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

2. 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

3. 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

4. Best Practices: Five “A’s”

6. 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)
On a scale of , 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)
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)
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)

7. 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

8. 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.

9. 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

10. 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

11. Assist: Building Motivation: Personal and relevant

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

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

14. 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)

15. 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

16. 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

17. 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.

18. 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

19. 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)

20. Assist: Common Elements

21. Recognize Danger Situations

22. Develop Coping Skills

23. 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.

24. 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.

25. Creating a Personalized Action Plan

26. Supportive Environment

27. 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.

28. 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

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

30. Questions?

31. Suggested reading
2008 Treating Tobacco Use and Dependence, Clinical Practice Guideline.
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.