ASSISTING PATIENTS with QUITTING CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE Released June 2000 Sponsored by the AHRQ (Agency for Healthcare Research and Quality) of the USPHS (US Public Heath Service) with: CDC (Centers for Disease Control) NCI (National Cancer Institute) NIDA (National Institute for Drug Addiction) NHLBI (National Heart Lung & Blood Institute) RWJF (Robert Wood Johnson Foundation) http://www.surgeongeneral.gov/tobacco/ EFFECTS OF CLINICIAN INTERVENTIONS The 5 A s Estimated abstinence at 5+ months 30 20 10 0 1.0 1.1 (0.9,1.3) No clinician Self-help material 1.7 (1.3,2.1) Nonphysician clinician Type of Clinician n = 29 studies 2.2 (1.5,3.2) Physician clinician ASK ADVISE ASSESS ASSIST ARRANGE Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000. The 5 A s (cont d) The 5 A s (cont d) Ask ASK about tobacco use Do you ever smoke or use any type of tobacco? I take time to ask all of my patients about tobacco use because it s important. ADVISE tobacco users to quit (clear, strong, personalized, sensitive) It s important that you quit as soon as possible, and I can help you. I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.
The 5 A s (cont d) Assess ASSESS readiness to make a quit attempt The 5 A s (cont d) Arrange ARRANGE follow- up care Number of sessions Estimated quit rate* Assist ASSIST with the quit attempt 0 to 1 2 to 3 4 to 8 More than 8 12.4% 16.3% 20.9% 24.7% * 5 months (or more) postcessation PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000. 5 A s: REVIEW ASK ADVISE about tobacco USE tobacco users to QUIT The (DIFFICULT) DECISION to QUIT Faced with change, most people are not ready to act. Change is not a single step, but a process. ASSESS ASSIST ARRANGE readiness to make a QUIT attempt with the QUIT ATTEMPT FOLLOW-UP care Typically, it takes multiple attempts. HOW CAN I LIVE WITHOUT TOBACCO? HELPING SMOKERS QUIT IS a CLINICIAN S RESPONSIBILITY Clinicians have a professional obligation to help their patients quit using tobacco. THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT. TAILORING the INTERVENTION to MEET the PATIENT S NEEDS PATIENTS DIFFER IN THEIR READINESS TO COMMIT TO QUITTING Persons NOT READY TO QUIT (in the next 30 days): Motivational interventions Persons READY TO QUIT (in next 30 days): Behavioral counseling Pharmacotherapy Persons who RECENTLY QUIT (in past 6 months): Relapse prevention interventions
IS a PATIENT READY to QUIT? Does the patient now use tobacco? Yes No FIVE STAGES THAT DESCRIBE a PERSON S READINESS to CHANGE STAGE 1: Not thinking about changing anytime soon Promote motivation Is the patient now ready to quit? No Yes Provide treatment The 5 A s Prevent relapse* Did the patient once use tobacco? Yes No Encourage continued abstinence *Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation. STAGE 2: Considering changing, but not yet STAGE 3: Getting ready to change soon STAGE 4: In the process of changing STAGE 5: Changed a while ago Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000. FIVE STAGES THAT DESCRIBE a PERSON S READINESS to CHANGE STAGES of CHANGE: A LINEAR VIEW STAGE 1: Precontemplation STAGE 2: Contemplation STAGE 3: Preparation Precontemplation Contemplation Quit date - 6 months - 30 days + 6 months Action Maintenance STAGE 4: Action STAGE 5: Maintenance Preparation ASSESS READINESS TO QUIT: STAGES of CHANGE, CYCLICAL VIEW Termination STAGES of CHANGE for TOBACCO CESSATION Does the patient now use tobacco? Relapse* Maintenance Action Precontemplation Contemplation Not ready to quit Yes Is the patient ready to quit now? No Yes No Did the patient once use tobacco? Yes No Preparation Precontemplation -or- Contemplation Preparation Action -or- Maintenance Never smoker * Patients can relapse out of the maintenance or action stages, reverting to earlier stages.
The STAGES of CHANGE during PRECONTEMPLATION STAGE 1: Precontemplation Not thinking about quitting in the next 6 months Patients might not be aware of the need to quit. They might be aware of the need but resist quitting. Pros of smoking outweigh the cons. GOAL: Move the patient into the contemplation stage. Strongly advise to quit Ask noninvasive questions Envelope Raise awareness of health consequences/concerns Demonstrate empathy, foster communication Leave decision up to patient DON Ts Persuade Cheerlead Tell patient how bad smoking is, in a judgmental manner The STAGES of CHANGE (cont d) during CONTEMPLATION STAGE 2: Contemplation Considering quitting in the next 6 months but not in the next 30 days Patients are aware of the need to quit. They are aware of the benefits of quitting. But they struggle with ambivalence about change. GOAL: Move the patient into the preparation stage. Strongly advise to quit Provide information Identify reasons for tobacco use Demonstrate empathy; increase motivation Encourage self-reevaluation of concerns Offer encouragement DON Ts Apply actionoriented interventions METHODS for INCREASING MOTIVATION 5 R s A DEMONSTRATION: COUNSELING a PATIENT who is NOT READY TO QUIT For patients who are not yet ready to quit: Relevance Risks Rewards Roadblocks Repetition TAILORED INTERVENTION MESSAGES CASE SCENARIO: MS. STEWART You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema. She uses two different inhalers for her emphysema. Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.
COUNSELING SCENARIO: KEY POINTS Ask about tobacco use Link inquiry to knowledge of disease Assess readiness to quit Aware of need to quit; not ready yet Advise to quit Discuss implications for disease progression COUNSELING SCENARIO: SUMMATION The clinician has Established a relationship Established yourself as a resource Planted a seed to move patient forward Opened a door to facilitate further counseling I will help you, when you are ready The STAGES of CHANGE (cont d) STAGE 3: Preparation Ready to quit in the next 30 days Patients are aware of the need to, and the benefits of, making the behavioral change. Getting ready to take action. Goal: Move the patient to the action stage. Praise the patient s readiness Assess tobacco use history Current use: Type(s) of tobacco, brand, amount Past use: duration, recent changes Past quit attempts: Number, date, length Methods used, compliance, duration Reasons for relapse Discuss key issues Reasons/motivation to quit Confidence in ability to quit Triggers for tobacco use Routines/situations associated with tobacco use Stress-related smoking Social support for quitting Concerns about post-cessation weight gain Concerns about withdrawal symptoms Facilitate quitting process Discuss methods for quitting (pros, cons) Pharmacotherapy: a treatment, not a crutch! Behavioral counseling Set a quit date! Recommend Tobacco Use Log (see handout)
TOBACCO USE LOG The Tobacco Use Log is most appropriate for patients who are getting ready to quit. Documenting tobacco use helps patients to understand when and why they use tobacco. Identifies activities or situations that trigger tobacco use. Information can be used to develop coping strategies to overcome the temptation to use tobacco. TOBACCO USE LOG: INSTRUCTIONS for USE Patient should continue regular tobacco use for a period of 3 or more days Each time any form of tobacco is used, the following information should be recorded on the log: Time of day Brief description of activity or situation during use Importance rating (scale of 1 3) Review log sheets to identify situations that trigger tobacco use Develop coping strategies to prevent relapse Discuss and develop coping strategies Cognitive Behavioral COPING with QUITTING (cont d) Cognitive strategies Review of commitment to quitting Distractive thinking Positive self-talks Relaxation through imagery Mental rehearsal and visualization COPING with QUITTING (cont d) Examples: Thinking about cigarettes doesn t mean you have to smoke one. Just because you think about something doesn t mean you have to do it! Tell yourself It s just a thought, or I am in control. Say the word STOP! out loud, or visualize a stop sign. When you have a craving, remind yourself that: The urge for a cigarette will only go away if I don t smoke. As soon as you get up in the morning, look in the mirror and say to yourself I am proud that I made it through another day without smoking. COPING with QUITTING (cont d) Behavioral strategies Control your environment Smoke-free home and workplace Alter or remove cues to tobacco use Modify behaviors that you associate with tobacco: when, what, where, how, with whom Actively avoid trigger situations Substitutes for smoking Water, chewing gum or hard candies (oral substitute) Take a walk, diaphragmatic breathing, self-massage Rely on social support Actively work to alleviate withdrawal symptoms
STRESS MANAGEMENT The Myths Smoking gets rid of all my stress I can t relax without a cigarette The Facts There will always be stress in one s life There are many ways to relax without a cigarette Smokers confuse the relief of withdrawal with the feeling of relaxation STRESS MANAGEMENT SUGGESTIONS: Deep breathing, shifting focus, taking a break. SOCIAL SUPPORT for QUITTING Key ingredients for successful quitting: Social support as part of treatment (intra-treatment) Social support outside of treatment (extra-treatment) PATIENTS SHOULD BE ADVISED TO: Ask family, friends, and coworkers for support ask them not to smoke around you, and not to leave cigarettes out Talk with your health-care provider Get individual, group, or telephone counseling Patients who receive social support and encouragement are more successful in quitting ADDRESSING CONCERNS about POSTCESSATION WEIGHT GAIN ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS Most quitters gain weight Most gain < 10 pounds, but there is a wide range Discourage strict dieting while quitting Recommend physical activity Encourage healthy diet, plan meals, eat fruits Increase water intake Chew sugarless gum Select nonfood rewards Maintain patient on pharmacotherapy shown to delay weight gain Refer patient to specialist or program Anger/irritability Anxiety Cravings Difficulty concentrating Hunger/weight gain Impatience Restlessness Drowsiness Fatigue Impaired task performance Nervousness Sleep disturbances Hughes et al. Arch Gen Psychiatry 1991;48:52 59. ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS (cont d) Most pass within 2 to 4 weeks after quitting Cravings can last longer, up to several months or years Often can be ameliorated with cognitive or behavioral coping strategies Refer to Withdrawal Symptoms Information Sheet Symptom, cause, duration, relief Discuss concept of slip versus relapse Let a slip slide Medication counseling Proper use, with demonstration Promote compliance Arrange follow-up Offer to assist throughout quit attempt Provide resources and referrals Congratulate the patient!
The STAGES of CHANGE (cont d) Actively trying to quit for good Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success. Withdrawal symptoms occur. At high risk for relapse. GOAL: Remain tobacco- STAGE 4: Action free for at least 6 months. during ACTION Praise progress - solicit commitment to quit for good Evaluate current quit attempt: Status of attempt Slips or relapse Medication use, plans for termination Ask about social support Identify temptations and triggers for relapse Negative affect, smokers, eating, alcohol, cravings, stress Encourage healthful alternative behaviors to replace tobacco use Offer tips for relapse prevention RELAPSE PREVENTION Congratulate success! Encourage continued abstinence Promote smoke-free environments Discuss benefits of quitting and successes achieved Discuss problems encountered and potential barriers to continued abstinence Strong or prolonged withdrawal symptoms? Add, combine, or extend use of pharmacotherapy agents Social support Discuss ongoing sources of support Schedule follow-up visits or calls; refer to support groups The STAGES of CHANGE (cont d) STAGE 5: Maintenance Tobacco- free for 6 months Patients remain vulnerable to relapse. GOAL: Remain tobacco- free for life. DURING MAINTENANCE Congratulate continued success Continue to offer tips for relapse prevention Assess temptations and triggers Discuss and suggest coping strategies Encourage alternative behaviors Provide positive reinforcement Precontemplation STAGES of CHANGE: A REVIEW Quit date - 6 months - 30 days + 6 months Contemplation Preparation Action Maintenance
CESSATION COUNSELING: SUMMARY Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS stage at each contact Tailor intervention messages (ASSIST) Be a good listener Minimal intervention in absence of time for more intensive intervention ARRANGE follow-up Use the referral process, if needed WHAT IF a patient asks you about your use of tobacco? The RESPONSIBILITY of HEALTH PROFESSIONALS It is inconsistent to provide health care and at the same time remain silent (or inactive) about a major health risk. TOBACCO CESSATION is an important component of THERAPY. DR. GRO HARLEM BRUNTLAND, DIRECTOR-GENERAL of the WHO: If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked. US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Washington, DC: Public Health Service, 2001.