Goals for Training: 1. Participants will be confident in their ability to effectively assess a smoker s current willingness to quit.

Size: px

Start display at page:

Download "Goals for Training: 1. Participants will be confident in their ability to effectively assess a smoker s current willingness to quit."

Katrina Burns
5 years ago
Views:

1 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 1 Goals for Training: 1. Participants will be confident in their ability to effectively assess a smoker s current willingness to quit. 2. Participants will be able to provide a basic appropriate cessation message matched to a smoker s current state of readiness to assist patient in the process of change. 3. Participants will have a basic understanding of nicotine addiction and cessation medications. Goals for Working with Patients: Change is possible when a person has the desire and willingness to change, and at the same time has the tools, skills, and knowledge to get through the tension of change, then action is possible. Increase motivation and instill hope Boost self-efficacy Address ambivalence Encourage behavioral and social support Establish Rapport The Five A s Stages of Change Model Assessment tools Motivational Interviewing Motivation Cognitive-Behavioral Therapy Relapse Prevention Nicotine Addiction and cessation medications Agenda:

2 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 2 The Five A s 2008 Treating Tobacco Use and Dependence, Clinical Practice Guideline, page 34. The Five R s : Relevance, Risks, Roadblocks, Repetition, Rewards

3 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 3 Prochaska, Norcross, DiClemente, (1994). Changing for Good. Avon Books: New York.

4 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 4

5 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 5

6 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 6 Five Steps for Behavioral Change Maintenance The effort to maintain change and avoid addictive behavior. Lasts 6 months to a lifetime. Change Techniques to Use Maintain your commitment, have an ICE Plan to avoid relapse (page 83. Letting go Taking action to stop addictive behavior. Lasts 1 to 6 months. addictive behavior within 30 days. Use your Action Plan. Preparation Planning to quit Make a commitment to change. Make a Plan and practice. Have a smoking corner and smoke by the clock. Hanging on (Contemplation) Thinking of changing but not too soon. Focus is on the problem instead of the solution. Examine beliefs, confront fears, and resolve ambivalence. Not even thinking about quitting (Pre-contemplation) No desire to stop smoking. Build desire and motivation by creating ambivalence.

7 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 7 Motivational Interviewing Miller, and Rollnick. (2002). Motivational Interviewing. The Guilford Press: New York. Rollnick, Miller, & Butler (2008). Motivational Interviewing in Health Care. The Guilford Press, New York. Spirit of MI v opposite approach: Collaboration v confrontation Evocation v education Autonomy v authority Four guiding principles: Resist the righting reflex Understand your client's motivation Listen to your client Empower your client

8 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 8 Four general principles: Express Empathy o Acceptance facilitates change Not the same as agreement or approval Accepting patients as they are and where they are at o Understand patient s feelings and perspective o Reflective listening is fundamental o Understanding that ambivalence is normal Develop Discrepancy o Ambivalence makes change possible o Without discrepancy, there is no ambivalence o Change is motivated by a perceived discrepancy between present behavior and important personal goals or values Contrast current behavior with internal values Patient presents arguments for change Roll with Resistance o Avoid arguing for change and opposing resistance o Patient is primary source in finding answers and solutions o New perspectives are invited, but not imposed o Resistance is a signal to respond differently Support Self-efficacy o Important motivator is patient s belief in the possibility of change o Is not all or none, but varies across situations o Patients need skills to succeed, seldom are the skills totally present or entirely absent o Feedback should be provided about deficiencies in performance, not in the person

9 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 9 Motivational Interviewing Tools EARS (OARS) Elaborate Ask short Open-ended questions: Tell me more about What are some of good things you like about smoking? What are some not-so-good things about smoking? What concerns you most about smoking (or quitting)? What would happen if you were to quit? What happened when you quit before? What would it be like if you were smoke-free? If you were to quit smoking, how might you do it? What would happen if you were to quit now? On a scale of 1 to 10, how important is it you to be smoke-free? How confidence are you that you can be successful? How ready are you to try? Affirm Encouragement, instill hope and support self-efficacy Reflectively listen Reflect back change talk Listen to understand, not to reply Summarize Reframe into positive

10 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 10 Change Talk: DARN CaT

11 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 11

12 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 12 Benefits of Becoming Smoke-Free You are escaping from a nicotine addiction for reasons. The more reasons you can think of, the easier it will be to quit and to stay quit. So list all kinds of benefits. Be specific. Try to add to your list each day. 1. Better health 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10._ Benefits of Continuing to Smoke ( I smoke because... ) 1. No withdrawal symptoms 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10._ Consequences of Continuing to Smoke You cannot continue to smoke without good consequences. For every benefit of quitting there is an opposite consequence if you do not stop. 1. Health gets worse. 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10._ Consequences of Quitting ( When I quit I am afraid of...") 1. Withdrawal symptoms 2. _ 3. _ 4. _ 5. _ 6. _ 7. _ 8. _ 9. _ 10._

13 Objectives: B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 13 Cognitive-Behavioral Therapy Focused on immediate problems Structured and goal-oriented Focus is on coping by thinking differently and acting differently Treatment Elements: Provide smokers with practical counseling o Problem solving skills o Skills training Provide support and encouragement Cognitive-Behavioral Tools Cognitive: Think about positive health benefits or negative consequences of smoking I can breathe better, walk without gasping for breath, I have more energy. Review commitment to quit Each morning repeat, I m proud to make it another day smoke-free. NOPE, not one puff ever. I m a puff away from a pack a day. Distraction / Refocus thoughts Deliberate refocus of thoughts when a craving comes up. Positive self-talk I can do this. Relaxation through imagery Meditation, visualization Mental rehearsal, visualization Preparing for situations by envisioning how to handle them without smoking.

14 Behavioral: B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 14 Substitution (countering) Active diversion Exercise Relaxation techniques Reward Environmental control Helping relationships

15 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 15

16 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 16 Time Activity-Feeling Rating Time Activity-Feeling Rating _ 10. Time Activity-Feeling Rating Time Activity-Feeling Rating Time Activity-Feeling Rating Time Activity-Feeling Rating

17 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 17 Time Activity-Feeling Rating Time Activity-Feeling Rating _ _ 20. Time Activity-Feeling Rating Time Activity-Feeling Rating Time Activity-Feeling Rating Time Activity-Feeling Rating

18 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 18 Creating An Action Plan Write your best tips next to each trigger. Sometimes it helps to have a specific tip or plan of action for each specific trigger. If you have quit before, what techniques worked for you then? My Common Triggers: What I can do instead of smoking: Mornings: _ Afternoons: _ Evenings:

19 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 19 Short Term (Action) Relapse Prevention Manage withdrawal symptoms and cravings Ritual replacement (habits) Long Term (Maintenance) Stress, negative emotions Weight gain Positive social events or situations (celebrations) Alcohol Being around other smokers

20 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 20

21 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 21 Weight Gain Average weight gain is about 10 to 12 pounds but 50 to 100 pounds of fat need to be gained to do as much damage to your body as one pack of cigarettes. Decide it is more important for your health to stop smoking and if you can do that, you can do anything. If you do gain weight, you can lose it later on. There are eight different reasons why you might gain weight: 1. A change in metabolism can account for three to six pounds. About 70 percent of weight gain is due to an increase in calorie consumption, not metabolism. Exercise, walk twenty minutes more per day than you normally do. 2. Smoking can inhibit hunger. This may be because smokers hold food in their stomachs longer than non-smokers, or it may be that nicotine affects the appetite/satiety hormones. After quitting you may feel hungrier than before. Have small, low-calorie, high fiber snacks throughout the day. Include some protein and drink water. Nicotine Replacement Products can act as an appetite suppressant and Bupropion has shown to limit weight gain. 3. Withdrawing from nicotine can cause changes in your blood sugar which can cause you to crave sugar. Substitute raw fruit and vegetables for pastries, candy bars and junk food. 4. You may eat more food as a substitution for the hand-to-mouth motion of smoking or as an oral fixation. Stock up on low-fat crunchy foods, keep healthy snacks available. Increase your intake of vegetables. Cut a straw the size of a cigarette or use a pretzel stick and pretend to smoke it. Sip water frequently. Use the nicotine inhaler.

22 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l Using food as a reward for not smoking. Find other rewards than food. Stay conscious about the amount of food you are eating. 6. Eating more to delay having the after a meal craving. Only eat when you are hungry. Stop eating once you are full. Leave the table immediately. Go brush your teeth, have a breath mint, chew gum. Use a smaller plate. Immediately clear the table and hand wash the dishes. It is hard to smoke with wet hands. Keep a Food Diary. Before you eat, write down what you are going to eat, where you are, what you are doing and how you are feeling; similar to your Tobacco Use Record. 7. Food tastes and smells better once you have quit smoking. Eat slower, put your fork down in between bites. Savor the flavor of each bite. Decide how much you will eat before you start and do not take seconds. 8. Emotional eating: Using food as a substitute for not dealing with feelings and emotional needs. To escape from boredom, tension, depression, stress. Your most vulnerable times are with: Hunger, Anger (Alcohol, and Anxiety), Loneliness, and Tired: HALT and take care of your emotional needs. Continue your Food Diary, paying particular attention to how you are feeling when you are eating. Only eat when you are hungry. Learn the difference between hunger and emotional eating. When the desire to eat comes up, have an apple or some other healthy food. If you are having true hunger, you will eat the apple. If you do not want the apple, what need, other than hunger, do you need to address?

23 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 23

24 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 24 Participant Information and Medical History Name Mailing Address City _ Zip Code Occupation Telephone address 1. Years of Schooling (e.g. High School is 12) 2. Marital Status Married Living together Never Married Separated Divorced Widowed 3. How many other tobacco users are in your household? 4. Does your spouse or significant other use tobacco? Yes or No 5. Are there any children/grandkids under 18 living in your household? Yes or No 6. Please fill in the NUMBER of each of the following that you use DAILY: (e.g. 10 cigarettes a day) Cigarettes/Day Cigars/Day Bowls of Pipe Tobacco/Day ml E-liquid Smokeless Tobacco Less than ½ can or pouch/day 1/2 1 ½ cans or pouches/day More than 1 ½ cans or pouches/day 7. How soon after you wake up do you smoke your first cigarette or use nicotine? Within 5 Minutes 6-30 minutes minutes After 60 minutes 8. How old were you when you started using tobacco? 9. How many years have you smoked? 10. How many serious quit attempts have you made in your life? 11. What is the longest time you have ever been tobacco free? Years Months Days Hours 12. What happened that you started again?

25 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l On a scale of 1-10, how motivated are you to quit using tobacco at this time? (1= no motivation, 10 = highly motivated) On a scale of 1 10, how confident are you that you will not be using tobacco 6 months from now?(1= no confidence, 10 = very confident) What do you feel is your biggest obstacle to becoming smoke-free? 16. On a scale of 1 10, how concerned are you about gaining weight? (1= no concerns, 10 = very concerned) When do you use tobacco (i.e. what are your triggers)? Check all that apply: Coffee, tea, soda Relaxing As a reward Alcohol Stress Taking a break After meals Angry Downtime Driving Anxious Boredom On the phone Depressed/Sad Other Watching TV, reading Happy On the computer Frustrated Social situations Tired With other smokers Lonely 18. Have you experienced any of the following withdrawal symptoms when you stopped using tobacco? Irritability Headaches Trouble sleeping Nervousness Lack of energy Anxiety Cough Depression Hunger/Sweet tooth Impatience Trouble concentrating None of the above Dizziness Other (specify): Constipation/gas/stomach pain Cravings to smoke 19. Which of the following tobacco cessation methods have you used? Cold Turkey Acupuncture/Pressure Self Help Materials Hypnosis Formal program None Other :

26 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l Please answer the following questions about tobacco cessation medications: Helpful? Ever Scale 1-10 Side What Side Used (10=Most Helpful) Effects? Effects? Nicotine Gum Y N Y N Nicotine Patch Y N Y N Nicotine Inhaler Y N Y N Nicotine Nasal Spray Y N Y N Nicotine Lozenge Y N Y N Zyban/Wellbutrin/BupropionY N Y N Chantix/Varencline Y N Y N Combination medication used? Medical History (Disclaimer: Providing this information is optional and will be used solely for the purposes of helping you stop nicotine use). 1. Please check if you have any of the following: Heart disease Depression High blood pressure Anxiety Diabetes Schizophrenia Stroke Bipolar disorder COPD (Emphysema, Chronic Other medical or psychological Obstructive Bronchitis) problems Cancer (type): 2. Please mark Yes or No: History of seizures, convulsions, epilepsy History of head trauma, knocked unconscious, or brain tumor History of eating disorder (anorexia, bulimia) Currently on Wellbutrin or Zyban Currently on an MAO inhibitor (Nardil, Parnate) Kidney disease Liver disease Difficulty sleeping/insomnia Pregnant, planning on pregnancy, or breast-feeding Heart attack, angina, chest pain, or abnormal heart rhythm Dental or jaw problems (including dentures) Asthma Using stimulants or diet medication

27 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l Do you drink alcohol (beer, wine, hard liquor)? Yes or No If yes, average # drinks per week: < >28 4. Over the last 2 weeks, how often have you been bothered by any of the following problems? 0= Not at all 1= Several days 2= More than half the days 3= Nearly everyday Little interest or pleasure in doing things Feeling down, depresses, or hopeless Trouble falling or staying asleep, or sleeping to much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way 5. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult

28 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 28 ICD-10 Diagnostic Codes for Nicotine Dependence, effective October 1, Injuries.pdf F17 Nicotine Dependence Excludes1: History of tobacco dependence (Z87.891); tobacco use not otherwise specified (NOS) (Z72.0) Excludes2: Tobacco use (smoking) during pregnancy, childbirth and the puerperium (O99.33); toxic effect of tobacco and nicotine (T65.2) see below F17.2 Nicotine dependence F17.20 Nicotine dependence, unspecified F Nicotine dependence, unspecified, uncomplicated F Nicotine dependence, unspecified, in remission F Nicotine dependence unspecified, with withdrawal F Nicotine dependence, unspecified, with other nicotine-induced disorders F Nicotine dependence, unspecified, with unspecified nicotineinduced disorders F17.21 Nicotine dependence, cigarettes F Nicotine dependence, cigarettes, uncomplicated F Nicotine dependence, cigarettes, in remission F Nicotine dependence, cigarettes, with withdrawal F Nicotine dependence, cigarettes, with other nicotine-induced disorders F Nicotine dependence, cigarettes, with unspecified nicotineinduced disorders F17.22 Nicotine dependence, chewing tobacco F Nicotine dependence, chewing tobacco, uncomplicated F Nicotine dependence, chewing tobacco, in remission F Nicotine dependence, chewing tobacco, with withdrawal F Nicotine dependence, chewing tobacco, with other nicotineinduced disorders F Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders F17.29 Nicotine dependence, other tobacco product F Nicotine dependence, other tobacco product, uncomplicated F Nicotine dependence, other tobacco product, in remission F Nicotine dependence, other tobacco product, with withdrawal F Nicotine dependence, other tobacco product, with other nicotineinduced disorders F Nicotine dependence, other tobacco product, unspecified nicotine-induced disorders

29 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 29 Maternal Tobacco Use and Exposure (099.3, P04.2, P96.8) O99 Maternal diseases classified elsewhere but complicating pregnancy, childbirth, and the puerperium O99.3 Mental disorders and diseases of the nervous system complicating pregnancy, childbirth and the puerperium O99.33 Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium Use additional code from F17 to identify type of tobacco O Smoking (tobacco) complicating pregnancy, unspecified trimester O Smoking (tobacco) complicating pregnancy, first trimester O Smoking (tobacco) complicating pregnancy, second trimester tobacco) complicating pregnancy, third trimester O Smoking (tobacco) complicating childbirth O Smoking (tobacco) complicating the puerperium P04 Newborn (suspected to be) affected by noxious substances transmitted via placenta or breast milk P04.2 Newborn (suspected to be) affected by maternal use of tobacco Newborn (suspected to be) affected by exposure in utero to tobacco smoke Excludes2: Newborn exposure to environmental tobacco smoke (P96.81) P96 Other conditions originating in the perinatal period P96.8 Other specified conditions originating in the perinatal period P96.81 Exposure to (parental) (environmental) tobacco smoke in the perinatal period Toxic Effect of Tobacco and Nicotine (T65.2) T65 Toxic effect of other and unspecified substances T65.2 Toxic effect of tobacco and nicotine Excludes2: Nicotine dependence (F17.2) T65.21Toxic effect of chewing tobacco T Toxic effect of chewing tobacco, accidental (unintentional) Toxic effect of chewing tobacco not otherwise specified (NOS) T Toxic effect of chewing tobacco, intentional self-harm T Toxic effect of chewing tobacco, assault T Toxic effect of chewing tobacco, undetermined T65.22Toxic effect of tobacco cigarettes Toxic effect of tobacco smoke Use additional code for exposure to second hand tobacco smoke (Z57.31, Z77.22) T Toxic effect of tobacco cigarettes, accidental (unintentional)

30 B e s t P r a c t i c e s i n C e s s a t i o n C o u n s e l i n g : M a n u a l 30 Toxic effect of tobacco cigarettes not otherwise specified (NOS) T Toxic effect of tobacco cigarettes, intentional self-harm T Toxic effect of tobacco cigarettes, assault T Toxic effect of tobacco cigarettes, undetermined T65.29 Toxic effect of other tobacco and nicotine T Toxic effect of other tobacco and nicotine, accidental (unintentional) Toxic effect of other tobacco and nicotine not otherwise specified (NOS) T Toxic effect of other tobacco and nicotine, intentional self-harm T Toxic effect of other tobacco and nicotine, assault T Toxic effect of other tobacco and nicotine, undetermined Environmental Tobacco Smoke Exposure (Z57.31, Z77.22) Z57 Occupational exposure to risk factors Z57.3 Occupational exposure to other air contaminants Z57.31 Occupational exposure to environmental tobacco smoke (Z57.31) Excludes2: Exposure to environmental tobacco smoke (Z77.22) Z77 Other contact with and (suspected) exposures hazardous to health Z77.2 Contact with and (suspected) exposure to other hazardous substances Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke Exposure to second hand tobacco smoke (acute) (chronic) Passive smoking (acute) (chronic) Excludes1: Nicotine dependence (F17.2) tobacco use (Z72.0) Excludes2: Occupational exposure to environmental tobacco smoke (Z57.31) Counseling and Medical Advice Services, Not Elsewhere Classified (Z71.6, Z72.0) Z71 Persons encountering health services for counseling and medical advice, not elsewhere classified Z71.6 Tobacco abuse counseling Use additional code for nicotine dependence (F17.2) Z72 Problems related to lifestyle Z72.0 Tobacco use Tobacco use not otherwise specified (NOS) Excludes1: History of tobacco dependence (Z87.891); nicotine dependence ( F17.2); tobacco dependence (F17.2); tobacco use during pregnancy (O99.33) History of (noncurrent) Nicotine Dependence (Z87.891) Z87 Personal history of other diseases and conditions Z87.8 Personal history of other specified conditions Z Personal history of nicotine dependence Excludes1: Current nicotine dependence (F17.2)

A Guide to Help You Reduce and Stop Using Tobacco

Let s Talk Tobacco A Guide to Help You Reduce and Stop Using Tobacco Congratulations for taking this first step towards a healthier you! 1-866-710-QUIT (7848) albertaquits.ca It can be hard to stop using