integrating tobacco cessation treatment into practice statewide conference

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  • 7/28/2019 Integrating tobacco cessation treatment into practice Statewide Conference

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    IntegratingTobaccoCessationTreatmentintoPractice 4/22/2013

    HeatherOsterbergAloi,MA,CTTSM 1

    Heather Osterberg-Aloi, MS, CTTS-M

    Senior Program Specialist

    1. Participants will learn how to assess motivation to quittobacco use.

    2. Participants will learn specific treatment strategies thatmatch the clients motivational level, including pre-contemplation, contemplation, preparation, action,

    .

    3. Participants will learn how to integrate motivationalinterviewing style and identify teachable momentsto provide personalized feedback with clients.

    4. Participants will learn specific content that could beintegrated into patient education activities.

    In collaboration with the client, identify specificand measurable treatment objectives.

    Plan individualized treatments that account forpatient assessment factors identified during the

    .

    Collaboratively develop a treatment plan thatuses evidence-based strategies to assist the

    client in moving toward a quit attempt, and/orcontinued abstinence from tobacco.

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    Preparation Assessment

    Tobacco Use History

    Dependence Level

    Motivation for change

    Help them understand their tobacco use and the process ofquitting

    e ei iv i

    Action Teach specific strategies (i.e. medication, identifying trigger

    situation and relapse prevention)

    Success is Quitting and Staying Tobacco Free

    Maintenance (Living As A Non-Smoker) Help client understand that maintenance of non tobacco use is

    ultimate goal.

    Learn to live as a non-smoker

    Tobacco Use History History of Usage/ Time To First Cigarette Cigarettes Per Day Age at First Use/Regular Use Previous Quit Attempts (last 3)

    Level of Dependence Fagerstrom Test for Nicotine Dependence Tobacco Use Self Assessment

    Motivational Level Importance Confidence Scale Decisional Balance

    1. Ask about tobacco use at each visit

    2. Advise tobacco users to quit

    .

    4. Assist tobacco users to quit

    5. Arrange for follow-up

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    CO Score

    Fagerstrom Score

    Motivation Level

    Money Spent

    Medical Condition

    Use of all Forms of Tobacco, NRT, etc.

    Explore their first experience with tobacco use

    Tell me about the first time you started smoking?

    Why did they start?

    Family Environment - Supportive vs. Discouraging

    How did your parents react when they learned you were

    smoking?

    How does your significant other feel about your smoking?

    A CO meter measures the amount ofcarbon monoxide in your body.

    My CO reading is: __________

    One of the most deadly chemicals found incigarettes smoke is carbon monoxide (CO).

    When you smoke, you replace oxygen withcarbon monoxide in your blood. YOU

    0-8: Normal to very low smoking orsecond hand smoking

    8-12 Worryyou are affecting yourhealth

    12-25 Cause for alarmyou areharming yourself

    25-40 Dan er or hazard to ou health

    ARE POISIONING YOURSELF!

    The body needs oxygen to survive so theheart works harder to deliver oxygen. Thisputs smokers at greater risk for havingheart attacks.

    CO is an odorless and colorless gas andeven though you cant see it, smell it, ortaste it, it can kill you. This is the reasonwe have C

    O detectors in our homes.Environmental safety literature states thatCO readings above 36ppm pose seriousdangers to health and would evacuatebuildings at this level.

    Over 40 Severe Dangertakeimmediate action

    Great News: If you quit smoking, yourCO level will go back down to 0 and

    you will begin to feel better. You willbe at the level of someone who neversmoked. Your heart and lungs willbenefit immediately and you will feelbetter.

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    Give the client directions and reassure them that once youbegin you will remind them as they go along.

    Sit up straight in the chair with both feet flat on the floor.

    When I say go, you will take a deep breath and hold it for 15seconds. The machine will help you count down for 15seconds.

    When it gets to zero, close your lips tightly around thecardboard tube and blow out (exhale) into the tube for aslong as you can.

    Do not blow too hard or it can affect the reading by

    disengaging the valve pin in the meter; just breathe outgently.

    View output number and explain the reading to your client.

    Actively smoking

    Not thinking of making a change

    In denial, maybe angry, defensive

    I am not ready.I dont want to quit smoking.Im only here because my

    Look to provide multiple interventions vs. single-episodetreatment

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    Weighing the costs versus the benefits of smoking andidentify the ambivalence and move in the direction ofpositive change.

    What are the good things about using cigarettes and whatare the not-so- ood thin s?

    When you look at this list of pros and cons, what do youthink?

    What do you enjoy most about smoking?

    How might your life be better if you stopped?

    Benefits of continuing to use tobacco Benefits of becoming tobacco free

    Help Client Understand Their Own Reasonsfor Smoking or Not Smoking

    Costs of continuing to use tobacco Costs of giving up tobacco

    Still smoking- Ambivalent about stopping

    Thinking of making a change

    May look for the magic bullet cure

    aug t etween es re to stop an ear o stopp ng

    Feeling a sense of loss

    Could become stuck in this stage

    Assist them in finding alternative strategies

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    Who in your life close to you uses tobaccoproducts and how will their use effect yourquitting?

    How does others in your life feel about yourtobacco use?

    Who can be supportive to you in your quittingprocess? (Not every non-smoker is supportive)

    Whom do you know may potentially sabotageyour plans to quit?

    How important is it for you right now tochange your use of tobacco?

    On a scale of 0 to 10, what number would you give yourself?

    .....not at all extremelyimportant important

    A. Why are you at ___ and not at 0?

    B. What would need to happen for you to get from _ to __?

    How confident are you right now to changeyour use of tobacco?

    On a scale of 0 to 10, what number would you give yourself?

    0 ....10not at all extremelyconfident confident

    A. Why are you at ___ and not at 0?

    B. What would need to happen for you to get from _ to __?

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    Relevance: How relevant to the tobacco user is quitting?

    Risks: What are potentials risks from tobacco use?

    Roadblocks: What are their personal obstacles to quitting

    Repetition: Needed to facilitate change

    Still smoking

    Wanting to make a change

    Has significantly resolved ambivalence

    Motivated to stop

    Ma tr to make smaller chan es reducincpd, a day tobacco free)

    Willing to set a quit date

    Preparing behaviorally, emotionally, and

    physically to stop smoking Assist with disarming triggers and cues

    Restricting smoking no longer smoking in thecar, or in your home only going outside maybe even for a walk

    Substituting NRT for a cigarette -could useNRT gum or lozenge

    Could also try going to Nic-A

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    Setting a Quit Date

    Talk to family and friends let them know you a re quittingtobacco products

    Anticipate for setbacks

    Remove all paraphernalia from the home, cars, etc.

    Talk to your doctor about NRT

    Stopped smoking

    Smoker who is not smoking

    Experiences desire to return to use

    Follows concrete Stop Smoking Plan

    Uses resources (Nic-A, 12 Steps, Group)

    Use of NRT and/or Zyban

    Practice the 4-Ds:

    Delay

    eep rea e

    Drink water

    Do something different

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    Can identify relapse triggers and specificmeasures to cope with those triggers

    Having made the change in behavior

    And has incor orated into self

    Im an ex-smoker. It was tough, but it was worth it.

    Smoking is not an option

    I cant have just one

    Can occur anywhere along the recovery continuum,even after a period of abstinence

    Is marked by a return to pattern of thoughts &behaviors associated with a previous stage

    Return to ambivalence & conflicts

    Loss of interest, commitment, motivation

    A return to a previous stages thoughts or behaviors

    You know, I thought I was ready but

    Make an appointment to talk aboutquitting, including treatment options

    Support the development of supportgroups here and in the community

    LAHL, Quitters group, Nic-A

    Become aware of other resources at cityand state level

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    Tailor treatment to the individual

    Different recovery for different clients

    Evaluate current motivation

    Match treatment to stage of motivation

    Consider phases of treatment

    Express Empathy

    Develop a Discrepancy

    vo rgumen a on

    Roll with Resistance

    Support Self-Efficacy

    Use your OARS

    Open-ended questioning

    Affirmation

    Reflective listening

    Summarizing

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    Desire: I want to change.

    Ability: I think I can do it.

    eason: can n s sc oo o

    Need: I cant go on this way

    Commitment: I will do whatever it takes

    Link with other recoveries and behaviors

    Impact on medical conditions

    Effects on socialization

    Financial costs of tobacco use

    Carbon Monoxide reading and feedback Very impactful on clients Reality of daily impact of the behavior

    Overall goal: gain knowledge and live a healthier lifestyle

    Group facilitation, educational and motivational based

    Role-plays, examples, assessment questions

    ,

    Developed to help smokers at any motivational level to quit

    Group I: LAHL for lower motivated

    Group II: Quit Smoking for more motivated

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    Can be used in a variety of clinical settings

    Inpatient or outpatient

    Clients can advance from Group to Group

    Learn about related issues:

    , ,

    Sessions:

    Individually or collectively

    Risks associated with smoking, cigarette contents,

    benefits of quitting, ways to quit smoking, CO testing etc.

    Learn about related issues: Nutrition, physical activity, and stress management

    Available for download:http://rwjms.umdnj.edu/addiction/documents/2012lahl.pdf

    Steinberg, M.L., Ziedonis, D.M., Krejci, J.A., and Brandon, T.H. MotivationalInterviewing With Personalized Feedback: A Brief Intervention for Motivating Smokerswith Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consultingand Clinical Psychology 72(4):723-728, 2004.

    Ziedonis, D.M., Williams, J.M., Steinberg, M., Foulds, J. Addressing tobacco addiction inoffice-based management of psychiatric disorders: practical considerations. PrimaryPsychiatry13(2):51-63, 2006.

    Boudreaux E.D., Baumann, B.M., Firedman, K., Ziedonis, D.M. Smoking stage of- .

    Emergency Medicine 12(3): 211-218, 2005

    Sobell, L.K. and Sobell, M.B. Group Therapy for Substance Use Disorders: AMotivational Cognitive-Behavioral Approach. New York ,NY: Guilford, 2011.

    Toolkits for clinicians from The Alliance for the Prevention and Treatment of NicotineAddiction (APTNA): www.aptna.org/APTNA_Prov_Toolkits.html

    Treating Tobacco Use and Dependence - Public Health Service Clinical PracticeGuideline (2008) Update:http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf