Project TEACH
Behavioral Strategies in Tobacco
Treatment: Identifying Triggers
Nancy Huang, MA, LPC
Disclosure
• No relevant conflict of interest to disclose.
The Five A’s Model
All Clinicians should…
1. Ask about tobacco use
2. Advise to quit
3. Assess willingness to make a quit attempt
4. Assist in quit attempt
5. Arrange follow up
Stages of Change
Preparation
“Intending to take action in the next month”
 Taking steps in creating a plan of action
 Explore past experience with quitting smoking
 “Testing the waters”
Preparation Continued
• Treatment Strategies
– Identify barriers/obstacles
– Problem solving
– Develop change strategy with small steps
• Individualized
• Achievable
• Measurable Learned Behavior
Smoking is a Learned Behavior through…
1. Repetition •
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20 pack‐year history
10 puffs x 20 cigarettes = 200 puffs/day
200 puffs X 30 days = 6000 puffs/month
6000 x 12 months = 72,000 puffs/year
72,000 x 20 years = 1,440,000 puffs/life
2. Conditioning
• Previously benign events becomes
 Triggers
Identify Triggers
• A cue or signal to engage in a certain behavior – External Triggers
• Environmental factors that trigger cigarette craving
– Internal Triggers
• Subjective thoughts and emotions that elicit desire to smoke
Environmental Factors
• People
– “Tell me about your family or others that live with you.”
– “What is it like to live with another smoker?”
– “Tell me about any co‐workers/friends that smoke with you, if any.”
– “Anyone else that you smoke with regularly?”
Environmental Factors Continued
• Places
– “Tell me about the places you smoke.”
• Inside or outside their home
• Inside their car
• A favorite spot for smoking • Standing outside of an Alcoholic Anonymous meeting
• During break at IOP/PHP
Environmental Factors Continued
• Things
– “Tell me about your morning routine”
• Cigarette tastes better with coffee and/or soda
– “Tell me about your drinking”
• I tend to smoke a lot more while drinking beer and relaxing in the evening.
Psychological Factors
• Emotions
‐ “What do you do to relax in stressful times?”
‐ “When do you always find yourself with a cigarette?”
‐ “How do you reward yourself after overcoming a challenge?”
Psychological Factors
• Thoughts
‐ “What was on your mind that triggered you to smoke?”
‐ “What do you tell yourself after you smoked a cigarette?” ‐ “How long does your cigarette craving last?”
Identifying Triggers
• Initial Intake Assessment
– “Tell me about your smoking”
– “What does your typical day look like with cigarettes?”
Typical Day
Typical Day
• Waking up in AM
• Coffee
• Driving
• Stress
• After Meals
• Break Time
• Phone Call
• Idle Time
• Before Bed
Coping Strategies
• Change AM Routine
• Drink less/different
• Keep hand busy
• Deep breathing
• Wash dishes
• Walk
• Color, Stay inside
• Distraction
Preparing for the Quit Day
• Set a quit date
– Within 1 month
– Encourage them to share their quit date with loved ones
– Validate their commitment to quit smoking
– Enhance self efficacy with small behavioral changes
Develop a Plan: Before a Quit Date
• Cigarette reduction before quit attempt
• Avoid Triggers
• Ask other smokers to step outside
• Escape Triggers
• Walk away from other smokers
• Cope with Triggers
• Self talk and affirmations
Develop a Plan: Before a Quit Date
Continued
• Cigarette reduction before quit attempt
• Delay
• First cigarette in AM, Time between cigarettes
• Limiting Access
• Remove cigarettes from pocket or purse
• Find a replacement behavior Develop a Plan: Before a Quit Date
Continued
Process to building Self Efficacy, because…
• There is no wrong way to quit smoking.
Develop a Plan: On Quit Date
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Stay busy and active
Distract self with different projects
Surround self with supporters
Reward self with something positive
A day that they would look forward to
The MI Spirit
• Style of Motivational Interviewing
– Give advice respectfully
– Ask for permission
– Respect individual’s autonomy
– Avoid argument
– Offer a menu of options
– “This is what worked for others, and it may work for you.”
Acknowledgements
Department of Behavioral Science
• Paul Ciniciripini, Ph.D., Chair, Director
• Maher Karam‐Hage, MD, Professor, Med Director
• Jan Blalock, Ph.D., Associate Professor
• Vance Rabius, Ph.D. , Instructor
• Diane Beneventi, Ph.D., Supervisor
• Mark Evans, LCSW, Senior Counseling Associate
References
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Fiore. M.C., Jaen, C.R., T.B., et al. (2008) Treating Tobacco Use and Dependence. Update. Clinical Practice Guideline. Rockville, MD; USDHHS, PHS, May 2008.
Prochaska, J. O., DiClemente, C. C. (2005). The transtheoretical approach. In: Norcross, JC; Goldfried, MR. (eds.) Handbook of psychotherapy integration (2nd ed). New York: Oxford University Press, 147–171.
http://psychology.tools/stages‐of‐change.html
http://stepupprogram.org/docs/handouts/STEPUP_Stages_of_Change.pdf