Freshstart Facilitator Training

Freshstart: History of Tobacco Control

• Nicotiana tabacum - native to the Western Hemisphere and was unknown to Europeans prior the voyage of discovery. Native Americans used tobacco in their culture for religious and for recreational purposes. In many other cultures, tobacco was used by shamans and was reserved for ritual use.

• Tobacco was introduced to France in 1556, Portugal in 1558, and Spain in 1559, and England in 1565.

•The first successful commercial crop was cultivated in Virginia in 1612 by Englishman John Rolfe. Within seven years, it was the colony's largest export.

Freshstart:

• The Virginia Colonies in North America developed around a tobacco economy in the early 17th century. Tobacco was exported to Europe for pipe smoking and stuff, while cigars came for the Spanish colonies. Tobacco was used as an exchange medium in this era.

•At first, tobacco was produced mainly for pipe-smoking, chewing, and snuff. Cigars didn't become popular until the early 1800s. Cigarettes, which had been around in crude form since the early 1600s, didn't become widely popular in the United States until after the Civil War, with the spread of "Bright" tobacco, a uniquely cured yellow leaf grown in Virginia and North Carolina.

Freshstart: Mass Production of Tobacco

• Cigarette sales surged again with the introduction of the "White Burley" tobacco leaf and the invention of the first practical cigarette-making machine, sponsored by tobacco baron James Buchanan "Buck" Duke, in the late 1880s.

•James Bonsack invented the cigarette making machine in 1881 that could make 120, 000 cigarettes in a day. Bonsack went into business with Buck Duke and they built a factory. They made 10 million cigarettes the first year and about 1 billion 5 years later.

Freshstart: Research Begins

• In the May 27, 1950 issue of JAMA, Morton Levy published the first major study definitively linking smoking to lung cancer.

• In the same issue, "Tobacco Smoking as a Possible Etiologic Factor in Bronchiogenic Carcinoma: A Study of 684 Proved Cases," by Ernst L. Wynder and Evarts A. Graham of the United States, found that 96.5% of lung cancer patients interviewed were moderate heavy-to-chain-smokers.

• 1950 : RICHARD DOLL and A BRADFORD HILL publish first report on Smoking and Carcinoma of the Lung in the British Medical Journal, finding that heavy smokers were fifty times as likely as nonsmokers to contract lung cancer.

Freshstart: Smoking and Cancer

•In 1964, Luther Terry, M.D., released the report of the Surgeon General's Advisory Committee on Smoking and Health. That landmark document, now referred to as the first Surgeon General's Report on Smoking and Health, was America's first widely publicized official recognition that cigarette smoking is a cause of cancer and other serious diseases.

• The 1964 report on smoking and health had an huge impact on public attitudes and policy. A Gallup Survey conducted in 1958 found that only 44 percent of Americans believed smoking caused cancer, while 78 percent believed so by 1968.

Freshstart: Public Health Interventions

•In 1965, Congress required all cigarette packages distributed in the United States to carry a health warning, and since 1970 this warning is made in the name of the Surgeon General. In 1969, cigarette advertising on television and radio was banned, effective September 1970.

•Cigarette sales in the U.S. have fallen by more than 21% since the state Attorneys General negotiated the landmark 1998 tobacco Master Settlement Agreement (MSA), which imposed public health restrictions on the advertising, promotion and marketing of cigarettes by tobacco companies.

Freshstart: Review and Discussion (III)

• Review Material

• Questions?

Freshstart: Comprehensive Tobacco Control

• Preventing the initiation of tobacco use among young people.

• Promoting quitting among young people and adults.

• Eliminating nonsmokers’ exposure to environmental tobacco smoke (ETS).

• Identifying and eliminating the disparities related to tobacco use and its effects among different population groups.

CDC Best Practices for Comprehensive TobaccoControl Programs, August 1999

Freshstart: ACS and Tobacco Control

RESEARCH and EPIDEMIOLOGY•The American Cancer Society is the largest source of private, not-for-profit cancer research funds in the US, second only to the federal government in total dollars spent. In 2004, the Society spent nearly $131 million in research. Since 1946, the Society has invested more than $2.8 billion in cancer research.

•Internationally, the department collaborates with the World Health Organization to publish tobacco control country profiles, plus a monograph on tobacco consumption, production, and trade in 197 countries.

Freshstart: ACS and Tobacco Control

•COMMUNITY PROGRAMS and SERVICES•The American Cancer Society works collaboratively with our national partners to implement comprehensive tobacco control programs. The Society advocates for social environmental change at the national, state, and community levels that prevents young people from starting to use tobacco and provides support for those who wish to stop smoking.

•The Society has joined other health, education, and social service agencies to promote comprehensive school health education and National School Health Education Standards.

Freshstart: ACS and Tobacco Control

ADVOCACY•Grassroots action, direct lobbying, and applied policy analysis work to influence policy, laws, and regulations affecting the Society's nationwide priorities and 2015 goals.

•Enhance or ensure the role of the US Food and Drug Administration in regulating tobacco products

•Ensure funds derived from the 1998 multi-state tobacco settlement are at least partially obligated toward tobacco prevention and cessation programs

•Enact smoke-free ordinances at the local and state level to ensure all workers are protected from secondhand smoke exposure in their place of employment

Freshstart: ACS Tobacco Milestones

•1954 The Society's Hammond-Horn study shows the first link between smoking and lung cancer.

•1959 The Society's Cancer Prevention Study I (CPS I) begins, which shows that cigarette smoking leads to early death from lung cancer.

•1960 The Society takes a leading role in challenging and eliminating tobacco advertising.

•1970 The Surgeon General concurs with the findings of Society research irrefutably linking cigarette smoking to cancer.

•1977 The Society's first annual Great American Smokeout® publicizes the dangers of smoking with the media and the general public.

•1982 Freshstart program is developed and implemented nationwide.

Freshstart: ACS Tobacco Milestones

•1982 The Society joins with the American Heart Association and American Lung Association to form the Coalition on Smoking or Health to advocate for federal tobacco control policy.

•1982 The Society launches Cancer Prevention Study II (CPS II) of 1.2 million volunteers to determine risk factors for cancer mortality. To date, the study has demonstrated that secondhand smoke increases mortality from lung cancer and heart disease.

•1990 The Society pushes legislation for clean indoor air acts in local communities, tobacco taxation, and elimination tobacco industry advertising targeting children.

•1990 At the 7th World Conference on Tobacco or Health in Perth, Australia, Society representatives launch the "Trade for Life" program to fight the aggressive marketing of cigarettes in developing countries.

Freshstart: ACS Tobacco Milestones

•1991 Society-funded research shows that young children recognize Joe Camel as easily as Mickey Mouse, demonstrating that the cartoon character reaches an audience well under the legal smoking age

•1991 The American Stop Smoking Intervention Study for Cancer Prevention (ASSIST) Program launches. This is the world's largest demonstration project for tobacco control and is a joint effort between the National Cancer Institute (NCI) and the Society.

•1993 The US Environmental Protection Agency classifies environmental tobacco smoke as a Group A (known human) carcinogen

•1994 The Society asks the FDA to reconsider regulation of tobacco products and prompts congressional hearings.

Freshstart: ACS Tobacco Milestones

•1999 Through Operation Settle Up, the Society helps secure nearly $300 million in settlement money earmarked for state tobacco prevention and control programs.

•2000 Society epidemiologists prove that long-term cigarette smoking is associated with increased risk of death from colon cancer.

•2000 ACS launches clinical trial in Texas for Quitline. By 2005, Quitline has served over 190,000 callers.

•2005 ACS targets lung cancer for 2015 goals:-reduce incidence of cancer by 25%-reduce mortality by 50%-increase quality of life for survivors

Freshstart: Nicotine and It’s Effects

• As a stimulant - immediately after exposure to nicotine, there is a "kick" caused in part by the drug's stimulation of the adrenal glands and resulting discharge of epinephrine (adrenaline). The rush of adrenaline stimulates the body and causes a sudden release of glucose as well as an increase in blood pressure, respiration, and heart rate.

• Nicotine also suppresses insulin output from the pancreas, which means that smokers are always slightly hyperglycemic.

• In addition, nicotine indirectly causes a release of dopamine in the brain regions that control pleasure and motivation.

• In contrast, nicotine can also exert a sedative effect, depending on the level of the smoker's nervous system arousal and the dose of nicotine taken.

Freshstart:

• Can effect the way medications are metabolized; important to tell physician about quit if taking medications

• May be masking depression, anxiety or other mental health condition

• Tobacco dependence is a true addiction with a clear neurophysiological components

• Pharmacotherapy allows quitter to focus on behavioral and psychological aspects of quitting

• People using NRT are 1.5 – 2 times more likely to successfully quit than are those using placebo

Freshstart: Foundations of Tobacco Cessation

• US Public Health Service’s Clinical Practice Guidelines: Treating Tobacco Use and Dependence

• Identifies effective, experimentally validated tobacco dependence treatment and practices using meta-analysis

• Additionally, ACS programs integrate counseling strategies identified as effective in treating addiction

Freshstart: Intensive Treatment Findings

• There is a strong dose relationship between counseling intensity and cessation success – and effectiveness increases with treatment intensity. (sessions longer than 10 minutes with 4 or more sessions)

• Involving multiple types of providers may enhance abstinence rates.

• Proactive telephone counseling, individual and group counseling are equally effective.

Freshstart:

• Particular types of counseling and behavioral therapies are especially effective. Should involve problem solving/skill training and intra-treatment and extra-treatment social support. Pharmacotherapies such as bupropion SR or nicotine replacement therapies increase abstinence rates. Use should be encouraged for all quitters, with a few special circumstances.

•Tobacco dependence treatments are effective across diverse populations (gender, age, ethnicity).

Freshstart: Choosing a Cessation Program

FreshstartChoice of quitting strategies

Enhanced social support

Connection to community

Quit with a friend/partner

May work better for hardcore quitters

QuitlineConfidentiality

Specific quitting program

Convenience

Support from counselor

Can start any time

Freshstart: How People Change

• Stages of Change - Prochaska & DiClemente

Freshstart: Stages of Change

• Precontemplation – “I have no interest in changing”

• Contemplation – “I want to change, but I really like the way things are.”

• Preparation – “I am ready to change.”

• Action – “I have changed.”

• Maintenance – “I have changed and am continuing the change.”

• Relapse can occur at any time or any stage.

Freshstart: Ambivalence

• Heart of the change process

• Occurs throughout the stages of change

• Ignoring ambivalence leads to resistance and failure

Freshstart: Decisional Balance

• Increases motivation by identifying barriers to problem-solve

Disadvantages of Tobacco Disadvantages of Quitting(What are the negative consequences (What are the negative consequencesof smoking?) of quitting?)

Advantages of Tobacco Advantages of Quitting

(What are the benefits of smoking?) (What are the benefits of quitting?)

Freshstart: Supporting Change

• Active listening and empathy

• Normalizing ambivalence

• Encouraging participants to find their own solutions

• Supporting hope and ability to change

•Offering choices and information

•Teaching problem solving and coping mechanisms

Freshstart The program in detail.

You have what it takes!

1. You are committed to the maintenance of health through good self-care.

2. You believe it is important that individuals stop smoking.

3. You enjoy working with groups.

4. You are empathetic, perceptive, and have a good sense of humor.

5. You have the ability to speak in a direct, simple manner.

Freshstart: Qualities of a Facilitator

• A non-smoker • An ex-smoker (off cigarettes for more than six months)• Has group facilitation skills• Is an advocate for smoking cessation• Is objective• Will understand the goals of Freshstart• Will accept the time commitment to lead the Freshstart

program within your organization from start to finish• Is empathetic, fair, and has good communication skills

Freshstart: Qualifications of a Facilitator

• Four one-hour group sessions that take place twice a week for two weeks.

• Freshstart is flexible: – You may offer longer sessions

– You may conduct the programs over four weeks

KEY: Freshstart content must always be presented

Freshstart: How It Works

• Freshstart Facilitator Training PowerPoint• Freshstart Four Session Training PowerPoint• Freshstart Facilitator Guide * • Freshstart Participant Guide * • Freshstart Program Brochures

• Index cards 3½ x 5*

*Indicates materials needed for each Freshstart session

Freshstart: Program Materials

• Information and statistics may be obtained from the Society Web site: www.cancer.org: – Cancer Facts and Figures 2006*– Cancer Prevention and Early Detection 2006*

• American Cancer Society print materials related to tobacco use can be ordered by calling: 1-800-ACS-2345– When Smokers Quit– Set Yourself Free: A Smokers Guide– Smart Move

Freshstart: Additional Materials

• See that all participants are involved in the Freshstart process

• Be able to summarize the program content• Be familiar with the Participant’s Guide as well as the

Facilitator’s Guide• Begin and end sessions on time• Keep a record of participants’ progress• Report number of participants who attend the Freshstart

program (Freshstart Reporting Excel Spreadsheet)• Encourage and support participants

Freshstart: Facilitator Responsibilities

• You are not a lecturer.

• You are NOT expected to be an expert on all aspects of smoking.

Freshstart: Your Role as a Facilitator

• Phase One: Individual attention

• Phase Two: Strategies and Information

• Phase Three: Review and Discussion

• Phase Four: Assignments

Freshstart: General Session Format

• 15 – 20 minutes in length

• Personal Introductions (Session One)

• Questions / Sharing of experiences (Session Two – Four)

Freshstart: Phase I: Individual Attention

• 15 – 20 minutes

• Content addresses session objective(s)

• Questions at this time should be for clarification only (discussion will follow)

Freshstart: Phase II: Strategies and Information

• 15 – 20 minutes

• Brief review of materials covered

• Discussion of content presented

• Encourage participants to share ideas and experiences

Freshstart: Phase III: Review and Discussion

• 5 minutes

• Tell participants which section of their Freshstart Guide to read prior to the next group session.

• Call attention to the individual goals participants have set for themselves– Quit date– Approach to quitting

Freshstart: Phase IV: Assignments

BASIC REMINDERS:

• Be familiar with the Facilitator’s Guide and the Participant’s Guide.

• Do not announce the beginning of each phase

Freshstart: Program Content

• Welcome participants/Facilitator introduction

• Introduce/explain the Freshstart Program

• Distribute Participant Guides

• Discuss Nicotine Dependence and Addiction; Psychological Reasons for Smoking

• Quitting Reminders

Freshstart: Session One

Participant Introductions – Four Questions

1. What benefits do you hope to achieve from quitting?

2. What triggers your desire to smoke?

3. What motivated you to come today?

4. What is the average number of cigarettes you smoked up to this session?

Freshstart: Individual Attention (I)

Review session one objectives

• Fears of Quitting Tobacco

• Approaches to Quitting

- Cold Turkey

- Gradual (tapering vs. postponing)

- The Quitline

- Nicotine Replacement Therapy (NRT)

• Physiological Effects of Smoking

• Physical Effects of Smoking

Freshstart: Strategies and Information (I)

• Review Material

• Questions?

• Making This Attempt Your Last

Freshstart: Review and Discussion (I)

Freshstart: Assignments (I)

• Set a Quit Date!

• www.cancer.org – What approach is better for you?

• Review Session One

Freshstart: Individual Attention (II)

• Questions from session one

• Personal experiences to share

• Session Two Objective

Freshstart: Strategies and Information (II)

• Withdrawal Symptoms

• Fighting Withdrawal Symptoms

• Being Assertive

• Thinking Positively

• Making This Time Unique

Freshstart: Review and Discussion (II)

• Review Material

• Questions?

Freshstart: Assignments (II)

• Keep individual Quit Date

• Review Session Two – start using relaxation exercises

• Four Practical Tips

• Complete Assertiveness Chart at home

Freshstart: Individual Attention (III)

• Questions from Session Two

• Share personal experiences

• Session Three Objective

Freshstart: Strategies and Information (III)

• Physical Improvements Following Cessation

• Weight Gain

• Alcohol

• Interpersonal Support

Freshstart: Review and Discussion (III)

• Review Material

• Questions?

Freshstart: Assignments (III)

• Review Session Three – continue using relaxation exercises

• Four Practical Tips

Freshstart: Individual Attention (IV)

• Questions from Session Three

• Share personal experiences

• Session Four Objective

Freshstart: Strategies and Information (IV)

• Ripple Benefits of Smoking

• How to Avoid Returning to Smoking

• Long-term Benefits

• What If You Still Haven’t Quit or You Have a Relapse?

Freshstart: Review and Discussion (IV)

• Review Material

• Questions?

Freshstart: Assignments (IV)

• Exchanging phone numbers

• Review all sessions of the Freshstart program, including Additional Tips to Help You Remain Smoke Free

• Contact American Cancer Society 1-800-ACS-2345

Freshstart: Additional Materials

Freshstart Reporting Sheets

• Freshstart Facilitator Training

• Freshstart Cessation Program

Ordering Materials for Freshstart sessions

Thank you!

Questionsacsworkplacesolutions@cancer.org