Heather Osterberg-Aloi, MS, CTTS-M Senior Program Specialist

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Participants will learn how to assess motivation to quit tobacco use. Participants will learn specific treatment strategies that match the clients motivational level, including precontemplation, contemplation, preparation, action, and maintenance levels. Participants will learn how to integrate motivational interviewing style and identify teachable moments to provide personalized feedback with clients. Participants will learn specific content that could be integrated into patient education activities.

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In collaboration with the client, identify specific and measurable treatment objectives. Plan individualized treatments that account for patient assessment factors identified during the intake assessment and history gathering.

Collaboratively develop a treatment plan that uses evidence-based strategies to assist the client in moving toward a quit attempt, and/or continued abstinence from tobacco.

Preparation

Assessment
Tobacco Use History Dependence Level Motivation for change

Help them understand their tobacco use and the process of quitting
Bolster their motivation

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. 2. 3.

Ask about tobacco use at each visit Advise tobacco users to quit Assess willingness to quit

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Assist tobacco users to quit

Arrange for follow-up

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? How soon to daily use? 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 of carbon monoxide in your body. My CO reading is: __________ One of the most deadly chemicals found in cigarettes smoke is carbon monoxide (CO).

0-8: Normal to very low smoking or second hand smoking 8-12 Worryyou are affecting your health 12-25 Cause for alarmyou are harming yourself 25-40 Danger or hazard to you health Over 40 Severe Dangertake immediate action Great News: If you quit smoking, your CO level will go back down to 0 and you will begin to feel better. You will be at the level of someone who never smoked. Your heart and lungs will benefit immediately and you will feel better.

When you smoke, you replace oxygen with carbon monoxide in your blood. YOU ARE POISIONING YOURSELF!
The body needs oxygen to survive so the heart works harder to deliver oxygen. This puts smokers at greater risk for having heart attacks. CO is an odorless and colorless gas and even though you cant see it, smell it, or taste it, it can kill you. This is the reason we have CO detectors in our homes. Environmental safety literature states that CO readings above 36ppm pose serious dangers to health and would evacuate buildings at this level.

Give the client directions and reassure them that once you begin 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 15 seconds. The machine will help you count down for 15 seconds. When it gets to zero, close your lips tightly around the cardboard tube and blow out (exhale) into the tube for as long as you can. Do not blow too hard or it can affect the reading by disengaging the valve pin in the meter; just breathe out gently.

View output number and explain the reading to your client.

Actively smoking Not thinking of making a change In denial, maybe angry, defensive Rationalizes consequences
I am not ready. I dont want to quit smoking. Im only here because my

Look to provide multiple interventions vs. single-episode treatment

Weighing the costs versus the benefits of smoking and identify the ambivalence and move in the direction of positive change. What are the good things about using cigarettes and what are the not-so-good things? When you look at this list of pros and cons, what do you think? What do you enjoy most about smoking? How might your life be better if you stopped?

Help Client Understand Their Own Reasons for Smoking or Not Smoking

Benefits of continuing to use tobacco

Benefits of becoming tobacco free

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 Caught between desire to stop and fear of stopping

Feeling a sense of loss

Could become stuck in this stage

Assist them in finding alternative strategies

Who in your life close to you uses tobacco products and how will their use effect your quitting? How does others in your life feel about your tobacco use? Who can be supportive to you in your quitting process? (Not every non-smoker is supportive) Whom do you know may potentially sabotage your plans to quit?

How important is it for you right now to change your use of tobacco?
On a scale of 0 to 10, what number would you give yourself? 0 .....10 not at all extremely important 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 change your use of tobacco?
On a scale of 0 to 10, what number would you give yourself? 0 ....10 not at all extremely confident confident A. Why are you at ___ and not at 0?

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

Relevance: How relevant to the tobacco user is quitting? Risks: What are potentials risks from tobacco use? Rewards: What are the benefits of quitting?

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 May try to make smaller changes (reducing cpd, 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 the car, or in your home only going outside maybe even for a walk Skip a cigarette

Substituting NRT for a cigarette -could use NRT gum or lozenge Could also try going to Nic-A

 Setting a Quit Date Talk to family and friends let them know you are quitting
tobacco 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 Deep breathe

Drink water Do something different

Can identify relapse triggers and specific measures to cope with those triggers Having made the change in behavior

And has incorporated 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 about quitting, including treatment options Support the development of support groups here and in the community LAHL, Quitters group, Nic-A Become aware of other resources at city and state level

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 Avoid Argumentation

Roll with Resistance Support Self-Efficacy

Use your OARS Open-ended questioning

Affirmation
Reflective

listening

Summarizing

Desire: I want to change. Ability: I think I can do it. Reason: I can finish school if I do it

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

Open ended format, rolling admission

Developed to help smokers at any motivational level to quit

Group I: LAHL for lower motivated Group II: Quit Smoking for more motivated

Can be used in a variety of clinical settings Inpatient or outpatient Clients can advance from Group to Group Learn about related issues:

Nutrition, physical activity, and stress management 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. Motivational Interviewing With Personalized Feedback: A Brief Intervention for Motivating Smokers with Schizophrenia To Seek Treatment for Tobacco Dependence. Journal of Consulting and Clinical Psychology 72(4):723-728, 2004. Ziedonis, D.M., Williams, J.M., Steinberg, M., Foulds, J. Addressing tobacco addiction in office-based management of psychiatric disorders: practical considerations. Primary Psychiatry 13(2):51-63, 2006. Boudreaux E.D., Baumann, B.M., Firedman, K., Ziedonis, D.M. Smoking stage of change and interest in any emergency department-based intervention. Academic Emergency Medicine 12(3): 211-218, 2005 Sobell, L.K. and Sobell, M.B. Group Therapy for Substance Use Disorders: A Motivational Cognitive-Behavioral Approach. New York ,NY: Guilford, 2011. Toolkits for clinicians from The Alliance for the Prevention and Treatment of Nicotine Addiction (APTNA): www.aptna.org/APTNA_Prov_Toolkits.html Treating Tobacco Use and Dependence - Public Health Service Clinical Practice Guideline (2008) Update: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf