IT’S TIME:
Indigenous
Tools and
Strategies
on Tobacco –
Interventions,
Medicines & Education
A Toolkit for Commercial Tobacco Interventions
FACILITATOR
MANUAL
S
T
H
E
T
U
D
STOP SMOKING TREATMENT for ONTARIO PATIENTS
Y
Acknowledgements
We are grateful to the following members of the Engagement Circle who have generously shared their time,
experience and wisdom as co-authors of this resource:
Lisa Cameron, Lac La Croix First Nation Health Station
Yvonne Corbiere, Manager, Aboriginal Tobacco Program Cancer Care Ontario
Ruth Ann Cyr, RN, M.Ed, CDE, Toronto Council Fire Native Cultural Centre
Judy Desmoulin, Long Lake 58 First Nation
Jeff D’Hondt MSW, RSW, Aboriginal Services, Centre for Addiction and Mental Health
William Elliot, ICADC, Assistant Director of Program and Development / Alumni Liaison
Westover Treatment Centre
Suzanne Fitzpatrick, Fort William First Nation – Dilico Family and Child Services
Shari Gilligan, Fort William First Nation
John Etherington, Ontario Federation of Indian Friendship Centres
MaryAnn Notarianni, National Association of Friendship Centres
Richard San Cartier, BScN, PHCNP, ITCC, CDE, RN (EC), North Shore Tribal Council
Shannon Van Every, SOADI Education Coordinator, Southern Ontario Aboriginal Diabetes Initiative
Brian Slegers, Aboriginal Liaison Rainbow District School Board
Patti Ironstand RN, BScN, Creator of I Can Quit (Aboriginal-specific TEACH adapted program),
Janice Burgess, PACT/TAR program in SK
Jaimee Marks, PACT/TAR program in SK
Rolanda Manitowabi, Ngwaagan Gamig Recovery Centre Inc. (Rainbow Lodge)
Fran Masterson, Rama First Nation
Sharon McLean, First Peoples Group
Dr. Peter Menzies, Sagamok Anishnawbek First Nation
Andrew Snowball, Addiction and Mental Health Program Trainer
Ontario Federation of Indian Friendship Centres
Mary Griffiths RN BScN CPRP, St. Joseph’s Healthcare - Centre for Mountain Health Services
Elder Vern Harper, Centre for Addiction and Mental Health
EJ Kwandibens, Urban Aboriginal Healthy Living Programme Trainer, Ontario Federation of Indian
Friendship Centres
We would also like to thank Joyce Helmer from the Indigenous Health Knowledge Centre for her time and
expertise on the instructional design and content development of the toolkit.
We would like to honour and credit Patti Ironstand RN, BScN, Tobacco Project Coordinator, BTC Indian
Health for the idea of narrative healing through storytelling.
We would also like to acknowledge the artistic contribution of 7th Generation Image Markers (Native Child
and Family Services Toronto).
Consulting and resource locating:
Janice Burgess BSP, PACT/TAR Program Coordinator, SK
Ruth Ann Cyr, RN, M.Ed, CDE, UAHLP Coordinator, Toronto Council Fire
Stephanie Cohen, MSW, RSW at the Nicotine Dependence Clinic
The Enaahtig Healing Lodge and Learning Centre
Members of the Network for Aboriginal Mental Health Research (NAMHR)
Chiefs of Ontario
Anishnawbe Health Toronto
Toronto Council Fire Little Embers program
All of these materials can be freely copied, shared and adapted, in accordance with the First Nations
principles of OCAP (Ownership, Control, Access and Possession). Feel free to supplement the toolkit with
your own materials.
Centre for Addiction and Mental Health (CAMH) -Nicotine Dependence Service
Peter Selby, MBBS, CCMR, MSc, FASAM, Executive Director, Marilyn Herie, PhD, RSW, TEACH Director, Laurie Zawertailo, PhD, STOP
Research Scientist, Rosa Dragonetti, MSc, Manager, Sarwar Hussain, MSc, Assistant Manager, Karina Czyzewski, MA, Aboriginal
Projects Coordinator, Julia Lecce, MA, TEACH Project Coordinator, Megan Barker, MA, TEACH Continuing Medical Education
Coordinator, Stephanie Sliekers, BA, TEACH Community Health and Education Associate, Myra Fahim, BSc, BEd TEACH Community
Health and Education Associate, Justine Mascarenhas, MSc, STOP Research Coordinator
it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
CIRCLE ONE:
WHO USES COMMERCIAL TOBACCO?
Illustration of the Four Teaching Circles: Themes and Content
you
are here
HOW TO CHANGE?
Discuss and implement
approaches, treatments
and helpers to increase
the odds of quitting
WHAT?
Understand tobacco
as harmer and as healer,
as well as the role of
medications
circle ONE
4
3
1
2
WHO USES
COMMERCIAL TOBACCO?
Understand
prevalence and
how people and
communities
are affected
WHY CHANGE?
Enhance
motivation to quit
commercial tobacco
1
it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
Four Rounds of the Teaching Circle
Every Circle will have four rounds: Circle members move from exploring their own pre-existing
knowledge (Self-Knowledge), through generating New Knowledge (NK), Integrating Knowledge
(IK), and taking Action (A). Please see the following pages for the full guide and individual
activities for each Round.
SK
Round 1 - Self Knowledge (SK)
Round One is a combination of sharing experiences and building trust. In order to move forward,
participants need to establish a collaborative working relationship and begin a democratic
dialogue. Out of the shared experiences, themes emerge -- issues that people share, problems
they face, differences of opinion.
NK
Round 2 - Finding Patterns (New Knowledge) (NK)
Round Two is to identify these themes (find patterns) and analyze them. How do these problems
work? Where do they come from? Add/acquire/master new information from the facilitator or the
group. A crucial part of this step is learning how to use the new information and seeing how it
affects the analysis of problems carried out in the previous step.
IK
Round 3 - Integration of Knowledge (IK)
Round Three is planning for action and practicing skills. This is where people are creating
strategy and tactics, thinking about what they want and how they plan to get it. Activities and
worksheets can be incorporated here.
A
Round 4 - Action (A)
Round Four is crucial. The connection between education and action is not a solid line. It is not so
predictable. Any given educational process may not produce action. Or it may take a long time, or
come up in an unexpected way. The educator may or may not have a connection to that step and
certainly does not control it.
5 apply in action
The end of this learning
journey is reconstruction
and assessment. This step
overlaps with the first step of a
new spiral. Here is the model
that incorporates the four
rounds discussed above:
2
A
practise skills
strategize and
plan for action
SK start with the
IK
experience of
the participants
NK
add new information and theory
look for
patterns
[ image inspired by Paulo Freire’s Pedagogy of the Oppressed, 1970 ]
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it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
Circle 1: Facilitators’ Checklist
IMPORTANT NOTE: All of the following activities and resources are optional in the sense that
you can (and should) tailor the Teaching Circle to the needs of your group and community.
Content and Activities
Resources and Preparation
* Invite an Elder to offer an Opening Prayer/Ceremony/
Gathering Song
Opening and Welcome
* Print a sign-in sheet to track attendance. (See
Additional Resources section in the Tool-Kit)
* Bring a stress ball, rubber chicken (or some other funny
object) for the Icebreaker Activity. (see p. 5)
SK Round One: Self-Knowledge (SK)
a. Introduce Learning Outcomes for this circle
b. What is your relationship with tobacco?
See page 6
See page 6
* Print and cut out the pre-formatted Tobacco Trivia cards
included in this package. (see pp. 7-18)
NK
Round Two: New Knowledge (NK)
a. Tobacco Trivia: It’s all in the Cards!
b. Traditional Use of Tobacco
* Invite an Elder or Traditional Knowledge Keeper to
speak about traditional tobacco use. (see page 19)
* Print out enough copies for each participant of The Use
of Sacred Tobacco is Our Tradition handout (see pp. 20)
* Have a flip chart and markers to capture ideas, images
and words the circle members brainstorm. (see p. 20-21)
* Bring coloured markers for participants to outline on
IK
the flipchart their idea of the Typical Canadian Smoker
Round Three: Integration of
Knowledge (IK)
a. The Aboriginal/Indigenous Smoker
(see p. 22)
* Print enough copies for each participant of the
Summary of Tobacco Use Facts and Stats handouts.
(see Appendix to this section, p.p. 24-27) or refer
members to their Participant Handbook
A
Round Four: Action (A)
a. What does this information mean to you?
See page 22.
* Print enough Evaluation handouts for each Circle
Wrap-Up
member (See Additional Resources section of the Tool-kit)
* Collect the completed Evaluation Forms
Closing the Circle
circle ONE
* Invite an Elder to offer a Closing Prayer/Ceremony/
Traveling Song
3
it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
Opening and Welcome
• Introduce yourself as the helper/facilitator for the Circle
• Opening Prayer/Ceremony/Gathering Song as per community context and if applicable by an
invited Elder or the facilitator
• Welcome participants – may be done by the Elder
• Provide logistical information, which can include:
-- Sign-in (if using): Direct participants to sign-in sheet on resource table (optional and based
on community preference); breaks, washrooms, refreshments, etc.
-- Content that will be covered: Describe the overall content of the four Teaching Circles, as
well as the content in this first Teaching Circle.
• Example introduction to the content and structure of the sessions:
Thank you for coming today to explore and talk about traditional and commercial tobacco, and our individual experiences and experiences as a community with tobacco.
We will meet together for four different Teaching Circles, and each Circle has its own
theme. This Teaching Circle (Circle 1) is called: “Who uses commercial tobacco?” In
this Circle, we will talk about some of the interesting facts and statistics about commercial tobacco use, as well as the consequences of tobacco use for ourselves, our
community, our wider society and our Mother Earth. In the other Teaching Circles we
will look at reasons to change use of commercial tobacco (Circle 2), understanding
tobacco as both a healer and harmer as well as the role of medications (Circle 3), and
how to quit using commercial tobacco (Circle 4). Everyone’s voice is important, since
we all have experience with commercial tobacco – either ourselves or with our families,
friends and community. In this way we all have teachings to share and we can all learn.
• Invite the circle participants to introduce themselves in a way that is comfortable for them.
They can simply provide their first name or introduce themselves in the traditional way
whatever is preferable to the participant. Be clear in your direction that this is simply a brief
introduction.
4
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it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
• Icebreaker activity: Have a stress ball (or rubber chicken or something funny) and throw it
across the circle calling out the participants name, that person then throws the ball to another
person calling out their name until everyone’s name has been called out. This helps everyone
remember each other’s name and usually results in some laughter if the item being thrown is
unusual.
circle ONE
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it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
SK Round One: Self Knowledge (SK)
This round will afford the participants the opportunity to articulate their addiction (or not) and how tobacco has impacted their lives.
a. Introduce the intended learning outcomes for Circle 1:
-- To describe your relationship to tobacco and why quitting commercial tobacco use is
important
-- To summarize smoking prevalence in Canada and among Aboriginal Peoples.
b. Ask the question, “What is your relationship to tobacco?” Tell the participants that you are
going to proceed around the circle and invite them to participate if they choose to. Let them
know that they can pass if they need more time to think about their response. You will keep
going around the circle until everyone has had an opportunity to speak. It is not necessary
that everyone provide an answer. The responses will be varied and may include sacred use,
chew, snuff etc…individuals may talk about their exposure to others smoking as a child, peer
pressure and so on.
NK Round Two: New Knowledge (NK)
This round is best delivered interactively but can also be effective with a video,
guest speakers or formal presentations.
Activity A: Tobacco Trivia: It’s all in the Cards (20 – 30 minutes)
INSTRUCTIONS:
Using the pre-formatted “Tobacco Trivia” quiz (see following pages) create a deck of cards
with the quiz question on one side of the card and the correct answers on the other side. Print
on heavy paper (card stock) and use a paper cutter to make your own cards to use for this
activity. Pass the deck of cards around the circle and have each participant take one or more
cards (depending on the number of people in the circle). As you go around the circle ask each
participant to read the question(s) and have a large group discussion on the answers. Feel free
to add other questions as well, especially specific questions that relate to your community that
would be important to include.
PRINTING TIP: Set your printer to “2-sided printing” or “duplex printing” and you will end up with
the cards having front and back text (Questions on the front and Answers on the back).
6
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it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
Q1: C igarette smoking is the primary cause
Q2: Smoking commercial tobacco during
of which cancer? (Hint: This cancer is
pregnancy can be associated with which
recognized as the most lethal type of
outcomes?
cancer)
a. low birth weight babies
a. Breast cancer
b. spontaneous abortion
b. Lung cancer
c. Sudden Infant Death Syndrome (SIDS)
Q3: Smokeless commercial tobacco products
Thatcher, 2001
d. Pancreatic cancer
Thatcher, 2001
c. Cancer of the mouth
d. stillbirths
e. All of the above
Q4: What percentage of Aboriginal peoples in
may actually be ________ addictive than
Canada smoke cigarettes?
cigarette or pipe smoking because the
nicotine levels reached in the blood tend
a. 35%
to be higher than smoking cigarettes
b. 43%
c. 57%
a. less
Q5: Carbon monoxide, a deadly chemical in
d. 78%
Q6: How many hours after quitting smoking
cigarettes, stays in the blood hemoglobin
commercial tobacco does it take to reduce
(the protein in red blood cells that carries
the risk of having a heart attack, and to
oxygen) for as long as 6 hours
improve sense of smell and taste ?
a. True
a. 24
b. False
b. 48
Thatcher, 2001
Thatcher, 2001
Q7: In Canada, recreational use of commercial
c. 72
d. 100
Q8: Three days after quitting smoking,
tobacco has a societal and economic
former users of commercial tobacco will
impact of ________ dollars per year.
experience:
a. re-growth of nerve endings
b. $ 3.4 million
b. enhanced ability to smell and taste
c. $ 6.7 million
c. increased lung capacity
d. relaxation of bronchial tubes
CAMh, 2011
d. $ 9.5 billion
Thatcher, 2001
a. $ 2.8 billion
circle ONE
Thatcher, 2001
c. more
Thatcher, 2001
b. equally
e. All of the above
7
it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
A2:
A1:
e. All of the above
b. Lung cancer
A4:
A3:
c. 57 %
c. More
A6:
A5:
b. 48
a. True
A8:
A7:
e. All of the above
d. $ 9.5 billion
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Q9: Research has shown that second hand
Q10: There are more people killed by
smoke from commercial tobacco:
commercial tobacco use than by:
a. contains less ammonia than inhaled smoke
a. murder, alcohol abuse & HIV/AIDS combined
b. has fewer cancer- causing agents
b. fatal car collisions
c. is not dangerous if the windows are open
c. drug abuse
d. is even more dangerous than inhaled smoke
d. alcohol abuse
Thatcher, 2001
Thatcher, 2001
Q11: Leukoplakia consists of whitish or
Q12: A pproximately how many Canadians die
grayish patches of cells that form in the
every year from the effects of commercial
mouths of people who use smokeless
tobacco use?
tobacco products. These patches in the
a. 1,000
mouth:
b. 2,500
d. 37,000
c. tend to become cancerous
d. can be treated by brushing your teeth daily
Q13: C igarette butts have what effect on
Rehm et al., 2010
c. 20,000
b. can be reduced by gargling with water
Thatcher, 2001
a. only occur in older people
Q14: If you are using three tins of snuff per
Mother Earth?
week, quitting will save you how much
money over a year? ($5 per tin)
a. They are the number one type of litter on the
b. They break down in our Earth’s soil.
causing agents that can be swallowed by
animals and children
d. Both A and C are correct.
Q15: Despite brushing your teeth and flossing,
a. $330
b. $500
Severson et al., 2010
c. They have a plastic coating with cancer
Cancer Care Ontario, 2011
planet.
c. $620
d. $780
Q16: Using commercial smokeless tobacco
smokeless tobacco can still cause:
can result in lesions (sores) in the mouth
that can become cancerous. These
a. pancreatic cancer
products can also cause cancers of the:
b. bad breath
c. gum disease
Severson et al., 2010
circle ONE
a. chest
Severson et al., 2010
d. all of the above
b. cheeks
c. face and neck
d. ears
9
it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
A10:
A9:
a. Murder, alcohol abuse & HIV/AIDS combined
d. Is even more dangerous than inhaled smoke
A12:
A11:
b. 37,000
c. Tend to become cancerous
A14:
A13:
d. $780
d. Both A and C are correct.
A16:
A15:
c. Face and neck
d. All of the above
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Q17: Symptoms of nicotine withdrawal include
Q18: The chemical arsenic found in
poor concentration, craving for nicotine
commercial tobacco smoke is also found
and increased appetite. Increased
in:
appetite can last for up to:
a. rocket fuel
b. 2 weeks
c. paint stripper
c. 10 weeks
d. plastics
d. 1 month
Q19: C ommercial tobacco use harms the male
Britton, 2004
b. ant poison
Britton, 2004
a. 12 days
Q20: Nonsmokers exposed to secondhand
reproductive system by causing:
smoke at home or at work increase their
heart disease risk by what percentage?
a. infertility
a. 5%
c. impotence
b. 15%
d. All of the above
c. 25%
Britton, 2004
Q21: C hildren who are exposed to secondhand
Rehm et al., 2010
b. sperm deformity
d. 40%
Q22: Which country produced more than 40
smoke are more likely to experience:
per cent of the world’s tobacco leaf in
2007?
a. respiratory illness
a. China
c. risk of cancer
b. Brazil
d. all of the above
c. United States of America
Britton, 2004
Q23: Secondhand smoke is harmless if what
Tobacco Atlas, 2007
b. asthma
d. Indonesia
Q24: Health warnings on tobacco packages
distance is kept between you and the
cost governments:
smoker.
a. $0 per pack
a. 1.5 meters
b. 35 cents per pack
b. 2 meters
c. 75 cents per pack
c. 5 meters
d. $1 per pack
Britton, 2004
circle ONE
Britton, 2004
d. There is no safe distance
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A18:
A17:
b. Ant poison
c. 10 weeks
A20:
A19:
c. 25%
d. All of the above
A22:
A21:
a. China
d. All of the above
A24:
A23:
a. $0 per pack
d. There is no safe distance
12
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Q25: The global tobacco market is estimated
Q26: The predominant psychoactive drug in
to have total sales of what amount in
tobacco is:
2012?
a. $130 billion
a. formaldehyde
b. $267.8 billion
b. nicotine
c. $378 billion
c. tar
d. $464.4 billion
d. pyridine
Britton, 2004
Britton, 2004
Q27: The American Environmental Protection
Q28: What is one of the ways that smoking
Agency (EPA) indicates that 10 parts per
commercial tobacco damages your
million of hydrogen cyanide is safe. This is the
lungs?
same gas that is used in gas chambers and
can be found in cigarette smoke. What amount
a. formation of black, oil-like residue
does cigarette smoke produce on average?
b. reduction of mucous
d. decreased cough
c. 950 parts per million
d. 1,600 parts per million
Q29: People who smoke commercial tobacco
Britton, 2004
c. increased action of cilia to remove debris
b. 100 parts per million
Britton, 2004
a. 30 parts per million
Q30: Strategies to deal with nicotine
and who have chronic bronchitis face a
withdrawal include:
greater risk of lung cancer if:
a. temporarily avoiding activities that remind
a. they are less than 20 years of age and smoke
you of smoking
more than 10 cigarettes per day
b. c alling a trusted friend or an Elder for
b. they are over 50 years of age and smoke
d. quitting at any age reduces the risk – but all
smokers are at risk
Britton, 2004
c. they have smoked for 5 years or more
Severson et al., 2010
support
more than 20 cigarettes per day
Q31: Nicotine is the main ingredient in
c. reminding yourself of why you quit using
commercial tobacco in the first place
d. All of the above, and more
Q32: People who have recently quit using
commercial tobacco that causes cancer.
commercial tobacco can experience
sleep disturbances. Some ways to cope
a. True
with this include:
b. False
a. avoid or reduce caffeine
Severson et al., 2010
Severson et al., 2010
circle ONE
b. drink water and avoid alcohol
c. go to bed later
d. All of the above
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A26:
A25:
b. Nicotine
d. $464.4 billion
A28:
A27:
a. Formation of black, oil-like residue
d. 1,600 parts per million
A30:
A29:
d. All of the above, and more!
d. Quitting at any age reduces the risk – but all
smokers are at increased risk
A32:
A31:
d. All of the above
b. False
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Q33: At what point during a pregnancy should
Q34: Using Nicotine Replacement Therapy to
a woman stop smoking commercial tobacco,
help quit using commercial tobacco can:
in order for the unborn baby to benefit?
a. during the first trimester
a. double a person’s chances of quitting
b. before 6 months in the pregnancy
b. help the brain recover from nicotine
dependence
c. Quitting during the pregnancy is too
woman quits
Q35: What percentage of Aboriginal peoples
c. be used for as long as a person needs
Severson et al., 2010
when a woman quitspregnancy when a
Severson et al., 2010
stressful for the baby and is not advisable
d. a baby benefits at any point in the pregnancy
d. all of the above
Q36: How many chemicals can be found in
live with at least one person who uses
tobacco smoke?
commercial tobacco?
a. 10
a. 18%
b. 170
b. 33%
c. 2700
Severson et al., 2010
d. 70%
Severson et al., 2010
c. 59%
d. 4700
Q38: This chemical found in cigarettes has
Q37: A male who begins smoking before the
age of 15 and continues to smoke is only
an adverse effect on the body’s immune
half as likely to live to the age of _______
system.
as someone who never smokes.
a. ammonia
b. hydrogen cyanide
a. 65
c. 75
d. 80
Q39: Which types of cigarettes are the most
a. Australia
tobacco
b. Germany
b. Premium brand commercial tobacco
d. Sweden
Tobacco Atlas, 2007
circle ONE
c. Canada
Severson et al., 2010
d. A ll cigarettes are equally harmful
d. cadmium
than men?
a.C igarettes made with organically grown
c. C ontraband tobacco cigarettes
c. carbon monoxide
Q40: In which country do more women smoke
harmful?
cigarettes
Severson et al., 2010
Severson et al., 2010
b. 70
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A34:
A33:
d. All of the above
d. A baby benefits at any point in the
pregnancy when a woman quits
A36:
A35:
d. 4700
c. 59%
A38:
A37:
d. cadmium
c. 75
A40:
A39:
d. Sweden
a. All cigarettes are equally harmful
Many Swedish men use a smokeless tobacco
product called Snus.
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Q41: Unless smoking trends change
Q42: Every ______ of the year in 2010, 12
dramatically, tobacco will eventually kill
million cigarettes were smoked around
______ million of today’s teenagers and
the world.
children.
a. Second
b. 130
c. Hour
c. 250
d. 300
Q43: What are some ways of offering
Tobacco Atlas, 2007
b. Minute
Tobacco Atlas, 2007
a. 45
d. Day
Q44: Traditional and commercial tobacco are
traditional tobacco?
grown from the same kind of seeds.
a. give thanks to the Creator
a.
b. in a pipe ceremony
True
c. sprinkled on the ground
b.
d. all of the above
False
NCIDC, 2011
NCIDC, 2011
Q45: Traditional tobacco used in a pipe
Q46: What are the four sacred medicines?
ceremony is addictive
a. Sage
a. True
b. Sweet grass
b. False
c. Tobacco
d. Cedar
e. All of above
NCIDC, 2011
NCIDC, 2011
Q47: What are the benefits of traditional
Q48: Not all Sacred Pipes contain tobacco
tobacco?
when smoked
a. Discipline
a. True
b. Respect for the Creator and all creation
b. False
c. Understanding of ones’ culture
d. Spiritual development
NCIDC, 2011
circle ONE
NCIDC, 2011
e. All of the above
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A42:
A41:
d. Day
c. 250
A44:
A43:
b. False
d. All of the above
original form of tobacco that is used by
Aboriginal people in the traditional sense is
nicotiana rustica, Most commercial tobacco is
now grown from nicotiana tabacum.
CAMH/Teach Project, 2011
There are 2 different types of seeds: The
A46:
A45:
e. All of above
c. False
The smoke is not inhaled and traditional
tobacco is typically used less than once a
month.
A48:
A47:
a. True
e. All of the above
Some contain a mixture of tobacco and other
herbs. Some do not contain tobacco at all.
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Activity B: Traditional Use of Tobacco
If you have an invited Elder or Traditional Knowledge Keeper who will be speaking about
traditional tobacco use, invite him or her to share their teachings about traditional tobacco and
how it is different from commercial tobacco. If an Elder is not present at this Circle, you may
choose to do the following activity:
Step 1: A
sk students to ‘brainstorm’ the topic of Aboriginal people and tobacco. “What do you
think of when I say “Aboriginal people and tobacco?”
Step 2: C
apture all ideas, images, words on flip chart. Identify if possible negative, neutral, and
positive images or words.
Step 3: D
iscuss: How similar is this to what we each knew about tobacco before? What ideas did
we have about Aboriginal people and tobacco? Are they the same now? Were there any
surprises, anything you did not expect?
circle ONE
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[ Online handout: http://www.ncidc.org/tupe/sacred.htm ]
The Use of Sacred Tobacco is Our Tradition
Our ancestors have used sacred Tobacco for thousands of years.
Tobacco has grown on the North American continent for at least
the last 8000 years.
Sacred sa•cred (say-krid) adj.
1. Dedicated to or set apart for worship.
2. Worthy of religious veneration.
3. Made or declared holy.
4. Dedicated or devoted exclusively to a single use, purpose, or person.
5. Worthy of respect; venerable.
6. Of or relating to religious objects, rites, or practices.
Tribal Elders are dedicated to keeping tobacco sacred. Tobacco is offered to the Creator of the
earth, for our land, our fish, our acorns, and our life. The Creator gives us many gifts. Tobacco is a
gift to be used in a sacred way, with respect.
When used traditionally with respect and honor, tobacco can promote good health and assist
with spiritual guidance and growth. Each Tribe has different ceremonial uses. Learn yours, use
it, respect it. Indigenous peoples have a common knowledge of sacred, of respect, and of honor.
Tribal Elders are dedicated to keeping tobacco sacred. We thank the Creator of Mother Earth for
our life. We offer her sacred tobacco in our ceremonies with respect.
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[ Online handout: http://www.ncidc.org/tupe/sacred.htm ]
Traditional Uses of Tobacco:
Risk of Cancer:
Very low, none if not inhaled.
Type of Use:
• Tobacco offerings to the earth, the drum, a river or a fire. Offerings are often placed/scattered
by hand and are rarely smoked.
• Smoking a Sacred Pipe (not all pipes contain tobacco when smoked. In fact some tribes
do not use tobacco at all. Some tribal people will use a blend of tobacco with other herbs in
their pipe).
• Offered to a Healer or an Elder as a sign of respect.
Benefits:
• Discipline.
• Respect for the Creator and all creation.
• Understanding of one’s culture.
• Spiritual development.
Special Notes:
There are many traditional ways to use tobacco. It is smoked in some traditional ceremonies.
However, it is generally used less than once a month. There is very little risk of cancer when used
this way.
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IK Round Three: Integration of Knowledge (IK)
Activity A: The Aboriginal/Indigenous Smoker (20 minutes)
INSTRUCTIONS:
In groups of three, ask members to define a ‘typical smoker’ (commercial tobacco and/or
traditional tobacco) in my community. Ask them to reflect on the similarities and differences
between the typical smoker in the community vs. in Canada as a whole.
Optional Handouts: Summary of Tobacco Use Facts and Stats (See Appendix at the end of this
document) to share similarities and differences.
A Round Four: Action (A)
Activity A: What does this information mean to you?
INSTRUCTIONS:
Bringing the participants back into the big circle ask: “What does this information mean to you?”
Let the participants know that they do not have to share if they do not want to. Once everyone has
made their contribution provide an overview of the session. Reaffirm that there are similarities
and differences in tobacco use and encourage the participants to continue to try to understand
where they fit into the picture.
Wrap-up
This can be done orally as part of the circle process or copies of the Facilitator and Workshop
evaluations can be distributed.
Encourage participants to complete the evaluation. Tip: if you choose to hand out a paper copy
have the participants fill it out while still in the Circle before you close.
Closing and Last Words
Reiterate the opening words of welcome. Thank them for having the courage to participate.
Closing Prayer/Travelling Song, if applicable.
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Appendix with Optional Handouts:
Summary of Tobacco Use Facts and Stats and “Where do I Fit in?”– see following pages.
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Summary of Tobacco Use Facts and Stats
What you need to know!
“Fast facts” on commercial tobacco use worldwide
• Tobacco is the leading cause of preventable death in the developed world
• Tobacco kills 1 in 5 Canadians, or 45,000 people every year (more than deaths due to
traffic accidents, suicides, homicides, drug abuse and HIV-AIDS combined) (Physicians
for a Smoke-Free Canada, 2003)
• Economic impact of smoking estimated at $17 billion every year (Rehm et al., 2006)
• 90% of people who smoke became addicted before age 18 (Fiore et al., 2008)
• Tobacco-related disease accounts for at least 500,000 hospital days each year in Ontario
alone (MHPS, 2009)
• 18% of Canadians age 15 and over are current smokers (CTUMS, 2010)
• 19% of the Aboriginal population in Canada, between the ages of grade 7 – 12 are current
smokers
• Rates of smoking are much higher among sub-populations: e.g.,90% - people with
schizophrenia, 90% - people with opioid dependence (Kalman, Morisette and George,
2005; NIDA, 2008)
“Fast facts” on commercial tobacco cessation treatment
• 70% of smokers want to quit, and the remaining 30% would likely choose to not start, or
would not want their child to smoke (Fiore et al., 2008)
• Just 3-5% of unassisted quit attempts are successful, compared with up to 20% success
for those receiving cessation counselling and medications (Fiore, Baker et al., 2008)
• Outcomes of evidence-based cessation interventions are comparable with other chronic
disease management (hypertension, asthma, diabetes) (West and Shiffman, 2007)
Canadian Practice Guidelines for Commercial Tobacco
• For Canadian Practice Guidelines for Commercial Tobacco Cessation, please go to
www.can-adaptt.net.
• CAN-ADAPTT Guidelines have also been developed for tobacco interventions with
Aboriginal peoples, which can be accessed online at
http://can-adaptt.net/English/Guideline/Aboriginal%20Peoples/Home.aspx.
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Gender-Specific Smoking Prevalence across the World
Canada
19%
17%
Mexico
37%
12%
Men
Women
Russian Fed
70%
27%
France Germany
Portugal
37% Belarus
37%
41%
US
26% 64%
China
27%
31%Spain
Iran 24%
26%
59%
36%
24%
21%
Philippines
4%
31% Egypt
2%
39%
25% Kenya India
24%
28%
9%
1%
Brazil
1%
1%
South Africa
20%
25%
Australia
Chile 13%
28%
8%
42%
22%
31%
Shafey et al. The Tobacco Atlas, 2009.
Differences by Province (smoking Prevalence ages 15+)
61%
36%
36%
20%
19%
17%
12%
20%
21% 24%
16%
21% 19%
Territory data obtained using 2009 Canadian Community Health Survey; Provincial data obtained using CTUMS 2010 Wave 1 data.
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Current Canadian Adult Smokers (15+) by Province, 1999 & 2009
CTUMS, 2009
Where Do I Fit In?
Average
Number of cigarettes smoked/
cigarettes
day, by age
Group
CTUMS, 2009
Smoking Status in Ontario
CTUMS, 2009
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References
Canadian Cancer Society, Heart and Stroke Foundation of Canada and Physicians for a Smoke-Free Canada. New global
tobacco treaty welcomed [press release]. Ottawa: Physicians for a Smoke-Free Canada; 2003 Feb 28.
Available online at: www.smoke-free.ca/eng_home/news_press_Feb28-2003.htm
Centers for Disease Control and Prevention (CDC). State-specific prevalence of cigarette smoking and quitting among
adults—United States, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:1124–1127.
Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US
Department of Health and Human Services. Public Health Service; May 2008. Available at: www.surgeongeneral.gov/
tobacco/default.htm.
Fiore MC, J. C., Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for
Clinicians. . Rockville, MD, U.S. Department of Health and Human Services. Public Health Service. Available online at:
http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm
Health Canada. (2010). Canadian Tobacco Use Monitoring Survey Wave 1, February – June 2010: Statistics of smoking
prevalence in Canada.
Available online at: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2010/w-p-1_
sum-som-eng.php
Kalman, D., S. B. Morissette, et al. (2005). “Co-morbidity of smoking in patients with psychiatric and substance use
disorders.” Am J Addict 14(2): 106-23.
Pinto A., Manson HE. (March 10, 2011). Tobacco related disparities and equity. Presented at the Smoke-Free Ontario
Knowledge Exchange Forum, Toronto, Ontario
Rehm, J., B. Taylor, et al. (2006). “Avoidable burden of disease: conceptual and methodological issues in substance abuse
epidemiology.” Int J Methods Psychiatr Res 15(4): 181-91.
Results-based Plan Briefing Book 09-10 (2009). Ministry of Health Promotion.
Available online at: www.mhp.gov.on.ca/English/.../RbP_BriefingBook_2009-10.pdf
Shafey O, Eriksen M, Ross H, Mackay J. (2009).The Tobacco Atlas 3rd ed. Atlanta: American Cancer Society.
Swartz SH, Hays JT. Office-based intervention for tobacco dependence. Med Clin North Am. 2004;88:1623–1641.
Statistics Canada (2009). Canadian Community Health Survey (CCHS): Smokers by sex, province and territory.
Available online at: http://www40.statcan.ca/l01/cst01/health74b-eng.htm
WHO Report on the Global Tobacco Epidemic http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
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CIRCLE two:
WHY CHANGE?
Illustration of the Four Teaching Circles: Themes and Content
HOW TO CHANGE?
WHO USES
COMMERCIAL TOBACCO?
Discuss and implement
approaches, treatments
and helpers to increase
the odds of quitting
WHAT?
Understand tobacco
as harmer and as healer,
as well as the role of
medications
4
3
Understand
1
2
prevalence and
how people and
communities
are affected
you
are here
WHY CHANGE?
Enhance
motivation to quit
commercial tobacco
The Teaching Circles are based on the model outlined on the following page wherein each of the
four Teaching Circles has four rounds of learning: Round 1, Self-Knowledge (SK); Round 2:, New
Knowledge (NK); Round 3, Integration of Knowledge (IK); Round 3, Action (A). This is a suggested
model, but the Circles are not restricted to this format –elaborating, condensing and tailoring are
all expected.
The Teaching Circles can be offered in the order they are presented—i.e. Circle 1: Who?, Circle
2: Why?, Circle 3: What?, Circle 4: How?—or you may choose to select and adapt any of the
activities in any order. Circles may be abbreviated to be offered in a shorter period of time, such
as half a day, or extended over several weeks.
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Four Rounds of the Teaching Circle
Every Circle will have four rounds: Circle members move from exploring their own pre-existing
knowledge (Self-Knowledge), through generating New Knowledge (NK), Integrating Knowledge
(IK), and taking Action (A). Please see the following pages for the full guide and individual
activities for each Round.
SK
Round 1 - Self Knowledge (SK)
Round One is a combination of sharing experiences and building trust. In order to move forward,
participants need to establish a collaborative working relationship and begin a democratic
dialogue. Out of the shared experiences, themes emerge -- issues that people share, problems
they face, differences of opinion.
NK
Round 2 - Finding Patterns (New Knowledge) (NK)
Round Two is to identify these themes (find patterns) and analyze them. How do these problems
work? Where do they come from? Add/acquire/master new information from the facilitator or the
group. A crucial part of this step is learning how to use the new information and seeing how it
affects the analysis of problems carried out in the previous step.
IK
Round 3 - Integration of Knowledge (IK)
Round Three is planning for action and practicing skills. This is where people are creating
strategy and tactics, thinking about what they want and how they plan to get it. Activities and
worksheets can be incorporated here.
A
Round 4 - Action (A)
Round Four is crucial. The connection between education and action is not a solid line. It is not so
predictable. Any given educational process may not produce action. Or it may take a long time, or
come up in an unexpected way. The educator may or may not have a connection to that step and
certainly does not control it.
5 apply in action
The end of this learning
journey is reconstruction
and assessment. This step
overlaps with the first step of a
new spiral. Here is the model
that incorporates the four
rounds discussed above:
30
A
practise skills
strategize and
plan for action
SK start with the
IK
experience of
the participants
NK
add new information and theory
look for
patterns
[ image inspired by Paulo Freire’s Pedagogy of the Oppressed, 1970 ]
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Circle 2: Facilitators’ Checklist
IMPORTANT NOTE: All of the activities and resources are optional in the sense that you can and
should tailor the Teaching Circles to the needs of your group and community.
Content and Activities
Resources and Preparation Required
* Invite an Elder to offer an Opening Prayer/Ceremony/Gathering Song
Opening and Welcome
* Print a sign-in sheet to track attendance. (See Additional Resources
section in the Tool-Kit)
SK Round One: Self-Knowledge (SK)
a. Learning Outcomes
See page 33
If I could quit smoking I could
* Bring a flip chart and colourful markers for circle members to record
their answers. (see p. 33)
NK
Round Two: New Knowledge (NK)
a. Important Decision Exercise
* Bring a flip chart and colourful markers for circle members to record
b. The Stages of Change
* Print enough copies for each circle member of the Stages of Change
their answers. (see page 33-34)
handout (see page 34-35) or refer members to their Participant Handbook
c. How much is smoking costing
you?
IK
* Bring blank paper, calculators and pencils for circle members to
calculate the costs of their smoking (see page 36)
Round Three: Integration of Knowledge (IK)
a. How motivated am I right now?
* Print enough copies for each circle member of the Readiness Ruler
handout .(see p.37) OR
* Write numbers 1 – 10 individually on flip chart paper and post the ten
pages across the room. (see p 37) OR
* Have a flip chart ready to draw the Readiness Ruler, and have circle
members record their self-ratings. (see p 37-38) OR
* Print enough copies for each circle member of the handout: Commercial
Tobacco Cessation Medicine Wheel: An Anishnawbek Approach (see page 39)
(or refer members to their Participant Handbook)
b. Decisional Balance
* Print enough copies for each circle member of the handout Decisional
Balance. (see p 41) OR
* Bring a flip chart to record costs and benefits of smoking. (see p 41)
(or refer members to their Participant Handbook)
A
Round Four: Action (A)
a. Ways to Support Change
* Bring a flip chart and colourful markers to record the changes circle
b. The Seven Grandfather
* Print enough copies of the Ojibway Traditional Values of Teachings of the
members plan on taking. (see page 42)
Teachings
Seven Grandfathers handout for each circle member. (see page 43)
(or refer members to their Participant Handbook)
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Wrap-Up
* Print enough Evaluation handouts for each circle member (See
Additional Resources section of the Tool-kit)
* Collect the completed Evaluation Forms
Closing the Circle
Invite an Elder to offer a Closing Prayer/Ceremony/Traveling Song.
Opening and Welcome
• Introduce yourself as the helper/facilitator for the Circle
• Opening Prayer/Ceremony/gathering song as per community context and if applicable by an
invited Elder or the facilitator
• Welcome participants – may be done by the Elder
• Provide logistical information, which can include:
-- Sign-in (if using): Direct participants to sign-in sheet on resource table (optional and based
on community preference); breaks, washrooms, refreshments, etc.
-- Content that will be covered: Describe the overall content of the four Teaching Circles, as
well as the content in this second Teaching Circle.
-- Example introduction to the content and structure of Circle 2:
Thank you for coming today to continue our conversation and exploration about traditional and commercial tobacco. Last time we went over the four different Teaching
Circles, and we completed Circle 1: “Who uses commercial tobacco?” In Circle 1, we
talked about some of the interesting facts and statistics about commercial tobacco
use, as well as the consequences of tobacco use for ourselves, our community, our
wider society and our Mother Earth. In this Circle (Circle 2), we will look at reasons to
change our use of commercial tobacco, and how important or confident we feel about
changing. In our next two Circles, we will discuss tobacco as both a healer and harmer
and the role of medications (Circle 3), and how to quit using commercial tobacco
(Circle 4). A reminder as well that we all have teachings to share and we can all learn
from each-other. We are all students, and we are all teachers.
• Invite the circle participants to introduce themselves again (if there are new members), in
the same way they did in the previous Circle. New members can provide their first name or
introduce themselves in the traditional way, whatever is preferable to the participant. Be clear
in your direction that this is simply a brief (re)introduction.
• Icebreaker activity: Have everyone stand up and look at someone else in the Circle. Taking
turns around the circle each participant will call out the person’s name and with a fist pump
call out “YOU ARE AWESOME!”
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Four Rounds of Learning and Knowing
SK Round One: Self Knowledge (SK)
This round will afford the participants the opportunity to articulate what motivated or motivates them to use commercial tobacco.
Activity A: Introduce the intended learning outcomes for Circle Two:
• To enhance motivation to quit using commercial tobacco.
• To understand what keeps a person using commercial tobacco.
• To identify what it would take to make one or more small steps in the direction of change and
how traditional teachings can support change.
Activity B: If I could quit smoking I could…
Ask members to finish the sentence “If I quit smoking I could…” Write the answers down on a flip
chart so that everyone can see. Answers can only be used once, see how many benefits people
can generate. You can also incorporate a ball into this exercise, to make the dialogue more
spontaneous and lively. One person starts with a ball and then throws it to someone else in the
group, whoever has the ball, then finishes the statement.
Inform the Circle members that that they can pass if they need more time to think about their
response. You will keep going around the circle until everyone has had an opportunity to speak. It
is not necessary that everyone provide an answer.
NK Round Two: New Knowledge (NK)
This round is best delivered interactively but can also be effective with a video, guest speakers or
formal presentations.
Activity A: Important Decision Exercise (15 minutes)
INSTRUCTIONS
Have the group work in pairs and answer the follow questions.
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This exercise directly relates to the change process by normalizing feelings of ambivalence, and
depending on the examples shared, it may highlight the notion that people tend to resist change
when they feel forced to make a change, and how choosing the status quo often feels like the
easiest path to take.
Think of an area in their own life where they’ve been trying to make an important decision (it
doesn’t necessarily have to be about commercial tobacco cessation – other examples might
include: exercising more, eating healthier, being more organized, etc.).
Questions: (Write in a flip chart)
1.
How long have you been thinking about this change?
2.
What are the pros and cons of changing and the pros and cons of staying the same?
3.
What would happen if you were told that you have to make this change right now?
Ask members to share whatever details they feel comfortable sharing, either in pairs or as a large
group. Especially reflect on peoples’ feelings elicited by the idea of being told to change right
away (Question 3). Note that “people are most able to change when they feel free not to.” Reflect
to the group that the decision to quit using commercial tobacco is something that each individual
must come to on his or her own, and this Circle is focused on examining where everyone is at
with respect to making a decision to change – not on trying to force anyone to make a change.
Activity B: The Stages of Change (15 minutes)
Provide the Stages of Change model (see following page) as a handout or as a resource to this
activity.
Instructions:
This exercise helps people reflect on where they are in the process of changing their use of
commercial tobacco. Explain the Stages of Change (see diagram, next page).
The “stages of change” model outlines well defined, predictable experiences through which all
individuals pass in resolving a problematic behavior:
•
•
•
•
•
34
Precontemplation: denial/lack of awareness of the problem
Contemplation: ambivalence toward change, feeling “stuck”
Preparation/determination: concrete resolution/decision to change
Action: actually initiating behavior change
Maintenance: prevention of relapse.
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Note that this is not a linear model – people may cycle in and out of the different stages in a
dynamic way.
Ask members to go around the Circle and say what stage they think they are in for quitting
commercial tobacco use. Let people know that they can pass if they do not know the answer or
would prefer not to speak.
8
Contemplation
Precontemplation
ion
on
Action
n
Maintenance
ce
Preparation
on
Adapted from: Prochaska, J.O. and DiClemente. C.C. (1984). The Transtheoretical Approach: Crossing Traditional Boundaries of
Therapy. Homewood, IL:Dow Jones/Irwin.
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Activity C: How much is smoking costing you? (15 minutes)
Instructions:
This can be facilitated in a large group with each person doing their own calculations. Begin by
asking the group a general question about how much they think an average person spends on
commercial tobacco per year. Have a brief discussion about how they came to that figure. Then
ask each member in the Circle to do his or her own calculation. No one will be asked to share this
publicly unless they volunteer.
Step 1: Ask participants to write down the cost of 1 pack of cigarettes.
Step 2: Ask them to multiply the cost of 1 pack by the number of packs they use in a week.
Step 3: Ask them to multiply that number by 52 weeks.
Step 4: A
sk them to multiply that number by the number of years they have been smoking
commercial tobacco.
Depending on the math skills in the group you may want to do this with or
for them by providing an example. You will need to know the cost of a pack
of cigarettes or bag of tobacco in your community. TIP: Bring a calculator
(or 2 or 3) to this session!
Sample calculation:
1: 1 pack of cigarettes = $5.00
2: Smoke 7 packs per week (7 x 5 = $35.00)
3: 35 x 52 weeks = $1,820.00 per year spent on cigarettes
4: Smoke for 22 years (1,820 x 22 = $40,040.00 spent on cigarettes.
Step 5: I n the large group, brainstorm what they could buy or do with the money they spend. You
could begin by writing the following statement on a flip chart:
“If I had ____ dollars I would….”.
36
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IK Round Three: Integration of Knowledge (IK)
Activity A: How motivated am I right now? (10 minutes)
Instructions:
Ask members to rate their importance and confidence of quitting commercial tobacco use
on a scale from 1-10 (where 1= lowest importance or confidence; 10 = highest importance or
confidence). There are four options on how to facilitate this activity (see below).
Option 1:
Give members handouts of the Readiness Ruler and ask them to circle the number that best
represents how important it is to them at this time to quit smoking, and how confident they feel at
this time about their ability to quit smoking.
Debrief and ask: “Why did you choose ___ number instead of zero?” (This elicits reasons for
changing.)
Then ask: “What would it take to go from _____ number to [higher] number?” (This elicits actions
they could take.)
Do this for both importance and confidence.
How important is it to change this behaviour?
How confident are you that you could make this change?
Option 2:
Post sheets of paper marked with numbers from 1-10 along one of the walls of the room. Ask
people to get out of their chairs and go and stand beside the number that best represents
importance of quitting.
Debrief and ask: “Why did you choose ___ number instead of zero?”
(This elicits reasons for changing.)
Then ask: “What would it take to go from _____ number to [higher] number?”
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(This elicits actions they could take.)
Then do the same for confidence of quitting.
Note that this option is more “public” and may not be suitable for all groups.
Option 3:
Draw the importance and confidence rulers on a flip chart, and turn the flipchart around so that it
is facing away from the group. Then, one at a time, ask people to go and mark an “x” to show their
self-ratings of importance and confidence. After everyone is done, turn the flip chart around so
that the group can see how they compare with others, and where the group as a whole is at with
respect to confidence and importance of change.
Debrief and ask: “What do we as a group have in common? Where are we different?” “What could
each person do to increase the importance or confidence of changing?”
Note that this version of the activity affords more anonymity to the group.
Option 4:
Use the handout: “Commercial Tobacco Cessation Medicine Wheel: An Anishnawbek Approach”,
and invite discussion around the circle on the importance and confidence questions written on
the Wheel. Ask: “What would it take to make quitting more important? What would it take to
make you feel more confident in your ability to quit?”
Note that these activity options may not be equally appropriate or relevant for all communities,
individuals or groups. Choose or adapt the one that fits best.
At the end of the activity – regardless of which option you choose – ask:
“What was it like to do this exercise? What made it easy or difficult?”
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COMMERCIAL TOBACCO CESSATION MEDICINE WHEEL
AN ANISHNAWBEK APPROACH
YOUR HEALTH & WELL-BEING - IT’S UP TO YOU!
SPIRITUAL ASPECT OF
QUITTING TOBACCO
eg: confusion, loss of
10
connectedness, and/or problems
in the physical, emotional or
mental aspects.
PHYSICAL ASPECT OF
TOBACCO USE
How has your tobacco use
impacted you?
How has quitting in the past
affected you?
EMOTIONAL ASPECT OF QUITTING TOBACCO
eg: low self-esteem, loss of ability to cope,
relationship difficulties, etc.
How important is it to change this behaviour?
BR
How ready are you to make
this change?
AV
E
10
RY W I S
UTH H
TR
ON
E
How confident are you that you
could make this change?
DO
10
MENTAL ASPECT OF QUITTING TOBACCO
eg: poor judgment/decision making, difficulty
concentrating, bipolar illnesses, depression, etc.
LOVE T EC
SP
Y
T
S
HUMILITY 10
RE
M
Anishnawbek teachings maintain that a person contains the four directions which must be in
balance to achieve health. This wheel is a combination of these teachings and the work of the
TEACH project and motivational interviewing
The numbers serve as a guide to help the person(s’) explore change and gives the helper an idea
of the balance of the person(s)
The Gifts of the Seven Grandfathers (which are interwoven into daily life) are given to the people
to help them understand and attain health and well-being.
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Activity B: Decisional Balance: The pros and cons of change, and the pros and
cons of staying the same (15 minutes)
Instructions:
There are two options for facilitating this activity (see below).
Option 1:
Hand out copies of the “Decisional Balance” exercise, and ask members to write down what
they see as the costs and benefits of change (quitting commercial tobacco), and the costs
and benefits of staying the same (continuing to use commercial tobacco). After people have
completed this individual activity, ask them to get into groups of three and share the main costs
and benefits they wrote down. Then coming back to the Circle, members can share the things
they had in common and highlights of what they discussed in their small groups.
Option 2:
Ask the group to brainstorm costs and benefits, and write them on a flip chart. Encourage the
group to reflect on the most important benefits of quitting commercial tobacco use, as well as
the major things they would be giving up or are concerned about (costs).
Benefits
(Change)
Costs
(No Change)
Debrief:
At the end of this activity, ask Circle members to imagine a set of scales, with the costs on one
side and the benefits on the other.
Ask:
“Which way do the scales tip for you right now? What would need to be added to the
side of change in order for the benefits to outweigh the costs?”
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Decision to Change Worksheet
Try to fill out personal reasons for why you continue to smoke commercial tobacco or why you
may want to quit.
Continue Smoking
Quit Smoking
Reward
Feel better about myself
Helps getting started in the morning (routine)
Set a good example for children and community
Helps me deal with stress
Save money
Smells bad
It will be hard to quit
Costs too much
I will miss smoking
Skin damage
Other people might not support me wanting to quit
Benefits
Out of breath when I walk
Costs
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A
Round Four: Action (A)
Activity A: Ways to support change (15 minutes)
Bringing the participants back into the big circle, on the flip chart create a list of ‘Small steps I
can take this week in the direction of change’.
Examples:
• Smoke outside instead of in the home
• Not smoke in my car
• Buy a brand of cigarettes I don’t like as much so I will smoke less
• Commit to smoking one less cigarette per day
• Delay smoking by 15 minutes.
Let the participants know that they can pass if they want to.
Activity B: The Seven Grandfather Teachings
If it is appropriate for this group, ask members in the Circle to volunteer to take turns reading
the traditional values teachings of the Seven Grandfathers. If you have a Traditional Elder
or Knowledge Keeper in the Circle who will share his or her teachings about the Seven
Grandfathers, or traditional values, that is also a way to share these teachings. Then discuss how
these values can support Circle members in their process of change.
For example, Aakde’win (bravery) is to face the foe (commercial tobacco) with integrity. What
actions could a person take to demonstrate this?
Once everyone has made their contribution provide an overview of the session. Reaffirm
that there are similarities and differences in why individual would want to quit and provide
encouragement to continue to try to understand where they fit in to the picture.
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OJIBWAY TRADITIONAL VALUES TEACHINGS
OF THE SEVEN GRANDFATHERS
The Seven Gifts
These are the teachings that were given to the Nishnaabe Nation.
“Remember that the other Nations were given teachings that are slightly different from these.
But in all the teachings of different Nations there are commonalities. This sameness refers to the
basic Truth that interweaves all natural ways of living.”
Benton-Banai, Edward. The Mishomis book : the voice of the Ojibway St. Paul, Minn. : Indian Country Press, 1979.
1.
Nbwaakaawin
To cherish Knowledge is to know WISDOM.
2.
Zaagidiwin
To know LOVE is to know peace.
3.
Mnaadendiwin
To honour all of the Creation is to have RESPECT.
4.
Aakde’win
BRAVERY is to face the foe with integrity.
5.
Gwekwaadziwin
HONESTY in facing a situation is to be brave.
6.
Dbadendizwin
HUMILITY is to know yourself as a sacred part of the Creation.
7.
Debwewin
TRUTH is to know all of these things.
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Wrap-up
1. This can be done orally as part of the circle process or copies of the Facilitator and Workshop
evaluations can be distributed.
2. Encourage participants to complete the evaluation. Tip: if you choose to hand out a paper
copy have the participants fill it out while still in the Circle before you close.
3. Last words
a.Reiterate the opening words of welcome. Thank them for having the courage to participate.
4. Closing Prayer/Travelling Song if applicable
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CIRCLE THREE:
WHAT IS TOBACCO?
Illustration of the Four Teaching Circles: Themes and Content
HOW TO CHANGE?
WHO USES
COMMERCIAL TOBACCO?
Discuss and implement
approaches, treatments
and helpers to increase
the odds of quitting
WHAT?
1
you
are here
Understand tobacco
as harmer and as healer,
as well as the role of
medications
4
3
2
Understand
prevalence and
how people and
communities
are affected
WHY CHANGE?
Enhance
motivation to quit
commercial tobacco
The Teaching Circles are based on the model outlined on the following page wherein each of the
four Teaching Circles has four rounds of learning: Round 1, Self-Knowledge (SK); Round 2:, New
Knowledge (NK); Round 3, Integration of Knowledge (IK); Round 3, Action (A). This is a suggested
model, but the Circles are not restricted to this format –elaborating, condensing and tailoring are
all expected.
The Teaching Circles can be offered in the order they are presented—i.e. Circle 1: Who?, Circle
2: Why?, Circle 3: What?, Circle 4: How?—or you may choose to select and adapt any of the
activities in any order. Circles may be abbreviated to be offered in a shorter period of time, such
as half a day, or extended over several weeks.
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Four Rounds of the Teaching Circle
Every Circle will have four rounds: Circle members move from exploring their own pre-existing
knowledge (Self-Knowledge), through generating New Knowledge (NK), Integrating Knowledge
(IK), and taking Action (A). Please see the following pages for the full guide and individual
activities for each Round.
SK
Round 1 - Self Knowledge (SK)
Round One is a combination of sharing experiences and building trust. In order to move forward,
participants need to establish a collaborative working relationship and begin a democratic
dialogue. Out of the shared experiences, themes emerge -- issues that people share, problems
they face, differences of opinion.
NK
Round 2 - Finding Patterns (New Knowledge) (NK)
Round Two is to identify these themes (find patterns) and analyze them. How do these problems
work? Where do they come from? Add/acquire/master new information from the facilitator or the
group. A crucial part of this step is learning how to use the new information and seeing how it
affects the analysis of problems carried out in the previous step.
IK
Round 3 - Integration of Knowledge (IK)
Round Three is planning for action and practicing skills. This is where people are creating
strategy and tactics, thinking about what they want and how they plan to get it. Activities and
worksheets can be incorporated here.
A
Round 4 - Action (A)
Round Four is crucial. The connection between education and action is not a solid line. It is not so
predictable. Any given educational process may not produce action. Or it may take a long time, or
come up in an unexpected way. The educator may or may not have a connection to that step and
certainly does not control it.
5 apply in action
The end of this learning
journey is reconstruction
and assessment. This step
overlaps with the first step of a
new spiral. Here is the model
that incorporates the four
rounds discussed above:
46
A
practise skills
strategize and
plan for action
SK start with the
IK
experience of
the participants
NK
add new information and theory
look for
patterns
[ image inspired by Paulo Freire’s Pedagogy of the Oppressed, 1970 ]
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Circle 3: Facilitators’ Checklist
IMPORTANT NOTE: All of the activities and resources are optional in the sense that you can and
should tailor the Teaching Circles to the needs of your group and community.
Content and Activities
Resources and Preparation Required
Opening and Welcome
Invite an Elder to offer an Opening Prayer/Ceremony/Gathering Song
Print a sign-in sheet to track attendance. (See Additional Resources section in
the Tool-Kit)
SK Round One: Self-Knowledge (SK)
a. Learning Outcomes
See p 49
b. Medicine Wheel
Print enough copies for each Circle member of the How does commercial
tobacco affect you and others in your life? handout (see p 50)
(or refer members to their Participant Handbook)
c. Honouring Tobacco
Teachings
Bring a traditional tobacco tie to pass around to Circle members.
(see p 50-51)
Print enough copies for each circle member of the Fact Sheet on Traditional
Tobacco and Honouring Tobacco Teaching handout (see p 51-52)
(or refer members to their Participant Handbook)
NK
Round Two: New Knowledge (NK)
a. Presentation on
Cessation Medications
Invite a Pharmacist/Nurse/Doctor to discuss evidence-based treatment for
commercial tobacco cessation.
Include refreshments as a part of this activity.
b. Nicotine Replacement
Therapy (NRT)
Prepare a Nicotine Replacement Therapy (NRT) toolkit to demonstrate the
medication options to circle members (see p 53)
Print enough copies for each Circle member of the Costs of Smoking vs.
Nicotine Replacement Therapy handout (see p 53) (or refer members to
their Participant Handbook)
c. Myths and Facts of NRT
Print enough copies for each Circle member of the Myths and Facts on
Nicotine Replacement Therapy handout (see p 55)
(or refer members to their Participant Handbook)
IK
Round Three: Integration of Knowledge (IK)
a. Withdrawal Symptoms:
It’s all in the cards!
a. Smoking Lung
Print a set of cards, making sure to select in your printer settings ‘doublesided’ printing. (see p 58-67)
You will need an empty dish soap bottle, a cork, cotton balls or white tissue
paper, glue or duct tape and a cigarette. Follow the instructions outlined in
the activity to assemble the “Smoking Lung”. (see p 68)
b. Tar Jar
You will need a glass jar, 1 cup of molasses and cigarettes butts. Follow the
instructions outlined in the activity to assemble the “Tar Jar”. (see p 69)
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A
Round Four: Action (A)
a. Commercial Tobacco Use
Self-Assessment and
Goal-setting
Wrap-Up
Print enough copies for each Circle member of the Fagerstrom Test for
Nicotine Dependence and the Goal Statement forms. (see p 71)
(or refer members to their Participant Handbook)
Print enough Evaluation handouts for each Circle member (See Additional
Resources section of the Tool-kit)
Collect the completed Evaluation Forms
Closing the Circle
Invite an Elder to offer a Closing Prayer/Ceremony/Traveling Song.
Opening and Welcome
• Introduce yourself as the helper/facilitator for the Circle
• Opening Prayer/Ceremony/gathering song as per community context and if applicable by an
invited Elder or the facilitator
• Welcome participants – may be done by the Elder
• Provide logistical information, which can include:
-- o Sign-in (if using): Direct participants to sign-in sheet on resource table (optional and
based on community preference); breaks, washrooms, refreshments, etc.
-- o Content that will be covered: Describe the overall content of the four Teaching Circles, as
well as the content in this third Teaching Circle.
-- o Example introduction to the content and structure of the sessions:
Thank you for coming today to this third of four Teaching Circles focused on commercial tobacco use. As you might recall, each Circle has its own theme. The theme for
Circle 1 was: “Who uses commercial tobacco?” In the previous Teaching Circle (Circle
2), we looked at motivation for change. In this Circle (Circle 3) , we will discuss tobacco
as both a healer and harmer, and medication options to help a person quit smoking commercial tobacco. In the final Circle, (Circle 4), we will look at strategies to quit
commercial tobacco. Everyone’s voice is important, since we all have experience with
commercial tobacco – either ourselves or with our families, friends and community. In
this way we all have teachings to share and we can all learn.
• If necessary, invite the circle participants to introduce themselves again, in the same way
they did in the previous Circle. New participants can provide their first name or introduce
themselves in the traditional way, whatever is preferable to the participant. Be clear in your
direction that this is simple a brief introduction.
• Icebreaker activity: Have the participants line up facing you. You give the person facing you
‘high five’ and very quickly - like a domino effect the person must turn around and high five the
person behind them. This should only take 1 – 2 minutes. If the group is small you can have the
person at the end run to the front of the line and start all over again.
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SK Round One: Self Knowledge (SK)
This round will help the Circle members understand the many and complex effects of commercial tobacco and nicotine on the body, as well as give members
the opportunity to assess their level of dependence on commercial tobacco and
to set a goal for change.
Activity A: Learning Outcomes
Introduce the intended learning outcomes for Teaching
Circle three:
• To explore the differences between traditional tobacco
and commercial tobacco
• To examine the effects of commercial tobacco on
the body
• To explore medications that can help increase the
odds of quitting successfully
• To set a goal for change.
Activity B: Medicine Wheel (10 minutes)
How does commercial tobacco affect you and others in
your life?
Instructions:
Using a Medicine Wheel (see following page), if that is
applicable in your area, have individuals identify different
effects of commercial tobacco for each of the four
quadrants (Physical, Emotional, Social and Spiritual).
Have an open discussion on how the mental effects of
nicotine in commercial tobacco affect other parts of our
lives as well. You can use the included resource template
as a handout, or create or adapt one that is common in
your area.
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How does commercial tobacco affect you and others in your life?
physical
Example:
I have a cough
especially in the mornings
Example: Feeling bad because I want to set
a good example for my kids
Example:
Tobacco is a gift from
the Creator, and I want to
honour that gift
spiritual
Example: Thinking about how smoking
cigarettes is hurting my body
emotional
mental
Activity C: Honouring Tobacco Teachings (15 minutes)
How is traditional tobacco different from commercial tobacco?
Traditional tobacco may or may not be applicable to individuals, communities and Nations. You
may wish to adapt this activity or choose not to incorporate these teachings, depending on the
group.
Instructions:
Ask the members in the Circle to share their understanding or experience with traditional
tobacco. Let them know that they can pass if they wish. You can use the information below,
and/or ask a traditional Elder or Knowledge Keeper to share his or her teachings on traditional
tobacco. The theme of this activity is how tobacco can be both healer and “harmer” – that
traditional tobacco is very different from commercial tobacco.
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FACT SHEET ON TRADITIONAL TOBACCO
Adapted from: “Building and Sustaining Partnerships: A Resource Guide to Address Non- Traditional Tobacco Use”, prepared for the First
Nation and Inuit Health Branch, Health Canada. October (2003).
1. Tobacco has been used in Aboriginal communities for thousands of years before contact with
Europeans and the rise of recreational smoking. Tobacco was grown and cultivated with other
natural herbs such as sweet grass and lavender.
2. Not all Aboriginal populations across Canada use tobacco as a traditional, sacred part of their
culture. This is because of the differences in culture, climate and geography. Plant products
such as willow bark, sweet-grass, cedar and sage were smoked in pipes and used instead of
tobacco by some nations.
3. There are two varieties of tobacco:
-- Nicotania rustica or Indian Tobacco – traditional
-- Nicotania tabacum or commercial tobacco - non-traditional
4. Traditional tobacco was:
-------
cultivated separately from other crops
burnt over the fire
thrown on water
left on the ground
smoked in a pipe either by an individual or passed around a circle of people
chewed
5. Generally, traditional tobacco or the above substitutes were an important component of
Indigenous cultures in two main aspects:
----------
Ceremonial
communication with the spirits (smoke)
thanking the Creator
praying for a good harvest or better fish catch
rites of passage ceremonies (birth, weddings, funerals)
sealing the peace with enemies (pipe)
Medicinal
To treat earaches and snakebites
To purify the mind and heal the body.
6. Some nations have a “pipe carrier”, a special medicine person who uses tobacco the
traditional way to communicate with the Creator.
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7. Today, traditional tobacco is still regarded as sacred by most Aboriginal groups and retains
its spiritual and, in some cases, medicinal value. However, because tobacco has been a vital
part of Aboriginal culture for so long, its traditional use is sometimes given as a justification
for smoking or chewing commercial tobacco. Such confusion can hinder efforts to reduce the
consumption and deal with the harmful effects of non-traditional tobacco use.
Honouring Tobacco Teaching
My first teaching of the Sacred Traditions of North American Tribal Peoples was from
my grandmother, a Mohawk woman who I lived with from the age of three to the age
of eight. One of the teachings around the Sacred Tobacco had to do with the tobacco
plant’s living process being a reflection of my own living process.
Tobacco seeds are very tiny and from one of these tiny seeds grows this beautiful five
to eight foot tall plant from spring to fall in a single turning of the Medicine Wheel of the
seasons. My Grandmother began the teaching by showing me one of these tiny seeds
and explaining that everything that was necessary for the mature plant was in that tiny
seed and these great gifts of beauty and power would manifest themselves if the seed
and the growing plant were in the proper nurturing and caring environment.
She then went on to say that just as with the tobacco seed- the creator had placed in
my all the gifts I needed to become a complete and whole human being so long as I
were in the proper nurturing and caring environment. As the tobacco seedlings grew
and matured – she regularly revisited them with me – deepening the teachings – that
I may have in my heart a living appreciation of the process of life and my own connectedness with my own gifts and with all life. When we make offerings of tobacco to the
forest, the water, the fire, the earth, or when we use the tobacco in Sacred Pipe Ceremonies – we are honouring these connection and expressing our deep gratitude for
the beauty of life and for the peace that can be n our hearts when we walk in the Sacred
Way of our ancestors.
In learning so young many of the Sacred traditions of our relationship with tobacco – I
came to appreciate as a adult that when tobacco is used as a commodity or used to
feed an addiction it is not being used in a Sacred Way.
David Spirit Eagle Summerville (cited in Honouring our Health: An Aboriginal tobacco strategy for British Columbia)
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NK Round Two: New Knowledge (NK)
This round is best delivered interactively but can also be effective with a video,
guest speakers or formal presentations.
Activity A: Formal Presentation on Cessation Medications (30 minutes)
Invite a Pharmacist/Doctor/Nurse to provide a formal presentation tailored to the members of
the Circle. The health practitioner can talk about evidence-based commercial tobacco cessation
approaches (such as medication and counselling), and answer questions that members may
have. This can be a social activity with refreshments.
OR
Activity B: Nicotine Replacement Therapy (NRT) Toolkit (10 minutes)
Create a toolkit of the various NRT products. You can put all of these items in a small clear plastic
container for easy storage and transport. Explain each of the products and how they can be used.
Pass them around so participants can see them, touch them, smell them if applicable.
You may want to print out and include the following summary of the products with the cost and
where and how they can be accessed, as well as how the cost of NRT compares with the cost of
smoking commercial tobacco.
Costs of Smoking vs. Nicotine Replacement Therapy
Approx. Cost/Week
Name-brand patch
$34.00
No-name patch
$22.00
Nicotine gum (10 pieces/day)
$99.00 (3 boxes at $33.00)
Nicotine inhaler (5 cartridges/day)
$150 (3.5 boxes at $42.00)
Cheap brand of cigarettes (7 packs)
$40.00
Name-brand cigarettes (7 packs)
$66.00
Contraband Cigarettes
$7.00 - $15.00
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OR
Activity C: Myths and Facts About Nicotine Replacement Therapy Quiz
(15 minutes)
Discuss as a group the questions outlined in the Myths and Facts on Nicotine Replacement
Therapy (see next page). After the facilitator has provided the answers, discuss as a group the
idea of using NRT as a quit commercial tobacco aid within their community.
Sometimes people object to using NRT because they “don’t want to put chemicals into their
body” – but you can note that nicotine is not the physically harmful chemical in cigarettes
(although it is the one that is addictive when smoked – when taken in NRT it is not typically
addictive as the nicotine is delivered more slowly to the brain, and at lower levels than those
obtained from cigarette smoking). They are getting the nicotine already from commercial
tobacco – along with all of the other thousands of chemicals in cigarettes! (see below).
Nicotine
Insecticide
Stearic Acid
Candle Wax
Toluene
Industrial
Solvent
Ammonia
Toilet Cleaner
Cadmium
Batteries
Hexamine
Barbeque
Lighter
Butane
Lighter Fluid
Paint
Methanol
Rocket Fuel
54
Carbon
Monoxide
Arsenic
Poison
Methane
Sewar
Gas
Acetic
Acid
Vinegar
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Myths and Facts of Nicotine Replacement Therapy (NRT)
How much do you know about medications to help people quit smoking?
Take this True-or-False quiz and find out.
Myth or Fact?
True or
False?
1. Nicotine is one of the harmful substances in cigarettes.
2. Nicotine addiction is equally likely whether the nicotine is obtained from cigarettes,
nicotine patch, gum, lozenge or inhaler.
3. Nicotine patches, gum, lozenge and inhalers carry significant health risks if used by
people who smoke.
4. Smoking while on the patch causes heart attacks.
5. People with heart disease should not use nicotine replacement medications.
6. Pregnant women should never use nicotine replacement medications.
7. People under age 18 should never use nicotine replacement medications.
8. Stop-smoking medications should not be used in combination with one-another.
9. People using nicotine replacement medications should not exceed the dose
recommended on the medication package.
10. Stop-smoking medications are only appropriate for short-term use.
11. Nicotine replacement medications should not be used by people who just want to cut
down on the number of cigarettes they smoke.
(adapted from Ontario Medical Association Position Paper: Rethinking stop-smoking medications: Treatment myths and medical realities,
January, 2008).
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Answers:
1. False: The thousands of toxins in tobacco smoke are harmful. Nicotine is not associated with
cancers or chronic respiratory conditions.
2. False: Cigarettes are far more addictive than nicotine replacement, primarily because of how
they deliver nicotine.
3. False: Nicotine replacement therapy is safe for smokers.
4. False: The use of nicotine replacement does not increase cardiovascular risk,
5. False: It is more dangerous for people with heart disease to continue smoking than to use
nicotine replacement, and many such patients are not able to quit on their own.
6. False: nicotine replacement is safer for the fetus than smoking, and is appropriate for
pregnant women who are unable to quit using behavioural interventions.
7. False: Most daily smokers begin smoking before age 18, and are already getting nicotine from
cigarettes. Nicotine replacement should be considered for youth who are regular smokers who
are unable or unwilling to quit using behavioural interventions.
8. False: The nicotine patch/gum/lozenge/inhaler can be used at the same time and/or in
combination with bupropion (Zyban).
9. False: Smokers should be in control of how and how much they use nicotine replacement
medications.
10. False: Nicotine replacement should be used for as long as needed to maintain or prolong
tobacco abstinence.
11. False: Nicotine replacement can be used by people who are not ready to quit as a way to
reduce their smoking, and progress towards a longer-term goal of abstinence.
(adapted from Ontario Medical Association Position Paper: Rethinking stop-smoking medications: Treatment myths and medical realities,
January, 2008).
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IK Round Three: Integration of Knowledge (IK)
Activity A: It’s all in the Cards! (25 minutes)
Have the participants pass around the Health Effects of Commercial Tobacco Use cards, and
read aloud each health effect to the group.
After each card is read, allow time for the group to identify their knowledge around each topic,
and what their experience is with each health effect.
The following is some information about the duration of commercial tobacco withdrawal
symptoms to share with the group as cards are read aloud:
Symptoms
Duration
Prevalence
Irritability / Aggression
< 4weeks
50%
Depression
< 4 weeks
60%
Restlessness
<4 weeks
60%
Poor concentration
< 2 weeks
60%
Increase appetite
> 10 weeks
70%
Light-headedness
< 48 hours
10%
Night-time awakenings
< 1 week
25%
Constipation
> 4 weeks
17%
Mouth ulcers
> 4 weeks
40%
Urges to smoke
> 2 weeks
70%
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If appropriate, you can share with the group how Nicotine Replacement medications can alleviate
withdrawal and increase the chances that a quit attempt will be successful.
Nicotine Replacement Therapy
• Provides the body with nicotine to help
minimize withdrawal symptoms and
cravings
• Eliminates toxic substances one gets from
cigarettes
• Shown to almost double quit rates
• Most effective when combined with
counselling
• Can be used to help “reduce” smoking
-- Can start before quit date
58
Who Should Not Use NRT?
• Not everyone needs NRT
• Not everyone can afford NRT
• Studies show that NRT is not effective for
those that smoke 10 cigarettes or less or
are non-daily smokers
• Need to assess case by case
-- Depends on the preferences of the
person
-- Use tools to assess dependence
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Possible Withdrawal Symptom:
Occasional dizziness
Possible Withdrawal Symptom:
Hunger
Possible Withdrawal Symptom:
Shakiness
Possible Withdrawal Symptom:
More Coughing
circle three
Possible Withdrawal Symptom:
Headache
Possible Withdrawal Symptom:
Constipation
Possible Withdrawal Symptom:
Sweating
Possible Withdrawal Symptom:
Decreased
Concentration
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Breathing is improved upon decreased
One in four people healing from commercial
commercial tobacco consumption. An
tobacco use report having a mild headache at
increase in oxygen absorption causes dizziness
some points during their quitting process.
that may occur in the first few days and only
lasting a few seconds.
This is a very common symptom as nicotine
Reduction of commercial tobacco
reduces appetite. When quitting, you will feel
consumption causes the body to slow down
like eating more. The body will take in more
digestion. This usually lasts for only 3-4 days.
of the nutrition from food whether you eat
A health practitioner should be contacted with
more or not. It is important to know that not all
any further concerns.
people gain weight when quitting and healthy
eating and exercise can help with this.
A common symptom of nicotine withdrawal is
an increase in sweating for several weeks. Hot
baths or showers can help with the sweat.
When experiencing nicotine withdrawal,
hands may shake slightly for several weeks.
As the body gets used to the non-smoking
environment, this symptom will subside.
Nicotine withdrawal can cause a decrease in
As the lungs heal themselves, the phlegm gets
focus, making it difficult to concentrate on
cleaned out, causing an increase in coughing.
tasks at hand. These are normal and are part
This can last for a few weeks and eventually will
of physical, emotional and spiritual healing
lead to the disappearance of coughing linked
from commercial tobacco.
to commercial tobacco consumption.
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Possible Withdrawal Symptom:
Feeling Fatigued
Possible Withdrawal Symptom:
Irritability
Possible Withdrawal Symptom:
Sadness
Possible Withdrawal Symptom:
?
circlethree
Possible Withdrawal Symptom:
Nervousness
Possible Withdrawal Symptom:
Anxiety
Possible Withdrawal Symptom:
?
Possible Withdrawal Symptom:
?
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Cravings and stress associated with
nicotine withdrawal can lead to feelings of
nervousness. These are normal and are part of
physical, emotional and spiritual healing from
commercial tobacco.
When quitting, the body works hard to heal
from the damage caused by the harmful
substances. This can lead to feelings or
exhaustion and tiredness. These are normal
and are part of physical, emotional and
spiritual healing from commercial tobacco.
Cravings and stress associated with nicotine
Cravings and emotional stress associated
withdrawal can lead to feelings of anxiety.
with nicotine withdrawal can lead to increased
These are normal and are part of physical,
irritability. These are normal and are part of
emotional and spiritual healing from
physical, emotional and spiritual healing from
commercial tobacco.
commercial tobacco
Cravings and emotional stress associated
?
with nicotine withdrawal can lead to feelings
of sadness. These are normal and are part of
physical, emotional and spiritual healing from
commercial tobacco.
?
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Effects of Commercial Tobacco Use:
Cardiovascular Disease
Effects of Commercial Tobacco Use:
Lung Cancer
Effects of Commercial Tobacco Use:
Preterm Delivery
Effects of Commercial Tobacco Use:
Mental Health
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Effects of Commercial Tobacco Use:
Chronic Obstructive
Pulmonary Disease
Effects of Commercial Tobacco Use:
Birth-weight
Effects of Commercial Tobacco Use:
Sudden Infant Death
Syndrome
Effects of Commercial Tobacco Use:
Morbidity
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The risk of Chronic Obstructive Pulmonary
Commercial tobacco users have double the
Disease (COPD) is greatly increased with
risk of developing heart disease as compared
commercial tobacco use.
to those that don’t.
USDHHS, 1990
Wald & Hackshaw, 1996
The use of commercial tobacco decreases the
The risk of contracting lung cancer is 15 times
birth-weight of newborn babies.
greater than that of nonsmokers.
MacArthur & Knox, 1988
Boffetta et al., 1999
The use of commercial tobacco increases the
The use of commercial tobacco increases the
chances of Sudden Infant Death Syndrome
chances of preterm delivery.
(SIDS).
DiFranza & Lew, 1995
MacArthur & Knox, 1988
Commercial tobacco use reduces life span and
Use of commercial tobacco does not help to
increases days of illness.
reduce stress.
USDHHS, 1990
West, 1993
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Effects of Commercial Tobacco Use:
Teenagers and Children
Effects of Commercial Tobacco Use:
Conception
Effects of Commercial Tobacco Use:
Ulcers
Effects of Commercial Tobacco Use:
Immune System
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Effects of Commercial Tobacco Use:
Non-smokers
Effects of Commercial Tobacco Use:
Other Cancers
Effects of Commercial Tobacco Use:
Non-fatal Diseases
Effects of Commercial Tobacco Use:
Surgery
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Exposure to secondhand smoke can increase
a nonsmokers heart disease risk by 25% and
long cancer by 20%. There is NO risk-free level
Commercial tobacco will eventually kill 250
million of teenagers and children.
exposure of secondhand smoke.
Shafey et al., 2009
Shafey et al., 2009
There is an increased risk of death from
The use of commercial tobacco decreases
cancers of the upper respiratory tract,
the chances of conception in both men and
esophagus, bladder and pancreas.
women.
USDHHA, 1990
Chia et al., 2000
Commercial tobacco is strongly linked with
Commercial tobacco use is a cause of ulcers of
non-fatal debilitating diseases including
the stomach and duodenum.
deafness and blindness.
Jorgensen et al., 1998
Consumers of commercial tobacco are more
vulnerable to post-surgical complications than
non-smokers.
Moller et al., 2002
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Chao et al., 2002
Consumption of commercial tobacco causes
an impaired resistance to infection.
Shafey et al., 2009
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Effects of Commercial Tobacco Use:
Skin
Effects of Commercial Tobacco Use:
Mouth
Effects of Commercial Tobacco Use:
?
Effects of Commercial Tobacco Use:
?
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Effects of Commercial Tobacco Use:
Teeth
Effects of Commercial Tobacco Use:
Nose
Effects of Commercial Tobacco Use:
?
Effects of Commercial Tobacco Use:
?
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There is an increased likelihood of
There is a loss of skin tone, wrinkling and
gum disease, gingivitis, tooth loss and
premature aging found in the skin of those who
discoloration.
consume commercial tobacco.
Shafey et al., 2009
Shafey et al., 2009
Those who consume commercial tobacco have
Those who consume commercial tobacco have
an impaired sense of smell.
an impaired sense of taste and an increased
likelihood of having a sore throat.
Shafey et al., 2009
Shafey et al., 2009
?
?
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?
?
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Activity B: Smoking Lung (20 minutes)
HOW TO MAKE A “SMOKING LUNG”
Materials:
• An empty dishsoap bottle (clear)
• A cork
• Cotton balls or white tissue paper
• Glue or duct tape
• Cigarettes
This craft is an engaging way to visualize the build up of tar in the lung of a person who smokes.
Much (~70%) of the commercial tobacco smoke that a person inhales does not come back out
and collects in the alveoli (tiny air sacs) of the lungs. This activity can be used as a visual aid for a
group, as an activity done in a classroom, or as a craft for individuals in a group.
1. Rinse and remove labels from a clear plastic bottle, such as a dish detergent bottle.
Let dry.
2. Drill a hole in a cork. The cork should be similar in size to the neck of the bottle. The drilled
hole should be big enough so that a cigarette can fit snuggly in it.
3. Place some white tissue, streamer paper (not too dense) or cotton balls in the bottle. Leave a
bit in the neck of the bottle so that it can be held in place by the cork OR glue tip of paper to
inside of neck. This is so the paper stays put once the lung starts to “smoke”. Lungs are not
empty “receptacles” and contain numerous alveoli that act more like a sponge.
4. Glue cork in neck of bottle. Cork should be smug in neck so that cigarette smoke doesn’t
escape. If cork is not large enough, use glue or elastic bands to create a seal.
5. Away from everyone and public airways, place a cigarette in the hole of the cork. Light it.
Slowly and consistently make the “lung” inhale the smoke.
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Activity C: Tar Jar (5 minutes)
HOW TO MAKE A “TAR JAR”
This activity is an engaging way to visualize the build up of tar in the lungs of a person who
smokes. The “tar” represents an accumulation over one year for someone who smokes
approximately a pack a day.
Materials
• a glass jar
• 1 cup or 8 oz of molasses
• (optional) used cigarettes butts for added effect
Put the molasses (and butts) in the jar and use as a
display model.
YOUTUBE VIDEOS
There are many videos on youtube.com that chronicle experiments extracting the tar from
cigarettes. Some can be found here:
Tar in Cigarette
http://www.youtube.com/watch?v=-DbFBu_I_lA
Cigarette Experiment
http://www.youtube.com/watch?v=svKPwPWLq9w
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A
Round Four: Action (A)
Activity A: Commercial Tobacco Use Self-Assessment and Goal-setting (20
minutes)
Hand out the Fagerstrom Test for Nicotine Dependence and the Goal Statement. Ask members
to complete these forms individually – you may want to help with scoring the Fagerstrom Test.
Explain that this is a widely-used tool to assess a person’s level of dependence.
Note that the Goal Statement may not mean quitting for all Circle members – some people may
choose to set an interim goal.
Note that these activity options may not be equally appropriate or relevant for all communities,
individuals or groups. Choose or adapt the one that fits best.
At the end of the activity – regardless of which option you choose – ask:
“What was it like to do this exercise? What made it easy or difficult?”
There are some additional handouts at the end of this section:
• Medications for quitting commercial tobacco use
• Preparing for “quit day”
• Cutting down versus tapering commercial tobacco use.
These may or may not be helpful or appropriate. You can offer them to the group for anyone who
is interested.
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Fagerstrom Test for Nicotine Dependence
Not only is it important to know whether or not your patients smoke, it’s also important to know
how addicted to nicotine they actually are. Fagerstrom’s Test for Nicotine Dependence is an easy
way to assess your patient’s addiction. Have your patients answer the questions; each answer
gets a set amount of points. Add up the points and check out the score indicator below:
Questions
Answers
Points
1. How soon after you wake up do you smoke your first
Within 5 minutes
3
6 to 30 minutes
2
31-60 minutes
1
After 60 minutes
0
Yes
1
No
0
The first one in the morning
1
All others
0
10 or less
0
11-20
1
21-30
2
31 or more
3
Yes
1
No
0
Yes
1
No
0
cigarette?
2. Do you find it difficult to refrain from smoking in
places where it is forbidden such as church, the
library, or movie theatres?
3. Which cigarette would you hate most to give up?
4. How many cigarettes do you smoke? (20 cigarettes
are in a pack)
5. Do you smoke more frequently during the first hours
after waking than the rest of the day?
6. Do you smoke if you are so ill that you are in bed
most of the day?
Score:
0-2
3-4
5
6-7
8-10
Very Low Addiction
Low Addiction
Medium Addiction
High Addiction
Very High Addiction
Usually, people who score 6 or greater need additional
assistance in quitting smoking. This may mean Nicotine
Replacement Therapy or one-on-one counseling to problem
solve ways to overcome barriers and cope with withdrawal
symptoms.
This information is provided by WHISC - Women’s Health: Interventions for Smoking Cessation. It is part of the Provider Tool Kit for Assisting
Women to Quit Smoking. WHISC is a project funded by a grant from The Duke Endowment to Wake Forest University School of Medicine in
partnership with the Northwest AHEC (North Carolina) Program. January 2001
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Goal Statement
The behaviour I want to/need to change is: What is your goal now? Start date: Achievement date: Tip – If you are not ready to quit commercial tobacco, think about what a small goal might be.
One example might be to not smoke in your car, to smoke outside, or to not smoke for a three
hour period each day for a week. Any others?
Wrap Up
This can be done orally as part of the circle process or copies of the Facilitator and Workshop
evaluations can be distributed.
• Encourage participants to complete the evaluation. Tip: if you choose to hand out a paper
copy have the participants fill it out while still in the Circle before you close.
• Last words
-- Reiterate the opening words of welcome. Thank them for having the courage to participate.
• Closing Prayer/Travelling Song if applicable
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Medications for Quitting Commercial Tobacco Use
Medication
Nicotine
Nicotine
Nicotine
Nicotine
gum
lozenge
patch
inhaler
Bupropion
Varenicline
Treatment
Length
1-3 months
12 weeks
8-12 weeks
12-24 weeks
7-12 weeks
12 -24 weeks
Main Side
Effects
*Upset
stomach
*Hiccups
*Mouth
irritation
*Irregular
heartbeat
*Nausea
*Heartburn
*Hiccups
*Disturbed
sleep
(insomnia,
abnormal/
vivid
dreams)
*Headache
*Site rash
(pruritis
erythema,
burning)
*Irritation
of throat
and nasal
passages
*Sneezing
*C oughing
*D yspepsia
*Insomnia
*Nausea
*Dry mouth
*Nausea
*Sleep
disturbances
*C onstipation
*Flatulence
Dosage
2 mg, 4 mg
2 mg, 4 mg
5 mg, 10 mg,
15 mg
6-12
cartridges
per day
150-300 mg/
day
0.5 mg qd to 1
mg bid
Effectiveness
at six months
or longer†
(OR [CI])
1.66
(1.52-1.81)
3.69 *
(2.74-4.96)
1.81
(1.63-2.02)
2.14
(1.44-3.18)
2.06
(1.77-2.40)
2.83*
(1.91-4.19)
4mg, effectiveness at 6-weeks
Adapted from Le Foll & George (2007), Shiffman et al (2002)
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Preparing for Quit Day
• A few weeks prior to quit day, limit your smoking to only one room in your home or completely
make it smoke free. This room should be the least comfortable room in your house.
• Clean out your car and clean / deodorize your home.
• Visit your dentist to get your teeth cleaned. With the tar and nicotine removed from your teeth
you are literally starting with a fresh mouth.
• Monitor alcohol and caffeine consumption before and after quit date as these can been seen
as triggers to use. Cut down on caffeine after you quit, because people who don’t smoke
commercial tobacco are more sensitive to caffeine (for example, coffee will have a stronger
effect after you quit smoking).
• Get lots of rest leading up to your quit day.
• Drink lots of fluids as this can help with cravings.
• Use healthy substitutes such as sugarless gum, carrot sticks, sunflower seeds, raisons etc.
This will help keep your mouth stimulated.
• Repeat your reasons for quitting or post a list on your fridge where you will be constantly be
reminded.
• Plan activities for your first week of being smoke free. Keeping yourself occupied is important
as well as planning activities that do not place you in situations where you will be tempted to
smoke.
• Occupy your hands with toothpicks, pencil, rubber bands, stress balls, etc…
• Be aware of cigarette advertisements or other triggers.
• Never allow yourself to think that one cigarette won’t hurt. Many smokers relapse when they
believe they can control their smoking. This is harmful because even if you are able to control
your cigarette consumption for awhile it generally ends up increasing to where it was before
you quit.
• Use your support system and don’t be afraid to ask for help from community members, Elders,
family etc.
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Cold-Turkey vs. Cutting Down
People of ten ask which strategy is the best way for quitting commercial tobacco use.
Unfortunately there is no easy answer and this decision depends on each individual’s
preferences, strengths and weaknesses. Consider the following information before making your
decision.
Cold-Turkey
When a person quits cold turkey this means that he/she has gone from smoking his/her normal
amount of cigarettes to abruptly stopping completely. The amount of nicotine in blood stream
quickly drops off. As a result, the body may experience some withdrawal symptoms (restless,
irritable, appetite changes, sleep disturbances, headache, fatigue, coughing etc.). The benefit of
quitting this way is that it is quick and your body begins to heal itself immediately.
Cutting down or tapering
Some people decide to cut down the number of cigarettes that they smoke and thereby reduce
the amount of nicotine in the body. The benefit to this process is the potential reduction of
withdrawal symptoms. However some people find that it is difficult for them to maintain a
lower level of nicotine because the body begins to crave the original amount that the smoker
was consuming. Therefore they may find themselves going up and down with the amount that
they smoke because the body may experience mini withdrawal symptoms. To prevent this from
happening nicotine replacement therapies were developed. These products were designed to
lower the amount of nicotine in the body gradually to minimize withdrawal.
Whatever method of quitting you decide upon, it is important to be prepared. If you decide to
go cold-turkey, know what you are going to do on your quit date and have supports in place to
help you through your chosen date. Alternatively, if you are going to taper down, there are many
strategies that you can use to help you through this process.
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CIRCLE four:
HOW TO BECOME A NON-SMOKER
Illustration of the Four Teaching Circles: Themes and Content
HOW TO CHANGE?
Discuss and implement
approaches, treatments
and helpers to increase
the odds of quitting
WHAT?
Understand tobacco
as harmer and as healer,
as well as the role of
medications
WHO USES
COMMERCIAL TOBACCO?
you
are here
4
3
1
2
Understand
prevalence and
how people and
communities
are affected
WHY CHANGE?
Enhance
motivation to quit
commercial tobacco
The Teaching Circles are based on the model outlined on the following page wherein each of the
four Teaching Circles has four rounds of learning: Round 1, Self-Knowledge (SK); Round 2:, New
Knowledge (NK); Round 3, Integration of Knowledge (IK); Round 3, Action (A). This is a suggested
model, but the Circles are not restricted to this format –elaborating, condensing and tailoring are
all expected.
The Teaching Circles can be offered in the order they are presented—i.e. Circle 1: Who?, Circle
2: Why?, Circle 3: What?, Circle 4: How?—or you may choose to select and adapt any of the
activities in any order. Circles may be abbreviated to be offered in a shorter period of time, such
as half a day, or extended over several weeks.
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Four Rounds of the Teaching Circle
Every Circle will have four rounds: Circle members move from exploring their own pre-existing
knowledge (Self-Knowledge), through generating New Knowledge (NK), Integrating Knowledge
(IK), and taking Action (A). Please see the following pages for the full guide and individual
activities for each Round.
SK
Round 1 - Self Knowledge (SK)
Round One is a combination of sharing experiences and building trust. In order to move forward,
participants need to establish a collaborative working relationship and begin a democratic
dialogue. Out of the shared experiences, themes emerge -- issues that people share, problems
they face, differences of opinion.
NK
Round 2 - Finding Patterns (New Knowledge) (NK)
Round Two is to identify these themes (find patterns) and analyze them. How do these problems
work? Where do they come from? Add/acquire/master new information from the facilitator or the
group. A crucial part of this step is learning how to use the new information and seeing how it
affects the analysis of problems carried out in the previous step.
IK
Round 3 - Integration of Knowledge (IK)
Round Three is planning for action and practicing skills. This is where people are creating
strategy and tactics, thinking about what they want and how they plan to get it. Activities and
worksheets can be incorporated here.
A
Round 4 - Action (A)
Round Four is crucial. The connection between education and action is not a solid line. It is not so
predictable. Any given educational process may not produce action. Or it may take a long time, or
come up in an unexpected way. The educator may or may not have a connection to that step and
certainly does not control it.
5 apply in action
The end of this learning
journey is reconstruction
and assessment. This step
overlaps with the first step of a
new spiral. Here is the model
that incorporates the four
rounds discussed above:
78
A
practise skills
strategize and
plan for action
SK start with the
IK
experience of
the participants
NK
add new information and theory
look for
patterns
[ image inspired by Paulo Freire’s Pedagogy of the Oppressed, 1970 ]
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Circle 4: Facilitators’ Checklist
IMPORTANT NOTE: All of the activities and resources are optional in the sense that you can and
should tailor the Teaching Circles to the needs of your group and community.
Content and
Resources and Preparation Required
Activities
Opening and
Invite an Elder to offer an Opening Prayer/Ceremony/Gathering Song
Welcome
Print a sign-in sheet to track attendance. (See Additional Resources section in the
Tool-Kit)
Bring a Medicine Bag or gift box for circle members to pass around during the
Icebreaker Activity. (see p 81)
SK Round One: Self-Knowledge (SK)
a. Learning Outcomes
(see p 82)
b. Making the Switch
Invite a Traditional Elder or Knowledge Keeper to provide teachings on how to
make a tobacco tie. (see p 82)
OR
c. Collage of Goals and
Dreams
NK
Bring magazines, newspapers, scissors, glue and coloured poster paper for circle
members to use for their “Collage of Goals and Dreams”. (see p 82)
Round Two: New Knowledge (NK)
a. Paths to Healing
Invite a Traditional Elder or Knowledge Keeper to provide teachings on traditional
and Recovery
ways of healing from addiction and commercial tobacco use. (see p 83-84) AND/OR
from Commercial
Print enough copies of the handouts:
Tobacco
Traditional Healing from Commercial Tobacco UseGeneral Coping Strategies
Cutting Down or Tapering
How fast will I improve after quitting commercial tobacco?
or refer members to their Participant Handbook
IK
Round Three: Integration of Knowledge (IK)
a. Triggers and Helpers Print enough copies for each Circle member of the Medicine Wheel template
(see p 93) or refer members to their Participant Handbook OR
Print enough copies for each Circle member of the card handout, Triggers and
Coping Skills (see p 94) OR
Bring a flip chart to record Circle members’ Triggers and Helpers brainstorming
session. (see p 94)
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A
Round Four: Action (A)
a. Next Steps
Print copies for each Circle member of the handouts (see p__):
4 Steps to leading a healthier life
I can Quit planning wheel
Current Motivation and Next Steps
or refer members to their Participant Handbook
Wrap-Up
Print enough Evaluation handouts for each Circle member (See Additional
Resources section of the Tool-kit)
Collect the completed Evaluation Forms
Closing the Circle
Print each circle member’s Certificate of Completion.
and Celebration/
Plan a feast. Consider inviting the community (families, leaders, health
Feasting
authorities).
Ask the Health Director or the Chief to present the Certificates.
Provide a small gift of acknowledgment (sacred tobacco, affirmation cards, small
stone, or Medicine Pouch).
Opening and Welcome
• Introduce yourself as the helper/facilitator for the Circle
• Opening Prayer/Ceremony/gathering song as per community context and if applicable by an
invited Elder or the facilitator
• Welcome participants – may be done by the Elder
• Provide logistical information, which can include:
-- Sign-in (if using): Direct participants to sign-in sheet on resource table (optional and based
on community preference); breaks, washrooms, refreshments, etc.
-- Content that will be covered: Describe the overall content of the four Teaching Circles, as
well as the content in this first Teaching Circle.
-- Example introduction to the content and structure of the sessions:
Thank you for coming to the final Teaching Circle about traditional and commercial
tobacco. As a quick review, Circle 1 talked about some of the interesting facts and
statistics about commercial tobacco use, as well as the consequences. In Circle 2 we
looked at motivation to quit using commercial tobacco. Circle 3, discussed tobacco
as both a healer and harmer and the differences between traditional versus commercial tobacco and medication options. In this fourth and final Teaching Circle (Circle
4), we will discuss approaches that can help a person quit using commercial tobacco.
Everyone’s voice is important, since we all have experience with commercial tobacco
– either ourselves or with our families, friends and community. In this way we all have
teachings to share and we can all learn.
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• If needed, invite the circle participants to introduce themselves in a way that is comfortable for
them. They can simply provide their first name or introduce themselves in the traditional way
whatever is preferable to the participant. Be clear in your direction that this is simply a brief
introduction.
• Icebreaker activity: Gifting: Pass around either a beautiful Medicine Bag or a beautifully
wrapped gift box (whichever is more appropriate for your context). As each person holds
the container they are to identify the gift that they would give to the person next to them and
they can put anything in the box that they want. Start with yourself as the facilitator to model
the request. For instance as the facilitator you might say, “Sarah, I am giving you the gift of
courage.” And pass the container to Sarah. Sarah then provides her affirmation and passes it
to the next member of the Circle.
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SK Round One: Self Knowledge (SK)
Activity A: Introduce the intended learning outcomes for Circle Five
• Identify strategies and resources for quitting commercial tobacco use
• Review teaching and sharing from previous Teaching Circles and ask if there are any questions
or thoughts that have resulted from the previous work.
Activity B: Making the Switch (if applicable in your territory) (20 minutes)
Invite a Traditional Elder or Knowledge Keeper to come in and provide the teaching on how to
make a tobacco tie. You will need to assist with the provision of cloth, tobacco and embroidery
floss (the Elder can direct you).
Once everyone has received the teaching and created their own tobacco tie they can be
encouraged to hold their tie throughout the session. The Elder may talk about putting their
intention to quit into this sacred tobacco. The Elder may direct the participants to offer the
tobacco outside in a clean place or they may be collected and offered by the Elder.
This activity can help individuals to begin to think of the healing benefits of tobacco instead of
harmful effects. Members of the circle can pass this teaching on to family and friends or loved
ones who are also struggling with dependence on commercial tobacco.
OR
Activity C: Collage of Goals and Dreams (30 minutes)
Provide members in the Circle with a variety of magazines, newspapers, etc. as well as scissors,
glue and coloured poster paper. Invite people to look for images and words that represent their
goals and dreams – for their health and wellness, work, life, family, relationships etc. You can also
provide coloured markers or crayons for people to add art and embellishments to their collage.
After everyone is finished, invite each person to speak about the meaning of what they have put
on their collages. Let them know that any person is free to pass if he or she wishes.
This activity can help individuals to think about the goal they set for themselves in Circle 3, as
well as other goals and dreams that they have. This activity also sets the stage for the content in
this circle (strategies for change).
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NK Round Two: New Knowledge (NK)
This round is best delivered interactively but can also be effective with a video,
guest speakers or formal presentations.
Activity A: Paths to Healing and Recovery
from Commercial Tobacco (20-40 minutes)
For this activity you may choose one or more of the options below.
Option 1:
Invite a Traditional Elder or Knowledge Keeper to come in and provide teachings on traditional
ways of healing from addiction to commercial tobacco. If appropriate you may also want to give
the handout: “Healing from commercial tobacco use: Some traditional approaches” (next page).
Option 2:
Pursed Lip Breathing
BACKGROUND: Pursed lip breathing is one of the easiest methods to manage shortness of
breath. It provides a quick and easy way to slow down the pace of your breathing, making each
breath more effective.
Benefits of Pursed Lip Breathing
• Improves ventilation
• Releases trapped air in the lungs
• Keeps the airways open longer and decreases the work of breathing
• Prolongs exhalation to slow the breathing rate
• Improves breathing patterns by moving old air out of the lungs allowing for new air to enter the
lungs
• Relieves shortness of breath
• Induces general relaxation
Pursed Lip Breathing Technique - ask members to practice with you:
1. Relax your neck and shoulder muscles
2. Breathe in (inhale) slowly through your nose for two counts, keeping your moth closed. Don’t
take a deep breath: a normal breath will do. It may be helpful to count to yourself: inhale, one,
two.
3. Pucker or “purse” your lips as if you were going to whistle or gently flicker the flame of a
candle.
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4. Breathe out (exhale) slowly and gently through your pursed lips while counting to four. It may
help to count to yourself: exhale one, two three.
Tell the group that with regular practice this technique will seem natural. It is recommended to
practice at least 4-5 times per day to get the correct breathing pattern.
Option 3:
Coping skills that can help!
The handouts on the following pages have a wealth of tips and strategies for coping with cravings
and urges for commercial tobacco. You may wish to give these as handouts to the group and
discuss, or just facilitate a more general discussion. For example, go around the Circle and ask
each member to identify a strategy that appeals to him or her, and how this could be helpful.
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Healing from commercial tobacco use:
Some traditional approaches
The following are ideas and suggestions and may not necessarily apply to all Nations.
We recognize there are no universal or pan-Aboriginal approaches to healing commercial
tobacco use.
A community member should always begin their traditional healing path by consulting with
people s/he trusts to get referrals to respected and recognized Traditional Healers, Elders and
Medicine People within his/her community or organization. An Elder in the community would
be willing to help the community member who wants to quit by being available throughout the
process of their journey toward becoming a non-smoker. When you seek the help and advice of
an Elder, Healer or Medicine Person, and give your offering of tobacco, they know that a request
may be made as tobacco is so sacred.
Tobacco is the first plant that the Creator gave to the peoples of Turtle Island. It is used as an
offering for everything in every ceremony. “Always through tobacco,” the saying goes. Traditional
tobacco was given to us so that we can communicate with the spirit world. It opens up the
door to allow that communication to take place. When we make an offering of tobacco, we
communicate our thoughts and feelings through the tobacco as we pray for ourselves, our family,
relatives and others.
Tobacco has a special relationship to other plants: it is said to be the main activator of all the
plant spirits. It is like the key to the ignition of a car. When you use it, all things begin to happen.
Tobacco is always offered before picking medicines. When you offer tobacco to a plant and
explain why you are there, that plant will let all the plants in the area know why you are coming to
pick them.
We express our gratitude for the help the spirits give us through our offering of tobacco. It is put
down as an offering of thanks to the First Family, the natural world after a fast. Traditional people
make an offering of tobacco each day when the sun comes up.
Traditional tobacco is still grown in some communities. For example, the Haudenosaunee people
use a traditional tobacco that they grow themselves and that is very sacred to them. Tobacco
along with sage, cedar and sweetgrass make up the Four Sacred Medicines.
In addition to speaking to a traditional person and making offerings, a community member can
also find healing through ceremony such as:
• daily smudges with the sacred medicines and prayers
• going on a fast
• going to a sweat
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Many options are available for reconnecting with traditional activities, replacing unhealthy
environments and activities with healing ones, or distracting ones hands from the habit of
cigarette smoking, such as:
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spending time in the bush
traditional, jingle, fancy shawl, grass, chicken, etc. dancing
beadwork and craft-making
hunting, trapping, cooking traditional foods
singing
drumming
(In part adapted from “The Four Sacred Medicines”. Anishnawbe Health Toronto, 2000, and through consultation with the Enaahtig Healing
Lodge and Learning Centre.)
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General Coping Strategies
Things I can do
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Visit and Elder or Knowledge Keeper and offer to be a helper
Attend a sweat lodge ceremony
Smudge
Have a cedar bath
Drink a cup of cedar tea
Go in the bush
Sit by the water
Make a tobacco offering in gratitude for the day
Avoid people or places that trigger problematic coping strategies (i.e. tobacco use,
drinking, drug use, self-harm)
Identify and avoid high-risk situations.
Take a “buddy” when going to a risky place /situation.
Leave risky situations, or limit how long you stay.
Phone someone for support
Go for a walk.
Read a book.
Exercise or do something physical.
Stand tall and feel your body’s strength. Remind yourself that you are a strong person.
Hold onto something to ground yourself (chair you are sitting in, key ring, picture etc.)
Clean or do housework.
Do volunteer work
Try meditation, deep breathing, and relaxation tapes.
Try new hobbies or leisure activities.
Practice saying no with both your voice and body language.
Stay in contact with supportive people.
Take care of yourself if you are hungry, thirsty or tired.
Keep a visual reminder of the negative consequences of your problematic coping
strategies (i.e. court papers, photos)
Keep visual reminders or written lists of the positive consequences of the changes
you’ve made.
Reward yourself for your efforts.
Go to a support group.
Listen to music. Sing. Dance.
Cook and eat nutritious food.
Practice being kind to yourself
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Thoughts that can help
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Offer a daily prayer of gratitude
Talk to an Elder or Knowledge Keeper about the Seven Grandfather teachings
Think kind thoughts about yourself
Remember the positive things about using healthy coping strategies.
Remember the negative consequences of using problematic coping strategies.
Tell yourself that feelings, even difficult feelings, are normal.
Distract yourself by thinking about something else.
Recognize when you are making self-defeating statements or rationalizations
(i.e., I am such a loser).
Plan ahead for any risky situations or “loopholes” to your plan.
Imagine a stop sign when you are having intrusive thoughts or imagery.
Think about your future goals and how to achieve them.
Remind yourself that you only have to worry about what you have control over today.
Remind yourself that you are in the present and the past cannot hurt you now.
Make a commitment to yourself and remind yourself of it.
Think that you are in charge of whatever decisions you make about your safety.
Tell yourself that you are doing well so far and don’t want to interfere with the
progress.
When feeling overwhelmed, make a pro / con list and limit your decisions until you
feel less overwhelmed.
Monitor your use and urges to use problematic coping strategies
Think about the times in your life (even if few) where you have felt good about
yourself. Try to get in touch with the feelings of strength and success that went along
with those events.
When a negative belief about yourself pops into your head, try to remember where
it really came from—who originally planted those beliefs? Think about challenging
them with other information that you know about yourself, which proves the beliefs to
be false.
Be aware of any tendency you have to make general statements about yourself.
Being human means having good and bad days.
Post a copy of the Seven Grandfather teachings where you can review it each day
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Coping with feelings
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Talk to an Elder or Traditional Healer
Acknowledge your internalized oppression
Read inspiring literature on self-growth or recovery.
Ask yourself what you are feeling (go through a checklist of your common “feeling
triggers” –am I lonely, sad, anxious, scared).
Give yourself permission to feel emotions (don’t judge your feelings).
Express your feelings (cry, smile, etc.,).
Ask for support.
Talk to someone about your feelings.
Find a creative outlet for feelings (music, drawing, painting, poetry etc.,).
Get a journal and write to yourself.
Take time to soothe / nurture yourself.
Praise yourself for the progress you have made.
Use affirmations.
Light candles to help you to focus on your thoughts and feelings.
Write a letter to someone about how you are feeling (it is better to not send the letter,
keep it, burn it, bury it, flush it).
Get a punching bag, or hit a pillow or bed, scream into a pillow.
Throw rocks in the lake
Talk to a pet / spend time with animals.
Go to a spiritual place (anyplace you define as spiritual).
Create a safe or sacred place in your home.
Be kind to yourself.
If you are afraid of being overwhelmed by your emotions, imagine them coming
through a tap where you are able to control the flow
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Cutting Down or Tapering Strategies
for Commercial Tobacco Cessation
Some of these strategies may be more helpful than others. Try them out and then use
the ones that are most effective for you. You may also have some additional strategies
that you find helpful in which case we invite you to add those to this list.
1. Smoke only ½ of the cigarette.
2. Make your car, office, house smoke free
3. Enlist the support of your family, friends, and colleagues – tell them that you are
quitting so they won’t offer you cigarettes or smoke in front of you.
4. Buy a brand of cigarettes that you dislike.
5. Delay the time between each cigarette.
6. When you are craving a cigarette, try to wait 15 minutes.
7. Chew gum or crunchy foods (i.e.: carrot sticks)
8. Keep yourself busy and your hands occupied.
9. Track your cigarettes so you are aware of exactly how much you are smoking and
under what circumstances.
10. Avoid coffee, alcohol and any other triggers that you link with smoking.
11. Change your routine (i.e.: go for a walk immediately after meals, eat breakfast in
another room)
12. Others? 90
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How Fast Will I Improve after I stop using
commercial tobacco?
Everyone improves after quitting smoking at varying rates. This may be dependent on
amount smoked, years smoked, if you are exposed to second hand smoke (among other
factors).
Immediately
The air around you and your family and friends is
safer.
Within 20 minutes of last
Blood pressure drops
cigarette
Pulse rate drops to normal
Body temperature of hands and feet increases to
normal
After 8 hours
Carbon Monoxide level in blood drops
After 24 hours
Chance of heart attack decreases
After 48 hours
Nerve endings may re-grow
Ability of smell and taste enhanced
After 72 hours
Bronchial tubes relax; if undamaged, will make
breathing easier
Lung capacity increases
2 weeks to 3 months
Circulation improves
Walking becomes easier
Lung functioning may increase up to 20%
1 – 9 months
Coughing, sinus congestion, fatigue, shortness of
breath may decrease
Potential for cilia in lungs to re-grow, increasing
ability to handle mucus, clean the lungs and
reduce infection
1 year
The risk of heart disease is reduced by half of
someone who continues to smoke
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IK Round Three: Integration of Knowledge (IK)
Activity A: Triggers and Helpers (15 minutes)
This activity can be delivered in one of three ways, or you can adapt or tailor it further to the
needs and preferences of the members in the Circle.
Option 1:
Hand out the Medicine Wheel template (next page) and ask that the members either reflect
on or write in each section identifying a possible trigger to use commercial tobacco, and a
corresponding coping strategy that may work for them. For example, a person may identify how
coffee and a cigarette go together after a meal – and decide that switching to tea, or going for
a walk right away can help. When completed go around the Circle asking the members to share
some of the triggers and helping approaches that have either worked for them or they would like
to try – maybe they have heard about a certain approach working for others and would like to
share that information as well.
Option 2:
Hand out the “Triggers and Coping Skills” work sheet (following pages), and follow the same
process as above.
Option 3:
Using a flip chart, ask the group to brainstorm people, places or things that are associated
with using commercial tobacco (these are their “triggers”). For each trigger, invite the group to
identify at least 3 different actions or thoughts that could help the person to not use commercial
tobacco in that situation.
Example:
Trigger: Talking on the phone at home
Coping Strategies: • Make home smoke free (action)
• Remind myself of how far I have come (thought)
• Put a “No Smoking” sticker on my phone (action)
TIP: Print out the “coping cards” on the following pages and had them out to members in the
circle to carry with them.
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How does commercial tobacco affect you and others in your life?
physical
Example:
I have a cough
especially in the mornings
Example: Feeling bad because I want to set
a good example for my kids
emotional
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Example:
Tobacco is a gift from
the Creator, and I want to
honour that gift
spiritual
Example: Thinking about how smoking
cigarettes is hurting my body
mental
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Triggers and Coping Skills
Sample Plan
Triggers
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Coping Skills
Smoke with friend every day at breaks
Tell friend “I am quitting
After meals
Chew gum after meals;
get up from table right away
Stress at work gets too much on some days
Plan to take walks when stress is
high
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Three Options to Cope
Three Options to Cope
• Avoid the triggers or situations.
• Avoid the triggers or situations.
• Change the trigger or situations.
• Change the trigger or situations.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
Three Options to Cope
Three Options to Cope
• Avoid the triggers or situations.
• Avoid the triggers or situations.
• Change the trigger or situations.
• Change the trigger or situations.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
Three Options to Cope
Three Options to Cope
• Avoid the triggers or situations.
• Avoid the triggers or situations.
• Change the trigger or situations.
• Change the trigger or situations.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
Three Options to Cope
Three Options to Cope
• Avoid the triggers or situations.
• Avoid the triggers or situations.
• Change the trigger or situations.
• Change the trigger or situations.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
• Find an alternative or substitute for the
cigarette in response to the trigger or
situation.
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Pledge to Remember the 4 D’s
Pledge to Remember the 4 D’s
• Distract Yourself
• Distract Yourself
4 Ds
• Delay the cigarette
• Drink Fluids
4 Ds
• Delay the cigarette
• Drink Fluids
• Deep Breathing
• Deep Breathing
Pledge to Remember the 4 D’s
Pledge to Remember the 4 D’s
• Distract Yourself
• Distract Yourself
4 Ds
• Delay the cigarette
• Drink Fluids
4 Ds
• Delay the cigarette
• Drink Fluids
• Deep Breathing
• Deep Breathing
Pledge to Remember the 4 D’s
Pledge to Remember the 4 D’s
• Distract Yourself
• Distract Yourself
4 Ds
• Delay the cigarette
• Drink Fluids
4 Ds
• Delay the cigarette
• Drink Fluids
• Deep Breathing
• Deep Breathing
Pledge to Remember the 4 D’s
Pledge to Remember the 4 D’s
• Distract Yourself
• Distract Yourself
4 Ds
• Delay the cigarette
• Drink Fluids
• Deep Breathing
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4 Ds
• Delay the cigarette
• Drink Fluids
• Deep Breathing
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it’s time: indigenous tools and strategies on tobacco interventions, medicines and education | facilitator manual
A Round Four: Action (A)
Activity A: Next Steps
Hand out the 4 Steps to leading a healthier life and the I can Quit planning wheel and/or the
“Current Motivation and Next Steps” worksheet. In dyads have them discuss their next steps
and how they can begin to commit to a change in their patterns and work towards meeting their
goals.
The following is some additional information to share with the circle:
4 steps to stopping destructive behaviours and leading a healthier life:
1. STRATEGIZE
2. TAKE ACTION
3. OPTIMIZE
4. PREVENT RELAPSE (PERSEVERE)
The STOP acronym describes four psychosocial intervention steps to follow in sequence, to
change behaviour and adopt a healthier lifestyle. The tools themselves that we will be presenting
are not all specific to tobacco alone. They help guide people towards quitting smoking, but can
be used for other behaviour changes as well.
Setting the Stage
• Important aspects to consider
-- Quitting is a process
-- Automatic behavior: not always a conscious process
-- A pack/day = 110,000 hand to mouth repetitions/year
-- Linked with many behaviors: meals, alcohol, waking up, coffee, environment – group homes,
smoking rooms in hospitals
-- Linked with social relationships: breaks at work, parties, friends houses
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Step 1: STRATEGIZE
Strategize
• Can take 1 session or can happen over several
• Involves developing a quit plan:
-- Tracking smoking
-- Quit date
-- Triggers, coping skills, plan for high-risk events
-- Problem solving and coping skills
-- Support plan
-- Pharmacotherapy plan
Strategize: Psychological
• Identify all positive supports
-- Partner, family, friends, colleagues
-- Professionals – physician, pharmacist, dentist, nurse, etc
-- Other support – Smokers’ Helpline, groups, websites, self-help
• Identify all negative influences
-- Other smokers (partner, family)
-- People who don’t want the person to quit smoking
-- Unhelpful “encouragement” to quit
Strategize – Cognitive/Affective
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Personal relationship with cigarettes
Describe cigarettes as friend or lover
Can experience sense of loss when quitting
Help reframe this thinking… abusive friend or lover
Acknowledge these emotions
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Strategize – Behavioural
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Relaxation strategies
Physical activity
Groups
Rewarding accomplishments
Tracking sheets / Self-monitoring
-- Increase awareness of smoking behaviour
-- Identify triggers, challenges
-- Suggest which cigarettes will be easy and which will be more difficult
-- Begins to break the automatic smoking behaviour and possibly reduces the number of
cigarettes smoked
Strategize - Environmental
• Smoke-free environments
-- Make home and vehicle smoke-free
-- Explore areas of home to restrict smoking behaviour if entire home cannot go smoke-free
-- Work environment – avoiding smoking areas
-- Other
Strategize – Biological
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Pharmacotherapy
If a person is interested in medications, refer to physician/pharmacist or provide information
How much do they know about what is available?
What are the pros and cons of pharmacotherapy?
Who will help monitor this part of the quit plan?
Activity: Famous Last Words (15 minutes)
Provide one last chance for the participants to share any comments about themselves or the
program. This will give each person time to say thank you for the opportunity or say anything else
they need to at this point in the program. Have the participants complete the evaluation as the
final official task.
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Wrap up
• This can be done orally as part of the circle process or copies of the Facilitator and Workshop
evaluations can be distributed.
• Encourage participants to complete the evaluation. Tip: if you choose to hand out a paper
copy have the participants fill it out while still in the Circle before you close.
• Last words
Reiterate the opening words of welcome. Thank them for having the courage to participate.
Closing Prayer/Travelling Song if applicable
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4 Steps to leading a healthier life
1. STRATEGIZE
2. TAKE ACTION
3. OPTIMIZE
4. P
REVENT RELAPSE
(PERSEVERE)
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I CAN QUIT PLANNING SHEET
Prevent Relapse
Optimize
Strategize
Take Action
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Current Motivation and Next Steps
1.
Where were you when you started this process, and where are you now?
2.
What do you need to do to continue to make positive changes?
3.
What is your next step?
Completing this worksheet allows you to gain perspective on quitting commercial
tobacco use. Reflect on how this entire journey has gone from starting to think about
behaviour change, to continuing these efforts, and write down the next step that you need
to take moving forward. This gives you the chance to feel proud about the progress you
have made to date, gain confidence, and realize that even if you have not yet met your
ultimate goal – you are still farther ahead than when you first started!
Additional resources that can support me…
Keep this list handy. It can have names, contact information, websites, favourite quotes
etc – whatever is meaningful to you.
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Final Activity: A Celebration of Courage
After the last circle (Circle 4):
Plan a feast and formally present their certificate of completion. You may want to consider
inviting the community (families, leaders, health authorities etc.) Ask the Health Director or the
Chief to present the Certificates. Maybe have a small gift of acknowledgment – examples could
include: some sacred tobacco, affirmation cards, small stone, or Medicine pouch. It is important
to offer the opportunity for the participants to address the group assembled to build in some
time for this as they receive their certificate of completion. Not everyone will want to – they may
choose a spokesperson for their group.
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