Best Practices for Cessation Counseling By VJ Sleight, MA, TTS

Goals Participants will be confident in providing effective basic cessation counseling regardless of the time restraints by understanding the biopsychosocial motivations of clients who smoke. Goals for working with clients: Increase motivation and instill hope Boost self-efficacy Address ambivalence Encourage behavioral and social support

Agenda Best Practices for Cessation: Five A’s Stages of Change Model Ask, Advise, Assess, Assist, Arrange Stages of Change Model Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse. Counseling Methods: Motivational Interviewing Cognitive-Behavioral Therapy Relapse Prevention

Best Practices: Five “A’s”

Assess “I don’t want to quit!?!” (Pre-Contemplation) Yes/No: Are you willing to quit right now? Lickert Scales: On a scale of 1-10, how motivated are you to quit using tobacco at this time? (1= no motivation, 10 = highly motivated) 1 2 3 4 5 6 7 8 9 10 On a scale of 1 -10, how ready are you to set a quit date within the next 30 days? (1= not at all ready 10 = I’ve already set my date) 1 2 3 4 5 6 7 8 9 10 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) 1 2 3 4 5 6 7 8 9 10 Open-ended Question: “How do you feel about quitting?” “I don’t want to quit!?!” (Pre-Contemplation) “I want to quit but….” (Contemplation) “I’m ready, help me.” (Preparation)

Stages of Change Pre-Contemplation Contemplation Relapse Maintenance No intention of changing behavior Contemplation Aware a problem exists, not ready to commitment to action Preparation Intent on taking action Action Effective modification of behavior Maintenance Sustained change, new behavior replaces old Relapse Fall back on old behavior Stages of Change

Assess and Assist Intent to Quit No Intent to Quit Quit Smoking Pre contemplation – Contemplation – Preparation – Action – Maintenance Consciousness-Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment Reward Countering Environmental Control Helping Relationships Motivational Interviewing: A client centered method to enhance intrinsic motivation to change by exploring and resolving ambivalence. (Stage 1) (Stage two) Cognitive – Behavioral Therapy: Focus on coping by thinking differently and acting different Relapse Prevention: Help individuals maintain healthy behavior by anticipating and coping with relapse.

Pre-contemplation Contemplation Preparation Consequences of Continuing to Smoke Spend more money Health gets worse Bad role model Continue to stink Less energy More burn holes Can’t breath Spouse continues to nag Benefits of Continuing to Smoke Helps me concentrate Relieves my stress Controls my weight I enjoy smoking. It fills up time. It relaxes me All my friends smoke Consequences of Quitting Withdrawals I don’t know what to do when stressed I might gain weight What will I do with my time? What to I say to my smoking friends? Benefits of Becoming Smoke-free Save money Have better health Better role model Smell better More energy No more burn holes Breathe better Get along better with spouse Pre-contemplation Contemplation Preparation

Pre-contemplation Contemplation Preparation Consequences of Continuing to Smoke Listen for disadvantages of status quo Reframe as a Benefit of becoming smoke-free Benefits of Continuing to Smoke Use Motivational Interviewing to create and/or address ambivalence Reframe as a consequence of quitting Consequences of Quitting Listen for optimism and willingness to change. May use Cognitive-behavioral tools Benefits of Becoming Smoke-free Listen for advantages of change Contrast smoking with internal values Pre-contemplation Contemplation Preparation

Assist: Building Motivation: Personal and relevant

Assist: Motivational Interviewing Communication style: Guide instead of direct, or follow. Spirit of MI: Collaborative, evocative, honors client’s autonomy

M. I. Strategies Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy

M. I. Tools O A R S Ask Open ended questions (door openers) Affirm (Acceptance facilitates change) Listen Reflectively (Decreases resistance) Summarize (Client feels heard)

Listen for Change Talk Benefits of change (motivation) “I want to, I’d like to, I wish…” Disadvantages of status quo (motivation) “I ought, I should, I have to….. Optimism of ability (confidence) “I can, I could, I might be able….” Intent to quit (willingness) “I’m going to, I will

Assess and Assist Ask open ended questions Listen to the answer Summarize/reframe Repeat Intent to Quit No Intent to Quit Quit Smoking Pre contemplation – Contemplation – Preparation – Action – Maintenance Motivational Interviewing: A client centered method to enhance intrinsic motivation to change by exploring and resolving ambivalence. (Stage 1) (Stage two) Cognitive – Behavioral Therapy: Focus on coping by thinking differently and acting different

Assist: Set a Quit Date Within 30 days. Plan around important social events (ie Superbowl). Decide which is better: a week-day or on the weekend. The night before: Flush and Crush all remaining cigarettes. Have a plan written down.

Assist: Cognitive-Behavioral Therapy Focus is on immediate problems in a structured format, with the goal of coping by thinking and acting differently. Treatment elements: Support and encouragement Practical counseling in problem solving skills and skills training

Assist: Cognitive-Behavioral Therapy Cognitive tools: Think about positive health benefits or negative consequences of smoking Review commitment Distraction/refocus thoughts Positive self-talk Relaxation through imagery Mental rehearsal Visualization Behavioral tools: Substitution (countering; Active diversion such exercise, and/or relaxation techniques) Reward Environmental control Helping relationships (supportive environment)

Assist: Common Elements

Recognize Danger Situations

Develop Coping Skills

Creating a Smoking Corner Make a smoking corner: Away from all household activities., outside someplace you don’t normally smoke. In your smoking corner, don’t do anything else except smoke. The purpose is not to multi-task but to be conscious of what you are doing. If you are driving when it is your “time” to smoke, pull over to a safe area; get out of your car to smoke. Don’t smoke with other people. If your work place has a designated smoking area, try to only go there at your time to smoke, do not talk to the other smokers and leave as soon as the butt is put out.

Smoke by the Clock Smoke by the clock. Don’t smoke whenever you want to but let the clock dictate when you smoke. Choose a time schedule so you smoke often enough to not have strong withdrawals or cravings. Smoking a pack a day is one cigarette every hour;. 10 cigarettes a day is every two hours;. Two packs a day is every half hour. Don’t try to cut down; the purpose is to learn new behaviors while your brain is still calm by smoking and to break your old associations. When it is your “time” to smoke, go to your smoking corner, stand and smoke (unless you have a physical challenge). If you don’t feel the need to smoke when it is your time to smoke, you don’t have to but you can’t have another cigarette until it is your next time to smoke.

Creating a Personalized Action Plan

Supportive Environment

Assess and Assist Intent to Quit No Intent to Quit Quit Smoking Pre contemplation – Contemplation – Preparation – Action – Maintenance Consciousness-Raising Social Liberation Emotional Arousal Self-Reevaluation Commitment Reward Countering Environmental Control Helping Relationships Motivational Interviewing: A client centered method to enhance intrinsic motivation to change by exploring and resolving ambivalence. (Stage 1) (Stage two) Cognitive – Behavioral Therapy: Focus on coping by thinking differently and acting different Relapse Prevention: Help individuals maintain healthy behavior by anticipating and coping with relapse.

Relapse Prevention Short Term Long Term Manage withdrawal symptoms Ritual replacement (habits) Long Term Stress, negative emotions Weight gain Positive social events or situations Alcohol Being around other smokers

Seven FDA Approved Medications Nicotine Replacement Gum Lozenge/mini-lozenge Nasal Spray-Rx only Inhaler-Rx only Patch Non-Nicotine Zyban (bupropion) Chantix (varenicline)

Questions?

Suggested reading 2008 Treating Tobacco Use and Dependence, Clinical Practice Guideline. http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf 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. Prochaska, Norcross, DiClemente, (1994). Changing for Good. Avon Books: New York. Sleight. (2010). Tips to Win at Quitting. E-book . Sleight. (2013 est.). Selling Good Health. E-book.