interviewing.pdf 10. Els, C., Kunyk, D., & Selby, P. (2013). Disease interrupted: Tobacco reduction and cessation. Toronto, ON: Createspace Publishing. 11. Manske, S., Miller, S., Moyer, C., Phaneuf, M., & Cameron, R. (2004, July/August). Best practice in group-based smoking cessation: Results of a literature review applying effectiveness, plausibility, and practicality criteria. American Journal of Health Promotion, 18(6), Morris, C., Waxmonsky, J., Giese, A., Graves, M., & Turnbull, J. (2009). Smoking cessation for persons with mental illnesses: A toolkit for mental health providers. Denver, CO: University of Colorado at Denver and Health Sciences Center, Department of Psychiatry. 13. Signal Behavioral Health Network. (2008). Tobacco treatment for persons with substance use disorders: A toolkit for substance abuse treatment providers. Denver, CO: Author. Alberta Health Services

112 APPENDICES Appendix 8(a) Tobacco Dependence and Cessation Consult Form 8.16 Tobacco Free Futures

113 Appendix 8(a) Tobacco Dependence and Cessation Consult Form (page 1) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Tobacco Dependence and cessation consult Birthdate (yyyy-mon-dd) Gender Personal Health Number Complete the Tobacco Dependence and Cessation Brief Intervention form (#18251) prior to this consult. This consult to be completed for all patients requiring further behavioural support. Are you having or have you had any nicotine withdrawal symptoms? (e.g. Irritable, nervous, restless, trouble concentrating, trouble sleeping, depressed, increased appetite) No Yes, action taken pattern of use Type of tobacco used (check all that apply) Cigarette Cigar/cigarillo Pipe Chew/spit Waterpipe (e.g. Hookah) Other (specify) current pattern of use (amount, frequency, last use, how soon after waking) Historical patterns (amount, frequency, number of years) previous Treatment Quit attempts (last attempt, length of time, total number of quit attempts, longest quit) Exposure to second-hand smoke At home Live in multi-family dwelling In the car Not exposed Other (specify) past Relapse Discharge from healthcare site Withdrawal symptoms Stopped medication Stopped behavioural support Use of alcohol, other drugs Household smoker Family/friends smoke Stress Other (specify) cessation Medications Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Patch Nicotine Mouth Spray Bupropion SR Varenicline Other (specify) behavioural Supports Group counselling Individual counselling Self help materials Online support Other (specify) Comments (Include perceived effectiveness of previous treatment or approaches) Alternative Treatments Acupuncture Herbal remedies Hypnosis Other (specify) No Treatment Cold turkey Tapering down 18252(Rev ) Page 1 of 3 Alberta Health Services

114 Appendix 8(a) Tobacco Dependence and Cessation Consult Form (page 2) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Tobacco Dependence and cessation consult Name (last, first) Birthdate (yyyy-mon-dd) Gender Personal Health Number Information on current use What are the good things about your tobacco use? What are the not so good things? barriers/concerns about quitting Withdrawal/Cravings Fear of failure Loss time to self/ Breaks Enjoyment Weight gain Other (specify) Stress/Stress relief Cost of medication Discouragement/Lack of willpower Cost/Timing groups Work environment Home environment Not ready Disruption of social relations Stressors Financial Work or unemployment Family Mental illness Physical illness Triggers/concerns about relapse Other smokers in the home Dealing with stress At work Social events Other (specify) Housing Other (specify) Readiness to change which statement describes how you feel about your tobacco use I have quit smoking and I will never smoke again I have quit smoking, but I worry about slipping back I still smoke but I have begun to change and I m ready to set a quit date I definitely plan to quit smoking within the next 30 days I definitely plan to quit smoking in the next 6 months I sometimes think about quitting smoking, but I have no plans to quit I enjoy smoking and have no interest in quitting for my lifetime 18252(Rev ) Page 2 of Tobacco Free Futures

115 Appendix 8(a) Tobacco Dependence and Cessation Consult Form (page 3) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Tobacco Dependence and cessation consult Birthdate (yyyy-mon-dd) Gender Personal Health Number Not at all Slightly Moderately considerable Extremely Recently, how concerned have you been by your tobacco use? How important is it to change your tobacco use right now? How confident are you that you can make these changes? Health Care Provider rating of importance of treatment at this time. Comments Treatment plan (patient/care provider/family mutually agreed upon goals and actions) What would you like to do next? How can I help you? Date (yyyy-mon-dd) Goal (reduce, quit, other, including time frame) Action/Tasks/Activities to achieve goal Response/progress Initials plan for leaving healthcare site (Refer to Tobacco Dependence and Cessation Brief Intervention - form #18251) Health Care Providers Name (print) Signature Date (yyyy-mon-dd) Time (hh:mm) 18252(Rev ) Page 3 of 3 Alberta Health Services

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117 Chapter 9 Pharmacotherapy Alberta Health Services

118 PHARMACOTHERAPY TREATMENTS Pharmacotherapy plays an important role in tobacco cessation treatment. Evidence indicates that using pharmacotherapy on its own doubles a person s chance of successfully quitting tobacco. 1 Except in the presence of contraindications, it is recommended that available treatments be used with all patients attempting to quit smoking. 2,3 A number of first-line smoking cessation medication options have been approved for use in Canada, including various forms of nicotine replacement therapy (NRT), bupropion SR and varenicline. 4 Decisions about whether to use pharmacotherapy, including the type of product that is appropriate, should be made in collaboration with the patient/client. 1 Table 9.1 summarizes information related to odds ratios and abstinence rates for various medications 6 months after quitting, compared with placebo, based on a meta-analysis of the research. 5 Research suggests that combined therapies and higher doses or longer treatment times improves abstinence rates. 5 Pharmacotherapy myths 4 NRT is hazardous. Smoking while using NRT causes heart attacks. Patients with heart disease should not use NRT. Various NRTs cannot be used at the same time as or in combination with bupropion. Cessation medications are only for short-term use. NRT can only be used by those who are ready to quit. It is essential that health care providers are knowledgeable about pharmacotherapy products so that they can tailor a treatment plan to meet the patient/client s needs, dispel misconceptions about the drug therapies and address any concerns that arise. 1 Table 9.1: Summary of Pharmacotherapy Effectiveness 3 Medication Odds Ratio (95% CI) Abstinence Rate (95% CI) PLACEBO VARENICLINE (2 mg/day) 3.1 ( ) 33.2 ( ) NICOTINE NASAL SPRAY 2.3 ( ) 26.7 ( ) HIGH-DOSE NICOTINE PATCH (>25 mg) 2.3 ( ) 26.5 ( ) NICOTINE GUM (>14 weeks) 2.2 ( ) 26.1 ( ) NICOTINE INHALER 2.1 ( ) 24.8 ( ) BUPROPION SR 2.0 ( ) 24.2 ( ) NICOTINE PATCH (6 14 weeks) 1.9 ( ) 23.4 ( ) NICOTINE PATCH (>14 weeks) 1.9 ( ) 23.7 ( ) NICOTINE GUM (6 14 weeks) 1.5 ( ) 19.0 ( ) Note: Nicotine nasal spray is not currently available in Canada 9.2 Tobacco Free Futures

119 Nicotine replacement therapy (NRT) It is not the nicotine, but rather, the thousands of toxins in tobacco and the products of combustion, that are responsible for the majority of tobacco-related illness. 4 The purpose of NRT is to provide a tobacco user with a clean source of nicotine that will help reduce cravings for tobacco by reducing physiological withdrawal and allowing the user to develop behavioural strategies that support cessation. NRT makes it easier to quit using tobacco by replacing some, but not all, of the nicotine normally consumed. 4 Signs and symptoms of nicotine withdrawal normally appear within two hours of last nicotine use, peak in 24 to 48 hours and last from several days to four weeks. 1 In the case of hospitalized clients, where temporary cessation may be enforced by the circumstances of their illness and the smoke-free environment, NRT may be a valuable comfort measure to reduce signs and symptoms of withdrawal. 4 The AHS formulary currently includes NRT in the form of transdermal patches, gums, lozenges, inhalers, and mouth sprays. DSM-5 signs and symptoms of nicotine withdrawal: 6 irritability (frustration or anger) anxiety difficulty concentrating restlessness insomnia depressed mood increased appetite Use of NRT at higher doses and in a combination of preparations (e.g., patch plus gum) have been found to be more effective in highly dependent tobacco users and those with a history of severe withdrawal. It has been found that many people do not use cessation medications as recommended, leading to decreased effectiveness. Education of correct techniques for medication use is important to achieve optimum withdrawal relief. 3 Some forms of NRT are eligible for coverage under Alberta Drug Benefits. Please refer to Table 18.2 in Chapter 18 ( Transition and Continuing Care ) for more information. Alberta Health Services

120 Non-nicotine prescription medications Bupropion SR and varenicline are also considered first-line pharmacotherapy for tobacco cessation; however, unlike NRT, both are available by prescription only. These two products have different mechanisms of action, but both have been found to be effective treatment options. Bupropion SR (Zyban, Wellbutrin SR ) is an antidepressant that is thought to mimic the effects of nicotine on dopamine and noradrenaline receptors in the brain. It has been found through randomized control trials to reduce the desire to smoke, suppress withdrawal symptoms and reduce weight gain associated with tobacco cessation. 3 Studies have shown that bupropion SR doubles the chances of tobacco cessation and, when used in combination with NRT, may have better results. 7 Bupropion SR is currently available in the AHS formulary. Varenicline (Champix ) acts at the level of the nicotinic receptors in the brain, preventing the binding of nicotine at those sites and stimulating some dopamine release. These actions decrease the pleasure associated with tobacco use and result in decreased cravings and withdrawal symptoms. 8 The safety of varenicline used in combination with NRT or buproprion has been demonstrated in small preliminary studies to date. 5,9 For more detail on pharmacotherapy options, see Table 9.2. Health care providers should conduct regular assessments of patients/clients who are taking these medications to determine adherence to treatment, adjust medications as necessary to ensure withdrawal relief and rule out nicotine toxicity. For inpatients who decline NRT support, regular assessment of withdrawal symptoms may provide teachable moments and opportunities to reassess change in willingness to accept support. Signs of nicotine toxicity 10 nausea abdominal pain vomiting diarrhea hyper-salivation perspiration headache dizziness hearing and visual disturbances mental confusion weakness Bupropion and varenicline are eligible for coverage under Alberta Drug Benefits. Please refer to Table 18.2 in Chapter 18 ( Transition and Continuing Care ) for more information. See appendices: Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy Follow Up/Discharge Orders 9.4 Tobacco Free Futures

121 Table 9.2: Summary of Pharmacotherapy for Nicotine Withdrawal Support 3,8 Drug Preparations Common Side effects Correct Use Drug interactions* NICOTINE PATCH sustained release provides a steady, slow release of nicotine over 16 or 24 hours of use average $3 $5/day available in 21 mg, 14 mg and 7 mg dosages per 24 hours (under AHS formulary) also available in 15 mg, 10 mg and 5 mg dosages per 16 hours (not under AHS formulary) dosage should be titrated dependent on history of tobacco use recommended patch(es) used daily for 6 weeks, then reassess; strength is reduced over time may be used alone or in combination with other NRTs, bupropion SR or varenicline 5,7,9 skin irritation vivid dreams insomnia headache nausea apply to a clean, dry, hairless area remove old patch prior to application of new one change sites daily to prevent skin irritation patient/client is normally advised not to use tobacco while using the patch; however, continued use is generally not considered dangerous and does not imply treatment failure if insomnia and vivid dreams are a concern, patch should be removed prior to bedtime Nicotine may reduce the sedative effects of benzodiazepines decrease subcutaneous absorption of insulin reduce effectiveness of beta-blockers lessen effectiveness of opioid analgesia Changes in drug metabolism are similar on NRT to those seen when quitting without NRT. Adjustments in these types of medications may be necessary. NICOTINE GUM immediate release effect within 15 minutes of use average $2 $8/day (6 25 pieces) available in 2 mg and 4 mg dosages approved under AHS formulary dosage should be titrated dependent on history of tobacco use recommended one piece every hour as needed; maximum 20 pieces per day recommended that number and frequency be decreased over time (reduction with intent to quit using nicotine gum may also be considered 15 ) may be used alone or in combination with other NRT, bupropion SR or varenicline 5,7,9 mouth or throat soreness jaw ache hiccups flatulence upset stomach insomnia headache nausea absorbed through the lining in the mouth do not eat or drink for 15 minutes before or during use the term gum is misleading, as proper use is bite, bite, park, repeat bite gum until a peppery taste or tingling occurs; park gum between cheek and gums; repeat when sensation goes away do not swallow Nicotine may reduce the sedative effects of benzodiazepines decrease subcutaneous absorption of insulin reduce effectiveness of beta-blockers lessen effectiveness of opioid analgesia Changes in drug metabolism are similar on NRT to those seen when quitting without NRT. Adjustments in these types of medications may be necessary. Alberta Health Services

122 Table 9.2 (continued) Drug Preparations Common Side effects Correct Use Drug interactions* NICOTINE LOZENGE immediate release effect within 15 minutes of use average $4 $10/day (6 15 lozenges) available in 1 mg, 2 mg and 4 mg dosages approved under AHS formulary dosage should be titrated dependent on history of tobacco use recommended one lozenge every hour as needed; maximum 20 lozenges per day. should dissolve within minutes recommended that number and frequency be decreased over time may be used alone or in combination with other NRT, bupropion SR or varenicline 5,7,9 mouth or throat soreness hiccups upset stomach insomnia headache nausea absorbed through the lining of the mouth do not eat or drink for 15 minutes before taking the lozenge do not chew or swallow the lozenge slowly suck until there is a strong taste, then rest the lozenge in the cheek, wait 1 minute or until taste fades and then repeat. may be useful for those who cannot chew gum sugar-free and safe for use by people with diabetes Nicotine may reduce the sedative effects of benzodiazepines decrease subcutaneous absorption of insulin reduce effectiveness of beta-blockers lessen effectiveness of opioid analgesia Changes in drug metabolism are similar on NRT to those seen when quitting without NRT. Adjustments in these types of medications may be necessary. NICOTINE INHALER immediate release effect within 15 minutes of use average $6 $12/day (6 12 cartridges) available in a 10 mg cartridge that delivers 4 mg of nicotine through about 80 inhalations (over 20 minutes of active puffing) approved under AHS formulary dosage should titrated dependent history of tobacco use recommended one cartridge every 20 minutes as needed; maximum 16 cartridges/day recommended that number and frequency be decreased over time, stopping when reduced to 1 or 2 cartridges per day may be used alone or in combination with other NRT, bupropion SR or varenicline 5,7,9 mild local irritation of mouth, sinus or throat cough dry mouth hiccups insomnia headache nausea hand-mouth activity from using the inhaler is preferred by some quitters the inhaler is useful for those with poor oral health or dentures, and for those who cannot chew gum similar in appearance to a cigarette: designed to be puffed on not a true inhaler; the nicotine is delivered and absorbed through the lining in the mouth allows fine tuning of how much and how often the user consumes nicotine Nicotine may reduce the sedative effects of benzodiazepines decrease subcutaneous absorption of insulin reduce effectiveness of beta-blockers lessen effectiveness of opioid analgesia Changes in drug metabolism are similar on NRT to those seen when quitting without NRT. Adjustments in these types of medications may be necessary. 9.6 Tobacco Free Futures

123 Table 9.2 (continued) Drug Preparations Common Side effects Correct Use Drug interactions* NICOTINE MOUTH SPRAY immediate release effect within 60 seconds of use average $3 8/day (15 45 sprays) available in a dispenser that contains 150 sprays; each spray delivers 1 mg of nicotine. dosage should titrated dependent on history of tobacco use recommended 1 or 2 sprays as needed; maximum dose is 2 sprays at a time, 4 sprays per hour and 64 sprays per day recommended that number and frequency be decreased over time, stopping when reduced to 2 4 sprays per day may be used alone or in combination with other NRT, bupropion SR or varenicline 5,7,9 hiccups throat irritation increased salivation tingling sensation of the mouth/lips insomnia headache nausea absorbed through the lining in the mouth do not eat or drink for 15 minutes before using the spray if using the spray for the first time, or if the spray has not been used for two days, load the spray pump by pressing on the dispenser several times until a fine spray is released point the spray nozzle towards the open mouth and hold as close as possible to the mouth, avoiding the lips press down on the dispenser to release a spray into the mouth do not inhale while spraying and avoid swallowing for a few seconds afterwards expect a strong mint taste in the mouth Nicotine may reduce the sedative effects of benzodiazepines decrease subcutaneous absorption of insulin reduce effectiveness of beta-blockers lessen effectiveness of opioid analgesia Changes in drug metabolism are similar on NRT to those seen when quitting without NRT. Adjustments in these types of medications may be necessary. BUPROPION SR sustained release average $2 $3/day begin treatment 1 or 2 weeks before quit date approved under AHS formulary usual dose 150 mg in a.m. for 3 days; increase to 150 mg twice daily for 7 12 weeks may be used alone or in combination with NRT or varenicline 5,7,9 insomnia dry mouth headache weight loss agitation should be monitored for unusual feelings of agitation, hostility, aggression, depressed mood, hallucinations, changes in behaviour or suicidal thoughts contraindicated for those who have seizures, eating disorders, active alcohol addiction or who are on monoamine oxidase Inhibitors insomnia may be avoided by taking evening dose earlier Some drugs in the following classes have the potential to significantly interact with buproprion SR: alkylating agents muscle relaxants tricyclic antidepressants antipsychotics anti-arrhythmics MAO inhibitors antiseizure medications beta blockers phenobarbital H2 blockers Alberta Health Services

124 Table 9.2 (continued) Drug Preparations Common Side effects Correct Use Drug interactions* VARENICLINE average $3.50 $4.50/day begin treatment 1 or 2 weeks before quit date approved under AHS formulary usual dose 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for 12 weeks alternate maintenance dose 0.5 mg twice daily for 12 weeks may be extended for an additional 12 weeks nausea insomnia vivid dreams headache constipation agitation, depression, suicidal thoughts should be monitored for unusual feelings of agitation, hostility, aggression, depressed mood, hallucinations, changes in behaviour or suicidal thoughts should be monitored for and informed of symptoms of heart attack and stroke and instructed to seek immediate medical help if they experience them take with food to reduce nausea; nausea may subside with continued use insomnia may be avoided by taking the evening dose at supper No significant drug interactions are known Note: Refer to product monographs for more detailed information. All medications need to be closely monitored and adjusted accordingly * Polycyclic aromatic hydrocarbons in the tar of tobacco smoke affect liver enzymes (cytochrome P-450) causing faster metabolism of some drugs. Numerous medications may be affected once a person stops smoking including antidepressants (tricyclics, fluvoxamine), antipsychotics (clozapine, olanzapine, haloperidol), caffeine, benzodiazepines (chlordiazepoxide, diazepam), nifedipine, propafenone, theophylline, verapamil, and warfarin. 1,7 9.8 Tobacco Free Futures

125 Special considerations There are some specific populations who may have additional needs when considering the use of cessation pharmacotherapy. YOUTH Tobacco use is a major concern for children under the age of 18, and it is important to note that the majority of adult smokers were also daily users as youths. 3 NRT is a safer option than smoking or using other tobacco products, and should be considered when supporting all tobacco users. 11 Factors such as the degree of dependence, amount of product used per day and body weight should be considered when prescribing any medications for this age group. 3 PREGNANT AND BREASTFEEDING WOMEN Exposure to tobacco during pregnancy causes risks for women and their unborn babies, which is why many women are motivated to quit at this time. It is most beneficial that women quit before conception, but there are benefits to quitting at any time during pregnancy. Health care providers should be aware that many pregnant women are reluctant to disclose their tobacco use. 3 There is no safe level of nicotine exposure in pregnancy; however, NRT should be considered for women who are not able to abstain with behavioural support alone. If NRT is used, it is recommended that lower dosages of the intermittent delivery systems (e.g., gum, lozenges or inhalers) are prescribed rather than the nicotine patch. 2,3 Varenicline has not been studied for use in pregnancy. 11 Many women who are successful in quitting tobacco use during pregnancy relapse in the postpartum period. Support must continue for postpartum and breastfeeding women, as they and their newborns will both benefit. Because nicotine from NRT can be transferred through breast milk, it is recommended that, as with pregnancy, lower dosages of the intermittent delivery systems are prescribed and used after breastfeeding. 2,3 The benefits of pharmacotherapy support outweigh the risks to mother and baby during pregnancy and lactation. 2 ADDICTIONS AND MENTAL HEALTH Patients/clients with mental health conditions, including addictions, have higher rates of tobacco use than the general population. Those dealing with mental health issues benefit from the same type of cessation support as the general public. It is important for health care providers to have an awareness of the impact of smoking cessation on comorbid conditions and recognize that these patients/clients are at higher risk of relapse. 2 Many people with mental health conditions use tobacco to relieve some of their symptoms, and cessation may exacerbate co-morbid conditions (e.g., worsening of depression or anxiety) or affect the action of some psychiatric medications. 1 Bupropion SR, with or without NRT, may be an appropriate choice for cessation support for those suffering from or with a history of depression. Smoking complicates the treatment of some mental disorders by decreasing blood levels of neuroleptics. 8 Hydrocarbons in the tar of tobacco smoke affect enzymes from the liver, causing faster metabolism of some drugs; therefore, smokers may require larger doses to achieve therapeutic effect, running an increased risk of adverse effects. 3,8 People with mental health disorders who stop smoking while taking medications for their illness should be monitored to determine if dosage reductions in their medication are necessary. 8 Thus, close monitoring of the amount smoked, cessation treatment, medication side effects and psychiatric symptoms are important when addressing tobacco dependence treatment in populations with psychiatric populations. 2 Alberta Health Services

126 CARDIAC CONDITIONS It is more dangerous for patients with heart disease to continue using tobacco products than to use NRT to support cessation. Smoking causes the activation of coagulation, which can lead to clotting and cause heart attacks. Toxins such as carbon monoxide also cause reduced oxygen delivery to the heart. Studies have shown that use of NRT is safe with cardiac patients and should be considered for those who are having difficulty quitting without pharmacotherapy support. 11 In recent years, there have been drug safety concerns related to the use of varenicline being associated with adverse cardiovascular events. However, a 2012 meta-analysis of the all of the published randomized controlled studies related to varenicline has concluded that there is no significant increase in the risk of cardiovascular serious adverse events attributed to varenicline use. 12 Assessing nicotine withdrawal It has been generally acknowledged that most tobacco users have difficulty quitting because of their addiction to nicotine and the resulting withdrawal symptoms they face when they do stop. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), lists seven symptoms characteristic of nicotine withdrawal: irritability, restlessness, insomnia, anxiety, depressed mood, increased appetite and difficulty concentrating. 2 Although more recent literature proposes there may be some value in including additional symptoms, these factors, with the addition of craving tobacco, are the items that are routinely assessed and measured in a variety of tools to support tobacco research. 13,14 The use of a nicotine withdrawal scale for assessment of withdrawal is not a component of the Tobacco Free Futures initiative. The program uses training and resources to educate staff in assessment without the use of a formal tool. Some health care sites implementing the program may be interested in developing and using a formal assessment tool. The following information on nicotine withdrawal scales is provided as background information. Over the past 25 years, an array of nicotine withdrawal questionnaires have been developed, some intended to be self-reported and others based on observation. Reviews of eight commonly used tools do not identify a clear preference, as they all have identified strengths and weaknesses. One key difference that may impact choice is the length, which ranges from 7 to 28 items. 10,14 Although these tools were not designed for clinical use, adopting a standardized approach to monitor tobacco withdrawal and effectiveness of pharmacotherapy by health care providers may be an appropriate application. The Minnesota Nicotine Withdrawal Scale (MNWS), developed in 1986, is concise and one of the most widely used tools. This self-report scale asks the user to rate their experience on a 5-point scale where 0 means none and 4 means severe. 10,13 The original eight validated symptoms from the MNWS are included in Table 9.3. The available withdrawal scales do not provide direction regarding a threshold score for initiating or modifying pharmacotherapy; however, Toll et al. (2007) indicate that the MNWS does provide a brief measure of overall withdrawal severity that can be used to guide clinical treatment decisions for supportive pharmacotherapy and counselling Tobacco Free Futures

127 Table 9.3: Assessing Nicotine Withdrawal Withdrawal scale (adapted from Minnesota Nicotine Withdrawal Scale) If receiving pharmacotherapy and moderate to severe withdrawal symptoms persist reassess: technique, dose and frequency. 0 = none 1 = slight 2 = mild 3 = moderate 4 = severe Symptoms Desire/cravings Anger/irritability/frustration Anxiety/nervousness Difficulty concentrating Restlessness Insomnia/sleep problems/waking at night Increased appetite/weight gain Depressed mood* Total score: Caution Quitting smoking can decrease tolerance to caffeine. Symptoms associated with this increase in caffeine effect can often be confused with nicotine withdrawal symptoms. *Complete brief mood assessment (PHQ-2) if moderate to severe depressed mood identified. A 2005 comparison and evaluation of five nicotine withdrawal scales identified that one of the weaknesses of the MNWS was that it was less sensitive to identifying depression. 14 To address potential patient/client safety concerns related to pharmacotherapy, those who report moderate to severe depressed mood when assessed with the MNWS should be screened further to determine if referral for mental health support is required. There are several questionnaires available that simplify depression screening and can enhance routine inquiry about the most prevalent and treatable mental health conditions. There is strong evidence for the use of the Personal Health Questionnaire-2 (PHQ-2) as a brief depression screening measure. The PHQ-2 inquires about the frequency of depressed mood and absence of pleasure over the past two weeks. The total PHQ-2 score can range from 0 to 6 with a score of 3 as the optimal cutpoint for screening purposes. A score of 3 or higher would indicate a referral to a mental health specialist. 15 PHQ-2 15 Over the past two weeks, how often have you been bothered by any of the following problems? (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day) 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless Alberta Health Services

128 PHARMACOTHERAPY STAFF ROLES AND DOCUMENTATION Defining staff roles and client care documentation are essential processes that will have a direct impact on the success of the implementation and sustainability of the Tobacco Free Futures initiative. Staff roles The staff who will perform and document the following client-centred activities need to be identified: 1. connecting to a prescriber or distributing pharmacotherapy for cessation 2. providing patient education regarding the correct use of cessation pharmacotherapy 3. arranging for ongoing pharmacotherapy support throughout a client s quit attempt or period of abstinence 4. continuous monitoring of medications Documentation The Tobacco Dependence and Cessation Pharmacotherapy Initiation and Followup/ Discharge Orders have been developed to provide sites across the province with access to standardized order sets. The recommendations for dosing of first-line cessation pharmacotherapy are based on product monographs and the available literature. They have been developed in collaboration with AHS Pharmacy Services and reviewed by the Cancer Care Strategic Clinical Network. All forms are now available through the provincial Alberta Health Services forms inventory and can be accessed through approved zone forms ordering processes: Edmonton Zone: call (780) (Data Group) or visit the online catalogue North Zone: call (780) (Data Group) or visit the online catalogue Calgary Zone: call (403) (Data Group) or visit the online catalogue Central Zone: call (780) (Wetaskiwin Production Services) South Zone: call (403) (former Chinook) or (403) , extension 1088 (former Palliser) See appendices: Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy Follow up/discharge Orders 9.12 Tobacco Free Futures

129 References 1. Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P. (2007). The tobacco dependence treatment handbook: A guide to best practice. New York: Guilford Press. 2. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 3. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: US Department of Health and Human Services, Public Health Service. 4. Ontario Medical Association (2008). Rethinking stop-smoking medications: Treatment myths and medical realities. OMA Postion Paper. Toronto, ON: Author. 5. Ebbert, J., Croghan, I., Sood, A., et al. (2009). Varenicline and bupropion sustainedrelease combination therapy for smoking cessation. Nicotine & Tobacco Research, 11, American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.) Washington, DC: Author. 7. Desai, H., Krejci, J., & Brandon, T. (2004) Smoking in patients receiving psychotropic medications a pharmacokinetic perspective. CNS Drugs, 15, Lexicomp. (2011). Lexicomp online. Retrieved from 9. Ebbert, J., Burke, M., Hays, J., et al. (2009). Combination treatment with varenicline and nicotine replacement therapy. Nicotine & Tobacco Research, 11(5), Hughes, J. (2007). Measurement of the effects of abstinence from tobacco: A qualitative review. Psychology of Addictive Behaviours, 1, Rigotti, N., Munafo, M., & Stead, L. (2007). Interventions for smoking cessation in hospitalised patients Cochrane Database of Systematic Reviews, 2007, 3. Art. No.: CD Prochaska, J., & Hilton J. (2012). Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: Systematic review and meta analysis. British Medical Journal, 344, e2856. Retrieved from Toll, B., O Malley, S., McKee, S., Salovey, P., & Krishnan-Sarin, S. (2007). Confirmatory factor analysis of the Minnesota Nicotine Withdrawal Scale. Psychology of Addictive Behaviours, 21, West, R., Ussher, M., Evans, M., & Rashid, M. (2006). Assessing DSM-IV nicotine withdrawal symptoms: A comparison and evaluation of five different scales. Psychpharmacology, 184, Kroenke, K., Spitzer, R., & Williams, J. (2003) The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41, Alberta Health Services

130 Appendices Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy Followup/Discharge Orders 9.14 Tobacco Free Futures

131 Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders (page 1) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Birthdate (yyyy-mon-dd) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Gender Personal Health Number See Prescribing and Administering Tobacco Pharmacotherapy for additional drug information. Allergies: List or Up to date in electronic system Diagnosis Date (yyyy-mon-dd) Time (hh:mm) Orders Initial Nicotine Free Period Required. No NRT to be used for hours. Start date at hours Nicotine Patch Cigarettes Per Day Recommended Dose Patch(es) daily x 6 weeks then reassess. Patch may be combined with gum, lozenge, inhaler, mouth spray, buproprion SR or varenicline mg nicotine patch mg nicotine patch mg nicotine patch mg (use 21 mg +7 mg nicotine patches). 36 or greater Nicotine Gum Cigarettes Per Day Consider a total daily dose of 35 mg or 42 mg. Dose = mg (use mg + mg nicotine patches). Alternate Dose (specify) Recommended Dose One piece every 1 hour as needed x 12 weeks then reassess; maximum 20 pieces per day or titrated to individual patient effect. Gum may be combined with patch, lozenge, inhaler, mouth spray, buproprion SR or varenicline. 20 or less 2 mg nicotine gum. 21 or more 4 mg nicotine gum. Alternate Dose (specify) Nicotine Lozenge Cigarettes Recommended Dose One lozenge every 1 hour as needed x 12 weeks then Per Day reassess; maximum 20 lozenges per day or titrated to individual patient effect. Lozenge may be combined with patch, gum, inhaler, mouth spray, buproprion SR or varenicline. 20 or less 1 mg nicotine lozenge (OR recommended initial dose if using lozenge with patch). 21 or more 2 mg nicotine lozenge. Alternate Dose (specify) Nicotine Inhaler Recommended Dose One cartridge every 20 minutes as needed x 12 weeks then reassess; maximum 16 cartridges per day or titrated to individual patient effect. Inhaler may be combined with patch, gum, lozenge, mouth spray, buproprion SR or varenicline. 10 mg Nicotine Inhaler (equal to 4 mg inhaled). Use cartridges per day. Alternate Dose (specify) 18282(Rev ) White Chart Canary Pharmacy Page 1 of 2 Alberta Health Services

132 Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders (page 2) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Birthdate (yyyy-mon-dd) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Gender Personal Health Number See Prescribing and Administering Tobacco Pharmacotherapy for additional drug information. Orders Nicotine Mouth Spray Recommended Dose 1 to 2 sprays every 30 minutes as needed x 12 weeks then reassess; maximum 2 sprays at a time, 4 sprays per hour or 64 sprays per day. Mouth spray may be combined with patch, gum, lozenge, inhaler, buproprion SR or varenicline. 1 mg nicotine per spray delivered. 1 bottle Alternate Dose (specify) Bupropion Sustained Release (SR) Initial Recommended Dose Treatment should be started 1 week before quit date and continued x 7-12 weeks then reassess (Quit date if known ); if this is not possible bupropion and NRT and be used concurrently for the first week. NRT can then be stopped or continued. Initial Dose 150 mg orally once daily for 3 days and stop. Start date (yyyy-mon-dd) Maintenance Dose 150 mg orally twice daily for weeks and reassess. Start date (yyyy-mon-dd). (Usual maintenance dose 7-12 weeks. May be up to 24 weeks). Alternate Dose (specify) Varenicline Recommended Dose Treatment should be started 1 week before quit date and continued x 7-12 weeks then reassess (Quit date if known ); if this is not possible varenicline and NRT and be used concurrently for the first week. NRT can then be stopped or continued. Initial Dose mg orally once daily for 3 days; then 0.5 mg orally twice daily for 4 days. Maintenance Dose: 1 mg orally twice daily for weeks, and reassess. Start date (yyyy-mon-dd). (Initial treatment period is 12 weeks. May be repeated for an additional 12 weeks) Alternate Maintenance Dose 0.5 mg orally twice daily for weeks. (consider dose adjustment in renal impairment.) Prescriber Name (print) Signature Date (yyyy-mon-dd) Time (hh:mm) 18282(Rev ) White Chart Canary Pharmacy Page 2 of 2 (Side A) 9.16 Tobacco Free Futures

133 Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders (page 3) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders Suggestions for Prescribing and Administering Tobacco Pharmacotherapy Research indicates the use of first-line pharmacotherapy can double chances of successful long-term cessation. When used in combination (e.g. Patch plus Gum), success rates increase further. Generalized Information on Smoking Cessation and Medications: Thorough consideration should be given to using a nicotine replacement therapy (NRT) treatment option, before prescribing bupriopion or varenicline. In many cases, NRT should be tried first. Smoking tobacco can alter the metabolism of a number of medications, including caffeine. This is primarily due to substances in tobacco smoke. Contact Pharmacy as needed. Signs of nicotine withdrawal include nicotine cravings, restlessness, insomnia, anxiety, difficulty concentrating, mood changes, decreased heart rate, increased appetite. Signs of nicotine toxicity include nausea, vomiting, dizzy, headache, increased heart rate. Nicotine Patch Nicotine Gum/ Nicotine Lozenge Nicotine Inhaler Nicotine Mouth Spray Bupropion Sustained Release (SR) Cautions: Use with caution with generalized skin disorders (such as psoriasis). May be removed at bedtime if patients experience sleep disturbances such as vivid dreams or insomnia. 7, 14 & 21 mg patches are 24 hour release dosage forms; 5, 10 & 15 mg patch are 16 hour release dosage forms. Cautions: Avoid using GUM in temporomandibular joint disorder, those with dentures and undergoing dental work If switching between lozenge to gum: 1 mg nicotine lozenge equals 2 mg nicotine gum and 2 mg nicotine lozenge equals between 2-4 mg nicotine gum (approximately). Avoid eating or drinking during use and 15 minutes before/after use. Cautions: Use with caution in bronchospastic disease (such as asthma). Cautions: Do not inhale or swallow while spraying. Hold spray in mouth for a few seconds before resuming normal swallowing. Do not eat or drink 15 minutes before/after using. Cautions: All patients should be monitored for neuropsychiatric changes, particularly those with mental health illness. Contraindications: Do not use if: history of seizures, conditions predisposing to seizures (such as head trauma, withdrawal from alcohol and/or benzodiazepines), eating disorder, active alcohol addiction, monoamine oxidase inhibitors (phenelzine, moclobemide, tranylcypromine) in the past 14 days. Consider dose adjustments in renal and hepatic impairment. Drug Interactions: Buproprion is a CYP2B6 substrate and a CYP2D6 inhibitor. Clearance of bupropion may be decreased by inhibitors or increased by inducers of CYP2B6. May increase levels of other CYP2D6 substrates. Examples: caution with paroxetine, risperidone, beta-blockers (metoprolol), type 1 C antiarrythmics (propafenone, flecanide), clopidogrel, ticlopidine due to CYP interactions. Varenicline Cautions: Use with caution in those with mental illness, especially schizophrenia, bipolar disorder or major depressive disorders. All patients should be monitored for neuropsychiatric changes. Inform patients of the symptoms of heart attack and stroke; instruct them to seek medical attention if they experience any of these symptoms. Contraindications: In severe renal impairment (Cr/Cl less than 30mL/min) recommend dose to be titrated to a maximum of 0.5 mg twice daily. Administration: Take with food. Specific Populations Pregnancy: Behavioral/cognitive techniques should be trialed first. If ineffective NRT can be used as almost all of the concerns with smoking during pregnancy are due to combustible components other than nicotine. Short acting preparations, such as nicotine gum should be trialed first since they typically deliver a lower amount of daily nicotine than patches. Patches should be used secondarily for those women who are experiencing nicotine withdrawal symptoms or may be used first line for those exhibiting nausea and vomiting. Patches should be worn for 16 hours in this group. Lactation: Recommendations same as pregnancy. Avoid breastfeeding immediately after use to reduce infant nicotine exposure. Cardiac Disease: Short acting nicotine replacement agents may be trialed first in those with a history of poorly controlled cardiovascular disease. Monitor for elevated blood pressure that can be associated with treatment if NRT is combined with bupropion. Mental Health: Close monitoring of patient s mental health status and/or addiction status is necessary. Regular medication dosages should be monitored and adjusted as necessary. Varenicline should be used with caution in those with schizophrenia, bipolar disorder or major depressive disorder. Patients taking bupropion or varenicline may be at increased risk of neuropsychiatric symptoms (agitation, depressive mood, behavioral changes, suicidal ideation), therefore should be closely monitored, especially those with pre-existing mental illness. These symptoms may arise as a result of smoking cessation with or without treatment, and causality has not been determined. Adolescents: Limited research.offer NRT as part of a risk reduction strategy. Start with short acting NRT first. NRT may need to be used for some non daily tobacco users. Reassess within hours of initiation. Diabetes: Nicotine, such as nicotine in tobacco and NRT, can affect hemoglobin A1C levels, carbohydrate metabolism, and insulin absorption. Monitor blood glucose to determine if medication or dietary adjustments are needed for optimal diabetes management. Chew/snuff: Limited research. Start with nicotine patch (changing patch dose if needed) as follows: Less than 2 cans/pouches per week equals14 mg patch, 2-3 cans/pouches per week equals 21 mg patch, greater than 3 cans/pouches equals 42 mg patch. Add gum or lozenge if needed. Do not use inhaler in this group. Reassess NRT needs within 48 hours of initiation. Cigar/Cigarillo/Pipe: Limited research. Start with short acting NRT first. Patch may need to be used for some daily cigar or pipe users. Reassess within 48 hours of initiation (Rev ) Page 2 of 2 (Side B) Alberta Health Services

134 Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy Followup/Discharge Orders (page 1) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Tobacco Dependence and Cessation Pharmacotherapy Followup/Discharge Orders Birthdate (yyyy-mon-dd) Gender Personal Health Number o Nicotine Patch Recommended Titration: After initial 6 weeks decrease to the next lower dosing increment every 2-4 weeks, or slower, based on patient response o Nicotine Patch ( mg+ mg) daily x weeks; then o Nicotine Patch ( mg+ mg) daily x weeks; then o Nicotine Patch 28 mg (21mg+7mg) daily x weeks; then o Nicotine Patch 21 mg daily x weeks; then o Nicotine Patch 14 mg daily x weeks; then o Nicotine Patch 7 mg daily x weeks o Alternate Dose (specify) Number of Refills o Nicotine Gum Recommended Titration: Month 1: pieces/day x 14 days, then 8-15 pieces/day; Month 2: 4-10 pieces/day; Month 3: 2-5 peces/day; Month 4: 1 piece for urge only One piece as instructed every 1-2 hour(s) as needed; Maximum: 20 pieces/day x weeks o 4 mg Nicotine Gum o 2 mg Nicotine Gum o Alternate Dose (specify) Number of Refills o Nicotine Lozenge Recommended Titration: Week 1-6: 1 lozenge every 1-2 hours; Week 7-9: 1 lozenge every 2-4 hours; Week 10-12: 1 lozenge every 4-8 hours; Week 13-24: 1-2 lozenges per day for urge only One lozenge as instructed every 1-2 hour(s) as needed; Maximum: 20 pieces/day x weeks o 4 mg Nicotine Lozenge (polacrilex) o 2 mg Nicotine Lozenge o 1 mg Nicotine Lozenge o Alternate Dose (specify) Number of Refills o Nicotine Inhaler Recommended Titration: 6-16 cartridges per day x 12 weeks. Then taper over an additional 6-12 weeks. Stop when at 1-2 cartridges per day One cartridge as directed every 20 minutes as needed; Maximum 16/day o 10 mg Nicotine Inhaler (equal to 4 mg inhaled) Use up to cartridges per day X weeks Number of Refills o Nicotine Mouth Spray Recommended Titration: Week 1-6: 1 to 2 sprays every 30 minutes as needed; Week 7-9: start reducing the number of sprays per day, until using half the number of sprays per day that were used initially; Week 10-12: reduce to 2-4 sprays per day. 1 to 2 sprays every 30 minutes as needed; maximum 2 sprays at a time, 4 sprays per hour or 64 sprays per day. o 1 mg nicotine per spray delivered. 1 bottle x weeks. Number of Refills 18283(Rev ) White - Chart Canary - Pharmacy Page 1 of Tobacco Free Futures

135 Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy Followup/Discharge Orders (page 2) Patient label placed here (if applicable) or if labels are not used, minimum information below is required. Name (last, first) Tobacco Dependence and Cessation Pharmacotherapy Followup/Discharge Orders Birthdate (yyyy-mon-dd) Gender Personal Health Number Bupropion SR and Varenicline Treatment should begin one week before quit date. Usual maintenance dose: 7-12 weeks (buproprion SR); 12 weeks (varenicline) o Bupropion Sustained Release (SR): o Initial Dose: 150 mg orally once daily for 3 days; then o Maintenance Dose: 150 mg orally twice daily x weeks, and reassess o Alternate Dose (include duration) Number of Refills o Varenicline o Initial Dose: 0.5 mg orally once daily for 3 days; then 0.5 mg orally twice daily for 4 days; then o Regular Maintenance Dose: 1 mg orally twice daily x weeks, and reassess o Alternate Maintenance Dose: 0.5 mg twice daily x weeks (Consider dose adjustment in renal impairment) Number of Refills Referral/Information Provided o Patient provided information sheet on tobacco cessation programs. Patient to complete registration OR o Referral done to tobacco cessation program. Name of Program o AlbertaQuits Helpline Referral (form #09973) o AlbertaQuits Groups o AlbertaQuits Online o Other, specify (e.g. PCN group) Prescriber Name (print) Signature Date (yyyy-mon-dd) Time(hh:mm) 18283(Rev ) White - Chart Canary - Pharmacy Page 2 of 2 Alberta Health Services

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137 Preparing Staff 10. Communication 11. Training AlbertaQuits.ca

138 PREPARING STAFF FOR TOBACCO FREE FUTURES IMPLEMENTATION Communication and training are essential processes that will have a direct impact on the success of the initial implementation and sustainability of the Tobacco Free Futures initiative. The following two chapters will provide valuable information for site management and steering committees to consider, as well as the tools and resources to support these processes. Chapter 10: Communications The importance of a strong communications plan throughout engagement, planning, implementation and sustainability. How to identify and connect with key audiences. How to connect with AHS Communications advisors. Tools available to support site and/or program communications plans. Chapter 11: Training The importance of training on the attitude, knowledge and skills staff require to implement the Tobacco Free Futures initiative. Competency-based training to match role requirements. Training and professional development opportunities in Alberta. How to access training opportunities.

139 Chapter 10 Communication Alberta Health Services

140 Introduction to Tobacco Free Futures site communications plan A strong communication plan is an essential component of the Tobacco Free Futures initiative implementation success. The goal of the plan is to increase awareness of the program and the supports available to staff, patients/clients and the general public. Various target groups need to be engaged and given relevant information at different phases of the implementation process, using a range of media and resources. Target groups within the health care setting include management steering committee members identified tobacco leads health care professionals support staff, including volunteers physicians referring organizations patients/clients the general public This chapter outlines a general Tobacco Free Futures communication plan that integrates key messages and may need to be tailored to meet individual site needs. The appendices include a variety of templates and other resources that can be adapted and/or adopted for use. These templates and resources have been developed in collaboration with the AHS Marketing and Communications teams and are intended to provide succinct communication throughout the implementation process. Resources for management, staff and physicians are intended to: develop awareness and engage the reader in the Tobacco Free Futures initiative, outline implementation timelines and provide information on training requirements and availability, as well as performance expectations. Communication targeted for clients and the general public includes information about the AHS Tobacco and Smoke Free Environments Policy and available support for tobacco users. Implementation planning tool tasks: communications 1. Arrange engagement presentation(s) for management and others as necessary. 2. Send invitation to join site steering committee to identified potential members. 3. Inform managers and supervisors of established timelines for implementation. 4. Inform staff and physicians of established timelines for implementation. 5. Create awareness of availability and expectations of staff training to all managers and supervisors. 6. Notify identified tobacco practice leads of training expectations and supportive role. 7. Inform front-line health care providers of training opportunities and expectations. 8. Inform physicians of expected role in support of tobacco treatment and education opportunities. 9. Inform referring organizations of implementation plans. 10. Inform site visitors and clients of AHS Tobacco and Smoke Free Environments Policy and supports available. 11. Inform staff of sustainability plans and celebrate success of implementation Tobacco Free Futures

141 All resources are available free of charge for AHS sites implementing the Tobacco Free Futures initiative. The resources provided are not intended to be the exclusive materials used to communicate the program. Sites may feel the need to develop additional resources and communication tools. To download and/or order any resources, visit Engaging AHS Communications team Sites considering and/or planning to implement the Tobacco Free Futures initiative should advise their AHS Communications advisor of their implementation plan and timeline. Note that Communications advisors will not assume responsibility for communication during the implementation roll-out. Rather, advisors are to be consulted in a strategic capacity, for guidance tailored to the respective sites and their planned implementation of Tobacco Free Futures. This may include advising on the potential use of Zone News, Insite and external outreach, as appropriate to the specific site and/or zone implementation. Sites or teams who are unsure of their appropriate Communications contact can visit the Communications Insite page at or Shannon Evans, Senior Communications Advisor Population Public Health Provincial, at shannon.evans@albertahealthservices.ca. The Tobacco Reduction Program Communication Plan is supported by Heather Kipling, Communications Advisor. She can be contacted by at heather.kipling@albertahealthservices.ca. Alberta Health Services

142 Communications for initial engagement Once a site has identified an interest in implementing the Tobacco Free Futures initiative, communication to key stakeholders within the site need to occur. The following table outlines available resources that will help inform and engage site leaders, as well as tools that will help create general site awareness about planned implementation. Table 10.1: Communication Tools for Site Engagement IMPLEMENTATION MILESTONE/TASK Engage support of key decision makers and champions at AHS health care setting implementing the Tobacco Free Futures initiative. TARGET AUDIENCE Senior site management COMMUNICATION RESOURCE Appendix 10(a) Tobacco Free Futures Overview Appendix 10(b) Tobacco Free Futures Invitation to Join Site Steering Committee USE/PURPOSE Key site management and staff champions from target groups team member(s) may attend initial meetings to present information on the program and answer questions a standard engagement PPP is available on the secure TFF section of the albertaquits.ca website. /memo template sent by senior site management or designate to identified potential members to inform members of their role in implementing the Tobacco Free Futures initiative to inform members of date, time and location of initial meeting /memo template sent by senior site management or steering committee chairs to all site managers to create awareness of Tobacco Free Futures initiative and supports available to inform of established timelines/target dates for implementation of Tobacco Free Futures initiative /memo template sent by senior site management or steering committee chairs to all site staff and physicians to create awareness of Tobacco Free Futures initiative and supports available to inform of established timelines/target dates for implementation of Tobacco Free Futures initiative Site management Appendix 10(c) Tobacco Free Futures: Implementation Information for Management Staff and physicians Appendix 10(d) Tobacco Free Futures: Implementation Information for Staff and Physicians 10.4 Tobacco Free Futures

143 Preparing staff for implementation Training of staff and physicians is a key element in the successful implementation of the Tobacco Free Futures initiative. Managers, tobacco leads, staff and physicians will need to be informed of how the program affects their role and/or the role of their team, as well as the availability of training opportunities. The following table outlines the resources available to communicate with these key target audiences regarding the site s timelines for implementation, staff roles and training opportunities/requirements. Table 10.2: Communication Tools for Site Preparation IMPLEMENTATION MILESTONE/TASK Identify tobacco leads and inform managers, leaders, physicians and staff about training expectations and availability on site. TARGET AUDIENCE All site managers COMMUNICATION RESOURCE Appendix 10(e) Tobacco Free Futures Staff Training Expectations: Information for Management USE/PURPOSE Tobacco leads Appendix 10(f) Tobacco Free Futures Invitation to Site Tobacco Practice Leads /memo template sent by senior site management or steering committee chairs to all site managers to inform of the different training opportunities, including general orientation presentation to inform of tobacco leadership opportunities to describe staff roles to create awareness of availability and expectations of training for staff /memo template sent by senior site management or steering committee chairs to identified tobacco practice leads to inform staff member of identification as tobacco lead to describe the role of tobacco practice leads in implementation of the Tobacco Free Futures initiative to create awareness of training expectations and availability for tobacco practice leads template sent by site management or tobacco lead as appropriate to update staff on implementation plans and role expectations to inform of training opportunities and expectations Front-line health care professionals Appendix 10(g) Tobacco Free Futures Frontline Health Professional Staff Training Appendix 10(h) Tobacco Free Futures Implementation: Information for Physicians Physicians working at AHS facilities /memo template sent by site medical director or designate to create awareness of implementation of Tobacco Free Futures initiative and supports available at AHS facilities to describe expected role of physicians in delivery of brief intervention while at the site to identify physician education opportunities letter template sent by site management to create awareness of implementation of Tobacco Free Futures initiative at the site so referring organizations can prepare patients/clients Referral sources to site Appendix 10(i). Tobacco Free Futures Implementation: Information for Referring Organizations Alberta Health Services

144 Site-wide awareness of program and supports As sites approach their go-live dates, it is important to create awareness of the Tobacco Free Futures initiative. The visual resources identified in Table 10.3 communicate key messages to patients/clients and visitors, including welcome to our tobacco- and smoke free environment, going without tobacco can be difficult and we can help. Sites may choose to continue to display posters and window clings in the months and years following implementation as ongoing reinforcement of the program. Table 10.3: Communication Tools for Site Implementation and Sustainability IMPLEMENTATION MILESTONE/TASK Go-live dates and ongoing implementation of Tobacco Free Futures initiative at facility TARGET AUDIENCE Patients and visitors COMMUNICATION RESOURCE Appendix 10(j) Supplementary Communication Resources USE/PURPOSE a selection of visual resources that may be posted or displayed throughout the site to inform general public of key messages steering committees should connect with site management to determine where resources may be used kiosks are available for zone wide sharing between sites. For more information, contact the AHS Tobacco Reduction Program at tru@albertahealthservices.ca access all available resources through online catalogue: /memo template sent by senior site management or steering committee chairs to all site staff, physicians and managers to inform and celebrate success of training, implementation and patient outcomes Sustainability Staff, physicians and managers Appendix 10(k) Tobacco Free Futures Thank You to Staff, Physicians and Managers 10.6 Tobacco Free Futures

145 Appendices Appendix 10(a) Tobacco Free Futures Overview Appendix 10(b) Tobacco Free Futures Invitation to Join Site Steering Committee Appendix 10(c) Tobacco Free Futures Implementation: Information for Management Appendix 10(d) Tobacco Free Futures Implementation: Information for Staff and Physicians Appendix 10(e) Tobacco Free Futures Staff Training Expectations: Information for Management Appendix 10(f) Tobacco Free Futures Invitation to Site Tobacco Practice Leads Appendix 10(g) Tobacco Free Futures Front-line Health Professional Staff Training Appendix 10(h) Tobacco Free Futures Implementation: Information for Physicians Appendix 10(i) Tobacco Free Futures Implementation: Information for Referring Organizations Appendix 10(j) Supplementary Communication Resources Appendix 10(k) Tobacco Free Futures Thank You to Staff, Physicians and Managers Alberta Health Services

146 Appendix 10(a) Tobacco Free Futures Overview AN ALBERTA BASED HEALTH SYSTEM TOBACCO CESSATION INITIATIVE The Tobacco Free Futures Initiative Designed to SUPPORT Albertan s who are impacted by exposure to tobacco products EVIDENCE BASED using promising practices. Supports a LINKED REFERRAL across the continuum of care. what IS THE INITIATIVE? Tobacco Free Futures is a tobacco cessation systems change initiative that was developed for the Alberta Health Services (AHS) context. The initiative is grounded in the available literature and supports the integration of tobacco cessation support into healthcare within AHS. The aim is to contribute to decreasing tobacco use and to supporting the achievement of Alberta Cancer Prevention Legacy Fund vision of preventing cancer through innovative research and prevention strategies. How was IT DEVElopED Tobacco Free Futures was developed through a collaborative process with contributions from individuals and groups from across the province. It has been heavily informed by the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) led by the Centre for Addiction and Mental Health (CAMH), and by the Ottawa Model for Smoking Cessation from the Ottawa Heart Institute. Tobacco Free Futures was funded from through the Alberta Cancer Prevention Legacy Fund (ACPLF). Funding has allowed for the development of provincial standards of care, practice guidelines, documentation standards (paper and electronic), training, and supplementary resources. Sustainability at the end of the 2014 funding cycle will be through the AHS Tobacco Reduction Program (TRP). what IS THE ScopE? Tobacco Free Futures can be adapted for use in settings across the continuum of care. It has been implemented in many care settings across the province including: urban inpatient acute care; rural inpatient acute care; additions detoxification and residential treatment; public health programs; home care; continuing care; and outpatient services. How IS THE INITIATIVE IMplEMENTED? Sites or programs work through a series of processes to plan and implement Tobacco Free Futures to fit their specific context. Engagement of management and physician leadership. Formation of a multidisciplinary steering committee. Completion of site/program AHS Tobacco and Smoke Free Environments Policy compliance assessment. Determination of staff roles and documentation standards. Standardization of pharmacotherapy supports and ordering process. Identification of resources for staff and patients/clients. Implementation of a site/program communication plan. Training of staff and prescribers. Planning for sustainability. How will THE TRp SuppoRT YouR SITE/pRoGRAM? Our team will provide support and guidance to your site/program steering committee; develop and supply resources that will guide such as resource binders, posters, forms, patient handouts and cessation aids; provide resources to facilitate staff education; and provide links to provincial networks and resources. contact INfoRMATIoN For more information, please contact the Tobacco Reduction Program Phone: TRU@albertahealthservices.ca Tobacco Free Futures

147 Appendix 10(b) Tobacco Free Futures Invitation to Join Site Steering Committee Invitation to Join <INSERT SITE NAME>Tobacco Free Futures Steering Committee Alberta Health Services (AHS) is rolling-out Tobacco Free Futures; a program to improve the treatment of tobacco dependency and nicotine addiction for patients and clients. Tobacco Free Futures provides the necessary tools, resources and training for health care professionals to support patients and clients with their tobacco dependency. Our site is planning to implement the program. We are inviting you to help by joining the Tobacco Free Futures Steering Committee. Tobacco Free Futures uses an integrated care pathway based on best practices for consistent, connected treatment of tobacco dependency across the health care continuum. Front-line healthcare teams, will be trained to: ASK every patient about tobacco use in the last year. ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients who currently use tobacco to quit with a personalized message. ASSESS patient s readiness to quit tobacco, and interest in withdrawal support. ASSIST with cessation medications for withdrawal support. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued cessation medications The steering committee will manage the implementation process and act as an advisory body to management, healthcare professional and other support staff. We are recruiting members from the following groups: senior management unit management physicians nursing pharmacy respiratory therapy workplace health and safety protective services patient registration other (e.g., clinical education, allied health professionals, community supports or professional working with specific populations) The steering committee s first meeting will be <INSERT INFORMATION HERE>. Please confirm your interest in joining the committee and your attendance at the meeting with <INSERT CONTACT HERE>. For more information, visit albertaquits.ca. Alberta Health Services

148 Appendix 10(c) Tobacco Free Futures Implementation: Information for Management Tobacco Free Futures Implementation at <INSERT SITE >: Information for Management Alberta Health Services (AHS) implemented its Tobacco and Smoke Free Environments Policy on April 1, The policy, which prohibits use of tobacco products on sites owned, operated, leased as well as those that receive service delivery funding from AHS, supports AHS commitment to providing safe and healthy tobacco free environments. To best support tobacco dependent and/or addicted AHS patients and clients while in our care and to improve the treatment of tobacco dependency and nicotine addiction both in our facilities and beyond, AHS is rolling out the Tobacco Free Futures program. Implementation of the cross-continuum Tobacco Free Futures program will ensure our front-line health care teams have the necessary tools, resources and training to: ASK every patient about tobacco use in the last year. ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients who currently use tobacco to quit with a personalized message. ASSESS patient s readiness to quit tobacco, and interest in withdrawal support. ASSIST with cessation medications for withdrawal support. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued cessation medications <INSERT SITE > has established a Tobacco Free Futures Steering Committee to undertake implementation planning, with a target implementation date of <INSERT DATE >. Over the coming weeks, the steering committee will be: completing pre-implementation assessments, determining staff roles and reviewing documentation standards in the patient record, ensuring pharmacotherapy is available and reviewing ordering processes, identifying and ordering supplementary resources for staff and patients, communicating with staff, and the site at large, arranging and scheduling training for all staff, planning for sustainability and continuous improvement. For information on implementation at <INSERT SITE >, please contact <INSERT NAME OF CONTACT> at <INSERT CONTACT INFORMATION>. Sincerely, <INSERT NAME> (to be determined by Site Leadership) For more information, visit albertaquits.ca Tobacco Free Futures

149 Appendix 10(d) Tobacco Free Futures Implementation: Information for Staff and Physicians Tobacco Free Futures Implementation Information for <INSERT SITE > Staff and Physicians Alberta Health Services (AHS) implemented its Tobacco and Smoke Free Environments Policy on April 1, The policy, which prohibits use of tobacco products on sites owned, operated, leased as well as those that receive service delivery funding from AHS, supports AHS commitment to providing safe and healthy tobacco free environments. To best support patients and clients while in our care and to improve the treatment of tobacco dependency and nicotine addiction at our facility, <INSERT SITE> and beyond, AHS is rolling out the Tobacco Free Futures program. Implementation of the cross-continuum Tobacco Free Futures program will ensure <INSERT SITE> frontline healthcare teams have the necessary tools, resources and training to: ASK every patient about tobacco use in the last year. ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients who currently use tobacco to quit with a personalized message. ASSESS patient s readiness to quit tobacco, and interest in withdrawal support. ASSIST with cessation medications for withdrawal support. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued cessation medications Implementation of the Tobacco Free Futures model at <INSERT SITE> is planned for <INSERT DATE> and training for physicians and frontline healthcare professionals <INSERT SITE> will begin <INSERT DATE>. Your manager will inform you of more details in the following weeks and months. For more information on the AHS Tobacco and Smoke Free Environments Policy including supports available for staff visit: Thank you for your support. Together, we can make a difference for our patients and clients. Sincerely, <INSERT NAME> (to be determined by Site Leadership) For more information, visit albertaquits.ca. Alberta Health Services

150 Appendix 10(e) Tobacco Free Futures Staff Training Expectations: Information for Management Tobacco Free Futures <INSERT SITE> Expectations for Training: Information for Management As was communicated on <INSERT DATE>, <INSERT SITE> is implementing the Tobacco Free Futures program on <INSERT DATE> to improve the treatment of tobacco dependency and nicotine addiction for patients and clients. <INSERT SITE> recognizes that training is essential to ensure that staff have the knowledge and tools to effectively address tobacco dependence and nicotine addiction. The level of knowledge required will be dependent on staff roles and training has been developed to meet different needs. As a manager, you will have an important role to support <INSERT SITE> tobacco practice leads, staff, physicians and patients/clients. Training required by Tobacco Practice Leads (from Patient Care Units or Practice Areas): As a manager, we request your support to identify one or more Tobacco Practice Leads from each of your clinical areas. These leads will play an important role in implementation of the program: supporting training and ongoing implementation by front-line staff. Further information on a 3 hour Tobacco Practice Lead Training workshop will be provided to selected participants by <INSERT CONTACT>. Please submit your selected Tobacco Practice Leads to <INSERT CONTACT NAME & IFORMATION> by <INSERT DATE>. Training required by Front-line Health care Professionals: At <INSERT SITE>, it has been decided that front-line health care professionals including <INSERT TEAMS OR DISCIPLINES> will be required to complete the online Brief Tobacco Intervention Training through MyLearning Link. These staff will be required to complete the minute training by <INSERT DATE>. More information will be communicated via <INSERT MODE OF COMMUNICATION> by <INSERT DATE>. Overview Session Required by All Staff (Including non-clinical supports): A brief 10 minute overview of the Tobacco Free Futures program, AHS Tobacco and Smoke Free Environments Policy and supports available for staff is available in a face to face presentation. All employees are required to complete this session prior to <DATE>. Training is available on <INSERT DATE & TIME> at <INSERT LOCATION>. <ADDITIONAL TRAINING DATES & TIMES IF APPLICABLE>. Should you have any questions in the meantime, please don t hesitate to contact <INSERT NAME> at <INSERT CONTACT INFORMATION>. Sincerely, <INSERT NAME>(to be determined by Site Leadership) For more information, visit albertaquits.ca Tobacco Free Futures

151 Appendix 10(f) Tobacco Free Futures Invitation to Site Tobacco Practice Leads Invitation to Become a <INSERT SITE> Tobacco Practice Lead As was communicated on <INSERT DATE>, <INSERT SITE> is implementing the Tobacco Free Futures program on <INSERT DATE> to improve the treatment of tobacco dependency and nicotine addiction for patients and clients. All <INSERT SITE> front-line health care professionals will be trained to implement the Tobacco Free Futures program, which will allow our teams to care consistently for AHS patients and clients with tobacco dependency and nicotine addiction. You have been selected as a tobacco practice lead and will have an important role to support staff in helping their patients. A 3 hour tobacco practice lead training workshop will provide you with all of the information and resources you will need to support staff and patients in your practice area. The training includes: a review of the Tobacco Free Futures program <INSERT SITE> implementation plan; how to support the online Brief Tobacco Intervention Training for staff in your clinical area; and an overview of resources and supports for patients/clients, staff and tobacco practice leads. You are scheduled to attend the Tobacco Practice Lead Training: On <INSERT DATE AND TIME> <INSERT LOCATION AND ROOM NUMBER> Please complete the online Brief Tobacco Intervention Training available through MyLearning Link prior to your workshop; it should take minutes. On behalf of the <INSERT SITE> tobacco steering committee, thank you for your support with this important initiative. Please contact <INSERT NAME> at <INSERT CONTACT INFORMATION> with any questions. Sincerely, <INSERT NAME> (to be determined by Site Leadership) For more information, visit albertaquits.ca. Alberta Health Services

152 Appendix 10(g) Tobacco Free Futures Front-line Health Professional Staff Training Tobacco Free Futures Training for <INSERT SITE> Front-line Health Professional Staff As was communicated on <INSERT DATE>, <INSERT SITE> is implementing the Tobacco Free Futures program on <INSERT DATE> to improve the treatment of tobacco dependency and nicotine addiction for patients and clients. As a frontline health professional, you will have an important role to support <INSERT SITE> patients and clients. Therefore, <INSERT SITE> front-line health care professionals are being trained with the Brief Tobacco Intervention Training so that they will be confident to: ASK every patient about tobacco use in the last year. ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients who currently use tobacco to quit with a personalized message. ASSESS patient s readiness to quit tobacco, and interest in withdrawal support. ASSIST with cessation medications for withdrawal support. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued cessation medications You are required to complete the online Brief Tobacco Intervention Training through MyLearning Link by <INSERT DATE AND TIME>. The training will take approximately minutes to complete. Following completion please present your certificate to <INSERT NAME> at <INSERT CONTACT INFORMATION>. Should you have any questions in the meantime, please don t hesitate to contact <INSERT NAME> at <INSERT CONTACT INFORMATION>. Sincerely, <INSERT NAME> (to be determined by Site Leadership) For more information, visit albertaquits.ca Tobacco Free Futures

153 Appendix 10(h) Tobacco Free Futures Implementation: Information for Physicians Tobacco Free Futures Implementation at <INSERT SITE>: Information for Physicians As was communicated on <INSERT DATE>, <INSERT SITE> is implementing the Tobacco Free Futures program on <INSERT DATE> to improve the care of patients and clients who are dependent on the use of tobacco products. Using an integrated care pathway, Tobacco Free Futures enables consistent, connected treatment across the health care continuum. As a physician, you have a key role in supporting tobacco dependent patients and clients, including ordering pharmacotherapy, as medically appropriate. Prior to implementation, <INSERT SITE> front-line health care teams will be trained to: ASK every patient about tobacco use in the last year. ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients who currently use tobacco to quit with a personalized message. ASSESS patient s readiness to quit tobacco, and interest in withdrawal support. ASSIST with cessation medications for withdrawal support. Link to behavioural support. ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for continued cessation medications To this end, we have arranged opportunities for you and your physician colleagues to learn more about Tobacco Free Futures, including the use of pharmacotherapy in the treatment of tobacco dependence and nicotine addiction. These learning opportunities are available via <INSERT MODE OF LEARNING> on <INSERT DATE OF LEARNING OPPORUNITY >. <INSERT OTHER INFORMATION ON LEARNING OPPORTUNITY> (e.g., sign up, time, location). Should you have any questions in the meantime, please don t hesitate to contact <INSERT NAME> at <INSERT CONTACT INFORMATION>. Sincerely, <INSERT NAME> <INSERT TITLE> Site Medical Director or appropriate alternate (to be determined by Site Leadership) For more information, visit albertaquits.ca. Alberta Health Services

154 Appendix 10(i) Tobacco Free Futures Implementation: Information for Referring Organizations Alberta Health Services Tobacco and Smoke free Environments policy information and Tobacco Free Futures implementation at <INSERT SITE > Information for <REfERRING AGENcY> Alberta Health Services (AHS) implemented its Tobacco and Smoke free Environments policy on April 1, The policy supports AHS commitment to providing safe and healthy tobacco-free environments for patients, staff and visitors alike. The policy prohibits the use of tobacco products on AHS owned, operated and leased sites, as well as those that receive service delivery funding from AHS. beginning <INSERT DATE>, the use of tobacco products will be prohibited at <INSERT SITE >. To best support patients and clients while in our care, and improve the treatment of tobacco dependency and nicotine addiction at <INSERT SITE> and beyond, AHS is rolling out the Tobacco Free Futures program at the facility. Implementation of the cross-continuum Tobacco Free Futures program at <INSERT SITE> will ensure of front-line health care teams have the necessary tools, resources and training to support patients and clients in the following ways at the facility: All patients/clients will be asked about their tobacco use in the last year. All patients/clients will be made aware of the AHS Tobacco and Smoke Free Environments Policy and the supports available to them. Patients/clients who are interested in withdrawal support will be provided with cessation medications (e.g., nicotine replacement therapy) as a comfort measure while at <INSERT SITE>. Whenever possible, additional supports and resources will be made available to patients/clients at <INSERT SITE>. Ongoing support on discharge will be arranged through a referral to AlbertaQuits or other service available in the community. Implementation of the Tobacco Free Futures model at <INSERT SITE> is planned for <INSERT DATE>. For more information on the AHS Tobacco and Smoke Free Environments Policy, visit: For more information on Tobacco Free Futures, visit: albertaquits.ca Health Provider page. For more information on supports and resources at <INSERT SITE>, please contact <INSERT NAME OF CONTACT>at <INSERT CONTACT INFORMATION>. Thank you for your support. Together, we can make a difference for our patients and clients. Sincerely, <INSERT NAME> (to be determined by Site Leadership) Tobacco Free Futures

155 Appendix 10(j) Supplementary Communication Resources Sample Supplementary Communication Resources Health Professional Poster Modifiable PDF format which allows sites/ programs to personalize with key staff messages. Not available to order. Available on secure TFF site Albertaquits.ca (11 x 11 ) Double-sided self-adhesive window cling decal that reads, WELCOME to our tobacco and smoke free environment. Going without tobacco is hard; we can help. Window Cling Staff & General Public Table Tent 2-sided, folded resource. Side 1: Creating Tobacco Free Futures with your help. Side 2: QUITTING IS HARD. It s easier with support, we can help. Card includes QR code web addresses (11 x 17 ) Single-sided self-adhesive window cling decal that reads WELCOME to our tobacco and smoke free environment. Going without tobacco is hard; we can help. Decal includes QR code and albertaquits.ca web address Cling Style Poster Tobacco Free Futures Kiosk Display includes banners, backdrop and resource table suitable for manned display. Kiosks are available for zone wide sharing and can be accessed by contacting tru@albertahealthservices.ca Note: the resources available may change over time refer to online ordering catalog Albertquits.ca for current listing. Alberta Health Services

156 Appendix 10(k) Tobacco Free Futures Thank You to Staff, Physicians and Managers <INSERT SITE> and Tobacco Free Futures Thank You! On <INSERT DATE>, <INSERT SITE> successfully implemented the Tobacco Free Futures program ensuring AHS patients and clients receive the best support while in our care and improving the treatment of tobacco dependency and nicotine addiction. With your ongoing efforts, <INSERT SITE> will continue to offer a seamless and integrated level of cessation support for all our patients and clients who use tobacco pproducts. Your help continues to be key to the success of the Tobacco Free Futures program at <INSERT SITE>. Just think, a healthcare provider who sees five to ten clients/patients a day and uses the brief tobacco intervention with each could help 24 patients quit in a single year. Your interventions will continue to benefit clients year after year. The provincial Tobacco Free Futures program team will also continue to support you. To learn more about Tobacco Free Futures and the supports available to you, visit albertaquits.ca, Health Provider page. Congratulations and thank you for your support. Together, we are making a difference for our patients and clients. Sincerely, <INSERT NAME> (to be determined by Site Leadership) For more information, visit albertaquits.ca Tobacco Free Futures

157 Chapter 11 Training Alberta Health Services

158 Effective treatment for tobacco dependence and nicotine addiction within Alberta Health Services (AHS) first depends on the availability of tobacco treatment training for health care providers. Historically, this training has been minimal. It is now more important than ever that health care providers are able to support clients who are affected by the use of tobacco products. This is because of the well-known connections between tobacco and increased rates of cancer and chronic disease poorer health treatment outcomes an increased burden on the health care system The complexity and intensity of tobacco treatment must match the needs of the individual tobacco user. For instance, some individuals who use tobacco may only require brief intervention from a health care provider; others, however, with more complex or concurrent concerns, may require more intensive support. This approach is consistent with the continuum of care for the treatment of nicotine dependence, as recommended by Canada s national clinical practice guidelines. 2 Identification of core competencies helps to enhance the quality and consistency of smoking cessation support given by health care professionals. 1 Implementation planning tool tasks: training 1. Review available training options and decide what will be required as a standard. 2. Determine training needs and expectations for all staff. 3. Add tobacco training to existing education tracking systems (e.g., new hire orientation training). 4. Review AHS Tobacco and Smoke Free Environments policy and available supports with all staff (clinical and non clinical). 5. Train tobacco practice leads. 6. Train front-line health care professionals in brief tobacco intervention. 7. Train physicians and other prescribers. 8. If applicable, train health professionals in intensive tobacco cessation counselling. AHS TOBACCO TREATMENT TRAINING Competency-based training will improve and enhance the quality and consistency of tobacco cessation support in Alberta. AHS offers several training opportunities based on competencies, which in turn focus on learning outcomes: addressing what the learners are expected to do, rather than what they are expected to learn. A competency is the ability to perform a defined, real-world task in a specific context. Learning objectives are more specific statements of observable and measurable behaviours that are necessary to master each competency; they suggest how students knowledge, skills and attitudes will be different because of the learning experience. 3 Knowledge is the condition of knowing something with familiarity that is gained through experience or association. Skill is the ability to use one s knowledge effectively and readily. Attitude is the mental position, emotion, or feeling toward a fact or state Tobacco Free Futures

159 Knowledge know what Ability Skill know how Attitude know why Health care providers offering varying degrees of support will require different competencies to carry out the responsibilities of a given treatment plan. For example, a front-line health professional working in an urgent care setting would not need to be proficient in group counselling in order to provide competent tobacco treatment for his or her clients. The remainder of this section outlines the variety of tobacco cessation training opportunities available through AHS to meet the needs of health care professionals. New online tobacco basics and comprehensive tobacco treatment courses are under development and should be available in the fall of For more information about tobacco reduction and cessation training availability, contact tru@albertahealthservices.ca or call Brief tobacco intervention training There are a wide variety of opportunities to help individuals who use tobacco products. A brief tobacco intervention, delivered in less than three minutes, is potentially one of the most effective interventions available. This intervention uses a 5 A s model: ASK clients about their tobacco use ADVISE of the importance of quitting ASSESS their readiness to quit and interest in support for nicotine withdrawal ASSIST with cessation medications and counselling supports ARRANGE for ongoing follow-up support Following this training, participants will be able to integrate brief tobacco treatment as a part of their front-line work provide clear and accurate information about tobacco use, the scope of the health impact on the population and the causes and consequences of tobacco use conduct a brief tobacco intervention provide clear and accurate information about available pharmacotherapy options and their proper use provide relevant resources to individuals who are not ready to quit, who are ready to quit and who have recently quit describe and use methods for documenting brief tobacco interventions Alberta Health Services

160 Table 11.1: Brief Tobacco Intervention Training Details TIME 1.5 to 2 hours. AUDIENCE All current and future health care professionals who provide direct client care. PREREQUISITES None. ACCESS If you are an AHS employee, please take this training through MyLearning. If you are not an AHS employee, contact tru@albertahealthservices.ca. Comprehensive tobacco intervention: TRAC TRAC is a comprehensive training program that builds the capacity of health care providers to provide intensive tobacco cessation counselling. After completing this course, participants will be able to use the 5 A s model for brief and intensive tobacco cessation counselling support clients using non-judgmental counselling techniques and other effective tools describe the available pharmacotherapy support understand specific populations and their unique challenges in tobacco reduction and cessation use effective strategies for helping reduce harm identify tobacco cessation programs and services available in Alberta Table 11.2: TRAC Training Details TIME 2 days. AUDIENCE All current and future health care professionals who provide direct client care. PREREQUISITES None. ACCESS This training is offered in a classroom setting. To access the registration form, visit albertaquits.ca Tobacco Free Futures

161 Group cessation training: QuitCore facilitator training QuitCore is a free group cessation program in which individuals are provided the tools, skills and strategies they need to quit smoking or using other forms of tobacco. These sessions provide participants with an opportunity for participatory shared learning and group support during their journey to become tobacco free. The groups are led by trained health care professionals. This training module provides health care professionals with the information and skills needed to effectively facilitate a QuitCore group cessation program. On completion of the QuitCore facilitator training, participants will be able to describe the structure of the QuitCore and AlbertaQuits framework discuss how to incorporate adult education principles into effective facilitation describe effective instructional practices for use with groups review and practice how to deliver each of the QuitCore sessions review cessation medication (prescription and NRT) information for QuitCore participants review nutrition and active living information for QuitCore participants discuss the role of mentor support and the facilitator toolkit The AHS Tobacco Reduction Program (TRP) will provide facilitator and participant manuals, resource materials and mentorship support. Table 11.3: QuitCore Facilitator Training Details TIME 1.5 days. AUDIENCE PREREQUISITES Health care professionals who will be facilitating tobacco cessation group counselling. Individuals who are interested in training as QuitCore facilitators need to have completed tobacco training through TRAC, Provincial Concurrent Capable Learning Series (PCCLS) tobacco cessation core training or the Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health (TEACH) program. This training is offered free to health professionals from AHS and non-ahs settings. Note: Interested professionals will need a letter of support from their manager/ supervisor to confirm they will be able to offer the program once trained. ACCESS This training is offered in a classroom setting. To access the registration form, visit albertaquits.ca. Alberta Health Services

162 Cessation medication training for special populations: Tobacco cessation pharmacology for the mental health population training Tobacco Cessation Pharmacology for the Mental Health Population Training is training for prescribers that is facilitated by a pharmacist. At the end of this training, participants will be able to understand the prevalence and impact of tobacco use among people being treated for addictions and mental health conditions understand how to prepare a tobacco cessation pharmacotherapy protocol for persons with mental health conditions learn about monitoring of drugs and drug levels for toxicity as tobacco use is reduced review drug interactions and the metabolism of specific psychiatric medications following smoking cessation understand the comprehensive factors that may contribute to tobacco use among people being treated for addictions and mental health conditions This training is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of the Royal College of Physicians and Surgeons of Canada and is approved by the University of Calgary s Office of Continuing Medical Education and Professional Development (Faculty of Medicine). Participants will receive one hour of credit under Section 1. Table 11.4: Tobacco Cessation Pharmacology for the Mental Health Population Training Details TIME 1.5 hours. AUDIENCE PREREQUISITES This training is intended for psychiatrists and pharmacists. However, other health professionals working with mental health clients would also benefit from attending. None. However, TRAC training is recommended. ACCESS This training is offered in a classroom setting. To access the registration form, visit albertaquits.ca Tobacco Free Futures

163 AHS SITE CAPACITY-BUILDING TRAINING AND EDUCATION The Tobacco Reduction Program s capacity-building training modules and education opportunities aim to develop the attitudes, knowledge and skills to guide education and other initiatives that will prevent, protect and reduce the harms of tobacco use. For more information on our capacity-building training modules and opportunities, please contact tru@albertahealthservices.ca. Tobacco Free Futures: Tobacco practice lead training Brief tobacco interventions are potentially one of the most effective things that a health professional can do to improve a person s quality of life and increase their lifespan. Tobacco Free Futures is an integrated health system approach to tobacco treatment that incorporates support for Albertans who are affected by the use of tobacco products. This training will provide participants with the foundational tools, resources and interpersonal skills that are needed to support the integration of tobacco treatment into practice and mentor front-line staff who are expected to support clients who use tobacco. On completion of the Tobacco Practice Lead training, participates will be able to provide clear and accurate information about the model and benefits of implementation as a standard of care identify information about the implementation of Tobacco Free Futures within the context of specific site or program settings identify potential considerations for supporting staff who will take online tobacco training identify the site- or program-specific processes related to training, including communication, access and the accurate recording of participation identify the forms, resources and tools available to help site or program tobacco practice leads support front-line staff implement brief tobacco intervention Table 11.5: Tobacco Practice Lead Training Details TIME 3 hours. AUDIENCE PREREQUISITES Tobacco practice leads may represent a variety of health professional disciplines (e.g., registered nurses, respiratory therapists, pharmacists, or social workers) and hold a variety of designated roles within their practice area (e.g., clinical leads or educators). They will be designated to this role by the site and/or program management. Brief Tobacco Intervention Training. ACCESS Training is offered in a classroom or facilitated webinar. Training will be arranged in collaboration with sites/programs who are implementing the Tobacco Free Futures initiative. Alberta Health Services

164 Health care systems change management: Tobacco Free Futures guidelines implementation workshop Integrating tobacco intervention into health care delivery requires the active involvement of clinicians, health care systems, administrators and decision makers. These efforts represent an opportunity to increase rates of treatment delivery, quit attempts and successful tobacco cessation. This training explores 10 processes important to organizational change management. After this workshop, participants will have the foundational knowledge, tools and resources needed to provide leadership and guidance to support a health care setting in implementing the Tobacco Free Futures initiative. On completion of this training, participants will be able to recognize the importance of treating tobacco dependence and nicotine addiction in health care settings recognize best practices in tobacco cessation for health care settings and the advantages of systematically integrating brief tobacco treatment in sites, programs and zones across the province understand the considerations of implementing a systems approach to tobacco cessation based on specific contexts recognize the available implementation tools, resources, supports, training and networking opportunities Table 11.6: Tobacco Free Futures Guidelines Implementation Workshop Details TIME 7.5 hours. AUDIENCE PREREQUISITES This training module is intended for designated AHS site management and tobacco champions who will provide vision, leadership and guidance for the implementation of the Tobacco Free Futures initiative at a site or within a program. None. ACCESS Training is offered in a classroom or facilitated webinar. Training will be arranged in collaboration with sites and programs who will be implementing the Tobacco Free Futures initiative Tobacco Free Futures

165 REFERENCES 1. Bullen, C., Walker, N., Whittaker, R., McRobbie, H., Glover, M., & Frasher, T. (2008). Smoking cessation competencies for health workers in New Zealand. Journal of the New Zealand Medical Association, 121(1276), Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 3. Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention. (2012). Knowledge, skills, and attitudes (KSAs) for the Public Health Preparedness and Response Core Competency Model. Retrieved from Alberta Health Services

166

167 Final Planning 12. Sustainability 13. Continuous Improvement AlbertaQuits.ca

168 PLANNING FOR SUSTAINABILITY AND CONTINUOUS IMPROVEMENT OF TOBACCO FREE FUTURES Planning for sustainability has been an integral part of the development and implementation of the Tobacco Free Futures initiative, but continued activities at the provincial and the individual health care setting levels will help ensure that systems changes are sustained and high-quality cessation support is ongoing. The following two chapters provide valuable information for site management and steering committees to consider, as well as the tools and resources to support these processes. Chapter 12: Sustainability How to gain the support of leadership on an ongoing basis. Understand considerations for the continuous management of resources after the initial implementation. How to support future training and professional development needs. How to recognize the hard work of staff and a successful implementation. Chapter 13: Continuous Improvement Recognize that the key to the success of the continuous quality improvement process is leadership. How the AHS site conducts an annual assessment, from which a quality improvement plan is generated. The work currently underway to define standardized metrics and reporting processes for tobacco cessation activities within AHS. How to access training and tools for the model that is used within AHS for quality improvement (the AHS Improvement Way (AIW)).

169 Chapter 12 Sustainability Alberta Health Services

170 SUSTAINing tobacco Free Futures The sustainability of the Tobacco Free Futures initiative will be determined by the organization s capacity to maintain support to engaged AHS sites and to implement the initiative at new sites. Campbell, Pieters, Mullen and Reece (2011) demonstrate that while hospital-based smoking cessation interventions, such as the Ottawa Model for Smoking Cessation, can be effective in helping smokers quit, long-term sustainability is required to improve health and health care usage at the population level. 2 Plans to transition the program into AHS operations are currently underway. A literature review by Scheirer (2005) identified five key factors related to the sustainability of new programs: 3 a clear alignment of the program with the organization s goals and procedures identification of champions to provide leadership through implementation and sustainability clearly identified and communicated benefits to all stakeholders (including staff and clients) the ability to modify the program to fit organizational contexts the availability of stakeholders in other organizations to provide support Table 12.1 outlines project alignment in consideration of these factors Tobacco Free Futures

171 Table 12.1: Supporting Program Sustainability Key Factor Alignment of program with organization s goals and procedures Identification of program champions Identification of benefits to stakeholders Modification to fit organization s context Support from other organizations and stakeholders Related Actions Support AHS vision and key strategic documents, such as the Health Plan Support the Tobacco and Smoke Free Environments Policy. Designed to become routine standard of care within core services across the continuum of care. Support the Changing Our Future: Alberta s Cancer Plan to Support the Creating Connections: Alberta s Addiction and Mental Health Strategy. Support the Creating Tobacco Free Futures: Alberta s Strategy to Prevent and Reduce Tobacco Use targets. Collaboration with Tobacco Reduction Program staff. Collaboration with Provincial Tobacco Cessation Advisory Committee. Leadership from Provincial Tobacco Free Futures Advisory Committee. Collaboration and direction from AHS Cancer Care, Addiction and Mental Health and other Strategic Clinical Networks. Leadership from Zone steering committees. Leadership from health care site steering committees. Identification and training of site tobacco practice leads. Support for all Albertans who use tobacco products. Recommended standard of care provides guidance for all health care professionals, including training. Support for all Albertans who are exposed to second-hand smoke. Support for AHS staff. Adaption of the CAN-ADAPTT guidelines to fit the AHS context. Developing AHS standardized resources, including website, Tobacco Free Futures guidelines, training and professional resources, patient resources and documentation tools. Flexibility for implementation in health care settings across the continuum of care. Process of implementation driven at the site steering committee (leadership) level. Alberta Health and Wellness. Internal support to AHS sites through the Tobacco Reduction Program. Alberta Health Services

172 Planning for sustainability has been an integral part of the development and implementation of the Tobacco Free Futures initiative, but continued activities at the provincial and individual health care setting levels will help ensure that systems changes are sustained and high quality cessation support is ongoing. Program tools have been developed to help guide and document individual health care sites through the implementation and sustainability phases and reflect the shift in focus of key action areas. Implementation Sustainability Initial planning Ongoing leadership Resource development Resource management Preparing staff Training and professional development Final planning Celebrating success The remainder of this chapter will focus on considerations for provincial and site sustainability related to the above-noted phases. See appendices: Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool Leadership Guidance and leadership for the Tobacco Free Futures initiative will be maintained through the Tobacco Reduction Program, in consultation with Population, Public and Aboriginal Health leadership, the Provincial Cessation Steering Committee, Strategic Clinical Networks and other key stakeholders. Resource management Many resources have been developed to support the implementation of Tobacco Free Futures. Whenever possible, these resources and processes have been standardized for all of AHS. Resource management functions related to these resources, including review, revision, printing (as appropriate) and distribution, will continue at a provincial level through the Tobacco Reduction Program. These resources include the AlbertaQuits website ( Tobacco Free Futures guidelines and associated tools training (online through AHS MyLearning Link and supplementary professional resources supplementary patient resources patient documentation forms pharmacotherapy order sets electronic medical records 12.4 Tobacco Free Futures

173 Training and professional development Initial staff training, as outlined in Chapter 11 ( Training ), is a key step in successful program implementation. However, ongoing education to refresh or update existing staff knowledge and the orientation of new staff is essential to ensure consistent messaging. At a provincial level, activities led by the Tobacco Reduction Program are required to ensure availability of relevant, quality and up-to-date training for all health professionals, including the physicians and support staff. These opportunities may include the general orientation for all Alberta Health Services staff regarding the Tobacco and Smoke Free Environments Policy and supports available to patients/clients and staff opportunities for specialized tobacco training for professionals treating tobacco dependence, especially with specific populations training for tobacco practice leads who will continue to support front-line staff in specific sites/health care settings during implementation brief tobacco intervention training for front-line health care professionals professional development opportunities that allow for knowledge transfer and networking Celebrating success Post-implementation, it is important to take time to evaluate and celebrate success as a continuing validation of the importance of the program and its relevance within the organization and each health care setting. Knowledge transfer opportunities have been ongoing throughout development of the Tobacco Free Futures initiative. Information about Tobacco Free Futures has been and will continue to be disseminated locally, provincially, nationally and internationally. Individual health care sites should look for opportunities to share program successes and challenges, both within their site and externally. For example, as part of the survey process, Accreditation Canada surveyors identify what they consider to be leading or exemplary practices of high quality leadership and service delivery. In 2007, the Ottawa Model of Smoking Cessation, a model similar to Tobacco Free Futures, was identified as one such leading practice. 1 Alberta Health Services

174 REFERENCES 1. Accreditation Canada. (2007). Leading practices: Survey year Ottawa, ON: Author. 2. Campbell, S., Pieters, K., Mullen, K., & Reece, R. (2011). Examining sustainability in a hospital setting: case of smoking cessation. Implement Science, 6, 108. Retrieved from 3. Scheirer, M. (2005). Is sustainability possible? A review and commentary on empirical studies of program sustainability. American Journal of Evaluation, 26(3), Retrieved from -%20Sustainability% PDF.pdf 12.6 Tobacco Free Futures

175 APPENDICES Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool Alberta Health Services

176 Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool (page 1) Tobacco Free Futures Sustainability plan Date: Site/Program: Key Contact: Phone: Using the data and key informants that are available to you, complete the following assessment tool. Responses and improvement goals should be discussed with the site committee and all affected stakeholders. The completed sustainability plan should be retained for site records and a copy sent to tru@albertahealthservices.ca. SITE leadership RESouRcE MANAGEMENT TASKS 1.0 Steering committee 1.1 Identify purpose of steering committee post implementation. 1.2 Review and revise terms of reference. Appendix 4(a) 1.3 Update committee membership. Appendix 4(b) 1.4 Identify and communicate revised meeting schedule. 2.0 Documentation 2.1 Maintain supply of up-to-date forms through approved printers. 2.2 Ensure most up to date forms are available ( 2.3 Assign responsibility for ongoing ordering and stocking of forms. 2.4 Determine process for communicating future documentation revisions/changes. 3.0 pharmacotherapy 3.1 Monitor use of cessation pharmacotherapy products. 3.2 Maintain stock of formulary products based on use. 3.3 Ensure most up-to-date order sets are stocked and used ( 4.0 cessation resources 4.1 Review resources available, identify resource gaps and confirm core resources ( 4.2 Establish process for maintaining ordering, stocking and distribution of resources. 4.3 Assign responsibility for ordering, stocking and distribution. persons RESpoNSIblE AND comments Tobacco Free Futures 1/ Tobacco Free Futures

177 Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool (page 2) TRAINING AND professional DEVElopMENT wrap up AND IMpRoVEMENT planning 5.0 All employees TASKS 5.1 Confirm general orientation of staff to policy and supports. 6.0 Tobacco practice leads 6.1 Identify ongoing role and responsibility of tobacco practice leads. 6.2 Identify person responsible for maintaining capacity by replacing tobacco practice leads with turnover. 6.3 Identify person responsible for arranging training of new tobacco practice leads. 6.4 Develop process for ongoing communication with tobacco practice leads (e.g., regular meetings or distribution list). 7.0 front-line staff 7.1 Confirm standard for training front-line health professionals (Chapter 11). 7.2 Integrate standard into existing training opportunities (e.g., new hire training and skills days). 7.3 Identify person responsible for annual updates. 7.4 Identify person responsible for maintaining training records. 8.0 physicians 8.1 Identify and communicate training opportunities for physicians. 8.2 Identify person responsible to arrange site based training or rounds opportunities. 8.3 Identify person responsible to orientate new physicians and medical students to program. 9.0 celebrate success 9.1 Share successes with site/program and beyond (e.g., newsletters and conferences). 9.2 Identify and communicate successes to stakeholders, staff, and clients/families. 9.3 Identify person responsible for coordinating activities to highlight program (e.g., World No Tobacco Day). 9.4 Highlight program implementation in quarterly reports and accreditation activities Quality assessment and improvement planning 10.1 Review quality improvement assessment tool and quality improvement plan template Complete quality improvement assessment and quality improvement plan. Appendices 13(a) and 13(b) 10.3 Identify date of next quality improvement assessment. persons RESpoNSIblE AND comments Tobacco Free Futures 2/2 Alberta Health Services

178

179 CHAPTER 13 Continuous Improvement Alberta Health Services

180 INTRODUCTION TO QUALITY IMPROVEMENT LEADERSHIP Quality services are services that are provided in a safe, effective, recipient-centred, timely, equitable and recovery-oriented fashion. Alberta Health Services s strategic direction is structured around improving the health of Albertans through a focus on well-being and ensuring all of the care we provide is safe and of high quality. The three goals of our organization quality, access and sustainability are connected and work together. 1 Six key dimensions of quality have been developed by the Health Quality Council of Alberta to measure quality throughout the organization: Appropriateness: Health services are relevant to users needs and are based on accepted or evidence-based practice. Safety: Mitigate risks to avoid unintended or harmful results. Efficiency: Resources are used optimally in achieving desired outcomes. Accessibility: Health services are obtained in the most suitable setting, and within a reasonable time and distance. Acceptability: Health services are respectful and responsive to users needs, preferences and expectations. Effectiveness: Health services are based on scientific knowledge. 1 Quality improvement is a systematic approach to assessing services and improving them on a priority basis. Processes must be continually reviewed and improved. Even incremental changes make an impact, and providers can almost always find an opportunity to make things better. Quality improvement activities emerge from a systematic and organized framework, which should be understood, accepted and used throughout the health care setting. The key to the success of the continuous quality improvement process is leadership. There are several ways that leaders of health care settings can provide support to quality improvement activities. Tobacco Free Futures site steering committee The Tobacco Free Futures site steering committee provides ongoing operational leadership of continuous quality improvement activities. Following the initial rollout, the committee should plan to meet at least four times per year and should consist of individuals from the following units: senior management unit management physicians nursing pharmacy respiratory therapy workplace health and safety protective services client registration and admitting others (e.g., clinical educators, allied health professionals, community supports or professionals working with specific populations) 13.2 Tobacco Free Futures

181 The responsibilities of the committee may include developing and approving an annual quality improvement plan as part of the plan, establishing measurable objectives based on priorities identified through the use of established criteria for improving quality in AHS assessing information based on defined indicators, taking action as required through quality improvement initiatives to solve problems and pursuing opportunities to improve quality establishing and supporting specific quality improvement initiatives regularly reporting to senior management on quality improvement activities formally adopting AHS s approach to continuous quality improvement (the AHS Improvement Way) The Tobacco Reduction Program may also provide support and guide implementation of Tobacco Free Futures quality improvement activities at the site. Leaders support quality improvement activities by coordinating and communicating the results of measurement activities related to quality improvement initiatives and overall efforts to improve the quality of tobacco treatment. PERFORMANCE MEASUREMENT Performance measurement is the process of regularly assessing the results produced by the program. It involves identifying processes, systems and outcomes that are integral to the performance of the service delivery system, selecting indicators of these processes, systems and outcomes, and analyzing information related to these indicators on a regular basis. Continuous quality improvement involves taking action as needed based on the results of data analysis and the performance opportunities they identify. The purpose of measurement and assessment is to assess the stability of processes or outcomes to determine whether there is an undesirable degree of variation or a failure to perform at an expected level identify problems and opportunities to improve processes assess the outcome of the care provided assess whether a new or improved process meets performance expectations Through the support of the Alberta Cancer Prevention Legacy Fund, work is currently underway to define standardized metrics and reporting processes for tobacco cessation activities within AHS. The standardized tobacco treatment metrics for AHS are expected to be available in August Pending approval, further work will be done to establish a monitoring and reporting system based on these metrics. For more information about standardized metrics and reporting processes, contact tru@albertahealthservices.ca. Alberta Health Services

182 Annual assessment Assessments should be completed by the Tobacco Free Futures site steering committee annually. These assessment are conducted by the AHS site and kept on file, along with the quality improvement plan that is generated based on the assessment. These documents may be shared and reviewed with the Tobacco Reduction Program. Annual assessments help set the goals and objectives of the site s quality improvement plan, and can be accomplished by comparing actual performance with self over time pre-established standards, goals or expected levels of performance information concerning evidence-based practices other clinics or similar service providers See appendices: Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment Appendix 13(b) Tobacco Free Futures Quality Improvement Plan QUALITY IMPROVEMENT USING THE AHS IMPROVEMENT WAY Once the performance of the Tobacco Free Futures systems change processes and tobacco treatment have been measured, assessed and analyzed, the information gathered is used to identify a continuous quality improvement initiative. The decision to undertake the initiative is based upon site and organizational priorities. The model used within Alberta Health Services for quality improvement is the AHS Improvement Way (AIW). In its simplest form, the AIW is a common organization wide approach for solving problems, making improvements and managing change based on Lean Six Sigma process improvement methods. AIW is an improvement process that has been designed for all levels of AHS. Whether you are on the frontlines, working in a leadership position or working in an administrative role, you will be able to apply the AIW to the work you do each day. 1 Training and resources are available. Four steps of the AHS Improvement Way (AIW) 1 1. Define opportunity: Describe the problem, opportunity and goal, confirm as a priority and link to AHS strategic goals. 2. Build understanding: Validate opportunity, baseline performance, use facts/data to pinpoint waste, variation, root causes, design criteria. 3. Act to improve: Develop, test, measure and refine changes, manage risks, confirm achievement of intended outcome(s). 4. Sustain results: Ensure ongoing measures and monitoring, the capacity to support new practices, accountability and support. For more information, tools, templates and training on the AHS Improvement Way approach, visit: Tobacco Free Futures

183 REFERENCES 1. Alberta Health Services. (2014). Alberta Health Services Health Plan and Business Plan Edmonton, AB: Author. Retrieved from publications/ahs-pub health-plan.pdf Alberta Health Services

184 APPENDICES Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment Appendix 13(b) Tobacco Free Futures Quality Improvement Plan 13.6 Tobacco Free Futures

185 Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment (page 1) Tobacco Free Futures Annual Quality Improvement Assessment Date: Site/Program: Key Contact: Phone: Using the data and key informants that are available to you, complete the following assessment tool. Responses and improvement goals should be discussed with the committee and all impacted stakeholders. A copy of the completed assessment should be sent to tru@albertahealthservices.ca. SEcTIoN 1 The questions in this section will assist you in determining if there are ways to improve the leadership and implementation of the Tobacco Free Futures initiative at your site. YES No 1. Is site leadership still engaged and supportive of the Tobacco Free Futures initiative? 2. Are all service areas and professions still represented on the committee? 3. Is the meeting frequency still appropriate? leadership & IMplEMENTATIoN 4. Have the terms of reference for the committee changed? 5. Are there service areas or units that have not fully implemented Tobacco Free Futures? 6. Have any service areas requested further support from the committee? 7. Have any new service areas been established since the initial rollout? 8. Are the proper Tobacco Reduction Act and AHS Tobacco and Smoke Free Environment signs still in place? 9. Are there any areas on AHS property that seem to have high tobacco use? 10. Any groups of individuals struggling with compliance? comments: Tobacco Free Futures 1/3 Alberta Health Services

186 Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment (page 2) SEcTIoN 2 The questions in this section will assist you in determining if there are ways to improve the support and resources available to clients, families, visitors, and staff at your site. YES No 1. Have AHS tobacco treatment documentation standards changed? If so have site processes been updated and communicated? 2. Have documentation practices changed at the site? If so, do they reflect AHS tobacco treatment documentation standards? RESouRcE MANAGEMENT 3. Do clients who use tobacco require further support than what is currently offered on site? (e.g., beyond brief tobacco intervention?) 4. Do staff who use tobacco require further support than what is currently offered? 5. Have there been any changes in the availability or use of cessation medications within AHS? 6. Are there any changes in the resources available to clients and families? 7. Are there any changes in resources available to staff and volunteers? 8. Are there any improvements that can be made to the way the integrated care pathway has been implemented? 9. Is the connection to continued support still occurring for all interested clients? comments: SEcTIoN 3 The questions in Section 3 will assist you in determining if there are ways to improve the education offered to staff, students, and physicians at your site. YES No TRAINING & professional DEVElopMENT 1. Is information about the policy included in the staff orientation? 2. Has there been significant staff turnover? (greater than 10%) 3. Has additional training taken place for new staff? 4. Are all tobacco practice leads still in place for each area? Has additional training taken place? 5. Is there a need for ongoing or further skills development? 6. Have training records been maintained? 7. Do physician groups require further training? 8. Has training been identified for all student and new hires? comments: Tobacco Free Futures 2/ Tobacco Free Futures

187 Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment (page 3) SEcTIoN 4 Review the answers and comments in the sections 1-3 and identify the priority areas for your site to focus on for the next year. Record your selected improvements in this section as quality improvement goals. From the above data, the following quality improvement goals have been identified for the next year: 1. IMpRoVEMENT GoAlS The completed assessment will assist in the development of the quality improvement plan. For further information see the Tobacco Free Futures Guidelines Appendix 13(b): Quality Improvement Plan. Tobacco Free Futures 3/3 Alberta Health Services

188 Appendix 13(b) Tobacco Free Futures Quality Improvement Plan (page 1) Tobacco Free Futures Quality Improvement plan Date: Site/Program: Key Contact: Phone: The following Quality Improvement Plan serves as the foundation of the commitment of <site name> to continuously improve the quality of the treatment and services it provides. Use the information available to you, especially from your completed quality improvement assessment, to develop your quality improvement plan for the Tobacco Free Futures initiative at your site. Your plan should be discussed with the committee and all impacted stakeholders especially site/program leadership. The completed plan should be retained for site records and a copy sent to tru@albertahealthservices.ca. QuAlITY IMpRoVEMENT committee The Quality Improvement Committee will consist of the following members: Name position (indicate chair) The responsibilities of the Committee will include: Annually developing and approving a quality improvement plan. As part of the plan, establishing measurable objectives based upon priorities identified through the use of established criteria for improving quality in AHS. Periodically assessing information based on defined indicators, taking action as evidenced through quality improvement initiatives to solve problems and pursue opportunities to improve quality. Establishing and supporting specific quality improvement initiatives. Reporting to senior management on quality improvement activities on a regular basis. Formally adopting AHS s approach to continuous quality improvement (the AHS Improvement Way). Tobacco Free Futures 1/ Tobacco Free Futures

189 Appendix 13(b) Tobacco Free Futures Quality Improvement Plan (page 2) QuAlITY IMpRoVEMENT committee (continued) The Tobacco Reduction Program will provide support and guide implementation of the Tobacco Free Futures quality improvement activities at the site in the following ways: Identify agreed role of TRP Zone Coordinator Communication will take place through the following methods: Describe communication tactics to for leadership, staff and patients/clients. Committee meetings will adhere to the following guidelines: Identify the frequency of meetings and additional responsibilities such as who will be responsible for organizing the meeting schedule and maintaining meeting notes. Tobacco Free Futures 2/4 Alberta Health Services

190 Appendix 13(b) Tobacco Free Futures Quality Improvement Plan (page 3) GoAlS AND objectives The following are the ongoing long term goals for the <insert site name> Tobacco Free Futures Committee and the specific objectives for accomplishing these goals for the <Indicate the current year>. Selection of your goals may be guided by the Quality Improvement Assessment Tool. You do not need to select all goals; the list should be tailored to your program. Each selected goal should have specific, measurable objective(s) so you will be able to clearly determine whether they have been met at the end of the year. The ways in which these goals will be accomplished should be outlined in the planned activities section below. Goals objectives AlIGNMENT with AHS STRATEGIc priorities The quality improvement goals for the <insert site name> Tobacco Free Futures Committee support Alberta Health Services Strategic Priorities and <INSERT SITE NAME> priorities in the following ways: Goals List how goal aligns with AHS strategic priorities and site/program priorities planned AcTIVITIES The timelines for accomplishing the identified goals are to begin work on <INSERT START DATE> and complete work on <INSERT END DATE>. The table below outlines the planned activities to accomplish these goals including resources required, and budget implications. # Activity comments person Responsible Start Date End Date cost Tobacco Free Futures 3/ Tobacco Free Futures

191 Appendix 13(b) Tobacco Free Futures Quality Improvement Plan (page 4) EXpEcTED benefits The expected benefits of implementing the improvement plan include: List expected benefits AppRoVAl Name Title Signature Date Tobacco Free Futures 4/4 Alberta Health Services

192

193 Specific Care Settings 14. Surgical Care 15. Emergency and Urgent Care 16. Home Care 17. Public Health 18. Transition and Continuing Care AlbertaQuits.ca

194 Implementation of Tobacco Free Futures in specific care settings The Tobacco Free Futures model is intended to be relevant to and implemented across the continuum of care, providing consistency in messaging and treatment for all tobacco users. In Chapter 7 of these guidelines ( Brief Intervention ), the standard care pathway and considerations for implementation were introduced, which are applicable in many care settings, both inpatient and outpatient. This section will focus on the factors related to specific care settings that may require further consideration for implementation. Chapter 14: Surgical Care All elective patients who smoke should be directed to resources to quit prior to admission to hospital (e.g., CAN-ADAPTT). Benefits of cessation during the peri-operative period. Implementation considerations for surgical settings. Chapter 15: Emergency and Urgent Care Supporting cessation in an emergency or urgent care setting. Implementation considerations for emergency and urgent care settings. Chapter 16: Home Care Addressing tobacco use in a home care setting. Modified care pathway for the home care setting. Considerations for implementation in the home care setting. Chapter 17: Public Health Addressing tobacco use and exposure in a variety of public health programs and services. Modified care pathway for the public health setting. Considerations for implementation in public health settings. Chapter 18: Transition and Continuing Care Addressing tobacco use and exposure in transition and continuing care settings. Creating tobacco and smoke-free environments in transition and continuing care settings. Modified care pathway for transition and continuing care settings. Considerations for implementation in transition and continuing care settings.

195 Chapter 14 Surgical Care Alberta Health Services

196 Addressing tobacco use in Surgical care The preoperative period represents a crucial time to address tobacco use among elective surgery patients. Tobacco use affects postoperative outcomes due to complications related to smoking effects on cardiovascular and respiratory systems negative effects on wound and bone healing interference with immune response and overall recovery 1,2,3,4 Complications related to surgical interventions are important to patients and expensive to the health care system, leading to extended recovery periods and longer hospital stays. 5 Evidence suggests that providing intensive smoking cessation intervention 4 8 weeks before surgery is optimal to increase the likelihood of reducing pulmonary complications and promoting long-term abstinence. However, brief interventions less than 4 8 weeks before admission are effective in supporting short-term abstinence, with insufficient evidence to determine whether they reduce overall complications. 5 CAN-ADAPTT Guidelines (2011) All elective patients who smoke should be directed to resources to assist them to quit smoking prior to hospital admission or surgery, where possible. 6 Patients may not be seen preoperatively by surgeons, anesthesiologists or nurses more than 4 weeks prior to surgery, which limits the opportunity to recommend the optimal cessation advice of 4 8 weeks. Clinicians may be hesitant to recommend cessation in the brief period before surgery (<8 weeks) due to the myth that short-term cessation may be associated with increased pulmonary complications related to the transient increases in coughing and mucous production after abstinence. This concern has been documented in the medical literature based on the over interpretation of results of two studies conducted in the Mayo Clinic in the 1980s. 7,8,9 A current anesthesia text still inappropriately recommends that if you are unable to advise the patient to stop smoking 8 weeks or more before surgery, it is preferable for the patient to continue smoking to minimize the increase in pulmonary complications in recent quitters, which may be higher than current smoking. 10,11 A recent review by Shi and Warner (2011) refutes this advice, concluding that there was an over interpretation of the Mayo Clinic studies. The authors of the Mayo Clinic studies did not report statistically significant findings of increased complication rates in recent quitters and were careful not to make this conclusion. 7 Results did show that longer periods of abstinence are necessary for pulmonary benefit. 7,8,9 Concern about pulmonary complications should not prevent clinicians from helping their patients quit smoking at any time before surgery. 7 The Shi and Warner (2011) review concluded that (1) no individual study has found that brief preoperative smoking abstinence significantly increases pulmonary risk, (2) meta analysis of the available studies also does not find a significant increase in risk, and (3) there is no support for the purported underlying mechanism contributing to risk Tobacco Free Futures

197 Tobacco Free Futures in surgical care Although smoking cessation prior to surgery reduces the incidence of postoperative complications, only a minority of anesthesiologists, surgeons and nurses actively assist their patients to quit smoking or develop a plan to manage the consequences of involuntary perioperative cessation. 12,13 It is optimal to implement smoking cessation intervention before the surgery (>8 weeks); however, this may be difficult from a practical perspective, considering the unique characteristics of this health care setting. Identified barriers include short time frame between preoperative visit and surgery (<8 weeks) lack of coverage for cessation medication outside the hospital setting difficulty coordinating between family physicians and hospitals to promote smoking cessation with patients preoperatively 7 Despite these barriers, preadmission clinics are ideal locations for 1. identifying patients who use tobacco 2. delivering a brief intervention 3. planning for in-hospital pharmacotherapy 4. initiating referral of patients post-discharge to community cessation services 14 Patients reported that the possibility of reducing perceived vulnerability to postoperative complications promoted motivation to quit or reduce smoking prior to operation. 5 The brief intervention model outlined in Chapter 7 ( Brief Intervention ) can be easily integrated into the preoperative care setting. Table 14.1 outlines potential considerations for implementation of the model in the preoperative setting. Alberta Health Services

198 Table 14.1: Treatment Model: Considerations for Preoperative Care Settings Model component Considerations ARRANGE ASSIST ASSESS ADVISE ASK ASK all patients if they have used tobacco in the past year. ASK about pattern of use. ADVISE all patients regardless of tobacco use status or tobacco-free environment policy. ADVISE current tobacco users to stop using tobacco. Personalize message. ASSESS readiness to quit. ASSESS interest in support for relief of withdrawal. ASSIST the patient who is not interested, support autonomy and offer brief information. ASSIST the patient who is interested with link to prescriber pharmacotherapy support and/or behavioural support. ARRANGE follow-up on discharge for any pharmacotherapy started and link to further behavioural support. All tobacco users should be identified during the preoperative phase. Relevant forms used in pre-assessment phase should be modified as necessary to document tobacco use status. Patients and family/support persons should be made aware of the AHS Tobacco and Smoke Free Environments Policy as part of their preparation for the surgical experience. It is more effective to tailor advice to quit in relation to planned procedure and direct benefits of cessation on recovery. Having surgery presents a powerful teachable opportunity for tobacco cessation and makes any time a good time for preoperative patients to quit. 7 The stress associated with having surgery and awaiting results of procedures may make it difficult for users to quit. 5 Provide self-help information to all patients who are identified as tobacco users including the resource, Getting Ready for Surgery or Procedure: What You Should Know About Your Tobacco Use (order through the online catalog at Patients who are interested in using pharmacotherapy preoperatively should be linked to appropriate prescribing authority (e.g., anaesthesiologist or surgeon). NRT is safe and effective to be used in the perioperative period. 5,12,15,16,17 Pharmacotherapy initiated in the preoperative period should be continued in the postoperative period for inpatients. Appendix 9(a) Ensure communication between OR staff and inpatient surgical unit for continuity of care. Appendix 7(a) For outpatient surgical patients who are interested, facilitate discharge pharmacotherapy. Appendix 9(b) Follow-up after hospitalization is key factor of effective interventions. 18 Link to post-discharge behavioural support. Appendix 7(b) 14.4 Tobacco Free Futures

199 References 1. Moller, A., & Tonneson, H. (2006). Risk reduction: Perioperative smoking intervention. Best Practices in Research Clinical Anesthesiology, 20, Rennard, S., Togo, S., & Holz, O. (2006). Cigarette smoke inhibits alveolar repair: A mechanism for the development of emphysema. Proceedings of the American Thoracic Society, 3, Rogliani, M., Labardi, L., Silvi, E., Maggiulli, F., Grimaldi, M., & Cervelli, V. (2006) Smokers: Risks and complications in abdominal dermolipectomy. Aesthetic Plastic Surgery, 30, U.S. Department of Health and Human Services (USDHHS). (2004). The health consequences of smoking. A report of the Surgeon General. Washington, DC: Author. Retrieved from index.htm 5. Thomsen, T., Villebro, N., & Møller, A. (2010). Interventions for preoperative smoking cessation. Cochrane Database of Systematic Reviews 7. Art no.:cd Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 7. Shi, Y., & Warner, D. (2011). Brief preoperative smoking abstinence: Is there a dilemma? Anesthesia & Analgesia, 113(6), Warner, M., Divertie, M., & Tinker, J. (1984). Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients. Anesthesiology, 60, Warner, M., Offord, K., Warner, M. E., Lennon, R., Conover, M., & Jansson-Schumacher U. (1989). Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: A blinded prospective study of coronary artery bypass patients. Mayo Clinic Proceedings, 64, Roizen, M. (1990). Anesthetic implications of concurrent diseases. In R. Miller (Ed.), Miller s anesthesia. (3rd ed.) (p. 839). New York: Churchill Livingstone. 11. Roizen, M., & Fleisher, L. (2010) Anesthetic implications of concurrent diseases. In R. Miller (Ed), Miller s anesthesia. (7th ed.) (pp ). Philadelphia: Churchill Livingstone. 12. Warner, D. (2007). Tobacco dependence in surgical patients. Current Opinion in Anaesthesiology, 20, Warner, D., Sarr, M., Offord, K., & Dale, L. (2004). Anesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesthesia & Analgesia, 99, Zaki, A., Abrishami, A., Wong, J., & Chung, F. (2008). Interventions in the preoperative clinic for long term smoking cessation: A quantitative systematic review. Canadian Journal of Anaesthesia, 55, Alberta Health Services

200 15. France, E., Glasgow, R., & Marcus, A. (2001). Smoking cessation interventions among hospitalized patients: What have we learned? Preventative Medicine, 32, Simon, J., Solkowitz, S., Carmody, T., & Browner, W. (1997). Smoking cessation after surgery: A randomized trial. Archives of Internal Medicine, 157, Warner, D., Patten, C., Ames, S., Offord, K., & Schroeder, D. (2005). Effect of nicotine replacement therapy on stress and smoking behavior in surgical patients. Anesthesiology, 102, Rigotti, N., Munafo, M., & Stead, L. (2007). Interventions for smoking cessation in hospitalised patients (Review). Cochrane Database of Systematic Reviews, 3. Art no.:cd Tobacco Free Futures

201 Chapter 15 Emergency and Urgent Care Alberta Health Services

202 Addressing tobacco use in emergency and urgent care Emergency departments (EDs) provide another underused health care setting to support tobacco users by coordinating with and linking to cessation supports. 1 In the fiscal year, Alberta Health Services reported 2,118,956 ED and urgent care visits. 2 It has been reported that tobacco users account for a disproportionate share of ED visits with cited rates from 20% to 40%, and higher rates were noted in urban EDs. 1,3,4 Using a conservative rate of 25%, this translates into more than 500,000 visits by tobacco users to Alberta EDs and urgent care centres annually. Brief tobacco interventions result in an estimated 2% to 4% of current tobacco users quitting. 5 If brief tobacco interventions were performed consistently in emergency and urgent care departments in Alberta, this could translate to 10,000 to 20,000 people quitting annually. Although EDs deal with many patient visits for life-threatening emergencies for which brief tobacco intervention would not be appropriate, a considerable number of tobacco-using patients present for non-emergency health care. 6 Emergency and urgent care settings are often the primary source of health care for persons of lower socio-economic status, as well as ethnic minority populations. 7 The prevalence of tobacco use among patients/clients in emergency care is high. For non-emergent patients, minimal contact strategies, such as a brief tobacco intervention, should become part of an ED s routine practice. 7 Assessment of exposure to second-hand smoke (SHS) is appropriate, particularly for children who present in emergency and urgent care settings with conditions such as asthma, respiratory infections and otitis media, which are known to be linked to tobacco exposure. 8 In Alberta, the rates of household exposure to SHS for children aged 0 11 years has decreased significantly from 28% in 1999 to only 5% reported in This positive trend can be further supported during visits to EDs and urgent care centres. These visits present opportunities to engage parents/caregivers and have been found to have a positive effect on their efforts to quit tobacco use or limit their child s exposure. 8 CAN-ADAPTT guidelines (2011) Health care providers caring for children and adolescents should counsel parents/guardians about the potential harmful effects of second-hand smoke on the health of their children Tobacco Free Futures

203 Tobacco Free Futures model in emergency and urgent care Potential barriers to implementing tobacco treatment into routine practice in ED settings include lack of time, lack of patient interest and beliefs that this setting is inappropriate for cessation advice and care. 11 A 2002 systematic review of the literature, focussing on tobacco intervention in the ED, recommended routine screening of all patients for tobacco use and referral of tobacco users to further cessation support, even though there is limited data to support ED practice, given the strong evidence to support intervention in primary care settings the burden of disease related to tobacco use the relative ease of brief tobacco intervention 5 For over a decade, it has been proposed that tobacco use status be added as a new fifth vital sign, alongside blood pressure, pulse, temperature and respiratory rate. 11 The brief intervention model outlined in Chapter 7 ( Brief Intervention ) can be easily integrated into the emergency and urgent care settings. Table 15.1 outlines potential considerations for implementating the model in emergency and urgent care settings. A study of emergency department patients identified that, of those who smoked, 68% wanted to quit and 49% wanted to quit within a month. 1 Alberta Health Services

204 Table 15.1: Treatment Model: Considerations for Emergency and Urgent Care Settings Model component Considerations ARRANGE ASSIST ASSESS ADVISE ASK ASK all patients if they have used tobacco in the past year. ASK about pattern of use. ADVISE all patients regardless of tobaccouse status about the Tobacco and Smoke Free Environments Policy. ADVISE current tobacco users to stop using tobacco. Personalize message. ASSESS readiness to quit. ASSESS interest in support for relief of withdrawal. ASSIST the patient who is not interested in support with brief information. ASSIST the patient who is interested with link to prescriber pharmacotherapy support and/or behavioural support. ARRANGE followup after discharge for any pharmacotherapy started and link to further behavioural support. All tobacco users should be identified during visits, as appropriates. Parents/guardians of children should be asked about SHS exposure. Electronic or paper-based forms used in the care setting should be modified as necessary to document tobacco use status. Consider as a vital sign. 12 Appendix 7(a) Patients and family/support persons should be made aware of Tobacco and Smoke Free Environments Policy. Many patients admitted to inpatient care are first seen in emergency care. Initiating brief intervention at time of admission may strengthen consistent messaging around the policy. Integrating brief advice to quit into routine practice in the ED has the added benefit of reaching patients who may experience a teachable moment if the reason for the visit is related to their tobacco use. 13 Assessing readiness to quit is appropriate for patients presenting with non-emergent conditions. Admission to an ED or urgent care setting may mean a stay of several hours. Therefore, the offer of pharmacotherapy support for nicotine withdrawal should be made to all tobacco users as a comfort measure. 17% of highly motivated tobacco users will quit when provided with nothing more than a self-help brochure. 1 Identified self-help resources for patients should be stocked in the department and easily accessible to staff and patients ( The AHS standard initiation order set can be used to facilitate shortterm NRT use while a patient is under care in the ED. Appendix 9(a) Ensure communication between ED and inpatient staff to facilitate continuity of care for patients who are admitted for further care. Appendix 7(a) Pharmacotherapy initiated in ED should be continued for inpatients. Appendix 9(a) When available, it is appropriate to arrange for a consultation with an onsite tobacco counsellor/specialist. Appendix 8(a) For patients who are interested, facilitate discharge pharmacotherapy. Appendix 9(b) Follow-up after hospitalization is a key factor in effective interventions. Link to community behavioural support, preferably by fax referral. Appendix 7(b) 15.4 Tobacco Free Futures

205 References 1. Lowenstein, S., Tomlinson, D., Koziol-McLain, J., & Prochazka, A. (1995). Smoking habits of emergency department patients: An opportunity for disease prevention. Academic Emergency Medicine, 2, Alberta Health Services. (2011) annual report. Edmonton, AB: Author. 3. Richman, P., Dinowitz, S., Nashed, A., Eskin, B., Sylvan, E., Allegra, C., Allegra, J., & Mandell, M. (2000). The emergency department as a potential site for smoking cessation intervention: A randomized, controlled trial. Academic Emergency Medicine, 7, Smith, P. (2011). Tobacco use among emergency department patients. International Journal of Enviornmental Research and Public Health, 8, Bernstein, S., & Becker, B. (2002). Preventive care in the emergency department: Diagnosis and management of smoking and smoking-related illness in the emergency department: A systematic review. Academic Emergency Medicine, 9, Elders, M. (1995). Smoking cessation efforts. Academic Emergency Medicine, 2, Greenberg, M., Weinstock, M., Fenimore, D., & Sierzega, G. (2008). Emergency department tobacco cessation program: Staff participation and intervention success among patients. Journal of the American Osteopathic Association, 108(8), Tanski, S., Klein, J., Winickoff, J., Auinger, P., & Weitzman, M. (2003). Tobacco counseling at well-child and tobacco-influenced illness visits: Opportunities for improvement. Pediatrics, 111(2), Statistics Canada. (2012). Canadian tobacco use monitoring survey (CTUMS): Smoking prevalence Retrieved from research-recherche/stat/_ctums-esutc_prevalence/prevalence-eng.php 10. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). CAN-ADAPTT Canadian smoking cessation clinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from Prochazka, A., Koziol-McLain, J., Tomlinson, D., & Lowenstein, S. (1995). Smoking cessation counseling by emergency physicians: Opinions, knowledge, and training needs. Academic Emergency Medicine, 2, Ahluwalia, J., Gibson, C., Kenney, E., Wallace, D., & Resnicow, K. (1999). Smoking status as a vital sign. Journal of General Internal Medicine, 14, Richmond, R. (1999). Opening the window of opportunity: Encouraging patients to stop smoking. Heart, 81, Alberta Health Services

206 15.6 Tobacco Free Futures

207 Chapter 16 Home Care Alberta Health Services

208 Addressing tobacco use in home care settings Delivery of professional and support services in the home is an important alternative in the continuum of care provided by health authorities such as Alberta Health Services. Caring for clients in the home and community helps to reduce strain on inpatient facilities and to decrease health system costs. More than that, delivery of home care provides an opportunity to support the health, safety, comfort and, in many cases, independent living of clients in their preferred environment. Home care caseloads include clients of all ages and stages of life, including those who need minimal assistance for a short time (e.g., post-surgical wound care) have chronic illness and require ongoing assistance to maintain health and independence (e.g., diabetes, cardiovascular and chronic obstructive pulmonary disease (COPD)) are at the end of life and require palliative care 1 Tobacco use, and specifically smoking, is known to have a negative impact on the healing of wounds by temporarily decreasing tissue perfusion and oxygenation, weakening both inflammatory and reparative cell functions. Smoking cessation has the ability to reverse some of these processes within hours and weeks; however, there seems to be a longer term impact for those who are former tobacco users. Improvement in the inflammatory response after cessation does lead to reduction in wound infections post-cessation. Studies suggest that nicotine replacement therapy has no effect on wound healing. 2 Chronic conditions, including cancer, cardiovascular disease, COPD, diabetes and asthma, are highly affected and exacerbated by tobacco use. Tobacco users who are living with these conditions will see their health benefit significantly from cessation. 3 In the case of COPD, supporting tobacco cessation is the single most effective intervention Within the first hour after a cigarette is put out, blood flow, tissue oxygen and metabolism return to normal. 2 for preventing the condition and the only intervention known to slow declining lung function for those who already have COPD. 4 It is important to note that, for those receiving treatment for cancer (whether it includes radiation, chemotherapy and/or surgery), tobacco use has been found to decrease treatment effectiveness, exacerbate side effects and interfere with wound healing. 5 Palliative clients often continue using tobacco products, although declining health, restricted mobility and reduced access to tobacco products may affect their ability to meet their nicotine needs. Nicotine withdrawal has been identified as a cause of delirium and terminal restlessness in palliative clients who were heavy tobacco users but are not currently able to smoke. Studies have identified a high prevalence of depression, sleep problems and anxiety in those with advanced cancer, all of which may also be affected by nicotine withdrawal. Identifying tobacco use and treating nicotine withdrawal is an important component of palliative care Tobacco Free Futures

209 Tobacco Free Futures model in home care Health professionals working in home care settings have an important opportunity to identify tobacco use and provide advice and supportive care to their clients. Home care visits provide a window of opportunity or teachable moments, especially when a client is being treated for diseases and conditions that are related to and significantly affected by tobacco use. 3 For example, it is not surprising that research shows that motivation and interest in tobacco cessation increases after as user receives a diagnosis of cancer, particularly for those whose cancers have a strong relationship to tobacco, such as head, neck and lung. 5 The brief intervention model outlined in Chapter 7 ( Brief Intervention ) has been modified for application in the home care setting and is presented in Figure Table 16.1 then outlines potential considerations for implementation of the model in the home care setting. See appendices: Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) Alberta Health Services

210 Figure 16.1: Tobacco Free Futures: A Home Care Setting Treatment Model Brief tobacco intervention Ask every patient/client about tobacco use in the home. Document on patient/client chart. Advise ask Have you or anyone in your home used any tobacco products in the past year? No Positive reinforcement. Yes Inform of 2-hour tobacco-free time period prior to and during home care visit. Advise to quit with personalized message. Document on patient/client chart. There is no safe level of exposure to second-hand smoke. We ask all our clients to refrain from tobacco use 2 hours prior to and during a scheduled home care visit. Not using tobacco is one of the best things for the health of everyone in the home. Assess Assess readiness to quit. Assess interest in pharmacotherapy and behavioural support. Assess interest in a tobacco-free home and car. Document on patient/client chart. Are you/they interested in support to quit or to make your home and car tobacco-free? Yes No Support autonomy. Leave offer of support open. Document on patient/client chart. Assist Assist patient/client and/or family member with self-support materials. Document on patient/client chart. Arrange Arrange further support by completing appropriate linked referral(s). Document on patient/client chart. Provide ongoing support at next visit Tobacco Free Futures

211 Table 16.1: Treatment Model: Considerations for Home Care Settings Model component Considerations ARRANGE ASSIST ASSESS ADVISE ASK ASK all clients if they or their family members have used tobacco in the past year. ASK about pattern of use. ASK about exposure to second-hand smoke ADVISE current tobacco users to stop using tobacco. Personalize message. ADVISE client and household members that there is no safe level of exposure to secondhand smoke. ADVISE of policy, as applicable. ASSESS readiness to quit. ASSESS interest in support for relief of withdrawal. ASSESS interest in making home and car tobacco-free. ASSIST the patient who is not interested in support with brief information. ASSIST the patient who is interested with link to prescriber pharmacotherapy support and/or behavioural support. ARRANGE follow-up and link to further behavioural support. All tobacco users should be identified during initial visits. Tobacco use by household members and exposure to second-hand smoke should be identified. Electronic or paper-based forms used in home care should be modified to document tobacco use status. Appendices 7(a) and 16(a) Integrate brief tobacco intervention into routine practice in the home care environment to maintain continuity of care. Approaching tobacco use in the home must be done respectfully, recognizing that health care providers may be viewed as guests in the client s home. Community health professionals should request that clients and household members refrain from using tobacco for two hours prior and during a scheduled home visit. Electronic or paper-based forms used in home care should be modified to document advice. Appendix 7(a) Assessing readiness to quit and interest in tobacco-free homes and cars is appropriate for all clients who use tobacco. Assess interest in withdrawal relief through pharmacotherapy for those who are interested in quitting or reducing tobacco use. Short-term relief may be of interest to those who have mobility issues. Electronic or paper-based forms used in home care should be modified to document assessment. Appendices 7(a) and 16(a) Identified self-help resource for clients who are not interested and interested should be readily available to distribute to clients ( Communication between inpatient units and home care staff will facilitate continuity of care for clients who have been receiving treatment before discharge. Consider building into referral process. Pharmacotherapy is recommended for all clients who are interested except in the case of direct contraindications. Clients with conditions such as oral cancers may be unable to use short-acting NRT products (e.g.,gum, sprays, inhalers or lozenges). Instead, products such as the patch, bupropion or varenicline may be appropriate. 3 Electronic or paper-based forms used in home care should be modified as necessary to document assistance. Appendices 7(a) and 16(a) Link to community behavioural support, preferably by fax referral. Appendix 7(b) Alberta Health Services

212 References 1. Alberta Health Services. (2012). Home living. Edmonton, AB: Author. Retrieved from 2. Sorensen, L. (2012). Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation and nicotine replacement therapy. A systematic review. Annals of Surgery, 255(6), Fiore, M., Bailey, W., Cohen, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 4. O Donnell, D., Hernandez, P., Kaplan, A., et al. (2008). Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease Update 2008 Highlights for primary care. Canadian Respiratory Journal, 15(Suppl A), 1A 8A. 5. Gritz, E., Fingeret, M., Vidrine, D., Laze, A., Mehta, N., & Reece, G. (2006). Successes and failures of the teachable moment: Smoking cessation in cancer patients. Cancer, 106(1), Quibell, R., & Baker, L. (2005). Nicotine withdrawal and nicotine replacement in the palliative care setting. Journal of Pain and Symptom Management, 30(3), Tobacco Free Futures

213 APPENDICES Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) Alberta Health Services

214 Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) (page 1) Assessment Name: Tobacco Cessation Community Mnemonic: PCZTOBACCODEP01 Acuity/ACCIS: 20; Prof Health; Face-Face Intervention Number: Protocol: ZTOBDEP Move Date: 30/08/ Tobacco Free Futures

215 Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) (page 2) Alberta Health Services

216 Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) (page 3) PROTOCOL Tobacco Dependence and Cessation Brief Intervention Community Protocol Developed: May 2012 Revision: ASK - About tobacco use by client or other household members. If YES for client: Complete the type of tobacco, amount, years of use and last use questions. If NO for client AND household members: INTERVENTION STOPS HERE ADVISE If CLIENT AND/OR HOUSEHOLD MEMBERS DO USE tobacco products: - Advise that there is no safe level of exposure to environmental tobacco use and that a tobacco free environment is in the best interests of their health or everyone in the home. Personalize message as appropriate; example link to respiratory condition. - Request that client and/or household members refrain from smoking for 2 hours prior to and during a scheduled home care visit. If CLIENT DOES USE tobacco: - ALSO give personalized advice to quit using a non-judgmental approach: is most effective when personalized to the individual and their condition e.g. impact on wound healing. CONTINUE WITH THE INTERVENTION ASSESS - Readiness to quit: using a scale of 1-10 (1 = least, 10 = most) - Interest in support to quit or manage short term nicotine withdrawal. - Interest in support to make home and/or vehicle tobacco free. If NO Respect choice and leave offer of support open - Give appropriate self help information tailored to client who is not ready to quit. INTERVENTION STOPS HERE If YES, CONTINUE INTERVENTION ASSIST - Provide self help information tailored to client who is ready to quit and/or how to make your home and/or vehicle tobacco free. - Provide information on available pharmacotherapy and link to prescriber. - Provide information on behavioural counselling and availability in community. - Other (specify) CONTINUE WITH THE INTERVENTION Tobacco Free Futures

217 Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol (2012) (page 4) ARRANGE Arrange further support by completing appropriate community linked referral If NO, INTERVENTION STOPS HERE If YES, Referral/Information provided and/or fax referral to: - AlbertaQuits ( ) - Helpline, Groups - AlbertaQuits.ca - online - Primary Care Network - Other, specify REFERENCES (All available at tobaccofreefutures.ca) - Tobacco Free Futures Guidelines - Tobacco Free Futures Training for Brief Tobacco Intervention in Healthcare Settings - Creating a Tobacco Free Future: A Brief Intervention Pocket Guide for Health Professionals - AHS Tobacco and Smoke Free Environments Policy Alberta Health Services

218 16.12 Tobacco Free Futures

219 Chapter 17 Public Health Alberta Health Services

220 Delivered by a multidisciplinary public health team ADDRESSING TOBACCO USE IN PUBLIC HEALTH SETTINGS The Tobacco Free Futures initiative is relevant to and can be implemented across the continuum of care, providing consistent messaging and treatment for all those who are affected by tobacco use. Chapter 7 ( Brief Intervention ) introduced the standard care pathway and considerations for implementation, which are applicable in many inpatient and outpatient care settings, including public health. This chapter will focus on factors related to public health settings that may require further consideration for implementation. Public Health clinics have the potential for effective, large-scale delivery of smoking cessation interventions that can reach at risk populations. 1 In Alberta, public health services are diverse, and their availability varies from community to community, depending on the population and its needs. Services associated with strengthening the public s health include those that focus on health promotion as well as disease and injury prevention. Public health programs and services are delivered by a multidisciplinary team of health care professionals in clinic, community and home settings. This chapter will identify opportunities for integrating brief tobacco intervention as a standard of care within public health services, including preconception care, prenatal care, postnatal care, well-child clinics, early childhood development services, school health, dental health, adult immunization and communicable disease control. Public health management will make decisions regarding the expectations of integrating brief tobacco intervention within programs and service delivery, as well as the training of front-line staff from various health disciplines. Figure 17.1: Public Health Programming and Brief Tobacco Intervention Preconception health Communicable disease control Prenatal health Adult health Brief tobacco intervention Postnatal health Dental health Well child clinic School health Early childhood development 17.2 Tobacco Free Futures

221 Importance of tobacco treatment in public health Public health programs have the potential to deliver effective tobacco interventions on a large scale. It is particularly important that public health services have been identified as a major source of maternal and child health information and care for women of a lower socioeconomic status and, thus, present an opportunity for intervention with this at-risk population. 3 Several studies have established both the short- and long-term effectiveness of tobacco cessation interventions in public health, and it is currently recommended that brief tobacco intervention be integrated into routine care. 1,4,5,6 The following content summarizes some of the literature related to the relevance of tobacco treatment for the following public health services: preconception care, prenatal care, postnatal care, well-child clinics, early childhood development services, school health, dental health, adult immunization and communicable disease control. More detail about the specific populations often served by these programs will be found in Chapters 20 ( Reproductive Years ) and 21 ( Youth and Family ). PRECONCEPTION A number of public health services, and primarily those that focus on sexual health, provide an opportunity to affect the overall health of clients during the preconception phase of their reproductive years. Young adults frequently access sexual health clinics for services such as birth control advice, pregnancy confirmation, pregnancy options counselling and referral, as well as treatment for sexually transmitted infections. The young adult demographic (ages 20 24) has the highest reported tobacco use rates in Alberta, at 24%. 7 Tobacco use has a significant impact on a person s overall health, including the reproductive health of this population. The impact of tobacco use on fertility for both men and women has been documented by a 2008 literature review, which identified tobacco use as a compromising factor in all of the systems involved in reproduction. 8 For women, tobacco use is a known risk factor for precancerous changes and cancer of the cervix. 9 Sexual health clinics have long cautioned women about the dangers of smoking while taking oral contraceptive pills because of a higher risk for serious cardiovascular disease, stroke and high blood pressure. 8 Tobacco use also has effects on the ovaries, fallopian tubes and uterus, which can result in decreased fertility. Not only are women who use tobacco less likely to become pregnant, but they are also more likely to experience miscarriage. Tobacco use has been shown to affect the success of implantation and resulting pregnancies during in vitro fertilization (IVF) treatment. 8 Using alcohol, tobacco or illicit drugs during preconception is a strong predictor of prenatal use by childbearing women. Screening for these substances is therefore recommended for women who are at risk of becoming pregnant, planning to become pregnant or are pregnant already. 11 Screening for tobacco use during preconception should also include males, as research confirms that the chemicals in tobacco affect the male reproductive system as well. Male smokers have decreased production of, lower motility of and increased genetic abnormalities in their sperm. 8 It is recommended that everyone of reprductive age should avoid tobacco use and exposure. 20 The 5 A s approach is an effective tool for screening both men and women for tobacco use and linking them to treatment. 4,5 See Chapter 20: Reproductive Years Exposure to one-time brief interventions in public health clinics is sufficient to enhance a client s abstinence for up to 12 months, and to take action toward quitting and motivation and readiness to quit for up to 18 months. 2 Alberta Health Services

222 PRENATAL Although the reported rates of tobacco use during pregnancy are declining in Canada and other industrialized nations, supporting sustained cessation during pregnancy and postpartum remains an ongoing challenge for public health. 12 Alberta s rate of tobacco use during pregnancy is reported as 14.8%, but rates vary widely across the zones. Statistics from the Alberta Perinatal Health Program for 2011 show a high of 22.5% in the North Zone, 21% in the Central Zone, 18.3% in the South Zone, 13.3% in Edmonton and a low of 9.6% in Calgary. 13 These rates are based on self-reported tobacco use, and health professionals should be aware that the non-disclosure of tobacco use during pregnancy is not uncommon. A number of studies have demonstrated that women report they are not smoking even though their biological specimens test positive for tobacco use, suggesting that they are reluctant to disclose their use. 11 The increasing denormalization of tobacco use has created an environment wherein pregnant women who smoke often feel stigmatized, thereby increasing the need for a non-judgmental approach from their health professionals. 12 Tobacco use during pregnancy has known consequences for the general health of the mother, the viability of the pregnancy and the health of the developing fetus. Smoking has been linked to spontaneous abortion, ectopic pregnancy, and complications including placenta previa, placenta abruptio and the preterm rupture of membranes. A fetus that is exposed to tobacco during development is more likely to suffer from intrauterine growth restriction (IUGR), prematurity and be of low birth weight. 11 Prenatal exposure to tobacco has also been linked to health consequences in childhood, including sudden infant death syndrome (SIDS), cognitive impairment, behaviour problems and being overweight. 11,14,15 Although women are highly motivated to stop tobacco use during pregnancy, many are unable to quit or sustain a quit for the duration of their pregnancy. 12 While a focus on pregnant women is justified by the added health risks associated with tobacco use during pregnancy, opportunities to support partners and families could be missed if other public health services are ignored. 16 The impact of continued tobacco use by partners and families on pregnant women is twofold: the potential exposure of second- and third hand smoke to the pregnant mother and developing fetus, and the use around a pregnant woman who has quit tobacco may heighten her risk of relapse. 4,12 Many expectant and new fathers continue to use tobacco, and their reasons are very different than their pregnant partners, often linked to their masculine identity at work and home. 16 It is important to note that a British Columbia study found that few men had considered the impact of their tobacco use on their partner s effort to quit smoking. 16 In Alberta, public health programming for pregnancy often includes the delivery of prenatal education as well as programs for monitoring high-risk pregnancies (typically in larger urban centres). The brief tobacco intervention outlined in Figure 17.2 can be integrated into these services. Health care professionals should advise all pregnant women to stop using tobacco and inform them that there are benefits to stopping at any time during their pregnancy. Partners and family members should also be offered smoking cessation interventions and a smoke-free home should be encouraged to protect mother and baby from exposure to second-hand smoke. 4,5 See Chapter 20: Reproductive Years Relapse rates during pregnancy and the postpartum period 25% before giving birth 50% within 4 months 70% to 90% by one year Tobacco Free Futures

223 POSTNATAL Public health postnatal care for families is provided in homes and clinics across Alberta. Public health professionals who provide early postpartum care, breastfeeding support and well-child clinics are in a unique position to help prevent relapse by linking women and their partners to available support. The opportunity to repeat the brief tobacco intervention multiple times in this all-important first year is key, considering that half of all women who used tobacco may have quit or cut down during their pregnancy. However, relapse rates in this population remain extremely high. 12 Consistent with the findings of relapse among postpartum women, one randomized, controlled trial found that a significant decrease in smoking by male partners during pregnancy was not sustained at 2-, 6- or 12-month follow-ups. 16 Having a partner who smokes is a well-documented risk factor for postpartum relapse. Therefore, it is preferable that addressing tobacco use be directed at both parents whenever possible. It is the mother who is seen most often during postnatal visits, but research suggests that it is best to engage with new fathers directly whenever possible, and thereby relieving women of the responsibility of bringing up their partner s cessation on their own. Women report that efforts to regulate a male partner s smoking can cause a significant amount of tension in a relationship. Canadian studies also suggest that despite a reported heightened interest by new fathers in reducing or quitting tobacco use during pregnancy and postpartum, they were not routinely asked about their tobacco use by health care providers. 16 See Chapter 20: Reproductive Years WELL-CHILD CLINICS Well-child clinics for the target population of 0 to 6 year olds are a core service for public health across the province, with scheduled visits recommended at 2, 4, 6, 12 and 18 months, as well as at 4 6 years. In addition to immunizations, these visits also provide an opportunity for family-centred care, which includes anticipatory guidance related to health promotion and injury prevention. Guidelines from the Canadian Action Network for the Advancement, Dissemination and Adoption of Practiceinformed Tobacco Treatment (CAN-ADAPTT) recommend that health care providers in child health settings counsel parents and guardians about the potential harmful effects of second-hand smoke on their children. 4 Reducing parental tobacco use is a key element in encouraging health and development during early childhood, particularly among those living in difficult social and economic circumstances. 17 Prenatal and postnatal exposure to environmental tobacco smoke has been linked to negative health outcomes for children, including SIDS, ear infections, asthma, respiratory infections, cognitive impairment and behaviour problems. Children who are exposed to household smokers are also more likely to become smokers themselves. 14,18 See Chapter 21: Youth and Family When counselling families about the impact of environmental tobacco smoke, health care professionals should be aware that negative effects of second-hand smoke have become widely known and are accepted amongst the general population. However, effects of thirdhand smoke are not as well understood. A U.S. survey indicated that 95% of non-smokers and 84% of smokers agreed that second-hand smoke is harmful to children, as compared with 65% of non-smokers and 43% of smokers who agreed that third-hand smoke is harmful to children. 19 For more information on second- and third-hand smoke, refer to Chapter 2 ( The Effects of Tobacco Exposure ). Alberta Health Services

224 Implementing the modified pathway recommended in Figure 17.2 as a standard of care during these child-centred visits helps improve the health of all family members. Research has demonstrated that intervening with parents during child-centred care can increase the parents interest in their own cessation, quit attempts and quit rates. 5 Supporting cessation for parents and caregivers not only improves their health, but is also primary prevention for children trying to improve their health outcomes by eliminating their exposure to secondand third-hand smoke. 18,20 Public health professionals are in a position to influence parents/ caregivers who are willing to address tobacco use through repeated and consistent messaging provided during well-child clinic interactions. 3,21 EARLY CHILDHOOD DEVELOPMENT Early intervention services, parenting education and high-risk family visitation programs that focus on the early childhood years create another window of opportunity to address tobacco use and exposure. The information presented under the postnatal and well-child clinics sections is also relevant in the context of these programs. Children who are referred to early childhood development programs often have a number of health challenges, which make them more vulnerable to the effects of tobacco exposure. Multiple programs where families receive services should be equipped to identify, counsel and refer parents and guardians for tobacco treatment. 14 See Chapter 21: Youth and Family SCHOOL HEALTH PROGRAMS Tobacco use patterns for youth typically evolve during the adolescent years and are affected by factors such as access to tobacco, genetic predisposition and social influences. From the first puff they take, youth should be considered at risk for continued tobacco use, which may transition from experimentation to regular or daily smoking. 4 School health programs may offer an opportunity to influence youth tobacco use through prevention or cessation activities. The effectiveness of the 5 A s approach has not been established with this population, but health care professionals who work with youth are encouraged to ASK about use of all tobacco products and ADVISE that they not start or that they stop any current use. The Canadian guidelines for youth also suggest that more research is needed to establish the effectiveness of treatment for this population, but they acknowledged that a number of school-based programs have provided evidence of value. 4 See Chapter 21: Youth and Family DENTAL HEALTH PROGRAMS There are clear links between tobacco use (both smoked and smokeless) and oral health. Those who use tobacco products are more likely to develop cancer of the mouth and throat, gum disease, halitosis, stained teeth and tongues, dulling of the taste buds and delayed healing after dental surgery. Smokeless tobacco users frequently experience the formation of oral leukoplakias (white patches) that may develop into cancerous lesions. 4,22 Studies have shown that dentists and dental hygienists can effectively deliver brief tobacco interventions to clients who use any tobacco products. 5 The Canadian Association of Dental Hygienists advocates for integrating tobacco cessation support into client-centred practice. 23 Public health dental services are often targeted at children, so, like other well-child clinics, they offer a primary prevention opportunity by addressing the child s parent s or caregiver s tobacco use and his or her exposure to environmental tobacco smoke. See Chapter 21: Youth and Family 17.6 Tobacco Free Futures

225 ADULT IMMUNIZATION PROGRAMS Public health also provides access to vaccines for adults through targeted programs such as annual influenza campaigns, adult immunization clinics and travel health services. The fast-flow format of an influenza clinic may not be the most appropriate opportunity for a brief tobacco intervention; this intervention may be more appropriate within the context of a longer immunization appointment or travel health counselling. A tobacco user who is preparing for travel, especially that which involves long flights, may need support in exploring strategies to deal with the nicotine withdrawal that may be experienced during the flight. COMMUNICABLE DISEASE CONTROL PROGRAMS Communicable diseases, particularly those that affect the respiratory system, are negatively impacted by tobacco use. Tuberculosis (TB) research has established a relationship between smoking and/or exposure to second-hand smoke on the disease s process, treatment and recovery. Not only do smokers have a higher risk of infection with TB, but they also have higher rates of disease recurrence and mortality. Smoking during treatment has been shown to decrease effectiveness and slow recovery. 5,24,25 International and Canadian guidelines recommend intervention, and treatment is appropriate for all TB clients who are exposed to tobacco. 5,24,25 CAN-ADAPTT recommends that all tobacco users with TB should be informed of the impact that smoking and second-hand smoke exposure have on the disease and the effectiveness of treatment. 24 Tobacco Free Futures in public health settings At an operational level, public health management will need to decide how to integrate the Tobacco Free Futures initiative as a standard of care. Brief tobacco intervention by a health care provider, including a referral to intensive treatment supports, is an effective option for most of the services and programs included in this portfolio. 2 Evidence suggests that all public health services, including prenatal programs, family planning, well-child clinics and postnatal care, integrate tobacco interventions with provider advice to clients. 1,2 By offering brief tobacco intervention with a nonjudgmental approach, health care professionals will not only screen for tobacco use, but also provide the help and support that clients and their families need. The brief intervention model outlined in Chapter 7 ( Brief Intervention ) has been modified for use in the public health setting and is presented in Figure Table 17.1 then outlines some of the considerations for implementing the model in the public health setting. See appendices: Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) Alberta Health Services

226 Figure 17.2: Tobacco Free Futures: Public Health Brief Intervention Model Tobacco use prevention and cessation treatment ask Ask client or family member/caregiver about tobacco use, personal and/or in the home (e.g., exposure to second- and third-hand smoke (SHS and THS)) at each home or clinic visit. Document as per approved practice. Have you or anyone in your home used any tobacco products in the past year? Have you and/or your child been exposed to SHS or THS? Yes No Positive reinforcement. Advise to quit with personalized message. Advise about the importance of smoke-free environments. Document as per approved practice. Advise Not using tobacco is one of the best things for your health (and the health of everyone in the home, especially your children). There is no safe level of exposure to SHS. Assess Assess readiness to quit. Assess interest in cessation support. Assess interest in making environments tobacco-free. Document as per approved practice. On a scale of 1 to 10, how important is it for you to quit? Are you interested in support to help you quit? Are you interested in support to quit or to make your home and car tobacco-free? No Support autonomy. Leave offer of support open. Document as per approved practice. Yes Assist Assist patient/client and/or family member with self-support materials. Document as per approved practice. Arrange Arrange further support by completing appropriate linked referral(s). Document as per approved practice. Provide ongoing support at next visit Tobacco Free Futures

227 Table 17.1: Treatment Model: Considerations for Public Health Settings Model component Considerations ASK ASK clients/family members if anyone in the household has used tobacco in the past year. Research suggests that asking a pregnant woman about her tobacco use, with a multiple choice question, can improve disclosure (e.g., Which of the following best describes your tobacco use? I don t use tobacco now and didn t before I got pregnant. I use tobacco regularly, and that hasn t changed since I got pregnant. I use tobacco but have cut down since I got pregnant. ). 5,11 Asking parents about their tobacco use in the last year at a child centred visit can give an indication about potential exposure to second- and third-hand smoke (e.g., Has anyone in the home used tobacco products in the last year? ). Asking about tobacco use in the home can be relevant at any visit, but it is especially important when talking to clients (and their family members) who are in preconception and actively trying to conceive, are pregnant or have children in the home. Clients and families who are making repeated visits in a relatively brief period of time (e.g., at well-child clinics) need to be approached in a way that acknowledges that this is a repeat screening (e.g., I noticed that at your last visit you said that no one in the home was using tobacco. Is this still the case? ). Relevant electronic or paper forms used in public health should be modified or created to document the ask. Appendices 7(a), 17(a), 17(b) and 17(c) Alberta Health Services

228 Table 17.1 (continued) Model component Considerations ADVISE ASSESS ADVISE clients/family members of the importance of a tobacco-free home and vehicle. ADVISE current tobacco users to quit. Personalize the message. REQUEST home visit clients refrain from tobacco use prior to and during visit. ASSESS readiness to quit. ASSESS interest in tobacco free homes and vehicles. A tobacco-free home environment should be encouraged so that pregnant women, breastfeeding women and children can avoid exposure to second-hand smoke 4 (e.g., Research shows that there is no safe level of exposure to second-hand smoke for you or your developing baby ). Advise that there is no safe level of exposure to environmental tobacco use and that a tobacco-free environment is in the best interests of the client, as well as anyone else in the home, including pets (e.g., Your child is more vulnerable to the effects of smoke in the air and on the surfaces in your house. Her lungs are developing, she breathes faster and she crawls around, touches surfaces and puts things in her mouth ). Many parents are motivated to quit or create tobacco-free environments for their children. 20 If applicable, inform clients and families of restrictions regarding smoking in vehicles or environments with children present (e.g., bylaws, provincial legislation). Advice to quit should be given in a non-judgmental manner and personalized based on how important it is for the tobacco user to change 4,5 (e.g., It is important for me to advise you that quitting smoking is one of the most important things you can do for your health and to protect your developing baby ). Health professionals should request that clients and household members refrain from tobacco use for two hours prior to and during a scheduled home visit. Approaching tobacco use in the home must be done respectfully, recognizing that health care providers are guests in a client s home (e.g., It is our practice to respectfully ask that household members refrain from smoking for two hours before and during our visits ). Health professionals must acknowledge their potential to expose others to third-hand smoke based on their personal tobacco use/exposure and take steps to protect clients. Electronic or paper forms used in public health should be modified or created to document the advise. Appendices 7(a), 17(a), 17(b) and 17(c) Assessing readiness to quit is appropriate for all clients who self identify as tobacco users. Assessing interest in creating tobacco-free homes and vehicles is appropriate for all clients who use tobacco or disclose others use in the home. The majority of parents who use tobacco agree that exposure to second-hand smoke is detrimental to their child s health, but may not be as aware of the risks of third-hand smoke. 19 Electronic or paper forms used in public health should be modified or created to document the assess. Appendices 7(a), 17(a), 17(b) and 17(c) Tobacco Free Futures

229 Table 17.1 (continued) Model component Considerations ASSIST ARRANGE ASSIST the client/family member who is not ready to quit by supporting his or her autonomy. ASSIST the client/family member who is ready to quit with self-support materials and brief information. ARRANGE further support through referrals to behavioural support. Support clients where they are at in their readiness to change (e.g., I understand that you are not ready to discuss your tobacco use at this time, It sounds like you are ready to start thinking about quitting. I can give you some information that might be helpful in making your decision ). Encourage smoke-free personal spaces for family members if the client is uninterested in quitting at this time (e.g., I understand that you are not interested in quitting at this time, but it sounds like you would like some information on making your home and car smoke free ). Offer information on tobacco-free homes and vehicles. Materials should include information on second- and third-hand smoke. Many parents take action to reduce their family s exposure to second hand smoke, but may not be aware that some of the techniques they are using are not effective (e.g., smoking by an open window, using fans or deionizers). Advocate for a complete ban on smoking in the home and vehicle. 19 Families who live in a multi-unit dwelling where smoking is permitted in individual units may find it difficult to provide a truly smoke-free home. Support families by providing information about harm reduction. Support a person ready to quit by offering self-support materials and referring to for more information. Provide information on pharmacotherapy regarding safety and efficacy (e.g., Medicines to help you stop smoking are safe and effective, and can double your chances of success. I recommend speaking to your doctor or pharmacist about options that might be right for you ). Electronic or paper forms used in public health should be modified or created to document the assist. Appendices 7(a), 17(a), 17(b) and 17(c) Link to ongoing supports such as the AlbertaQuits helpline, preferably by a fax (or electronically, if available) referral that is completed by a health professional (e.g., If you like, I can make a referral to the AlbertaQuits helpline for you. A trained tobacco counsellor will contact you to discuss what supports might be right for you ). Provide further support at the client s next visit. If applicable, arrange referral to a prescribing authority for pharmacotherapy support (e.g., physician, nurse practitioner or pharmacist). Electronic or paper forms used in public health should be modified or created to document the arrange. AHS Health Information Management confirms that fax referral forms are considered transitory records. As long as there is documentation that a referral was sent and confirmation that the referral was received, the paper copy of the fax may be shredded. Appendices 7(a), 17(a), 17(b) and 17(c) Alberta Health Services

230 REFERENCES 1. Manfredi, C., Crittenden, K., Warnecke, R., Engler, J., Cho, Y., & Shaligram, C. (1999). Evaluation of motivational smoking cessation intervention for women in public health clinics. Preventive Medicine, 28, Mandredi, C., Crittenden, K., Cho, Y., & Gao, S. (2004). Long-term effects (up to 18 months) of a smoking cessation program among women smokers in public health clinics. Preventive Medicine, 38, Manfredi, C., Crittenden, K., Cho, Y., Englen, J., & Warnecke, R. (2000). Minimal smoking cessation interventions in prenatal, family planning and well-child public health clinics. American Journal of Public Health, 3(90), Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved from 5. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 6. Garg, A., Butz, A., Dworkin, P., Lewis, R., Thompson R., & Serwint, J. (2007). Improving the management of family psychosocial problems at low-income children s well-child care visits: The WE CARE project. Pediatrics, 120(3), Statistics Canada. (2012). Canadian tobacco use monitoring survey (CTUMS). Retrieved from prevalence/prevalence-eng.php#annual_12 8. Soares, S., & Melo, M. (2008). Cigarette smoking and reproductive function. Current Opinion in Obstetrics and Gynecology, 20, Canadian Cancer Society. (2013). Risk factors for cervical cancer. Retrieved from Health Canada. (2008). The scoop. Retrieved from Floyd, R., Jack, B., Cefelo, R., Atrash, H., Mahoney, J., Herron, A., Husten, C.,et al. (2008). The clinical content of preconception care: Alcohol, tobacco and illicit drug exposures. American Journal of Obstetrics and Gynecology, 199(6), Greaves, L., Poole, N., Okoli, C., Hemsing, N., Qui, A., Bialystok, L., & O Leary, R. (2011). Expecting to quit: A best-practices review of smoking cessation interventions for pregnant and postpartum girls and women (second edition). Vancouver, BC: British Columbia Centre for Excellence for Women s Health. 13. Alberta Perinatal Health Program. (2011). Maternal smoking rates, Alberta by Zone, Edmonton: Author. 14. DiFranza, J., Aligne, A., & Weitzman, M. (2004). Prenatal and postnatal environmental tobacco smoke exposure and children s health. Pediatrics, 113(4), Tobacco Free Futures

231 15. Oken, E., Levitan, E., & Gillman, M. (2008). Maternal smoking during pregnancy and child overweight: A systematic review and meta-analysis. International Journal of Obesity, 32, Bottorff, J., Oliffe, J., Greaves, L., Poole, N., Sarbit, G., & Hemsing, N. (2012). Imagine: Gender-specific tobacco reduction and cessation strategies in pregnancy and the postpartum. In C. Els, D. Kunyk, & P. Selby (Eds.), Disease interrupted: Tobacco reduction and cessation (pp ). Toronto, ON: Createspace Publishing. 17. World Health Organization. (1999). International consultation on environmental tobacco smoke (ETS) and child health. Retrieved from youth/en/ 18. Tanski, S., Klein, J., Winickoff, J., Auinger, P., & Weitzman, M. (2003). Tobacco counseling at well-child and tobacco-influenced illness visits: Opportunities for improvement. Pediatrics, 111(2), Winickoff, J., Friebely, J., Tanski, S., Sherrod, C., Matt, G., Hovell, M., & McMillen, C. (2009). Beliefs about the health effects of thirdhand smoke and home smoking bans. Pediatrics, 123(1), Rosen, L., Noach, M., Winicokoff, J., & Hovell, M. (2012). Parental smoking cessation to protect young children: A systematic review and meta-analysis. Pediatrics, 129(1), Winickoff, J., Park, E., Hipple, B., Berkowitz, A., Vieira, C., Friebely, J., Healey, E., et al. (2008). Clinical effort against secondhand smoke exposure: Development of framework and intervention. Pediatrics, 122(2), Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Oral health and smoking: Key messages for health providers and policy makers. Toronto, ON: Author. Retrieved from Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the role of the dental hygienist: A CDHA postion paper. Retrieved from pdfs/profession/resources/1004_tobacco.pdf 24. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Tuberculosis and smoking: Key messages for healthcare providers and policy makers. Toronto, ON: Author. Retrieved from Sheets2.aspx 25. Schneider, N., & Novotny, T. (2007). Addressing smoking cessation in tuberculosis control. Bulletin of the World Health Organization, 85, Retrieved from Alberta Health Services

232 APPENDICES Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) Tobacco Free Futures

233 Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) (page 1) Assessment Name: PH Brief Intervention Number: Tobacco Intervention Mnemonic: PHZTOBDEP02 Protocol: ZPHTOBACCO Acuity: n/a Move Date: Jan 20/2014 Alberta Health Services

234 Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) (page 2) Tobacco Free Futures

235 Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) (page 3) PROTOCOL PH Brief Tobacco Intervention Protocol Developed: June 2012 Revision: December 2013 ASK - About tobacco use by client or other household members. If YES for client and/or household member CONTINUE WITH INTERVENTION If NO for client and household members INTERVENTION STOPS HERE. Exceptions may be considered in case of recent quits (in last year) as risk of relapse may be very high for clients such as new parents. ADVISE If CLIENT AND/OR HOUSEHOLD MEMBERS DO USE tobacco products: - Advise that there is no safe level of exposure to environmental tobacco use and that a tobacco free environment is in the best interests of the health or everyone in the home. Personalize message as appropriate; example in the best interest of their newborn or children. - As per AHS policy and community laws/bylaws as appropriate - Clinics - advise of AHS Tobacco and Smoke Free Policy for all properties. - Home visits - request that household members refrain from smoking for 2 hours prior and during a scheduled home visit. - If applicable inform of restrictions regarding smoking in vehicles with children present. If CLIENT DOES USE tobacco ALSO; - Give personalized advice to quit using a non-judgmental approach: is most effective when personalized to the individual and their situation e.g. desire to start a family, effect on breastfeeding, relapse in the postpartum period. CONTINUE WITH THE INTERVENTION ASSESS - Readiness to quit: Importance - Interest in support to quit - Interest in support to make home and/or vehicle tobacco free If NO Respect choice and leave offer of support open. INTERVENTION STOPS HERE If YES for either to any of above CONTINUE WITH INTERVENTION ASSIST PHZTOBDEP02 3 Alberta Health Services

236 Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol (2014) (page 4) - Provide Quit Kit as or self help information tailored to client who is ready to quit &/or how to make your home &/or vehicle tobacco free. - Provide basic information on effectiveness of pharmacotherapy and link to prescriber (physician, pharmacist). - Provide information on behavioural counselling and availability in community. - Other (specify) CONTINUE WITH THE INTERVENTION ARRANGE Arrange further support by completing appropriate community linked referral If NO, STOP INTERVENTION If YES, Referral/Information provided &/or fax referral to: - AlbertaQuits( ) - Helpline, Groups - AlbertaQuits.ca - online - Primary Care Network - Other, specify REFERENCES - Tobacco Free Futures Guidelines (available at on Health Provider page) - AHS Tobacco and Smoke Free Environments Policy PHZTOBDEP Tobacco Free Futures

237 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 1) Assessment Name: PH Newborn Intervention Number: Assessment (Birth - 2 Months) Mnemonic: PHZNEWBORN09 Protocol: ZPHNEWBORN Acuity: n/a Move Date: Jan 20/2014 Alberta Health Services

238 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 2) 2 PHZNEWBORN Tobacco Free Futures

239 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 3) 3 PHZNEWBORN09 Alberta Health Services

240 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 4) 4 PHZNEWBORN Tobacco Free Futures

241 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 5) 5 PHZNEWBORN09 Alberta Health Services

242 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 6) 6 PHZNEWBORN Tobacco Free Futures

243 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 7) 7 PHZNEWBORN09 Alberta Health Services

244 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 8) 8 PHZNEWBORN Tobacco Free Futures

245 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 9) 9 PHZNEWBORN09 Alberta Health Services

246 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 10) 10 PHZNEWBORN Tobacco Free Futures

247 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 11) 11 PHZNEWBORN09 Alberta Health Services

248 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 12) PROTOCOL (Tobacco Only) NEWBORN ASSESSMENT PARAMETERS Developed: July 2010 Revision: January 2011, June 2011, December 2011, November 2012, January 2014 May 2013 Aligned with Alberta Health Services Public Health Nursing Maternal/Newborn Practice Manual The Meditech term protocol refers to information that supports documentation using specific assessment screens. Users are responsible to follow the current Alberta Health Services policies, procedures and guidelines or when none available guidance documents for their service area; using clinical judgment based on current evidence-based practice. Support for assessment is available from the Alberta Health Services Public Health Nursing Maternal/Newborn Practice Manual. Only descriptors in the assessment that require definitions or further clarification are included in this document. TOBACCO Exposure to tobacco: Tobacco free environment is in the best interests of the health of everyone in the home especially in the best interest of the children Consider exposure to tobacco in all settings, including other locations where care is provided (grandparents, daycare) and public places There is no safe level of exposure to environmental tobacco - Second Hand Smoke (SHS) and Third Hand Smoke (THS) Chemicals from tobacco smoke pass to baby in mother s breastmilk, thus the baby may be more likely to refuse feedings, be cranky, sleep poorly and spit up. Although nicotine passes through to breastmilk, evidence supports better outcomes for the newborn as the benefits of breastfeeding outweigh the negative impact of nicotine and other contaminants passing through the breastmilk Children breathe faster and have a greater lung surface area to body size/weight than adults, so they absorb more harmful chemicals from second-hand smoke. Children are at higher risk for health concerns related to tobacco exposure SIDS, respiratory infections and asthma Enclosed spaces retain and concentrate the harmful chemicals released when tobacco burns. This makes smoking in vehicles especially dangerous. Make home and vehicle tobacco free and when this is not possible, use tobacco outside away from windows and doors, change or cover clothing and wash hands after smoking Keep tobacco products out of children s reach Tobacco policies/laws AHS policy - as appropriate for clinic visits. This facility, and other AHS facilities, and grounds are tobacco free. Tobacco use is prohibited Home visits Staff exposure to tobacco products can be minimized when household members refrain from smoking for 2 hours prior and during a scheduled home visit. 12 PHZNEWBORN Tobacco Free Futures

249 Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014) (page 13) Provincial laws - Tobacco Reduction Act - Smoking is prohibited in all indoor public places and workplaces in Alberta. The legislation does not currently include restrictions on smoking in private homes, or public recreation areas. In November 2013 the Alberta Government passed Bill 33 which bans smoking in a vehicle containing children and youth under the age of 18. Some community bylaws restrict smoking in outdoor recreation venues. 13 PHZNEWBORN09 Alberta Health Services

250 Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) (page 1) Assessment Name: PH Infant/Preschool Intervention Number: Assessment Mnemonic: PHZINFANTCL06 Protocol: ZPHINFANT Acuity: n/a Move Date: Jan 20/ Tobacco Free Futures

251 Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) (page 2) Alberta Health Services

252 Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) (page 3) Tobacco Free Futures

253 Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014) (page 4) PROTOCOL (Tobacco Only) INFANT/PRESCHOOL ASSESSMENT PARAMETERS Developed: January 2011 Revision: June 2011, January 2014 Meditech uses the term protocol for the information that supports documentation in assessment screens. Users are responsible to follow the current policies, procedures and guidelines for their service area, using clinical judgment based on current evidence-based practice. Only descriptors in the assessment that require definitions or further clarification are included in this document. TOBACCO Exposure to tobacco: tobacco free environment is in the best interests of the health of everyone in the home especially in the best interest of the children Consider exposure to tobacco in all settings, including other locations where care is provided (grandparents, daycare) and public places there is no safe level of exposure to environmental tobacco - Second Hand Smoke (SHS) and Third Hand Smoke (THS) Chemicals from tobacco smoke pass to baby in mother s breastmilk, thus the baby may be more likely to refuse feedings, be cranky, sleep poorly and spit up. Although nicotine passes through to breastmilk, evidence supports better outcomes for the newborn as the benefits of breastfeeding outweigh the negative impact of nicotine and other contaminants passing through the breastmilk Children breathe faster and have a greater lung surface area to body size/weight than adults, so they absorb more harmful chemicals from second-hand smoke. children are at higher risk for health concerns related to tobacco exposure SIDS, respiratory infections and asthma Enclosed spaces retain and concentrate the harmful chemicals released when tobacco burns. This makes smoking in vehicles especially dangerous. Make home and vehicle tobacco free and when this is not possible, use tobacco outside away from windows and doors, change or cover clothing and wash hands after smoking Keep tobacco products out of children s reach Tobacco policies/laws AHS policy - as appropriate for clinic visits This facility, and other AHS facilities, and grounds are tobacco free. Tobacco use is prohibited Home visits Staff exposure to tobacco products can be minimized when household members refrain from smoking for 2 hours prior and during a scheduled home visit. Provincial laws - Tobacco Reduction Act - Smoking is prohibited in all indoor public places and workplaces in Alberta. The legislation does not currently include restrictions on smoking in private homes, or public recreation areas. In November 2013 the Alberta Government passed Bill 33 which bans smoking in a vehicle containing children and youth under the age of 18. Some community bylaws restrict smoking in outdoor recreation venues. Alberta Health Services

254 Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) (page 1) TITLE TobAcco EXpoSuRE INTERIM DEPARTMENT GUIDELINE CENTRAL ZONE APPLICABILITY APPROVED Public Health Nursing - Maternal Child 01 January 2012 APPROVED BY LAST UPDATE Public Health Nursing Management Team 23 January 2014 DEPARTMENT NEXT REVIEW Public Health Nursing 01 February 2017 The electronic copy posted on the PHN Shared Drive is considered the current copy OBJ ECTIVES To enhance Public Health Nurses (PHN) existing knowledge about: Tobacco exposure Current best practice in tobacco reduction Evidence based tobacco reduction resources Risk behaviours and stages of change to promote health behaviour change in clients and families DEFINITIONS brief Tobacco Intervention (BTI) means a short focussed session to screen for tobacco use. Empathetic personalized assistance is provided, focussed on increasing the individual s insight and awareness regarding his/her tobacco use and his/her motivation for change. The BTI does not require in-depth knowledge about smoking cessation. The process is guided by 5 As; Ask, Advise, Assess, Assist, Arrange. (Previous practice addressed all these components within the ask, advise, assist/refer headings.) Mainstream smoke means the smoke that is exhaled by those that smoke. Second-hand smoke (SHS), also called passive smoking, means smoke made up of mainstream and side stream smoke. Side stream smoke means the smoke that comes from the burning end of a cigarette, pipe or cigar and other smoked tobacco products Third-hand smoke (THS) means residual tobacco smoke pollutants that remain on surfaces long after the cigarette or other smoked tobacco product is extinguished. It is deposited on, penetrates and accumulates on all surfaces it comes in contact with each time someone smokes: any surface material such as; hair, skin, fabric, clothing, curtains, car seats, carpet, furniture, toys, furniture, and walls. Tobacco free means there is no tobacco use in the house or car at anytime by anyone; not even in a room with the door closed or the window open; or in an attached garage. A 100% tobacco -free home is one where visitors, family and friends are asked not to smoke any form of tobacco inside. Tobacco free also encompasses no use of any form of smokeless tobacco or electronic smoking products (ESP), like e-cigarettes indoors as recent evidence has shown smokeless tobacco use in enclosed spaces has health consequences for those other than the Tobacco Free Futures

255 Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) (page 2) DEPARTMENT GUIDELINE APPROVED / REVISED DATE PAGE TOBACCO EXPOSURE 23 January of 5 user. More research is needed to evaluate health consequences of second-hand exposure to nicotine, especially among vulnerable populations, including children, pregnant women and people with cardiovascular conditions. BACKGROUND Central Zone presently has the second highest rate of maternal prenatal tobacco use in the province (see APHR Data Sheet) with some community rates as high as 50% prevalence. A substantial proportion of women who quit smoking during pregnancy resume smoking before delivery or postpartum: 25% before delivery, 50% within 4 months, 70-90% by 1 year postpartum. This indicates the importance of addressing tobacco use as often as possible. Public health clinics have the potential for large-scale delivery of effective tobacco interventions. Several studies have established both the short-term and long-term effectiveness of smoking cessation interventions in public health clinics. Current recommendations are that brief tobacco interventions occur in multiple settings (well child visits, postnatal visits) for all household members. Of particular importance, public health clinics are a major source of maternal and child care for lower socioeconomic women and thus present an opportunity for intervention with this at risk population. Client and family centered care honors the strengths, cultures, traditions, and experience that each person brings to the client/family-professional partnership. It acknowledges that a family has control and power to define, analyze and act upon situations Many people will not identify themselves as a person who smokes for various reasons such as they don t buy them but get them from others or they only smoke socially. Identifying caregivers who have quit within the last year provides an opportunity to offer relapse prevention supports. People may have a misunderstanding of the definition of a 100% tobacco-free environment. Some may think smoking near an open window, in a room with the door shut or in an attached garage is keeping their home/vehicle safe from the harmful constituents in tobacco products. Tobacco free also includes avoiding all forms of smokeless tobacco and electronic smoking products indoors. Smokeless tobacco use also can produce a second-hand-like effect. Evidence has shown that median nicotine concentrations for residences with smokeless tobacco users were significantly greater than median nicotine concentrations for tobacco-free homes and similar to median nicotine concentrations in homes of those where active smoking occurs. Electronic smoking products like e-cigarettes, are designed to generate inhalable nicotine aerosol (vapour). When an e-cigarette user takes a puff, the nicotine solution is heated and the vapour is taken into the lungs. Although no sidestream vapour is generated between puffs, some of the mainstream vapour is exhaled by the e-cigarette user. Evidence shows that ESPs are a source of second-hand exposure to nicotine. Background information relevant for professional practice is found in Appendix I Tobacco Use and Exposure Facts for Professionals. Three types of tobacco cessation supports are provided by Alberta Quits: Helpline ( Quit) - A free smoking cessation help-line available from 8am to 8pm, seven days a week for all residents of Alberta. Trained counselors will develop a quit plan, deal with cravings and provide ongoing support. Helpline counselors will call only three times to a client before giving up on the contact. Alberta Health Services

256 Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) (page 3) DEPARTMENT GUIDELINE APPROVED / REVISED DATE PAGE TOBACCO EXPOSURE 23 January of 5 Online - Around the clock internet-based quit smoking service, available free of charge for all Albertans. Expert advice, online peer support, quitting strategies, reminders and more can be accessed by any computer by providing an Alberta postal code. Alberta Quits Groups (QuitCore) Register online for a Quit Core group cessation program in your area facilitated by professionally trained leaders and attended by people looking for peer support, encouragement and advice to help them quit tobacco. Availability of this program varies by community and may not be regularly available in smaller centers. PROCEDURE 1.1. Routinely plan to offer brief tobacco interventions (BTI) at the initial home visit after the birth of the newborn and the 6 month well child clinic visit Brief tobacco interventions may be offered at any point of contact as appropriate. Reference Tobacco Use and Exposure Facts for Professionals (Appendix I) Use the Tobacco Free Futures: Public Health Brief Intervention Model Flow Chart (Appendix II). It is a 5 step approach for brief tobacco interventions, messaging, support and referrals. It only takes a few minutes and does not require in depth knowledge about smoking cessation Reference Brief Tobacco Intervention Sample Scripting (Appendix III) to facilitate discussion with clients, as needed The 5A approach includes: ASK about tobacco use Carefully, respectfully and non-judgementally approach clients about tobacco use and/or exposure to tobacco for themselves or any household contacts. o o o o o Do you or any of your child s caregivers currently use or have used any tobacco products in the past year? Separately scheduled time may be required for client or partner counselling or support. Reference Brief Tobacco Intervention Sample Scripting (Appendix III) for additional scripting options. If currently using tobacco products, ask about pattern of use. please describe what restrictions you have in your home/vehicle? If the client or other family/caregivers/household members residing with the client DO NOT USE tobacco products and there is no indication of exposure to tobacco products from caregivers outside the residence, STOP HERE. (See Brief Tobacco Intervention Sample Scripting Appendix III) Tobacco Free Futures

257 Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) (page 4) DEPARTMENT GUIDELINE APPROVED / REVISED DATE PAGE TOBACCO EXPOSURE 23 January of 5 o o If exposure to tobacco products from caregivers outside the residence is identified, offer second and/or third-hand smoke messages appropriate to situation for information and/or support. If tobacco use by the client or other family/caregivers/household members residing with the client is identified continue to ADVISE ADVISE provide client-centered advice that is personalized and nonjudgmental to the individual and their situation. o o o o Inform client that all AHS facilities and grounds are tobacco-free. Recommend tobacco users quit by providing messages relevant to the client. Reference Brief Tobacco Intervention Sample Scripting (Appendix III) as needed. Describe a tobacco free environment and strategies to achieve this. Clients who live in multi-unit dwellings may find it difficult to make their homes truly tobacco free because of lack of legislation and are therefore, involuntarily exposed to SHS or THS. i) Offer pamphlet Second Hand Smoke and Multi-Unit Dwellings. ASSESS all tobacco users readiness to quit or reduce tobacco use and interest in cessation support. Assess client s interested in support to: o o Quit or reduce using tobacco products Make home and/or vehicle smoke /tobacco free Client answers yes to either of the above questions: Continue to ASSIST. Client answers no: Support their autonomy Offer resources for future support Reference Brief Tobacco Intervention Sample Scripting (Appendix III) as needed. Offer harm reduction strategies to reduce SHS or THS exposure. i.e. only smoke outside away from doors and windows, wear a jacket or other covering over clothing that can be removed before coming back into the house. Wash hands, face before handling baby. Alberta Health Services

258 Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone) (page 5) DEPARTMENT GUIDELINE APPROVED / REVISED DATE PAGE TOBACCO EXPOSURE 23 January of 5 ASSIST client by discussing available cessation supports such as pharmacotherapy and behavioural support options ARRANGE ongoing support for the client o o o Client has access to internet for referral: Ask permission to provide referral to Alberta Quits website; This site enables clients to access the Helpline for telephone support, electronic cessation supports like text messaging tips and to sign up for group cessation support in their area. Client has no access to internet for referral: Ask permission to complete a fax referral to the Alberta Quits Helpline. The Helpline provides assistance and support for people who are ready to quit. Counsellors are trained to assess an individual s level of addiction to nicotine, and assist him/her to tailor an individualized quit plan and link him/her with available community supports. Client consents to referral ii) iii) iv) Offer Alberta Quits pamphlet, or Alberta Quits fridge magnet For those without internet access, complete the Alberta Quits Help Line fax referral form (Alberta Health Services Insite ->Employee Tools -> Forms Library -> List of Forms -> Alberta Quits Helpline Referral). Fax the completed form to the Alberta Quits Help Line o Client declines referral v) Suggest accessing contacting a health care provider or Health Link when ready. o Ask permission to provide handout materials and information found on the PHN Client Resource Master list. DocuMENTATIoN Document assessment findings, anticipatory guidance and referrals according to Meditech protocol. APPENDICES Appendix I Tobacco Use and Exposure Facts for Professionals Appendix II Tobacco Free Futures: Public Health Brief Intervention Model Flow Chart Appendix III Brief Tobacco Intervention Sample Scripting Tobacco Free Futures

259 Chapter 18 Transition and Continuing Care Alberta Health Services

260 IMPLEMENTATION OF TOBACCO FREE FUTURES IN TRANSITION AND CONTINUING CARE Continuing care refers to an integrated range of services supporting the health and well being of individuals living in their own homes, or in supportive living or long-term care settings. Continuing care clients are not defined by age, diagnosis or the length of time they may require service, but by their need for care. They may be young adults with acquired brain injuries, adults with developmental disabilities or seniors. This section of the guidelines will focus on how health care providers can support tobacco dependent patients/clients who are in acute care, are receiving transition care and are awaiting transfer to alternate care settings reside in designated supportive living settings reside in long-term care facilities In 2008, the Alberta Government published the Continuing Care Strategy: Aging in the Right Place. This five-year strategy reported 14,500 seniors and persons with chronic illnesses or disabilities living in long-term care facilities. It also acknowledged that, due to the shortfall in available space, there were many more patients occupying hospital beds who did not need acute services but, due to advancing age and/or complex medical and psycho-behavioural issues, were unable to be discharged. 1 AHS is committed to supporting the Continuing Care Strategy with the right level of services provided in the right settings. AHS increased capacity within the system by adding 3,000 new continuing care spaces by Further capacity will be required to deal with the increasing and aging population of Alberta. It is anticipated that by 2031, one in five Albertans will be a senior. 2 AHS Transition Care/Coordinated Access Services provides the link between acute care services and those available in the community across the spectrum of continuing care. These services vary somewhat throughout the province; however, they all ensure an assessment of patients and clients in their current settings and facilitate the placement or transfer from one level of care to another in an efficient and timely manner. These services are normally undertaken in collaboration with an expanded health care team and the client/patient s family. 2 In some acute care hospitals, transition care units or beds have been added in order to free up acute care beds, reducing wait times for treatment and surgery. Transition units provide a stop gap for clients who are awaiting placement in a continuing care setting that is more appropriate for their care needs. Clients who use tobacco products are finding it increasingly difficult to find a continuing care living option where they can continue to use tobacco products. Their situations are often complicated by cognitive problems and associated behaviours. This creates delays in moving to the right setting for those individuals who are unwilling or unable to stop their tobacco use Tobacco Free Futures

261 Prevalence of tobacco use Among seniors, the mortality rate of current smokers is double that of those who have never smoked. Eight of the top 14 causes of death among seniors have been linked to smoking and 50% of all long-term smokers die of tobacco-related illnesses. The majority of seniors who currently smoke have been smokers for most of their lives, having had their first cigarette by age 20. These seniors are often less accepting of the health risks associated with smoking and may actually see smoking as a positive coping mechanism. 3 Individuals with intellectual or developmental disabilities are not immune to tobacco use and dependence. Existing data is limited, but it clearly indicates that these individuals also smoke cigarettes and are more likely to do so if they are higher functioning, live in less restrictive environments, are male or have concurrent substance use disorders. 4 In 2010, 9% of Canadians 65 years and over were current smokers. Smoking was more prevalent amongst Aboriginal seniors, with 22% for First Nations seniors, 24% for Metis seniors and 36% for Inuit seniors. 3 Canadian tobacco use statistics from 2012 identify 16.1% of people 15 years and over as current smokers. The prevalence was highest amongst young adults, with 21.8% for year olds and 20.3% for year olds. Adults 55 years and over had the second-lowest prevalence rate, at 12.2%. More males than females were current smokers, at 18.4% and 13.9%, respectively, continuing a downward trend for both genders. 5 In Alberta, 17.4% of people 15 years and over were current smokers in The prevalence was, again, highest amongst young adults, at 24.5% for year olds, followed by 18% for adults 45 years and over. More females than males were current smokers, at 17.7% and 17.1%, respectively. This represents an increase for females and a decrease for males compared to Alberta has been home to 40% of national smokeless tobacco sales (e.g., snuff, chew) for more than 10 years. Smokeless tobacco use is most prevalent in males, with 9% aged years and 2% 30 years and older reporting using snuff or chew in the past month, as of In Alberta, the highest prevalence of smokeless tobacco users tends to be found in the oil and gas and agricultural industries, especially the rodeo. A 2012 survey of 510 participants at two Alberta rodeos found that 27% of males and 1% of females used smokeless tobacco products, compared to 2% in general population of Western Canada. One half of Canadians who have tried smokeless tobacco products live in the western provinces, even though this region is home to less than one third of the Canadian population. 6 Smokeless tobacco products contain high levels of nicotine and are linked to cancers of the mouth and digestive tract, cardiovascular disease and dental decay. Alberta Health Services

262 Integration of tobacco-free environments in continuing care The provincial Tobacco Reduction Act (TRA) prohibits smoking in public places, which includes group living facilities such as supportive living and long-term care facilities. An exemption clause allows operators to permit smoking by residents as long as they provide designated smoking rooms that have separate ventilation systems that conform to the regulations. Alberta Health Services s Tobacco and Smoke Free Environments Policy exceeds the restrictions outlined in the TRA, and since all designated continuing care spaces in the province operate under the auspices of AHS, they fall under the scope of this policy. Many private continuing care providers have also made the decision to implement tobacco free policies voluntarily, for a variety of reasons. See Chapter 5: Policy The physical and cognitive challenges make nursing home residents 2 3 times more likely to be burned by cigarettes. 7 There is a trend across Canada towards care facilities being smoke free, including the elimination of designated indoor smoking areas. The dilemma, however, is that not every person who is awaiting placement for or living in continuing care settings is ready or interested in quitting, and when the only available alternative is a smoke-free facility, there may be resistance from clients or their families. For continuing care sites in the process of becoming tobacco free, management, staff, residents and families will often continue debating the merits of such policies. One frequently cited argument is that these facilities are also residents homes and a person should be free to make personal choices within his or her home. There may also be concern about making residents who are smokers feel stigmatized, controlled and as though one of their few remaining pleasures is being taken away. Although some may concede health benefits at any age, there is also an attitude that their life expectancy is minimal anyway, and even if a resident stops smoking, there may not be a significant benefit, especially when compared to the perceived difficulty of quitting. Staff and family often express concern for client/resident safety when they are required to go outside to use tobacco, potentially exposing them to hazards such as inclement weather. There are also concerns about the risks related to fire safety if residents attempt to hide their smoking habits while in a smoke-free facility. 8 Some advocate that, at a minimum, designated outdoor smoking areas should be available for residents. However, a 2004 study of one geropsychiatric nursing home found that the creation of an outdoor designated smoking area was counterproductive. In this environment, residents who were classified as safe smokers were allowed to use the outdoor area, while those identified as unsafe smokers had enforced cessation that was supported with behavioural and pharmacotherapy interventions. As a result, staff found that ongoing triggers by those using tobacco caused the unsafe smokers to experience increased agitation and also led to altercations with safe smokers, resulting in the facility choosing to become completely tobacco free Tobacco Free Futures

263 The purpose of making multi-unit dwellings and health care environments (including continuing care settings) smoke and tobacco free is not to force people to quit. Rather, it is to protect everyone in those environments from the hazards of secondand third-hand smoke. As per the requirements of the TRA, many facilities have dealt with this issue by providing special ventilated smoking areas. While this has been a strategy in the past, current research has found that the only way to protect non-smokers from exposure to second-hand smoke is to remove all smoking from indoor environments. The American Society of Heating and Air-Conditioning Engineers (ASHRAE) The evidence is clear that there is no safe level of exposure to second-hand smoke and therefore all staff, clients/residents and the public have a right to be protected. 11 has stated that because there is no acceptable level of exposure to the chemicals found in cigarette smoke, there is no acceptable ventilation standard for second-hand smoke. 12,13 There are several well-founded safety concerns related to tobacco use and residents in continuing care. Smoking poses an obvious and documented fire safety threat for all residents of group living facilities. In Canada and the United States, smoking materials are the leading cause of death in residential fires. 14 Those over age 65 are twice as likely to die in home-related fires than the average person, and that risk increases with age: those 75 and older are three times more likely, and 85 and older are 3.5 times more likely. 15 Smoking materials account for 72% of fire-related deaths and 43% of fire-related injuries in long-term care facilities. The acuity of care for residents in long-term settings will only increase as more complex care is moved out of hospitals and less complex care remains in the home. Increased acuity will result in increased smoking risks. Facilities that allow resident smoking can have additional costs, such as increased insurance premiums, as well as additional cleaning, staff supervision and supplies related to tobacco use (e.g., smoking aprons). In some cases, additional human resources are needed to supervise smokers, taking staff away from other nursing duties. The Tobacco and Smoke Free Environments Policy stipulates that AHS employees and other persons acting on behalf of AHS shall not facilitate patient/client use of tobacco products. 16,17 See Chapter 5: Policy Supporting clients with brain injury and concurrent disorders Within the continuing care population are those people living with acquired brain injuries and concurrent disorders. These people are cited as the most difficult to assist in finding a continuing care living option. There is limited research on these types of patients/residents related to tobacco reduction and institutionalization. Most head injuries occur in males years of age, and result from motor vehicle collisions and alcohol use. Some patients may also already have a mental illness or substance use disorder. It is difficult to distinguish between symptoms related to mental health, substance use and brain injuries, as many of them overlap (e.g., memory problems, emotional outbursts, difficulty initiating tasks). Health professionals typically treat these problems separately, which can create other difficulties, as the cause of specific behaviours may not be correctly identified. Treatment can therefore take up to three times longer, with the patient/resident going through cycles of getting better and slipping back again. 10 Alberta Health Services

264 Table 18.1 outlines some of the general treatment considerations for those with acquired brain injuries and concurrent disorders. Further detail regarding tobacco treatment for clients with mental illness and addiction, including a section on Alzheimer s disease and dementia, can be found in chapter 19 ( Addictions and Mental Health ). Table 18.1: Treating Acquired Brain Injuries and Concurrent Disorders 10 Symptoms brain injury and mental illness may have in common: Symptoms brain injury and substance abuse may have in common: Acquired brain injury (ABI) workers should: Addiction workers should: memory problems unpredictable behaviour being very emotional concrete thinking seemingly low motivation impaired capacity for insight substance abuse social isolation failing to acknowledge having a problem short-term memory loss impaired thinking difficulty with balance/coordination impulsivity mood disturbances (diminished emotional control) personality changes diminished judgment fatigue depression sleep problems decreased frustration tolerance educate ABI clients/family about risks of using substances involve family/social networks in supporting client to address issue take specific history of client s past and current substance use ask what effect substance use is having on client s life (e.g., social life, family, job, legal) assess stressors/risk factors that might cause client to begin using (e.g., isolation, boredom, depression, job loss) help clients find meaningful, substance-free activities establish ongoing contact with addiction professionals to exchange information and ensure client gets appropriate treatment screen for acquired brain injury (ABI): ask about crashes, blows to the head, falls, fights, periods of unconsciousness and hospitalization adapt substance abuse treatment for people with ABI: slow down and use simple language provide extra time for clients to complete tasks repeat information and use short, simple phrasing encourage client to take notes anticipate off- topic remarks keep instructions brief and clear encourage feedback (ask Do you understand? ) give rest periods reduce distractions consult with ABI specialists to tailor treatment to client s learning style remain in contact to monitor progress and make changes, as needed 18.6 Tobacco Free Futures

265 Tobacco Free Futures in transition and continuing care Everyone who uses tobacco products benefits from quitting, no matter their age. Those benefits include improved health, increased quality of life, greater satisfaction with leisure activities and social relationships, more money in their pockets and better access to housing. Even someone who does not quit smoking until age 60 can increase their life expectancy by three years, compared to those who continue to smoke. 3 A study from the United States found that quitting smoking at 65 years of age leads to an increased life expectancy of years for males and years for females. Older smokers who try to quit are more likely to seek assistance and more likely to be successful in their efforts. 18 Cessation rates in older women are shown to increase with brief interventions by a physician or health professional, receiving the correct information and thinking quitting is not difficult, especially when they smoke fewer than 10 cigarettes per day. 19 Health professionals working in home care, transition and continuing care settings have an important opportunity to identify tobacco use and provide advice and supportive care to their patients/clients. It is important to have family support for patients/residents as they become tobacco free. Family members need to be involved in the initial discussions so they understand the policy, the benefits to the patient/resident and what supports are available (e.g., nicotine replacement therapy, educational materials, cessation counselling). The AHS Vascular Risk Reduction Project (2014) advocates consideration of tobacco use as a vital sign in every patient contact. Continuity of care planning is essential as a client transfers from one setting to another. It is also key to maintain communication between the care teams, the patient/resident and the family members. The brief intervention model outlined in chapter 7 ( Brief Intervention ) was modified for the home care setting in chapter 16 ( Home Care). In this chapter it has been modified once again in Figure 18.1 for clients in transition or continuing care. Table 18.3 outlines potential considerations for implementation of the model in transition and continuing care settings. More intensive support, as outlined in chapter 8 ( Intensive Cessation Counselling ) may be required to assist those who are interested in cessation. Zone coordinators with the Tobacco Reduction Program are available to support transition and continuing care settings as they implement the Tobacco Free Futures guidelines in settings managed both by AHS and its contracted partners. See Chapters 16: Home Care and 19: Addictions and Mental Health Alberta Health Services

266 Figure 18.1: Tobacco Free Futures: Transition and Continuing Care Intervention Model Tobacco use prevention and treatment. ask Identify tobacco use status of every client/patient needing facility or supportive living services. Document on patient/client chart. Has patient/client used any tobacco products in the past year? Yes No Positive reinforcement. Inform patient and family of Tobacco and Smoke Free Environments and facility living/supportive living availability. What type? How much? How often? Last use? Advise Inform patient/client and family/guardian of Tobacco and Smoke Free Environments Policy and facility living/supportive living availability. Advise of importance to quit with personalized message. Document on patient/client chart. Assess Assess for cognitive impairment (e.g., dementia/delirium). No cognitive impairment identified: Assess patient/client interest in pharmacotherapy support for withdrawal. Assess patient/ client readiness to quit. Cognitive impairment identified: Assess family/guardian interest in pharmacotherapy support for patient/client withdrawal. Assess family/guardian readiness for patient/client to quit. Document on patient/client chart. Is patient/client and/or family/guardian interested in support to reduce patient/client withdrawal symptoms or help to quit? Yes No Support autonomy. Inform the patient/client and family/guardian of limited care options. Leave offer of support open and monitor withdrawal. Assist Assist with pharmacotherapy for withdrawal including ordering, patient and family/guardian education, ongoing monitoring of withdrawal symptoms and mood assessment. Assist with onsite behavioural support and/or modification of environmental factors including ongoing follow-up. Document on patient/client chart. Arrange Arrange further support by including treatment plan in transfer orders to supportive living/facility living site. Arrange for continued pharmacotherapy by listing cessation medications on medication profile and transfer orders. Document on patient/client chart Tobacco Free Futures

267 Pharmacotherapy should be considered to mitigate the nicotine withdrawal symptoms of all patients/residents, especially in settings that restrict or prohibit tobacco use. 21,22 All patients/ clients in acute care who are awaiting placement should be given access to a safe and comfortable detoxification from tobacco, as is done with other addicting substances, to prevent the emergence of nicotine withdrawal symptoms. 23 See Chapter 9: Pharmacotherapy Individuals living in community or supportive living settings may be eligible for coverage of nicotine replacement therapy and/or cessation medications through the Alberta Health Supplementary Health Benefit Program or the Alberta Human Services Drug Benefit Supplement. Table 18.2 summarizes present coverage, which is subject to change. Refer to for up-to-date information. Alberta Health Services

268 Table 18.2: Alberta Drug Benefit Cessation Medication Coverage Eligibility MEDICATION APPLIES TO CLIENTS OF COVERAGE CRITERIA Nicotine replacement therapy (NRT) mouth spray inhaler patch gum lozenge Varenicline tartrate (Champix ) Bupropion SR (Zyban ) Alberta Health/Alberta Blue Cross Child and Family Services Alberta Child Health Benefit Children and Youth Services Income Support Learners Program Alberta Human Services (AISH) Alberta Adult Health Benefit First Nations and Inuit Health Branch non-insured health benefits Alberta Health/Alberta Blue Cross Non-group coverage Coverage for seniors Alberta Widow s Pension Plan Palliative Care Drug Coverage Alberta Child Health Benefit Income Support Learners Program Alberta Human Services (AISH) Alberta Adult Health Benefit First Nations and Inuit Health Branch non-insured health benefits Alberta Health/Alberta Blue Cross Child and Family Services Alberta Child Health Benefit Children and Youth Services Income Support Learners Program Alberta Human Services (AISH) Alberta Adult Health Benefit First Nations and Inuit Health Branch non-insured health benefits Restricted benefit Coverage is limited to a lifetime maximum of $500 per participant for all over-the-counter smoking cessation products listed in the Alberta Human Services Drug Benefit Supplement Does not include lozenges Quantity limited for each product for one year from when first prescription was filled: 945 pieces for gum, inhaler and lozenges patches, depending on type Mouth spray not included Restricted benefit This product is a benefit for patients 18 years of age and older for smoking cessation treatment in conjunction with smoking cessation counselling Coverage will be granted for a total of 12 weeks Special authorization coverage may be granted for a maximum of 24 weeks of therapy per year Quantity limited to 165 tablets for one year from when first prescription filled Regular benefit Quantity limited to 180 tablets for one year from when first prescription filled Note: Benefit criteria are subject to change. Refer to Alberta Health and Health Canada for up-to-date information. Sources: Alberta Drug Benefit List (2014): Health Canada Drug Benefit List (2013): Tobacco Free Futures

269 Table 18.3: Treatment Model: Considerations for Transition and Continuing Care Settings Model component Considerations ASK ADVISE ASSESS ASK all clients if they have used tobacco in the past year. ASK about patterns of use. ASK about exposure to second-hand smoke (SHS). ADVISE current tobacco users to stop using tobacco. Personalize message. ADVISE client and household members that there is no safe level of exposure to SHS. ADVISE of policy, as applicable. ASSESS readiness to quit. ASSESS interest in support for relief of withdrawal. All tobacco users should be identified during assessment, preferably before or, at a minimum, during admission to transition care units or continuing care facilities. Electronic or paper-based forms used in the care setting should be modified as necessary to document tobacco use status. Status should be communicated with transfer information. All patients/clients/residents and their families must be advised of the tobacco policy of the current facility and the facility they will be placed in for the long term. Engagement of the family is critical from the outset. Clients and family should be informed of the impact of their tobacco use status on placement within continuing care facilities. Family, clients and volunteers must be informed of the policy that staff cannot facilitate smoking behaviour (e.g., purchasing or lighting tobacco, supervising). All clients and families should be informed that there are health benefits to quitting tobacco at any age. Advice must be communicated in a non-judgmental manner and tailored to each individual. Electronic or paper-based forms used in the care setting should be modified as necessary to document what has been advised. Assessing readiness to quit is appropriate for all clients who use tobacco. Assess interest in withdrawal relief through pharmacotherapy for those who are interested in quitting or reducing their tobacco use. Whenever possible, assessment should be performed by a tobacco specialist. Assessment of patient s interest in quitting and/or interest in receiving support for withdrawal symptoms may take several visits to complete. It is important for the care provider to establish a relationship with the patient. For patients who don t initially appear to be ready to make a change, the offer of support should be left open. It is still important, however, to monitor for signs of withdrawal and of changes in interest in receiving treatment. A follow-up assessment should be arranged for no more than three months after the initial assessment has been completed. Electronic or paper-based forms used in the care setting should be modified as necessary to document the assessment. Alberta Health Services

270 Table 18.3 (continued) Model component Considerations ASSIST ARRANGE ASSIST the patient who is not interested in support with brief information. ASSIST the patient who is interested with link to prescriber pharmacotherapy support and/or behavioural support. ARRANGE follow-up and link to further behavioural support. It is recommended that the care team hold an initial meeting to frame the approach for each patient within the first week of that patient being admitted to the unit or facility. A multidisciplinary health care team approach, involving physicians, nurses, recreational therapists, protection services and tobacco cessation specialists is recommended. For extra ongoing support, it is recommended that a tobacco specialist, either onsite or from the community, provide the one-on-one support that the patient might need. The tobacco specialist can coordinate the patient assessment document the patient s tobacco use history and assessments according to site standards coordinate involvement of the family, nursing and other professionals and resources, as needed provide tobacco behavioural counselling and support provide pharmacotherapy assessment, support and proper use teaching Communication between the transition and continuing care staff will facilitate continuity of care for clients who have been receiving treatment before transfer. Consider building this into referral process. Depending on the patient/client s cognitive capabilities, there may be a need to focus on the environmental factors that contribute to the addictive behaviour. Longer treatment times may be needed to establish trust and rapport with the patient. Pharmacotherapy is recommended for all clients who are interested, except in the case of direct contraindications. Clients with conditions such as oral cancers may be unable to use short-acting NRT products (e.g., gum, spray, inhaler, lozenge), so products such as the patch, bupropion or varenicline may be appropriate. Electronic or paper-based forms used in the care setting should be modified as necessary to document the assistance. Ongoing tobacco dependence support is essential for a patient/client who is transferred to an alternate level of care Tobacco Free Futures

271 References 1. Alberta Health. (2008). Continuing care strategy: Aging in the right place. Edmonton, AB: Author. 2. Alberta Health Services. (n.d.). Seniors health. Retrieved from albertahealthservices.ca/2321.asp 3. Butler-Jones, D. (2010). The chief public health officer s report on the state of public health in Canada. Ottawa, ON: Public Health Agency of Canada. Retrieved from Steinberg, M. L., Heimlich, L., & Williams, J. M. (2009). Tobacco use among individuals with intellectual or developmental disabilities: A brief review. Intellectual and Developmental Disabilities, 47(3), PROPEL Centre for Population Health Impact. (2014). Tobacco use in Canada: Patterns and trends. Waterloo, ON: University of Waterloo. Retrieved from tobaccoreport.ca/2014/tobaccouseincanada_2014.pdf 6. Physicians for a Smoke-Free Canada. (2011). Smokeless tobacco: Key findings from CTUMS 2007 and the Canadian Community Health Survey (CCHS), Ottawa, ON: Author. Retrieved from 7. Watt, C. A., Corosella, A. M., Podgorski, C., & Ossip-Klein, D. J. (2004). Attitudes toward giving smoking cessation advice among nursing staff at a long-term care facility. Psychology of Addictive Behaviors, 18(1), Dykeman, M. J. (n.d.). Smoking and long-term care homes. Toronto, ON: Canadian Bar Association. Retrieved from 9. Hartz, G., & Kuhlman, G. (2004). Smoking cessation for geropsychiatic patients in longterm care. Psychiatric Services, 55(4), McGlynn, C. (2005). The triple whammy of acquired brain injury and concurrent disorders. Crosscurrents, 9(1). Retrieved from crosscurrents/acquired_brain_injury_and_concurrent_disorders.html 11. Els, C., Kunyk, D., & Selby, P. (2012). Disease interrupted: Tobacco reduction and cessation. Edmonton, AB: CreateSpace Independent Publishing. 12. American Society of Heating and Air-conditioning Engineers. (1999). Ventilation for indoor air quality standard 62. Atlanta, GA: Author. 13. Physicians for a Smoke-free Canada. (2001). Ventilation of second-hand smoke. Ottawa, ON: Author. Retrieved from Wijayasinghe, M. (2007). Fire losses in Canada: Year 2007 and selected years. Edmonton, AB: Office of the Fire Commissioner, Alberta Municipal Affairs. 15. Karter, Jr., M. J. (2008). Fire loss in the United States, Quincy, MA: Fire Analysis and Research Division, National Fire Protection Association. Retrieved from net/firereports/2007firelossus.pdf Alberta Health Services

272 16. Alberta Health Services. (n.d.). Tobacco and Smoke Free Environments Policy. Retrieved from Alberta Health Services. (2011). AHS Tobacco and Smoke Free Environments Policy: Special considerations protocol. Retrieved from tms-trp-tsfe-policy-special-considerations-protocol.pdf 18. Legacy for Health. (2009). Older adults and smoking. Retrieved from Donze, J., Ruffieux, C., & Cornuz, J. (2007). Determinants of smoking and cessation in older women. Age and Aging, 36, Smith, P., Reilly, K., Miller, N., DeBusk, R., & Taylor, C. (2002). Application of a nursemanaged inpatient smoking cessation program. Nicotine and Tobacco Research, 4, Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 22. Canadian Action Network for the Advancement, Dissemination and Adoption of Practiceinformed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation and clinical practice guideline (version 2). Toronto, ON: Centre for Addiction and Mental Health. Retrieved from Williams, J. (2008). Eliminating tobacco use in mental health facilities: Patients rights, public health, and policy issues. Journal of the American Medical Association, 299, Tobacco Free Futures

273 Specific Populations 19. Addiction and Mental Health 20. Reproductive Years 21. Youth and Family AlbertaQuits.ca

274 Implementation of Tobacco Free Futures Within Specific Populations Although much progress has been made with the reduction of tobacco use and exposure in the general population, there are still disparities within specific populations. The following chapters will provide an overview of the literature and considerations for treatment when dealing with specific populations. Chapter 19: Addictions and Mental Health The prevalence of tobacco use in persons with addiction and mental health conditions. The importance of addressing tobacco use and exposure in addiction and mental health settings. CAN-ADAPTT guidelines for treating persons with addictions and mental health concerns. The effectiveness of behavioural support and pharmacotherapy in tobacco treatment for those with concurrent mental health and addictions conditions. The impact of tobacco use on persons with specific mental health diagnoses (e.g., schizophrenia) and associated considerations for treatment. Chapter 20: Reproductive Years Importance of an approach to tobacco treatment for women and adolescent girls during the reproductive years that is woman centred, reduces stigma, includes harm reduction and is trauma informed. The prevalence and impact of tobacco use for women and adolescent girls (who are not pregnant or postpartum) during the reproductive years. The prevalence of use and impact of tobacco use on women and adolescent girls (who are pregnant and postpartum) and their babies. CAN-ADAPTT guidelines for treating pregnant and breastfeeding women. Recommendations and treatment considerations for women and adolescent girls (who are not pregnant or postpartum) during the reproductive years including brief tobacco intervention, intensive treatment and pharmacotherapy. Care pathway, summary recommendations and treatment considerations for women (who are pregnant or postpartum) including brief tobacco intervention, intensive treatment and pharmacotherapy. Summary recommendations and treatment considerations for adolescent girls (who are pregnant or postpartum) including brief tobacco intervention, intensive treatment and pharmacotherapy. Chapter 21: Youth and Family Under development

275 Chapter 19 Addiction and Mental Health Alberta Health Services

276 Introduction Prevalence of tobacco use in addictions and mental health Although smoking prevalence in the general population has decreased, there are many individuals who have not been able to quit. Two important groups are those with psychiatric disorders and those with substance use disorders. According to data from the United States, rates of smoking are 2 to 4 times higher among people with psychiatric disorders and substance use disorders. 1 In fact, tobacco users with psychiatric disorders consume nearly half of all the cigarettes consumed in the United States. 2,3 Figure 19.1: Prevalence of Current Smokers With Psychiatric and Substance Use Disorders Note: SZ = schizophrenia, BPD = bipolar disorder, MDD = major depressive disorder, PD = panic disorder, OCD = obsessive-compulsive disorder, PTSD = post-traumatic stress disorder Multiple explanations have been offered for the high rate of smoking among people with addictions and mental illness, including genetic factors, the physical effects of nicotine, selfmedication, limited education, poverty, unemployment, peers and the mental health treatment system, wherein tobacco use is generally tolerated and not seen as a health issue. 1,2 A recent study found evidence in internal tobacco industry documents that the tobacco industry monitored or directly funded research supporting the idea that individuals with schizophrenia were less susceptible to the harms of tobacco and needed tobacco as self-medication. 4 These documents also revealed that the industry has promoted smoking in psychiatric settings by providing cigarettes and supporting efforts to block hospital smoking bans Tobacco Free Futures

277 Impact of tobacco use and exposure Like other smokers, those who are mentally ill have a high risk of smoking-related death. Individuals with serious mental illness die, on average, 25 years prematurely, with the leading causes being chronic tobacco-related diseases. 5 Among clients in treatment for substance use disorders who smoke, 51% died of tobacco-related causes a rate double that of the general population. 6 Persons with psychiatric or substance-use disorders are at higher risk than individuals in the general population for many tobacco-related diseases, including larynx cancer esophageal cancer trachea, bronchus and lung cancer pancreatic cancer stroke cardiovascular disease diabetes pneumonia The relative risks of developing cancers of the mouth and throat are 7 times greater for tobacco users, 6 times greater for those who use alcohol and 38 times greater for those who use both alcohol and tobacco. 10 chronic obstructive pulmonary disease, asthma and other respiratory illnesses 1,3,6 With a risk of death from these tobacco-related diseases that is 2 to 4 times greater than the general population, treating tobacco dependence is central to addressing the disproportionate morbidity and mortality rates among people with serious mental illness. 5,6,7 Tobacco treatment in addictions and mental health settings Health benefits aside, people with addiction and mental health concerns have other reasons to quit tobacco, including improved overall quality of life, greater satisfaction with leisure activities, greater satisfaction with social relationships, more money and better access to housing. 7,8 These outcomes are significant not only to the individual but also to the health care system in Alberta, which uses outcome measurements such as the Health of the Nation Outcome Scales (HONOS) to inform decision-making and program planning across addiction and mental mealth care. 9 Integration of Tobacco-Free Treatment Tobacco use has long been an accepted part of the culture of care in addictions and mental health treatment. In treatment, smoking is often associated with social activities or with breaks. People may smoke to feel part of a group and may be afraid that quitting tobacco will damage their social relationships in treatment. 10 In substance abuse treatment settings, smoke breaks can reinforce the social connection to tobacco. This is unfortunate because these settings provide an ideal opportunity for initiating tobacco treatment services, motivating clients to quit and supporting clients in staying tobacco-free. 7 Table 19.1 outlines some of the findings of facilities that have no tobacco-use ban or partial tobacco-use bans compared to those that have become completely tobacco-free (no tobacco use indoors or outdoors). Alberta Health Services

278 Table 19.1: Impact of Incomplete or Complete Bans of Tobacco Use in Treatment Facilities Conflict and AGgression Staff Time Patient Cessation Partial or No Ban There is significant evidence that the bartering and control of tobacco products between staff and patients can be a source of conflict. 11 The amount of time spent on facilitating tobacco use is estimated at up to four hours per day, including getting cigarettes, giving cigarettes, lighting cigarettes, managing patient disputes over cigarettes, cleaning up cigarettes and observing patient smoking on or off the unit. 7 Studies have shown increases in tobacco use during admittance to addiction and mental health facilities where tobacco use is permitted. 14 Complete Ban Psychiatric care settings that have implemented tobacco and smoke-free policies that completely eliminate tobacco use report fewer behavioural problems, decreased coercion, decreased violence, no increase in discharges against medical advice and reduced seclusion or restraints. 11,2,12 Hospitals that do not permit smoking experienced significantly fewer aggression issues related to tobacco use compared to hospitals that do. 13 Implementing policies of complete tobacco use bans have been shown to reduce the amount of time staff spend managing the smoking culture. 11 Staff also report an increase in job satisfaction. 13 When complete smoking bans are in place, there are no cues for patients to smoke. Coupled with access to cessation supports such as pharmacotherapy, many patients are surprised by how well they can manage without tobacco. 7 Despite these benefits, restrictive policies alone seem to have little or no effect on tobacco cessation. 15 Offering cessation treatment, especially for relief of withdrawal symptoms, is an important part of support for clients during periods of abstinence. 2 In fact, it has been reported that failure to address nicotine withdrawal is associated with a rate of discharges against medical advice that is twice as high for smokers who are offered support for withdrawal than that of non-smokers. 16 Health Providers in Addictions and Mental Health There is strong evidence that tobacco use is closely linked to severe mental illness and has a major detrimental impact on individuals lives. Yet the historic smoking culture still prevails within the majority of addictions and mental health settings. For instance, cigarettes continue to be used as a means of reward and punishment for inpatients. 17 Cessation programs for clients accessing mental health services have cited the negative attitudes of staff and their refusal to engage with cessation programs as their greatest challenge. 17 Addictions and mental health professionals are ideally positioned to treat tobacco dependence. They are able to combine psychopharmacological and behavioural/counselling treatment, often are trained in substance abuse treatment and are able to identify and address any changes in psychiatric symptoms during the withdrawal period. Unfortunately, 19.4 Tobacco Free Futures

279 many of these professionals maintain the view that smoking is an effective coping mechanism for their clients and a means of self-medicating in order to cope with symptoms. 17 There is reluctance among these professionals to acknowledge the importance and feasibility of addressing smoking, which may be rooted in the misconception that people with severe mental illness generally do not want to quit smoking or that clients will become violent. The evidence does not support these assumptions. 11,17 It is clear that much work needs to be done to raise awareness amongst health care professionals working in addictions and mental health about the importance of quitting. These professionals are well suited to support their clients in their tobacco cessation. Especially for people with cognitive impairment, a consistent approach, where all health care professionals encourage tobacco cessation, is needed. 18 It is recommended that addressing tobacco be integrated into the routine care provided at addictions and mental health treatment settings, including mandatory training at all staff levels. 19 Change is urgently required to prevent a widening of existing health disparities. TOBACCO TREATMENT RECOMMENDATIONS Those dealing with mental health issues benefit from the same type of cessation support as the general public. All smokers with psychiatric disorders, including substance use disorders, should be offered tobacco dependence treatment. 20,21 It is important for health care providers to be aware of the impact of smoking cessation on comorbid conditions and recognize that these patients/clients are at higher risk of relapse. 21 CAN-ADAPTT smoking cessation guidelines The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice informed Tobacco Treatment (CAN-ADAPTT) is a practice-based research network facilitating research and knowledge exchange among practitioners, researchers and policy makers in the area of smoking cessation. CAN-ADAPTT s guideline for smoking cessation is intended to guide practice and is not intended to serve as a comprehensive overview of smoking cessation management. 21 The CAN-ADAPTT Guideline Development Group has provided the following Grade 1A summary statements (strong recommendations with high-quality evidence) for addictions and mental health: Summary Statement #1 Health care providers should screen persons with mental illness and/or addictions for tobacco use. Summary Statement #2 Health care providers should offer counselling and pharmacotherapy treatment to persons who smoke and have a mental illness and/or addiction to other substances. Summary Statement #3 While reducing smoking or abstaining (quitting), health care providers should monitor the patients /clients psychiatric condition(s) (mental health status and/or other addiction(s)). Medication dosage should be monitored and adjusted as necessary. For more information, visit the CAN-ADAPTT website: Alberta Health Services

280 Nicotine dependency and withdrawal The psychological and physiological similarities between tobacco dependence, psychiatric disorders and substance use disorders could account for the high rates of tobacco use in the population that has addictions and mental health disorders. Most smokers with mental health concerns smoke significantly more, have increased levels of nicotine dependency and are therefore at even greater risk of smoking-related harm. Heavy smokers tend to have more symptoms during nicotine withdrawal, including mood difficulties. 2 Common psychiatric and addiction withdrawal symptoms are very similar to nicotine withdrawal symptoms, including cannabis: irritability, difficulty sleeping, strange nightmares, craving and anxiety cocaine: depression, fatigue, increased appetite, insomnia or hypersomnia, vivid and unpleasant dreams, psychomotor retardation and agitation prescription stimulants abuse: depression, fatigue, increased appetite, insomnia or hypersomnia, vivid and unpleasant dreams, psychomotor retardation and agitation methamphetamine: depression, anxiety, fatigue and intense craving for the drug inhalants: mild withdrawal syndromes (e.g., irritability, restlessness, insomnia, headaches, poor concentration) can occur with long-term abuse opioids: restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (when quitting cold turkey ) and leg movements psychiatric disorders (e.g., major depression, anxiety disorders): sleep disturbance (increased or decreased), decreased energy, difficulty concentrating, changes in appetite (increase or decrease), anxiety, depressed mood, anger, irritably and frustration 22,23 Many of the neurotransmitter systems that are affected by nicotine administration through tobacco use are involved in the pathogenesis of psychiatric and substance use disorders, including dopamine: schizophrenia, bipolar disorders and alcohol and drug addiction norepinephrine: bipolar disorders, major depressive disorders and cocaine dependence serotonin: major depression and PTSD acetylcholine: schizophrenia and major depression endogenous opioid peptides: opioid and alcohol dependence glutamate: schizophrenia, bipolar disorders and major depression gamma-aminobutyric acid (GABA): schizophrenia, major depressive disorders and cocaine dependence endocannabinoids: cannabis and opioid dependence 24 Some researchers suggest that tobacco may also be used by patients to self medicate for transient relief of psychiatric symptoms Tobacco Free Futures

281 Readiness to quit People with psychiatric and substance use disorders have the same levels of motivation and desire to quit as does the general population. In 2009, Calgary s Foothills Medical Clinic found that 51% of addiction and mental health patients were pre-contemplative (no timeline or not interested in quitting), 12.7% contemplative (desired to quit in the next 6 months), and 36.2% preparatory (desired to quit in the next 30 days) or action-oriented (actively cutting down or quit recently). 25 The motivation in outpatient addiction and mental health patients is 47.4% pre-contemplative, 38.6% contemplative and 14.0% preparatory or action oriented. 8 In the general North American population, those rates are 40% pre-contemplative, 40% contemplative and 20% preparatory or action-oriented. 26 Figure 19.2: Readiness to Quit General population Not currently interested in quitting A&MH inpatient Seriously considering quitting in the next 6 months A&MH outpatient Actively quitting or quit recently 0% 25% 50% 75% 100% The majority of current smokers in the Foothills Medical Clinic research (79.3%, n = 92) expressed concern about their smoking, with 40.5% (n = 47) somewhat concerned, 20.7% (n = 24) considerably concerned and 18.1% (n = 21) seriously concerned. 25 Ratings of concern about smoking and the perceived difficulty of quitting did not vary significantly across the diagnostic groups. 25 Those with higher nicotine dependence did not have statistically greater concerns about their smoking than others. 25 Brief tobacco intervention Tobacco use negatively affects mental health treatment. 24 Increasing evidence indicates that individuals with psychiatric disorders can be aided in quitting smoking without threat to their mental health recovery. Integration of tobacco cessation treatment within psychiatric settings is encouraged so that clinicians can identify and address nicotine withdrawal and any changes in psychiatric symptoms during the quit attempt. 7 Addiction and mental health clients can quit smoking without adverse effect to their mental health recovery. Alberta Health Services

282 Alzheimer s Disease and Dementia Smoking cessation could prevent or slow the progression of dementia and should become an integral part of the prevention and treatment of dementia. 27 Smoking cessation in older adults should receive the same attention as other modifiable risk factors, such as hypertension and diabetes. 28 In Alberta, persons aged 45 and up have a lower rate of cigarette smoking compared with other age groups, at 17.2%. 29 Traditionally, it was thought that older adults were not interested in quitting and there was no clinical reason for an older tobacco user to quit. 30 In fact, older adults are just as willing as younger adults to try to stop using tobacco. 28 There is now a substantial body of evidence of meaningful benefits of tobacco cessation, even after many years of tobacco use. 31 Older persons who quit can significantly reduce their risk of other chronic illnesses, such as lung cancer, stroke, coronary artery disease, peripheral vascular disease and chronic obstructive pulmonary disease enhance their quality and length of life improve their mobility and prevent the loss of mobility improve their physical strength 33,34,35,36 Given the health benefits of quitting tobacco at any age, the potential difficulty of placement into longer term care or daily assisted living settings and the risk of fire and injury with declining cognitive ability, tobacco treatment should be a part of the standard of care for all persons, especially for older adults with dementia. Treatment considerations COGNITIVE DEFICITS AND COMORBID CONDITIONS The proper treatment of cognitive deficits related to dementia and other comorbid conditions is a critical first step in the overall care of the person. 36 Comorbid conditions are common in elderly patients with cognitive impairment and could impact tobacco treatment attempts if not addressed. 36 Disorders to be considered include sensory deficits (especially deficits in vision or hearing), dental problems, depression and other medical conditions that commonly affect the elderly. 36 Properly managing comorbid conditions could improve tobacco cessation treatment outcomes. There is growing evidence in clinical practice that clients engaging in tobacco treatment should be screened for mild to moderate degrees of cognitive impairment. 30 Executive cognitive functions are essential to behavioural self-regulation and are essential for sustaining behaviour change over time, including the behaviour change required for tobacco cessation. 37 Although Brega et al. (2008) found that impaired executive cognitive functioning has only a modest impact on the success of tobacco cessation efforts in older populations, interventions targeting behaviour change in older adults should consider the special needs of those with executive impairment. 37,30 Understanding the status of a patient s executive function will allow health care professionals to arrange the resources and enlist the multidisciplinary support to enhance a patient s tobacco treatment outcomes Tobacco Free Futures

283 FAMILY EDUCATION AND SUPPORT The most important factor for successful smoking cessation for persons with dementia is to engage and educate the person s family, particularly the primary agent or decision maker. 38,36 An alliance between the family and the health care team is the principal means of ensuring the treatment plan is followed. The physical and emotional health of the family, especially the primary caregiver, is critical to the care of the patient with dementia. 39 Family members who are in a caregiving role have a higher rate of depression and physical illness. 39 A close working relationship not only helps minimize caregiver distress and improve satisfaction with treatment, but also decreases agitation and anxiety in the patient. 40 At or soon after admission, the health care team, including the admitting physician, should meet with the patient and the family to answer questions and provide information about quitting tobacco and treatment options. The health care team can help family members by educating them to use strategies to reduce behavioural disturbances and promote tobacco cessation. MODIFYING THE ENVIRONMENT People with clinically significant degrees of cognitive impairment, particularly to their executive functions, are unlikely to be able to carry out actions, sustain effort or learn new behaviours. 30 For such persons, smoking cessation programs that rely heavily on the individual to regulate his or her smoking behaviour independently, without considerable external support, are liable to produce poor outcomes. 37 When an individual has an impaired ability to regulate his or her own behaviour, considerable assistance from others (e.g., health professionals, family, guardians) and environmental structures (e.g., modifying the environment to make it more difficult to engage in the smoking habit) may be required. 37 Depending on the cognitive capabilities of the individual, there may be an increased need to focus on the environmental factors that contribute to the addictive behaviour. Effective strategies include removing triggers and environmental cues of tobacco use washing all clothes of a smoker as soon as they come into the care setting to eliminate the smell of tobacco, which could trigger the urge to smoke in patients and staff who use or have previously used tobacco removing visual cues from the environment (e.g., seeing others using tobacco, being in an area where patients would have used tobacco before quitting) 38 ADDRESSING PERSEVERATION AND AGITATION One of the most overwhelming aspects of caring for a person suffering from dementia involves the accompanying behavioural problems of perseveration and agitation. Patients with dementia will often perseverate, or repeatedly ask to use tobacco, even if they just had a cigarette. This can quickly escalate to agitation. Strategies that address the individual s needs decrease rates of inappropriate behaviours. Despite the many difficulties of conducting research in this population, a wide variety of approaches have been tried successfully. Many non-pharmacological approaches resulted in a statistically and clinically meaningful improvement in the manifestation of behaviour problems. The principles listed below, which received consistent support in the research, should be considered primary targets for future non-pharmacologic interventions: medical and nursing care that effectively address limitations in functioning, including pain, sensory limitations, sleep problems and limitations on autonomy (e.g., physical restraints) Alberta Health Services

284 provision of social contact provision of meaningful stimuli or activity tailoring the intervention to the individual staff training to improve care reduction in stressful stimuli or increasing relaxation during care activities, including longer treatment times, in order to establish trust and rapport with the patient and explaining all procedures and activities to the patient in simple language before performing them providing the patient with a predictable routine (e.g., exercise, meals and bedtime should be routine and punctual) breaking complex tasks into smaller steps 41,36,38 Redirecting or diverting the patient will often abruptly end or lessen the perseveration. 36 Arguing will only increase the agitation. 36 Change the subject and engage the patient s long term memory, such as asking about a spouse or children or a favourite sport or hobby. 38 One tactic is to keep a memory book or photo album of pictures of the past. 38 Reinforce and remind the patient that he or she is now a non-smoker, and eventually they will believe it. 38 If the person asks for a cigarette, you could also try telling them they just had one. 38 Using drug therapies to treat perseveration and agitation associated with dementia should only be considered when all other non-pharmacologic interventions have been exhausted. 36 When drug therapy is necessary, psychosocial interventions should continue, as they may enable a reduced dosage or duration of the drug treatment. 36 CESSATION MEDICATIONS Evidence indicates that the use of pharmacotherapy on its own doubles the chance of success for those attempting to quit tobacco use. 20 Nicotine withdrawal may be more severe in patients with dementia because of their pre-existing cholinergic deficit. 42 This highlights the importance of using cessation medications to reduce signs and symptoms of nicotine withdrawal. Except in the presence of contraindications, it is recommended that available treatments be used with all patients attempting to quit smoking. 21,20 As drugs are known to metabolize differently in the elderly, when adding any pharmacotherapy you should always adhere to the general guidelines of start low and go slow. Start at the lowest possible dose and increase doses slowly to prevent side effects and toxicity. The first-line smoking cessation medication options approved for use in Canada include various forms of nicotine replacement therapy (NRT), bupropion SR and varenicline, which are outlined in Chapter 9 ( Pharmacotherapy ). Decisions about whether to use pharmacotherapy, including the type of product appropriate, should be made in collaboration with the patient/client and his or her family. 43 While most cessation medications would presumably work in patients with dementia, it is important to note that some may be better suited to an individual with cognitive impairment than others. For instance, learning to use a nicotine inhaler may prove to be a challenge. Nicotine withdrawal in patients with dementia may be easily managed with transdermal nicotine replacement therapy. 42 Weatherall (1992) reported a case of a 69-year-old male with dementia for whom the use of a transdermal nicotine patch led to a dramatic and almost complete cessation of demands for tobacco use, allowing the care team to instead focus on treatment of other health concerns Tobacco Free Futures

285 ANXIETY DISORDERS Prevalence The prevalence of tobacco use is higher among individuals with anxiety disorders than in the general population. The percentage of current smokers who also suffer from an anxiety disorder varies according to the disorder, from 31% for social phobia, 54% for generalized anxiety disorder, to 66% for post-traumatic stress disorder. 3 On average, persons with anxiety disorders smoke for longer, which exposes them to a greater risk of tobacco-related harm. 44 The association between tobacco use and anxiety disorders may be due to shared common predisposing factors (e.g., genetic predisposition), neurobiological mediators or a tendency to experience negative affect states. 45 Generalized personality-based factors may be relevant to the relationship between panic attacks and smoking, but it is unclear whether specific individual differences (e.g., anxiety sensitivity) or social-environmental factors play similar roles. 45 Treatment considerations In one study, participants who smoked and were identified as ever meeting criteria for a panic attack, social anxiety or generalized anxiety disorder reported higher levels of nicotine dependence and pre-quit withdrawal symptoms. 46 Participants received six 10-minute individual counselling sessions and either single-agent pharmacotherapy (nicotine patch, nicotine lozenge, or bupropion SR) or combination pharmacotherapy treatment (nicotine patch and nicotine lozenge, or bupropion SR and nicotine lozenge). 46 Those ever meeting criteria for panic attacks or social anxiety disorder showed greater quit-day negative affect and were less likely to be abstinent at 8 weeks and 6 months after quitting. 46 They did not show benefits from single-agent pharmacotherapy or combination pharmacotherapy treatment. 46 It could be argued that anxiety disorders and life circumstances surrounding these individuals justify a higher level of support in order to achieve equitable outcomes. 44 Medications to reduce anxiety (anxiolytics) may help smokers trying to quit, but there have not been an adequate number of trials, and the available evidence neither supports nor rules out an effect of anxiolytics such as buspirone, diazepam, meprobamate, ondansetron and beta blockers on smoking cessation. 47 In view of this uncertainty and the side effects of these drugs, there is little justification for using them for the purposes of smoking cessation. 47 Clonidine, a drug that has some anxiolytic effects, does show evidence of efficacy, but the incidence of side effects from its use is relatively high. 47,48 Alberta Health Services

286 DEPRESSION Prevalence Tobacco use and depression are strongly connected. People with depression are about twice as likely to be smokers as individuals who are not depressed. 1,3 Tobacco use and depression may be associated through the following mechanisms: shared genetic factors, shared environmental influences, bidirectional causality and self-medication. 49 Treatment considerations Compared to people in the general population who smoke, those with depression are more nicotine dependent and more likely to suffer from negative mood changes after nicotine withdrawal. 49 Their withdrawal symptoms should therefore be monitored closely. Several tools are available to simplify depression screening and enhance routine inquiry about mnetal health problems related to depression, which are the most prevalent and treatable mental health conditions. There is strong evidence for the use of the Personal Health Questionnaire-2 (PHQ-2) as a brief depression screening measure. The PHQ-2 assesses the frequency of depressed mood and the absence of pleasure over a 2-week period. Total PHQ- 2 scores range from 0 to 6, with a score of 3 as the optimum. A score of 3 or higher indicates that the user should be referred to a mental health specialist. 50 To address potential patient/client safety concerns, those who report a past history of clinical depression or currently report a moderate to severe depressed mood should be screened further to determine whether referral for mental health support is required. PHQ-2 50 Over the past two weeks, how often have you been bothered by any of the following problems? (0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day) 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless It is often thought that smokers with depression do not want to quit smoking. In fact, several studies show the opposite. 49 Unfortunately, smokers with depression are not often encouraged by health professionals to quit, due to the misconception that cessation will exacerbate their depressive symptoms. 49 Evidence now suggests that quitting smoking may improve rather than exacerbate depressive symptoms in those who are able to remain abstinent. 49,51 Furthermore, research shows no differences in cessation outcomes as a function of the type of depression (recurrent versus single episode), the severity of depression, or whether the depression was current or in remission. 52 Evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. 49 Buproprion SR, with or without NRT, may be an appropriate choice for cessation support for those suffering from or with a history of depression. 49 A recent review found pooled results from four trials, suggesting that the use of bupropion may increase long-term cessation in smokers with a history of depression. 49 Unfortunately, there was not enough evidence to evaluate the effectiveness of the other antidepressants in smokers with current or past depression Tobacco Free Futures

287 SCHIZOPHRENIA Prevalence Tobacco use among individuals with schizophrenia is significantly higher than in the general population, with prevalence estimated to be between 58% and 88%. 3 Several biological, psychological and social factors appear to contribute to these high rates of tobacco use and dependence and the low rates for smoking cessation in persons with schizophrenia. Nicotine transiently improves abnormalities in sensorimotor gating and visuospatial working memory (VSWM) for individuals with schizophrenia. 45 Smoking may therefore be a form of self-medication for psychological symptoms; however, it may also be explained by addiction, dependence, tolerance or self-medicating nicotine withdrawal. 45 Psychosocial factors are also important in understanding the high rates of tobacco use in people with schizophrenia. Social factors that increase smoking risks for this population include limited education, poverty, unemployment, peer influence and the mental health treatment system. 45 Treatment considerations Similar to smokers with other psychiatric disorders, about half of individuals with schizophrenia are heavy smokers and have higher nicotine dependence. 45 Studies that compared heavy and lighter smokers in this population found that heavy smoking was associated with increased positive symptoms, decreased negative symptoms, increased substance use, more frequent psychiatric hospitalizations, fewer parkinsonian or extrapyramidal side effects, increased suicide risk and polydipsia. 45 Studies have shown that clients do not show worsening symptoms of schizophrenia during periods of tobacco abstinence or while stopping smoking. 11 There is some evidence to suggest that people with schizophrenia may experience more severe withdrawal symptoms during the first week of a quit attempt than other would-be quitters. 11 Individuals with schizophrenia appear to be able to quit tobacco with the support of psychosocial treatment, tobacco cessation medications and social support. 45 Although many of these patients experience difficulties and may relapse, they are still interested in reducing their smoking. 45 The initial challenge is often to motivate individuals with schizophrenia to attempt quitting. Engaging less-motivated patients with psychosocial interventions is important, given the high rates of tobacco dependence. One study found that motivational interviewing with personalized feedback is effective in motivating 32% of smokers with schizophrenia to seek smoking cessation treatment within one month, compared with 11% among those receiving an educational intervention and 0% among those provided with information only. 54 Participants received a single motivational interviewing session that lasted approximately 40 minutes and concluded with advice to quit smoking and with a referral for treatment to a specialized tobacco dependence treatment program. 53 Personalized feedback based on the assessment interview was provided using a form created by a computerized program. 53 A major goal of the feedback was to create a discrepancy between the participants current behaviour and their future goals. Feedback included graphical representations of participant responses, including their level of nicotine dependence as compared with normative data the amount of carbon monoxide in their expired breath as compared with nonsmokers the medical consequences of smoking the money spent on cigarettes the importance of quitting smoking their confidence in their ability to quit 53 Alberta Health Services

288 Motivational interviewing is effective in motivating smokers with schizophrenia or schizoaffective disorders to seek tobacco dependence treatment and may also have implications for smokers with schizophrenia who are already being treated for tobacco dependence. It can allow those individuals to become more engaged in treatment, thereby improving retention rates and treatment outcomes. 53 Once a person is ready to quit, there are clinical studies showing that different intensities of psychosocial treatment interventions have been effective. 45 This includes one-to-one and group-based counselling, using interventions tailored to the population, cognitive-behavioural therapy approaches, social skills training and contingency monetary reinforcement. 45 Pharmacotherapy may be particularly important for smokers with serious mental illness who have high levels of nicotine dependence. Psychiatric inpatient clients who were not given a prescription for nicotine replacement therapy were more than twice as likely to be discharged from the hospital against medical advice. 11 Looking only at the number of cigarettes smoked by individuals with schizophrenia may be a less reliable measure of dependence, as there is evidence that these smokers take more puffs per cigarette and therefore have higher levels of nicotine and cotinine compared to individuals without schizophrenia who smoke the same number of cigarettes. 45 Given the high levels of dependence in individuals with schizophrenia who smoke, higher doses of cessation medications are an important treatment consideration. Higher doses of nicotine replacement therapy (e.g., 6 mg of nicotine gum) have the added benefit of improving sensorimotor gating. 45 An important component of tobacco cessation treatment for persons on psychotropic medications is close monitoring of the amount smoked, cessation treatment, medication side effects and psychiatric symptoms. 21 As a result of the polycyclic aromatic hydrocarbons in the tar of tobacco smoke, the metabolism of psychotropic medications, as well as other psychiatric medication blood levels, can be increased in cigarette smokers due to the induction of cytochrome P-450 hepatic enzymes. 54 Numerous medications may be affected once a person stops smoking, including antidepressants (tricyclics, fluvoxamine) antipsychotics (clozapine, olanzapine, haloperidol) caffeine benzodiazepines (chlordiazepoxide, diazepam) nifedipine propafenone theophylline verapamil warfarin 54 Smokers frequently need higher doses of these types of medications to have the same therapeutic effect, and thereby run an increased risk of adverse effects. 2,3 Clients on psychotropic medications must be reviewed by health care professionals when quitting smoking, as they may need their medication dosages adjusted in order to avoid drug toxicity due to increased drug levels in their blood. 55, Tobacco Free Futures

289 SUBSTANCE USE DISORDERS Prevalence Clients in treatment for substance use disorders have extraordinarily higher rates of tobaccorelated health problems than the general population, as approximately 75% to 80% of clients in substance abuse treatment settings use tobacco. 3 Addiction to tobacco appears to follow the same biochemical and behavioural processes as those that determine addiction to other substances. In fact, heavier smoking is linked to increased drug and alcohol use severity. 2 Current tobacco use is strongly associated with abuse/dependence on alcohol, cannabis and other substances. 56,57 Former smokers have higher rates of alcohol-use and cannabis-use disorders. 57 Because of the frequent concurrent use of the two drugs, substances of abuse and smoking may become associated through a process called cue conditioning. 58 In general, conditioning models of addiction suggest that cues previously paired with drug use (e.g., the sight of a liquor bottle or the smell of a lighted cigarette) will elicit conditioned responses, including cravings and associated physiological activity. 58 These cue-elicited cravings and physiological reactions, in turn, can motivate ongoing drug use and increase the probability of relapse among people who are abstinent. 58 The substantial overlap between substances of abuse and tobacco use cues may elicit cravings and consumption of either drug. 58 Treatment considerations Evidence indicates that tobacco use interventions, including counselling and medication, are effective in treating smokers who are receiving treatment for other substance use and addictions. 20 Counsellors and agencies providing substance abuse treatment have traditionally ignored their clients tobacco use, even though studies consistently show that many clients want to quit and want help in quitting. A growing body of evidence indicates that treating tobacco use actually helps clients address their alcohol and other drug problems, and integrating tobacco treatment into mainstream substance abuse treatment is rapidly becoming best practice. Substance abuse counsellors have considerable knowledge and skills about how to help clients deal with their use of addictive substances. These are directly applicable to treatment of tobacco. However, counsellors should be educated about the addictive properties of nicotine and receive training specifically about tobacco treatment. 10 There is some evidence that treatment outcomes improve when multiple types of clinicians are involved in tobacco treatment. 2 For example, one counselling strategy is to have a medical/health care clinician deliver messages about health risks and benefits, as well as deliver pharmacotherapy, while behavioural health clinicians deliver additional interventions, such as cognitive behavioural therapy. Persons who do not participate in many activities may become bored and smoke more to keep themselves busy. Recreation therapists could offer additional programming and supports in place of the time clients would have otherwise spent using tobacco. Smokers with a history of alcohol problems may find nicotine more reinforcing, and experience more nicotine dependence criteria and withdrawal symptoms compared with smokers without alcohol problems. 2 In health care settings, all patients should be given access to a safe and comfortable detoxification from tobacco, as is done with other addicting substances, to prevent the emergence of nicotine withdrawal symptoms. 11 Pharmacotherapy should be considered for all clients to mitigate their nicotine withdrawal symptoms, especially in settings that restrict or prohibit tobacco use. 21,20 Alberta Health Services

290 Increasingly, research suggests that tobacco treatment does not jeopardize recovery from other substances. In fact, it may improve outcomes for the treatment of other substance use disorders. 2 A review of tobacco treatment interventions for individuals with substance abuse problems found that smoking cessation interventions were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. 16 Tobacco cessation supports recovery from other addictions and is associated with improved sobriety from other addictions, whereas continued tobacco use is associated with worse drug treatment outcomes. 7 Tobacco dependence interventions during addictions treatment appear to enhance, rather than compromise, long-term sobriety. Both individual and group counselling are effective treatment options for treating tobacco use. Evidence also supports the use of motivational interviewing in substance use treatment settings. 59 The type of counselling offered can be selected based on what fits best within a care setting and for the type of clients seen at a particular facility. More intensive interventions are more effective than less intensive interventions and should be offered whenever possible. The U.S. guidelines (2008) define intensive interventions as having a minimum of four face-to-face sessions. 20 Self-help interventions, such as giving clients pamphlets or lists of community resources, appear to have a limited impact on their own; however, tailored materials that address specific issues and concerns can be useful additions to behavioural interventions or pharmacotherapy. 10 Relapse to tobacco use following treatment for substance use and tobacco use is a concern. 60 Helping a person maintain his or her tobacco cessation is strengthened by offering follow-up support after treatment. 59 Follow-up telephone calls are also helpful and increase abstinence rates after discharge Tobacco Free Futures

291 REFERENCES 1. Kalman, D., Baker Morissette, S., & George, T. (2005). Co-morbidity of smoking in patients with psychiatric and substance use disorders. American Journal on Addictions, 14, Ziedonis, D., & Williams, J. (2003). Management of smoking in people with psychiatric disorders. Current Opinion in Psychiatry, 16, Lasser, K., Wesley, B., Woolhandler, S., Himmelstein, D., McCormick, D., & Bor, D. (2000). Smoking and mental illness: A population-based prevalence study. Journal of the American Medical Association, 284, Prochaska, J., Hall, S., & Bero, L. (2008). Tobacco use among individuals with schizophrenia: What role has the tobacco industry played? Schizophrenia Bulletin, 34, Colton, C., & Manderscheid, R. (2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease, 3, A Hurt, R., Offord, K., Croghan, I., Gomez-Dahl, L., Kottke, T., Morse, R., & Melton, L. (1996). Mortality following inpatient addictions treatment: Role of tobacco use in a community-based cohort. Journal of the American Medical Association, 275, Prochaska, J. (2009). Ten critical reasons for treating tobacco dependence in inpatient psychiatry. Journal of the American Psychiatric Nurses Association, 5, Dixon, L., Medoff, D., Wohlheiter, M., DiClemente, C., Goldberg, R., Kreyenbuhl, J., Adams, C., Lucksted, A., & Davin, C. (2007). Correlates of severity of smoking among persons with severe mental illness. American Journal on Addictions, 16, Alberta Health Services. (2010). Addiction and mental health implementation priorities Edmonton, AB: Author. 10. Signal Behavioral Health Network. (2007). Tobacco treatment toolkit for substance abuse treatment provider. Denver, CO: Author. 11. Williams, J. (2008). Eliminating tobacco use in mental health facilities patients rights, public health, and policy issues. Journal of the American Medical Association, 299, Schroeder, S., & Morris, C. (2010). Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health, 31, Monihan, K., Schacht, L., & Parks J. (2007). A comparative analysis of smoking policies and practices among state psychiatric hospitals. Alexandria, VA: National Association of State Mental Health Program Directors Research Institute, Inc. (NRI). 14. Toussaint, D., VanDeMark, N., Silverstein, M., & Stone, E. (2009). Exploring factors related to readiness to change tobacco use for clients in substance abuse treatment. Journal of Drug Issues, Alberta Health Services

292 15. El-Guebaly, N., Cathcart, J., Currie, S., Brown, D., & Gloster, S. (2002). Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatric Services, 53, Prochaska, J., Delucchi, K., & Hall, S. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment recovery. Journal of Consulting and Clinical Psychology, 72, Ratchen, E., Britton, J., & McNeill, A. (2011). The smoking culture in psychiatry: Time for change. The British Journal of Psychiatry, 198, Fiore M., & Baker, T. (2011). Treating smokers in the health care setting. New England Journal of Medicine, 365(13), Hughes, J. (2007). Review depression during tobacco abstinence. Nicotine & Tobacco Research, 9, Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al. (2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 21. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice- Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation clinical practice guideline (version 2). Toronto, ON: Centre for Addicition and Mental Health. Retrieved from National Institute on Drug Abuse. (2012). The science of drug abuse and addiction: Commonly abused drugs and health effects. Retrieved from drugs-abuse/commonly-abused-drugs/health-effects 23. Carlat, T. (1998). The psychiatric review of symptoms: A screening tool for family physicians. American Family Physician, 58, Sacco, K., Bannon, K., & George, T. (2004). Nicotinic receptor mechanisms and cognition in normal states and neuropsychiatric disorders. Journal of Psychopharmacology, 18, Solty, H., Crockford, D., White, W., & Currie, S. (2009). Cigarette smoking, nicotine dependence, and motivation for smoking cessation in psychiatric inpatients. The Canadian Journal of Psychiatry, 54, Etter, J., Perneger, T., Ronchi, A., & Sociol, D. (1997). Distributions of smokers by stage: International comparison and association with smoking prevalence. Preventive Medicine, 26, Cataldo, J., & Glantz, S. (2010). Smoking cessation and Alzheimer s disease: Facts, fallacies and promise. Expert Review of Neurotherapeutics, 10, Andrews, J., Health, J., & Graham-Garcia, J. (2004). Management of tobacco dependence in older adults: Using evidence-based strategies. Journal of Gerontological Nursing, 30(12), Statistics Canada. (2011). Canadian tobacco use monitoring survey (CTUMS). Ottawa, ON: Author. 30. Allen, C. (2008). What determines the ability to stop smoking in old age? Age and Ageing, 37, Tobacco Free Futures

293 31. Appel, D., & Aldrich, T. (2003). Smoking cessation in the elderly. Clinics in Geriatric Medicine, 19, LaCroix, A., & Omenn, G. (1992). Older adults and smoking. Clinics in Geriatric Medicine, 8, Lam, T., Li, Z., Ho, S., et al. (2007). Smoking, quitting and mortality in an elderly cohort of 56,000 Hong Kong Chinese. Tobacco Control, 16, Yates, L., Djousse, L., Kurth, T., et al. (2008). Exceptional longevity in mn: Modifiable factors associated with survival and function to age 90 years. Archives of Internal Medicine, 168, Rapuri, P., Gallagher, J., & Smith, L. (2007). Smoking is a risk factor for decreased physical activity in elderly women. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62, Cummings, J., & Frank, J. (2002). Guidelines for managing Alzheimer s disease: Part II. Treatment. American Family Physician, 65, Brega, A., Grigsby, J., Kooken, R., Hamman, R., & Baxter, J. (2008). The impact of executive cognitive functioning on rates of smoking cessation in the San Luis Valley Health and Aging Study. Age and Ageing, 37, Kammerer, H. (2012, November). Tobacco cessation for medically complex elderly patients with dementia on behavioural unit at Glenrose Rehabilitation Hospital. Presentation. Edmonton, AB: Alberta Health Services, Glenrose Rehabilitation Hospital. 39. Cummings, J. & Frank, J. (2002). Guidelines for managing Alzheimer s disease: Part I. Assessment. American Family Physician, 65, Haupt, M., Karger, A., & Janner, M. (2000). Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers. International Journal of Geriatric Psychiatry, 15, Cohen-Mansfield, J. (2001). Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary, and critique. American Journal of Geriatric Psychiatry, 9, Weatherall, A. (1992). Successful use of a transdermal nicotine patch to manage a smoker with dementia. Australian and New Zealand Journal of Medicine, 22, Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P. (2007). The tobacco dependence treatment handbook: A guide to best practice. New York: Guilford Press. 44. Lawrence, D., Considine, J., Mitrou, F., & Zubrick, S. (2010). Anxiety disorders and cigarette smoking: Results from the Australian Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 44, Ziedonis, D., Hitsman, B., Beckham, J., Zvolensky, M., et al. (2008). Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research, 10, Piper, M., Cook, J., Schlam, T., & Jorenby, D. (2011). Anxiety diagnoses in smokers seeking cessation treatment: Relations with tobacco dependence, withdrawal, outcome, and response to treatment. Addiction, 106(2), Alberta Health Services

294 47. Hughes, J., Stead, L., & Lancaster, T. (2011). Anxiolytics for smoking cessation. The Cochrane Collaboration, Gourlay, S., Stead, L., & Benowitz, N. (2008). Clonidine for smoking cessation. The Cochrane Collaboration, Van der Meer, R., Willemsen, M., Smit, F., & Cuijpers, P. (2013). Smoking cessation interventions for smokers with current or past depression. The Cochrane Collaboration, Kroenke, K., Spitzer, R., & Williams, J. (2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41, Prochaska, J., Hall, S., Tsoh, J., Eisendrath, S., et al. (2008). Treating tobacco dependence in clinically depressed smokers: Effect of smoking cessation on mental health functioning. American Journal of Public Health, 98, Hall, S., & Prochaska, J. (2009). Treatment of smokers with co-occurring disorders: Emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5, Steinberg, M., Ziedonis, D., Krejci, J., & Brandon, T. (2004). Motivational interviewing with personalized feedback: A brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence. Journal of Consulting and Clinical Psychology, 72, Desai, H., Seabolt, J., & Jann, M. (2001). Smoking in patients receiving psychotropic medications a pharmacokinetic perspective. CNS Drugs, 15, Farnam, C. (1999). Zyban: A new aid to smoking cessation treatment will it work for psychiatric patients? Journal of Psychosocial Nursing & Mental Health Service, 37, Falk, D., Yi, H., & Hiller-Sturmhöfel, S. (2006). An epidemiologic analysis of co-occurring alcohol and tobacco use and disorders: Findings from the national epidemiologic survey on alcohol and related conditions. Alcohol Research & Health, 3, Degenhardt, L., & Hall, W. (2001). The relationship between tobacco use, substance-use disorders and mental health: Results from the National Survey of Mental Health and Wellbeing. Nicotine & Tobacco Research, 3, Petry, N., & Oncken, C. (2002). Cigarette smoking is associated with increased severity of gambling problems in treatment-seeking gamblers. Addiction, 97, Baca, C. & Yahne, C. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36, Morisano, D., Bacher, I., Audrain-McGovern, J., & George T. (2009). Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders. Canadian Journal of Psychiatry, 54, Dunn, K., Sigmon, S., Reimann, E., Heil, S., & Higgins, S. (2009). Effects of smoking cessation on illicit drug use among opioid maintenance patients: A pilot study. Journal of Drug Issues, 39, Apollono, D., & Malone, R. (2005). Marketing to the marginalised: Tobacco industry targetting of the homeless and mentally ill. Tobacco Control, 14, Tobacco Free Futures

295 APPENDICES Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery Alberta Health Services

296 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 1) DETOX WORKSHOP: TOBACCO USE IN RECOVERY PURPOSE Awareness and information LEARNING OBJECTIVES During this workshop, participants will: learn about the health consequences of tobacco use and the health benefits of tobacco cessation become aware that quitting tobacco use can help them stay clean and sober become aware of tobacco withdrawal and the supports and resources available to manage it while in recovery become aware of the tobacco cessation resources available to them on discharge MATERIALS This workshop is intended to be a facilitator led group discussion. The following handouts and resources will help to facilitate the discussion: Big cigarette display AlbertaQuits cost savings wheel AlbertaQuits brochure AlbertaQuits fax referral sheet Carbon Monoxide Monitor PREPARATION 1. Read through the workshop. 2. Familiarize yourself with the Carbon Monoxide Monitor. 3. Assemble documents participants might be interested in. SUGGESTED PRESENTER Counsellor, or nurse if available. KEY Suggested script [Q] Questions to ask participants Interactive learning activity Tobacco Free Futures

297 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 2) Tobacco Use in Recovery 2012 Workshop overview This workshop is divided into 3 main topic areas: 1. Why talk about tobacco? 2. Tobacco and recovery from other addictions 3. Supports when you leave detox During the workshop, encourage participants to share their own experiences. It s important to convey three main ideas: (1) that tobacco is very addictive, but that quitting is possible and healthy; (2) going without tobacco is an opportunity to work on new skills and give your body a chance to recover; and (3) there are supports available to help with the recovery process. Using the phrase tobacco use instead of smoking will make sure that you are including clients who use smokeless tobacco products like snuff and chew. In this workshop, we will give you some information about tobacco use in recovery. We will give you information about the effects of tobacco and how it affects substance abuse. We will help you understand the supports available to you and help you make a choice that fits your situation. Topic 1: Why talk about tobacco? WHO USES TOBACCO? [Q] What percent of Albertans do you think currently smoke? In 2011, 17% of Albertans age 15+ were current smokers. (Statistics Canada, 2010) People with alcohol and other drug addictions have higher rates of tobacco use. In fact 75% of people with other addictions currently smoke. (Kalman, D., Baker Morissette, S., & George, T., 2005) [Q] Why do you think more people with alcohol and other drug addictions use tobacco? Tobacco use often goes hand in hand with alcohol and other drug use. It s often used for many of the same reasons as other drugs. For Example: as a way to socialize with other people, to deal with stress or boredom, to get a break from a busy day. (Petry N., & Oncken C., 2002) WHAT S IN TOBACCO? Most tobacco users know their use is unhealthy but many don t know what s really in tobacco products. Here are some facts about commercial tobacco products: The tobacco products you buy in stores are very different from the sacred tobacco used in traditional native ceremonies. The tobacco industry adds many chemicals to make tobacco products more addictive. (USDHHS, 2010) 2 Residential Detox Workshop Alberta Health Services Alberta Health Services

298 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 3) Tobacco Use in Recovery 2012 There are more than 7,000 chemicals in tobacco smoke (USDHHS, 2010). More than 69 of them are known to cause cancer. Most people already know about the harmful effects of tobacco use (USDHHS, 2010). Half of people in recovery from alcohol and drug addictions will die from a tobacco related disease (CAN-ADAPPT, 2011). LEARNING ACTIVITY Use the big cigarette display to review some of the harmful chemicals found in tobacco products. THE GOOD THINGS ABOUT GOING WITHOUT TOBACCO The good news is that when you go without tobacco, your body begins to recover very quickly. Quitting is one of the best things you can do to improve your health and the health of your families and friends. LEARNING ACTIVITY Ask clients to review the health benefits poster or handout. Which health benefits are the most important to them? Within minutes of the last tobacco use, the body will start a process of healing that will continue to over the following weeks, months and years (AADAC, 2007). Within: 20 minutes blood pressure drops to a person s normal level 8 hours blood carbon monoxide levels drop to normal 24 hours chances of having a heart attack decrease 2 weeks to 3 months circulation improves 9 months lung function improves with less coughing, congestion, fatigue and shortness of breath 1 year risk of coronary heart disease reduces by half 5 years risk of stroke significantly reduced 10 years risk of lung cancer death reduced by half 15 years risk of coronary heart disease is same as a non-smoker [Q] If you did choose to remain tobacco free after leaving detox, what else would you look forward to? Some other benefits of stopping tobacco use include (AADAC, 2007): better sense of taste and smell cleaner smelling person, home and car positive role model for children and other people money saved freedom from addiction improved self esteem no worries about exposing family, friends and coworkers to second-hand smoke LEARNING ACTIVITY Handout the AlbertaQuits cost savings wheel. Allow some time for clients to figure out how much they would save if they remained tobacco free. Alberta Health Services Residential Detox Workshop Tobacco Free Futures

299 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 4) Tobacco Use in Recovery 2012 Topic 2: Tobacco and recovery from other addictions There are good reasons to be tobacco-free during detox. Nicotine is a highly addictive substance that is found in tobacco. It acts in the same part of the brain as other addictive substances (Els C., 2008). In fact, tobacco use often goes hand in hand with alcohol or other drug use. It is important to remember that the other chemicals found in tobacco are responsible for the harmful effects, not nicotine (OMA, 2008). WILL STOPPING TOBACCO USE IMPACT RECOVERY FROM ALCOHOL OR SUBSTANCE USE? You might think it s too stressful for you to quit tobacco use while dealing with other addictions or you may have heard the myth that it isn t a good idea to stop using everything at once. Tobacco may trigger a relapse into alcohol or other drug use. In fact it may be easier to quit tobacco use while in recovery. Quitting smoking increases your chances of staying clean and sober from alcohol and other drugs by 25% (Prochaska, J., Delucchi, K., Hall, S., 2004). In long-term recovery there is a higher risk of relapse if you continue to use tobacco. Because the detox facility is tobacco free, you can give yourself a better chance of staying free of alcohol or other drugs. WHAT TO YOU EXPECT WHEN YOU GO WITHOUT TOBACCO It s important to understand how you will feel when you go without tobacco. Your body has become used to the effects of nicotine, and when you go without tobacco your body and brain adjust to getting rid of nicotine. This is a sign that your body is starting to repair itself. This adjustment is what we call withdrawal. [Q] When you have to go without tobacco how do you feel? The eight common symptoms of nicotine withdrawal are (West R., Ussher M., Evans M. & Rashid M., 2006): tobacco cravings irritability restlessness insomnia anxiety depression increased appetite poor concentration People who stop using tobacco products either by choice or by circumstance may start to experience withdrawal symptoms within minutes to hours of last use (Abrams D., Niaura R., Brown R., Emmons K., Goldstein M. & Monti P., 2007). The good news is that there are medications and tips to help with withdrawal. MEDICATIONS TO HELP WITH WITHDRAWAL 4 Residential Detox Workshop Alberta Health Services Alberta Health Services

300 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 5) Tobacco Use in Recovery 2012 Medications can at least double your chances of success. They ease withdrawal symptoms and cravings when you can t use tobacco or while you adjust to quitting. Nicotine Replacement Therapy (NRT) is a proven way to ease the symptoms of nicotine withdrawal. Nicotine gum, patch, inhaler, lozenge, and mouth spray are all available in Canada. In detox, we have the nicotine patch and the nicotine lozenge available to help you. These products provide your body with less nicotine than you would get if you smoked and contain none of the other toxic chemicals that are in tobacco. It s also important to note that the nicotine from the replacement therapies takes a lot longer to get to your brain then when you smoke a cigarette or use chew. This means that there is less of a chance of you getting addicted to the medicines then to cigarettes or chew. Prescription Medications Champix and Zyban The smoking cessation medications available in Canada are called Champix and Zyban. Both are nicotine free and available through a prescription from your doctor. Talk to your doctor or pharmacist for more information. It is important to learn how to use any of these medicines properly in order for them to be effective. Read instructions carefully and talk a nurse or counsellor. TIPS FOR CRAVINGS Cravings usually last no more than 10 to 20 minutes. Some people find the following tips help them with withdrawal and cravings (Fiore M., Bailey W., Cohen S., et al., 2008) (Rogojanski J., Vettese L., Antony M., 2011): Drink lots of water Deep breathe Delay the urge to smoke Do something else to take your mind of the urge Topic 3: Supports when you leave detox ALBERTAQUITS RESOURCES AND SUPPORTS In Alberta there are a number of tobacco support options that are widely available under the umbrella of AlbertaQuits. LEARNING ACTIVITY Handout the AlbertaQuits Brochure and the AlbertaQuits Helpline fax referral. Discuss the various supports available through AlbertaQuits and encourage clients that are interested in further support to complete the fax referral form. AlbertaQuits Helpline is a free telephone service available from 8 am to 8 pm seven days a week for all residents of Alberta toll free at QUIT (7848). They provide translation services in 180 languages. Trained Cessation Counsellors are available to help individuals develop a quit plan, deal with cravings and difficult situations, and provide ongoing support throughout their quit. Patients/clients can initiate their own contact with the helpline or healthcare providers may initiate that contact on behalf of the client/patient by completing the standard fax referral. Alberta Health Services Residential Detox Workshop Tobacco Free Futures

301 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 6) Tobacco Use in Recovery 2012 AlbertaQuits Online An internet-based quit smoking service, available free-of-charge for all Albertans. The online community is available to users 24 hours a day 7 days a week. The site provides expert advice; online peer support, quitting strategies, reminders and more. This community can be accessed at from any computer simply by providing a postal code to verify the user is an Alberta resident. AlbertaQuits Groups Also called QuitCore, these face to face support groups that are available in certain locations across the province. They are facilitated by professionally trained leaders and attended by people looking for peer support, encouragement and advice to help them quit tobacco. The program consists of either six or eight 90-minute sessions over a period of 10 to 14 weeks and incorporates common best practices to help tobacco users quit. More information can be found at or by calling QUIT (7848). ADDICTION TREATMENT PROGRAMS THAT SUPPORT TOBACCO CESSATION The more we learn about how tobacco use impacts recovery, the more we see tobacco supports integrated into addiction treatment. If you are thinking about giving up tobacco while you work on your other addictions, you might be interested in treatment programs that can support your tobacco cessation. A counsellor can help you decide which programs would be a good fit for you. STOP SMOKING MEDICINES ON DISCHARGE If you are thinking about remaining tobacco free when you leave detox, you may want to continue to use the nicotine patch or nicotine gum. A doctor or pharmacist can help you decide which will be the best option for you. Talk to a counsellor about options that might be available to help with the cost of the medications. Optional Topic: Carbon Monoxide Monitor WHAT IS CARBON MONOXIDE? Carbon Monoxide (CO) is a toxic, odourless, colourless, tasteless gas. When inhaled, CO competes with oxygen in the bloodstream. It binds more strongly then oxygen to hemoglobin, a molecule in your blood that carries oxygen and other nutrients to your body tissues. This starves the body tissues of the oxygen vital to repair, regeneration and general living. A simple test with a CO monitor will measure the levels of toxic carbon monoxide (CO) inhaled from tobacco smoke. This gives you an idea of how tobacco is impacting your health and body. Because CO levels return to normal quickly after quitting, if you have been in detox for a few days you will already see an improvement in your reading. INFECTION CONTROL AND MAINTENANCE Washing hands before and after testing is highly recommended for both operator and user as part of a sensible infection control regime. NEVER use alcohol containing hand sanitizer or cleaning products that contain alcohol or other organic solvents as these vapours will damage the sensor within the instrument. The monitor uses disposable cardboard mouthpieces that connect to the monitor via a D-piece. The disposable 6 Residential Detox Workshop Alberta Health Services Alberta Health Services

302 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 7) Tobacco Use in Recovery 2012 cardboard mouthpieces are single-use only as re-use can increase the risk of cross infection. The D-piece contains a one-way valve to prevent patients drawing air back from the monitor. An integrated infection control filter removes and traps >99.9% of airborne bacteria. It is preferable that the user attaches their own mouthpiece to the D-piece before the breath test, and detaches and disposed of it once the test is complete. Whilst the user is exhaling, the operator should avoid positioning themselves in front of the exhaust of the instrument. To clean the CO monitor, wipe the external surfaces of the instrument with a product specifically developed for this purpose such as the instrument cleansing wipes that contain an anitmicrobial liquid that eradicates dangerous bacteria in less than one minute and is laboratory proven to be effective against Norovirus, C. Diff and MRSA. It is recommended that wipes are used once and for one surface only. NEVER use alcohol or cleaning products contain alcohol or other organic solvents as these vapours will damage the sensor within the instrument. Under no circumstances should the instrument be immersed in or splashed with liquid. USING THE CO MONITOR Follow these steps to take a CO reading: 1. Clean the monitor and D-piece as indicated above. Wash your hands with non-alcohol based cleanser. Attach the D-piece to the monitor. 2. Turn the monitor on by pressing and holding down on the blue button. Once the monitor is on, ensure the pointing hand symbol is pointing to the exhaling face. You can change the selection by pushing the blue button. Once you are sure the exhaling face is being pointed to, click the blue button twice quickly (like a computer mouse) to begin the breath test. 3. Have the individual who will be providing the breath sample attach their own disposible cardboard tube. 4. First explain to the individual what they will be expected to do and then double click the blue button, pass the monitor the individual and have them: Immediately take a deep breath Hold breath for 15 seconds as the clock on the monitor counts down Put mouth around cardboard tube when the monitor begins to beep Exhale completely through tube after the monitor beeps a longer beep Breath carbon monoxide is measured in parts per million (ppm CO) and blood carboxyhaemoglobin in percentages (%COHb). The two are compatible and convertible, CO relating to lung/breath and COHb to blood gas some monitors display both. Carbon Monoxide readings demonstrate the levels of poisonous inhaled CO in the lungs while Carboxyhaemoglobin readings show the percentage of vital oxygen that has been replaced in the bloodstream. The cut-off points may vary depending on the CO monitor you use. Check the users guide for specific levels. Also, description of the levels that come with the CO Monitor can be difficult to interpret because they often suggest that a smoker is not addicted if their CO reading is lower than 26 which is often not the case. More meaningful interpretations are provided on in the chart below. Alberta Health Services Residential Detox Workshop Tobacco Free Futures

303 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 8) Tobacco Use in Recovery 2012 CO Reading (ppm) Responses to Exposure 0-2 non-smoker living in an unpolluted environment. <10 16 Smokers can have readings under 10 if they have not smoked for some time or do not inhale. Light smoker or smoker who has not smoked many cigarettes today. Loss of oxygen to vital organs. 32 Legal limit for 8 hour workplace exposure 54 Heavy smoker. Air pollution emergency alert. 60 Smoker who is rarely seen not smoking. Headaches, nausea, nervous system slows down, difficulty thinking clearly, vision difficulties. WHAT CAN AFFECT CO LEVELS? There are several person specific and environmental factors that can impact CO level readings: How deeply you inhale A smoker may be smoking fewer cigarettes and still have higher CO readings if they are smoking more aggressively and inhaling more smoke. This effect can be offset by the use of nicotine replacement therapy (NRT). Type of tobacco Pipe or cigar smoke is much more concentrated and will give surprisingly high COHb readings. Other sources of CO in the environment High ambient levels of CO could give a higher than expected reading. It could be useful to check other family members in order to eliminate possible chronic CO poisoning (for example at home or in the car). Other diseases Lactose intolerance (an allergy to dairy products) produces hydrogen gas in the intestine. Some of this gas may be excreted via the lungs and interfere with CO readings. Alcohol can also influence CO results, such as the acetone from the breath of diabetics. Marijuana Will elevate blood CO (COHb), especially when mixed with tobacco. 8 Residential Detox Workshop Alberta Health Services Alberta Health Services

304 Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 9) Tobacco Use in Recovery 2012 References AADAC. (2007). Tobacco Basics Handbook. Edmonton: Alberta Alcohol and Drug Abuse Commission. Abrams D., Niaura R., Brown R., Emmons K., Goldstein M. & Monti P. (2007). The tobacco dependence treatment handbook: A guide to best practice. New York: Guilford Press. CAN-ADAPPT. (2011, February 28). Retrieved from CAN-ADAPTT Canadian Smoking Cessation Guideline Version 2: Els C. (2008). Tobacco Addiction: What do we know, and where do we go? Edmonton, AB. Fiore M., Bailey W., Cohen S., et al. (2008). Treating Tobacco Use and Dependence. Rockville, MD: US Department of Health and Human Services, Pulbic Health Service. Kalman, D., Baker Morissette, S., & George, T. (2005). Co-Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders. The American Journal on Addictions, 14, OMA. (2008). Rethinking Stop-Smoking Medications: Treatment myths and medical realities. Toronto, ON: Ontario Medical Association Position Paper. Petry N., & Oncken C. (2002). Cigarette Smoking is associated with increased severity of gambling problems in treatment-seeking gamblers. Addiction, 97, Prochaska, J., Delucchi, K., Hall, S. (2004). A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment Recovery. Journal of Consulting and Clinical Psychology, 72 (6), Rogojanski J., Vettese L., Antony M. (2011). Coping with Cigarette Cravings: comparison of suppression versus mindfulness-based strategies. Mindfulness, 2, Statistics Canada. (2010). Canadian Tobacco Use Monitoring Survey (CTUMS). Retrieved November 17, 2012, from USDHHS. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smokingattributable disease: A report of the Surgeon General. Rockville, MD: United States Department of Health and Human Services, Public Health Service. West R., Ussher M., Evans M. & Rashid M. (2006). Assessing DSM-IV nicotine withdrawal symptoms: A comparison and evaluation of five different scales. Psychpharmacology, 184, Alberta Health Services Residential Detox Workshop Tobacco Free Futures

305 Chapter 20 Reproductive Years Alberta Health Services

306 Introduction This chapter is intended to assist health care providers in supporting women and adolescent girls to stop using tobacco. The chapter is divided into the following sections: Women and girls of reproductive age (aged ) Pregnant and postpartum women (aged ) Pregnant and postpartum adolescents (aged 10 17) Each section begins with a summary of the recommendations for behavioural support and pharmacotherapy. In the section for pregnant and postpartum women, a modified version of brief intervention treatment model is also presented. Each section also includes information on the prevalence of tobacco use/exposure, effects of tobacco use/exposure and standards for providing behavioural support and pharmacotherapy. The information included in this chapter is guided by the following evidence-informed approaches, as discussed by Greaves and colleagues in Expecting to Quit: A Best-Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women Woman-centred approach A woman-centred approach prioritizes women s health before, during and after pregnancy. This is a conscious move away from the traditional focus on fetal health, which overlooks the value of supporting a woman to stop using tobacco for her own sake, outside of her capacity to bear a child. From a fetus-centred perspective, there is little incentive for a pregnant woman to maintain cessation after her baby is born, and there is little reason for a mother to quit using tobacco if she can manage to use it away from children. Focusing on the impact of tobacco use on the fetus also causes the woman to feel guilty, which diminishes her self-esteem and confidence in her identity as a good mother. 1 A woman-centred approach enables long-term cessation by building a woman s motivation to quit in order to improve her own health, regardless of whether she is pregnant or cares for children. The rationale for this approach is that by focusing on the mother first, the child also benefits. Woman-centred care builds the woman s sense of value, confidence and self efficacy, supporting her ability to improve her own health and the health of her family Stigma reduction Evolving social attitudes and anti-tobacco efforts have resulted in the stigmatization of tobacco use, especially during pregnancy. Negative public opinion toward tobacco use in general, especially toward women who use tobacco while pregnant or caring for young children, often erodes women s self-image and confidence. It can also cause them to hide their tobacco use from their health-care providers, or resist discussing it in a productive way. When providing tobacco cessation support to women, health-care providers are encouraged to be sensitive to the stigma that pregnant and postpartum tobacco users face, and recognize the ways this can manifest itself in patient-caregiver relationships Tobacco Free Futures

307 3. Harm reduction Some women are not ready to quit using tobacco, or feel they cannot quit at the time of brief tobacco intervention. Quitting may be a low priority for some women for a variety of reasons, such as heavy tobacco use, substance abuse or mental health issues, vulnerability in an abusive relationship or other stressful circumstances. It is important to respect a woman s right to decide what she can and cannot take on. 1 When it is clear that a woman will not consider quitting tobacco now, the emphasis should be on helping her identify the steps she can take to reduce the negative impacts of tobacco use on herself and others. This could include assistance to reduce her tobacco use, improve her nutrition or reduce the impact of second-and third-hand smoke on others. It may also include helping her determine whether nicotine replacement therapy (NRT) would be the best option to help her reduce the harmful impacts of tobacco use Trauma-informed care There is a strong correlation between substance use and the experience of trauma, including domestic violence. The prevalence of smoking among women who have experienced trauma is between two and four times higher than that of women who have not. 1 Women who have experienced trauma, either in childhood or adulthood, respond differently to health promotion efforts, especially those that can be seen as confrontational or directive, than women who have not. Trauma-informed care is sensitive to these differences, and is characterized by trauma awareness (understanding trauma and being alert to the potential traumatic histories of clients accessing a service), an emphasis on safety (avoiding potential triggers for re traumatization and providing physical and emotional safety), empowering environments (giving clients personal control) and emphasizing clients strengths and skill building. 1 Further information about trauma-informed care is available from and Exposure to environmental tobacco smoke is a significant concern for women and girls during the reproductive years. Tobacco smoke is classified into three categories: 1. First-hand smoke, which is inhaled by the person smoking 2. Second-hand smoke, which is either exhaled by a person who smokes or released from the end of a burning cigarette 3. Third-hand smoke, which refers to the tobacco smoke residue and gases that are left behind on surfaces, upholstery, clothing, draperies and carpets, and in vehicles, after a cigarette has been smoked Refer to chapter 2 ( The Effects of Tobacco Exposure ) for more information on these types of tobacco smoke. Alberta Health Services

308 Women and girls of reproductive age (NOT PREGNANT OR BREASTFEEDING) The information in this section provides information on providing tobacco cessation support to women (aged ) and girls (aged 10 17) of reproductive age who are not currently pregnant or breastfeeding. Recommendations for treatment of this population are summarized in Table Table 20.1: Tobacco Free Futures Summary Recommendations for Supporting Women and Girls of Reproductive Age to Stop Using Tobacco To support women who are not pregnant or breastfeeding to stop using tobacco, use the standard 5A s as per the guidelines outlined in chapter 7 ( Brief Intervention ). To support adolescent girls who are not pregnant or breastfeeding to stop using tobacco, use the 5A s for adolescents as per the guidelines outlined in chapter 21 ( Youth and Family ). Provide women who are not pregnant or breastfeeding with pharmacotherapy support as per the guidelines outlined in chapter 9 ( Pharmacotherapy ). Provide adolescent girls who are not pregnant or breastfeeding with pharmacotherapy support as per the guidelines outlined in chapter 21 ( Youth and Family ). Offer behavioural support alongside pharmacotherapy to both women and adolescent girls of reproductive age as outlined in chapter 8 ( Intensive Cessation Counselling ). Prevalence According to the Canadian Tobacco Use Monitoring Survey (CTUMS), 16% of Canadians aged 25 years and older (about 3.9 million) currently smoked in 2012, a figure that is unchanged from 2011 (17%), but lower than the rate in 2001 (21%). 2 In this age group, a higher percentage of men than women smoked daily or occasionally (19% of men compared with 14% of women). Men who smoked daily consumed an average of 17.4 cigarettes per day, a higher number than for women (12.9). 2 Tobacco use among women and adolescent girls is declining nationally. 2 However; it is still a significant health risk to many women and girls. In Alberta, 18% of women aged 25 and older smoked daily or occasionally in 2012, compared to 17% of men in the same age group. 2 Smoking among youth aged 15 to 19 had a prevalence of 11% (approximately 233,000). While this is virtually unchanged from the 12% reported in 2011, it is the lowest rate of current smoking recorded for this age group since Health Canada first reported smoking prevalence, and it is lower than the rate reported in 2001 (22%). Seven percent of youth reported smoking daily, consuming an average of 11.1 cigarettes per day, while 4% of youth reported smoking occasionally. A higher percentage of male than female youth reported currently smoking (12% and 9%, respectively) Tobacco Free Futures

309 In Alberta, 16% of females aged smoked daily or occasionally in 2012, compared to 19% of males in the same age group. 2 The prevalence of spit tobacco, also known as smokeless tobacco, use is lower than the prevalence of other tobacco product use, especially among women and adolescent girls compared to men and adolescent boys. CTUMS data indicates that 8% of Canadians aged 15 and older reported having ever tried spit tobacco products, but does not differentiate this statistic by gender. 2 Among young people, 5% of youth aged and 12% of young adults aged reported having ever tried spit tobacco. The prevalence of spit tobacco use within the past 30 days was under 1% for Canadians aged 15 years and older, 1% for youth aged and 2% for young adults aged While these statistics do not differentiate by gender, Youth Smoking Survey data indicates that 7.1% of boys between grades 6 and 12 have ever tried spit tobacco, compared to 1.5% of girls. 3 In 2010, Alberta sales of spit tobacco comprised 39% of overall national sales. 5 The prevalence of spit tobacco use is significantly higher for Alberta males aged but remains relatively low for females in this age group. However, despite the low prevalence, it is important to screen using language that is inclusive of all types of tobacco use including spit. Impact of tobacco use The full extent of the effects of tobacco use on women is not fully understood because of large gaps that currently exist in the biomedical research However, as reported by Ontario s Program Training and Consultation Centre, smoking is known to cause the following health risks for women: 6 Tobacco affects the health of women and girls differently than it affects men and boys. 6 Cardiovascular disease: Smoking is a major cause of cardiovascular disease, a term that refers to more than one disease of the circulatory system, including the heart and blood vessels, whether the blood vessels are affecting the lungs, the brain, kidneys or other parts of the body. Women who smoke as little as 1 4 cigarettes each day have twice the risk of cardiovascular disease as women who have never smoked. 6 Lung cancer: Smoking causes about 80% of lung cancer deaths in women. The risk of dying from lung cancer is about 13 times higher among women who smoke cigarettes compared with women who have never smoked. 6 Breast cancer: There is a causal association between active smoking (someone intentionally inhaling tobacco smoke) and both pre- and postmenopausal breast cancer. There is also a causal relationship between second-hand smoke and breast cancer in younger, primarily pre-menopausal women who have never smoked. There is currently insufficient evidence to make similar conclusions between second-hand smoke exposure and post-menopausal breast cancer. 6 Other cancers: In addition to lung and breast cancer, women who smoke have increased risks of cancers of the mouth and throat, esophagus, larynx (voice box), bladder, pancreas, liver, colon, rectum, cervix and kidneys. Smoking also appears to increase the risk for some types of ovarian tumours. 6 Chronic obstructive pulmonary disease (COPD): Women who smoke have markedly increased risks of developing and dying of COPD, which is a respiratory disease affecting both the airways and alveolar sacs of the lungs. Over time, as the disease advances, breathing difficulties can result in severe disability and death. The risk increases with the number of cigarettes smoked per day. 6 Alberta Health Services

310 Osteoporosis: Smoking causes loss of bone mass in both men and women, leading to higher risk of fracture. In particular, a meta-analysis of data from postmenopausal women demonstrates that smoking increases the risk of hip fracture. The U.S. Surgeon General has estimated the risk of hip fracture to be 55% higher in people who smoke than in those who do not smoke (male and female). 6 Reproductive health and pregnancy: Smoking has profound effects on women s reproductive health and menstrual function. Women who smoke are more likely to experience primary and secondary infertility and delays in conceiving as compared to non-smoking women. 6 Other health issues: The health effects of tobacco use mentioned above is not exhaustive. Research is ongoing, with causality and possible new links of diseases continuing to be discovered, especially in tobacco users who are genetically predisposed. 6 Please refer to chapter 21 ( Youth and Family ) for a discussion of the impact of tobacco use among adolescent girls. Treatment considerations Brief tobacco intervention While the 5A s are considered clinical best practice for the general population, there is a lack of research on how best to adapt this approach for use with women and girls of reproductive age. A review of the literature on smoking cessation interventions for women indicates that the standard 5A s approach is used with this population group, although there are numerous studies that indicate that women face unique barriers to quitting. 7,8,9 These include: concern for the potential for weight gain Women face different barriers to quitting tobacco use than men do. 7,8,9 nicotine replacement therapy (NRT) (especially gum and patches) may not be as effective for women, due to hormonal, physiological and pharmacokinetic differences that exist and become more prevalent in pregnancy tobacco withdrawal symptoms and responses to tobacco cessation pharmacotherapy vary by menstrual cycle phase greater likelihood of depression women experience greater rewarding effects of nicotine and more intense stress produced by withdrawal than men male partners have been shown to provide less effective support to women than women give to men women may be more susceptible to environmental cues (e.g., friends and moods) associated with the tobacco use ritual women have more non-pharmacologic cues/motives that reinforce tobacco use (e.g., for socialization) some women enjoy the feeling of control associated with tobacco use 20.6 Tobacco Free Futures

311 Intensive cessation support The United States clinical practice guideline for treating tobacco use and dependence indicates that women are more likely to seek assistance in their quit attempts than are men. 7 Its research suggests that women benefit from the same interventions as men do, although the data are mixed on whether they benefit as much as men do. As mentioned previously, the characteristics of nicotine dependence among women are different than those in men. This means that women face unique stressors and barriers to quitting. Women have also been found to be less likely to quit successfully than men, and require more interventions to successfully quit than men do. 10 They also require targeted approaches to prevent smoking initiation. For these reasons, there is a need for clinical approaches that are sensitive to the unique nature of women s neurological and psychosocial responses to tobacco use. 11 Despite the need for targeted interventions for women, there is a lack of research available on best practice interventions specific to women. While there is a wealth of research on interventions for adults as a group, and for pregnant women as a group, comparatively little research has been done on interventions for women who are not pregnant. Greaves and colleagues highlight the need for woman-centred approaches that go beyond a woman s capacity for carrying a child: Because the approach to cessation during pregnancy seems motivated primarily by a desire to lessen the deleterious effects of smoking on fetal health, it has framed the interventions on fetal health outcomes and confined them largely to the period of pregnancy. As a result, pre-pregnancy and post-pregnancy tobacco cessation interventions, which would focus primarily on women s health, have garnered proportionately less attention and emphasis. As Jacobson claimed in 1986, in rich countries, most women are not pregnant most of the time, which led her to conclude that smoking cessation campaigns ignore most women most of the time. 1 Research does, however, point to the increased importance of intensive cessation support, in general, for women over men. Intensive interventions may be better able to address the unique psychosocial issues women face while attempting to quit using tobacco, such as concerns over weight gain and a greater sensitivity to environmental and social cues. 12 Women are also significantly more likely than men to list social factors, such as support from peers or family members, as the reason for quitting, indicating that there may be additional utility for women in intensive supports that include social support elements. 13 The increased importance of these interventions in women versus Women quit more successfully when they access a combination of behavioural cessation support and pharmacotherapy than when they access either support on its own. 14,15 men is shown particularly in their effects when implemented in addition to pharmacological support. Implementing high-intensity interventions in conjunction with pharmacological treatments significantly improves long-term cessation results in women, and is of much greater importance in determining outcomes for women than for men. 14,15 There is a similar lack of research on intensive interventions for teenage girls who are not pregnant, although it is likely that they would benefit from a targeted approach. For more information, see the discussion on intensive cessation support for youth and adolescents in chapter 21 ( Youth and Family ). Alberta Health Services

312 Pre-conception cessation support All women and girls of reproductive age should be screened for tobacco use. Those who are currently using tobacco should be encouraged to quit for their own health, regardless of whether they are planning to have a child. Those who are planning to have a child or are at risk of becoming pregnant should be provided with targeted support to stop using tobacco before they conceive. Pre-conception cessation strategies to reduce harm to the infant from prenatal tobacco exposure include 16 encouraging each man, woman and couple to have a reproductive life plan that includes tobacco reduction improving public awareness of the importance of preconception health behaviours and seeking support and services providing a risk assessment, education and health promotion counselling to women and girls of reproductive age to reduce risk and improve pregnancy outcomes supporting tobacco-using women who are in the interconception care period (between pregnancies) and offer intensive intervention when a previous pregnancy has had an adverse outcome (e.g., infant death, low birth weight, preterm birth) offering tobacco education and intervention at pre-pregnancy check-ups to those considering conceiving Pharmacological interventions Research on pharmacological cessation interventions for women of reproductive age suffers from a lack of gender-differentiated studies and best practice recommendations. Most of these instead address the general adult population, without detailing how to tailor treatment to achieve better outcomes specifically for women. However, there is considerable research pointing to the decreased long-term efficacy of pharmacological interventions when given in isolation for women versus men generally, and to variable outcomes based on the type of drug and concurrent interventions used. Nicotine replacement therapy Cessation trials using NRT have consistently reported lower long-term quit rates for women versus men. 17 The reasons for the difference are not well understood, but studies indicate that it may be attributed more to non-nicotine factors (e.g., the sensory effects of smoke inhalation, conditioned responses to smoke stimuli and secondary social reinforcement of smoking behaviours) than to the effects of the nicotine itself, given that women have demonstrated a reduced neural sensitivity to the effects of nicotine. 12 Pharmacotherapy options for women of reproductive age include NRT, bupropion and varenicline. These options are effective for women, but may not be as effective as they are for men. 14, Tobacco Free Futures

313 Bupropion and varenicline Cessation trials using bupropion show similar results to NRT trials, with women attaining lower overall cessation rates after being treated with the drug than men. 18 Trials of varenicline demonstrated significantly higher likelihood of participants quitting compared to bupriopion SR. Cessation rates of varenicline are significant compared to a matching oral placebo, however, show no difference between sexes. 19 Varenicline and buproprion are effective pharmacological options that can be considered as pharmacological options, subject to the general clinical guidelines and contraindications applicable to the patient Discussion Despite the indication that pharmacotherapy treatments are less effective for women than men, they still increase women s chances of quitting and can be used to assist women of reproductive age with smoking cessation. Considerable research still points to NRT significantly increasing cessation outcomes for women in general. 20,21,22 Additionally, while there are poorer outcomes for women than men with bupropion, women are still twice as likely to quit using bupropion than with a placebo, indicating that the pharmacological effect, if not the outcome, might be similar across genders. 22 Providing behavioural supports concurrently with pharmacological support significantly improves outcomes for women. 13 Research has consistently demonstrated that the availability of behavioural supports provided concurrently with the chosen pharmacological intervention increases outcomes significantly for women, potentially due to a better ability to address the non-nicotine factors influencing addiction. 14,15,22 There is some evidence that women may not be advised about pharmacological cessation supports as often as men. 23 Despite differential outcomes, and irrespective of which treatment is recommended (whether on its own, or in addition to others), it is important to ensure that pharmacological treatments are offered to women in instances where clinical guidelines indicate they are warranted. No published research or clinical guidelines were identified for pharmacological treatments specifically for teenage girls who are not pregnant. Please refer to the discussion on pharmacological support for adolescents in chapter 21 ( Youth and Family ). Pregnant and postpartum women The information in this section provides information on providing tobacco cessation support to women (aged ) who are either pregnant or gave birth to a child in the last year. Figure 20.1 outlines the recommended brief intervention treatment model for pregnant and postpartum women. Detailed considerations related to implementing this model are discussed in Table Alberta Health Services

314 Figure 20.1: Tobacco Free Futures: Brief Intervention Model for Pregnant and Postpartum Women Tobacco use prevention and cessation treatment Ask every patient/client about tobacco use. Use multiple choice options to increase disclosure. Document as per approved practice. ask Please choose the statement that best describes your current tobacco use (all types) 1. I have never used any kind of tobacco product. 2. I stopped using tobacco before I found out I was pregnant, and I am not using it now. 3. I stopped using tobacco after I found out I was pregnant, and I am not using it now. 4. I use tobacco some now, but I have cut down since I found out I was pregnant. 5. I use tobacco regularly now, about the same as before I found out I was pregnant. If 3, 4 or 5 What type? How much? How often? Last use? NO &5 Positive reinforcement. Positive reinforcement. Focus on relapse prevention. Acknowledge harm reduction. Support autonomy. Ask about exposure to second- and third-hand smoke (SHS and THS). Document as per approved practice. Does anyone use tobacco products in your home or vehicles? Have you (and/or your child/children) been exposed to SHS or THS? YES Advise Advise to quit with a personalized message focusing on women-centred approach to reduce stigma and support long-term abstinence. Advise about the importance of smoke-free environments. Inform of AHS Tobacco and Smoke Free Environments Policy as appropriate. Document as per approved practice. Not using tobacco is one of the best things for your health, as well as the health of your children. There is no safe level of exposure to SHS. YES Assess Assess readiness to stop or reduce tobacco use. Assess interest in temporary or permanent cessation support. Assess interest in making environment tobacco-free. Document as per approved practice. On a scale of 1-10, how important is it to you to quit or reduce your tobacco use? Are you interested in support to help you quit? Are you interested in support to make your home and vehicle tobacco-free? YES NO Support autonomy. Leave offer of support open. Monitor withdrawal for inpatients. Document as per approved practice. Assess mental status. Document as per approved practice. (e.g., Edinburgh Postpartum Depression Scale or PHQ-2) Assist Offer self-help resources. Link to behavioural counselling to support reduction, quit or relapse prevention as appropriate. Support pharmacotherapy if behavioural support is unsuccessful including: linking to prescribing authority and/or ordering medication, ongoing monitoring of withdrawal symptoms and mood assessment. Document as per approved practice. Arrange Arrange further support by completing appropriate onsite and/or linked referral(s). Arrange for continued pharmacotherapy if appropriate. Document as per approved practice Tobacco Free Futures

315 Table 20.2: Tobacco Free Futures Summary Recommendations for Supporting Pregnant and Postpartum Women to Stop Using Tobacco Behavioural cessation support (e.g., multiple counseling sessions, motivational interviewing, cognitive behavioral therapy) is recommended as first line treatment before pharmacotherapy at all points during pregnancy. NRT should only be offered during pregnancy when counselling has failed and after an informed discussion with the patient regarding the risks and benefits of using tobacco and NRT. Low-dose, intermittent-delivery NRTs (e.g., lozenges, gum, buccal inhalers or mouth spray) are preferred over continuous dosing of the patch. New mothers should be encouraged to breastfeed, even if they are using tobacco or NRT. Bupropion and varenicline should only be considered with pregnant and breastfeeding women after behavioural interventions and NRT have failed. Prior to initiating either treatment, advise women that current research does not conclusively demonstrate the efficacy and safety of either of these medications in pregnancy and lactation, and discuss the risks and benefits of using them versus using tobacco. Prevalence Smoking during pregnancy is declining in Canada, from 17.7% in 2001 to 13.4% in ,25,26 Data from Alberta indicates a similar trend, dropping from 24.8% in 1999 to 13.8% in Within Alberta, there is a wide variation in prevalence between Alberta Health Services zones, ranging from a high of 21.6% in the Central Zone to a low of 9.1% in the Calgary Zone. It is important to note that these statistics are based on self-reported incidences of tobacco use, not biochemical indicators. Because of the stigma associated with tobacco use, especially during pregnancy, it is likely that many women do not report their tobacco use, meaning the prevalence is actually higher than the available data suggests. Tobacco use during pregnancy is declining in Alberta. 27 However, it is still a leading cause of health problems for mothers and adverse birth outcomes for newborns. 28 Alberta Health Services

316 Figure 20.2: Maternal Smoking, Alberta, by Zone of Residence, While there is little data on the prevalence of spit tobacco use among pregnant women, estimates based on non-pregnant women suggest that the prevalence is less than 1%. 2 However, despite the relatively low prevalence of spit tobacco use compared to smoking, it is important to screen using language that is inclusive of all tobacco use, rather than asking only about smoking. Prevalence statistics aside, tobacco use during pregnancy continues to be a leading cause of health problems for mothers and adverse birth outcomes for newborns Tobacco Free Futures

317 Impact of tobacco use Tobacco use during pregnancy not only affects the health of the mother, fetus and newborn, but also continues to affect the health of the child as he or she grows up. The known effects of tobacco on pregnant women and their children are summarized in Table Table 20.3: Effects of Tobacco Use During Pregnancy on Women and Their Children For the mother: 1 lower estrogen levels, leading to early menopause and subfertility increased risk of cardiovascular diseases increased risk of pulmonary diseases decreased production of breast milk and duration of breastfeeding in early months For the fetus: 28 increased risk of ectopic pregnancy (implantation of the embryo outside the uterine cavity) increased risk of spontaneous abortion (miscarriage) increased risk of preterm labour increased risk of premature rupture of membranes increased risk of placental problems (previa and abruption) growth restrictions For the newborn child: 28,29 low birth weight (on average approximately 200 grams smaller) increased risk of fetal and neonatal mortality increased risk of congenital malformations increased risk of admission to the neonatal intensive care unit (NICU) increased risk of sudden infant death syndrome (SIDS) decreased volume of breast milk available and shortened duration of breastfeeding in early months For the older child: 28 increased risk of childhood respiratory illnesses (e.g., asthma, pneumonia, bronchitis) increased risk of other childhood medical problems (e.g., ear infections) increased risk of learning problems (e.g., difficulties with reading, mathematics, general ability) increased risk of behavioural problems increased risk of attention deficit hyperactivity disorder (ADHD) Alberta Health Services

318 Readiness to quit Women are more likely to quit using tobacco when they are pregnant. As described by Chamberlain and colleagues, a higher proportion of women stop smoking during pregnancy than at other times in their lives. 30 They describe the characteristics of women who spontaneously quit (i.e., women who smoked prior to conception but quit on their own shortly after becoming pregnant and before entering prenatal care) as follows: Women are more likely to quit using tobacco when they are pregnant than when they are not. 30 Up to 49% of women who smoked before pregnancy spontaneously quit before their first antenatal visit, a quit rate substantially higher than reported in the general population. However, these spontaneous quitting rates may be lower among women with lower socio economic status. There are significant psychosocial differences between women who spontaneously quit and women who continue to smoke in late pregnancy. Women who spontaneously quit usually smoke less, are more likely to have stopped smoking before, have a nonsmoking partner, have more support and encouragement at home for quitting, are less seriously addicted, and have stronger beliefs about the dangers of smoking. Pregnant women are also more likely to use coping strategies to avoid relapse than non-pregnant women, however less than a third of these women remain abstinent after one year postpartum, supporting qualitative evidence that many women see pregnancy as a temporary period of abstinence for the sake of the baby. Despite high relapse rates, some studies suggest that the long-term effects of spontaneous quitting in pregnancy are significant, and others argue this success is important to recognise to avoid pathologising smoking cessation and eroding confidence in human agency to overcome problems. 30 Greaves and colleagues highlight the need to encourage motivation among pregnant women who smoke to quit for their own sake, not just that of their baby. 1 The majority of smoking interventions for women focus on the period of time that they are pregnant, and aim to build on their motivation to quit for the sake of the baby. This focus on fetal health not only diminishes the value of women s health and treats the woman primarily as a reproductive vessel, but also fails to address a more long-term motivation for becoming and remaining abstinent from tobacco after the baby is born. 1 Quitting and stress A commonly held misperception is that quitting tobacco use during pregnancy causes stress to the mother that would harm the baby more than tobacco use does, and therefore pregnant women should not attempt to quit until after the baby is born. 31 Quitting tobacco use during pregnancy is not harmful to the fetus. 31 While many people believe that tobacco use relaxes them, it actually creates physiological stress symptoms such as elevated heart rate and blood pressure. Pregnant women should be encouraged to quit as early in their pregnancy as possible, but the fetus will benefit even if the mother quits late in the pregnancy Tobacco Free Futures

319 Partner and social support A woman s readiness to quit is strongly influenced by her partner s tobacco use status and the prevalence of tobacco use within her immediate social circle. It is also dependent on her perception of the level of support she can expect from her partner and friends. When providing support, it is important to acknowledge the presence of people who smoke in the lives of pregnant women and to determine the dynamics of those relationships. The tobacco use of a woman s partner, close family and friends must be considered when assisting her effort to quit using tobacco. 1 As described by Greaves and colleagues, women who smoke often use smoking to organize, bind and sometimes disengage from their social relationships. Pregnant women have these and other complicating factors overlaid on their use of tobacco, compounded by their views regarding fetal health and whether or not these views coincide with those of their partners and friends. 1 While it is necessary to pursue information about a partner s smoking behaviour and try to intervene, it is crucial to do so in a way that respects the complex social dynamics within couples and between friends. It is critical to acknowledge power, control and abuse issues between partners in a way that ensures women s safety. 1 Further information and support for women and their partners is available in the handbook Couples and Smoking: What You Need to Know When You are Pregnant available from Nicotine dependence and withdrawal Some women may have higher motivation to quit using tobacco when they are pregnant, but many also face unique barriers to quitting during pregnancy. Pregnant women seem to metabolize and clear nicotine from the body faster than non-pregnant women, making quitting more difficult. 32,33 The physiological adaptations in pregnancy that accelerate nicotine metabolism may also cause more negative feelings of so-called nicotine hunger and unpleasant symptoms associated with nicotine withdrawal. 34,35 As a result, some pregnant women who use nicotine replacement therapy find they need a higher dosage to help them manage withdrawal symptoms. For more information, please refer to the content pharmacotherapy that follows. CAN-ADAPTT smoking cessation guidelines The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice informed Tobacco Treatment (CAN-ADAPTT) is a practice-based research network facilitating research and knowledge exchange among practitioners, researchers and policy makers in the area of tobacco cessation. CAN-ADAPTT s Guideline for Smoking Cessation is intended to guide practice and is not intended to serve as a comprehensive overview of tobacco cessation management. 28 Table 20.4 outlines the summary statements that have been developed to guide tobacco treatment for pregnant and breastfeeding women. Alberta Health Services

320 Table 20.4: CAN-ADAPTT Guidelines for Pregnant and Breastfeeding Women 28 ADVISE assist Tobacco cessation should be encouraged for all pregnant, breastfeeding and postpartum women. GRADE: 1A A smoke-free home environment should be encouraged for pregnant and breastfeeding women to avoid exposure to second-hand smoke. GRADE: 1B During pregnancy and breastfeeding, counselling is recommended as first line treatment for tobacco cessation. GRADE: 1A If counselling is found ineffective, intermittent dosing nicotine replacement therapies (e.g., lozenges, gum) are preferred over continuous dosing of the patch after a risk-benefit analysis. GRADE: 1C Partners, friends and family members should also be offered tobacco cessation interventions. GRADE: 2B Grades of evidence are based on the strength of the recommendation (1=strong, 2=weak,) and the quality of the evidence (A=high, B=moderate, C=low) For more information on the CAN-ADAPTT Guidelines, visit: Treatment considerations Brief tobacco intervention The brief intervention (5A s) approach targeted especially for pregnant and postpartum women was introduced in Figure The standard 5A s outlined in chapter 7 ( Brief Intervention ), the public health 5A s outlined in chapter 17 ( Public Health ), and the 5A s for pregnant and postpartum women outlined by the American College of Obstetricians and Gynecologists, have been combined and modified to consider the unique needs of pregnant and postpartum women within the Alberta context. Many health-care providers have the opportunity to provide tobacco intervention support to pregnant and postpartum women, including but not limited to prenatal care providers (including family doctors, obstetricians and midwives) prenatal educators NICU nurses public health nurses (including those conducting early postpartum visits and well child visits) pharmacists lactation consultants Table 20.5 outlines factors for health professionals to consider when implementing the 5A s model for pregnant and postpartum women Tobacco Free Futures

321 Table 20.5: Treatment Model: Considerations for Pregnant and Postpartum Women and Girls Model component Considerations ASK ASK all patients clients if they have used tobacco before or during pregnancy. ASK about patterns of use. ASK about exposure to second- and thirdhand smoke. Screening for tobacco use should occur automatically as part of the initial history. Societal stigma about tobacco use, especially during pregnancy, may cause some patients to feel uncomfortable discussing whether they use tobacco and how much. Some data suggest that 13% to 26% of pregnant women who use tobacco may not disclose that they use tobacco when asked about it as a part of a routine clinical interview. 36 The manner in which health-care providers ask about tobacco use status during the initial appointment can dramatically improve the accuracy of the response. Rather than asking AHS s standardized yes-no question Have you or anyone in your home used any tobacco products in the past year?, a multiple-choice response is recommended to improve disclosure with pregnant and postpartum women, and to provide useful information for counselling. This approach has been shown to improve disclosure by 40% for all women, including those of various ethnic backgrounds. 36 The multiple-choice response format has been shown to be effective whether delivered verbally or in written form. The recommended question to determine women s tobacco use status is: Please choose the statement that best describes your current tobacco use (including smoking and spit tobacco use): 1. I have never used any kind of tobacco product. 2. I stopped using tobacco before I found out I was pregnant, and I am not using it now. 3. I stopped using tobacco after I found out I was pregnant, and I am not using it now. 4. I use tobacco sometimes now, but I have cut down since I found out I was pregnant. 5. I use tobacco regularly now, about the same as before I found out I was pregnant. In addition to asking about the woman s tobacco use, ask about the tobacco use status of those she lives with, which may indicate her exposure to second- and third-hand smoke. It may also help determine how much support women who are using tobacco will have in quitting and avoiding relapse. Congratulate recent quitters for having quit, and reiterate the importance of staying tobacco free and avoiding situations where others are using tobacco. Let all women know that you will be asking how she is doing at future visits. Tobacco use is one of only a few important risk factors that can be modified and should therefore be tracked as a vital sign at every visit, just as blood pressure would be tracked. 7 Document both the tobacco use of the woman and those she lives with at every visit. Electronic or paper forms used in clinics/units should be modified to document the ask. Alberta Health Services

322 Table 20.5: (continued) Model component Considerations advise ADVISE to quit and/or remain tobacco free with a personalized message. ADVISE about the importance of a tobacco-free home and vehicle. ADVISE of AHS Tobacco and Smoke Free Environments Policy as appropriate. Advice to quit should be clear, supportive and personalized, with unequivocal messages about the benefits of quitting for both the patient and her baby. An effective way to start the discussion about quitting is to say, Not using tobacco is one of the best things for your health, as well as the health of your children. Use positive language and focus on the positive benefits of quitting. Although health-care providers are keenly aware of the short- and long term health risks tobacco use poses to mothers and their families, it is common for patients to minimize risks, especially if they or people they know have had uncomplicated, healthy pregnancies while smoking. Consider the following messages: 36 Impacts for women: You will be less likely to develop heart disease, stroke, lung cancer, chronic lung disease and other smoke-related diseases. You will have more energy and won t feel as tired. Your blood pressure and pulse rate will drop and your circulation will improve, making exercise easier. You will cough less and breathe more easily. You will have fewer sinus congestions and colds. You will be more likely to live to know your grandchildren. You will have more money to spend on other things. Your clothes, hair and home will smell better. Your senses of taste and smell will improve. You will feel good about what you have done for yourself and your family. Impacts for baby: Your baby will get more oxygen, even after just one day of not smoking. Your baby is less likely to have bronchitis and asthma. There is less risk that your baby will be born too early. There is a better chance that you and your baby will be discharged from the hospital at the same time. Acknowledge barriers to quitting while providing encouragement. If a woman suggests cutting down as a strategy, let her know that while reducing her consumption may reduce her health risks, quitting altogether is the best thing she can do for herself and her family. 36 Communicate clear, supportive advice to quit without admonishing or making the patient feel criticized. Be sensitive to the stigma of tobacco use during pregnancy and the possibility that the woman may have experienced trauma. See the discussion of stigma reduction and traumainformed care earlier in this chapter. Electronic or paper forms used in clinics/units should be modified to document the advise Tobacco Free Futures

323 Table 20.5: (continued) Model component Considerations assess ASSESS readiness to quit or reduce tobacco use. ASSESS interest in cessation support. ASSESS interest in tobacco-free homes and vehicles. ASSESS mental status. Assess the patient s interest in quitting or reducing harm using the following questions: On a scale of 1 10, how important is it to you to quit or reduce your tobacco use? Are you interested in support to help you quit? For women who are not yet ready to quit, if time permits, use techniques designed to increase the patient s motivation to quit (e.g., motivational interventions) as outlined in chapter 8 ( Intensive Cessation Counselling ). Work to reduce harm by offering support to create a smoke-free environment in the home, using the following question: Are you interested in information to help make your home and car tobacco free? A tobacco-free environment in the home can be achieved by making the following suggestions: making the home and vehicle tobacco free moving all smoking outside cracking a window open does not prevent harm using a smoking jacket when going outside to smoke removing the smoking jacket and washing hands to remove smoking residue before holding babies and children putting up signs to remind others not to smoke in the home washing clothes, bedding and toys that have been exposed to smoke painting walls, washing fabrics and surfaces, and replacing belongings, if necessary Women with untreated mental health conditions (e.g., depression) are at a higher risk for tobacco dependence, and may already be using bupropion as an anti-depressant. Assess and document the woman s state of mental health using standard approved practice. The Edinburgh Postnatal Depression Scale (EPDS) is used widely throughout Alberta as an initial screening tool to identify postpartum depression. The Personal Health Questionnaire-2 (PHQ-2) is an alternate brief depression screening tool and is discussed in chapter 9 ( Pharmacotherapy ). Electronic or paper forms used in clinics/units should be modified to document the assessments. Alberta Health Services

324 Table 20.5: (continued) Model component Considerations assist arrange ASSIST the client/ patient who is ready to quit, reduce or prevent relapse with self-support materials and brief information and links to behavioural counselling. ASSIST when appropriate with pharmacotherapy for withdrawal support. ASSIST the client/ patient who is not ready to quit or reduce by supporting autonomy. ARRANGE link to ongoing behavioural support. ARRANGE continued pharmacotherapy, as appropriate. Provide pregnancy-specific self-help materials and other tobacco cessation supports. Resources are available from the online resource catalogue at Albertaquits.ca, including Baby Steps: A Guide to Help Pregnant and Postpartum Women Quit Smoking The Right Time, The Right Reasons: Dads Talk about Reducing and Quitting Smoking Link to onsite behavioural support, if available (e.g., for inpatients), and discuss available referral options. Consider links to behavioural support for those who may need relapse prevention support (e.g., developing a postpartum relapse prevention plan for those in their last month of pregnancy). If pharmacotherapy is identified as appropriate (if behavioural support is unsuccessful or the woman is unwilling to quit, but will consider use of a cessation aid temporarily), provide link to prescriber and/or facilitate order. Encourage problem-solving techniques to help the woman cope with cravings, withdrawal symptoms or social situations. Provide ongoing monitoring for withdrawal and mood assessment. Provide a positive, supportive social environment in the clinic/unit. Help the woman identify people in her own environment who can help and encourage her to quit. It is important to be sensitive to the possibility of disapproval from partners and co-habitants. Ensure the woman s safety prior to suggesting she ask her partner or other co-habitants to help her quit. In cases where the woman does not feel comfortable asking for support from her partner or other co-habitants, advise her to stay away from second-hand smoke wherever possible, and refer her to confidential sources of support. Electronic or paper forms used in clinics/units should be modified to document the assist. Link to ongoing supports such as the AlbertaQuits helpline, preferably by fax (or electronically, if available), as referrals completed by health professionals are more effective than asking a client/patient to self refer Appendix 7(b) Ensure that the 5A s approach is continued throughout pregnancy, and, where possible, after delivery. Continue to ask all women, whether or not they have quit, about their tobacco use status throughout the duration of care. When possible, visits should allow time to monitor the woman s progress, reinforce the steps she is taking to quit and promote problem-solving skills. Clinics could consider offering Quitcore group cessation support as a service at their site Tobacco Free Futures

325 Breastfeeding mothers New mothers who use tobacco are advised to continue breastfeeding while they attempt to quit. Although small amounts of nicotine passes through to the breast milk, the benefits of breastfeeding to the newborn outweigh the negative impact of nicotine and other contaminants passing through the breast milk. 37,38 New mothers who use tobacco are advised to continue to breastfeed while they attempt to 37, 38 quit. Nicotine ingested through breast milk may cause the baby to refuse feedings, be cranky, sleep poorly and spit up Mothers who use tobacco may also have a reduced milk supply. 43,44 They are therefore advised to time their tobacco use to right after the baby nurses, to help the nicotine clear from their milk before the next feeding. 37 Refer women who are having difficulty breastfeeding to a lactation consultant or other healthcare providers knowledgeable about breastfeeding. Intensive cessation support Numerous studies and reviews have been conducted to determine which types of interventions are most effective in assisting pregnant and postpartum women to stop smoking. 1,30 Unfortunately, none has been able to identify which interventions are most consistently effective across this population. Among studies that demonstrate effectiveness in helping pregnant women quit using tobacco, the interventions summarized in Table 20.6 commonly appear. 1,30 Table 20.6: Effective Behavioural Support for Pregnant and Postpartum Women 1,30 Tobacco Intervention Brief intervention and intensive counselling are interventions that provide motivation to quit, support to increase problem solving and coping skills, and may incorporate trans-theoretical models of change. This includes interventions such as motivational interviewing, cognitive behaviour therapy, psychotherapy, relaxation, problem solving facilitation and other strategies. Health education interventions are those where women are provided with information about the risks of smoking and advice to quit, but are not given further tailored support or advice about how to make this change. They include interventions where the woman was provided with automated support such as self-help manuals or automated text messaging, but no personal interaction. Self-help manuals often take the form of a take-home, patient-focused guide to quitting, usually incorporating some skill building, tips on reduction and cessation, and advice. Supporting AHS Resources AlbertaQuits helpline counsellors Tobacco reduction counsellors/specialists Addiction counsellors Mental health therapists Respiratory health therapists Doctors, pharmacists, nurses, social workers and other health professionals with recognized brief and/or intensive tobacco counselling training AlbertaQuits website: a self-guided interactive program. Once registered, the user is able to access community forums, cessation tools, texting support, equit tips and resources to create a personal quit plan. Cessation resources such as Baby Steps: A Guide to Help Pregnant and Postpartum Women Quit Smoking are completed by the patient, but have limited advice for her unique situation. This resource is available for order in the website resource catalogue. Alberta Health Services

326 Table 20.6 (continued) Tobacco Intervention Feedback interventions are those where the mother is provided with information about the fetal health status or measurement of by-products of tobacco smoking. This includes interventions such as ultrasound monitoring and carbon monoxide or urine cotinine measurements, with results fed back to the mother. Incentive-based interventions include those interventions where women receive a financial incentive (e.g., gift vouchers contingent on their smoking cessation). Social support (peer and/or partner) includes those interventions where the intervention explicitly included support from a peer (including self-nominated peers, peers trained by project staff or support from health care professionals) or partners, as a strategy to promote smoking cessation. Personal follow-up refers to communication with the patient aimed at sustaining the impact of other intervention components and offering encouragement, often through the postpartum period. Supporting AHS Resources Medical procedures create opportunities for consultation on the tobacco-related harms associated with a patient s health outcome. Tobacco reduction counsellors/specialists, pharmacists and other health professionals have used the CO monitor as a motivation and relapse prevention tool when counselling patients. Although research is being done on this area, currently there is no provincial financial incentive program within AHS for pregnant women. QuitCore group counselling sessions provide Albertans (aged 18+) with the tools and skills they need to quit using tobacco for good. Sessions are scheduled, and include tailored guidance. Peer and family/friend support is also included. Groups are unisex, and efforts are made to make this environment a safe place to share personal experiences with tobacco use. For inquires to run your own QuitCore program, contact tru@albertahealthservices.ca. The AlbertaQuits helpline provides ongoing support, with an average of 10 minutes per call. The support provided includes seven scheduled call-backs, but can be adapted to meet the needs of the caller. Follow-up calls are generally scheduled for quit day two days after quit day two weeks after quit day one month after quit day three months after quit day six months after quit day one year after quit day Tobacco Free Futures

327 Relapse prevention While many women quit using tobacco while they are pregnant, a high percentage will resume their tobacco use after giving birth. According to the 2009 Canadian Maternity Experiences Survey, 47% of women who had quit smoking by the third trimester had resumed smoking daily or occasionally in the postpartum period. 24 However, reported rates of relapse vary and according to Greaves et al may be as high as 70 90% by one year postpartum. 1 This has health implications for both women and children. 24 As many as 25% of women may resume smoking before delivery, 50% within four months and 70-90% by one year postpartum. 1 As described by Pregnets (Centre for Addiction and Mental Health), predictors of relapse include high nicotine dependence, postpartum depression, friends or family who smoke, low education, low income, age (youth), lack of social support and lack of prenatal care. 38 Relapse rates tend to be lower among women who breastfeed, although often breastfeeding only delays relapse, rather than helping avoid it altogether. During pregnancy, many women quit more for the baby than for themselves. This means they are less motivated to quit for good and do not develop long-term strategies to remain tobacco free. Effective relapse prevention strategies focus on the mother s health as the motivation for continued abstinence. Late pregnancy is an opportune time to initiate discussions about the risks of postpartum relapse and build strategies to avoid it. The considerations outlined in Table 20.7, as described by the American College of Obstetricians and Gynecologists (ACOG) may help address postpartum relapse. 36 Table 20.7: Considerations to Address Postpartum Relapse Maintain good chart documentation Continue with 5As approach at postpartum visits Documentation is required for systematic follow up on the patient s tobacco use status. Documentation is also beneficial in tracking a patient s tobacco use status and progress with remaining tobacco free. The majority of women who quit using tobacco during pregnancy relapse within a year of delivery. Patients who gain a significant amount of weight during pregnancy may be at higher risk for relapse than patients who do not. Alberta Health Services

328 Table 20.7: (Continued) Maintain positive counselling Address slips and relapse, as necessary Language is important when considering how to counsel patients to remain tobacco free. Reinforce the positive effects of quitting, including improved maternal and infant health. Continue to advise about the benefits to the family of having a tobacco-free home environment and the potential harms of secondand third hand smoke in the home environment, which may increase the risk of consequences such as sudden infant death syndrome (SIDS), bronchitis and asthma, as well as more common childhood conditions (e.g., colic and otitis media). Continue to praise the patient s effort in quitting. To reinforce the patient s desire to be a good mother, say, for example, You have really helped your baby get off to a great start by providing a tobacco free home, so she/he can continue to grow and be healthy. Reassure the patient of your continued assistance in her attempts to quit and remain tobacco free. If a patient is concerned about her weight after delivery while she is trying to quit smoking or maintain smoking cessation, the following suggestions might help: Don t focus on losing weight while trying to quit using tobacco. Quit first, then address weight issues. Choose healthy foods. Participate in physical activities. Reassure the patient and encourage her to try again. Tell her that people who quit using tobacco successfully after they slip tell themselves, This was a mistake, not a failure. Remind the patient that most people who quit using tobacco successfully have relapsed, and that each quit attempt puts her closer to never using tobacco again. Encourage her to quit using tobacco immediately, and put the quit date in writing. Encourage the patient to get rid of all tobacco materials (e.g., cigarettes, matches, lighters, ashtrays, snus and e-cigarettes). Ask the patient to think about what made her want to use tobacco so she will understand the trigger and develop a plan to avoid it or cope with it next time. For patients who relapse, remind them of the positive effects of quitting. Suggest that the patient use the self-help materials she received during pregnancy to remind her of good reasons for quitting, ways to handle slips and techniques for remaining tobacco free. If appropriate, offer or link to prescriber for pharmacological treatment Tobacco Free Futures

329 Continuity of care is another key component of ensuring that patients are adequately supported after quitting. Motivation to quit is a dynamic factor that changes throughout any period of cessation. Providing consistent tobacco cessation support into the postpartum period should be ensured. 1 This could include follow-up phone calls, targeted support groups or home visits. This requires coordination across the continuum of care from staff who have adequate addictions training and knowledge to support mothers at risk of relapse. Vulnerable groups Some women are especially vulnerable to tobacco use and addiction, including those in the following groups: 1 women of low socio-economic status women with mental health problems women who use other substances women who have experienced trauma Aboriginal women adolescent girls and young women Education, income, employment, and socialsupport networks are the key determinants of socioeconomic status that consistently indicate an inverse relationship with smoking in pregnancy. 1 Health care providers have to be sensitive to the characteristics of subgroups and understand the importance of helping all of these women and girls. It is important to recognize that not only are they more likely to use tobacco but they also experience more challenges with quitting and relapse. 1 Refer to chapter 19: ( Addiction and Mental Health) and Expecting to Quit for more information on tobacco treatment for these subgroups. Electronic cigarettes (e-cigarettes) Electronic cigarettes, also known as e-cigarettes, are battery-operated devices that have cartridges with liquid chemicals in them. Some people mistakenly believe that these devices are harmless compared to smoking. Some use them as a cessation aid, although there is no evidence that they help people quit smoking. Health Canada, the U.S. Food and Drug Administration and the World Health Organization do not support e-cigarettes as stop smoking products. Women and adolescents should be discouraged from using electronic smoking devices. Pharmacological interventions Numerous studies have been conducted to determine the safety and efficacy of pharmacological treatments for pregnant and postpartum women. This research is inconclusive as it relates to safety, and suggests that the pharmacological treatments used most commonly with the general population are not as effective with this population group, due in part to the fact that nicotine replacement therapy (NRT) is metabolized faster during pregnancy, meaning that higher doses are likely to be needed. 45 In the absence of strong evidence to support the use of medication to assist pregnant and postpartum women to stop using tobacco, intensive cessation support (e.g., multiple counselling sessions, motivational interviewing, cognitive behavioural therapy) is recommended as first line treatment. 7,28,45 Alberta Health Services

330 Nicotine replacement therapy If counselling is found ineffective, NRT can be considered as a second line option. However, there is a lack of consistency amongst clinical guideline recommendations on this point, due to limited evidence on the effectiveness and safety of NRT during pregnancy. The point at which counselling can be determined to be ineffective is subject to the professional opinion of the provider and the personal motivation of the woman. This must be assessed on an individual basis in consultation with a prescribing authority such as physician, pharmacist or nurse practitioner. Some evidence from randomized controlled trials indicates that NRT may be effective in pregnancy for decreasing tobacco use and improving pregnancy outcomes. 28 However, NRT is generally less effective for pregnant women than for the general population, likely due to the pharmacokinetic and physiological changes that occur during pregnancy, which may necessitate higher doses. 45 In terms of safety, the benefits of NRT seem to outweigh potential risks. While nicotine exposure through NRT most likely has adverse effects on the fetus during pregnancy, tobacco use exposes the fetus to more toxic chemicals than nicotine alone. 7 NRT also typically provides less nicotine than tobacco smoke. 48 However, the available data cannot support or exclude an association between first trimester NRT use and an increased risk of congenital defects. 28 Until further evidence is gathered, NRT should only be offered during pregnancy when counselling has failed and after an informed discussion with the patient regarding the risks and benefits of using tobacco and NRT. When NRT is recommended to a pregnant woman, low-dose, intermittent delivery NRTs (e.g., lozenges, gum, buccal inhalers, and mouth spray) is preferred over continuous dosing of the patch. 28,46,47 If the patch is used, the woman should consider removing it at night. NRT should be discontinued if the woman continues to use tobacco at the same rate, and alternative treatment should be considered. 49 As with all medications prescribed during pregnancy, close monitoring is required throughout the woman s use of NRT. Regarding breastfeeding and NRT use, nicotine freely passes in and out of breast milk. Factors that influence the amount of nicotine ingested by the infant include the concentration of nicotine in the maternal blood (affected by tobacco product consumption), frequency of breastfeeding, and the time between tobacco use and breastfeeding. However, there is a NRT should only be offered during pregnancy when counselling has failed, and after an informed discussion with the patient regarding the risks and benefits of using 28, 46, 47 tobacco and NRT. New mothers should be encouraged to breastfeed, even if they are using tobacco. 1 relatively low oral availability of nicotine in breast milk, and it is unlikely that this low level of exposure is harmful to the infant. The importance of continuing to breastfeed, regardless of tobacco use status, should be stressed, because the benefits of breastfeeding to both the mother and child outweigh the risks associated with nicotine exposure through tobacco use or NRT. 1 Breastfeeding women, like pregnant women, should use intermittent rather than continuous dosage NRT formulations, at the lowest recommended dosage. Bupropion and varenicline There is limited evidence for the safety and effectiveness of both bupropion and varenicline for tobacco use cessation during pregnancy and while breastfeeding. Two major reviews of the clinical evidence of pharmacological use with this population draw somewhat different conclusions. Coleman and colleagues found that there are insufficient studies investigating the fetal impacts of either bupropion or varenicline use in pregnancy to draw any conclusions about the safety of using either Tobacco Free Futures

331 Greaves and colleagues refer to evidence from one controlled but non-randomized study 50 that found that bupropion is more effective than a placebo for pregnant women who smoke, but that there may be an increased risk for spontaneous abortion among women treated with bupropion during pregnancy. They indicate that clinicians currently suggest bupropion can be used with pregnant women who smoke. 1 They do not discuss the use of varenicline with this population. Similarly, leading clinical practice guidelines offer conflicting recommendations regarding the use of bupropion and varenicline with pregnant and breastfeeding women, with Canadian recommendations diverging from the others. CAN-ADAPTT s Canadian smoking cessation guidelines state that there is no evidence of harm related to the use of bupropion during pregnancy, and it may therefore be considered an alternative to NRT for a sub-population of pregnant women who smoke. It also states that more research is needed on the effectiveness and safety of both bupropion and varenicline as a tobacco cessation aid for pregnant and breastfeeding women. 28 The Society of Obstetricians and Gynecologists of Canada state that further research is needed on the safety and efficacy of bupropion and varenicline before they can be recommended for routine use in pregnancy. 49 Motherisk states that bupropion use during pregnancy does not appear to be associated with increased risk of major congenital malformations, but there are no adequate studies on rates of spontaneous abortion among pregnant women taking bupropion for smoking cessation. Regarding varenicline, Motherisk states that because limited data are available regarding its use during pregnancy, it is only advisable to use this product as a tobacco cessation aid during pregnancy when the benefits of treatment substantially outweigh any undue risk (e.g., in heavy smokers with failed quit attempts or who have not responded to other tobacco cessation aids). 51 U.S. guidelines state that neither bupropion nor varenicline has been shown to be effective for treating tobacco dependence in pregnant women who smoke, nor have either of these been evaluated in breastfeeding patients. It does not comment on its safety or provide a recommendation for its use with this population group, but identifies this as an area requiring more research. 7 Australian guidelines state that neither bupropion nor varenicline has been shown to be effective or safe for smoking cessation treatment in pregnant and breastfeeding women who smoke, and does not recommend its use with this population. 47 U.K. guidelines state that neither bupropion nor varenicline should be offered to pregnant or breastfeeding women. 52 New Zealand guidelines state that there is insufficient evidence to recommend the use of bupropion or varenicline by pregnant women. 48 Based on the available evidence, these guidelines recommend that bupropion and varenicline should only be considered with pregnant and breastfeeding women after behavioural interventions and NRT have failed. Prior to initiating either treatment, advise women that current research does not conclusively demonstrate the efficacy and safety of either of these medications in pregnancy and lactation, and discuss the risks and benefits of using them versus using tobacco. Alberta Health Services

332 Pregnant and postpartum adolescents The information in this section provides information on providing tobacco cessation support to adolescent girls (aged 10 17) who are either pregnant or gave birth to a child in the last year. Table 20.8: Tobacco Free Futures Summary Recommendations for Supporting Pregnant and Postpartum Adolescents to Stop Using Tobacco To support pregnant adolescents while they stop using tobacco, use a combination of the 5A s for women (Figure 20.1) and the 5A s for adolescents outlined in chapter 21 ( Youth and Family ). Pregnant and postpartum adolescents should receive pharmacological support following the recommendations outlined for pregnant and postpartum women earlier in this chapter. The risks and benefits of all treatment options must be discussed with the patient and their caregivers prior to initiation. Prevalence Pregnant adolescents have significantly higher rates of smoking than older pregnant women. According to Canadian Maternity Experiences Survey data from , mothers between the ages of 15 and 19 reported the highest proportion of smoking during pregnancy: 29% in this age group reported smoking daily or occasionally, compared to 11% among all pregnant women. 24 Figure 20.3: Canadian Tobacco Use in Pregnancy by Age: 24 Proportion of women who reported smoking daily, occasionally and not at all, by time period and maternal age, Canada, Source: Public Health Agency of Canada, Tobacco Free Futures