1. Very Brief Advice on Smoking (VBA)
National Centre for Smoking Cessation and Training (NCSCT)
Very Brief Advice on Smoking (VBA)
Date and venue

2. Introductions, expectations and overview of training
Carry out introductions and small group work.

3. Aims and objectives: Aims
To provide training in the knowledge and skills necessary to deliver effective very brief advice on smoking to patients.   
Learning objectives
By the end of the course, participants will:
Have knowledge of the main harmful effects of smoking and the benefits of cessation
Be aware of the patterns and prevalence of smoking within their country and region
Have a working understanding of tobacco dependence
Understand the principles of VBA
Feel confident in delivering the components of VBA (Ask, Advise and Act) and in dealing with common patient responses, and issues that arise
Be aware of what support is available to smokers wishing to quit
Read through to reinforce the purpose and focus of the training.

4. Health effects of smoking and benefits of cessation
Explain that some behaviours present a serious health risk and that these are sometimes called health behaviours: smoking, misuse of alcohol, drug misuse, obesity and lack of physical activity.
Ask the group to call out:
What are the most prevalent modifiable risk factors within your clinical area?
Apart from health behaviours, what else impacts on the health of your patients (wider determinants)?
How important do you think it is to raise the issue of health behaviours?
What issue do you find it hardest to raise and why?
Respond appropriately, reinforcing that these are ‘modifiable’ behaviours, that we have a role in helping to modify these – but acknowledging it can be difficult for patients and appears tricky for us.

5. Health effects of smoking
The link between smoking and increased morbidity and mortality is firmly established.
About 4,000 chemical compounds in cigarette smoke; of which over 40 are known to cause cancer. The three important components of cigarette smoke are:
Nicotine  
Tar  
Carbon monoxide
Nicotine is the drug in cigarettes which is addictive (it is what keeps smokers smoking), but does not cause cancer and has at most a small effect on risk of cardiovascular disease.
Tar is the name given to all the other chemicals in the smoke particles and it is these that are linked to cancer, lung disease, heart disease and the other disorders caused by smoking.
Carbon monoxide is a gas inhaled by smokers from cigarettes; it is linked to heart disease and has adverse effects in pregnancy.

6. Health effects of smoking
xx,xxx deaths in country in date attributable to smoking
Main causes of death:
Coronary heart disease
Cancer
Chronic Obstructive Pulmonary Disease
Average loss of life = 10 years
The risk of lung cancer increases the longer a person smokes. Smoking also causes deaths from other cancers and circulatory diseases.
About half of smokers die prematurely because of their smoking. On average, those smokers who die because of their smoking die 20 years earlier than non-smokers.
All smokers suffer from some of the non-fatal diseases linked to smoking …………..

7. Health effects of smoking
Serious non-fatal disorders for which tobacco use is a known or probable cause, or an exacerbating factor
Aortic aneurism
Cerebrovascular disease
Peripheral vascular disease
Vascular dementia
Pneumonia
Asthma attacks
Surgical complications
Osteoporosis
Tuberculosis
Type II Diabetes
Peptic ulcers
Macular degeneration
Cataract
Hearing loss
Sudden Infant Death Syndrome
Spontaneous abortion
Stillbirth
Low birth weight
Infertility
Many of these conditions are age-related (e.g. macular degeneration, oesteoporosis, hearing loss) – in fact on average smokers experience disorders of old age 12 years earlier than non-smokers.

8. Benefits of cessation
There is strong evidence that by stopping smoking, however late in life, smokers can reduce their risk of premature death and can improve their current and future health.
“Stopping smoking is the single most important thing that smokers can do to improve their current and future health.”

9. Benefits of cessation
Major health benefits within weeks of stopping smoking:
Steep decline in lung function halted (progression of COPD is dramatically slowed)
Reduced risk of post-operative complications
Reduced risk of sudden death from cardiac arrest
Respiratory infections are less likely to occur
Reduced risk of low birth weight in infants and complications of pregnancy
Reduced severity of asthma attacks
Improved complexion
Read through bullet points.
Also, mention freedom from addiction and availability of increased amount of disposable income.
Smoking cessation does cause temporary short-term withdrawal symptoms, which we will cover when we look at tobacco dependence.

10. Benefits of cessation
Major health benefits within a year of stopping smoking:
Reduced risk of cardiovascular disease
Major health benefits within several years of stopping smoking:
Rise in lung cancer risk is halted
Reduced risk of other cancers
A healthy adult who stops smoking before 35 years of age can have a normal life expectancy.
After the age of 35, every year that a smoker delays quitting will cost an average of three months of life.

11. Benefits of cessation
Stopping smoking doesn’t just add years to life, it adds life to years.
Ex-smokers cannot only expect a longer life than those who continue to smoke, but a healthier life as well. Former smokers experience fewer days of illness than current smokers, are fitter and feel much healthier.

12. Health effects of smoking and benefits of cessation Any questions?
Explain that further reading is suggested in the Key learning outcomes document in their folder.

13. Patterns and prevalence of smoking
To be completed by country teams……

14. Break: 30 minutes

15. Tobacco dependence: why smokers don’t just quit
Explain that of course some smokers do ‘just quit’, but that these tend to be the less dependent smokers and not the patients that we meet through our work.

16. What does it mean to be dependent upon tobacco?
Divide participants into groups of three or four
Ask them to consider what the main features of tobacco dependence are and what this means for dependent smokers
Ask small groups to feedback/summarise their conclusions and discuss as a group
A quick word on terminology. There is an academic distinction between the terms ‘addiction’ and ‘dependence’: Addictions are activities that are given an unhealthy priority because of a disordered motivational system. Dependence refers to the nature of that disorder. It varies from individual to individual and behaviour to behaviour.
But these terms can and are used interchangeably and it is important to use words that our patients understand.

17. DSM-5 Tobacco Use Disorder 1
DSM-5 Tobacco Use Disorder 1. Tobacco is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control tobacco use. 3. A great deal of time is spent in activities necessary to obtain tobacco, use tobacco, or recover from tobacco’s effects. 4. Craving or a strong desire or urge to use tobacco. 5. Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work). 6. Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco. (e.g., arguments with others about tobacco use). 7. Important social, occupational, or recreational activities are given up or reduced because of tobacco use. 8. Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco. 9. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of tobacco to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of tobacco Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for tobacco. b. Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms.
This is the latest diagnostic criteria from the most recent Diagnostic and Statistical Manual of Mental Disorders, fifth edition of the American Psychological Association. The DSM-V is used by many medics to assist with diagnosis, which in the case of tobacco isn’t particularly helpful.
Individuals are classed as having this disorder if they meet two or more of the criteria for tobacco use within a 12 month-period.
Explain that these criteria are most suited to illicit substance misuse and don’t really fit tobacco use in most countries where it is legal, available and often affordable. Point out explicitly that 1, 3, possibly 4, and 5, 6, and 7 don’t fit most smokers and that number 9 doesn’t describe tobacco use in any shape or form.
Let’s have a look at how it feels for smokers to be dependent.

18. What is tobacco dependence?
Tobacco dependence is a chronic relapsing-remitting condition that kills half of sufferers and usually begins in childhood.

19. Tobacco dependence
“Nicotine delivered through tobacco smoke should be regarded as an addictive drug, and tobacco use the means of self-administration”
Royal College of Physicians, 2000
The key concept of dependence according to PRIME theory is ‘motivational balance’
It looks like nicotine is a moderately addictive substance that becomes highly addictive when administered by smoking tobacco.
Tobacco acts on the motivational system, in fact tobacco dependence can be considered a disorder of motivation. This is important to remember.

20. How does tobacco dependence develop?
Operant conditioning
Habits result from experience of reward and punishment
Classical conditioning
Stimuli take on motivational value by being associated with other stimuli
Drive theory
Behaviours derive from biological imperatives
Operant conditioning
First there is what is known as ‘positive reinforcement’. This occurs when a behaviour (e.g. puffing on a cigarette) is followed by what the brain considers to be a ‘reward’. When this happens the behaviour becomes more likely to occur in the future and the more often the behaviour-reward sequence occurs the more entrenched the behaviour becomes. The process does not require the individual to be aware of what is going on, it does not involve an active decision making process. It does not even require the individual to feel positive pleasure. The system operates in a part of the brain that evolved many millions of years ago to train animals to engage in behaviours that help with survival and reproduction. The system is involved in a dog learning to sit up and beg. Nicotine taps into this system trains the smokers in effect to ‘sit up and beg’ for a puff on a cigarette.
The second part of the operant conditioning process involves what is known as ‘negative reinforcement’. Whereas the first part, positive reinforcement, involves seeking out rewarding stimuli, negative reinforcement involves escaping from or avoiding unpleasant stimuli – punishment. As with positive reinforcement it requires no conscious decision making. Nicotine taps into this system because after a relatively short period of smoking the body adapts physiologically to the presence of nicotine. From that point onwards periods of abstinence lead to the body compensating for nicotine when it is not actually present – the physiological systems become unbalanced. Even a relatively brief interval without smoking (such as the normal interval between cigarettes) leads to a characteristic withdrawal syndrome that is unpleasant. Smoking a cigarette removes these symptoms very quickly.
Cigarettes are highly dependence forming because of rapid nicotine delivery (positive reinforcement) and relatively short half-life [2 hours] (negative reinforcement)
Classical conditioning
There are also secondary reinforcers (the sight of the cigarette pack, the striking of a match,) and situations associated with smoking and with the nicotine hit (drinking coffee, speaking on the phone, having a drink etc) which further reinforces the effects of nicotine.
Drive theory
This argues that a drive (or hunger) develops so that the smoker feels driven to smoke by some deep need.

21. Tobacco dependence
Is not just a neurological condition, but also about personality traits, social experience and identity.
Tobacco dependence is a bio-psycho-social condition affecting motivation.
What sort of identity we hold or how we label ourselves is crucial to our behaviour.
There is no such thing as an addictive personality…but there are personality traits (such as novelty seeking, risk taking, anxiety etc) which make people more likely to become addicted to certain drugs.
And of course the world around us influences how we think and act.
Tobacco dependence is a complex condition involving biological, psychological and sociological elements. It is a disorder of motivation.

22. How do we measure tobacco dependence?
Fagerstrom Test of Nicotine/Cigarette Dependence (FTND/FTCD) Heaviness of Smoking Index (HSI)
1. How soon after you wake up do you smoke your first cigarette?
Within 5 minutes = 3
6-30 minutes = 2
31-60 minutes = 1
More than 60 minutes = 0
2. How many cigarettes per day do you usually smoke?
10  or less = 0
11  to 20 = 1
21 to 30 = 2
31 or more = 3
You have a copy of the six-item FTND in your pack. Two of the six items are predictive however and so we just need to ask these two simple questions – this is called the Heaviness of Smoking Index.
Quite simply, the higher the score, the more tobacco dependent. More dependent smokers will find it harder to quit and will need more support and more medication for longer to give them a good chance of quitting.

23. Tobacco dependence
Cigarette dependence reveals itself as powerful desires and urges to smoke when smokers try to stop. These go alongside feelings of aggression, depressed mood, increased appetite, restlessness and difficulty concentrating which weaken the resolve not to smoke. The problem is usually strongest in the first few weeks of stopping and declines after that but sometimes it persists and the desire and urge to smoke can be triggered months or years after stopping.
This is what it feels like for smokers, this is when they become aware that they are dependent.
So when a quit attempt ‘fails’ or smokers relapse back to smoking, it is not that they have made a conscious decision to do this, or that they lack the will – it is a condition of dependence. Their motivation to quit is affected by their tobacco dependence which includes withdrawal symptoms.

24. Tobacco dependence: withdrawal symptoms
Effect
Prevalence
Typical duration
Irritability or aggression
> 25%
< 4 weeks
Increased appetite
> 10 weeks
Difficulty concentrating
Restlessness
>25%
Depressed mood
< 25%
Urge to smoke
> 10 weeks but declining
Sleep disturbance
Most of the tobacco withdrawal symptoms reduce and then disappear within four weeks of quitting, as long as smokers do not have even a single puff on a cigarette. The exceptions are increased appetite and urges to smoke – both of which diminish with time.
Urges to smoke will become less frequent as time passes, but can strike in the future and be severe. Mention that urges to smoke involve both ‘nicotine hunger’ and cue-induced urges to smoke.
Depressed mood and urges to smoke are predictive of relapse.

25. Tobacco dependence: withdrawal signs
Effect
Prevalence
Typical duration
Weight gain
> 25%
permanent
Cough / sore throat
< 25%
< 4 weeks
Mouth ulcers
> 2 weeks
Constipation
<25%
Reduced heart rate
Increased skin temperature
Reduced tremor
Weight gain happens because nicotine raises the metabolic rate – meaning smokers weigh less than they should do given the amount they eat and the amount of exercise that they do. Smokers should know that cessation leads to weight gain in 80 – 90% of those achieving abstinence, but it is more than 10kg in only 10–20% of quitters. They also deserve to be told that it is permanent unless they make special efforts to prevent it or lose it again. On average, smokers gain about 4.7kg during the first year of continuous abstinence.
Coughs, sore throat and mouth ulcers are a consequence of quitting being ‘stressful’ resulting in decreased serum immunoiglobin A (sIgA), an antibody playing a crucial role in the immune function.

26. Tobacco dependence Any questions?
Explain that further reading is suggested in the Key learning outcomes document in their folder.

27. Introduction to Very Brief Advice on Smoking (VBA)
Very brief advice in smoking (VBA) is a public health intervention delivered by individuals.
It is a proven way of triggering quit attempts, and then supporting the quit attempts of those patients who decide that they would like to stop smoking.

28. The 3 T’s
Tension
Creating a feeling of dissatisfaction with smoking; cognitive dissonance
Triggers
Multiple prompts and opportunities to make a quit attempt
Treatment
Effective and available treatment to aid the quit attempt
Explain that for a quit attempt to be triggered we need the smoker to feel ‘tension’. This can be stimulated by smokefree environments, high prices, awareness of the health consequences of smoking etc
Triggers to quit are delivered repeatedly in the hope that one of them prompts a quit attempt. Advice from a health professional is an important trigger – and also increases ’tension’ whether or not it leads directly to a quit attempt.
Once a quit attempt is triggered we want to give the patient the best possible chance of success.

29. The 3 T’s Motivational ‘tension’
Level at which quit attempt is generated
Here’s how it could look graphically……[talk through]
Time
Increased motivational
‘tension’
Low level of motivation
Trigger

30. VBA is a simple form of advice designed to be used opportunistically in less than 30 seconds in almost any consultation with a smoker.
VBA involves: establishing smoking status (ASK); advising on quitting (ADVISE) and acting on the patients response to your advice (ACT). In a large study across the whole of England, it was found that smokers were almost twice as likely to try to stop if they had been offered help by their GP, than if they had only been advised to stop. The importance of recommending both support and treatment in the VBA is highlighted by a study which showed that compared with no advice to smokers, the odds of quitting are 68% higher if stop smoking medication is offered and 217% higher with offer of support.
This research project has tried to adapt VBA for your context and we’ll be looking at this simple intervention in more detail after lunch.
But here’s a short film showing how it should be done in the UK….[show 30 Seconds DVD]

31. 30 Seconds

32. Lunch: 60 minutes

33. VBA: ASK
The first thing to do with our patients is to establish whether they smoke or not, this is called their smoking status. We do this simply by asking them.
Here’s an example of some English GPs establishing smoking status …….. [Show Ask chapter from VBA training DVD]

34. Film clip: Ask chapter
It is worth recognising that patients view smoking as a legitimate health topic and therefore will not resent you bringing up the issue. In fact, not talking to our patients about smoking may leave them with the impression that you’re not concerned about it.
Ask whether there are any reasons why participants cannot establish smoking status ……… respond appropriately.
Mention that for smokers who have recently quit (within the last four weeks), it might be best to record them as a ‘recent ex-smoker’ rather than an ‘ex-smoker’ because of the high chances of relapse.
Ask what we might say to never smokers and ex-smokers? ……… respond appropriately.

35. VBA: ADVISE
Having established if a patient smokes the next component of VBA involves a simple statement of the benefits of quitting and that help is available.

36. “Stopping smoking is the single most important thing that you can do for your health. Help is available and many of my patients have found this useful. Would you like some help to quit?”
You can choose your own words but something like this:
The example above makes it clear that you are concerned for their health and advise that they should quit smoking. It also offers practical help and gives hope if other patients have been helped to quit.
Split into pairs, hand out patient response sheet and carry out exercise.
After 5 minutes, call group back and go through responses on next slides…..

37. “Stopping smoking is the single most important thing that you can do for your health. Help is available and many of my patients have found this useful. Would you like some help to quit?” Response 1:   “I don’t think I’m ready to quit but I could try and cut down.”
Ask for participants to call out their responses.
Possible response:
Talk to your patient about ‘compensatory smoking’ (see Training Manual) and explain why only quitting completely will help protect their health, now and in the future.

38. “Stopping smoking is the single most important thing that you can do for your health. Help is available and many of my patients have found this useful. Would you like some help to quit?” Response 2:   “Hmm, I’m not sure. I’d like to but it might just be too tricky at the moment.”
Ask for participants to call out their responses.
Possible response:
Say that it is up to them, but the sooner they quit the better and they need to be aware of putting quitting off for ‘the right time’. There is no time when it will be easy, but the longer they smoke the harder it may become.
Inform your patient that you are concerned about the fact that they are smoking and that you will ask them about their smoking the next time that you see them. Say that the help you have offered will remain available.

39. “Stopping smoking is the single most important thing that you can do for your health. Help is available and many of my patients have found this useful. Would you like some help to quit?” Response 3:   “Yeah, I’d like to try and stop please.”
Ask for participants to call out their responses.
Use the responses of participants to gauge their knowledge of what help is available.
We can now move on to the final component of VBA: ACT

40. VBA: ACT
Having advised a patient of the importance of quitting smoking, and having offered help, we now need to act on their decision on whether to make a quit attempt or not.
Let’s look at how we can respond to their decision…..

41. Many smokers will not accept your offer of help, feeling that it simply isn’t the right time to stop
Ask the group to call out how they would respond to a patient not wanting to quit.
“If the smoker is not interested in stopping you just say that is fine, that help will always be available and to let you know if they change their mind. Or, as most smokers see their GP several times a year, there is plenty of opportunity to remind them that help is there when they are ready.”
It is important to remember that although the patient didn’t act on your advice, it is not a waste of time as it alerts them that you are concerned about their smoking, would like them to stop and that help is available.

42. Some smokers will accept your offer of help
Ask the group to call out how they would respond to a patient who does want to quit.
We can now move on to look at what support is available to your patients, including what you can do to assist them with their quit attempt.

43. Any questions about VBA?

44. Supporting quit attempts
Having triggered a quit attempt we want our patients to have the best possible chance of quitting.
This involves a combination of medication and support – and the aim is to deliver the optimum available to your patients.

45. Supporting quit attempts: medication
We will look at the main principles of smoking cessation medications and then have a brief look at the specific medications available to your patients.

46. Medication: main principles
Ensure that the patient has a realistic expectation of the medication. It will help with their quit attempt but it is not a magic bullet.
Explain the effectiveness of the medication.
Recommend / prescribe a medication according to patient choice, and what’s available and appropriate for the patient.
Prescribe medication according to national guidelines on an abstinent-contingent basis. In other words, offer a two-week prescription and only issue another prescription if the patient is continuing with their quit attempt.
Review the patient’s progress regularly and check on medication usage and side-effects.
“There are medications that make quitting easier. In fact, people who use these medicines when they quit smoking are twice as likely to be successful than those who try and quit without using them. They are safe and do not cause cancer, strokes, heart or lung disease.”

47. Stop smoking medications
To be completed by country team: list available medications
Present the slide(s) for each available medication and discuss usage.

48. Supporting quit attempts: behavioural support
Behavioural support from a trained stop smoking practitioner roughly doubles a smoker’s chances of quitting, a similar effect size as that of stop smoking medications.

49. Behavioural support: pre-quit
Assess tobacco dependence and prior quit attempts
Inform patients of withdrawal symptoms and how to manage urges to smoke
Agree on medication choice and ensure supply
Set a quit date with the client after which they will not smoke even a puff on a cigarette
Explain the importance of abrupt cessation and the ‘not-a-puff’ rule
Get client to commit to you to not smoke even one puff on a cigarette after their quit date
[Talk through each behaviour change technique, discussing their importance and how to deliver them]
[If required, film clips are available for: Assess current and past smoking behaviour / History of quit attempts / Assess readiness and ability to quit / Assess nicotine addiction / Advise on environmental restructuring / Advise on changing routine / Advise on the use of social support / Explain the importance of Carbon Monoxide monitoring / Explain the importance of the 'not a puff' rule’ / Set a quit date / Prompt commitment / Measure carbon monoxide (CO) / Advise on restructuring social life]

50. Behavioural support: post-quit
Check on progress. Reinforce the ‘not-a-puff’ rule if necessary
Ask about withdrawal symptoms, specifically urges to smoke, and how patient has dealt with them
Review medication usage and supply
Get client to commit to you to not smoke even one puff on a cigarette
[Talk through each behaviour change technique, discussing their importance and how to deliver them.]
[If required, film clips are available for: Progress since quit date / Responding to clients who have smoked / Rewarding post-quit abstinence / Assess withdrawal symptoms / Ask about medication use / Respond to Carbon Monoxide reading]

51. Break: 30 minutes

52. Dealing with smokers’ questions
[Conduct this exercise as described in the training manual]

53. Help for smokers
To be completed by country teams……

54. Course evaluation and next steps
Make sure that you explain what will happen after the course in terms of delivering, recording and evaluating their VBA delivery.
Make sure that participants complete the post-training questionnaire
Make sure that participants complete the course evaluation
Hand out attendance certificates

55. Good luck!
Country teams to enter their contact details on this slide……