Tobacco Cessation
Interventions
Lunch and Learn Seminar
Series for Physicians,
Family Health Teams, and
other Health/Allied Health
Practitioners
Session 3:
Brief Cessation
Counselling: The 4Point Plan
Faculty: Stephanie Cohen, MSW, RSW
Housekeeping
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Please sign-in
Please ensure you have completed Learning Assessment 1
http://www.surveymonkey.com/s/fhtjune2011la1
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2
A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
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Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Stephanie Cohen, MSW, RSW
[email protected]
(416) 535-8501 ext. 7415
Stephanie Cohen received her Masters of Social Work Degree from the
University of Toronto in 1997. Since that time, Stephanie has been
working in the field of addictions and mental health at the Centre for
Addiction and Mental Health (formerly the Addiction Research
Foundation). Initially she worked as a clinician in the Opiate Clinic, with
pregnant women in the methadone program. However, for the past 11
years she has been working in a variety of roles in the Nicotine
Dependence Clinic; clinical, educational and managerial. She has been a
member of the TEACH faculty since the initial pilot program in 2006. In
addition, she has had the opportunity travel across the province and
across the country working with a diverse array of health care
practitioners in the field of nicotine dependence. Presently, her role is a
blend of clinical and educational duties. In 2009, she became a member
of the Motivational Interviewing Network of Trainers (M.I.N.T.)
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Disclosures
Stephanie Cohen
No Disclosures
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 3: Learning Objectives
1.
2.
3.
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Review the EBB (Environment/Behaviour/Biology)
framework for treatment planning and intervention
Review 4 key strategies for behaviour change:
1. Strategize
2. Take action
3. Optimize
4. Prevent relapse (persevere)
Apply a structured set of tools for psychosocial
cessation counselling
EBB Model for Smoking Cessation:
Environment, Behaviour and Biology
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EBB: Environment, Behaviour, Biology
A three domain
adaptive model
Addresses behavioural,
environmental, &
biological determinants
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Dr. Peter Selby, 2010
Individual and population
level; expands the current
bio-psycho-social model.
Environment


Environmental
determinants either
promote or protect
against substance
use
Interventions should
address these deficits
home, work, social, dealer, financial
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Dr. Peter Selby, 2010
Behaviour
•
Behavioural dimensions, including the level of
motivation to change, are assessed to develop
an individualized treatment plan.

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Dr. Peter Selby, 2010
Interventions address
attitudes, knowledge
and skills necessary to
recover regardless of
treatment philosophy
Biology
•
•
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Medications may
be prescribed for
withdrawal
management,
relapse
prevention and or
maintenance.
Other co-morbid medical and psychiatric disorders
that complicate addictions may also be treated
concurrently.
Dr. Peter Selby, 2010
Behaviour Change
Roadmap:
THE 4 POINT PLAN
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Important Aspects to Consider
Quitting is a process
= 110,000 hand to mouth
repetitions/year
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Important aspects to consider
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4 steps to stopping destructive
behaviours and leading a healthier life:
1.
2.
3.
4.
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STRATEGIZE
TAKE ACTION
OPTIMIZE
PREVENT RELAPSE
(PERSEVERE)
Step 1:
STRATEGIZE
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1.
Strategize
– # of sessions?
– Developing a quit plan
in conjunction with the
client
– Use EBB framework
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Strategize - Environment
Smoke-free environment
–
–
–
–
–
–
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Home, areas of the home
Work
Car
Social events
Paraphernalia
Social Circle
Strategize: Support Systems
Positive supports:
– Partner, family,
friends, colleagues
– Professionals :
physician,
pharmacist, nurse,
etc.
– Other supports:
helpline, groups,
websites, etc.
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Strategize: Support Systems
Negative influences:
– Other smokers
(partner, family)
– People who don’t
want client to quit
smoking
– Unhelpful
“encouragement” to
quit
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Strategize – Set a Goal
• Quit Date
• Prevents delay
• Time to reduce,
practice
• Refine quit plan
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Goal Statement
The behaviour I want to/need to change is:
What is your goal now?
START DATE:
ACHIEVEMENT DATE:
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Readiness Ruler
People usually have several things they would like to change in their lives – this may be
only one of those things. Answer the following three questions with respect to the goal you
have set.
How important is it to change this behaviour?
0
1
2
3
4
5
6
7
8
9
10
How confident are you that you could make this change?
0
1
2
3
4
5
6
7
8
9
10
How ready are you to make this change?
0
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1
2
3
4
5
6
7
8
9
10
For Reflection: “Readiness Ruler”
What are 3 reasons you are at ______ and not
zero?
1.
2.
3.
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Reasons for Change
Making a commitment to meeting your goal is important to
your success. Sometimes, it’s easy to forget why you’re
making the change, so write down your reasons and use this
as a reminder to yourself when things seem tough!
The most important reasons why I want to change are:
1
____________________________________________________________
2
____________________________________________________________
3
____________________________________________________________
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Decision to Change Worksheet
Changing my current
behaviour
Benefits
Costs
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Continuing the behaviour in
the same way
Daily Diary
Keeping a diary is a key part of any behaviour change program. It gives you accurate details about
the behaviour you want to change, and can also help you to identify high risk situations. This diary
can also help you to see when you aren’t likely to engage in this behaviour, and to identify what was
different about those days. Keeping a diary takes time and commitment, but research has shown that
simply keeping track of a behaviour can lead to change!
What is your goal for this week?
__________________________________________________________________
Date
Behaviour
Describe the situation (e.g., were you
alone or with others, at home or in a social
setting, etc.)
Thoughts and Feelings (What
were you thinking and feeling in
this situation?)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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© CAMH/TEACH Project
Daily Diary - Baseline
Think back to the last week starting today and make a note
when you engaged in the current behaviour(s).
Date
Behaviour
Describe the situation (e.g., were you
alone or with others, at home or in a social
setting, etc.)
Thoughts and Feelings (What
were you thinking and feeling in
this situation?)
Monday
Tuesday
Wednesday
 Increase awareness of smoking behaviour
 Helps identify triggers and challenges
Thursday
 Identifies easy/difficult cigarettes to quit
Friday
 Breaks automaticity of smoking behaviour
Saturday
 Possibly reduces number of cigarettes
Sunday
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Identifying Barriers and Solutions to
Change
Possible Barriers:
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Proposed Solutions:
© CAMH/TEACH Project
Step 2:
TAKE ACTION
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Triggers and Consequences
• Identify and describe high-risk situations
• Describe types of triggers usually associated
with the situation
• Describe the types of
consequences
associated with the
situation
• How often does this
type of situation
occur?
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Triggers and Consequences Worksheet
High-risk situation: _______________________
1. Briefly describe one of your most serious high-risk situations.
2. Describe as specifically as possible the types of triggers usually associated
with this situation.
3. Describe as specifically as possible the types of consequences usually
associated with this situation (immediate and delayed consequences, and
positive and negative consequences).
4. How often did this type of situation occur in the past year? What percentage
of your total behaviour over the past year occurred in this type of situation?
_____________%
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Step 3:
OPTIMIZE
YOUR
STRATEGY
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Optimize Strategy
Identify problems
Potential Solutions
? Changes in mood
? Withdrawal symptoms
? Low motivation
? Weight gain
? Lapses/slips
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 Referral
 Adjust meds
 Decisional Balance
 Nutrition, Exercise
 Review
Optimize Strategy
•
•
•
•
•
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Continue identifying triggers, stressful
situations
Continue self-monitoring
Maintain smoke-free environments
Reset quit/reduce date if needed
Congratulate your client for coming
back
Doing a 360:
•
•
Social supports (family members, friends
colleagues)
Professionals ( MD, RN, Pharmacists, others)
•
•
•
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Asking for Feedback
Feedback on my plan?
Things missing?
Watch for saboteurs and enlist
supporters
Notes and Important Numbers
Smokers’ Helpline:
1-877-513-5333
Ontario Lung Association:
1-888-344-5864
My Quit Buddy:
(416) 555-5555
Other personal and professional supports___
___________________________________
___________________________________
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Step 4:
PREVENT
RELAPSE
(Persevere)
“ A Slip is Not a Fall ”
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EBB and Relapse
• The three domains can help identify which
areas need further optimization
• Also helps clinicians
understand that
continued use and
relapse is not exclusively
a lack of personal
motivation or ability but
multi-factorial in nature.
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Prevent Relapse (2)
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Were there any slips/relapses? What
happened?
What can be done in those situations again
so things are different?
Which options worked and what more
needs to be done?
Prevent Relapse (3)
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
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Pharmacotherapy – long term use for those that
would benefit
Staying engaged in treatment / counselling / groups
when possible
What other supports will remain available beyond
treatment?
Planning for relapse
–
–
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What situations/triggers might lead to a slip or relapse?
Is there a plan on how to deal with those situations?
Preventing Relapse - The Health Care
Provider
Follow-up calls:
– Support/Counselling
– Evaluation
– Re-engaging client if
needed
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Questions?
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Applying the Skills:
Practice Exercise:
Consider a behaviour you would like to
change – something that you are ambivalent
about or have been meaning to change for
awhile.
Complete the tools on the following slides…
47
Readiness Ruler
People usually have several things they would like to change in their lives – this may be
only one of those things. Answer the following three questions with respect to the goal you
have set.
How important is it to change this behaviour?
0
1
2
3
4
5
6
7
8
9
10
How confident are you that you could make this change?
0
1
2
3
4
5
6
7
8
9
10
How ready are you to make this change?
0
48
1
2
3
4
5
6
7
8
9
10
For Reflection: “Readiness Ruler”
What are 3 reasons you are at ______ and not
zero?
1.
2.
3.
49
Reasons for Change
Making a commitment to meeting your goal is important to
your success. Sometimes, it’s easy to forget why you’re
making the change, so write down your reasons and use this
as a reminder to yourself when things seem tough!
The most important reasons why I want to change are:
1
____________________________________________________________
2
____________________________________________________________
3
____________________________________________________________
50
Decision to Change Worksheet
Changing my current
behaviour
Benefits
Costs
51
Continuing the behaviour in
the same way
Discussion and Debrief
1.
2.
3.
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What was it like writing down your responses
using these tools?
How did using these tools impact your
confidence, readiness or importance of
change?
How might you use this learning in your
application of the tools with your patients?
For reflection/discussion…
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
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What will you take away from this session?
How will your learning impact your clinical
practice?
What is one thing you will commit to trying with
patients in the coming week?
Resources
Available for PDF download
http://www.teachproject.ca/publicdownloads/SOR_Booklet.pdf
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Remember …
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A link to the Online Course Evaluation will be
sent by e-mail.
A link to Learning Assessment 2 will also be
sent by e-mail. This must be completed by
June 29th in order to receive your Letter of
Completion
Next session: July 20th 2011:
Motivational Interviewing Part 1: How to ask
patients about tobacco use and using FRAMES
**Application period is now open**
Thank
you!
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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