HSE - Brief Intervention for Smoking Cessation - Participant Resource

Brief Intervention for Smoking Cessation

National Training Programme

National Tobacco Control Office

Health Service Executive Oak House, Millennium Park

Naas, Co. Kildare

Telephone: 045 880400 www.hse.ie

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http://www.hse.ie

http://www.hse.ie

http://www.QUIT.ie

The development of an accredited National Training Programme is one of the key priorities of the HSE cross service group responsible for implementation of the HSE’s Tobacco Control Framework. The course is recognised for CPD by The Irish College of General Practitioners (5.5 CPD credits and 2 GMS study leave sessions for registered doctors) and has been awarded Category 1 Approval from An Bord Altranais (6 CEUs for registered nurses and midwives). This resource was delivered in collaboration between Health Promotion, the Irish Health Promoting Health Services’ Network and the National Tobacco Control Office.

Available online at www.hse.ie/bitobacco.

September 2012

http://www.hse.ie/bitobacco

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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCETable of Contents

1. Introduction 2

2. Understanding Tobacco Use 4

What’sInaCigarette? 4

What’sinCigaretteSmoke? 4

WhyDoPeopleSmoke? 5

TheStoryofSmoking 7

TobaccoQuiz 8

3. Brief Intervention for Smoking Cessation 11

FrameworkforBriefInterventionforSmokingCessation–The5As 12

4. Stages of Change 13

Prochaska&DiClemente’sCycleofChange 13

5. Effecting Change 15

ClientCentredApproach 15

MotivationalInterviewing 15

ResponsesforChallengingStatements 18

6. Tools and Techniques to Support Quitting 20

Top10TipsforSuccessfulQuitting 20

WithdrawalSymptoms 22

MedicationsfortheTreatmentofTobaccoDependence 24

ComparisonofNicotineDeliveryDevices 28

DrugInteractionswithSmoking 29

7. Benefits of Quitting 31

8. Bibliography 32

Appendices

WHOCodeofPracticeonTobaccoControl 35

TFUCharter 36

FiveKeyToolsforSuccessfulInterventions 37

UsefulResources 42

TableofContents

BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCE

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Intr

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ThisresourcehasbeendevelopedaspartoftheHSEBriefInterventionforSmokingCessationNationalTrainingProgramme.Itisapracticalguidetosupportprofessionalswhohaveundertakenthetrainingprogrammeandwillassistinintegratingbriefinterventionsintodailypractice.

Theresource(www.hse.ie/bitobacco)includesinformationandreferencematerialsonthekeytopicspresentedduringthecourseincluding:

• latesttobaccostatisticsforIreland

• smokingbehaviourandaddiction

• 5AsFrameworkforBriefInterventionforSmokingCessation

• Prochaska&DiClemente’sstagesofchangemodel

• motivationalapproachwhenraisingtheissueofsmoking

• OARS:communicationsforeffectiveinterventions

• toolsandsupportstohelpsmokersquit.

Tobacco or Health

Smokingplacesanenormousburdenofillnessandmortalityonoursociety.Itaffectsthealmost1millionpeoplewhosmokeinIreland,andtheirfamilies,whilecreatinganenormouscostforourhealthserviceeachyear.

1inevery2smokerswilldiefromatobaccorelateddisease,andmostsmokerslosebetween10to15qualitylifeyears.Tobaccouseisthesinglebiggestcauseofcancerandchronicrespiratorydiseasesandisasignificantcauseofcardiovasculardisease.Thismajorcauseofdeath,illness,chronicdisabilityandinequalityispreventable,yetaccountsforsome5,500deathsinIrelandeachyear.

DepartmentofHealthestimatesthattobaccousecoststheexchequersomewhereintheregionof€1-2bnperannum.Arecentstudyofhospitaldischargesshowsthatsmokingrelateddiseasesaccountedfor3.7%oftotaldischarges,butaccountedfor9.4%oftotalcosts,totalling€280min2008.ThesecostsdonottakeaccountofthecostsforOPD,GP,communitybasedservicesandsocialservicesfromsmoking.Thestudyalsohighlightedthatdespitea25%declineinoverallmortalityrates(fromallcausesofdeath)inIrelandfromtheyear2000,thedeclineindeathsattributabletotobaccoisonly10%.

Reducingthenumberofsmokersinoursocietyisthesinglemostsignificantstepthatcanbetakentoimprovepopulationhealthandreducepressureonthehealthsystem–thisrequiresasustainedmulti-facetedapproach.

In2010,theHSEadoptedtheTobaccoControlFrameworktoinformHSEpolicyandprovideacoherentresponsetotobaccouseinIreland.AnumberofactionsfromtheFrameworkareprioritisedintheHSE’sNationalServicePlans,includingtrainingallhealthcareworkerstohavethenecessaryskillstoaddresssmokingasacareissue.Healthcareprofessionalsareideallyplacedtoraisetheissueofsmokingwithserviceusers–andwiththerightmixofknowledge,skillsandattitudecanreally“makeeverycontactcount”byencouragingandsupportingsmokerstoquit.

1. Introduction

http://www.hse.ie/bitobacco


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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEIntroduction

Brief Interventions

BriefInterventionsarearangeofeffectivebehaviourchangeinterventionsthatareclient-centred,shortindurationandusedinavarietyofsettingsbyhealthandotherprofessionals.Theyuseanempathicapproach,emphasisingselfefficacy,personalresponsibilityforchange,informationgivinganddetailsofresourcesavailabletosupportchange.

Forsmokingcessation,briefinterventionsinvolveopportunisticadvice,discussion,negotiationandencouragementthattypicallytakebetween5and10minutes.Theinterventionmayinvolvereferraltoamoreintensivetreatmentifappropriate.Interventionsshouldberecordedandfollowedupasappropriate.

BriefInterventionsforsmokingcessationaremoresuccessfulwhenusedwithclientswho:

• areunlikelytoneed/seekorattendspecialisttreatment

• areunsure/ambivalentaboutquitting

• mayrequireaccesstootherappropriateservices.

Framework for Brief Intervention for Smoking Cessation

The5AsThefivecomponentsoftheFrameworkare:

1. Ask: systematicallyidentifyallsmokersateveryvisit.Recordsmokingstatus,no.ofcigarettessmokedperday/weekandyearstartedsmoking.

2. Advise: urgeallsmokerstoquit.Adviceshouldbeclearandpersonalised.

3. Assess: determinewillingnessandconfidencetomakeaquitattempt;notethestageofchange.

4. Assist: aidthesmokerinquitting.Providebehaviouralsupport.Recommend/prescribepharmacologicalaids.Ifnotreadytoquitpromotemotivationforfutureattempt.

5. Arrange: follow-upappointmentwithin1weekorifappropriaterefertospecialistcessationserviceforintensivesupport.Documenttheintervention.

AdaptedfromFioreMC,JaénCR,BakerTB,etal.TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.April2009.


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What’s in a Cigarette?

Acigaretteisaveryefficientandhighlyengineereddrug-deliverysystem.Theprimaryingredientincigarettesistobacco(includingreconstitutedtobaccoandgeneticallymodifiedtobacco)towhichhundredsofchemicaladditivesareintroducedduringthemanufacturingprocess.600differentaddictivesarecurrentlyapprovedforuseinthemanufactureofcigarettesandtheseincludehumectants(moisturisers)toprolongshelflife,sugarstomakethesmokeseemmilderandeasiertoinhale;andflavouringssuchaschocolate,cinnamonandvanilla.Whilesomeadditivesmayappearquiteharmless,othersaretoxicoraddictiveintheirownright,orincombination.Whenadditivesareburned,newproductsareformedandthesetoomaybetoxicorpharmacologicallyactive.

What’s in Cigarette Smoke?

Tobaccosmokeismadeupofsidestreamsmokefromtheburningtipofthecigaretteandmainstreamsmokethatisinhaledbythesmoker.Manytoxinsarepresentinhigherconcentrationsinsidestreamsmokethaninmainstreamsmokeduetothelowertemperatureatwhichthecigaretteburnswhennotbeingsmoked.

Cigarettesmokecontainsmorethan7,000chemicalsandcompoundswhicharereleasedintotheairasparticlesandgases.Hundredsaretoxicandatleast69causecancer.Tobaccosmokeisaknownhumancarcinogen.Thechemicalsintobaccosmokereachthelungsveryquicklywhenasmokerinhales,andthengoquicklyfromthelungsintothebloodwhichcarriesthesechemicalstotissuesallaroundthebody.

Theparticulatephaseincludesnicotine,tar,benzeneandbenzo(a)pyrene.Thegasphaseincludescarbonmonoxide,ammonia,dimethylnitrosamine,formaldehydeandhydrogencyanide.

Nicotineisadeadlypoison–asmallamountinjectedintotheblood-streamcankillapersoninlessthananhour.Tobaccosmokecontainsverytinyamountsofnicotineandinthedosesobtainedfromsmokedtobaccoisnotasignificantcontributortodisease.Itishoweverhighlyaddictive–accordingtotheWHOitismoreaddictivethanheroinandcocaine.

Nicotineisastimulantwhichaffectsmanybodysystems,includingthebrain,theheartandthenervoussystem.Nicotineisabsorbedbythebodyveryquickly,reachingthebrainwithin10-20seconds.Itactivatestherewardpathwaysinthebrainandincreaseslevelsofdopamineintherewardcircuits,creatingfeelingsofpleasureforthesmoker.Theacuteeffectsofnicotineandthefeelingsofrewarddonotlastmorethanafewminutes.Asnicotinelevelsfallinthebody,smokersfeelanurgentdesiretosmoke(atintervalsof20-45minutesdependingonconsumptionrates)inordertorestorethesepleasurablefeelingsandavoidwithdrawal.

Chronicexposuretonicotinecausesstructuralchangesinthebrainbydesensitisingnicotinereceptorsandincreasingthenumberofnicotinicreceptorsthusincreasingtheurgeforthenextcigaretteandresultinginaddiction.

Nicotineincreasestheheartrateandbloodpressure,leadingtotheheartneedingmoreoxygen.

Tar isthecollectionofsolidparticlesthatsmokersinhalewhentheylightacigarette.Itisamixtureoflotsofchemicals,manyofwhichcausecancer.Tarcanstainsmokers’fingersandteethanditgathersinthelungsasastickybrownsubstanceincreasingasmoker’sriskoflungcancer,emphysema,andbronchialdisorders.

Carbon Monoxide isacolourlessgaswithnosmellwhichisreleasedfromburningtobaccoandstickstoredbloodcellsinplaceofoxygen.Thislowerstheblood’sabilitytocarryoxygenaroundthebodytovitaltissuesandorganssuchastheheartandbrain.Carbonmonoxidealsokillscilia(hairsliningthelungs)andreducesthelungs’abilitytocleartoxinsmakingiteasierforotherchemicalstoattackthem.Upto15%ofasmoker’sbloodcanbecarryingcarbonmonoxideinsteadofoxygen.

2. UnderstandingTobaccoUse

Cancer-causing Chemicals

Toxic Metals

Poison Gases


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nderstanding Tobacco Use

Why Do People Smoke?

Tobaccouseisacomplexbehaviourinfluencedbyarangeofphysiological,behaviouralandcognitivefactorswhichiswhypeoplecontinuetosmoke,despitewidelypublicisedevidenceofthehealth,socialandfinancialburdenitcauses.

Physical addiction

TheWHOdefinesaddictionas‘repeateduseofapsychoactivesubstanceorsubstances,totheextentthattheuser(referredtoasanaddict)isperiodicallyorchronicallyintoxicated,showsacompulsiontotakethepreferredsubstance(orsubstances),hasgreatdifficultyinvoluntarilyceasingormodifyingsubstanceuse,andexhibitsdeterminationtoobtainpsychoactivesubstancesbyalmostanymeans’.

Thetermdependenceasappliedtoalcoholandotherdrugs,isdefinedbytheWHOas‘aneedforrepeateddosesofthedrugtofeelgoodortoavoidfeelingbad’.InDSM-IIIR(DiagnosticandStatisticalManualofMentalDisorders),dependenceisdefinedas‘aclusterofcognitive,behaviouralandphysiologicsymptomsthatindicateapersonhasimpairedcontrolofpsychoactivesubstanceuseandcontinuesuseofthesubstancedespiteadverseconsequences’.

Otherchemicalsinclude:

Cancer-Causing Chemicals

• Formaldehyde:Usedtoembalmdeadbodies

• Benzene:Foundingasoline

• Polonium210:Radioactiveandverytoxic

• Vinylchloride:Usedtomakepipes

Toxic Metals

• Chromium:Usedtomakesteel

• Arsenic:Usedinpesticides

• Lead:Onceusedinpaint

• Cadmium:Usedtomakebatteries

Poison Gases

• Hydrogencyanide:Usedinchemicalweapons

• Ammonia:Usedinhouseholdcleaners

• Butane:Usedinlighterfluid

• Toluene:Foundinpaintthinners

USDepartmentofHealthandHumanServices,CDC,OfficeonSmokingandHealth,2010.AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease:WhatitMeanstoUs.


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ClassificationofDependence

• Strongdesiretotakeasubstance,takingmorethanintendedforlonger

• Difficultyquittingorcontrollinguse

• Considerabletimespentobtaining,usingand/orrecoveringfromuse

• Higherprioritygiventothedrugthanothersocialactivities

• Continuedusedespiteknowledgeofharm

• Tolerancedevelops

• Withdrawalsyndrome

Tobaccodependenceexhibitsclassiccharacteristicsofdrugdependence.Nicotineispsychoactive,toleranceproducing,andcausesphysicalandpsychologicaldependencecharacterisedbywithdrawalsymptomsandcravings.

Automatic habit

Smokingisoftenassociatedwithandreinforcedbyroutineactivities,peopleandsituations–attheendofameal,drivingthecar,chattingonthephone,socialisingwithcertainfriends,drinkingtea/coffee/alcohol.Forsomepeople,thefeel,smellandsightofacigaretteandtheritualofhandling,lightingandsmokingthecigaretteareallpartoftheenjoymentandpleasureofsmoking.Withinashorttime,smokingbecomesanchoredindailylife,andoftenbecomesanunconscioushabitwhereapackof20canbesmokedwithoutthepersonrememberingmanyoftheindividualcigarettes.

Psychological dependence

Emotionaldependenceisafeatureoftobaccouseandcanmanifestitselfinmanyways.

Smokingisoftenusedasanaidtoreduceand/orcontrolnegativefeelingsofanxiety,frustrationoranger.Cigarettesareoftenusedtocopewithstressandthelevelofconsumptionmayincreasewhenapersonfeelsunderpressure.However,becausenicotineisastimulantitdoesn’tactuallyhelpapersonrelax–asmokerwill“feelbetter”becausehavingacigarettewillrestorenicotinelevelsinthebodypreventingwithdrawal.

Manysmokersusecigarettestogivestructuretotheirdailyroutinebyprovidingbreaks–forsomethismaybewhentheymeetupwithfellowsmokers,forothersitmaybetimetobealone.Thisbehaviourcanbetriggeredbyboredom,lonelinessorexcitement.

Smokingissometimesusedtoconveyconfidenceandcreateanimpressionthatapersonisincontrol;itcanbeanice-breakerinsocialsituationsformanyindividuals.

Tobacco dependence shows many features of a chronic disease

Sevenoutoftensmokerswanttoquitandfouroutoftensmokersmakeaquitattempteveryyear.However,onlyasmallminorityofsmokerswillquitsuccessfullyinaninitialquitattempt.Themajorityofuserscontinuetosmokeformanyyearsandtypicallycyclethroughmultipleperiodsofrelapseandremission.

Tobaccodependenceisadiseasethatdeservestreatmentinthesamewayasotherchronicdiseases.Effectivetreatmentshavebeenidentifiedandshouldbeusedwitheverysmoker.


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The Story of Smoking

First try

Experimentation

‘Social’ smoker

Adult non-smoker

Regular smoker

Adult smoker

Cessation

Resumption of smoking

Tobacco environment

Family influences Personal beliefs and values

ENVIRONMENT

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Psychosocial influences

Personal physiological factors

Comm

unity norms

Exposureto •tobaccomarketing

Imagesofsmoking •inpopularmedia

Tobaccoindustry •

Access •

Price •

Parentalsmoking •

Siblingsmoking •

Parentalvaluesand •attitudesresmoking

Socio-economic •status

• Noriskintrying

• Itwon’thappentome

• Curiosity

• Individualchoice

• Adulthoodaspirations

• Perceptionsofsmokingnorms

• Risk-takingpropensity

• Self-esteem/self-image

Peeraffiliations •andfriendships

Connectednessto •schooland/orhome

Senseofalienation •

• Genetics

• Inuteroexposure

• Pubertyandadolescence

• Adultsmokingprevalence

• Restrictionsonsmoking

• Attitudestoyouthandyouthculture

• Socio-economicandculturalcontext

ScolloMM,WinstanleyMHTobaccoinAustralia:FactsandIssues.Thirdedition.InfluencesonUptakeofSmoking2008.

What support does a person need to increase their chances of making a successful quit attempt?

• Supportiveenvironment

• Supportfromhealthprofessionals

• Easyaccesstosmokingcessationsupport

• Personalcopingstrategies

• Familysupport

• Supportofpharmacologicalaidsinsomecases


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Tobacco Quiz

1. Howmanychemicalsintobaccosmoke?

a) 2,000+ b) 4,000+ c) 7,000+

2. Howmanyofthesechemicalsareknowntobecancercausing?

a) None b) 35 c) 69

3. Onaverage,byhowmanyminutesdoeseverycigaretteshortenasmoker’slife?

a) 30minutes b) 11 minutes c) Notatall

4. WhatpercentageofmeninIrelandsmoke?

a) 16% b) 25% c) 31%

5. WhatpercentageofwomeninIrelandsmoke?

a) 14% b) 21% c) 27%

6. HowmanypeopledieinIreland,onaverageeachyear,fromtobaccorelateddiseases?

a) 3,000 b) 5,500 c) 7,000

7. HowmanypeoplearediagnosedwithlungcancerinIrelandeachyear?

a) 700 b) 900 c) 1,910

8. WhichtypeofcancerhasthehighestdeathratesamongwomeninIreland?

a) Breast b) Lung c) Cervical

9. Womenwhosmokeinpregnancyincreasetheriskof?(chooseoneormore)

a) Ectopic pregnancy

b) Low birth weight babies

c) Babies which are slower to develop

10. Smokinghasnoeffectonfertility?

a) True b) False


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11. Childrenaremorelikelytosmokeiftheirparentsand/orfriendssmoke?

a) True b) False

12. Youngpeoplewhosmokecanexperiencethesamelevelofwithdrawalasadultsmokers?

a) True b) False

13. Itisillegalforunder18stobuytobaccoproducts?

a) True b) False

14. Second-handsmokecancauseincreasedriskof?(chooseoneormore)

a) Heart disease b) Cancer c) Asthma and Bronchitis

15. Smokersinhale85%oftobaccosmoke?

a) True b) False

16. Childrenexposedtosecond-handsmokehaveanincreasedriskof(chooseoneormore)

a) Asthma and bronchitis b) Lower respiratory infections c) Middle ear disease

d) Bacterial meningitis e) Sudden Infant Death Syndrome

17. Whatdoesnicotinedo?(chooseoneormore)

a) Causes addiction b) Nothing c) Causes increase in heart rate

18. Howquicklydoesnicotinereachthebrain?

a) 10-20 seconds b) 30seconds c) 60seconds

19. Whatdoescarbonmonoxidedo?(chooseoneormore)

a) Displaces oxygen when you inhale

b) Nothing

c) Aids hardening of the arteries (Atherosclerosis)

20. QuittingsmokingraisesthelevelofHDL(thegoodcholesterol)inthebody?

a) True b) False


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21. Whatdoestardo?(chooseoneormore)

a) Nothing b) Causes cancer c) Causes smoker’s cough

22. Light/Lowtarcigarettesarelessharmfulthanregularcigarettes?

a) True b) False

23. Whichofthefollowingchemicalsareintobaccosmoke?

Nicotine Formaldehyde Ammonia Nickel

Arsenic Butane DDT Hydrogen Cyanide

Lead methanol Polonium 210 Radon Acetone

24. In2006,thetotalcostofrespiratorydiseasestotheIrishhealthservicewasestimatedat?

a) €65million b) €250million c) €437 million

25. In2008,whatwastheaveragecostofahospitaladmissionfortobaccorelatedillness?

a) €3,700 b) €5,700 c) €7,700

26. WhatpercentageofdeathsinIrelandiscausedbytobaccouse?

a) 5% b) 19% c) 38%

27. Oneineverytwosmokerswilldiefromatobaccorelateddisease?

a) True b) False

28. Peoplewithmentalhealthissuesaremorelikelytousetobacco?

a) True b) False

29. Cardiovasculardiseaseisthemostcommoncauseofdeathinschizophrenicpatients?

a) True b) False

30. HowmanyIrishchildrendoestheTobaccoIndustryneedtorecruiteachday,tomaintainprofits?

a) 25 b) 50 c) 75


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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBrief Intervention

Brief Intervention Definition

BriefInterventionsinvolveopportunisticadvice,discussion,negotiationorencouragement…Forsmokingcessation,briefinterventionstypicallytakebetween5and10minutes

(NICE Guidelines, Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings, 2006)

• Unassistedquitrate=2-3%

• Briefadviceinterventionincreasesquitrateby1to3percentagepoints

(Cochrane Review, Physician Advice for Smoking Cessation, 2008)

Brief Intervention – The Evidence

• Interventionfromhealthprofessionalshasbeenshownrepeatedly,inrandomisedcontrolledtrials,toincreasethepercentageofsmokerswhostopandremainabstinentfor6monthsormore

• Itisahighlycosteffectiveintervention

(West et al, Smoking Cessation Guidelines for Health Professionals: An Update, 2000)

Missed Opportunities

• Only38%ofcurrentsmokerswhoattendedaGPorotherhealthprofessionalinthelastyearreportedthatthehealthprofessionalhaddiscussedquittingsmokingwiththemduringtheirconsultation.

(Brugha et al, SLÁN 2007 Survey of Lifestyle, Attitudes and Nutrition in Ireland: Implications for Policy and Services, 2009)

3. BriefInterventionforSmokingCessation


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Framework for Brief Intervention for Smoking Cessation

The5As

systematically identify all smokers at every visit. Record smoking status, no. of cigarettes smoked per day/week and year started smoking.

ASK �

urge all smokers to quit. Advice should be clear and personalised.

ADVISE �

determine willingness and confidence to make a quit attempt; note the stage of change.

ASSESS �

aid the smoker in quitting. Provide behavioural support. Recommend/prescribe pharmacological aids. If not ready to quit promote motivation for future attempt.

ASSIST �

follow-up appointment within 1 week or if appropriate refer to specialist cessation service for intensive support. Document the intervention.

ARRANGE �



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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEStages of C

hange

ProchaskaandDiClemente(1983)describedaseriesofstagesthroughwhichpeoplepasswhenmakingbehaviourchange.Ateachstageapersonisthinkingandfeelingdifferentlyabouttheproblembehaviourandwillfinddifferentprocessesandinterventionshelpfulinmovingon.Thismodelismostoftenpictureddiagrammaticallyasacircle.

The Wheel of Change (Trans-Theoretical Model of Behaviour Change)

E s t a b l i s h ed Change

MAINTENANCE

ACT ION

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CON T E M P L AT I ON

P R E - CON T E M P L AT I ON

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4. StagesofChange


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Pre-contemplation Stage• Nointerestatallinchangingbehaviour

• Seesmanypersonaladvantagesinit• Hasmostlypositivethoughtsaboutthebehaviour

Contemplation Stage• Awareofsomepersonaldisadvantages

• Hasthoughtaboutchangingsomeaspectsofthebehaviour• Stillhasmanyreasonsforcontinuing

Preparation Stage• Intendingtomakeachange

• Knowswhytheywanttochange• Planningwhenandhowtodoit

Action• Believingthatchangeispossible• Actuallymakingaquitattempt

Maintenance• Thebehaviourchangeisongoing• Abletocopewithoutrelapsing

• Supportandencouragementneeded

Relapse• Thisattemptunsuccessful

• Returnstooneoftheabovestages

Itiscommontogoaroundthemodel3-4timesbeforereachingthemaintenancestage,henceitsname–thecycleofchange/wheelofchange.Passingthroughthiscyclewilltaketime,whichcanbemonthsoryearsdependingonindividualcircumstances.

E s t a b l i s h ed Change

MAINTENANCE

ACT ION

PR

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P R E - CON T E M P L AT I ON

REL

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MAINTENANC

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ACT ION

PR

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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEEffecting C

hange

Client Centred Approach

Theclient-centredapproachconsiderstheclientholistically.Itisanon-directivebehaviourchangeapproachwhichenhancesrapportbuilding.Thisapproachallowstheclienttoacceptresponsibilityfortheirownhealthandthereforetosettheirowngoals.Thehealthprofessional’sroleismorefocussedonlisteningwithemphasisonhowtosaythingsratherthanwhattosay.

Core conditions of client-centred approach

• Acceptance

• Empathy

• Genuineness

While using the client-centred approach, the client:

• Istheexpertaboutthemselvesandtheirsituation

• Isthedecisionmaker

• Hastherightnottochange

• Hasthecapacitytofindtheirownanswers,withpossibleassistancefromthehealthprofessional

Motivational Interviewing

MotivationalInterviewing(MI)isanevidencebasedclinicalmethodforhelpingpeopletomakechange,firstproposedin1983byWilliamMillerandfurtherdevelopedinthe1990sbyMillerandRollnick.Itisaclient-centred,directive,behaviourchangeapproachwhichresolvesambivalenceandresistance.Ambivalenceisacknowledgedasasignificantfactorinthechangeprocess.Readinesstochangeisalsoacentralconceptasreadinesscanvaryconstantlythroughoutthecycleofchange.Recognisingwheretheclientisatisthestartingpointinanyconsultationandiskeytoaneffectiveoutcome.

TheunderlyingspiritofMIisthatchangecomesfromwithintheindividual,notfromsomeoutsideforce.Itistheclient’splace(notthehealthprofessional’s)tostateandresolvetheirambivalence.Thehealthprofessional’sroleistodrawonandenhancetheclient’sinternalmotivationtomakechanges,basedontheirowndecisionsandchoice.Theclientisallowedtodotheirownselfpersuadingandproblemsolvingandisencouragedtostatetheiruncertaintyinaclearandcompleteway.Selfmotivationalstatements(changetalk)areelicited;thisiswheretheclientbeginstotalkabouttheirneedforchange,advantagesofchanging,theirabilityandintentiontochange.‘Changetalk’leadstocommitmentandanincreasedprobabilityofbehaviourchange.

5. EffectingChange


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Five general principles of Motivational Interviewing:

1. Express Empathy –seetheworldthroughclient’seyes.Benon-judgemental;leaveasideone’sownviewsandvalues.

2. Develop Discrepancy –facilitateclienttoidentifythediscrepancybetweencurrentbehaviourandfuturegoals.

3. Avoid Argumentation –it’scounterproductive.Lookforinconsistenciesandconsequencesthatconflictwithimportantgoals.

4. Roll with Resistance –defusetheresistance.Beempatheticandnon-judgementalandencourageclienttodeveloptheirownsolutionsandexaminenewperspectives.

5. Support Self-Efficacy –clientisresponsibleforchoosingandcarryingoutpersonalchange.Beliefinthepossibilityofchangeisagoodmotivatorandpreviouseffortsandsuccessescanbeelicitedtobuildself-confidence.

EffectivemotivationalinterviewingencompassesthefollowingcommunicationtechniquescommonlyreferencedbytheacronymOARS:

• Openendedquestions–allowsclienttoexpresstheirperspectiveandprovidesinsightsfortheconsultation.

• Affirmations–showsappreciationandsupportfortheclient’sstatements.Theycanbeverbalornon-verbal.

• Reflectivelistening–addsdirectiontotheconsultationandhelpsfocusonchangestatements.

• Summarising–drawsanumberofstrandstogetherandclarifiesandreflectstheclient’sownthoughtsbacktothem.

Asking permission hasalsobeenshowntobeapowerfultool.Itcommunicatesrespectfortheclientandresultsinincreasedlikelihoodofdiscussingchange.

Inmotivationalinterviewingthefocusshiftsfromgivinginformationandadvice,tohelpingclientsexploreconcerns,uncertainties,reasonsforchange,andideasandstrategiestomakechangehappen.

Examples of how to raise the issue of smoking using non-threatening language

What questions could you ask someone who would like to quit?

• Tellmealittlebitaboutyoursmoking?

• You’vetoldmeyouareasmoker.Whatdoyoumostenjoyaboutsmoking?

• What’snotsogoodaboutyoursmoking?

• Whatdoyourememberaboutyourpreviousquitattempts?

• Whydoyouwanttostopsmokingnow?

• Haveyouthoughtaboutitbefore?Yes–howlonghaveyoubeenthinkingaboutquitting?


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• Whatisyourunderstandingofthebenefitsofquitting?

• Whatsupportsdoyouhaveinhelpingyouquit?

• Howimportantisthistoyou(onascaleof1-10)?

• Howconfidentdoyoufeelthatyoucanquit?(onascaleof1-10)?

• Ifyouweretosetaquitdate,whenwouldbeagoodtimetoquit?

• Howdoyouthinkyoucanbesupported?

• Whatwouldyouliketodowiththemoneyyousave?

What questions can you ask someone who tried to quit before but didn’t succeed?

• Whatisitthatmakesyouthinkyoucouldn’tmanagethistime?

• Whydoyouwanttostopagain?

• Whatdidyouusetohelpyoulasttime?

• Howlongdidyoustopfor?

• Whatdidyoufinddifficult?

• Whatdoyoumeanbytried?

• Whatsupportdidyouhave?

• Whatdoyouthinkyouwouldorcoulddodifferentlythistime?

• Howimportantisitforyoutotryandstopagain(onascaleof1-10)?

• Whatstrategiesdoyouthinkyoucouldusetobemorepreparedthistime?

• Howconfidentdoyoufeelthistime(onascaleof1-10)?

What questions can you ask someone who says “I’ve cut down”?

• Whatpromptedyoutocutdown?

• Whatdifferenceshaveyounoticedsincecuttingdown?

• Howmanyhaveyoucutdownfrom–to?

• Howareyoucopingwiththereduction?

• Areyourfamilysupportive?–Inwhatway?

• Whatfurtherchangesdoyoufeelyoucouldmake?

• Howhaveyouchangedyourlifestyle/socialcircle?

• Whatisthenextstepforyou?Wheredoyouwanttogofromhere?

• Whatrewardswouldhelptokeepyoumotivatedwhileyouarequitting?

• Let’stalkabouthowtobaccodependencetreatmentscouldhelpyoutoquitcompletely.


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What questions can you ask someone who says they have stopped?

• Welldone.Howdidyoudoit?

• Whatisthenextstepforyou?

• Howareyoucopingwithit?

• Whatstrategiesdoyouuse?

• Whatsupportdoyouhave?

• Doyoufeelbetternow?Inwhatway?

• Howhaveyoumanagedaroundothersmokers?

Responses for Challenging Statements

Statement 1

“Mygrannysmoked40adayandshelivedwellintohereighties.”

Response:

Soundslikeyourgrannywasoneoftheluckyones!

Whatwasherhealthlikeforthelatterpartofherlife?

Didsheevertrytostop?Whydoyouthinkthatwas?

Statement 2

“Well,Ihavecutdownandchangedtoa‘lighter’brand.”

Response:

Whatmadeyoudecidetodothat?

Howdoyoufeelnowthatyouhavedonethat?

Wheredoyouwanttogofromhere?

Whydoyoufeelthatsmoking‘light’cigaretteswillprotectyou?

Statement 3

“I’vetriedtostopsomanytimesinthepastanditjustdoesn’twork”.

Response:

Whydoyouthinkithasn’tworkedbefore?

Whatdoyouthinkyoucoulddodifferentlythistime?


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Statement 4

“Ihavealmostmanagedtostop,butmypartnersmokesandIkeephavingtheoddonewithhim.”

Response:

Howdoesthatmakeyoufeel?

Whatwouldyouliketodo?

Howdoesyourpartnerfeelaboutyousmoking?

Whatsupportwouldyouneedtomakethatfinalefforttoquit?

Statement 5

“What’sthepoint–thedamageisdonealready.”

Response:

Whatdoyouthinkwillhappennowifyoucontinuetosmoke?

Howdoyouthinkyouwouldfeelifyoudidstop?

Didyoueverstopbefore?Howdidyoufeelthen?

Statement 6

“It’snotlikeI’mhurtinganyoneelsebysmoking.”

Response:

Haveyoueverheardaboutrisks/harmfromsecondhandsmoke?

Tellmewhyyoubelieveyoursmokingdoesn’taffectanyoneelse.

Inwhatwaydoyouthinkyoursmokingmightbeaffectingyourself?

Statement 7

“SureI’monlysmoking,itcouldbeworse,Icouldbedoingdrugsorsomethingelse.”

Response:

Itsoundslikeyouthinksmokingissaferthandoingdrugs?

Youseemtobelievethat‘onlysmoking’isokayforyourhealth–isthatright?


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Top 10 Tips for Successful Quitting

1. Prepare to Quit Smoking

Writedownyourreasonsforstoppingandkeepthemcloseathand.Weighuptheprosandcons.

2. Make a Date to Quit

Somesmokerscutdowngraduallywithaplanforaquitdate.However,mostpeoplewhosuccessfullyquitsmokingdosobystoppingaltogetherandnotbygraduallycuttingdown.Pickyourdaytoquitandsticktoit.

3. Support

Seekthesupportoffamilyorfriends.

4. Change Your Routine and Plan Ahead

Smokingisoftenlinkedtocertaintimesandsituationssuchasthefirstsmokeinthemorning,drinkingcoffeeoralcohol.Thesearecalledyourtriggers.Replacetriggerswithnewactivitiesthatyoudon’tassociatewithsmoking.Forexample,ifyoualwayshadacigarettewithacupofcoffee,switchtoteaforawhile;orfortwoweeksbeforeyourquitdatehaveyourcoffeebutpracticedelayingbyfiveminutesoneday,sixminutesthenextdayandsoonuntilyoubreaktheassociationbetweencoffeeandsmoking.

5. Exercise Regularly

Regularexercisecontributestogoodhealth;helpstomanageyourweightandcanalsoimprovethebody’sabilitytomeetthedemandsandstressesofdailyliving.

6. Think Positive

Youmayfindyouexperiencewithdrawalsymptomsonceyoustopsmoking.Theseareverypositivesignsthatyourbodyisrecoveringfromtheeffectsoftobacco.Coughing,irritabilityandsleepdisturbancearesomecommonsymptoms.Don’tworry,theyareallperfectlynormalandshoulddisappearwithinafewweeks.

6. ToolsandTechniquestoSupportQuitting


20 21

BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCETools and Techniques to Support Q

uitting

7. Learn to Deal with Cravings

Cravingscanoccurfrequentlyduringthefirstfewdaysafterstopping.Acravingincreasesinintensityoveraperiodof3-5minutesandthenbeginstosubside.

Tips for dealing with cravings – The 4 Ds:

• Delay atleast3minutesandtheurgewillpass.

• Drink aglassofwaterorfruitjuice.

• Distract yourself.Moveawayfromthesituation.

• Deep breaths.Breatheslowlyanddeeply.

8. Save Money

Startsavingthemoneyyouwouldnormallyspendontobacco.Workouthowmuchyouspendoncigarettesperweek,monthandyear.Thenwatchyoursavingsgrow.

9. Watch What You Eat

Ifyouareworriedaboutgainingweight,beextracarefulwithyourdiet.Avoidsnackingonchocolatebarsandbiscuits,trysomefruitorchewsugarfreeguminstead.

10. Take One Day at a Time

Remember,everydaywithoutacigaretteisgoodnewsforyourhealth,yourfamilyandyourpocket.


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Withdrawal Symptoms

Quittingsmokingbringsaboutavarietyofphysicalandpsychologicalwithdrawalsymptoms.Forsomepeople,copingwithwithdrawalsymptomsislikeridingarollercoaster–theremaybesharpturns,slowclimbs,andunexpectedplunges.Mostphysicalsymptomsmanifestwithinthefirstonetotwodays,peakwithinthefirstweek,andsubsidewithintwotofourweeks.Anynewsymptomsshouldbenotifiedtoahealthprofessional,especiallyifsevere.Recentmedicationchangesandcaffeineintakecanhaveanimpactonsymptoms.Itmaytakelongertobreakthepsychologicaldependencecausedbyconstanttriggersandsocialcuesassociatedwithsmoking.

SYMPTOM CAUSE DURATION RELIEF

Craving for a cigarette

Nicotineisastronglyaddictivedrug,andwithdrawalcausescravings

Acravingforacigarettecanlastforbetween3-5minutesfrequentlyfor2-3days;canhappenformonthsoryears

Waitouttheurge,whichlastsonlyafewminutes

Distractyourself

Exercise(takewalks)

Drinkaglassofwaterorfruitjuice

Breatheslowlyanddeeply

Useofanicotinemedicationmayhelp

Irritability Thebody’scravingfornicotinecanproduceirritability

2-4weeks Takewalks

Tryhotbaths

Userelaxationtechniques

Dizziness Thebodyisgettingextraoxygen 1-2days Useextracaution

Changepositionsslowly

Chest tightness Tightnessislikelyduetotensioncreatedbythebody’sneedfornicotineormaybecausedbysoremusclesfromcoughing

Afewdays Userelaxationtechniques

Trydeepbreathing

UseofNRTmayhelp

Constipation, stomach pain, gas

Intestinalmovementdecreasesforabriefperiod

1-2weeks Drinkplentyoffluids

Addfruit,vegetables,andwhole-graincerealstodiet

Cough, dry throat, nasal drip

Thebodyisgettingridofmucus,whichhasblockedairwaysandrestrictedbreathing

Afewdays Drinkplentyoffluids

Avoidadditionalstressduringfirstfewweeks


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SYMPTOM CAUSE DURATION RELIEF

Depressed mood

Itisnormaltofeelsadforaperiodoftimeafteryoufirstquitsmoking.Manypeoplehaveastrongurgetosmokewhentheyfeeldepressed

1-2weeks Increasepleasurableactivities

Talkwithyourclinicianaboutchangesinyourmoodwhenquitting

Getextrasupportfromfriendsandfamily

Difficulty concentrating

Thebodyneedstimetoadjusttonothavingconstantstimulationfromnicotine

Afewweeks Planworkloadaccordingly

Avoidadditionalstressduringfirstfewweeks

Fatigue Nicotineisastimulant 2-4weeks Takenaps

Donotpushyourself

Useofanicotinemedicationmayhelp

Hunger Cravingsforacigarettecanbeconfusedwithhungerpangs;sensationmayresultfromoralcravingsorthedesireforsomethinginthemouth

Uptoseveralweeks

Drinkwaterorlow-calorieliquids

Bepreparedwithlow-caloriesnacks

Insomnia Nicotineaffectsbrainwavefunctionandinfluencessleeppatterns;coughinganddreamsaboutsmokingarecommon

2-4weeks Limitcaffeineintakebecauseitseffectswillincreasewithquittingsmoking

Userelaxationtechniques

AdaptedfromMaterialsfromtheNationalCancerInstitute,U.S.NationalInstitutesofHealth.


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Medications for the Treatment of Tobacco Dependence

Long Acting Medications

PRODUCT USE ADVANTAGES DISADVANTAGES PRECAUTIONS SIDE EFFECTS EST COST (AUG 2012)

Nicotine Patch* Applyeachdaytoclean,dryhairlessskin

Ifusing24hrpatch,startwith21mgpatchdailyifsmokesmorethan10cigs/day;cantaperto14mgatweek6to8;then7mgforweek9,10ifnocravings

Ifusingthe16hrpatch,startwith25mgpatchdailyifsmokesmorethan15-20cigs/dayuntilweek8completed,taperto15mgforweek9,10andthen10mgforweek11,12ifnocravings

Placeandforget

Overthecounter,candecreasemorningcravingsifwornatnight(24hrpatchonly)

Passive–noactiontotakewhencravingoccurs

Notrecommendedtousewhilesmoking.Useonlywithdoctor’sprescriptionwithin4weeksofheartattack,inpatientswithseriousunderlyingarrhythmiasandworseningangina

Notrecommendedinpregnancyandbreastfeeding–useshortactingmedicationwithGPprescription

Skinreaction–50%ofpatients,usuallymild.*Rotatesites

Canexperiencevividdreamsorsleepdisturbanceatnightwith24hrpatch

Nic CQ

€27for1/52of21mg,14mg,and7mg.

€47for2/52of21mg.

Nicotinell

For1/52=€26/21mg,€25/14mgand€24/7mg.

3/52of21mg=€61

Nicorette

€24for1/52of25mg,15mgand10mg.

Champix/Varenicline*

0.5mgoncedailydays1-3

0.5mgtwicedailydays4-7

Then1mgtwicedaily.

Useupto12weeks.Extra12weeksifrequired

Reduceswithdrawalandmaypreventrelapse

Passive–noactiontotakewithcravings.Prescriptionrequired

Donotuseifyouhaveseverekidneydisease

Notlicensedinpregnancyorbreastfeeding

AcuteDepressiveDisease

Blackboxedwarningforneuropsychiatricsymptoms

Nausea(30%)usuallymild–canreduceto0.5mglevel.Takewithfood.Insomnia

€132onDPSper1monthsupply

4/52starterpack€131

4/521mgbdpack€131

Zyban*

Wellbutrin SR

Wellbutrin XL

Bupropion

150mgeachmorningfor3-7days,then300mg/day

Startpriortoquitdate

Dosesmustbeatleast8hoursapart;takesecondpillinearlyeveningtoreduceinsomnia

Lessweightgainwhileusing

Safetosmokewhiletaking

Sideeffectscommon


DoNotUsewith:Seizuredisorders;currentuseofWellbutrinorMAOinhibitors;electrolyteabnormalities;eatingdisorders

Monitorbloodpressure


Insomnia(40%)DrymouthHeadacheAnxietyRash

Flexibledosing(keepingat150mg/day)helpfulwithsideeffects



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Medications for the Treatment of Tobacco Dependence

Long Acting Medications


Nicotine Patch* Applyeachdaytoclean,dryhairlessskin

Ifusing24hrpatch,startwith21mgpatchdailyifsmokesmorethan10cigs/day;cantaperto14mgatweek6to8;then7mgforweek9,10ifnocravings

Ifusingthe16hrpatch,startwith25mgpatchdailyifsmokesmorethan15-20cigs/dayuntilweek8completed,taperto15mgforweek9,10andthen10mgforweek11,12ifnocravings

Placeandforget

Overthecounter,candecreasemorningcravingsifwornatnight(24hrpatchonly)

Passive–noactiontotakewhencravingoccurs

Notrecommendedtousewhilesmoking.Useonlywithdoctor’sprescriptionwithin4weeksofheartattack,inpatientswithseriousunderlyingarrhythmiasandworseningangina

Notrecommendedinpregnancyandbreastfeeding–useshortactingmedicationwithGPprescription

Skinreaction–50%ofpatients,usuallymild.*Rotatesites

Canexperiencevividdreamsorsleepdisturbanceatnightwith24hrpatch

Nic CQ

€27for1/52of21mg,14mg,and7mg.

€47for2/52of21mg.

Nicotinell

For1/52=€26/21mg,€25/14mgand€24/7mg.

3/52of21mg=€61

Nicorette

€24for1/52of25mg,15mgand10mg.

Champix/Varenicline*

0.5mgoncedailydays1-3

0.5mgtwicedailydays4-7

Then1mgtwicedaily.

Useupto12weeks.Extra12weeksifrequired

Reduceswithdrawalandmaypreventrelapse


Donotuseifyouhaveseverekidneydisease


AcuteDepressiveDisease

Blackboxedwarningforneuropsychiatricsymptoms

Nausea(30%)usuallymild–canreduceto0.5mglevel.Takewithfood.Insomnia


4/52starterpack€131

4/521mgbdpack€131

Zyban*

Wellbutrin SR

Wellbutrin XL

Bupropion

150mgeachmorningfor3-7days,then300mg/day

Startpriortoquitdate

Dosesmustbeatleast8hoursapart;takesecondpillinearlyeveningtoreduceinsomnia

Lessweightgainwhileusing

Safetosmokewhiletaking

Sideeffectscommon


DoNotUsewith:Seizuredisorders;currentuseofWellbutrinorMAOinhibitors;electrolyteabnormalities;eatingdisorders

Monitorbloodpressure


Insomnia(40%)DrymouthHeadacheAnxietyRash

Flexibledosing(keepingat150mg/day)helpfulwithsideeffects



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Short Acting Medications


Nicotine Gum* 2mg and 4mg

2mgand4mg(4mgifsmokesmorethan20cigs/day)

Takeevery1-2hrsasneeded.Chewandpark

Useasneeded

Canselfdose

Availableoverthecounter

Difficulttochew Avoidfoodandacidicdrinks15minutesbeforeandwhileusing*(decreasedabsorption–reducedeffect)

Jawpain

Nausea/heartburnifswallowingsaliva

2mg€9/30;€28/105;€44/210

4mg€11/30;€34/105;€55/210

Nicotine Inhaler* 15mg

Puffasneeded.Useupto6cartridges/day,lessneededifusingcombinationtherapy.Oralabsorbed–noneedtoinhaledeeply.Eachcartridgelastsfor20-40minutesofinhaling

Useasneeded

Mimicshandtomouthactionofsmoking

Advisetousenonsmokinghandtohold.

Visibleinhand Avoidfoodandacidicdrinksbeforeandwhileusing.Cautionuseinasthmaticclients

Cough;throatirritation(usuallymild)

€12for18cartridges


Nicotine Lozenge* 2mg and 4mg

2and4mg(4mgifsmokeswithin30minsofwaking)

Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow.Useapprox9perdayforfirst6weeksthentaper.

Easeofuse

Overthecounter

Flexibledosing

Avoidfoodandacidicdrinksbeforeandwhileusing

Hiccups


2mg€14/36€26/72

4mg€14/36€26/72

Nicotine Microtab* 2mg

Placeunderthetongueandleavetodissolve.Donotchew.Useevery1-2hoursifsmokesmorethan20cigs/day

Useasneeded

Overthecounter

Flexibledosing

Discrete



€11for30

€25for100

Nicotine Mini Lozenge 1.5mg and 4mg

1.5and4mg(4mgifsmokeswithin30minsofwaking)Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow

Useasneeded

Overthecounter

Flexibledosing

Discrete


Hiccups


1.5mg€7/20€20/60

4mg€7/20€20/60

*AvailableonGMS.AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.Disclaimer–Theabovelistismeantasaguideonlyandthemanufacturers’instructionsshouldalwaysbeadheredto


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Short Acting Medications


Nicotine Gum* 2mg and 4mg

2mgand4mg(4mgifsmokesmorethan20cigs/day)

Takeevery1-2hrsasneeded.Chewandpark

Useasneeded

Canselfdose

Availableoverthecounter

Difficulttochew Avoidfoodandacidicdrinks15minutesbeforeandwhileusing*(decreasedabsorption–reducedeffect)

Jawpain


2mg€9/30;€28/105;€44/210

4mg€11/30;€34/105;€55/210

Nicotine Inhaler* 15mg

Puffasneeded.Useupto6cartridges/day,lessneededifusingcombinationtherapy.Oralabsorbed–noneedtoinhaledeeply.Eachcartridgelastsfor20-40minutesofinhaling

Useasneeded

Mimicshandtomouthactionofsmoking

Advisetousenonsmokinghandtohold.

Visibleinhand Avoidfoodandacidicdrinksbeforeandwhileusing.Cautionuseinasthmaticclients

Cough;throatirritation(usuallymild)



Nicotine Lozenge* 2mg and 4mg

2and4mg(4mgifsmokeswithin30minsofwaking)

Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow.Useapprox9perdayforfirst6weeksthentaper.

Easeofuse

Overthecounter

Flexibledosing


Hiccups


2mg€14/36€26/72

4mg€14/36€26/72

Nicotine Microtab* 2mg

Placeunderthetongueandleavetodissolve.Donotchew.Useevery1-2hoursifsmokesmorethan20cigs/day

Useasneeded

Overthecounter

Flexibledosing

Discrete



€11for30

€25for100

Nicotine Mini Lozenge 1.5mg and 4mg

1.5and4mg(4mgifsmokeswithin30minsofwaking)Take1lozengeevery1-2hours.Parkbetweencheekandgum–dissolvesinmouth.Donotcheworswallow

Useasneeded

Overthecounter

Flexibledosing

Discrete


Hiccups


1.5mg€7/20€20/60

4mg€7/20€20/60

*AvailableonGMS.AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.Disclaimer–Theabovelistismeantasaguideonlyandthemanufacturers’instructionsshouldalwaysbeadheredto


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Comparison of Nicotine Delivery Devices

TOBACCO PRODUCTS

NICOTINE DELIVERY DEVICE

NICOTINE IN PRODUCT

APPROX AMOUNT OF NICOTINE DELIVERED

COMMENTS

Marlboro Gold 13mg 1-3mg AlsodeliversawiderangeofcarcinogensandothertoxinsMarlboro Red 13mg 1-3mg

Cigars 10-40mg Highlyvariable

Moist Snuff 3-12mg Variesdependingonphandothercharacteristics

NICOTINE REPLACEMENT PRODUCTS

NICOTINE DELIVERY DEVICE

NICOTINE IN PRODUCT

APPROX AMOUNT OF NICOTINE DELIVERED

COMMENTS

Nicotine Gum 2mgpiece Upto0.8mg Onlydeliversnicotinetouser

Nicotine Gum 4mgpiece Upto1.5mg

Nicotine Patch

Step 1

Step 2

Step 3

10mg/16hours

15mg/16hours

25mg/16hours

Nicotine Patch

Step 1

Step 2

Step 3

7mg/24hours

14mg/24hours

21mg/24hours

Nicotine Inhaler 15mg/cartridge Upto3mg/cartridge

Nicotine Microtabs 2mg Approx1mg

Nicotine Lozenge 2mg Approx1mg

Nicotine Lozenge 4mg Approx2mg

Nicotine Mini Lozenge 1.5mg Upto0.8mg

Nicotine Mini Lozenge 4mg Approx2mg

AdaptedwithpermissionfromDrMichaelSteinbergMD,MPH–TobaccoDependenceProgram,UMDNJ.


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Drug Interactions with Smoking

Manyinteractionsbetweentobaccosmokeandmedicationshavebeenidentified.Tobaccosmokemayinteractwithmedicationsthroughpharmacokineticorpharmacodynamicmechanisms.Pharmacokineticinteractionsaffecttheabsorption,distribution,metabolism,oreliminationofotherdrugs,potentiallycausinganalteredpharmacologicresponse.ThemajorityofpharmacokineticinteractionsaretheresultofinductionofhepaticcytochromeP450enzymes(primarilyCYP1A2).Pharmacodynamicinteractionsaltertheexpectedresponseoractionsofotherdrugs.Themostclinicallysignificantinteractionsaredepictedintheshadedareasofthetable.

DRUG/CLASS MECHANISM OF INTERACTION AND EFFECTS

Benzodiazepines(diazepam,chlordiazepoxide

• Pharmacodynamicinteraction:decreasedsedationanddrowsiness.• Maybecausedbycentralnervoussystemstimulationbynicotine.

Beta-blockers • Pharmacodynamicinteraction:lesseffectiveantihypertensiveandratecontroleffects.

• Maybecausedbynicotine-mediatedsympatheticactivation.

Caffeine • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby56%.• Caffeinelevelsmayincreaseaftercessation.

Chlorpromazine(Thorazine) • Decreasedareaunderthecurve(AUC)(36%)andserumconcentrations(24%).

• Smokersmayexperiencelesssedationandhypotensionandrequirehigherdosagesthannonsmokers.

Clozapine(Clozaril) • Increasedmetabolism(inductionofCYP1A2);plasmaconcentrationsdecreasedby28%.

Flecainide(Tambocor) • Clearanceincreasedby61%;troughserumconcentrationsdecreasedby25%.

• Smokersmayrequirehigherdosages.

Fluvoxamine(Luvox) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby25%;decreasedplasmaconcentrations(47%).

• Dosagemodificationsnotroutinelyrecommendedbutsmokersmayrequirehigherdosages.

Haloperidol(Haldol) • Clearanceincreasedby44%;serumconcentrationsdecreasedby70%.

Heparin • Mechanismunknownbutincreasedclearanceanddecreasedhalf-lifeareobserved.


Insulin • Insulinabsorptionmaybedecreasedsecondarytoperipheralvasoconstriction;smokingmaycausereleaseofendogenoussubstancesthatantagonisetheeffectsofinsulin.



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DRUG/CLASS MECHANISM OF INTERACTION AND EFFECTS

Mexiletine(Mexitil) • Clearance(viaoxidationandglucuronidation)increasedby25%;half-lifedecreasedby36%.

Olanzapine(Zyprexa) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby40-98%.

•Dosagemodificationsnotroutinelyrecommendedbutsmokersmayrequirehigherdosages.

Opioids(propoxyphene,pentazocine)

• Pharmacodynamicinteraction:decreasedanalgesiceffect;higherdosagesnecessaryinsmokers.

• Mechanismunknown.

Propranolol(Inderal) • Clearance(viasidechainoxidationandglucuronidation)increasedby77%.

Oralcontraceptives • Pharmacodynamicinteraction:increasedriskofcardiovascularadverseeffects(e.g.,stroke,myocardialinfarction,thromboembolism)inwomenwhosmokeanduseoralcontraceptives.

• Riskincreaseswithageandwithheavysmoking(15ormorecigarettesperday)andisquitemarkedinwomenoverage35years.

Tacrine(Cognex) • Increasedmetabolism(inductionofCYP1A2);half-lifedecreasedby50%;serumconcentrationsthreefoldlower.


Theophylline(TheoDur,etc) • Increasedmetabolism(inductionofCYP1A2);clearanceincreasedby58-100%;half-lifedecreasedby63%.

•Theophyllinelevelsshouldbemonitoredifsmokingisinitiated,discontinued,orchanged.

•Maintenancedosesareconsiderablyhigherinsmokers.

RxforchangeUCSF,adaptedfromZevinS,BenowitzNL.Druginteractionswithtobaccosmoking.ClinPharmacokinet1999;36:425-438.


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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBenefits of Q

uitting

Within 20 minutes Bloodpressuredrops,pulseratesdropstonormal,bodytemperatureofhandsandfeetreturntonormal

Within 8-12 hours Carbonmonoxidelevelsinthebloodstartreturningtonormalandwithinafewdaysarethesameasnonsmokers

Within 24-48 hours Riskofheartattackbeginstodecrease

Within 48 hours Abilitytosmellandtasteimproves

Within 72 hours Breathinggetseasierasbronchialtubesrelax,lungcapacityincreases

Within 3 weeks Mucusinthelungsloosen,lungfunctionandcirculationimproves

Within 2-3 months Bloodflowsmoreeasilytoarmsandlegs,lungfunctionbeginstoincrease

After 1 year Riskofsuddendeathfromheartattackisalmostcutinhalf

After 5 years Theriskofsmokingrelatedcancersandstrokeisgreatlyreduced.

Within 10-15 years Riskofheartattackfallstothesameassomeonewhohasneversmoked.Riskoflungcancerfallstohalfthatofanonsmokerandtheriskofcancerofthemouth,throat,esophagus,bladder,cervixandpancreasdecreases.

AdaptedfromBurnside,G.Spiers,A.,Winckles,W.HelpSmokersQuitKit.UlsterCancerFoundation,NorthernIreland;WHOFactSheetAboutHealthBenefitsofSmokingCessation;NHSSmokeFree‘WhyQuitTimeline’;AmericanCancerSocietyWhenSmokersQuit–WhatAreTheBenefitsOverTime?

What is Smoking Costing You?

NUMBER OF CIGARETTES

SMOKED EACH DAY

NUMBER OF CIGARETTES SMOKED IN

A YEAR

WASTED HOURS

COST PER DAY

€

COST PER WEEK

€

COST PER MONTH

€

COST PER YEAR

€

5 1,825 122 2.28 15.93 69.20 830.38

10 3,650 243 4.55 31.85 138.40 1,660.75

15 5,475 365 6.83 47.78 207.59 2,491.13

20 7,300 487 9.10 63.70 276.79 3,321.50

40 14,600 973 18.20 127.40 553.58 6,643.00

60 21,900 1,460 27.30 191.10 830.38 9,964.56

Packof20cigarettescosts€9.10@May2012.

7. BenefitsofQuitting


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iogr

aphy

AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease:WhatitMeanstoYou(2010).Availableathttp://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf

AReportoftheSurgeonGeneral:HowTobaccoSmokeCausesDisease2010–TheBiologyandBehavioralBasisforSmoking-AttributableDiseaseFactSheet.Availableathttp://www.surgeongeneral.gov/library/reports/tobaccosmoke/factsheet.html

BaborTF,Higgins-BiddleJC(2001)BriefInterventionforHazardousandHarmfulDrinking,AManualforUseinPrimaryCare.Geneva:WorldHealthOrganisation.

BrughaR,TullyN,DickerP,ShelleyE,WardM,McGeeH(2009)SLÁN2007SurveyofLifestyle,AttitudesandNutritioninIreland.SmokingPatternsinIreland:ImplicationsforPolicyandServices.DepartmentofHealthandChildren.Dublin:TheStationeryOffice.

ButtonTMM,ThaparA,McGuffinP(2005)RelationshipbetweenAntisocialBehaviour,Attention-DeficitHyperactivityDisorderandMaternalPrenatalSmoking.BritishJournalofPsychiatry.Vol.187:155-60.

CampaignforTobacco-FreeKids(2012).Availableathttp://www.tobaccofreekids.org/research/factsheets/pdf/0001.pdf

CancerinIreland2011:AnnualReportoftheNationalCancerRegistry(2011).Availableathttp://www.ncri.ie/pubs/pubfiles/AnnualReport2011.pdf

FioreMC,JaénCR,BakerTB,etal.(April2009)TreatingTobaccoUseandDependence:2008Update.QuickReferenceGuideforClinicians.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.

GrantBF,HasinDS,ChouSP,StinsonFS,DawsonDA(2004)NicotineDependenceandPsychiatricDisordersintheUnitedStates:ResultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedConditions.ArchivesofGeneralPsychiatry.Vol.61(11):1107-15.Availableathttp://archpsyc.jamanetwork.com/article.aspx?articleid=482090

HealthServiceExecutiveQUITCampaign(2011).Availableathttp://www.quit.ie/en/1_in_every_2_smokers

HoweG,WesthoffC,VesseyM,andYeatesD(1985)EffectsofAge,CigaretteSmokingandOtherFactorsonFertility:FindingsinaLargeProspectiveStudy.BritishMedicalJournal(ClinResEd).Vol.290:1697-700.

HowellF(2011)SmokingRelatedDischarges,BedDaysandCostsintheAcuteHospitalSector,ProceedingsoftheFacultyofPublicHealthMedicineRCPISummerMeeting,page21.Dublin.Availableathttp://www.rcpi.ie/Documents/SSM%20final%20programme%20for%20web%20170511.pdf

InternationalAgencyforResearchonCancer(2004)IARCMonographsontheEvaluationofCarcinogenicRiskstoHumans:TobaccoSmokeandInvoluntarySmoking.Vol.83.Lyon(France):InternationalAgencyforResearchonCancer.

IrishThoracicSociety(2008)INHALEReport,2ndEd.Dublin:IrishThoracicSociety.

8. Bibliography

http://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/pdfs/consumer.pdf

http://www.surgeongeneral.gov/library/reports/tobaccosmoke/factsheet.html

http://www.surgeongeneral.gov/library/reports/tobaccosmoke/factsheet.html

http://www.tobaccofreekids.org/research/factsheets/pdf/0001.pdf


http://www.ncri.ie/pubs/pubfiles/AnnualReport2011.pdf

http://www.ncri.ie/pubs/pubfiles/AnnualReport2011.pdf

http://archpsyc.jamanetwork.com/article.aspx?articleid=482090

http://archpsyc.jamanetwork.com/article.aspx?articleid=482090

http://www.quit.ie/en/1_in_every_2_smokers

http://www.rcpi.ie/Documents/SSM%20final%20programme%20for%20web%20170511.pdf


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BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEBibliography

LeHouezecJ(2003)RoleofNicotinePharmacokineticsinNicotineAddictionandNicotineReplacementTherapy:AReview.TheInternationalJournalofTuberculosisandLungDiseaseVol.7(9):811–9.Availableathttp://www.ncbi.nlm.nih.gov/pubmed/12971663

MillerBJ,PaschallCB3rd,SvendsenDP(2006)MortalityandMedicalCo-MorbidityamongPatientswithSeriousMentalIllness.PsychiatrisServicesVol.57(10):1482-7.Availableathttp://www.ncbi.nlm.nih.gov/pubmed/17035569

MillerWR,RollnickS(1991)MotivationalInterviewing:PreparingPeopletoChangeAddictiveBehaviour.NewYork:GuilfordPress.

MillerWR,RollnickS(2002)MotivationalInterviewing,PreparingPeopleforChange(2nded).NewYork:TheGuilfordPress.

NationalInstituteforHealthandClinicalExcellence(2006)BriefInterventionsforSmokingCessationinPrimaryCareandOtherSettings,PublicHealthInterventionGuidance1:QuickReferenceGuide.London:NationalInstituteforHealthandClinicalExcellence.

NilsenP,KanerE,BarborTF(2008)BriefInterventionThreeDecadesOn:AnOverviewofResearchFindingsandStrategiesforMoreWidespreadImplementation.NordicStudiesonAlcoholandDrugsVol.25:453-67.

OfficeofTobaccoControl(2004)SecondHandSmoke–theFacts.Availableathttp://www.ntco.ie/uploads/final.pdf

OfficeofTobaccoControl(2012).Availableathttp://www.otc.ie/research.asp#section1

PassiveSmokingandChildren(2010).Availableathttp://old.rcplondon.ac.uk/professional-Issues/Public-Health/Documents/Preface-to-passive-smoking-and-children-March-2010.pdf

ProchaskaJO,andDiClementeCC(1983)StagesandProcessesofSelfChangeofSmoking:TowardanIntegrativeModelofChange.JournalofConsultingandClinicalPsychology.Vol.51(3):390-5.

PublicHealth(Tobacco)Act,2002.Availableathttp://www.irishstatutebook.ie/2002/en/act/pub/0006/sec0045.html

RisksAssociatedwithSmokingCigaretteswithLowMachine-MeasuredYieldsofTarandNicotine.SmokingandTobaccoControlMonograph13(2001).Availableathttp://cancercontrol.cancer.gov/tcrb/monographs/13/m13_complete.pdf

RogersCR(1951)Client-CenteredTherapy:ItsCurrentPractice,ImplicationsandTheory.Oxford,England:HoughtonMifflin.

RollnickS,MasonP,ButlerC(1991)HealthBehaviourChange:AGuideforPractitioners.Edinburgh:ChurchillLivingstone.

http://www.ncbi.nlm.nih.gov/pubmed/12971663



http://www.ntco.ie/uploads/final.pdf

http://www.ntco.ie/uploads/final.pdf

http://www.otc.ie/research.asp#section1

http://old.rcplondon.ac.uk/professional-Issues/Public-Health/Documents/Preface-to-passive-smoking-and-children-March-2010.pdf

http://old.rcplondon.ac.uk/professional-Issues/Public-Health/Documents/Preface-to-passive-smoking-and-children-March-2010.pdf

http://www.irishstatutebook.ie/2002/en/act/pub/0006/sec0045.html

http://www.irishstatutebook.ie/2002/en/act/pub/0006/sec0045.html

http://cancercontrol.cancer.gov/tcrb/monographs/13/m13_complete.pdf

http://cancercontrol.cancer.gov/tcrb/monographs/13/m13_complete.pdf


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ScolloMM,WinstanleyMH(2008)TobaccoinAustralia:FactsandIssues.ThirdEdition.InfluencesonUptakeofSmoking.Availableathttp://www.tobaccoinaustralia.org.au/downloads/chapters/Ch5_Uptake.pdf

SeltzerV(2003)SmokingasaRiskFactorintheHealthofWomen.InternationalJournalofGynecology&Obstetrics.Vol.82:393-7.Availableathttp://www.ijgo.org/article/S0020-7292(03)00227-3/fulltext

ShawM,MitchellR,DorlingD(2000)TimeforaSmoke?OneCigaretteReducesyourLifeby11minutes.BMJ.Vol.320:53.Availableathttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117323/

Smoking’sImmediateEffectsontheBody(2009).Availableathttp://www.tobaccofreekids.org/research/factsheets/pdf/0264.pdf

SteadLF,BergsonG,Lancaster,T(2008)PhysicianAdviceforSmokingCessation(Review).TheCochraneCollaboration:JohnWiley&SonsLtd.

TheHealthConsequencesofInvoluntaryExposuretoTobaccoSmoke:AReportoftheSurgeonGeneral–ChildrenareHurtbySecondhandSmoke(2007).Availableathttp://www.surgeongeneral.gov/library/reports/secondhandsmoke/factsheet2.html

TsuangMT,StoneWS,LyonsMJ(2007)RecognitionandPreventionofMajorMentalandSubstanceUseDisorders.Washington,DC:AmericanPsychiatricPublishing.

WarnerKE(2007)InSearchoftheElusive‘ReplacementSmoker’:WhytheTobaccoIndustryHasn’tGivenUponIreland’sKids…andWhyYouShouldn’tEither.Availableathttp://www.otc.ie/article.asp?article=366

WestR,McNeillM,RawM(2000)SmokingCessationGuidelinesforHealthProfessionals;AnUpdate.Thorax.Vol.55:987-99.

What’sinaCigaretteFactSheet,(2009).Availableathttp://ash.org.uk/files/documents/ASH_117.pdf

WorldHealthOrganisation(1993)TheICD-10ClassificationofMentalandBehaviouralDisorders–DiagnosticCriteriaforResearch.Geneva:WorldHealthOrganisation.

http://www.tobaccoinaustralia.org.au/downloads/chapters/Ch5_Uptake.pdf

http://www.ijgo.org/article/S0020-7292(03)00227-3/fulltext

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117323/



http://www.surgeongeneral.gov/library/reports/secondhandsmoke/factsheet2.html

http://www.surgeongeneral.gov/library/reports/secondhandsmoke/factsheet2.html

http://www.otc.ie/article.asp?article=366

http://ash.org.uk/files/documents/ASH_117.pdf


34 35

BRIEF INTERVENTION FOR SMOKING CESSATION – PARTICIPANT RESOURCEA

ppendices

Preamble:Inordertocontributeactivelytothereductionoftobaccoconsumptionandincludetobaccocontrolinthepublichealthagendaatnational,regionalandgloballevels,itisherebyagreedthathealthprofessionalorganisationswill:

1. Encourageandsupporttheirmemberstoberolemodelsbynotusingtobaccoandbypromotingatobacco-freeculture.

2. Assessandaddressthetobaccoconsumptionpatternsandtobacco-controlattitudesoftheirmembersthroughsurveysandtheintroductionofappropriatepolicies.

3. Maketheirownorganisations’premisesandeventstobaccofreeandencouragetheirmemberstodothesame.

4. Includetobaccocontrolintheagendaofallrelevanthealth-relatedcongressesandconferences.

5. Advisetheirmemberstoroutinelyaskpatientsandclientsabouttobaccoconsumptionandexposuretotobaccosmoke–usingevidence-basedapproachesandbestpractices–giveadviceonhowtoquitsmokingandensureappropriatefollow-upoftheircessationgoals.

6. Influencehealthinstitutionsandeducationalcentrestoincludetobaccocontrolintheirhealthprofessionals’curricula,throughcontinuededucationandothertrainingprogrammes.

7. ActivelyparticipateinWorldNoTobaccoDayevery31May.

8. Refrainfromacceptinganykindoftobaccoindustrysupport–financialorotherwise–andfrominvestinginthetobaccoindustry,andencouragetheirmemberstodothesame.

9. Ensurethattheirorganisationhasastatedpolicyonanycommercialorotherkindofrelationshipwithpartnerswhointeractwithorhaveinterestsinthetobaccoindustrythroughadeclarationofinterest.

10. Prohibitthesaleorpromotionoftobaccoproductsontheirpremises,andencouragetheirmemberstodothesame.

11. Activelysupportgovernmentsintheprocessleadingtosignature,ratificationandimplementationoftheWHOFrameworkConventiononTobaccoControl.

12. Dedicatefinancialand/orotherresourcestotobaccocontrol–includingdedicatingresourcestotheimplementationofthiscodeofpractice.

13. Participateinthetobacco-controlactivitiesofhealthprofessionalnetworks.

14. Supportcampaignsfortobaccofreepublicplaces.

AdoptedandsignedbytheparticipantsoftheWHOInformalMeetingonHealthProfessionalsandTobaccoControl;28-30January2004;Geneva,Switzerland.

Appendices

WHOCodeofPracticeonTobaccoControlforHealthProfessionalOrganisations


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TFUCharter

HPH & ENSH Collaborative Taskforce on Tobacco Tobacco Free United – (TFU)

As Health Personnel (Doctor, Nurse or other):

1. I am conscious of the harmful effects of tobacco• toeachsmoker/tobaccouser• toeachpersonwholiveswithasmoker• tosociety

2. I know that exposure to environmental tobacco smoke also called “second hand smoke” and “passive smoking” is a widespread source of morbidity and mortality that imposes a significant cost on society.

3. I am conscious that tobacco is a drug that causes psychological and pharmacological dependence

4. I am ready to motivate tobacco user to quit

5. I am willing to discourage tobacco use of any kind:• bypresentingmyselfasagoodrolemodelbynotsmokingorusingtobacco• bypromotingthedesignationandmaintenanceofhealthcareserviceastobaccofree• bydevelopingskillstoclarifytobaccoaddictionandmotivatetobaccousersandrelativestoquit• bypromotingtobaccocessationinmysociallife

6. I realise that I have a great responsibility, not only towards patients but also to colleagues and to the general public and, in particular, towards the young generations• Iincitemanagerstoapproveandtakeappropriatepreventivemeasures

We – as Health Personnel (Doctors, Nurses and other) – join our efforts and strength to reduce tobacco consumption in the knowledge that it is the single most important voluntary risk factor and the cause of many early deaths in our communities.

Name&Surname

Profession

Hospital/Service

City Country

Date / /

Signature

IgivepermissiontopublishmynameintheCharterRegisteronpaper&web(pleasetick):

This Charter is based on the TFU Pact on Tobacco for Hospitals and Health Services and can be found online http://www.ensh.eu/tfu-form.php

http://www.ensh.eu/tfu-form.php


36 37


ppendices

FiveKeyToolsforSuccessfulInterventions

1. Framework for Brief Intervention for Smoking Cessation

The5As

systematically identify all smokers at every visit. Record smoking status, no. of cigarettes smoked per day/week and year started smoking.

ASK �

urge all smokers to quit. Advice should be clear and personalised.

ADVISE �

determine willingness and confidence to make a quit attempt; note the stage of change.

ASSESS �

aid the smoker in quitting. Provide behavioural support. Recommend/prescribe pharmacological aids. If not ready to quit promote motivation for future attempt.

ASSIST �

follow-up appointment within 1 week or if appropriate refer to specialist cessation service for intensive support. Document the intervention.

ARRANGE �



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2. Referral Pathways to National & Local Smoking Cessation Support Services

Thereisawiderangeofsupportsavailabletohelpsmokerstoquit.Theseinclude:

1. QUIT.ie isaHSEhealtheducationwebsiteaimedatencouragingsmokerstoquit.Ithasinformationonthehealthimpactsofsmoking,benefitsofquitting,usefultipsonhowtomeasurelevelofaddictionandacostcalculator.ThereisalsoanoptiontosignuptoaQUITplanandreceiveongoingemailsupportduringthefirstsixweeks.

2. ‘You can QUIT’ facebookpagewww.facebook.com/HSEquitisanonlinecommunitysupportingquittersthroughtheirquitjourney.

3. HSE’sNational Smokers’ QUITline 1850 201 203 offersaconfidentialcounsellingservicetoanyoneseekingsupportorinformationaboutquittingsmoking.Theserviceisavailable8am-10pmMondaytoSaturday.

4. HSESmoking Cessation Services providespecialistsupporttoclientseitherincommunityorhealthservicesettings(seelist).Servicesvarybetweenareasandcanincludeone-to-one,grouportelephonesupport.Servicesareavailablefreeofcharge.

HSE DUBLIN MID-LEINSTERDublinSouthEast 012744297DublinSouthCentral 014632800DublinSouthWest 014632800DublinWest 014632800Kildare 014632800Longford 1800242505Laois 1800242505Offaly 1800242505Westmeath 1800242505WicklowEast 012744297WicklowWest 014632800

HSE DUBLIN NORTH EASTCavan 0416850671DublinNorthCity 018976184DublinNorthCounty 018976184Louth 0416850671Meath 0416850671Monaghan 0416850671

HSE SOUTHCarlow 0567761400CorkCity 0214921641CorkNorth 02258634CorkWest 02840418Kerry 0667195617Kilkenny 0567761400TipperarySouth 0526177037Waterford 051846712Wexford 1850201203

HSE WESTClare 0656865841Donegal 1850200687LetterkennyGeneralHospital 0749123678GalwayUniversityHospital 091542103Leitrim 1850200687Limerick 061301111Mayo 1850201203Roscommon 1850201203Sligo 1850200687SligoGeneralHospital 0719174548TipperaryNorth 1850201203

http://www.QUIT.ie

http://www.facebook.com/HSEquit


38 39


ppendices

3. Fagerstrom Test for Nicotine Dependence

Score 8+ = high dependence

Score 5-7 = moderate dependence

Score 3-4 = low to moderate dependence

Score 0-2 = low dependence

QUESTION RESPONSE SCORE

1. Howsoonafteryouwakeupdoyousmokeyourfirstcigarette?

After60minutes

31-60minutes

6-30minutes

Within5minutes

0

1

2

3

2. Doyoufinditdifficulttorefrainfromsmokinginplaceswhereitisforbidden?

No

Yes

0

1

3. Whichcigarettewouldyouhatemosttogiveup? Thefirstinthemorning

Anyother

1

0

4. Howmanycigarettesdoyousmokeperday? 10orless

11-20

21-30

31ormore

0

1

2

3

5. Doyousmokemorefrequentlyduringthefirsthoursafterwaking,thanduringtherestoftheday?

No

Yes

0

1

6. Doyousmokeevenifyouaresoillthatyouareinbedmostoftheday?

No

Yes

0

1

AdaptedfromHeathertonTF,KozlowskiLT,FreckerRC,FagerstromKO.TheFagerstromTestforNicotineDependence:ArevisionoftheFagerstromToleranceQuestionnaire.BritishJournalofAddictions1991;86:1119-27.

Themostdistinctiveindicatorsofnicotinedependenceare:

• Timetofirstcigaretteafterwaking

• Thenumberofcigarettessmokedperday


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4. Decisional Balance Tool

REASONS TO STAY THE SAME REASONS TO CHANGE

Benefits:

Whatdoyoulikeaboutsmoking?

•

•

•

•

•

•

Concerns:

Whatconcernsyouaboutsmoking?

•

•

•

•

•

•

Concerns:

Whatconcernswouldyouhaveifyouweretoquit?

•

•

•

•

•

•

Benefits:

Whatarethebenefitsofquitting?

•

•

•

•

•

•

On a scale of 1-10, how ready are you to quit smoking?

(1 = not ready; 10 = ready)

� 1 2 3 4 5 6 7 8 9 10 �

On a scale of 1-10, how confident are you that, if you tried, you could quit for good?

(1 = not at all confident; 10 = very confident)

� 1 2 3 4 5 6 7 8 9 10 �

On a scale of 1-10, how important is quitting smoking to you?

(1 = not at all important; 10 = very important)

� 1 2 3 4 5 6 7 8 9 10 �


40 41


ppendices

5. Smoking Diary

1. Number of cigarettes smoked

DAY MORNING AFTERNOON EVENING TOTAL

1

2

3

4

5

6

7

2. Other things to consider

WhyIneededtosmoke?

WheredidIsmokemost?

Whowith?

Desiretosmoke*

HowmuchdidIenjoyit?**

HowdidIfeelafter?

*10isaverystrongdesiretosmoke,1isnodesireatall.**10isreallyenjoyedcigarette,1isdidn’tenjoyatall.


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UsefulResources

HSEQuitSmokingWebsite www.quit.ie

HSETobaccoFreeCampusPolicy www.hse.ie/tobaccofreecampus

HSENationalTobaccoControlOffice www.ntco.ie

CochraneReviews www.cochrane.co.uk

TreatTobacco www.treatobacco.net

WorldHealthOrganisation www.who.int/tobacco/mpower

USSurgeonGeneral http://www.surgeongeneral.gov/initiatives/tobacco/index.html

NationalInstituteforClinicalExcellence www.nice.org.uk

SocietyforResearchonNicotineandTobacco www.srnt.org

SocietyfortheStudyofAddiction www.addiction-ssa.org

AgencyforHealthcareQualityResearch www.ahrq.gov

Motivational Interviewing: Preparing People to Change Addictive Behaviour

WilliamRMiller&StephenRollnick(1991)

GuilfordPress:NewYork

Motivational Interviewing: Preparing People for Change



Health Behaviour Change: A Guide for Practitioners

StephenRollnick,PipMason&ChrisButler(1991)

ChurchillLivingstone:Edinburgh

Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual

MaryMardenVelasquez,GaylynGaddyMaurer,CathyCrouch,CarloC.DiClemente


http://www.quit.ie

http://www.hse.ie/tobaccofreecampus

http://www.ntco.ie

http://www.cochrane.co.uk

http://www.treatobacco.net

http://www.who.int/tobacco/mpower

http://www.surgeongeneral.gov/initiatives/tobacco/index.html

http://www.nice.org.uk

http://www.srnt.org

http://www.addiction-ssa.org

http://www.ahrq.gov


42 43


UsefulResources

HSEQuitSmokingWebsite www.quit.ie

HSETobaccoFreeCampusPolicy www.hse.ie/tobaccofreecampus

HSENationalTobaccoControlOffice www.ntco.ie

CochraneReviews www.cochrane.co.uk

TreatTobacco www.treatobacco.net

WorldHealthOrganisation www.who.int/tobacco/mpower

USSurgeonGeneral http://www.surgeongeneral.gov/initiatives/tobacco/index.html

NationalInstituteforClinicalExcellence www.nice.org.uk

SocietyforResearchonNicotineandTobacco www.srnt.org

SocietyfortheStudyofAddiction www.addiction-ssa.org

AgencyforHealthcareQualityResearch www.ahrq.gov

Motivational Interviewing: Preparing People to Change Addictive Behaviour



Motivational Interviewing: Preparing People for Change



Health Behaviour Change: A Guide for Practitioners

StephenRollnick,PipMason&ChrisButler(1991)

ChurchillLivingstone:Edinburgh

Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual

MaryMardenVelasquez,GaylynGaddyMaurer,CathyCrouch,CarloC.DiClemente


Notes

http://www.quit.ie

http://www.hse.ie/tobaccofreecampus

http://www.ntco.ie

http://www.cochrane.co.uk

http://www.treatobacco.net

http://www.who.int/tobacco/mpower

http://www.surgeongeneral.gov/initiatives/tobacco/index.html

http://www.nice.org.uk

http://www.srnt.org

http://www.addiction-ssa.org

http://www.ahrq.gov


44

Notes

National Tobacco Control Office

Health Service Executive Oak House, Millennium Park

Naas, Co. Kildare

Telephone: 045 880400 www.hse.ie

http://www.hse.ie

http://www.hse.ie