Tobacco Cessation Skill Building Workshop Facilitator Guide

Transcription

1 Tobacco Cessation Skill Building Workshop Facilitator Guide

2

3 TABLE OF CONTENTS Facilitator Preparation Guide... i Advanced Preparation Checklist... i Supplies Needed... ii Preparation Checklist for the Day of the Workshop... ii 1.0 Module 1: Overview of Tobacco Use Brief Workshop Overview of Tobacco Use Why Address Tobacco Use Benefits of Quitting Tobacco Use in Nunavut Quick Facts About Tobacco Use Effects of Second-Hand Smoke How Does Nicotine Addiction Happen? Module 2: Brief Tobacco Intervention - The 5As The 5As A Framework for Conducting a Brief Tobacco Intervention LESSON PLAN The 5As Brief Tobacco Intervention Instruction Overview of the 5As Instruction ASK Instruction ADVISE Instruction ASSESS Stage of Change Instruction ASSES-Motivation/Confidence Related to Quitting Instruction ASSIST Instruction ARRANGE Supplemental Information Barriers to ASKing about Tobacco Use Reframing ADVISE National Guidelines Case Activities ADVISE Case Demonstrations ASSESS Role Plays: Stage of Change; Motivation/Confidence ASSIST Case Demonstrations The 5As Role Plays Resources... 35

4 2.6.1 The Stages of Change Stage Appropriate Interventions ASSESS: Stage of Change Card Game The 5As Guideline Handout Module 3: Motivational Interviewing Level Communication Skills & the Spirit of Motivational Interviewing LESSON PLAN: Communication Skills & Motivational Interviewing Level Instruction introduce OARS Techniques Instruction - Open Ended Questions Instruction Affirmation Instruction Reflection Instruction Summary Instruction The Righting Reflex Instruction The Spirit of Motivational Interviewing Instruction Additional Communication Techniques (optional) Module 4: Motivational Interviewing Level The Process of Motivational Interviewing Level LESSON PLAN Motivational Interviewing Level Instruction The Process of Motivational Interviewing Instruction Engaging Instruction Focusing Instruction Change and Sustain Talk Instruction Evoking Motivation Instruction Evoking Confidence Instruction Planning Evoking Commitment Instruction Relapse Management Evoking Persistence Case Activities Dealing with Discord Evoking Motivation Evoking Confidence Evoking Commitment Planning Relapse Management Recognizing Change Talk vs. Sustain Talk... 74

5 4.3.7 Role Plays: Motivational Interviewing Participant Role Plays: Motivational Interviewing Participant Role Plays: Motivational Interviewing Participant Module 5: Nicotine Replacement Therapy Nicotine Replacement Therapy LESSON PLAN Nicotine Replacement Therapy Instruction NRT Overview Instruction Forms of NRT Instruction Recommending an NRT Regimen Instruction What is covered by the (NIHB) Program? Instruction Drug Interactions and Tobacco Supplemental Information Nicotine Replacement Products Case Activities Resources NRT Fact Sheet Module 6: Prescription Medications Prescription Medications LESSON PLAN Prescription Medications Instruction Overview of Prescription Medications Instruction Varenicline Instruction Dosing Instruction Adverse Effects of Varenicline Instruction Buproprion Instruction Dosing Instruction Adverse Effects of Buproprion Instruction What is covered by the (NIHB) Program? Resources Medication Info Sheet APPENDIX 1 Cessation Tools Lesson Plan: Smokerlyzer/CO Monitor Lesson Plan: Pig Lung Demonstration Lesson Plan: Smokey Sue Smokes For Two

6 Lesson Plan: Teeth in Tobacco Juice Lesson Plan: Mr. Gross Mouth Lesson Plan: Clem s Phlegm Jar Lesson Plan: Cost Calculator APPENDIX 2 Client Resources

7 Facilitator Preparation Guide The Tobacco Cessation Skill Building Workshop Facilitator s Guide has been created to educate community health workers and health care professionals on the best tobacco cessation practices to help community members quit or reduce their tobacco use. This resource provides information about the impact of tobacco, how to maximize effective communications when working with your clients and community members, different cessation aids available and how to effectively use them, and available community resources. There are six modules in this Guide. These modules can be worked through individually or applied as stand-alone lessons. Each module and its related activities vary in length, but will take approximately one hour to complete with a group. In order to get the most out of this Guide, we recommend reading through this facilitator preparation guide and completing the workshop preparation checklists. By the end of this section, the facilitator will understand the various tools and information needed to successfully facilitate the Tobacco Cessation Skill Building Workshop. Workshop facilitators should take advantage of the various tobacco demonstration tools to enhance participant learning. Many of the cessation tools (Smokey Sue Smokes For Two; pig s lungs demonstration; Smokerlyzer carbon monoxide monitor; etc.) can be found at your local community health centre or Canadian Prenatal Nutrition Program (CPNP) group. We advise reading over each lesson plan (See Appendix 1) so you are familiar with the purpose and appropriate use of each tool and/or model demonstration. Advanced Preparation Checklist To prepare to facilitate the skill building workshop, please complete the following: Carefully review the skill building workshop binder Review all lesson plans and patient resources Review all video clips, role playing demonstrations, and case study examples Book the meeting space where the workshop will be held Customize and send invitations to attendees. Send a reminder two to three days before the workshop Purchase incentives may require buying a gift card or small prizes from the local store to attract participants and sustain interest i

8 Prepare food and beverages preferably healthy options such as fresh fruit, vegetables, water or tea Supplies Needed Skill building workshop binders with extra copies Lesson Plans Fact sheets (5 A s, Nicotine Replacement Therapy (NRT), Prescription medications) Smoking cessation materials if available (NRT and medication examples, Quit Kits, cost wheels) Flip chart, paper, markers and pens Timer or watch Name tags or tent cards Preparation Checklist for the Day of the Workshop Skill building workshop binders with a few extras Demonstration videos (if available) Demonstration case studies Stages of change cards Role playing cases Supplemental Handouts Food and Beverages ii

9 1.0 Module 1: Overview of Tobacco Use 1

10 2

11 Skill Building Workshop Facilitator Guide 1.1 Brief Workshop Overview of Tobacco Use This module has been created to provide some facts about tobacco use, the challenges of tobacco use in Nunavut, and the dangerous health effects of tobacco use on individuals and families. The information outlined in this section also explains why it s so important for health care providers to talk about tobacco use during their daily interactions with community members who smoke, or use other tobacco products. Goal: By the end of this section, participants will have a basic understanding of the tobacco epidemic in Nunavut and the important role health care providers play in reducing the harm of tobacco use. Learning Objectives: Describe the impact of tobacco use in Nunavut List the benefits of quitting tobacco use Identify five factors that contribute to the high rate of tobacco use in Nunavut List 10 short-term and long-term health effects of tobacco use Identify the harms associated with exposure to second-hand smoke Describe how people become addicted to nicotine 3

12 4

13 1.2 Why Address Tobacco Use? Tobacco use is the leading preventable cause of premature death, disease and disability in Nunavut. Tobacco use is not a habit or lifestyle choice; it s a true addiction. For most people who use tobacco, it takes numerous attempts to quit before they finally quit for good. Most people who are dependent on tobacco need support to successfully quit in the long term. Brief advice from a health care professional can increase the chance that someone who uses tobacco will make a quit attempt. It is therefore important to discuss a client s tobacco use during every health-related interaction when appropriate. 1.3 Benefits of Quitting Quitting tobacco is the single best thing a person can do for their health. The benefits are immediate and significant. Quitting tobacco prevents premature death, decreases the risk of developing many diseases, and can positively affect the lives of those living with chronic diseases. Cessation at any point in life can improve an individual s health and slow the progression of chronic diseases. The health benefits of quitting smoking begin within 30 minutes and continue for years, including: Within 20 minutes blood pressure and heart rate drop to normal Within 8 hours energy increases, carbon monoxide levels decrease and oxygen levels increase Within 48 hours sense of taste and smell improve, risk of heart attack decreases Within 2 weeks lung function improves up to 30% and physical activity becomes easier Within 9 months coughing, congestion, fatigued, and shortness of breath decrease After 1 year risk of heart attack is cut in half After 10 years risk of lung cancer is halved, risk of stroke is the same as a non-smoker, and cancers of the mouth, bladder, kidney and pancreas decrease After 15 years risk of heart attack is the same as a non-smoker 1.4 Tobacco Use in Nunavut Many Indigenous people in North America have a long tradition of using tobacco for ceremonial, healing or spiritual purposes. Tobacco was never part of traditional Inuit culture however. It was not part of Inuit life until the European whalers and fur traders introduced it in the 1700s. The harmful health effects were not known at that time and tobacco use gradually became normal for most Nunavummiut. 5

14 Today, Nunavut has the highest smoking rate in Canada with over 62% of people aged 12 and older in Nunavut using tobacco on a daily basis. This is more than three times the Canadian average of 18%. It is estimated between 60% - 80% of pregnant women in Nunavut use tobacco throughout their pregnancy. Some factors that contribute to the high tobacco use rates and make quitting difficult include: o Poverty o Poor nutrition o Level of education o Unemployment o Housing conditions o The continued effects of colonization 1.5 Quick Facts About Tobacco Use There are over 7,000 chemicals in tobacco smoke, 70 of which are known to cause cancer. Nicotine is the addictive substance in tobacco and is considered to be more addictive than heroin or cocaine. While extremely addictive, nicotine itself is not the harmful substance in tobacco. It is the thousands of other chemicals in tobacco smoke such as various carcinogens, carbon monoxide, and arsenic that make it so toxic. Tar, the black sticky substance from tobacco smoke, causes damage to the lungs, teeth, and gums, and carries most of the poisons. The consequences of tobacco use are well known. It is the leading risk factor for the most prevalent and deadly diseases: cancer, cardiovascular disease and respiratory disease. Short term health effects of tobacco use: o Addiction especially for youth who can show signs of addiction after smoking just a few cigarettes a day o Yellow teeth and finger nails o Smelly clothes, hair and breath o Increased coughing o Asthma attacks o Respiratory infections o Decreased ability in sports Long term health effects of Tobacco use: o Heart disease o Stroke o Lung cancer o Cancers of the mouth, lip, throat, pancreas, bladder and cervix 6

15 o o Chronic Obstructive Pulmonary Disease (COPD) Lung conditions (asthma, tuberculosis, emphysema, pneumonia) Tobacco use is also known to contribute to: o o o o o o o o o o Perinatal complications Decreased fertility Impaired immune response Impaired healing Poor oral health Increased risk of peptic ulcer disease Osteoporosis Sleep disturbances Premature aging Impaired sense of taste and smell 1.6 Effects of Second-Hand Smoke Harms associated with tobacco use are not confined to the smoker. Second-hand smoke, the smoke blown out by the smoker and from the burning end of a cigarette, lingers in the air and exposes individuals nearby to the same poisons as the person smoking. Even small amounts of second-hand smoke can be harmful. But the longer you are around second-hand smoke, the more it can hurt you. Infants and young children are even more affected by second-hand smoke. Exposure to secondhand smoke increases the risk of: o Sudden Infant Death Syndrome (SIDS) o Difficulty breathing o Lung problems (bronchitis, pneumonia) o Asthma o Middle ear infections The only way to avoid exposure to second-hand smoke is to keep cars, homes, and other enclosed spaces smoke-free. 1.7 How Does Nicotine Addiction Happen? Nicotine hits the brain in about 10 seconds after inhaling from a cigarette. In the brain, nicotine binds to the nicotine receptors, which then stimulates the release of dopamine in the reward center of the brain. Dopamine creates a sense of pleasure, reduced stress and a desire for more hits of nicotine. 7

16 The reward of dopamine is reinforced with every hit of nicotine and becomes associated with various triggers, such as drinking coffee, alcohol or being around friends who smoke. With long term tobacco use, users develop a tolerance to nicotine and require higher doses to satisfy cravings and achieve the same effect. The brain has become used to nicotine as a normal part of its function, and the user will experience withdrawal if they have not smoked or chewed in a while. Withdrawal symptoms are most easily relieved by smoking or chewing tobacco. Withdrawal symptoms include: o Intense cravings to smoke or chew tobacco o Feeling anxious or irritable o Feeling down or sad o Restlessness and difficulty sleeping o Difficulty concentrating 8

17 2.0 Module 2: Brief Tobacco Intervention - The 5As 9

18 10

19 Skill Building Workshop Facilitator Guide Goal: 2.1 The 5As A Framework for Conducting a Brief Tobacco Intervention By the end of this workshop, participants will be able to describe how to conduct a brief tobacco intervention using the 5As approach and demonstrate each of the five steps during a simulated health professional/client interaction. Learning Objectives: By the end of this workshop, participants will be able to: 1. Describe the 5As framework 2. ASK about tobacco use 3. ADVISE a patient/client to quit tobacco use in a clear and personalized manner 4. ASSESS a patient/client s readiness to quit using the stages of change model 5. ASSESS a patient/client s motivation and confidence related to quitting tobacco 6. ASSIST a patient/client in a manner appropriate for their stage of change 7. ARRANGE follow-up support for a patient/client by referring to a resource appropriate for their stage of change Materials and Resources: 5As Demonstration Video (if available) ADVISE Demonstration Case Studies ASSIST Demonstration Case Studies Stage of Change Cards ASSESS Role Play Cases 5As Role Play Cases 5As Guideline handout 11

20 12

21 2.2 LESSON PLAN: The 5As Brief Tobacco Intervention Activity - Icebreaker Instruction Overview of the 5As The 5As is an evidence-based framework for health care providers to support tobacco quit attempts. The 5As include: o ASK about tobacco use o ADVISE tobacco users to consider a quit attempt o ASSESS readiness to quit using tobacco o ASSIST in promoting, preparing for and attempting a quit o ARRANGE for follow-up support By integrating the 5As into practice, health care providers can assist with access to medications, counseling and follow-up for a greater number of tobacco users interested in quitting. Even a brief intervention (1-3 minutes) from a health care provider can have a positive impact on cessation rates and can increase the likelihood of a successful quit attempt by 30%. The odds of a successful quit attempt are increased further with more intense interventions of a half-hour or more. Only 3 to 5% of those who attempt a quit using will power alone will be successful in maintaining a quit for 6 to 12 months. Thus, people who use tobacco need support to increase their chances of a successful quit. Activity The 5As - Video Demonstration 1. Play the video demonstration of a health care provider applying the 5As to an interaction with a client 2. If a video is not available a pair of facilitators can do a role play demonstration 3. Ask participants to share their reflections on what they observed in the demonstration 13

22 2.2.2 Instruction ASK Health care providers working in settings that have a screening system or process in place for asking about tobacco use with all clients are three times more likely to get involved in treating tobacco dependence. Review reasons to consistently ASK about tobacco use: o Tobacco use is the most important, preventable risk factor for heart disease, lung disease and cancer there are few interventions that equal tobacco cessation in terms of impact on healthrelated quality of life. o It is our responsibility to have this information when we are caring for our patient/clients tobacco use status is an essential element of the medical history. It is no less important than knowing whether a patient has diabetes, hypertension or a medication allergy. o A change in tobacco status can cause significant drug interactions. People who quit can metabolize medications slower and thus medications may then accumulate in their blood. o If someone is interested in quitting WE CAN HELP! How to ASK: Have you used any tobacco products in the last month? Optional Discussion: What are the perceived barriers to consistently ASKing about tobacco use? (See Supplemental Information for more details.) Instruction ADVISE It is more effective if tobacco users receive a consistent and accurate message from all health care providers. How should the message be delivered? CLEAR and PERSONALIZED. This could include a statement like, As your health care provider, I m concerned about the increased risk of a second heart attack associated with your continued smoking. (Link to their current situation a condition they are experiencing now, like asthma or recent heart attack). Optional Discussion: Reframing ADVISE. (See Supplemental Information for more details.) Activity ADVISE Case Demonstration 1. Distribute the ADVISE demonstration case studies to pairs of participants. (See Section 2.6, Case Activities section) 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of client. 3. After each reading, ask the group to share their observations. 14

23 2.2.4 Instruction ASSESS Stage of Change It is important that health care providers assess a patient/client s readiness to quit using tobacco to determine the most appropriate intervention and/or focus for the conversation. An effective framework for assessing readiness to quit is Prochaska s Stages of Change Model. Review the Stages of Change model (see Resources section). How to ASSESS: A simple open-ended question: So what are your thoughts on smoking? The patient/client s response will provide clues as to their stage of change: o Pre-contemplation: I m a hundred years old lighting my cigarette is the only enjoyment I get! o Contemplation: I really should quit, but smoking keeps me from gaining weight. o Preparation: Should I try lozenges or gum? Maybe I should get some advice. o Action: I haven t had a smoke in 2 weeks I m really going to quit this time. o Maintenance: Eight months without a cigarette I m really doing it this time! o Relapse: I needed this cigarette today has been one of those days. Activity ASSESS Stage of Change Card Game 1. Give each participant a Stage of Change card. 2. Ask participants to walk around the room asking each of the other participants the question What are your thoughts on smoking?. 3. When asked, the other participant will read the line on the card. 4. The asking participant names the stage of change based on the response read to them from the card. 5. Run the activity for a set amount of time depending on group size e.g. 5 minutes. 15

24 2.2.5 Instruction ASSESS Motivation/Confidence Related to Quitting Motivation and ability to quit can be assessed by determining importance and confidence. A low rating of one or both of these elements identified by your client, provides a focus for supporting the individual i.e. Do you need help to increase motivation or help to increase confidence in quitting (or both)? IMPORTANCE: The patient s recognition of the benefits of changing a behaviour On a scale of 1-10, how important is it for you to quit smoking? (With 10 being very important). CONFIDENCE: The patient s belief in their ability to change a behaviour - On a scale of 1-10, how confident are you that you can be successful? (With 10 being very confident). Activity ASSESS Stage of Change; Motivation/Confidence Role Play 1. Distribute role play cases to pairs of participants. (See Section 2.6, Case Activities) 2. The individual playing the health care provider tries to determine stage of change and level of importance/confidence by asking appropriate questions. They can stop the role play as soon as the assessment has been done. 3. Once the first case is completed, the participants switch roles. 4. Have a short discussion after the role plays to allow participants to share their thoughts. 16

25 2.2.6 Instruction ASSIST ASSIST in a way that is appropriate for their stage of change. (See Supplemental Information for stage appropriate interventions) Support that is appropriate for the individual s stage of change include: o Helping those who are pre-contemplative or contemplative by eliciting their personal reasons to quit using tobacco (increase motivation). o Helping those who are in preparation develop a quit plan and solutions for the barriers that make quitting tobacco difficult; helping with accessing appropriate medications. o Helping those in action or maintenance continue to address barriers to success and to use medication appropriately. o Helping those who have relapsed explore the situation as a learning opportunity and prepare for another quit attempt. Activity ASSIST Case Demonstration 1. Distribute the ASSIST demonstration case studies to pairs of participants. (See Section 2.6, Case Activities) 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of patient/client. 3. After each reading, ask the group to share their observations. 17

26 2.2.7 Instruction ARRANGE Nicotine dependence is a chronic relapsing condition and requires follow-up and ongoing support. Timing: o Follow-up contact should begin soon after the quit date, preferably during the first week. o A second follow-up contact is recommended within the first month. o Schedule further follow-up contacts as needed. Action During Follow-up Contact: o For all patients/clients, identify problems already encountered and anticipate challenges for staying tobacco-free in the immediate future. o Assess medication use and problems. o For patients/clients who have quit, congratulate them on their success. o If tobacco use has occurred, review what contributed to the relapse and encourage commitment to another quit attempt. Consider use of or link to more intensive treatment. If the health care provider does not have the capacity to continue providing follow-up support, then REFER to another resource appropriate for the individual s stage of change. Review community resources that support tobacco quit attempts (Nunavut Quitline, local programs, Tobacco Has No Place Here Facebook page, Youth Centre, CPNP Program). Activity Role Play Using the 5As 1. Distribute role play cases to pairs of participants. (See Section 2.6, Case Activities) 2. The participant playing the health care provider uses the 5As to support the participant playing the patient/client. 3. Once the first case is completed, the participants switch roles. 4. Have a short discussion after the role plays to allow participants to share their thoughts. 18

27 2.3 Supplemental Information Barriers to ASKing about Tobacco Use Time Health care providers often state they don t have time to ask about tobacco use. However, simply asking takes very little time, perhaps 30 seconds. It is true that a tobacco cessation intervention may not be practical at any given point in time. However, ASKing is simply the process of acquiring information on the individual s tobacco use status. The subsequent intervention can be brief or postponed to a mutually convenient time. Fear Health care providers may be afraid to ask about tobacco use. o Some may not want to offend the patient/client. Any offense taken is owned by that patient/client; they choose to respond to the question in that manner. The health care providers need to know tobacco use status for the reasons outlined above. It is no different than asking about age or weight; the patient may take offense, but the information is required to deliver client-centred care. o Some may be afraid because they don t know what to say or how to deal with difficult questions or sensitive topics. Further training may be required to empower the health care provider. Attitude It s not my job, They don t want to quit, or It s their choice to smoke. o These statements reveal that the health care provider does not recognize that tobacco use is the single most important, preventable risk factor for heart disease, lung disease and cancer and that tobacco cessation is likely the most effective intervention for reducing risk. o It also reveals that the health care provider does not recognize that tobacco addiction is a chronic, relapsing disorder that requires multiple interventions and continuing support. In most cases, it is not a lifestyle choice. The majority of smokers want to quit. I use tobacco How can I help someone if I use tobacco myself? o A health care provider who uses tobacco can certainly feel uncomfortable advising tobacco users to quit and supporting quit attempts. It may be useful to remember that most people struggle with some form of unhealthy behaviour. The health care provider is trained to facilitate behaviour change and provide recommendations on the options available to support a tobacco quit attempt. This expertise is independent of whether or not the health care provider is also a tobacco user (or alcohol user, over-eater, etc.) Reframing ADVISE Many approaches to supporting behavior change discourage health care providers from issuing unrequested advice. A directive statement advising the individual to quit smoking can trigger resistance 19

28 and compromise the therapeutic relationship. If the individual wants to quit and is well aware of the consequences of tobacco use, what can be gained by advising that individual to quit? How do we reconcile the importance of clear messaging from health care providers, such as advising them to quit - against the risks of uninvited advice? Expression of Concern Advice can be less off-putting if it is delivered as an expression of concern from the health care provider. Rather than stating, You should quit smoking to reduce your risk of a second heart attack, we can state, As your health care provider, I m concerned about the increased risk of a second heart attack associated with continued smoking. In this case, we have avoided a directive approach that can challenge an individual s sense of autonomy, yet we have made our concern clear. Ask Permission Autonomy is less likely to be threatened if the health care provider asks the individual s permission to share concerns or provide information and/or advice. The statements are no longer unrequested, rather, introduced into the conversation with the individual s consent. Affirmation If someone clearly wants to quit and is well aware of the risks associated with tobacco use, an affirmation may be a more effective statement than advice. An affirmation is an explicit acknowledgment and appreciation for an individual s strengths and positive decisions related to tobacco use. (i.e. I see that you have come up with some good plans for avoiding situations that might trigger cravings when you quit. ) Timing Unfortunately, the time to issue an expression of concern or affirmation is not the same in every conversation on tobacco use. The health care provider must listen carefully and strategically offer advice, information or an affirmation of an individual s strengths and positive decisions. 20

29 2.4 National Guidelines There are two national Guidelines that frame these training modules as follows: 1. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Retrieved from ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf 2. US Department of Health and Human Services (2008). Treating tobacco use and dependence: 2008 update. Retrieved from 21

30 22

31 2.5 Case Activities 23

32 24

33 2.5.1 ADVISE Case Demonstrations: Instructions You will be asked to read one of the following cases out loud with your partner. Decide which one of you will read the role of the health care provider and who will read the role of the client. When asked, read the lines as if reading the script for a play. After the reading, there will be a group discussion. Case 1 The client is a 69-year old man who has recently been diagnosed with COPD. He is at the clinic to learn about the management of his condition. HCP Hi Pauloosie, before we talk about medication, I wanted to ask whether you have used any tobacco products in the last month? Client Yes I smoke cigarettes, about a pack a day. HCP And what are your thoughts on smoking right now? Client Well, my doctor basically said I need to quit. HCP And what do you think? Client I m not sure. I want to see how I do with these puffers. HCP May I share my concerns about COPD and tobacco use? Client Sure. HCP Having COPD means that breathing will become more and more difficult. You may find it difficult to do your normal daily activities. Client What about the medications? HCP The medications will help relieve some shortness of breath, but only quitting smoking will give you a chance at keeping your lungs working as good as possible for as long as possible. Client Really? Maybe I need to give quitting some serious thought. Case 2 The client is a 54-year old man who has just had a dental check-up. The visiting dentist has noticed white patches in his mouth. HCP OK Johnny, before we finish today, may I ask a couple more questions. Client Sure. HCP Have you used any tobacco products in the past month? Client Sure I chew tobacco safer than smoking. 25

34 HCP For some conditions perhaps. May I share a concern based on some things I ve noticed during this appointment. Client Yes OK HCP Aside from significant staining on your teeth, I noticed some white patches in your mouth. I occasionally see them in people who chew tobacco. My concern is that they can be an early form of cancer. What are your thoughts on using tobacco right now? Client I haven t given it much thought at all until now. Will the cancer stop if I quit? HCP The risk of anything more serious developing will certainly be less if you quit chewing tobacco. We will keep a close eye on your mouth. Case 3 The client is a 24-year old female. She and her husband are wanting to have a baby. She is visiting the clinic to discuss preparing for pregnancy. HCP Congratulations Malaya, this must be an exciting decision for you. Client Yes we are both very excited. HCP OK before we get into nutrition and so on, may I ask if you have used any tobacco products in the past month? Client Wow you got to that quickly. Yes I smoke and I know I will need to quit once I get pregnant. HCP Excellent. I m pleased you are committed to protecting your baby. May I share a concern I have, however? Client Yes absolutely. HCP First, I m concerned that continued smoking may impact your ability to get pregnant. Are you aware that tobacco use can decrease fertility? Client I didn t know that what else are you concerned about? HCP I m concerned that quitting smoking might be more difficult if you wait until you are pregnant it can be a stressful time. Client You think I should quit now? HCP What do you think? Client Well it makes some sense. 26

35 2.5.2 ASSESS Role Plays: Stage of Change; Motivation/Confidence Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for Case 2. When playing health care provider, your objective is to determine the client s stage of change, their level of importance related to quitting tobacco, and their level of confidence in being able to quit tobacco. Once you have determined these three things you may end the role play. When playing client, you are given a back story. You can make up any information that is missing. Try and play the client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. Case 1 - Client You are a 72-year old female Elder in a small community. You live alone, your husband passed away and so did most of your friends. Your children have grown and moved away. You used to enjoy sewing traditional clothing and doing beadwork, but in your 60 s started getting arthritis and now using your hands is very painful. You have smoked a pack a day since you were a teenager and you really enjoy it. It is the one thing that gives you pleasure; it almost feels like cigarettes are your best friend. Your doctor has advised you to quit because smoking makes your arthritis worse, but you think he is too young to know what he is talking about and you feel upset and angry when he tells you to quit. Case 2 Health Care Provider Your client is a 23-year old female who has just found out she is pregnant with her 1st baby. Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for Case 1. When playing health care provider, your objective is to determine the client s stage of change, their level of importance related to quitting tobacco, and their level of confidence in being able to quit tobacco. Once you have determined these three things you may end the role play. 27

36 When playing the client, you are given a back story. You can make up any information that is missing. Try and play the client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. Case 1 Health Care Provider You are seeing a 72-year old female Elder who has severe arthritis and lives alone. Her doctor recently recommended she quit smoking. Case 2 Client You are a 23-year old female and you have just found out you are pregnant. You have been smoking about a half a pack of cigarettes a day since you were 14 years old. You know you need to quit for your baby, but you don t really know where to begin. You are scared of taking NRT or medications because you think they might harm your baby, but you don t think you can quit cold turkey either. You have a quit date in mind, but want some help to get you through that first few days ASSIST Case Demonstrations: Instructions You will be asked to read one of the following cases out loud with your partner. Decide which one of you will read the role of the health care provider and who will read the role of the client. When asked, read the lines as if reading the script for a play. After the reading, there will be a group discussion. Pre-contemplative The client is a 49-year old male carver who has smoked most of his life. He has advanced COPD. HCP So Joanasie, what are your thoughts on smoking right now? Client Well, it steadies my hand and I enjoy it. I really hope this isn t going to be a quit smoking talk. HCP We don t need to talk about quitting smoking, however, would you allow me to share what concerns me about your use of tobacco? Client Sure but make it short. HCP You have a fairly bad lung condition. I m concerned that you will begin to find it difficult to get along normally if you continue to smoke. Client I appreciate that concern, but I just can t see myself giving it up. 28

37 HCP It s your decision, but please remember that I will always be happy to help if you ever change your mind. Client I will. Thanks again for your concern. Contemplative The client is an 18-year old male student who began smoking in high school. HCP So Jamesee, what are your thoughts on smoking right now? Client I don t know. It helps me with stress, but it is costing me money I don t want to spend. HCP Tell me more about your money concerns. Client I ve been accepted to university in Ottawa. I need to save for expenses. HCP What an opportunity congratulations. Attending university sounds important to you. Client Yes it is which is why I want to quit smoking to save money for expenses. HCP That makes complete sense. Client But I know I m gonna be stressed moving away from home. Maybe I should just put it off until I graduate. HCP And you ll have enough money saved? Client That s the problem. Probably not. HCP What would need to happen to allow you to quit smoking now, but also manage the stress you might experience moving away from home. Client Hmm. I guess I should start thinking of other ways of dealing with stress and getting by when I feel lonely. I need to think some more on this, but maybe I can quit smoking. Thanks for your help. Preparation The client is a 38-year old female nurse who started smoking ten years ago. HCP So Martha, what are your thoughts on smoking right now? Client I really need to quit. I have to set a good example for my patients. HCP That s a strong professional attitude. On a scale of 1-10, how confident are you that you can succeed. Client I d say about a 5. HCP What will make it difficult? Client Withdrawal and my complete inability to handle stress when I want a cigarette so badly. HCP What are you thinking might help with that? Client I know there are nicotine patches or medications like Champix. I d like to find out more about them. 29

38 HCP Sure both are excellent strategies that improve your chances of success. Do you have a quit date in mind? Client Soon but I think I want to first decide on the medication I will use can you help me with that? HCP Absolutely. Tell me what you know already. Action The client is a 45-year old man who quit smoking about a month ago. HCP Simeonie, congratulations on your decision to quit and your success so far. You must be very happy. Client I am. I really think I can do it this time. HCP Are you taking any medication to help you quit? Client Yes I have some nicotine patches and some gum for when I need it. HCP And how is all that going. Client Great no problems so far. HCP Okay have there been any difficulties you would like to discuss? Client Well yes. As you can see, I m a little on the heavy side and I know that is bad for my diabetes and so on. I ve been exercising, but I think I m eating more since I quit smoking. HCP You don t want to gain any more weight. In fact you would prefer to lose weight? Client Exactly. HCP Well you have already done the right thing in deciding to exercise. That will help prevent excessive weight gain. Remember also that the health benefit from quitting smoking far exceeds any health risks from gaining a few pounds. Client Yes I will keep that in mind. HCP Would it be helpful to talk about a few other things that might help you prevent weight gain? Client I d really appreciate that. Relapse The client is a 59-year old woman who started smoking again 6 months ago. HCP Pitsiula, may I ask if you ve used any tobacco products in the last month? Client Well unfortunately, I have. HCP Unfortunately? Tell me more about that. Client I started smoking again six months ago after being quit for 10 years. HCP You are disappointed? Client Yes. 30

39 HCP Would it be OK with you if we talked a little bit more about starting to smoke again? Client I suppose for a bit. HCP First off, you obviously have a great deal of strength and character to be successful for so long. When people start smoking again after being quit for a long time, it can be related to a new and stressful experience. Does that apply to you? Client Yes. HCP In what way? Client I lost my son to a snowmobile accident six months ago. I just couldn t deal with it I had to smoke. HCP I m so sorry this must be one of the worst experiences in your life. Client Yes, it is. HCP What are your thoughts on trying to quit again? Client I don t see the point. HCP What was going through your mind when you lit that first cigarette? Client I don t know, um I don t think I really intended to start smoking again. I just needed a few to calm me down, but then I couldn t stop. HCP If you were to go back in time and prevent yourself from having just the few cigarettes to smoking regularly again, what would you do? Client (Pause). There was a point... I remember I decided that I had lost interest in not smoking and I just wanted to be a smoker again. If I could go back I would have a meeting with myself before I carried on with the decision. Does that make sense? HCP Completely. You would stop for a moment and carefully consider what you would be giving up by smoking again. Client Yes. HCP So what are you thinking now? Client I m thinking maybe it s possible. But just thinking. HCP That is the first step. Is there anything I can do to help you think things through? Client - No you ve been very helpful. HCP Okay please come and see me again when you are ready for the next steps. Client Thanks I will The 5As Role Plays: Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for the same client as in the ASSESS role play (Case 2). 31

40 As the health care provider, apply the 5As to your interaction with the client. Ensure that you ARRANGE for appropriate follow-up. When playing client, you are given a back story. You can make up any information that is missing. Try and play the client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. Case 1 - Client You are a 72-year old female Elder in a small community. You live alone, your husband passed away and so did most of your friends. Your children have grown and moved away. You used to enjoy sewing traditional clothing and doing beadwork, but in your 60 s started getting arthritis and now using your hands is very painful. You have smoked a pack a day since you were a teenager and you really enjoy it. It is the one thing that gives you pleasure; it almost feels like cigarettes are your best friend. Your doctor has advised you to quit because smoking makes your arthritis worse, but you think he is too young to know what he is talking about and you feel upset and angry when he tells you to quit. Case 2 Health Care Provider Your client is a 23-year old female who has just found out she is pregnant with her 1st baby. Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for the same client as in the ASSESS role play (Case 1). As the health care provider, apply the 5 A s to your interaction with the client. Ensure that you ARRANGE for appropriate follow-up. When playing client, you are given a back story. You can make up any information that is missing. Try and play the client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. Case 1 Health Care Provider You are seeing a 72-year old female Elder who has severe arthritis and lives alone. Her doctor recently recommended she quit smoking. Case 2 Client You are a 23-year old female and you have just found out you are pregnant. You have been smoking about a half a pack of cigarettes a day since you were 14 years old and you know you need to quit for 32

41 your baby, but you don t really know where to begin. You are scared of taking NRT or medications because you think they might harm your baby, but you don t think you can quit cold turkey either. You have a quit date in mind but want some help to get you through that first few days. 33

42 34

43 2.6 Resources 35

44 36

45 2.6.1 The Stages of Change Pre-contemplation No intention of quitting in the next 6 months (or ever) The perceived benefits of smoking outweigh the risks Will deny any advantage to quitting and may doubt they could quit even if they tried Contemplation Has considered the possibility of quitting, but not yet motivated to try The perceived benefits of smoking are as great as the perceived risks Ambivalent or undecided Preparation Planning to quit in the next several days to months Perceived risks of smoking (or benefits of quitting) are greater than perceived benefits of continued smoking May be trying to anticipate barriers Action Has quit for less than 6 months and intend to keep going forward Trying to anticipate or deal with barriers to success Maintenance Has been tobacco-free for greater than 6 months Continues to anticipate or deal with barriers to success Relapse Lapse Having 1-2 cigarettes during a quit attempt Relapse Returning to a regular tobacco use behaviour i.e. have ended the quit attempt Lapse and relapse are learning opportunities Stage-Appropriate Interventions Pre-contemplation Accept the decision Offer information Invite the individual to return if they ever do decide to quit tobacco Contemplation Promote their personal motivation to quit tobacco (e.g. ask What are some of your concerns related to tobacco use? OR What would be the most positive thing about quitting? ) Weigh the pros and cons; Offer information Preparation Help client develop goals and plans Ask about their perceived barriers and potential solutions (e.g. So cigarettes help you manage stress. What are your thoughts on managing stress without cigarettes? ) Discuss Nicotine Replacement Therapy or prescription products Discuss a quit date 37

46 Action/Maintenance Ask how the attempt is going; What s working and what has been difficult? Suggest ways to avoid or reduce triggers Discuss solutions to stated barriers Help identify support persons Identify strategies to prevent or cope with relapse Assess their response to medication (it taking) Relapse Help reframe the relapse as a learning opportunity Review the circumstances that led to relapse and explore how they might be overcome next time Ask about readiness for another quit attempt 38

47 2.6.3 ASSESS: Stage of Change Card Game Here s how the game works. One participant will ask What are your thoughts on tobacco? The participant with the card reads the response. The first participant then states the stage of change. The participant with the card confirms whether he or she is right (or asks him/her to try again). The damage is done. I d rather enjoy the last years of my life smoking as much as I want. PRECONTEMPLATIVE Nobody s going to get me to quit snuff. PRECONTEMPLATIVE I can t afford cigarettes anymore, but I don t know how else to relax. CONTEMPLATIVE My new boyfriend hates cigarettes I d give them up but I just don t want to gain weight. CONTEMPLATIVE I m really beginning to feel crappy from smoking cigarettes, but I just don t think I could ever actually quit. CONTEMPLATIVE Should I wait until Jan 1 st to quit smoking or should I do it before Christmas? PREPARATION 39

48 Tomorrow, I m going to look into getting some of that nicotine gum. PREPARATION It s been 10 weeks, maybe I ll step down to a lower dose of patch. ACTION I quit smoking seven years ago. MAINTENANCE What are my friends going to say when I tell them I really want to quit smoking? PREPARATION I ve been off cigarettes for three months I m so happy! ACTION I was doing great until my girlfriend left me. Now I m smoking again. RELAPSE I don t know what happened six months free of snuff then I just took it up again. RELAPSE 40

49 41

50 2.6.4 INSERT THE 5AS GUIDELINE HANDOUT HERE 42

51 44

52 3.0 Module 3: Motivational Interviewing Level 1 45

53 46

54 Skill Building Workshop Facilitator Guide 3.1 Communication Skills & the Spirit of Motivational Interviewing Goal: By the end of this workshop, participants will be able to apply communication techniques that help form a trusting relationship with a client. Learning Objectives: By the end of this workshop, participants will be able to: 1. Demonstrate use of the OARS Communication Techniques Open-ended questions, Affirmations, Reflections and Summaries - in a conversation with a workshop partner 2. Recognize the righting reflex in a role play demonstration 3. Recognize the four components of the Spirit of Motivational Interviewing in a role play demonstration Materials and Resources: Righting Reflex Demonstration Video (if available) Spirit of Motivational Interviewing Demonstration Video (if available) 47

55 48

56 3.2 LESSON PLAN: Communications Skills & Motivational Interviewing Level 1 Activity Icebreaker Instruction Introduce OARS Techniques Open-ended questions Affirmations Reflections Summaries Instruction Open Ended Questions An open-ended question cannot be answered with a yes or no response. E.g. What are your thoughts on tobacco? instead of Do you want to quit smoking? An open-ended question allows the client to think about their responses and provide the information they wish to share. The response to an open-ended question tends to provide more information than the response to closed-ended questions. For this reason, they can be a more effective way to get to know your client and their needs. Activity Open-Ended Questions 1. Ask participants to form pairs. 2. Give the participants a conversation theme. For example your last vacation. 3. One partner then asks the other closed-ended questions to learn about that person s last vacation. E.g. Did you go out of town? Did you go somewhere warm? 4. Then, the other participant asks open-ended questions to learn about that person s last vacation. E.g. How was your last vacation? What happened? 5. Discuss as a group which method was better for learning about the person s last vacation? 49

57 3.2.3 Instruction Affirmation An affirmation is a statement that recognizes an individual s strengths and positive actions or decisions. Affirmations can support an individual s sense of confidence in being able to successfully change a behaviour. Affirmations must be genuine. Example: o (Client) I really need to quit smoking. o (HCP) I m so pleased to hear you speak with such commitment. o o (Client) Last time I quit, I was good for four months then I just started again. (HCP) You must have learned a lot during those four months. Activity Affirmation 1. Ask participants to form pairs. 2. One participant describes their experience and thoughts related to helping someone quit tobacco. 3. The partner listens for examples of personal strengths and positive actions or decisions and provides a genuine affirmation. 4. Partners then switch roles. 5. Discuss as a group what was the experience like trying to provide genuine affirmations? How did it feel to receive a genuine affirmation? 50

58 3.2.4 Instruction Reflection A reflection is a statement that speaks back what the health care provider thinks the client is trying to express. The client can then confirm or clarify what they were trying to say. Reflections are more effective when the health care provider listens very intently to what the client is saying. A reflection is a powerful way to express empathy, i.e. that the health care provider understands the client s point of view. Example o (Client) I don t know how I can quit smoking with my husband out of town so much and my eldest son getting into trouble at school every third day! o (HCP) So you have a lot of stress in your life right now and smoking helps you cope? o o (Client) I know I shouldn t smoke since I m pregnant, but my boyfriend smokes around me all the time and it s hard not to smoke. (HCP) So, more support would be helpful for you? Activity Reflection 1. Ask participants to form pairs. 2. One partner describes a situation they are struggling with (could be a behaviour change like trying to get more exercise or conflict with a friend or family member, etc.). 3. The other partner listens and provides reflections in their own words - on what they think their partner is saying. 4. Partners switch roles. 5. After each reflection, the first partner confirms that the reflection was accurate or provides further clarification. 6. Discuss as a group what was the experience like trying to provide accurate reflections? How did it feel to receive a reflection? 51

59 3.2.5 Instruction Summary A summary statement is a type of reflection that pulls together several things that have been discussed during the conversation with a client. It is an effective way to prepare for next steps in the discussion, to link elements of the discussion or to bring a conversation back on track. Example (HCP) So you have been smoking most of your life and have never made a serious quit attempt. You really depend on smoking for relaxation yet you are really concerned about the persistent cough. Where should we go from here? Activity Summary 1. Ask participants to form pairs. 2. One partner describes how they are hoping to get involved or increase involvement in supporting clients to quit tobacco. 3. The other partner listens and then summarizes the key points of the conversation as they understand it. 4. Partners switch roles. 5. Discuss as a group what was the experience like trying to provide a summary? 52

60 3.2.6 Instruction The Righting Reflex Health care providers often experience the righting reflex or the natural desire of helpers to set things right to prevent harm and promote client well-being. Sometimes health care providers and their patients/clients expect the health care provider to have all the answers and know the best way forward. This may be true for recommending drug therapy or a surgical intervention, but is rarely true for exploring why and how to go about changing one s behavior. The righting reflex can result in a directive approach versus a more collaborative approach to helping people. When this happens, the client may become defensive or resist change, particularly when they are undecided about that change. Activity Righting Reflex Video Demonstration 1. Play the video demonstration of a health care provider demonstrating the righting reflex with a client. 2. If a video is not available a pair of facilitators can do a role play demonstration. 3. Ask participants to share their reflections on what they observed in the video. 53

61 3.2.7 Instruction The Spirit of Motivational Interviewing The underlying spirit of motivational interviewing is a non-confrontational, collaborative approach that honours the clients autonomy and respects their feelings and concerns. There are four components to the Spirit of MI. These components describe the mindset that we as the health care providers need to adopt to successfully support behaviour change like quitting tobacco. Briefly, the four components are: o o o o Partnership The health care provider and the client are equal partners in working towards a common goal. A directive expert-client relationship can result in the client feeling like a passive receiver of advice rather than a full partner working towards a common goal. Acceptance The health care provider has complete regard for the individual s absolute worth and right to make their own decisions. The health care provider strives to understand the person s situation through reflective listening and recognizes their personal strengths and achievements through affirmations. Compassion Motivational interviewing is not manipulation. The health care provider is genuinely interested in helping the client in a manner that is accepting and respectful of their personal values and change goals. Evocation To evoke means to help the client identify and express their own motivation for change and to identify their own barriers to success and develop solutions to overcome them. This is very different from the expert approach that involves telling the individual why they need to change and providing instructions on how to do it. Activity The Spirit of Motivational Interviewing Video Demonstration 1. Play the video demonstration of a health care provider applying the spirit of motivational interviewing to an interaction with a client. 2. If a video is not available a pair of facilitators can do a role play demonstration. 3. Ask participants to share their reflections on what they observed in the video and identify examples of each component of the spirit of motivational interviewing. 54

62 3.2.8 Instruction Additional Communication Techniques (optional) Additional approaches to communication are also useful and generally recommended when applying motivational interviewing techniques: Asking Permission The health care provider can ensure a collaborative spirit and respect for autonomy if permission is asked before introducing information or advice into the conversation. (HCP) Can I share a few of my concerns related to smoking and your recurring lung infections? Expressions of Concern Advice ( You should stop smoking to reduce your risk of a second heart attack ) - may be better received if framed as an expression of concern from the health care provider s perspective ( As your nurse, I m concerned about the increased risk of a second heart attack associated with your continued smoking ). This expression of concern should be relevant to the client s circumstance a condition they are experiencing now versus something they could get in the future from smoking. Silence It is important to allow individuals some quiet time to think about answers to questions, particularly open ended questions that may require considerable thought. If the health care provider breaks the silence when he/she is experiencing discomfort with silence, the client s thought process may be interrupted and they may be unable to finish putting together a response. 55

63 56

64 4.0 Module 4: Motivational Interviewing Level 2 57

65 58

66 Skill Building Workshop Facilitator Guide Goal: 4.1 The Process of Motivational Interviewing: Level 2 By the end of this workshop, participants will be able to apply basic motivational interviewing techniques to interactions with their patients/clients. Learning Objectives: By the end of this workshop, participants will be able to: 1. Describe the four steps in the Process of Motivational Interviewing: Engaging, Focusing, Evoking and Planning. 2. Discuss techniques for dealing with discord after observing a role play demonstration. 3. Distinguish between change talk and sustain talk. 4. Discuss techniques for evoking motivation after observing a role play demonstration. 5. Discuss techniques for evoking confidence after observing a role play demonstration. 6. Discuss techniques for relapse management after observing a role play demonstration. 7. Demonstrate the use of motivational interviewing during a role play with a partner. Materials and Resources: Demonstration Case Studies Change Talk/Sustain Talk Statements Motivational Interviewing Demonstration Video Motivational Interviewing Role Play Cases (Includes Role Play Observer Checklist at end of roleplay section) 59

67 60

68 4.2 LESSON PLAN: Motivational Interviewing Level 2 Activity - Icebreaker Instruction The Process of Motivational Interviewing There are four steps in the process of motivational interviewing. Each step builds on the previous step: o o o o Engaging Creation of a trusting therapeutic partnership that helps the client feel safe to discuss their issues, concerns and hopes. Focusing Identify a change goal that the client is willing to consider and discuss. This also includes identifying a specific objective for the current interaction. Evoking Helping the client to identify and express their own motivation for change, to identify their own barriers to success and to develop solutions to overcome those barriers. Planning - Development of practical next steps the client will use to achieve their change goal Instruction Engaging Engagement in a therapeutic partnership will most likely occur when the health care provider embraces the Spirit of Motivational Interviewing and uses the OARS communication techniques (as covered in the first MI Skill Building Workshop: Open ended questions, affirmations, reflections and summaries). Despite best efforts, discord can develop in the therapeutic partnership. The patient/client may become defensive, confrontational or disengaged. Strategies that can help restore engagement include: Reflection o o (P) I can t believe another person is talking to me about smoking. (HCP) So, a lot of your health care providers have been bringing up the subject and you haven t found it particularly helpful? Emphasize Autonomy o o (P) Listen I m not really ready to quit smoking. (HCP) That s ok, only you can decide when the time is right. Reframing 61

69 o o (P) I ve tried quitting hundreds of times so don t get on me about it now. (HCP) So, you ve had a lot of experience with what works and what doesn t. Apologize o o (P) I know all that. (HCP) I m very sorry. I didn t mean to start lecturing. Affirm o o (P) You ve never smoked. You can t understand how difficult it is to quit. (HCP) Yes, you are right. You are overcoming a very difficult addiction. Shift Focus o o (P) I m tired of health care people constantly forcing me to quit smoking. (HCP) I don t want to force you. I am here to help with whatever goal seems reasonable to you. Activity Dealing with Discord 1. Distribute the demonstration case studies to one pair of participants. 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of the patient/client. 3. After each reading, ask the group to share their observations Instruction Focusing Focusing occurs when the patient/client and the health care provider collaboratively determine a change goal e.g. to quit using tobacco. There may be circumstances when the client s change goal does not match the hopes of the health care provider e.g. to only reduce tobacco instead of quitting altogether. In these cases, the health care provider will either have to gently negotiate a different goal or accept the client s decision and work towards that goal. Focusing can also be used to determine the objective(s) for a given interaction or session. Examples: o Determine the patient/client s health goal e.g. On Jan 1st, I will quit smoking so that my breathing can improve (or at least not get worse). o Determine an objective for that interaction or session e.g. By the end of today s session, I will have worked out two strategies for managing my morning cravings. 62

70 The assessment techniques discussed in the 5As workshop can help identify the client s health goals and objectives for a given interaction Instruction Change and Sustain Talk Change talk occurs when the client speaks in favour of change. Sustain talk occurs when the client speaks in favour of not changing. Motivational interviewing involves encouraging or evoking change talk in favour of sustain talk. Change talk can be classified into several categories represented by the acronym, DARN CAT: o Desire, Ability, Reasons and Need are collectively known as preparatory change talk in that they do not suggest change will happen, just that change is regarded as desirable, important or possible. o Commitment, Activation and Taking steps are known as mobilizing change talk in that there is a suggestion of intent to follow-through with change. Change Talk Examples: o DESIRE I want to quit smoking o ABILITY I could quit smoking if I figured out how to manage stress o REASONS I could save a lot of money if I quit smoking o NEED I must quit smoking or else o COMMITMENT I will quit smoking next Monday o ACTIVATION I m ready to do what it takes to quit smoking o TAKING STEPS Yesterday, I looked into getting nicotine patches Sustain talk may also take the form of DARN CAT statements but in favour of not changing. Activity Recognizing Change Talk 1. Ask participants to form pairs. 2. One partner reads a list of statements. 3. After each statement is read, the other partner states whether it is change talk or sustain talk. If it is change talk, they then identify which of the DARN CAT categories the statement is. 4. Partners switch roles and repeat exercise with a second set of statements. 5. Review all the statements as a group. 63

71 4.2.5 Instruction Evoking Motivation Evoking change talk using the OARS communication techniques will help a client identify their personal motivation to quit using tobacco (See Module 3.0). Evoking motivation is typically required for clients who are pre-contemplative or contemplative about quitting tobacco (See 5A s Guide for description of Stages of Change). As the client expresses more change talk, they may move from being undecided about change to wanting to change (for reasons that are important to them). Activity Evoking Motivation 1. Distribute the demonstration case studies to one pair of participants. 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of the patient/client. 3. After each reading, ask the group to share their observations, with particular focus on the communication techniques used. 64

72 4.2.6 Instruction Evoking Confidence Patients/clients who are ready and willing to quit may not feel ABLE to quit i.e. they have low to moderate confidence. The health care provider can help to support the patient/client s self-efficacy i.e. their sense of capability to successfully quit tobacco. Patients/clients in the preparation, action and maintenance stages may be wrestling with low to moderate confidence. Evoking confidence involves using the OARS communication techniques to help the patient/client identify their own barriers to successfully quitting tobacco, and to come up with their own solutions to overcoming those barriers. (See SBW MI1 Module). Activity Evoking Confidence 1. Distribute the demonstration case studies to one pair of participants. 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of patient/client. 3. After each reading, ask the group to share their observations, with particular focus on the communication techniques used. 65

73 4.2.7 Instruction Planning Evoking Commitment Motivational interviewing is intended to support the patient/client by helping to increase motivation and confidence so that they are willing to commit to a plan for behaviour change e.g. quitting tobacco. In terms of stage of change, this is moving from preparation to action. If the health care provider pushes the change plan before the patient/client is ready, they may resist moving forward with a quit attempt. How to determine whether the patient/client is ready to make a plan: o Change talk (particularly mobilizing change talk) is much more frequent than sustain talk. o The patient/client has actually taken preliminary steps towards change (e.g. arranging for nicotine replacement, getting rid of ashtrays). o There is a sense of resolve within the patient/client that action is the next step. o The patient/client is imagining life with a new behaviour e.g. life without tobacco, breathing better, saving money. o The patient/client is asking questions about what to do next. Strategies for supporting the development of a plan include: o Confirming the goal o Exploring options o Asking what might actually work o Summarizing the conversation o Troubleshooting potential pitfalls Activity Planning - Evoking Commitment 1. Distribute the demonstration case studies to one pair of participants. 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of patient/client. 3. After each reading, ask the group to share their observations, with particular focus on the communication techniques used. Activity Motivational Interviewing - Video Demonstration 1. Play the video demonstration of a health care provider applying motivational interviewing to an encounter with a patient/client. 2. If a video is not available a pair of facilitators can do a role play demonstration. 66

74 3. Ask participants to share their reflections on what they observed in the demonstration. Activity Motivational Interviewing 1. Distribute three role play cases to groups of three. For each case, one participant plays the patient/client, one plays the health care provider and the other plays the observer (the observer is given a checklist to help evaluate the role play). 2. The participant playing the health care provider uses motivational interviewing to support the participant playing the patient/client. 3. Once each case is completed, participants switch roles. 4. Have a short discussion after the role plays to allow participants to share their thoughts. 67

75 4.2.8 Instruction Relapse Management Evoking Persistence Those attempting to change behaviours may experience a relapse, particularly during the first months of the attempt. This can be due to a decrease in motivation, confidence and commitment, or to situations that make it difficult to sustain the new behaviour. Health care providers can help provide continued support as the patient/client moves from action to maintenance. Strategies to help manage relapse include: o o o o Help the patient/client understand that relapse is a normal part of behaviour change Reframe failure as a learning opportunity Explore the circumstances associated with relapse and, through evocation, help the patient/client develop strategies to overcome those circumstances in the future Identify and affirm successes and strengths demonstrated during the change attempt Activity Relapse Management Evoking Persistence 1. Distribute the demonstration case studies to one pair of participants. 2. Ask each pair to read out their case, one reading the role of health care provider, the other reading the role of patient/client. 3. After each reading, ask the group to share their observations, with particular focus on the communication techniques used. 68

76 4.3 Case Activities 69

77 70

78 Case Demonstrations: Instructions You will be asked to read one of the following cases out loud with your partner. Decide which one of you will read the role of the health care provider and who will read the role of the patient/client. When asked, read the lines as if reading the script for a play. After the reading, there will be a group discussion Dealing with Discord The client is a 69-year old man who has recently been diagnosed with COPD. He is at the clinic to learn about the management of his condition. HCP Hi Pauloosie, before we talk about your medication, I wanted to ask whether you have used any tobacco products in the last month? Client Yes I smoke cigarettes, about a pack a day. HCP And what are your thoughts on smoking right now? Client Well, my doctor basically said I need to quit. HCP And what do you think? Client I m not sure. I want to see how I do with these puffers. HCP Pauloosie I m really concerned about what will happen to your lungs if you don t quit. Client I m growing tired of being told to quit smoking. May I go now? HCP I m very sorry. I didn t mean to start lecturing. I need to respect what you wish to do right now. May I start again and ask how I can be of most help to you? Client Sure that s OK. I probably need more information to read so I can learn more about this Evoking Motivation The client is a 48-year old man who works at the Iqaluit airport in cargo. He came in to talk about smoking, but doesn t really seem to be ready. HCP So, Johnny, what are your thoughts on smoking? Client I don t know. I came in to talk, but honestly I m probably not that interested in quitting. HCP What moved you to actually come in and see me? Client I told my wife I would see someone. She is constantly nagging me. HCP You were trying to get your wife off your back. Client That s about right. HCP On a scale of 1-10, how important is it for you to quit smoking right now. 71

79 Client I d say about a six. HCP Six. Why a six and not a three? Client (pause for 20 seconds) Because I actually want to quit. I m tired of it, I m feeling crappy and I know it s because of smoking. I just don t think I can. HCP So not trying to quit may be more related to how hard it is going to be for you? Client Yes you could say that. HCP What would it take to start thinking seriously about a quit attempt. Client I guess I just need someone to listen and help me through this. HCP If it s OK with you I d be happy to help you out. Client That sounds good Evoking Confidence The client is the same 48-year old man from the previous case. He is now motivated to quit and is willing to talk more about how he might do it. HCP Johnny what will be most difficult about quitting? Client Well as much as I do want to quit, smoking makes me happy in the moment. HCP Tell me more about that. Client I work long hours at the airport. It s cold.and smoking.it keeps me company and keeps me warm. HCP Is it helping you with boredom? Client Not exactly. I like my job. Smoking just provides a sort of comfort. HCP Like your favourite blanket on a cold night? Client Sure that s close to the feeling. HCP How do you think you might get this comfort without cigarettes? Client I don t know. HCP What other circumstance have you experienced that is similar but you managed with something besides cigarettes. Client (pause for 20 seconds) Ice fishing. My buddy and I drink this tea to keep us warm. I actually don t smoke that much when I m fishing. HCP Is that something you could drink at work. Client Absolutely a lot of guys bring a thermos of coffee or something. It seems so obvious. I could try this but it will still be hard. I know I ll get cravings. HCP Any thoughts on managing cravings? Client I once tried using the patch. It was sort of helpful. HCP Would you be interested in some more information on options for nicotine replacement therapy? 72

80 Client Yes, please Evoking Commitment - Planning The client, Johnny, has returned one week later to continue the discussion on quitting smoking. HCP Hi Johnny. How are things? Client Well, I read further on the nicotine replacement stuff that we discussed last week and I think the patch with the inhaler will work good. HCP That s great. The combination of the two products will increase your chances of success. What else do we need to consider so that you can be successful? Client I was thinking about this and I noticed that I immediately go for a cigarette when my wife tries to talk about money with me. HCP Money is stressful for you? Client Always has been. HCP And how do you think you will manage this? Client Well I do realize that if I don t smoke I ll save money. That is going to be a big help. HCP That is certainly another positive. Client Otherwise maybe I need to ask her to lay off the money conversation for a while. She may be willing to do that. HCP Will it really be possible to not talk about money for a few months? Client Actually probably not. We always need to discuss something about money at least every week. HCP So what else might work? Client I don t think there is an easy answer. For now I think I will just use the nicotine inhaler if I m beginning to feel on edge. I need to work on how money problems affect me. HCP That is a really important thing to learn about yourself, Johnny. You are really showing a strong commitment to be successful. Client Thanks. HCP Any thoughts on a quit date? Client Next Monday will work. HCP How are you going to prepare for your quit day? Client Well, on SundayI m getting rid of ashtrays and throwing away any remaining cigarettes. I will have my thermos of tea ready on Monday morning. I m going to get the patches and inhaler organized tomorrow and I m really going to work on how I deal with money conversations but I know if I need it I ve got the inhaler. 73

81 4.3.5 Relapse Management It has been three months since the last appointment with Johnny. He has come in to the clinic to talk. HCP Hi Johnny. It s great to see you. How is everything going? Client Horrible I started smoking again. HCP You must be disappointed, but this does happen. You are working on a lot of things that take time and practice to master. You were successful for over three months. Client That s a better way of looking at it, I guess. HCP What happened? Client Money. HCP Tell me more. Client My wife and I were having a money conversation. I was using the inhaler and she asked whether I was going to stop using that thing every time we have a money conversation. I got up and left for the store, got some cigarettes and here I am. HCP It sounds like it might have been more related to being angry at your wife for saying what she said when you were doing so well at not smoking. Client You are probably right. Yes. HCP What have you shared with your wife about the stress you experience during money talks. Client Well, nothing actually. HCP What might help in this situation? Client It would probably help to tell her why I use the nicotine inhaler and that it is keeping me from smoking cigarettes. I also need to tell her that I am working on managing stress because I am. HCP That is a great idea. What are your thoughts about trying again? Client I ve got to I was doing so well. This has really helped to talk it through Recognizing Change Talk vs. Sustain Talk Instructions Read out the following statements to your partner. Your partner will identify if the statement is change talk or sustain talk. If it is change talk, your partner will name the category (DARN CAT). 1. I like smoking when I m out hunting (Sustain) 2. I would like to cut down how much I smoke (Change Desire) 3. I need to quit so I don t have another heart attack (Change Need) 4. I don t want to talk about quitting smoking (Sustain) 74

82 Instructions 5. Smoking is not healthy for me (Change Reason) 6. I will quit smoking on Monday (Change Commitment) 7. I looked into getting nicotine gum (Change Taking Steps) 8. Quitting smoking will help me save money (Change Reason) Read out the following statements to your partner Your partner will identify if the statement is change talk or sustain talk If it is change talk, your partner will name the category (DARN CAT) 1. My wife hates the smell of my clothes when I smoke (Change Reason) 2. Smoking helps me with stress (Sustain) 3. I removed all the ashtrays from the house (Change Taking Steps) 4. I could quit smoking if I could get over the cravings (Change Ability) 5. Smoking is the only enjoyment I get (Sustain) 6. I must quit smoking or else (Change Need) 7. I will quit smoking once I move into the new house (Change Commitment) 8. All my friends smoke (Sustain) Role Plays: Motivational Interviewing Participant 1 Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for Case 2. When playing health care provider, your objective is to determine the patient/client s stage of change, their level of importance related to quitting tobacco, and their level of confidence in being able to quit tobacco. Once you have determined these three things you may end the role play. When playing patient/client, you are given a back story. You can make up any information that is missing. Try and play the client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. When playing observer, use the observer checklist to make notes on the role play both what went well and what might be some encouraging points of improvement. 75

83 Case 1 - Client You are a 46-year old female who just adopted your three grandchildren. You have been able to cut down on smoking, but aren t quite ready to give it up. You smoke about a half a pack a day now, but were smoking a pack and a half a few months ago. You know you should quit smoking to be healthy and to have enough energy and money to take care of the kids. However, taking care of the kids adds stress and makes you a little bit scared to quit because smoking helps you relax. Maybe you will think about it in the New Year. Case 2 Health Care Provider Your client is a 46-year old female who has just adopted her three grandchildren. Case 3 Observer Role Plays: Motivational Interviewing Participant 2 Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for Case 1. When playing health care provider, your objective is to determine the patient/client s stage of change, their level of importance related to quitting tobacco, and their level of confidence in being able to quit tobacco. Once you have determined these three things you may end the role play. When playing the client, you are given a back story. You can make up any information that is missing. Try and play the patient/client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. When playing observer, use the observer checklist to make notes on the role play both what went well and what might be some encouraging points of improvement. Case 1 Health Care Provider Your client is a 28-year old man who works as a corrections officer in Iqaluit. Case 2 Observer Case 3 Client 76

84 You are a 28-year old male working as a corrections officer at the Baffin Correctional Centre. You ve been smoking since age 11 and you are up to about a pack and a half a day. Your job is very stressful and the 12 hour shifts make you very tired. Everyone at work smokes and it s the only enjoyment you all get. You do not want to discuss quitting. You like smoking and wish people would get off your back about it. You have asthma, but you don t think it s because of smoking as it runs in your family Role Plays: Motivational Interviewing Participant 3 Instructions You and your partner will take turns playing the health care provider in a role play. You are the health care provider for Case 3. When playing health care provider, your objective is to determine the patient/client s stage of change, their level of importance related to quitting tobacco, and their level of confidence in being able to quit tobacco. Once you have determined these three things you may end the role play. When playing the client, you are given a back story. You can make up any information that is missing. Try and play the patient/client as realistically as possible. There is no need to share information a person wouldn t typically share unless asked a relevant question. When playing observer, use the observer checklist to make notes on the role play both what went well and what might be some encouraging points of improvement. Case 1 Observer Case 2 Client You are a 52-year old man who just had a mild heart attack while on a seal hunt with your friends. You smoke about a pack and a half a day and have been smoking since about age 20. The doctor told you to try to stop smoking right away or you would risk having a stronger heart attack next time. You really like smoking when you are out on the land with the boys, but you are also afraid of having another heart attack. You think you are still young enough to get away with a little smoking. You think you could cut down and maybe just smoke while you are out hunting. Case 3 Health Care Provider Your client is a 52-year old man who just had a mild heart attack while on a seal hunt. 77

85 Observer Checklist Open Ended Questions Affirmations Reflections Summaries Asking Permission Expressing Concern Evoking Change Talk Evoking Confidence 78

86 5.0 Module 5: Nicotine Replacement Therapy 79

87 80

88 Skill Building Workshop Facilitator Guide Goal: 5.1 Nicotine Replacement Therapy By the end of this workshop, participants will be able to review nicotine replacement therapy options with clients and make recommendations on specific regimens within their scope of practice. Learning Objectives: By the end of this workshop, participants will be able to: 1. Describe how Nicotine Replacement Therapy (NRT) works 2. Demonstrate the correct use of nicotine replacement products 3. Recommend an NRT dosing regimen (within scope of practice) for a client 4. Recommend an NRT dosing regimen (within scope of practice) for a pregnant client 5. Identify potential drug interactions associated with quitting tobacco Materials and Resources: Demo NRT Products Placebo gum/lozenge for demonstrating technique NRT Case Studies Supplemental Handout Nicotine Replacement Therapy 81

89 82

90 5.2 LESSON PLAN: Nicotine Replacement Therapy Activity - Icebreaker Instruction Nicotine Replacement Therapy Overview Nicotine Replacement Therapy (NRT) can prevent or reduce the withdrawal symptoms that tobacco users experience when they reduce or stop using tobacco products. Examples of withdrawal include: o o o o o o o o o Feeling depressed or sad Trouble sleeping Feeling cranky, frustrated or angry Feeling anxious, nervous or restless Difficulty concentrating Increased appetite Coughing and dry mouth Headaches and feeling dizzy Upset stomach and constipation Nicotine is the addictive chemical in tobacco, but does not cause the harm associated with tobacco use. Nicotine replacement is far less addictive than cigarettes or chewing tobacco. NRT provides only nicotine; the other harmful chemicals in tobacco are avoided. NRT does not replicate the experience of smoking a cigarette; it is intended to reduce the cravings and keep the client comfortable while they get used to living without tobacco. NRT can double the chances of successfully quitting tobacco Instruction Forms of NRT There are two basic types of nicotine replacement therapy: 1. Long Acting Patch: These products provide a continuous level of nicotine delivered through the skin over a 24 hour period. They are useful for preventing or reducing the frequency and severity of withdrawal symptoms. There are three strengths of nicotine: 21 mg, 14 mg and 7 mg. 2. Short Acting Forms: 83

91 Short acting forms include gum, lozenge, inhaler and oral mist. The gum and lozenge are available in two strengths (typically 2 mg and 4 mg). NOTE: The oral mist is not readily available in Nunavut. Short acting NRT products like gum, lozenges, inhalers and oral mist provide a single dose of nicotine to be used as needed to treat cravings and other withdrawal symptoms. These products are best for people who smoke less than 10 cigarettes a day - or for an extra dose of nicotine as needed to help with breakthrough cravings in those who are using the patch. Activity Administration of Nicotine Replacement Therapy 1. Facilitator demonstrates the use of each NRT product (patch, gum, lozenge and inhaler) and provides information on common side effects. (See Supplemental Information section) 2. In pairs, participants practice demonstrating the use of each NRT product. The participant receiving the demonstration may ask any question about use of the product. 3. Partners switch roles and repeat exercise Instruction Recommending an NRT Regimen Remind participants that they should be aware of their scope of practice as it relates to recommending and monitoring medication therapy. STEP 1: Review Contraindications (inadvisable to take these medications because of a likely adverse reaction): Avoid gum for people with dentures, poor teeth or jaw disorders Avoid any product to which the patient has a known allergy Pregnancy Nicotine will cross the placenta and pass into breast milk. There are risks to the fetus or infant. However, nicotine replacement is far less dangerous than using tobacco during pregnancy or breast feeding. Attempt behavioural support alone; if not successful: o Introduce short acting nicotine replacement as needed for withdrawal symptoms; o If not successful, introduce a conservative dose of patch (e.g. 7 mg patch for 8 hours a day only remove before bed). The objective is to determine the lowest helpful dose of nicotine replacement to help the expectant or new mother remain tobacco-free. Additional resources for health care providers and patients: (Center for Addictions and Mental Health) 84

92 Adolescents There is no evidence that NRT use is harmful in adolescents: o Encourage behavioural interventions first. o Use NRT in combination with behavioural interventions. Cardiac Disease NRT does not increase the risk of a heart attack. NRT is safe to use in people with stable coronary artery disease. STEP 2: Determine client preference STEP 3: Determine initial dose The following starting regimens are a guideline only; the dose may need adjustment depending on the person s response to therapy. Combination Therapy The combination of a long acting patch with an as needed short acting form of NRT improves the likelihood of a successful quit attempt over the patch alone. People can experience breakthrough cravings or withdrawal while on any dose of patch. The short acting form can be particularly useful in the following situations: o First thing in the morning, especially if the person doesn t wear the patch overnight o After stepping down to a lower dose of patch (or off the patch entirely) o When experiencing stress or strong triggers for tobacco use despite wearing a patch 85

93 STEP 4: Tapering off of nicotine replacement therapy: The objective of NRT is to gradually reduce the dose until the client is completely off of nicotine. NRT product information typically describes a 12 week tapering schedule, however, this may not be suitable for many tobacco users. Ongoing use of NRT is always preferable to using tobacco. Empower your client with the knowledge that they can decide when to start tapering their dose. They can also revert back to the previous dose if a tapering attempt did not go well. Reduce to Quit People can use any form of NRT to help prepare for a quit attempt or to reduce the amount of tobacco used (if they are not ready to quit completely). This means the client may use tobacco and NRT together. Though not recommended on product labeling, this is considered safe Instruction - What is covered by the Non-Insured Health Benefits (NIHB) Program? Nicotine Gum - NIHB covers 945 pieces per year. This is about six pieces a day for five months. Nicotine Patches - NIHB covers 140 NicoDerm patches per year. This is about a four-month supply OR NIHB will cover 168 Habitrol patches per year. This is about a five-month supply. Nicotine Lozenges - NIHB covers 945 lozenges per year. This is about six lozenges a day for five months. Nicotine Inhalers - NIHB covers 945 inhalers per year. This is about six cartridges a day for five months. Note: See NRT fact sheet in Resources section Instruction Drug Interactions and Tobacco When tobacco burns, combustion products are inhaled by the smoker that can increase the activity of (or induce) an enzyme in the liver (Cytochrome P450 1A2) this enzyme is responsible for the metabolism of several drugs and caffeine. When a person quits or reduces cigarette use, they may start metabolizing medications slower. Consequently, drugs metabolized by the enzyme are cleared from the body more slowly resulting in potentially increased blood levels of these medications if the same dose is continued. This interaction is not present with chewing tobacco. The drugs most affected by this interaction include: o Clozapine 86

94 o Olanzapine o Fluvoxamine o Duloxetine o Theophylline o Caffeine Clients on these medications should be monitored for increased pharmacologic effect and/or side effects. Dose reduction may be necessary. Monitoring should continue for several weeks. If the client resumes smoking, the enzyme induction will gradually return (causing increased metabolism) and another dose adjustment may be required. Regarding caffeine, when people quit smoking, they may metabolize caffeine more slowly leading to increased levels of caffeine in the blood. Thus, people should be made aware of this possible effect, and be encouraged to reduce how much coffee they drink or switch to decaffeinated beverages. Nicotine does NOT increase the activity of cytochrome P450 1A2. Clients who use NRT will still experience this effect if they reduce or quit smoking cigarettes. Another important interaction to consider is the compounded cardiovascular risk associated with tobacco use and oral contraceptives. The risk increases with age (particularly those older than 35 years) and amount of tobacco used. Women who use oral contraceptives should be clearly advised of this risk and encouraged to stop using tobacco. Activity Recommending Nicotine Replacement Therapy 1. Facilitator works through an example case study with the whole group. 2. Distribute case studies to pairs of participants. 3. Each pair reviews the case and develops a recommended approach to nicotine replacement therapy for the client. 4. Each pair takes turns reviewing their recommendations during a group discussion. 87

95 88

96 Patch 5.3 Supplemental Information Nicotine Replacement Products Dose: Available in 21mg, 14mg & 7mg strengths that deliver nicotine through the skin over 24 hours: o Most regimes follow a tapering schedule over 8-12 weeks, at which time the user is encouraged to stop the patches. Administration: Apply new patch daily to clean, hairless skin. Rotate sites on the body. o o o Lotions or sunscreen applied prior to patch may prevent sticking. Dispose out of reach of children and pets. May swim or shower with patch on, but remove prior to prolonged or vigorous exercise due to the risk of excessive nicotine absorption. Side Effects: Skin reactions may be a transient reaction or an allergy to a patch component. o Try an alternate brand of patch or manage with hydrocortisone cream. o Mild tingling, burning or itch are normal and should disappear within one hour. o May remove the patch at bedtime if experiencing sleep disturbance attributed to use of the patch. Gum Dose: May be used as needed for cravings and other withdrawal symptoms OR on a regular schedule (e.g. hourly) to prevent withdrawal symptoms. o Available as a 2mg (usual dose) and 4 mg strength (the higher strength may be useful for individuals highly dependent on nicotine e.g. smoke 1 st cigarette within 30 minutes of awakening). Administration: Gum should be chewed slowly until a peppery or minty taste emerges - then parked between cheek and gum for 1 minute to allow for release of nicotine. Continue for 30 minutes or until taste dissipates. DO NOT SWALLOW. Contraindication: Active temporomandibular joint disease; dentures. 89

97 Absorption: Acidic beverages (e.g. coffee, juices, pop) are best not consumed while using the gum, as they may reduce the absorption of nicotine. Side Effects: Mouth soreness, hiccups, dyspepsia, and jaw ache. May be due to incorrect chewing technique. Lozenge Dose: May be used as needed for cravings and other withdrawal symptoms OR on a regular schedule (e.g. hourly) to prevent withdrawal symptoms. o Available as a 2mg (usual dose) and 4 mg strength (the higher strength may be useful for individuals highly dependent on nicotine e.g. smoke 1st cigarette within 30 minutes of awakening). Administration: Lozenge is placed in mouth and allowed to dissolve slowly over minutes. DO NOT CHEW OR SWALLOW. The lozenge should occasionally be moved from one side of the mouth to the other. There may be a tingling sensation in the mouth. Absorption: Acidic beverages (e.g. coffee, juices, pop) are best not consumed while using the lozenge, as they may reduce the absorption of nicotine. Side Effects: Mouth soreness, hiccups, dyspepsia, and cough. Inhaler Dose: May be used as needed for cravings and other withdrawal symptoms OR on a regular schedule (e.g. hourly) to prevent withdrawal symptoms. o 10 mg cartridge delivers about 4 mg of nicotine to oral mucosa over 20 minutes of puffing. Each cartridge delivers up to 80 puffs of nicotine aerosol. Administration: Lightly puff on mouthpiece. DO NOT INHALE DEEPLY INTO LUNGS. Store at room temperature as lower temperatures reduce the amount of nicotine available from inhaler. Absorption: Absorption occurs in the oral mucosa, not in the lungs. o Acidic beverages (e.g. coffee, juices, pop) are best not consumed while using the inhaler as they may reduce the absorption of nicotine. Side Effects: Mouth and throat irritation, hiccups, dyspepsia, and cough. May be related to incorrect technique. 90

98 5.4 Case Activities 91

99 92

100 NRT Case Studies You and your partner will be assigned one of the following cases to review. Based on the information given, develop a recommended approach to using nicotine replacement therapy for the client. You will present your recommendations during a group discussion. Example Case (facilitator will review with the group) The client is a 37-year old female who smokes about a pack and a half a day. She has smoked since she was fourteen and tried quitting two years ago by using the patch. That quit attempt lasted about 10 days. She wants to try a different approach this time she will gradually reduce her cigarettes, but wonders if she should use nicotine replacement as well. Case 1 The client is a 48-year old man who has been smoking since he was 12 years old. He currently smokes one and a half packs per day. He is also a heavy coffee drinker (up to 10 cups daily). He has never used NRT before, but has made several cold turkey quit attempts none lasting more than a couple of days. Case 2 The client is a 28-year old female who has just found out she is pregnant. She smokes cigarettes a day. She has smoked since she was 11 years old and has never tried to quit. Case 3 The client is a 52-year old female with chronic schizophrenia. Her schizophrenia has been managed very well on clozapine. She smokes almost two packs a day and has smoked since she can remember. Case 4 The client is a 35-year old male who chews about two tins of tobacco per week. He also has a history of depression and has been on an antidepressant, duloxetine, for six years. He used to play a lot of hockey and has many missing teeth in his mouth. 93

101 94

102 5.5 Resources 95

103 96

104 5.5.1 INSERT NRT FACT SHEET HERE 97

105 98

106 6.0 Module 6: Prescription Medications 99

107 100

108 Skill Building Workshop Facilitator Guide Goal: 6.1 Prescription Medications By the end of this workshop, participants will be able to review the different prescription medication options with clients and explain both the benefits and adverse effects of each. Learning Objectives: By the end of this workshop, participants will be able to: 1. Describe the two different prescription medication options to help people quit 2. Describe how the medications work 3. Describe medication dosing regime 4. Identify potential adverse effects of each medication option Materials and Resources: Demo Cessation Medication Products Demonstration Case Studies Supplemental Handouts Varenicline and Bupropion Info Sheet 101

109 102

110 6.2 LESSON PLAN: Prescription Medications Activity - Icebreaker Instruction Overview of Prescription Medications There are two non-nicotine prescription medications for smoking cessation available in Canada: o Champix, also known as Varenicline o Zyban, also known as Bupropion Instruction - Varenicline Varenicline binds to the same receptors in the brain as nicotine. It has two effects: o It stimulates the release of dopamine that helps satisfy the cravings for tobacco. o It prevents nicotine from binding to the receptor. If someone uses tobacco while on Varenicline, they won t experience the same benefits from nicotine, thereby making the act of smoking less satisfying. Varenicline is easily absorbed in the body. Absorption is unaffected by food or the time of day the medication is taken. Elimination half-life is about 24 hours. Mostly excreted as unchanged drug in the urine. Note: While Varenicline has not been approved for use in combination with NRT, best practices in tobacco cessation now uses this combination and have found it is safe and well-tolerated. Emerging research also supports this approach. (Koegelenberg et al 2014) Instruction Dosing Clients should begin taking medications 7-10 days before their quit date. o They can continue smoking as normal during this time. Dosing starts at 0.5mg orally once daily for days 1 through 3. Increase frequency of dose taking 0.5mg orally twice a day for days 4 through 7; then 1mg twice daily for duration of the therapy. Recommended duration of treatment is 12 weeks. An additional 12 weeks can increase the likelihood of long-term abstinence from tobacco Instruction Adverse Effects of Varenicline Nausea 103

111 Constipation Flatulence Vomiting Abnormal or vivid dreams try reducing dose if disturbing to client. They may have to discontinue therapy if dreams are persistent. Insomnia and Headaches Psychiatric Effects agitation, depression and suicidal ideation have been reported. Nausea is the most common adverse effect from Varenicline. It may go away with time and can be reduced by taking the medicine with a full glass of water and food. If nausea doesn t improve, the person can try a reduced dose, which may still be effective. People may also complain of abnormal dreams. If the dreams are distressing or disturb sleep, the person can try a reduced dose. Headache and insomnia can also occur. There has been some controversy related to people experiencing serious psychiatric effects like agitation, depression and suicidal thoughts. The latest evidence indicates that the symptoms are most likely from quitting tobacco in general and not the medication, however, anyone experiencing these symptoms should stop therapy and seek medical help. People with a pre-existing mental health condition should be made aware of the risks and monitored carefully Instruction Bupropion (not commonly used in Nunavut) Originally developed as an antidepressant and is not commonly used in Nunavut for smoking cessation. It is not fully understood how Bupropion works, but is thought to increase dopamine and norepinephrine within key areas of the brain. This reduces or prevents cravings and withdrawal symptoms when stopping tobacco use. Bupropion can be used in combination with nicotine replacement therapy products to help obtain better quitting results for the client Instruction Dosing 150mg daily for 3 days. Then 150mg twice daily for the rest of the duration of therapy. Duration of therapy is typically 12 weeks, but individuals can continue therapy for increased chances of a successful quit attempt. Bupropion can be taken with or without food. Tablets should not be crushed or chewed. 104

112 6.2.7 Instruction Adverse Effects of Bupropion Headaches Dizziness Insomnia Weight loss Tachycardia Dry mouth Mild to serious psychiatric effects reported Little risk of sexual dysfunction or weight gain Risk of seizures for those with a seizure disorder or who are at risk of seizures (e.g. alcohol withdrawal) Instruction - What is covered by the Non-Insured Health Benefits (NIHB) Program? Varenicline (Champix ) 165 tablets per year (3-month supply) Bupropion (Zyban ) 180 tablets per year (3-month supply) 105

113 106

114 6.3 RESOURCES 107

115 108

116 6.3.1 INSERT PRESCRIPTION MEDICATION HANDOUT HERE 109

117 110

118 APPENDIX 1: Cessation Tools This section contains additional lesson plans for a variety of cessation tools, diagrams, and models that can be used in one-on-one settings with clients, at health fairs, displays at health centres, or presentations in the community. 111

119 112

120 Lesson Plan: Smokerlyzer/CO Monitor 113

121 Learning Objective: The participants will be able to describe that carbon monoxide from smoking harms the body. What is the Carbon Monoxide Monitor: The Smokerlyzer is a breath analysis education tool that gives people a reading of how much carbon monoxide (CO) is in their body. Carbon monoxide is a gas produced from smoking that harms the body. Use the Smokerlyzer to educate people on the impact of smoking on their body, motivate people to quit smoking and track progress in quitting. It is not a diagnostic tool. Target Group for the Carbon Monoxide Monitor: The Smokerlyzer is best used with smokers or those who are exposed to second-hand smoke. Use it in individual or group sessions (classrooms, at community health groups, or one-on-one sessions) to show the health impacts of smoking. Materials: Smokerlyzer/Carbon Monoxide monitor Plastic D-piece SteriBreath plastic mouthpieces (enough for everybody to be tested) Cleansing wipes How to Use the Carbon Monoxide Monitor: 1. Turn on the monitor with 1 long press. 2. Attach the plastic D-piece into the hole below the blue button and put a new SteriBreath plastic mouth piece in it. 3. When the monitor is ready, the main screen will come on and 2 green lights on either side of the screen will flash. 4. Double-click the button to start the test. The person taking the test should breathe in and hold their breath for 15 seconds while the Smokerlyzer counts down. NOTE: If the machine is due for calibration, an extra screen will appear. Send the machine to the Tobacco Reduction Team in Iqaluit for calibration. 5. The monitor will beep during the last 3 seconds of the countdown. The person should blow slowly into the mouthpiece. If they cannot hold their breath for the full 15 seconds, they should 114

122 hold it for as long as they can and then breathe into the mouthpiece. They should empty their lungs completely. 6. The monitor will show the CO rating, and the coloured lights beside the screen will light up accordingly. Look at the table to tell the person their reading (see page 3). 7. Remove the D-piece between tests to allow fresh air to flow around the sensor. To repeat the test, double click the blue button to return to the main screen and continue from step Turn off the Smokerlyzer with 1 long press. 9. To clean the Smokerlyzer, remove the D-piece and wipe the monitor with the cleaning wipes that are supplied. Keep the monitor away from water. Do not wipe the D-piece. Tips to Make Your Presentation Work: Make use of the chart in the lesson plan to provide greater meaning of the individual ratings from the Smokerlyzer. Can be used with any other tobacco or oral health related lesson plans or presentations. Meaning of the Readings from the Smokerlyzer: Light color Description Adult reading Youth reading Green This is where a person really wants to be with less than 2% Carbon Monoxide (CO) in their blood. Most people have a small amount of CO in their breath, this is due to the air quality around them. Yellow Having a reading in this zone would indicate a light smoker or a non-smoker breathing in poor air quality or second-hand smoke. There are things that can be done to reduce this reading down to the target Green Zone. 1 Red Having a reading in the red zone indicates the person Reds may well be a regular smoker with higher levels of Reds CO in their blood. They need not despair! Help is at Reds hand to help reduce or give up smoking in order to Reds flashing reduce the reading down into the target Green Zone Key Facts Carbon Monoxide (CO) is a poisonous gas that you cannot see or smell. It is formed by the incomplete burning of any combustible product. 115

123 CO gets into the blood stream and binds with blood cells that should be carrying oxygen through the body. High levels of CO can lead to heart disease, circulation problems and high blood pressure. High levels of CO are caused by smoking as CO is inhaled with every puff. Second hand smoke contains 5 times more CO than the smoke being inhaled by a smoker. Breathing in CO from exhaust fumes or leaking gas appliances can also cause a high level of CO in the body. A false high level of CO can occur when a person has alcohol on their breath or when they have bad gas. Key Messages: Smoking causes the carbon monoxide levels in the body to increase. Carbon monoxide can harm us. Carbon monoxide levels can return quickly to normal by quitting smoking. 116

124 Lesson Plan: Pig Lung Demonstration 117

125 Learning Objective: Participants will be able to describe the effect of smoking on the lungs. What is the Pigs Lung Demonstration Model? A demonstration model that shows the real-life damage that happens to the lungs because of smoking. Both sets of lungs are assembled onto the frames with the pump attached. Air is pumped into the lungs to show the lungs in action. This compares the differences between the smoker and non-smoker set of lungs. Target Group for this Model: This model can be used with any age group. Use it in group sessions (classrooms, at community health groups, or health fairs) to show the impact of smoking on the lungs. Materials: Pig Lungs with demonstration tray and pump Lung Cancer Fact Sheet (Nunavut, ) Rubber gloves for you and group Garbage can Preparing for Using the Pig Lung Demonstration Model: Before the presentation, familiarize yourself with the model. Place the tray and assembled frame on a level surface. Connect the lungs securely to the part of the tube that is open and faces down. Connect the pump to the other open part of the tube. Press the pump gently in order to inflate the lungs. The healthy lung deflates easily, while the diseased lung has trouble deflating due to the impact of disease. How to Use the Pig Lung Demonstration Model: Begin by asking the group to name the organ of the body that is most affected by smoking - lungs. 118

126 Explain that because our lungs are inside of us that it is difficult to see what they look like and what is happening to them when people smoke. Describe to the group that you are going to show them two lungs today: one is the healthy nonsmoker s lung and the other is the unhealthy smoker s lung. Make clear to the group that pig s lungs are used because they are similar in shape and size to human lungs (140 pound person). Also, the meat of the pig was not wasted. The lungs of the pig were made to look like those of a 20 year smoker by injecting dye after the pig was dead. Show the non-smoker s lung and have the group take note of its colour. Slowly begin pumping the non-smoker s lung with your hand. Allow 3-4 seconds to pass between compressions. Show how the lung completely fills with air and quickly returns to normal size when you stop pumping Show the smoker s lung and have the group take note of its colour. Explain that the colour is from the build up of tar from cigarettes. Slowly begin pumping the smoker s lung with your hand. Allow 3-4 seconds to pass between compressions. Point out how the unhealthy emphysema lung inflates slowly, and then fails to return to normal size between breaths. This is similar to what a person who has emphysema might experience while breathing. With your gloved hand, point out the cancerous lesion in the bottom of the lobe of the lung and how it is blocking off the air. Ask the group how they think the person with these lungs would breathe. Finally, show the group the emphysema and the holes in the lungs. You can let individuals come up and touch the lung. Have each person take one glove to use. Let them feel the tumour and the emphysema. Finish by talking with the group about how important our lungs are for living. Talk about activities like hockey, square-dancing, volleyball, soccer, basketball, biking and walking and how much we need our lungs to be able to do all these things. Tips to Make Your Presentation Work: The pig lungs can be very distracting so consider using them at the end of a lesson. Key Facts: Exposure to cigarette smoke greatly increases the risk of lung diseases, such as emphysema and/or lung cancer. 119

127 Emphysema occurs when the walls of tiny air sacs inside the lungs break down and form larger, limp air sacs. As a result, the lungs lose their elasticity and overinflate when a person breathes in. These overinflated lungs make it difficult to expel air and leads to shortness of breath. Lung cancer occurs when a tumor develops in the lung. Lung cancer is the most common cancer in Nunavut. Nunavummiut have the highest lung cancer rates in Canada. Lung cancer is a very serious disease. There is a 62% mortality (death) rate within 1 year of diagnosis. Key Messages: Exposure to cigarette smoke (smokers or second-hand smoke) greatly increases the risk of getting lung diseases, such as lung cancer or emphysema. In healthy non-smoker lungs, the lungs inflate and deflate easily, which allows for oxygen to be transported around the body. In diseased lungs, the lungs do not inflate and deflate as easily, causing shortness of breath and less oxygen in the body. It is best to never start smoking, in order to keep your lungs healthy like the pink lungs in the model. If you are already a smoker, you can help your lungs become healthier by quitting or reducing your tobacco use. 120

128 Lesson Plan: Smokey Sue Smokes for Two 121

129 Learning Objective: Participants will be able to describe the impact that smoking has on an unborn child. What is Smokey Sue Smokes for Two? A demonstration model that shows smoking by a woman has an impact on an unborn child. Target Group for this Model: Use it in individual or group sessions (classrooms, at community health groups, or one-on-one sessions) to show the impact of smoking on unborn babies. This resource can be used in presentations along with any other tobacco resources and lesson plans. Pregnant women and those who care for pregnant women may be especially interested in this visual model. Materials: Smokey Sue Smokes for Two Model Cigarette and match or lighter Water Ashtray How to Use Smokey Sue Smokes for Two: Pump the bulb at the back of the doll with a lit cigarette in the dolls mouth to simulate a woman smoking. Here is how it is done: Remove the dolls head from the top of the jar. Fill the jar ¾ full with water. Place the head back on the jar. Go outside. Place a filtered cigarette into the dolls mouth so some of the filter is still visible. Light the cigarette while squeezing the black bulb at the back of the doll. Make sure an ashtray is under the cigarette to catch the ashes. Continue to pump the bulb every few seconds until the cigarette is totally smoked. 122

130 Tips to Make Your Presentation Work: Ask participants to notice the dark colour on the surface of the water, and ask what they think is causing this. Ask participants whether they think this tar is having an effect on the baby. Tar is just one of the substances that are taken into the body when smoking any kind of substance. Ask the participants if they know of some gases that are taken into the body when smoking. Key Facts Carbon monoxide in tobacco smoke is a gas that prevents the unborn baby from getting enough oxygen. Smoking during pregnancy can increase the chance of stillbirth, miscarriage, premature birth, birth defects, low birth weight and sudden infant death syndrome (SIDS). Key Messages: Everything that is taken into the body during pregnancy will affect the unborn baby. Quitting/reducing smoking before, during and after pregnancy is the best thing that can be done for the mother and baby s health. 123

131 124

132 Lesson Plan: Teeth in Tobacco Juice 125

133 Learning Objective: Participants will be able to describe how the use of smokeless tobacco harms the teeth. What is Teeth in Tobacco Juice? A realistic model that shows what smokeless tobacco does to the teeth. Target Group for this Model: Use it in individual or group sessions (classrooms, at community health groups, or one-on-one sessions) to show the health impacts of smokeless tobacco. Materials: Teeth in Tobacco Juice jar Chewing Tobacco Fact Sheet How to Use Teeth in Tobacco Juice: Before the presentation, familiarize yourself with the jar and the Chewing Tobacco Fact Sheet Pass around the jar to the group while discussing the key facts and harms caused by smokeless tobacco. Tips to Make Your Presentation Work: Can be used with any other tobacco or oral health related lesson plans or presentations. Key Facts Other names for smokeless tobacco: Snuff, Spit, Chew or Chewing Tobacco How smokeless tobacco is used: Smokeless tobacco is held in the mouth between the teeth and cheek. Users spit out a black, tarry juice that forms when the tobacco is mixed with saliva. It is absorbed quickly into the bloodstream through the lining of the mouth which makes it more addictive than smoking cigarettes. 126

134 Key Messages: Effects of smokeless tobacco: People who use chewing tobacco suffer permanent gum and bone loss, unlike cigarette smokers who may heal soon after quitting. Who uses it: Smokeless tobacco is associated with professional sports, but has become more popular with teenagers. Using smokeless tobacco is more addictive than smoking cigarettes. It is very hard to quit if you start. Users of smokeless tobacco can suffer permanent gum, bone or tooth loss which does not get better after they quit. Using smokeless tobacco puts you at higher risk for cancers in your mouth and throat. Teenagers who start to use smokeless tobacco may not realise how addictive it is or the damage it can do to their mouths. Do not use smokeless tobacco. 127

135 128

136 Lesson Plan: Mr. Gross Mouth 129

137 Learning Objective: Participants will be able to describe the effects of smokeless tobacco use on the teeth, tongue and gums. What is Mr. Gross Mouth? A hinged, life-size model of the teeth, tongue and gums showing the effects of using smokeless tobacco. This hand-painted, realistic model comes mounted on a wooden display base and comes with a jar of tobacco to create tobacco juice. 6" x 4" x 8". Comes in a carrying case. Target Group for Mr. Gross Mouth: This model can be used for elementary and high school students. Use it in individual or group settings to teach about the harmful effects of smokeless tobacco. Materials: Mr. Gross Mouth model Chewing Tobacco Fact Sheet How to Use Mr. Gross Mouth: Use the model to show the damage caused by using smokeless tobacco by passing it around the group to take a closer look while describing the key messages about smokeless tobacco. Tips to Make Your Presentation Work: Can be used with any other tobacco or oral health related lesson plans or presentations. Key Facts of Smokeless Tobacco: Other names for smokeless tobacco: Snuff, Spit, Chew, Chewing Tobacco How it is used: Smokeless tobacco is held in the mouth between the teeth and cheek. Users spit out a black, tarry juice that forms when the tobacco is mixed with saliva. 130

138 It is absorbed into the bloodstream quickly through the lining of the mouth and is more addictive than smoking cigarettes. Harmful effects: People who chew tobacco suffer permanent gum and bone loss, unlike smokers, who usually heal very quickly after quitting. Who uses smokeless tobacco: Smokeless tobacco is widely used in professional sports and is getting more popular with teenagers. Key Messages: Smokeless tobacco is more addictive than cigarettes. This means it is very hard to quit if you start. Users of smokeless tobacco suffer permanent gum and bone loss which does not get better after they quit. Using smokeless tobacco gives you a gross mouth just like in this model. Teenagers who start to use smokeless tobacco may not realise how additive it is or the damage it can do to their mouths. Don t use smokeless tobacco! 131

139 132

140 Lesson Plan: Clem s Phlegm Jar 133

141 Learning Objective: Be able to describe how much unhealthy phlegm builds up in the body from smoking cigarettes. What is Clem s Phlegm Jar? A realistic demonstration model of 2 weeks worth of phlegm that would be coughed up by a smoker. This jar will grab the attention of your participants and shows a nasty side effect of smoking. Target Group for Clem s Phlegm Jar: This model can be used for elementary and high school students. Materials: Clem s Phlegm Jar How to Use Clem s Phlegm Jar: Pass around the jar of phlegm to each participant. Ask participants how long they think it takes a smoker to cough up the amount of phlegm contained in the jar. Talk about how much mucus is produced in just 2 weeks. Smoking causes thick mucus to build up in the lungs which causes smokers to continue to cough until they can spit out the thick, nasty liquid. Tips to Make Your Presentation Work: Combine this lesson with other quit smoking lessons. 134

142 Lesson Plan: Cost Calculator 135

143 136

144 Learning Objective: To be able to describe how much it costs to use tobacco regularly. What is a Cost Calculator? It is a paper cost wheel that can quickly determine how much a person spends on tobacco in 1 week, 1 month, 1 year, 5 years, 10 years and 20 years based on the number of cigarettes smoked in a day or the number of cans of chew used in a week. Two versions are available: one for cigarettes and the other for chewing tobacco. Who Should Use this Cost Calculator? The target group for cost calculator is anybody who uses tobacco and needs motivation to consider quitting. It can be used with individuals at community events, in schools with youth, or with groups. Materials: Chewing Tobacco Cost Calculator Cigarette Cost Calculator Actual Calculator (optional) How to Use the Cost Calculator: An opening line that always works is want to see something scary? They always say YES! Ask the participant(s) how many they use each day (cigarettes) or how much they use each week (chewing tobacco). Ask them how much each package of cigarettes or can of chew costs them. Let them know the amount used for the cost calculator might be slightly different. If you have brought along an actual calculator, you can show them exactly what their tobacco use costs. Spin the wheel so the white arrow lands on the number of cigarettes per day or the number of cans of chew per week. Read out the cost for 1 week, 1 month, 1 year, 5 years, 10 years and 20 years. Get people talking! You can ask these questions to get the participants talking and thinking about this new information: o o Are you surprised by the cost? Why or why not? What are your feelings about this? 137