TFF Web 2015 11 20

TOBACCO AS A VITAL SIGN
The Tobacco Free Futures guidelines provide health care providers and teams with an overview of the
knowledge, skills and resources to address a major crippler and killer: tobacco dependency. With the
publication of the 2014 Surgeon Generals Report: The Health Consequences of Smoking50 Years
of Progress, tobacco reduction efforts mark an important milestone: it has been a half century since the
1964 U.S. Surgeon Generals Report on Smoking and Health first warned of the health consequences
of tobacco use. Although great gains have been made, the 2014 report reaffirms that tobacco use and
exposure continues to take a toll on the population that we care for. Tobacco use and exposure still kills
at least one in two of its regular users and is responsible for 30% of all cancer-related deaths in Alberta.
It is important that we recognize tobacco use is as important a vital sign as blood pressure or heart rate
in assessing someones health.
Creating Tobacco Free Futures: Albertas Strategy to Prevent and Reduce Tobacco Use 20122022
clearly identifies tobacco reduction as a priority for our province. The four strategic directions
(prevention, protection, cessation and knowledge translation and capacity building) offer a
comprehensive approach to reducing tobacco use and exposure. We have seen the provincial
prevalence of tobacco use fall from 36% in 1985 to 17.7% in 2011 (as defined by current smokers).
Unfortunately, the risk reduction and health improvement has not been shared uniformly across the
Alberta population. There are communities and specific populations where the use of tobacco remains
over 40%.
Tobacco use continues to shorten lives and cause premature disability. In Alberta, the costs of treating
tobacco-related illness alone are estimated to be $470.6 million per year. We have the necessary
knowledge and tools to help our patients and clients with their tobacco dependency, if we are only
prepared to use them.
Offering tobacco treatment as a standard of care requires changes to our systems to support all
tobacco users. The starting point is having health care providers prepared to ASK every patient/client
who presents in a health care setting if they use tobacco, ADVISE all tobacco users to quit, ASSESS
their readiness to quit and interest in withdrawal support, ASSIST by providing pharmacotherapy and
behavioural support and ARRANGE ongoing support.
Funding from the Alberta Cancer Prevention Legacy Fund (ACPLF) for 20102014, along with support
from the Canadian Cancer Society, has enabled the development of the Tobacco Free Futures
guidelines and supplementary resources. These tools have been developed through a collaborative
process, with contributions from many individuals and groups from across the province who have
shared their time and wisdom to inform and validate the final products. The 2014 guidelines and tools
have gone through an extensive revision and new content has been added. New chapters continue
to address implementation in a variety of care settings and with specific populationsfor example,
the unique challenges of addressing tobacco with clients who face other addictions and mental health
conditions.
With the ACPLF funding ending in September 2014, Tobacco
Free Futures has been incorporated within the range of
services offered by Alberta Health Services (AHS) to Albertans.
The Tobacco Reduction Program will work with health care
facilities and programs across the province to help join those
who have already implemented the innovation. Together we
can realize the goal of providing a seamless and integrated
system of support for all Albertans who are affected by the use
of tobacco products.
I hope you will take up the challenge and become a champion
for implementing the Tobacco Free Futures model in your
health care setting.
Sincerely,
Brent Friesen MD FRCPC

Medical Officer of Health
AHS Tobacco Reduction Program
Alberta Health Services 2014
Disclaimer
Every effort has been made to ensure the links in this document are up to date; however, we
cannot guarantee they will work. Some links will give error messages because of the security
settings on the source files. These files are accessible to AHS staff only. AHS staff can
access the documents by copying and pasting the link into their browsers.
Copyright
Copyright 2014. Alberta Health Services. All rights reserved. Alberta Health Services
cannot guarantee the validity of the information contained in these guidelines. No part of this
document may be reproduced, modified or redistributed in any form without the prior written
permission of Alberta Health Services.
ii
Tobacco Free Futures
Contents
Opening message: Tobacco as a vital sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Introduction
1. Tobacco Free Futures: A systems change management model . . . . . . . . . . . . . . . 1.1
Supporting cessation in health care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2
Alignment with strategic priorities and policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6
Site/program implementation of Tobacco Free Futures . . . . . . . . . . . . . . . . . . . . . . . . 1.11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.12
2. The effects of tobacco exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1
Tobacco facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9
Initial planning
3. Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1
Leadership support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5
4. Tobacco Free Futures site steering committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1
Forming a multidisciplinary committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2
Tobacco Free Futures workshop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4
5. Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1
Tobacco-free environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2
AHS Tobacco and Smoke Free Environments Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2
TSFE policy protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3
Use of tobacco-like products on AHS property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5
TSFE policy-supporting resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.9
6. Timelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1
Purpose of timelines and schedules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2
Creating an implementation timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8
iii
Resource and support planning

7. Brief intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1
Tobacco cessation support models for health care settings . . . . . . . . . . . . . . . . . . . . . . 7.2
Brief tobacco intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3
Brief tobacco intervention staff roles and documentation . . . . . . . . . . . . . . . . . . . . . . . . 7.8
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.9
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.10
8. Intensive cessation counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1
Guidelines for intensive cessation support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2
Transtheoretical model of change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4
Clients not yet ready to quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.5
Clients ready to quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9
Clients who have recently quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.12
Staff roles and documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.15
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.16
9. Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1
Pharmacotherapy treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.2
Assessing nicotine withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.10
Pharmacotherapy staff roles and documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.13
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.14
Preparing staff
10. Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1
Introduction to the Tobacco Free Futures site communications plan . . . . . . . . . . . . . . 10.2
Communications for initial engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4
Preparing staff for implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.5
Site-wide awareness of program and supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.7
11. Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1
AHS tobacco treatment training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2
AHS site capacity-building training and education . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.9
iv
Final Planning
12. Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1
Sustaining Tobacco Free Futures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.6
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.7
13. Continuous improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1
Introduction to quality improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2
Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2
Performance measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3
Quality improvement using the AHS Improvement Way . . . . . . . . . . . . . . . . . . . . . . . . 13.4
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.6
Specific care settings
14. Surgical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1
Addressing tobacco use in surgical care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.5
15. Emergency and urgent care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1
Addressing tobacco use in emergency and urgent care . . . . . . . . . . . . . . . . . . . . . . . . 15.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.5
16. Home care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1
Addressing tobacco use in home care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.6
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.7
17. Public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.1
Addressing tobacco use in public health settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.12
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.14
18. Transition and community care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1
Implementation of Tobacco Free Futures in transition and continuing care . . . . . . . . . 18.2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.13
Specific Populations
19. Addiction and mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.2
Tobacco treatment recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5
Alzheimers disease and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.8
Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.11
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.12
Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.13
Substance use disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.17
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.21
20. Reproductive years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.2
Women and girls of reproductive age (not pregnant or breastfeeding) . . . . . . . . . . . . . 20.4
Pregnant and postpartum women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.9
Pregnant and postpartum adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.32
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.35
21. Youth and family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (under development)
22. Adults with cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.2
Tobacco Treatment Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.6
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.13
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.16
vi
Introduction
1. Tobacco Free Futures: A Systems Change
Management Model
2. The Effects of Tobacco Exposure
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Introduction
The Tobacco Free Futures guidelines describe an integrated health system tobacco
cessation model that is based on best practices. These guidelines were developed
as a resource for managers, tobacco steering committee members and other health
professionals to assist healthcare sites/programs implement the tobacco cessation
support model. The resource and accompanying tools (see appendices) have been
written and developed based on the organizational context of Alberta Health Services
(AHS). This introductory section includes two chapters that will provide the background
information for the sections that follow.
Chapter 1: Tobacco Free Futures:

A Systems Change Management Model

Background information about the development of the Tobacco Free Futures

initiative.
An overview of a systems approach for tobacco cessation treatment.
Highlights of the national CAN-ADAPTT smoking cessation guidelines.
Alignment with strategic priorities in the Alberta Health Services context.
Summary of the phases and processes for implementation of the Tobacco Free
Futures initiative.
Chapter 2: The Effects of Tobacco Exposure

Review of key health consequences related to tobacco exposure.
Types of tobacco commonly used in Alberta.
Review of the psychological and physiological effects of nicotine.
An overview of the impact of environmental exposure to tobacco.
The health benefits of tobacco cessation.
Chapter 1
Tobacco Free Futures:

A Systems Change
Management Model
1.1
SUPPORTING CESSATION IN Health care SETTINGS

The Tobacco Free Futures initiative
Tobacco Free Futures is an integrated health systems
tobacco cessation model that was developed for the Alberta
Health Services (AHS) context. The initiative is grounded in
the available literature, including established national and
international guidelines, and offers anintegrated level of
cessation support for Albertans who use tobacco products.
The aim of the model is to help decrease tobacco use
and support the Alberta Cancer Prevention Legacy Funds
vision of preventing cancer through innovative research
andprevention strategies.
The Canadian Cancer

Society reports that the
use of tobacco products
is responsible for about
30% of all cancer deaths
in Canada.1
Tobacco Free Futures was developed to support AHS systems change related to tobacco
cessation treatment, providing guidance and standardized resources that can support
adopting tobacco treatment as a standard of care. Tobacco interventions can range from
brief intervention (the 5 As model: ASK, ADVISE, ASSESS, ASSIST and ARRANGE) to
moreintensive treatment and can be delivered across the continuum of care.
This Alberta-based initiative was developed through a collaborative process, with
contributions from individuals and groups from across the province. It has been heavily
informed by the Canadian Action Network for the Advancement, Dissemination and Adoption
of Practice-Informed Tobacco Treatment (CAN-ADAPTT), led by the Centre for Addiction and
Mental Health (CAMH) in Toronto, and by the Ottawa Model for Smoking Cessation from the
Ottawa Heart Institute.
Tobacco Free Futures was funded for 20102014 through the Alberta Cancer Prevention
Legacy Fund (ACPLF). Targeted funding allowed for the development of provincial standards
of care, practice guidelines, documentation standards (paper and electronic), training and
supplementary resources.
To date, the initiative has been implemented in many care settings across the province,
including urban inpatient acute care, rural inpatient acute care, addictions detoxification
andresidential treatment, public health programs, home care, continuing care and
outpatientservices.
1.2
Figure 1.1: Tobacco Cessation Linked System of Support
Community
Resources
Healthy public policy
Supportive environments
Partnerships
Referrals
Patient/client
self-management
Informed,
engaged
patient
Ask
Advise
Health care Setting

Integrated tobacco support
Multidisciplinary
team to support
treatment
Assess
Evidence-based
guidelines and
education
Assist
Arrange
Information
system to support
treatment
Prepared,
proactive health
care team
Adapted by Tobacco Free Futures from the Chronic Care Model (Wagner et al., 2002) 12
A systems approach for effective tobacco treatment

The framework in Figure 1.1 is an adaptation of Wagner et al.s Chronic Care Model (2002).
Itillustrates how a linked system of support from community members across the continuum
of care can positively impact the treatment of tobacco dependence and nicotine addiction.2
This framework views the health system as part of a larger
Tobacco use is not a
community. Effective tobacco dependence and nicotine
addiction management requires an appropriately organized
lifestyle choice. It is a
health care system that has access to necessary resources
chronic ,relapsing condition
available in the broader community. The health system must
grounded in an addiction
have in place the leadership, supports and resources required
tonicotine.3
to meet the needs of patients who use tobacco products.2,4
These factors support the development of informed, engaged
patients as well as prepared, proactive health care teams. Preparation means having the
necessary skills, expertise, information, time and resources to assure effective treatment.2
1.3
The middle section of the framework represents the enhancements that contribute to
productive interactions between providers and patients.

Patient/client self-management: empowering patients with the information and

confidence to make the best use of their involvement with their health care team.
Multidisciplinary team: meeting the needs of patients who require more time, a
broader array of resources and closer follow-up.
Evidence-based guidelines: using explicit plans and protocols.
Education: providing training and decision support through guidelines and other tools.
Information systems: supporting population-based care, including provider reminders

and feedback.
The 5As model, used between the health care team (in a variety of settings) and the client,
assures the delivery of services that will improve tobacco treatment outcomes. Desired
outcomes of tobacco treatment include measures of clinical care, health status, satisfaction,
health care usage and cost.2
CAN-ADAPTT smoking cessation guidelines

The Canadian Action Network for the Advancement,
Dissemination and Adoption of Practiceinformed Tobacco
Treatment (CAN-ADAPTT) completed a literature review and
developed a set of practice-informed and evidence-based
smoking cessation practice guidelines that are intended
for use by Canadian health care providers in a variety of
settings.4
CAN-ADAPTT guidelines advocate for the 5 As model as
a basis for intervention for all health care providers. They
also provide direction for the care of specific populations,
including Aboriginal peoples, hospital-based populations,
people with mental health or addictions concerns, pregnant
and breastfeeding women, and youth (children and
adolescents).4 These guidelines informed the Tobacco
Free Futures initiative. For more information about the
CANADAPTT guidelines, see Table 1.1.
1.4
CAN-ADAPTTs vision is
a Canada where health
care providers have
access to the tools needed
to deliver up to date
evidencebased smoking
cessation interventions
to reduce the prevalence
of tobacco use and
dependence.4
Table 1.1: CAN-ADAPTT Guidelines for General and Hospital-Based Populations5

Hospital-based populations
Facilities should have systems in place to
ask every patient/client about his or her

tobacco use and update that status on a
regular basis
Grade 1A*
identify all tobacco users
clearly advise all patients/clients who use

tobacco to quit
Grade 1C
provide clear advice to quit
Grade 1C
ASSESS
Grade 1C
assess the willingness of patients/clients to

begin treatment to quit
Grade 1C
assess the willingness of patients/clients to

begin treatment to quit (or manage withdrawal)
Grade 1C
ASSIST
make patients/clients aware of

hospital tobaccopolicies
Grade 1A
offer assistance to every tobacco user who is

willing to begin treatment to quit
Grade 1A
assist with minimum brief intervention
Grade 1A
when possible, assist with
intensive counselling
Grade 1A
combine counselling and pharmacotherapy,
which are more effective than either one
on its own
Grade 1A
link all elective patients who use tobacco

to resources to help them quit before
admission orsurgery
Grade 1B
manage a clients tobacco
withdrawal during hospital stay,
including pharmacotherapy
Grade 1C
promote a clients attempts
towards quitting
Grade 1A
ARRANGE
ADVISE
ASK
General
Health care providers should
conduct follow-up, provide support and

modify treatment as necessary
Grade 1C
refer patients/clients to relevant
resources
Grade 1A
link patients to follow-up support upon

discharge
Grade 1A
arrange continued pharmacotherapy
use posthospitalization
Grade 1B
*Grades of evidence are based on the strength of the recommendation (1 = strong, 2 = weak) and
the quality of the evidence (A = high, B = moderate, C = low).
1.5
Alignment with strategic priorities and policies

The Tobacco Free Futures initiative aligns with or complements a number of Alberta and AHS
strategic documents and policies, including the AHS mission, values, health and business
plans, as well as the ACPLF framework. A number of Government of Alberta-led strategic
documents, including tobacco, mental health and cancer care frameworks, provide guidance
for the development of the initiative. Two key corporate policies are also reflected in the
Tobacco Free Futures guidelines.
Alberta Health Services strategic documents

AHS VALUES
AHS has identified seven values to lead our work, actions and decisions.5 These values
havebeen integrated into the development of the Tobacco Free Futures initiative in the
following ways:

Respect: understanding and meeting the client where he or she is at in relation to

tobacco cessation and recognizing the need for support for nicotine withdrawal when
a client is placed in a tobacco-free environment.
Accountability: developing guidelines that are practice-informed and based on

currentevidence.
Transparency: providing clearly defined expectations for clients, staff and visitors.
Engagement: developing the Tobacco Free Futures guidelines and tools in a

collaborative way, involving stakeholders from across the organization.
Safety: supporting client safety by treating nicotine withdrawal to prevent unsafe

behaviours, including elopement from care, being discharged against medical advice
and using tobacco products on site.
Learning: supporting and promoting the development of new knowledge through

health care provider training and client resources.
Performance: providing the best possible care to clients who are affected by
exposure to tobacco products.
For more information on AHS values, visit:

http://insite.albertahealthservices.ca/3819.asp
AHS HEALTH PLAN (20132016)
The health plan outlines the plan of action for the next three years, and focuses on three
strategic directions.6 Implementating the Tobacco Free Futures initiative can directly or
indirectly help support the goals and performance measures set out under each of these
strategic directions. Table 1.2 outlines the ways in which a system approach to tobacco
treatment can support the identified goals, objectives and performance measures for each
ofthe strategic directions.
1.6
Table 1.2: Tobacco Free Futures: Supporting the AHS Health Plan6
Strategic direction
Tobacco Free Futures supports
Bringing appropriate care

to communities
Strengthens integration and collaboration for tobacco treatment across the

continuum of care.
Addresses the needs of complex, high-needs populations who are significantly
affected by tobacco use, including persons with mental health problems and
addictions, as well as those with significant chronic diseases, such as diabetes,
congestive heart failure and chronic obstructive pulmonary disease.
Reducing tobacco use and exposure can improve a persons overall health and
decrease hospital admissions (primary and readmission) as well as lengths of
stay.
Supporting tobacco cessation for the elderly can also help facilitate placement
incontinuing care.
Partnering for better

health outcomes
Tobacco exposure affects all major systems in the body and is a key risk factor
in the development of cancer and chronic disease.
Identifying and providing treatment for tobacco use can improve overall health
outcomes and reduce the incidence of cancer and chronic disease.
Supports the work of Strategic Clinical Networks (SCNs). To date there has
been engagement with all established SCNs and direct collaboration with the
Cancer Care and Addiction and Mental Health SCNs.
Achieving health system

sustainability
Reduction in tobacco use and exposure can lead to improved recovery following
surgery or illness, reduced hospital stays and therefore decreased wait times.
Practice guidelines, training and standardized order sets help ensure that
cessation medications available on formulary provide the best therapeutic value.
For more information on the AHS health plan, visit:

ALBERTA CANCER PREVENTION LEGACY FUND
The Alberta Cancer Prevention Legacy Fund: Strategic Framework 20132016 was developed
to guide the annual $25 million investment by the province into the ACPLF over the next three
years. The ACPLFs mission statement is to transform cancer prevention for Albertans through
innovative population-based initiatives, screening and collaborative, focused research.7 The
vision and mission for the fund are based on the evidence that 50% of cancer cases are
related to modifiable factors, including tobacco. The plan includes a coordinated approach to
prevention and screening through seven innovation teams.7
The Tobacco Free Futures initiative falls under the Acute Care Innovation Team, and has been
funded by ACPLF to September 2014. Sustaining the initiative at the end of the funding cycle
will be supported by the AHS Tobacco Reduction Program (TRP). The success of Tobacco
Free Futures has led to a number of new projects under the Acute Care Innovation Team that
are focused on continued innovation to support data collection and to extend the reach of
theinitiative.
1.7
Alberta strategies
TOBACCO REDUCTION STRATEGY
Creating Tobacco Free Futures: Albertas Strategy to Prevent and Reduce Tobacco Use,
20122022 is a 10-year strategy that provides guidance and performance targets for the
development of initiatives within the province. It outlines the goals and objectives under four
strategic directions: prevention, protection, cessation and knowledge translation and capacity
building.8
The Tobacco Free Futures initiative is closely aligned to the goals and objectives of cessation
and knowledge translation and capacity building. But it is also supportive of prevention and
protection. Table 1.3 identifies the key links between the strategy and this initiative.
Table 1.3: Tobacco Free Futures: Supporting the Alberta Tobacco Reduction Strategy8
Strategic
direction
Goal
Objectives linked to Tobacco Free Futures
Prevention
To prevent youth,
young adults, pregnant
women and at-risk
populations from using
tobacco, tobacco-like
products, smokeless
tobacco and other
related products
1.2: Awareness of the harms associated with tobacco,

tobaccolike products and smokeless tobacco.
Protection
To protect Albertans
from the harms of
tobacco, tobacco-like
products, smokeless
tobacco and secondhand smoke.
2.1: More Albertans will be protected from tobacco, tobacco-like

products, smokeless tobacco and second-hand smoke.
To expand
comprehensive
cessation initiatives.
3.1: Albertans will have increased access to and availability of

tobacco cessation supports and resources.
Cessation
2.2: Awareness of the harms associated with second-hand

smoke from tobacco and tobacco-like products.
3.2: Enhanced awareness of tobacco cessation services.

3.3: Promoted cessation supports for specific settings and
populations and increased uptake.
Knowledge
translation and
capacity building
To support links
between prevention,
protection and
cessation outcomes.
4.2: Increased awareness of tobacco reduction initiatives.

4.3: Enhanced stakeholder engagement.
4.5: Enhanced training opportunities.
4.7: Improved enforcement of tobacco reduction legislation
and improved policies.
4.8: Implemented research and evaluation strategies.
For more information on the Alberta Tobacco Reduction Strategy, visit:

http://www.health.alberta.ca/documents/Tobacco-Reduction-Strategy-2012.pdf
1.8
ADDICTION AND MENTAL HEALTH STRATEGY

The purpose of Creating Connections: Albertas Addiction and Mental Health Strategy is to
provide direction for the transformation of the addiction and mental health system in Alberta.
The overall goal is to reduce the prevalence of addiction, mental health problems and
mental illness through promotion, prevention, assessment, treatment and support activities.
This strategy aligns with or complements other provincial strategies, including the Creating
Tobacco Free Futures.9
The fourth strategic direction in the strategy is focused on addressing the complex needs of
this population.9 The Tobacco Free Futures initiative includes activities and resources that
increase understanding of tobacco dependence as a chronic condition based on a nicotine
addiction as well as the strong links between and impacts of tobacco use related to other
addictions and mental illness. Chapter 19 (Addictions and Mental Health) provides health
care providers with background information related to tobacco use for this specific population.
For more information on Albertas Addiction and Mental Health Strategy, visit:
http://www.health.alberta.ca/documents/Creating-Connections-2011-Strategy.pdf
ALBERTAS CANCER PLAN
Changing Our Future: Albertas Cancer Plan to 2030 provides a long-term strategy for cancer
care and prevention for the province. The plan outlines 10 strategies for change, including
reduc[ing] the risk of cancer through coordinated and integrated prevention strategies.10
Tobacco has a high profile in the overall strategy. To realize its vision, it will be necessary
to reduce the use of and exposure to tobacco, which accounts for one-third of all cancer
cases.10 The primary actions related to the prevention strategy include the need to
implementthe Creating Tobacco Free Futures Strategy.10
For more information on Albertas cancer plan, visit:
http://www.health.alberta.ca/documents/Cancer-Plan-Alberta-2013.pdf
1.9
AHS corporate policies

AHS TOBACCO AND SMOKE FREE ENVIRONMENTS POLICY
The Alberta Health Services Tobacco and Smoke Free Environments Policy (TSFE) builds
upon the protection provided through the provincial Tobacco Reduction Act by prohibiting
tobacco use on AHS property. The policy, which came into effect April 1, 2011, prohibits
tobacco use in or on all grounds, facilities, property or vehicles in an area owned, operated,
leased or funded by Alberta Health Services.11
The policy outlines the commitment to a smoke- and tobacco-free environment while
ensuringthe well-being of clients who use tobacco products. It is essential to ensure
the comfort of clients who use tobacco while they are receiving care in AHS facilities.11
TobaccoFree Futures provides support for successful implementation of this policy.
For more information, see Chapter 5 (Policy).
AHS HARM REDUCTION POLICY
AHS is committed to harm reduction as an approach to working with clients who use
psychoactive substances, including tobacco. Harm reduction is defined in the policy as
policies, programs and practices that aim primarily to reduce the adverse health, social
oreconomic consequences of the use of legal and illegal psychoactive substances without
necessarily reducing consumption. The policy accepts that abstinence may not be a realistic
goal for some people.12
The support provided through the Tobacco Free Futures initiative recognizes that clients,
especially those who are being treated as inpatients or residents, may not be ready to quit
tobacco use. However, they still require support for nicotine withdrawal that is associated
withadmission to a tobacco-free facility.
For more information on the AHS Harm Reduction Policy, visit:
https://extranet.ahsnet.ca/teams/policydocuments/1/clp-harm-reduction-for-psychoactivesubstance-use-policy.pdf
1.10
SITE/PROGRAM IMPLEMENTATION OF
TOBACCO FREE FUTURES
Evidence strongly suggests that health care delivery systems institutionalize the consistent
identification, documentation and treatment of every tobacco user seen in a health care
setting.3,4 Within the Tobacco Free Futures guidelines are the information, direction and tools
toguide the model implementation in a specific health care site or program.
Implementation phases and processes

Four phases of implementation, along with their associated processes, have been identified
based on development and testing of the model. The processes are not intended to be
completed in a linear fashion or in isolation from one another; rather, they are interrelated
and often overlap during the implementation timeline. Refer to Table 1.4 for a detailed outline
of the phases and associated processes that should be considered when planning and
implementing the model at health care sites.13
Table 1.4: Phases and Processes of Tobacco Free Futures Site/Program

Implementation
Engage the support of senior management and physician leadership.
Phase 1
Initial planning
Form a multidisciplinary Tobacco Free Futures site steering committee.

Complete a Tobacco and Smoke Free Environments Policy assessment.
Set a timeline for implementation of all processes, including a go-live date.
Determine staff roles and ensure tobacco treatment will be documented in the
client record.
Phase 2
Resource and
supportplanning
Ensure pharmacotherapy is available in formulary, and stocked on site, and adopt

standard ordering or referral processes, if applicable.
Identify and stock print resources for staff and clients.
Phase 3
Preparing staff
Phase 4
Final planning
Implement a communication plan for site leadership, staff, clients and visitors.
Arrange and schedule training for staff.
Plan for sustainability and continuous improvement.
1.11
REFERENCES
1. Alberta Cancer Board. (2007). Evidence supporting tobacco control policies (briefing
note). Calgary, AB: Author.
2. Wagner, E., Davis, C., Schaefer, J., Von Korff, M., & Austin, B. (2002). A survey of
leadingchronic disease management programs: Are they consistent with the literature?
Journal of Nursing Care Quality, 16, 6780.
3. Fiore, M., Jaen, C., Baker, T., Bailey, W., Benowitz, N., Curry, S., Dorfman, S., et al.
(2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of
Healthand Human Services, Public Health Service.
4. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation
guideline (version two). Toronto, ON: Centre for Addiction and Mental Health. Retrieved
from http://can-adaptt.net.
5. Alberta Health Services. (n.d.) Leading with values. Retrieved from
6. Alberta Health Services. (2013). Alberta Health Services Health Plan and Business Plan
(201316): Better quality, better outcomes, better value. Retrieved from
http://www.albertahealthservices.ca/Publications/ahs-2013-16-health-business-plan.pdf
7. Alberta Health Services & Alberta Innovates Health Solutions. (2013). Alberta Cancer
Prevention Legacy Fund: Strategic framework 20132016. Edmonton, AB: Authors.
8. Government of Alberta. (2012). Creating tobacco-free futures: Albertas strategy to
prevent and reduce tobacco use 20122022. Retrieved from
http://www.health.alberta.ca/documents/Tobacco-Reduction-Strategy-2012.pdf
9. Government of Alberta. (2011). Creating connections: Albertas addiction and mental
health strategy. Retrieved from http://www.health.alberta.ca/documents/CreatingConnections-2011-Strategy.pdf
10. Government of Alberta. (2013). Changing our future: Albertas cancer plan to 2030.
Retrieved from http://www.health.alberta.ca/documents/Cancer-Plan-Alberta-2013.pdf
11. Alberta Health Services. (2011). Tobacco and Smoke Free Environments Policy.
Retrievedfrom http://insite.albertahealthservices.ca/9783.asp
12. Alberta Health Services. (2013). Harm reduction for psychoactive substance use.
Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-harm-reductionfor-psychoactive-substance-use-policy.pdf
13. University of Ottawa Heart Institute. (2009). Ottawa model for smoking cessation
inpatientimplementation guidelines. Ottawa, ON: Author.
1.12
Chapter 2
The Effects of
Tobacco Exposure
2.1
TOBACCO FACTS
Health consequences of tobacco use and exposure
Although there has been great progress in tobacco control in both Canada and the United
States, tobacco use is still considered the single greatest preventable cause of chronic
disease and premature death.1 The U.S. government has just released the 2014 Surgeon
Generals Report: The Health Consequences of Smoking50 Years of Progress, which is an
update 50 years after a 1964 report first alerted the public to the health impacts of tobacco
use. Since then, research has continued expanding our knowledge of the impact of tobacco
exposure through active and passive smoking, the systems in the body and their relationship
to acute and chronic illness.2 Tobacco smoke contains over 7,000 chemicals, of which at least
172 are toxic substances and 69 are known carcinogens.3 Tobacco is the only consumer
product that will kill at least one of every two regular users when used as intended by the
manufacturer.4
Tobacco exposure affects the health not only of those who use the products, but also of those
who experience environmental exposure. In 2012, the Canadian Tobacco Use Monitoring
Survey reported that 16.1% of Canadians and 17.4% of Albertans aged 15 and over were
smokers, and that the average daily smoker in Canada consumed 15 cigarettes per day.
In 2010, 34% of respondents reported being exposed to second-hand smoke at least once
per week.5 Every year more than 37,000 Canadians die from tobacco-related illnesses; this
translates to a death about every 11 minutes. Thousands more are diagnosed with illness due
to use of the product. Two Canadian teenagers will start smoking cigarettes every10minutes,
and one of them may die because of that decision.6
The health consequences of tobacco use and exposure include a wide variety of acute and
chronic illnesses. Tobacco use and exposure is estimated to be responsible for about 30%
of all cancer-related deaths in the province.7 Figure 2.1 illustrates the impact tobacco has
onmany systems of the body.3
Figure 2.1: Health Risks of Tobacco Use and Exposure
2.2
In Alberta, as in the rest of Canada, the impact of tobacco-related illness places a huge strain
on the health care system. Based on current estimates that Albertans make up approximately
11% of the Canadian population, provincial costs are estimated in the range of $118 million
to $179 million per year to treat hospitalized tobacco users.8 Canadian estimates identify
that 20% of patients admitted to hospital are smokers.9 The risk of hospitalization for current
smokers aged 4574 is 80% higher than for non-smokers. Smokers aged 4554 will stay in
hospital on average 1.5 days longer than non-smoking patients; those aged 6574 will stay
an average of 6 days longer.8
Types of tobacco
All tobacco products are potentially addictive and hazardous to a persons health. There are
many forms of tobacco that are commonly used, including the following:
Cigarettes contain more than 7,000 chemicals, 69 of which are known carcinogens.
Terms such as low tar and light cigarettes are misleading and do not reduce the
risk of disease. Cigarettes are highly engineered devices that allow nicotine to be
delivered to the brain quickly and efficiently.3
Cigars/cigarillos, like cigarettes, contain toxic and cancer-causing chemicals that
are harmful to smokers and non-smokers.10 A large cigar can contain as much
nicotine as a package of cigarettes. Cigarillos are small, slender cigars about the
sizeof a cigarette. The use of cigarillo products is rising in Alberta, especially among
teens and young adults; flavour additives enhance the appeal. Health Canada
considers smoking cigarillos as having the same health risks as cigarettes.11, 12

Spit tobacco (also known as chew, snus and snuff) products are made of tobacco,
water and additives, including flavours. They are designed to be chewed, sucked or,
in some cases, inhaled through the nose. For chew tobacco (spit or spitless), nicotine
and other chemicals are released from the product and absorbed through the blood
vessels of the cheek. In Canada, the market trend for using smokeless tobacco has
shifted from older males to boys and young men. These products contain over 3,000
chemicals, including 28 known carcinogens.
Waterpipes (also known as hookah, narghile and shisha) come in different shapes
and sizes, but all have a similar design that involves smoke passing through water
before inhalation. The use of waterpipes is increasing in Alberta, especially among
youth and young adults. Products smoked in waterpipes are often marketed as
having minimal or no tar, nicotine or tobacco, but these claims have often been found
to be inaccurate. Whether or not the products contain tobacco, the resulting smoke
can have negative impacts on a persons health. A waterpipe user can inhale as
much smoke in one hour as someone who has smoked 100 cigarettes. Waterpipe
use is not a safe alternative to smoking cigarettes.16

Electronic smoking products are battery-powered devices that look like cigarettes
and vaporize a chemical mixture that may or may not include nicotine. Users puff
on the electronic smoking product and inhale the fine, heated mist. Health Canada
advises Canadians not to purchase or use e-cigarettes because these products may
pose health risks and have not been fully evaluated for safety, quality and efficacy.17
2.3
Figure 2.2: Tobacco Products
Psychological and physiological effects of nicotine

In order to effectively support tobacco users, it is important
to recognize the psychological and physiological effects of
nicotine. Inhaling or absorbing the toxic substances is the
primary cause of many of the health issues related to tobacco
use; however, nicotine is the addictive agent. Repeated
exposure to nicotine leads to dependence on the substance.
Cigarettes and other tobacco products are designed to
maximize nicotines delivery to the brain.4
Traditionally, tobacco
use has been viewed as
a bad habit or lifestyle
choice; however, more
recently tobacco use
has been acknowledged
as a chronic,relapsing
condition.18
Following inhalation or absorption, nicotine travels very

quickly via the bloodstream to the brain and binds with
nicotinic receptors. Stimulation of these receptors causes the
initiation and maintenance of anaddiction. These receptors
also play a role in stimulating other brain centres, contributing
to the release of dopamine, which results in the sensation of pleasure.4
2.4
Figure 2.3: Psychological and Physiological Effects of Nicotine

1. When someone uses tobacco, they take in more than
7,000 chemicals, including nicotine.
2. Nicotine moves to the lungs, where it is absorbed into
the bloodstream.
3. The heart pumps the nicotine throughout the body,
including the brain.
4. It only takes seven seconds for nicotine to reach the
brain.
5. The release of dopamine in the brain causes the high
and euphoria that enhance nicotines addictive effect.
6. Repeated exposure results in the development of
tolerance, and larger doses of tobacco are required to
produce the same stimulating effects.
7. When an adequate dose of nicotine isnt maintained, the
tobacco user will experience symptoms of withdrawal.
Tobacco users normally use enough tobacco to maintain a constant level of nicotine in
their blood. But when that level drops, they will experience withdrawal symptoms. Signs
and symptoms of nicotine withdrawal normally appear within two hours of a users last
nicotine use, peak in 2448 hours and last from several days to four weeks. The intensity
ofwithdrawal symptoms can impact the success of a quit attempt.19
A tobacco user who is abstaining or quitting deals not only with physiological withdrawal
but also the conditioned response to the behaviours and cues that have accompanied their
tobacco use, including the smell of tobacco, ashtrays, lighters, driving in the car, talking on
the phone and drinking coffee.3
Tobacco dependence, and the associated DSM 5 diagnosis of tobacco use disorder, is a
chronic, relapsing condition, not just a bad habit or lifestyle choice.20 Once a user becomes
dependent on tobacco, it is rare that they are successful with their first quit attempt. The
majority of users go through cycles of relapse and remission, which are typical of chronic
conditions. Health care providers must be aware that effective treatment is comprehensive
and recognizes the potential for relapse within days, months and even years. They must also
recgonize the need to connect clients to ongoing support.18
Environmental exposure to tobacco

Tobacco smoke is classified into three categories: first-hand smoke, which is inhaled by the
smoker; second-hand smoke, which is either exhaled by a smoker or released from the end
of a burning cigarette; and third-hand smoke, which refers to the tobacco smoke residue and
gases that are left behind after a cigarette has been smoked.
2.5
SECOND-HAND SMOKE
Second-hand smoke (SHS) consists of sidestream smoke
(the smoke released from the burning end of a cigarette) and
mainstream smoke (the smoke exhaled by the smoker).21
Sidestream smoke makes up about 85% of SHS.22 It has
a different chemical composition than mainstream smoke
because it is generated at lower burning temperatures,
and the combustion (burning) is not as clean or complete.23
Exposure to SHS causes disease and premature death
in children and adults who do not smoke.21 Traces of
carcinogens and other toxins are found in the blood, urine,
saliva and breast milk of non-smokers, even after limited
exposure to SHS.21
There are no safe

levels of exposure to
SHS.3 Compared to
mainstream smoke,
SHScontains more
carbon monoxide,
tarand nicotine.
SHS exposure has immediate adverse effects on the adult cardiovascular system and causes
coronary heart disease. Adult non-smokers who live with smokers increase their risk of heart
disease by about 25%.21,24 Exposure to SHS is also a cause of lung cancer in non-smokers.21
Estimates indicate that more than 300 non-smokers die each year in Canada from lung
cancer that is related to SHS.25
Because their bodies are developing, infants and young children are especially vulnerable
to the toxins in SHS.21,26 Infants whose mothers smoke while pregnant and those who are
exposed to SHS after birth are at increased risk of death from sudden infant death syndrome
(SIDS), are more likely to have a low birth weight and are more likely to have weaker
lungs than babies who are not exposed.21 Infants with low birth weights are at increased
risk of dying within the first year of life and are more likely to go on to develop coronary
heart disease and type 2 diabetes.27,28 SHS exposure also causes acute lower respiratory
infections, such as bronchitis and pneumonia, and children who already have asthma
experience more frequent and severe attacks. SHS also increases a childs risk of ear
infections.21
Opening windows in buildings or vehicles does not provide protection from exposure to SHS.
Ventilation may mask some of the odour; however, the technology to remove carcinogens
from the air does not exist. Only environments that are completely smoke free provide full
protection from exposure to SHS.
2.6
THIRD-HAND SMOKE
Third-hand smoke (THS) is a more recently coined term to
describe the residual tobacco smoke pollutants that remain
on surfaces and in dust after tobacco has been smoked and
are reemitted back into the air in the gas phase or react with
oxidants and other compounds in the environment to form
secondary pollutants.29 The smoke residue, which includes
many types of particulate matter (including heavy metals
such as arsenic, lead and cyanide), builds up on and in
many cases is absorbed into surfaces, furnishings, clothing,
draperies and carpets.30,31
Anyone who smokes

in a home, car or other
enclosed area in which
non-smokers later are
present is exposing
those non-smokers to
potent carcinogens.33
The burning of tobacco also releases nicotine in the form of a vapour that attaches to
surfaces such as walls, floors, carpeting, drapes and furniture.32 Nicotine reacts with
nitrous acid (a common air pollutant, one source of which is burning tobacco) and forms
carcinogenic tobacco-specific nitrosamines (TSNAs).32 The nicotine can last for weeks to
months on indoor surfaces and results in the continued creation of carcinogens, which are
then inhaled, absorbed or ingested.30,32 The more a person smokes in the home or car, the
more TSNAs are formed, resulting in high levels of tobacco toxins that last well beyond the
period of active smoking.33,34
Children are uniquely susceptible to THS exposure because they breathe near, crawl
on, playon, touch and even taste contaminated surfaces.34 Children can also ingest
tobacco residue by placing their hands in their mouths after touching surfaces that are
contaminated with THS.30
More research is needed into the health impact of exposure to THS; however, scientific
experts on THS recommend 100% smoke-free homes and vehicles and suggest that
replacing nicotine-laden furnishings, carpets and wall board can significantly reduce
exposure.32
2.7
Health benefits of tobacco cessation

Quitting is one of the best things a tobacco user can do to improve his or her health and
protect the health of his or her families and friends.
Within minutes of a persons last substance use, his or her body will start a process of healing
that will continue over the following weeks, months and years. Figure 2.4 identifies many of
the health benefits of tobacco cessation.35
Other benefits include35

being a positive role model for children
saving money
freedom from addiction
no worries about exposing family, friends and coworkers to SHS
Figure 2.4: Health Benefits of Tobacco Cessation
2.8
REFERENCES
1. World Health Organization (WHO). (2000). Global strategy for the prevention and control
of non-communicable diseases. Geneva: Author.
2. United States Department of Health and Human Services (USDHHS). (2014). The health
consequences of smoking50 years of progress: A report of the Surgeon General.
Rockville, MD: Author.
3. United States Department of Health and Human Services (USDHHS). (2010).
How tobacco smoke causes disease: The biology and behavioral basis for
smokingattributable disease: A report of the Surgeon General. Atlanta, GA: Author.
4. Els, C. (2009). Tobacco addiction: What do we know, and where do we go?
Retrieved from http://www.lung.ca/crc/pdf/CEls3of3.pdf
5. Statistics Canada. (2012). Canadian Tobacco Use Monitoring Survey (CTUMS).
Retrieved from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_
ctums-esutc_2012/ann-eng.php
6. Health Canada. (n.d.) About tobacco control. Retrieved from http://hc-sc.gc.ca/hc-ps/
tobac-tabac/about-apropos/index-eng.php
7. Alberta Cancer Board (ACB). (2007). Evidence supporting tobacco control policies
(briefing note). Calgary, AB: Author.
8. Wilkins, K., Sheilds, M., & Rotermann, M. (2009). Smokers use of acute care
hospitalsa prospective study. Health Reports 2009, 20(4), 7583.
9. University of Ottawa Heart Institute. (2009). Ottawa model for smoking cessation inpatient
implementation guideline. Ottawa, ON: Author.
10. National Cancer Institute (NCI). (2010). Cigar smoking and cancer: Fact sheet.
Retrievedfrom http://www.cancer.gov/cancertopics/factsheet/Tobacco/cigars
11. Alberta Health Services (AHS). (2009). Flavour additives in tobacco products: A gateway
to tobacco addiction. Edmonton, AB: Author.
12. Health Canada. (2010). Little cigars...big concerns. Retrieved from http://www.hc-sc.
gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/tobac-tabac/little-cig-petits/little-cig-petitseng.pdf
13. Alberta Health Services (AHS).(2009). Marketing flavoured spit tobacco to youth:
Anindustry success story. Edmonton, AB: AHS Tobacco Reduction Program.
14. Health Canada (2010). Smokeless tobacco products: A chemical and toxicity analysis.
Retrieved from http://www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/smokeless-sansfumee/
index-eng.php
15. Hoffman, D., & Djoerdevic, M. (1997). Chemical composition and carcinogenicity of
smokeless tobacco. Advances in Dental Research, 3(11), 322329.
16. Alberta Health Services (AHS) (2011). Waterpipe tobacco use (strategic brief).
Edmonton,AB: AHS Tobacco Reduction Program.
17. Alberta Health Services (AHS). (2012). Electronic smoking products (strategic brief).
Edmonton, AB: AHS Tobacco Reduction Program.
Healthand Human Services, Public Health Service.
2.9
19. Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti P. (2007). The
tobacco dependence treatment handbook: A guide to best practice. New York: Guilford
Press.
20. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, DC : Author.
21. United States Department of Health and Human Services (USDHHS). (2006). The
health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon
General. Rockville, MD: Author.
22. Canadian Council for Tobacco Control (CCTC). (2001). What is secondhand smoke?
Retrieved from http://nnsw.ca/previous/2006/factsheet-shs
23. Witschi, H., Joad, J., & Pinkerton, K. (1997). The toxicology of environmental tobacco
smoke. Annual Review of Pharmacological Toxicology, 37, 2952.
24. Law, M., Morris, J., & Wald, N. (1997). Environmental tobacco smoke exposure and
ischemic heart disease: An evaluation of the evidence. British Medical Journal, 315(18),
973977.
25. De Groh, M., & Morrison, H. (2002). Environmental tobacco smoke and deaths from
coronary heart disease in Canada. Chronic Diseases in Canada, 23(1), 1316. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/11876831
26. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT). (2011). CAN-ADAPTT Canadian Smoking
Cessation Guideline. Toronto, ON: Centre for Addiction and Mental Health.
27. Human Resources and Skills Development Canada. (n.d.). Indicators of well-being in
Canada: Healthlow birth weight. Retrieved from http://www4.hrsdc.gc.ca/.3ndic.1t.4r@eng.jsp?iid=4
28. Lumley, J., Chamberlain, C., Dowswell, T., Oliver, S., Oakley, L., & Watson, L. (2009).
Interventions for promoting smoking cessation during pregnancy. Cochrane Database of
Systematic Reviews 2009, 3. Art. No. CD001055.
29. Burton, A. (2011). Does the smoke ever really clear? Thirdhand smoke exposure raises
new concerns. Environmental Health Perspectives, 119, a70a74.
30. Americans for Nonsmokers Rights. (2011). Thirdhand smoke. Retrieved from
http://www.no-smoke.org/learnmore.php?id=671
31. Dale, L. (2011). What is third-hand smoke and why is it a concern? Retrieved from
http://www.mayoclinic.com/health/third-hand-smoke/AN01985
32. Sleiman, M., Gundel, L., Pankow, J., Jacob, P., Singer, B., & Destaillats, H. (2010).
Atmospheric chemistry special feature: Formation of carcinogens indoors by surfacemediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke
hazards. Proceedings of the National Academy of Sciences, 107(15), 65766581.
33. Dreyfuss, J. (2010). Thirdhand smoke identified as potent, enduring carcinogen. CA
Cancer Journal for Clinicians, 60(4), 203204.
34. Winickoff, J., Friebely, J., Tanski, S., Sherrod, C., Matt, G., Hovell, M., & McMillen, R.
(2009). Beliefs about the health effects of thirdhand smoke and home smoking bans.
Pediatrics, 123, e74e79.
35. The Lung Association. (2012). Smoking and tobacco: Benefits of quitting. Retrieved
from http://www.lung.ca/protect-protegez/tobacco-tabagisme/quitting-cesser/benefitsbienfaits_e.php
2.10
Initial Planning
3. Engagement
4. Tobacco Free Futures: Steering Committee
5. Policy
6. Timelines
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
INITIAL PLANNING
Initial planning involves the formative processes to set the stage for implementation,
includingengaging site and/or program leadership, forming a Tobacco Free Futures steering
committee, completing an assessment of how the site is complying with the AHS Tobacco and
Smoke Free Environments Policy and setting initial timelines for implementation of the model.
The following four chapters will provide valuable information for senior site leadership and the
site committee to consider, as well as tools and resources to support these processes.
Chapter 3: Engagement

Overview of the importance of site/program senior management and physician

leadership support.
How to get formal approval to implement the Tobacco Free Futures initiative.
Review of tools and techniques available for gaining support of senior site or
programmanagement.
Chapter 4: Tobacco Free Futures Steering Committee

Review of the purpose of a multidisciplinary committee and recommended

membership.
Overview of a learning opportunity for persons expected to provide leadership and

guidance to support a health care setting in implementing the Tobacco Free Futures
initiative.
Review of tools and resources available to support the committee.
Chapter 5: Policy

Overview of the AHS Tobacco and Smoke Free Environments Policy and related
protocols.
Review of staff roles and responsibilities as outlined by the policy.
Review of policy enforcement.
Review of use of tobacco-like products on AHS property.
Identify policy supporting resources available to AHS sites.
Chapter 6: Timelines

Overview of the purpose of timelines and schedules in planning for implementation.
How to create an implementation timeline and plan for your site or program.
Identify tools available to support implementation planning.
Chapter 3
Engagementx
3.1
LEADERSHIP SUPPORT
Implementing a site systems-based approach to tobacco
treatment will require the commitment and support of
senior management and leadership from physicians to be
successful. Once a health care setting has identified an
interest in implementing the Tobacco Free Futures initiative,
key stakeholders within the setting will need to be engaged.
Importance of support from leadership
Administrators should
ensure that institutional
changes promoting tobacco
dependence treatment are
implemented universally
and systematically.1
Successful change management requires a commitment from executives and senior

managers, whether the change is occurring in a department or in the entire organization.
Senior leaders can do the following to make sure their change management is successful:
3.2
Establish a clear vision for the Tobacco Free Futures change management process.
Paint a picture of where the site will end up and what the anticipated outcomes are.
Appoint a champion who is in charge of the Tobacco Free Futures change

management process and who makes sure others are involved, too.
Pay attention to the changes as they happen. Ask how things are going. Focus on
progress as well as barriers for the initiative.
As an involved participant, sponsor portions of the process to increase active

involvement and interaction with other site members.
Establish a structure that will support the Tobacco Free Futures initiative.
Thisincludes forming the committee and presentations to leadership groups.
Change the measurement, reward and recognition systems to measure and

rewardmeeting new expectations as they arise.
Solicit and act upon feedback from other members of the organization.
Recognize the human element in the change. People have different needs and
different ways of reacting to change. They need time to adjust to it.
Senior leaders must participate in the training that other organization members
attend, but even more importantly, they must display what they learned from the
sessions, readings, interactions, tapes, books or research.
Engagement tools and techniques

Obtaining engagement from leadership means gaining its support of the Tobacco Free
Futures initiative, including senior leaders understanding, commitment and action. How
can you accomplish this? Health organizations base their operations on business plans and
sound strategies. Identifying how new initiatives support the goals of AHS is an important first
step in gaining the support of leadership.
The individual responsible for engaging leadership must create a vision of a future that
connects the decision-makers with the goals of the organization. AHSs vision is to become
the best-performing publicly funded health system in Canada. Chapter 1 (Tobacco Free
Futures: A Systems Change Management Model) outlines the ways in which the Tobacco
Free Futures initiative aligns with and supports AHS values and a number of AHS and
provincial government strategic documents.
Any approach must guide the leadership team through the same thought processes and
engage them in their decision-making activities. Chapter 10 (Communication) outlines
various resources available to inform leadership of the Tobacco Free Futures initiative and
change management processes. Failing to engage leadership is one of the most frequently
cited reasons for problems with the sustainability of improvements and can easily threaten
the long-term viability of the initiative. A memorandum of understanding should be used to
gain formal approval to implement the Tobacco Free Futures initiative.
See appendices:
Appendix 3(a) Tobacco Free Futures Memorandum of Understanding
3.3
REFERENCES
Health and Human Services, Public Health Service.
3.4
APPENDICES
Appendix 3(a) Memorandum of Understanding
3.5
Appendix 3(a) Memorandum of Understanding (page 1)
Memorandum of Understanding for Tobacco Free Futures between Tobacco Reduction Program and
<INSERT SITE>
This MEMORANDUM OF UNDERSTANDING is hereby made and entered into by and between the Alberta
Health Services Tobacco Reduction Program and <INSERT SITE> steering committee.
A) PURPOSE:
To outline the roles, responsibilities, expectations and services provided/received through the
Tobacco Free Futures program.
Provide terms of reference that clearly outline the above components for both parties.
B) STATEMENT OF MUTUAL BENEFITS AND INTERESTS:
Tobacco Free Futures supports an integrated system approach to tobacco treatment across the
continuum of Alberta health care.
Current evidence supports the integration of tobacco treatment into routine health care.
By participating in Tobacco Free Futures, the site steering committee and/or zone advisory
committee will receive information, access to resources and consultative support from the
Tobacco Reduction Program team to support implementation the Tobacco Free Futures systems
approach to tobacco treatment using outlined processes.
Tobacco Free Futures aligns with and supports the strategic directions outlined in the AHS
Health Plan and Business Plan and supports the AHS Tobacco and Smoke Free Environments
policy.
C) TOBACCO REDUCTION PROGRAM SHALL:

Coordinate a facilitated process that enables AHS health care settings to integrate the Tobacco
Free Futures initiative.
Facilitate access to existing resources and materials that support implementation of the Tobacco
Offer support and guidance where appropriate throughout the implementation processes
3.6
Appendix 3(a) Memorandum of Understanding (page 2)
D) <INSERT SITE> SHALL:

Provide a point of contact to the Tobacco Reduction Program for the duration of the
implementation. If the original point of contact changes, <INSERT SITE> will contact the Tobacco
Reduction Program with the name of a new point of contact.
Obtain approval from senior decision makers with a vested interested in the impact and
outcomes of new initiatives at <INSERT SITE>.
Adhere to the implementation processes, documentation standards, training standards and
resources associated with Tobacco Free Futures.
Participate in monitoring and reporting processes in alignment with Tobacco Reduction Program
standards.
Submit completed copies of all Tobacco Free Futures initiative forms and templates including
but not limited to memorandum of understanding, steering committee terms of reference,
implementation planning tool, training records, sustainability planning and quality improvement
tools.
E) IT IS MUTUALLY UNDERSTOOD AND AGREED BY AND BETWEEN ALL PARTIES THAT:
Tobacco Free Futures is designed to improve the quality of tobacco dependence and nicotine
addiction care of AHS clients; processes and resources may be adapted during implementation
to reflect new best-practice evidence and/or evaluation of participating sites. Participating sites
will be an integral part of contributing feedback and participating in the evaluation and ongoing
monitoring/reporting to ensure that this objective is met.
All information collected via Tobacco Free Futures is private and confidential. Any data or sitespecific information will be maintained according to Alberta Health Services privacy and security
of information standards including compliance with the Health Information Act (HIA) and the
Freedom of Information and Protection of Privacy Act (FOIP). For reporting purposes, data will
be anonymous and aggregated.
Participation in Tobacco Free Futures is entirely voluntary, and either party may withdraw or
terminate this agreement at any time. Participating Alberta Health Services sites and/or the
Tobacco Reduction Program will provide notice (in writing) two weeks in advance of the
termination date.
Commencement/Expiration: This agreement is effective <INSERT START DATE>, expiring
<INSERT END DATE>.
F) APPROVAL:
NAME
POSITION
SIGNATURE
DATE
3.7
Chapter 4
Tobacco Free
Futures Steering
Committeex
4.1
FORMING A MULTIDISCIPLINARY COMMITTEE

Site leadership will appoint at least one individual to act as site champion(s) for the Tobacco
Free Futures initiative. Leadership and the site champion(s) will establish a committee to
provide vision, leadership and guidance for the implementation of the initiative. The committee
will act to make informed decisions regarding the integration of tobacco treatment and support
into routine care offered to clients and their families at the site.
This Tobacco Free Futures guidelines and associated tools are designed to support
committeesin

implementing the AHS Tobacco and Smoke Free Environments Policy
implementing tobacco treatment through systems change management processes
identifying and supporting relevant training for frontline staff and tobacco practice leads
communicating with stakeholders, staff and clients
providing guidance and support to ad hoc working groups
planning for sustainability and continuous quality improvement
The committee should be as representative of the site services and health professional groups
as possible. Recruitment from the following groups is strongly encouraged:

senior management
unit management
physicians
nursing
pharmacy
respiratory therapy
workplace health and safety
protective services
patient registration
other (e.g., clinical education, allied health professionals, community supports

orprofessionals working with specific populations)
A Tobacco Reduction Program team member may participate in an ex officio capacity.

Regular meetings of the committee are important to ensure timely implementation of
theinitiative. Templates for meeting agendas and meeting notes are available at
http://insite.albertahealthservices.ca/902.asp.
See appendices:
Appendix 4(a) Site Committee Draft Terms of Reference
Appendix 4(b) Site Committee Contact Form
4.2
TOBACCO FREE FUTURES WORKSHOP

Integrating tobacco intervention into health care delivery requires the active involvement of
clinicians, health care systems, administrators and decision makers. These efforts represent
an opportunity to increase rates of treatment delivery, quit attempts and successful tobacco
cessation.
The Tobacco Free Futures implementation workshop explores the 10processes important
to organizational change management as defined by the Tobacco Free Futures initiative
in Chapter 1 (Tobacco Free Futures: A Systems Change Management Model). After this
workshop, participants will have the foundational knowledge, tools and resources to provide
leadership and guidance to support a health care setting in implementing the Tobacco Free
Futures initiative. Anyone who will be supporting the implementation is strongly encouraged
toattend the workshop. For more information, see Chapter 11 (Training).
4.3
APPENDICES
Appendix 4(a) Site Committee Draft Terms of Reference
4.4
Appendix 4(a) Site Committee Draft Terms of Reference (page 1)
Site Steering committee

Terms of Reference
puRpoSE
Reporting to the <INSERT SITE> leadership team, the <INSERT SITE> Tobacco Free Futures site steering
committee will provide vision, leadership and guidance for the implementation of the Tobacco Free
Futures initiative. The committee will act to make informed decisions regarding the integration of tobacco
treatment and support into routine care offered to clients and their families at the <INSERT SITE>.
Ad hoc working groups will be formed on an as necessary basis to support the systems change
management processes. This may include review of evidence, development of processes, adoption of
documentation standards, roll-out of staff education and review of resources. Ad hoc groups will report to
the committee.
obJEcTIVES
1. Support the implementation of tobacco treatment through systems change management
processes.
2. Provide guidance and support to ad hoc working groups.
3. Identify and support relevant training for front-line staff and tobacco practice leads.
4. Support evaluation of the implementation process.
5. Support the collaboration and integration of all stakeholders and working groups.
6. Support sustainability and continuous quality improvement.
7. Support implementation of AHS Tobacco and Smoke-Free Environments Policy.
RElATED polIcY
Make linkages with related polices (e.g., AHS Tobacco and Smoke Free Environments Policy)
MEMbERSHIp
Representation from the following groups is recommended:
Senior management
Unit management
Physicians
Nursing
Pharmacy
Respiratory Therapy
Workplace Health & Safety
Protective Services
Patient registration
Other (e.g., clinical education, allied health professionals, community supports or professionals
working with specific populations)
A Tobacco Reduction Program team member may participate in an ex officio capacity.
4.5
Appendix 4(a) Site Committee Draft Terms of Reference (page 2)
RolES AND RESpoNSIbIlITIES

chair/co-chairs
Facilitate and provide leadership for the committee and its members
Model and ensure a commitment to the project, inter-professional collaborative practice and
capacity-building for members
Chair meetings efficiently and effectively:
o be on time and start on time
o be organized and prepared
o maintain order and focus
o be available as a resource to the committee
committee members
Attend meetings on a regular basis
Identify an alternate when unable to attend
Participate in discussion and work of the committee
Establish and maintain a mechanism to share information and gather feedback/input from
colleagues
Share information with key stakeholders
MEETINGS
Regular meetings of the committee shall be held monthly or at the call of the chair.
The chair will be responsible to prepare and distribute the agenda to committee members prior to
the meeting. Agenda items will be sent by committee members to the committee chair.
Minutes of all meetings shall be recorded and distributed to all members of the committee and
working groups following the meetings.
Decision-making processes will use a consensus decision-making process whereby members
work collaboratively to develop recommendations, provide guidance and support in decision
making.
Consensus decision making does not imply unanimity.
Alternates may be appointed by individual committee members.
GuIDING pRINcIplES
Inclusive
Transparent
Respectful
Evidence-informed
Accountable
Flexible
AppRoVAl
Date of Approval: ____________________
Date of Review:
____________________
Signatures:
4.6
NAME
DEPARTMENT/UNIT
Site:
POSITION
PHONE NUMBER
Date:
E-MAIL ADDRESS
1/1
Steering committee contact form
4.7
CHAPTER 5
Policy
5.1
TOBACCO-FREE ENVIRONMENTS
Environments that restrict or prohibit tobacco use are seen as windows of opportunity for
initiating tobacco cessation treatment.9 Evidence suggests that even a brief intervention is
effective in promoting tobacco treatment, but support during admission to health care facilities,
with follow-up after discharge, is more effective at sustaining quit rates.9 Albertas Tobacco
Reduction Act (TRA) protects people from exposure to cigarette smoke by prohibiting smoking
with five metres (16 feet) of a doorway, open window or air intake in a public place or workplace,
including work vehicles.6
AHS TOBACCO and SMOKE FREE ENVIRONMENTS

POLICY
The Alberta Health Services Tobacco and Smoke Free Environments Policy (TSFE) builds
upon the protection provided through the TRA by prohibiting tobacco use on AHS property.1
The policy, which came into effect on April 1, 2011, prohibits tobacco use in or on all grounds,
facilities, property or vehicles in an area owned, operated, leased or funded by Alberta Health
Services.1 Property includes parking areas, vehicles parked in parking lots, and sidewalks
on site.1 The policy applies to all agencies/facilities that receive 50% or more of their funding
from AHS.1
The policy outlines a commitment to a smoke- and tobacco-free environment while ensuring
the well-being of clients who use tobacco products. It is essential to also ensure the comfort
ofthese clients while they are receiving care in AHS facilities.
Access AHS Tobacco and Smoke Free Environments Policy at:
Staff roles and responsibilities

Under the TSFE policy, Alberta Health Services employees and other persons acting on
behalf of AHS shall not facilitate any clients use of tobacco products.1 This means that
staff may not purchase tobacco products or take clients outside to smoke or use other
forms of tobacco.1 If the site manager and the clients physician have authorized special
considerations for that client, it is the responsibility of families or friends to accompany him
or her.2 It is not appropriate for clinicians to request, either in writing or verbally, that AHS
Protective Services and/or the contracted service providers, take patients outside to use
tobacco products. Protective Services has been directed not to comply with such requests.
Staff who are not compliant with the TSFE policy are subject to the measures outlined in the
AHS Progressive Discipline Policy, which include dismissal.1
THIRD-HAND SMOKE
Third-hand smoke is the residual tobacco smoke pollutants that remain on surfaces after
tobacco has been smoked, and are then re-emitted back into the gas phase to yield secondary
pollutants.2,3,5 For more information on third-hand smoke, see Chapter 2 (The Effects of
Tobacco Exposure). Although more research is required to better understand the health
impact of third-hand smoke, the smell of third-hand smoke is offensive to many people
andcan be a trigger for those who use tobacco; thus, staff are encouraged not to expose
patients to it by avoiding smoking while at work.
5.2
CESSATION SUPPORT FOR STAFF

Cessation counselling support for AHS staff is available through www.albertaquits.ca and the
Employee and Family Assistance Program (EFAP). For cessation medication coverage, staff
can access their employee health benefits. Staff without coverage for cessation medications
through their health benefits can access a fund to have 80% of the cost of nicotine
replacement therapy reimbursed.
AHS staff can access the cessation medication reimbursement form by visiting:
Enforcement
Under the TRA, the manager of a facility must not permit smoking in a prohibited area.6
Managers who permit smoking where it is prohibited are liable for fines ranging from up to
$10,000 for a first offence and up to $100,000 for a second or subsequent offence.6
Many of AHSs Protective Services staff are trained community peace officers and have the
authority to fine people who are not complying with the TRA. AHS community peace officers
monitor facilities and approach anyone not compliant with the Act to inform and educate them
about the legislation and to redirect them to an alternative location. Individuals who are not in
compliance with the TRA may be subject to a fine of $287.6 AHS intends to warn patients and
visitors prior to issuing fines. Although only Protective Services staff can fine people under
the TRA, all AHS staff have the authority and responsibility to ask people to comply with the
TSFE policy.1
Staff are subject to disciplinary actions for non-compliance with all AHS policies, including the
TSFE. AHS Progressive Discipline Procedure #EAR-02-04 commences with a verbal warning
and progresses to a written warning, suspension with or without pay, and dismissal. Staff may
also be fined under the TRA.
For more information, see:
http://insite.albertahealthservices.ca/trp/tms-trp-ahs-standard-tobacco-enforce.pdf
TSFE POLICY PROTOCOLS

Special considerations protocol
The most senior site manager at a site that is not yet tobacco free may provide special
considerations to clients. This is only if the tobacco is used in accordance with the TRA, its
regulations and any applicable municipal bylaws, if the tobacco use is kept away from public
view and if the site manager works with the AHS Population, Public, and Aboriginal Health
Division to transition the site into becoming tobacco free in accordance with the AHS Tobacco
Reduction Implementation Plan.2
AHS clients may also qualify for an exemption from the TSFE policy if they are able to
use tobacco out of public view, at an outdoor designated tobacco use area, at their site by
themselves or with the support of family/friends under the following situations:2
the patient/resident is considered to be palliative and nicotine replacement threapy

(NRT) and/or medications are not effectively managing their nicotine withdrawal
the client is not able to use NRT/medications due to medical contraindications

(e.g.,allergies or adverse reactions)
the client is a long-term care resident who refuses to use NRT/medications
5.3
the client is a long-term care resident with dementia or who is unable to understand
or comply with policy
the client is mandated in a psychiatric unit
the client is a person with developmental disabilities who is unable to understand

how to use NRT or unable to comply with the policy due to behaviours/mannerisms
(e.g.,aggressive behaviour, unable to communicate)
the client is in an emergency room and refuses to comply with policy
If a client is deemed to meet the criteria of one of the situations listed above, the site
manager, attending physician and staff may agree to grant special consideration for that
individual.2 The client may then use tobacco in accordance with the TRA and any applicable
municipal bylaws. The tobacco use must also be kept awayfrom public view, in an area
agreed to by site leadership and protective services.2
The TSFE special considerations protocol is available at:
http://insite.albertahealthservices.ca/trp/tms-trp-tsfe-policy-special-considerations-protocol.pdf
Ceremonial tobacco use protocol

The traditional ceremonial use of tobacco has powerful spiritual meaning to many Aboriginal
peoples. The tobacco plant is treated with a great deal of respect: being picked at the right
time, cured naturally in sunlight and blended with other plants native to the area (e.g., sage,
lavender, sassafras, sweetgrass). Many spiritual ceremonies involve the burning of these
substances (e.g., the sacred sweetgrass ceremony). Because this burning may produce
smoke, care must be taken in providing a safe setting for these rituals.
Spiritual and cultural ceremonies involving traditional tobacco use may be permitted at sites
in designated spaces identified by site managers or directors. Due to the spiritual significance
of ceremonial tobacco use, it is preferred that the ceremony be held in a chapel, if available.
If the patient is in intensive care, the attending physician must be consulted before granting
approval for the ceremony. Criteria for granting approval for performing the ceremony in the
patients room includes

the well-being of the critically ill patient
the safety and well-being of staff and other patients in the area
no oxygen or flammable anesthetics being used in the immediate area (turning off all
free-flowing oxygen units in the room during the ceremony)
substances being lit outside the patients room in the main area of ICU, in the case of
a ventilated patient
taking care to keep the burning ceremony as far away as possible from any medical
equipment
the ceremony taking place in a single or isolation room
Protective Services and maintenance staff should be notified in advance of any ceremonies
performed in the chapel, any inpatient room or any other area protected by a smoke detector.
Site protocol will be followed to bypass, remove and/or disable the smoke detector(s). Once
the smoke detector has been disabled, the site manager will be notified and the ceremony
can begin. The site manager will ensure the room is continuously monitored while the
smoke detector is disabled. Upon completion of the ceremony, the site manager will advise
maintenance staff to reactivate the smoke detector.
5.4
USE OF TOBACCO-LIKE PRODUCTS ON AHS PROPERTY

The use of tobacco-like products, including electronic cigarettes and medical marijuana,
isrestricted on AHS property.
Electronic smoking products

The category of electronic smoking products (ESPs), also known as electronic cigarettes,
e-cigarettes and electronic nicotine delivery systems (ENDS), is described in Chapter 2
(The Effects of Tobacco Exposure). ESPs may not be used indoors at AHS sites because
there is not enough evidence demonstrating the safe, indoor use of the product for users
and those exposed to the vapour emitted from the products. Clients who request ESPs
should be informed that ESPs are also not approved as smoking cessation aids by Health
Canada. Those clients who require assistance in managing their nicotine dependence or
support in quitting smoking should be offered cessation medications that have been clinically
tested and approved by Health Canada as outlined in Chapter 9 (Pharmacotherapy).
For more information on electronic smoking products, visit:

http://insite.albertahealthservices.ca/trp/tms-trp-electronic-smoking-products-ahs-property.pdf
http://insite.albertahealthservices.ca/trp/tms-trp-ahs-electronic-smoking-products.pdf
http://insite.albertahealthservices.ca/trp/tms-trp-electronic-cigarettes-lets-talk.pdf
Medical marijuana
Marijuana (cannabis, referred to in federal legislation as marihuana) is a tobaccolike
material consisting of the dried tops and leaves of the cannabis plant, Cannabis sativa.4
Possession of marijuana in Canada is a criminal offense unless an individual has
authorization to possess or a licence to produce marijuana for medical purposes from
Health Canada. Marijuana produced, possessed and used legally under Health Canadas
regulations is known as medical marijuana.
The Authorization to Possess Marihuana for Medical Purposes permits qualified applicants
to possess and use dried marijuana, subject to the federal Marihuana Medical Access
Regulations.8 This authorization does not grant the unrestricted public use of medical
marijuana. Medical marijuana is also legally available in prescription drug form, which is
made with synthetic versions of chemicals naturally occurring in the plant. The medical
marijuana products available in Canada are a spray form called Sativex and oral (pill form)
products dronabinol (Marinol) and nabilone (Cesamet).4
AHS provides a safe and healthy environment for patients, visitors, staff, physicians and
volunteers by implementing the TSFE policy.1 In keeping with the TSFE policy and the
TRA, the smoking of medical marijuana on AHS property is restricted.6 Any persons that
do not have the expressed written permission of AHS, including all outpatients, visitors
and staff, are not permitted to smoke marijuana on AHS property, even if they possess an
Authorization to Possess Marihuana for MedicalPurposes.
5.5
AHS has the sole discretion to permit patients, on a case-by-case basis, to smoke medical
marijuana on AHS property. Permission will be granted only if the inpatients medical
practitioner deems that the only effective or medically appropriate treatment of the inpatients
condition(s) and symptom(s) is inhalation of marijuana smoke. To be eligible to receive this
permission, inpatients must have a current, valid Authorization to Possess Marihuana for
Medical Purposes under Health Canadas Marihuana Medical Access Regulations. The site
manager for the AHS facility, in consultation with the inpatients medical practitioner, will
specify an appropriate location and time for treatment that minimizes the risk of others being
exposed to second-hand smoke. The inpatient may only smoke medical marijuana in the
location and at the times specified by the AHS site manager.
This is supported by the recommendation from Heath Canada advising against public use of
medical marijuana:
Given the nature of marihuana and the fact that the provision of marihuana is for
your personal treatment needs, Health Canada recommends not consuming this
controlled substance in a public place. Please take note that persons in charge
of public or private establishments (e.g., bars and restaurants) can request
that you not smoke marihuana on their premises, even if you have authority to
possess marihuana for medical purposes. There may also be municipal bylaws
that prevent smoking. In addition, others should not be exposed to second-hand
marihuana smoke. 7
For more information on medical marijuana use on AHS property, visit:
http://insite.albertahealthservices.ca/trp/tms-trp-medical-marijuana-ahs-property.pdf
TSFE POLICY-SUPPORTING RESOURCES

There are many resources to support the implementation of Tobacco Free Futures and the
TSFE policy.
Policy assessment
Sites are expected to fully implement and comply with the AHS TFSE policy. A policy
assessment tool is available to help the site committee identify its successes and challenges
with the policy. The assessment will be used to develop goals and objectives for the sites
success in achieving a minimum 95% compliance rate. Please note that a 5% window exists
to accommodate clients being granted special consideration only.
See appendices:
Appendix 5(a): Tobacco and Smoke Free Environments Policy Assessment Tool
Policy consultation team

Alberta Health Services has established the TSFE policy consultation team to support sites
that have questions or challenges related to the TSFE policy. The team can be contacted via
tru@albertahealthservices.ca.
Print resources
Print resources are available to health professionals in Alberta through the Tobacco
Reduction Program online catalogue: http://www.albertaquits.ca/helping-others-quit/
healthcare-providers/tools-and-resources.php.
In some cases, quantities may be limited. Some resources are also available to download.
5.6
Some of the resources that may be most helpful in supporting Tobacco Free Futures and
TSFE are highlighted in Table 5.1 below.
Table 5.1. Tobacco and Smoke Free Environments Policy Print Resources
Window cling decal
Double-sided selfadhesive window
cling decal that reads,
Welcome to our
tobacco and smoke
free environment.
Going without tobacco
is hard; we can help.
Tobacco Free Futures modifiable poster

Insert your site-specific
message to staff.
Examples include
training dates and
information on new
resources.
Cling Poster
Single-sided cling poster
that reads Welcome to
our tobacco and smoke
free environment. Going
without tobacco is hard;
we can help. Decal
includes QR code and
albertaquits.ca address.
Exterior signage
This sandwich-style board
can be used outdoors on
AHS property to promote
awareness of the policy and
available cessation support.
Tobacco Reduction Act exterior sign

This exterior sign informs
people that they are subject
to a fine for violating the
Tobacco Reduction Act.
No-smoking stencil for sidewalks

Some AHS sites have
worked with local printers
to develop large reusable
stencils of the standard
no smoking symbol. They
use the stencil to paint
sidewalks/pavement in
strategic locations around
facility. Costs vary among
local suppliers but have
averaged about $200.
5.7
REFERENCES
1. Alberta Health Services. (2011a). Tobacco and Smoke Free Environments
Policy. Edmonton, AB: Author. Retrieved from https://extranet.ahsnet.ca/teams/
policydocuments/1/clp-ahs-pol-tobacco-and-smoke-free-environments.pdf
2. Alberta Health Services. (2011b). Tobacco and Smoke Free Environments Policy,
Guidelines for special considerations. Edmonton, AB: Author. Retrieved from
http://insite.albertahealthservices.ca/trp/tms-trp-tsfe-policy-special-considerationsprotocol.pdf
3. Burton, A. (2011). Does the smoke ever really clear? Thirdhand smoke exposure raises
new concerns. Environmental Health Perspectives, 119, a70a74. Retrieved from
http://ehp.niehs.nih.gov/119-a70/
4. Canadian Centre for Substance Abuse. (n.d.). Clearing the smoke on cannabis, medical
use of cannabis and cannabinoids. Retrieved from http://www.ccsa.ca/Resource%20
Library/CCSA-Medical-Use-of-Cannabis-2012-en.pdf
5. Dale, L. (2011). What is third-hand smoke and why is it a concern? Rochester, MN: Mayo
Clinic. Retrieved from http://www.mayoclinic.com/health/third-hand-smoke/AN01985
6. Government of Alberta. (n.d.). AHS compliant with Albertas Tobacco Reduction Act.
Retrieved from http://www.albertahealthservices.ca/3192.asp
7. Health Canada. (n.d.). Application for autorization to possess dried marihuana. Ottawa,
ON: Author. Retrieved from http://www.hc-sc.gc.ca/dhp-mps/marihuana/how-comment/
forms_complete-eng.php#form_a-eng
8. Health Canada. (n.d.). Marihuana medical access regulations. Retrieved from
http://lois-laws.justice.gc.ca/PDF/SOR-2001-227.pdf
9. Rigotti, N., Munafo, M., & Stead, L. (2012). Interventions for smoking cessation in
hospitalised patients. The Cochrane Database of Systematic Reviews, 16(5), CD001837.
5.8
APPENDICES
Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool
5.9
Appendix 5(a) Tobacco and Smoke Free Environments Policy Assessment Tool (page 1)
Tobacco Free Futures policy Assessment Tool

This tool is intended to help you identify components of the AHS Tobacco and Smoke free Environments policy
(referred to in document as Policy) that your site may need for focus on. The completed assessment tool should be
retained for site records and a signed copy sent to the Tobacco Reduction Program at tru@albertahealthservices.ca.
Site: ________________________________________________ Date: ______________________________________
Person/Group Completing Assessment: _________________________________________________________________
Key Contact: _____________________ Phone: _____________________ Email: _______________________________
Select the most appropriate answer for each of the following
regarding staff awareness of the Policy and availability of
cessation supports for staff.
All
(close to
100%)
Most
(around
75%)
Some
(around
50%)
Few
(around
25%)
None
(close to
0%)
1. To what extent are clinical staff aware of the policy?
2. To what extent are non-clinical staff aware of the policy?
3. To what extent are clinical staff aware of the cessation

support available to them?
4. To what extent are non-clinical staff aware of the cessation

support available to them?
5. To what extent are clinical staff compliant with the Policy?
6. To what extent are non-clinical staff compliant with the

Policy?
7. Select the medium/media used at your site to ensure staff awareness of the Policy: (check all that apply)
Policy is discussed in all new staff orientations.
Policy is discussed regularly in meetings.
Posters are displayed at the site.
Policy is included in zone newsletter communications.
Policy is included in staff email communications.
No media have been used.
Other, specify __________________________________________________________________________
8. Is there a system in place at your site to address staff non-compliance with the Policy?
Yes
No
9. Has your site used any of the following communications media to make clients and visitors aware of the Policy:
(check all that apply)
Indoor Policy posters
Outdoor Policy posters
Tobacco Free Futures posters
Direct personal communications with patients and visitors
None
Others, specify __________________________________________________________________________
coMMENTS:
5.10
All
(close to
100%)
Most
(around
75%)
Some
(around
50%)
Few
(around
25%)
None
(close to
0%)
10. To what extent are clients who enter your site informed of
the Policy by a staff member?
11. To what extent are clients assessed for tobacco use?
12. To what extent are clients who smoke specifically informed

of the Policy by a staff member?
13. To what extent are clients who smoke offered cessation

medications?
14. To what extent are clients who smoke offered counselling

support?
15. To what extent are clients who smoke offered cessation

information and resources on discharge?
Reflecting on the practices at your site, select the most

appropriate answer for each of the following.
16. Overall, to what extent are clients and visitors compliant with the Policy?
Clients and visitors are fully compliant with the Policy: clients/visitors do not smoke on the site grounds.
Clients and visitors are mostly compliant with the Policy: few clients/visitors are found to smoke on the site
grounds.
Clients and visitors are somewhat compliant with the Policy: some clients/visitors are found to smoke on the site
grounds.
Clients and visitors are not compliant with the Policy: clients/visitors continue to smoke on the site grounds.
coMMENTS:
Select the most appropriate answer regarding implementation of and compliance with
the Policy.
Yes
No
Unsure
17. Does your site have a Champion for the Policy?
18. Does Protective Services support compliance with the Policy at your site?
19. Have there been any safety incidents related to the Policy?
20. Are you experiencing any tobacco litter issues?
21. Has your site designated a location for client tobacco use under specific considerations?
Yes, our site has designated an out of public view outdoor space for special considerations.
Specific considerations have been granted but not specifically in an out of public view space.
No, clients continue to smoke in their desired location.
No, clients at our site do not meet the criteria for specific considerations.
Tobacco Free Futures 2
of 3
5.11
22. Which of the following groups most present a challenge in terms of compliance with the Policy?
site staff
protective services officers
clients
visitors
none
other, specify ______________________________________________________________________________
23. Select the answer that best summarizes the status of your site with respect to implementation of and compliance with
the Policy:
The Policy is fully implemented, and there is no tobacco use on this AHS property.
The Policy is mostly implemented with some challenges remaining.
The Policy is somewhat implemented with challenges remaining.
The Policy has not been implemented, and challenges currently impede implementation.
coMMENTS:
GoAlS
Upon reviewing the answers and comments in the above sections, identify the priority areas for your site in order to
comply with the AHS Tobacco and Smoke Free Environments Policy. Record your priority areas in section below as
Policy Compliance Goals.
polIcY coMplIANcE GoAlS
From the above data, the following policy compliance goals have been identified for our site:
1.
2.
3.
4.
plANNED AcTIVITIES
The timelines for accomplishing the identified goals are to begin work on <INSERT START DATE> and complete work on
<INSERT END DATE>. The table below outlines the planned activities to accomplish these goals including resources
required, and budget implications.
#
Task
comments
person
Responsible
Start Date
End Date
cost
1
2
3
4
5
The completed assessment tool should be retained for site records and a signed copy sent to the Tobacco Reduction
Program at tru@ablertahealthservices.ca.
Tobacco Free Futures 3
5.12
of 3
CHAPTER 6
Timelines
6.1
PURPOSE OF TIMELINES AND SCHEDULES

Timelines and schedules are essential planning tools in nearly every step in the planning
process. They are extremely helpful in keeping you focused and on track. You can be as
specific as you want for every area of implementation. A thought-out schedule of activities
guarantees that significant and essential tasks are met in a timely manner. Think of the
schedule as an opportunity to double check everything, leaving all questions answered
and tasks done.
The complexity or simplicity of your timeline will be determined by the size and services of
your health care setting. Timelines are useful in your committee meetings, in delegating
responsibilities and in following up on tasks.
CREATING AN IMPLEMENTATION TIMELINE

Baseline assessment
A number of factors will influence the length of time needed to implement the Tobacco Free
Futures initiative, including

site leadership support
current tobacco treatment practices
other initiatives occurring at the site
staff availability for training and supporting the implementation of the initiative
the size of the site and the number of units/services
number of staff
The baseline assessment planning tool, along with the policy compliance assessment tool
found in Chapter 5 (Policy) will help determine the length of time needed to implement the
Tobacco Free Futures initiative at a particular site.
See appendices:
Appendix 6(a) Tobacco Free Futures Baseline Assessment
6.2
Creating an implementation plan

Timelines are used to meet critical dates. The best time to create an event timeline is during
or after the initial meetings of the committee, after the policy assessment and baseline
assessment are complete. Remember: the purpose of the timeline is to keep you on track, so
set the timeline early and update it as necessary. One way to create a timeline is to start from
the go-live date and then work backward. Revise your timeline as often as you need to. The
point is to get everything down on paper and give you enough time to complete each task.
The committee will need to determine if a complete site or staged implementation timeline
will work best for your setting. A complete site rollout could allow for units to support each
other throughout the process; however, competing organizational demands might make a
staged implementation a better alternative. Setting a realistic go-live date for the site will
allow the committee to set timelines to guide the implementation process. The go-live date
should also occur after staff training is complete.
As a general rule, allow a minimum of 16 months to complete all 10 Tobacco Free
Futures processes, as outlined in Chapter 1 (Tobacco Free Futures: A Systems Change
Management Model). Suggested timelines for activities in each of the four implementation
phases are outlined in Tables 6.1, 6.2, 6.3 and 6.4 below. An expanded version of these
tables in Appendix 6(b) can be used as a worksheet, along with the information you have
gathered through the baseline and policy assessments, to develop an implementation plan
for your site.
See appendices:

Appendix 6(b) Tobacco Free Futures Implementation Plan
6.3
Table 6.1: Implementation Phase One Suggested Timelines

Milestones/Tasks
Timeline (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1.0 Establish the support of senior site leadership.

1.2 Establish the support of senior physician leadership.
1.3 Connect with the Tobacco Reduction Program to identify your zone
coordinator.
1.4 Complete and sign memorandum of understanding.
1.5 Send signed copy of memorandum to Tobacco Reduction Program.
2.0 Tobacco Free Futures site committee
2.1 Appoint chair(s) for committee.
2.2 Send site designates to Tobacco Free Futures workshop.
2.3 Select members for multidisciplinary committee and assign alternate
members.
Initial Planning
2.4 Complete committee contact list.

2.5 Ensure each committee member has a copy of the guidelines and toolkit.
2.6 Review Tobacco Free Futures initiative and 10 change processes.
2.7 Establish terms of reference for committee.
3.0 Policy assessment planning.
3.1 Review AHS Tobacco and Smoke Free Environments policy and protocols.
3.2 Complete policy assessment.
3.3 Identify policy compliance goals and planned activities.
3.4 Review goals and activities with site senior leadership and gain approval.
3.5 Senior leadership and committee to communicate activities.
3.6 Send copy of completed policy assessment to Tobacco Reduction Program.
3.7 Establish policy compliance working group.
3.8 Working group implements policy compliance planned activities.
4.0 Implementation timelines.
4.1 Complete site baseline assessment.
4.2 Review specific care setting and specific populations information.
4.3 Determine cessation support required by all client populations on site.
4.4 Develop implementation plan and set go-live date.
4.5 Review implementation plan with senior site leadership and gain approval.
4.6 Send copy of approved implementation plan to Tobacco Reduction Program.
6.4
Table 6.2: Implementation Phase Two Suggested Timelines

Milestones/Tasks
Timeline (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
5.0 Brief intervention planning

5.1 Review brief intervention processes and integrated care pathway.
5.2 Determine clients to receive brief intervention support on site.
5.3 Identify staff responsible for brief tobacco intervention.
5.4 Compare current practice and AHS standards.
5.5 Determine where documentation will reside in client charts.

5.6 Change site client charts or use new form for each affected unit.
5.7 Review referral options and establish site standard.
5.8 Review and adopt site standards for self-help materials.
5.9 Review and adopt site standards for staff print resources.
Resource Development
5.10 Identify how resources will be made accessible to all staff and clients.
6.0 Intensive counselling support planning
6.1 Review AHS standards for intensive tobacco counselling.
6.2 Determine clients to receive intensive counselling support on site.
6.3 Identify staff responsible for each component of intensive counselling.
6.4 Compare current documentation and AHS standards.
6.5 Determine where documentation will reside in client charts.

6.6 Change charts or use new form for each affected unit/service area.
6.7 Review and adopt site standard self-help materials for intensive counselling.
7.0 Pharmacotherapy planning
7.1 Review AHS standards for cessation pharmacotherapy.
7.2 Determine clients to receive pharmacotherapy support on site.
7.3 Amend and order stock pharmacotherapy based on formulary.
7.4 Identify staff responsible for pharmacotherapy support.
7.5 Compare current documentation and AHS standards.
7.6 Determine where documentation will reside in site client charts.
7.7 Change site client charts or use new form for each affected unit.
7.8 Adopt site standard client self-help materials for pharmacotherapy.
6.5
Table 6.3: Implementation Phase Three Suggested Timelines

Milestones/Tasks
Timeline (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
8.0 Communication plan

8.1 Review communication rationale and tools.
8.2 Arrange presentation to senior site management to engage support.
8.3 Send invitation to join site committee.
8.4 Inform site mangers of established timelines for implementation.
8.5 Inform staff and physicians of established timelines for implementation.
8.6 Inform all managers of training availability and expectations.
8.7 Notify identified tobacco leads of their training and roles.

Preparing Staff
8.8 Inform frontline health care professionals of training.

8.9 Inform referring health professionals of site plans for implementation.
8.10 Inform prescribers of education opportunities.
8.11 Inform clients / visitors of AHS Tobacco and Smoke Free Environments policy.
8.12 Inform staff of sustainability plans and celebrate successes.
9.0 Training
9.1 Review AHS training options and availability.
9.2 Identify staff to be tobacco practice leads. Determine training needs.
9.3 Identify training for brief intervention, intensive counselling and prescribers.
9.4 Determine format that will be used as site standards for training.
9.5 Add tobacco training attendance to new hire training lists.
9.6 Schedule and deliver orientation to all staff for AHS policy.
9.7 Schedule and deliver training for tobacco practice leads.
9.8 Schedule and deliver training for brief tobacco intervention.
9.9 Schedule and deliver training for intensive counselling.
9.10 Schedule and deliver training for prescribers.
6.6
Table 6.4: Implementation Phase Four Suggested Timelines

Milestones/Tasks
Timeline (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
10.0 Sustainability
Final Planning
10.1 Review information regarding sustainability.

10.2 Develop sustainability plan.
10.3 Review sustainability plan with senior site leadership and gain approval.
10.4 Send copy of approved sustainability plan to Tobacco Reduction Program.

11.0 Continuous improvement
11.1 Review information regarding continuous improvement.
11.2 Complete quality improvement assessment.
11.3 Complete quality improvement plan.
11.4 Review assessment and plan with senior site leadership and gain approval.
11.5 Send copies of assessment and plan to Tobacco Reduction Program.
6.7
APPENDICES
Appendix 6(b) Tobacco Free Futures Implementation Plan
6.8
Appendix 6(a) Tobacco Free Futures IBaseline Assessment (page 1)
Tobacco Free Futures baseline Assessment

Date: __________________Site/Program: __________________________________________________
Key Contact: ___________________Phone: ___________________Email: ________________________
Using the data and key informants that are available to you, complete the following assessment tool. Responses and
improvement goals should be discussed with the committee and all affected stakeholders.
SITE DEMoGRApHIc DATA
ITEM
RESpoNSE/Comments
1. Number of inpatient admissions

annually
2. Number of outpatient admissions
annually
3. Number of unit managers
4. Number of clinical educators
5. Number of nurse specialists
6. Number of RNs
7. Number of RNAs / LPNs
8. Number of other health care
professionals
9. Number of support staff (e.g.,
administrative)
10. Number of non-professional staff
(e.g., housekeeping,
maintenance)
11. Number of physicians
12. Number of medical residents
13. Number of students
14. Number of Protective Services
staff
15. Names of units and number of
beds in each unit
1/2
6.9
Appendix 6(a) Tobacco Free Futures IBaseline Assessment (page 2)
Completing the following section will help you understand what the current tobacco treatment practice is at your site.
For detailed information regarding the current status of compliance with the AHS Tobacco and Smoke Free
Environments Policy, complete the Tobacco Free Futures policy assessment tool in Appendix 5(a) of the guidelines.
cuRRENT TobAcco TREATMENT pRAcTIcE
ITEM
RESpoNSE (YES/No)/Comments
1. Site leadership engaged

2. Integrated care pathways for tobacco
treatment
3. Tobacco use identified and documented
for all admissions
4. Cessation medications available on site
and standard orders in place
5. Training for tobacco dependence and
nicotine withdrawal offered to health care
providers
6. Intensive cessation support services on
site
7. Client self help materials readily available
8. Links to resources in community
9. Process to follow-up with clients after
initial treatment
10. Process for communicating with staff
11. Process for monitoring and reporting on
progress to staff
The completed assessment will assist in the development of your site/program implementation plan. Refer to the
Tobacco Free Futures implementation plan in Appendix 6(b) of the guidelines.
The completed baseline assessment should be retained for site records and a copy sent to
6.10
2/2

1/7
Using the data and key informants that are available to you, establish baseline activities and timelines for the implementation plan. The plan should be
agreed to by the committee and senior site leadership.
10. Plan for sustainability and continuous improvement.
9. Arrange and schedule training for all staff.
8. Implement a communication plan for site leadership, staff, clients and visitors.
7. Stock print resources for staff and clients.
6. If applicable, ensure pharmacotherapy is available in formulary, stocked on site, and adopt standard
ordering or referral processes.
5. Determine staff roles and ensure tobacco treatment will be documented in the client record.
4. Set a timeline for implementation of the 10 processes.
3. Complete Policy Assessment and implement any identified activities.
2. Form a multidisciplinary Tobacco Free Futures steering committee.
1. Engage the support of senior management and physician leadership.
The following 10 change management processes are the basis for the implementation plan for your site:
The Tobacco Free Futures implementation plan will be the primary document used by your committee to integrate tobacco treatment into routine care at
your site. The plan should be kept as up-to-date as possible. The completed plan should be retained for site records and a signed copy sent to the
Tobacco Reduction Program at tru.albertahealthservices.ca.
Key Contact: ___________________ Phone: ___________________ Email: ________________________
Date: __________________ Site/Program: __________________________________________________
TOBACCO FREE FUTURES IMplEMENTATIoN plAN
Appendix 6(b) Tobacco Free Futures Implementation Plan (page 1)
6.11
6.12
MIlESToNES/TASKS
3.2 Complete policy assessment. Appendix 5(a)
3.1 Review AHS Tobacco and Smoke Free Environments

Policy and related protocols. Chapter 5
3.0 policy assessment and planning
Appendix 4(a)
2.7 Establish terms of reference for committee.
2.6 Review Tobacco Free Futures initiative and 10 change

management processes. Chapters 1& 2
2.5 Ensure each committee member has a copy of the

Tobacco Free Futures guidelines and toolkit.
2.4 Complete committee contact list. Appendix 4(b)
2.3 Select members for multidisciplinary committee and

assign alternate members. Chapter 4
2.2 Send site designates to Tobacco Free Futures

implementation workshop. Chapter 11
2.1 Appoint chair(s) for committee.
2.0 Site Tobacco Free Futures steering committee
1.5 Send signed copy of memorandum to Tobacco

Reduction Program.
Appendix 3(a)
1.4 Complete and sign memorandum of understanding.
1.3 Connect with Tobacco Reduction Program to identify

your zone coordinator.
Chapter 3
1.2 Establish the support of senior physician leadership.
Chapter 3
1.0 leadership engagement
pHASE 1
ScHEDulE
Start finish
pERSoN(S)
RESpoNSIblE
NoTES
2/7
INITIAl plANNING
Appendix 5(a)
4.6 Send copy of approved implementation plan to Tobacco

Reduction Program.
4.5 Review implementation plan with senior site leadership

and gain approval.
4.4 Develop implementation plan and set go live date.
4.3 Determine cessation support required by all client

populations on site. Chapters 79
4.2 Review specific care setting and specific population

information relevant to your site. Chapters 1421
4.1 Complete baseline assessment. Appendix 6(a)
4.0 Implementation timelines
3.8 Working group implements policy compliance planned

activities and reports on progress to committee.
3.7 Establish policy compliance working group.
3.6 Send copy of completed policy assessment to Tobacco

Reduction Program. Appendix 5(a)
3.5 Senior leadership and committee to communicate policy

goals and planned activities with all affected
stakeholders.
3.4 Review goals and activities with site senior leadership

and gain approval. Appendix 5(a)
3.3 Identify policy compliance goals and planned activities.
3/7
6.13
6.14
MIlESToNES/TASKS
6.2 Determine clients to receive intensive tobacco

counselling support on site.
6.1 Review AHS standards for intensive tobacco

counselling. Chapter 8
6.0 Intensive counselling support planning
5.10 Identify staff responsible for ordering and how resources

will be made accessible to all staff and clients.
5.9 Review and adopt site standards for staff print

resources. www.albertaquits.ca
5.8 Review and adopt site standard self-help materials.

What will be given to patients not ready to quit and
those who are ready to quit? www.albertaquits.ca.
5.7 Review referral options available locally and provincially.

Establish site standard for referral and documentation
process. Appendix 7(b)
5.6 Change existing patient/client chart forms or adopt new

form for brief tobacco intervention for each unit/service
area.
5.5 Determine where the brief tobacco intervention

documentation will reside in patient/client charts.
Appendix 7(a)
5.4 Identify any discrepancies between current brief tobacco

intervention documentation and AHS standards.
5.3 Identify staff responsible for each component of the brief

tobacco intervention.
5.2 Determine clients to receive brief tobacco intervention

support on site.
5.1 Review AHS standard brief tobacco intervention

processes and integrated care pathway. Chapter 7
5.0 brief intervention planning
pHASE 2
ScHEDulE
Start finish
pERSoN(S)
RESpoNSIblE
NoTES
4/7
RESouRcE AND SuppoRT plANNING

will be made accessible to staff and clients.
7.8 Review and adopt site standard client self-help materials

for pharmacotherapy. www.albertaquits.ca
7.7 Change existing order sets or adopt standard order set

for pharmacotherapy for each affected unit/service area.
7.6 Determine where the pharmacotherapy documentation

will reside in site client charts.
7.5 Identify any discrepancies between current

pharmacotherapy prescribing and documentation and
AHS standards. Appendix 9(a) & 9(b)
7.4 Identify staff responsible for each component of

pharmacotherapy support.
7.3 Review cessation medications available on AHS

formulary and compare to those currently available on
site (inpatient/outpatient pharmacies, stocks on
wards/units). Amend and order stock if needed.
7.2 Determine clients to receive pharmacotherapy support

on site.
Chapter 9
7.1 Review AHS standards for cessation pharmacotherapy.
7.0 pharmacotherapy planning

will be made accessible to staff and clients.
6.7 Review and adopt site standard self help materials for
intensive tobacco counselling. www.albertaquits.ca
6.6 Change existing patient/client chart forms or adopt new

form for intensive tobacco counselling for each affected
unit/service area.
6.5 Determine where the intensive tobacco counselling

documentation will reside in site client charts.
Appendix 8(a)
6.4 Identify any discrepancies between current intensive

tobacco counselling documentation and AHS standards.
6.3 Identify staff responsible for each components intensive

tobacco counselling.
5/7
6.15
6.16
MIlESToNES/TASKS
9.3 Determine training needs and expectations for brief

intervention staff, intensive counselling staff and
prescribers. Chapter 11
9.2 Identify staff to be tobacco practice leads. Determine

training needs and expectations. Chapter 11
9.1 Review AHS training options and availability. Chapter 11
9.0 Training
8.12 Inform staff of sustainability plans and celebrate success

of implementation. Appendix 10(k).
8.11 Inform visitors and patients of tobacco and smoke-free

environment and supports available. Appendix 10(j).
8.10 Inform physicians of expected role in support of brief

intervention and education opportunities. Appendix 10(h).
8.9 If applicable, inform referring agencies of site plans for

implementing Tobacco Free Futures. Appendix 10(i)
8.8 Inform front-line health care professionals of training

opportunities and expectations. Appendix 10(g)
8.7 Notify identified tobacco practice leads of training

expectations and supportive role. Appendix 10(f)
8.6 Create awareness of availability and expectations of

staff training to all site managers. Appendix 10(e)
8.5 Inform staff and physicians of established timelines/

target dates for implementation. Appendix 10(d)
8.4 Inform site mangers of established timelines/target

dates for implementation. Appendix 10(c)
8.3 Send invitation to join site Tobacco Free Futures

steering committee to identified members. Appendix 10(b)
8.2 Arrange presentation to senior site management to

engage support. Appendix 10(a)
8.1 Review communication information and tools. Chapter 10
8.0 communication plan
pHASE 3
ScHEDulE
Start finish
pERSoN(S)
RESpoNSIblE
NoTES
6/7
pREpARING STAff
MIlESToNES/TASKS
11.5 Send copies of assessment and quality improvement

plans to Tobacco Reduction Program.
11.4 Review assessment and plan with senior site leadership

and gain approval.
11.3 Complete quality improvement plan. Appendix 13(b).
Appendix 13(a).
11.2 Complete quality improvement assessment.
Chapter 13.
11.1 Review information on continuous improvement.
11.0 continuous improvement
10.4 Send copy of approved sustainability plan to Tobacco

Reduction Program.
10.3 Review sustainability plan with senior site leadership

and gain approval.
10.2 Develop sustainability plan. Appendix 12(a)
10.1 Review information on sustainability. Chapter 12.
10.0 Sustainability
pHASE 4
9.10 Schedule and deliver training for prescribers.
9.9 Schedule and deliver training for intensive counselling.
9.8 Schedule and deliver training for brief tobacco

intervention.
9.7 Schedule and deliver training for tobacco practice leads.
9.6 Schedule and deliver orientation to all staff (clinical and

non-clinical) for AHS policy and supports available.
9.5 Add tobacco training attendance to existing education

tracking systems.
9.4 Determine format that will be used as site standards for

training.
ScHEDulE
Start finish
pERSoN(S)
RESpoNSIblE
NoTES
7/7
6.17
fINAl plANNING
Resource and
Support Planning
7. Brief Intervention
8. Intensive Cessation Counselling
9. Pharmacotherapy
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
TOBACCO INTERVENTION RESOURCE AND

SUPPORT PLANNING
Every tobacco user who expresses the willingness to begin treatment to quit should be
offered assistance. Brief interventions of 1 to 3 minutes are effective and should be offered at
every available opportunity. However, because there is a strong doseresponse relationship
between the session length and successful treatment, intensive interventions should be used
whenever possible.
The following three chapters will provide valuable information to consider when planning
which form of tobacco support will be offered as a part of routine care. Important factors to
consider are the average length of stay for the client and the staff available within the care
setting, as well as the considerations outlined in the Specific Care Settings and Specific
Populations sections of these guidelines.
Chapter 7: Brief Intervention

Importance of integrating tobacco cessation supports into health care treatment.
The 5 As of the brief tobacco intervention.
Care pathway for minimal support.
Suggested staff roles in providing brief tobacco intervention.
Tools available to support brief tobacco intervention.
Chapter 8: Intensive Cessation Counselling

Guidelines for intensive cessation support.
Effective counselling options to support persons who are not ready to quit, who are
ready to quit and who have recently quit.
Suggested staff roles in providing intensive cessation counselling.
Tools to support delivery of intensive cessation counselling.
Chapter 9: Pharmacotherapy

Use of pharmacotherapy in supporting temporary abstinence and long-term cessation.
Overview of special considerations for specific populations.
Assessing nicotine withdrawal.
Staff roles in relations to delivery of pharmacotherapy.
Tools to support pharmacotherapy treatment.
Chapter 7
Brief Intervention
7.1
TOBACCO CESSATION SUPPORT MODELS

FOR Health care settings
Treatment in or admission to a health care facility provides an important opportunity to
support temporary and long-term cessation. The majority of smokers report a desire to quit,
and many of them will have made a quit attempt in the past 12 months.1 Patients who are
admitted or treated for smoking-related illness are often even more motivated to overcome
their addiction. It is essential to recognize that not every tobacco user is ready to attempt
cessation; however, a review of the literature has found that even a brief prompt with limited
counselling can lead to a quit rate of 3% to 13% and more intensive intervention that includes
follow-up sessions can lead to a 13% to 40% quit rate.2
Benefits of Tobacco Cessation on Health and Recovery of Patients/Clients

Receiving Care in a Health Care Setting3
1. Improved wound and bone healing
2. Reduced risk of wound infections
3. Decreased risk of cardiopulmonary complications

4. Decreased need for postoperative intensive care
5. Improved surgical results
6. Decreased risk of repeat heart attacks
7. Decreased risk for second primary tumors in patients with lung, head and neck cancer
Those who are addicted to nicotine require intervention and support to maximize their
success for cessation. Reliance on willpower alone is an outdated approach, as only
3% to 5% of those who attempt without treatment will be successful to sustain a quit
for 612 months.4
The most effective way to manage this chronic, relapsing condition is by combining
behavioural and pharmaceutical cessation interventions. The delivery of clean nicotine
in the form of nicotine replacement therapy (NRT) is a safe alternative to manage
symptoms of withdrawal. Drugs such as bupropion SR and varenicline also help to
managethe cravings.4
7.2
Brief Tobacco Intervention

Tobacco dependence treatments are clinically and cost-effective relative to other medical
disease prevention interventions.5 The Tobacco Free Futures initiative has developed care
pathways (algorithms), based on the 5 As approach, for general and specific care settings,
as well as specific populations. Supplementary resources are also provided to guide
implementation in Alberta health care settings across the continuum of care. Figure7.1
outlines the recommended general treatment pathway for health care facilities. The 5 As
approach is to ASK every patient who presents to the facility if they use tobacco, ADVISE
all tobacco users to quit, ASSESS the users readiness to quit and interest in withdrawal
support, ASSIST by identifying, providing and documenting both pharmacotherapy and
behavioural support and ARRANGE follow-up support. Using motivational interviewing
withanonjudgmental approach is foundational to the 5 As model.5
Current evidence supports the implementation of the 5 As approach for health professionals
in any setting to identify and provide at least minimal support for every tobacco user.2,5
Content in Chapters 3 to 6 of the Initial Planning section provides an overview of specific
contextual considerations to integrating the model at a health care facility. Motivational
interviewing has been taken into consideration in the development of the supporting
script outlined in Table7.1. Treatment models for specific care settings and patient/client
populations are discussed further in later related sections.
ASK
The first step in treating tobacco use and dependence is to identify tobacco users.
CANADAPTT recommends that all patients be asked if they use tobacco and have
their tobacco-use status documented on a regular basis.5 The consistent identification,
documentation, and treatment of every tobacco user seen in a health care setting will
affect a large number of tobacco users. In fact, the identification of smokers itself
increases rates of clinician intervention.
The identification of tobacco users should take into account

the use of all forms of tobacco, including cigarettes,

cigars/cigarillos, spit/chew, pipes and waterpipes
the quantity and duration of use to determine level of

tobacco dependence and nicotine addiction
the time since last use
Research indicates that

a high percentage of
those who ultimately
return to smoking will
do so by six months.2
Based on pattern and history of use, tobacco-use status can be categorized as follows:
Never: no history of use of any tobacco products
Current: continued use of tobacco products
Recent quit: cessation within the last year; currently not using tobacco products
Former: no use of tobacco products in the past year
7.3
Exposure to environmental or second-hand smoke (SHS)

causes disease and premature death in children and adults.6
The CAN-ADAPTT guidelines for youth, as well as pregnant
and breastfeeding women, provides support for addressing
exposure to SHS, which will be addressed in the proposed
algorithims for these specific populations.
Scientific evidence
indicates that there is no
risk-free level of exposure
to second-hand smoke.6
ADVISE
Evidence shows that a health providers brief advice to quit tobacco use increases abstinence
rates.2,5,7 All patients who currently use tobacco should be given personalized motivational
advice to quit by physicians and other health care professionals. Patients identified as former
or never tobacco users should be complimented and advised to continue abstaining. The
more personalized the advice, the more effective it is. Consideration should also be given to
personalizing the message based on the patients concerns, as well as potential teachable
moments that may be cued by the patients illness.2,5,7
Further advice should be given about the facilitys Tobacco and Smoke
Free Environments Policy.8 Policies are intended to support the health
of all; therefore, all staff members have a role to play.9 Every patient,
regardless of his or her smoking status, should be advised of the
Tobacco and Smoke Free Environments Policy.5 Withdrawal from
nicotine begins within hours of a persons last tobacco use, so clinicians
have a duty of care to ensure the comfort and safety of their patients
and their patients families.4
Refer to the AHS Tobacco and Smoke Free Environments Policy at
Brief advice
from a health
professional
can double the
chances of a
successful quit
attempt.10
https://extranet.ahsnet.ca/teams/policydocuments/1/clp-ahs-pol-tobacco-and-smoke-freeenvironments.pdf
ASSESS
Current tobacco users should be assessed for their readiness to make a quit attempt and,
in the case of inpatient settings, their readiness to get help managing withdrawal during
their hospital stay. Proper assessment of a users readiness to quit will ensure the most
appropriate treatment is provided.
7.4
ASSIST
It is important to assist patients/clients by improving their comfort through the relief of nicotine
withdrawal, promoting patient safety, and engaging the patient in their healing process.
Both pharmacotherapy and behavioural support are effective tobacco dependence and
nicotine addiction treatment options.2,5 The combination of
medication and counselling is more effective than either
As many as 30% to 60% of
alone. Whenever feasible and appropriate, both methods
should be provided to all patients willing to be supported,
patients who seek tobacco
except in the presence of contraindications.2,5 Furthermore,
dependence treatment have
continued assessment of adherence to treatment and the
a past history of depression
adjustment of pharmacotherapy to ensure withdrawal relief
that may be exacerbated by
should be considered. Recognition of ongoing withdrawal
withdrawal.4
symptoms may also provide teachable moments to reassess
a patients readiness to change their tobacco use.
Nicotine is known to have anti-anxiety, anti-pain and antidepressant effects, and tobacco
iscommonly used to self-treat during stressful and negative situations.10 Although most
patients with histories of depression are able to stop tobacco use with few adverse effects,
health professionals should closely monitor for changes in affect with a brief mood
assessment.2,4 Results from a brief mood assessment may indicate the need for more
in-depth assessment and referral.
Pharmacotherapy and behavioural patient interventions and supporting documentation are
discussed further in the chapters of this section.
ARRANGE
Follow-up support should be arranged for every patient who is a current tobacco user and
forall former tobacco users who are interested. Upon discharge, it is important to arrange
follow up for cessation supports and treatments that were initiated in the course of care.
It is also important to provide links to available support for any users who did not begin
treatment in the course of care but who are now interested. Telephone counselling, face-toface counselling (both group and individual) and tailored self-help materials are all effective
formats of treatment.2,5 Any pharmacotherapy that has been started in the health care setting
should alsobe arranged for upon discharge.
See appendices:
Appendix 7(b) AlbertaQuits Helpline Referral Form
7.5
Figure 7.1: Tobacco Free Futures: A Health System Tobacco Cessation Model
Tobacco use prevention and cessation treatment
ask
Ask every patient/client about tobacco use.

Document on patient/client chart.
Have you used any tobacco products in the past year?
No
Positive reinforcement.
Inform of AHS Tobacco and
Smoke Free Environments
Policy.
No
Support autonomy. Offer

information on withdrawal.
Leave offer of support open
and monitor withdrawal
symptoms.
Yes
Assess
Advise
What type? How much? How often? Last use?
Inform of AHS Tobacco and Smoke Free Environments Policy.

Advise to quit with personalized message.
Assess interest in pharmacotherapy support for withdrawal.

Assess readiness to quit.
Assess interest in behavioural support.
Are you interested in support to reduce your withdrawal

symptoms or to help you quit?
Assist
Assist with pharmacotherapy for withdrawal, including referral to

prescribing authority and/or ordering and ongoing monitoring of
withdrawal symptoms and mood assessment.
Link to behavioural support.
Arrange
Yes
Arrange further support by completing appropriate onsite and/or

community-linked referral(s).
Arrange for continued pharmacotherapy (e.g., on transfer/discharge).
7.6
ASSIST
ASSESS
ADVISE
ASK
Table 7.1: Suggested General 5 As Script

ASK all patients/clients if they have
used tobacco.
All patients/clients: Have you used any tobacco products in

the past year?
For current tobacco users and

recent quitters, ask about pattern
of use.
Current use and recent quit: What type of tobacco products

do/did you use? How much and how often do/did you use
tobacco? When was the last time you used tobacco? Do/did
you use any other tobacco products?
ADVISE all patients/clients

regardless of tobacco-use status
of Tobacco and Smoke Free
Environments Policy.
No current use: Thats great! In case you have any visitors,

Id like to let you know that this facility is tobacco-free and so
are the grounds.
For current tobacco users, advise

the patient/client to stop using
tobacco. Personalize message.
Current use: While you are here, you wont be able to use
any tobacco products in the hospital or on the grounds. And as
your health care provider, I need to let you know that research
shows the best thing you can do for your health and the health
of those around you is to not use tobacco.
ASSESS interest in support for relief

of withdrawal.
Current use and recent quit: Are you interested in

medication to help manage your withdrawal symptoms?
For current tobacco users, assess

readiness to quit.
Are you interested in more information or support to make/

sustain a change in your tobacco use?
ASSIST the patient/client who is

not interested in support with brief
information.
Not interested: Id like to leave you with some brief

information on withdrawal symptoms and support available.
Please let me or another health care provider know if you
change your mind.
For the patient/client who

is interested, assist with
pharmacotherapy for relief of
withdrawal, including ongoing
monitoring for withdrawal symptoms
and mood assessment.
Interested: Im going to let your doctor know that you are

interested in medication for withdrawal. Id also like to offer
you some brief information on withdrawal symptoms and on
strategies and supports that can help you quit.
ARRANGE
Link to behavioural support.

ARRANGE for follow up on
discharge for any pharmacotherapy
started and link to further
behavioural support.
Interested: I will provide you with an outline of the NRT you

were on in hospital so you can continue it on discharge OR
Your physician has provided a prescription for you to continue
the medication you started while in our facility when you go
home.
Id also like to offer you some information on other support
available in the community. If you are interested, I would like to
refer you to a free and confidential cessation service to ensure
youre successful with your plan and to offer you more help.
7.7
BRIEF INTERVENTION STAFF ROLES

AND DOCUMENTATION
Defining staff roles and client care documentation are essential processes that will have a
direct impact on the success of the implementation and sustainability of the Tobacco Free
Futures initiative.
Staff roles
The staff who will perform and document the following client-centred activities need to be
identified:
1. screening for tobacco use
2. informing visitors, families and clients of the AHS Tobacco and Smoke Free
Environments Policy
3. informing clients of the importance of quitting tobacco
4. informing clients of the available cessation resources
5. assessing clients readiness to quit and their interest in resources
6. assisting clients who are not interested in support with brief information
7. assisting clients who are interested in support with pharmacotherapy for relief of
withdrawal symptoms, including ongoing monitoring and mood assessment
8. arranging for follow up for any pharmacotherapy started and linking the client to
ongoing behavioural support
Documentation
The AHS Brief Tobacco Intervention Form is intended to facilitate a brief tobacco intervention.
It contains the pertinent information as outlined in this chapter. This form has been reviewed
by the Cancer Care Strategic Clinical Network and adopted as an Alberta Health Services
standardized form.
All forms are now available through the provincial Alberta Health Services forms inventory
and can be accessed through approved zone forms ordering processes or through the AHS
Forms Library on Insite:

Edmonton Zone: call (780) 577-8295 (Data Group) or visit the online catalogue
North Zone: call (780) 577-8295 (Data Group) or visit the online catalogue
Calgary Zone: call (403) 207-6652 (Data Group) or visit the online catalogue
Central Zone: call (780) 361-4180 (Wetaskiwin Production Services)
South Zone: call (403) 388-6123 (former Chinook) or (403) 502-8648,

extension 1088 (former Palliser)
See appendices:
Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form
7.8
References
1. The Lung Association. (2008). Making quit happen: Canadas challenges to smoking
cessation. Ottawa, ON: Author.
(2008).Treating Tobacco Use and Dependence. Rockville, MD: U.S. Department of
3. Center for Tobacco Research and Innovation. (2000). Treating tobacco use and
dependence in hospitalized patients. Madison, WI: University of Wisconsin Medical
School. Retrieved from http://www.ctri.wisc.edu/HC.Providers/Guideline%20Hospital%20
Info.pdf
4. Els, C. (2008). Tobacco addiction: What do we know, and where do we go? Montreal,
QC: Snell Medical Communications.
5. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT.) (2011). Canadian smoking cessation
cinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved
from http://can-adaptt.net
6. World Health Organization. (2008). International consultation on environmental tobacco
smoke (ETS) and child health. Retrieved from http://www.who.int/tobacco/publications/
youth/en/
7. Stead, L., Bergson, G., & Lancaster T. (2008). Physician advice for smoking cessation.
Cochrane Database of Systematic Reviews, 2008, 2. Art. No.: CD000165.
8. Schultz, A., Bottorff, J., & Johnson, J. (2006). An ethnographic study of tobacco control
inhospital settings. Tobacco Control, 15, 317 322.
9. Rigotti, N., Munafo, M., & Stead, L. (2007). Interventions for smoking cessation
in hospitalised patients. Cochrane Database of Systematic Reviews, 2007, 3.
Art.No.:CD001837.
10. Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P. (2007). The
Press.
7.9
Appendices
Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form
7.10
Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form (page 1)
Patient label placed here (if applicable) or if labels are not
used, minimum information below is required.
Name (last, first)
Birthdate (yyyy-Mon-dd)
Gender
Tobacco Dependence and cessation

brief Intervention
Personal Health Number
The AlbertaQuits Helpline Referral (form #09973) may accompany this form.
Ask
Have you used any tobacco
products in the last year?
Type of tobacco (check all that apply)

Cigarette
Cigar/cigarillo
Pipe
Chew/spit
Waterpipe (e.g.Hookah)
Other (specify)__________________________________________________
Amount (e.g. cig/day)
Years of use Last use
No
Yes, complete this information
Advise
currently not using tobacco products
Positive reinforcement
Advise of AHS policy STop
current tobacco use
Advise of AHS policy
Advice to quit with personalized message
coNTINuE
Assess
On a scale of 1-10 how important is it for you to stop using tobacco right now? (1 = least, 10 = most)
1
Assess interest in medication to manage

nicotine withdrawal.
No, complete this information
10
Assist
Give information pamphlet
Behavioural counselling (if available)
Other (specify)______________________________________
Facilitate Pharmacotherapy Order
Give information pamphlet
Behavioural counselling (if available)
Other (specify)______________________________________
Yes, complete this information
Arrange
Interest in referral for ongoing support.
No, STop
Yes, Referral/Information provided
AlbertaQuits Helpline Referral (form #09973)
AlbertaQuits Groups 1-866-710-7848
AlbertaQuits Online www.albertaquits.ca
Other, specify (e.g. Primary Care Network group) ___________________________________________________
Provider Name (print)
Signature
Date (yyyy-Mon-dd)
Time (hh:mm)
18251 (Rev2013-06)
7.11
Appendix 7(a) Tobacco Dependence and Cessation Brief Intervention Form (page 2)
Tobacco Dependence and cessation

brief Intervention
Suggested script to guide the brief intervention
Note: Below is a script to help guide the brief tobacco intervention. Modification to fit a specific context
may be necessary. Be sure to personalize the advice to the patient/client whenever possible.
Ask
Advise
Have you used any tobacco products in the last year?
current tobacco use

As this building and the grounds around it are tobacco free areas, we want to help our
patients stay tobacco free while they are here. Research has shown that one of the best
things you can do to improve your health, is to stop using tobacco. I (we) cannot stress
enough how important it is for you to quit.
currently not using tobacco products
That is great! In case you have any visitors Id like to let you know that this building and its
grounds are tobacco-free.
Assess
Interest in medication to manage withdrawal

I can arrange for medication to help make your stay more comfortable. Are you interested in
managing nicotine withdrawal?
Readiness to quit
On a scale of 1-10 how important is it for you to stop using tobacco right now?
Arrange
7.12
I can arrange for someone from a free and confidential service to contact you and provide
you with support and information. Would you like me to set this up for you?
AlbertaQuits Helpline Referral
Please complete all sections and fax to the AlbertaQuits Helpline at 1.866.979.3553
Client Demographics
Last Name
First Name
Street Address
o Male
o Female
Home Phone
City
Postal Code
Contact Information
When and where would the client like to be contacted?
o AM
o PM
o Weekday
Gender
Alternate Phone
o Home Phone
o Alternate Phone
o Weekend
Preferred Date (yyyy-Mon-dd)

Consent for leaving message on clients voicemail recieved?
o Yes
o No
Language interpreter required?
o Yes, language/dialect (specify)
o No
Referring Source
Physician/PCN/Program/Site
Physician Fax Number
Address
Reason for Referral (main concern)
o Help for self
o Help for someone else
o Help during pregnancy
o Information
o Relapse prevention
o Other (specify)
09973(2011-02)
7.13
Chapter 8
Intensive Cessation
Counselling
8.1
GUIDELINES FOR INTENSIVE CESSATION SUPPORT

Beginning smoking cessation interventions during a health care visit, such as
hospitalization, has been shown to help people quit. In their review of clinical trials,
Rigotti, Munafo and Stead (2008) found that programs designed to stop smoking that
begin during a clients hospital stay and that include follow-up support for at least one
month after discharge are also effective.1 Suchprograms are useful to all hospitalized
smokers, regardless of their admitting diagnosis.1
There is a strong correlation between the intensity of tobacco dependence counselling
and its effectiveness.2 Whenever possible, intensive tobacco cessation programs should
consist of four or more sessions, with each session lasting longer than 10 minutes.2
Clinical guidelines for treatment of tobacco dependence in the U.S. and Canada advocate
for both behavioural counselling and pharmacotherapy as effective options. Evidence
suggests that a combination of counselling and medication is more effective than either
one factor on its own and, whenever feasible and appropriate, both should be provided
to all patients.3,1 It is recommended that senior leadership at AHS health care settings
consider how they will offer counselling support to any individuals who are interested.2
The United States Clinical Practice Guidelines for Treating Tobacco Use and
Dependence recommend the following components in an intensive intervention:2
1. Making an assessment of the clients interest in participating in an intensive
treatment program. This can include other information useful in the counselling
process, including the clients readiness to quit, the clients confidence in quitting,
how important it is to client that he or she quit, the clients levels of stress and
nicotine dependence, the state of the clients social network and environment,
and the state ofthe clients psychiatric comorbidity and substance use.
2. Using a team of medical and non-medical professionals to provide intensive
counselling and pharmacotherapy support.
3. A minimum of four sessions, with each session lasting 10 minutes or longer.
4. A program format that includes either individual or group counselling. Telephone
counselling is also effective and can supplement treatment. Using self-help
materials and web-based support is optional.
5. Counselling and behavioural therapies that include practical counselling (problem
solving/skills training) and intra-treatment social support. These can include
basic information about tobacco use and successful quitting, the development
of coping skills, and identifying triggers and high-risk situations that increase the
risk of tobacco useor relapse.
6. Offering appropriate medication to all clients.
7. Offering treatment to all tobacco users, regardless of which populations they
belong to.
8.2
The complexity and intensity of tobacco treatment needs to match the needs of the individual
client. For instance, some individuals may require only brief intervention from a health care
provider; others with more complex or concurrent concerns may require more intensive
support. This is consistent with a continuum of care approach for the treatment of nicotine
dependence, as recommended by Canadas national clinical practice guidelines.2 The U.S.
guidelines identify three categories of tobacco user: not yet ready to quit (pre-contemplation),
ready to quit (contemplation or preparation) and recently quit (action or maintenance). These
guidelines recommend tailoring the treatment approach depending on where a person is at in
his or her readiness to quit.2
Implementation planning tool tasks

1. Determine the cessation support required by all patient populations on site.
Which populations require more intensive support?
2. Identify staff responsible for providing more intensive cessation support on site.
3. Review and adopt AHS documentation standards for more intensive tobacco
cessation treatment (modify for electronic purposes as necessary).
4. Identify how new forms will be made accessible to participating practice areas
and persons responsible for ordering them.
A variety of supplementary cessation-support resources for clients and health professionals
can be found at http://www.albertaquits.ca/helping-others-quit/healthcare-providers/index.php.
See appendices:
Appendix 8(a) Tobacco Dependence and Cessation Consult Form
8.3
TRANSTHEORETICAL MODEL OF CHANGE

Research shows that people tend to go through similar processes when they make changes
in their lives, and that this process can be conceptualized in a series of steps or stages. The
stages of change model shown in Figure 8.1, part of the transtheoretical model of change
(TTM), depicts this process.4 The stages of change are dynamic: a person may move through
them once, or may cycle through them several times before achieving success.4 Individuals
may also move back and forth between stages on any single issue, or be in multiple stages of
change at the same time.
Figure 8.1: The Transtheoretical Model of Change
The transtheoretical model focuses on the decision-making of the individual and is a model of
intentional change. It operates on the assumption that people do not change their behaviours
quickly or decisively. Rather, change in behaviour, especially habitual behaviour, occurs
continuously through a cyclical process. It is important to remember that the transtheoretical
model is not a theory, but a model; different behavioural theories and constructs can be
applied to various stages of the model where they may be most effective. Some of the
limitations of the model include5,6
8.4
the model ignores the social context in which change occurs (e.g., socio-economic
status and income)
the lines between the stages can be arbitrary, with no set criteria of how to determine
a persons actual stage of change
there is no clear sense for how much time is needed for each stage, or how long a
person can remain in a stage
the model assumes that individuals make coherent and logical plans in their
decisionmaking process, when this is not always true
CLIENTS NOT YET READY TO QUIT

Many of the clients who acknowledge their use of tobacco products may not be ready to
accept support to quit.
Motivational interviewing
Motivational interviewing (MI) and stages of change are complementary. Embedded in MI is
the need to meet clients where they are. The stages of change help identify where a person
is in the change process. A counsellor will use different MI strategies with clients in different
stages.
MI is most commonly used in the pre-contemplation and contemplation stages. In these
stages, it is important for the counsellor to follow the clients lead. Examples work well in the
early stages, as concrete thinking may prevail. A clients motivation to continue the change
process fluctuates, as does his or her ambivalence. MI can also be used as clients transition
through the stages. In the preparation, action and maintenance stages, MI can be woven
throughout the skill-building process in order to maintain the clients readiness to change.
MI is not a technique but rather a style, a facilitative way of being with people. It is a
collaborative, goal-orientated style of communication with particular emphasis on the
language of change. MI is designed to strengthen a persons personal motivation for, and
commitment to, a specific behaviour by eliciting and exploring the persons own reasons for
change within an atmosphere of acceptance and compassion. This approach is used when
the individual is ambivalent about change. The use of MI techniques have been shown to be
effective in conducting brief interventions as outlined in Chapter 7 (Brief Intervention).
In MI, the relationship the health professional creates with the client is crucial.7 With the use
of a supportive, warm, non-judgmental and collaborative approach, you convey empathy and
sensitivity through your words and tone of voice, and you demonstrate genuine concern and
an awareness of the clients experiences. The health professional follows the clients lead in
the discussion, instead of structuring the discussion according to your own agenda.7
FOUNDATIONAL PRINCIPLES (THE SPIRIT) OF MOTIVATIONAL INTERVIEWING
Four principles underlie all aspects of the MI approach: partnership, acceptance, compassion
and evocation.7 The first principle refers to the partnership between client and clinician. This
partnership is central to the spirit of MI7 and is seen as an active collaboration. The clinician
creates a positive interpersonal atmosphere that is conducive to change in which the client
does most of the talking.
The second principle is acceptance, which is the support of the individuals autonomy.7 The
health professionals role is to recognize and support the clients autonomy to change and
make decisions, to use empathy to understand the clients perspective and to affirm the
clients strengths and efforts.7
Compassion refers to the commitment to pursue the welfare and best interests of the client.7
A clinician working with the spirit of compassion builds rapport and trust within the therapeutic
relationship.
The fourth and final foundational principle is evocation. This refers to the drawing out of
the clients experiences, ideas and goals related to change.7 The spirit of MI emphasizes
the fact that the client already possesses what is needed to make changes in his or her
life. The health professional seeks to evoke and strengthen these motivations by gaining
8.5
an understanding of the clients perspective and resources, rather than focusing on deficits.
Ambivalent clients are aware of the arguments for making change and those for staying the
same. MI is about evoking what is already present, not installing what is missing.
A concept of MI that has recently changed is roll with resistance. The concept was that
arguing for change with a client will likely trigger the client to argue against change, which
can feel like resistance.7 In MI, resistance is a signal to do something else. Miller and Rollnick
(2013) deconstruct the concept of rolling with resistance into its two components: sustain talk
and discord.7 They write that their discomfort with the concept of resistance has continued
growing, particularly because it seems to place the responsibility for the phenomenon
within the client onlyas though one were blaming the client for being difficult. Even if it is
unintentional and arisies from subconscious defenses, the concept of resistance nevertheless
focuses on client pathology, thereby underemphasizing interpersonal factors. So if we delete
resistance from our clinical vocabulary and focus instead on sustain talk and discord, we are
in a better position to attract a client into recovery than responding to him or her as a resistant,
non-compliant person in denial.
TECHNIQUES IDENTIFIED IN MOTIVATIONAL INTERVIEWING
Engaging. Establish the foundation of a good working relationship where an atmosphere of
acceptance and trust allows the client to explore his or her concerns. Engagement is enabled
through a person-centred style where listening is a key tool in establishing the relationship.
Inpractice, this means the client should be doing most of the talking.
Focusing. Come to an agreement on the target substance behaviour and maintain direction.
Focusing in MI is an ongoing process of seeking and maintaining that identified direction and,
within it, more specific achievable goals. There are three styles of focusing that a counsellor
can draw from while talking to their client.
Directing is used when the client requires the professional to provide his or her expertise or
knowledge. This style states to the client that the counsellor knows what must be done to solve
a problem. It may also be considered the traditional health professional-to-client relationship.
Following is useful at the beginning of a consultation, when you are trying to understand
the client. This style is predominantly listening, and good listening comes without instructing,
agreeing or disagreeing, warning or analyzing. This style states that you are letting the client
make decisions in his or her own time and without any pressure to change one way oranother.
Guiding is used to help the client find his or her way. An effective guide will present what is
possible and what options are available, and the client decides what they want to do with the
support of the counsellor to get there. In behaviour change, this style indicates to the client
that the counsellor will assist them in solving problems themselves.
Evoking. Draw out a clients change talk. In MI, it is the counsellors task to recognize change
talk, elicit it and strategically respond to it. Evocation has been described as the heart of MI.
Through this process there is a clear change goal that the counsellor and client work towards.
Strategic, directional use of the client-centred OARS micro-counselling skills assists the
counsellor in attending to change talk.
Planning is the collaborative development of a specific change goal and supporting plan,
followed by working with the individual to build confidence and self-efficacy. Once the client
has identified significant reasons for change, and made a commitment for change, the
counsellors role is to assist in making the change process occur through careful planning.
8.6
Once the change plan is developed, the client commits to the plan. The counsellor assists the
client in implementing and adjusting the plan. During this process, the counsellor will also be
aiming to consolidate and strengthen the clients commitment to change.
Sustain talk refers to the clients own motivations and statements favouring the status quo.
Hearing sustain talk represents and predicts movement away from change. There is nothing
inherently oppositional about sustain talkit is simply one side of ambivalence. Miller and
Rollnick suggest responding to sustain talk with reflective listening.
Discord refers to the working relationship between counsellor and client. Discord may be
present if any of the following becomes apparent during the session: defending, seeing the
counsellor as an adversary, interrupting or disengagement. Miller and Rollnick suggest reflective
listening as a key tool. Alternatives may include apologizing, affirming or shifting focus.
Change talk refers to self-motivational statements. Have the client voice personal concerns and
intentions, rather than try to persuade the client that change is necessary. Hearing their own
arguments for change leads clients to believe in the need for change. Eliciting change talk helps
resolve ambivalence and move forward, and as such is a key MI skill. Although a counsellor may
want to hear change talk, an MI counsellor avoids imposing it against the clients will. The goal is
to elicit it from the client in a collaborative fashion. Miller and Rollnick (2013) have suggested a
number of methods to elicit change talk, including7

asking evocative questions
using an importance ruler (see box below)
elaborating
looking back/forward
exploring goals and values (e.g., a decisional balance)
Tools for eliciting change talk8

The importance ruler is used to assess
how important it is for the client to
change. Importance, confidence and
readiness can be explored with the use
of this tool.
1. On a scale of 1 to 10 (1 = not
important, 10 = very important),
how important is it for you right
now to change?
2. On a scale of 1 to 10, how confident

are you that you could make this
change?
3. On a scale of 1 to 10, how ready are
you to make this change now?
Follow-up questions can be used to

elicit motivating statements, help
explore or further clarify a clients
response and help determine next steps.
Follow-up questions may include
Why have you put yourself there?
Is there anything you can think of

that would help you move up a step?
Is there anything I can do to help
you move up a step?
The decisional balance tool can be used

to assess barriers to change. It can help
clients weigh out their pros and cons in
making a change.
The good things
about tobacco use
The not so good

things about
tobacco use
The not so good

The good things
things about quitting about quitting
8.7
See appendices:
Change talk can occur in several forms that make up the acronym DARN CAT:

Desire statements indicate a desire to make a change.
Ability statements speak to the clients self-efficacy or belief in the ability to make
changes.
Reasons statements reflect on the reasons the client gives for considering a change.
Need statements indicate a need for change.
Commitment language indicates the strength of change talk.
Activation statements, such as I am ready to, indicate they are moving towards
action.
Taking steps indicates the person has taken some form of action towards change
(e.g., I have not had a cigarette today).
Change statements are important to recognize and then emphasize through reflecting
or directing the client to further elaboration. These statements are avenues to the most
important part of change talk: the C in DARN CAT, or commitment language. For example,
a person could say, I might change, I could consider changing, Im planning to change
or I will change. The last two examples represent authentic commitment. The strength of
the verb in the sentence corresponds with the strength of the commitment language. An
important counselling skill is addressing a clients commitment to change over the course of
the interview by recognizing and responding to change talk. The goal is a strengthening of
theclients commitment level.9
MOTIVATIONAL INTERVIEWING MICROSKILLS
The following strategies for MI can be used by health professionals in the counselling
process: open-ended questions, affirmations, reflective listening, summaries and informing/
advising.7
Asking open- versus closed-ended questions helps clients get started talking.7 An open
question is one that does not invite one-word responses. With open-ended questions, a
counsellor sets an interested, open and collaborative tone. A client is then more likely to
provide more information, explore issues of concern and reveal what is most important to him
or her.
Affirmations are genuine, direct statements of support during the counselling sessions that
are usually directed at something specific and change oriented that the client has done.7
These statements demonstrate that the counsellor understands and appreciates at least part
of what the client is dealing with and is supportive of the client as a person.
Another microskill is listening reflectively, and doing so is one way of demonstrating empathy.7
Listening reflectively is about being quiet and actively listening to the client, then responding
with a statement that reflects the essence of what the client said or what you think the
client meant. There are several levels of reflection, ranging from simple to more complex.
The counsellor is strategic in what is reflected in order to guide the client towards resolving
ambivalence and the positives of making change.
8.8
The microskill of summaries serves several purposes. Summaries communicate that you
have an understanding of what the client has said and help structure a session to stay on
important topics. Most importantly, they provide an opportunity to emphasize the positive
statements a client has made about change. This gives the client another opportunity
to hear what he or she has said in the context provided by the counsellor. Summaries
should represent change talk statements. An important aspect of the counsellor role
in MI is providing clients with information on a range of facts, diagnoses and treatment
recommendations. The main means of conveying this type of information is by informing
and advising the client. Before offering the information, it is necessary to ask the clients
permission to do so. This is in keeping with the spirit of motivational interviewing and
honouring client autonomy. When providing information or advice to the client, it is important
to acknowledge directly that the client is free to decide what he or she wants to do with it.
CLIENTS READY TO QUIT

The Clinical Practice Guidelines for Treating Tobacco Use and Dependence developed in the
United States have found three types of counselling and behavioural therapies to be effective:
problem-solving/skills training, intra-treatment social support and extra-treatment social
support. The guidelines recommend these therapies be used with all patients attempting
tobacco cessation.2
Practical counselling: Problem solving and skills development

People most likely to benefit from intensive counselling interventions are those people who
also have a more difficult time quitting, including people who are more heavily addicted to
tobacco, people with concurrent disorders, people from deprived socio-economic groups
andthose who live with others who smoke.
See appendices:
COGNITIVE BEHAVIOURAL THERAPY
A cognitive-behavioural model provides many useful strategies that can be incorporated
into an intensive counselling approach. Cognitive behavioural therapy (CBT) focuses on
changing the thoughts, feelings and behaviours that accompany tobacco use and addiction.
These approaches are guided by the principles of social learning theory and as such can
facilitate skill building, problem solving and relapse prevention strategies. In order to increase
the chances of a successful quit attempt, an individual should be supported in planning and
preparation in advance. 10
The first sessions of intensive counselling typically incorporate many of the following
strategies: self-monitoring, increasing awareness of smoking triggers, developing
coping strategies, increasing support, setting a quit date and discussing initiation of
pharmacotherapy, when applicable. The counsellor should schedule regular follow up
toassess responses, provide support and modify treatments as necessary.10
8.9
SOCIAL COGNITIVE THEORY

Banduras social cognitive theory (SCT) is well regarded as a comprehensive theory of
behaviour change that is grounded in considerable research.10 Group cessation programs
that achieved the highest cessation rates typically incorporated the major concepts of
SCT.10 Specifically, the programs with the highest cessation rates addressed outcome
expectations by providing educational information about smoking and its effect on a persons
health (e.g.,that smoking increases health risks, and that quitting lowers those risks).10
These programs enhanced behavioural capacity by promoting learning through behavioural
skills training focused on smoking cessation. The top programs built self-control through
selfmonitoring, goal setting, problem solving, and self-reward. They also addressed
emotional coping responses through training in problem solving, coping with withdrawal,
stress management and practicing skills in emotional situations. Finally, these programs
helped create a supportive environment through social support such as buddy systems.10
Thefollowing is a summary of components found in cessation programs that achieved the
highest cessation rates:10
1. Identify situations, thoughts and feelings that trigger and maintain smoking.
2. Set personal target dates to quit smoking. Plan and practice in advance.
3. Provide efficient ways of learning new ways of thinking and behaving to support
nonsmoking.
4. Ensure participants experiment with behaviour changes between sessions and
review these experiences with the group.
5. Build participants confidence so that they can make the changes required to quit
permanently.
6. Provide training in problem solving and stress management to deal with the
emotional pressure of smoking cessation.
7. Ensure rewards for quit efforts.
8. Help participants redefine how they think about their efforts to quit.
9. Correct misperceptions about smoking and non-smoking.
10. Build social support for the participants efforts to quit and to remain a non-smoker.
11. Create physical environments that are conducive to cessation efforts for at least
sixmonths.
Each of these principles, and the program components that address them, need to be
tailored to each individuals need. Group cessation programs that incorporate a range of SCT
concepts can help a wider variety of people, who learn in different ways and who exist in
different environments.
Individual intensive cessation counselling will customize these approaches to each client.
Table 8.1 outlines suggested activities for each of the 11 counselling components.
8.10
Table 8.1: Suggested Activities for Intensive Counselling Components10,11

Counselling Component
Suggested Activities
Identify situations, thoughts

and feelings that trigger and
maintain smoking.
Clients should record their tobacco use patterns for at least one weekday and one
weekend day prior to quitting. This will provide precise information on where and
when they smoke, what the situations in which they smoke are, how they think
about smoking and how strong a craving they had for each cigarette.
Use a tobacco use journal.
Set personal target dates to

quit smoking. Plan and practice
in advance.
Clients should choose a quit date that will present the fewest challenges based on
their record of tobacco use patterns.
Clients may reduce their number of daily cigarettes in preparation but quit
completely on their target date.
Provide efficient ways of

learning new ways of thinking
and behaving to support
nonsmoking.
Observing the behaviour and practicing it with feedback are the best ways for a
person to learn.
Roleplay a difficult situation (e.g., counsellor and client, facilitator and group members).
Show participants appropriate behaviours (e.g., with a video).
Review and ask participants to evaluate their own practice.
Ensure participants experiment

with behaviour changes between
sessions and review these
experiences with the group.
Have clients record their smoking or feelings about smoking.

Practice difficult situations.
Enlist support or help.
Build participants confidence

so that they can make the
changes required to quit
permanently.
Have participants rehearse how to handle difficult situations and receive feedback
on their performance.
Have them try out new actions in a safe setting, progressing to more difficult
situations. This increases confidence and self-efficacy.
Have them monitor how they think and feel about their performance.
Provide training in
problem solving and stress
management to deal with the
emotional pressure of smoking
cessation.
Practice with relaxation exercises or mindfulness techniques.

Suggest increased physical activity to counter stress.
Incorporate relaxation in daily routines as alternatives to smoking.
Ensure rewards for quit efforts.
Clients should define small and large rewards for performaning their desired
behaviours (e.g., resisting urges to smoke).
Use money saved from buying tobacco products to make special purchases (selfidentified rewards).
Notice the sense of accomplishment they feel from taking control of these aspects
of their lives.
Help participants redefine how

they think about their efforts to
quit.
Reframe strong urges as recovery symptoms. The body is healing itself.

Instead of seeing slips as failures, redefine them as opportunities to learn resilience
and better responses to similar situations in the future.
Correct misperceptions about

smoking and non-smoking.
Provide information about immediate benefits from quitting tobacco in terms of

health, finances and social situations.
Build social support for the

participants efforts to quit and
to remain a nonsmoker.
Provide information to significant others on what to expect of the clients tobacco

cessation journey. Coach them on what is helpful support and what is not.
Ensure support continues for at least six months.
Create physical environments

that are conducive to cessation
efforts for at least six months.
Provide tobacco free signs for participants to use in their homes or vehicles.
Suggest clients get their car interiors professionally cleaned as an incentive to
avoid further smoking in their cars.
8.11
Clients who have recently quit

Tobacco users who have recently quit are at high risk of relapse and may need ongoing
support from health professionals. Although research suggests that the majority of former
tobacco users will relapse within six months, some may not until years later. Any former
tobacco user should be commended for his or her success and strongly encouraged to
remain tobacco free. Health professionals should be ready to discuss issues such as2

the benefits of cessation and remaining tobacco free
any successes experienced (e.g., length of quit, decreased withdrawal symptoms,

improved overall health)
any threats to continued cessation (e.g., ongoing withdrawal symptoms, weight gain,
depression, significant stress) and ways to manage them
the ongoing use and effectiveness of pharmacotherapy
the stress associated with recovery from concurrent issues and ways clients can
minimize their risk of relapse
encouraging clients to seek out support from their family and friends for quitting
(if the client does not have support people in his or her life, discuss the possibility
ofsupport through the AlbertaQuits helpline or website)
Tobacco dependence is a chronic, relapsing condition similar to other addictive substances

such as alcohol, cocaine and heroin. Clients may need frequent reminders about the
possibility of relapse and the need to develop relapse prevention plans. Counsellors must
continually assess their clients tobacco status and adjust services and techniques to match
each clients needs.
Prescriptive relapse prevention

A central element of all clinical approaches to relapse prevention is anticipating problems that
are likely to arise, identifying them and helping clients develop effective strategies to cope
with them without having a lapse.
For patients in the preparation and action stages of change, providing practical
problemsolving skills training results in higher abstinence rates.2 It is important that clients
are prepared to see the experience of a lapse as an opportunity to learn and fine-tune
approaches, rather than as a failure. Common high-risk situations and suggested coping
strategies are outlined in Table 8.2.
8.12
Table 8.2: Suggested Relapse Prevention Strategies10,12,13

Commonly Reported
HighRisk Situation
Suggested Strategy
Lack of support for

cessation
Schedule follow-up visits or telephone calls with the client.

Help the client identify sources of support within his or her environment,
such as family, friends or their church.
Refer the client to an appropriate program or organization that offers
cessation counselling or support, if you or your agency is not able to offer
the necessary services.
Negative mood or
depression
Provide counselling.
Prescribe appropriate medications.
Refer the client to a specialist.
Strong or prolonged
withdrawal symptoms
Consider extending the use of an approved pharmacotherapy or adding/

combining medications to reduce strong withdrawal symptoms.
Use behavioural techniques to reduce cravings.
Weight gain
Discourage strict dieting. Emphasize the importance of a healthy diet.

Recommend starting or increasing physical activity.
Reassure the client that some weight gain after quitting is common and
appears to be self-limiting.
Refer client to a specialist, dietitian or weight management program.
Flagging motivation/
feeling deprived
Reassure client that these feelings are common.

Recommend rewarding activities.
Follow up to ensure that the client is not engaged in periodic tobacco use.
Emphasize that beginning to smoke (even a puff) will increase urges and
make quitting more difficult.
See appendices:
8.13
STAFF ROLES AND DOCUMENTATION

direct impact on the success of the initial implementation and sustainability of the Tobacco
Staff roles
identified:
1. providing more intensive cessation support, such as one-on-one intensive
counselling or group cessation counselling
Documentation
The Tobacco Dependence and Cessation Consult Form is intended to facilitate an intensive
counselling session or sessions. It outlines the pertinent information as outlined in this
chapter. This form has been reviewed by the Cancer Care Strategic Clinical Network and
adopted as Alberta Health Services clinical policy.
and can be accessed through approved zone forms ordering processes or through the AHS
Forms Library on Insite:

South Zone: call (403) 388-6123 (former Chinook) or (403) 502-8648, extension 1088
(former Palliser)
See appendices:
8.14
REFERENCES
hospitalised patients (Review). The Cochrane Library, 4, 152.
(2008). Treating tobacco use and dependence. Rockville, MD: U.S. Department of Health
and Human Services, Public Health Service.
3. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPPT). (2011). Canadian smoking cessation
clinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health. Retrieved
4. Prochaska, J., Diclemente, C., & Norcross, J. (1993). In search of how people change:
Applications to addictive behaviors. Journal of Addictions Nursing, 5(1), 216.
5. Whitelaw, S., Baldwin, S., Bunton, R., & Flynn, D. (2000). The status of evidence and
outcomes in stages of change research. Health Education Research, 15(6), 707718.
6. Behaviour Works Australia. (2012). Stage theories and behaviour change. Melbourne,
Australia: Monash University, Monash Sustainability Institute. Retrieved from http://
www.behaviourworksaustralia.org/wp-content/uploads/2012/09/BWA_StageTheories.pdf
7. Miller, W., & Rollnick, S. (2013). Motivational interviewing: Helping people change
(applications of motivational interviewing) (3rd ed.). New York: Guilford Press.
8. Miller, W., & Rollnick, S. (2002). Motivational interviewing preparing people for change
(2nd ed.). New York: Guilford Press.
9. InSight: Alcohol and Other Drug Education and Training Unit, Metro North Mental
HealthAlcohol and Drug Service. (2013). Induction module 5: Motivational inteviewing.
Brisbane, Australia: Queensland Government. Retrieved from http://www.dovetail.org.au/
insight/modules/Module%205%20Motivational%20Interviewing.pdf
10. Els, C., Kunyk, D., & Selby, P. (2013). Disease interrupted: Tobacco reduction and
cessation. Toronto, ON: Createspace Publishing.
11. Manske, S., Miller, S., Moyer, C., Phaneuf, M., & Cameron, R. (2004, July/August).
Best practice in group-based smoking cessation: Results of a literature review applying
effectiveness, plausibility, and practicality criteria. American Journal of Health Promotion,
18(6), 409423.
12. Morris, C., Waxmonsky, J., Giese, A., Graves, M., & Turnbull, J. (2009). Smoking
cessation for persons with mental illnesses: A toolkit for mental health providers. Denver,
CO: University of Colorado at Denver and Health Sciences Center, Department of
Psychiatry.
13. Signal Behavioral Health Network. (2008). Tobacco treatment for persons with substance
use disorders: A toolkit for substance abuse treatment providers. Denver, CO: Author.
8.15
APPENDICES
8.16
Appendix 8(a) Tobacco Dependence and Cessation Consult Form (page 1)

Name (last, first)
Tobacco Dependence and cessation consult
Gender
Complete the Tobacco Dependence and Cessation Brief Intervention form (#18251) prior to this consult.
This consult to be completed for all patients requiring further behavioural support.
Are you having or have you had any nicotine withdrawal symptoms? (e.g. Irritable, nervous, restless, trouble
concentrating, trouble sleeping, depressed, increased appetite)
No
Yes, action taken ____________________________________________
pattern of use
Type of tobacco used (check all that apply)
Cigarette
Cigar/cigarillo
Pipe
Chew/spit
Waterpipe (e.g. Hookah)
Other (specify) ____________________________________________
current pattern of use
Historical patterns
Exposure to second-hand
(amount, frequency, last use, how soon
(amount, frequency, number of years)
smoke
after waking)
At home
Live in multi-family dwelling
In the car
Not exposed
Other (specify)__________________
previous Treatment
Quit attempts (last attempt, length of time, total number of quit attempts, longest quit)
past Relapse
cessation Medications
behavioural Supports
Discharge from healthcare site
Nicotine Gum
Group counselling
Withdrawal symptoms
Nicotine Inhaler
Individual counselling
Stopped medication
Nicotine Lozenge
Self help materials
Stopped behavioural support
Nicotine Patch
Online support
Use of alcohol, other drugs
Nicotine Mouth Spray
Household smoker
Bupropion SR
Family/friends smoke
Varenicline
Stress
Other (specify)________
Other
(specify)_________
Other (specify)_______________
Comments (Include perceived effectiveness of previous treatment or approaches)
18252(Rev2013-06)
Alternative
Treatments
Acupuncture
Herbal remedies
Hypnosis
Other
(specify)_____________
No Treatment
Cold turkey
Tapering down
Page 1 of 3
8.17

Name (last, first)
Gender
Information on current use

What are the good things about your tobacco use?
What are the not so good things?
barriers/concerns about quitting

Withdrawal/Cravings
Fear of failure
Loss time to self/ Breaks
Enjoyment
Weight gain
Other (specify)____________
Stress/Stress relief
Cost of medication
Discouragement/Lack of willpower
Cost/Timing groups
Work environment
Not ready
Stressors
Home environment
Disruption of social relations
Triggers/concerns about relapse
Financial
Other smokers in the home
Work or unemployment
Dealing with stress
Family
At work
Mental illness
Social events
Physical illness
Other (specify)____________________
Housing
Other (specify)__________________
Readiness to change
which statement describes how you feel about your tobacco use
I have quit smoking and I will never smoke again
I have quit smoking, but I worry about slipping back
I still smoke but I have begun to change and Im ready to set a quit date
I definitely plan to quit smoking within the next 30 days
I definitely plan to quit smoking in the next 6 months
I sometimes think about quitting smoking, but I have no plans to quit
I enjoy smoking and have no interest in quitting for my lifetime
18252(Rev2013-06)
8.18
Page 2 of 3

Name (last, first)
Gender
Recently, how concerned have you been by

your tobacco use?
How important is it to change your tobacco
use right now?
How confident are you that you can make
these changes?
Not at all
Slightly
Moderately considerable Extremely
Health Care Provider rating of importance of

treatment at this time.
Comments
Treatment plan (patient/care provider/family mutually agreed upon goals and actions)
What would you like to do next? How can I help you?
Date
(yyyy-Mon-dd)
Goal
(reduce, quit, other,

including time frame)
Action/Tasks/Activities
to achieve goal
Response/progress
Initials
plan for leaving healthcare site (Refer to Tobacco Dependence and Cessation Brief Intervention - form #18251)
Health Care Providers Name (print)

18252(Rev2013-06)
Signature
Date (yyyy-Mon-dd)
Time (hh:mm)
Page 3 of 3
8.19
Chapter 9
Pharmacotherapy
9.1
PHARMACOTHERAPY TREATMENTS
Pharmacotherapy plays an important role in tobacco
cessation treatment. Evidence indicates that using
pharmacotherapy on its own doubles a persons
chance of successfully quitting tobacco.1 Except in
the presence of contraindications, it is recommended
that available treatments be used with all patients
attempting to quit smoking.2,3 A number of first-line
smoking cessation medication options have been
approved for use in Canada, including various forms
of nicotine replacement therapy (NRT), bupropion
SR and varenicline.4 Decisions about whether to use
pharmacotherapy, including the type of product that is
appropriate, should be made in collaboration with the
patient/client.1
Table 9.1 summarizes information related to odds
ratios and abstinence rates for various medications
6 months after quitting, compared with placebo,
based on a meta-analysis of the research.5 Research
suggests that combined therapies and higher doses or
longer treatment times improves abstinence rates.5
Pharmacotherapy myths4
NRT is hazardous.
Smoking while using NRT

causes heart attacks.
Patients with heart disease

should not use NRT.
Various NRTs cannot be used

at the same time as or in
combination with bupropion.
Cessation medications are only

for short-term use.
NRT can only be used by those
who are ready to quit.
It is essential that health care providers are knowledgeable about pharmacotherapy

products so that they can tailor a treatment plan to meet the patient/clients needs,
dispelmisconceptions about the drug therapies and address any concerns that arise.1
Table 9.1: Summary of Pharmacotherapy Effectiveness3

Medication
Odds Ratio (95% CI)
Abstinence Rate (95% CI)
PLACEBO
1.0
13.8
VARENICLINE (2 mg/day)
3.1 (2.53.8)
33.2 (28.937.8)
NICOTINE NASAL SPRAY
2.3 (1.73.0)
26.7 (21.532.7)
HIGH-DOSE NICOTINE PATCH (>25 mg)
2.3 (1.73.0)
26.5 (21.332.5)
NICOTINE GUM (>14 weeks)
2.2 (1.53.2)
26.1 (19.733.6)
NICOTINE INHALER
2.1 (1.52.9)
24.8 (19.131.6)
BUPROPION SR
2.0 (1.82.2)
24.2 (22.226.4)
NICOTINE PATCH (614 weeks)
1.9 (1.72.2)
23.4 (21.325.8)
NICOTINE PATCH (>14 weeks)
1.9 (1.72.3)
23.7 (21.026.6)
NICOTINE GUM (614 weeks)
1.5 (1.21.7)
19.0 (16.521.9)
Note: Nicotine nasal spray is not currently available in Canada
9.2
Nicotine replacement therapy (NRT)

It is not the nicotine, but rather, the thousands of toxins
in tobacco and the products of combustion, that are
responsible for the majority of tobacco-related illness.4
The purpose of NRT is to provide a tobacco user with a
clean source of nicotine that will help reduce cravings
for tobacco by reducing physiological withdrawal and
allowing the user to develop behavioural strategies
that support cessation. NRT makes it easier to quit
using tobacco by replacing some, but not all, of the
nicotine normally consumed.4 Signs and symptoms of
nicotine withdrawal normally appear within two hours of
last nicotine use, peak in 24 to 48 hours and last from
several days to four weeks.1
In the case of hospitalized clients, where temporary
cessation may be enforced by the circumstances of
their illness and the smoke-free environment, NRT may
be a valuable comfort measure to reduce signs and
symptoms of withdrawal.4 The AHS formulary currently
includes NRT in the form of transdermal patches, gums,
lozenges, inhalers, and mouth sprays.
DSM-5 signs and

symptoms of nicotine
withdrawal:6
irritability
(frustration or anger)
anxiety
difficulty concentrating
restlessness
insomnia
depressed mood
increased appetite
Use of NRT at higher doses and in a combination of preparations (e.g., patch plus gum) have
been found to be more effective in highly dependent tobacco users and those with a history
of severe withdrawal. It has been found that many people do not use cessation medications
as recommended, leading to decreased effectiveness. Education of correct techniques for
medication use is important to achieve optimum withdrawal relief.3
Some forms of NRT are eligible for coverage under Alberta Drug Benefits. Please refer to
Table 18.2 in Chapter 18 (Transition and Continuing Care) for more information.
9.3
Non-nicotine prescription medications

Bupropion SR and varenicline are also considered first-line pharmacotherapy for tobacco
cessation; however, unlike NRT, both are available by prescription only. These two products
have different mechanisms of action, but both have been found to be effective treatment
options. Bupropion SR (Zyban, Wellbutrin SR) is an antidepressant that is thought to mimic
the effects of nicotine on dopamine and noradrenaline receptors in the brain. It has been
found through randomized control trials to reduce the desire to smoke, suppress withdrawal
symptoms and reduce weight gain associated with tobacco cessation.3 Studies have shown
that bupropion SR doubles the chances of tobacco cessation and, when used in combination
with NRT, may have better results.7 Bupropion SR is currently available in the AHS formulary.
Varenicline (Champix) acts at the level of the
nicotinic receptors in the brain, preventing the
binding of nicotine at those sites and stimulating
some dopamine release. These actions decrease
the pleasure associated with tobacco use and result
in decreased cravings and withdrawal symptoms.8
The safety of varenicline used in combination with
NRT or buproprion has been demonstrated in small
preliminary studies to date.5,9
Signs of nicotine toxicity10
For more detail on pharmacotherapy options, see

Table 9.2. Health care providers should conduct
regular assessments of patients/clients who are
taking these medications to determine adherence
to treatment, adjust medications as necessary to
ensure withdrawal relief and rule out nicotine toxicity.
For inpatients who decline NRT support, regular
assessment of withdrawal symptoms may provide
teachable moments and opportunities to reassess
change in willingness to accept support.
perspiration
nausea
abdominal pain
vomiting
diarrhea
hyper-salivation
headache
dizziness
hearing and visual

disturbances
mental confusion
weakness
Bupropion and varenicline are eligible for coverage under Alberta Drug Benefits. Please refer
to Table 18.2 in Chapter 18 (Transition and Continuing Care) for more information.
See appendices:
Appendix 9(a) Tobacco Dependence and Cessation Pharmacotherapy Initiation Orders
Appendix 9(b) Tobacco Dependence and Cessation Pharmacotherapy
FollowUp/Discharge Orders
9.4
Table 9.2: Summary of Pharmacotherapy for Nicotine Withdrawal Support3,8

Drug
NICOTINE PATCH
sustained
release
provides a
steady, slow
release of
nicotine over 16
or 24 hours of
use
average
$3$5/day
Preparations
Common Side
effects
available in 21 mg, 14mg

and 7 mg dosages per
24 hours (under AHS
formulary)
skin irritation
also available in 15 mg,

10mg and 5 mg dosages
per 16 hours (not under
AHS formulary)
headache
vivid dreams
insomnia
nausea
dosage should be titrated

dependent on history of
tobacco use
recommended patch(es)
used daily for 6 weeks,
then reassess; strength is
reduced over time
immediate
release
effect within
15minutes of
use
average
$2$8/day
(625 pieces)
available in 2 mg and 4 mg
dosages
approved under AHS
formulary
tobacco use
recommended one piece
every hour as needed;
maximum 20 pieces
perday
recommended that
number and frequency
be decreased over time
(reduction with intent to
quit using nicotine gum
may also be considered15)
apply to a clean, dry,

hairless area
remove old patch prior to
application of new one
change sites daily to
prevent skin irritation
patient/client is normally
advised not to use tobacco
while using the patch;
however, continued use is
generally not considered
dangerous and does not
imply treatment failure
if insomnia and vivid
dreams are a concern,
patch should be removed
prior to bedtime
may be used alone or in

combination with other
NRTs, bupropion SR
orvarenicline5,7,9
NICOTINE GUM
Correct Use
mouth
or throat
soreness
jaw ache
hiccups
absorbed through the

liningin the mouth
do not eat or drink for
15minutes before or
during use
the term gum is

misleading, as proper use
upset stomach
is bite, bite, park, repeat
insomnia
bite gum until a peppery
taste or tingling occurs;
headache
park gum between cheek
nausea
and gums; repeat when
sensation goes away
flatulence
do not swallow
Drug interactions*
Nicotine may
reduce the sedative effects
of benzodiazepines
decrease subcutaneous
absorption of insulin
reduce effectiveness of
beta-blockers
lessen effectiveness of
opioid analgesia
Changes in drug metabolism
are similar on NRT to those
seen when quitting without
NRT. Adjustments in these
types of medications may
benecessary.
Nicotine may
of benzodiazepines
beta-blockers
opioid analgesia
benecessary.

NRT, bupropion SR
orvarenicline5,7,9
9.5
Table 9.2 (continued)

Drug
NICOTINE
LOZENGE
immediate
release
effect within
15minutes of
use
average
$4$10/day
(615 lozenges)
Preparations
available in 1 mg, 2 mg
and 4 mg dosages
Common Side
effects
Correct Use
Drug interactions*
mouth
or throat
soreness
absorbed through the lining Nicotine may

of the mouth
approved under AHS
of benzodiazepines
formulary
hiccups
15minutes before taking
the lozenge
upset stomach

do
not
chew
or
swallow
the
insomnia
tobacco use
lozenge
beta-blockers
headache
recommended one lozenge
slowly suck until there is
nausea
every hour as needed;
a strong taste, then rest
opioid analgesia
maximum 20 lozenges per
the lozenge in the cheek,
day.
wait 1 minute or until taste Changes in drug metabolism
fades and then repeat.
should dissolve within
2030 minutes
may be useful for those
who cannot chew gum
recommended that
number and frequency be
sugar-free and safe for use benecessary.
decreased over time
by people with diabetes
NRT, bupropion SR
orvarenicline5,7,9
NICOTINE
INHALER
immediate
release
effect within
15minutes of
use
available in a 10 mg
cartridge that delivers
4mg of nicotine through
about 80 inhalations
(over 20minutes of active
puffing)
approved under AHS
formulary
average
dosage should titrated
$6$12/day
dependent history of
(612 cartridges)
tobacco use
recommended one
cartridge every 20 minutes
as needed; maximum
16cartridges/day
recommended that
be decreased over time,
stopping when reduced to
1 or 2 cartridges per day
mild local
irritation of
mouth, sinus
or throat
cough
dry mouth
hiccups
insomnia
headache
nausea
hand-mouth activity
from using the inhaler is
preferred by some quitters
Nicotine may
the inhaler is useful for

those with poor oral health
or dentures, and for those
who cannot chew gum
similar in appearance to a
cigarette: designed to be
puffed on
not a true inhaler; the
nicotine is delivered and
absorbed through the lining
in the mouth
allows fine tuning of how
much and how often the
user consumes nicotine

of benzodiazepines
beta-blockers
opioid analgesia
benecessary.

NRT, bupropion SR
orvarenicline5,7,9
9.6

Drug
Preparations
NICOTINE MOUTH available in a dispenser

that contains 150 sprays;
SPRAY
each spray delivers 1 mg
immediate
of nicotine.
release
dosage should titrated
effect within
60seconds of
tobacco use
use
recommended 1 or
average
2 sprays as needed;
$38/day
maximum dose is 2 sprays
(1545 sprays)
at a time, 4sprays per hour
and 64sprays per day
Common Side
effects
hiccups
throat irritation
increased
salivation
tingling
sensation of
the mouth/lips
insomnia
headache
nausea
recommended that
be decreased over time,
stopping when reduced to
24 sprays per day
Correct Use
absorbed through the lining Nicotine may

in the mouth
of benzodiazepines
15minutes before using
the spray
if using the spray for the
first time, or if the spray
has not been used for
two days, load the spray
pump by pressing on
the dispenser several
times until a fine spray is
released
point the spray nozzle
towards the open mouth
and hold as close as
possible to the mouth,
avoiding the lips

NRT, bupropion SR
orvarenicline5,7,9
Drug interactions*
beta-blockers
opioid analgesia
benecessary.
press down on the

dispenser to release a
spray into the mouth
do not inhale while
spraying and avoid
swallowing for a few
seconds afterwards
expect a strong mint taste
in the mouth
BUPROPION SR
sustained
release
average
$2$3/day
begin treatment 1 or
2weeks before quit date
insomnia
approved under AHS

formulary
headache
usual dose 150 mg in

a.m. for 3days; increase
to 150mg twice daily for
712weeks
combination with NRT
orvarenicline5,7,9
dry mouth
weight loss
agitation
should be monitored
for unusual feelings
of agitation, hostility,
aggression, depressed
mood, hallucinations,
changes in behaviour or
suicidal thoughts
Some drugs in the following

classes have the potential
to significantly interact with
buproprion SR:
contraindicated for those

who have seizures, eating
disorders, active alcohol
addiction or who are
on monoamine oxidase
Inhibitors
tricyclic antidepressants
insomnia may be avoided

by taking evening dose
earlier
beta blockers
alkylating agents
muscle relaxants
antipsychotics
anti-arrhythmics
MAO inhibitors
antiseizure medications
phenobarbital
H2 blockers
9.7

Drug
VARENICLINE
average
$3.50$4.50/day
Preparations
Common Side
effects
begin treatment 1 or
2weeks before quit date
nausea
approved under AHS

formulary
vivid dreams
usual dose 0.5 mg once

daily for 3 days, then
0.5mg twice daily for
4days, then 1 mg twice
daily for 12 weeks
alternate maintenance
dose 0.5 mg twice daily
for12 weeks
may be extended for an
additional 12weeks
insomnia
headache
constipation
agitation,
depression,
suicidal
thoughts
Correct Use
should be monitored
for unusual feelings
of agitation, hostility,
aggression, depressed
mood, hallucinations,
changes in behaviour or
suicidal thoughts
Drug interactions*
No significant drug
interactions are known
should be monitored for

and informed of symptoms
of heart attack and stroke
and instructed to seek
immediate medical help
ifthey experience them
take with food to reduce
nausea; nausea may
subside with continued use
insomnia may be avoided
by taking the evening dose
at supper
Note: Refer to product monographs for more detailed information. All medications need to be closely monitored and adjusted accordingly
* Polycyclic aromatic hydrocarbons in the tar of tobacco smoke affect liver enzymes (cytochrome P-450) causing faster metabolism of
some drugs. Numerous medications may be affected once a person stops smoking including antidepressants (tricyclics, fluvoxamine),
antipsychotics (clozapine, olanzapine, haloperidol), caffeine, benzodiazepines (chlordiazepoxide, diazepam), nifedipine,propafenone,
theophylline, verapamil, and warfarin.1,7
9.8
Special considerations
There are some specific populations who may have additional needs when considering the
use of cessation pharmacotherapy.
YOUTH
Tobacco use is a major concern for children under the age of 18, and it is important to note
that the majority of adult smokers were also daily users as youths.3 NRT is a safer option
than smoking or using other tobacco products, and should be considered when supporting all
tobacco users.11 Factors such as the degree of dependence, amount of product used per day
and body weight should be considered when prescribing any medications for this age group.3
PREGNANT AND BREASTFEEDING WOMEN
Exposure to tobacco during pregnancy causes risks for women and their unborn babies,
which is why many women are motivated to quit at this time. It is most beneficial that women
quit before conception, but there are benefits to quitting at any time during pregnancy. Health
care providers should be aware that many pregnant women are reluctant to disclose their
tobacco use.3 There is no safe level of nicotine exposure in pregnancy; however, NRT should
be considered for women who are not able to abstain with behavioural support alone. If NRT
is used, it is recommended that lower dosages of the intermittent delivery systems (e.g., gum,
lozenges or inhalers) are prescribed rather than the nicotine patch.2,3 Varenicline has not
been studied for use in pregnancy.11
Many women who are successful in quitting tobacco use during pregnancy relapse in the
postpartum period. Support must continue for postpartum and breastfeeding women, as
they and their newborns will both benefit. Because nicotine from NRT can be transferred
through breast milk, it is recommended that, as with pregnancy, lower dosages of the
intermittent delivery systems are prescribed and used after breastfeeding.2,3 The benefits
of pharmacotherapy support outweigh the risks to mother and baby during pregnancy
andlactation.2
ADDICTIONS AND MENTAL HEALTH
Patients/clients with mental health conditions, including addictions, have higher rates of
tobacco use than the general population. Those dealing with mental health issues benefit
from the same type of cessation support as the general public. It is important for health care
providers to have an awareness of the impact of smoking cessation on comorbid conditions
and recognize that these patients/clients are at higher risk of relapse.2 Many people with
mental health conditions use tobacco to relieve some of their symptoms, and cessation
may exacerbate co-morbid conditions (e.g., worsening of depression or anxiety) or affect
the action of some psychiatric medications.1 Bupropion SR, with or without NRT, may be
an appropriate choice for cessation support for those suffering from or with a history of
depression.
Smoking complicates the treatment of some mental disorders by decreasing blood levels
of neuroleptics.8 Hydrocarbons in the tar of tobacco smoke affect enzymes from the liver,
causing faster metabolism of some drugs; therefore, smokers may require larger doses
to achieve therapeutic effect, running an increased risk of adverse effects.3,8 People with
mental health disorders who stop smoking while taking medications for their illness should
be monitored to determine if dosage reductions in their medication are necessary.8 Thus,
close monitoring of the amount smoked, cessation treatment, medication side effects and
psychiatric symptoms are important when addressing tobacco dependence treatment
inpopulations with psychiatric populations.2
9.9
CARDIAC CONDITIONS
It is more dangerous for patients with heart disease to continue using tobacco products
than to use NRT to support cessation. Smoking causes the activation of coagulation, which
can lead to clotting and cause heart attacks. Toxins such as carbon monoxide also cause
reduced oxygen delivery to the heart. Studies have shown that use of NRT is safe with
cardiac patients and should be considered for those who are having difficulty quitting without
pharmacotherapy support.11
In recent years, there have been drug safety concerns related to the use of varenicline being
associated with adverse cardiovascular events. However, a 2012 meta-analysis of the all of
the published randomized controlled studies related to varenicline has concluded that there
is no significant increase in the risk of cardiovascular serious adverse events attributed to
varenicline use.12
Assessing nicotine withdrawal

It has been generally acknowledged that most tobacco users have difficulty quitting because
of their addiction to nicotine and the resulting withdrawal symptoms they face when they do
stop. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5), lists
seven symptoms characteristic of nicotine withdrawal: irritability, restlessness, insomnia,
anxiety, depressed mood, increased appetite and difficulty concentrating.2 Although more
recent literature proposes there may be some value in including additional symptoms, these
factors, with the addition of craving tobacco, are the items that are routinely assessed and
measured in a variety of tools to support tobacco research.13,14
The use of a nicotine withdrawal scale for assessment of withdrawal is not a component of
the Tobacco Free Futures initiative. The program uses training and resources to educate
staff in assessment without the use of a formal tool. Some health care sites implementing the
program may be interested in developing and using a formal assessment tool. The following
information on nicotine withdrawal scales is provided as background information.
Over the past 25 years, an array of nicotine withdrawal questionnaires have been developed,
some intended to be self-reported and others based on observation. Reviews of eight
commonly used tools do not identify a clear preference, as they all have identified strengths
and weaknesses. One key difference that may impact choice is the length, which ranges
from 7 to 28 items.10,14 Although these tools were not designed for clinical use, adopting a
standardized approach to monitor tobacco withdrawal and effectiveness of pharmacotherapy
by health care providers may be an appropriate application.
The Minnesota Nicotine Withdrawal Scale (MNWS), developed in 1986, is concise and one
of the most widely used tools. This self-report scale asks the user to rate their experience on
a 5-point scale where 0 means none and 4 means severe.10,13 The original eight validated
symptoms from the MNWS are included in Table 9.3. The available withdrawal scales do not
provide direction regarding a threshold score for initiating or modifying pharmacotherapy;
however, Toll et al. (2007) indicate that the MNWS does provide a brief measure of overall
withdrawal severity that can be used to guide clinical treatment decisions for supportive
pharmacotherapy and counselling.13
9.10
Table 9.3: Assessing Nicotine Withdrawal

Withdrawal scale (adapted from Minnesota Nicotine Withdrawal Scale)
If receiving pharmacotherapy and moderate to severe withdrawal symptoms persist reassess: technique, dose
and frequency.
0 = none 1 = slight 2 = mild 3 = moderate 4 = severe
Symptoms
Desire/cravings
Anger/irritability/frustration
Anxiety/nervousness
Difficulty concentrating
Restlessness
Insomnia/sleep problems/waking at night
Increased appetite/weight gain
Depressed mood*
4
Total score:
Caution
Quitting smoking can decrease tolerance to caffeine. Symptoms associated with this increase in caffeine effect
can often be confused with nicotine withdrawal symptoms.
*Complete brief mood assessment (PHQ-2) if moderate to severe depressed mood identified.
A 2005 comparison and evaluation of five nicotine withdrawal scales identified that one of
the weaknesses of the MNWS was that it was less sensitive to identifying depression.14 To
address potential patient/client safety concerns related to pharmacotherapy, those who report
moderate to severe depressed mood when assessed with the MNWS should be screened
further to determine if referral for mental health support is required. There are several
questionnaires available that simplify depression screening and can enhance routine inquiry
about the most prevalent and treatable
mental health conditions. There is strong
PHQ-215
evidence for the use of the Personal
Health Questionnaire-2 (PHQ-2) as a
Over the past two weeks, how often have you
brief depression screening measure.
been bothered by any of the following problems?
The PHQ-2 inquires about the frequency
(0 = not at all, 1 = several days, 2 = more than
of depressed mood and absence of
half the days, 3 = nearly every day)
pleasure over the past two weeks. The
1. Little interest or pleasure in doing things
total PHQ-2 score can range from 0to 6
with a score of 3as the optimal cutpoint
2. Feeling down, depressed or hopeless
for screening purposes. Ascore of 3
or higher would indicate a referral to a
mental health specialist.15
9.11
PHARMACOTHERAPY STAFF ROLES AND

DOCUMENTATION
direct impact on the success of the implementation and sustainability of the Tobacco Free
Futures initiative.
Staff roles
identified:
1. connecting to a prescriber or distributing pharmacotherapy for cessation
2. providing patient education regarding the correct use of cessation pharmacotherapy
3. arranging for ongoing pharmacotherapy support throughout a clients quit attempt or
period of abstinence
4. continuous monitoring of medications
Documentation
The Tobacco Dependence and Cessation Pharmacotherapy Initiation and Followup/
Discharge Orders have been developed to provide sites across the province with access
to standardized order sets. The recommendations for dosing of first-line cessation
pharmacotherapy are based on product monographs and the available literature. They have
been developed in collaboration with AHS Pharmacy Services and reviewed by the Cancer
Care Strategic Clinical Network.
and can be accessed through approved zone forms ordering processes:

South Zone: call (403) 388-6123 (former Chinook) or (403) 502-8648, extension 1088
(former Palliser)
See appendices:
Followup/Discharge Orders
9.12
References
Press.
(2008). Treating tobacco use and dependence. Rockville, MD: US Department of Health
4. Ontario Medical Association (2008). Rethinking stop-smoking medications: Treatment
myths and medical realities. OMA Postion Paper. Toronto, ON: Author.
5. Ebbert, J., Croghan, I., Sood, A., et al. (2009). Varenicline and bupropion sustainedrelease combination therapy for smoking cessation. Nicotine & Tobacco Research,
11, 234239.
6. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders. (5th ed.) Washington, DC: Author.
7. Desai, H., Krejci, J., & Brandon, T. (2004) Smoking in patients receiving psychotropic
medications a pharmacokinetic perspective. CNS Drugs, 15, 469494.
8. Lexicomp. (2011). Lexicomp online. Retrieved from http://online.lexi.com
9. Ebbert, J., Burke, M., Hays, J., et al. (2009). Combination treatment with varenicline and
nicotine replacement therapy. Nicotine & Tobacco Research, 11(5), 572576.
10. Hughes, J. (2007). Measurement of the effects of abstinence from tobacco: A qualitative
review. Psychology of Addictive Behaviours, 1, 127137.
hospitalised patients Cochrane Database of Systematic Reviews, 2007, 3.
Art. No.: CD001837.
12. Prochaska, J., & Hilton J. (2012). Risk of cardiovascular serious adverse events
associated with varenicline use for tobacco cessation: Systematic review and
metaanalysis. British Medical Journal, 344, e2856. Retrieved from
http://www.bmj.com/content/344/bmj.e2856.pdf%2Bhtml.
13. Toll, B., OMalley, S., McKee, S., Salovey, P., & Krishnan-Sarin, S. (2007). Confirmatory
factor analysis of the Minnesota Nicotine Withdrawal Scale. Psychology of Addictive
Behaviours, 21, 216225.
14. West, R., Ussher, M., Evans, M., & Rashid, M. (2006). Assessing DSM-IV nicotine
withdrawal symptoms: A comparison and evaluation of five different scales.
Psychpharmacology, 184, 619627.
15. Kroenke, K., Spitzer, R., & Williams, J. (2003) The Patient Health Questionnaire-2:
Validity of a two-item depression screener. Medical Care, 41, 12841292.
9.13
Appendices
Followup/DischargeOrders
9.14

(page 1)
Name (last, first)
Tobacco Dependence and Cessation

Pharmacotherapy Initiation Orders
Gender
See Prescribing and Administering Tobacco Pharmacotherapy for additional drug information.
Allergies: List or Up to date in electronic system
Diagnosis
Date (yyyy-Mon-dd)
Time (hh:mm)
Orders
Initial
Nicotine Free Period Required. No NRT to be used for __ hours. Start date _______ at __ hours
Nicotine Patch
Cigarettes
Per Day
5-10
11-15
16-25
26-35
36 or greater
Recommended Dose Patch(es) daily x 6 weeks then reassess. Patch may be

combined with gum, lozenge, inhaler, mouth spray, buproprion SR or varenicline.
7 mg nicotine patch.
28 mg (use 21 mg +7 mg nicotine patches).
Consider a total daily dose of 35 mg or 42 mg.
Dose = _____mg (use ___mg + __mg nicotine patches).
Alternate Dose (specify) ________________________________________
Nicotine Gum
Recommended Dose One piece every 1 hour as needed x 12 weeks then
Cigarettes
reassess; maximum 20 pieces per day or titrated to individual patient effect. Gum
Per Day
may be combined with patch, lozenge, inhaler, mouth spray, buproprion SR or
varenicline.
20 or less
2 mg nicotine gum.
21 or more
4 mg nicotine gum.
Alternate Dose (specify) _____________________________________
Nicotine Lozenge
Recommended Dose One lozenge every 1 hour as needed x 12 weeks then
Cigarettes
reassess; maximum 20 lozenges per day or titrated to individual patient effect.
Per Day
Lozenge may be combined with patch, gum, inhaler, mouth spray, buproprion SR
or varenicline.
20 or less
1 mg nicotine lozenge (OR recommended initial dose if using lozenge with patch).
21 or more
2 mg nicotine lozenge.
Nicotine Inhaler
Recommended Dose One cartridge every 20 minutes as needed x 12 weeks then reassess;
maximum 16 cartridges per day or titrated to individual patient effect. Inhaler may be combined
with patch, gum, lozenge, mouth spray, buproprion SR or varenicline.
10 mg Nicotine Inhaler (equal to 4 mg inhaled). Use ______ cartridges per day.
18282(Rev2014-02)
White Chart
Canary Pharmacy
Page 1 of 2
9.15

(page 2)
Name (last, first)

Pharmacotherapy Initiation Orders
Gender
See Prescribing and Administering Tobacco Pharmacotherapy for additional drug information.
Orders
Initial
Nicotine Mouth Spray

Recommended Dose 1 to 2 sprays every 30 minutes as needed x 12 weeks then reassess;
maximum 2 sprays at a time, 4 sprays per hour or 64 sprays per day. Mouth spray may be
combined with patch, gum, lozenge, inhaler, buproprion SR or varenicline.
1 mg nicotine per spray delivered. 1 bottle
Bupropion Sustained Release (SR)
Recommended Dose Treatment should be started 1 week before quit date and continued x 7-12
weeks then reassess (Quit date if known_____); if this is not possible bupropion and NRT and be
used concurrently for the first week. NRT can then be stopped or continued.
Initial Dose 150 mg orally once daily for 3 days and stop. Start date (yyyy-Mon-dd)_________
Maintenance Dose 150 mg orally twice daily for ____ weeks and reassess.
Start date (yyyy-Mon-dd) _________. (Usual maintenance dose 7-12 weeks. May be up to 24 weeks).
Varenicline
Recommended Dose Treatment should be started 1 week before quit date and continued
x 7-12 weeks then reassess (Quit date if known _____); if this is not possible varenicline and NRT
and be used concurrently for the first week. NRT can then be stopped or continued.
Initial Dose - 0.5 mg orally once daily for 3 days; then 0.5 mg orally twice daily for 4 days.
Maintenance Dose: 1 mg orally twice daily for ____ weeks, and reassess.
Start date (yyyy-Mon-dd) _________. (Initial treatment period is 12 weeks. May be repeated for an
additional 12 weeks)
Alternate Maintenance Dose 0.5 mg orally twice daily for ____ weeks. (consider dose adjustment
in renal impairment.)
Prescriber Name (print)
18282(Rev2014-02)
9.16
Signature
White Chart
Date (yyyy-Mon-dd)
Canary Pharmacy
Time (hh:mm)
Page 2 of 2 (Side A)

(page 3)
Tobacco Dependence and Cessation Pharmacotherapy

Initiation Orders
Suggestions for Prescribing and Administering Tobacco Pharmacotherapy
Research indicates the use of first-line pharmacotherapy can double chances of successful long-term cessation. When used in
combination (e.g. Patch plus Gum), success rates increase further.
Generalized Information on Smoking Cessation and Medications: Thorough consideration should be given to using a nicotine
replacement therapy (NRT) treatment option, before prescribing bupriopion or varenicline. In many cases, NRT should be tried first.
Smoking tobacco can alter the metabolism of a number of medications, including caffeine. This is primarily due to substances in
tobacco smoke. Contact Pharmacy as needed.
Signs of nicotine withdrawal include nicotine cravings, restlessness, insomnia, anxiety, difficulty concentrating, mood changes,
decreased heart rate, increased appetite.
Signs of nicotine toxicity include nausea, vomiting, dizzy, headache, increased heart rate.
Nicotine Patch
Cautions: Use with caution with generalized skin disorders (such as psoriasis). May be removed at
bedtime if patients experience sleep disturbances such as vivid dreams or insomnia. 7, 14 & 21 mg
patches are 24 hour release dosage forms; 5, 10 & 15 mg patch are 16 hour release dosage forms.
Nicotine Gum/
Cautions: Avoid using GUM in temporomandibular joint disorder, those with dentures and undergoing
Nicotine Lozenge
dental work If switching between lozenge to gum: 1 mg nicotine lozenge equals 2 mg nicotine gum and
2 mg nicotine lozenge equals between 2-4 mg nicotine gum (approximately). Avoid eating or drinking during
use and 15 minutes before/after use.
Nicotine Inhaler
Cautions: Use with caution in bronchospastic disease (such as asthma).
Nicotine Mouth
Cautions: Do not inhale or swallow while spraying. Hold spray in mouth for a few seconds before resuming
Spray
normal swallowing. Do not eat or drink 15 minutes before/after using.
Bupropion
Cautions: All patients should be monitored for neuropsychiatric changes, particularly those with mental
Sustained Release
health illness.
(SR)
Contraindications: Do not use if: history of seizures, conditions predisposing to seizures (such as head
trauma, withdrawal from alcohol and/or benzodiazepines), eating disorder, active alcohol addiction,
monoamine oxidase inhibitors (phenelzine, moclobemide, tranylcypromine) in the past 14 days. Consider
dose adjustments in renal and hepatic impairment.
Drug Interactions: Buproprion is a CYP2B6 substrate and a CYP2D6 inhibitor. Clearance of bupropion
may be decreased by inhibitors or increased by inducers of CYP2B6. May increase levels of other CYP2D6
substrates. Examples: caution with paroxetine, risperidone, beta-blockers (metoprolol), type 1 C
antiarrythmics (propafenone, flecanide), clopidogrel, ticlopidine due to CYP interactions.
Varenicline
Cautions: Use with caution in those with mental illness, especially schizophrenia, bipolar disorder or major
depressive disorders. All patients should be monitored for neuropsychiatric changes. Inform patients of the
symptoms of heart attack and stroke; instruct them to seek medical attention if they experience any of these
symptoms.
Contraindications: In severe renal impairment (Cr/Cl less than 30mL/min) recommend dose to be titrated
to a maximum of 0.5 mg twice daily.
Administration: Take with food.
Pregnancy: Behavioral/cognitive techniques should be trialed first. If ineffective NRT can be used as almost all of the concerns with
smoking during pregnancy are due to combustible components other than nicotine. Short acting preparations, such as nicotine gum
should be trialed first since they typically deliver a lower amount of daily nicotine than patches. Patches should be used secondarily
for those women who are experiencing nicotine withdrawal symptoms or may be used first line for those exhibiting nausea and
vomiting. Patches should be worn for 16 hours in this group.
Lactation: Recommendations same as pregnancy. Avoid breastfeeding immediately after use to reduce infant nicotine exposure.
Cardiac Disease: Short acting nicotine replacement agents may be trialed first in those with a history of poorly controlled
cardiovascular disease. Monitor for elevated blood pressure that can be associated with treatment if NRT is combined with
bupropion.
Mental Health: Close monitoring of patients mental health status and/or addiction status is necessary. Regular medication
dosages should be monitored and adjusted as necessary. Varenicline should be used with caution in those with schizophrenia,
bipolar disorder or major depressive disorder. Patients taking bupropion or varenicline may be at increased risk
of neuropsychiatric symptoms (agitation, depressive mood, behavioral changes, suicidal ideation), therefore should be closely
monitored, especially those with pre-existing mental illness. These symptoms may arise as a result of smoking cessation with or
without treatment, and causality has not been determined.
Adolescents: Limited research .Offer NRT as part of a risk reduction strategy. Start with short acting NRT first. NRT may need to
be used for some non daily tobacco users. Reassess within 24-48 hours of initiation.
Diabetes: Nicotine, such as nicotine in tobacco and NRT, can affect hemoglobin A1C levels, carbohydrate metabolism, and insulin
absorption. Monitor blood glucose to determine if medication or dietary adjustments are needed for optimal diabetes management.
Chew/snuff: Limited research. Start with nicotine patch (changing patch dose if needed) as follows: Less than 2 cans/pouches per
week equals14 mg patch, 2-3 cans/pouches per week equals 21 mg patch, greater than 3 cans/pouches equals 42 mg patch. Add
gum or lozenge if needed. Do not use inhaler in this group. Reassess NRT needs within 48 hours of initiation.
Cigar/Cigarillo/Pipe: Limited research. Start with short acting NRT first. Patch may need to be used for some daily cigar or pipe
users. Reassess within 48 hours of initiation.
18282(Rev2013-12)
Page 2 of 2 (Side B)
9.17

Followup/Discharge Orders (page 1)
Name (last, first)

Pharmacotherapy Followup/Discharge Orders
Gender
o Nicotine Patch Recommended Titration: After initial 6 weeks decrease to the next lower dosing
increment every 2-4 weeks, or slower, based on patient response
o Nicotine Patch ____ (____ mg+___mg) daily x ____ weeks; then
o Nicotine Patch ____ (____ mg+___mg) daily x ____ weeks; then
o Nicotine Patch 28 mg (21mg+7mg) daily x ____ weeks; then
o Nicotine Patch 21 mg daily x ___ weeks; then
o Nicotine Patch 14 mg daily x ___ weeks; then
o Nicotine Patch 7 mg daily x ___ weeks
o Alternate Dose (specify)______________________________________________________________
n Number of Refills
o Nicotine Gum Recommended Titration: Month 1: 10-20 pieces/day x 14 days, then 8-15 pieces/day;
Month 2: 4-10 pieces/day; Month 3: 2-5 peces/day; Month 4: 1 piece for urge only
One piece as instructed every 1-2 hour(s) as needed; Maximum: 20 pieces/day x ____ weeks
o 4 mg Nicotine Gum
o 2 mg Nicotine Gum
n Number of Refills
o Nicotine Lozenge Recommended Titration: Week 1- 6: 1 lozenge every 1-2 hours; Week 7-9:
1 lozenge every 2-4 hours; Week 10-12: 1 lozenge every 4-8 hours; Week 13-24: 1-2 lozenges per day
for urge only
One lozenge as instructed every 1-2 hour(s) as needed; Maximum: 20 pieces/day x ____ weeks
o 4 mg Nicotine Lozenge (polacrilex)
o 2 mg Nicotine Lozenge
o 1 mg Nicotine Lozenge
n Number of Refills
o Nicotine Inhaler Recommended Titration: 6-16 cartridges per day x 12 weeks. Then taper over an
additional 6-12 weeks. Stop when at 1-2 cartridges per day
One cartridge as directed every 20 minutes as needed; Maximum 16/day
o 10 mg Nicotine Inhaler (equal to 4 mg inhaled) Use up to cartridges per day _____ X _____ weeks
n Number of Refills
o Nicotine Mouth Spray Recommended Titration: Week 1-6: 1 to 2 sprays every 30 minutes as needed;
Week 7-9: start reducing the number of sprays per day, until using half the number of sprays per day
that were used initially; Week 10-12: reduce to 2- 4 sprays per day.
1 to 2 sprays every 30 minutes as needed; maximum 2 sprays at a time, 4 sprays per hour or 64 sprays
per day.
o 1 mg nicotine per spray delivered. 1 bottle x _____ weeks.
n Number of Refills
18283(Rev2014-02)
9.18
White - Chart
Canary - Pharmacy
Page 1 of 2

Followup/Discharge Orders (page 2)
Name (last, first)

Pharmacotherapy Followup/Discharge Orders
Gender
n Bupropion SR and Varenicline Treatment should begin one week before quit date. Usual
maintenance dose: 7-12 weeks (buproprion SR); 12 weeks (varenicline)
o Bupropion Sustained Release (SR):
o Initial Dose: 150 mg orally once daily for 3 days; then
o Maintenance Dose: 150 mg orally twice daily x ______ weeks, and reassess
o Alternate Dose (include duration)_______________________________________________________
n Number of Refills
o Varenicline
o Initial Dose: 0.5 mg orally once daily for 3 days; then 0.5 mg orally twice daily for 4 days; then
o Regular Maintenance Dose: 1 mg orally twice daily x ____ weeks, and reassess
o Alternate Maintenance Dose: 0.5 mg twice daily x ____ weeks (Consider dose adjustment in renal impairment)
n Number of Refills
Referral/Information Provided
o Patient provided information sheet on tobacco cessation programs. Patient to complete registration
OR
o Referral done to tobacco cessation program. Name of Program
o AlbertaQuits Helpline Referral (form #09973)
o AlbertaQuits Groups 1-866-710-7848
o AlbertaQuits Online www.albertaquits.ca
o Other, specify (e.g. PCN group)___________________________________________________________
Prescriber Name (print)
Signature
Date (yyyy-Mon-dd) Time(hh:mm)
18283(Rev2014-02)
White - Chart
Canary - Pharmacy
Page 2 of 2
9.19
Preparing Staff
10. Communication
11. Training
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
PREPARING STAFF FOR TOBACCO FREE FUTURES

IMPLEMENTATION
Communication and training are essential processes that will have a direct impact on the
success of the initial implementation and sustainability of the Tobacco Free Futures initiative.
Thefollowing two chapters will provide valuable information for site management and steering
committees to consider, as well as the tools and resources to support these processes.
Chapter 10: Communications

The importance of a strong communications plan throughout engagement, planning,

implementation and sustainability.
How to identify and connect with key audiences.
How to connect with AHS Communications advisors.
Tools available to support site and/or program communications plans.
Chapter 11: Training

The importance of training on the attitude, knowledge and skills staff require to
implement the Tobacco Free Futures initiative.
Competency-based training to match role requirements.
Training and professional development opportunities in Alberta.
How to access training opportunities.
Chapter 10
Communication
10.1
Introduction to Tobacco Free Futures site

communications plan
A strong communication plan is an essential component of the Tobacco Free Futures initiative
implementation success. The goal of the plan is to increase awareness of the program and
the supports available to staff, patients/clients and the general public. Various target groups
need to be engaged and given relevant information at different phases of the implementation
process, using a range of media and resources. Target groups within the health care setting
include

management
steering committee members
identified tobacco leads
health care professionals
support staff, including

volunteers
physicians
referring organizations
patients/clients
the general public
This chapter outlines a general

Tobacco Free Futures communication
plan that integrates key messages
and may need to be tailored to meet
individual site needs. The appendices
include a variety of templates and
other resources that can be adapted
and/or adopted for use. These
templates and resources have been
developed in collaboration with the
AHS Marketing and Communications
teams and are intended to provide
succinct communication throughout
theimplementation process.
Resources for management, staff and
physicians are intended to: develop
awareness and engage the reader in
the Tobacco Free Futures initiative,
outline implementation timelines
and provide information on training
requirements and availability, as
well as performance expectations.
Communication targeted for clients and
the general public includes information
about the AHS Tobacco and Smoke
Free Environments Policy and available
support for tobacco users.
10.2
Implementation planning tool tasks:

communications
1. Arrange engagement presentation(s)
formanagement and others as necessary.
2. Send invitation to join site steering

committee to identified potential members.
3. Inform managers and supervisors of
established timelines for implementation.
4. Inform staff and physicians of established
timelines for implementation.
5. Create awareness of availability and
expectations of staff training to all
managers and supervisors.
6. Notify identified tobacco practice leads of

training expectations and supportive role.
7. Inform front-line health care providers of
training opportunities and expectations.
8. Inform physicians of expected role
in support of tobacco treatment and
education opportunities.
9. Inform referring organizations of
implementation plans.
10. Inform site visitors and clients of AHS

Tobacco and Smoke Free Environments
Policy and supports available.
11. Inform staff of sustainability plans and
celebrate success of implementation.
All resources are available free of charge for AHS sites implementing the Tobacco Free
Futures initiative. The resources provided are not intended to be the exclusive materials used
to communicate the program. Sites may feel the need to develop additional resources and
communication tools. To download and/or order any resources, visit www.albertaquits.ca.
Engaging AHS Communications team

Sites considering and/or planning to implement the Tobacco Free Futures initiative should
advise their AHS Communications advisor of their implementation plan andtimeline.
Note that Communications advisors will not assume responsibility for communication during
the implementation roll-out. Rather, advisors are to be consulted in a strategic capacity, for
guidance tailored to the respective sites and their planned implementation of Tobacco Free
Futures. This may include advising on the potential use of Zone News, Insite and external
outreach, as appropriate to the specific site and/or zone implementation.
Sites or teams who are unsure of their appropriate Communications contact can visit the
Communications Insite page at http://insite.albertahealthservices.ca/1002.asp or email
Shannon Evans, Senior Communications AdvisorPopulation Public Health Provincial, at
shannon.evans@albertahealthservices.ca. The Tobacco Reduction Program Communication
Planis supported by Heather Kipling, Communications Advisor. She can be contacted by
email at heather.kipling@albertahealthservices.ca.
10.3
Communications for initial engagement

Once a site has identified an interest in implementing the Tobacco Free Futures initiative,
communication to key stakeholders within the site need to occur. The following table outlines
available resources that will help inform and engage site leaders, as well as tools that will
help create general site awareness about planned implementation.
Table 10.1: Communication Tools for Site Engagement

IMPLEMENTATION
MILESTONE/TASK
TARGET
AUDIENCE
Engage support
of key decision
makers and
champions at
AHS health
care setting
implementing the
Tobacco Free
Futures initiative.
Senior site
management
Appendix
10(a) Tobacco
Free Futures
Overview
team member(s) may attend initial meetings to present

information on the program and answer questions
a standard engagement PPP is available on the
secure TFF section of the albertaquits.ca website.
Key site
management
and staff
champions
from target
groups
Appendix
10(b) Tobacco
Free Futures
Invitation to Join
Site Steering
Committee
email/memo template
sent by senior site management or designate to
identified potential members
to inform members of their role in implementing the
Tobacco Free Futures initiative
to inform members of date, time and location of initial
meeting
Site
management
Appendix
10(c) Tobacco
Free Futures:
Implementation
Information for
Management
email/memo template
sent by senior site management or steering committee
chairs to all site managers
to create awareness of Tobacco Free Futures initiative
and supports available
to inform of established timelines/target dates for
implementation of Tobacco Free Futures initiative
Staff and
physicians
Appendix
10(d) Tobacco
Free Futures:
Implementation
Information
for Staff and
Physicians
email/memo template
sent by senior site management or steering committee
chairs to all site staff and physicians
to create awareness of Tobacco Free Futures initiative
and supports available
to inform of established timelines/target dates for
implementation of Tobacco Free Futures initiative
10.4
COMMUNICATION
RESOURCE
USE/PURPOSE
Preparing staff for implementation

Training of staff and physicians is a key element in the successful implementation of the
Tobacco Free Futures initiative. Managers, tobacco leads, staff and physicians will need
to be informed of how the program affects their role and/or the role of their team, as well
as the availability of training opportunities. The following table outlines the resources
available to communicate with these key target audiences regarding the sites timelines
forimplementation, staff roles and training opportunities/requirements.
Table 10.2: Communication Tools for Site Preparation

IMPLEMENTATION
MILESTONE/TASK
Identify tobacco
leads and inform
managers,
leaders,
physicians
and staff
about training
expectations
andavailability
on site.
TARGET
AUDIENCE
COMMUNICATION
RESOURCE
USE/PURPOSE
All site
managers
Appendix
10(e) Tobacco
Free Futures
Staff Training
Expectations:
Information for
Management
email/memo template sent by senior site management

or steering committee chairs to all site managers
to inform of the different training opportunities,
including general orientation presentation
to inform of tobacco leadership opportunities
to describe staff roles
to create awareness of availability and expectations of
training for staff
Tobacco
leads
Appendix
email/memo template sent by senior site management
10(f) Tobacco
or steering committee chairs to identified tobacco
Free Futures
practice leads
Invitation to Site to inform staff member of identification as tobacco lead
Tobacco Practice to describe the role of tobacco practice leads in
Leads
implementation of the Tobacco Free Futures initiative
to create awareness of training expectations and
availability for tobacco practice leads
Front-line
Appendix 10(g)
health care
Tobacco Free
professionals Futures Frontline Health
Professional
Staff Training
email template sent by site management or tobacco

lead as appropriate
to update staff on implementation plans and role
expectations
to inform of training opportunities and expectations
Physicians
Appendix
working at
10(h) Tobacco
AHS facilities Free Futures
Implementation:
Information for
Physicians
email/memo template sent by site medical director or

designate
to create awareness of implementation of Tobacco Free
Futures initiative and supports available at AHS facilities
to describe expected role of physicians in delivery of
brief intervention while at the site
to identify physician education opportunities
Referral
sources to
site
letter template sent by site management

to create awareness of implementation of Tobacco
Free Futures initiative at the site so referring
organizations can prepare patients/clients
Appendix10(i).
Tobacco
Free Futures
Implementation:
Information
for Referring
Organizations
10.5
Site-wide awareness of program and supports

As sites approach their go-live dates, it is important to create awareness of the
Tobacco Free Futures initiative. The visual resources identified in Table 10.3 communicate
key messages to patients/clients and visitors, including welcome to our tobacco- and
smokefree environment, going without tobacco can be difficult and we can help. Sites
may choose to continue to display posters and window clings in the months and years
following implementation as ongoing reinforcement of the program.
Table 10.3: Communication Tools for Site Implementation and Sustainability

IMPLEMENTATION
MILESTONE/TASK
TARGET
AUDIENCE
Go-live dates
and ongoing
implementation
of Tobacco Free
Futures initiative
at facility
Patients and
visitors
Appendix 10(j)
Supplementary
Communication
Resources
a selection of visual resources that may be posted or

displayed throughout the site to inform general public
of key messages
steering committees should connect with site
management to determine where resources may be
used
kiosks are available for zonewide sharing between
sites. For more information, contact the AHS Tobacco
Reduction Program at tru@albertahealthservices.ca
access all available resources through online
catalogue: http://www.albertaquits.ca/helping-othersquit/healthcare-providers/tools-and-resources/orderonline.php
Sustainability
Staff,
physicians
and
managers
Appendix 10(k)
Tobacco Free
Futures Thank
You to Staff,
Physicians and
Managers
email/memo template
sent by senior site management or steering
committee chairs to all site staff, physicians and
managers
to inform and celebrate success of training,
implementation and patientoutcomes
10.6
COMMUNICATION
RESOURCE
USE/PURPOSE
Appendices
Appendix 10(a) Tobacco Free Futures Overview
Appendix 10(b) Tobacco Free Futures Invitation to Join Site Steering Committee
Appendix 10(c) Tobacco Free Futures Implementation: Information for Management
Appendix 10(d) Tobacco Free Futures Implementation: Information for Staff and Physicians
Appendix 10(e) Tobacco Free Futures Staff Training Expectations: Information for Management
Appendix 10(f) Tobacco Free Futures Invitation to Site Tobacco Practice Leads
Appendix 10(g) Tobacco Free Futures Front-line Health Professional Staff Training
Appendix 10(h) Tobacco Free Futures Implementation: Information for Physicians
Appendix 10(i) Tobacco Free Futures Implementation: Information for Referring Organizations
Appendix 10(j) Supplementary Communication Resources
Appendix 10(k) Tobacco Free Futures Thank You to Staff, Physicians and Managers
10.7
Appendix 10(a) Tobacco Free Futures Overview
AN ALBERTA BASED HEALTH

SYSTEM TOBACCO
CESSATION INITIATIVE
The Tobacco Free Futures Initiative

Designed to SUPPORT Albertans who
are impacted by exposure to tobacco

products
EVIDENCE BASED using promising
practices.
Supports a LINKED REFERRAL across the
continuum of care.
wHAT IS THE INITIATIVE?

Tobacco Free Futures is a tobacco cessation systems
change initiative that was developed for the Alberta
Health Services (AHS) context. The initiative is
grounded in the available literature and supports the
integration of tobacco cessation support into healthcare
within AHS.
The aim is to contribute to decreasing tobacco use and
to supporting the achievement of Alberta Cancer
Prevention Legacy Fund vision of preventing cancer
through innovative research and prevention strategies.
How wAS IT DEVElopED
Tobacco Free Futures was developed through a
collaborative process with contributions from individuals
and groups from across the province. It has been
heavily informed by the Canadian Action Network for
the Advancement, Dissemination and Adoption of
Practice-informed Tobacco Treatment (CAN-ADAPTT)
led by the Centre for Addiction and Mental Health
(CAMH), and by the Ottawa Model for Smoking
Cessation from the Ottawa Heart Institute.
Tobacco Free Futures was funded from 2010-2014
through the Alberta Cancer Prevention Legacy Fund
(ACPLF). Funding has allowed for the development of
provincial standards of care, practice guidelines,
documentation standards (paper and electronic), training,
and supplementary resources.
Sustainability at the end of the 2014 funding cycle will be
through the AHS Tobacco Reduction Program (TRP).
10.8
wHAT IS THE ScopE?

Tobacco Free Futures can be adapted for use in
settings across the continuum of care. It has been
implemented in many care settings across the province
including: urban inpatient acute care; rural inpatient
acute care; additions detoxification and residential
treatment; public health programs; home care;
continuing care; and outpatient services.
How IS THE INITIATIVE IMplEMENTED?
Sites or programs work through a series of processes to
plan and implement Tobacco Free Futures to fit their
specific context.
Engagement of management and physician

leadership.
Formation of a multidisciplinary steering committee.
Completion of site/program AHS Tobacco and

Smoke Free Environments Policy compliance
assessment.
Determination of staff roles and documentation

standards.
Standardization of pharmacotherapy supports and

ordering process.
Identification of resources for staff and

patients/clients.
Implementation of a site/program communication

plan.
Training of staff and prescribers.
Planning for sustainability.
How wIll THE TRp SuppoRT YouR

SITE/pRoGRAM?
Our team will
provide support and guidance to your site/program
steering committee;
develop and supply resources that will guide such as

resource binders, posters, forms, patient handouts and
cessation aids;
provide resources to facilitate staff education; and
provide links to provincial networks and resources.
coNTAcT INfoRMATIoN
For more information, please contact the Tobacco
Reduction Program
Phone: 780. 422.1350
Email: TRU@albertahealthservices.ca.
Appendix 10(b) Tobacco Free Futures Invitation to Join Site Steering Committee
Invitation to Join <INSERT SITE NAME>Tobacco Free Futures Steering Committee

Alberta Health Services (AHS) is rolling-out Tobacco Free Futures; a program to improve the treatment of
tobacco dependency and nicotine addiction for patients and clients. Tobacco Free Futures provides the
necessary tools, resources and training for health care professionals to support patients and clients with
their tobacco dependency. Our site is planning to implement the program.
We are inviting you to help by joining the Tobacco Free Futures Steering Committee.
Tobacco Free Futures uses an integrated care pathway based on best practices for consistent, connected
treatment of tobacco dependency across the health care continuum. Front-line healthcare teams, will
be trained to:
ASK every patient about tobacco use in the last year.
ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise patients
who currently use tobacco to quit with a personalized message.
ASSESS patients readiness to quit tobacco, and interest in withdrawal support.
ASSIST with cessation medications for withdrawal support. Link to behavioural support.
ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for
continued cessation medications
The steering committee will manage the implementation process and act as an advisory body to
management, healthcare professional and other support staff. We are recruiting members from the
following groups:
senior management
unit management
physicians
nursing
pharmacy
respiratory therapy
protective services
patient registration
other (e.g., clinical education, allied health professionals, community supports or professional
working with specific populations)
The steering committees first meeting will be <INSERT INFORMATION HERE>. Please confirm your
interest in joining the committee and your attendance at the meeting with <INSERT CONTACT HERE>.
For more information, visit albertaquits.ca.
10.9
Appendix 10(c) Tobacco Free Futures Implementation: Information for Management
Tobacco Free Futures Implementation at <INSERT SITE >: Information for Management
Alberta Health Services (AHS) implemented its Tobacco and Smoke Free Environments Policy on April 1,
2011. The policy, which prohibits use of tobacco products on sites owned, operated, leased as well as
those that receive service delivery funding from AHS, supports AHS commitment to providing safe and
healthy tobacco free environments.
To best support tobacco dependent and/or addicted AHS patients and clients while in our care and to
improve the treatment of tobacco dependency and nicotine addiction both in our facilities and
beyond, AHS is rolling out the Tobacco Free Futures program.
Implementation of the cross-continuum Tobacco Free Futures program will ensure our front-line
health care teams have the necessary tools, resources and training to:
ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy. Advise
patients who currently use tobacco to quit with a personalized message.
ARRANGE further support by completing referral to AlbertaQuits or other services.
Arrange for continued cessation medications
<INSERT SITE > has established a Tobacco Free Futures Steering Committee to undertake
implementation planning, with a target implementation date of <INSERT DATE >.
Over the coming weeks, the steering committee will be:
completing pre-implementation assessments,
determining staff roles and reviewing documentation standards in the patient
record,
ensuring pharmacotherapy is available and reviewing ordering processes,
identifying and ordering supplementary resources for staff and patients,
communicating with staff, and the site at large,
arranging and scheduling training for all staff,
planning for sustainability and continuous improvement.
For information on implementation at <INSERT SITE >, please contact <INSERT NAME OF CONTACT> at
<INSERT CONTACT INFORMATION>.
Sincerely,
<INSERT NAME> (to be determined by Site Leadership)

10.10
Appendix 10(d) Tobacco Free Futures Implementation: Information for Staff and
Physicians
Tobacco Free Futures Implementation Information for <INSERT SITE > Staff and Physicians
Alberta Health Services (AHS) implemented its Tobacco and Smoke Free Environments Policy on April 1,
2011. The policy, which prohibits use of tobacco products on sites owned, operated, leased as well as
those that receive service delivery funding from AHS, supports AHS commitment to providing safe and
healthy tobacco free environments.
To best support patients and clients while in our care and to improve the treatment of tobacco
dependency and nicotine addiction at our facility, <INSERT SITE> and beyond, AHS is rolling out the
Tobacco Free Futures program.
Implementation of the cross-continuum Tobacco Free Futures program will ensure <INSERT SITE>
frontline healthcare teams have the necessary tools, resources and training to:
ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange
for continued cessation medications
Implementation of the Tobacco Free Futures model at <INSERT SITE> is planned for <INSERT DATE> and
training for physicians and frontline healthcare professionals <INSERT SITE> will begin <INSERT DATE>.
Your manager will inform you of more details in the following weeks and months.
For more information on the AHS Tobacco and Smoke Free Environments Policy including supports
available for staff visit: http://insite.albertahealthservices.ca/9783.asp.
Thank you for your support. Together, we can make a difference for our patients and clients.
Sincerely,

10.11
Appendix 10(e) Tobacco Free Futures Staff Training Expectations: Information for
Management
Tobacco Free Futures <INSERT SITE> Expectations for Training: Information for Management
As was communicated on <INSERT DATE>, <INSERT SITE> is implementing the Tobacco Free Futures
program on <INSERT DATE> to improve the treatment of tobacco dependency and nicotine addiction for
patients and clients. <INSERT SITE> recognizes that training is essential to ensure that staff have the
knowledge and tools to effectively address tobacco dependence and nicotine addiction. The level of
knowledge required will be dependent on staff roles and training has been developed to meet different
needs.
As a manager, you will have an important role to support <INSERT SITE> tobacco practice leads, staff,
physicians and patients/clients.
Training required by Tobacco Practice Leads (from Patient Care Units or Practice Areas): As a manager,
we request your support to identify one or more Tobacco Practice Leads from each of your clinical areas.
These leads will play an important role in implementation of the program: supporting training and
ongoing implementation by front-line staff. Further information on a 3 hour Tobacco Practice Lead
Training workshop will be provided to selected participants by <INSERT CONTACT>. Please submit your
selected Tobacco Practice Leads to <INSERT CONTACT NAME & IFORMATION> by <INSERT DATE>.
Training required by Front-line Health care Professionals: At <INSERT SITE>, it has been decided that
front-line health care professionals including <INSERT TEAMS OR DISCIPLINES> will be required to
complete the online Brief Tobacco Intervention Training through MyLearning Link. These staff will be
required to complete the 90120 minute training by <INSERT DATE>. More information will be
communicated via <INSERT MODE OF COMMUNICATION> by <INSERT DATE>.
Overview Session Required by All Staff (Including non-clinical supports): A brief 10 minute overview of
the Tobacco Free Futures program, AHS Tobacco and Smoke Free Environments Policy and supports
available for staff is available in a face to face presentation. All employees are required to complete this
session prior to <DATE>. Training is available on <INSERT DATE & TIME> at <INSERT LOCATION>.
<ADDITIONAL TRAINING DATES & TIMES IF APPLICABLE>.
Should you have any questions in the meantime, please dont hesitate to contact <INSERT NAME> at
Sincerely,
<INSERT NAME>(to be determined by Site Leadership)

10.12
Appendix 10(f) Tobacco Free Futures Invitation to Site Tobacco Practice Leads
Invitation to Become a <INSERT SITE> Tobacco Practice Lead
patients and clients.
All <INSERT SITE> front-line health care professionals will be trained to implement the Tobacco Free
Futures program, which will allow our teams to care consistently for AHS patients and clients with
tobacco dependency and nicotine addiction.
You have been selected as a tobacco practice lead and will have an important role to support staff in
helping their patients.
A 3 hour tobacco practice lead training workshop will provide you with all of the information and
resources you will need to support staff and patients in your practice area. The training includes:
a review of the Tobacco Free Futures program <INSERT SITE> implementation plan;
how to support the online Brief Tobacco Intervention Training for staff in your clinical area; and
an overview of resources and supports for patients/clients, staff and tobacco practice leads.
You are scheduled to attend the Tobacco Practice Lead Training:
On <INSERT DATE AND TIME>
<INSERT LOCATION AND ROOM NUMBER>
Please complete the online Brief Tobacco Intervention Training available through MyLearning Link prior
to your workshop; it should take 90120 minutes.
On behalf of the <INSERT SITE> tobacco steering committee, thank you for your support with this
important initiative. Please contact <INSERT NAME> at <INSERT CONTACT INFORMATION> with any
questions.
Sincerely,

10.13
Appendix 10(g) Tobacco Free Futures Front-line Health Professional Staff Training
Tobacco Free Futures Training for <INSERT SITE> Front-line Health Professional
Staff
patients and clients. As a frontline health professional, you will have an important role to support
<INSERT SITE> patients and clients.
Therefore, <INSERT SITE> front-line health care professionals are being trained with the Brief Tobacco
Intervention Training so that they will be confident to:
ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange for
continued cessation medications
You are required to complete the online Brief Tobacco Intervention Training through MyLearning Link
by <INSERT DATE AND TIME>. The training will take approximately 90120 minutes to complete.
Following completion please present your certificate to <INSERT NAME> at <INSERT CONTACT
INFORMATION>.
Sincerely,

10.14
Appendix 10(h) Tobacco Free Futures Implementation: Information for Physicians
Tobacco Free Futures Implementation at <INSERT SITE>: Information for Physicians

program on <INSERT DATE> to improve the care of patients and clients who are dependent on the use of
tobacco products. Using an integrated care pathway, Tobacco Free Futures enables consistent,
connected treatment across the health care continuum.
As a physician, you have a key role in supporting tobacco dependent patients and clients, including
ordering pharmacotherapy, as medically appropriate.
Prior to implementation, <INSERT SITE> front-line health care teams will be trained to:
ADVISE all patients about the AHS Tobacco and Smoke Free Environments Policy.
Advise patients who currently use tobacco to quit with a personalized message.
ARRANGE further support by completing referral to AlbertaQuits or other services. Arrange
for continued cessation medications
To this end, we have arranged opportunities for you and your physician colleagues to learn more about
Tobacco Free Futures, including the use of pharmacotherapy in the treatment of tobacco dependence
and nicotine addiction. These learning opportunities are available via <INSERT MODE OF LEARNING> on
<INSERT DATE OF LEARNING OPPORUNITY >. <INSERT OTHER INFORMATION ON LEARNING
OPPORTUNITY> (e.g., sign up, time, location).
Sincerely,
<INSERT NAME>
<INSERT TITLE> Site Medical Director or appropriate alternate (to be determined by Site Leadership)
10.15
Appendix 10(i) Tobacco Free Futures Implementation: Information for Referring

Organizations
Alberta Health Services Tobacco and Smoke free Environments policy information and
Tobacco Free Futures implementation at <INSERT SITE >
Information for <REfERRING AGENcY>
Alberta Health Services (AHS) implemented its Tobacco and Smoke free Environments policy on
April 1, 2011. The policy supports AHS commitment to providing safe and healthy tobacco-free
environments for patients, staff and visitors alike. The policy prohibits the use of tobacco products on
AHS owned, operated and leased sites, as well as those that receive service delivery funding from AHS.
beginning <INSERT DATE>, the use of tobacco products will be prohibited at <INSERT SITE >.
To best support patients and clients while in our care, and improve the treatment of tobacco dependency
and nicotine addiction at <INSERT SITE> and beyond, AHS is rolling out the Tobacco Free Futures
program at the facility.
Implementation of the cross-continuum Tobacco Free Futures program at <INSERT SITE> will ensure of
front-line health care teams have the necessary tools, resources and training to support patients and
clients in the following ways at the facility:
All patients/clients will be asked about their tobacco use in the last year.
All patients/clients will be made aware of the AHS Tobacco and Smoke Free Environments Policy
and the supports available to them.
Patients/clients who are interested in withdrawal support will be provided with cessation
medications (e.g., nicotine replacement therapy) as a comfort measure while at <INSERT SITE>.
Whenever possible, additional supports and resources will be made available to patients/clients
at <INSERT SITE>.
Ongoing support on discharge will be arranged through a referral to AlbertaQuits or other service
available in the community.
Implementation of the Tobacco Free Futures model at <INSERT SITE> is planned for <INSERT
DATE>.
For more information on the AHS Tobacco and Smoke Free Environments Policy, visit:
For more information on Tobacco Free Futures, visit: albertaquits.ca Health Provider page.
For more information on supports and resources at <INSERT SITE>, please contact <INSERT NAME OF
CONTACT>at <INSERT CONTACT INFORMATION>.
Thank you for your support. Together, we can make a difference for our patients and clients.
Sincerely,
10.16
Appendix 10(j) Supplementary Communication Resources

Sample Supplementary Communication Resources
Health Professional Poster
Modifiable PDF format
which allows sites/
programs to personalize
with key staff messages.
Not available to order.
Available on secure TFF
site Albertaquits.ca
Window Cling
(11 x 11) Double-sided
self-adhesive window
cling decal that reads,
WELCOME to our
tobacco and smoke free
environment. Going
without tobacco is hard;
we can help.
Staff & General Public Table Tent

2-sided, folded resource.
Cling Style Poster

(11 x 17) Single-sided
self-adhesive window
cling decal that reads
WELCOME to our
tobacco and smoke
free environment.
Going without tobacco
is hard; we can help.
Decal includes QR code
and albertaquits.ca
webaddress
Side 1: Creating
with your help.
Side 2: QUITTING IS
HARD. Its easier with
support, we can help.
Card includes QR code
web addresses
Tobacco Free Futures Kiosk

Display includes banners, backdrop and resource table
suitable for manned display. Kiosks are available for
zone wide sharing and can be accessed by contacting
tru@albertahealthservices.ca
Note: the resources available may change over time refer to online ordering catalog Albertquits.ca for current listing.
10.17
Appendix 10(k) Tobacco Free Futures Thank You to Staff, Physicians and Managers
<INSERT SITE> and Tobacco Free Futures Thank You!

On <INSERT DATE>, <INSERT SITE> successfully implemented the Tobacco Free Futures program ensuring
AHS patients and clients receive the best support while in our care and improving the treatment of
tobacco dependency and nicotine addiction.
With your ongoing efforts, <INSERT SITE> will continue to offer a seamless and integrated level of
cessation support for all our patients and clients who use tobacco pproducts. Your help continues to be
key to the success of the Tobacco Free Futures program at <INSERT SITE>.
Just think, a healthcare provider who sees five to ten clients/patients a day and uses the brief tobacco
intervention with each could help 24 patients quit in a single year. Your interventions will continue to
benefit clients year after year.
The provincial Tobacco Free Futures program team will also continue to support you. To learn more
about Tobacco Free Futures and the supports available to you, visit albertaquits.ca, Health Provider
page.
Congratulations and thank you for your support.

Together, we are making a difference for our patients and clients.
Sincerely,

10.18
Chapter 11
Training
11.1
Effective treatment for tobacco

dependence and nicotine addiction
within Alberta Health Services (AHS)
first depends on the availability of
tobacco treatment training for health care
providers. Historically, this training has
been minimal. It is now more important
than ever that health care providers are
able to support clients who are affected
by the use of tobacco products. This is
because of the well-known connections
between tobacco and
Identification of core competencies helps

to enhance the quality and consistency of
smoking cessation support given by health
care professionals.1
increased rates of cancer

andchronic disease
Implementation planning tool tasks: training
poorer health treatment

outcomes
an increased burden on the

health care system
1. Review available training options and decide

what will be required as a standard.
The complexity and intensity of tobacco

treatment must match the needs of the
individual tobacco user. For instance,
some individuals who use tobacco may
only require brief intervention from a
health care provider; others, however,
with more complex or concurrent
concerns, may require more intensive
support. This approach is consistent with
the continuum of care for the treatment of
nicotine dependence, as recommended
by Canadas national clinical practice
guidelines.2
2. Determine training needs and

expectations for all staff.
3. Add tobacco training to existing education

tracking systems (e.g., new hire orientation
training).
4. Review AHS Tobacco and Smoke Free
Environments policy and available
supports with all staff (clinical and
nonclinical).
5. Train tobacco practice leads.
6. Train front-line health care professionals

in brief tobacco intervention.
7. Train physicians and other prescribers.
8. If applicable, train health professionals in

intensive tobacco cessation counselling.
AHS TOBACCO TREATMENT TRAINING

Competency-based training will improve and enhance the quality and consistency of
tobacco cessation support in Alberta. AHS offers several training opportunities based on
competencies, which in turn focus on learning outcomes: addressing what the learners
are expected to do, rather than what they are expected to learn. A competency is the
ability to perform a defined, real-world task in a specific context. Learning objectives are
more specific statements of observable and measurable behaviours that are necessary to
master each competency; they suggest how students knowledge, skills and attitudes will
be different because of the learning experience.3 Knowledge is the condition of knowing
something with familiarity that is gained through experience or association. Skill is the
ability to use ones knowledge effectively and readily. Attitude is the mental position,
emotion, or feeling toward a fact or state.
11.2
Knowledge
know what
Ability
Skill
know how
Attitude
know why
Health care providers offering varying degrees of support will require different competencies
to carry out the responsibilities of a given treatment plan. For example, a front-line health
professional working in an urgent care setting would not need to be proficient in group
counselling in order to provide competent tobacco treatment for his or her clients.
The remainder of this section outlines the variety of tobacco cessation training opportunities
available through AHS to meet the needs of health care professionals. New online tobacco
basics and comprehensive tobacco treatment courses are under development and should be
available in the fall of 2014. For more information about tobacco reduction and cessation training
availability, contact tru@albertahealthservices.ca or call 780-422-1350.
Brief tobacco intervention training

There are a wide variety of opportunities to help individuals who use tobacco products. Abrief
tobacco intervention, delivered in less than three minutes, is potentially one of the most
effective interventions available. This intervention uses a 5 As model:

ASK clients about their tobacco use
ADVISE of the importance of quitting
ASSESS their readiness to quit and interest in support for nicotine withdrawal
ASSIST with cessation medications and counselling supports
ARRANGE for ongoing follow-up support
Following this training, participants will be able to
integrate brief tobacco treatment as a part of their front-line work
provide clear and accurate information about tobacco use, the scope of the health
impact on the population and the causes and consequences of tobacco use
conduct a brief tobacco intervention
provide clear and accurate information about available pharmacotherapy options and
their proper use
provide relevant resources to individuals who are not ready to quit, who are ready to
quit and who have recently quit
describe and use methods for documenting brief tobacco interventions
11.3
Table 11.1: Brief Tobacco Intervention Training Details

TIME
1.5 to 2 hours.
AUDIENCE
All current and future health care professionals who provide direct client care.
PREREQUISITES
None.
ACCESS
If you are an AHS employee, please take this training through MyLearning.
Ifyou are not an AHS employee, contact tru@albertahealthservices.ca.
Comprehensive tobacco intervention: TRAC

TRAC is a comprehensive training program that builds the capacity of health care providers
to provide intensive tobacco cessation counselling. After completing this course, participants
will be able to

use the 5 As model for brief and intensive tobacco cessation counselling
support clients using non-judgmental counselling techniques and other effective tools
describe the available pharmacotherapy support
understand specific populations and their unique challenges in tobacco reduction and
cessation
use effective strategies for helping reduce harm
identify tobacco cessation programs and services available in Alberta
Table 11.2: TRAC Training Details

TIME
2 days.
AUDIENCE
All current and future health care professionals who provide direct client care.
PREREQUISITES
None.
ACCESS
This training is offered in a classroom setting. To access the registration form,

visit albertaquits.ca.
11.4
Group cessation training: QuitCore facilitator training

QuitCore is a free group cessation program in which individuals are provided the tools, skills
and strategies they need to quit smoking or using other forms of tobacco. These sessions
provide participants with an opportunity for participatory shared learning and group support
during their journey to become tobacco free. The groups are led by trained health care
professionals. This training module provides health care professionals with the information
and skills needed to effectively facilitate a QuitCore group cessation program. On completion
of the QuitCore facilitator training, participants will be able to

describe the structure of the QuitCore and AlbertaQuits framework
discuss how to incorporate adult education principles into effective facilitation
describe effective instructional practices for use with groups
review and practice how to deliver each of the QuitCore sessions
review cessation medication (prescription and NRT) information for QuitCore

participants
review nutrition and active living information for QuitCore participants
discuss the role of mentor support and the facilitator toolkit
The AHS Tobacco Reduction Program (TRP) will provide facilitator and participant manuals,
resource materials and mentorship support.
Table 11.3: QuitCore Facilitator Training Details

TIME
1.5 days.
AUDIENCE
Health care professionals who will be facilitating tobacco cessation group

counselling.
PREREQUISITES
Individuals who are interested in training as QuitCore facilitators need to have

completed tobacco training through TRAC, Provincial Concurrent Capable
Learning Series (PCCLS) tobacco cessation core training or the Centre
for Addiction and Mental Health (CAMH) Training Enhancement in Applied
Cessation Counselling and Health (TEACH) program. This training is offered
free to health professionals from AHS and non-AHS settings.
Note: Interested professionals will need a letter of support from their manager/
supervisor to confirm they will be able to offer the program once trained.
ACCESS

11.5
Cessation medication training for special populations: Tobacco

cessation pharmacology for the mental health population training
Tobacco Cessation Pharmacology for the Mental Health Population Training is training for
prescribers that is facilitated by a pharmacist. At the end of this training, participants will be
able to

understand the prevalence and impact of tobacco use among people being treated
for addictions and mental health conditions
understand how to prepare a tobacco cessation pharmacotherapy protocol for

persons with mental health conditions
learn about monitoring of drugs and drug levels for toxicity as tobacco use is reduced
review drug interactions and the metabolism of specific psychiatric medications

following smoking cessation
understand the comprehensive factors that may contribute to tobacco use among
people being treated for addictions and mental health conditions
This training is an Accredited Group Learning Activity (Section 1) as defined by the

Maintenance of Certification program of the Royal College of Physicians and Surgeons
of Canada and is approved by the University of Calgarys Office of Continuing Medical
Education and Professional Development (Faculty of Medicine). Participants will receive
onehour of credit under Section 1.
Table 11.4: Tobacco Cessation Pharmacology for the Mental Health Population Training Details
TIME
1.5 hours.
AUDIENCE
This training is intended for psychiatrists and pharmacists. However, other

health professionals working with mental health clients would also benefit from
attending.
PREREQUISITES
None. However, TRAC training is recommended.
ACCESS

11.6
AHS SITE CAPACITY-BUILDING TRAINING AND

EDUCATION
The Tobacco Reduction Programs capacity-building training modules and education
opportunities aim to develop the attitudes, knowledge and skills to guide education and
other initiatives that will prevent, protect and reduce the harms of tobacco use. For more
information on our capacity-building training modules and opportunities, please contact
Tobacco Free Futures: Tobacco practice lead training

Brief tobacco interventions are potentially one of the most effective things that a health
professional can do to improve a persons quality of life and increase their lifespan. Tobacco
Free Futures is an integrated health system approach to tobacco treatment that incorporates
support for Albertans who are affected by the use of tobacco products.
This training will provide participants with the foundational tools, resources and interpersonal
skills that are needed to support the integration of tobacco treatment into practice and mentor
front-line staff who are expected to support clients who use tobacco. On completion of the
Tobacco Practice Lead training, participates will be able to

provide clear and accurate information about the model and benefits of
implementation as a standard of care
identify information about the implementation of Tobacco Free Futures within the
context of specific site or program settings
identify potential considerations for supporting staff who will take online tobacco
training
identify the site- or program-specific processes related to training, including

communication, access and the accurate recording of participation
identify the forms, resources and tools available to help site or program tobacco
practice leads support front-line staff implement brief tobacco intervention
Table 11.5: Tobacco Practice Lead Training Details

TIME
3 hours.
AUDIENCE
Tobacco practice leads may represent a variety of health professional

disciplines (e.g., registered nurses, respiratory therapists, pharmacists, or
social workers) and hold a variety of designated roles within their practice area
(e.g., clinical leads or educators). They will be designated to this role by the
site and/or program management.
PREREQUISITES
Brief Tobacco Intervention Training.
ACCESS
Training is offered in a classroom or facilitated webinar. Training will be

arranged in collaboration with sites/programs who are implementing the
Tobacco Free Futures initiative.
11.7
Health care systems change management: Tobacco Free Futures

guidelines implementation workshop
Integrating tobacco intervention into health care delivery requires the active involvement of
clinicians, health care systems, administrators and decision makers. These efforts represent
an opportunity to increase rates of treatment delivery, quit attempts and successful tobacco
cessation.
This training explores 10 processes important to organizational change management. After
this workshop, participants will have the foundational knowledge, tools and resources needed
to provide leadership and guidance to support a health care setting in implementing the
Tobacco Free Futures initiative.
On completion of this training, participants will be able to

recognize the importance of treating tobacco dependence and nicotine addiction in

health care settings
recognize best practices in tobacco cessation for health care settings and the
advantages of systematically integrating brief tobacco treatment in sites, programs
and zones across the province
understand the considerations of implementing a systems approach to tobacco

cessation based on specific contexts
recognize the available implementation tools, resources, supports, training and

networking opportunities
Table 11.6: Tobacco Free Futures Guidelines Implementation Workshop Details

TIME
7.5 hours.
AUDIENCE
This training module is intended for designated AHS site management and
tobacco champions who will provide vision, leadership and guidance for the
implementation of the Tobacco Free Futures initiative at a site or within a
program.
PREREQUISITES
None.
ACCESS
Training is offered in a classroom or facilitated webinar. Training will be

arranged in collaboration with sites and programs who will be implementing
the Tobacco Free Futures initiative.
11.8
REFERENCES
1. Bullen, C., Walker, N., Whittaker, R., McRobbie, H., Glover, M., & Frasher, T. (2008).
Smoking cessation competencies for health workers in New Zealand. Journal of the
New Zealand Medical Association, 121(1276), 5770.
2. Canadian Action Network for the Advancement, Dissemination and Adoption of
Practice-Informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking
cessation cinical practice guideline. Toronto, ON: Centre for Addiction and Mental
Health. Retrieved from http://can-adaptt.net
3. Office of Public Health Preparedness and Response, Centers for Disease Control
and Prevention. (2012). Knowledge, skills, and attitudes (KSAs) for the Public
Health Preparedness and Response Core Competency Model. Retrieved from
http://www.asph.org/userfiles/KSA.pdf
11.9
Final Planning
12. Sustainability
13. Continuous Improvement
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
PLANNING FOR SUSTAINABILITY AND CONTINUOUS

IMPROVEMENT OF TOBACCO FREE FUTURES
Planning for sustainability has been an integral part of the development and implementation
of the Tobacco Free Futures initiative, but continued activities at the provincial and the
individual health care setting levels will help ensure that systems changes are sustained
and high-quality cessation support is ongoing. The following two chapters provide valuable
information for site management and steering committees to consider, as well as the tools
and resources to support these processes.
Chapter 12: Sustainability

How to gain the support of leadership on an ongoing basis.
Understand considerations for the continuous management of resources after the

initial implementation.
How to support future training and professional development needs.
How to recognize the hard work of staff and a successful implementation.
Chapter 13: Continuous Improvement

Recognize that the key to the success of the continuous quality improvement process
is leadership.
How the AHS site conducts an annual assessment, from which a quality improvement
plan is generated.
The work currently underway to define standardized metrics and reporting processes
for tobacco cessation activities within AHS.
How to access training and tools for the model that is used within AHS for quality
improvement (the AHS Improvement Way (AIW)).
Chapter 12
Sustainability
12.1
SUSTAINing tobacco Free Futures

The sustainability of the Tobacco Free Futures initiative will be determined by the
organizations capacity to maintain support to engaged AHS sites and to implement the
initiative at new sites. Campbell, Pieters, Mullen and Reece (2011) demonstrate that while
hospital-based smoking cessation interventions, such as the Ottawa Model for Smoking
Cessation, can be effective in helping smokers quit, long-term sustainability is required to
improve health and health care usage at the population level.2 Plans to transition the program
into AHS operations are currently underway.
A literature review by Scheirer (2005) identified five key factors related to the sustainability of
new programs:3

a clear alignment of the program with the organizations goals and procedures
identification of champions to provide leadership through implementation and

sustainability
clearly identified and communicated benefits to all stakeholders (including staff and
clients)
the ability to modify the program to fit organizational contexts
the availability of stakeholders in other organizations to provide support
Table 12.1 outlines project alignment in consideration of these factors.
12.2
Table 12.1: Supporting Program Sustainability

Key Factor
Related Actions
Alignment of program with

organizations goals and
procedures
Support AHS vision and key strategic documents, such as the Health Plan
20122016.
Support the Tobacco and Smoke Free Environments Policy.
Designed to become routine standard of care within core services across the
continuum of care.
Support the Changing Our Future: Albertas Cancer Plan to 2030.
Support the Creating Connections: Albertas Addiction and Mental Health
Strategy.
Support the Creating Tobacco Free Futures: Albertas Strategy to Prevent
and Reduce Tobacco Use 20122022 targets.
Identification of program
champions
Collaboration with Tobacco Reduction Program staff.

Collaboration with Provincial Tobacco Cessation Advisory Committee.
Leadership from Provincial Tobacco Free Futures Advisory Committee.
Collaboration and direction from AHS Cancer Care, Addiction and Mental
Health and other Strategic Clinical Networks.
Leadership from Zone steering committees.
Leadership from health care site steering committees.
Identification and training of site tobacco practice leads.
Identification of benefits to
stakeholders
Support for all Albertans who use tobacco products.

Recommended standard of care provides guidance for all health care
professionals, including training.
Support for all Albertans who are exposed to second-hand smoke.
Support for AHS staff.
Modification to fit
organizations context
Adaption of the CAN-ADAPTT guidelines to fit the AHS context.

Developing AHS standardized resources, including www.albertaquits.ca
website, Tobacco Free Futures guidelines, training and professional
resources, patient resources and documentation tools.
Flexibility for implementation in health care settings across the continuum
ofcare.
Process of implementation driven at the site steering committee
(leadership) level.
Support from other

organizations and
stakeholders
Alberta Health and Wellness.

Internal support to AHS sites through the Tobacco Reduction Program.
12.3
Planning for sustainability has been an integral part of the development and implementation
of the Tobacco Free Futures initiative, but continued activities at the provincial and individual
health care setting levels will help ensure that systems changes are sustained and high
quality cessation support is ongoing.
Program tools have been developed to help guide and document individual health care
sites through the implementation and sustainability phases and reflect the shift in focus
of key action areas.
Implementation
Sustainability
Initial planning
Ongoing leadership
Final planning
Celebrating success
Resource development
Preparing staff
Resource management
Training and professional development
The remainder of this chapter will focus on considerations for provincial and site sustainability
related to the above-noted phases.
See appendices:
Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool
Leadership
Guidance and leadership for the Tobacco Free Futures initiative will be maintained through
the Tobacco Reduction Program, in consultation with Population, Public and Aboriginal Health
leadership, the Provincial Cessation Steering Committee, Strategic Clinical Networks and
other key stakeholders.
Resource management
Many resources have been developed to support the implementation of Tobacco Free
Futures. Whenever possible, these resources and processes have been standardized for
all of AHS. Resource management functions related to these resources, including review,
revision, printing (as appropriate) and distribution, will continue at a provincial level through
the Tobacco Reduction Program. These resources include
12.4
the AlbertaQuits website (www.albertaquits.ca)
Tobacco Free Futures guidelines and associated tools
training (online through AHS MyLearning Link and www.albertaquits.ca)
supplementary professional resources
supplementary patient resources
patient documentation forms
pharmacotherapy order sets
electronic medical records
Training and professional development

Initial staff training, as outlined in Chapter 11 (Training), is a key step in successful program
implementation. However, ongoing education to refresh or update existing staff knowledge
and the orientation of new staff is essential to ensure consistent messaging.
At a provincial level, activities led by the Tobacco Reduction Program are required to ensure
availability of relevant, quality and up-to-date training for all health professionals, including the
physicians and support staff. These opportunities may include

the general orientation for all Alberta Health Services staff regarding the Tobacco and
Smoke Free Environments Policy and supports available to patients/clients and staff
opportunities for specialized tobacco training for professionals treating tobacco

dependence, especially with specific populations
training for tobacco practice leads who will continue to support front-line staff in
specific sites/health care settings during implementation
brief tobacco intervention training for front-line health care professionals
professional development opportunities that allow for knowledge transfer and

networking
Celebrating success
Post-implementation, it is important to take time to evaluate and celebrate success as
a continuing validation of the importance of the program and its relevance within the
organization and each health care setting.
Knowledge transfer opportunities have been ongoing throughout development of the Tobacco
Free Futures initiative. Information about Tobacco Free Futures has been and will continue to
be disseminated locally, provincially, nationally and internationally.
Individual health care sites should look for opportunities to share program successes and
challenges, both within their site and externally. For example, as part of the survey process,
Accreditation Canada surveyors identify what they consider to be leading or exemplary
practices of high quality leadership and service delivery. In 2007, the Ottawa Model of
Smoking Cessation, a model similar to Tobacco Free Futures, was identified as one such
leading practice.1
12.5
REFERENCES
1. Accreditation Canada. (2007). Leading practices: Survey year 2007. Ottawa, ON: Author.
2. Campbell, S., Pieters, K., Mullen, K., & Reece, R. (2011). Examining sustainability in a
hospital setting: case of smoking cessation. Implement Science, 6, 108. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184081/#B15
3. Scheirer, M. (2005). Is sustainability possible? A review and commentary on empirical
studies of program sustainability. American Journal of Evaluation, 26(3), 320347.
Retrieved from http://hmcrc.srph.tamhsc.edu/Meetings/8th%20Meeting/Scheirer%20
-%20Sustainability%2009-07-05PDF.pdf
12.6
APPENDICES
Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool
12.7
Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool (page 1)
Tobacco Free Futures Sustainability plan

improvement goals should be discussed with the site committee and all affected stakeholders. The completed
sustainability plan should be retained for site records and a copy sent to tru@albertahealthservices.ca.
SITE lEADERSHIp
TASKS
pERSoNS RESpoNSIblE AND coMMENTS
1.0 Steering committee

1.1 Identify purpose of steering committee post
implementation.
1.2 Review and revise terms of reference. Appendix 4(a)
1.3 Update committee membership. Appendix 4(b)
1.4 Identify and communicate revised meeting schedule.

2.0 Documentation
2.1 Maintain supply of up-to-date forms through approved
printers.
RESouRcE MANAGEMENT
2.2 Ensure most up to date forms are available

(www.albertaquits.ca).
2.3 Assign responsibility for ongoing ordering and stocking
of forms.
2.4 Determine process for communicating future
documentation revisions/changes.
3.0 pharmacotherapy
3.1 Monitor use of cessation pharmacotherapy products.
3.2 Maintain stock of formulary products based on use.
3.3 Ensure most up-to-date order sets are stocked and
used (www.albertaquits.ca).
4.0 cessation resources
4.1 Review resources available, identify resource gaps
and confirm core resources (www.albertaquits.ca).
4.2 Establish process for maintaining ordering, stocking
and distribution of resources.
4.3 Assign responsibility for ordering, stocking and
distribution.
12.8
1/2
Appendix 12(a) Tobacco Free Futures Sustainability Planning Tool (page 2)
TASKS
pERSoNS RESpoNSIblE AND coMMENTS
5.0 All employees

5.1 Confirm general orientation of staff to policy and
supports.
TRAINING AND pRofESSIoNAl DEVElopMENT
6.0 Tobacco practice leads

6.1 Identify ongoing role and responsibility of tobacco
practice leads.
6.2 Identify person responsible for maintaining capacity
by replacing tobacco practice leads with turnover.
6.3 Identify person responsible for arranging training of
new tobacco practice leads.
6.4 Develop process for ongoing communication with
tobacco practice leads (e.g., regular meetings or
email distribution list).
7.0 front-line staff
7.1 Confirm standard for training front-line health
professionals (Chapter 11).
7.2 Integrate standard into existing training opportunities
(e.g., new hire training and skills days).
7.3 Identify person responsible for annual updates.
7.4 Identify person responsible for maintaining training
records.
8.0 physicians
8.1 Identify and communicate training opportunities for
physicians.
8.2 Identify person responsible to arrange site based
training or rounds opportunities.
8.3 Identify person responsible to orientate new
physicians and medical students to program.
wRAp up AND IMpRoVEMENT plANNING
9.0 celebrate success

9.1 Share successes with site/program and beyond
(e.g., newsletters and conferences).
9.2 Identify and communicate successes to stakeholders,
staff, and clients/families.
9.3 Identify person responsible for coordinating activities
to highlight program (e.g., World No Tobacco Day).
9.4 Highlight program implementation in quarterly reports
and accreditation activities.
10.0 Quality assessment and improvement planning
10.1 Review quality improvement assessment tool and
quality improvement plan template.
10.2 Complete quality improvement assessment and
quality improvement plan. Appendices 13(a) and
13(b)
10.3 Identify date of next quality improvement
assessment.
2/2
12.9
CHAPTER 13
Continuous
Improvement
13.1
INTRODUCTION TO QUALITY IMPROVEMENT

Quality services are services that are provided in a safe, effective, recipient-centred, timely,
equitable and recovery-oriented fashion. Alberta Health Servicess strategic direction is
structured around improving the health of Albertans through a focus on well-being and
ensuring all of the care we provide is safe and of high quality. The three goals of our
organizationquality, access and sustainabilityare connected and work together.1 Six
key dimensions of quality have been developed by the Health Quality Council of Alberta to
measure quality throughout the organization:

Appropriateness: Health services are relevant to users needs and are based on
accepted or evidence-based practice.
Safety: Mitigate risks to avoid unintended or harmful results.
Efficiency: Resources are used optimally in achieving desired outcomes.
Accessibility: Health services are obtained in the most suitable setting, and within a
reasonable time and distance.
Acceptability: Health services are respectful and responsive to users needs,

preferences and expectations.
Effectiveness: Health services are based on scientific knowledge.1
Quality improvement is a systematic approach to assessing services and improving them on

a priority basis. Processes must be continually reviewed and improved. Even incremental
changes make an impact, and providers can almost always find an opportunity to make things
better. Quality improvement activities emerge from a systematic and organized framework,
which should be understood, accepted and used throughout the health care setting.
LEADERSHIP
The key to the success of the continuous quality improvement process is leadership.
There are several ways that leaders of health care settings can provide support to quality
improvement activities.
Tobacco Free Futures site steering committee

The Tobacco Free Futures site steering committee provides ongoing operational leadership
of continuous quality improvement activities. Following the initial rollout, the committee
should plan to meet at least four times per year and should consist of individuals from
thefollowingunits:
13.2
senior management
unit management
physicians
nursing
pharmacy
respiratory therapy
protective services
client registration and admitting
others (e.g., clinical educators, allied health professionals, community

supports or professionals working with specific populations)
The responsibilities of the committee may include

developing and approving an annual quality improvement plan
as part of the plan, establishing measurable objectives based on priorities identified

through the use of established criteria for improving quality in AHS
assessing information based on defined indicators, taking action as required through

quality improvement initiatives to solve problems and pursuing opportunities to
improve quality
establishing and supporting specific quality improvement initiatives
regularly reporting to senior management on quality improvement activities
formally adopting AHSs approach to continuous quality improvement (the AHS

Improvement Way)
The Tobacco Reduction Program may also provide support and guide implementation of
Tobacco Free Futures quality improvement activities at the site.
Leaders support quality improvement activities by coordinating and communicating the
results of measurement activities related to quality improvement initiatives and overall efforts
to improve the quality of tobacco treatment.
PERFORMANCE MEASUREMENT
Performance measurement is the process of regularly assessing the results produced by
the program. It involves identifying processes, systems and outcomes that are integral to the
performance of the service delivery system, selecting indicators of these processes, systems
and outcomes, and analyzing information related to these indicators on a regular basis.
Continuous quality improvement involves taking action as needed based on the results of
data analysis and the performance opportunities they identify. The purpose of measurement
and assessment is to

assess the stability of processes or outcomes to determine whether there is an

undesirable degree of variation or a failure to perform at an expected level
identify problems and opportunities to improve processes
assess the outcome of the care provided
assess whether a new or improved process meets performance expectations
Through the support of the Alberta Cancer Prevention Legacy Fund, work is currently
underway to define standardized metrics and reporting processes for tobacco cessation
activities within AHS. The standardized tobacco treatment metrics for AHS are expected
to be available in August 2014. Pending approval, further work will be done to establish a
monitoring and reporting system based on these metrics.
For more information about standardized metrics and reporting processes, contact
13.3
Annual assessment
Assessments should be completed by the Tobacco Free Futures site steering committee
annually. These assessment are conducted by the AHS site and kept on file, along with the
quality improvement plan that is generated based on the assessment. These documents may
be shared and reviewed with the Tobacco Reduction Program. Annual assessments help set
the goals and objectives of the sites quality improvement plan, and can be accomplished
bycomparing actual performance with

self over time
pre-established standards, goals or expected levels of performance
information concerning evidence-based practices
other clinics or similar service providers
See appendices:
Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment
Appendix 13(b) Tobacco Free Futures Quality Improvement Plan
QUALITY IMPROVEMENT USING THE AHS

IMPROVEMENT WAY
Once the performance of the Tobacco Free
Futures systems change processes and
tobacco treatment have been measured,
assessed and analyzed, the information
gathered is used to identify a continuous
quality improvement initiative. The decision
to undertake the initiative is based upon
site and organizational priorities. The
model used within Alberta Health Services
for quality improvement is the AHS
Improvement Way (AIW).
In its simplest form, the AIW is a common
organizationwide approach for solving
problems, making improvements and
managing change based on Lean Six
Sigma process improvement methods.
AIW is an improvement process that
has been designed for all levels of AHS.
Whether you are on the frontlines, working
in a leadership position or working in an
administrative role, you will be able to
applythe AIW to the work you do each
day.1 Training and resources are available.
Four steps of the AHS Improvement Way

(AIW)1
1. Define opportunity: Describe the
problem, opportunity and goal, confirm as
a priority and link to AHS strategic goals.
2. Build understanding: Validate
opportunity, baseline performance, use
facts/data to pinpoint waste, variation,
root causes, design criteria.
3. Act to improve: Develop, test, measure

and refine changes, manage risks, confirm
achievement of intended outcome(s).
4. Sustain results: Ensure ongoing measures

and monitoring, the capacity to support
new practices, accountability and support.
For more information, tools, templates

and training on the AHS Improvement Way approach, visit:
http://insite.albertahealthservices.ca/aiw.asp.
13.4
REFERENCES
1. Alberta Health Services. (2014). Alberta Health Services Health Plan and Business Plan
20122015. Edmonton, AB: Author. Retrieved from http://www.albertahealthservices.ca/
publications/ahs-pub-2012-2015-health-plan.pdf
13.5
APPENDICES
Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment
Appendix 13(b) Tobacco Free Futures Quality Improvement Plan
13.6
Appendix 13(a) Tobacco Free Futures Quality Improvement Assessment (page 1)

Annual Quality Improvement Assessment
improvement goals should be discussed with the committee and all impacted stakeholders. A copy of the completed
assessment should be sent to tru@albertahealthservices.ca.
SEcTIoN 1
The questions in this section will assist you in determining if there are ways to improve the leadership and
implementation of the Tobacco Free Futures initiative at your site.
YES
No
1. Is site leadership still engaged and supportive of the Tobacco Free Futures initiative?
2. Are all service areas and professions still represented on the committee?
lEADERSHIp & IMplEMENTATIoN
3. Is the meeting frequency still appropriate?

4. Have the terms of reference for the committee changed?
5. Are there service areas or units that have not fully implemented Tobacco Free
Futures?
6. Have any service areas requested further support from the committee?
7. Have any new service areas been established since the initial rollout?
8. Are the proper Tobacco Reduction Act and AHS Tobacco and Smoke Free
Environment signs still in place?
9. Are there any areas on AHS property that seem to have high tobacco use?
10. Any groups of individuals struggling with compliance?
coMMENTS:
1/3
13.7
SEcTIoN 2
The questions in this section will assist you in determining if there are ways to improve the support and resources
available to clients, families, visitors, and staff at your site.
YES
No
1. Have AHS tobacco treatment documentation standards changed? If so have site

processes been updated and communicated?
RESouRcE MANAGEMENT
2. Have documentation practices changed at the site? If so, do they reflect AHS tobacco
treatment documentation standards?
3. Do clients who use tobacco require further support than what is currently offered on site?
(e.g., beyond brief tobacco intervention?)
4. Do staff who use tobacco require further support than what is currently offered?
5. Have there been any changes in the availability or use of cessation medications within
AHS?
6. Are there any changes in the resources available to clients and families?
7. Are there any changes in resources available to staff and volunteers?
8. Are there any improvements that can be made to the way the integrated care pathway has
been implemented?
9. Is the connection to continued support still occurring for all interested clients?
coMMENTS:
SEcTIoN 3
The questions in Section 3 will assist you in determining if there are ways to improve the education offered to staff,
students, and physicians at your site.
TRAINING & pRofESSIoNAl DEVElopMENT
YES
No
1. Is information about the policy included in the staff orientation?

2. Has there been significant staff turnover? (greater than 10%)
3. Has additional training taken place for new staff?
4. Are all tobacco practice leads still in place for each area? Has additional training
taken place?
5. Is there a need for ongoing or further skills development?
6. Have training records been maintained?
7. Do physician groups require further training?
8. Has training been identified for all student and new hires?
coMMENTS:
13.8
2/3
SEcTIoN 4
Review the answers and comments in the sections 1-3 and identify the priority areas for your site to focus on for the next
year. Record your selected improvements in this section as quality improvement goals.
From the above data, the following quality improvement goals have been identified for the next year:
IMpRoVEMENT GoAlS
1.
2.
3.
4.
The completed assessment will assist in the development of the quality improvement plan. For further information see the
Tobacco Free Futures Guidelines Appendix 13(b): Quality Improvement Plan.
3/3
13.9
Appendix 13(b) Tobacco Free Futures Quality Improvement Plan (page 1)

Quality Improvement plan
The following Quality Improvement Plan serves as the foundation of the commitment of <site name> to continuously
improve the quality of the treatment and services it provides.
Use the information available to you, especially from your completed quality improvement assessment, to develop
your quality improvement plan for the Tobacco Free Futures initiative at your site. Your plan should be discussed
with the committee and all impacted stakeholders especially site/program leadership. The completed plan should be
retained for site records and a copy sent to tru@albertahealthservices.ca.
QuAlITY IMpRoVEMENT coMMITTEE
The Quality Improvement Committee will consist of the following members:

Name
position (indicate chair)
The responsibilities of the Committee will include:

Annually developing and approving a quality improvement plan.
As part of the plan, establishing measurable objectives based upon priorities identified through the use of
established criteria for improving quality in AHS.
Periodically assessing information based on defined indicators, taking action as evidenced through quality
improvement initiatives to solve problems and pursue opportunities to improve quality.
Establishing and supporting specific quality improvement initiatives.
Reporting to senior management on quality improvement activities on a regular basis.
Formally adopting AHSs approach to continuous quality improvement (the AHS Improvement Way).
13.10
1/4
QuAlITY IMpRoVEMENT coMMITTEE (continued)
The Tobacco Reduction Program will provide support and guide implementation of the Tobacco Free Futures quality
improvement activities at the site in the following ways:
Identify agreed role of TRP Zone Coordinator
Communication will take place through the following methods:

Describe communication tactics to for leadership, staff and patients/clients.
Committee meetings will adhere to the following guidelines:

Identify the frequency of meetings and additional responsibilities such as who will be responsible for organizing the
meeting schedule and maintaining meeting notes.
2/4
13.11
GoAlS AND obJEcTIVES
The following are the ongoing long term goals for the <insert site name> Tobacco Free Futures Committee and the
specific objectives for accomplishing these goals for the <Indicate the current year>.
Selection of your goals may be guided by the Quality Improvement Assessment Tool. You do not need to select all
goals; the list should be tailored to your program. Each selected goal should have specific, measurable objective(s)
so you will be able to clearly determine whether they have been met at the end of the year. The ways in which these
goals will be accomplished should be outlined in the planned activities section below.
Goals
objectives
AlIGNMENT wITH AHS STRATEGIc pRIoRITIES
The quality improvement goals for the <insert site name> Tobacco Free Futures Committee support Alberta Health
Services Strategic Priorities and <INSERT SITE NAME> priorities in the following ways:
List how goal aligns with AHS strategic priorities and site/program
priorities
Goals
plANNED AcTIVITIES
The timelines for accomplishing the identified goals are to begin work on <INSERT START DATE> and complete
work on <INSERT END DATE>. The table below outlines the planned activities to accomplish these goals including
resources required, and budget implications.
#
Activity
comments
person
Responsible
Start Date
End Date
cost
1
2
3
4
5
6
7
13.12
3/4
EXpEcTED bENEfITS
The expected benefits of implementing the improvement plan include:

List expected benefits
AppRoVAl
Name
Title
Signature
Date
4/4
13.13
Specific Care
Settings
14. Surgical Care
15. Emergency and Urgent Care
16. Home Care
17. Public Health
18. Transition and Continuing Care
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
Implementation of Tobacco Free Futures

in specific care settings
The Tobacco Free Futures model is intended to be relevant to and implemented across
the continuum of care, providing consistency in messaging and treatment for all tobacco
users. In Chapter 7 of these guidelines (Brief Intervention), the standard care pathway
and considerations for implementation were introduced, which are applicable in many care
settings, both inpatient and outpatient. This section will focus on the factors related to specific
care settings that may require further consideration for implementation.
Chapter 14: Surgical Care

All elective patients who smoke should be directed to resources to quit prior to
admission to hospital (e.g., CAN-ADAPTT).
Benefits of cessation during the peri-operative period.
Implementation considerations for surgical settings.
Chapter 15: Emergency and Urgent Care
Supporting cessation in an emergency or urgent care setting.
Implementation considerations for emergency and urgent care settings.
Chapter 16: Home Care

Addressing tobacco use in a home care setting.
Modified care pathway for the home care setting.
Considerations for implementation in the home care setting.
Chapter 17: Public Health

Addressing tobacco use and exposure in a variety of public health programs

andservices.
Modified care pathway for the public health setting.
Considerations for implementation in public health settings.
Chapter 18: Transition and Continuing Care

Addressing tobacco use and exposure in transition and continuing care settings.
Creating tobacco and smoke-free environments in transition and continuing care

settings.
Modified care pathway for transition and continuing care settings.
Considerations for implementation in transition and continuing care settings.
Chapter 14
Surgical Care
14.1
Addressing tobacco use in Surgical care

The preoperative period represents a crucial time to address tobacco use among elective
surgery patients. Tobacco use affects postoperative outcomes due to complications related to

smoking effects on cardiovascular and respiratory systems
negative effects on wound and bone healing
interference with immune response and overall recovery1,2,3,4
Complications related to surgical interventions are important to

patients and expensive to the health care system, leading to
extended recovery periods and longer hospital stays.5
Evidence suggests that providing intensive smoking cessation
intervention 48 weeks before surgery is optimal to increase the
likelihood of reducing pulmonary complications and promoting
long-term abstinence. However, brief interventions less than
48weeks before admission are effective in supporting short-term
abstinence, with insufficient evidence to determine whether they
reduce overall complications.5
CAN-ADAPTT
Guidelines (2011)
All elective patients
who smoke should be
directed to resources
to assist them to quit
smoking prior to
hospital admission
or surgery, where
possible. 6
Patients may not be seen preoperatively by surgeons,

anesthesiologists or nurses more than 4 weeks prior to surgery,
which limits the opportunity to recommend the optimal cessation advice of 48 weeks.
Clinicians may be hesitant to recommend cessation in the brief period before surgery
(<8weeks) due to the myth that short-term cessation may be associated with increased
pulmonary complications related to the transient increases in coughing and mucous
production after abstinence. This concern has been documented in the medical literature
based on the over interpretation of results of two studies conducted in the Mayo Clinic in the
1980s.7,8,9 A current anesthesia text still inappropriately recommends that if you are unable
to advise the patient to stop smoking 8weeks or more before surgery, it is preferable for the
patient to continue smoking to minimize the increase in pulmonary complications in recent
quitters, which may be higher than current smoking.10,11
A recent review by Shi and Warner (2011) refutes this
advice, concluding that there was an over interpretation
of the Mayo Clinic studies. The authors of the Mayo
Clinic studies did not report statistically significant
findings of increased complication rates in recent
quitters and were careful not to make this conclusion.7
Results did show that longer periods of abstinence are
necessary for pulmonary benefit.7,8,9
Concern about pulmonary

complications should not
prevent clinicians from helping
their patients quit smoking at
any time before surgery.7
The Shi and Warner (2011) review concluded that (1) no individual study has foundthat brief
preoperative smoking abstinence significantly increases pulmonary risk, (2)metaanalysis
of the available studies also does not find a significant increase in risk, and(3)there is no
support for the purported underlying mechanism contributing to risk.7
14.2
Tobacco Free Futures in surgical care

Although smoking cessation prior to surgery reduces the incidence of postoperative
complications, only a minority of anesthesiologists, surgeons and nurses actively assist
their patients to quit smoking or develop a plan to manage the consequences of involuntary
perioperative cessation.12,13 It is optimal to implement smoking cessation intervention
before the surgery (>8 weeks); however, this may be difficult from a practical perspective,
considering the unique characteristics of this health care setting. Identified barriers include

short time frame between preoperative visit and surgery (<8 weeks)
lack of coverage for cessation medication outside the hospital setting
difficulty coordinating between family physicians and hospitals to promote smoking

cessation with patients preoperatively7
Despite these barriers, preadmission clinics are ideal

locations for
1. identifying patients who use tobacco
2. delivering a brief intervention
3. planning for in-hospital pharmacotherapy
4. initiating referral of patients post-discharge to
community cessation services14
Patients reported that

the possibility of reducing
perceived vulnerability to
postoperative complications
promoted motivation to quit
or reduce smoking prior to
operation.5
The brief intervention model outlined in Chapter 7 (Brief Intervention) can be easily
integrated into the preoperative care setting. Table 14.1 outlines potential considerations
forimplementation of the model in the preoperative setting.
14.3
Table 14.1: Treatment Model: Considerations for Preoperative Care Settings
ADVISE
ASK
Model component
ASK all patients if they have used
tobacco in the past year.
All tobacco users should be identified during the

preoperative phase.
ASK about pattern of use.
Relevant forms used in pre-assessment phase should be

modified as necessary to document tobacco use status.
ADVISE all patients regardless of

tobacco use status or tobacco-free
environment policy.
ADVISE current tobacco users to stop
using tobacco. Personalize message.
ASSESS
ASSESS readiness to quit.

ASSESS interest in support for relief
of withdrawal.
ASSIST the patient who is not

interested, support autonomy and
offer brief information.
ASSIST
Considerations
ASSIST the patient who is

interested with link to prescriber
pharmacotherapy support and/or
Patients and family/support persons should be made

aware of the AHS Tobacco and Smoke Free Environments
Policy as part of their preparation for the surgical
experience.
It is more effective to tailor advice to quit in relation to
planned procedure and direct benefits of cessation on
recovery.
Having surgery presents a powerful teachable opportunity
for tobacco cessation and makes any time a good time for
preoperative patients to quit.7
The stress associated with having surgery and awaiting
results of procedures may make it difficult for users to
quit.5
Provide self-help information to all patients who are
identified as tobacco users including the resource, Getting
Ready for Surgery or Procedure: What You Should Know
About Your Tobacco Use (order through the online catalog
at www.albertaquits.ca).
Patients who are interested in using pharmacotherapy
preoperatively should be linked to appropriate prescribing
authority (e.g., anaesthesiologist or surgeon). NRT
is safe and effective to be used in the perioperative
period.5,12,15,16,17
Pharmacotherapy initiated in the preoperative period
should be continued in the postoperative period for
inpatients. Appendix 9(a)
ARRANGE
Ensure communication between OR staff and inpatient

surgical unit for continuity of care. Appendix 7(a)
14.4
ARRANGE follow-up on discharge for

any pharmacotherapy started and link
to further behavioural support.
For outpatient surgical patients who are interested,

facilitate discharge pharmacotherapy. Appendix 9(b)
Follow-up after hospitalization is key factor of effective
interventions.18 Link to post-discharge behavioural support.
Appendix 7(b)
References
1. Moller, A., & Tonneson, H. (2006). Risk reduction: Perioperative smoking intervention.
Best Practices in Research Clinical Anesthesiology, 20, 237248.
2. Rennard, S., Togo, S., & Holz, O. (2006). Cigarette smoke inhibits alveolar repair: A
mechanism for the development of emphysema. Proceedings of the American Thoracic
Society, 3, 703708.
3. Rogliani, M., Labardi, L., Silvi, E., Maggiulli, F., Grimaldi, M., & Cervelli, V. (2006)
Smokers:Risks and complications in abdominal dermolipectomy. Aesthetic Plastic
Surgery, 30, 422425.
4. U.S. Department of Health and Human Services (USDHHS). (2004). The health
consequences of smoking. A report of the Surgeon General. Washington, DC: Author.
Retrieved from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/
index.htm
5. Thomsen, T., Villebro, N., & Mller, A. (2010). Interventions for preoperative smoking
cessation. Cochrane Database of Systematic Reviews 7. Art no.:CD002294.
7. Shi, Y., & Warner, D. (2011). Brief preoperative smoking abstinence: Is there a dilemma?
Anesthesia & Analgesia, 113(6), 13481351.
8. Warner, M., Divertie, M., & Tinker, J. (1984). Preoperative cessation of smoking and
pulmonary complications in coronary artery bypass patients. Anesthesiology, 60, 380
383.
9. Warner, M., Offord, K., Warner, M. E., Lennon, R., Conover, M., & Jansson-Schumacher
U. (1989). Role of preoperative cessation of smoking and other factors in postoperative
pulmonary complications: A blinded prospective study of coronary artery bypass patients.
Mayo Clinic Proceedings, 64, 609616.
10. Roizen, M. (1990). Anesthetic implications of concurrent diseases. In R. Miller (Ed.),
Millers anesthesia. (3rd ed.) (p. 839). New York: Churchill Livingstone.
11. Roizen, M., & Fleisher, L. (2010) Anesthetic implications of concurrent diseases. In
R. Miller (Ed), Millers anesthesia. (7th ed.) (pp. 11031104). Philadelphia: Churchill
Livingstone.
12. Warner, D. (2007). Tobacco dependence in surgical patients. Current Opinion in
Anaesthesiology, 20, 279283.
13. Warner, D., Sarr, M., Offord, K., & Dale, L. (2004). Anesthesiologists, general surgeons,
and tobacco interventions in the perioperative period. Anesthesia & Analgesia, 99,
17661773.
14. Zaki, A., Abrishami, A., Wong, J., & Chung, F. (2008). Interventions in the preoperative
clinic for long term smoking cessation: A quantitative systematic review. Canadian Journal
of Anaesthesia, 55, 1121.
14.5
15. France, E., Glasgow, R., & Marcus, A. (2001). Smoking cessation interventions among
hospitalized patients: What have we learned? Preventative Medicine, 32, 376388.
16. Simon, J., Solkowitz, S., Carmody, T., & Browner, W. (1997). Smoking cessation after
surgery: A randomized trial. Archives of Internal Medicine, 157, 13711376.
17. Warner, D., Patten, C., Ames, S., Offord, K., & Schroeder, D. (2005). Effect of nicotine
replacement therapy on stress and smoking behavior in surgical patients. Anesthesiology,
102, 11381146.
18. Rigotti, N., Munafo, M., & Stead, L. (2007). Interventions for smoking cessation
in hospitalised patients (Review). Cochrane Database of Systematic Reviews, 3.
Artno.:CD001837.
14.6
Chapter 15
Emergency and
Urgent Care
15.1
Addressing tobacco use in emergency and

urgent care
Emergency departments (EDs) provide another underused health care setting to support
tobacco users by coordinating with and linking to cessation supports.1 In the 20102011 fiscal
year, Alberta Health Services reported 2,118,956 ED and urgent care visits.2 It has been
reported that tobacco users account for a disproportionate share of ED visits with cited rates
from 20% to 40%, and higher rates were noted in urban EDs.1,3,4 Using a conservative rate
of 25%, this translates into more than 500,000 visits by tobacco users to Alberta EDs and
urgent care centres annually. Brief tobacco interventions result in an estimated 2% to 4% of
current tobacco users quitting.5 If brief tobacco interventions were performed consistently in
emergency and urgent care departments in Alberta, this could translate to 10,000 to 20,000
people quitting annually.
Although EDs deal with many patient visits for life-threatening emergencies for which brief
tobacco intervention would not be appropriate, a considerable number of tobacco-using
patients present for non-emergency health care.6 Emergency and urgent care settings are
often the primary source of health care for persons of lower socio-economic status, as well
as ethnic minority populations.7 The prevalence of tobacco use among patients/clients in
emergency care is high. For non-emergent patients, minimal contact strategies, such as a
brief tobacco intervention, should become part of an EDs routine practice.7
Assessment of exposure to second-hand smoke
(SHS) is appropriate, particularly for children who
present in emergency and urgent care settings with
conditions such as asthma, respiratory infections
and otitis media, which are known to be linked to
tobacco exposure.8 In Alberta, the rates of household
exposure to SHS for children aged 011 years has
decreased significantly from 28% in 1999 to only
5% reported in 2009.9 This positive trend can be
further supported during visits to EDs and urgent care
centres. These visits present opportunities to engage
parents/caregivers and have been found to have a
positive effect on their efforts to quit tobacco useor
limit their childsexposure.8
15.2
CAN-ADAPTT guidelines (2011)

Health care providers caring for
children and adolescents should
counsel parents/guardians about
the potential harmful effects of
second-hand smoke on the health
oftheir children.10
Tobacco Free Futures model in emergency and urgent care

Potential barriers to implementing tobacco treatment into routine practice in ED settings
include lack of time, lack of patient interest and beliefs that this setting is inappropriate for
cessation advice and care.11
A 2002 systematic review of the literature, focussing on tobacco intervention in the ED,
recommended routine screening of all patients for tobacco use and referral of tobacco users
to further cessation support, even though there is limited data to support ED practice, given

the strong evidence to support intervention in primary care settings
the burden of disease related to tobacco use
the relative ease of brief tobacco intervention5
For over a decade, it has been proposed that tobacco use status be added as a new fifth
vitalsign, alongside blood pressure, pulse, temperature and respiratory rate.11
The brief intervention model outlined in Chapter 7
(Brief Intervention) can be easily integrated into
the emergency and urgent care settings. Table 15.1
outlines potential considerations for implementating
the model in emergency and urgent care settings.
A study of emergency department

patients identified that, of those
who smoked, 68% wanted to quit
and 49% wanted to quit within
amonth.1
15.3
Table 15.1: Treatment Model: Considerations for Emergency and Urgent Care Settings
ASSESS
ADVISE
ASK
Model component
ASK all patients if they
have used tobacco in the
past year.
All tobacco users should be identified during visits, as appropriates.

Parents/guardians of children should be asked about SHS exposure.
Electronic or paper-based forms used in the care setting should be

modified as necessary to document tobacco use status. Consider as
avital sign.12 Appendix 7(a)
ADVISE all patients

regardless of tobaccouse status about the
Tobacco and Smoke Free
Environments Policy.
Patients and family/support persons should be made aware of

Tobacco and Smoke Free Environments Policy. Many patients
admitted to inpatient care are first seen in emergency care. Initiating
brief intervention at time of admission may strengthen consistent
messagingaround the policy.
ADVISE current tobacco

users to stop using
tobacco. Personalize
message.
ASSESS readiness to
quit.
ASSESS interest in
support for relief
of withdrawal.
not interested in support
with brief information.
ASSIST
Considerations
ASSIST the patient

who is interested
with link to prescriber
pharmacotherapy support
and/or behavioural
support.
Integrating brief advice to quit into routine practice in the ED has the
added benefit of reaching patients who may experience a teachable
moment if the reason for the visit is related totheir tobacco use.13
Assessing readiness to quit is appropriate for patients presenting with

non-emergent conditions.
Admission to an ED or urgent care setting may mean a stay of several
hours. Therefore, the offer of pharmacotherapy support for nicotine
withdrawal should be made to all tobacco users as a comfort measure.
17% of highly motivated tobacco users will quit when provided with
nothing more than a self-help brochure.1 Identified self-help resources
for patients should be stocked in the department and easily accessible
to staff and patients (www.albertaquits.ca).
The AHS standard initiation order set can be used to facilitate shortterm NRT use while a patient is under care in the ED. Appendix 9(a)
Ensure communication between ED and inpatient staff to facilitate
continuity of care for patients who are admitted for further care.
Appendix 7(a)
Pharmacotherapy initiated in ED should be continued for inpatients.
Appendix 9(a)
ARRANGE
When available, it is appropriate to arrange for a consultation with an

onsite tobacco counsellor/specialist. Appendix 8(a)
15.4
ARRANGE followup after discharge for

any pharmacotherapy
started and link to further
For patients who are interested, facilitate discharge pharmacotherapy.

Appendix 9(b)
Follow-up after hospitalization is a key factor in effective interventions.
Link to community behavioural support, preferably by fax referral.
Appendix 7(b)
References
1. Lowenstein, S., Tomlinson, D., Koziol-McLain, J., & Prochazka, A. (1995). Smoking habits
of emergency department patients: An opportunity for disease prevention. Academic
Emergency Medicine, 2, 165171.
2. Alberta Health Services. (2011). 20102011 annual report. Edmonton, AB: Author.
3. Richman, P., Dinowitz, S., Nashed, A., Eskin, B., Sylvan, E., Allegra, C., Allegra, J., &
Mandell, M. (2000). The emergency department as a potential site for smoking cessation
intervention: A randomized, controlled trial. Academic Emergency Medicine, 7, 348353.
4. Smith, P. (2011). Tobacco use among emergency department patients. International
Journal of Enviornmental Research and Public Health, 8, 253263.
5. Bernstein, S., & Becker, B. (2002). Preventive care in the emergency department:
Diagnosis and management of smoking and smoking-related illness in the emergency
department: A systematic review. Academic Emergency Medicine, 9, 720729.
6. Elders, M. (1995). Smoking cessation efforts. Academic Emergency Medicine,
2, 161162.
7. Greenberg, M., Weinstock, M., Fenimore, D., & Sierzega, G. (2008). Emergency
department tobacco cessation program: Staff participation and intervention success
among patients. Journal of the American Osteopathic Association, 108(8), 391396.
8. Tanski, S., Klein, J., Winickoff, J., Auinger, P., & Weitzman, M. (2003). Tobacco
counseling at well-child and tobacco-influenced illness visits: Opportunities for
improvement. Pediatrics, 111(2), 162167.
9. Statistics Canada. (2012). Canadian tobacco use monitoring survey (CTUMS): Smoking
prevalence 19992012. Retrieved from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/
research-recherche/stat/_ctums-esutc_prevalence/prevalence-eng.php
10. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT). (2011). CAN-ADAPTT Canadian smoking
cessation clinical practice guideline. Toronto, ON: Centre for Addiction and Mental Health.
Retrieved from http://can-adaptt.net
11. Prochazka, A., Koziol-McLain, J., Tomlinson, D., & Lowenstein, S. (1995). Smoking
cessation counseling by emergency physicians: Opinions, knowledge, and training
needs. Academic Emergency Medicine, 2, 211216.
12. Ahluwalia, J., Gibson, C., Kenney, E., Wallace, D., & Resnicow, K. (1999). Smoking
status as a vital sign. Journal of General Internal Medicine, 14, 402408.
13. Richmond, R. (1999). Opening the window of opportunity: Encouraging patients to stop
smoking. Heart, 81, 456458.
15.5
15.6
Chapter 16
Home Care
16.1
Addressing tobacco use in home care settings

Delivery of professional and support services in the home is an important alternative in the
continuum of care provided by health authorities such as Alberta Health Services. Caring
for clients in the home and community helps to reduce strain on inpatient facilities and to
decrease health system costs. More than that, delivery of home care provides an opportunity
to support the health, safety, comfort and, in many cases, independent living of clients in their
preferred environment. Home care caseloads include clients of all ages and stages of life,
including those who

need minimal assistance for a short time (e.g., post-surgical wound care)
have chronic illness and require ongoing assistance to maintain health and
independence (e.g., diabetes, cardiovascular and chronic obstructive pulmonary
disease (COPD))
are at the end of life and require palliative care1
Tobacco use, and specifically smoking, is known to have a negative impact on the healing
of wounds by temporarily decreasing tissue perfusion and oxygenation, weakening both
inflammatory and reparative cell functions. Smoking cessation has the ability to reverse
some of these processes within hours and weeks; however, there seems to be a longer
term impact for those who are former tobacco users. Improvement
in the inflammatory response after cessation does lead to reduction
Within the first
in wound infections post-cessation. Studies suggest that nicotine
hour after a
replacement therapy has no effect on wound healing.2
cigarette is put
out, blood flow,
tissue oxygen and
metabolism return
to normal.2
Chronic conditions, including cancer, cardiovascular disease, COPD,

diabetes and asthma, are highly affected and exacerbated by tobacco
use. Tobacco users who are living with these conditions will see their
health benefit significantly from cessation.3 In the case of COPD,
supporting tobacco cessation is the single most effective intervention
for preventing the condition and the only intervention known to slow declining lung function
for those who already have COPD.4 It is important to note that, for those receiving treatment
for cancer (whether it includes radiation, chemotherapy and/or surgery), tobacco use has
been found to decrease treatment effectiveness, exacerbate side effects and interfere with
woundhealing.5
Palliative clients often continue using tobacco products, although declining health,
restricted mobility and reduced access to tobacco products may affect their ability to
meet their nicotine needs. Nicotine withdrawal has been identified as a cause of delirium
and terminal restlessness in palliative clients who were heavy tobacco users but are not
currently able to smoke. Studies have identified a high prevalence of depression, sleep
problems and anxiety in those with advanced cancer, all of which may also be affected
by nicotine withdrawal. Identifying tobacco use and treating nicotine withdrawal is an
importantcomponentofpalliativecare.5
16.2
Tobacco Free Futures model in home care

Health professionals working in home care settings have an important opportunity to identify
tobacco use and provide advice and supportive care to their clients. Home care visits provide
a window of opportunity or teachable moments, especially when a client is being treated
for diseases and conditions that are related to and significantly affected by tobacco use.3
For example, it is not surprising that research shows that motivation and interest in tobacco
cessation increases after as user receives a diagnosis of cancer, particularly for those
whosecancers have a strong relationship to tobacco, such as head, neck and lung.5
The brief intervention model outlined in Chapter 7 (Brief Intervention) has been modified for
application in the home care setting and is presented in Figure 16.1. Table 16.1 then outlines
potential considerations for implementation of the model in the home care setting.
See appendices:
Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol
(2012)
16.3
Figure 16.1: Tobacco Free Futures: A Home Care Setting Treatment Model
Brief tobacco intervention
ask
Ask every patient/client about tobacco use in the home.

Have you or anyone in your home used any tobacco

products in the past year?
No
Yes
Assess
Advise
Inform of 2-hour tobacco-free time period prior to and during home care visit.
There is no safe level of exposure to second-hand

smoke. We ask all our clients to refrain from tobacco
use 2 hours prior to and during a scheduled home care
visit. Not using tobacco is one of the best things for the
health of everyone in the home.

Assess interest in pharmacotherapy and behavioural support.
Assess interest in a tobacco-free home and car.
Are you/they interested in support to quit or to make

your home and car tobacco-free ?
No
Support autonomy.
Leave offer of support
open. Document on
patient/client chart.
Assist
Assist patient/client and/or family member with self-support materials.

Arrange
Yes
Arrange further support by completing appropriate linked referral(s).

Provide ongoing support at next visit.
16.4
Table 16.1: Treatment Model: Considerations for Home Care Settings
ASK
Model component
Considerations
ASK all clients if they or their

family members have used
tobacco in the past year.
All tobacco users should be identified during initial visits.
Electronic or paper-based forms used in home care should be

modified to document tobacco use status. Appendices 7(a) and 16(a)
Tobacco use by household members and exposure to second-hand

smoke should be identified.
ASK about exposure to

second-hand smoke
ADVISE

users to stop using tobacco.
Personalize message.
ADVISE client and household
members that there is no safe
level of exposure to secondhand smoke.
ADVISE of policy, as
applicable.
ASSESS

ASSESS interest in support
for relief of withdrawal.
ASSESS interest in making
home and car tobacco-free.
ASSIST

not interested in support with
brief information.
ASSIST the patient who
is interested with link to
prescriber pharmacotherapy
support and/or behavioural
support.
Integrate brief tobacco intervention into routine practice in the home

care environment to maintain continuity of care.
Approaching tobacco use in the home must be done respectfully,
recognizing that health care providers may be viewed as guests in the
clients home. Community health professionals should request that
clients and household members refrain from using tobacco for two
hours prior and during a scheduled home visit.
modified to document advice. Appendix 7(a)
Assessing readiness to quit and interest in tobacco-free homes and
cars is appropriate for all clients who use tobacco.
Assess interest in withdrawal relief through pharmacotherapy for those
who are interested in quitting or reducing tobacco use. Short-term
relief may be of interest to those who have mobility issues.
modified to document assessment. Appendices 7(a) and 16(a)
Identified self-help resource for clients who are not interested
and interested should be readily available to distribute to clients
(www.tobaccofreefutures.ca).
Communication between inpatient units and home care staff will
facilitate continuity of care for clients who have been receiving
treatment before discharge. Consider building into referral process.
Pharmacotherapy is recommended for all clients who are interested
except in the case of direct contraindications. Clients with conditions
such as oral cancers may be unable to use short-acting NRT products
(e.g.,gum, sprays, inhalers or lozenges). Instead, products such as the
patch, bupropion or varenicline may be appropriate.3
ARRANGE
Electronic or paper-based forms used in home care should be modified as

necessary to document assistance. Appendices 7(a) and 16(a)
ARRANGE follow-up and
link to further behavioural
support.
Link to community behavioural support, preferably by fax referral.

Appendix 7(b)
16.5
References
1. Alberta Health Services. (2012). Home living. Edmonton, AB: Author. Retrieved from
2. Sorensen, L. (2012). Wound healing and infection in surgery: the pathophysiological
impact of smoking, smoking cessation and nicotine replacement therapy. A systematic
review. Annals of Surgery, 255(6), 10691079.
3. Fiore, M., Bailey, W., Cohen, S., et al. (2008). Treating tobacco use and dependence.
Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
4. ODonnell, D., Hernandez, P., Kaplan, A., et al. (2008). Canadian Thoracic Society
recommendations for management of chronic obstructive pulmonary diseaseUpdate
2008Highlights for primary care. Canadian Respiratory Journal, 15(Suppl A), 1A8A.
5. Gritz, E., Fingeret, M., Vidrine, D., Laze, A., Mehta, N., & Reece, G. (2006). Successes
and failures of the teachable moment: Smoking cessation in cancer patients. Cancer,
106(1), 1727.
6. Quibell, R., & Baker, L. (2005). Nicotine withdrawal and nicotine replacement in the
palliative care setting. Journal of Pain and Symptom Management, 30(3), 205207.
16.6
APPENDICES
Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment & Protocol
(2012)
16.7
Appendix 16(a) AHS Meditech Community Brief Tobacco Intervention Assessment &
Protocol (2012) (page 1)
Assessment Name: Tobacco Cessation Intervention Number: 1252503

Community
Mnemonic: PCZTOBACCODEP01
Protocol: ZTOBDEP
Acuity/ACCIS: 20; Prof Health;
Move Date: 30/08/12
Face-Face
16.8
16.9
PROTOCOL
Tobacco Dependence and Cessation Brief Intervention Community Protocol
Developed: May 2012
Revision:
ASK
- About tobacco use by client or other household members.
If YES for client: Complete the type of tobacco, amount, years of use and last use questions.
If NO for client AND household members: INTERVENTION STOPS HERE
ADVISE
If CLIENT AND/OR HOUSEHOLD MEMBERS DO USE tobacco products:
- Advise that there is no safe level of exposure to environmental tobacco use and that a tobacco
free environment is in the best interests of their health or everyone in the home. Personalize
message as appropriate; example link to respiratory condition.
- Request that client and/or household members refrain from smoking for 2 hours prior to and
during a scheduled home care visit.
If CLIENT DOES USE tobacco:
- ALSO give personalized advice to quit using a non-judgmental approach: is most effective when
personalized to the individual and their condition e.g. impact on wound healing. CONTINUE
WITH THE INTERVENTION
ASSESS
- Readiness to quit: using a scale of 1 - 10 (1 = least, 10 = most)
- Interest in support to quit or manage short term nicotine withdrawal.
- Interest in support to make home and/or vehicle tobacco free.
If NO
Respect choice and leave offer of support open - Give appropriate self help information tailored
to client who is not ready to quit. INTERVENTION STOPS HERE
If YES, CONTINUE INTERVENTION
ASSIST
- Provide self help information tailored to client who is ready to quit and/or how to make your
home and/or vehicle tobacco free.
- Provide information on available pharmacotherapy and link to prescriber.
- Provide information on behavioural counselling and availability in community.
- Other (specify)
CONTINUE WITH THE INTERVENTION
16.10
ARRANGE
Arrange further support by completing appropriate community linked referral
If NO, INTERVENTION STOPS HERE
If YES, Referral/Information provided and/or fax referral to:
- AlbertaQuits (1.866.710.7848) - Helpline, Groups
- AlbertaQuits.ca - online
- Primary Care Network
- Other, specify
REFERENCES (All available at tobaccofreefutures.ca)

- Tobacco Free Futures Guidelines
- Tobacco Free Futures Training for Brief Tobacco Intervention in Healthcare Settings
- Creating a Tobacco Free Future: A Brief Intervention Pocket Guide for Health Professionals
- AHS Tobacco and Smoke Free Environments Policy
16.11
16.12
Chapter 17
Public Health
17.1
ADDRESSING TOBACCO USE IN

PUBLIC HEALTH SETTINGS
The Tobacco Free Futures initiative is relevant to and can be
implemented across the continuum of care, providing consistent
messaging and treatment for all those who are affected by
tobacco use. Chapter 7 (Brief Intervention) introduced the
standard care pathway and considerations for implementation,
which are applicable in many inpatient and outpatient care
settings, including public health. This chapter will focus on
factors related to public health settings that may require further
consideration for implementation.
Public Health clinics

have the potential for
effective, large-scale
delivery of smoking
cessation interventions
that can reach at risk
populations.1
In Alberta, public health services are diverse, and their availability varies from community to
community, depending on the population and its needs. Services associated with strengthening
the publics health include those that focus on health promotion as well as disease and injury
prevention. Public health programs and services are delivered by a multidisciplinary team of
health care professionals in clinic, community and home settings.
This chapter will identify opportunities for integrating brief tobacco intervention as a standard
of care within public health services, including preconception care, prenatal care, postnatal
care, well-child clinics, early childhood development services, school health, dental health,
adult immunization and communicable disease control. Public health management will make
decisions regarding the expectations of integrating brief tobacco intervention within programs
and service delivery, as well as the training of front-line staff from various health disciplines.
Figure 17.1: Public Health Programming and Brief Tobacco Intervention

Preconception
health
Prenatal
health
Communicable
disease control
red by a
live
m
De
Adult
health
Brief
tobacco
intervention
health tea
lic
m
ub
isciplinary
tid
p
l
u
Dental
health
Well child
clinic
School
health
17.2
Postnatal
health
Early childhood
development
Importance of tobacco treatment in public health

Public health programs have the potential to deliver effective
tobacco interventions on a large scale. It is particularly important
that public health services have been identified as a major source
of maternal and child health information and care for women of
a lower socioeconomic status and, thus, present an opportunity
for intervention with this at-risk population.3 Several studies
have established both the short- and long-term effectiveness of
tobacco cessation interventions in public health, and it is currently
recommended that brief tobacco intervention be integrated into
routine care.1,4,5,6
Exposure to one-time
brief interventions in
public health clinics is
sufficient to enhance
a clients abstinence
for up to 12 months,
and to take action
toward quitting
and motivation and
readiness to quit for
upto 18 months.2
The following content summarizes some of the literature related

to the relevance of tobacco treatment for the following public
health services: preconception care, prenatal care, postnatal care,
well-child clinics, early childhood development services, school health, dental health, adult
immunization and communicable disease control. More detail about the specific populations
often served by these programs will be found in Chapters 20 (Reproductive Years) and 21
(Youth and Family).
PRECONCEPTION
A number of public health services, and primarily those that focus on sexual health, provide
an opportunity to affect the overall health of clients during the preconception phase of their
reproductive years. Young adults frequently access sexual health clinics for services such as
birth control advice, pregnancy confirmation, pregnancy options counselling and referral, as well
as treatment for sexually transmitted infections. The young adult demographic (ages 2024)
has the highest reported tobacco use rates in Alberta, at 24%.7 Tobacco usehasa significant
impact on a persons overall health, including the reproductive health of this population.
The impact of tobacco use on fertility for both men and women has been documented by
a 2008 literature review, which identified tobacco use as a compromising factor in all of
the systems involved in reproduction.8 For women, tobacco use is a known risk factor for
precancerous changes and cancer of the cervix.9 Sexual health clinics have long cautioned
women about the dangers of smoking while taking oral contraceptive pills because of a higher
risk for serious cardiovascular disease, stroke and high blood pressure.8 Tobacco use also
has effects on the ovaries, fallopian tubes and uterus, which can result in decreased fertility.
Not only are women who use tobacco less likely to become pregnant, but they are also
more likely to experience miscarriage. Tobacco use has been shown to affect the success
of implantation and resulting pregnancies during in vitro fertilization (IVF) treatment.8 Using
alcohol, tobacco or illicit drugs during preconception is a strong predictor of prenatal use by
childbearing women. Screening for these substances is therefore recommended for women
who are at risk of becoming pregnant, planning to become pregnant or are pregnantalready.11
Screening for tobacco use during preconception should also include males, as research
confirms that the chemicals in tobacco affect the male reproductive system as well. Male
smokers have decreased production of, lower motility of and increased genetic abnormalities in
their sperm.8
It is recommended that everyone of reprductive age should avoid tobacco use and
exposure.20 The 5As approach is an effective tool for screening both men and women for
tobacco use and linking them to treatment.4,5
See Chapter 20: Reproductive Years
17.3
PRENATAL
Although the reported rates of tobacco use during pregnancy are declining in Canada
and other industrialized nations, supporting sustained cessation during pregnancy and
postpartum remains an ongoing challenge for public health.12 Albertas rate of tobacco use
during pregnancy is reported as 14.8%, but rates vary widely across the zones. Statistics
from the Alberta Perinatal Health Program for 2011 show a high of 22.5% in the North Zone,
21% in the Central Zone, 18.3% in the South Zone, 13.3% in Edmonton and a low of 9.6%
in Calgary.13 These rates are based on self-reported tobacco use, and health professionals
should be aware that the non-disclosure of tobacco use during pregnancy is not uncommon.
A number of studies have demonstrated that women report they are not smoking even though
their biological specimens test positive for tobacco use, suggesting that they are reluctant
to disclose their use.11 The increasing denormalization of tobacco use has created an
environment wherein pregnant women who smoke often feel stigmatized, thereby increasing
the need for a non-judgmental approach from their health professionals.12
Tobacco use during pregnancy has known consequences for the general health of the
mother, the viability of the pregnancy and the health of the developing fetus. Smoking
has been linked to spontaneous abortion, ectopic pregnancy, and complications including
placenta previa, placenta abruptio and the preterm rupture of membranes. A fetus that is
exposed to tobacco during development is more likely to suffer from intrauterine growth
restriction (IUGR), prematurity and be of low birth weight.11 Prenatal exposure to tobacco
has also been linked to health consequences in childhood, including sudden infant death
syndrome (SIDS), cognitive impairment, behaviour problems and being overweight.11,14,15
Although women are highly motivated to stop tobacco use during pregnancy, many are
unable to quit or sustain a quit for the duration of their pregnancy.12
While a focus on pregnant women is justified by the added
Relapse rates during
health risks associated with tobacco use during pregnancy,
pregnancy and the
opportunities to support partners and families could be missed
16
postpartum period
if other public health services are ignored. The impact of
continued tobacco use by partners and families on pregnant
25% before giving
women is twofold: the potential exposure of second- and
birth
thirdhand smoke to the pregnant mother and developing fetus,
and the use around a pregnant woman who has quit tobacco
50% within 4 months
may heighten her risk of relapse.4,12 Many expectant and new
70% to 90% by one
fathers continue to use tobacco, and their reasons are very
year.12
different than their pregnant partners, often linked to their
masculine identity at work and home.16 It is important to note that
a British Columbia study found that few men had considered the
impact of their tobacco use on their partners effort to quit smoking.16
In Alberta, public health programming for pregnancy often includes the delivery of prenatal
education as well as programs for monitoring high-risk pregnancies (typically in larger urban
centres). The brief tobacco intervention outlined in Figure 17.2 can be integrated into these
services. Health care professionals should advise all pregnant women to stop using tobacco
and inform them that there are benefits to stopping at any time during their pregnancy.
Partners and family members should also be offered smoking cessation interventions and
a smoke-free home should be encouraged to protect mother and baby from exposure to
second-hand smoke.4,5
17.4
POSTNATAL
Public health postnatal care for families is provided in homes and clinics across Alberta.
Public health professionals who provide early postpartum care, breastfeeding support and
well-child clinics are in a unique position to help prevent relapse by linking women and their
partners to available support. The opportunity to repeat the brief tobacco intervention multiple
times in this all-important first year is key, considering that half of all women who used
tobacco may have quit or cut down during their pregnancy. However, relapse rates in this
population remain extremely high.12 Consistent with the findings of relapse among postpartum
women, one randomized, controlled trial found that a significant decrease in smoking by
male partners during pregnancy was not sustained at 2-, 6- or 12-month follow-ups.16 Having
a partner who smokes is a well-documented risk factor for postpartum relapse. Therefore,
it is preferable that addressing tobacco use be directed at both parents whenever possible.
It is the mother who is seen most often during postnatal visits, but research suggests that it
is best to engage with new fathers directly whenever possible, and thereby relieving women
of the responsibility of bringing up their partners cessation on their own. Women report that
efforts to regulate a male partners smoking can cause a significant amount of tension in a
relationship. Canadian studies also suggest that despite a reported heightened interest by
new fathers in reducing or quitting tobacco use during pregnancy and postpartum, they were
not routinely asked about their tobacco use by health care providers.16
WELL-CHILD CLINICS
Well-child clinics for the target population of 0 to 6 year olds
are a core service for public health across the province, with
scheduled visits recommended at 2, 4, 6, 12 and 18 months,
as well as at 46 years. In addition to immunizations, these
visits also provide an opportunity for family-centred care, which
includes anticipatory guidance related to health promotion and
injury prevention. Guidelines from the Canadian Action Network
for the Advancement, Dissemination and Adoption of Practiceinformed Tobacco Treatment (CAN-ADAPTT) recommend that
health care providers in child health settings counsel parents and
guardians about the potential harmful effects of second-hand
smoke on their children.4
Reducing parental
tobacco use is a key
element in encouraging
health and development
during early childhood,
particularly among
those living in difficult
social and economic
circumstances.17
Prenatal and postnatal exposure to environmental tobacco smoke has been linked to
negative health outcomes for children, including SIDS, earinfections, asthma, respiratory
infections, cognitive impairment and behaviour problems. Children who are exposed to
household smokers are also more likely to become smokers themselves.14,18
See Chapter 21: Youth and Family
When counselling families about the impact of environmental tobacco smoke, health care
professionals should be aware that negative effects of second-hand smoke have become
widely known and are accepted amongst the general population. However, effects of thirdhand smoke are not as well understood. A U.S. survey indicated that 95% of non-smokers
and 84% of smokers agreed that second-hand smoke is harmful to children, as compared
with 65% of non-smokers and 43% of smokers who agreed that third-hand smoke is harmful
to children.19 For more information on second- and third-hand smoke, refer to Chapter 2
(TheEffects of Tobacco Exposure).
17.5
Implementing the modified pathway recommended in Figure 17.2 as a standard of care

during these child-centred visits helps improve the health of all family members. Research
has demonstrated that intervening with parents during child-centred care can increase the
parents interest in their own cessation, quit attempts and quit rates.5 Supporting cessation
for parents and caregivers not only improves their health, but is also primary prevention for
children trying to improve their health outcomes by eliminating their exposure to secondand third-hand smoke.18,20 Public health professionals are in a position to influence parents/
caregivers who are willing to address tobacco use through repeated and consistent
messaging provided during well-child clinic interactions.3,21
EARLY CHILDHOOD DEVELOPMENT
Early intervention services, parenting education and high-risk family visitation programs that
focus on the early childhood years create another window of opportunity to address tobacco
use and exposure. The information presented under the postnatal and well-child clinics
sections is also relevant in the context of these programs.
Children who are referred to early childhood development programs often have a number
of health challenges, which make them more vulnerable to the effects of tobacco exposure.
Multiple programs where families receive services should be equipped to identify, counsel
and refer parents and guardians for tobacco treatment.14
SCHOOL HEALTH PROGRAMS
Tobacco use patterns for youth typically evolve during the adolescent years and are affected
by factors such as access to tobacco, genetic predisposition and social influences. From the
first puff they take, youth should be considered at risk for continued tobacco use, which may
transition from experimentation to regular or daily smoking.4
School health programs may offer an opportunity to influence youth tobacco use through
prevention or cessation activities. The effectiveness of the 5 As approach has not been
established with this population, but health care professionals who work with youth are
encouraged to ASK about use of all tobacco products and ADVISE that they not start or
that they stop any current use. The Canadian guidelines for youth also suggest that more
research is needed to establish the effectiveness of treatment for this population, but they
acknowledged that a number of school-based programs have provided evidence of value.4
DENTAL HEALTH PROGRAMS
There are clear links between tobacco use (both smoked and smokeless) and oral health.
Those who use tobacco products are more likely to develop cancer of the mouth and throat,
gum disease, halitosis, stained teeth and tongues, dulling of the taste buds and delayed
healing after dental surgery. Smokeless tobacco users frequently experience the formation
oforal leukoplakias (white patches) that may develop into cancerous lesions.4,22
Studies have shown that dentists and dental hygienists can effectively deliver brief tobacco
interventions to clients who use any tobacco products.5 The Canadian Association of Dental
Hygienists advocates for integrating tobacco cessation support into client-centred practice.23
Public health dental services are often targeted at children, so, like other well-child clinics,
they offer a primary prevention opportunity by addressing the childs parents or caregivers
tobacco use and his or her exposure to environmental tobacco smoke.
17.6
ADULT IMMUNIZATION PROGRAMS

Public health also provides access to vaccines for adults through targeted programs such
as annual influenza campaigns, adult immunization clinics and travel health services. The
fast-flow format of an influenza clinic may not be the most appropriate opportunity for a brief
tobacco intervention; this intervention may be more appropriate within the context of a longer
immunization appointment or travel health counselling. A tobacco user who is preparing for
travel, especially that which involves long flights, may need support in exploring strategies to
deal with the nicotine withdrawal that may be experienced during the flight.
COMMUNICABLE DISEASE CONTROL PROGRAMS
Communicable diseases, particularly those that affect the respiratory system, are negatively
impacted by tobacco use. Tuberculosis (TB) research has established a relationship between
smoking and/or exposure to second-hand smoke on the diseases process, treatment and
recovery. Not only do smokers have a higher risk of infection with TB, but they also have
higher rates of disease recurrence and mortality. Smoking during treatment has been shown
to decrease effectiveness and slow recovery.5,24,25
International and Canadian guidelines recommend intervention, and treatment is appropriate
for all TB clients who are exposed to tobacco.5,24,25 CAN-ADAPTT recommends that all
tobacco users with TB should be informed of the impact that smoking and second-hand
smoke exposure have on the disease and the effectiveness of treatment.24
Tobacco Free Futures in public health settings

At an operational level, public health management will need to decide how to integrate the
Tobacco Free Futures initiative as a standard of care. Brief tobacco intervention by a health
care provider, including a referral to intensive treatment supports, is an effective option for
most of the services and programs included in this portfolio.2 Evidence suggests that all
public health services, including prenatal programs, family planning, well-child clinics and
postnatal care, integrate tobacco interventions with provider advice to clients.1,2 By offering
brief tobacco intervention with a nonjudgmental approach, health care professionals will
not only screen for tobacco use, but also provide the help and support that clients and their
families need.
The brief intervention model outlined in Chapter 7 (Brief Intervention) has been modified for
use in the public health setting and is presented in Figure 17.2. Table 17.1 then outlines some
of the considerations for implementing the model in the public health setting.
See appendices:
Appendix 17(a) AHS Meditech PH Brief Tobacco Intervention Assessment and Protocol
(2014)
Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014)
Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014)
Appendix 17(d) AHS Tobacco Exposure Interim Department Guideline (Central Zone)
17.7
Figure 17.2: Tobacco Free Futures: Public Health Brief Intervention Model
ask

Ask client or family member/caregiver about tobacco use,
personal and/or in the home (e.g., exposure to second- and
third-hand smoke (SHS and THS)) at each home or clinic visit.
Document as per approved practice.
Have you or anyone in your home used any tobacco products

in the past year?
Have you and/or your child been exposed to SHS or THS?
No
Positive
reinforcement.
No
Support autonomy.
Leave offer of
support open.
Document as per
approved practice.
Yes
Assess
Advise

Advise about the importance of smoke-free environments.
Not using tobacco is one of the best things for your health (and the
health of everyone in the home, especially your children).
There is no safe level of exposure to SHS.

Assess interest in cessation support.
Assess interest in making environments tobacco-free.
On a scale of 1 to 10, how important is it for you to quit?
Are you interested in support to help you quit?
Are you interested in support to quit or to make
your home and car tobacco-free?
Assist
Assist patient/client and/or family member with self-support materials.

Arrange
Yes
Arrange further support by completing appropriate linked referral(s).

Provide ongoing support at next visit.
17.8
Table 17.1: Treatment Model: Considerations for Public Health Settings

Model component
ASK clients/family members
if anyone in the household
has used tobacco in the
pastyear.
Considerations
Research suggests that asking a pregnant woman about her
tobacco use, with a multiple choice question, can improve disclosure
(e.g.,Which of the following best describes your tobacco use? I dont
use tobacco now and didnt before I got pregnant. I use tobacco
regularly, and that hasnt changed since I got pregnant. I use tobacco
but have cut down since I got pregnant.).5,11
ASK
Asking parents about their tobacco use in the last year at a

childcentred visit can give an indication about potential exposure to
second- and third-hand smoke (e.g., Has anyone in the home used
tobacco products in the last year?).
Asking about tobacco use in the home can be relevant at any visit,
but it is especially important when talking to clients (and their family
members) who are in preconception and actively trying to conceive,
are pregnant or have children in the home.
Clients and families who are making repeated visits in a relatively brief
period of time (e.g., at well-child clinics) need to be approached in a
way that acknowledges that this is a repeat screening (e.g., I noticed
that at your last visit you said that no one in the home was using
tobacco. Is this still the case?).
Relevant electronic or paper forms used in public health should be
modified or created to document the ask. Appendices 7(a), 17(a), 17(b)
and 17(c)
17.9

Model component
ADVISE clients/family
members of the importance
of a tobacco-free home and
vehicle.
users to quit. Personalize
themessage.
REQUEST home visit clients
refrain from tobacco use prior
to and during visit.
Considerations
A tobacco-free home environment should be encouraged so that
pregnant women, breastfeeding women and children can avoid
exposure to second-hand smoke4 (e.g., Research shows that there
is no safe level of exposure to second-hand smoke for you or your
developing baby).
Advise that there is no safe level of exposure to environmental
tobacco use and that a tobacco-free environment is in the best
interests of the client, as well as anyone else in the home, including
pets (e.g., Your child is more vulnerable to the effects of smoke in the
air and on the surfaces in your house. Her lungs are developing, she
breathes faster and she crawls around, touches surfaces and puts
things in her mouth).
Many parents are motivated to quit or create tobacco-free
environments for their children.20
ADVISE
If applicable, inform clients and families of restrictions regarding

smoking in vehicles or environments with children present
(e.g.,bylaws, provincial legislation).
Advice to quit should be given in a non-judgmental manner and
personalized based on how important it is for the tobacco user to
change4,5 (e.g., It is important for me to advise you that quitting
smoking is one of the most important things you can do for your
healthand to protect your developing baby).
Health professionals should request that clients and household
members refrain from tobacco use for two hours prior to and during
a scheduled home visit. Approaching tobacco use in the home must
be done respectfully, recognizing that health care providers are
guests in a clients home (e.g., It is our practice to respectfully ask
that household members refrain from smoking for two hours before
and during our visits).
Health professionals must acknowledge their potential to expose
others to third-hand smoke based on their personal tobacco
use/exposure and take steps to protect clients.
Electronic or paper forms used in public health should be modifiedor
created to document the advise. Appendices 7(a), 17(a), 17(b) and 17(c)
ASSESS

ASSESS interest in
tobaccofree homes
andvehicles.
Assessing readiness to quit is appropriate for all clients who

selfidentify as tobacco users.
Assessing interest in creating tobacco-free homes and vehicles is
appropriate for all clients who use tobacco or disclose others use in
the home.
The majority of parents who use tobacco agree that exposure to
second-hand smoke is detrimental to their childs health, but may not
be as aware of the risks of third-hand smoke.19
Electronic or paper forms used in public health should be modified or
created to document the assess. Appendices 7(a), 17(a), 17(b) and 17(c)
17.10

Model component
ASSIST the client/family
member who is not ready to
quit by supporting his or her
autonomy.
ASSIST the client/family
member who is ready to quit
with self-support materials
and brief information.
Considerations
Support clients where they are at in their readiness to change
(e.g.,Iunderstand that you are not ready to discuss your tobacco
use at this time, It sounds like you are ready to start thinking about
quitting. I can give you some information that might be helpful in
making your decision).
Encourage smoke-free personal spaces for family members if the
client is uninterested in quitting at this time (e.g., I understand
that you are not interested in quitting at this time, but it sounds like
you would like some information on making your home and car
smokefree).
Offer information on tobacco-free homes and vehicles. Materials
should include information on second- and third-hand smoke.
ASSIST
Many parents take action to reduce their familys exposure to

secondhand smoke, but may not be aware that some of the techniques
they are using are not effective (e.g., smoking by an open window,
using fans or deionizers). Advocate for a complete ban on smoking
inthe home and vehicle.19
Families who live in a multi-unit dwelling where smoking is permitted in
individual units may find it difficult to provide a truly smoke-free home.
Support families by providing information about harm reduction.
Support a person ready to quit by offering self-support materials and
referring to www.albertaquits.ca for more information.
Provide information on pharmacotherapy regarding safety and efficacy
(e.g., Medicines to help you stop smoking are safe and effective, and
can double your chances of success. I recommend speaking to your
doctor or pharmacist about options that might be right for you).
created to document the assist. Appendices 7(a), 17(a), 17(b) and 17(c)
ARRANGE further support
through referrals to
Link to ongoing supports such as the AlbertaQuits helpline, preferably

by a fax (or electronically, if available) referral that is completed by
a health professional (e.g., If you like, I can make a referral to the
AlbertaQuits helpline for you. A trained tobacco counsellor will contact
you to discuss what supports might be right for you).
ARRANGE
Provide further support at the clients next visit.

If applicable, arrange referral to a prescribing authority for
pharmacotherapy support (e.g., physician, nurse practitioner or
pharmacist).
created to document the arrange.
AHS Health Information Management confirms that fax referral forms
are considered transitory records. As long as there is documentation
that a referral was sent and confirmation that the referral was received,
the paper copy of the fax may be shredded. Appendices 7(a), 17(a),
17(b) and 17(c)
17.11
REFERENCES
1. Manfredi, C., Crittenden, K., Warnecke, R., Engler, J., Cho, Y., & Shaligram, C. (1999).
Evaluation of motivational smoking cessation intervention for women in public health
clinics. Preventive Medicine, 28, 5160.
2. Mandredi, C., Crittenden, K., Cho, Y., & Gao, S. (2004). Long-term effects (up to 18
months) of a smoking cessation program among women smokers in public health clinics.
Preventive Medicine, 38, 1019.
3. Manfredi, C., Crittenden, K., Cho, Y., Englen, J., & Warnecke, R. (2000). Minimal smoking
cessation interventions in prenatal, family planning and well-child public health clinics.
American Journal of Public Health, 3(90), 423427.
6. Garg, A., Butz, A., Dworkin, P., Lewis, R., Thompson R., & Serwint, J. (2007). Improving
the management of family psychosocial problems at low-income childrens well-child care
visits: The WE CARE project. Pediatrics, 120(3), 547558.
7. Statistics Canada. (2012). Canadian tobacco use monitoring survey (CTUMS). Retrieved
from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_
prevalence/prevalence-eng.php#annual_12
8. Soares, S., & Melo, M. (2008). Cigarette smoking and reproductive function. Current
Opinion in Obstetrics and Gynecology, 20, 281291.
9. Canadian Cancer Society. (2013). Risk factors for cervical cancer. Retrieved from
http://www.cancer.ca/en/cancer-information/cancer-type/cervical/risks/?region=on#Smoking
10. Health Canada. (2008). The scoop. Retrieved from http://www.hc-sc.gc.ca/hc-ps/tobactabac/youth-jeunes/scoop-primeur/index-eng.php
11. Floyd, R., Jack, B., Cefelo, R., Atrash, H., Mahoney, J., Herron, A., Husten, C.,et al.
(2008). The clinical content of preconception care: Alcohol, tobacco and illicit drug
exposures. American Journal of Obstetrics and Gynecology, 199(6), 333339.
12. Greaves, L., Poole, N., Okoli, C., Hemsing, N., Qui, A., Bialystok, L., & OLeary, R.
(2011). Expecting to quit: A best-practices review of smoking cessation interventions
for pregnant and postpartum girls and women (second edition). Vancouver, BC: British
Columbia Centre for Excellence for Womens Health.
13. Alberta Perinatal Health Program. (2011). Maternal smoking rates, Alberta by Zone,
19992011. Edmonton: Author.
14. DiFranza, J., Aligne, A., & Weitzman, M. (2004). Prenatal and postnatal environmental
tobacco smoke exposure and childrens health. Pediatrics, 113(4), 10071015.
17.12
15. Oken, E., Levitan, E., & Gillman, M. (2008). Maternal smoking during pregnancy and
child overweight: A systematic review and meta-analysis. International Journal of Obesity,
32, 201210.
16. Bottorff, J., Oliffe, J., Greaves, L., Poole, N., Sarbit, G., & Hemsing, N. (2012). Imagine:
Gender-specific tobacco reduction and cessation strategies in pregnancy and the
postpartum. In C. Els, D. Kunyk, & P. Selby (Eds.), Disease interrupted: Tobacco
reduction and cessation (pp. 277294). Toronto, ON: Createspace Publishing.
17. World Health Organization. (1999). International consultation on environmental tobacco
smoke (ETS) and child health. Retrieved from http://www.who.int/tobacco/publications/
youth/en/
18. Tanski, S., Klein, J., Winickoff, J., Auinger, P., & Weitzman, M. (2003). Tobacco
counseling at well-child and tobacco-influenced illness visits: Opportunities for
improvement. Pediatrics, 111(2), 162167.
19. Winickoff, J., Friebely, J., Tanski, S., Sherrod, C., Matt, G., Hovell, M., & McMillen, C.
(2009). Beliefs about the health effects of thirdhand smoke and home smoking bans.
Pediatrics, 123(1), 7479.
20. Rosen, L., Noach, M., Winicokoff, J., & Hovell, M. (2012). Parental smoking cessation
to protect young children: A systematic review and meta-analysis. Pediatrics, 129(1),
141152.
21. Winickoff, J., Park, E., Hipple, B., Berkowitz, A., Vieira, C., Friebely, J., Healey, E., et al.
(2008). Clinical effort against secondhand smoke exposure: Development of framework
and intervention. Pediatrics, 122(2), 367375.
22. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT). (2011). Oral health and smoking: Key
messages for health providers and policy makers. Toronto, ON: Author. Retrieved from
https://www.nicotinedependenceclinic.com/English/teach/Pages/Smoking-Fact-Sheets2.aspx
23. Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the
role of the dental hygienist: A CDHA postion paper. Retrieved from http://www.cdha.ca/
pdfs/Profession/Resources/1004_tobacco.pdf
24. Canadian Action Network for the Advancement, Dissemination and Adoption of PracticeInformed Tobacco Treatment (CAN-ADAPTT). (2011). Tuberculosis and smoking: Key
messages for healthcare providers and policy makers. Toronto, ON: Author. Retrieved
from https://www.nicotinedependenceclinic.com/English/teach/Pages/Smoking-FactSheets2.aspx
25. Schneider, N., & Novotny, T. (2007). Addressing smoking cessation in tuberculosis
control. Bulletin of the World Health Organization, 85, 733820. Retrieved from
http://www.who.int/bulletin/volumes/85/10/07-043794/en/
17.13
APPENDICES
(2014)
Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol (2014)
Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol (2014)
17.14
(2014) (page 1)
Assessment Name: PH Brief

Tobacco Intervention
Mnemonic: PHZTOBDEP02
Acuity: n/a
Intervention Number: 1252505

Protocol: ZPHTOBACCO
Move Date: Jan 20/2014
17.15
(2014) (page 2)
17.16
PHZTOBDEP02
(2014) (page 3)
PROTOCOL
PH Brief Tobacco Intervention Protocol
Developed: June 2012
Revision: December 2013
ASK
- About tobacco use by client or other household members.
If YES for client and/or household member CONTINUE WITH INTERVENTION
If NO for client and household members INTERVENTION STOPS HERE. Exceptions may be
considered in case of recent quits (in last year) as risk of relapse may be very high for clients
such as new parents.
ADVISE
If CLIENT AND/OR HOUSEHOLD MEMBERS DO USE tobacco products:
- Advise that there is no safe level of exposure to environmental tobacco use and that a tobacco
free environment is in the best interests of the health or everyone in the home. Personalize
message as appropriate; example in the best interest of their newborn or children.
- As per AHS policy and community laws/bylaws as appropriate
- Clinics - advise of AHS Tobacco and Smoke Free Policy for all properties.
- Home visits - request that household members refrain from smoking for 2
hours prior and during a scheduled home visit.
- If applicable inform of restrictions regarding smoking in vehicles with children present.
If CLIENT DOES USE tobacco ALSO;
- Give personalized advice to quit using a non-judgmental approach: is most effective when
personalized to the individual and their situation e.g. desire to start a family, effect on
breastfeeding, relapse in the postpartum period.
ASSESS
- Readiness to quit: Importance
- Interest in support to quit
- Interest in support to make home and/or vehicle tobacco free
If NO
Respect choice and leave offer of support open. INTERVENTION STOPS HERE
If YES for either to any of above CONTINUE WITH INTERVENTION
ASSIST
PHZTOBDEP02
17.17
(2014) (page 4)
- Provide Quit Kit as or self help information tailored to client who is ready to quit &/or how to
make your home &/or vehicle tobacco free.
- Provide basic information on effectiveness of pharmacotherapy and link to prescriber
(physician, pharmacist).
- Provide information on behavioural counselling and availability in community.
- Other (specify)
ARRANGE
Arrange further support by completing appropriate community linked referral
If NO, STOP INTERVENTION
If YES, Referral/Information provided &/or fax referral to:
- AlbertaQuits(1.866.710.7848) - Helpline, Groups
- AlbertaQuits.ca - online
- Primary Care Network
- Other, specify
REFERENCES
- Tobacco Free Futures Guidelines (available at www.albertaquits.ca on Health Provider page)
- AHS Tobacco and Smoke Free Environments Policy
PHZTOBDEP02
17.18
Appendix 17(b) AHS Meditech Newborn Assessment and Tobacco Protocol

(2014)(page1)
Assessment Name: PH Newborn

Assessment (Birth - 2 Months)
Mnemonic: PHZNEWBORN09
Acuity: n/a
Intervention Number: 0251515

Protocol: ZPHNEWBORN
17.19

(2014)(page2)
17.20
PHZNEWBORN09

(2014)(page3)
PHZNEWBORN09
17.21

(2014)(page4)
17.22
PHZNEWBORN09

(2014)(page5)
PHZNEWBORN09
17.23

(2014)(page6)
17.24
PHZNEWBORN09

(2014)(page7)
PHZNEWBORN09
17.25

(2014)(page8)
17.26
PHZNEWBORN09

(2014)(page9)
PHZNEWBORN09
17.27

(2014)(page10)
10
17.28
PHZNEWBORN09

(2014)(page11)
11
PHZNEWBORN09
17.29

(2014)(page12)
PROTOCOL (Tobacco Only)
NEWBORN ASSESSMENT PARAMETERS
Developed: July 2010
Revision: January 2011, June 2011, December 2011, November 2012, January 2014
May 2013 Aligned with Alberta Health Services Public Health Nursing Maternal/Newborn Practice
Manual
The Meditech term protocol refers to information that supports documentation using specific
assessment screens. Users are responsible to follow the current Alberta Health Services policies,
procedures and guidelines or when none available guidance documents for their service area; using
clinical judgment based on current evidence-based practice.
Support for assessment is available from the Alberta Health Services Public Health Nursing
Maternal/Newborn Practice Manual.
Only descriptors in the assessment that require definitions or further clarification are included in this
document.
TOBACCO
Exposure to tobacco:
Tobacco free environment is in the best interests of the health of everyone in the home
especially in the best interest of the children
Consider exposure to tobacco in all settings, including other locations where care is provided
(grandparents, daycare) and public places
There is no safe level of exposure to environmental tobacco - Second Hand Smoke (SHS) and
Third Hand Smoke (THS)
Chemicals from tobacco smoke pass to baby in mothers breastmilk, thus the baby may be more
likely to refuse feedings, be cranky, sleep poorly and spit up. Although nicotine passes through
to breastmilk, evidence supports better outcomes for the newborn as the benefits of
breastfeeding outweigh the negative impact of nicotine and other contaminants passing
through the breastmilk
Children breathe faster and have a greater lung surface area to body size/weight than adults, so
they absorb more harmful chemicals from second-hand smoke.
Children are at higher risk for health concerns related to tobacco exposure SIDS, respiratory
infections and asthma
Enclosed spaces retain and concentrate the harmful chemicals released when tobacco burns.
This makes smoking in vehicles especially dangerous.
Make home and vehicle tobacco free and when this is not possible, use tobacco outside away
from windows and doors, change or cover clothing and wash hands after smoking
Keep tobacco products out of childrens reach
Tobacco policies/laws
AHS policy - as appropriate for clinic visits. This facility, and other AHS facilities, and grounds are
tobacco free. Tobacco use is prohibited
Home visits Staff exposure to tobacco products can be minimized when household members
refrain from smoking for 2 hours prior and during a scheduled home visit.
12
17.30
PHZNEWBORN09

(2014)(page13)
Provincial laws - Tobacco Reduction Act - Smoking is prohibited in all indoor public places and
workplaces in Alberta. The legislation does not currently include restrictions on smoking in
private homes, or public recreation areas.
In November 2013 the Alberta Government passed Bill 33 which bans smoking in a vehicle
containing children and youth under the age of 18.
Some community bylaws restrict smoking in outdoor recreation venues.
13
PHZNEWBORN09
17.31
Appendix 17(c) AHS Meditech Infant/Preschool Assessment and Tobacco Protocol

(2014)(page1)
Assessment Name: PH Infant/Preschool Intervention Number: 0251510

Assessment
Mnemonic: PHZINFANTCL06
Protocol: ZPHINFANT
Acuity: n/a
17.32

(2014)(page2)
PHZINFANTCL06
17.33

(2014)(page3)
17.34

(2014)(page4)
PROTOCOL (Tobacco Only)
INFANT/PRESCHOOL ASSESSMENT PARAMETERS
Developed: January 2011
Revision: June 2011, January 2014
Meditech uses the term protocol for the information that supports documentation in
assessment screens. Users are responsible to follow the current policies,
procedures and guidelines for their service area, using clinical judgment based
on current evidence-based practice.
Only descriptors in the assessment that require definitions or further
clarification are included in this document.
TOBACCO
Exposure to tobacco:
tobacco free environment is in the best interests of the health of everyone in the home
especially in the best interest of the children
Consider exposure to tobacco in all settings, including other locations where care is
provided (grandparents, daycare) and public places
there is no safe level of exposure to environmental tobacco - Second Hand Smoke (SHS)
and Third Hand Smoke (THS)
Chemicals from tobacco smoke pass to baby in mothers breastmilk, thus the baby may
be more likely to refuse feedings, be cranky, sleep poorly and spit up. Although nicotine
passes through to breastmilk, evidence supports better outcomes for the newborn as
the benefits of breastfeeding outweigh the negative impact of nicotine and other
contaminants passing through the breastmilk
Children breathe faster and have a greater lung surface area to body size/weight than
adults, so they absorb more harmful chemicals from second-hand smoke.
children are at higher risk for health concerns related to tobacco exposure SIDS,
respiratory infections and asthma
Enclosed spaces retain and concentrate the harmful chemicals released when tobacco
burns. This makes smoking in vehicles especially dangerous.
Make home and vehicle tobacco free and when this is not possible, use tobacco outside
away from windows and doors, change or cover clothing and wash hands after smoking
Keep tobacco products out of childrens reach
Tobacco policies/laws
AHS policy - as appropriate for clinic visits This facility, and other AHS facilities, and
grounds are tobacco free. Tobacco use is prohibited
Home visits Staff exposure to tobacco products can be minimized when household
members refrain from smoking for 2 hours prior and during a scheduled home visit.
Provincial laws - Tobacco Reduction Act - Smoking is prohibited in all indoor public
places and workplaces in Alberta. The legislation does not currently include restrictions
on smoking in private homes, or public recreation areas.
In November 2013 the Alberta Government passed Bill 33 which bans smoking in a
vehicle containing children and youth under the age of 18.
Some community bylaws restrict smoking in outdoor recreation venues.
PHZINFANTCL06
17.35
(page 1)
INTERIM DEPARTMENT GUIDELINE

CENTRAL ZONE
TITLE
TobAcco EXpoSuRE
APPLICABILITY
Public Health Nursing - Maternal Child
APPROVED BY
Public Health Nursing Management Team
DEPARTMENT
Public Health Nursing
APPROVED
01 January 2012
LAST UPDATE
23 January 2014
NEXT REVIEW
01 February 2017
The electronic copy posted on the PHN Shared Drive is considered the current copy
OBJ ECTIVES
To enhance Public Health Nurses (PHN) existing knowledge about:
Tobacco exposure
Current best practice in tobacco reduction
Evidence based tobacco reduction resources
Risk behaviours and stages of change to promote health behaviour change in clients
and families
DEFINITIONS
brief Tobacco Intervention (BTI) means a short focussed session to screen for tobacco use.
Empathetic personalized assistance is provided, focussed on increasing the individuals insight
and awareness regarding his/her tobacco use and his/her motivation for change. The BTI does
not require in-depth knowledge about smoking cessation. The process is guided by 5 As; Ask,
Advise, Assess, Assist, Arrange. (Previous practice addressed all these components within the
ask, advise, assist/refer headings.)
Mainstream smoke means the smoke that is exhaled by those that smoke.
Second-hand smoke (SHS), also called passive smoking, means smoke made up of
mainstream and side stream smoke.
Side stream smoke means the smoke that comes from the burning end of a cigarette, pipe or
cigar and other smoked tobacco products
Third-hand smoke (THS) means residual tobacco smoke pollutants that remain on surfaces
long after the cigarette or other smoked tobacco product is extinguished. It is deposited on,
penetrates and accumulates on all surfaces it comes in contact with each time someone
smokes: any surface material such as; hair, skin, fabric, clothing, curtains, car seats, carpet,
furniture, toys, furniture, and walls.
Tobacco free means there is no tobacco use in the house or car at anytime by anyone; not
even in a room with the door closed or the window open; or in an attached garage. A 100%
tobacco -free home is one where visitors, family and friends are asked not to smoke any form of
tobacco inside. Tobacco free also encompasses no use of any form of smokeless tobacco or
electronic smoking products (ESP), like e-cigarettes indoors as recent evidence has shown
smokeless tobacco use in enclosed spaces has health consequences for those other than the
17.36
(page 2)
DEPARTMENT GUIDELINE
TOBACCO EXPOSURE
APPROVED / REVISED DATE
23 January 2014
PAGE
2 of 5
user. More research is needed to evaluate health consequences of second-hand exposure to

nicotine, especially among vulnerable populations, including children, pregnant women and
people with cardiovascular conditions.
BACKGROUND
Central Zone presently has the second highest rate of maternal prenatal tobacco use in the
province (see APHR Data Sheet) with some community rates as high as 50% prevalence. A
substantial proportion of women who quit smoking during pregnancy resume smoking before
delivery or postpartum: 25% before delivery, 50% within 4 months, 70-90% by 1 year
postpartum. This indicates the importance of addressing tobacco use as often as possible.
Public health clinics have the potential for large-scale delivery of effective tobacco interventions.
Several studies have established both the short-term and long-term effectiveness of smoking
cessation interventions in public health clinics. Current recommendations are that brief tobacco
interventions occur in multiple settings (well child visits, postnatal visits) for all household
members. Of particular importance, public health clinics are a major source of maternal and
child care for lower socioeconomic women and thus present an opportunity for intervention with
this at risk population.
Client and family centered care honors the strengths, cultures, traditions, and experience that
each person brings to the client/family-professional partnership. It acknowledges that a family
has control and power to define, analyze and act upon situations
Many people will not identify themselves as a person who smokes for various reasons such as
they dont buy them but get them from others or they only smoke socially. Identifying caregivers
who have quit within the last year provides an opportunity to offer relapse prevention supports.
People may have a misunderstanding of the definition of a 100% tobacco-free environment.
Some may think smoking near an open window, in a room with the door shut or in an attached
garage is keeping their home/vehicle safe from the harmful constituents in tobacco products.
Tobacco free also includes avoiding all forms of smokeless tobacco and electronic smoking
products indoors. Smokeless tobacco use also can produce a second-hand-like effect.
Evidence has shown that median nicotine concentrations for residences with smokeless
tobacco users were significantly greater than median nicotine concentrations for tobacco-free
homes and similar to median nicotine concentrations in homes of those where active smoking
occurs. Electronic smoking products like e-cigarettes, are designed to generate inhalable
nicotine aerosol (vapour). When an e-cigarette user takes a puff, the nicotine solution is heated
and the vapour is taken into the lungs. Although no sidestream vapour is generated between
puffs, some of the mainstream vapour is exhaled by the e-cigarette user. Evidence shows that
ESPs are a source of second-hand exposure to nicotine.
Background information relevant for professional practice is found in Appendix I Tobacco Use
and Exposure Facts for Professionals.
Three types of tobacco cessation supports are provided by Alberta Quits:
Helpline (1-866-710-Quit) - A free smoking cessation help-line available from 8am to

8pm, seven days a week for all residents of Alberta. Trained counselors will develop a
quit plan, deal with cravings and provide ongoing support. Helpline counselors will call
only three times to a client before giving up on the contact.
17.37
(page 3)
PAGE
TOBACCO EXPOSURE
23 January 2014
3 of 5
Online - Around the clock internet-based quit smoking service, available free of charge
for all Albertans. Expert advice, online peer support, quitting strategies, email reminders
and more can be accessed by any computer by providing an Alberta postal code.
Alberta Quits Groups (QuitCore) Register online for a Quit Core group cessation
program in your area facilitated by professionally trained leaders and attended by people
looking for peer support, encouragement and advice to help them quit tobacco.
Availability of this program varies by community and may not be regularly available in
smaller centers.
P ROCEDURE
1.1.
Routinely plan to offer brief tobacco interventions (BTI) at the initial home visit after
the birth of the newborn and the 6 month well child clinic visit.
1.2.
Brief tobacco interventions may be offered at any point of contact as appropriate.

Reference Tobacco Use and Exposure Facts for Professionals (Appendix I).
1.3.
Use the Tobacco Free Futures: Public Health Brief Intervention Model Flow Chart
(Appendix II). It is a 5 step approach for brief tobacco interventions, messaging,
support and referrals. It only takes a few minutes and does not require indepth
knowledge about smoking cessation.
1.4.
Reference Brief Tobacco Intervention Sample Scripting (Appendix III) to facilitate

discussion with clients, as needed.
1.5.
The 5A approach includes:
ASK about tobacco use
Carefully, respectfully and non-judgementally approach clients about tobacco use

and/or exposure to tobacco for themselves or any household contacts.
17.38
Do you or any of your childs caregivers currently use or have

used any tobacco products in the past year? Separately scheduled
time may be required for client or partner counselling or support.
Reference Brief Tobacco Intervention Sample Scripting (Appendix III)

for additional scripting options.
If currently using tobacco products, ask about pattern of use.
please describe what restrictions you have in your

home/vehicle?
If the client or other family/caregivers/household members residing

with the client DO NOT USE tobacco products and there is no
indication of exposure to tobacco products from caregivers outside the
residence, STOP HERE. (See Brief Tobacco Intervention Sample
Scripting Appendix III)
(page 4)
PAGE
TOBACCO EXPOSURE
23 January 2014
4 of 5
If exposure to tobacco products from caregivers outside the residence

is identified, offer second and/or third-hand smoke messages
appropriate to situation for information and/or support.
If tobacco use by the client or other family/caregivers/household

members residing with the client is identified continue to ADVISE
ADVISE provide client-centered advice that is personalized and nonjudgmental to the individual and their situation.
o
Inform client that all AHS facilities and grounds are tobacco-free.
Recommend tobacco users quit by providing messages relevant to the

client. Reference Brief Tobacco Intervention Sample Scripting
(Appendix III) as needed.
Describe a tobacco free environment and strategies to achieve this.
Clients who live in multi-unit dwellings may find it difficult to make their
homes truly tobacco free because of lack of legislation and are
therefore, involuntarily exposed to SHS or THS.
i)
Offer pamphlet Second Hand Smoke and Multi-Unit Dwellings.
ASSESS all tobacco users readiness to quit or reduce tobacco use and
interest in cessation support. Assess clients interested in support to:
o
Quit or reduce using tobacco products
Make home and/or vehicle smoke /tobacco free
Client answers yes to either of the above questions:
Continue to ASSIST.
Client answers no:
Support their autonomy
Offer resources for future support
Reference Brief Tobacco Intervention Sample Scripting

(Appendix III) as needed.
Offer harm reduction strategies to reduce SHS or THS

exposure. i.e. only smoke outside away from doors
and windows, wear a jacket or other covering over
clothing that can be removed before coming back into
the house. Wash hands, face before handling baby.
17.39
(page 5)
PAGE
TOBACCO EXPOSURE
23 January 2014
5 of 5
ASSIST client by discussing available cessation supports such as

pharmacotherapy and behavioural support options
ARRANGE ongoing support for the client

o
Client has access to internet for referral:

Ask permission to provide referral to Alberta Quits website;
www.albertaquits.ca This site enables clients to access the
Helpline for telephone support, electronic cessation supports
like text messaging tips and to sign up for group cessation
support in their area.
Client has no access to internet for referral:

Ask permission to complete a fax referral to the Alberta Quits
Helpline. The Helpline provides assistance and support for
people who are ready to quit. Counsellors are trained to
assess an individuals level of addiction to nicotine, and assist
him/her to tailor an individualized quit plan and link him/her
with available community supports.
Client consents to referral

ii) Offer Alberta Quits pamphlet, or Alberta Quits fridge magnet
iii) For those without internet access, complete the Alberta Quits Help
Line fax referral form (Alberta Health Services Insite ->Employee Tools
-> Forms Library -> List of Forms -> Alberta Quits Helpline Referral).
iv) Fax the completed form to the Alberta Quits Help Line
Client declines referral

v) Suggest accessing www.albertaquits.ca, contacting a health care
provider or Health Link when ready.
Ask permission to provide handout materials and information found on the

PHN Client Resource Master list.
DocuMENTATIoN
Document assessment findings, anticipatory guidance and referrals according to Meditech
protocol.
AP P ENDICES
17.40
Appendix I Tobacco Use and Exposure Facts for Professionals
Appendix II Tobacco Free Futures: Public Health Brief Intervention Model Flow Chart
Appendix III Brief Tobacco Intervention Sample Scripting
Chapter 18
Transition and
Continuing Care
18.1
IMPLEMENTATION OF TOBACCO FREE FUTURES

IN TRANSITION AND CONTINUING CARE
Continuing care refers to an integrated range of services supporting the health and well being
of individuals living in their own homes, or in supportive living or long-term care settings.
Continuing care clients are not defined by age, diagnosis or the length of time they may
require service, but by their need for care. They may be young adults with acquired brain
injuries, adults with developmental disabilities or seniors.
This section of the guidelines will focus on how health care providers can support
tobaccodependent patients/clients who

are in acute care, are receiving transition care and are awaiting transfer to alternate
care settings
reside in designated supportive living settings
reside in long-term care facilities
In 2008, the Alberta Government published the Continuing Care Strategy: Aging in the Right
Place. This five-year strategy reported 14,500 seniors and persons with chronic illnesses or
disabilities living in long-term care facilities. It also acknowledged that, due to the shortfall in
available space, there were many more patients occupying hospital beds who did not need
acute services but, due to advancing age and/or complex medical and psycho-behavioural
issues, were unable to be discharged.1 AHS is committed to supporting the Continuing Care
Strategy with the right level of services provided in the right settings. AHS increased capacity
within the system by adding 3,000 new continuing care spaces by 2013. Further capacity will
be required to deal with the increasing and aging population of Alberta. It is anticipated that
by 2031, one in five Albertans will be a senior.2
AHS Transition Care/Coordinated Access Services provides the link between acute care
services and those available in the community across the spectrum of continuing care.
Theseservices vary somewhat throughout the province; however, they all ensure an
assessment of patients and clients in their current settings and facilitate the placement or
transfer from one level of care to another in an efficient and timely manner. These services
are normally undertaken in collaboration with an expanded health care team and the
client/patients family.2
In some acute care hospitals, transition care units or beds have been added in order to free
up acute care beds, reducing wait times for treatment and surgery. Transition units provide
a stop gap for clients who are awaiting placement in a continuing care setting that is more
appropriate for their care needs. Clients who use tobacco products are finding it increasingly
difficult to find a continuing care living option where they can continue to use tobacco
products. Their situations are often complicated by cognitive problems and associated
behaviours. This creates delays in moving to the right setting for those individuals who are
unwilling or unable to stop their tobacco use.
18.2
Prevalence of tobacco use

Among seniors, the mortality rate of current smokers is double that of those who have never
smoked. Eight of the top 14 causes of death among seniors have been linked to smoking and
50% of all long-term smokers die of tobacco-related illnesses. The majority of seniors who
currently smoke have been smokers for most of their lives, having had their first cigarette by
age 20. These seniors are often less accepting of the health risks associated with smoking
and may actually see smoking as a positive coping mechanism.3
Individuals with intellectual or developmental disabilities are not immune to tobacco use and
dependence. Existing data is limited, but it clearly indicates that these individuals also smoke
cigarettes and are more likely to do so if they are higher functioning, live in less restrictive
environments, are male or have concurrent substance use disorders.4
In 2010, 9% of Canadians 65 years and over were current smokers. Smoking was more
prevalent amongst Aboriginal seniors, with 22% for First Nations seniors, 24% for Metis
seniors and 36% for Inuit seniors.3 Canadian tobacco use statistics from 2012 identify 16.1%
of people 15 years and over as current smokers. The prevalence was highest amongst
young adults, with 21.8% for 2534 year olds and 20.3% for 2024 year olds. Adults 55 years
and over had the second-lowest prevalence rate, at 12.2%. More males than females were
current smokers, at 18.4% and 13.9%, respectively, continuing a downward trend for both
genders.5
In Alberta, 17.4% of people 15 years and over were current smokers in 2012. The prevalence
was, again, highest amongst young adults, at 24.5% for 2024 year olds, followed by 18%
for adults 45 years and over. More females than males were current smokers, at 17.7%
and 17.1%, respectively. This represents an increase for females and a decrease for males
compared to 2011.5
Alberta has been home to 40% of national smokeless tobacco sales (e.g., snuff, chew)
for more than 10 years. Smokeless tobacco use is most prevalent in males, with 9% aged
1519years and 2% 30 years and older reporting using snuff or chew in the past month,
as of 2008. In Alberta, the highest prevalence of smokeless tobacco users tends to be
found in the oil and gas and agricultural industries, especially the rodeo. A 2012 survey
of 510 participants at two Alberta rodeos found that 27% of males and 1% of females
used smokeless tobacco products, compared to 2% in general population of Western
Canada. Onehalf of Canadians who have tried smokeless tobacco products live in the
western provinces, even though this region is home to less than one third of the Canadian
population.6Smokeless tobacco products contain high levels of nicotine and are linked to
cancers of the mouth and digestive tract, cardiovascular disease and dental decay.
18.3
Integration of tobacco-free environments

incontinuing care
The physical and

cognitive challenges
make nursing home
residents 23 times
more likely to be
burned by cigarettes.7
The provincial Tobacco Reduction Act (TRA) prohibits smoking

in public places, which includes group living facilities such
as supportive living and long-term care facilities. An exemption
clause allows operators to permit smoking by residents as long
as they provide designated smoking rooms that have separate
ventilation systems that conform to the regulations. Alberta
Health Servicess Tobacco and Smoke Free Environments
Policy exceeds the restrictions outlined in the TRA, and since all designated continuing care
spaces in the province operate under the auspices of AHS, they fall under the scope of this
policy. Many private continuing care providers have also made the decision to implement
tobaccofree policies voluntarily, for a variety of reasons.
See Chapter 5: Policy
There is a trend across Canada towards care facilities being smoke free, including the
elimination of designated indoor smoking areas. The dilemma, however, is that not every
person who is awaiting placement for or living in continuing care settings is ready or
interested in quitting, and when the only available alternative is a smoke-free facility, there
may be resistance from clients or their families.
For continuing care sites in the process of becoming tobacco free, management, staff,
residents and families will often continue debating the merits of such policies. One frequently
cited argument is that these facilities are also residents homes and a person should be
free to make personal choices within his or her home. There may also be concern about
making residents who are smokers feel stigmatized, controlled and as though one of their
few remaining pleasures is being taken away. Although some may concede health benefits
at any age, there is also an attitude that their life expectancy is minimal anyway, and even if
a resident stops smoking, there may not be a significant benefit, especially when compared
to the perceived difficulty of quitting. Staff and family often express concern for client/resident
safety when they are required to go outside to use tobacco, potentially exposing them to
hazards such as inclement weather. There are also concerns about the risks related to fire
safety if residents attempt to hide their smoking habits while in a smoke-free facility.8
Some advocate that, at a minimum, designated outdoor smoking areas should be available
for residents. However, a 2004 study of one geropsychiatric nursing home found that the
creation of an outdoor designated smoking area was counterproductive. In this environment,
residents who were classified as safe smokers were allowed to use the outdoor area,
while those identified as unsafe smokers had enforced cessation that was supported with
behavioural and pharmacotherapy interventions. As a result, staff found that ongoing triggers
by those using tobacco caused the unsafe smokers to experience increased agitation
and also led to altercations with safe smokers, resulting in the facility choosing to become
completely tobacco free.9
18.4
The purpose of making multi-unit dwellings and health care

The evidence is clear
environments (including continuing care settings) smoke and
that there is no safe
tobacco free is not to force people to quit. Rather, it is to protect
everyone in those environments from the hazards of secondlevel of exposure to
and third-hand smoke. As per the requirements of the TRA,
second-hand smoke
many facilities have dealt with this issue by providing special
and therefore all staff,
ventilated smoking areas. While this has been a strategy in the
clients/residents and
past, current research has found that the only way to protect
the public have a right
non-smokers from exposure to second-hand smoke is to
to be protected.11
remove all smoking from indoor environments. The American
Society of Heating and Air-Conditioning Engineers (ASHRAE)
has stated that because there is no acceptable level of exposure to the chemicals found in
cigarette smoke, there is no acceptable ventilation standard for second-hand smoke.12,13
There are several well-founded safety concerns related to tobacco use and residents
in continuing care. Smoking poses an obvious and documented fire safety threat for all
residents of group living facilities. In Canada and the United States, smoking materials are
the leading cause of death in residential fires.14 Those over age 65 are twice as likely to die
in home-related fires than the average person, and that risk increases with age: those 75
and older are three times more likely, and 85 and older are 3.5 times more likely.15 Smoking
materials account for 72% of fire-related deaths and 43% of fire-related injuries in long-term
care facilities. The acuity of care for residents in long-term settings will only increase as
more complex care is moved out of hospitals and less complex care remains in the home.
Increased acuity will result in increased smoking risks.
Facilities that allow resident smoking can have additional costs, such as increased insurance
premiums, as well as additional cleaning, staff supervision and supplies related to tobacco
use (e.g., smoking aprons). In some cases, additional human resources are needed to
supervise smokers, taking staff away from other nursing duties. The Tobacco and Smoke
Free Environments Policy stipulates that AHS employees and other persons acting on
behalfof AHS shall not facilitate patient/client use of tobacco products.16,17
See Chapter 5: Policy
Supporting clients with brain injury and concurrent disorders

Within the continuing care population are those people living with acquired brain injuries
and concurrent disorders. These people are cited as the most difficult to assist in finding a
continuing care living option. There is limited research on these types of patients/residents
related to tobacco reduction and institutionalization. Most head injuries occur in males
2030years of age, and result from motor vehicle collisions and alcohol use. Some patients
may also already have a mental illness or substance use disorder. It is difficult to distinguish
between symptoms related to mental health, substance use and brain injuries, as many of
them overlap (e.g., memory problems, emotional outbursts, difficulty initiating tasks). Health
professionals typically treat these problems separately, which can create other difficulties, as
the cause of specific behaviours may not be correctly identified. Treatment can therefore take
up to three times longer, with the patient/resident going through cycles of getting better and
slipping back again.10
18.5
Table 18.1 outlines some of the general treatment considerations for those with acquired
brain injuries and concurrent disorders. Further detail regarding tobacco treatment for clients
with mental illness and addiction, including a section on Alzheimers disease and dementia,
can be found in chapter 19 (Addictions and Mental Health).
Table 18.1: Treating Acquired Brain Injuries and Concurrent Disorders10

Symptoms brain injury
and mental illness may
have in common:
memory problems
unpredictable behaviour
being very emotional
concrete thinking
seemingly low motivation
impaired capacity for insight
substance abuse
social isolation
failing to acknowledge having a problem
Symptoms brain injury

and substance abuse
may have in common:
short-term memory loss

impaired thinking
difficulty with balance/coordination
impulsivity
mood disturbances (diminished emotional control)
personality changes
diminished judgment
fatigue
depression
sleep problems
decreased frustration tolerance
Acquired brain injury

(ABI) workers should:
educate ABI clients/family about risks of using substances

involve family/social networks in supporting client to address issue
take specific history of clients past and current substance use
ask what effect substance use is having on clients life
(e.g., social life, family, job, legal)
assess stressors/risk factors that might cause client to begin using
(e.g., isolation, boredom, depression, job loss)
help clients find meaningful, substance-free activities
establish ongoing contact with addiction professionals to exchange
information and ensure client gets appropriate treatment
Addiction workers
should:
screen for acquired brain injury (ABI): ask about crashes, blows to the head,
falls, fights, periods of unconsciousness and hospitalization
adapt substance abuse treatment for people with ABI: slow down and use
simplelanguage
provide extra time for clients to complete tasks
repeat information and use short, simple phrasing
encourage client to take notes
anticipate off- topic remarks
keep instructions brief and clear
encourage feedback (ask Do you understand?)
give rest periods
reduce distractions
consult with ABI specialists to tailor treatment to clients learning style
remain in contact to monitor progress and make changes, as needed
18.6
Tobacco Free Futures in transition and continuing care

Everyone who uses tobacco products benefits from quitting, no matter their age. Those
benefits include improved health, increased quality of life, greater satisfaction with leisure
activities and social relationships, more money in their pockets and better access to housing.
Even someone who does not quit smoking until age 60 can increase their life expectancy
by three years, compared to those who continue to smoke.3 A study from the United States
found that quitting smoking at 65 years of age leads to an increased life expectancy of
1.42years for males and 2.73.7 years for females. Older smokers who try to quit are
more likely to seek assistance and more likely to be successful in their efforts.18 Cessation
rates in older women are shown to increase with brief interventions by a physician or health
professional, receiving the correct information and thinking quitting is not difficult, especially
when they smoke fewer than 10 cigarettes per day.19
Health professionals working in home care, transition and continuing care settings have an
important opportunity to identify tobacco use and provide advice and supportive care to their
patients/clients.
It is important to have family support for patients/residents
as they become tobacco free. Family members need to be
involved in the initial discussions so they understand the
policy, the benefits to the patient/resident and what supports
are available (e.g., nicotine replacement therapy, educational
materials, cessation counselling).
The AHS Vascular Risk

Reduction Project (2014)
advocates consideration of
tobacco use as a vital sign
in every patient contact.
Continuity of care planning is essential as a client transfers from one setting to another. It is
also key to maintain communication between the care teams, the patient/resident and the
family members.
The brief intervention model outlined in chapter 7 (Brief Intervention) was modified for the
home care setting in chapter 16 (Home Care). In this chapter it has been modified once
again in Figure 18.1 for clients in transition or continuing care. Table 18.3 outlines potential
considerations for implementation of the model in transition and continuing care settings.
More intensive support, as outlined in chapter 8 (Intensive Cessation Counselling) may be
required to assist those who are interested in cessation. Zone coordinators with the Tobacco
Reduction Program are available to support transition and continuing care settings as they
implement the Tobacco Free Futures guidelines in settings managed both by AHS and its
contracted partners.
See Chapters 16: Home Care and 19: Addictions and Mental Health
18.7
Figure 18.1: Tobacco Free Futures: Transition and Continuing Care Intervention Model
Tobacco use prevention and treatment.
ask
Identify tobacco use status of every client/patient needing

facility or supportive living services.
Has patient/client used any tobacco products
in the past year?
No
Yes
Inform patient and family of
Tobacco and Smoke Free
Environments and facility
living/supportive living
availability.
Assess
Advise
What type? How much? How often? Last use?
Inform patient/client and family/guardian of Tobacco and Smoke Free

Environments Policy and facility living/supportive living availability.
Advise of importance to quit with personalized message.
Assess for cognitive impairment (e.g., dementia/delirium).

No cognitive impairment identified: Assess patient/client interest
in pharmacotherapy support for withdrawal. Assess patient/
client readiness to quit. Cognitive impairment identified: Assess
family/guardian interest in pharmacotherapy support for patient/client
withdrawal. Assess family/guardian readiness for patient/client to quit.
Is patient/client and/or family/guardian
interested in support to reduce patient/client
withdrawal symptoms or help to quit?
No
Assist
Assist with pharmacotherapy for withdrawal including ordering, patient

and family/guardian education, ongoing monitoring of withdrawal
symptoms and mood assessment.
Assist with onsite behavioural support and/or modification of
environmental factors including ongoing follow-up.
Arrange
Yes
Arrange further support by including treatment plan in transfer orders

to supportive living/facility living site.
Arrange for continued pharmacotherapy by listing cessation
medications on medication profile and transfer orders.
18.8
Support autonomy.
Inform the patient/client
and family/guardian of
limited care options. Leave
offer of support open and
monitor withdrawal.
Pharmacotherapy should be considered to mitigate the nicotine withdrawal symptoms of all

patients/residents, especially in settings that restrict or prohibit tobacco use.21,22 All patients/
clients in acute care who are awaiting placement should be given access to a safe and
comfortable detoxification from tobacco, as is done with other addicting substances, to
prevent the emergence of nicotine withdrawal symptoms.23
See Chapter 9: Pharmacotherapy
Individuals living in community or supportive living settings may be eligible for coverage
of nicotine replacement therapy and/or cessation medications through the Alberta Health
Supplementary Health Benefit Program or the Alberta Human Services Drug Benefit
Supplement. Table 18.2 summarizes present coverage, which is subject to change. Refer to
http://www.health.alberta.ca/services/benefits-supplementary.html for up-to-date information.
18.9
Table 18.2: Alberta Drug Benefit Cessation Medication Coverage Eligibility

MEDICATION
Nicotine replacement
therapy (NRT)
mouth spray
inhaler
patch
gum
lozenge
Varenicline tartrate
(Champix)
Bupropion SR
(Zyban)
APPLIES TO CLIENTS OF
COVERAGE CRITERIA
Alberta Health/Alberta Blue Cross

Child and Family Services
Alberta Child Health Benefit
Children and Youth Services
Income Support
Learners Program
Alberta Human Services (AISH)
Alberta Adult Health Benefit
Restricted benefit
Coverage is limited to a lifetime
maximum of $500 per participant for
all over-the-counter smoking cessation
products listed in the Alberta Human
Services Drug Benefit Supplement
Does not include lozenges
First Nations and Inuit Health Branch

non-insured health benefits
Quantity limited for each product for

one year from when first prescription
was filled:
945 pieces for gum, inhaler and
lozenges
7084 patches, depending on type
Mouth spray not included

Non-group coverage
Coverage for seniors
Alberta Widows Pension Plan
Palliative Care Drug Coverage
Income Support
Learners Program
Restricted benefit
This product is a benefit for patients
18 years of age and older for smoking
cessation treatment in conjunction with
smoking cessation counselling
Coverage will be granted for a total of
12 weeks
Special authorization coverage may be
granted for a maximum of 24 weeks of
therapy per year

Quantity limited to 165 tablets for one

year from when first prescription filled

Child and Family Services
Children and Youth Services
Income Support
Learners Program
Regular benefit

Quantity limited to 180 tablets for one

year from when first prescription filled
Note: Benefit criteria are subject to change. Refer to Alberta Health and Health Canada for up-to-date information.
Sources:
Alberta Drug Benefit List (2014): https://www.ab.bluecross.ca/dbl/publications.html
Health Canada Drug Benefit List (2013):
http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/provide-fournir/pharma-prod/med-list/index-eng.php
18.10
Table 18.3: Treatment Model: Considerations for Transition and Continuing Care Settings
Model component
ASK
ASK all clients if they have

used tobacco in the past year.
ASK about patterns of use.
ASK about exposure to
second-hand smoke (SHS).
users to stop using tobacco.
Personalize message.
ADVISE
ADVISE client and household

members that there is no safe
level of exposure to SHS.
ADVISE of policy, as
applicable.
Considerations
All tobacco users should be identified during assessment, preferably
before or, at a minimum, during admission to transition care units or
continuing care facilities.
modified as necessary to document tobacco use status.
Status should be communicated with transfer information.
All patients/clients/residents and their families must be advised of the
tobacco policy of the current facility and the facility they will be placed
in for the long term.
Engagement of the family is critical from the outset.
Clients and family should be informed of the impact of their
tobaccouse status on placement within continuing care facilities.
Family, clients and volunteers must be informed of the policy that
staff cannot facilitate smoking behaviour (e.g., purchasing or lighting
tobacco, supervising).
All clients and families should be informed that there are health
benefits to quitting tobacco at any age.
Advice must be communicated in a non-judgmental manner and
tailored to each individual.
modified as necessary to document what has been advised.

ASSESS interest in support
for relief of withdrawal.
Assessing readiness to quit is appropriate for all clients who use

tobacco.
Assess interest in withdrawal relief through pharmacotherapy for those
who are interested in quitting or reducing their tobacco use.
ASSESS
Whenever possible, assessment should be performed by a tobacco

specialist.
Assessment of patients interest in quitting and/or interest in receiving
support for withdrawal symptoms may take several visits to complete.
It is important for the care provider to establish a relationship with the
patient.
For patients who dont initially appear to be ready to make a change,
the offer of support should be left open. It is still important, however, to
monitor for signs of withdrawal and of changes in interest in receiving
treatment.
A follow-up assessment should be arranged for no more than three
months after the initial assessment has been completed.
modified as necessary to document the assessment.
18.11

Model component
Considerations

not interested in support with
brief information.
It is recommended that the care team hold an initial meeting to frame

the approach for each patient within the first week of that patient being
admitted to the unit or facility.
ASSIST the patient who

is interested with link to
prescriber pharmacotherapy
support and/or behavioural
support.
A multidisciplinary health care team approach, involving physicians,

nurses, recreational therapists, protection services and tobacco
cessation specialists is recommended.
For extra ongoing support, it is recommended that a tobacco
specialist, either onsite or from the community, provide the one-on-one
support that the patient might need. The tobacco specialist can
coordinate the patient assessment
document the patients tobacco use history and assessments
according to site standards
coordinate involvement of the family, nursing and other professionals
and resources, as needed
ASSIST
provide tobacco behavioural counselling and support

provide pharmacotherapy assessment, support and proper use
teaching
Communication between the transition and continuing care staff
will facilitate continuity of care for clients who have been receiving
treatment before transfer. Consider building this into referral process.
Depending on the patient/clients cognitive capabilities, there may
be a need to focus on the environmental factors that contribute to
the addictive behaviour. Longer treatment times may be needed to
establish trust and rapport with the patient.
Pharmacotherapy is recommended for all clients who are interested,
except in the case of direct contraindications. Clients with conditions
such as oral cancers may be unable to use short-acting NRT products
(e.g., gum, spray, inhaler, lozenge), so products such as the patch,
bupropion or varenicline may be appropriate.
ARRANGE

modified as necessary to document the assistance.
ARRANGE follow-up and
link to further behavioural
support.
18.12
Ongoing tobacco dependence support is essential for a patient/client

who is transferred to an alternate level of care.
References
1. Alberta Health. (2008). Continuing care strategy: Aging in the right place. Edmonton, AB:
Author.
2. Alberta Health Services. (n.d.). Seniors health. Retrieved from http://insite.
albertahealthservices.ca/2321.asp
3. Butler-Jones, D. (2010). The chief public health officers report on the state of public
health in Canada. Ottawa, ON: Public Health Agency of Canada. Retrieved from http://
www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/pdf/cpho_report_2010_e.pdf
4. Steinberg, M. L., Heimlich, L., & Williams, J. M. (2009). Tobacco use among
individuals with intellectual or developmental disabilities: A brief review. Intellectual and
Developmental Disabilities, 47(3), 197207.
5. PROPEL Centre for Population Health Impact. (2014). Tobacco use in Canada:
Patterns and trends. Waterloo, ON: University of Waterloo. Retrieved from http://www.
tobaccoreport.ca/2014/TobaccoUseinCanada_2014.pdf
6. Physicians for a Smoke-Free Canada. (2011). Smokeless tobacco: Key findings from
CTUMS 2007 and the Canadian Community Health Survey (CCHS), 200809. Ottawa,
ON: Author. Retrieved from http://www.smoke-free.ca
7. Watt, C. A., Corosella, A. M., Podgorski, C., & Ossip-Klein, D. J. (2004). Attitudes
toward giving smoking cessation advice among nursing staff at a long-term care facility.
Psychology of Addictive Behaviors, 18(1), 5663.
8. Dykeman, M. J. (n.d.). Smoking and long-term care homes. Toronto, ON: Canadian Bar
Association. Retrieved from https://www.cba.org/cba/sections_elder/pdf/Smoking.pdf
9. Hartz, G., & Kuhlman, G. (2004). Smoking cessation for geropsychiatic patients in longterm care. Psychiatric Services, 55(4), 454.
10. McGlynn, C. (2005). The triple whammy of acquired brain injury and concurrent
disorders. Crosscurrents, 9(1). Retrieved from http://www.reseaufranco.com/en/best_of_
crosscurrents/acquired_brain_injury_and_concurrent_disorders.html
11. Els, C., Kunyk, D., & Selby, P. (2012). Disease interrupted: Tobacco reduction and
cessation. Edmonton, AB: CreateSpace Independent Publishing.
12. American Society of Heating and Air-conditioning Engineers. (1999). Ventilation for indoor
air quality standard 62. Atlanta, GA: Author.
13. Physicians for a Smoke-free Canada. (2001). Ventilation of second-hand smoke. Ottawa,
ON: Author. Retrieved from http://www.smoke-free.ca
14. Wijayasinghe, M. (2007). Fire losses in Canada: Year 2007 and selected years.
Edmonton, AB: Office of the Fire Commissioner, Alberta Municipal Affairs.
15. Karter, Jr., M. J. (2008). Fire loss in the United States, 2007. Quincy, MA: Fire Analysis
and Research Division, National Fire Protection Association. Retrieved from http://tkolb.
net/FireReports/2007FireLossUS.pdf
18.13
16. Alberta Health Services. (n.d.). Tobacco and Smoke Free Environments Policy. Retrieved
from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-ahs-pol-tobacco-andsmoke-free-environments.pdf
17. Alberta Health Services. (2011). AHS Tobacco and Smoke Free Environments Policy:
Special considerations protocol. Retrieved from http://insite.albertahealthservices.ca/trp/
tms-trp-tsfe-policy-special-considerations-protocol.pdf
18. Legacy for Health. (2009). Older adults and smoking. Retrieved from
http://www.legacyforhealth.org
19. Donze, J., Ruffieux, C., & Cornuz, J. (2007). Determinants of smoking and cessation in
older women. Age and Aging, 36, 5357.
20. Smith, P., Reilly, K., Miller, N., DeBusk, R., & Taylor, C. (2002). Application of a nursemanaged inpatient smoking cessation program. Nicotine and Tobacco Research,
4,211222.
22. Canadian Action Network for the Advancement, Dissemination and Adoption of Practiceinformed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian smoking cessation
and clinical practice guideline (version 2). Toronto, ON: Centre for Addiction and Mental
Health. Retrieved from http://www.can-adaptt.net
23. Williams, J. (2008). Eliminating tobacco use in mental health facilities: Patients rights,
public health, and policy issues. Journal of the American Medical Association, 299,
571573.
18.14
19. Addiction and Mental Health
20. Reproductive Years
21. Youth and Family
22. Adults with Cancer
AlbertaQuits.ca
fb.com/AlbertaQuits
@AlbertaQuits
Implementation of Tobacco Free Futures

Within Specific Populations
Although much progress has been made with the reduction of tobacco use and exposure
in the general population, there are still disparities within specific populations. The following
chapters will provide an overview of the literature and considerations for treatment when
dealing with specific populations.
Chapter 19: Addictions and Mental Health

The prevalence of tobacco use in persons with addiction and mental health
conditions.
The importance of addressing tobacco use and exposure in addiction and mental
health settings.
CAN-ADAPTT guidelines for treating persons with addictions and mental health
concerns.
The effectiveness of behavioural support and pharmacotherapy in tobacco treatment

for those with concurrent mental health and addictions conditions.
The impact of tobacco use on persons with specific mental health diagnoses
(e.g.,schizophrenia) and associated considerations for treatment.
Chapter 20: Reproductive Years

Importance of an approach to tobacco treatment for women and adolescent girls

during the reproductive years that is woman centred, reduces stigma, includes harm
reduction and is trauma informed.
The prevalence and impact of tobacco use for women and adolescent girls (who are
not pregnant or postpartum) during the reproductive years.
The prevalence of use and impact of tobacco use on women and adolescent girls
(who are pregnant and postpartum) and their babies.
CAN-ADAPTT guidelines for treating pregnant and breastfeeding women.
Recommendations and treatment considerations for women and adolescent girls

(who are not pregnant or postpartum) during the reproductive years including brief
tobacco intervention, intensive treatment and pharmacotherapy.
Care pathway, summary recommendations and treatment considerations for women

(who are pregnant or postpartum) including brief tobacco intervention, intensive
treatment and pharmacotherapy.
Summary recommendations and treatment considerations for adolescent girls (who

are pregnant or postpartum) including brief tobacco intervention, intensive treatment
and pharmacotherapy.
Chapter 21: Youth and Family

Under development
Chapter 22: Adults with Cancer

The prevalence of tobacco use in cancer patients and survivors.
The impact of tobacco use and exposure on cancer treatment and prognosis.
Review of cancer diagnosis as a window of opportunity and teachable moment for

cancer patients and their families including: motivation to quit, quit behaviours and
risk of relapse.
Recommendations for tobacco treatment in cancer care including: brief tobacco

intervention, intensive cessation support and pharmacotherapy.
Implementation considerations for patients in cancer care settings.
Chapter 19
Addiction and
Mental Health
19.1
Introduction
Prevalence of tobacco use in addictions and mental health
Although smoking prevalence in the general population has decreased, there are many
individuals who have not been able to quit. Two important groups are those with psychiatric
disorders and those with substance use disorders. According to data from the United States,
rates of smoking are 2 to 4 times higher among people with psychiatric disorders and
substance use disorders.1 In fact, tobacco users with psychiatric disorders consume nearly
half of all the cigarettes consumed in the United States.2,3
Figure 19.1: Prevalence of Current Smokers

With Psychiatric and Substance Use Disorders
100
90
80
70
60
50
40
30
20
10
0
88
70
60
66
75
80
80
56
22
23
Note: SZ = schizophrenia, BPD = bipolar disorder, MDD = major depressive disorder,

PD = panic disorder, OCD = obsessive-compulsive disorder, PTSD = post-traumatic
stress disorder
Multiple explanations have been offered for the high rate of smoking among people with
addictions and mental illness, including genetic factors, the physical effects of nicotine, selfmedication, limited education, poverty, unemployment, peers and the mental health treatment
system, wherein tobacco use is generally tolerated and not seen as a health issue.1,2 Arecent
study found evidence in internal tobacco industry documents that the tobacco industry
monitored or directly funded research supporting the idea that individuals with schizophrenia
were less susceptible to the harms of tobacco and needed tobacco as self-medication.4
These documents also revealed that the industry has promoted smoking in psychiatric
settings by providing cigarettes and supporting efforts to block hospital smoking bans.4
19.2
Impact of tobacco use and exposure

Like other smokers, those who are mentally ill have a high
risk of smoking-related death. Individuals with serious mental
illness die, on average, 25 years prematurely, with the leading
causes being chronic tobacco-related diseases.5 Among clients
in treatment for substance use disorders who smoke, 51% died
of tobacco-related causesa rate double that of the general
population.6 Persons with psychiatric or substance-use disorders
are at higher risk than individuals in the general population for
many tobacco-related diseases, including
The relative risks of

developing cancers of
the mouth and throat
are 7 times greater for
tobacco users, 6 times
greater for those
who use alcohol and
38 times greater for
those who use both
alcohol and tobacco.10
larynx cancer
esophageal cancer
trachea, bronchus and lung cancer
pancreatic cancer
stroke
cardiovascular disease
diabetes
pneumonia
chronic obstructive pulmonary disease, asthma and other respiratory illnesses1,3,6
With a risk of death from these tobacco-related diseases that is 2 to 4 times greater than the
general population, treating tobacco dependence is central to addressing the disproportionate
morbidity and mortality rates among people with serious mental illness.5,6,7
Tobacco treatment in addictions and mental health settings

Health benefits aside, people with addiction and mental health concerns have other reasons
to quit tobacco, including improved overall quality of life, greater satisfaction with leisure
activities, greater satisfaction with social relationships, more money and better access to
housing.7,8 These outcomes are significant not only to the individual but also to the health
care system in Alberta, which uses outcome measurements such as the Health of the Nation
Outcome Scales (HONOS) to inform decision-making and program planning across addiction
and mental mealth care.9
Integration of Tobacco-Free Treatment
Tobacco use has long been an accepted part of the culture of care in addictions and mental
health treatment. In treatment, smoking is often associated with social activities or with breaks.
People may smoke to feel part of a group and may be afraid that quitting tobacco will damage
their social relationships in treatment.10 In substance abuse treatment settings, smoke breaks
can reinforce the social connection to tobacco. This is unfortunate because these settings
provide an ideal opportunity for initiating tobacco treatment services, motivating clients to quit
and supporting clients in staying tobacco-free.7 Table 19.1 outlines some of the findings of
facilities that have no tobacco-use ban or partial tobacco-use bans compared to those that
have become completely tobacco-free (no tobacco use indoors or outdoors).
19.3
Table 19.1: Impact of Incomplete or Complete Bans of Tobacco Use in

TreatmentFacilities
Partial or No Ban
There is significant evidence that the bartering
and control of tobacco products between staff
and patients can be a source of conflict.11
Psychiatric care settings that have

implemented tobacco and smoke-free
policies that completely eliminate tobacco
use report fewer behavioural problems,
decreased coercion, decreased violence,
no increase in discharges against
medical advice and reduced seclusion or
restraints.11,2,12 Hospitals that do not permit
smoking experienced significantly fewer
aggression issues related to tobacco use
compared to hospitals that do.13
The amount of time spent on facilitating

tobacco use is estimated at up to four hours
per day, including getting cigarettes, giving
cigarettes, lighting cigarettes, managing
patientdisputes over cigarettes, cleaning up
cigarettes and observing patient smoking on
oroff the unit.7
Implementing policies of complete tobacco

use bans have been shown to reduce
the amount of time staff spend managing
the smoking culture.11 Staff also report an
increase in job satisfaction.13
Studies have shown increases in tobacco

use during admittance to addiction and
mental health facilities where tobacco use
ispermitted.14
When complete smoking bans are in place,

there are no cues for patients to smoke.
Coupled with access to cessation supports
such as pharmacotherapy, many patients
are surprised by how well they can manage
without tobacco.7
Conflict
and
AGgression
Staff Time
Patient
Cessation
Complete Ban
Despite these benefits, restrictive policies alone seem to have little or no effect on tobacco
cessation.15 Offering cessation treatment, especially for relief of withdrawal symptoms, is an
important part of support for clients during periods of abstinence.2 In fact, it has been reported
that failure to address nicotine withdrawal is associated with a rate of discharges against
medical advice that is twice as high for smokers who are offered support for withdrawal than
that of non-smokers.16
Health Providers in Addictions and Mental Health
There is strong evidence that tobacco use is closely linked to severe mental illness and has
a major detrimental impact on individuals lives. Yet the historic smoking culture still prevails
within the majority of addictions and mental health settings. For instance, cigarettes continue
to be used as a means of reward and punishment for inpatients.17 Cessation programs for
clients accessing mental health services have cited the negative attitudes of staff and their
refusal to engage with cessation programs as their greatest challenge.17
Addictions and mental health professionals are ideally positioned to treat tobacco
dependence. They are able to combine psychopharmacological and behavioural/counselling
treatment, often are trained in substance abuse treatment and are able to identify and
address any changes in psychiatric symptoms during the withdrawal period. Unfortunately,
19.4
many of these professionals maintain the view that smoking is an effective coping mechanism
for their clients and a means of self-medicating in order to cope with symptoms.17 There
is reluctance among these professionals to acknowledge the importance and feasibility of
addressing smoking, which may be rooted in the misconception that people with severe
mental illness generally do not want to quit smoking or that clients will become violent.
Theevidence does not support these assumptions.11,17
It is clear that much work needs to be done to raise awareness amongst health care
professionals working in addictions and mental health about the importance of quitting. These
professionals are well suited to support their clients in their tobacco cessation. Especially for
people with cognitive impairment, a consistent approach, where all health care professionals
encourage tobacco cessation, is needed.18 It is recommended that addressing tobacco be
integrated into the routine care provided at addictions and mental health treatment settings,
including mandatory training at all staff levels.19 Change is urgently required to prevent a
widening of existing health disparities.
TOBACCO TREATMENT RECOMMENDATIONS

Those dealing with mental health issues benefit from the same type of cessation support as
the general public. All smokers with psychiatric disorders, including substance use disorders,
should be offered tobacco dependence treatment.20,21 It is important for health care providers
to be aware of the impact of smoking cessation on comorbid conditions and recognize that
these patients/clients are at higher risk of relapse.21

The Canadian Action Network for the Advancement, Dissemination and Adoption of
Practiceinformed Tobacco Treatment (CAN-ADAPTT) is a practice-based research
networkfacilitating research and knowledge exchange among practitioners, researchers
and policy makers in the area of smoking cessation. CAN-ADAPTTs guideline for smoking
cessation is intended to guide practice and is not intended to serve as a comprehensive
overview of smoking cessation management.21
The CAN-ADAPTT Guideline Development Group has provided the following Grade 1A
summary statements (strong recommendations with high-quality evidence) for addictions and
mental health:

Summary Statement #1 Health care providers should screen persons with mental
illness and/or addictions for tobacco use.
Summary Statement #2 Health care providers should offer counselling and

pharmacotherapy treatment to persons who smoke and have a mental illness and/or
addiction to other substances.
Summary Statement #3 While reducing smoking or abstaining (quitting), health

care providers should monitor the patients/clients psychiatric condition(s) (mental
health status and/or other addiction(s)). Medication dosage should be monitored and
adjusted as necessary.
For more information, visit the CAN-ADAPTT website:

www.can-adaptt.net
19.5
Nicotine dependency and withdrawal

The psychological and physiological similarities between tobacco dependence, psychiatric
disorders and substance use disorders could account for the high rates of tobacco use in the
population that has addictions and mental health disorders. Most smokers with mental health
concerns smoke significantly more, have increased levels of nicotine dependency and are
therefore at even greater risk of smoking-related harm. Heavy smokers tend to have more
symptoms during nicotine withdrawal, including mood difficulties.2 Common psychiatric and
addiction withdrawal symptoms are very similar to nicotine withdrawal symptoms, including

cannabis: irritability, difficulty sleeping, strange nightmares, craving and anxiety
cocaine: depression, fatigue, increased appetite, insomnia or hypersomnia,

vivid and unpleasant dreams, psychomotor retardation and agitation
prescription stimulants abuse: depression, fatigue, increased appetite, insomnia or

hypersomnia, vivid and unpleasant dreams, psychomotor retardation and agitation
methamphetamine: depression, anxiety, fatigue and intense craving for the drug
inhalants: mild withdrawal syndromes (e.g., irritability, restlessness, insomnia,

headaches, poor concentration) can occur with long-term abuse
opioids: restlessness, muscle and bone pain, insomnia, diarrhea, vomiting,

coldflashes with goose bumps (when quitting cold turkey) and leg movements
psychiatric disorders (e.g., major depression, anxiety disorders): sleep disturbance

(increased or decreased), decreased energy, difficulty concentrating, changes
in appetite (increase or decrease), anxiety, depressed mood, anger, irritably
andfrustration22,23
Many of the neurotransmitter systems that are affected by nicotine administration through
tobacco use are involved in the pathogenesis of psychiatric and substance use disorders,
including

dopamine: schizophrenia, bipolar disorders and alcohol and drug addiction
norepinephrine: bipolar disorders, major depressive disorders and cocaine

dependence
serotonin: major depression and PTSD
acetylcholine: schizophrenia and major depression
endogenous opioid peptides: opioid and alcohol dependence
glutamate: schizophrenia, bipolar disorders and major depression
gamma-aminobutyric acid (GABA): schizophrenia, major depressive disorders

andcocaine dependence
endocannabinoids: cannabis and opioid dependence24
Some researchers suggest that tobacco may also be used by patients to selfmedicatefor
transient relief of psychiatric symptoms.24
19.6
Readiness to quit
People with psychiatric and substance use disorders have the same levels of motivation
and desire to quit as does the general population. In 2009, Calgarys Foothills Medical Clinic
found that 51% of addiction and mental health patients were pre-contemplative (no timeline
or not interested in quitting), 12.7% contemplative (desired to quit in the next 6 months), and
36.2% preparatory (desired to quit in the next 30 days) or action-oriented (actively cutting
down or quit recently).25 The motivation in outpatient addiction and mental health patients
is47.4% pre-contemplative, 38.6% contemplative and 14.0% preparatory or actionoriented.8
In the general North American population, those rates are 40% pre-contemplative,
40%contemplative and 20% preparatory or action-oriented.26
Figure 19.2: Readiness to Quit
General population
40
40
20
Not currently interested in quitting
A&MH inpatient
51
13
36
Seriously considering quitting in

the next 6 months
Actively quitting or quit recently
A&MH outpatient
47
0%
25%
39
50%
14
75%
100%
The majority of current smokers in the Foothills Medical Clinic research (79.3%, n =92)
expressed concern about their smoking, with 40.5% (n = 47) somewhat concerned,
20.7%(n= 24) considerably concerned and 18.1% (n = 21) seriously concerned.25 Ratings
of concern about smoking and the perceived difficulty of quitting did not vary significantly
acrossthe diagnostic groups.25 Those with higher nicotine dependence did not have
statistically greater concerns about their smoking than others.25

Tobacco use negatively affects mental health treatment.24 Increasing evidence indicates
that individuals with psychiatric disorders can be aided in quitting smoking without threat to
their mental health recovery. Integration of tobacco cessation treatment within psychiatric
settings is encouraged so that clinicians can identify and address nicotine withdrawal and any
changes in psychiatric symptoms during the quit attempt.7 Addiction and mental health clients
can quit smoking without adverse effect to their mental health recovery.
19.7
Alzheimers Disease and Dementia

Smoking cessation could prevent or slow the progression of dementia and should become an
integral part of the prevention and treatment of dementia.27 Smoking cessation in older adults
should receive the same attention as other modifiable risk factors, such as hypertension
and diabetes.28 In Alberta, persons aged 45 and up have a lower rate of cigarette smoking
compared with other age groups, at 17.2%.29 Traditionally, it was thought that older adults
were not interested in quitting and there was no clinical reason for an older tobacco user to
quit.30 Infact, older adults are just as willing as younger adults to try to stop using tobacco.28
Thereis now a substantial body of evidence of meaningful benefits of tobacco cessation,
evenafter many years of tobacco use.31 Older persons who quit can

significantly reduce their risk of other chronic illnesses, such as lung cancer, stroke,
coronary artery disease, peripheral vascular disease and chronic obstructive
pulmonary disease
enhance their quality and length of life
improve their mobility and prevent the loss of mobility
improve their physical strength33,34,35,36
Given the health benefits of quitting tobacco at any age, the potential difficulty of placement
into longer term care or daily assisted living settings and the risk of fire and injury with
declining cognitive ability, tobacco treatment should be a part of the standard of care for
allpersons, especially for older adults with dementia.
Treatment considerations
COGNITIVE DEFICITS AND COMORBID CONDITIONS
The proper treatment of cognitive deficits related to dementia and other comorbid conditions
is a critical first step in the overall care of the person.36 Comorbid conditions are common in
elderly patients with cognitive impairment and could impact tobacco treatment attempts if
not addressed.36 Disorders to be considered include sensory deficits (especially deficits in
vision or hearing), dental problems, depression and other medical conditions that commonly
affect the elderly.36 Properly managing comorbid conditions could improve tobacco cessation
treatment outcomes.
There is growing evidence in clinical practice that clients engaging in tobacco treatment
should be screened for mild to moderate degrees of cognitive impairment.30 Executive
cognitive functions are essential to behavioural self-regulation and are essential for sustaining
behaviour change over time, including the behaviour change required for tobacco cessation.37
Although Brega et al. (2008) found that impaired executive cognitive functioning has only a
modest impact on the success of tobacco cessation efforts in older populations, interventions
targeting behaviour change in older adults should consider the special needs of those with
executive impairment.37,30 Understanding the status of a patients executive function will allow
health care professionals to arrange the resources and enlist the multidisciplinary support to
enhance a patients tobacco treatment outcomes.
19.8
FAMILY EDUCATION AND SUPPORT

The most important factor for successful smoking cessation for persons with dementia is to
engage and educate the persons family, particularly the primary agent or decision maker.38,36
An alliance between the family and the health care team is the principal means of ensuring
the treatment plan is followed. The physical and emotional health of the family, especially
the primary caregiver, is critical to the care of the patient with dementia.39 Family members
who are in a caregiving role have a higher rate of depression and physical illness.39 A close
working relationship not only helps minimize caregiver distress and improve satisfaction with
treatment, but also decreases agitation and anxiety in the patient.40
At or soon after admission, the health care team, including the admitting physician, should
meet with the patient and the family to answer questions and provide information about
quitting tobacco and treatment options. The health care team can help family members by
educating them to use strategies to reduce behavioural disturbances and promote tobacco
cessation.
MODIFYING THE ENVIRONMENT
People with clinically significant degrees of cognitive impairment, particularly to their
executive functions, are unlikely to be able to carry out actions, sustain effort or learn
new behaviours.30 For such persons, smoking cessation programs that rely heavily on the
individual to regulate his or her smoking behaviour independently, without considerable
external support, are liable to produce poor outcomes.37
When an individual has an impaired ability to regulate his or her own behaviour, considerable
assistance from others (e.g., health professionals, family, guardians) and environmental
structures (e.g., modifying the environment to make it more difficult to engage in the smoking
habit) may be required.37 Depending on the cognitive capabilities of the individual, there may
be an increased need to focus on the environmental factors that contribute to the addictive
behaviour. Effective strategies include

removing triggers and environmental cues of tobacco use
washing all clothes of a smoker as soon as they come into the care setting to
eliminate the smell of tobacco, which could trigger the urge to smoke in patients
andstaff who use or have previously used tobacco
removing visual cues from the environment (e.g., seeing others using tobacco,
beingin an area where patients would have used tobacco before quitting)38
ADDRESSING PERSEVERATION AND AGITATION

One of the most overwhelming aspects of caring for a person suffering from dementia
involves the accompanying behavioural problems of perseveration and agitation. Patients
with dementia will often perseverate, or repeatedly ask to use tobacco, even if they just had
a cigarette. This can quickly escalate to agitation. Strategies that address the individuals
needs decrease rates of inappropriate behaviours. Despite the many difficulties of conducting
research in this population, a wide variety of approaches have been tried successfully.
Many non-pharmacological approaches resulted in a statistically and clinically meaningful
improvement in the manifestation of behaviour problems. The principles listed below, which
received consistent support in the research, should be considered primary targets for future
non-pharmacologic interventions:

medical and nursing care that effectively address limitations in functioning,

including pain, sensory limitations, sleep problems and limitations on autonomy
(e.g., physical restraints)
19.9
provision of social contact
provision of meaningful stimuli or activity
tailoring the intervention to the individual
staff training to improve care
reduction in stressful stimuli or increasing relaxation during care activities, including

longer treatment times, in order to establish trust and rapport with the patient and
explaining all procedures and activities to the patient in simple language before
performing them
providing the patient with a predictable routine (e.g., exercise, meals and bedtime
should be routine and punctual)
breaking complex tasks into smaller steps41,36,38
Redirecting or diverting the patient will often abruptly end or lessen the perseveration.36
Arguing will only increase the agitation.36 Change the subject and engage the patients
longterm memory, such as asking about a spouse or children or a favourite sport or hobby.38
One tactic is to keep a memory book or photo album of pictures of the past.38 Reinforce and
remind the patient that he or she is now a non-smoker, and eventually they will believe it.38
Ifthe person asks for a cigarette, you could also try telling them they just had one.38
Using drug therapies to treat perseveration and agitation associated with dementia should
only be considered when all other non-pharmacologic interventions have been exhausted.36
When drug therapy is necessary, psychosocial interventions should continue, as they may
enable a reduced dosage or duration of the drug treatment.36
CESSATION MEDICATIONS
Evidence indicates that the use of pharmacotherapy on its own doubles the chance of
success for those attempting to quit tobacco use.20 Nicotine withdrawal may be more severe
in patients with dementia because of their pre-existing cholinergic deficit.42 This highlights
the importance of using cessation medications to reduce signs and symptoms of nicotine
withdrawal. Except in the presence of contraindications, it is recommended that available
treatments be used with all patients attempting to quit smoking.21,20 As drugs are known to
metabolize differently in the elderly, when adding any pharmacotherapy you should always
adhere to the general guidelines of start low and go slow. Start at the lowest possible dose
and increase doses slowly to prevent side effects and toxicity.
The first-line smoking cessation medication options approved for use in Canada include
various forms of nicotine replacement therapy (NRT), bupropion SR and varenicline,
which are outlined in Chapter 9 (Pharmacotherapy). Decisions about whether to
use pharmacotherapy, including the type of product appropriate, should be made in
collaborationwith the patient/client and his or her family.43
While most cessation medications would presumably work in patients with dementia, it is
important to note that some may be better suited to an individual with cognitive impairment
than others. For instance, learning to use a nicotine inhaler may prove to be a challenge.
Nicotine withdrawal in patients with dementia may be easily managed with transdermal
nicotine replacement therapy.42 Weatherall (1992) reported a case of a 69-year-old male
with dementia for whom the use of a transdermal nicotine patch led to a dramatic and almost
complete cessation of demands for tobacco use, allowing the care team to instead focus on
treatment of other health concerns.42
19.10
ANXIETY DISORDERS
Prevalence
The prevalence of tobacco use is higher among individuals with anxiety disorders than in
the general population. The percentage of current smokers who also suffer from an anxiety
disorder varies according to the disorder, from 31% for social phobia, 54% for generalized
anxiety disorder, to 66% for post-traumatic stress disorder.3 On average, persons with
anxiety disorders smoke for longer, which exposes them to a greater risk of tobacco-related
harm.44 The association between tobacco use and anxiety disorders may be due to shared
common predisposing factors (e.g., genetic predisposition), neurobiological mediators or a
tendency to experience negative affect states.45 Generalized personality-based factors may
be relevant to the relationship between panic attacks and smoking, but it is unclear whether
specific individual differences (e.g., anxiety sensitivity) or social-environmental factors play
similarroles.45
In one study, participants who smoked and were identified as ever meeting criteria for a
panic attack, social anxiety or generalized anxiety disorder reported higher levels of nicotine
dependence and pre-quit withdrawal symptoms.46 Participants received six 10-minute
individual counselling sessions and either single-agent pharmacotherapy (nicotine patch,
nicotine lozenge, or bupropion SR) or combination pharmacotherapy treatment (nicotine
patch and nicotine lozenge, or bupropion SR and nicotine lozenge).46 Those ever meeting
criteria for panic attacks or social anxiety disorder showed greater quit-day negative affect
and were less likely to be abstinent at 8 weeks and 6 months after quitting.46 They did
not show benefits from single-agent pharmacotherapy or combination pharmacotherapy
treatment.46 It could be argued that anxiety disorders and life circumstances surrounding
these individuals justify a higher level of support in order to achieve equitable outcomes.44
Medications to reduce anxiety (anxiolytics) may help smokers trying to quit, but there have
not been an adequate number of trials, and the available evidence neither supports nor
rules out an effect of anxiolytics such as buspirone, diazepam, meprobamate, ondansetron
and beta blockers on smoking cessation.47 In view of this uncertainty and the side effects of
these drugs, there is little justification for using them for the purposes of smoking cessation.47
Clonidine, a drug that has some anxiolytic effects, does show evidence of efficacy, but the
incidence of side effects from its use is relatively high.47,48
19.11
DEPRESSION
Prevalence
Tobacco use and depression are strongly connected. People with depression are about twice
as likely to be smokers as individuals who are not depressed.1,3 Tobacco use and depression
may be associated through the following mechanisms: shared genetic factors, shared
environmental influences, bidirectional causality and self-medication.49
Compared to people in the general population who smoke, those with depression are more
nicotine dependent and more likely to suffer from negative mood changes after nicotine
withdrawal.49 Their withdrawal symptoms should therefore be monitored closely. Several
tools are available to simplify depression screening and enhance routine inquiry about
mnetal health problems related to depression, which are the most prevalent and treatable
mental health conditions. There is strong evidence for the use of the Personal Health
Questionnaire-2 (PHQ-2) as a brief depression screening measure. The PHQ-2 assesses the
frequency of depressed mood and the absence of pleasure over a 2-week period. Total PHQ2 scores range from 0 to6, with a score of 3 as the optimum. A score of 3 or higher indicates
that the user should be referred to a mental health specialist.50
To address potential patient/client
safety concerns, those who report
a past history of clinical depression
or currently report a moderate to
severe depressed mood should
be screened further to determine
whether referral for mental health
support is required.
PHQ-250
Over the past two weeks, how often have you
been bothered by any of the following problems?
(0 = not at all, 1 = several days, 2=more than
halfthe days, 3 = nearly every day)
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
It is often thought that smokers

with depression do not want to quit
smoking. In fact, several studies show the opposite.49 Unfortunately, smokers with depression
are not often encouraged by health professionals to quit, due to the misconception that
cessation will exacerbate their depressive symptoms.49 Evidence now suggests that quitting
smoking may improve rather than exacerbate depressive symptoms in those who are able
to remain abstinent.49,51 Furthermore, research shows no differences in cessation outcomes
as a function of the type of depression (recurrent versus single episode), the severity of
depression, or whether the depression was current or in remission.52
Evidence suggests that adding a psychosocial mood management component to a
standardsmoking cessation intervention increases long-term cessation rates in smokers
with both current and past depression when compared with the standard intervention
alone.49 Buproprion SR, with or without NRT, may be an appropriate choice for cessation
support for those suffering from or with a history of depression.49 A recent review found
pooled results from four trials, suggesting that the use of bupropion may increase long-term
cessation in smokers with a history of depression.49 Unfortunately, there was not enough
evidence to evaluate the effectiveness of the other antidepressants in smokers with current
orpastdepression.49
19.12
SCHIZOPHRENIA
Prevalence
Tobacco use among individuals with schizophrenia is significantly higher than in the general
population, with prevalence estimated to be between 58% and 88%.3 Several biological,
psychological and social factors appear to contribute to these high rates of tobacco use
and dependence and the low rates for smoking cessation in persons with schizophrenia.
Nicotine transiently improves abnormalities in sensorimotor gating and visuospatial working
memory (VSWM) for individuals with schizophrenia.45 Smoking may therefore be a form of
self-medication for psychological symptoms; however, it may also be explained by addiction,
dependence, tolerance or self-medicating nicotine withdrawal.45 Psychosocial factors are also
important in understanding the high rates of tobacco use in people with schizophrenia. Social
factors that increase smoking risks for this population include limited education, poverty,
unemployment, peer influence and the mental health treatment system.45
Similar to smokers with other psychiatric disorders, about half of individuals with
schizophrenia are heavy smokers and have higher nicotine dependence.45 Studies that
compared heavy and lighter smokers in this population found that heavy smoking was
associated with increased positive symptoms, decreased negative symptoms, increased
substance use, more frequent psychiatric hospitalizations, fewer parkinsonian or
extrapyramidal side effects, increased suicide risk and polydipsia.45 Studies have shown
that clients do not show worsening symptoms of schizophrenia during periods of tobacco
abstinence or while stopping smoking.11 There is some evidence to suggest that people with
schizophrenia may experience more severe withdrawal symptoms during the first week of a
quit attempt than other would-be quitters.11
Individuals with schizophrenia appear to be able to quit tobacco with the support of
psychosocial treatment, tobacco cessation medications and social support.45 Although many
of these patients experience difficulties and may relapse, they are still interested in reducing
their smoking.45 The initial challenge is often to motivate individuals with schizophrenia
to attempt quitting. Engaging less-motivated patients with psychosocial interventions is
important, given the high rates of tobacco dependence. One study found that motivational
interviewing with personalized feedback is effective in motivating 32% of smokers with
schizophrenia to seek smoking cessation treatment within one month, compared with 11%
among those receiving an educational intervention and 0% among those provided with
information only.54 Participants received a single motivational interviewing session that lasted
approximately 40 minutes and concluded with advice to quit smoking and with a referral
for treatment to a specialized tobacco dependence treatment program.53 Personalized
feedback based on the assessment interview was provided using a form created by a
computerized program.53 A major goal of the feedback was to create a discrepancy between
the participants current behaviour and their future goals. Feedback included graphical
representations of participant responses, including
their level of nicotine dependence as compared with normative data
the amount of carbon monoxide in their expired breath as compared with nonsmokers
the medical consequences of smoking
the money spent on cigarettes
the importance of quitting smoking
their confidence in their ability to quit53
19.13
Motivational interviewing is effective in motivating smokers with schizophrenia or

schizoaffective disorders to seek tobacco dependence treatment and may also have
implications for smokers with schizophrenia who are already being treated for tobacco
dependence. It can allow those individuals to become more engaged in treatment, thereby
improving retention rates and treatment outcomes.53
Once a person is ready to quit, there are clinical studies showing that different intensities of
psychosocial treatment interventions have been effective.45 This includes one-to-one and
group-based counselling, using interventions tailored to the population, cognitive-behavioural
therapy approaches, social skills training and contingency monetary reinforcement.45
Pharmacotherapy may be particularly important for smokers with serious mental illness who
have high levels of nicotine dependence. Psychiatric inpatient clients who were not given a
prescription for nicotine replacement therapy were more than twice as likely to be discharged
from the hospital against medical advice.11 Looking only at the number of cigarettes smoked
by individuals with schizophrenia may be a less reliable measure of dependence, as there is
evidence that these smokers take more puffs per cigarette and therefore have higher levels
of nicotine and cotinine compared to individuals without schizophrenia who smoke the same
number of cigarettes.45 Given the high levels of dependence in individuals with schizophrenia
who smoke, higher doses of cessation medications are an important treatment consideration.
Higher doses of nicotine replacement therapy (e.g., 6 mg of nicotine gum) have the added
benefit of improving sensorimotor gating.45
An important component of tobacco cessation treatment for persons on psychotropic
medications is close monitoring of the amount smoked, cessation treatment, medication
side effects and psychiatric symptoms.21 As a result of the polycyclic aromatic hydrocarbons
in the tar of tobacco smoke, the metabolism of psychotropic medications, as well as other
psychiatric medication blood levels, can be increased in cigarette smokers due to the
induction of cytochrome P-450 hepatic enzymes.54 Numerous medications may be affected
once a person stops smoking, including

antidepressants (tricyclics, fluvoxamine)
antipsychotics (clozapine, olanzapine, haloperidol)
caffeine
benzodiazepines (chlordiazepoxide, diazepam)
nifedipine
propafenone
theophylline
verapamil
warfarin54
Smokers frequently need higher doses of these types of medications to have the same
therapeutic effect, and thereby run an increased risk of adverse effects.2,3 Clients on
psychotropic medications must be reviewed by health care professionals when quitting
smoking, as they may need their medication dosages adjusted in order to avoid drug
toxicitydue to increased drug levels in their blood.55,21
19.14
SUBSTANCE USE DISORDERS

Prevalence
Clients in treatment for substance use disorders have extraordinarily higher rates of tobaccorelated health problems than the general population, as approximately 75% to 80% of clients
in substance abuse treatment settings use tobacco.3 Addiction to tobacco appears to follow
the same biochemical and behavioural processes as those that determine addiction to other
substances. In fact, heavier smoking is linked to increased drug and alcohol use severity.2
Current tobacco use is strongly associated with abuse/dependence on alcohol, cannabis and
other substances.56,57 Former smokers have higher rates of alcohol-use and cannabis-use
disorders.57 Because of the frequent concurrent use of the two drugs, substances of abuse
and smoking may become associated through a process called cue conditioning.58 In general,
conditioning models of addiction suggest that cues previously paired with drug use (e.g., the
sight of a liquor bottle or the smell of a lighted cigarette) will elicit conditioned responses,
including cravings and associated physiological activity.58 These cue-elicited cravings and
physiological reactions, in turn, can motivate ongoing drug use and increase the probability
of relapse among people who are abstinent.58 The substantial overlap between substances
ofabuse and tobacco use cues may elicit cravings and consumption of either drug.58
Evidence indicates that tobacco use interventions, including counselling and medication,
are effective in treating smokers who are receiving treatment for other substance use
and addictions.20 Counsellors and agencies providing substance abuse treatment have
traditionally ignored their clients tobacco use, even though studies consistently show that
many clients want to quit and want help in quitting. A growing body of evidence indicates that
treating tobacco use actually helps clients address their alcohol and other drug problems,
and integrating tobacco treatment into mainstream substance abuse treatment is rapidly
becoming best practice.
Substance abuse counsellors have considerable knowledge and skills about how to help
clients deal with their use of addictive substances. These are directly applicable to treatment
of tobacco. However, counsellors should be educated about the addictive properties of
nicotine and receive training specifically about tobacco treatment.10 There is some evidence
that treatment outcomes improve when multiple types of clinicians are involved in tobacco
treatment.2 For example, one counselling strategy is to have a medical/health care clinician
deliver messages about health risks and benefits, as well as deliver pharmacotherapy, while
behavioural health clinicians deliver additional interventions, such as cognitive behavioural
therapy. Persons who do not participate in many activities may become bored and smoke
more to keep themselves busy. Recreation therapists could offer additional programming
andsupports in place of the time clients would have otherwise spent using tobacco.
Smokers with a history of alcohol problems may find nicotine more reinforcing, and
experience more nicotine dependence criteria and withdrawal symptoms compared with
smokers without alcohol problems.2 In health care settings, all patients should be given
access to a safe and comfortable detoxification from tobacco, as is done with other addicting
substances, to prevent the emergence of nicotine withdrawal symptoms.11 Pharmacotherapy
should be considered for all clients to mitigate their nicotine withdrawal symptoms, especially
in settings that restrict or prohibit tobacco use.21,20
19.15
Increasingly, research suggests that tobacco treatment does not jeopardize recovery from
other substances. In fact, it may improve outcomes for the treatment of other substance use
disorders.2 A review of tobacco treatment interventions for individuals with substance abuse
problems found that smoking cessation interventions were associated with a 25% increased
likelihood of long-term abstinence from alcohol and illicit drugs.16 Tobacco cessation
supports recovery from other addictions and is associated with improved sobriety from
other addictions, whereas continued tobacco use is associated with worse drug treatment
outcomes.7 Tobacco dependence interventions during addictions treatment appear to
enhance, rather than compromise, long-term sobriety.
Both individual and group counselling are effective treatment options for treating tobacco
use. Evidence also supports the use of motivational interviewing in substance use treatment
settings.59 The type of counselling offered can be selected based on what fits best within a
care setting and for the type of clients seen at a particular facility. More intensive interventions
are more effective than less intensive interventions and should be offered whenever possible.
The U.S. guidelines (2008) define intensive interventions as having a minimum of four
face-to-face sessions.20 Self-help interventions, such as giving clients pamphlets or lists
of community resources, appear to have a limited impact on their own; however, tailored
materials that address specific issues and concerns can be useful additions to behavioural
interventions or pharmacotherapy.10
Relapse to tobacco use following treatment for substance use and tobacco use is a
concern.60 Helping a person maintain his or her tobacco cessation is strengthened by offering
follow-up support after treatment.59 Follow-up telephone calls are also helpful and increase
abstinence rates after discharge.59
19.16
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19.20
APPENDICES
Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery
19.21
Appendix 19(a) Residential Detox Workshop: Tobacco Use in Recovery (page 1)
DETOX WORKSHOP:
TOBACCO USE IN RECOVERY
PURPOSE
Awareness and information
LEARNING OBJECTIVES
During this workshop, participants will:
learn about the health consequences of tobacco use and the health benefits of tobacco cessation
become aware that quitting tobacco use can help them stay clean and sober
become aware of tobacco withdrawal and the supports and resources available to manage it while in
recovery
become aware of the tobacco cessation resources available to them on discharge
MATERIALS
This workshop is intended to be a facilitator led group discussion. The following handouts and resources will
help to facilitate the discussion:
Big cigarette display
AlbertaQuits cost savings wheel
AlbertaQuits brochure
AlbertaQuits fax referral sheet
Carbon Monoxide Monitor
PREPARATION
1.
2.
3.
Read through the workshop.

Familiarize yourself with the Carbon Monoxide Monitor.
Assemble documents participants might be interested in.
SUGGESTED PRESENTER
Counsellor, or nurse if available.
KEY
Suggested script
[Q] Questions to ask participants
Interactive learning activity
19.22

Tobacco Use in Recovery 2012
Workshop overview
This workshop is divided into 3 main topic areas:
1. Why talk about tobacco?
2. Tobacco and recovery from other addictions
3. Supports when you leave detox
During the workshop, encourage participants to share their own experiences. Its important to convey three
main ideas: (1) that tobacco is very addictive, but that quitting is possible and healthy; (2) going without
tobacco is an opportunity to work on new skills and give your body a chance to recover; and (3) there are
supports available to help with the recovery process.
Using the phrase tobacco use instead of smoking will make sure that you are including clients who use
smokeless tobacco products like snuff and chew.
In this workshop, we will give you some information about tobacco use in recovery. We will give you
information about the effects of tobacco and how it affects substance abuse. We will help you understand
the supports available to you and help you make a choice that fits your situation.
Topic 1: Why talk about tobacco?

WHO USES TOBACCO?
[Q] What percent of Albertans do you think currently smoke?

In 2011, 17% of Albertans age 15+ were current smokers. (Statistics Canada, 2010)
People with alcohol and other drug addictions have higher rates of tobacco use. In fact 75% of people
with other addictions currently smoke. (Kalman, D., Baker Morissette, S., & George, T., 2005)
[Q] Why do you think more people with alcohol and other drug addictions use tobacco?
Tobacco use often goes hand in hand with alcohol and other drug use. Its often used for many of the
same reasons as other drugs. For Example: as a way to socialize with other people, to deal with
stress or boredom, to get a break from a busy day. (Petry N., & Oncken C., 2002)
WHATS IN TOBACCO?
Most tobacco users know their use is unhealthy but many dont know whats really in tobacco products.
Here are some facts about commercial tobacco products:
The tobacco products you buy in stores are very different from the sacred tobacco used in
traditional native ceremonies. The tobacco industry adds many chemicals to make tobacco
products more addictive. (USDHHS, 2010)
Residential Detox Workshop | Alberta Health Services
19.23

There are more than 7,000 chemicals in tobacco smoke (USDHHS, 2010). More than 69 of them
are known to cause cancer. Most people already know about the harmful effects of tobacco use
(USDHHS, 2010). Half of people in recovery from alcohol and drug addictions will die from a
tobacco related disease (CAN-ADAPPT, 2011).
LEARNING ACTIVITY
Use the big cigarette display to review some of the harmful chemicals found in
tobacco products.
THE GOOD THINGS ABOUT GOING WITHOUT TOBACCO
The good news is that when you go without tobacco, your body begins to recover very quickly. Quitting is
one of the best things you can do to improve your health and the health of your families and friends.
LEARNING ACTIVITY
Ask clients to review the health benefits poster or handout. Which health
benefits are the most important to them?
Within minutes of the last tobacco use, the body will start a process of healing that will continue to
over the following weeks, months and years (AADAC, 2007). Within:
20 minutes blood pressure drops to a persons normal level
8 hours blood carbon monoxide levels drop to normal
24 hours chances of having a heart attack decrease
2 weeks to 3 months circulation improves
9 months lung function improves with less coughing, congestion, fatigue and shortness of
breath
1 year risk of coronary heart disease reduces by half
5 years risk of stroke significantly reduced
10 years risk of lung cancer death reduced by half
15 years risk of coronary heart disease is same as a non-smoker
[Q] If you did choose to remain tobacco free after leaving detox, what else would you look forward to?
Some other benefits of stopping tobacco use include (AADAC, 2007):
better sense of taste and smell
cleaner smelling person, home and car
positive role model for children and other people
money saved
freedom from addiction
improved self esteem
no worries about exposing family, friends and coworkers to second-hand smoke
LEARNING ACTIVITY
Handout the AlbertaQuits cost savings wheel. Allow some time for clients to
figure out how much they would save if they remained tobacco free.
Alberta Health Services | Residential Detox Workshop
19.24

Topic 2: Tobacco and recovery from other addictions
There are good reasons to be tobacco-free during detox. Nicotine is a highly addictive substance that is
found in tobacco. It acts in the same part of the brain as other addictive substances (Els C., 2008). In fact,
tobacco use often goes hand in hand with alcohol or other drug use. It is important to remember that the
other chemicals found in tobacco are responsible for the harmful effects, not nicotine (OMA, 2008).
WILL STOPPING TOBACCO USE IMPACT RECOVERY FROM ALCOHOL OR SUBSTANCE USE?
You might think its too stressful for you to quit tobacco use while dealing with other addictions or you
may have heard the myth that it isnt a good idea to stop using everything at once. Tobacco may trigger a
relapse into alcohol or other drug use. In fact it may be easier to quit tobacco use while in recovery.
Quitting smoking increases your chances of staying clean and sober from alcohol and other drugs by 25%
(Prochaska, J., Delucchi, K., Hall, S., 2004).
In long-term recovery there is a higher risk of relapse if you continue to use tobacco. Because the detox
facility is tobacco free, you can give yourself a better chance of staying free of alcohol or other drugs.
WHAT TO YOU EXPECT WHEN YOU GO WITHOUT TOBACCO
Its important to understand how you will feel when you go without tobacco. Your body has become used
to the effects of nicotine, and when you go without tobacco your body and brain adjust to getting rid of
nicotine. This is a sign that your body is starting to repair itself. This adjustment is what we call
withdrawal.
[Q] When you have to go without tobacco how do you feel?

The eight common symptoms of nicotine withdrawal are (West R., Ussher M., Evans M. & Rashid M.,
2006):
tobacco cravings
irritability
restlessness
insomnia
anxiety
depression
increased appetite
poor concentration
People who stop using tobacco products either by choice or by circumstance may start to experience
withdrawal symptoms within minutes to hours of last use (Abrams D., Niaura R., Brown R., Emmons K.,
Goldstein M. & Monti P., 2007). The good news is that there are medications and tips to help with
withdrawal.
MEDICATIONS TO HELP WITH WITHDRAWAL

4
19.25

Medications can at least double your chances of success. They ease withdrawal symptoms and cravings
when you cant use tobacco or while you adjust to quitting.
Nicotine Replacement Therapy (NRT) is a proven way to ease the symptoms of nicotine withdrawal.
Nicotine gum, patch, inhaler, lozenge, and mouth spray are all available in Canada. In detox, we have the
nicotine patch and the nicotine lozenge available to help you. These products provide your body with less
nicotine than you would get if you smoked and contain none of the other toxic chemicals that are in
tobacco. Its also important to note that the nicotine from the replacement therapies takes a lot longer to
get to your brain then when you smoke a cigarette or use chew. This means that there is less of a chance
of you getting addicted to the medicines then to cigarettes or chew.
Prescription Medications Champix and Zyban The smoking cessation medications available in Canada
are called Champix and Zyban. Both are nicotine free and available through a prescription from your
doctor. Talk to your doctor or pharmacist for more information.
It is important to learn how to use any of these medicines properly in order for them to be effective. Read
instructions carefully and talk a nurse or counsellor.
TIPS FOR CRAVINGS
Cravings usually last no more than 10 to 20 minutes. Some people find the following tips help them with
withdrawal and cravings (Fiore M., Bailey W., Cohen S., et al., 2008) (Rogojanski J., Vettese L., Antony M.,
2011):
Drink lots of water
Deep breathe
Delay the urge to smoke
Do something else to take your mind of the urge
Topic 3: Supports when you leave detox

ALBERTAQUITS RESOURCES AND SUPPORTS
In Alberta there are a number of tobacco support options that are widely available under the umbrella of
AlbertaQuits.
LEARNING ACTIVITY
Handout the AlbertaQuits Brochure and the AlbertaQuits Helpline fax referral.
Discuss the various supports available through AlbertaQuits and encourage
clients that are interested in further support to complete the fax referral form.
AlbertaQuits Helpline is a free telephone service available from 8 am to 8 pm seven days a week for all
residents of Alberta toll free at 1-866-710-QUIT (7848). They provide translation services in 180 languages.
Trained Cessation Counsellors are available to help individuals develop a quit plan, deal with cravings and
difficult situations, and provide ongoing support throughout their quit. Patients/clients can initiate their
own contact with the helpline or healthcare providers may initiate that contact on behalf of the
client/patient by completing the standard fax referral.
19.26

AlbertaQuits Online An internet-based quit smoking service, available free-of-charge for all Albertans.
The online community is available to users 24 hours a day 7 days a week. The site provides expert advice;
online peer support, quitting strategies, email reminders and more. This community can be accessed at
www.albertaquits.ca from any computer simply by providing a postal code to verify the user is an Alberta
resident.
AlbertaQuits Groups Also called QuitCore, these face to face support groups that are available in certain
locations across the province. They are facilitated by professionally trained leaders and attended by
people looking for peer support, encouragement and advice to help them quit tobacco. The program
consists of either six or eight 90-minute sessions over a period of 10 to 14 weeks and incorporates
common best practices to help tobacco users quit. More information can be found at www.albertaquits.ca
or by calling 1-866-710-QUIT (7848).
ADDICTION TREATMENT PROGRAMS THAT SUPPORT TOBACCO CESSATION
The more we learn about how tobacco use impacts recovery, the more we see tobacco supports
integrated into addiction treatment. If you are thinking about giving up tobacco while you work on your
other addictions, you might be interested in treatment programs that can support your tobacco cessation.
A counsellor can help you decide which programs would be a good fit for you.
STOP SMOKING MEDICINES ON DISCHARGE
If you are thinking about remaining tobacco free when you leave detox, you may want to continue to use
the nicotine patch or nicotine gum. A doctor or pharmacist can help you decide which will be the best
option for you. Talk to a counsellor about options that might be available to help with the cost of the
medications.
Optional Topic: Carbon Monoxide Monitor

WHAT IS CARBON MONOXIDE?
Carbon Monoxide (CO) is a toxic, odourless, colourless, tasteless gas. When inhaled, CO competes with
oxygen in the bloodstream. It binds more strongly then oxygen to hemoglobin, a molecule in your blood
that carries oxygen and other nutrients to your body tissues. This starves the body tissues of the oxygen
vital to repair, regeneration and general living. A simple test with a CO monitor will measure the levels of
toxic carbon monoxide (CO) inhaled from tobacco smoke. This gives you an idea of how tobacco is
impacting your health and body. Because CO levels return to normal quickly after quitting, if you have
been in detox for a few days you will already see an improvement in your reading.
INFECTION CONTROL AND MAINTENANCE

Washing hands before and after testing is highly recommended for both operator and user as part of a
sensible infection control regime. NEVER use alcohol containing hand sanitizer or cleaning products that
contain alcohol or other organic solvents as these vapours will damage the sensor within the instrument. The
monitor uses disposable cardboard mouthpieces that connect to the monitor via a D-piece. The disposable
19.27

cardboard mouthpieces are single-use only as re-use can increase the risk of cross infection. The D-piece
contains a one-way valve to prevent patients drawing air back from the monitor. An integrated infection
control filter removes and traps >99.9% of airborne bacteria.
It is preferable that the user attaches their own mouthpiece to the D-piece before the breath test, and
detaches and disposed of it once the test is complete. Whilst the user is exhaling, the operator should avoid
positioning themselves in front of the exhaust of the instrument.
To clean the CO monitor, wipe the external surfaces of the instrument with a product specifically developed
for this purpose such as the instrument cleansing wipes that contain an anitmicrobial liquid that eradicates
dangerous bacteria in less than one minute and is laboratory proven to be effective against Norovirus, C. Diff
and MRSA. It is recommended that wipes are used once and for one surface only. NEVER use alcohol or
cleaning products contain alcohol or other organic solvents as these vapours will damage the sensor within
the instrument. Under no circumstances should the instrument be immersed in or splashed with liquid.
USING THE CO MONITOR

Follow these steps to take a CO reading:
1. Clean the monitor and D-piece as indicated above. Wash your hands with non-alcohol based cleanser.
Attach the D-piece to the monitor.
2. Turn the monitor on by pressing and holding down on the blue button. Once the monitor is on, ensure
the pointing hand symbol is pointing to the exhaling face. You can change the selection by pushing the
blue button. Once you are sure the exhaling face is being pointed to, click the blue button twice quickly
(like a computer mouse) to begin the breath test.
3. Have the individual who will be providing the breath sample attach their own disposible cardboard tube.
4. First explain to the individual what they will be expected to do and then double click the blue button,
pass the monitor the individual and have them:
Immediately take a deep breath
Hold breath for 15 seconds as the clock on the monitor counts down
Put mouth around cardboard tube when the monitor begins to beep
Exhale completely through tube after the monitor beeps a longer beep
Breath carbon monoxide is measured in parts per million (ppm CO) and blood carboxyhaemoglobin in
percentages (%COHb). The two are compatible and convertible, CO relating to lung/breath and COHb to
blood gas some monitors display both. Carbon Monoxide readings demonstrate the levels of poisonous
inhaled CO in the lungs while Carboxyhaemoglobin readings show the percentage of vital oxygen that has
been replaced in the bloodstream.
The cut-off points may vary depending on the CO monitor you use. Check the users guide for specific levels.
Also, description of the levels that come with the CO Monitor can be difficult to interpret because they often
suggest that a smoker is not addicted if their CO reading is lower than 26 which is often not the case. More
meaningful interpretations are provided on in the chart below.
19.28

CO Reading
(ppm)
Responses to Exposure
0-2
non-smoker living in an unpolluted environment.
<10
Smokers can have readings under 10 if they have not

smoked for some time or do not inhale.
16
Light smoker or smoker who has not smoked many

cigarettes today. Loss of oxygen to vital organs.
32
Legal limit for 8 hour workplace exposure
54
Heavy smoker. Air pollution emergency alert.
60
Smoker who is rarely seen not smoking. Headaches,

nausea, nervous system slows down, difficulty thinking
clearly, vision difficulties.
WHAT CAN AFFECT CO LEVELS?

There are several person specific and environmental factors that can impact CO level readings:
How deeply you inhale A smoker may be smoking fewer cigarettes and still have higher CO
readings if they are smoking more aggressively and inhaling more smoke. This effect can be offset by
the use of nicotine replacement therapy (NRT).
Type of tobacco Pipe or cigar smoke is much more concentrated and will give surprisingly high
COHb readings.
Other sources of CO in the environment High ambient levels of CO could give a higher than
expected reading. It could be useful to check other family members in order to eliminate possible
chronic CO poisoning (for example at home or in the car).
Other diseases Lactose intolerance (an allergy to dairy products) produces hydrogen gas in the
intestine. Some of this gas may be excreted via the lungs and interfere with CO readings. Alcohol can
also influence CO results, such as the acetone from the breath of diabetics.
Marijuana Will elevate blood CO (COHb), especially when mixed with tobacco.
19.29

References
AADAC. (2007). Tobacco Basics Handbook. Edmonton: Alberta Alcohol and Drug Abuse Commission.
Abrams D., Niaura R., Brown R., Emmons K., Goldstein M. & Monti P. (2007). The tobacco dependence
treatment handbook: A guide to best practice. New York: Guilford Press.
CAN-ADAPPT. (2011, February 28). Retrieved from CAN-ADAPTT Canadian Smoking Cessation Guideline
Version 2: http://can-adaptt.net
Els C. (2008). Tobacco Addiction: What do we know, and where do we go? Edmonton, AB.
Fiore M., Bailey W., Cohen S., et al. (2008). Treating Tobacco Use and Dependence. Rockville, MD: US
Department of Health and Human Services, Pulbic Health Service.
Kalman, D., Baker Morissette, S., & George, T. (2005). Co-Morbidity of Smoking in Patients with
Psychiatric and Substance Use Disorders. The American Journal on Addictions , 14, 106123.
OMA. (2008). Rethinking Stop-Smoking Medications: Treatment myths and medical realities. Toronto,
ON: Ontario Medical Association Position Paper.
Petry N., & Oncken C. (2002). Cigarette Smoking is associated with increased severity of gambling
problems in treatment-seeking gamblers. Addiction , 97, 745-753.
Prochaska, J., Delucchi, K., Hall, S. (2004). A Meta-Analysis of Smoking Cessation Interventions With
Individuals in Substance Abuse Treatment Recovery. Journal of Consulting and Clinical Psychology , 72
(6), 1144-1156.
Rogojanski J., Vettese L., Antony M. (2011). Coping with Cigarette Cravings: comparison of suppression
versus mindfulness-based strategies. Mindfulness , 2, 14-26.
Statistics Canada. (2010). Canadian Tobacco Use Monitoring Survey (CTUMS). Retrieved November 17,
2012, from http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=4440&lang=en&db
USDHHS. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smokingattributable disease: A report of the Surgeon General. Rockville, MD: United States Department of
West R., Ussher M., Evans M. & Rashid M. (2006). Assessing DSM-IV nicotine withdrawal symptoms: A
comparison and evaluation of five different scales. Psychpharmacology , 184, 619-627.
19.30
Chapter 20
Reproductive Years
20.1
Introduction
This chapter is intended to assist health care providers in supporting women and adolescent
girls to stop using tobacco. The chapter is divided into the following sections:

Women and girls of reproductive age (aged 1045+)
Pregnant and postpartum women (aged 1845+)
Pregnant and postpartum adolescents (aged 1017)
Each section begins with a summary of the recommendations for behavioural support and
pharmacotherapy. In the section for pregnant and postpartum women, a modified version of
brief intervention treatment model is also presented. Each section also includes information
on the prevalence of tobacco use/exposure, effects of tobacco use/exposure and standards
for providing behavioural support and pharmacotherapy.
The information included in this chapter is guided by the following evidence-informed
approaches, as discussed by Greaves and colleagues in Expecting to Quit: A Best-Practices
Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women.1
1. Woman-centred approach
A woman-centred approach prioritizes womens health before, during and after pregnancy.
This is a conscious move away from the traditional focus on fetal health, which overlooks the
value of supporting a woman to stop using tobacco for her own sake, outside of her capacity
to bear a child.
From a fetus-centred perspective, there is little incentive for a pregnant woman to maintain
cessation after her baby is born, and there is little reason for a mother to quit using tobacco if
she can manage to use it away from children. Focusing on the impact of tobacco use on the
fetus also causes the woman to feel guilty, which diminishes her self-esteem and confidence
in her identity as a good mother.1
A woman-centred approach enables long-term cessation by building a womans motivation
to quit in order to improve her own health, regardless of whether she is pregnant or cares
for children. The rationale for this approach is that by focusing on the mother first, the child
also benefits. Woman-centred care builds the womans sense of value, confidence and
selfefficacy, supporting her ability to improve her own health and the health of her family.1
2. Stigma reduction
Evolving social attitudes and anti-tobacco efforts have resulted in the stigmatization of
tobacco use, especially during pregnancy. Negative public opinion toward tobacco use in
general, especially toward women who use tobacco while pregnant or caring for young
children, often erodes womens self-image and confidence. It can also cause them to hide
their tobacco use from their health-care providers, or resist discussing it in a productive way.
When providing tobacco cessation support to women, health-care providers are encouraged
to be sensitive to the stigma that pregnant and postpartum tobacco users face, and recognize
the ways this can manifest itself in patient-caregiver relationships.1
20.2
3. Harm reduction
Some women are not ready to quit using tobacco, or feel they cannot quit at the time of brief
tobacco intervention. Quitting may be a low priority for some women for a variety of reasons,
such as heavy tobacco use, substance abuse or mental health issues, vulnerability in an
abusive relationship or other stressful circumstances. It is important to respect a womans
right to decide what she can and cannot take on.1
When it is clear that a woman will not consider quitting tobacco now, the emphasis should be
on helping her identify the steps she can take to reduce the negative impacts of tobacco use
on herself and others. This could include assistance to reduce her tobacco use, improve her
nutrition or reduce the impact of second-and third-hand smoke on others. It may also include
helping her determine whether nicotine replacement therapy (NRT) would be the best option
to help her reduce the harmful impacts of tobacco use.1
4. Trauma-informed care
There is a strong correlation between substance use and the experience of trauma, including
domestic violence. The prevalence of smoking among women who have experienced trauma
is between two and four times higher than that of women who have not.1 Women who have
experienced trauma, either in childhood or adulthood, respond differently to health promotion
efforts, especially those that can be seen as confrontational or directive, than women who
have not. Trauma-informed care is sensitive to these differences, and is characterized by
trauma awareness (understanding trauma and being alert to the potential traumatic histories
of clients accessing a service), an emphasis on safety (avoiding potential triggers for
retraumatization and providing physical and emotional safety), empowering environments
(giving clients personal control) and emphasizing clients strengths and skill building.1
Further information about trauma-informed care is available from www.jeantweed.com
and www.expectingtoquit.ca.
Exposure to environmental tobacco smoke is a significant concern for women and girls during
the reproductive years. Tobacco smoke is classified into three categories:
1. First-hand smoke, which is inhaled by the person smoking
2. Second-hand smoke, which is either exhaled by a person who smokes or released
from the end of a burning cigarette
3. Third-hand smoke, which refers to the tobacco smoke residue and gases that are left
behind on surfaces, upholstery, clothing, draperies and carpets, and in vehicles, after
a cigarette has been smoked
Refer to chapter 2 (The Effects of Tobacco Exposure) for more information on these
types oftobacco smoke.
20.3
Women and girls of reproductive age

(NOT PREGNANT OR BREASTFEEDING)
The information in this section provides information on providing tobacco cessation
support to women (aged 1845+) and girls (aged 1017) of reproductive age who are not
currently pregnant or breastfeeding. Recommendations for treatment of this population are
summarized in Table 20.1.
Table 20.1: Tobacco Free Futures Summary Recommendations for Supporting

Women and Girls of Reproductive Age to Stop Using Tobacco

To support women who are not pregnant or breastfeeding to stop using tobacco, use the standard 5As
as per the guidelines outlined in chapter 7 (Brief Intervention).
To support adolescent girls who are not pregnant or breastfeeding to stop using tobacco, use the 5As
for adolescents as per the guidelines outlined in chapter 21 (Youth and Family).
Provide women who are not pregnant or breastfeeding with pharmacotherapy support as per the
guidelines outlined in chapter 9 (Pharmacotherapy).
Provide adolescent girls who are not pregnant or breastfeeding with pharmacotherapy support as per
the guidelines outlined in chapter 21 (Youth and Family).
Offer behavioural support alongside pharmacotherapy to both women and adolescent girls of
reproductive age as outlined in chapter 8 (Intensive Cessation Counselling).
Prevalence
According to the Canadian Tobacco Use Monitoring Survey
(CTUMS), 16% of Canadians aged 25 years and older
(about 3.9 million) currently smoked in 2012, a figure that is
unchanged from 2011 (17%), but lower than the rate in 2001
(21%).2 In this age group, a higher percentage of men than
women smoked daily or occasionally (19% of men compared
with 14% of women). Men who smoked daily consumed an
average of 17.4 cigarettes per day, a higher number than for
women (12.9).2
Tobacco use among women

and adolescent girls is
declining nationally.2
However; it is still a
significant health risk to
many women and girls.
In Alberta, 18% of women aged 25 and older smoked daily or occasionally in 2012, compared
to 17% of men in the same age group.2
Smoking among youth aged 15 to 19 had a prevalence of 11% (approximately 233,000).
While this is virtually unchanged from the 12% reported in 2011, it is the lowest rate of current
smoking recorded for this age group since Health Canada first reported smoking prevalence,
and it is lower than the rate reported in 2001 (22%). Seven percent of youth reported smoking
daily, consuming an average of 11.1 cigarettes per day, while 4% of youth reported smoking
occasionally. A higher percentage of male than female youth reported currently smoking
(12%and 9%, respectively).2
20.4
In Alberta, 16% of females aged 1524 smoked daily or occasionally in 2012, compared to
19% of males in the same age group.2
The prevalence of spit tobacco, also known as smokeless tobacco, use is lower than the
prevalence of other tobacco product use, especially among women and adolescent girls
compared to men and adolescent boys. CTUMS data indicates that 8% of Canadians aged
15 and older reported having ever tried spit tobacco products, but does not differentiate this
statistic by gender.2 Among young people, 5% of youth aged 1519 and 12% of young adults
aged 2024 reported having ever tried spit tobacco. The prevalence of spit tobacco use
within the past 30 days was under 1% for Canadians aged 15 years and older, 1% for youth
aged 1519 and 2% for young adults aged 2024. While these statistics do not differentiate
by gender, Youth Smoking Survey data indicates that 7.1% of boys between grades 6 and
12have ever tried spit tobacco, compared to 1.5% of girls.3
In 2010, Alberta sales of spit tobacco comprised 39% of overall national sales.5 The prevalence
of spit tobacco use is significantly higher for Alberta males aged 1519 but remains relatively
low for females in this age group. However, despite the low prevalence, it is important to
screenusing language that is inclusive of all types of tobacco use including spit.
Impact of tobacco use

The full extent of the effects of tobacco use on women is not
fully understood because of large gaps that currently exist in
the biomedical research However, as reported by Ontarios
Program Training and Consultation Centre, smoking is known
to cause the following health risks for women:6
Tobacco affects the

health of women and
girls differently than it
affects men and boys.6
Cardiovascular disease: Smoking is a major cause of cardiovascular disease, a term

that refers to more than one disease of the circulatory system, including the heart and
blood vessels, whether the blood vessels are affecting the lungs, the brain, kidneys or
other parts of the body. Women who smoke as little as 14 cigarettes each day have
twice the risk of cardiovascular disease as women who have never smoked.6
Lung cancer: Smoking causes about 80% of lung cancer deaths in women. The
risk of dying from lung cancer is about 13 times higher among women who smoke
cigarettes compared with women who have never smoked.6
Breast cancer: There is a causal association between active smoking (someone

intentionally inhaling tobacco smoke) and both pre- and postmenopausal breast
cancer. There is also a causal relationship between second-hand smoke and breast
cancer in younger, primarily pre-menopausal women who have never smoked. There
is currently insufficient evidence to make similar conclusions between second-hand
smoke exposure and post-menopausal breast cancer.6
Other cancers: In addition to lung and breast cancer, women who smoke have
increased risks of cancers of the mouth and throat, esophagus, larynx (voice box),
bladder, pancreas, liver, colon, rectum, cervix and kidneys. Smoking also appears to
increase the risk for some types of ovarian tumours.6
Chronic obstructive pulmonary disease (COPD): Women who smoke have

markedly increased risks of developing and dying of COPD, which is a respiratory
disease affecting both the airways and alveolar sacs of the lungs. Over time, as
thedisease advances, breathing difficulties can result in severe disability and death.
Therisk increases with the number of cigarettes smoked per day.6
20.5
Osteoporosis: Smoking causes loss of bone mass in both men and women, leading
to higher risk of fracture. In particular, a meta-analysis of data from postmenopausal
women demonstrates that smoking increases the risk of hip fracture. The U.S.
Surgeon General has estimated the risk of hip fracture to be 55% higher in people
who smoke than in those who do not smoke (male and female).6
Reproductive health and pregnancy: Smoking has profound effects on womens

reproductive health and menstrual function. Women who smoke are more likely to
experience primary and secondary infertility and delays in conceiving as compared to
non-smoking women.6
Other health issues: The health effects of tobacco use mentioned above is not
exhaustive. Research is ongoing, with causality and possible new links of diseases
continuing to be discovered, especially in tobacco users who are genetically
predisposed.6
Please refer to chapter 21 (Youth and Family) for a discussion of the impact of
tobacco use among adolescent girls.
While the 5As are considered clinical best practice for
the general population, there is a lack of research on how
best to adapt this approach for use with women and girls
of reproductive age. A review of the literature on smoking
cessation interventions for women indicates that the standard
5As approach is used with this population group, although
there are numerous studies that indicate that women face
unique barriers to quitting.7,8,9 These include:
20.6
Women face different

barriers to quitting
tobacco use than
mendo.7,8,9
concern for the potential for weight gain
nicotine replacement therapy (NRT) (especially gum and patches) may not be as
effective for women, due to hormonal, physiological and pharmacokinetic differences
that exist and become more prevalent in pregnancy
tobacco withdrawal symptoms and responses to tobacco cessation pharmacotherapy

vary by menstrual cycle phase
greater likelihood of depression
women experience greater rewarding effects of nicotine and more intense stress
produced by withdrawal than men
male partners have been shown to provide less effective support to women than
women give to men
women may be more susceptible to environmental cues (e.g., friends and moods)
associated with the tobacco use ritual
women have more non-pharmacologic cues/motives that reinforce tobacco use

(e.g.,for socialization)
some women enjoy the feeling of control associated with tobacco use
Intensive cessation support

The United States clinical practice guideline for treating tobacco use and dependence
indicates that women are more likely to seek assistance in their quit attempts than are men.7
Its research suggests that women benefit from the same interventions as men do, although
the data are mixed on whether they benefit as much as men do.
As mentioned previously, the characteristics of nicotine dependence among women are
different than those in men. This means that women face unique stressors and barriers to
quitting. Women have also been found to be less likely to quit successfully than men, and
require more interventions to successfully quit than men do.10 They also require targeted
approaches to prevent smoking initiation. For these reasons, there is a need for clinical
approaches that are sensitive to the unique nature of womens neurological and psychosocial
responses to tobacco use.11
Despite the need for targeted interventions for women, there is a lack of research available
on best practice interventions specific to women. While there is a wealth of research on
interventions for adults as a group, and for pregnant women as a group, comparatively little
research has been done on interventions for women who are not pregnant. Greaves and
colleagues highlight the need for woman-centred approaches that go beyond a womans
capacity for carrying a child:
Because the approach to cessation during pregnancy seems motivated primarily
by a desire to lessen the deleterious effects of smoking on fetal health, it has
framed the interventions on fetal health outcomes and confined them largely to
the period of pregnancy. As a result, pre-pregnancy and post-pregnancy tobacco
cessation interventions, which would focus primarily on womens health, have
garnered proportionately less attention and emphasis. As Jacobson claimed in
1986, in rich countries, most women are not pregnant most of the time, which
led her to conclude that smoking cessation campaigns ignore most women most
of the time.1
Research does, however, point to the increased importance
Women quit more
of intensive cessation support, in general, for women over
successfully when they
men. Intensive interventions may be better able to address the
access a combination
unique psychosocial issues women face while attempting to quit
using tobacco, such as concerns over weight gain and a greater
of behavioural
sensitivity to environmental and social cues.12 Women are also
cessation support and
significantly more likely than men to list social factors, such
pharmacotherapy than
as support from peers or family members, as the reason for
when they access either
quitting, indicating that there may be additional utility for women
support on its own.14,15
in intensive supports that include social support elements.13 The
increased importance of these interventions in women versus
men is shown particularly in their effects when implemented in addition to pharmacological
support. Implementing high-intensity interventions in conjunction with pharmacological
treatments significantly improves long-term cessation results in women, and is of much
greater importance in determining outcomes for women than for men.14,15
There is a similar lack of research on intensive interventions for teenage girls who are not
pregnant, although it is likely that they would benefit from a targeted approach. For more
information, see the discussion on intensive cessation support for youth and adolescents in
chapter 21 (Youth and Family).
20.7
Pre-conception cessation support

All women and girls of reproductive age should be screened for tobacco use. Those who
are currently using tobacco should be encouraged to quit for their own health, regardless of
whether they are planning to have a child. Those who are planning to have a child or are at
risk of becoming pregnant should be provided with targeted support to stop using tobacco
before they conceive. Pre-conception cessation strategies to reduce harm to the infant from
prenatal tobacco exposure include16

encouraging each man, woman and couple to have a reproductive life plan that
includes tobacco reduction
improving public awareness of the importance of preconception health behaviours

and seeking support and services
providing a risk assessment, education and health promotion counselling to women

and girls of reproductive age to reduce risk and improve pregnancy outcomes
supporting tobacco-using women who are in the interconception care period

(between pregnancies) and offer intensive intervention when a previous pregnancy
has had an adverse outcome (e.g., infant death, low birth weight, preterm birth)
offering tobacco education and intervention at pre-pregnancy check-ups to those

considering conceiving
Pharmacological interventions
Research on pharmacological cessation interventions for women of reproductive age suffers
from a lack of gender-differentiated studies and best practice recommendations. Most of
these instead address the general adult population, without detailing how to tailor treatment
to achieve better outcomes specifically for women. However, there is considerable research
pointing to the decreased long-term efficacy of pharmacological interventions when given in
isolation for women versus men generally, and to variable outcomes based on the type of
drug and concurrent interventions used.
Nicotine replacement therapy
Cessation trials using NRT have consistently reported lower
long-term quit rates for women versus men.17 The reasons for
the difference are not well understood, but studies indicate
that it may be attributed more to non-nicotine factors (e.g., the
sensory effects of smoke inhalation, conditioned responses to
smoke stimuli and secondary social reinforcement of smoking
behaviours) than to the effects of the nicotine itself, given that
women have demonstrated a reduced neural sensitivity to the
effects of nicotine.12
20.8
Pharmacotherapy
options for women
of reproductive age
include NRT, bupropion
and varenicline. These
options are effective for
women, but may not be
as effective as they are
formen.14,18
Bupropion and varenicline

Cessation trials using bupropion show similar results to NRT trials, with women attaining
lower overall cessation rates after being treated with the drug than men.18 Trials of varenicline
demonstrated significantly higher likelihood of participants quitting compared to bupriopion
SR. Cessation rates of varenicline are significant compared to a matching oral placebo,
however, show no difference between sexes.19 Varenicline and buproprion are effective
pharmacological options that can be considered as pharmacological options, subject to
thegeneral clinical guidelines and contraindications applicable to the patient
Discussion
Despite the indication that pharmacotherapy treatments
are less effective for women than men, they still increase
womens chances of quitting and can be used to assist women
of reproductive age with smoking cessation. Considerable
research still points to NRT significantly increasing cessation
outcomes for women in general.20,21,22 Additionally, while there
are poorer outcomes for women than men with bupropion,
women are still twice as likely to quit using bupropion than with
a placebo, indicating that the pharmacological effect, if not the
outcome, might be similar across genders.22
Providing behavioural
supports concurrently
with pharmacological
support significantly
improves outcomes for
women.13
Research has consistently demonstrated that the availability of behavioural supports provided
concurrently with the chosen pharmacological intervention increases outcomes significantly
for women, potentially due to a better ability to address the non-nicotine factors influencing
addiction.14,15,22
There is some evidence that women may not be advised about pharmacological cessation
supports as often as men.23 Despite differential outcomes, and irrespective of which treatment
is recommended (whether on its own, or in addition to others), it is important to ensure that
pharmacological treatments are offered to women in instances where clinical guidelines
indicate they are warranted.
No published research or clinical guidelines were identified for pharmacological treatments
specifically for teenage girls who are not pregnant. Please refer to the discussion on
pharmacological support for adolescents in chapter 21 (Youth and Family).
Pregnant and postpartum women

The information in this section provides information on providing tobacco cessation support
to women (aged 1845+) who are either pregnant or gave birth to a child in the last year.
Figure 20.1 outlines the recommended brief intervention treatment model for pregnant and
postpartum women. Detailed considerations related to implementing this model are discussed
in Table 20.5.
20.9
Figure 20.1: Tobacco Free Futures:

Brief Intervention Model for Pregnant and Postpartum Women
ask
Ask every patient/client about tobacco use.

Use multiple choice options to increase disclosure.
Please choose the statement that best describes your current tobacco use (all types)
1. I have never used any kind of tobacco product.
2. I stopped using tobacco before I found out I was pregnant, and I am not using it now.
3. I stopped using tobacco after I found out I was pregnant, and I am not using it now.
4. I use tobacco some now, but I have cut down since I found out I was pregnant.
5. I use tobacco regularly now, about the same as before I found out I was pregnant.
If 3, 4 or 5 What type? How much? How often? Last use?
NO
1
2
3
4
4&5
Focus on relapse prevention.
Acknowledge harm reduction.
Support autonomy.
Ask about exposure to second- and third-hand smoke (SHS and THS).
Does anyone use tobacco products in your home or vehicles?
Have you (and/or your child/children) been exposed to SHS or THS?
Advise
YES
Advise to quit with a personalized message focusing on women-centred approach
to reduce stigma and support long-term abstinence.
Advise about the importance of smoke-free environments.
Inform of AHS Tobacco and Smoke Free Environments Policy as appropriate.
Not using tobacco is one of the best things for your health, as well as the health of your children.
There is no safe level of exposure to SHS.
YES
Assess
Assess readiness to stop or reduce tobacco use.

Assess interest in temporary or permanent cessation support.
Assess interest in making environment tobacco-free.
On a scale of 1-10, how important is it to you to quit or reduce your tobacco use?
Are you interested in support to help you quit?
Are you interested in support to make your home and vehicle tobacco-free?
Assist
Offer self-help resources.

Link to behavioural counselling to support reduction, quit or relapse prevention as appropriate.
Support pharmacotherapy if behavioural support is unsuccessful including: linking to
prescribing authority and/or ordering medication, ongoing monitoring of
withdrawal symptoms and mood assessment.
Arrange
YES
Arrange further support by completing appropriate onsite and/or linked referral(s).

Arrange for continued pharmacotherapy if appropriate.
20.10
NO
Support autonomy.
Leave offer of support open.
Monitor withdrawal for
inpatients.
Document as per approved
practice.
Assess mental status.
Document as per approved
practice.
(e.g., Edinburgh Postpartum
Depression Scale or PHQ-2)

Pregnant and Postpartum Women to Stop Using Tobacco

Behavioural cessation support (e.g., multiple counseling sessions, motivational interviewing, cognitive
behavioral therapy) is recommended as first line treatment before pharmacotherapy at all points during
pregnancy.
NRT should only be offered during pregnancy when counselling has failed and after an informed
discussion with the patient regarding the risks and benefits of using tobacco and NRT. Low-dose,
intermittent-delivery NRTs (e.g., lozenges, gum, buccal inhalers or mouth spray) are preferred over
continuous dosing of the patch.
New mothers should be encouraged to breastfeed, even if they are using tobacco or NRT.
Bupropion and varenicline should only be considered with pregnant and breastfeeding women after
behavioural interventions and NRT have failed. Prior to initiating either treatment, advise women
that current research does not conclusively demonstrate the efficacy and safety of either of these
medications in pregnancy and lactation, and discuss the risks and benefits of using them versus
usingtobacco.
Prevalence
Smoking during pregnancy is declining in Canada, from 17.7%
in 2001 to 13.4% in 2005.24,25,26 Data from Alberta indicates a
similar trend, dropping from 24.8% in 1999 to 13.8% in 2012.27
Within Alberta, there is a wide variation in prevalence between
Alberta Health Services zones, ranging from a high of 21.6%
in the Central Zone to a low of 9.1% in the Calgary Zone. It is
important to note that these statistics are based on self-reported
incidences of tobacco use, not biochemical indicators. Because
of the stigma associated with tobacco use, especially during
pregnancy, it is likely that many women do not report their
tobacco use, meaning the prevalence is actually higher than
theavailable data suggests.
Tobacco use during

pregnancy is declining
in Alberta.27 However,
it is still a leading cause
of health problems for
mothers and adverse
birth outcomes for
newborns.28
20.11
Figure 20.2: Maternal Smoking, Alberta, by Zone of Residence, 1999201227
While there is little data on the prevalence of spit tobacco use among pregnant women,
estimates based on non-pregnant women suggest that the prevalence is less than 1%.2
However, despite the relatively low prevalence of spit tobacco use compared to smoking, it is
important to screen using language that is inclusive of all tobacco use, rather than asking only
about smoking.
Prevalence statistics aside, tobacco use during pregnancy continues to be a leading cause of
health problems for mothers and adverse birth outcomes for newborns.
20.12

Tobacco use during pregnancy not only affects the health of the mother, fetus and newborn,
but also continues to affect the health of the child as he or she grows up. The known effects
of tobacco on pregnant women and their children are summarized in Table 20.3.
Table 20.3: Effects of Tobacco Use During Pregnancy on Women and Their Children
For the mother: 1
lower estrogen levels, leading to early menopause and subfertility
increased risk of cardiovascular diseases
increased risk of pulmonary diseases
decreased production of breast milk and duration of breastfeeding in early months
For the fetus: 28
increased risk of ectopic pregnancy (implantation of the embryo outside the uterine cavity)
increased risk of spontaneous abortion (miscarriage)
increased risk of preterm labour
increased risk of premature rupture of membranes
increased risk of placental problems (previa and abruption)
growth restrictions
For the newborn child: 28,29
low birth weight (on average approximately 200 grams smaller)
increased risk of fetal and neonatal mortality
increased risk of congenital malformations
increased risk of admission to the neonatal intensive care unit (NICU)
increased risk of sudden infant death syndrome (SIDS)
decreased volume of breast milk available and shortened duration of breastfeeding in early months
For the older child: 28
increased risk of childhood respiratory illnesses (e.g., asthma, pneumonia, bronchitis)
increased risk of other childhood medical problems (e.g., ear infections)
increased risk of learning problems (e.g., difficulties with reading, mathematics, general ability)
increased risk of behavioural problems
increased risk of attention deficit hyperactivity disorder (ADHD)
20.13
Readiness to quit
Women are more likely to quit using tobacco when they are
pregnant. As described by Chamberlain and colleagues, a higher
proportion of women stop smoking during pregnancy than at
other times in their lives.30 They describe the characteristics
of women who spontaneously quit (i.e.,women who smoked
prior to conception but quit on their own shortly after becoming
pregnant and before entering prenatal care) as follows:
Women are more likely

to quit using tobacco
when they are pregnant
than when they are not.30
Up to 49% of women who smoked before pregnancy spontaneously quit

before their first antenatal visit, a quit rate substantially higher than reported
in the general population. However, these spontaneous quitting rates may be
lower among women with lower socioeconomic status. There are significant
psychosocial differences between women who spontaneously quit and women
who continue to smoke in late pregnancy. Women who spontaneously quit
usually smoke less, are more likely to have stopped smoking before, have a nonsmoking partner, have more support and encouragement at home for quitting,
are less seriously addicted, and have stronger beliefs about the dangers of
smoking. Pregnant women are also more likely to use coping strategies to avoid
relapse than non-pregnant women, however less than a third of these women
remain abstinent after one year postpartum, supporting qualitative evidence that
many women see pregnancy as a temporary period of abstinence for the sake
of the baby. Despite high relapse rates, some studies suggest that the long-term
effects of spontaneous quitting in pregnancy are significant, and others argue this
success is important to recognise to avoid pathologising smoking cessation and
eroding confidence in human agency to overcome problems.30
Greaves and colleagues highlight the need to encourage motivation among pregnant women
who smoke to quit for their own sake, not just that of their baby.1 The majority of smoking
interventions for women focus on the period of time that they are pregnant, and aim to
build on their motivation to quit for the sake of the baby. This focus on fetal health not only
diminishes the value of womens health and treats the woman primarily as a reproductive
vessel, but also fails to address a more long-term motivation for becoming and remaining
abstinent from tobacco after the baby is born.1
Quitting and stress
A commonly held misperception is that quitting tobacco use
during pregnancy causes stress to the mother that would harm
the baby more than tobacco use does, and therefore pregnant
women should not attempt to quit until after the baby is born.31
Quitting tobacco use

during pregnancy is not
harmful to the fetus.31
While many people believe that tobacco use relaxes them, it actually creates physiological
stress symptoms such as elevated heart rate and blood pressure. Pregnant women should
be encouraged to quit as early in their pregnancy as possible, but the fetus will benefit even
ifthe mother quits late in the pregnancy.31
20.14
Partner and social support

A womans readiness to quit is strongly influenced by her
partners tobacco use status and the prevalence of tobacco
use within her immediate social circle. It is also dependent on
her perception of the level of support she can expect from her
partner and friends. When providing support, it is important to
acknowledge the presence of people who smoke in the lives
of pregnant women and to determine the dynamics of those
relationships.
The tobacco use of a

womans partner, close
family and friends must
be considered when
assisting her effort to
quit using tobacco.1
As described by Greaves and colleagues, women who smoke often use smoking to organize,
bind and sometimes disengage from their social relationships. Pregnant women have these
and other complicating factors overlaid on their use of tobacco, compounded by their views
regarding fetal health and whether or not these views coincide with those of their partners
and friends.1
While it is necessary to pursue information about a partners smoking behaviour and try to
intervene, it is crucial to do so in a way that respects the complex social dynamics within
couples and between friends. It is critical to acknowledge power, control and abuse issues
between partners in a way that ensures womens safety.1
Further information and support for women and their partners is available in the handbook
Couples and Smoking: What You Need to Know When You are Pregnant available from
www.facet.ubc.ca.
Nicotine dependence and withdrawal

Some women may have higher motivation to quit using tobacco when they are pregnant,
but many also face unique barriers to quitting during pregnancy. Pregnant women seem
to metabolize and clear nicotine from the body faster than non-pregnant women, making
quitting more difficult.32,33 The physiological adaptations in pregnancy that accelerate nicotine
metabolism may also cause more negative feelings of so-called nicotine hunger and
unpleasant symptoms associated with nicotine withdrawal.34,35 As a result, some pregnant
women who use nicotine replacement therapy find they need a higher dosage to help
them manage withdrawal symptoms. For more information, please refer to the content
pharmacotherapy that follows.

The Canadian Action Network for the Advancement, Dissemination and Adoption of
Practiceinformed Tobacco Treatment (CAN-ADAPTT) is a practice-based research network
facilitating research and knowledge exchange among practitioners, researchers and policy
makers in the area of tobacco cessation. CAN-ADAPTTs Guideline for Smoking Cessation
is intended to guide practice and is not intended to serve as a comprehensive overview of
tobacco cessation management.28 Table 20.4 outlines the summary statements that have
been developed to guide tobacco treatment for pregnant and breastfeeding women.
20.15
Table 20.4: CAN-ADAPTT Guidelines for Pregnant and Breastfeeding Women 28

ADVISE
Tobacco cessation should be encouraged for all pregnant, breastfeeding and postpartum women.
GRADE: 1A
A smoke-free home environment should be encouraged for pregnant and breastfeeding women to
avoid exposure to second-hand smoke.
GRADE: 1B
During pregnancy and breastfeeding, counselling is recommended as first line treatment for tobacco
cessation.
assist
GRADE: 1A
If counselling is found ineffective, intermittent dosing nicotine replacement therapies (e.g., lozenges,
gum) are preferred over continuous dosing of the patch after a risk-benefit analysis.
GRADE: 1C
Partners, friends and family members should also be offered tobacco cessation interventions.
GRADE: 2B
Grades of evidence are based on the strength of the recommendation (1=strong, 2=weak,) and the quality of
the evidence (A=high, B=moderate, C=low)
For more information on the CAN-ADAPTT Guidelines, visit: www.can-adaptt.net.
The brief intervention (5As) approach targeted especially for pregnant and postpartum
women was introduced in Figure 20.1. The standard 5As outlined in chapter 7
(BriefIntervention), the public health 5As outlined in chapter 17 (Public Health),
and the5As for pregnant and postpartum women outlined by the American College of
Obstetricians and Gynecologists , have been combined and modified to consider the
uniqueneeds of pregnant and postpartum women within the Alberta context.
Many health-care providers have the opportunity to provide tobacco intervention support
topregnant and postpartum women, including but not limited to

prenatal care providers (including family doctors, obstetricians and midwives)
prenatal educators
NICU nurses
public health nurses (including those conducting early postpartum visits and
wellchild visits)
pharmacists
lactation consultants
Table 20.5 outlines factors for health professionals to consider when implementing the
5Asmodel for pregnant and postpartum women.
20.16
Table 20.5: Treatment Model: Considerations for Pregnant and Postpartum Women and Girls
Model component
ASK all patients
clients if they have
used tobacco before
or during pregnancy.
ASK about patterns
of use.
ASK about exposure
to second- and thirdhand smoke.
Considerations
Screening for tobacco use should occur automatically as part of the initial
history. Societal stigma about tobacco use, especially during pregnancy,
may cause some patients to feel uncomfortable discussing whether they
use tobacco and how much. Some data suggest that 13% to 26% of
pregnant women who use tobacco may not disclose that they use tobacco
when asked about it as a part of a routine clinical interview.36
The manner in which health-care providers ask about tobacco use status
during the initial appointment can dramatically improve the accuracy of
the response. Rather than asking AHSs standardized yes-no question
Have you or anyone in your home used any tobacco products in the past
year?, a multiple-choice response is recommended to improve disclosure
with pregnant and postpartum women, and to provide useful information
for counselling. This approach has been shown to improve disclosure by
40% for all women, including those of various ethnic backgrounds.36 The
multiple-choice response format has been shown to be effective whether
delivered verbally or in written form.
The recommended question to determine womens tobacco use status is:
Please choose the statement that best describes your current tobacco use
(including smoking and spit tobacco use):
ASK
1. I have never used any kind of tobacco product.

2. I stopped using tobacco before I found out I was pregnant, and I am not
using it now.
3. I stopped using tobacco after I found out I was pregnant, and I am not
using it now.
4. I use tobacco sometimes now, but I have cut down since I found out
Iwas pregnant.
5. I use tobacco regularly now, about the same as before I found out I was
pregnant.
In addition to asking about the womans tobacco use, ask about the
tobacco use status of those she lives with, which may indicate her
exposure to second- and third-hand smoke. It may also help determine
how much support women who are using tobacco will have in quitting and
avoiding relapse.
Congratulate recent quitters for having quit, and reiterate the importance
of staying tobacco free and avoiding situations where others are using
tobacco.
Let all women know that you will be asking how she is doing at future visits.
Tobacco use is one of only a few important risk factors that can be modified
and should therefore be tracked as a vital sign at every visit, just as blood
pressure would be tracked.7 Document both the tobacco use of the woman
and those she lives with at every visit.
Electronic or paper forms used in clinics/units should be modified to
document the ask.
20.17
Table 20.5: (continued)

Model component
Considerations
ADVISE to quit and/or

remain tobacco free
with a personalized
message.
Advice to quit should be clear, supportive and personalized, with

unequivocal messages about the benefits of quitting for both the patient
and her baby. An effective way to start the discussion about quitting is to
say, Not using tobacco is one of the best things for your health, as well as
the health of your children.
ADVISE about the

importance of a
tobacco-free home
and vehicle.
advise
ADVISE of AHS
Tobacco and Smoke
Free Environments
Policy as appropriate.
Use positive language and focus on the positive benefits of quitting.

Although health-care providers are keenly aware of the short- and
longterm health risks tobacco use poses to mothers and their families,
itiscommon for patients to minimize risks, especially if they or people
theyknow have had uncomplicated, healthy pregnancies while smoking.
Consider the following messages:36
Impacts for women:
You will be less likely to develop heart disease, stroke, lung cancer,
chronic lung disease and other smoke-related diseases.
You will have more energy and wont feel as tired.
Your blood pressure and pulse rate will drop and your circulation will
improve, making exercise easier.
You will cough less and breathe more easily.
You will have fewer sinus congestions and colds.
You will be more likely to live to know your grandchildren.
You will have more money to spend on other things.
Your clothes, hair and home will smell better.
Your senses of taste and smell will improve.
You will feel good about what you have done for yourself and your family.
Impacts for baby:
Your baby will get more oxygen, even after just one day of not smoking.
Your baby is less likely to have bronchitis and asthma.
There is less risk that your baby will be born too early.
There is a better chance that you and your baby will be discharged from
the hospital at the same time.
Acknowledge barriers to quitting while providing encouragement.
If a woman suggests cutting down as a strategy, let her know that while
reducing her consumption may reduce her health risks, quitting altogether
is the best thing she can do for herself and her family.36
Communicate clear, supportive advice to quit without admonishing or
making the patient feel criticized. Be sensitive to the stigma of tobacco
use during pregnancy and the possibility that the woman may have
experienced trauma. See the discussion of stigma reduction and traumainformed care earlier in this chapter.
document the advise.
20.18

Model component
Considerations
ASSESS readiness to
quit or reduce tobacco
use.
Assess the patients interest in quitting or reducing harm using the following
questions: On a scale of 110, how important is it to you to quit or reduce
your tobacco use? Are you interested in support to help you quit?
ASSESS interest in
cessation support.
For women who are not yet ready to quit, if time permits, use techniques
designed to increase the patients motivation to quit (e.g., motivational
interventions) as outlined in chapter 8 (Intensive Cessation Counselling).
ASSESS interest in
tobacco-free homes
and vehicles.
Work to reduce harm by offering support to create a smoke-free

environment in the home, using the following question: Are you interested
in information to help make your home and car tobacco free?
assess
ASSESS mental
status.
A tobacco-free environment in the home can be achieved by making the

following suggestions:
making the home and vehicle tobacco free
moving all smoking outsidecracking a window open does not prevent
harm
using a smoking jacket when going outside to smoke
removing the smoking jacket and washing hands to remove smoking
residue before holding babies and children
putting up signs to remind others not to smoke in the home
washing clothes, bedding and toys that have been exposed to smoke
painting walls, washing fabrics and surfaces, and replacing belongings,
ifnecessary
Women with untreated mental health conditions (e.g., depression) are at a
higher risk for tobacco dependence, and may already be using bupropion
as an anti-depressant.
Assess and document the womans state of mental health using standard
approved practice. The Edinburgh Postnatal Depression Scale (EPDS)
is used widely throughout Alberta as an initial screening tool to identify
postpartum depression. The Personal Health Questionnaire-2 (PHQ-2) is
an alternate brief depression screening tool and is discussed in chapter 9
(Pharmacotherapy).
document the assessments.
20.19

Model component
ASSIST the client/
patient who is ready
to quit, reduce or
prevent relapse
with self-support
materials and brief
information and
links to behavioural
counselling.
assist
ASSIST when
appropriate with
pharmacotherapy for
withdrawal support.
ASSIST the client/
patient who is not
ready to quit or
reduce by supporting
autonomy.
Considerations
Provide pregnancy-specific self-help materials and other tobacco
cessationsupports.
Resources are available from the online resource catalogue at
Albertaquits.ca, including
Baby Steps: A Guide to Help Pregnant and Postpartum Women
QuitSmoking
The Right Time, The Right Reasons: Dads Talk about Reducing
andQuitting Smoking
Link to onsite behavioural support, if available (e.g., for inpatients), and
discuss available referral options. Consider links to behavioural support
for those who may need relapse prevention support (e.g., developing
a postpartum relapse prevention plan for those in their last month of
pregnancy).
If pharmacotherapy is identified as appropriate (if behavioural support is
unsuccessful or the woman is unwilling to quit, but will consider use of a
cessation aid temporarily), provide link to prescriber and/or facilitate order.
Encourage problem-solving techniques to help the woman cope with
cravings, withdrawal symptoms or social situations.
Provide ongoing monitoring for withdrawal and mood assessment.
Provide a positive, supportive social environment in the clinic/unit.
Help the woman identify people in her own environment who can help and
encourage her to quit. It is important to be sensitive to the possibility of
disapproval from partners and co-habitants. Ensure the womans safety
prior to suggesting she ask her partner or other co-habitants to help her
quit. In cases where the woman does not feel comfortable asking for
support from her partner or other co-habitants, advise her to stay away
from second-hand smoke wherever possible, and refer her to confidential
sources of support.
document the assist.
arrange
ARRANGE link to
ongoing behavioural
support.
ARRANGE continued
pharmacotherapy, as
appropriate.
Link to ongoing supports such as the AlbertaQuits helpline, preferably

by fax (or electronically, if available), as referrals completed by health
professionals are more effective than asking a client/patient to self refer
Appendix 7(b)
Ensure that the 5As approach is continued throughout pregnancy, and,
where possible, after delivery. Continue to ask all women, whether or not they
have quit, about their tobacco use status throughout the duration of care.
When possible, visits should allow time to monitor the womans progress,
reinforce the steps she is taking to quit and promote problem-solving skills.
Clinics could consider offering Quitcore group cessation support as a
service at their site.
20.20
Breastfeeding mothers
New mothers who use tobacco are advised to continue
breastfeeding while they attempt to quit. Although small
amounts of nicotine passes through to the breast milk, the
benefits of breastfeeding to the newborn outweigh the negative
impact of nicotine and other contaminants passing through the
breast milk.37,38
New mothers who use

tobacco are advised to
continue to breastfeed
while they attempt to
quit.37, 38
Nicotine ingested through breast milk may cause the baby

to refuse feedings, be cranky, sleep poorly and spit up.3942
Mothers who use tobacco may also have a reduced milk supply.43,44 They are therefore
advised to time their tobacco use to right after the baby nurses, to help the nicotine clear from
their milk before the next feeding.37
Refer women who are having difficulty breastfeeding to a lactation consultant or other healthcare providers knowledgeable about breastfeeding.
Numerous studies and reviews have been conducted to determine which types of
interventions are most effective in assisting pregnant and postpartum women to stop
smoking.1,30 Unfortunately, none has been able to identify which interventions are most
consistently effective across this population.
Among studies that demonstrate effectiveness in helping pregnant women quit using tobacco,
the interventions summarized in Table 20.6 commonly appear.1,30
Table 20.6: Effective Behavioural Support for Pregnant and Postpartum Women 1,30
Supporting AHS Resources
Brief intervention and intensive counselling

are interventions that provide motivation to quit,
support to increase problem solving and coping
skills, and may incorporate trans-theoretical models
of change. This includes interventions such as
motivational interviewing, cognitive behaviour
therapy,psychotherapy, relaxation, problem solving
facilitation and other strategies.
AlbertaQuits helpline counsellors
Health education interventions are those where

women are provided with information about the risks
of smoking and advice to quit, but are not given
further tailored support or advice about how to make
this change. They include interventions where the
woman was provided with automated support such
as self-help manuals or automated text messaging,
but no personal interaction. Self-help manuals often
take the form of a take-home, patient-focused guide
to quitting, usually incorporating some skill building,
tipson reduction and cessation, and advice.
Tobacco reduction counsellors/specialists

Addiction counsellors
Mental health therapists
Respiratory health therapists
Doctors, pharmacists, nurses, social workers and
other health professionals with recognized brief
and/or intensive tobacco counselling training
AlbertaQuits website: a self-guided interactive
program. Once registered, the user is able to
access community forums, cessation tools, texting
support, eQuit tips and resources to create a
personal quit plan.
Cessation resources such as Baby Steps: A Guide
to Help Pregnant and Postpartum Women Quit
Smoking are completed by the patient, but have
limited advice for her unique situation. This resource
is available for order in the www.albertaquits.ca
website resource catalogue.
20.21

Supporting AHS Resources
Feedback interventions are those where the

mother is provided with information about the fetal
health status or measurement of by-products of
tobacco smoking. This includes interventions such as
ultrasound monitoring and carbon monoxide or urine
cotinine measurements, with results fed back to the
mother.
Medical procedures create opportunities for

consultation on the tobacco-related harms
associated with a patients health outcome.
Incentive-based interventions include those

interventions where women receive a financial
incentive (e.g., gift vouchers contingent on their
smoking cessation).
Although research is being done on this area,

currently there is no provincial financial incentive
program within AHS for pregnant women.
Social support (peer and/or partner) includes those

interventions where the intervention explicitly included
support from a peer (including self-nominated
peers, peers trained by project staff or support from
healthcare professionals) or partners, as a strategy
to promote smoking cessation.
QuitCore group counselling sessions provide

Albertans (aged 18+) with the tools and skills they
need to quit using tobacco for good. Sessions
are scheduled, and include tailored guidance.
Peer and family/friend support is also included.
Groups are unisex, and efforts are made to make
this environment a safe place to share personal
experiences with tobacco use. For inquires
to run your own QuitCore program, contact
Personal follow-up refers to communication with

the patient aimed at sustaining the impact of other
intervention components and offering encouragement,
often through the postpartum period.
The AlbertaQuits helpline provides ongoing support,

with an average of 10 minutes per call. The support
provided includes seven scheduled call-backs, but
can be adapted to meet the needs of the caller.
Follow-up calls are generally scheduled for
Tobacco reduction counsellors/specialists,

pharmacists and other health professionals have
used the CO monitor as a motivation and relapse
prevention tool when counselling patients.
quit day
two days after quit day
two weeks after quit day
one month after quit day
three months after quit day
six months after quit day
one year after quit day
20.22
Relapse prevention
While many women quit using tobacco while they are pregnant,
a high percentage will resume their tobacco use after giving
birth. According to the 2009 Canadian Maternity Experiences
Survey, 47% of women who had quit smoking by the third
trimester had resumed smoking daily or occasionally in the
postpartum period.24 However, reported rates of relapse vary
and according to Greaves et al may be as high as 7090% by
one year postpartum.1 This has health implications for both
women and children.24
As many as 25% of
women may resume
smoking before delivery,
50% within four months
and 70-90% by one year
postpartum.1
As described by Pregnets (Centre for Addiction and Mental Health), predictors of relapse
include high nicotine dependence, postpartum depression, friends or family who smoke,
low education, low income, age (youth), lack of social support and lack of prenatal care.38
Relapse rates tend to be lower among women who breastfeed, although often breastfeeding
only delays relapse, rather than helping avoid it altogether.
During pregnancy, many women quit more for the baby than for themselves. This means they
are less motivated to quit for good and do not develop long-term strategies to remain tobacco
free. Effective relapse prevention strategies focus on the mothers health as the motivation for
continued abstinence.
Late pregnancy is an opportune time to initiate discussions about the risks of postpartum
relapse and build strategies to avoid it.
The considerations outlined in Table 20.7, as described by the American College of
Obstetricians and Gynecologists (ACOG) may help address postpartum relapse.36
Table 20.7: Considerations to Address Postpartum Relapse

Maintain good chart
documentation
Documentation is required for systematic follow up on the patients

tobacco use status.
Documentation is also beneficial in tracking a patients tobacco use
status and progress with remaining tobacco free.
Continue with 5As approach

atpostpartum visits
The majority of women who quit using tobacco during pregnancy

relapse within a year of delivery.
Patients who gain a significant amount of weight during pregnancy
may be at higher risk for relapse than patients who do not.
20.23
Table 20.7: (Continued)

Maintain positive counselling
Language is important when considering how to counsel patients to

remain tobacco free.
Reinforce the positive effects of quitting, including improved maternal
and infant health.
Continue to advise about the benefits to the family of having a
tobacco-free home environment and the potential harms of secondand thirdhand smoke in the home environment, which may increase
the risk of consequences such as sudden infant death syndrome
(SIDS), bronchitis and asthma, as well as more common childhood
conditions (e.g., colic and otitis media).
Continue to praise the patients effort in quitting.
To reinforce the patients desire to be a good mother, say, for example,
You have really helped your baby get off to a great start by providing
a tobacco free home, so she/he can continue to grow and be healthy.
Reassure the patient of your continued assistance in her attempts to
quit and remain tobacco free.
If a patient is concerned about her weight after delivery while she is
trying to quit smoking or maintain smoking cessation, the following
suggestions might help:
Dont focus on losing weight while trying to quit using tobacco.
Quitfirst, then address weight issues.
Choose healthy foods.
Participate in physical activities.
Address slips and relapse,

asnecessary
Reassure the patient and encourage her to try again. Tell her that
people who quit using tobacco successfully after they slip tell
themselves, This was a mistake, not a failure.
Remind the patient that most people who quit using tobacco
successfully have relapsed, and that each quit attempt puts her closer
to never using tobacco again.
Encourage her to quit using tobacco immediately, and put the quit date
in writing.
Encourage the patient to get rid of all tobacco materials
(e.g.,cigarettes, matches, lighters, ashtrays, snus and e-cigarettes).
Ask the patient to think about what made her want to use tobacco so
she will understand the trigger and develop a plan to avoid it or cope
with it next time.
For patients who relapse, remind them of the positive effects of
quitting.
Suggest that the patient use the self-help materials she received
during pregnancy to remind her of good reasons for quitting, ways to
handle slips and techniques for remaining tobacco free.
If appropriate, offer or link to prescriber for pharmacological treatment.
20.24
Continuity of care is another key component of ensuring that patients are adequately
supported after quitting. Motivation to quit is a dynamic factor that changes throughout any
period of cessation. Providing consistent tobacco cessation support into the postpartum
period should be ensured.1 This could include follow-up phone calls, targeted support groups
or home visits. This requires coordination across the continuum of care from staff who have
adequate addictions training and knowledge to support mothers at risk of relapse.
Vulnerable groups
Some women are especially vulnerable to tobacco use
andaddiction, including those in the following groups:1

women of low socio-economic status
women with mental health problems
women who use other substances
women who have experienced trauma
Aboriginal women
adolescent girls and young women
Education, income,
employment, and socialsupport networks are
the key determinants of
socioeconomic status that
consistently indicate an
inverse relationship with
smoking in pregnancy.1
Health care providers have to be sensitive to the characteristics of subgroups and understand
the importance of helping all of these women and girls. It is important to recognize that not
only are they more likely to use tobacco but they also experience more challenges with
quitting andrelapse.1
Refer to chapter 19: (Addiction and Mental Health) and Expecting to Quit for more
information on tobacco treatment for these subgroups.
Electronic cigarettes (e-cigarettes)
Electronic cigarettes, also known as e-cigarettes, are battery-operated devices that have
cartridges with liquid chemicals in them. Some people mistakenly believe that these
devices are harmless compared to smoking. Some use them as a cessation aid, although
there is no evidence that they help people quit smoking. Health Canada, the U.S. Food
and Drug Administration and the World Health Organization do not support e-cigarettes
as stopsmoking products. Women and adolescents should be discouraged from using
electronic smoking devices.
Numerous studies have been conducted to determine the safety and efficacy of
pharmacological treatments for pregnant and postpartum women. This research is
inconclusive as it relates to safety, and suggests that the pharmacological treatments used
most commonly with the general population are not as effective with this population group,
due in part to the fact that nicotine replacement therapy (NRT) is metabolized faster during
pregnancy, meaning that higher doses are likely to be needed.45
In the absence of strong evidence to support the use of medication to assist pregnant
and postpartum women to stop using tobacco, intensive cessation support (e.g., multiple
counselling sessions, motivational interviewing, cognitive behavioural therapy) is
recommended as first line treatment.7,28,45
20.25
Nicotine replacement therapy
NRT should only be
If counselling is found ineffective, NRT can be considered as

offered during pregnancy
a second line option. However, there is a lack of consistency
when counselling has
amongst clinical guideline recommendations on this point,
failed, and after an
due to limited evidence on the effectiveness and safety of
informed discussion with
NRT during pregnancy. The point at which counselling can
the patient regarding the
be determined to be ineffective is subject to the professional
risks and benefits of using
opinion of the provider and the personal motivation of the
woman. This must be assessed on an individual basis in
tobacco and NRT. 28, 46, 47
consultation with a prescribing authority such as physician,
pharmacist or nurse practitioner. Some evidence from
randomized controlled trials indicates that NRT may be effective in pregnancy for decreasing
tobacco use and improving pregnancy outcomes.28 However, NRT is generally less effective
for pregnant women than for the general population, likely due to the pharmacokinetic and
physiological changes that occur during pregnancy, which may necessitate higher doses.45
In terms of safety, the benefits of NRT seem to outweigh potential risks. While nicotine
exposure through NRT most likely has adverse effects on the fetus during pregnancy,
tobacco use exposes the fetus to more toxic chemicals than nicotine alone.7 NRT also
typically provides less nicotine than tobacco smoke.48 However, the available data cannot
support or exclude an association between first trimester NRT use and an increased risk of
congenital defects.28 Until further evidence is gathered, NRT should only be offered during
pregnancy when counselling has failed and after an informed discussion with the patient
regarding the risks and benefits of using tobacco and NRT. When NRT is recommended to a
pregnant woman, low-dose, intermittent delivery NRTs (e.g., lozenges, gum, buccal inhalers,
and mouth spray) is preferred over continuous dosing of the patch.28,46,47 If the patch is used,
the woman should consider removing it at night. NRT should be discontinued if the woman
continues to use tobacco at the same rate, and alternative treatment should be considered.49
As with all medications prescribed during pregnancy, close monitoring is required throughout
the womans use of NRT.
Regarding breastfeeding and NRT use, nicotine freely passes
New mothers should
in and out of breast milk. Factors that influence the amount
be encouraged to
of nicotine ingested by the infant include the concentration of
breastfeed, even if they
nicotine in the maternal blood (affected by tobacco product
are using tobacco.1
consumption), frequency of breastfeeding, and the time
between tobacco use and breastfeeding. However, there is a
relatively low oral availability of nicotine in breast milk, and it is unlikely that this low level of
exposure is harmful to the infant. The importance of continuing to breastfeed, regardless of
tobacco use status, should be stressed, because the benefits of breastfeeding to both the
mother and child outweigh the risks associated with nicotine exposure through tobacco use
or NRT.1 Breastfeeding women, like pregnant women, should use intermittent rather than
continuous dosage NRT formulations, at the lowest recommended dosage.
Bupropion and varenicline
There is limited evidence for the safety and effectiveness of both bupropion and varenicline
for tobacco use cessation during pregnancy and while breastfeeding. Two major reviews of
the clinical evidence of pharmacological use with this population draw somewhat different
conclusions.

20.26
Coleman and colleagues found that there are insufficient studies investigating
the fetal impacts of either bupropion or varenicline use in pregnancy to draw any
conclusions about the safety of using either.45
Greaves and colleagues refer to evidence from one controlled but non-randomized
study50 that found that bupropion is more effective than a placebo for pregnant
women who smoke, but that there may be an increased risk for spontaneous abortion
among women treated with bupropion during pregnancy. They indicate that clinicians
currently suggest bupropion can be used with pregnant women who smoke.1 They do
not discuss the use of varenicline with this population.
Similarly, leading clinical practice guidelines offer conflicting recommendations regarding the
use of bupropion and varenicline with pregnant and breastfeeding women, with Canadian
recommendations diverging from the others.

CAN-ADAPTTs Canadian smoking cessation guidelines state that there is no

evidence of harm related to the use of bupropion during pregnancy, and it may
therefore be considered an alternative to NRT for a sub-population of pregnant
women who smoke. It also states that more research is needed on the effectiveness
and safety of both bupropion and varenicline as a tobacco cessation aid for pregnant
and breastfeeding women.28
The Society of Obstetricians and Gynecologists of Canada state that further research
is needed on the safety and efficacy of bupropion and varenicline before they can be
recommended for routine use in pregnancy.49
Motherisk states that bupropion use during pregnancy does not appear to be
associated with increased risk of major congenital malformations, but there are
no adequate studies on rates of spontaneous abortion among pregnant women
taking bupropion for smoking cessation. Regarding varenicline, Motherisk states
that because limited data are available regarding its use during pregnancy, it is
only advisable to use this product as a tobacco cessation aid during pregnancy
when thebenefits of treatment substantially outweigh any undue risk (e.g., in heavy
smokers with failed quit attempts or who have not responded to other tobacco
cessation aids).51
U.S. guidelines state that neither bupropion nor varenicline has been shown to be
effective for treating tobacco dependence in pregnant women who smoke, nor have
either of these been evaluated in breastfeeding patients. It does not comment on
its safety or provide a recommendation for its use with this population group, but
identifies this as an area requiring more research.7
Australian guidelines state that neither bupropion nor varenicline has been shown to
be effective or safe for smoking cessation treatment in pregnant and breastfeeding
women who smoke, and does not recommend its use with this population.47
U.K. guidelines state that neither bupropion nor varenicline should be offered to
pregnant or breastfeeding women.52
New Zealand guidelines state that there is insufficient evidence to recommend the
use of bupropion or varenicline by pregnant women.48
Based on the available evidence, these guidelines recommend that bupropion and
vareniclineshould only be considered with pregnant and breastfeeding women after
behavioural interventions and NRT have failed. Prior to initiating either treatment, advise
women that current research does not conclusively demonstrate the efficacy and safety of
either of these medications in pregnancy and lactation, and discuss the risks and benefits
ofusing them versus using tobacco.
20.27
Pregnant and postpartum adolescents

The information in this section provides information on providing tobacco cessation support to
adolescent girls (aged 1017) who are either pregnant or gave birth to a child in the last year.

Pregnant and Postpartum Adolescents to Stop Using Tobacco
To support pregnant adolescents while they stop using tobacco, use a combination of the 5As for women
(Figure 20.1) and the 5As for adolescents outlined in chapter 21 (Youth and Family).
Pregnant and postpartum adolescents should receive pharmacological support following the
recommendations outlined for pregnant and postpartum women earlier in this chapter. The risks and
benefitsof all treatment options must be discussed with the patient and their caregivers prior to initiation.
Prevalence
Pregnant adolescents have significantly higher rates of smoking than older pregnant women.
According to Canadian Maternity Experiences Survey data from 200607, mothers between
the ages of 15 and 19 reported the highest proportion of smoking during pregnancy: 29% in
this age group reported smoking daily or occasionally, compared to 11% among all pregnant
women.24
Figure 20.3: Canadian Tobacco Use in Pregnancy by Age: 24

Proportion of women who reported smoking daily, occasionally
and not at all, by time period and maternal age, Canada, 200607
Source: Public Health Agency of Canada, 2009.
20.28
The prevalence of adolescent smoking during pregnancy is

higher in Alberta than in Canada as a whole. According to the
Alberta Perinatal Health Program, 41.2% of teenagers (aged
19 or younger) who gave birth in Alberta in 2012 smoked at
some point during their pregnancy.27 This compares to 13.8%
ofwomen of all ages who gave birth in Alberta in the same year.
Within Alberta, there is a wide variation between Alberta Health
Services zones, ranging from a high of 47.6% in the Central
Zone to a low of 36.2% in the South Zone.27
The prevalence of
smoking among
pregnant adolescents
in Alberta is three
times that of pregnant
women of all ages.27
While there is little data on the prevalence of spit tobacco use among pregnant women,
estimates based on non-pregnant women suggest that the prevalence is less than 1%.2
However, despite the relatively low prevalence of spit tobacco use compared to smoking,
itis important to screen for it using language that is inclusive of all tobacco use, rather than
asking only about smoking.

Women under the age of 20 are at higher risk for having preterm and low-birth-weight
infants, and pregnant adolescents under the age of 15 who use tobacco have twice the risk
of intrapartum stillbirth than pregnant women who use tobacco and are 15 years or older.
Adolescent pregnant women also experience higher rates of maternal anemia than older
women during pregnancy.1
While the 5As are accepted clinical practice for both pregnant women and adolescents,
there is a lack of research on how best to adapt the approach for use with pregnant or
postpartum teens. In the absence of such targeted recommendations, a combination of the
recommended approach for pregnant/postpartum women (as per the recommendations
outlined earlier in this chapter) and the approach for adolescents outlined in chapter 21
(Youth and Family) can be considered.
Successful interventions to help pregnant and postpartum adolescents quit using tobacco
include multiple components.1 One example includes a combination of education,
motivational interviewing, optional NRT and prevention, while another uses education,
counselling, peer modelling and support with an eight-week program based on cognitive
behavioural therapy.
Expecting to Quit reviewed a number of interventions for this population and concluded that
there is an urgent need to expand the current scope and duration of tobacco interventions,
and for general support to promote girls and young womens health. Such expanded
interventions should address and prevent harms associated with connected issues such as
alcohol and other substance use, childhood abuse and dating violence, smoking and other
substance use by partners and others living with the client, issues with body image, overall
self-esteem and depression. Promising practices in the prevention of substance use overall
and the promotion of girls empowerment that are grounded in social theory and emphasize
building and enhancing self-efficacy will be important to integrated approaches.1
Expecting to Quit also recommends the approaches outlined in Table 20.9 for addressing the
needs of pregnant adolescents and young women who use tobacco.1
20.29
Table 20.9: Recommended Approaches for Addressing Tobacco with Pregnant

Adolescents and Young Women 1
Approach
Supporting Resources
Tailoring approaches are well justified to integrate

education and support for reducing and quitting
tobacco use: in more settings, over time (beyond
pregnancy and immediate postpartum) and linked to a
range of connected health and social experiences.
Intensive counselling enables a tailored, long-term,

engaged approach. Patients needing intensive
support are advised to consult with a counsellor
(e.g.,AlbertaQuits Helpline counsellor, tobacco
reduction counsellor/specialists, addiction counsellors,
mental health therapists or any other health
professionals with recognized intensive tobacco
counselling training).
A harm-reduction approach is particularly important

when working with younger people who are at a time
in their development when experimentation and risk
taking are normal (and approaches that focus only
on cessation may not be immediately appealing).
Starting where adolescent girls and young women
are at, building on what is important to them, listening
for their interests and readiness, and assisting in
non-judgmental ways that connect their tobacco use
to coping with dating violence and other harms are
all relevant to a harm-reduction stance with pregnant
girls and young women.
There are many ways tobacco counsellors can help

patients reduce harm, including
Partners social support is vital in the adolescent

context where partners substance use plays a
significant role in girls and young womens tobacco
use, and where the orientation to peers and partners
is high. Although acceptance of gender-specific
approaches is still slow to gain momentum, supports
that address the different influences on and health
impacts of smoking for young women and men, and
factor in the high rate of violence against girls, are
essential.
The integration of social issues needs to be the
central focus of an approach with adolescent girls
and young women. Dating violence, co-existing
heavy alcohol use, positive body image, self harm,
depression, school connectedness, support during
key life transitions, poverty and accessing resources,
child abuse, positive gender identity development,
self worth, understanding sexuality, support for
making informed choices, finding purpose and cultural
identitythe social issues that could be explored and
integrated are extensive.
20.30
removing tobacco from their home and vehicles

creating a butt jar to recognize the volume of toxic
waste and the costs endured
keeping a tobacco use journal to identify tobacco
use behaviours, mood and emotions associated
with use
reducing cigarette/tobacco product usage
distraction techniques that may delay and dissipate
urges to use tobacco
Pregnant adolescents and young women in
relationships can be referred to or counselled with
the pamphlet Couples and Smoking: What You
Need to Know When You are Pregnant, available
at:www.thiswaytoahealthybaby.com
If a patient does not feel comfortable or safe
discussing plans to reduce harm from tobacco
usewith their partner/household member, they
canbe referred to Health Link Alberta at
1-866-408-LINK (5465) for links to additional
support.
There is a high correlation between the experience of
trauma and substance addiction, including tobacco
use. Trauma affects the way women think about
tobacco use and their attitudes towards quitting.
An introduction to trauma-informed practice can be
found at: www.jeantweed.com
While numerous studies have been done on the safety and efficacy of pharmacological
treatments both for pregnant women and for adolescents as a whole, there is a lack
of research on treatments specifically for pregnant adolescents as a sub-population.
Furthermore, as described earlier, the research that has been done on pregnant women
hasmostly been inconclusive, as is that done on adolescents.
As with the recommended pharmacological treatment for pregnant and postpartum women,
counselling (e.g., intensive cessation support) is recommended as first line treatment for
pregnant and postpartum teenage girls.
In the absence of conclusive evidence as to the safety and effectiveness of specific
medications (e.g., NRT, bupropion, varenicline) with this population, the recommendations
for pregnant and postpartum women, outlined earlier in this chapter, should be followed.
The risks and benefits of all treatment options must be discussed with the patient and her
caregivers prior to initiation.
20.31
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45. Coleman, T., Chamberlain, C., Davey, M., Cooper, S. E., & Leonardi-Bee, J. (2012).
Pharmacological interventions for promoting smoking cessation during pregnancy.
Cochrane Database of Systematic Reviews,9: CD010078.
46. Centre for Addiction and Mental Health, Nicotine Dependence Service. (2013). Tobacco
dependence treatment frequently asked questions. Toronto, ON: Author.
47. Royal Australian College of General Practitioners. (2011). Supporting smoking cessation:
A guide for health professionals. Melbourne, Australia: Author.
48. New Zealand Ministry of Health. (2007). New Zealand Smoking Cessation Guidelines.
Wellington, NZ: Author.
49. Wong, S., Ordean, A. & Kahan, M. (2011). Clinical practice guideline: Substance use in
pregnancy. Journal of Obstetrics and Gynaecology Canada, 33(4), 367-384.
50. Chan, B., Einarson, A., & Koren, G. (2005). Effectiveness of bupropion for smoking
cessation during pregnancy. Journal of Addictive Diseases, 24(2), 1923.
51. Cressman, A., Pupco, A., Kim, E., Koren, G., & Bozzo, P. (2012). Smoking cessation
therapy during pregnancy. Canadian Family Physician, 48(5), 525-527.
52. National Institute for Health and Care Excellence. (2010). Quitting smoking in pregnancy
and following childbirth. London, UK: Author.
20.34
Appendices
Appendix 20(a) Additional Resources for Health Care Providers Who Support Women and Girls
20.35
Appendix 20(a) Additional Resources for Health Care Providers Who Support Women
and Girls
20.36
CAN-ADAPTT: A website for smoking cessation knowledge exchange, networking and

clinical practice guidelines including guidelines for Specific Populations: Pregnant and
Breastfeeding Women. (www.nicotinedependenceclinic.com):
Expecting to Quit: A website that provides best practices review of smoking cessation
interventions for pregnant and postpartum girls and women from the British Columbia
Centre of Excellence for Womens Health (BCCEWH). A link to the main BCCEWH page
will take you to additional knowledge, event information, publications and more.
(www.expectingtoquit.ca)
Healthy Parents Healthy Children: AHSs online e-book, containing reliable information
about how to help children grow, learn and be healthy in the early years. Tobacco advice
is included. (www.healthyparentshealthychildren.ca)
Pregnets: A website that provides support for health-care providers and professionals,
as well as clients and patients themselves. Contains literature reviews, national guideline
links, current research and question-and-answer-style content to support women during
the childbearing years. (www.pregnets.ca)
FACETFamilies Controlling and Eliminating Tobacco: A website that provides

research and printable resources, including Couples and Smoking and The Right Time.
The Right Reasons: Dads Talk about Reducing and Quitting Smoking.(www.facet.ubc.ca)
Women and Healthy Living in Canada: A Health Canada-sponsored document

addressing how to support groups of women where smoking rates are higher, including
women living with low income and Aboriginal women. (http://www.pwhce.ca/pdf/HL_3_
SmokingtobaccoFactsheetWomenHealthyLivingProfile.pdf)
Liberation! Helping Women Quit Smoking: A brief tobacco intervention guide for health
professionals and care providers who offer counselling to clients/patients. This resource
was developed by the BCCEWH. (www.bccewh.bc.ca)
MotherRiskTreating the Mother and Protecting the Unborn: A website under

the auspices of the SickKids Hospital in Toronto, Ontario. Includes pregnancy and
breastfeeding-related advice on a variety of issues, including drug interaction information.
(www.motherrisk.org)
Women and Tobacco: A Casebook: A resource developed by BCCEWH that includes

information on; contexts and issues, strategies and interventions, advocacy and action,
diversity and equity issues, policy and research, discussion guides and resources.
(www.bccewh.bc.ca)
Health CanadaPregnancy and Smoking: Website discusses smoking during

pregnancy and related health risks for both mother and fetus. Also discusses
pre- and postnatal smoking-related issues and second-hand smoke during pregnancy.
(www.hc-sc.gc.ca)
Coalescing on Women and Substance Use: A website offering material from ongoing
projects related to womens substance use in Canada. Five key topic areas regarding
girls, women and substance use offer guidance on addressing a variety of issues
including violence and trauma, pregnancy, mothering, alcohol and substance use,
holistictreatment for First Nation/Inuit and in particular, addressing Women-centred
Tobacco Treatment (www.coalescing-vc.org)
Chapter 21
Youth and Family
21.1
21.2
Chapter 22
Adults with Cancer
22.1
INTRODUCTION
This chapter is intended to assist health care providers to implement brief and intensive
tobacco cessation support with adult cancer patients in Alberta. A cancer diagnosis offers
opportunities for tobacco use screening and cessation intervention with health benefits
cuttingacross cancer type and stage of prognosis.
In 2013, the Alberta Government published Changing Our Future: Albertas Cancer Plan
to 2030, which identifies the need for integrated prevention strategies to reduce the risk of
cancer and strengthen health promotion interventions across the continuum of care.1 While
Alberta has made clinical and policy advancements to inform tobacco cessation activities in
health care settings, tobacco screening and treatment support are not currently a systematic
part of routine care within CancerControl Alberta (CCA) services.2,3 A CCA clinical practice
guideline, Tobacco Screening and Treatment for Adult Cancer Patients has been developed
based on the three overarching recommendations identified in Table 22.1.
Table 22.1: Tobacco Free Futures Summary Recommendations for Supporting Adults
with Cancer
1. Brief tobacco intervention (up to 3 minutes) using the 5 As model (ASK, ADVISE, ASSESS, ASSIST,
ARRANGE) shall be offered to all cancer patients who are admitted to a CancerControl Alberta facility
or program.
2. All tobacco users shall be offered first-line cessation pharmacotherapy in combination with behavioural
counselling as the most effective tobacco treatment.
3. Health care providers shall engage in ongoing monitoring and follow-up of a cessation treatment plan.
4. Tobacco use screening, provision of advice, cessation information and referral should be offered to
accompanying family or caregivers, where appropriate.
See appendices:
Appendix 22(a) CancerControl Alberta Clinical Practice Guideline: Tobacco Screening and Treatment for Adult
Cancer Patients
Prevalence of tobacco use in cancer patients and survivors

While data for Canada is lacking, estimates from the United States show that rates of
continued smoking among cancer patients range from 7% to 60% depending on tumor
site.4 Smoking rates are highest among patients newly diagnosed with lung or head and
neck cancers, with rates approaching 40% compared with 23% among the general U.S.
population.4
Among cancer survivors, estimates suggest that between 15% and 33% continue to smoke,
with the highest smoking rates reported in younger survivors and survivors of bladder, lung
and ovarian cancer (Figure 22.1).5 Data further suggest that smoking rates remain higher in
the first year of diagnosis with cessation increasing in the years following.6
22.2
Figure 22.1: Percentage of Cancer Patients Still Smoking5

20
18
17.2
14.9
16
14
11.6
12
10
7.6
7.3
6.8
Melanoma
Kidney
Colorectal
8
6
4
2
0
Bladder
Lung
Ovarian
Source: Adapted from: American Association for Cancer Research, U.S. Cancer
Patients Still Smoking Nine Years After Diagnosis. Available at http://mb.cision.com/
Public/3069/9622656/bee578341521c87e_org.jpg
Impact of tobacco use and exposure

In Canada, smoking is responsible for an estimated 30% of all
cancer deaths and more than 85% of all lung cancer cases,
with strong associations to other cancer types, including mouth
(oral), esophageal, stomach, pancreatic, colorectal, bladder and
kidney cancers.7
In cancer patients and

survivors, the evidence is
sufficient to infer a causal
relationship between cigarette
smoking and adverse health
outcomes. Quitting smoking
improves the prognosis of
cancer patients.8
The clinical importance of tobacco cessation at time of

diagnosis is well supported by a growing body of research.
Cancer patients who continue to smoke experience higher
rates of all cause and cancer-specific mortality, higher cancer
treatment complications, reduced radiation and chemotherapy
efficacy, increased risk of cancer recurrence, increased risk of a second primary disease
and reduced quality of life (Table 22.2).8,9,10 The 2014 U.S. Surgeons General Report
specifically reports that the relative risk of cancer-specific mortality and allcause mortality
among cancer patients who smoke is 60% and 50% greater, respectively, compared
to patients who have never smoked, suggesting that tobacco cessation at diagnosis is
critical to improving the prognosis of adult patients with cancer.8
22.3
Table 22.2: Effects of tobacco use on cancer treatment and outcomes9

SURGERY
RADIATION
CHEMOTHERAPY
increased complications from

general anesthesia
decreased treatment efficacy
potential increase of side

effects, including:
increased risk of severe

pulmonary complications
increased risk of toxicity and side

effects, including:
poor wound healing, including:

decreased capillary blood flow
increased vasoconstriction
increased risk of infection
immune suppression
xerostomia (dry mouth)
weight loss
oral mucositis
fatigue
loss of taste
pulmonary and cardiac

toxicity
pneumonitis
soft-tissue and bone necrosis
poor voice quality
increased incidence of infection

altered pharmacology of some
medications
Source: Adapted From American Society of Clinical Oncology Tobacco Cessation Guide for Oncology Providers
Chemotherapy
When patients continue to smoke tobacco while undergoing
Smoking tobacco may
chemotherapy, the inhaled toxins may alter the pharmacology
of some anti-cancer drugs with resulting clinical implications.
alter the metabolism
There are a number of ways that smoked tobacco use can
of some chemotherapy
alter the pharmacokinetics of particular drugs, including
agents making them
increasing the amount of drug binding proteins such as
less effective.10, 11
alpha-1-acid glycoprotein (AAG), as well as altering the level
of some cytochrome P-450 (CYP) enzymes and uridine
5-diphosphoglucuronosyltransferase (UGT) isoenzymes that are responsible for drug
metabolism. Research has demonstrated the impact of each of these mechanisms with
several anti-cancer drugs.10,11
Erlotinib, a drug commonly used in the treatment of non-small cell lung and pancreatic
cancers, is primarily metabolized by CYPs 3A4 and 1A2. The polycyclic aromatic
hydrocarbons (PAH), released by the incomplete combustion of smoked tobacco, cause
induction of several CYP enzymes, including 1A2, resulting in more rapid metabolism and
decreased systemic exposure to the drug.11 Patients who currently smoked had a 23.5%
increase in drug clearance versus those who used to smoke or never smoked.10 Prescribing
information advises consideration of smoking history in dosing as it has been shown to be a
predictor of treatment outcomes with erlotinib.11
Irinotecan is a first-line therapy for colon and rectal cancer, which is converted to the active
and inactive metabolites by isoenzymes. Smoking induces many of the UGT isoenzymes
that convert irinotecan to its inactive metabolites, significantly lowering exposure to the active
metabolite SN-38. As a result, personalization of drug dosing for patients who smoke has
been proposed.10,11
22.4
Readiness to quit
Studies suggest that cancer patients are highly motivated to
quit. Among a group of newly diagnosed head and neck cancer
patients who smoked, 62% reported plans to quit within the
following three months and 38% had made quit several quit
attempts in previous years.12 Quit rates of a cohort of patients
who smoke and were diagnosed with cancer found that quit
rates were higher among cancer patients at two and four years
after diagnosis (31.3% and 43%, respectively) compared
to people who smoked but were not diagnosed with cancer
(19%and 33.9%, respectively).5 Results were similar by cancer
site and stage.5
Relapse is not so much

a failure of motivation
but is more tied to
the reality of their
nicotine addiction
and their sometimes
poor preparation for
attempting to quit.9
Despite high initial cessation motivation and quit attempts, relapse is common, ranging from
13% to 60%. A longitudinal study examining smoking behaviours following surgical treatment
among lung, head and neck cancer patients who smoked the week before surgery reported a
60% relapse rate at 12 months following their surgery compared to 13% of patients who were
abstinent pre-surgery.13 Low quitting self-efficacy, higher depression proneness, and greater
fears about cancer recurrence were among the reason cited for relapse, suggesting the need
for ongoing tobacco screening and treatment support.13
Family and social support

Social support is an important predictor of cessation success in cancer and non-cancer
patients. Studies suggest that a cancer diagnosis offers a comparable teachable moment for
smoking cessation among family members of cancer patients.4 A study looking at smoking
behaviours among family members of newly diagnosed lung cancer patients found that
71%stated an increased motivation following the diagnosis.14 Cancer patient-caregiver
dyadsin which one or both individuals continue to smoke following diagnosis have also
reported worse mental quality of life than non-smoking dyads.15
Assessment of family or caregiver tobacco can also help to determine patient exposure to
second-hand smoke, which has been shown to reduce successful smoking cessation in
other patient populations. Studies looking at patients with lung and head, and neck cancers
have found that exposure to smoking at home, as well as spousal and peer smoking is
associated with decreased rates of cessation16,17 with exposure to smoking across all three
environments, resulting in the lowest chances of cessation.16
See Chapter 2: The Effects of Tobacco Exposure for more information on the impact
of second-hand smoke.
22.5
Tobacco Treatment Recommendations

The 5As approach, as outlined in Chapter 7 (Brief Intervention),
is considered clinical best practice for the general population,
and has also been included in the recommendation in cancer
care treatment guidelines.19 Although limited in numbers,
studies that have tested the approach with cancer patients
havedemonstrated its applicability and the effectiveness of
briefadvice in motivating quit attempts.20,21,22,23
Tobacco cessation
intervention training
and resources in
oncology settings
may help improve the
implementation of the
5As to approach past
the ASK and ADVISE.18
Although many oncology health care providers acknowledge

the importance of tobacco cessation, most do not provide
interventions beyond advice to quit.15,24,25 Oncology health care providers such as nurses are
in an ideal position to provide cessation support considering their knowledge of the patients
underlying condition, experience in delivering patient education, and the rapport they form
with patients.26 For more details regarding considerations specific to implementing the 5As
with cancer patients/clients and their families, refer to Table 22.4.

The U.S. Department of Health and Human Services clinical practice guideline for treating
tobacco use and dependence indicates that there is a dose dependent response to quit
success and intensity of treatment, including behavioural counselling.27 These guidelines
have been endorsed by key U.S. oncology societies including: American Association for
Cancer Research, American Society of Clinical Oncology and the Oncology Nursing Society.18
Several studies to date have tested the efficacy of more intensive tobacco treatment
delivered by a nurse in a hospital setting and follow-up by phone specifically for clients with
cancer. Results demonstrated higher quit rates in the intervention group versus the usual
care control group, although results varied from study to study.28
A diagnosis of cancer creates some unique issues when implementing intensive tobacco
counselling for patients, and some strategies commonly used with the general population
may need to be modified due to limitations as a result of disease and/or treatment.26, 29
Cancer patients are frequently scheduled for treatments such as surgery, radiation and
chemotherapy that may shorten the timeframe to create and implement a quit plan. The
intensity of cancer treatment regimens also may make it difficult for patients to participate
instructured programs.26
See Chapter 8: Intensive Cessation Counselling for a more in-depth discussion
of how to approach intensive counselling for patients/clients at different stages of
change.
22.6
Pharmacological treatment is recommended for all patients/
clients as a component of tobacco cessation treatment. Chapter
9 (Pharmacotherapy) provided detailed discussion of the
first-line nicotine and non-nicotine options approved for use in
Canada. When using these products to support cancer patients
any considerations or contraindications related to the diagnosis
must be recognized and acknowledged in the treatment
plan.30,31 For more details, refer to Table 22.3.
Cancer patients who

continue to smoke after
diagnosis are often highly
addicted to nicotine and
may need combination
pharmacotherapies to
support their quit attempts.24
Table 22.3: Cessation pharmacotherapy and considerations for cancer patients

drug
considerations for oncology
Nicotine
Replacement
Therapy
Oral products, including gum, lozenge, spray and inhaler may be irritating to the oral
mucosa; therefore, they may not be appropriate for use for individuals
with oral cancer
with head and neck cancer who are undergoing radiation
who receive chemotherapy with a high incidence of stomatitis30
Some forms of NRT may be contraindicated in the immediate pre and/or post-operative
period in patients who undergo tissue reconstruction where revascularization is a
concern. These cases should be discussed on an individual basis with the surgeon
and healthcare team. In such cases, non-nicotine treatments for smoking cessation are
alternate options (e.g. varenicline, bupropion).32
Bupropion
For cancer patients with depression symptoms, bupropion increases abstinence rates,
lowers withdrawal and increases quality of life.33
Bupropion is contraindicated for patients with CNS tumour or any patient at increased
risk of seizure.34
In the general population, this option reduces the appetite increase and weight gain that
is associated with smoking cessation. This may negatively impact cancer patients who
may be struggling with nutrition and weight loss related to their treatments.30
There is evidence that bupropion may have a large effect on the metabolism of tamoxifen
by inhibiting conversion to active metabolites and decreasing effectiveness.35
Varenicline
No reported studies of interactions between varenicline and commonly used lung cancer
therapies.10
Varenicline should be used cautiously in patients with a history of seizures or conditions
that lower seizure threshold.36
A small study tested the effectiveness of varenicline and behavioural support in a cohort
of cancer patients; nausea was reported as the most common side effect, similar to rates
reported within the general population.37
Dosage and appropriateness of use may need to be considered for cancer patients who
are experiencing nausea as a side effect of cancer treatments.30
Standard product warnings include close monitoring for neuropsychiatric symptoms and
consideration of use of nicotine replacement therapy as a treatment option.36
Varenicline is tolerated in cancer patients, but given the psychological and medical
vulnerability of this population it may be preferable to use along with intensive
behavioural counselling.37
22.7
In Chapter 9 (Pharmacotherapy), the concept of routine

depression screening to address potential safety concerns
related to use of the non-nicotine pharmacotherapy options was
introduced. Throughout the cancer journey it is expected that all
patients will feel some degree of distress that will impact their
ability to cope; for some, distress may manifest as depression.39
CCA has integrated Screening for Distress as a standard of
care, based on the Canadian Partnership Against Cancer
recommendations and Accreditation Canada Standards.39,40
Distress is defined
as a multifactorial,
unpleasant, emotional
experience of a
psychological, social
and/or spiritual nature
that can interfere with
the ability to cope
effectively with cancer,
its physical symptoms
and its treatment.38
When reviewing the Screening for Distress questionnaire with

patients who have recently quit smoking or identify quitting
smoking as one of their practical current concerns, health
care providers should keep in mind that the tool screens for
five of the seven DSM-5 signs and symptoms of nicotine
withdrawal including: irritability (frustration or anger), anxiety, difficulty concentrating,
sleep disturbances, and depressed mood.39,41 Treatment for tobacco cessation, including
behavioural and/or pharmacotherapy support may be one option to support a patient
experiencing significant distress.
Tobacco Free Futures in cancer care settings

The brief intervention model outlined in Chapter 7 (Brief Intervention) has been modified
for use with adults who are receiving treatment for a cancer diagnosis and is presented
in Figure 22.2. Table 22.4 then outlines some of the considerations for implementing the
model in cancer care settings.
22.8
Figure 22.2: Tobacco Free Futures:

Brief Intervention Model for Adults with Cancer
Tobacco Screening
ASK
Brief tobacco intervention for adults with cancer

Ask every patient and accompanying family/caregiver about tobacco use (personal
and in the home) at first CancerControl appointment and at critical time points.
Document as per site standards.

in the past 30 days? Past year?
NO
Positive
reinforcement.
Document patient
response as per site
standards.
YES
STOP
Education and Assessment

Advise to quit (remain tobacco free) with personalized message (tailor to cancer type, stage and treatment).
Provide relapse prevention advice to recent quitters (within last year).
Advise to reduce exposure to second-hand smoke where possible (e.g., home and vehicle).
ASSESS
ADVISE
For patients, ask what type, how much, how often and last use.
It is never too late to stop using tobacco.

Quitting (remaining tobacco free) may improve your response to treatment and decrease side effects.
A tobacco-free environment will promote the health of everyone in the family and help prevent relapse.
Assess interest in counselling and/or medication to relieve withdrawal symptoms and achieve abstinence.
Are you interested in support to reduce your withdrawal symptoms,
to help you quit or to remain tobacco free?
Are you interested in a referral to the Tobacco Support Clinic (or other available services)?
ASSIST
Tobacco Treatment Plan
ARRANGE
Monitoring/Follow-up
YES
Refer to Tobacco Treatment and Support Clinic (or other available services).
When possible during an appointment, an available prescriber should order
cessation medication.
To maintain comfort from withdrawal during treatment:
a) For inpatients, provide cessation medication (initiation or continuation).
b) For ambulatory patients, encourage use of personal cessation medication.
Provide self-help resources to patient/family to support cessation and to
reduce exposure to second-hand smoke.
NO
Leave open offer of support.
Provide self-help materials,
including how to self-refer to
clinic/services
(patients and family).
Document as per site
standards.
Arrange ongoing support by referring patients to either

Tobacco Treatment and Support Clinic / AlbertaQuits / or other available services.
Arrange for continued pharmacotherapy (e.g., on transfer/discharge).
22.9
Table 22.4: Treatment Model: Considerations for Adults with Cancer

Model component
ASK all patients
if they have used
tobacco in the last
30days and in the
last year.
At minimum, screening for tobacco use should occur at the first oncology
visit at a CCA facility with follow-up screening/assessment at critical time
points (pre/post chemotherapy, radiation and/or transfer of care).
ASK about patterns

of use.
Even though many cancer patients report that they have quit right before
diagnosis, relapse is very common so its important to assess tobacco
use at each encounter.9 Congratulate recent quitters for having quit, and
reiterate the importance of staying tobacco-free and avoiding situations
where others are using tobacco.
ASK about exposure

to second-hand
smoke in home or
other environments.
ASK
Considerations
ASK accompanying
family members about
their tobacco use.
Since tobacco use status may change throughout the cancer journey,
some guidelines suggest more frequent screening (i.e., at every visit).9,18
Family members/caregivers who attend appointments with patients should

also be asked about their tobacco use. Cancer patients who smoke often
have social circles who smoke and live with others who smoke. As well as
being a teachable moment with regards to their own tobacco use, family
members dont always understand the impact of their tobacco use on the
patient in relation to exposure to second-hand smoke, as well as providing
a trigger for relapse.26
It is not unusual for cancer patients to be reluctant to disclose their
tobacco use because of perceived stigma and feelings of shame and guilt
associated with continued use.9 Studies have demonstrated that even
those who self- report not smoking may have tobacco use confirmed on
positive biochemical testing.42,43
Health care providers should approach patients with sensitivity when
asking about and discussing tobacco use.9
Let patients know that you will be asking about tobacco use at future visits.
Electronic or paper forms used in cancer care settings may require
modification to document the ASK.
22.10
Table 22.4: Continued
advise
Model component
Considerations
ADVISE patients
and/or family
members to quit
and/or remain
tobacco-free with
a personalized
message.
Advice to quit should be clear, supportive and personalized, with

unequivocal messages about the benefits of quitting for cancer treatment
outcomes.30
ADVISE patients
and/or family
members of Alberta
Health Services
(AHS) Tobacco
and Smoke Free
Environments Policy,
as appropriate.
Educate patients about how continued tobacco use during cancer

treatment can negatively affect outcomes related to surgery, radiation
andchemotherapy.9
Be supportive and tactful in advice to quit without admonishing or making

the patient feel criticized. Be sensitive to the stigma of tobacco use after a
cancer diagnosis and recognize that cancer patients are already blaming
themselves for their diagnosis especially, if it is tobacco-related.30
Use positive messaging and recognize that quitting smoking is one thing
that cancer patients can do to exert control over their health at a time when
that sense of control will be very challenged.18
Cancer patients diagnosed with a lower staged disease are at a higher risk
of continued smoking.26
Acknowledge barriers to quitting while providing encouragement.
Advise all patients and family members that tobacco use is restricted
on all AHS properties in accordance with the Tobacco and Smoke Free
Environments policy. This is especially important if patients are admitted
orhaving lengthy outpatient treatments.
modification to document the ADVISE.
Assess
ASSESS readiness
toquit or reduce
tobacco use.
ASSESS interest in
cessation treatment
(counselling and/
or medication) to
achieve abstinence
(quitting) and/or
relieve symptoms of
nicotine withdrawal.
Those with newly diagnosed cancer are often highly motivated to quit, but
quitting may still be very difficult in the long-term. This may be a reflection
of high levels of addiction.9
Readiness to quit can fluctuate significantly during the course of treatment;
not everyone will be ready to quit at the time of diagnosis so assessment
should be done repeatedly.9
For patients who are not yet ready to quit, it may be helpful to explore
current barriers. What would need to happen to make you feel ready to
make a serious quit attempt?
If a patient suggests cutting down as a strategy, let him/her know that while
reducing consumption may reduce health risks, quitting altogether is the
best thing he/she can do for his/her health.
modification to document the ASSESSment.
22.11
Table 22.4: Continued

Model component
ASSIST the patient
who is ready to quit,
reduce or prevent
relapse with selfsupport materials and
links to behavioural
counselling.
Assist
ASSIST, when
appropriate, with
pharmacotherapy for
withdrawal support.
ASSIST the patient
who is not ready to
quit or reduce tobacco
use by supporting
autonomy.
Considerations
The combination of pharmacotherapy and behavioural support is optimal
for tobacco cessation.27
Discuss referral options and link to intensive behavioural support
(i.e., CCA Tobacco Treatment and Support Clinic) or other available
services (e.g., AlbertaQuits, PCN or a family physician).
Even those who are not ready to quit need intervention, including patient
information resources and/or referrals to a tobacco cessation specialist
who can support during the appropriate stage of change.9
Resources specific to cancer patients and families are available.
If pharmacotherapy is identified as appropriate, provide link to a prescriber
and/or facilitate order.
Even cancer patients who are near the end of life can benefit from intervention
to manage comfort and withdrawal, especially if they are physically unable
to smoke or are in an environment that restricts tobacco use.
Provide ongoing monitoring for withdrawal and mood assessment.
Recognize that there are similarities between common signs and
symptoms of nicotine withdrawal and symptoms that cancer patients
frequently experience. DSM-5 symptoms of withdrawal include: irritability,
anxiety, difficulty concentrating, restlessness, insomnia, depressed mood
and increased appetite.41
The routine Screening for Distress will be useful to assist health care
providers to monitor nicotine withdrawal and mood, as well as identifying
patients who prioritize quitting smoking as an immediate concern.39,40
Social support is known to improve quit rates; however, many cancer
patients dont have the support that they need.26 Help patients identify
people in their own environment who can help and encourage them to quit.
modification to document the ASSIST.
Arrange
ARRANGE link to
ongoing behavioural
support.
ARRANGE continued
pharmacotherapy, as
appropriate.
Link to ongoing supports such as the CCA Tobacco Treatment and Support
Clinics and/or AlbertaQuits services (using appropriate referral process).
Referrals completed by health professionals are more effective than asking
a client/patient to self-refer.
Even though NRTs are considered over-the-counter products, providing a
written prescription often facilitates follow-through by patients and allows
for costs to be covered under some benefit plans.
modification to document the ARRANGE.
See Appendices:
Appendix 22 (a) CCA Clinical Practice Guideline: Tobacco Screening and Treatment for Adult Cancer Patients
Appendix 22 (b) Additional Resources for Health Care Providers who Support Adults with Cancer
Appendix 22 (c) Alberta Health Services Screening for Distress Checklist
22.12
REFERENCES
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Edmonton, AB: Author.
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3. Alberta Health Services. (2011). Tobacco and Smoke Free Environment Policy.
Edmonton, AB: Author.
4. McBride, C.M., & Ostroff, J.S. (2003). Teachable moments for promoting smoking
cessation: The context of cancer care and survivorship. Cancer Control, 10(4), 325-333.
5. Westmaas, J.L., Newton, C.C., Stevens, V. L., Flanders, W.D., Gapstur, S.M., & Jacobs,
E.J. (2015). Does a recent cancer diagnosis predict smoking cessation? An analysis from
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May 21, 2015).
8. United States Department of Health and Human Services. (2014). The health
consequences of smoking50 years of progress: A report of the Surgeon General,
9. American Society of Clinical Oncology. (2012). Tobacco cessation guide for oncology
providers. Alexandria, VA: Author.
10. OMalley, M., King, A.N., Conte, M., Ellingrod, V.L., & Ramnath, N. (2014). Effects of
cigarette smoking on metabolism and effectiveness of systemic therapy for lung cancer.
Journal of Thoracic Oncology, Official Publication of the International Association for the
Study of Lung Cancer, 9(7), 917-926.
11. Petros, W.P., Younis, I.R., Ford, J.N., & Weed, S.A. (2012). Effects of tobacco smoking &
nicotine on cancer treatment. Pharmacotherapy, 32(10), 920-931.
12. Logan, H.L., Fillingim, R.B., Bartoshuk, L.M., Sandow, P., Tomar, S.L., Werning, J.W., &
Mendenhall, W. M. (2010). Smoking status and pain level among head and neck cancer
patients. J Pain, 11(6), 528-534.
13. Simmons, V.N., Litvin, E.B., Jacobsen, P.B., Patel, R.D., McCaffrey, J.C., Oliver, J.A.,
etal. (2013). Predictors of smoking relapse in patients with thoracic cancer or head and
neck cancer. Cancer, 119, 1420-1427.
14. Butler, K.M., Rayens, M.K., Zhang, M., & Hahn, E.J. (2011). Motivation to quit smoking
among relatives of lung cancer patients. Public Health Nurse, 28(1), 43-50.
15. Weaver, K. E., Rowland, J. H., Augustson, E., & Atienza, A. A. (2011). Smoking
concordance in lung and colorectal cancer patient-caregiver dyads and quality of
life. Cancer Epidemiology, Biomarkers & Prevention: A Publication of the American
Association for Cancer Research, Cosponsored by the American Society of Preventive
Oncology, 20(2), 239-248.
16. Eng,L., Su, J., Qiu, X., Palepu, P.R., Hon, H., & Fadhel, E. (2014). Second-hand
smoke as a predictor of smoking cessation among lung cancer survivors. J Clin Oncol,
32,564570.
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17. Kashigar, A., Habbous, S., Eng, L., Irish, B., Bissada, E., Irish, J., et al. (2013). Social
environment, secondary smoking exposure, and smoking cessation among head and
neck cancer patients. Cancer, 119(15), 2701-2709.
18. Toll, B.A., Brandon, T.H., Gritz, E.R., Warren, G.W., & Herbst, R.S. (2013). Assessing
tobacco use by cancer patients and facilitating cessation: An American Association for
Cancer Research policy statement. Clin Cancer Res, 19(8), 1941-1948.
19. National Comprehensive Cancer Network (NCCN). (2015). NCCN Clinical practice
guidelines in oncology. Smoking cessation (Version 1). Fort Washington, PA: Author.
20. Bjurlin, M.A., Cohn, M.R., Kim, D.Y., Freeman, V.L., Lombardo, L., Hurley, S.D., &
Hollowell, C.M. (2013). Brief smoking cessation intervention: A prospective trial in the
urology setting. Journal of Urology, 189(5), 1843-1849.
21. Tang, M., Oakley, R., Dale, C., Purushotham, A., Moller, H., & Gallagher, J. (2014).
Asurgeon led smoking cessation intervention in a head and neck cancer centre. BMC
Health Services Research, 14(1), 636.
22. Thomsen, T., Esbensen, B.A., Samuelsen, S., Tonnesen, H., & Moller, A.M. (2009).
Brief preoperative smoking cessation counselling in relation to breast cancer surgery:
Aqualitative study. European Journal of Oncology Nursing, 13(5), 344-349.
23. Thomsen, T., Tonnesen, H., Okholm, M., Kroman, N., Maibom, A., Sauerberg, M.L., &
Moller, A.M. (2010). Brief smoking cessation intervention in relation to breast cancer
surgery: A randomized controlled trial. Nicotine & Tobacco Research, 12(11), 1118-1124.
24. Lally, R.M., Chalmers, K.I., Johnson, J., Kojima, M., Endo, E., Suzuki, S., et al. (2008).
Smoking behavior and patient education practices of oncology nurses in six countries.
European Journal of Oncology Nursing, 12(4), 372-379.
25. Taniguchi, C., Hibino, F., Kawaguchi, E., Maruguchi, M., Tokunaga, N., Saka, H., et al.
(2011). Perceptions and practices of Japanese nurses regarding tobacco intervention for
cancer patients. Journal of Epidemiology, 21(5), 391-397.
26. Duffy, S.A., Louzon, S.A., & Gritz, E.R. (2012). Why do cancer patients smoke and what
can providers do about it? Community Oncol, 9(11), 344-352.
(2008). Clinical practice guideline: Treating tobacco use and dependence. Rockville, MD:
United States Department of Health and Human Services Public Health Service.
28. Gritz, E.R.,Toll, B.A.,& Warren, G.W. (2014). Tobacco Use in the Oncology Setting:
Advancing Clinical Practice and Research. Cancer Epidemiol Biomarkers Prev.,
23(1):39.
29. Gritz, E.R., Fingeret, M.C., Vidrine, D.J., Lazev, A.B., Mehta, N.V., & Reece, G.P. (2006).
Successes and failures of the teachable moment: Smoking cessation in cancer patients.
Cancer 106, 17-27.
30. Karam-Hage, M., Cinciripini, P.M., & Gritz, E.R. (2014). Tobacco use and cessation for
cancer survivors: An overview for clinicians. CA Cancer J Clin, 64(4), 272-290.
31. Wippold, R., Karan-Hage, M., Blalock, J., & Cincirpini, P. (2015). Selection of optimal
tobacco cessation medication treatment in patients with cancer. Clinical Journal of
Oncology Nursing, 19(2), 170-176.
32. Winnipeg Regional Health Authority. (2013). Management of Tobacco Use and
Dependence: Regional Clinical Practice Guideline. Author. Retrieved from
http://www.wrha.mb.ca/professionals/tobacco/files/CPG-MgmtTobaccoUse.pdf.
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33. Schnoll, R.A., Martinez, E., Tatum, K.L., Weber, D.M., Kuzla, N., Glass, M., et al. (2010).
A bupropion smoking cessation clinical trial for cancer patients. Cancer Causes &
Control, 21(6), 811-820.
34. Pro Doc Lte. (2014). Product Monograph: Pr Bupropion SR (bupropion hydrochloride
sustained release tablets) Antidepressant. Laval, QC: Author
35. Desmarais, J.E., & Looper, K.J. (2009). Interactions between tamoxifen and
antidepressants via Cytochrome P450 2D6. J Clin Psychiatry, 70(12), 1688-97.
36. Pfizer. (2015). Product Monograph: Champix (varenicline tartrate tablets)
Smokingcessation aid. Kirkland, QC: Author.
37. Park, E.R., Japuntich, S., Temel, J., Lanuti, M., Pandiscio, J., Hilgenberg, J., et al. (2011).
A smoking cessation intervention for thoracic surgery and oncology clinics: A pilot trial.
Journal of Thoracic Oncology: Official Publication of the International Association for the
Study of Lung Cancer, 6(6), 1059-1065.
38. National Comprehensive Cancer Network (NCCN). (2013). NCCN Clinical practice
guidelines in oncology. Distress management. Fort Washington, PA: Author.
39. Canadian Partnership Against Cancer (CPAC). (2012). Screening for distress, the 6th vital
sign: A guide to implementing best practices in person-centred care. Toronto, ON: Author.
40. Alberta Health Services. (n.d.). Screening for distress. Calgary, AB: Author.
41. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of
mental disorders. (5th ed.). Washington, DC: Author.
42. Morales, N.A, Romano, M.A, Cummings, K.M., Marshall, J.R., Hyland, A.J., Hutson, A.,
et al. (2013). Accuracy of self-reported tobacco use in newly diagnosed cancer patients.
Cancer Causes Control, 24(6): 1223-1230.
43. Warren, G.W., Arnold, S.M., Valentino, J.P., Gal, T.J., Hyland, A.J., Singh, A.K., et al.
(2012). Accuracy of self-reported tobacco assessments in a head and neck cancer
treatment population. Radiother Oncol, 103(1): 45-48.
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APPENDICES
Appendix 22 (a) CancerControl Alberta Clinical Practice Guideline: Tobacco Screening and
Treatment for Adult Cancer Patients
Appendix 22 (b) Additional Resources for Health Care Providers who Support Adults with Cancer
Appendix 22 (c) Alberta Health Services Screening for Distress Checklist
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Appendix 22 (a) CancerControl Alberta Clinical Practice Guideline: Tobacco

Screening and Treatment for Adult Cancer Patients (Page 1)
CLINICAL PRACTICE GUIDELINE SUPP-001
Version 1
TOBACCO SCREENING AND TREATMENT FOR

ADULT CANCER PATIENTS
Effective Date: October, 2015
The recommendations contained in this guideline are a synthesis of currently accepted approaches to management, derived
from a review of relevant scientific literature. Clinicians applying these guidelines should, in consultation with the patient, use
independent medical judgment in the context of individual clinical circumstances to direct care.
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CLINICAL PRACTICE GUIDELINESUPP- 001

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TABLE OF CONTENTS
Background ....................................................................................................................................... 3
Guideline Questions........................................................................................................................... 3
Development and Revision History ..................................................................................................... 4
Search Strategy .................................................................................................................................. 4
Target Population .............................................................................................................................. 5
Scope ................................................................................................................................................ 5
Definitions ......................................................................................................................................... 5
Summary of Recommendations.......................................................................................................... 6
1. Tobacco Use Screening (Ask) .............................................................................................................. 6
2. Education and Assessment (Advise/Assess) ....................................................................................... 7
3. Tobacco Treatment Plan (Assist) ........................................................................................................ 7
4. Referral, Monitoring and Follow-Up (Arrange) ................................................................................... 8
Discussion ........................................................................................................................................ 9
Dissemination ............................................................................................................................... 13
Maintenance .................................................................................................................................. 13
Conflict of Interest ........................................................................................................................... 13
Appendices .................................................................................................................................... 14
Appendix A: Brief Tobacco Intervention Treatment Pathway................................................................ 14
Appendix B: Sample Brief Intervention Scripts ...................................................................................... 15
References ..................................................................................................................................... 17
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BACKGROUND
In 2015, an estimated 17,000 Albertans will be diagnosed with cancer and 6,500 people will die of it.1
Smoking is the leading preventable risk factor for cancer and is responsible for an estimated 30% of all
cancer-related deaths, as well as the majority of lung (75.6%) and larynx (74.3%) cancers within
Alberta.2,3
Tobacco screening and cessation treatment for cancer patients is a key to high-quality oncology care.
An estimated 25 - 80% of individuals who smoke will continue smoking following their diagnosis.4
Continued tobacco use following a cancer diagnosis is associated with reduced treatment effectiveness,
increased risk of cancer recurrence, greater treatment-related toxicity, increased risk of second primary
cancer and mortality.5,6 The 50th anniversary of the Surgeon General's report on smoking reported that
tobacco cessation at the time of cancer diagnosis could lower the risk of death by up to 40% with the
benefits of cessation being equal to, or even exceeding, the value of the latest cancer therapies.6
While Alberta has made clinical and policy advancements to inform tobacco cessation activities in
healthcare settings, tobacco use screening and the offer of treatment is routinely integrated as a
standard of practice in cancer care across the province.7,8 Tobacco intervention by health care
professionals has been shown to be effective in increasing the abstinence rate in cancer patients.9
The integration of tobacco screening and cessation treatment into oncology care has been
recommended by a number of national and international cancer-focused organizations as a best
practice intervention.4,9-15 This guideline outlines evidence-informed recommendations for tobacco
cessation treatment for adult cancer patients and their families in cancer care settings in Alberta.
GUIDELINE QUESTIONS
1. Are cancer patients who are current tobacco users, compared to those who are never or former
tobacco users, at increased risk for poorer cancer treatment outcomes, prognosis and quality of
life?
2. Is a cancer diagnosis an important window of opportunity or teachable moment for tobacco
cessation for patients and their families?
3. Does brief tobacco intervention (ASK, ADVISE, ASSESS, ASSIST, ARRANGE) in cancer care increase
tobacco cessation rates?
4. Does intensive tobacco interventions (multiple sessions that include problem solving and skills
training) in cancer care increase tobacco cessation rates?
5. Does cessation pharmacotherapy (with or without behavioural support) in cancer care, increase
tobacco cessation rates?
6. How does concurrent tobacco treatment (behavioural and/or pharmacotherapy support) impact
cancer treatment (e.g. chemotherapy, radiation surgery)?
7. What are the rates of desire to quit, quit attempts, quit success and relapse for cancer patients who
are identified as tobacco users?
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DEVELOPMENT AND REVISION HISTORY

This guideline builds on the Alberta Health Services Tobacco Free Future Guidelines, which were
informed by the national CAN-ADAPTT smoking cessation guidelines and the Ottawa Model for Smoking
Cessation and are currently implemented in many settings across the province.
This guideline was reviewed and endorsed by a working group representing CancerControl Alberta, the
Alberta Cancer Prevention Legacy Fund, and the Tobacco Reduction Program. Membership captured
key stakeholders involved in cancer care (medical oncologist, pharmacist, advanced practice nurse,
respiratory therapist) as well as Alberta Health Services staff with content expertise in tobacco
cessation and/or cancer treatment.
Recommendations were informed by the best available evidence (see Search Strategy below).
Following a first round of consensus by the working group, a consultation survey was circulated to
CancerControl and external (provincial, national and international) reviewers on the basis of their
clinical, content and/or methodological expertise. Final review of, and consensus on, the guideline was
reached by members of the internal working group.
A detailed description of the methodology followed during the guideline development process can be
found in the Guideline Resource Unit handbook.
SEARCH STRATEGY
The search strategy was selected and reviewed by members of the Guideline Working Group with
support from an Alberta Health Services research librarian.
The PubMED, EMBASE, Medline, Cochrane Database of Systematic Reviews, CINAHL, PsycINFO and
Pharmacy databases were searched from 2008 to February 2015 for literature on tobacco cessation
interventions in a cancer care setting and associated impacts on tobacco use reduction and/or cessation.
A variety of separate and combined search terms were used, including but not limited to: cancer
patients, caregiver, staff, tobacco intervention, tobacco cessation treatment, cessation
pharmacotherapy, cancer, cancer treatment, risk factors, quality of life, windows of opportunity,
recurrence, relapse and quit rates. Results were limited to randomized controlled trials, systematic
reviews and observational studies published in English. Grey literature (e.g., Google, Google Scholar,
ProQuest) as well as the reference lists of key articles were also searched for additional publications.
Excluded from the analysis were pediatric cancer patients, tobacco treatment interventions that occur
outside of cancer care (e.g. primary care) and non-oncology patients. A total of 74 studies were
identified for inclusion.
Clinical guidelines databases (e.g. National Institute for Health and Care Excellence, the National
Guidelines Clearinghouse, SAGE Directory,) and guideline bodies (i.e., CAN-ADAPTT, US Department of
Health and Human Services, National Comprehensive Cancer Network, American Society of Clinical
Oncology) were also searched for guidelines on smoking cessation in cancer care settings. The search
returned 8 guidelines.
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The Tobacco Screening and Treatment in Cancer Care Guidelines and supporting evidence can be
accessed at http://www.albertahealthservices.ca/cancerguidelines.asp
TARGET POPULATION
This guideline is written for use by health professionals working with adult cancer patients (aged 18
years and older) at any phase of the cancer care continuum regardless of cancer type, stage (including
metastatic) or treatment plan. Components of this guideline are also applicable to the patients family
and/or caregivers, where indicated. This guideline is intended for use in both inpatient and ambulatory
(outpatient) settings.
SCOPE
The recommendations contained in this guideline support the implementation of brief tobacco
intervention using the evidence-based 5 As model (ASK, ADVISE, ASSESS, ASSIST, ARRANGE). The
standards for more intensive intervention are not included in the guideline at this time.
DEFINITIONS
Authorized Prescriber means a health care professional who is permitted to prescribe medications
as defined by federal and provincial legislation, her/his regulatory college, Alberta Health Services,
and his/her practice setting (where applicable).
Tobacco Use includes the use of cigarettes, cigars, cigarillos, pipe, chew/spit, and waterpipe (e.g.,
Hookah)
Brief Tobacco Intervention (BTI) is an evidence-based technique involving a short focused session
to screen for tobacco use, offer cessation advice and treatment, and refer to more intensive
treatment or other supports if appropriate. The intervention aims to increase an individuals
awareness of their tobacco and motivation to change and is guided by the 5 A's model. BTI can be
delivered by a range of health professionals and is intended to less than 3 minutes.
Intensive Tobacco Interventions are delivered by health providers trained in cessation behavioural
counselling and follow best-practice guidelines for intensive tobacco treatment. An intensive
intervention involves a series of consultations that each last in excess of 10 minutes and involves
practical counselling, skills training and intra-treatment social support.
Health Record means the Alberta Health Services legal record of the patients diagnostic, treatment
and care information.
Health Professional means an individual who is a member of a regulated health discipline, as
defined by the Alberta Health Disciplines Act or Health Professions Act, and who provides
promotional, preventive, curative, or rehabilitative care as per their defined scope or role.
Patient means an adult who receives or has requested health care or services from Alberta Health
Services and its health care providers or individuals authorized to act on behalf of Alberta Health
Services. This term is inclusive of residents, clients and outpatients.
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SUMMARY OF RECOMMENDATIONS
1. Brief tobacco intervention (up to 3 minutes) using the 5 As model (ASK, ADVISE, ASSESS, ASSIST,
ARRANGE) shall be offered to all cancer patients who are admitted to a CancerControl Alberta
facility/program.
2. All tobacco users shall be offered first-line cessation pharmacotherapy in combination with
behavioural counselling as the most effective tobacco treatment.
3. Health professionals shall engage in ongoing monitoring and follow-up of cessation treatment
plan.
4. Tobacco use screening, provision of advice and cessation information and referral should be
offered to accompanying family and/or caregivers, where appropriate.
Note: A brief tobacco intervention treatment pathway within cancer care is provided in Appendix A.
The recommendations below offer more detailed guidance to implement a brief tobacco intervention.
1.
Tobacco Use Screening (ASK)

1.1 Routinely ask every patient and about their tobacco use at the first consult at a
CancerControl Alberta facility for a cancer diagnosis with follow-up screening and/or
assessment at critical time points, including but not limited to: pre/post chemotherapy,
radiation and/or transfer of care.
a) If patient is a tobacco user, screen should capture
tobacco use within past 30 days (high relapse risk)
tobacco use within the past year
exposure to second-hand smoke in the home
types of tobacco products used , including smokeless tobacco
pattern of use
b) If patient is NOT a tobacco user and not exposed to second hand smoke, STOP THE
INTERVENTION.
1.2 Document tobacco use status on all patient health record and/or site referral and discharge
forms.
1.3 Routinely ask accompanying caregivers/family members about their tobacco use and
exposure to second-hand smoke. No documentation required.
1.4 Reference the AHS Tobacco Dependence and Cessation Brief Intervention Form to facilitate
and document tobacco screening and intervention.
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Note about e-cigarette use: At this time, Health Canada has not fully evaluated e-cigarettes for safety, quality
and efficacy, and advises Canadians against the purchase or use of e-cigarettes/vaping products. Therefore
AHS recommends approved first-line cessation pharmacotherapy (Recommendation 3.3)
2.
Education and Assessment (ADVISE/ASSESS)

2.1 Inform patients and accompanying caregivers/family members that all AHS facilities and
grounds are tobacco free as per the AHS Tobacco and Smoke Free Environments Policy.
2.2 Provide recent quitters (past year) with brief relapse prevention advice on the importance of
remaining tobacco free.
2.3 Advise current tobacco users to quit. Tailor advice to the patients cancer type, stage and
treatment plan. Reference Brief Tobacco Intervention Sample Scripting (Appendix B) as
needed. Advice should focus on:
health effects of continued tobacco use, including impact on cancer treatment.
benefits of cessation.
benefit of counselling and medication as most effective treatment.
2.4 Assess interest in cessation treatment (counselling and/or medication) to achieve abstinence
or relieve symptoms of nicotine withdrawal.
2.5 Document any advice provided on patient health record and /or site referral and discharge
forms.
2.6 If appropriate, advise on importance of reducing exposure to second-hand-smoke with
message of cessation to accompanying caregivers/family members who identify as tobacco
users (see Recommendation 1.3). No documentation required.
2.7 Refer to AHS Tobacco Dependence and Cessation Brief Intervention Form to facilitate and
document tobacco screening and intervention.
3.
Tobacco Treatment Plan (ASSIST)

3.1 Provide patients and their families/caregivers with tobacco cessation information resources.
3.2 Based on interest, offer approved cessation pharmacotherapy (nicotine replacement therapy,
bupropion SR and/or varenicline) and counselling as the optimal treatment for tobacco
cessation. Cessation treatment should be offered to all patients prior to cancer treatment,
where possible.
3.3 Where patient expressed interest in cessation treatment, refer patient to the Tobacco
Treatment and Support Clinic using the Clinic Referral Form for more intensive counselling,
pharmacotherapy initiation, follow-up and/or management. Note: Caregivers and/or families
members who use tobacco can also be referred or self-refer.
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a) Where follow-up and response to cessation treatment can be monitored,

pharmacotherapy can be initiated by an available authorized prescriber (physician,
pharmacists, nurse practitioner). The following considerations and contraindications
should be noted:
Some forms of NRT may be contraindicated in the immediate pre/post-operative period
in patients who undergo tissue reconstruction where revascularization is a concern.
These cases should be discussed on an individual basis with the surgeon and healthcare
team. In such cases, non-nicotine treatments for smoking cessation (e.g.,varenicline,
bupropion) are alternate options to support cessation.
Oral NRT (e.g., gum, lozenge, spray, inhaler) may not be appropriate for use for
individuals with oral cancer or cancer patients whose treatment impacts the oral
mucosa.
Varenicline may cause nausea and should be prescribed with caution and with close
monitoring in patients undergoing nausea-inducing treatment, who have a history of
seizures or who are at seizure risk and/or in patients experiencing depressive
symptoms.
Bupropion should not be prescribed to patients at risk for seizures, patients taking MAO
inhibitors and/or breast cancer patients taking tamoxifen.
3.4 Where a patient is not interested in cessation treatment:
a) Leave offer of support open.
b) Provide contact information for Tobacco Treatment and Support Clinic with offer of selfreferral.
3.5 Inpatients without access to tobacco products for an extended period of time (e.g., admitted
to hospital, palliative), shall be offered appropriate NRT to support withdrawal as per site
standards. See Recommendation 3.2 (a) for clinical considerations around NRT use with
patients undergoing reconstructive surgery.
3.6 Outpatients receiving treatment(s) should be encouraged to use a personal supply of
cessation medication to manage withdrawal.
3.7 Document treatment plan on patient health record and/or site referral or discharge forms.
Refusal of treatment should also be noted.
4.
Referral, Monitoring and Follow-Up (ARRANGE)

4.1 Refer patient to Tobacco Treatment and Support Clinic and/or other community-linked
referrals (e.g., Alberta Quits) for on-going support
4.2 For inpatients, arrange for pharmacotherapy on transfer or discharge as per site standards.
This includes prescription for continuation of medication or referral to alternate prescriber
(e.g., pharmacists, family physician) to initiate and/or monitor.
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4.3 Document referral/discharge treatment plan on patients health record and/or site referral
or discharge forms.
Note: More detailed information on conducting a brief intervention, including sample scripts for non-cancer
populations can be found in the Tobacco Free Futures Guidelines. A new chapter on Adults with Cancer (chapter
22) has been added to these guidelines for further reference.
DISCUSSION
Impact of Continued Tobacco Use on Cancer Outcomes
Current evidence strongly supports quitting smoking following a cancer diagnosis. The 2014 Surgeon
Generals Report concluded that there is sufficient causal evidence between smoking and increased allcause mortality, increased cancer-specific mortality and increased risk of developing second primary
cancers.6 Smoking was further associated with an increased risk of cancer recurrence, poorer response
to treatment and increased treatment-related toxicity.6 Indeed, estimates suggest that quitting
smoking at the time of diagnosis could lower the risk of dying by up to 40% with the benefits of
cessation being equal to or exceeding the value of new cancer therapies for some cancer diagnoses.6
The benefits of cessation go beyond cancers known to be caused by tobacco use, with increased
mortality rates associated with continued smoking after diagnosis reported across cancer types and
stages of diagnosis.15-18 Results of a meta-analysis with early stage non-small-cell lung cancer (NSCLC)
and limited stage small-cell lung cancer showed continued smoking increased the risk of all-cause
mortality, recurrence and development of a second primary tumour.19 In patients with NSCLC, quitting
smoking was associated with an estimated five-year survival rate of 70% compared to 33% in those who
continued to smoke. Survival rates were comparable for patients with SCLC at 63% and 29% in quitters
and those who continued to smoke, respectively.19
There is consistent evidence that tobacco use, namely smoking, reduces the efficacy of radiation
therapy and some chemotherapy agents 6,20-22 and increases the risk for treatment-induced
complications including surgical site infections, pulmonary function and return to operating room.15,23-25
Studies further report an association between smoking and increased risk of recurrence following
cancer treatment (radiation, chemotherapy, surgery) among patients with head and neck cancers,
16,21,26,27
prostate cancer,28 urothelial cancer29,and gastrointestinal cancers.30
Impact of Tobacco Use on Cancer Treatment: Chemotherapy Considerations
Tobacco smoke can interfere with the pharmacokinetics (PK) mechanisms of several chemotherapy
drugs, potentially causing an altered pharmacologic response.22,31 Tobacco smoke increases the amount
of drug binding protein (AAG) resulting in induction of cytochrome-450 enzymes (primarily CYP1A2) and
UGT isoenzymes which metabolize several chemotherapy drugs, including erlotinib and irinotecan.
Because it is the tobacco smoke ,(not the nicotine component), that affects the PK mechanisms,
nicotine replacement therapy does not impact CYP1A2 activity or reduce cancer drug efficacy.
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Erlotinib
Commonly used in the treatment of non-small-cell lung and pancreatic cancers, erlotinib is primarily
metabolized by CYPs 3A4 and 1A2. Cigarette smoking has been shown to cause induction of several CYP
enzymes primarily by CYP3A4 but also by CYP1A2, resulting in more rapid metabolism and decreased
systemic exposure to the drug.31 Data analyzed from seven clinical trials that administered the standard
dose of erlotinib (150 mg once daily) found that smoking status was a significant covariate affecting
drug clearance.22 Patients who smoked and who were treated with erlotinib experienced a 23.5%
increase in clearance and had lower (nearly half) median steady-state trough plasma concentrations
compared to never and former smokers.22,32 An increased dose of erlotinib may benefit patients with
NSCLC who continue to smoke following diagnosis. Dosing consideration should also be given to
patients exposed to secondhand smoke.32
Irinotecan
Smoking is known to alter the pharmacokinetics (PK) of irinotecan (CPT-11), a topoisomerase-I inhibitor
used to treat a variety of cancers (e.g., colon, rectum, lung, bone). While not definitive, a study of
cancer patients treated with irinotecan (n=190) found those who smoked experienced 40% lower
systemic exposure to the active metabolite SN-38 (median, 0.54 v 0.87 ng x h/mL/mg; P < .001); 18%
faster clearance (median, 34.8 versus 29.5 l/hour, p = 0.001); and less neutropenia (6% in smokers
versus 38% in nonsmokers) (odds ratio [OR], 0.10; 95% CI, 0.02 to 0.43; P < .001) compared to nonsmokers. 33 The effects of smoking on irinotecan PK may be attributed to induction and modulation of
the CYP3A and UGT1A1 enzymes involved in the drugs metabolism.22,33 The personalization of
irinotecan therapy by increasing irinotecan doses in patients who smoke has been proposed. 31
Quit Behaviours and Efficacy of Tobacco Cessation among Cancer Patients
Long-term abstinence is an important performance measure and clinical outcome for cessation
interventions.34 In the United States , an estimated 62% of patients recently diagnosed with cancer
identified as current smokers, recent quitters (quit within the last 12 months),or former smokers.35
While cancer patients experience high short-term cessation rates, particularly among those with
smoking-related cancers, relapse is common and higher among those experiencing comorbid mental
health and/or addiction issues.36-38
Results of a longitudinal study examining smoking behaviours following surgical treatment among lung,
head and neck cancer patients (n=154) who smoked the week before surgery reported a 60% relapse
rate at 12 months following their surgery compared to 13% of patients who were abstinent presurgery.39 Using backward regression analysis, low quitting self-efficacy (p=.029), higher depression
proneness (p=.037), and fear over cancer recurrence (p=.028) were cited reasons for relapse.39
Tobacco Screening and Intervention in Cancer Care
The 5 As model (ASK, ADVISE, ASSESS, ASSIST, AND ARRANGE) is a recognized best practice to support
tobacco cessation across different health-care settings and populations, with emerging evidence of
potential effectiveness for cancer patients and their families.8,12,34,40-42
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A number of factors contribute to the success of tobacco cessation, including acknowledging and
diminishing feelings of guilt and shame linked with continued smoking following a cancer diagnosis,43
and the involvement of family members and/or caregivers.44,45
While few studies have addressed the optimal intensity of tobacco interventions with cancer patients
and their families, more intensive counselling with multiple sessions, combined with medication, has
been associated with higher quit rates in clinical settings.6,12 A brief intervention as a minimum is highly
recommended in cancer treatment settings and has been shown to increase quit rates by 1 - 3%. 2,40,41,46
The results of a meta-analysis used to inform the U.S. Public Health Service Clinical Practice Guideline
on treating tobacco use and dependence reported the following pooled odds ratio: 1.3 (95% CI=1.011.6) for brief counselling (<3 minutes); 1.6 (95% CI=1.2-2.0) for low intensity counseling (3-10 minutes);
and 2.3 (95% CI=2.0-2.7) for higher intensity counseling (>10 minutes).47
Initiating tobacco screening and intervention at the time of diagnosis and/or during the preoperative
period is consistently recommended as best practice regardless of cancer type or level of
intervention.8,12,34
Tobacco Treatment Consideration among Cancer Patients
There is consistent evidence that combining pharmacologic and behaviour counselling is the most
effective treatment and leads to the best cessation results among cancer and non-cancer patients.
While few controlled studies have tested the effectiveness of tobacco treatment interventions in
patients with cancer, current practice guidelines recommend nicotine replacement therapy (NRT),
bupropion and/or varenicline as first line pharmacotherapy in conjunction with behavioural /counselling
support.7,8,11,12
Results from a meta-analysis looking at odds ratios and abstinence rates for first-line cessation
medications compared with placebo 6 months after quitting in the general population found that
varenicline is more efficacious than both bupropion and the use of one NRT product but is similarly
efficacious to combination NRT.47 The number needed to treat (NNT) statistics at 12-month follow-up
for pharmacologic interventions is reported as 10 for both the NRT patch and inhaler, 8 for varenicline
and 10 for bupropion.48
Another meta-analysis comparing smoking cessation interventions with usual care in cancer patients
similarly found that the combined use of pharmacological (NRT and varenicline) and behavioural
therapy were most effective at improving quit rates.34
Clinical Considerations and Contraindications for Cancer Patients
Nicotine Replace Therapy (NRT)

Oral products, including gum, lozenges, spray and inhalers, may be irritating to the oral mucosa and
therefore may not be appropriate for use for individuals with oral cancer, or with head and neck
cancer who are undergoing radiation and/or receiving chemotherapy with high incidence of
stomatitis.49
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Some forms of NRT may be contraindicated in the immediate pre- and/or post-operative period in
patients who undergo tissue reconstruction where revascularization is a concern. These cases
should be discussed on an individual basis with the surgeon and health-care team. In such cases,
non-nicotine treatments for smoking cessation are alternate options (e.g., varenicline, bupropion).50
Bupropion
Bupropion is contraindicated for patients with CNS tumours or for any patient at increased risk of
seizure.47 In cancer patients experiencing depression symptoms, bupropion has been shown to
increase abstinence rates, decrease withdrawal symptoms and increase quality of life compared to
those with no depression symptoms.51
Bupropion is contraindicated in cancer patients taking tamoxifen as it impacts the metabolism of
tamoxifen by inhibiting conversion to its active metabolites.52 In the general population, bupropion
can reduce appetite and prevent weight gain and may warrant monitoring if prescribing in patients
who may experience weight loss related to their cancer treatments.49 There is a risk of potential
worsening symptoms of depression or emergence of suicidal thoughts and behaviours when taking
bupropion and therefore requires careful monitoring in cancer patients who may be psychologically
vulnerable.
Varenicline
To date, there are no reported studies of interactions between varenicline and commonly used lung
cancer therapies.22 A small study testing the effectiveness of varenicline and behavioural support in
a cohort of cancer patients reported nausea as the most common side effect, similar to rates
reported within general population.9 Dosage and appropriateness is therefore a consideration with
cancer patients who are experiencing nausea as a side effect of cancer treatments.49
Varenicline should be used cautiously in patients with a history of seizures or conditions that lower
seizure threshold.53 Close monitoring is required for neuropsychiatric symptoms with consideration
of nicotine replacement therapy as an alternate treatment option.53 Due to the psychological and
medical vulnerability of cancer patients, varenicline is encouraged to be used along with intensive
behavioural counselling to support cessation.9
54-56
While there have been studies of adverse cardiovascular events in patients taking varenicline
overall data suggest that the benefit of varenicline, as the most effective cessation drug in clinical
trials, outweighs the low risk of adverse events associated with its use.57 Personalization of
varenicline and close monitoring are still encouraged if prescribing in patients with cardiovascular
disease.
E-cigarettes
There is currently insufficient evidence to support the recommendation of e-cigarettes or
smokeless tobacco in tobacco cessation with cancer patients due to lack of evidence of their safety,
quality or efficacy.5
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DISSEMINATION
Present the guideline at the local and provincial tumour team meetings and weekly rounds.
Present guideline to the Cancer Strategic Clinical Network and other relevant SCN meetings
Post the guideline on the Alberta Health Services GURU website and Alberta Prevents Cancer
website
Conduct trainings with health-care professionals, including allied health, on implementing the
guideline.
Send electronic notification of new guideline to all members of Cancer Control Alberta
MAINTENANCE
A formal review of the guideline will be conducted in 2018 by the Tumour Team Council, with additional
input from identified members of the guideline working group, if needed. If critical new evidence is
brought forward before that time, the guideline working group will revise and update the document
accordingly.
CONFLICT OF INTEREST
Participation of the guideline working group members has been voluntary and the authors have not
been remunerated for their contributions. There was no direct industry involvement in the
development or dissemination of this guideline. CancerControl Alberta recognizes that although
industry support of research, education and other areas is necessary in order to advance patient care,
such support may lead to potential conflicts of interest. While some members of the working group are
involved in research funded by industry or have other such potential conflicts of interest, the
developers of this guideline are satisfied it was developed in an unbiased manner.
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APPENDIX A: BRIEF TOBACCO INTERVENTION TREATMENT PATHWAY
ASK
ADVISE
Ask every patient and accompanying family/caregiver about tobacco use (personal
and in the home) at first CancerControl appointment and at critical time points.

in the past 30 days? Past year?
NO
Positive
reinforcement.
Document patient
response as per site
standards.
YES
STOP
For patients ask: what type? how much? how often? last use?

Advise to quit (remain tobacco free) with personalized message (tailor to cancer type, stage and treatment).
Provide relapse prevention advice to recent quitters (within last year).
Advise to reduce exposure to second-hand smoke where possible (e.g. home & vehicle).
Education and Assessment
ASSESS
Tobacco Use Screening
Brief Tobacco Intervention for Adults with Cancer
It is never too late to stop using tobacco.

Quitting (remaining tobacco free) may improve your response to treatment and decrease side effects.
A tobacco-free environment will promote the health of everyone in the family and help prevent relapse.
Assess interest in counselling and/or medication to relieve withdrawal symptoms and achieve abstinence .
Are you interested in support to reduce your withdrawal symptoms
or to help you quit or remain tobacco free?
Are you interested in a referral to the Tobacco Support Clinic? (or other available services)
ASSIST
Tobacco Treatment Plan
ARRANGE
Monitoring/Referral
YES
Refer to Tobacco Treatment and Support Clinic (or other available services).
When possible at visit, available prescriber should order cessation medication.
To maintain comfort from withdrawal during treatment:
a) for inpatients, provide cessation medication (initiation or continuation).
b) for ambulatory patients, encourage use of personal cessation medication.
Provide self help resources to patient/family to support cessation
and reduction of exposure to second-hand smoke.
NO
Leave open offer of
support.
Provide self help,
materials including how to
self refer to clinic/services
(patients & family).
Document as per site
standards.
Arrange ongoing support by referring patients to either

Tobacco Treatment and Support Clinic / AlbertaQuits / or other available services.
Arrange for continued pharmacotherapy (e.g. on transfer/discharge).
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APPENDIX B: SAMPLE BRIEF INTERVENTION SCRIPTS

Patient Response
Whats the point in

quitting now? The
harm has already
been done.
My life is too
stressful to quit
smoking right now.
Health Professional Response
I understand why you might feel this way, but it is never

too late to quit. I know its hard, but stopping your
tobacco use can improve the effectiveness of your
chemotherapy and radiation treatments and may protect
you from getting a second primary cancer. I can refer you
to the Tobacco Treatment Support Clinic for help with
quitting. Provide family/patient with available
information resources.
This is a very stressful time for you and although
smoking gives you the feeling of relieving stress, it
actually puts more stress on your body. The staff at the
Tobacco Treatment and Support Clinic can help you find
new ways to deal with stress. You can contact them
directly or I can refer you. Provide family/patient with
available information resources.
Ive cut down, but I

dont think I can
quit completely.
It is great that you have cut down, but using any tobacco
may reduce the benefit/effectiveness of your treatment.
The Tobacco Treatment and Support Clinic can work with
you to develop a plan to quit completely. You can contact
them directly or I can refer you. Provide family/patient
with available information resources.
Now is not a good

time to talk about
my smoking.
I understand that this is a very difficult time for you and

that smoking may be your last concern. But, as your
doctor (member of oncology team), I want to help you
stay as healthy as possible and get the most out of your
treatment. Stopping smoking will do that. If you arent
ready right now, I can tell you how to contact the Tobacco
Treatment and Support Clinic when you are ready. We
can also discuss it further at your next appointment.
Provide family/patient with available information
resources.
I can understand that it feels like nagging, but as your
physician (member of oncology team) I want to help you
stay as healthy as possible and benefit the most from
your treatment. Quitting is one of the most important
things you can do. If you arent ready right now, I can tell
you how to contact the Tobacco Treatment and Support
Clinic when you are ready. Provide family/patient with
The last thing I

need right now is a
lecture about my
smoking. OR I
wish people would
stop nagging me
about my smoking.
Rationale
Addresses the myth that the

damage is done and focuses
on the current benefits of
quitting.
Acknowledges the patients

feelings, clarifies the myth
that smoking relieves stress
and provides assurance that
help is available to help deal
with the stress of the
diagnosis and quitting
tobacco.
Provides positive
reinforcement for efforts to
date, but encourages
continuing toward cessation.
Reinforces the fact that
support is available.
Acknowledges the patients
feelings, but reinforces the
importance of tobacco
cessation to support cancer
treatment plan. Supports
patient autonomy, but leaves
offer of support open.
Reinforces a non-judgmental
approach and reinforces the
importance of tobacco
cessation for cancer
treatment.
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Ive tried quitting

before and its just
too hard.
I actually really like

smoking/ using
tobacco products.
I know that quitting takes a lot of effort and it may take

(have taken) a few tries to be successful. Quitting is one
of the most important things you can do to maximize the
effectiveness of your cancer treatment. I can refer you to
the Tobacco Treatment Support Clinic or you can call
them when you are ready. Provide family/patient with
I can appreciate that the decision to quit is a big one, but
as your physician (member of oncology team) I want to
help you stay as healthy as possible and benefit the most
from your cancer treatment. Quitting is one of the most
important things you can do. I can refer you to the
Tobacco Treatment Support Clinic or you can call them
when you are ready. Provide family/patient with
Acknowledges that quitting is

difficult, but stresses the
importance of stopping
tobacco use and the help
that is available.
Reinforces the importance of
quitting for improved health
and cancer treatment
outcomes.
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O'Malley M, King AN, Conte M, Ellingrod VL, Ramnath N. Effects of cigarette smoking on
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27. Ouyang PY, Su Z, Mao YP, Liang XX, Liu Q, Deng W et al. Prognostic impact of cigarette smoking on
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28. Joshu CE, Mondul AM, Meinhold CL, Humphreys EB, Han M, Walsh PC et al. 011). Cigarette smoking
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29. Rink M, Zabor EC, Furberg H, Xylinas E, Ehdaie B, Novara G et al. Impact of smoking and smoking
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33. van der Bol JM, Mathijssen RH, Loos WJ, Friberg LE, van Schaik RH, de Jonge MJ et al. Cigarette
smoking and irinotecan treatment: pharmacokinetic interaction and effects on neutropenia. J Clin
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34. Nayan S, Gupta MK, Strychowski JE, Sommer DD. Smoking cessation interventions and cessation
rates in the oncology population. An updated systematic review and meta-analysis. Otolaryngol
Head Neck Surg 2013;149(2): 200-211.
35. Warren GW, Kasza KA, Reid ME, Cummings KM, Marshall JR. Smoking at diagnosis and survival in
cancer patients. Int J Cancer 2013; 132(2): 401410.
36. Toll BA, Brandon TH, Gritz ER, Warren GW, Herbst RS. Assessing tobacco use by cancer patients and
facilitating cessation: An American Association for Cancer Research policy statement. Clin Cancer
Res 2013; 19(8): 1941-1948.
37. Schnoll RA, Martinez E, Langer C, Miyamoto C, Leone F. Predictors of smoking cessation among
cancer patients enrolled in a smoking cessation program. Acta Oncol.2011;50(5): 678-684.
38. Hopenhayn C, Christian W J, Christian A, Studts J, Mullet T. Factors associated with smoking
abstinence after diagnosis of early stage lung cancer. Lung Cancer. 2013; 80(1): 55-61.
39. Simmons VN, Litvin EB, Jacobsen PB, Patel RD, McCaffrey JC, Oliver JA, et al. Predictors of smoking
relapse in patients with thoracic cancer or head and neck cancer. Cancer. 2013;119:14201427.
40. Tang M, Oakley R, Dale C, Purushotham A, Moller H, Gallagher J. A surgeon led smoking cessation
intervention in a head and neck cancer centre. BMC Health Serv Res.2014;14(1): 636.
41. Thomsen T, Tonnesen H, Okholm M, Kroman N, Maibom A, Sauerberg ML, Moller AM. Brief
smoking cessation intervention in relation to breast cancer surgery: A randomized controlled trial.
Nicotine Tob Res. 2010;12(11): 1118-1124
42. de Bruin-Visser JC, Ackerstaff AH, Rehorst H, Retel VP, Hilgers FJ. Integration of a smoking cessation
program in the treatment protocol for patients with head and neck and lung cancer. Eur Arch
Otorhinolaryngol.2012; 269(2): 659-665.
43. Cooley ME, LundinR, Murray L. Smoking cessation interventions in cancer care: Opportunities for
oncology nurses and nurse scientists. Annu Rev Nurs Res.2009; 27: 243-272.
44. Weaver KE, Rowland JH, Augustson E, Atienza AA. Smoking concordance in lung and colorectal
cancer patient-caregiver dyads and quality of life. Cancer Epidemiol Biomarkers Prev.
2011;20(2):239-248.
45. Patterson F, Wileyto EP, Segal J, Kurz J, Glanz K, Hanlon A. Intention to quit smoking: role of
personal and family member cancer diagnosis. Health Educ Res. 2010; 25(5): 792-802.
46. Bjurlin MA, Cohn MR, Kim DY, Freeman VL, Lombardo L, Hurley SD et al. Brief smoking cessation
intervention: A prospective trial in the urology setting. J Urol. 2013;189(5):1843-1849.
47. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical
Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health
Service. May 2008.
48. RxFiles drug comparison charts book. 10th ed. Smoking Cessation Pharmacotherapy. Saskatoon, SK:
Saskatoon Health Region; 2008. Available from www.RxFiles.ca
49. Karam-Hage M, Cinciripini .M, Gritz ER. Tobacco use and cessation for cancer survivors: an overview
for clinicians. CA Cancer J Clin. 2014; 64(4):272-290.
50. Winnipeg Regional Health Authority. (2013). Management of Tobacco Use and Dependence:
Regional Clinical Practice Guideline. Winnipeg, Manitoba, 2013. Retrieved from
http://www.wrha.mb.ca/professionals/tobacco/files/CPG-MgmtTobaccoUse.pdf
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51. Schnoll RA, Martinez E, Tatum KL, Weber DM, Kuzla N, Glass M et al. A bupropion smoking cessation
clinical trial for cancer patients. Cancer Causes Control. 2010; 21(6):811-820.
52. Desmarais JE, Looper KJ. Interactions between tamoxifen and antidepressants via Cytochrome P450
2D6. J Clin Psychiatry. 2009;70(12):1688-97.
53. Pfizer. Product Monograph: Champix (varenicline tartrate tablets) Smoking Cessation Aid.
Kirkland, QC: Author.2015
54. Singh S, Loke YK, Spangler JG, Furberg CD. Risk of serious adverse cardiovascular events associated
with varenicline: a systematic review and meta-analysis. CMAJ. 2011; 183 (12): 13591366
55. Prochaska J, Hilton J. Risk of cardiovascular serious adverse events associated with varenicline use
for tobacco cessation: systematic review and meta-analysis. BMJ.2012; 344: e2856
56. Ware J et al. Cardiovascular safety of varenicline: patient-level meta-analysis of randomized,
blinded, placebo-controlled trials. Am J Ther. 2013; 20: 235246
57. Sharma A et al. Cardiovascular adverse events associated with smoking-cessation
pharmacotherapies. Curr Cardiol Rep. 2015;17(1):554
58. Alberta Health Services. Tobacco Information Series: Electronic Smoking Products. Available at:
http://www.albertaquits.ca/files/AB/files/library/FINALElectronic_Smoking_Products_Tobacco_Info
rmation_Series_R1_.pdf (Accessed September 14, 2015)
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Appendix 22 (b) Additional Resources for Health Care Providers who Support Adults
with Cancer

American Society of Clinical Oncology (ASCO): Worlds leading professional

organization representing oncology physicians of all oncology subspecialties who care for
people with cancer. Website includes a repository of oncology practice guidelines, clinical
tools and resources. Tobacco specific resources for oncology providers are available.
(www.asco.org/practice-research/tobacco-cessation-and-control-resources)
CAN-ADAPTT: A website for smoking cessation knowledge exchange, networking and

clinical guidelines. (www.nicotinedepencenceclinic.com)
Canadian Partnership Against Cancer (CPAC): Partnership of cancer control partners

from across Canada working toward a shared goal of a future in which fewer Canadians
get and die from cancer and those living with the disease have an improved quality of life.
Current initiatives include integration of tobacco control and cancer control.
(www.partnershipagainstcancer.ca)
Cancer.Net: ASCOs patient information website. Provides information on the impact of

tobacco use during cancer treatment and stopping tobacco use after a cancer diagnosis.
(www.cancer.net/navigating-cancer-care/prevention-and-healthy-living/tobacco-use)
Centre for Addictions and Mental (CAMH) TEACH: Ontario knowledge translation
initiative to build interprofessional capacity in evidence-based tobacco dependence
treatment. Provides links to course schedules, online offering (courses and webinars),
aswell as archived events. (www.nicotinedependenceclinic.com/English/teach/)
National Comprehensive Cancer Network (NCCN): Is an alliance of 26 world-leading

cancer centres that are dedicated to patient care, research and education. NCCN has
recently published clinical practice guidelines for Smoking Cessation. (www.nccn.org)
National Cancer Institute (NCI): U.S. principal agency for cancer research and training.
Website hosts a comprehensive database of PDQ Cancer Information Summaries
patient and health professional education series on a variety of subjects, including
Smoking in Cancer Care. (www.cancer.gov/publications/pdq/information-summaries/
supportive-care)
American Association for Cancer Research (AACR): U.S. based organization

working to prevent and cure cancer through research, education, communication and
collaboration. Includes a policy statement on Assessing Tobacco Use by Cancer Patients
and Facilitating Cessation. (www.aacr.org)
U.S. Department of Health and Human Services (USDHHS): Repository for

documents, including the U.S. Tobacco Treatment Guidelines, as well as The Health
Consequences of Smoking50 Years of Progress: A Report of the Surgeon General.
(www.hhs.gov or www.surgeongeneral.gov/library/reports/index.html)
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Appendix 22 (c) Alberta Health Services Screening For Distress Checklist (Page 1)
Draft awaiting approval as of October 26, 2015
Patient Label
Talking About What Matters To You

Putting Patients First
Your answers will help us understand how you have felt since your last visit, and how you feel today.
Knowing this will help us care for you. If you cannot or do not wish to fill out this form for any reason please
let us know.
Note: Please make sure to fill out both sides of the form
A member of your healthcare team will go over the form with you and talk to you about what concerns you
the most today. If we are not able to talk about all of your concerns today, we will decide the next steps
together.
Date (yyyy-Mon-dd)
Completed by:
Patient Family
Assisted by family/health professional
Please answer the yes/no questions:

1. Have you been to Emergency and/or been admitted to hospital since your last visit?
Yes No
2. Have your medications changed since your last visit?(e.g. stopped, started, dose change)
Yes No
3. Have you had a fall since your last visit?
Yes No
4. Would you like information on Goals of Care or advance care planning (green sleeve)?
Yes No
5. Are you receiving home care services?
Yes No
6. Have you used tobacco in the past year?
Yes No
In the past 30 days?
Yes No
Please circle the number that best describes how you feel NOW
0 means you do not have that symptom, 10 means it is at its worst
No pain
9 10 Worst possible pain
No tiredness
9 10 Worst possible tiredness
No drowsiness
9 10 Worst possible drowsiness
No nausea
9 10 Worst possible nausea
No lack of appetite
9 10 Worst possible lack of appetite
No shortness of breath
9 10
No depression
9 10 Worst possible depression
No anxiety
9 10 Worst possible anxiety
Best well-being
9 10 Worst possible well-being
No___________
Other problem (e.g. constipation)
9 10 Worst possible _____________
(Tiredness=lack of energy)
(Drowsiness=feeling sleepy)
(Depression=feeling sad)
(Anxiety=feeling nervous)
(Well-being=how you feel overall)
Worst possible shortness of

breath
Continue on back side
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Appendix 22 (c) Alberta Health Services Screening For Distress Checklist (Page 2)
Draft awaiting approval as of October 26, 2015
What concerns have you had since your last visit? Check any boxes that have concerned you.
Emotional
Fears/Worries
Sadness
Frustration/Anger
Changes in appearance
Intimacy/Sexuality
Suicidal thoughts
Social/Family/Spiritual
Feeling alone
Feeling like a burden to others
Worry about friends/family
Support with children/partner
Meaning/Purpose of life
Faith
Practical
Work/School
Finances
Getting to and from
appointments
Home Care
Accommodation
Quitting tobacco
Drug costs
Health insurance
Alcohol intake
Physical
Fever/Chills
Bleeding/Bruising
Cough
Headaches
Concentration/Memory
Vision or hearing changes
Numbness/Tingling
Sensitivity to cold
Changes to skin/nails
Bladder problems
Lymphedema/Swelling
Range of motion
Strength
Speech difficulties
Sleep
Mobility
Dizziness
Walking/Mobility
Trouble with daily activities (e.g.
Nutrition
Weight gain (amount) _______
Weight loss (amount) _______
Special diet _____________
Difficulty swallowing
Mouth sores
Taste changes
Heartburn/Indigestion
Vomiting
Diarrhea
Constipation
Informational
Understanding my illness and/or
treatment
Talking with my health care team
Making treatment decisions
Knowing about available resources
Taking medications as prescribed
bathing, dressing)
Other Concerns: ______________________________

Thank you for filling out the form. The rest of the form will be completed by your
healthcare professional
To be filled out by a health care professional only - Screening Intervention Documentation

Time point in Cancer Journey:
Pre-treatment
Treatment
Post-treatment
Review of Form:
Patient declined to fill out form
Language barrier other ________________________
SFD reviewed by discussing with patient
If not reviewed why: Patient declined discussion Other: ________________
Patient Priority Concern Identified Patient indicated no concerns
Specify ONE priority concern (either ESAS or CPC):
ESAS:
Pain
Drowsiness Appetite
Depression
Well-being
Tiredness
Nausea
Shortness of breath
Anxiety
Other
CPC:
Emotional
Social/Family /Spiritual
Practical
Mobility
Nutrition
Physical
Informational
Other___________ Specific area:_______
Actions taken:
Provided information/Education
Provided emotional support
Self-Management
Referral made
No further action required
Referrals:
Referral suggested but patient declined
Home Care
Drug Access Coordinator
Other:______
Psychosocial Palliative Care
Spiritual Care
Pain & Symptom Rehab Services
Dietitian
Further details on action taken:
See progress notes/nursing documentation for further information

Reviewed By (Name of Health Care Professional)
Signature (of Health Care Professional)
Date (yyyy-Mon-dd)
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TOBACCO AS A VITAL SIGN

Brent Friesen MD FRCPC

Alberta Health Services 2014

Tobacco Free Futures

Alberta Health Services 2014

Resource and support planning

Tobacco Free Futures

Alberta Health Services 2015

Tobacco Free Futures

Chapter 1: Tobacco Free Futures:

Background information about the development of the Tobacco Free Futures

An overview of a systems approach for tobacco cessation treatment.

Highlights of the national CAN-ADAPTT smoking cessation guidelines.

Alignment with strategic priorities in the Alberta Health Services context.

Chapter 2: The Effects of Tobacco Exposure

Review of key health consequences related to tobacco exposure.

Types of tobacco commonly used in Alberta.

Review of the psychological and physiological effects of nicotine.

An overview of the impact of environmental exposure to tobacco.

The health benefits of tobacco cessation.

Tobacco Free Futures:

Alberta Health Services 2014

SUPPORTING CESSATION IN Health care SETTINGS

The Canadian Cancer

Tobacco Free Futures

Figure 1.1: Tobacco Cessation Linked System of Support

Health care Setting

A systems approach for effective tobacco treatment

Alberta Health Services 2014

Patient/client self-management: empowering patients with the information and

Evidence-based guidelines: using explicit plans and protocols.

Information systems: supporting population-based care, including provider reminders

CAN-ADAPTT smoking cessation guidelines

Tobacco Free Futures

Table 1.1: CAN-ADAPTT Guidelines for General and Hospital-Based Populations5

ask every patient/client about his or her

identify all tobacco users

clearly advise all patients/clients who use

provide clear advice to quit

assess the willingness of patients/clients to

assess the willingness of patients/clients to

make patients/clients aware of

offer assistance to every tobacco user who is

link all elective patients who use tobacco

conduct follow-up, provide support and

link patients to follow-up support upon

Alberta Health Services 2014

Alignment with strategic priorities and policies

Alberta Health Services strategic documents

Respect: understanding and meeting the client where he or she is at in relation to

Accountability: developing guidelines that are practice-informed and based on

Engagement: developing the Tobacco Free Futures guidelines and tools in a

Safety: supporting client safety by treating nicotine withdrawal to prevent unsafe

Learning: supporting and promoting the development of new knowledge through

For more information on AHS values, visit:

Tobacco Free Futures

Tobacco Free Futures supports

Bringing appropriate care

Strengthens integration and collaboration for tobacco treatment across the

Partnering for better

Achieving health system

For more information on the AHS health plan, visit:

Alberta Health Services 2014