14. Smoking cessation intervention is one of the
most cost-effective interventions in medicine
Compared with other preventive interventions,
smoking cessation is extremely cost-effective.
25. Health care professionals have a golden
opportunity to initiate smoking cessation
programs
– Credible
– Knowledgeable
– Supportive
– Resourceful
– Critical Incident
26. ‘All health professionals should understand
the principles of Brief Intervention for
smoking cessation.
It is to be routine practice to consider the
need for Brief Intervention at every patient
contact’
27. Brief advice on the dangers of smoking and the
benefits of stopping smoking should be given
at any opportunity.
Just 3 minutes of your time could help to improve
the health and life expectancy of smokers.
The time spent really is worthwhile.
41. The Three Link Chain
A is the addiction of nicotine – the “King” of
addictions
B is the behaviours or cues or triggers- a
smoker “trains” to smoke
C is the socio-cultural aspects of people
around you
49. Drivers of smoking - physical addiction
The brain is ‘switched on’ by nicotine, releasing ‘feel good’
chemicals (dopamine), as nicotine hijacks the role of
acetylcholine to release dopamine at the receptor
– Can occur after smoking one cigarette per day over
few days
– Inhaled and delivered to blood in seven seconds
– Hits the brain in ten seconds
Short ‘half-life’ of only 20 to 40 minutes, meaning smokers
need to be constantly ‘topped up’
The cycle of ‘feel good’, withdrawal, and ‘top up’ reinforces
addiction
50. Drivers of smoking - the behavioural
aspect
Smoking-associated environmental stimuli (cues)play
a role in reinforcing nicotine dependence
Stressors and triggers may lead to unexpected
cigarette use after quitting. These may lead to a full
relapse and failed cessation attempts
The most effective treatment includes both
pharmacological and behavioural therapy
51. No two smokers are similar , In some smokers the
addiction is very strong, others it is weak.
Some smokers smoke a few cigarettes per day ,
others are multi pack smokers.
Some smokers are surrounded by other smokers,
while others have very few people around them
who smoke.
65. Change is not something you
do to people, but with
people.
66.
67.
68.
69.
70.
71. The Stages of Change
Prochaska and DiClemente, 1984
?
Precontemplation Contemplation
Preparation
Action
Maintenance
72. The Five Stages of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
73. Pre-Contemplation Stage
Not ready to quit
Not interested in
changing
Are defensive
“I can’t quit”
“It will not happen to
me”
“I enjoy it to much”
74. Precontemplation
Person shows no intent to change a problem or
behavior.
Person is either unaware of the problem or unwilling to
change.
Individual sees more positive about the behavior than
negative.
Person sees behavior as under control or
manageable.
Any attempt to suggest that change is necessary is
likely to be met with immediate resistance.
75. Contemplation
Thinking about changing
Aware of the need to quit
Taking small steps to quit
“I know I need to quit”
“You know, I should quit”
“I want to quit within the
next 6 months”
76. Contemplation
Person is willing to consider changing.
Person will engage in weighing pros and cons
of change.
Person shows some discomfort/distress with the
ongoing behavior.
Person is still strongly ambivalent and can still
easily move back into a resistance mode if
defenses are triggered.
78. Smoke vs. Quit
Common Reasons not to Quit
Family and friends smoke
Withdrawal symptoms
Inability to cope with stress
Connection with smoking
Previous unsuccessful
attempts to quit
Common Reasons to Quit
Encouragement from family
and friends
Health improvements
To save money
Pregnancy
Smoke-free environment
policies
Desire to be a role model
Medical treatment that
requires abstinence
79. If we want to change something that we do,
we have to actively make a decision. It won’t
happen just by wishing.
79
84. Preparation
Person is getting ready to make the change.
Person clearly intends to change soon
“Planning to quit within the next 30 days”
There can be some evidence of actual change
beginning, such as “cutting down”.
Ambivalence is not apparent.
Defenses are not triggered when professional is
supporting the need to change.
86. Action
The change process has begun.
The behaviors and attitudes in question are
actively being changed.
The individual is learning and practicing the
skills necessary to be successful.
This stage may last for months in persons with
co-occurring conditions.
Ambivalence is gone
87. Action Stage
Ready for change
Prepared mentally to
change
“I am going to quit
smoking”
“I want to live to see
my grand children”
Last approximately 6
months
88. Maintenance Stage
Has quit smoking
Prepares for stress
Handles temptation
Reminds themselves
of what they have
accomplished
Continues to be
smoke-free
89. Maintenance
Person continues to sustain and strengthen
change.
Continues to practice skills to avoid a return to
old habits or ways of thinking.
Continues to receive encouragement and
support to solidify change process.
90. Relapse Stage
Most experience
Sees oneself as a
failure
A normal event
A person may go
through the stages of
change several times
before complete
cessation.
92. People do not move in a linear fashion
through the cessation process
92
93. Cessation is explained as a process, rather than
a single discrete event and smokers cycle
through the stages of being ready, quitting and
relapsing on an average of three to four times,
before achieving long term success.
Smokers will be in different stages of readiness
when the clinician sees them at different times, so
readiness needs to be constantly re-evaluated.
100. Barriers to quitting
When quitting, people have a hard time because
they…
Fear weight gain
Fear withdrawal symptoms
Give up a social activity to do with friends
Expect failure- may be they failed in the past
Think they cannot cope with tension and anxiety
Do not know enough about the benefits of quitting
Have a hard time changing daily routines that
include smoking
105. Brief Intervention for Tobacco:
The 5 A’s Approach
The 5 A’s approach is a simple,
brief way to address tobacco use
with every patient.
Altogether, the 5 A’s may take 1 –
5 minutes.
They do not need to be applied
in a rigid manner, and entire
office/clinical staff should be
involved.
The 5 A’s:
1. Ask
2. Advise
3. Assess
4. Assist
5. Arrange
106. Brief Counseling Intervention
– 5 A’s for Brief Smoking Cessation Counseling
(U.S. Department of Health and Human Services)
•Ask
•Advise
•Assess
•Assist
•Arrange
109. #1 ASK
Systematically identify all tobacco users
Identify and document smoking status for
every client at each visit
Make identification/documentation
as a vital sign
Client about tobacco use...
111. Ask: “Do you smoke?” and “Have you ever
smoked?” Once the current smoker is identified
you can take a brief smoking history as follows:
― Number of cigarettes smoked per day and the
year of starting smoking.
― For exsmokers the quit date should be recorded.
― Previous quit attempts and what happened.
― Presence of smoking related disease.
#1 ASK
126. Advise
Clear, Strong, Personalized
“Quitting smoking ...
―...is the single best thing you can do for
your health”
―...will reduce your risk of …”
Employ the teachable moment:
128. 128
Advise Examples
Appropriate:
“Ms. Smith, it is important for you to quit smoking.
As your Resource Mother, I need you to know
that quitting smoking increases your chances of
having a healthy baby. Your health will also
improve...”
Inappropriate:
“Ms. Smith, you need to quit smoking.”
129. #3 Assess
After providing a clear, strong, and personalized
message to quit, you must determine if the
patient is willing to quit at this time.
130. Assess readiness to quit
1. Assess stage of change
2. Assess nicotine dependence
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0
131. Assess stage of change
Copied with permission,
Ottawa Heart Institute, The Ottawa Model
141. Assess
Assess willingness to make quit attempt
now, e.g., within next 30 days
“On a scale of 1 to 10, how motivated are
you?”
If patient is willing to quit
Provide assistance
If patient is unwilling to quit
Provide motivational intervention (5 Rs )
142. 142
Three patient types
1. Current smoker who wants to quit.
2. Recent non-smoker
3. Current smoker who does not want to quit.
Target of
Assess step
143. The 5 A’s (cont’d)
readiness to make a quit attemptASSESS
with the quit attempt
1) Not ready to quit: enhance motivation (the 5 R’s)
2) Ready to quit: design a treatment plan
3) Recently quit: relapse prevention
ASSIST
145. 145
Assess Decision Flow
Yes
Does patient
currently
smoke?
Patient
willing to
quit?
Provide
appropriate
cessation
techniques (Step
4 of 5A
approach)
Yes
No
Provide
motivational
materials and
counseling
146. 146
Assess Decision Flow (cont)
YesDoes patient
currently
smoke?
Has patient
smoked in the
past?
Assist with
cessation
maintenance
(Step 4 of 5A
approach)
No
148. #4 Assist
Develop a quit plan
STAR:
- Set a quit date (within 2 weeks)
- Tell family, friends, coworkers
- Anticipate challenges to quitting
- Remove tobacco products from
environment
149. Choosing a quit date increases your chances of
success, because setting a specific goal increases
motivation.
The quit date should be soon ideally , within 2 weeks
in order to give the patient time to prepare to stop.
Advise against stopping at high-stress times ,
suggest instead a significant date (i.e. the patient's
or spouse's birthday or the first day of the month).
S = Set a quit date
151. The support and encouragement of friends and
loved ones can also help you reach your goal of
being smoke-free .
Tell them to praise your attempts to quit but be
careful not to overdo it.
They should never focus on setbacks, but focus only
on successes, no matter how small they may be ,
Every step towards quitting is a positive step.
T = Tell family, friends, and co-workers
you plan to quit and when.
152. Request that they plan something special to celebrate
your Quit Day, like a movie or dinner.
Ask them to be there for you if you want to talk – in
person or by telephone. Just having your partner or
loved one listen can be helpful.
Ask them to prepare snacks and a “quit kit” including
sugarless gum, mints, fruits, or soda.
Encourage them to plan a reward for when you
become an ex-smoker, perhaps lunch or a new book
or music CD.
T = Tell family, friends, and co-workers
you plan to quit and when.
153. Most importantly, if your family members or friends
are smokers, consider asking them to take steps to
quit along with you.
You may find that you can give each other the best
support.
If they aren’t ready to quit, take steps to keep their
smoking from being a temptation. Ask them to
pledge not to smoke around you, your home and
your car.
T = Tell family, friends, and co-workers
you plan to quit and when.
154. Nicotine addiction is just one of the reasons
people continue to smoke.
There may be triggers and habits that “set you
off ” or “tell” you to smoke.
Drinking coffee or alcohol, finishing a meal, and
feeling stressed are common examples of
triggers that may prompt you to smoke.
A = Anticipate challenges to quitting
155. When drinking coffee
While driving in the car
When bored or stressed
While watching television
While at a bar with friends
After meals
During breaks at work
While on the telephone
While with specific friends OR family
members who use tobacco
Routines/situations associated with
tobacco use
163. Identifying triggers
It is important to identify triggers that tend to
make you want to smoke.
Once you know your triggers, you can either
avoid them or change your behavior.
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3
166. Expecting challenges is an important part of
preparing to quit.
If you’ve tried to quit smoking before, you are
one step further along the road to quitting
smoking.
Review these previous quit attempts and think
about what you can do differently the next
time.
Remember
167. Anticipate challenges to planned quit
attempt, particularly during the critical first
few weeks. These include nicotine withdrawal
symptoms.
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169. Nicotine Withdrawal Symptoms
PrevalenceDurationSymptom
50%< 4 weeksIrritability
60%< 4 weeksDepression
60%< 2 weeksPoor concentration
60%< 4 weeksRestlessness
70%> 10 weeksIncreased appetite
70%> 2 weeksUrges to smoke
10%< 48 hoursLight-headedness
Most symptoms manifest within the first 1–2 days, peak
within the first week, and subside within 2–4 weeks.
Other: Depressed mood, impaired performance and Insomnia
172. After lots of repetition, the link between a trigger
and the urge to smoke becomes strong and
you may no longer be aware of how powerful
this is.
However, by facing each urge to smoke without
lighting up, you will begin to break the bonds
between triggers and urges to smoke.
Using healthy coping strategies to resist urges to
smoke will help you .
A = Anticipate challenges to quitting
173. Coping with Withdrawal
Cravings:
It takes 72 hours of abstinence to purge our blood of
nicotine. Cravings are more a response to
conditioning than to actual physical withdrawal.
Cravings are the mind’s way of warning us that it is
time to ingest nicotine to avoid physical discomfort.
For most smokers the brain starts to send gentle
reminders about every 20-30 minutes.17
3
174. Important facts about cravings are listed below:
― They occur close together in the early days of
quitting.
― Each craving is like a wave. It arrives reaches a
peak, and goes away even if you don’t smoke.
― Cravings last only a minute or two - Cravings can
be intense at times.
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4
175. ― Cravings go away with time as long as you do
not smoke.
― As time passes, you will have more time between
cravings, and they will be shorter.
― Cravings increase after a slip or relapse.
― Respond to cravings with cognitive (thinking) and
behavioral (doing) coping strategies.17
5
176. 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:
– “The urge for tobacco will only go away if I don’t use it.”
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
tobacco.”
Cognitive Coping Strategies: Examples
177. – Control your environment
Tobacco-free home and workplace
Remove cues to tobacco use; actively avoid trigger situations
Modify behaviors that you associate with tobacco: when,
what, where, how, with whom
– Substitutes for smoking
Water, sugar-free chewing gum or hard candies (oral
substitutes)
– Take a walk, diaphragmatic breathing, self-massage
– Actively work to reduce stress, obtain social support,
and alleviate withdrawal symptoms
Behavioral Coping Strategies
178. Cigarettes keep your hands busy , So when you
quit, your hands will miss having a cigarette to
handle.
Keep your hands busy with, pens, pencils, rubber
bands, or squeeze balls Items like these are
sometimes called “handling substitutes.”
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Cigarette Substitutes
179. Smoking also keeps your mouth busy. Use low-
calorie or no-calorie items such as hard candy,
sugarless gum, fresh fruits and vegetables, or
menthol cough drops. These items are sometimes
called “oral substitutes.”
It also may be helpful to brush teeth frequently,
use breath spray, or drink plenty of water.
17
9
Cigarette Substitutes
183. Focus on the positive
Positive thinking is an essential part of any effort
to quit smoking. Here are 3 ways to focus on the
positive:
1. Make a list of personal reasons to quit and keep
adding to it as you think of more.
2. Focus on the benefits of not smoking.
3. Build an attitude that you are better off as a non-
smoker than as a smoker.18
3
184. Positive Self-Talk
We are able to influence our level of stress, mood
and even our behavior by our own thoughts.
You can feel more upset, worried or depressed
by thinking of reasons why you can’t deal with
things.
In contrast, you can reduce stress by using
optimistic, encouraging, and motivational self-
talk.18
4
186. Additional ideas to help you in
your process:
Limiting your smoking:
― Don’t carry cigarettes with you
― Decide on less cigarettes each day or week
― Only buy one pack at a time
― Only roll the number that you are allowing for yourself
in a day
Aversion:
― Smell a dirty ashtray
― Keep a jar of used cigarettes and smell or touch them
when feeling the urge to smoke18
6
187. Change the way you smoke:
― Change the hand that you hold the cigarette
― Create non-smoking areas in the home
― Only smoke in areas that feel uncomfortable to you
― Do not allow other people to smoke with you
Change your routine
– Take a different route to work
– Drink tea instead of coffee
– Eat breakfast in a different place18
7
188. Learn New Skills & Behaviors
Change your routine:
― Start a new activity that occupies your hands
― Stop drinking alcohol or caffeine
― Practice refusing cigarettes
― Practice relaxation and visualizing yourself as a non-
smoker
― Get your teeth cleaned
― Clean your house and clothes
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8
189. key advice on successful quitting.
Abstinence-- total abstinence is essential.Not even a
single puff after the quit date
Alcohol-- Inform the patient that drinking alcohol is
highly associated with relapse.
Other smokers in the household-- The presence of
other smokers in the household, particularly a spouse,
is associated with lower success rates.
Urge the patient to quit with the other smoker and/or
develop specific plans to stay quit in a household
where others still smoke
18
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190. R = Remove tobacco products from
environment
1. Before Your Quit Date – Make Smoking Boring
2. Prior to quitting, avoid smoking in places where
you spend a lot of time (e.g., work, home, car).
3. Make your home smoke-free-Make it a rule never
to let anyone smoke in your home.
4. Get rid of all cigarettes, ashtrays, and lighters in
your home, car, and workplace.
5. Write down why you want to quit and keep this list
as a handy reminder.
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192. To pick the best method for quitting:
– Cold turkey or tapering (cutting down approach)?
– “Cold turkey” is the most effective method ,
Smokers who attempt to limit their intake over an
extended period seem to change their smoking
behaviour in an effort to maintain their usual
nicotine intake.
193. “Cutting down the number of cigarettes you
smoke is useful as a short-term measure.
However,experience shows patients rarely taper
all the way to zero.
Your cigarette intake usually creeps back up if
you don’t go ‘cold turkey’ at some point.”
19
3
194. All smokers can be given informations about
how to quit ( leaflets, booklets or other self-
help materials.
19
4
196. ― Review previous quit attempts. "What helped you?"
"What led to relapse?“
― Remember, many people try to quit several times
before quitting for good.
― Most people relapse, or start smoking again, within the
first three months after quitting.
― Certain things or situations can increase your chances
of smoking again, such as drinking alcohol, being
around other smokers, gaining weight, stress, becoming
depressed or having more bad moods than usual.
19
6
Be prepared for relapse.
197. What if I smoke after quitting?
• Relapse is common. Most people make multiple
attempts before they are successful.
If you smoke after quitting:
− Don’t blame yourself (none of us is perfect);
− Use the relapse as a learning experience rather
than as a sign of failure .
− Just try another quit attempt.
19
7
198. ― A slip, or a lapse or relapse, are terms that convey the
length of time and severity of the fall back into the
old addictive behaviors.
― A relapse is considered a full fall back into the old
addictive behaviors.
― A lapse or a slip is considered a single episode, one
day, and not that severely re-initiating - A lapse or
a slip is just a temporary return.
19
8
Lapse vs. Relapse
199. A lapse represents a temporary slip or return to a
previous behavior that one is trying to control or
quit (usually a one time occurrence)
A relapse represents a full-blown return to a
pattern of behavior that one has been trying to
moderate or quit altogether
19
9
200. ― A lapse is a one time occurrence in which one gives in
to the urge but then immediately realizes it was a
mistake.in this case the individual returns to his life of
recovery relatively quickly.
― A relapse is when one does not recover from a lapse
and fully returns to his pattern of addiction.
― Every relapse begins with a slip but not every slip needs
to become a relapse. People can learn to manage their
slips and go straight back on course as quickly as
possible.20
0
201. ― A “slip” is when someone who has quit smoking has
had a puff or a few cigarettes right after treatment but
does not return back to their regular smoking habit.
― “Relapse” is when someone who has quit smoking
resumes smoking one or more cigarettes a day for
a week or beyond a week.
― Slips are “red flags” that put the ex-smoker at risk for
relapse.
20
1
202. What to do when a lapse occurs?
― A lapse is when you take two or three puffs of a
cigarette but are able to stop yourself, examine and
understand why it happened and continue your
efforts to quit .
― It’s rather like learning to use a computer: you might
enter the wrong command occasionally, but you start
over, see why you did that, and move on at your own
pace. You learn from your mistakes and ultimately
reach your goal.
20
2
203. What to do when a lapse occurs?
― When a lapse occurs, don’t get discouraged! Get
back on track before it becomes a pattern.
― A lapse is an opportunity to learn, and it should not be
viewed as a failure.
― Think about what got in the way of your regular
schedule and what you can do to prevent it from
happening again in the future.
204. Occurrence of a lapse cannot be viewed as a
totally benign event; nor should it be cause for
catastrophe and giving in to a full-blown relapse.
During a lapse episode (slip) the most dangerous
period is the time immediately following the
event.
20
4
205. ― A relapse is when you do the same thing, but are
unable to stop yourself because you make a
negative judgment of your abilities or culpability. As
a result, you abandon your efforts to quit smoking.
― The more people use negative self-talk, the less likely
they will stop smoking.
― Catching negative self-talk and replacing it with
Positive Self-Talk help to keep smokers from relapsing.
20
5
What to do when a relapse occurs?
208. ― After problem-solving, put a plan into action to
anticipate high-risk situations.
― Think about whether you find it best to avoid these
situations altogether or face them using your best
coping strategies.
― Remember to use coping strategies, such as positive
self-coaching and engaging in a distracting activity
to increase your chances for future success
20
8
What to do when a relapse occurs?
211. Motivational Counseling (5 Rs ) is helpful to
individuals who are ambivalent or resistant to
change
21
1
212. Even when patients are not willing to make
a quit attempt, clinician-delivered brief
interventions enhance motivation and
increase the likelihood of future quit
attempts .
214. 5R’s for Patients Not Ready To
Make a Quit Attempt
Relevance
Risks
Rewards
Roadblocks
Repetition
215. When do we deliver the 5R’s?
5R interventions will be delivered to those who
are not ready to quit tobacco use after the
“Assess” stage of the 5A’s.
21
5
216. Relevance :Tailor advice and identify why it is
personally relevant to get the patient to quit.
Risks: Outline risks of continued smoking.
Rewards :Outline the benefits of quitting.
Roadblocks : Identify barriers to quitting and
provide treatment that could address barriers.
Repetition : Reinforce the motivational message
at every visit.
5R’s for Patients Not Ready To Make
a Quit Attempt
217. Roadblocks
Identify and address barriers to cessation:
Withdrawal symptoms
Fear of failure
Weight gain
Peer or social pressure
Depression
Coping with stress
Enjoyment of tobacco
21
7
219. Tips for implementing the
5R’s model
1. Let the patient do the talking. Don’t give lectures!
2. If the patient does not want to be a non-tobacco
user – focus more time on “Risks” and “Rewards”.
3. If the patient does want to be a non-tobacco user
but does not think he or she can quit successfully,
focus more time on “Roadblocks”.
21
9
220. Tips for implementing
5R’s model
Even if patients remain not ready to quit, end
positively with an invitation to them to come
back to you if they want to change. their minds.
22
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221. If possible, follow up with your patient either in
person or by telephone within a week of the
quit date.
A second follow-up is recommended within the
first month.
― “How is it going?”
― “How are you feeling?”22
1
#5 Arrange (Follow up with patients who
are trying to quit).
222. If the patient has not smoked, offer congratulations
and encouragement:
“You’re doing a great job. This is such an important
step to take.”
If the patient has smoked, consider revisiting previous
steps above.
“Quitting can be very difficult. It can often take
someone several tries to successfully quit. Would you
like to try again?”
22
2
223. If patient has relapsed, discuss circumstances of the
relapse, try to identify triggers and brainstorm ways to
prevent future relapses.
Emphasize that a relapse is a learning experience,
not a failure.
Explain that most people require several quit attempts
before they finally succeed and relapses are part of
the normal process of stopping smoking.
22
3
227. NoAsk: Do
you use
tobacco?
Have you
ever used
tobacco?
No No
intervention
Encourage
continued
cessation &
re-evaluate
next visit
Access
Readiness to
quit
Yes
Yes
Do you
want to
quit?
Yes
Advise
to quit
Assist and
Arrange
Call _____ at
______to make
appt.
No
Followup
next visit
5 “R’s”
Relevance
Risks
Rewards
Roadblocks
Repetition
Do you want
to quit within
the next 30
days?
Yes
No
Re-evaluate
next visit
Tobacco Use Assessment Protocol
228. (Ockene, et.al., 2000)
Brief interventions during medical visits
are cost-effective and could potentially
reach most smokers
Unfortunately, brief interventions are
not consistently delivered!
