Tobacco Cessation in Community Settings Introduction Hello and welcome to the Learning and Action Network event, Reaching Those in Need of Tobacco Cessation in Community Settings: Research, Recommendations and Resources. My name is Stephanie Champion. As you may know atom Alliance is a five-year, five-state initiative for powerful and sustainable change in healthcare quality. Thank you for taking the time to join us. We appreciate all you do to improve quality and achieve better outcomes in health and healthcare at a lower cost for patients and communities we serve. Now it is my pleasure to introduce Pamela Graves Luckett, she is a Certified Tobacco Treatment Specialist, a nationally recognized designation in the tobacco treatment arena. She holds a Master s degree in counseling and she is a senior behavioral health specialist of the tobacco quit line for Information Quality Healthcare and is a Master Trainer with the Society for Public Health Education for the smoking cessation and reduction in legacy treatment program which focuses on treating the tobacco -dependent pregnant and postpartum patient. Pamela is a licensed professional counselor. She is a trainer for the program of tobacco treatment interventions to healthcare providers and has provided trainings statewide to a variety of healthcare professionals and the general public over the last 18 years. Until recently, Pamela has been the Director for the Tobacco Quit Line since its inception in 1999. At that time Pamela was requested to design the clinical protocol and implement the Mississippi Tobacco Quit Line. Pamela provides presentations and trainings to healthcare providers in dealing with the tobacco dependent patient, as well as motivational interviewing techniques to help better discuss healthcare issues and other related topics. It is my pleasure to have her with us today for this presentation. And with that, the floor is yours. Outline of Training Thank you very much. This information is being presented to encourage providers to include questions regarding tobacco use and cessation as an integral part of the discussion of health and wellness for any tobacco-using patient. Suggestions on discussion topics, methods of addressing tobacco and referral sources are evidence-based and available at the end of this presentation. Why Tobacco Cessation? Of course, tobacco use is bad. But what are some of the reasons for designated treatment plans for quitting tobacco? Not only is nicotine highly addictive, but it backs up the fact that tobacco is not just a habit. The tobacco user is not just a weak-willed person who cannot quit. When tobacco users get help by using medications or products and counseling, they are as much as 60% more likely to make a long-term quit attempt. Not only is tobacco available, but a two to three pack per day smoker is using their drug of choice 40 to 50 times per day, 365 days per year,
year after year. For some, quitting tobacco has been harder than quitting cocaine, heroin or alcohol. The latest research shows the highly addicted tobacco user may have to make as many as 15 to 20 attempts before being able to quit for good. Counseling is important to help understand what was learned with each attempt and relapse and how to plan for the same issue in the next attempt. Importance of Providers Tobacco users see their healthcare provider at least once per year. Most, many times per year because they have more medical and health issues. Discussing their tobacco use even if they say are not ready to quit, plants a seed of considering this change of lifestyle. The fact that it came from their provider makes a greater impact. The CDC best practice recommendation to train providers has actually been reduced from 5 A s training to 2A s and an R training and that will be what we talk about here. It is also recommended that all clinical staff be prepared to mention tobacco use and at least make a referral, and we will also cover some tips on how to handle resistance or determine the level of motivation to quit. To push the point, healthcare providers can have the most influence on a patient's decision to quit. The two A s and an R are ask, advise, and refer. And we will take each one. A: Ask The ask component and we do understand that clinics are asking about tobacco use with every visit and I want to make a comment about why we are using the word tobacco and not just smoking. It has become pretty evident that if you are talking with a smokeless tobacco user, and you ask them if they smoke, they would tell you no. And they will not necessarily offer the information that they are a smokeless tobacco user, because that is not what you asked. In order to make sure that we are covering our bases, and being able to offer information and discuss tobacco use, it is recommended to refer to this as tobacco use and not only smoking. But it is a good idea to make sure that you are asking every patient, on every visit, and that there is a vital sign stamp and that the entire healthcare team understands that the question does indeed need to be asked. It helps explain that asking each visit helps the tobacco using patient realized the quitting is an important consideration for their health and the health of those around them. Motivational Interviewing Motivational interviewing techniques have been proven to work well in starting a discussion about a patient's tobacco use. In motivational interviewing, you are more successful when you are talking to someone about a touchy issue, and tobacco use can be very touchy with some patients. To ask the permission, do you mind if we talk about your tobacco use? If they say no, at least you have approached the fact that it is going to be something you will ask every time. But if
they say yes, they are going to feel more like they have given permission to breach the subject, because many people do not necessarily want to talk about their tobacco use when they are seeing the provider for what they perceive as a completely different reason. Sample Questions There are some easy questions to help tobacco using patients not feel compromised or on the spot with their provider. It will also plant the seed idea that they need to quit that it will not make them as defensive as it would if you started in on questions like, well, why haven't you quit? You know it's bad for you. But these are suggested questions. How much tobacco do you use? How soon after waking do you use tobacco? Have you ever tried to stop? What happened? Determining Level of Nicotine Addiction In tobacco cessation treatment there is a standard survey that is used with people to determine their level of addiction to the nicotine. The FTND in the stands for the Fagerstrom test for nicotine dependent survey. The questions here are for a smoker, smokeless tobacco user surveyed have been developed, but they are not quite as accurate as the ones for smoking, so this is one exception in the area of referring to smoking or tobacco. There are about nine questions to ask in the survey, but the two that truly determine a better view of the level of addiction are to ask how much do you smoke most days and how soon after waking do you use tobacco? We have found that tobacco users, smokers, the smoke 10 to 12 cigarettes per day can be just as highly addicted on this level as someone who is smoking a pack. It does need to be considered as part of the treatment as to where they fall in their level of addiction to the nicotine. A: Advise The healthcare provider like we said before, is a definitely a powerful mover in the direction of seeking treatment. And advising include strong and personalized ways to truly help the patient understands that this is a good idea and that they need to consider it on some level, but being able to say this is the most important health decision that you can possibly make for yourself and family. And as a clinician, I want to stress the fact that this is a decision that you need to consider and think about and I can help you with the referrals to help you quit. And if you tied the tobacco use into the reasons why they are visiting so much, also, the risk, the economics, the impact on others. Those often help someone understand that they need to consider an opportunity to stop tobacco use. Motivation Interviewing If you have asked the question and there is still resistance to change, or to even consider tobacco cessation, there may be some questions in motivational interviewing that would help them understand that this is not just a subject that is going to end right here.
Asking, what would you like to change if you could about your tobacco using behavior? That makes them think whether or not they are truly vested in their tobacco use or whether there is something they would change. Or if it is not a good time to think about quitting, what we need to change to make it a good time? That helps you find out many things about the person's pattern of behavior, as far as their tobacco use is concerned. Do the Math One comment that is heard often is why are the patches not cheaper? I cannot afford patches. We have found that a pack per day smoker and I will say at five dollars per pack is conservative. Many packs are anywhere from $8 to even $12 per pack depending on where you are in the nation, purchasing cigarettes. But for this reference, this is close to $1700 per year. The highest percent of tobacco users are those in a lower socioeconomic area and $1700 per year could go a long way to help their economic status. But when we also realize that the amount of money spent on two weeks of cigarettes or tobacco could easily purchase a 14-patch box of patches that would allow them an opportunity to quit. R: Refer / Motivation to Quit Patients who have a stronger desire to quit are more likely to stop. Try not to treat low motivation patients what they should do better. On this scale, if you ask the patient on a scale of zero to 10, how motivated are you to quit? If they say 0 to 3, ask them what would be the change for that to be higher? You might find out that they are not wanting to quit now because there is some big event or some big stressor that is headed in the next month or so. High motivation is excellent. But, people do wax and wane over time. Sometimes even overnight. Support high motivation, but be realistic. It may be lower tomorrow or the next time you talk to the patient. Asking directly, do you want to stop? That gives an honest answer in most cases on whether someone truly feels they are ready to make the life altering decision to quit tobacco use. Many times, that will be a hesitation and some of the reasons are the fear of failing. That may not be interested because they don't really understand the health risks, which is hard for us as healthcare providers, or to even think that someone would not understand the risks. But often you will talk to 4th and 5th generation tobacco users where everyone in the family smokes. They don't relate certain health disorders directly to the smoking pattern. Elevated levels of distress make it difficult to focus on quitting. And we understand in tobacco cessation that there are truly better times and others to try to quit. You want to make sure that you are leaving a positive impression with the patient. If they are low motivation, encourage them to let you know the next time you talk that they are ready to do something. And give them information that will help them decide on that. If they are moderate motivation, make a referral. If they are highly motivated, congratulate them and also, make a referral to programs that will be able to help them.
Motivational Interviewing This backs up what we talked about before. The motivational interviewing question, what we need to change to make your number higher, if it was high, what is making this a good time to quit? If they are not sure, asking what are the barriers that keeps him from making a decision right now. All of those do not take long. But they do give you a lot of insight into the patient's mental readiness to make the lifestyle change. What is Tobacco Cessation Treatment? What makes tobacco cessation treatment different than just trying to quit on their own? The motivational interviewing questions helped determine the level of readiness to quit and I am referring to actual tobacco cessation treatment. What are the components of that? We use a lot of cognitive behavioral counseling. We help to make the changes needed to be successful and often to them in a plan that allows the person who is trying to quit to make small changes first. One comment we often receive in tobacco cessation treatment, whether it is face-to-face, online or telephonic, is I am so glad you didn't tell me had quit tomorrow. There is a plan for quitting and the people who quit cold turkey are less likely to be successful than those who have made changes in a systematic way that has helped them develop their skills, especially their coping skills, to learn how not to smoke. Support counseling that encourages the person through the struggles or slips to also learned that it is not national and all or none mentality. If you have done well and you slip and smoke one or two cigarettes, that is a slip not a relapse. We encourage them to get back on not smoking, as soon as possible, but look at what created the situation to slip and what might he do better next time. Also, there is a discussion of making sure of compliance to medication, it's dose and proper use. A good example is used like the Nicorette gum. It is not chewed like regular gum. It will make you nauseated if it is chewed like regular gum. It is designed to be chewed several times and parked and used several times per day. Often times, that that is not clearly understood. Where is Tobacco Cessation Available? Tobacco cessation is available. There is a national network, 1-800 Quit Now is available in every state. The telephone number is nationwide but routes a person to the state for the area code of the telephone they are calling from. So, if they are calling from a Texas area code, they will get Texas. If they are calling from Mississippi, they will get Mississippi. It routes you to the appropriate state. Now that we are so mobile, if you have not changed the area code of your phone number, each tobacco quit line will be able to transfer you to the correct state. Face-to-face programs are available through many health organizations and some major employers. Many health-related organizations offer a cessation course. American Cancer and American Lung to name a few, they often train people within employer settings or even within
state-funded settings so that people are able to come to a once per week hour meeting for six weeks to discuss and try tobacco cessation. Mental health facilities are being trained to include tobacco cessation in their treatment plans for patients. It has become obvious that people with mental health and addiction disorders need to consider tobacco cessation along with dealing with the other addiction. The science is very clear. That someone can quit it all at one time and tobacco does not need to be used as a coping mechanism for everything else. Faith-based counseling can have an influence to make an initial intervention and referred on to programs and American Lung and American Cancer have set up programs in a faith-based environment where people feel comfortable and safe in coming to talk about issues like this. There are online referral options for people who would like to look at more information. These covered not only regular smoking, but you will see that a couple of those are chew free and stop chewing tobacco, so they do specifically cover smokeless tobacco use. The following slides are the reference information, where all of this information came from. Needless to say, there is a mountain of research information regarding tobacco and tobacco cessation. I encourage you to look at these references and look at CDC.gov/tobacco and access your local tobacco quit line for additional information as well. Many of these are based on clinical practice guidelines. The information that I have presented here is evidence-based and has been proven to be successful. All of these are excellent to give information and give a comfort level on being able to discuss tobacco use with your patient. Thank you for giving me this time to present this information to you. Closing A big thank you to Pamela and our participants for joining us today. atom Alliance staff is here to help. Please contact us if you have questions about what you have just heard or need technical assistance with your improvement initiatives. Thank you all for joining us and please continue to network with us through social media and have a great day.