GEORGETOWN UNIVERSITY School of Nursing & Health Studies TOBACCO CESSATION SESSION GUIDELINE SUGGESTIONS: Introduction for First

Session (10-15 minutes MAX): WELCOME to TCP .we are thrilled that you have made this important decision to quit smoking. INTRODUCTION of SELF ..I am ___ I work as a ___ at ___ AND I am a NON-SMOKER who is committed to promoting health and wellness for all. I enjoy helping others learn how to live healthy lives.I was a smoker in grad school..OR although I have never had to struggle with the problem of tobacco use, I have struggled with weight problems.so I know the difficulty of CHANGING a behavior AND look forward to sharing with you my experiences to be successful and you will find we will learn from each other as well INTRODUCTION of OTHERS ..ask to state name, where from, and what motivated them to come to the TCP FORMAT FOR EACH SESSION: review dates and times of sessions, emphasize each session will allow (1) 30-40 minutes for group discussion -how everyone doing since last session (2) 50 minutes to discuss strategies and information to help quit smoking (3) 20 minutes to review and allow open discussion about information discussed, and (4) 10 minutes to cover assignments for the following week
o o o o 1st SESSION OBJ = understanding why and how you smoke 2nd SESSION OBJ = managing the first few days of being smoke free 3rd SESSION OBJ = mastering obstacles to be smoke free 4th SESSION OBJ = staying smoke free and enjoying it forever

HOUSEKEEPING REMINDERS: bathroom location, water location, parking stickers, payment or paper work consideration if needed etc HOUSE RULES: o Important to stay POSITIVE, to attend ALL classes, to bring workbook every session, to complete workbook assignments and to stay committed to QUITTING o If paid and completed all classes AND relapse occurs, can return for FREE but must bring own materials o START THINKING OF YOUR QUIT DATEANY DAY STARTING NOW UP TO DAY BEFORE THE 3RD SESSION REVIEW ALA MATERIALS: encourage to do weekly assignments & listen to tape.our motto: all programs (ALA or ACS) are goodit is NOT THE PROGRAM but the INDIVIDUAL COMMITMENT that makes one successful to QUIT! Each time YOU quit = coming closer to a healthier life! PURPOSE OF TCP: To help YOU stop and stay off of cigarettes. We will address behaviors, thoughts and feelings that are relevant for smokers and we use group interaction to encourage and support change. If individual

appointments are needed for Rx intervention design, please let us know after the session.

First Session: OBJECTIVE: Understanding Why and How You Smoke

Individual attention Note, covered above Strategies & information Lets start with some facts about the nature of being hooked on cigarettes----as I talk about these concepts/topics think about how it relates to you REMIND ALA BROCHURE Facts about Cigarette Smoking NICOTINE DEPENDENCE/ ADDICTIONanswer these questions privately on a piece of paper (yes or no)----look at ALA workbook on addiction questionnaire o Do you smoke your 1st cigarette within 30 minutes of waking up o Do you smoke 20 cigarettes or more per day o At times when you cant smoke or havent go any cigarettes, do you crave them o Is it tough for you to keep from smoking for more than a few hours o When you are sick enough to stay in bed, do you still smoke o IF YOU ANSWER YES TO 2 OR MORE QUESTIONS HIGH PROBABILITY OF ADDICTION o Smoking is a habit to fill a need, an acceptance, a sense of belonging, a stress reducer, to control weight o Just think how many times you have lifted a cigarette to your mouth---this is a practiced habit----one pack per day x 20 years perhaps! This could equate to (CONSIDER WRITING ON BOARD): One cigarette = 10 inhalations 10 inhalations x 20 cigarettes per day = 200 practices 200 practices per day x 365 days per year = 73,000 practices 73,000 practices x 20 years = 1.5 MILLION TIMES YOU HAVE PRACTICED & STRENGTHENED YOUR SMOKING HABIT o The point of this exercise is that whether you have practiced this 1.5 million times or 1500 times, there is NO type of smoker (heavy or light) who cant be successful with quitting IF THEY JUST TRY AND DO IT PRACTICE! o But it is overwhelming because of the strong physiological need for nicotine----just like other addictive drugs as cocaine and heroin-your brain FEELS GOOD with it---so the 1st step to breaking free is to recognize this is an addiction! 2

PSYCHOLOGICAL REASONS FOR SMOKING o Smoking is an automatic habit-- you have learned to smoke o Most smokers know when they like to smoke: driving, drinking coffee, talking on the phone, having cocktails o Other smokers know that they like to smoke: to help cope with stress, deal with uncomfortable situations, relaxation, creativity o Other smokers know that they like to smoke: to deal with boredom, frustration, loneliness o WRITE DOWN PRIVATELY WHAT SITUATIONS OR ACTIVITIES IN WHICH YOU ARE LIKELY TO SMOKE AMBIVALENCE ABOUT STOPPING VERSUS SMOKING o You want to stop which is why you are here but you havent quit yet so you keep on smoking o Its not necessary to get rid of the desire to smoke before quitting BUT to decide what you want most: TO SMOKE OR TO STOP o Once you decide you want to quit more than you want to smokethe ambivalence is NOW changed into ACTION to STOP o ASK EACH PARTICIPANT to identify to the group what is ONE smoking trigger for them-----look at Pack Tracks in ALA workbook o ASK EACH PARTICIPANT to identify ONE benefit they hope to achieve by QUITTING

APPROACHES TO QUITTING o Many smokers quit through COLD TURKEY which is ABRUPT CESSATION o If smoking done gradually or tapering off that is not cold turkey o We recommend WHATEVER WORKS BEST FOR THE INDIVIDUAL! o We know that smoking lower nicotine/tar cigarettes often produces higher levels of chemicals like CO2 than high nicotine/tar cigarettes AND causes smokers to INHALE DEEPER AND MORE OFTEN o TYPES OF TAPERING APPROACHES if interested: Taper Approach = decrease number of cigarettes per day by 5 Note, evidence supports anything less than that is ineffective. RE: if smoke 30 per day, then plan 25/d, 20/d, 15/d, 10/d, 5/d THEN QUIT DAY Postponing Approach = delay time of day when start smoking by 2 hours RE: if start smoking at 7am q day, then start 9am, next day 11am, next day 1pm, next day 3pm, next day 5p, next day 7p, THEN QUIT DAY o TYPES OF NICOTINE REPLACEMENT THERAPY if interested:

NRT decreases cravingsyour body expects it and evidence supports that behavioral modification classes, such as our TCP, + nicotine replacement therapy (patch, gum, etc) + Zyban/Welbrutrin TRIPLES the success rate and decreases withdrawal symptoms OUR PURPOSE IS NOT TO GO INTO DETAILS ABOUT THESE AGENTS-THERAPIES BUT JUST TO LET YOU KNOW THEY ARE AVAILABLE AND FOR YOU TO DISCUSS THEM WITH YOUR HEALTHCARE PROVIDER OR ONE OF OUR TCP NPs (MUST MAKE INDIVIDUAL APPT) OTC NRT Gum / Nicrorette OTC NRT Patch / Nicoderm OTC NRT Lozenge / Commit Rx NRT Nasal Spray Rx NRT Inhaler Rx Zyban Accupuncture Hypnosis

PHYSIOLOGICAL EFFECTS OF SMOKING o There are 4000 chemicals in tobacco smoke that harm YOU and OTHERS o Causes increased risk for lung cancer, coronary artery disease, cerebrovascular disease, pulmonary infections and disease o Causes increased vasoconstriction resulting in increased HR, increased B/P, wrinkles and impotency o Show the POSITIVE effects of QUITTING smoking listed on our TCP promotional cards AFTER 20 MINUTES OF QUITTING, B/P DROPS, TEMPERATURE IN HANDS AND FEET INCREASES-ETC

Review & discussion This session we talked about why were smoking and the health effects associated with smoking We discussed that the FREEDOM from smoking will not be easy, BUT IT CAN BE DONEno matter if a heavy smoker or light smokerANYONE can quit if he/she keeps at it and practices to be smoke free! We discussed that there is NO SAFE cigarette, that smoking increases our HR and B/P and causes bad health effects We discussed that there are different methods to quit and different agents or therapies to help with the cravings ASK PARTICIPANTS IF QUESTIONS 4

Assignments By next week: identify your QUIT DATE, review pg 5 23, start pack tracks, complete pgs 19 & 23, & complete wallet card to carry Lets end my doing a RELAXATION TECHNIQUE- see attached guideline

Second Session: OBJECTIVE: Managing the First Few Days of Being Smoke Free
Individual attention ASK EACH PARTICIPANT to identify DATE TO QUIT ASK EACH PARTICIPANT to identify STRATEGY TO QUIT (cold turkey, NRT, tapering etc) ASK EACH PARTICIPANT to identify their thoughts/concerns about quitting Strategies & information Withdrawal Symptoms o Everyone reacts differently to nicotine withdrawal and these symptoms are mostly related to the chemical addiction described last week o The range of symptoms varies to no discomfort to mild discomfort to intense discomfort o The #1 MOST IMPORTANT thing to remember is that withdrawal symptoms are TEMPORARY ---usually disappearing within 1- 2 weeks. o The second MOST IMPORTANT thing to remember is that this is a NORMAL response for the body to repair itself and to return to a healthy state o Withdrawal symptoms include Craving an intense recurring hunger for a cigarette. Tension (the feel good drug not there) Tingling sensations in arms and legs (circulation returning!) Cough (cilia in lungs were paralyzed NOW returning!) Lightheaded or dizzy (oxygen regaining its normal supply, blood vessels re-dilating) Difficulty concentrating (oxygen regaining its normal supply; blood vessels re-dilating) SYMPTOMS THAT INTENSIFY OR DO NOT DISAPPEAR MAY BE RELATED TO SOMETHING ELSE; NOTIFY PROVIDER BEST WAY TO MANAGE CRAVING = The 4 Ds

o Deep breathing every time you want a cigarette, deep breathe 5 10 times! o Drink plenty of water flush out the toxins! o Do something- exercise, chew on a carrot or cinnamon stick call a friend for support o Delay--- the urge WILL pass HOLD ON for 5 minutes! Other TIPS to Success o Support system is crucialget friend/significant other to quit with you, call former smoker for support o Try to stay away from alcohol, sugar and coffee the first few days of quitting as these tend to stimulate the desire to smoke o Try to avoid high fatty foods as your metabolism will slow down without nicotine and you will have a tendency to gain weight (usually not more than 5 -10 lbs--- NOTE, gaining 10 lbs has less health risks than smoking) o Try to nibble on low calorie foods like apples, carrots, and celery sticks. Chew on gum and cinnamon sticks o Stretch out meals; eat slowly o Go to the gym and workout, sit in the stream, change normal routinewalk to work or jog in different area o Go to the spa or relax in a hot bath of bubbles o Think about reason for smoking (stress management) and apply assertiveness techniques (..speak up, short direct statements I think, I believe, In my opinion statements; ask for clarification and seek understanding; maintain eye contact; shake hands) and constructive thinking o ASK PARTICIPANTS ANY OTHER IDEAS TO HELP CRAVINGS (that they have tried or heard about) QUIT Day Preparation o Ask for support from co-workers. Tell them you are QUITTING and that you might be edgy or grumpy for a few days. TAKE A CHANCE, youll be surprised how supportive people can be! o Ask friends and family members not to smoke in your presence o On your quit day, hide ALL ashtrays and destroy ALL your cigarettes o Refresh car, clothes, and home so smoke free smell o On-line support can be found at www.quitnet.org where you can go to chat rooms as an additional source of support TIPS for Nicorette Gum Use o Do not smoke and chew o Chew one piece at a time, chew slowly until tingles in mouth (peppery taste) AND then park the gum between cheek and gum. When tingle is

gone, chew a few more times AND park it again. Repeat for 30 minutes to release most of nicotine o Wait 15 minutes after drinking before chewing the gum (improves absorption) o Usually requires 15 30 pieces per day to feel relief with withdrawal symptoms o Use DAILY for as long as it takes 3 6 months o Start weaning when your cravings decrease (cut down gradually try alternating with regular gum). When only chewing one or two pieces per day to stop using it. BUT carry nicorette gum for emergencies o Remember: CHEW IT RIGHT! CHEW ENOUGH! CHEW IT LONG ENOUGH! TIPS for Nicorette Patch Use o Remember: The patch is BETTER than smoking because it does not have the tar and other poisonous toxins/gases in it as cigarettes o Dont smoke and wear the patch o Can wear patch and chew gum at same time. Some individuals have stronger break through cravings and may require Rx nicotine nasal spray and/or inhaler o Apply to clean dry area and leave on as directed (most are 16 hour deliveries others are 24 hours) Identify YOUR Reward to Quit o ASK EACH PARTICIPANT TO CALCULATE THE COSTS OF THEIR SMOKING HABIT o ASK EACH PARTICIPANT identify ONE treat that they are going to buy themselves or treat they are going to give themselves when FREEDOM from smoking occurs

Review & discussion Know your plan for support Know your plan for CRAVINGS---the 4 Ds Know your plan for creating and maintaining a smoke-free environmentwhat makes you smoke Know your plan to reward yourself for quittingASK PARTICIPANTS TO LIST X3 REWARDS ON PG 25 GUEST SPEAKER WHO IS A FORMER SMOKER (OR PANEL)

Assignments By next week: review pg 25 51, complete bottom half of pg 44, complete pg 45, circle 3-5 stress reducers youll commit to use (pg49 & 50). Start an exercise plan and start increasing water intake. Plus COMPLETE CONTRACT AND START USING ALA STICKERS ON CALENDAR TO HELP STICK WITH QUIT DATE---listen to tape! Lets end my doing a RELAXATION TECHNIQUE- see attached guideline

Third Session: OBJECTIVE: Mastering Obstacles to Remain Smoke Free

Individual attention Congratulate group for QUITTING! Encourage those that slipped to try quitting again! ASK EACH PARTICIPANT to discuss what it has been like since they QUIT smoking ASK THOSE PARTICIPANTS THAT SLIPPED to discuss their relapse situation/trigger Strategies & information Physical Improvements o Some participants will be experiencing withdrawal symptoms and others will be enjoying benefits of QUITTING. o ASK PARTICPANTS who is already feeling better as a result of QUITTING-----anyone experiencingIncreased energy? Easier breathing? Improved taste and smell? Refer to benefits of health on back of our TCP promotional card ASK PARTICIPANTS WHAT COPING STRATEGIES THEY HAVE USED TO HELP WITH CRAVINGS Weight Gain o WHY some smokers gain weight after QUITTING Feel a need to put something in mouth to replace cigarettes

Decide to treat yourself by indulging in extra food as a reward for QUITTING Sense of taste and hence pleasure in eating is improved Overall health improved so that increases appetite Low Calorie Snacks o Stick with cinnamon/peppermint to put in mouth instead of chocolate o Nimble of healthy snacks: carrots, celery, non-butter popcorn Eat slow increase water intake o Exercise Start slow and build up tolerance Discuss exercise options Alcohol o The bond of drinking and smoking is by habit. o Alcohol is a depressant whereas nicotine is a stimulant o Most smokers feel stronger to resist the temptation to smoke if avoid alcohol o Prepare in your mind in advance how you will handle the pauses in conversation at parties because not smoking o Prepare in your mind in advance what to say if offered a cigarette Interpersonal Support o You have already accomplished a SIGNIFICANT goal; you have gone at least 48 hours without smoking --- some may have gone even one week o IF SLIPS dont blame yourself or feel guilty instead re-group AND thank for coming back to get focused again --- ask to identify what needs to be done differently in their plan--- you can learn from your mistakes and go back to being smoke free o REMEMBER your interpersonal support --- yes, successful ex-smokers do it on their own BUT it is helpful to obtain support during difficult times o Share your bad times and good times about smoking with people who will be constructive and supportive o Constructive and supportive individuals = (1) individuals who will NOT encourage you to take the easy way out and return to smoking, (2) individuals who will NOT call attention to your increased irritability, and (3) individuals who will NOT criticize if relapse occurs but will encourage to get back on the right track

Review & discussion ASK PARTICIPANTS to discuss strategies for the following situations: o Role-playing: How to say No to cigarettes RE; A co-worker is smoking tries to get you to smoke a low tar and low nicotine cigarette The passive response

 The aggressive response The assertive response o Role playing: Your boss yells at you at work The passive response The aggressive response The assertive response o Role playing: A friend says too bad now youre gaining weight The passive response The aggressive response The assertive response Assignments KEEP UP THE GOOD WORK AND REMAIN SMOKE FREE REMIND ABOUT ALA BROCHURE Control Your Weight By next week: review pg 51-60 --- listen to ALA tape If slipped, complete pg 42-43 and RE-NEW contract Lets end my doing a RELAXATION TECHNIQUE- see attached guideline

Fourth Session: OBJECTIVE: Staying Smoke Free and Enjoying it Forever

Individual attention CONGRATULATE all participants on their success. Be positive in encouraging any smoker who has not yet stopped --- help determine what issues remain as a possible stumbling block for them ASK PARTICIPANTS to discuss their experience of being smoke free for almost TWO weeks Strategies & information Benefits of Stopping Smoking o Discuss the ripple benefits of QUITTING o RE: things that are unexpected such as feeling proud of QUITTING and experiencing increased self-esteem o RE: becoming more assertive since QUITTING so that more outgoing and finding more pleasure in social situations o RE: energy level increased such that new activities enter life (new sport new hobby, more community service, etc) Avoiding Relapse

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o Planning ahead to avoid RELAPSE is essential o The cigarette crisis or emergency: RE: death in family.other people wanting to comfort may want to offer a cigarette. o The way to plan ahead is to think NOW of the reasons YOU would not want to return to smokingeven in crisis. Such as, no matter how bad things are, smoking will only make them worse o ASK PARTICIPANTS to PRIVATELY think of the strongest reason for never wanting to smoke again. Then ask to write it down and put in their wallet card and carry it with them. When the crisis occurs or temptation occurs, pull it out! o Another reason for relapse --- you feel so good smoke free and think one wont hurt me --- avoid the one cigarette and you will avoid all the others! o Review TIPS for managing stress and controlling weight Long-Term Benefits of QUITTING o The health benefits will continue to increase o Smokers cough or chronic bronchitis will disappear, risk for heart disease, emphysema, and various cancers will continue to decrease over time UNTIL eventually they have NO MORE RISK for these diseases than a NON-SMOKER o Finally if they are saving the money they used to spend on cigarettes, their savings will continue to grow as the price of cigarettes (and taxes) continue to rise

Passive Smoking and CLEAN AIR o Three fourths of all adults in the U.S. are NON-SMOKERS--congratulations, you have now joined the majority o We encourage you to be active in championing the protection of nonsmokers --- being around nonsmokers reinforces your NEW behavior! Tobacco Industry Advertisement o Remember BIG TOBACCO wants you to go back to smoking. Dont be misled by their advertisement. Their ads like to show the lives of beautiful and cool people smoking BUT remember to ask how cool and beautiful are those lives if you are a slave to a habit. Follow-Up o Remind calls will be placed to each participant 2 weeks from today, 6 months, and one year Review & discussion Encourage participants who did not quit that many successful ex-smokers have a history of failed attempts before they FINALLY SUCCEED! ASK PARTICIPANTS TO REVIEW THEIR REWARD LIST & DISCUSS HOW THEY ARE GOING TO CELEBRATE! Assignments CELEBRATE and remind to call faculty at TCP should they have nay questions or want to refer OTHERS or register for next session 11

REMIND ABOUT ALA BROCHURES Facts about Secondhand Smoke and Helping a Friend Quit Remind if paid and completed all classes AND relapse occurs, can return for FREE but must bring own materials ASK PARTICIPANTS TO Complete & TURN IN TCP Evaluation ( pg 67 IF NOT TORN OUT IN ADVANCE) WHILE YOU SIGN THEIR CERTIFICATES IF NOT DONE IN ADVANCE Distribute ALL-STAR PINS and CERTIFICATE OF QUITTING

Deep Breathing and Muscle Relaxation MEDITATION CLOSING EXERCISE

Learning and practicing relaxation techniques is one way to reduce feelings of stress. Deep breathing relaxation is the most effective in managing the stress response. Deep relaxation results in decreased heart and respiration rates, blood pressure, and muscle tension. With continued practice, deep relaxation can improve your sense of well-being and ability to cope with becoming SMOKE FREE. Sit comfortably and place one hand on chest and one hand on stomach. Take in a slow deep breath and feel your chest and abdomen expand, hold it for a second or two, then let the air out slowly and feel your chest and abdomen go back to its original position. Repeat taking deep inspirations through nostrils for the count of 5 and slow expirations through pursed lips for the count of 5 with a slight pause in between each breath. Closing your eyes while you are deep breathing will relax you even more. Everyone can turn their chairs around and face the wall to avoid eye contact with the group. Concentrate on your breathing, feel your chest and stomach expand as you breathe in nice and slow and deep. Breathe in through your nose and out through your lips. Nice and slow and deep.

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With eyes closed and thoughts to yourself, take a deep breath in, as you exhale, relax the muscles in your body and let the tension escape from you and say to yourself I WILL BE A NON-SMOKER, I have control over this I want my lungs to feel better & my heart to be stronger AND the air for others & myself to be healthier. Breathe nice and slow and deep to release the tension and say to yourself I CAN QUIT, I have control I am worth it, the best there is to be for me is to QUIT Think of your lungs becoming clear, breathing in nice and slow and deep and say to yourself I CAN QUIT, I have control Im not going to let nicotine ruin my life. Think about the smells of your favorite things that will return when you QUIT smoking the sweet smell of freshly cut grass, clean clothes, or spring flowers Breathe in and out and say to yourself I WILL BE A NON-SMOKER, I have control. I CAN DO THIS & WILL DO THIS because it is important to me. Continue to deep breathe for the count of 5 1,2,3,4,5 stretch your arms up and deep breathe for the count of 5 1,2,3,4,5 --bring your arms down and deep breathe for the count of 5 1,2,3,4,5. Now as youre ready open your eyes, feel relaxed and in control, you are closer to your day of better HEALTH and FREEDOM from smoking.

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