consultation model for worksite tobacco policy development and employee cessation programs 2002...

Consultation Model for Worksite Tobacco Policy Development and Employee Cessation Programs

2002 National Conference on Tobacco and HealthSan Francisco, CA

November 19-21, 2002

Debbie Marion, M.A. and Connie Machel, M.S. – Wellness Council of WVWilliam B. Webb, Ph.D., Oasis Behavioral Health ServicesNorman Montalto, D.O. WVU Family Medicine Department; Charleston Area Medical Center Freedom From Tobacco ProgramJane Whaley, R.N. – Director of Clinical and Training Services, Partners in Corporate Health

Presenters:

Consulting ModelOptimizes facilitation for acceptance and

effectiveness of:• Clean Indoor Air Regulations

• Tobacco Restriction Policies

• Employee Tobacco Treatment Programs

All interrelated and inter-dependent

Objectives

• Demonstrate the importance of comprehensive tobacco program for worksite tobacco restriction policy development

• Illustrate the need to link employer services to employee need

• Provide a consulting model for working with businesses to facilitate a systems change, affecting CIA regulations, tobacco policies and employee cessation rates

This Model a Result of:• Our work on tobacco and health issues with WV

businesses over the past two and one-half years• Collaboration with professionals in medicine,

addictions, mental health, policy and business areas • Evidence from most current research including

CDC’s Best Practices, Healthy People 2010, Surgeon General’s Report on Reducing Tobacco Use, Healthy Workforce 2010

Our Agenda

• Essential components of a comprehensive program

• The “missing link” we discovered• Stages of change, motivational interviewing

and business coaching basics• Consulting model • A model program/Case study• Q & A with our “experts”

• Employer coverage of nicotine replacement therapy and/or Zyban

• Employer coverage of individual and group tobacco addiction treatment

• Supportive programs, including stress management, healthy eating and physical activity

• Tobacco restriction policy to eliminate second hand smoke exposure and to promote cessation

Basic Components of a Comprehensive Worksite Tobacco Program

Is this enough?We (mistakenly) thought so!

• Research and our own experience with quitline clients

• Our Program: policy development, cessation resources and wellness programs

• Our initial approach: • Demonstrate health and economic benefits of

cessation • Encourage employer services• Provide information on tobacco restriction

policy development and cessation resources

The Reality

• Most already aware of costs/benefits• Most already offered or were willing to offer

supportive services• Ambivalence – aware of need to comply with

CIAs, develop policies, and reduce health care costs, BUT concerned with employee relations and unsure of procedures and resources

The Employees

• Tobacco use rates at client companies met or exceeded our state average

• Ambivalence – employees wanting to quit, but not taking advantage of services, smoker/non-smoker conflict, fear of change

Employee Needs• Cessation classes• NRT• Stress mgmt/coping

skills training• Weight mgmt/nutrition• Exercise/physical

activity• Support

Employer Services• Cessation classes• NRT• Stress mgmt/coping

skills training• Weight mgmt/nutrition• Exercise/physical

activity• Incentives

II. - The “Missing Link”

No connection

Our Answer to “The Missing Link”

Consulting Model Based on Stages of Change and Motivational Interviewing Theories

• Originated in smoking cessation and addictions treatments

• Stages of Change Theory • Motivational Interviewing • Applicable to both individuals and

organizations• Common Sense Approach

• Unaware of the problem • Not thinking about changing• Actively resistant to change• No intention to change within the next 6 months• Seeks help under pressure from others.

The Transtheoretical Model of Change: A Six-Step Process

Stage 1 - Precontemplation“What me, have a problem? No way!”

• Aware a problem exists• Thinking of changing, but ambivalent• Wants to change, but has no plan.• No commitment to action• May languish at this stage a long time.

Stage II – Contemplation“Maybe I need to change something,

but I’m not sure what to do”

• Unsuccessful change attempts• Thinking about change• Determines best method• Wants to change within a month• Makes specific plans for change

Stage III – Preparation“Yes, there’s a problem and I’m going to change it”

• Major behavioral change occurs now.• Change is activated• Biggest risk is relapse.• Requires considerable time and energy.

Stage IV –Action“I’m doing something about my problem.”

• Practicing the change for 6 months or more.• Incorporates change into current lifestyle.• Consolidates gains and prevents relapse.• Free of problem behavior, has effective substitutes.

Stage V – Maintenance“I’m an old pro now.”

• Change stable for at least one year.• New self-image • Lack of temptation • Solid self-efficacy • Healthier lifestyle • Top psychological and spiritual shape

“Committed to life at its fullest!”

Stage VI – Termination“I’m not even tempted anymore”

• A common occurrence which must be anticipated and resolved.

• Most relapsers do not give up.• Research indicates only about 20% of the population

make permanent change on the first try.• The majority of people fall back to the contemplation

or preparation (not pre-contemplation) stage.

Relapse: “Two steps forward and one step back.”

Ancilary Stage VII – Relapse/Recycling“Whoops! I slipped back into my old habit!”

Pre-cont. - Contemplation - Prep. - Action - Maintenance

1. Consciousness Raising 2. Social Liberation

3. Emotional Arousal 4. Self Reevaluation

5. Commitment 6. Reward 7. Countering 8. Environmental Control 9. Helping Relationships

Not Ready Unsure Ready Trying

1....2.... 3....4....5 6....7....8 9.....10

Pre-contemplation

Contemplation Preparation Action

Motivational Interviewing

“A method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”

Ambivalence• “I want to, and I don’t want to”• Ambivalence is a stage in the normal process of change• Getting “stuck” in ambivalence also common • Resolving ambivalence can be key to change • Attempts to force resolution of ambivalence may lead to

increased resistance

Motivational Interviewing

Resolving AmbivalenceThe Decisional Balance

Costs of Status QuoBenefits of Change

Costs of ChangeBenefits of Status Quo

• Collaboration NOT Confrontation (partnership)• Evocation NOT Education (drawing intrinsic motivation and resources from participant)• Autonomy (self-direction) NOT Authority

The Spirit of Motivational Interviewing

The Four General Principles of Motivational Interviewing

Principle 1: Express EmpathyPrinciple 2: Develop DiscrepancyPrinciple 3: Roll with ResistancePrinciple 4: Support Self-efficacy

Principle 1: Express Empathy.

• Acceptance facilitates change• Skillful reflective listening is fundamental.• Ambivalence is normal.

Principle 2: Develop Discrepancy.

• The individual rather than the helper should present the arguments for change.

• The change is motivated by a perceived discrepancy between present behavior and important personal goals or values.

Principle 3: Roll with Resistance

• Avoid arguing for change• Resistance is not directly opposed.• New perspectives are invited, but not imposed.• The individual is a primary resource in finding

answers and solutions.• Resistance is a signal to respond differently.

Principle 4: Support self-efficacy

• A person’s belief in the possibility of change is an important motivator.

• The individual, not the helper, is responsible for choosing and carrying out change.

• The helper’s own belief in the person’s ability to change becomes a self-fulfilling prophecy.

Motivational Interviewing:A Two-Phase Model

Phase I: Building Intrinsic Motivation for Change (“Why”)1. Opening strategies: Express Empathy

Use OARS• Open-ended questions• Affirm• Reflect• Summarize

(Estimate level of readiness to change)2. Decrease Resistance: Roll with Resistance Use appropriate reflections/strategies3. Evoke Change Talk: Develop Discrepancy Use M.I. methods to resolve ambivalence in the direction of change4. Responding to change talk: Support Self-Efficacy

Use EARS• Elaborate (Amplify)• Affirm (Reinforce)• Reflect (Empathy)• Summarize (Bouquet)

Phase II – Strengthening Commitment to Change (“How”)1. Recapitulation• Provide a “Grand Summary”2. Ask Key Questions3. Provide accurate, practical information, with permission4. Negotiate a Treatment Plan(See Form -pg. 137- Motivational Interviewing (2nd Ed.)5. End Tasks• Summary Reflection of Plan• Close the deal• Plan for follow-up or Booster Sessions

Integrating Stages of Change and Motivational Interviewing

• SOC = Natural, Incremental Process of Behavior Change

• MI = Methods for Moving Behavior Change Through the Stages

SOC & MI: Effects on Behavior Change at Organizational Level

• “How we speak is likely to be just as important as what we say”

• Both individual and systems-level forces influence the likelihood of behavior change in organizations, which is:

Increased by approaches that enhance individual motivation and build organizational supports

Decreased by approaches that cause individual resistance and set up organizational barriers

Deming’s 85-15 rule: Approx. 85% of opportunities for improvement are in systems changes; 15% are with

individuals.

This approach leads to environment which supports:

• Increased employee participation rates• Increased cessation attempts, quit rates and

maintenance • Increased acceptance of clean indoor air

regulations and policy changes• Incorporation of policy change into culture of

organization• Development of organizational and individual

concept of a “healthy” identity

Organizational Consulting ModelEntry:Explore organizational needsContractingPhysically entering systemPsychically entering system

Diagnosis and Implementation:Gather dataDefine problemSet goalsGenerate interventionsChoose interventionForm planImplement plan

EvaluationFollow-upPhasing out/Disengaging

Stages of Change:Assess SOC

Stages of Change:Match SOC to MI interventions and resources

Stages of Change:Reevaluate SOCMatch SOC to MI interventions and resources

Motivational Interviewing/Building Motivation to Change (Why?):Opening structureAgenda settingUse OARS

Motivational Interviewing/Strengthening Motivation to Change (How?):Recapitulation (Grand Summary)Key questionsProvide information/advise with permissionNegotiate a planSummary reflectionClose the dealUse OARS

Motivational Interviewing:Recapitulation (Grand Summary)Key questionsProvide information/advise with permissionNegotiate a planSummary reflectionClose the dealUse OARS

Resources: Match with SOC



Model ProgramCompany A – Site “Charlene”Blue collar company with 400 employees – 80% unionLocated in county that has no Clean Indoor Air (CIA)

ordinancePhase I - Entry:Onsite visit – discussed policy, cessation, wellness

components, CIA

Pre-Contemplation

Contemplation Preparation Action Relapse

PolicyClean Indoor Air

Cessation Wellness Components

WellnessComponents

Company A – Site “Judy”Blue collar company with 400 employees – 80% unionLocated in county that has no CIA ordinance

Phase I - Entry:Onsite visit – discussed policy, cessation, wellness

components, CIA

Pre-Contemplation Contemplation Preparation Action Maintenance

-Policy-Clean Indoor Air

Cessation WellnessComponents

WellnessComponents

Company A – Site “Debra”Blue collar company with 400 employees – non-unionLocated in county with CIA ordinance

Phase I - Entry:Meeting with Dr. Montalto –discussed cessation and

policy -no official onsite visit conducted


-Cessation-Policy

WellnessComponents

-WellnessComponents

CIA

Phase II – Diagnosis and ImplementationData and Problem: Survey results – 60% tobacco usage (both smoking and

smokeless) All three sites located in rural areas where smoking and

smokeless are part of the culture (work and home) Doctors in rural areas not trained in latest cessation techniques Employees buying generic patches to save money and not

using NRT correctly Shift work and long hours make it unappealing to drive to

Charleston High levels of stress

Phase II – Diagnosis and Implementation

Needs and Interests: Trained tobacco sub-specialist to provide cessation

treatment onsite and to multiple shifts Pharmacological products and appropriate dosage Information on new behavioral techniques and coping

mechanisms Individual support and group support Information on stress management and physical

activity

Phase II - InterventionInternal Intervention: Dr. Montalto provide onsite cessation treatment Quitline with free NRT and phone coaching (individual support) American Lung’s “Freedom From Smoking” (group support) Health Plan Coverage for Rx Physical Activity, Stress, and Weight Management Components Survival Kits

External Intervention: Approach union and professional association (trainers/inspectors)

affiliated with this company to encourage a total change in culture.

Site “Charlene” before intervention proposal

Site “Charlene” after acceptance of intervention proposal


-Policy-CIA


WellnessComponents


-CIA-Policy

-Cessation-WellnessComponents

Wellness Components

Site “Judy” before intervention proposal

Site “Judy” after intervention proposal


-Policy-CIA


WellnessComponents


CIA Policy -Cessation-WellnessComponents

WellnessComponents

Site “Charlene” before intervention proposal

Site “Charlene” after intervention proposal

Pre-Contemplation Contemplation Preparation Action Maintenance-Cessation-Policy

WellnessComponents

-WellnessComponents

-CIA

Pre-Contemplation Contemplation Preparation Action Maintenance-Policy-Cessation-WellnessComponents

-WellnessComponents

-CIA

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