assisting patients with quitting. released june 2000 sponsored by the ahrq (agency for healthcare...

ASSISTING PATIENTS with QUITTING

Released June 2000

Sponsored by the AHRQ (Agency for Healthcare Research and Quality) of the USPHS (US Public Heath Service) with:

CDC (Centers for Disease Control) NCI (National Cancer Institute) NIDA (National Institute for Drug

Addiction) NHLBI (National Heart Lung & Blood

Institute) RWJF (Robert Wood Johnson Foundation)

http://www.surgeongeneral.gov/tobacco/

CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE

EFFECTS OF CLINICIAN INTERVENTIONS

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

0

10

20

30

No clinician Self-helpmaterial

Nonphysicianclinician

Physicianclinician

Type of Clinician

Est

imate

d a

bst

inence

at

5+

month

s

1.0 1.1(0.9,1.3)

1.7(1.3,2.1)

2.2(1.5,3.2)

n = 29 studies

ASK

ADVISE

ASSESS

ASSIST

ARRANGE

The 5 A’s

The 5 A’s (cont’d)

Ask about tobacco use “Do you ever smoke or use any type of tobacco?”

“I take time to ask all of my patients about tobacco use—because it’s important.”

ASK


tobacco users to quit (clear, strong, personalized, sensitive) “It’s important that you quit as soon as possible,

and I can help you.”

“I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”

ADVISE


Assess readiness to make a quit attemptASSESS

Assist with the quit attemptASSIST

Arrange follow-up careARRANGE


Number of sessions

Estimated quit rate*

0 to 1 12.4%

2 to 3 16.3%

4 to 8 20.9%

More than 8 24.7%* 5 months (or more)

postcessation


PROVIDE ASSISTANCE THROUGHOUT THE QUIT PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPTATTEMPT

5 A’s: REVIEW

ASK about tobacco USE

ADVISE tobacco users to QUIT

ASSESS readiness to make a QUIT attempt

ASSIST with the QUIT ATTEMPT

ARRANGE FOLLOW-UP care

Faced with change, most people are not ready to act.

Change is not a single step, but a process.

Typically, it takes multiple attempts.

HOW CAN I LIVE WITHOUT

TOBACCO?

The (DIFFICULT) DECISION to QUIT

HELPING SMOKERS QUIT IS a CLINICIAN’S RESPONSIBILITY

Clinicians have a professional obligation to help their patients quit using tobacco.

THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.

PATIENTS DIFFER IN THEIR READINESS TO COMMIT TO QUITTING

PATIENTS DIFFER IN THEIR READINESS TO COMMIT TO QUITTING

TAILORING the INTERVENTION to MEET the PATIENT’S NEEDS

Persons NOT READY TO QUIT (in the next 30 days): Motivational interventions

Persons READY TO QUIT (in next 30 days): Behavioral counseling Pharmacotherapy

Persons who RECENTLY QUIT (in past 6 months): Relapse prevention interventions

IS a PATIENT READY to QUIT?Does the patient now use tobacco?

Is the patient now ready to quit?

Provide treatment

The 5 A’s

Promote motivation

Yes

YesNo

Did the patient once use tobacco?

Prevent relapse*

Encourage continued abstinence

Yes

No

No

*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation.


FIVE STAGES THAT DESCRIBE a PERSON’S READINESS to CHANGE

STAGE 1: Not thinking about changing anytime soon

STAGE 2: Considering changing, but not yet

STAGE 3: Getting ready to change soon

STAGE 4: In the process of changing

STAGE 5: Changed a while ago

FIVE STAGES THAT DESCRIBE a PERSON’S READINESS to CHANGE

STAGE 1: Precontemplation

STAGE 2: Contemplation

STAGE 3: Preparation

STAGE 4: Action

STAGE 5: Maintenance

STAGES of CHANGE:A LINEAR VIEW

Precontemplation ActionContemplation Maintenance

Quit date

Preparation

- 30 days- 6 months + 6 months

Maintenance

ContemplationAction

Preparation

Pre-contemplation

Termination

Relapse*

* Patients can relapse out of the maintenance or action stages, reverting to earlier stages.

ASSESS READINESS TO QUIT: STAGES of CHANGE, CYCLICAL VIEW

Not ready to quit

STAGES of CHANGE for TOBACCO CESSATION

Does the patient now use tobacco?

Is the patient ready to quit now?

PreparationPrecontemplation- or -

Contemplation

Yes

YesNo

Did the patient once use tobacco?

Action- or -

Maintenance

Never smoker

Yes

No

No

The STAGES of CHANGE

STAGE 1: Precontemplation

Not thinking about quitting in the next 6 months

Patients might not be aware of the need to quit. They might be aware of the need but resist quitting. Pros of smoking outweigh the cons.

GOAL: Move the patient into the contemplation stage.

STRATEGIES for COUNSELING during PRECONTEMPLATION

DON’Ts

Persuade

“Cheerlead”

Tell patient how bad smoking is, in a judgmental manner

DOs Strongly advise to quit

Ask noninvasive questions “Envelope”

Raise awareness of health consequences/concerns

Demonstrate empathy, foster communication

Leave decision up to patient

Considering quitting in the next 6 months but not in the next 30 days

Patients are aware of the need to quit.

They are aware of the benefits of quitting.

But they struggle with ambivalence about change.

STAGE 2: Contemplation

The STAGES of CHANGE (cont’d)

GOAL: Move the patient into the preparation stage.

STRATEGIES for COUNSELING during CONTEMPLATION

DON’Ts

Apply action-oriented interventions

DOs Strongly advise to quit

Provide information

Identify reasons for tobacco use

Demonstrate empathy; increase motivation

Encourage self-reevaluation of concerns

Offer encouragement

METHODS for INCREASING MOTIVATION—5 R’s

For patients who are not yet ready to quit:

Relevance Risks Rewards Roadblocks Repetition


TAILORED

INTERVENTION

MESSAGES

A DEMONSTRATION: COUNSELING a PATIENT who is NOT READY TO QUIT

CASE SCENARIO: MS. STEWART

You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema.

She uses two different inhalers for her emphysema.

COUNSELING SCENARIO: KEY POINTS

Ask about tobacco use Link inquiry to knowledge of disease

Assess readiness to quit Aware of need to quit; not ready yet

Advise to quit Discuss implications for disease progression

“I will help you, when you are ready”

The clinician has

Established a relationship

Established yourself as a resource

Planted a seed to move patient forward

Opened a door to facilitate further

counseling

COUNSELING SCENARIO:SUMMATION


Ready to quit in the next 30 days Patients are aware of the need to, and the

benefits of, making the behavioral change.

Getting ready to take action.

Goal: Move the patient to the action stage.

STAGE 3: Preparation

STRATEGIES for COUNSELING DURING PREPARATION

DOs Praise the patient’s readiness Assess tobacco use history

Current use: Type(s) of tobacco, brand, amount

Past use: duration, recent changes Past quit attempts:

Number, date, length Methods used, compliance, duration Reasons for relapse

DOs Discuss key issues

Reasons/motivation to quit Confidence in ability to quit Triggers for tobacco use Routines/situations associated with tobacco

use Stress-related smoking Social support for quitting Concerns about post-cessation weight gain Concerns about withdrawal symptoms


DOs Facilitate quitting process

Discuss methods for quitting (pros, cons)

Pharmacotherapy: a treatment, not a crutch! Behavioral counseling

Set a quit date! Recommend Tobacco Use Log (see

handout)


TOBACCO USE LOG

The Tobacco Use Log is most appropriate for patients who are getting ready to quit.

Documenting tobacco use helps patients to understand when and why they use tobacco.

Identifies activities or situations that trigger tobacco use.

Information can be used to develop coping strategies to overcome the temptation to use tobacco.

TOBACCO USE LOG: INSTRUCTIONS for USE

Patient should continue regular tobacco use for a period of 3 or more days

Each time any form of tobacco is used, the following information should be recorded on the log:

Time of day Brief description of activity or

situation during use “Importance” rating (scale of 1–3) Review log sheets to identify situations that trigger tobacco use

Develop coping strategies to prevent relapse

DOs

Discuss and develop coping strategies

Cognitive

Behavioral


COPING with QUITTING (cont’d)

Cognitive strategies

Review of commitment to quitting

Distractive thinking

Positive self-talks

Relaxation through imagery

Mental rehearsal and visualization


Examples: Thinking about cigarettes doesn’t mean you have to

smoke one. “Just because you think about something doesn’t mean you

have to do it!” Tell yourself “It’s just a thought,” or “I am in control.” Say the word STOP! out loud, or visualize a stop sign.

When you have a craving, remind yourself that: “The urge for a cigarette will only go away if I don’t smoke.”

As soon as you get up in the morning, look in the mirror and say to yourself

“I am proud that I made it through another day without smoking.”


Behavioral strategies Control your environment

Smoke-free home and workplace Alter or remove cues to tobacco use Modify behaviors that you associate with tobacco: when,

what, where, how, with whom Actively avoid trigger situations

Substitutes for smoking Water, chewing gum or hard candies (oral substitute)

Take a walk, diaphragmatic breathing, self-massage

Rely on social support Actively work to alleviate withdrawal symptoms

STRESS MANAGEMENT

Smoking gets rid of all my stress

I can’t relax without a cigarette

There will always be stress in one’s life

There are many ways to relax without a cigarette

The Myths The Facts

STRESS MANAGEMENT SUGGESTIONS:Deep breathing, shifting focus, taking a break.

Smokers confuse the relief of withdrawal with the feeling of relaxation

SOCIAL SUPPORT for QUITTING

Key ingredients for successful quitting: Social support as part of treatment (intra-

treatment) Social support outside of treatment (extra-

treatment)

Patients who receive social support and encouragement are more successful in quitting

PATIENTS SHOULD BE ADVISED TO: Ask family, friends, and coworkers for support – ask

them not to smoke around you, and not to leave cigarettes out

Talk with your health-care provider

Get individual, group, or telephone counseling

ADDRESSING CONCERNS about POSTCESSATION WEIGHT GAIN

Most quitters gain weight Most gain < 10 pounds, but there is a wide range

Discourage strict dieting while quitting Recommend physical activity Encourage healthy diet, plan meals, eat fruits Increase water intake Chew sugarless gum Select nonfood rewards

Maintain patient on pharmacotherapy shown to delay weight gain

Refer patient to specialist or program

Restlessness

Drowsiness

Fatigue

Impaired task performance

Nervousness

Sleep disturbances

Anger/irritability

Anxiety

Cravings

Difficulty concentrating

Hunger/weight gain

Impatience

ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS

Hughes et al. Arch Gen Psychiatry 1991;48:52–59.

Most pass within 2 to 4 weeks after quitting

Cravings can last longer, up to several months or years

Often can be ameliorated with cognitive or behavioral coping strategies

Refer to Withdrawal Symptoms Information Sheet

Symptom, cause, duration, relief

ADDRESS CONCERNS about WITHDRAWAL SYMPTOMS (cont’d)

DOs Discuss concept of slip versus

relapse “Let a slip slide”

Medication counseling Proper use, with demonstration Promote compliance

Arrange follow-up Offer to assist throughout quit attempt Provide resources and referrals Congratulate the patient!



Actively trying to quit for good Patients have quit using tobacco sometime in

the past 6 months and are taking steps to increase their success.

Withdrawal symptoms occur.

At high risk for relapse.

STAGE 4: Action

GOAL: Remain tobacco-free for at least 6 months.

STRATEGIES for COUNSELING during ACTION

DOs Praise progress - solicit commitment to quit for good Evaluate current quit attempt:

Status of attempt “Slips” or relapse Medication use, plans for termination

Ask about social support Identify temptations and triggers for relapse

Negative affect, smokers, eating, alcohol, cravings, stress

Encourage healthful alternative behaviors to replace tobacco use

Offer tips for relapse prevention

RELAPSE PREVENTION Congratulate success! Encourage continued abstinence

Promote smoke-free environments Discuss benefits of quitting and successes achieved Discuss problems encountered and potential barriers to

continued abstinence Strong or prolonged withdrawal symptoms?

Add, combine, or extend use of pharmacotherapy agents

Social support Discuss ongoing sources of support Schedule follow-up visits or calls; refer to support groups


Tobacco-free for 6 months Patients remain vulnerable to relapse.

STAGE 5: Maintenance

GOAL: Remain tobacco-free for life.

STRATEGIES for COUNSELING DURING MAINTENANCE

DOs

Congratulate continued success Continue to offer tips for relapse prevention

Assess temptations and triggers

Discuss and suggest coping strategies

Encourage alternative behaviors Provide positive reinforcement

STAGES of CHANGE: A REVIEW

Precontemplation ActionContemplation Maintenance

Quit date

Preparation

- 30 days- 6 months + 6 months

Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS stage at each contact Tailor intervention messages (ASSIST)

Be a good listener Minimal intervention in absence of time

for more intensive intervention ARRANGE follow-up

Use the referral process, if needed

CESSATION COUNSELING: SUMMARY

WHAT IF…

a patient asks you about your use of tobacco?

The RESPONSIBILITY of HEALTH PROFESSIONALS

It is inconsistent

to provide health care and

—at the same time—

remain silent (or inactive)

about a major health risk.

TOBACCO CESSATION is an important component of

THERAPY.

DR. GRO HARLEM BRUNTLAND,

DIRECTOR-GENERAL of the WHO:

“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”

US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Washington, DC: Public Health Service, 2001.

assisting patients with quitting. released june 2000 sponsored by the ahrq (agency for healthcare...

Documents

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patient ready

quit attempt5

tobacco cessationdoes

action stages

agofive stages

earlier stages

maintenancestages of