Tobacco Cessation Competency Class

Section 2: Assessment Tools & Types of Counseling

Objectives
• The participant will be able to discuss the assessment tools commonly used to screen and assess patients prior to enrollment in a tobacco cessation program. • The participant will be able to identify the stages of change a patient is in and provide the appropriate counseling to assist the patient in tobacco cessation.

Objectives con’t
• The participant will be able to follow the 4 as as described by the American cancer society when counseling patients who use tobacco. • The participant will be able to screen the patient with tobacco dependence for depression and provide the proper referral and/or enrollment in a tobacco cessation program.

Assessment Tools
• Nicotine Dependence • Stages of Change • Depression Screening

Nicotine Dependence
• Nicotine is a highly addictive drug naturally found in tobacco • Body becomes physically and psychologically dependent upon nicotine • Cutting back or quitting leads to withdrawal symptoms

Nicotine Dependence and Nicotine Withdrawal
• The “gold standard’ for diagnosis comes from the DSM IV • The key features for the diagnosis of Nicotine Dependence (305.1)
– Continued use despite wanting to quit – Prior quit attempts – Persistent use in the face of physical illness, – Tolerance – Presence of withdrawal symptoms

Nicotine Withdrawal (292.00)
• • • • • • • • Dysphoric or depressed mood Insomnia Irritability, frustration, or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

Measurement of Nicotine Dependence
• Fagerstrom Tolerance Questionnaire
– The nicotine rating item and the inhalation item were unrelated to biochemical measures

• Fagerstrom Test for Nicotine dependence
– At present, how long after waking up do you wait before having your first cigarette? – How many cigarettes do you smoke in a typical day?

The Fagerstrom score is a quicker approach adaptable to busy clinical settings
Patients who answer affirmatively to both questions are highly dependent on nicotine:

•Do you smoke more than 25 cigarettes per day? •Do you smoke within 5 Minutes of awakening? (Prochazka, 2000)

Withdrawal Symptoms
• Occur within a few hours after the last cigarette and peak about 48 – 72 hours later • Can last for a few days to several weeks • Symptoms include:
– – – – – Depression Frustration & Anger Irritability Difficulty concentrating; Trouble sleeping Headache and increased appetite

Dealing with Withdrawal
• Do not rationalize • Avoid people/places where you are tempted • Alter habits associated with smoking • Deep breathing • Visual imagery • Stay active • Remind yourself why you’ve quit

Behavior Change Research
• Health Belief Model • Stages of Change

Health Belief Model
You will be more likely to stop tobacco use if you:
– Believe that you could get a tobacco-related disease and this worries you – Believe that you can make an honest attempt at quitting – Believe that the benefits of quitting outweigh the benefits of continuing tobacco use – Know of someone who has had health problems as a result of their tobacco use

Transtheoretical Model of Change
• Developed by Prochaska and others • Identifies the stages a person goes through in making a change in behavior • Help the provider tailor counseling and therapy: Provide stage-appropriate advice and therapy • Demonstrates the benefits of identifying the smoker’s readiness to change before attempting to intervene
(Kottke, 1999)

Stages of Change
• • • • • • Pre-contemplation Contemplation Preparation Action Maintenance Relapse

Pre-contemplation
• No intention to change behavior in the immediate future • Unaware or under-aware of their problems • Not ready to change • Best Strategy: Offer general awareness information and counseling regarding their problem with tobacco dependence

Interventions for the Pre-contemplator
• Assess awareness and knowledge • Discuss pros and cons
– Benefits of quitting – Identify reasons for usage “triggers”

• Acknowledge their concerns • Advise of need to quit and personalize the message • Give self-help materials

Contemplation
• Aware that a problem exists and are seriously thinking about overcoming it • Have not yet made a commitment to change or take any action • Best Strategy: Motivate! Offer additional information regarding tobacco usage

Interventions for the Contemplator
• Discuss reasons for wanting to quit • Review barriers to quitting • Review resources and support for quitting • Review coping skills • Discuss strategies for quitting • Give self-help materials

Preparation
• Combines both an intention and behavior to change • Individual is intending to take action in the next month • Best Strategy – offer an intervention program….they are ready to address their tobacco addiction

Interventions for the Patient in the Preparation Phase
• • • • • • • Review reasons for quitting Resolve ambivalence Develop a QUIT PLAN Set a quit date Provide encouragement and provide support Give direct and positive message for quitting Have patient practice saying “No thank you, I don’t smoke” • Give self-help materials/Refer to support group

Action
• Individuals modify their behavior, experiences a/o environment in order to overcome their problems • Overt behavioral changes which require a considerable commitment of time and energy • Best Strategy: Offer continued support and reinforcement for positive changes. Assess and address relapse potential

Interventions for the Patient in the Action Phase
• Review reasons for quitting • Explore relationship with tobacco • Select a quit date • Review relapse triggers • Discuss obstacles to quitting • Encourage cessation efforts • Focus on progress • Offer referral to support group • Be sure to follow-up • Review coping strategies • Explore support system

On Quit Day
• Do not smoke; Do not use any tobacco products • Get rid of all tobacco products and paraphernalia (lighters, ashtrays, etc…) • Stay active • Drink lots of water • Avoid high-risk situations where the urge to smoke is strong • Avoid coffee and alcohol • Avoid being around individuals who are smoking

Maintenance
• Individual works to prevent relapse • Consolidates the gains attained during action • This stage lasts from six months to an indeterminate period • Best Strategy: Offer reinforcement and praise

Relapse
“Stopping smoking is easy to do….. I have done it thousands of times…..” -Mark Twain

Relapse and Smoking Cessation
• Relapse is the norm with nicotine dependence • Tobacco users seem to benefit from prior quit attempts
– Tobacco cessation is a process

• Motivate relapsers to try again • Most tobacco users make several serious quit attempts before they are successful

Who is likely to Relapse?
• Unable to cope with withdrawal and cravings • Highly dependent on nicotine • Copes poorly with stress and moods • Non-adherent • Ambivalence • Mental health issues

Treatment strategies for the patient in Relapse
• • • • • Identify barriers to success Review and explore negative feelings Explore successful quitting strategies Review relapse events and triggers Encourage and motivate patient to try again

Depression and Nicotine Dependence
• Complex association between depression and addiction to nicotine and tobacco • Persons with a vulnerability to depression are more likely to become regular smokers and to become dependent smokers • Level of nicotine dependence and number of cigarettes smoked are directly associated with the prevalence of major (Covey, 1999) depression

Depression Screening Tools
• The Beck Depression Inventory
– BDI is a good instrument for screening depressive disorders in community surveys – BDI cut-off score: greater than or equal to 13 – BDI when compared to SCAN (Schedules for Clinical Assessment in Neuropsychiatry) yielded 100% sensitivity; 99%specificity, and 98% diagnostic value
(Lasa, et.al., 2000)

Depression-Prone Smokers and Cessation
• Depression-Prone smokers have a lower quit rate • Depression-prone smokers experience more severe nicotine withdrawal • Smoking cessation can provoke severe depression in depression-prone smokers • Use the Beck Depression Inventory to screen patients for depression: consider concurrent therapy- referral to psychiatry
(Covey, 1999)

Counseling
• Individual provider counseling
– Physicians have contact with 70% of smokers annually – Smoking cessation provided by a physician is MORE cost-effective than screening PAP’s, mammograms, treating HTN or hyperlipidemia

• Group counseling • Proactive telephone counseling • Motivational counseling

Brief interventions during medical visits are costeffective and could potentially reach most smokers
•Unfortunately, brief interventions are not consistently delivered!
(Ockene, et.al., 2000)

National Patterns in the Treatment of Smokers by Physicians
• Smoking counseling by physicians
– 1991 – 16% of smokers’ visits – 1993 – 29% of smokers’ visits – 1995 – 21% of smokers’ visits

• Physicians identified patients’ smoking status at 67% of all visits in 1991 and this percentage did not increase over time • Nicotine Replacement Therapy
– 0.4% of smokers’ visits in 1991 to 2.2% in 1993 and decreased to 1.3% in 1995
(Thorndike, et.al., 1998)

Physician Interventions
• Primary care physicians were more likely to provide treatment to smokers than were specialists • All physicians were more likely to treat patients with smoking-related diagnoses • Physician practices for smoking intervention falls far short of national health objectives and practice guidelines
(Thorndike, et.al., 1998)

Individual Counseling: Four A’s NCI Guidelines
• ASK: ask about tobacco use at every visit and document in the patient record - the fifth vital sign • ADVISE: strongly! • ASSIST: plan, provide information, treatment, diary, routines, habit change • ARRANGE: referrals and follow-up

Provider Advice
• “As your physician, I must advise you to stop smoking.” • “I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.” • “I think it is important for you to quit smoking (smokeless tobacco) now and I will help you. Cutting down when you are ill is not enough.”

Advise
• Personalize the message • “Teachable moment” • Encourage the positive aspects of quitting
– Focusing on the negative effects of tobacco use and scare tactics are not effective strategies for motivating tobacco users to quit

• Motivational Counseling is helpful to individuals who are ambivalent or resistant to change

Advise
• Focus on the 4 R’s – Relevance of quitting – Risks of Tobacco – Rewards of quitting – Repeat the message

Assist
• • • • • • • Review quitting strategies Discuss potential problems Listen to concerns Provide stage based self-help materials Establish a plan Set a quit date Refer to specialist or program is needed

Assist/Pharmacotherapy
• Zyban • Nicotine Replacement Therapy (NRT)
– Gum – Transdermal patches – Nasal Spray – Nicotine inhaler

Smoking Cessation with Assistance
• Use of assistance for smoking cessation has increased over recent years, from 7.9% in 1986 to 19.9% in 1996. • Types of assistance: self-help, counseling, a/o NRT • Patients most likely to use assistance
– – – – Heavy smokers Women Usage increases with age Whites were more likely to use NRT than were other ethnic groups

Smokers’ preferences for assistance with cessation
• Given the several different options for assistance………….. 46% of current smokers stated they were interested in none of the options Of those interested in assistance: 67% preferred help from a medical professional 12.4% a stop smoking group 23% a book, pamphlet or quit kit 2.9% mail or telephone services
(owen & Davies, 1990)

Overall, those who used assistance had a higher success rate than those who did not: the 12-month abstinence rates were 15.2% and 7.0% respectively
(Zhu, et.al, 2000)

Arrange
• Follow-up • Ask: – Did you stop? – Are you tobacco free? – Any problems? • Provide encouragement!

Motivational Interviewing
• Developed and introduced in 1991 by Miller and Rollnick • HCP remains positive during counseling and praises all attempts to decrease or cease tobacco use • HCP shows empathy towards problems/withdrawals the patient is experiencing • HCP helps patient clarify his goals and provides the patient with treatment options

Group Counseling Behavioral Therapy
• Cessation rates average 20% for those willing to participate • American Lung Association “Freedom from Smoking” 1 year quit rate is 16% • American Cancer Society “Fresh Start Program” 1 year quit rate is 22% • Social support increases the smoker’s desire to quit, helps the smoker acquire the skills to become and remain abstinent and reinforces actions that have been taken to quit smoking
(Kottke, 1999)

Key Components for an Effective Behavioral Program
• Assessment of stages of change • Identification of barrier to quitting • Development of cessation and relapse prevention plans

(Prochazka, 2000)

Proactive Telephone Counseling
• The follow-up of all patients who have been counseled by their HCP to cease tobacco usage • Empower staff to become involved in the cessation process……this means delegate the phone call to someone else • Follow-up can double cessation rates

Any Last Questions?

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