Brief Counselling for Tobacco Use Cessation: A guide for health professionals

Brief Counselling for Tobacco Use Cessation: A guide for health professionals. Acknowledgements Originally written by: Karen McLean, with input from...
Author: Tobias Garrison
9 downloads 4 Views 1MB Size
Brief Counselling for Tobacco Use Cessation: A guide for health professionals.

Acknowledgements Originally written by: Karen McLean, with input from Josie d’Avernas (2008); Program Training and Consultation Centre. Revised by: Dearbhla Lynch and Erika Steibelt. Special thanks to Stephanie Cohen for her advice on Motivational Interviewing, and to Jennifer Lee, Krista Galic, Laura McCammon-Tripp, Cynthia Neilson, Lynn Ward and Grace Kuipers for their review. Designed by: Fuel Advertising The Program Training and Consultation Centre (PTCC) is a resource centre of the Smoke-Free Ontario (SFO) Strategy and is funded by Public Health Ontario. PTCC plays an important role in coordinating ongoing efforts to support the Government of Ontario’s Smoke-Free Ontario (SFO) Strategy. PTCC is unique in that it acts as a knowledge broker between local public health departments, the research community, and government. Its strategic priorities are to: •

 uild the capacity of Ontario’s 36 public health departments, seven (7) regional Tobacco Control Area Networks, and other B community-based agencies to plan and implement evidence-based tobacco control programs



Support moving evidence into action



Strengthen program development and applied research efforts



Build system capacity to support the Smoke-Free Ontario Strategy renewal

Brief Counselling for Tobacco Use Cessation was produced by PTCC with financial support from Public Health Ontario (PHO). The opinions expressed in this document are those of the authors, and no official endorsement by PHO is intended or should be inferred. Copyright 2012 Program Training and Consultation Centre. Reproduction is permitted provided the publication includes this acknowledgement: Reproduced with permission from the Program Training and Consultation Centre. For more information please contact PTCC toll-free at 1-800-363-7822 or visit www.ptcc-cfc.on.ca.

People want to quit. You can help. It can take as little as three minutes. Quitting smoking is the single best thing that a person can do for their health. Smoking is dangerous and results in huge costs to individuals, the health care system and society. Providing cessation interventions is proven to be cost-effective, and is widely supported in the scientific literature.1, 2 Evidence indicates that interventions do not need to be complicated or time-consuming. In fact, even a three minute conversation can lead to quitting.3 Brief cessation counselling can be as simple as asking about tobacco use, recommending quitting, and referring to community resources or providing self-help materials. Tobacco use is a chronic relapsing condition. Smoking cessation is not a single event, but a process. A process that may take years! Brief cessation counselling from a health professional such as a physician, dentist, pharmacist or nurse following steps as described in the 5 A’s (Ask, Advise, Assess, Assist and Arrange) can make a significant difference, increasing the number of smokers who attempt to quit and who eventually remain smoke-free.4 The repeated, consistent application of the 5A framework has the potential to dramatically change smoking behaviour in Ontario. People are more likely to quit on the advice of a professional – that professional could be you! This guide focuses on interventions you can accomplish in 10 minutes or less to help your clients quit smoking. Evidence from clinical practice guidelines indicates that quit rates can be enhanced by the use of simple and costeffective interventions delivered systematically and comprehensively.5, 6, 7 This guide is designed to: •

 rovide information and strategies to enable health professionals in Ontario to provide brief P cessation counselling – quickly, efficiently and effectively



 rovide background information to assist with understanding the evolution of comprehensive P tobacco control and current legislation that supports smoke-free living



 elp professionals address tobacco use by providing practical tips, useful tools and H evidence-based strategies

This guide explores the 5A framework, the parts that make up a brief intervention and how they can fit together. As you develop confidence and skill with the 5A framework, you may want to increase your attention to tobacco cessation. This guide goes beyond the basic implementation to include information about the stages of change, motivational approaches, medications, relapse prevention and resources for continuing education. Tips on how to incorporate these strategies into your practice are explored, as well as how to fit motivational interviewing techniques into your interventions. Depending on your clinical context, you may be able to increase the intensity of your intervention by going beyond a three-minute conversation. As we increase our investment in smoking cessation, the likelihood that people will change their smoking behaviour also increases.

3

Table of Contents

.

1. Background on Tobacco Use and Cessation. . . . . . . . . . . . . . . 6 2. Tobacco Control in Ontario: Progress and Areas for Improvement. . . . . . . . . . . . . . . . . . . . . 7 3. Understanding Smoking, and What It Takes to Quit. . . . . . . . . . 9 4. Health Benefits from Quitting Smoking. . . . . . . . . . . . . . . . . . . 10 5. Brief Interventions • The 5 A’s chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 • Overview of the 5 A’s: the Ask, Advise, Assess, Assist and Arrange Protocol . . . 12 6. The Stages of Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 • Using the Stages of Change in a conversation about quitting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 7. Increasing Motivation to Quit • The Spirit of Motivational Interviewing. . . . . . . . . . . . . . . . 21 • Principles of Motivational Interviewing. . . . . . . . . . . . . . . . 21 • Four Practical Strategies to Enhance Motivation. . . . . . . . 23 8. Pharmacotherapy Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 9. Frequently Asked Questions and Answers on Quitting. . . . . . . 27 Appendices Appendix 1: Clinical Best Practice Guidelines. . . . . . . . . . . 30 Appendix 2: Selected Resources for Smoking Cessation. . 32 Appendix 3: F  agerstrom Test for Nicotine Dependence (Revised) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Appendix 4: Stop-Smoking Medications Compared . . . . . . 38 Appendix 5: Q  uit Day Plan Template. . . . . . . . . . . . . . . . . . 40 Quit Day Plan Template (Completed Example).41 Appendix 6: Personalized Quit Plan Template . . . . . . . . . . 42 Appendix 7: The WHY Test. . . . . . . . . . . . . . . . . . . . . . . . . . 44 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

.

5

1. Background on Tobacco Use and Cessation In spite of significant progress in tobacco control under the Smoke-Free Ontario Strategy, smoking remains the number one preventable cause of premature death and disease in Ontario, with estimates ranging between 15 and 19%8, 9 of Ontarians continuing to smoke (daily and occasional smokers) and 13,00010 of all deaths in Ontario each year attributable to smoking. Half of all people who use tobacco products regularly throughout their lives die from smoking, typically losing 10 years of life.11 In addition to these direct effects, exposure to second-hand smoke increases children’s risk of sudden infant death syndrome (SIDS), acute respiratory infections, middle-ear infections, more severe asthma, other respiratory symptoms and decreased lung function.12 Exposure to smoke during pregnancy and early childhood also increases children’s risk of cognitive impairment, deficits in math and visio-spatial reasoning, and the number of missed days of school because of illness.13 Children and youth exposed to smoking are not only at risk for adverse health effects, but are also at increased risk of starting to use tobacco due to rolemodelling.14 While more than half of current smokers in Ontario express a serious intention to quit smoking, less than 10% of adult smokers report quitting for at least 30 days in the last year, and only 1.2% of previous-year smokers are successful in remaining abstinent for 12 months.15

6

Increasing tobacco-users’ motivation to quit smoking and creating a supportive environment with accessible programs and services helps contribute to success. There are many evidence-based tools, programs, medications and resources available to help people quit smoking. These vary in intensity of treatment from self-help alone (no formal support or structure, e.g., “cold turkey,” or using over the counter nicotine replacement medications without professional advice/ guidance) to small group interventions and intensive one-on-one counselling. Although half of all former smokers report that they quit on their first try,16 others require several attempts and medications before they succeed. Many try to cut down first, and most do not seek advice or assistance from community experts such as their physician, their public health department or a health/social service agency. Providing cessation interventions is a proven cost-effective clinical intervention.17 Current cessation programs in Ontario reach only a very small proportion of people who use tobacco products.18 Creating a tobacco-user support system where there is “no wrong door” for accessing cessation services would more effectively recruit, engage, support and assist current users.19

Screening for tobacco use and providing cessation treatment must be seen as part of a duty-of-care and a standard-of-practice for every health professional

When surveyed, over half of all smokers in Ontario say they would like to quit within six months, and about a quarter are considering quitting within 30 days.20 Even with these good intentions, less than 10% are successful.21 Despite this challenging situation, there is strong evidence that practitioners can make a significant difference in helping their clients quit.22 Health providers are ethically and professionally obliged to routinely offer evidence-based treatment to their patients who use tobacco industry products (including cigarettes, pipes,

cigars, chew, spit, and smokeless tobacco).23 Many effective evidencebased treatments exist, and tobacco use assessments and interventions can be done quickly and efficiently. Screening for tobacco use, and providing cessation treatment must be seen as part of a duty-of-care and a standardof-practice for every health professional, as is the case with other medical conditions.24 Some may even suggest that neglecting this duty is a failure to meet standards of care, resulting in medicolegal implications.25

2. Tobacco Control in Ontario: Progress and Areas for Improvement Tobacco control efforts over the past decade have achieved remarkable progress in Ontario; however, there is still much to do to achieve the goals of the Smoke-Free Ontario Strategy. As a result of provincial legislation, Ontarians now enjoy smoke-free public places, bars, restaurants and workplaces. The Smoke-Free Ontario Strategy has supported public health agencies throughout the province to collaborate with community partners and youth groups working to reduce tobacco use. Evidencebased smoking cessation support consistent with international standards can be obtained by contacting the Smokers’ Helpline. Training

is available for health professionals to build their skills in delivering smoking cessation interventions, and many other tobacco control initiatives are in place at the local level. As a result of heightened awareness of how second-hand smoke affects children, Ontario and seven other provinces and one territory have passed laws to ban smoking in vehicles when children under the age of 18 are present. Many other jurisdictions are considering similar action. As a result of this legislation, the exposure to second-hand smoke in vehicles for nonsmoking Ontarians over the age of 12 years was significantly lower in 2010 (6.5%) compared to

7

2007 (8%).26 Despite such regulatory measures affecting vehicles, 5% of children under the age of 12 in Ontario are still exposed to second-hand smoke in the home on a daily basis.27 Increasing population-wide quit rates is one strategy that ultimately helps reduce overall exposure to secondhand smoke. When fewer parents smoke, fewer children are exposed. According to the Canadian Tobacco Use Monitoring System, smoking rates have declined in Ontario from 23% (total of daily and non-daily smokers) in 1999 to 15.2% in 2010, yet 9% of young people between the ages of 15 and 19 smoke when it is against the law to sell or supply tobacco to anyone under the age of 19, and 19.4% of young adults between 20 and 24 years old smoke.28 Furthermore, in some First Nations populations, smoking rates remain as high as 43%29 (see Health Equity and Tobacco Use box). Tobacco products are still readily available where you buy your bread, milk and gas, yet medications to make it easier to quit are harder to obtain.

Comprehensive Tobacco Control (CTC) is the intersection between prevention, protection and cessation. All components complement and strengthen the others. Prevention decreases the supply of new users, and helps to ensure the elimination of tobacco use over time. Protection, intended to protect people from involuntary exposure, also makes tobacco use less visible and ‘normal’. Protection measures (like workplace policies, municipal bylaws and provincial legislation) reduce opportunities for people to use tobacco products. Such measures also reduce cues for people to smoke, decrease consumption, and encourage abstinence. Cessation reduces the amount of smoke and tobacco use that users and others are exposed to. Fewer adult users of tobacco products results in more positive role models for young people. Cessation also increases compliance with protection measures. The combination of prevention, protection and cessation measures helps to change the social environment around tobacco use, thereby accelerating the recovery of individuals, society and the health care system.35

Health Equity & Tobacco Use It is well recognized that reducing tobacco-related disparities is part of achieving health equity.30, 31 This includes addressing the unequal distribution of disease and the inequitable application and impact of interventions. Socially disadvantaged populations suffer relatively more tobacco-related disease than the general population.32 Smoking may account for most of the difference in health outcomes seen between social groupings.33 The most vulnerable populations within the tobacco control context include: young people (particularly young men and out-of-mainstream young people), Aboriginal/Inuit people, GLBT (gay, lesbian, bisexual and transgender) people, people with mental health issues and addictions, and people with low socioeconomic status.34 These populations are just as likely to attempt to quit as other smokers, but are less likely to succeed. Tobacco use is not simply a “lifestyle choice,” rather it is a risk behaviour shaped by physiological processes as well as the social determinants of health. Brief interventions can increase access to cessation services by helping to create low-barrier and personalized approaches to cessation support services in a range of settings across the health care and social service continuum.

8

3. Understanding Smoking and What it Takes to Quit .

Most tobacco users in Ontario want to quit, have tried in the past, and will try to quit within the next year.36 However, among those who try to quit, only a small proportion manage to stay smoke-free over the long-term without repeated attempts. Evidence demonstrates that receiving support increases the likelihood of success and yet, current cessation programs in Ontario reach only a very small proportion of smokers. Consistent implementation of the 5A framework by health care professionals can help to bridge the gap. In 2010, about half of Ontario smokers who visited a doctor in the past year received advice to quit, compared to about a third of those who visited a dentist.37 Unassisted quit attempts are successful only 3–5% of the time compared with up to 20% success for those receiving cessation counselling and medications.38 In 2010, of those current and former Canadian smokers who tried to quit in the past two years, the majority (61.4%) used some form of assistance. Nearly four in ten tried nicotine replacement therapy, more than one quarter made a deal with a friend or family member, and close to 20% used a product like Zyban.39 Brief counselling can not only increase the number of people making a quit attempt but also improve the methods and strategies smokers use to quit resulting in better overall success rates. Quitting smoking can be more difficult for some people than for others, depending on individual physical, psychological, emotional and social factors. Nicotine is the drug that makes smoking so addictive.40 When tobacco smoke is inhaled, nicotine reaches the brain in less

than 10 seconds.41 In addition to satisfying the craving for this drug, people tend to use smoking as a mechanism for tension and stress relief, a way to feel energized, to help concentrate on problem solving, to avoid food and to manage time. The urge for a cigarette is often associated with common triggers such as the ringing of the phone or enjoying coffee after a meal. To be successful at quitting smoking, these complex and varied reasons and perceived benefits of smoking must be addressed. The reasons people make a quit attempt are many and varied. Half of all former smokers report that they decided to quit over concerns for their health.42 Other reasons may include: the cost of cigarettes, concerns for one’s family, increasing restrictions on where one can smoke, the death of a close friend, family member or beloved pet from a smoking-related disease, and the desire to be a good role model for children. Whatever the reason for a quit attempt, other factors also come into play. When people reach the point that they believe quitting is more important than continuing to smoke, then change becomes possible. In addition to having good reasons to quit, people need to be confident in their ability to overcome the challenges associated with quitting. Perceived importance of making a change and confidence are key factors in determining how ready people are to make a quit attempt. Brief Cessation Counselling is about providing advice, assessing readiness and providing client-centred assistance tailored to different levels of readiness.

9

4. Health Benefits from Quitting Smoking Those who quit smoking, even after many years of smoking, will experience improvement to their health. Some of the benefits are immediate; others become apparent over the longer term.

physical benefits after quitting

10



20 minutes – Your blood pressure and pulse rate is back to normal.



8 hours – Notice that you can breathe easier? Your oxygen levels are back to normal and your chance of having a heart attack has gone down.



24 hours – Coughing a lot? That’s a good sign…your lungs are starting to clear out the mucus.



48 hours – You are nicotine-free. Enjoying food more? Your senses of taste and smell are improving.



72 hours – You’ll have more energy. Your lung capacity is increasing and your bronchial tubes are relaxing, so breathing and exercising is easier.



1 year – Your risk of heart attack has dropped by 50%.



10 years – Your risk of dying from lung cancer is cut in half.



10 – 15 years – Your risk of dying from a heart attack is the same as a person who has never smoked.43, 44, 45, 46

5. Brief Counselling Brief counselling for tobacco use cessation is guided by the 5A framework. The framework was designed to enable a variety of clinicians to identify tobacco users, assess their level of readiness and deliver effective interventions47 in 15 minutes or less. The 5 A’s can be implemented in as little as three minutes when time is an issue.

The framework provides a menu of options to allow for adaptation depending on the clinician’s skill and confidence with the framework, the individual client, the setting and the amount of time available. For more information on best practice clinical guidelines that support this approach, see Appendix 1.

the 5 A’s ASK • Initiate a conversation about tobacco use at every visit

ADVISE • Advise clients to quit in a strong, clear and personalized manner.

ASSESS • Assess clients’ willingness to make a quit attempt or modify their smoking behaviour.

ASSIST •A  ll clients can benefit from strategies to strengthen and enhance motivation to change their smoking behaviour. • Every tobacco user who expresses the willingness to quit should be offered assistance

BRIEF • • • • •

Practice active listening Affirm clients Use techniques to strengthen motivation Provide information about pharmacotherapy Provide self-help materials

INTERMEDIATE/INTENSIVE • • • • • • • • • • • • •

Use techniques to strengthen motivation Review smoking/quitting history Encourage self-monitoring (e.g., tracking) Explore ambivalence (e.g., decisional balance) Discuss reasons for smoking (e.g., WHY TEST) Utilize cognitive behavioural strategies Assist with the development of a quit plan Review potential challenges and triggers Determine level of addiction (e.g., Fagerstrom) Provide pharmacotherapy Encourage support of family and friends Provide training to enhance coping skills Assist with strategies to manage stress

ARRANGE • Schedule a follow-up appointment • Refer to available community supports • Refer to appropriate health care providers • Refer to Smoker’s Helpline (e.g., Quit Connection or Fax Referral Program)

Adapted from: CAN-ADAPTT Canadian Smoking Cessation Clinical Practice Guideline; U.S. Treating Tobacco Use and Dependence: 2008 Update; and the Registered Nurses’ Association of Ontario, Integrating Smoking Cessation into Daily Nursing Practice (2007).

11

Overview of the 5 A’s: the Ask, Advise, Assess, Assist and Arrange Protocol Ask All clients should be asked about tobacco use at every visit. Systematically identify and document tobacco use when possible. •

Have you used any form of tobacco product in the last six months?



Have you used tobacco in the last two weeks?



Do you smoke?

HOW the question is asked influences the level of detail in the response. In addition, people may not want to disclose their tobacco use status for fear of reproach. People are increasingly sensitive to the stigma associated with smoking as tobacco use becomes less “normal.” A nonjudgmental approach will enhance rapport and provide a safe environment for people to consider the possibility of change.

Advise Strongly urge all tobacco users to consider quitting. Use clear language. • As your clinician, the most important advice I can give you is to quit smoking. •

In light of ______________________, it is extremely important that you quit. How can I help?



Quitting is the best thing you can do for your health and well-being.

Whenever possible, tailor the advice by adding detail relevant to the client’s personal circumstances.

Assess Determine the client’s willingness to make a quit attempt. Sometimes a client’s intentions emerge as part of the conversation or are quite obvious. If not, a simple question will often elicit the client’s readiness. •

Are you thinking about quitting?



Have you considered quitting?



Are you ready to make a quit attempt?

Assessment is important so that we can tailor the ASSIST component of the 5A framework to meet the client’s needs. Use the Stages of Change Model (see pages 15–19) to inform your approach to the intervention. Use motivational methods (see pages 20–24) to increase motivation to quit. 12

Assist The type of intervention and counselling you provide during the ASSIST component will vary depending on the ASSESS Component, as well as the clinical setting and time available. The Stages of Change Model provides assistance identifying appropriate strategies for support based on the client’s readiness to make a quit attempt. For clients unwilling to make a quit attempt, use a motivational approach as described on page 20–24. Options for people willing to make a quit attempt include: using motivational methods to strengthen motivation and commitment to change; providing information about tobacco use, health effects and medication; providing practical counselling to help the client recognize potential challenges and develop coping skills to address them; helping with the development of a quit plan; and, providing supplementary materials and information about community resources for quitting. •

 ell me about your smoking…What do you like about it? Do you have any concerns about T smoking?



 n a scale of 1 to 10, how motivated/confident are you to make a quit attempt? Why? Why not O lower? What needs to happen for you to move closer to 10?



Tell me about the last time you quit smoking. What worked well? What could you do differently?



What do you think will be the most difficult thing to deal with? How can you prepare yourself?



Let’s talk about some of the medications available that can help.



Is there someone who is going to help you through this? What can she/he do to help?



What small changes do you think you can start to make in the next two weeks?



Are you ready to make a plan?

Arrange Arrange for continued support for the client. Schedule a follow-up appointment or refer to community resources. Smoker’s Helpline is a free, confidential and evidence-based service that provides nonjudgmental and personalized support to help people quit. •

Let’s set up another meeting to talk about this again.



 re you interested in trying Smoker’s Helpline? They provide support on the telephone, online A or via text messaging.



 ould you like some materials you can review at home? We can meet again to discuss what W you’ve learned.

If a client is not ready or willing to consider continued support, respect their perspective. Encourage clients to seek support when they are ready.

13

Different Approaches to the A’s The 5 A’s of treating tobacco dependence provide a useful framework for understanding tobacco treatment, and organizing a team to deliver that treatment. However, it may not be practical for one individual to complete all, and a team approach may be preferred. For example, one clinician may ask about tobacco use status, another prescribing clinician (e.g., physician, dentist, pharmacist, etc.) may deliver personal advice to quit, assess readiness and provide information about medication, and then that clinician may refer clients to another resource, either within the health care team or to a community partner that would deliver additional treatment or support. While full implementation of the 5 A’s in a clinical setting may yield superior results, the A’s can be adapted for different clinical contexts and different professional settings. In some cases, protocols have been tailored to 4 A’s or 3 A’s.48, 49

Contact Time Increases Abstinence The longer the conversation, the more likely people are to make a quit attempt. As Table 1 demonstrates, abstinence rates increase with the amount of contact time (up to 300 minutes). However, even a minimal (less than 3 minutes) intervention is effective, and thus every client who uses tobacco should be offered at least brief treatment.50

Total Contact Time

Estimated Abstinence Rate

None

11.0%



1–3 minutes

14.4%



4–30 minutes

18.8%



31–90 minutes

26.5%

91–300 minutes

28.4%



25.5%51

>300 minutes

Table 1

14

6. The Stages of Change

The first construct, the stages of change, are described in the chart below. The Stages of Change are usually conceptualized as a circular diagram with linear movement through the stages [See Figure 1]. It is important to note that progression is rarely simple and linear. People often move back and forth among the stages of change until finally quitting for good. In fact, it is also common for people to skip stages as they move back and forth. This is particularly likely in complex cases where circumstances beyond an individual’s immediate control influence their smoking behaviour (e.g., incarceration, hospitalization or pregnancy). While there is some debate in the scientific community about the universal effectiveness of Stages of Change,53 it can be helpful for assessing your client’s readiness to quit and determining the most appropriate approach to each intervention.

Precontemplation

.

the stages of change • the processes of change • decisional balance (or the pros and cons of changing) and • self-efficacy. •

In order to progress through the stages, people need to develop: • a growing awareness that the “pros” of changing their behaviour outweigh the “cons” (decisional balance), • confidence that they can make and sustain behaviour changes when faced with situations that may tempt them to relapse to their previous unhealthy behaviour (self-efficacy), and • strategies to help them make and sustain the change (processes of change).

stages of change

The Transtheoretical Model (otherwise known as the Stages of Change model) developed by DiClemente and Prochaska may serve as a useful guide to tailor your intervention.52 The model consists of:

Figure 1

Not thinking of quitting in the next six months

Contemplation Ambivalent, but thinking of quitting in the next six months. Preparation

Planning to quit in the next month.

Action

Quit in the last six months.

Maintenance

Quit for more than six months.

Relapse  Has returned from the Action or the Maintenance stage to an earlier stage.

15

decisional balance. SMOKING

NOT SMOKING

What benefits do you get from smoking?

What will you look forward to about not smoking?

What are some of the not-so-good things about smoking?

What negative things do you anticipate about stopping smoking?

..

..

Figure 2 Decisional Balance The use of the “decisional balance” can be a powerful way to contrast a client’s values with behaviour [See Figures 2 and 3]. Essentially, a decisional balance invites people to “weigh” the pros and cons of a given behaviour. This strategy acknowledges that people act in certain ways because there are benefits to doing so, as well as negative consequences or harms. It can help clients to see their dilemma clearly, and to make a conscious choice of direction. The goal of using the decisional balance is to elicit “change talk” (change talk comprises client verbalizations that signal desire, ability, reasons, need, or commitment to change). Since the decisional balance explores both the pros and cons of change, clients’ counterchange motivations naturally come up. Using this technique encourages clients to explore the negative side of their smoking in greater detail and depth than the positive side.54 The decisional balance can be useful when initial attempts to elicit pro-change talk have

16

been unsuccessful. It is also appropriate when the counsellor wants to avoid advocating for a change that the client has not brought up himself, or tipping the balance in a particular direction. Self-Efficacy Self-efficacy encompasses the situation-specific confidence a person has in being able to successfully take a specific action or cope with a high-risk situation without relapsing to their unhealthy behaviour.55 Supporting self-efficacy builds a sense of client personal responsibility. It recognizes that only the client can make change happen. One should consider the client to be the best expert on their own life. A client’s belief that change is possible is an important motivating factor in making a change. By demonstrating a belief in the client’s ability to change, clients build confidence in their ability to cope with the task or challenge. A client can identify their own approaches and strategies while the counsellor can focus their efforts on helping the client stay motivated and supporting self-efficacy.

Processes of Change The processes of change are the strategies that people can use to progress through the stages. When tailoring your approach to match your clients’ readiness to change, use specific and practical illustrations of the processes of change (as suggested below) to help them gain new insight about their smoking, and to progress towards a successful quit attempt. The chart on p. 18-19 provides some guidance on helping clients to use these processes to move to the next stage of behaviour change. • Consciousness-raising (becoming informed) involves increasing awareness of oneself and the nature of the problem using tools like a smoking diary or the Why Test [See Appendix 7]. • Dramatic relief (emotional arousal) is often triggered by an event relevant to the problem behaviour. This may occur through experiencing the health effects of smoking or experiencing the death of a loved one. • Environmental re-evaluation involves looking at how making or not making the proposed change would impact one’s social environment. For example, considering the effect of one’s tobacco use on others. • Social liberation (increasing alternatives) is about recognizing that society is more supportive of being tobacco-free and creating alternatives in the social environment that encourage behaviour change.

• Smoking benefits • Quitting downsides

S elf re-evaluation (creating a new self-image) arises from thinking about self-perception, values and goals and how smoking fits or conflicts with these. • Commitment (or self-liberation) involves accepting responsibility for making change and taking appropriate action. • Rewards (or reinforcement management) require a plan or strategy to reward steps taken toward behaviour change. • Countering (or counter-conditioning) is about substituting health behaviours for problem behaviours like replacing tobacco use with other activities that serve the same function. This may include substituting new behaviours to deal with stress and/or using medications to minimize withdrawal. • Environmental (or stimulus) control involves taking steps to reduce temptation so that quitting becomes easier to sustain. It may require removing triggers for tobacco use like ashtrays, cigarettes, lighters; setting up smoke-free spaces (e.g., home and car); and avoiding high-risk situations and people. • Helping relationships is about enlisting the support of others in one's quit attempt.56, 57 •

The next two pages provide a more in-depth look at how to use stage appropriate counselling to assess readiness and assist with a quit attempt.

• Smoking downsides • Quitting benefits

Figure 3 17

Using the Stages of Change in a conversation about quitting Stage-Based Approaches

Talking points

Pre-contemplation – Not thinking of quitting in the next six months. Goal: Increase awareness of the importance of quitting and introduce ambivalence by raising doubts about staying the same or identifying problems with the current behaviour. Help clients think about quitting.



Can we talk about your smoking for a moment?



 ell me about your smoking…what do you like T about it?



Do you have any concerns about smoking?

Target Change Process: Consciousness-raising, dramatic relief, environmental re-evaluation and self re-evaluation.



Can I share with you some information about…?



 uitting smoking is the single most important thing Q you can do for your health and well-being.



 n a scale of 1 to 10, how motivated are you to make O a quit attempt? Why? Why not lower? Why not higher?



When you are ready, here is a number to call.

Goal: Help clients move towards quitting soon. Increase self-confidence.



 ell me a little about yourself, and how smoking fits T into your life.

Target Change Process: Consciousness-raising, dramatic relief, environmental re-evaluation and self re-evaluation.



 re there any cigarettes that you would be willing to A give up? What might be a reasonable substitute?



 hat do you like about smoking? What other activity W would give you the same feelings?



 hat small change are you willing to try in the next two W weeks (changing routines, smoking outside, cutting down, quitting for a day, etc.)?



 hat challenges do you expect to face and how will W you overcome them?

Role of Self-Efficacy: Clients may lack confidence. Reframe any past quit attempts as learning experiences. Ask about feelings, pros and cons. Offer information and assistance when the client is ready. Contemplation – Ambivalent, but thinking of quitting in the next six months.

Role of Self-Efficacy: Build confidence by reexamining past experience. Set small achievable goals. Ask about pros and cons. Explore interest in cutting back or quitting for a day and encourage small changes in behaviour (e.g., making car/home smoke-free, quitting for a day). Suggest a future visit, offer information and assistance at any time.

Adapted from: Registered Nurses’ Association of Ontario. (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario; and the Haliburton, Kawartha, Pine Ridge District Health Unit.

18

Stage-Based Approaches Preparation – Planning to quit in the next month. Goal: Help clients prepare for quit, and develop skills. Target Change Process: Commitment, dramatic relief, self re-evaluation. Role of Self-Efficacy: Provide positive reinforcement. Assess motivation and confidence and how it can be improved. Ask about concerns, lessons learned from previous attempts. Advise by identifying barriers and discussing solutions. Assist by providing information, devising an action plan, setting a quit date and discussing Nicotine Replacement Therapy (NRT) and other stop smoking medications. Action – Quit in the last six months. Goal: Help clients not to smoke by understanding smoking triggers and developing and practicing coping skills. Target Change Process: Helping relationships, countering and environmental control. Role of Self-Efficacy: Assess motivation and confidence. Set small daily goals. Discourage an over reliance on willpower. Ask about a relapse prevention plan, triggers, weight gain, successes, NRT and other stop smoking medications. Assist by focusing on successes, resources/ referrals, encouraging rewards, developing social support network. Maintenance – Quit for more than six months. Goal: Help clients remain smoke-free for a lifetime. Target Change Process: Rewards, countering, environmental control, helping relationships. Role of Self-Efficacy: Beware of overconfidence and risks of slips. Explore self-image as a non-smoker. Ask about planning for the future. Advise on the risks of taking even one puff. Assist with preparation for difficult situations. Relapse – Return from Action Stage or Maintenance Stage to an earlier stage. Relapse should be recognized as a normal event in the process of making behavioural change. Reengage clients in the process of quitting smoking. Provide positive reinforcement on any success and strong encouragement to remain abstinent.

Talking points  ell me about the last time you quit smoking. T What worked well? What could you do differently? • Do you mind if we review the pros and cons of quitting? • Are you ready to make a plan? • What would be a good day in the next two weeks to schedule a quit attempt? • What small changes do you think you can start to make in advance of your quit date? • What do you think will be the most difficult thing to deal with? How can you prepare yourself? • Is there someone who is going to help you through this? • Would you like to talk about medications? • Here is a number you can call for more support/ resources. •

 n a scale of 1 to 10, how confident are you about O making a quit attempt? Why? Why not lower? Why not higher? • How will you cope with urges and withdrawal? • Do you know/think there is a difference between a slip and a relapse? • Can I share some ideas that other people have found useful? • How will you reward yourself? What milestones will you celebrate? •

 here do you see yourself in one year? How does W smoking fit into your future? • What might tempt you to slip? What can you do to avoid a slip? • How do you know when you are entering a risky situation? • Imagine your worst-case scenario. How can you prepare yourself to cope with the cravings? •

 uitting for even one day is a success. Let’s look at Q what we can learn from what happened. • Tell me about the last time you quit. What worked well? What was your biggest challenge? • It sounds like you’ve had a lot of practice with quitting. What can you do differently this time? • Let’s review your quit plan and see what changes you think will make a difference. •

19

7. Increasing Motivation to Quit All tobacco-users benefit from proactive assistance to quit. Unwillingness does not predict clients’ response to treatment. Motivation can increase when effective treatment is offered. Motivation is a dynamic state that can be a product of how the clinician engages with clients. Working in a respectful, nonjudgmental, collaborative way with clients can be empowering, and greatly enhances the likelihood that clients will think about, prepare, and take action to quit.58 When your clients do not seem receptive to the idea of quitting, consider the non-judgmental approach developed by William Miller in the late 1980s59 as a way to enhance motivation for change. While the method may seem simple, it is not easy. However, many health professionals will already have the skills required in their clinical repertoire. It may take a little longer initially but, with practice, a motivational approach can easily be integrated into even a brief intervention. A motivational approach can increase your clients’ interest in quitting – without judging, lecturing or providing them with specific instructions. Motivational Interviewing (MI) is a collaborative, person-centred form of guiding to elicit and strengthen motivation for change.60 It is an evidence-based approach to working with clients who are perceived to be ambivalent and/or reluctant to change their behaviour.61

.

Motivational Interviewing is a conversation about change. The approach has a spirit, and several principles. It also requires competency in several core communication skills, and is commonly delivered with the aid of several tools or strategies such as OARS (see Core Communication Skills textbox). This section describes the spirit and core communication skills before elaborating on the principles and techniques. Even without formal training, there are a number of practical tips and strategies that practitioners can use to integrate a motivational approach into brief interventions.62 The approach is in line with the key principles of tobacco cessation including a nowrong-door approach and reframing quit attempts as learning opportunities. It is also a good fit given the chronic, relapsing nature of quitting tobacco use.

OARS

Core communication skills O – Asking skillful open-ended questions

A – Making well-timed affirmation R – Making frequent and skillful reflective listening statements

S – Using summaries to communicate understanding

20

the spirit of motivational interviewing (MI).

The spirit of the approach is characterized as being collaborative, autonomy-supporting and evocative.63 The practitioner works with and alongside clients, addressing their concerns and helping them make progress towards their goals. Clients are the active decision-makers. The motivational interviewing (MI) practitioner seeks to draw out concerns and solutions from clients while recognizing that they are the best expert in their life. The spirit of MI is essentially the mindset that is required when one approaches clients with a conversation about behaviour change.64

With respect to counselling “style,” practitioners are encouraged to emphasize personal choice and control and to work in partnership with the client. The four key principles of motivational interviewing summarize the essence of this approach.65

principles of Motivational Interviewing 1. Express empathy

3. Roll with resistance

.

Let clients know that they have been understood: “So you’re feeling angry because your parents made you come here and talk with me today, and you’re not even convinced that your smoking is a problem.”

2. Develop discrepancy Develop discrepancy between your clients’ behaviour and personal values: “So, on the one hand, you tell me that you want to be a good parent, but you also mention that you’re concerned about the example you are setting for your son by smoking. How does that fit for you?”

.

Meet resistance with reflection: “So you’re not so sure that you even need to consider changing your tobacco use right now.”

4. Support self-efficacy .

.

Express optimism that clients are capable of making the change: “I have seen other people succeed before with this exact level of tobacco use.”

The principles of developing discrepancy and rolling with resistance are especially important in brief cessation counselling. Often, clinicians are inclined to implement “action stage” strategies, while clients are still in the precontemplation or contemplation stages of the change process. On the next page, take a look at two different responses to a client in the precontemplation stage (not thinking about quitting in the next six months). The first response does not help to increase motivation while the second one does. 21

Two different responses to clients in the precontemplation stage (not thinking of quitting in the next six months)

what NOT to do: a counter-motivational response Client: I know you think I should be worried about my smoking, but I’m not. Health Practitioner (HP): Well perhaps you would consider trying the patch. Continuing to smoke will make your asthma even worse than it is now. Client: So yes, it’s bad for me, but things are really stressful right now. HP: Well, quitting smoking is one of the most important things you can do to improve your health. I really encourage you to consider the patch, or even attend a smoking cessation group. Client: Thanks, I know it’s a problem. I’ll think about it.

what TO do: a motivational response Client: I know you think I should be worried about my smoking, but I’m not. HP: So, from your perspective, you have absolutely no concerns about your smoking. So there is no point in exploring it. [rolling with resistance] Client: Not exactly. I’m a little concerned about my asthma. Smoking doesn’t help it. I’m just feeling so stressed right now. I can’t even think about quitting. HP: So, it’s not that you lack concern. You know smoking is affecting your health. It just doesn’t seem possible right now. [listening reflectively, developing discrepancy] Client: Yeah, that’s it. I need to do something but I just can’t imagine life without cigarettes. HP: Many people smoke to deal with stress. There are other ways to cope. Would it help to talk about stress and strategies to deal with it? [expressing empathy, asking permission, exploring barriers to change] Client: Sure.

In the first example, an “action strategy” is presented by the clinician as a response to a resistant client statement. The clinician is clearly the “champion” for change, while the client’s investment in change is minimal. This example is in line with evidence that smokers report increased resistance to their general practitioner’s regular inquiries regarding their smoking status.66 The second example illustrates how rolling with resistance and developing discrepancy can open up conversational ground and facilitate a discussion of possible cessation treatment. In this example, the client is more active in articulating reasons for change and exploring options. In addition, the example shows how motivational 22

interviewing (MI) can be incorporated in a very brief (i.e., 20 a day). Stop smoking before starting.

Several weeks to several months or longer if necessary.

Light smokers (< 10 a day) start at 14 or 7 mg. Heavy smokers (> 10 cigarettes a day) start at 21 mg and taper down.

8 to 12 weeks or longer if necessary.

For the first 3 to 12 weeks, use at least 6 cartridges per day – do not use more than 12 in one day. Inhaler has a flexible dosing system. One cartridge is used up after 20 minutes of continuous puffing.

Initial treatment duration is up to 12 weeks. For the following 6–12 weeks, dosage is gradually reduced. Use beyond 6 months not recommended.

Non-Nicotine Medication

...

Zyban™

.

Available only by prescription

Champix®

.

Available only by prescription

38

..

..

150 mg once a day for 3 days, then twice a day. 7 to 12 weeks or longer Start 7 to 14 days before quit date. if necessary.

.5 mg pill once a day for 3 days, then twice a day for 4 days, then 1 mg pill twice a day. Start 7 to 14 days before quit date.

12 weeks

Possible side effects

When NOT to take it

Advantages

Pregnant* Breastfeeding*

Check with your doctor if you are pregnant,* breastfeeding,* or have an unstable medical condition.

You can control when to take the nicotine and how much. Satisfies oral craving. Delays some weight gain while you use it.

Skin reaction at site of patch. Disturbed sleep, nightmares.

Pregnant* Breastfeeding*

Check with your doctor if you are pregnant,* breastfeeding,* or have an unstable medical condition.

You need only apply once daily. No chewing. Can control cravings for 24 hrs. Delays some weight gain while you use it.

Possible mild irritation of mouth or throat, cough during initial use. Stomach upset may occur.

Pregnant* Breastfeeding*

Check with your doctor if you are pregnant,* breastfeeding,* or have an unstable medical condition.

Can help relieve nicotine withdrawal symptoms and provide the comfort of the hand-to-mouth ritual.

Dry mouth Insomnia

If you drink more than 4 drinks a day; take St. John’s Wort.

If you are pregnant* or breastfeeding*; have a seizure disorder; eating disorder, take monoamine oxidase inhibitors.**

Inexpensive. Improves depression. Minimal weight gain while you use it.

Nausea Insomnia Dreams

Do not use with nicotine patch or gum. Watch for mood or behaviour changes.

If you are pregnant; hypersensitive to Varenicline, history of psychiatric illness.

Very effective. Well tolerated. Minimal side effects.

Cautions

...

...

Burning throat. Hiccups if chewed too quickly. Dental problems.

..

...

* Many doctors believe that using the nicotine patch or gum is better than smoking during pregnancy and while breastfeeding because, by stopping smoking, you are not inhaling thousands of toxic chemicals from cigarette smoke. ** Remember to tell your doctor about any other medications you are taking. It is always a good idea to check with your doctor before beginning any medications for smoking cessation Adapted from: Integrating Smoking Cessation into Daily Nursing Practice. RNAO, 2007

39

Appendix 5 Quit Day Plan Template .

.

Morning Plan:

Afternoon Plan:

Evening Plan:

In case of strong urges I will…

40

Appendix 5 Quit Day Plan Template – Completed Example .

.

Morning Plan:

Instead of my usual coffee and a cigarette after breakfast, I will have tea and sit in a different place at the table. I will pack a survival kit to take to work with me, with cut up raw veggies, toothpicks, sugar-free gu m, worry beads and elastic bands so I have something to do with my hands instead of smoking.

Afternoon Plan:

At break time I will run errands and walk to the bank (where I can’t smoke). I will get some exercise while doing my chores and keeping busy. I’ ll also take a water bottle with me so I drink lots of water, and can put something without calories in my mouth – instead of lighting up.

Evening Plan:

This evening I will go to the movies with my quit-smoking buddy. That way I get some support if I a m feeling tempted, and can enjoy a fun night out while in a place where I can’t smoke – even if I wanted to.

In case of strong urges I will…

Practice my deep breathing first, then call my quit-smoking buddy for a pep talk to remind me why I want to quit. I will head outside for a quick walk around the block. If I’m still tempted to smoke, I will go and look at my sleeping children tucked in their beds and remind myself that I want to be healthy and strong and around for them when they are all grown up and have children of their own. 41

Appendix 6 Personalized quit plan template Quitting takes hard work and a lot of effort, but –

YOU CAN

a personalized quit plan for:

QUIT SMOKING Want to quit? Nicotine is a powerful addiction. Many people try to quit several times before they quit for good. Quitting is hard, but don’t give up. Each time you try to quit, the more likely you will be to succeed GOOD REASONS FOR QUITTING? List your reasons for wanting to quit…

GET READY Have you set a quit date? If so, what is it? Have you thought about past quit attempts? What worked and what did not?

GET SUPPORT AND ENCOURAGEMENT Tell your family, friends and coworkers you are quitting. Talk to your health care provider. Get group, individual or telephone counselling. List two people who have agreed to support your quit attempt…

42

GET MEDICATION AND USE IT CORRECTLY Talk with your health care provider about which medication will work best for you. List the medications (if any) that you have decided to try…

LEARN NEW SKILLS AND BEHAVIOURS There are a variety of strategies you can try to help you quit smoking. These include: distracting yourself from urges to smoke, changing daily routines, reducing stress, or planning to do something specific when you have the urge to smoke. List the skills and behaviours you plan to use…

BE PREPARED FOR DIFFICULT SITUATIONS It often helps to identify potential triggers and prepare yourself for dealing with them. List your potential triggers and how you plan to cope…

REWARD YOURSELF! Quitting smoking is hard. How will you reward yourself? How often (after the first smoke-free day, at the end of your first smoke-free week, etc.). List the possibilities…

CONGRATULATIONS. You are on your way to being smoke-free

.

Adapted from U.S. Department of Health and Human Services Public Health Service (2008) http://www.ahrq.gov/clinic/tobacco/tearsheet.pdf

43

Appendix 7 The WHY Test .

.

Next, to the following statements, mark the number that best describes your own experience. 1 = Never 2 = Rarely 3 = Once in a while 4 = Most of the time 5 = Always A. I smoke to keep myself from slowing down

.

B. Handling a cigarette is part of the enjoyment of smoking it

.

C. Smoking is pleasant and relaxing

..

D. I light up a cigarette when I feel angry about something E. When I’m out of cigarettes, it’s near-torture until I can get them

..

F. I smoke automatically, without even thinking

.

G. I smoke when other people around me are smoking

.

H. I smoke to perk myself up

.

I. Part of enjoying smoking is preparing to light up .

J. I get pleasure from smoking

.

K. When I feel uncomfortable or upset, I light up a cigarette .

L. I’m very much aware of it when I’m not smoking a cigarette

.

M. I often light up a cigarette while one is still burning in the ashtray .

N. I often light up a cigarette with friends when I’m having a good time .

O. When I smoke, part of my enjoyment is watching the smoke as I exhale it

.

P. I want a cigarette most often when I’m comfortable and relaxed

.

Q. I smoke when I’m ‘blue’ and want to take my mind off what is bothering me .

R. I get a real craving for a cigarette when I haven’t had one in a while .

S. I’ve found a cigarette in my mouth and haven’t remembered that is was there

.

T. I always smoke when I’m out with friends at a party, bar, etc. U. I smoke to get a lift

.

44

Appendix 7 The WHY Test Scorecard .

.

Write the number you put beside each letter in the WHY Test beside the same letter on the scorecard

A ____ H ____ U ____ Stimulation total ____

B ____ I ____ O ____ Handling total _____

It Stimulates Me With a high score here, you feel that smoking gives you energy, keeps you going. So, think about alternatives that give you energy, such as washing your face, brisk walking and jogging. .

I Want Something In My Hand There are a lot of things you can do with you hands without lighting up. Try doodling with a pencil, knitting or getting a dummy cigarette you can play with. .

It Feels Good A high score means that you get a lot of physical pleasure out of smoking. Various forms of exercise can be effective alternatives. People in this category may be helped by the use of nicotine gum or a nicotine patch. .

C ____ J ____ P ____ Pleasure total ______

It’s A Crutch Finding cigarettes to be comforting in moments of stress can make stopping tough, but there are many better ways to deal with stress. Learn to use relaxation breathing or another technique for deep relaxation instead. People in this category may be helped by the use of nicotine gum or a nicotine patch. .

D ____ K ____ Q ____ Crutch total ________

I’m Hooked In addition to having a psychological dependency to smoking, you may also be physically addicted to nicotine. It’s a hard addiction to break, but it can be done. People in this category may be helped by the use of nicotine gum or a nicotine patch. .

E ____ L ____ R ____ Craving total _______

F ____ M ____ S ____ Habit total _________

It’s Part of My Routine If cigarettes are merely part of your routine, one key to success is being aware of every cigarette you smoke. Keeping a diary or writing down every cigarette on the inside of the pack is a good way to do it. .

I’m A Social Smoker You smoke in social situations, when people around you are smoking and when you are offered a cigarette. It is important for you to remind others that you are a non-smoker. You may want to change your social habits to avoid the triggers, which may lead to smoking again. .

G ____ N ____ T ____ Social total ________

45

References

.

1 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

28 Health Canada. (2011). Canadian Tobacco Use Monitoring Survey (CTUMS) Overview of historical data, 1999–2010. Retrieved from http://www.hc-sc.gc.ca/hc-ps/ tobac-tabac/research-recherche/stat/_ctums-esutc_2010/ann-histo-eng.php#tab1

2 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion.

29 Public Health Agency of Canada and First Nations Information Governance Centre (2011). First Nations Regional Health Survey Phase 2 (2008-2010). Retrieved from http:// www.phac-aspc.gc.ca/cd0mc/publications/diabetes-diabete/facts-figures-faits-chiffres2011?chap6-eng.php

3 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 4 Ibid. 5 Ibid. 6 CAN-ADAPTT (The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment) Retrieved from https://www. nicotinedependenceclinic.com/English/CANADAPTT/Guideline/Default.aspx. 7 Registered Nurses’ Association of Ontario. (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Retrieved from: http://www.tobaccofreernao.ca/sites/ tobaccofreernao.ca/files/BPG_smokingcessation-rev-2007C.pdf. 8 Canadian Community Health Survey (2010). Statistics Canada, Share File, Ontario Ministry of Health and Long Term Care. As cited in: Physicians for a Smoke-Free Canada. (2011). Tobacco Use in Canada: Findings form the CCHS: Current (daily and occasional) smoking in Canadian Provinces, 2000-2010. Retrieved from: http://www. smoke-free.ca/pdf_1/2011/Canada-2010-smokingratesbyprovince.pdf 9 Health Canada. (2011). Canadian Tobacco Use Monitoring Survey (CTUMS) Overview of historical data, 1999–2010. Retrieved from http://www.hc-sc.gc.ca/hc-ps/ tobac-tabac/research-recherche/stat/_ctums-esutc_2010/ann-histo-eng.php#tab1 10 Rehm, J., Baliunas, D., Brochu, S., Fischer, B., Gnam, W., Patra, J., et al. The costs of substance abuse in Canada 2002. (2006). Ottawa, ON: Canadian Centre on Substance Abuse 11 Doll, R., Peto, R., Boreham, J., & Sutherland, I. (2004). Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal, 328, 1519 – 1527. 12 U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 13 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. P 95. 14 Ibid. 15 Ontario Tobacco Research Unit. (2011). Smoke-Free Ontario Strategy evaluation report: Ontario Tobacco Research Unit special report. Toronto, ON: Ontario Tobacco Research Unit. 16 Reid, J. L., & Hammond, D. (2011). Tobacco use in Canada: Patterns and trends, 2011 Edition. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. 17 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. 18 Ibid. 19 Ibid. 20 Ontario Tobacco Research Unit. (2011). Smoke-Free Ontario Strategy evaluation report: Ontario Tobacco Research Unit special report. Toronto, ON: Ontario Tobacco Research Unit. 21 Ibid. 22 Lancaster, T., & Stead, L. F. (2004) Physician advice for smoking cessation. Cochrane Database of Systematic Reviews (4). Art. No.: CD000165. 23 Els, C. & Kunyk, D. (2009). Benefits and risks of tobacco cessation: The fundamental importance of cessation must be recognized. Smoking Cessation Rounds, 3(4), 1-6. Retrieved from http://www.smokingcessationrounds.ca/crus/ screng0407.pdf 24 Els, C. (2008). Tobacco Addiction: What do we know, and where do we go? Retrieved from: http://www.newswire.ca/en/releases/mmnr/smr/ WhitePaperTobaccoAddiction.pdf 25 Torrijos, T. & Glantz, S. (2006). The U.S. Public Health Service “treating tobacco use and dependence clinical practice guidelines” as a legal standard of care. Tobacco Control, 15(6), 447-451. 26 Ontario Tobacco Research Unit. (2011). Smoke-Free Ontario Strategy Evaluation Report: Ontario Tobacco Research Unit special report. Toronto: Ontario Tobacco Research Unit. 27 Ibid.

46

30 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. 31 Cohen, B., Schultz, A. & Walsh, R. (2011). Exploring issues of equity within Canadian tobacco control initiatives: An environmental scan. Unpublished report. 32 Cohen, B., Schultz, A. & Walsh, R. (2011). Exploring issues of equity within Canadian tobacco control initiatives: An environmental scan. Unpublished report. 33 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. P 142. 34 Cohen, B., Schultz, A. & Walsh, R. (2011). Exploring issues of equity within Canadian tobacco control initiatives: An environmental scan. Unpublished report. 35 Ibid. 36 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. P 119. 37 Reid, J.L., Hammond, D., Burkhalter, R., Ahmed, R. (2012). Tobacco Use in Canada: Patterns and Trends, 2012 Edition. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. 38 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 39 Reid, J.L., Hammond, D., Burkhalter, R., Ahmed, R. (2012). Tobacco Use in Canada: Patterns and Trends, 2012 Edition. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. 40 The Royal Society of Canada. (1989). Tobacco, nicotine, and addiction/tabac, nicotine et toxicomanie. 41 Benowitz, N. L. (1990). Clinical pharmacology of inhaled drugs of abuse: implications in understanding nicotine dependence. In Research findings of smoking of abused substances. NIDA Research Monograph 99 (pp. 12–29). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. 42 Health Canada. (2003). Canadian Tobacco Use Monitoring Survey (CTUMS) Quitting Smoking. Retrieved from http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/researchrecherche/stat/_ctums-esutc_fs-if/2003-quit-cess_e.html 43 Health Canada. (2005). Health Concerns: Benefits of quitting. Retrieved from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/now.maintenant/road-voie/ benefits-avantages-eng.php 44 Mahmud, A., & Feely, J. (2003). Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension, 41(1), 183-187. 45 United States Department of Health and Human Services. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease. A report of the Surgeon General. Washington, D.C: Department of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 46 United States Department of Health and Human Services. (1988). The health consequences of smoking: Nicotine addiction. A report of the Surgeon General. Rockville, Maryland: Department of Health and Human Services, Centres for Disease Control and Prevention, Centre for Health Promotion and Education, Office on Smoking and Health. 47 Ibid. 48 Ibid. 49 Ibid. 50 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 51 Ibid. 52 Prochaska, J. O., Redding, C. A., & Evers, K. (2002). The transtheoretical model and stages of change. In: Glanz, K., Rimer,B. K., Lewis, F. M. (Eds.). Health behavior and health education: Theory, research, and practice (3rd ed., p.99-120). San Francisco, CA: Jossey Bass. 53 West, R. (2005). Time for a change: Putting the Transtheoretical (Stages of Change) Nodel to rest. Addiction, 100(8), 1036-1039. 54 Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 1–12.

55 Prochaska, J. O., Redding, C. A., & Evers, K. (2002). The transtheoretical model and stages of change. In: Glanz, K., Rimer,B. K., Lewis, F. M. (Eds.). Health behavior and health education: Theory, research, and practice (3rd ed., p.99-120). San Francisco, CA: Jossey Bass. 56 Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for Good. The revolutionary program that explains the six stages of change and teaches you how to free yourself from bad habits. New York: William Morrow and Company. As cited in Mason, P. (2001). Helping Smokers Change: A Resource Pack for Training Health Professionals. Copenhagen: World Health Organization Regional Office for Europe. Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0017/120293/E73085.pdf 57 Cancer Prevention Research Center at the University of Rhode Island. Detailed Overview of the Transtheoretical Model. Retrieved from: http://www.uri.edu/research/ cprc/TTM/detailedoverview.htm 58 TEACH Project. (2010).Fundamentals of tobacco interventions. Toronto, ON: Centre for Addiction and Mental Health. 59 Moyers, T. B. (2004). History and happenstance: How motivational interviewing got its start. Journal of Cognitive Psychotherapy: An International Quarterly18(4), 291-298. 60 Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 1–12. 61 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 62 Herie, M., & Selby, P. (2007). Getting beyond “Now is not a good time to quit smoking” Increasing motivation to stop smoking. Smoking Cessation Rounds, 1(2). Retrieved from http://www.smokingcessationrounds.ca/crus/screng0407.pdf 63 Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 1–12. 64 Rosengren D. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. NY, NY. Guilford. 65 Moyers, T.B. (2004). History and Happenstance: How motivational interviewing got its start. Journal of Cognitive Psychotherapy: An International Quarterly,18(4), 291-298. 66 Butler, C., Pill, R., & Stott, N. (1988). Qualitative study of patients’ perceptions of doctor’s advice to quit smoking: implications for opportunistic health promotion. British Medical Journal, 316,1878-1881. 67 Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press. 68 Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press. 69 Ontario Medical Association. (2008). Stop-Smoking Medications: Treatment Myths and Medical Realities. Retrieved from https://www.oma.org/HealthPromotion/Tobacco/ Pages/default.aspx 70 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 71 Cahill, K., Stead, L. F., & Lancaster, T. (2011). Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, 2, Art. No. CD006103. 72 U.S. Department of Health and Human Services. (1989). Reducing the health consequences of smoking: 25 years of progress: a report of the Surgeon General. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 73 Wu, P., Wilson, K., Dimoulas, P., & Mills, E. J. (2006). Effectiveness of smoking cessation therapies: a systematic review and meta-analysis. BMC Public Health.6,300. 74 Fiore, M. C., Jaen, C. R., Baker, T .B., et. al. (2008). Treating tobacco use and dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 75 Hughes, J. R., Stead, L. F., & Lancaster, T. (2007). Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews, 1, Art No. CD000031. 76 Biovail Corporation.(2004). Product monograph on Zyban.® Mississauga, ON: Biovail Corporation.. Retrieved from http://www.biovail.com/english/products/default.asp?s=1&product=253&viewer=patien t&state=displayProduct&country=Canada. 77 Gonzales, D., Rennard, S. I., Nides, M., Oncken, C., Azoulay, S., Billing, C. B., et al. (2006). Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. Journal of the American Medical Assocation,296(1):47-55. 78 Cahill, K., Stead, L. F., & Lancaster, T. (2011). Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, 2, Art No. CD006103. 79 Pfizer Canada. (2010). Health Canada endorsed important safety information on CHAMPIX (varenicline tartrate). Retrieved from http://www.hc-sc.gc.ca/dhp-mps/ medeff/advisories-avis/prof/_2010/champix_2_hpc-cps-eng.php

80 Health Canada. (2012). Information Update: Champix: Updated safety information for the smoking-cessation drug. Retrieved from http://www.hc-sc.gc.ca/ahc-asc/media/ advisories-avis/_2012/2012_07-eng.php 81 Godtfredsen, N. S., Holst, C., Prescott, E., Vesetbo, J., & Osler, M. (2002). Smoking reduction, smoking cessation, and mortality: a 16-year follow-up of 19,732 men and women from the Copenhagen Centre for Prospective Population Studies. American Journal of Epidemiology, 156 (11), 994-1001. 82 Fiore, M. C., Jaen, C. R., Baker, T.B., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 83 White, A. R., Rampes, H., Liu, J. P., Stead, L. F., & Campbell, J. (2011). Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews, 1, Art. No. CD000009. 84 Barnes, J., Dong, C. Y., McRobbie, H., Walker, N., Mehta, M., & Stead, L. F. (2010). Hypnotherapy for smoking cessation. Cochrane Database of Systematic Reviews, 10, Art. No. CD001008. 85 White, A. R., Rampes, H., Liu, J. P., Stead, L. F., & Campbell, J. (2011). Acupuncture and related interventions for smoking cessation. Cochrane Database of Systematic Reviews, 1, Art. No. CD000009. 86 Benowitz, N. L. (1990). Clinical pharmacology of inhaled drugs of abuse: implications in understanding nicotine dependence. In Research findings of smoking of abused substances. NIDA Research Monograph 99 (pp. 12 – 29). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. 87 U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease: The Biology and Behavioural Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from: http://www.surgeongeneral.gov/library/reports/tobaccosmoke/full_report.pdf 88 Reid, J.L., Hammond, D., Burkhalter R, Ahmed R.(2012). Tobacco Use in Canada: Patterns and Trends, 2012 Edition. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. 89 Cahill, K., Stead, L. F., & Lancaster, T. (2011). Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, 2, Art. No. CD006103. 90 Health Canada (2009). Health Canada advises Canadians not to use electronic cigarettes. Advisory 2009-53. Available at: http://www.hc-sc.gc.ca/ahc-asc/media/ advisories-avis/_2009/2009_53-eng.php 91 Tilson, M. (2011). E-cigarettes: Harm reduction panacea or tobacco control nightmare? Presentation slides from Smoking and Health Action Foundation/NonSmokers’ Rights Association Emerging Issues Workshop, Central East Tobacco Control Area Network, December 2, 2011. 92 Health Canada. (2011). Canadian Tobacco Use Monitoring Survey (2010) – Supplemental Tables-Annual. Retrieved from http://www.hc-sc.gc.ca/hc-ps/tobactabac/research-recherche/stat/_ctums-esutc_2010/ ann-eng.php 93 Fiore, M. C., Jaen, C. R., Baker, T. B., et. al. (2009). Treating tobacco use and dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. 94 Bassel, M., Elizabeth, S., Najat, S., & Alan, S. (2008). Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food and Chemical Toxicology, 46, 2991–2995. 95 Elizabeth, S., Najat, S., & Alan, S. (2010). Carcinogenic PAH in waterpipe charcoal products. Food and Chemical Toxicology, 48(11), 3242-3245. 96 Ontario Tobacco Research Unit. (2011). OTRU Update: Waterpipe smoking: a growing health concern. Toronto, ON: Ontario Tobacco Research Unit. 97 U.S. Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. 98 Matt, G. E., Quintana, P. J., Gundel, L. A., et al. (2011). Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Environmental Health Perspectives, 119(9), 1218-1226. 99 Smoke-Free Ontario – Scientific Advisory Committee. (2010). Evidence to Guide Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. 100 Matt, G. E., Quintana, P. J., Gundel, L. A., et al. (2011). Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Environmental Health Perspectives, 119(9), 1218-1226.

47