1. TACKLING TOBACCO DEATHS THE NURSES’ ROLE IN TOBACCO CONTROL AND SMOKING CESSATION JENNIFER PERCIVAL RCN TOBACCO POLICY ADVISOR

2. Tobacco is a public health priority Source: WHO In the year 2000 1 in every 6 deaths worldwide was caused by smoking By the year 2030 1 in every 3 deaths worldwide will be due to smoking 70% of these deaths will be in developing countries.

3. THIS ADVERT WAS USED IN THE 1950’S

4. Tobacco advertisers have no boundaries

5. Tobacco advertising has successfully encouraged more women to start smoking

9. Women and Tobacco In the UK lung cancer surpassed breast cancer as leading cause of cancer death in 1987 Now more women die from lung cancer than breast, ovarian, cervical & endometrial cancers combined

10. The true picture is very different

11. His research has shown: Half of all regular smokers die prematurely: ¼ in middle age (35-69) ¼ in old age Stopping before 35 avoids most of the risks of premature death. Stopping smoking works. WHO – ‘THE SILENT EPIDEMIC’ WORLD HEALTH ORGANISATION Epidemiologist Sir Richard Peto “Tobacco use is increasing. Over 100 million deaths from tobacco will occur during the next 20 years……. and if nothing changes there will be ONE BILLION deaths this century.”

13. The WHO Framework Convention on Tobacco Control (FCTC) Main Measures that 169 countries have signed up to Ban all tobacco advertising Increase Tax on tobacco products Take effective measures on Passive smoking Put large Warnings on tobacco products Provide Public Education campaigns Provide Cessation Guidelines and Services Take Action on illicit trade/smuggling Control sale of tobacco to children/ minors

15. Put large warnings on all tobacco products

16. Provide Public Education campaigns

17. WHO estimates that nearly 700 million, or almost half of the world’s children, breathe air polluted by tobacco smoke, particularly at home. Take effective measures on Passive smoking WHO estimates that nearly 700 million, or almost half of the world’s children, breathe air polluted by tobacco smoke, particularly at home.

18. Control sales of tobacco to minors!

21. A Chronic relapsing dependence syndrome Use of the addictive drug nicotine Reinforced by sensory, behavioural and social conditioning Entrenched by powerful withdrawal syndrome Promoted commercially, exempt from consumer protection legislation What is smoking?

22. Why are cigarettes so harmful? Nicotine 4,000 chemicals Tar Carbon monoxide

23. Light-headedness Sleep disturbance Poor concentration Craving Irritability/aggression Depression Restlessness Increased appetite <48 hrs 10% < 1 wk 25% <2 wks 60% > 2 wks 70% < 4 wks 50% < 4 wks 60% > 10 wks 70% Stopping Smoking Withdrawal effects: duration and frequency

24. Royal College of Physicians, Nicotine Addiction in Britain, 2000 Nicotine delivery

25. Nicotine Replacement Therapy, Zyban & Champix

26. Reasons for NRT failure Unrealistic expectations Incorrect use Not used for long enough Nicotine is often seen as the dangerous element in cigarette smoke Safety concerns can be a barrier to use

28. Core communication skills Boost the person’s motivation and self-efficacy Build rapport Use reflective listening Provide reassurance

29. Standard Treatment Programme Pre Quit Assessment Assess current readiness and ability to quit Inform the client about your programme Assess current smoking Assess past quit attempts Explain how tobacco dependence develops Assess nicotine dependence

30. My observations from working in the UK Stop Smoking services are that direct persuasion is not enough to make people decide to stop smoking

31. People want the ‘benefits’ of being a non smoker ……. without recognising the often long process of ‘change’ they need to go through to acquire them.

33. Miller WR et al. J Consult Clin Psychol 1993;61:455–61; Miller and Rollnick, 1991 You will have already observed that direct persuasion does not make people decide to change

34. GOOD ADVICE

36. “I knew you could get cancer from smoking, but I’d planned to give up long before that happened to me” Robert was diagnosed with cancer of his tonsils at age 36

37. ADVICE Reasons for Current Behaviour

38. ADVICE Reasons for Current Behaviour

40. Current Behaviour

41. Everyone has their own beliefs about safe behaviour This child is strapped in and protected from the sun but....?

43. A DIFFICULT TIME

44. Problem: Many pregnant women do not like to say they smoke A carbon monoxide (CO) test is an immediate and non-invasive biochemical method for helping to assess whether or not someone smokes

45. THE CHANGE PROCESS No-one changes their behaviour without first changing their attitudes and beliefs. When a client argues with you it means you have made a wrong assumption. Long term behaviour change takes time to consolidate

46. Principles of Motivational Interviewing Use a neutral manner to give clients information about the impact of their lifestyle on their health Help people interpret the health implications, risks and benefits of not changing. Assist people to explore for themselves the importance of making a specific change. Leave the responsibility for changing and the right to decide whether or not to change, with the client.

47. Helping people to stop smoking Avoid making pressure to change: this will create resistance. You can never win and, in the process, may lose the chance to help Roll with any resistance: do not argue with the patient if they say their action is not harmful. Instead, respectfully clarify their own thoughts or views Support the patient’s self-confidence: look for the positive aspects and build on them

49. HELPING PEOPLE TO STOP SMOKING WHAT WORKS? Find out what the tobacco user already knows about the risks and seek permission to provide further information. Link these facts to their current health status or medical condition. Explain the short and long term benefits of quitting and assess their understanding. Try asking: What do you think might happen to you if you continue to smoke?

50. PEOPLE NOT READY TO STOP Respect their view “It sounds like it would be hard for you to stop now” “Are you planning to be a life long smoker”? If they say NO Ask: “What would need to change for you to consider stopping smoking”? Explain your medical / social concerns Leave the subject open for future discussion

51. Asking questions can plant a seed of change ‘New thoughts’ often help people think differently about what they believe to be true.

52. Unsure about change? Help them explore the perceived advantages and disadvantages of smoking Ask more about what brought them to see you and find out their concerns Describe any ambivalence you notice Plant a seed of change

53. Helping people to stop smoking Show empathy: even if you do not share a person’s viewpoint, find ways to show that you understand and respect them Identify discrepancies: there are often differences between how a person behaves and how they see themselves Name these in a neutral way eg.’Don’t want their kids to start smoking’

55. People making plans to quit Congratulate this decision Check their expectations of changing Ask “What could get in your way?” “What can you do to avoid that”? “What help will you need?” “Who can you ask?”

56. Helping people to change Ask:- “What are you planning to do next”? “Who are you going to ask to support you?” “What quit date have you decided? Can you commit to not having a single puff of a cigarette from then onwards?” “What medication are you going to use?

57. RELAPSE Why do smokers return to tobacco? Stopping under pressure from someone else Lack of personal motivation Attaching insufficient importance to stopping Withdrawal symptoms Poor timing A question of self-image “I thought `just one’ wouldn’t hurt”

58. Relapse prevention Ask: What makes this a good time to stop? If they have tried many times before: What have you learnt from past attempts? What will you do differently now to stay stopped? How would you feel if you had a cigarette again? Who is going to support you?

59. 1. I’ve tried before, its too late now, the damage is already done” 2.“My doctor’s told me to see you about quitting smoking” 3 “I’ve really cut down since my heart attack.” 4 “I feel so low since I’ve stopped smoking and I crave a smoke all the time.” 5“I want to give up, but it’s hard as my partner smokes.” 6“I don’t like to ask my in-laws not to smoke in the house.”

60. Contact details jennifer.percival@usa.net Email address