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Keep Our University Free From Smoking. Submitted To King Saud University Program:. Ata Ulhaq, MD, FACEP, MPH. Smoke - Free Environment. Smoking Cessation [stopping smoking]. Represents the single most important step to enhance length and quality of life - PowerPoint PPT Presentation
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2009 Atwood & Clark Consultants Keep Our University Free From Smoking Ata Ulhaq, MD, FACEP, MPH Submitted To King Saud University Program: Smoke - Free Environment
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Page 1: Keep Our University  Free From Smoking

2009 Atwood & Clark Consultants

Keep Our University Free From Smoking

Ata Ulhaq, MD, FACEP, MPH

Submitted To King Saud University Program:

Smoke - Free Environment

Page 2: Keep Our University  Free From Smoking

2009 Atwood & Clark Consultants

Smoking Cessation [stopping smoking]

Represents the single most important step to enhance length and quality of life

Quitting smoking is not easy, but you can do it To have the best chance of success in quitting, you

need to know: what you're up against what your options are where to go for help

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Pathology of Smoking

Acute myeloid leukemia

Alzheimer’s Lupus SIDS Colic in babies Impotence Various cancers

Macular degeneration

Rheumatoid arthritis

Acid reflux Breast cancer Depression Thyroid disease

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Cardiovascular Pathology • Firmly established risk factor for

coronary heart disease and peripheral vascular disease

• Twofold or greater risk of coronary heart disease among smokers

• Severe atherosclerosis of the abdominal aorta

much greater risk of aortic aneurysm peripheral vascular disease

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Atherosclerosis

development of

atherosclerosis in

an artery

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Physiologic Responses• Accelerating atherogenesis or increasing the

probability of thrombosis reduction in plasma high-density lipoprotein cholesterol concentration elevation in plasma fibrinogen concentration

elevation in white blood cell count

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Smoker vs. Non Smoker

31 year old non-smoker

30 year old smoker

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Reversible

The rapid amelioration of the risk of cardiovascular disease after cessation of smoking suggests that these processes are readily reversible

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Cancers

Aside from the obvious lung cancer, smoking contributes to many other cancers of the body

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Cancer of the Oral Cavity

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Pharynx

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Esophagus

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Stomach

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Bladder

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Cervix

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Kidney Cancer

Advanced renal carcinoma

Papillary renal carcinoma

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Pancreas

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Carbon Monoxide - CO What Carbon

Monoxide is: CO is a poisonous,

colorless, odorless gas produced as a result of incomplete burning of carbon-containing fuels

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CO

What Happens When CO is Inhaled: When inhaled, CO quickly binds with

hemoglobin in red blood cells in the lungs, creating COHb

This can affect the amount of hemoglobin available for the transport of oxygen throughout the body

May in turn lead to symptoms of CO poisoning

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Carbon Monoxide in Cigarette Smoke

Cigarette smoke can contain high levels of carbon monoxide

Smokers generally have COHb levels in the blood that are many times greater than those who do not smoke

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CO and Secondhand Smoke

Because secondhand smoke may also contain high levels of CO, nonsmokers who breathe in ETS (Environmental Tobacco Smoke) have increased levels of CO in their blood as well

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CO and Secondhand Smoke

Secondhand smoke is a toxic cocktail of: over 4,000 chemical compounds 200 of which are known to be poisonous upwards of 60 that have been identified as

carcinogens

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Smoking During Pregnancy

When a pregnant woman smokes, her baby does too Poisons like carbon monoxide and nicotine travel to

the growing baby Prevents as much as 25 % of oxygen from reaching

the placenta Keeps baby from getting enough food More likely to deliver early or baby of low birth

weight

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Smoking and Pregnancy

Mothers can pass nicotine through breast milk

Nicotine can be found in mucus from the cervix of a female smoker

Nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants

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Smoking During Pregnancy, cont’d.

Children born to women who smoked during pregnancy are more likely to develop asthma and other lung problems as they grow older

May learn more slowly Infants are more likely to develop colds,

bronchitis, and other respiratory diseases if secondhand smoke is present in the home

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Smoking and Women

Female smokers are nearly 13 times more likely to die from COPD

Smoking is directly responsible for more than 90% of chronic obstructive pulmonary disease (COPD), or emphysema and chronic bronchitis deaths each year

Women who smoke also have an increased risk for developing cancers of the oral cavity, pharynx, larynx (voice box), esophagus, pancreas, kidney, bladder, and uterine cervix

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Smoking and Women Women who smoke double their risk for developing

coronary heart disease Postmenopausal women who smoke have lower

bone density Women who smoke have an increased risk for hip

fracture Cigarette smoking also causes skin wrinkling that

could make smokers appear less attractive and prematurely old

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Smoking and Women

Women who quit smoking relapse for different reasons than men Stress Weight control Negative emotions

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Smoking Among Seniors

Seniors face increased risks associated with smoking

hip fractures (both men and women)CataractsCOPDSmoking reduces bone density among menopausal

womennuclear cataracts of the lens of the eye (2-3 times the

risk of nonsmokers)

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Thank YouThank You

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Nicotine and Addiction

Part II

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Nicotine & Addiction

Why is quitting and staying quit hard for so many people?

Answer = Nicotine

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Addiction

Compulsive physiological/psychological need for a habit-forming substance

Dependence on a behavior or substance that one is powerless to stop

One of the most costly public health problems

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Addiction

A progressive syndrome; increases in severity over time unless treated

Characterized by frequent relapse, or return to the abused substance

Abusers often make repeated attempts to quit before they are successful

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Nicotine & Addiction

Nicotine: Drug found naturally in tobacco Highly addictive -- as addictive as heroin or cocaine Over time, a person becomes physically/emotionally

addicted to nicotine Studies show smokers must deal with both the

physical and psychological (mental) dependence to quit and stay quit

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Physical Dependence

“the appearance of characteristic withdrawal symptoms when the use of a substance is suddenly discontinued"

Nicotine is considered physically addictive because it physically alters your brain function

It produces withdrawal symptoms when you stop smoking

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Physical Dependence

Physical dependence is defined by the appearance of withdrawal symptoms when use is discontinued

Opiates (such as Herion) Benzodiazepines Barbiturates Alcohol Nicotine

Induce physical dependence

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Physiological Effects

When you inhale, nicotine is carried deep into your lungs

Absorbed quickly into the bloodstream Nicotine inhaled reaches the brain faster

than drugs that enter the body intravenously (IV)

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Physiological Effects

Nicotine affects many parts of the body: heart blood vessels hormones metabolism brain

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Physiological Effects cont’d.

Nicotine produces pleasant feelingsMakes the smoker want to smoke

more

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Physiological Effects cont’d.

Acts as a depressant by interfering with the flow of information between nerve cells

As the nervous system adapts to nicotine, smokers increase the number of cigarettes they smoke

This, in turn, increases the amount of nicotine in the smoker's blood

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Withdrawal Symptoms dizziness (which may

only last 1 to 2 days after quitting)

depression feelings of frustration,

impatience, and anger anxiety irritability increased appetite

sleep disturbances, i.e. trouble falling asleep/staying asleep, bad dreams or even nightmares

trouble concentrating restlessness headaches tiredness

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Psychological Addiction Much more complex than physical addiction Does not involve the nicotine in cigarettes or

the physical effects the nicotine has on your brain

Psychological dependence transpires when a person develops a daily routine and a habit of actually smoking the cigarettes

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Psychological Addiction: Pleasure

Smoking gives pleasure This "pleasure" comes in many ways:

the tactile pleasure of handling the cigarette oral pleasure of drawing on the cigarette "quick fix" in times of anxiety anger and stress social pleasure of smoking in situations of good

feelings such as bars, pubs or sporting events.

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Addiction: Psychological Aspects

To feel good (sensation seeking) To feel better (self-medicating) Move quickly from the voluntary period of

drug use to compulsive behavior motivated by craving

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Loss of control over use Continued use despite negative physical and

social consequences Believed to be strongly associated with

brain’s reward system

Addiction: Psychological Aspects

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Psychological Dependence

Dependency of the mind Leads to psychological withdrawal

symptoms CravingsIrritabilityInsomniaDepressionAnorexia, etc.

Addiction can be derived from any rewarding behavior

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Psychological Triggers

These triggers are usually brought on by stressful situations such as an argument, vehicle accident, not getting enough sleep or other demanding situations

You need to be able to recognize these stressful situations and react to them appropriately

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Psychologically Hooked

Over time, you become used to smoking in these situations

Your mind associates smoking with them and the pleasure that comes with them

You find yourself lighting up even if you aren't physically craving the nicotine...without even thinking about it!

At this point, you are psychologically hooked

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Why People Start & Continue SmokingStart

Desire to look cool Seduced to try tobacco by

glamorization of smoking in movies and advertisements

Peer pressure Rebellion Poor coping skills Social habit became

addiction

Continue Physical addiction Mental addiction Stress Around other

smokers Rely on pills/patches

rather than willpower

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You Generally Start Smoking

in an attempt to… change your self-image appear more attractivemore manlymore femininemore intelligent

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Sometimes You Start Smoking

in a misguided attempt to… calm your nerves cope with stress lose weight

Smoking does not help solve the source of your problems or compensate

for poor eating habits

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Other Reasons for Smoking

On a dare to show you are not timid or afraid To fit with the crowd (all my friends do it) To appear sophisticated or cool To be grown-up To assert your independence As a sign of protest, rebellion, or to defy authority Free samples from friends or advertisers

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Still More Reasons…

Influences from people you respect and admire

Parents or relatives smoked Images of famous actors, movie stars, or

role models

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Still More Reasons… Sports players who use chewing tobacco Famous scientists

(Einstein is the prototype of intellectual smokers; he looks so proud with a pipe in his mouth)

Portrayals by cigarette advertisements As a kind of "air freshener" when using the

toilet

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Reasons for Continuing

No particular reason, but the cigarettes are handy To reduce a feeling of anxiety or nervousness To calm down when upset or angry To socialize with other smokers When feeling restless As relaxation

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Reasons for Continuing Cont’d.

To take a break from work While having coffee or tea When having a drink with friends To satisfy an urge to smoke After a meal

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Reasons for Continuing Cont’d.

To pass the time while waiting for someone

When driving in the car When feeling depressed When drinking beer, wine, or liquor To celebrate something To think about a difficult problem

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You Have Been Smoking for a While

Now you know that smoking has not made youSmarterCoolerSexier

Smoking has not helped you to achieve your goals You are more aware your health suffers

Burning eyesHacking coughPhlegm in your throat So…

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Why Do You Still Smoke?

Out of habitPeople smoke under specific situations

as a kind of ritual Associating activities with smoking

establishes Pavlovian reflexes

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Pavlovian Reflexes

Named after Dr. Ivan Pavlov who was able to make his dogs salivate in the absence of food by just ringing a bell that had been associated with the dog's feeding time

In the same way, activities you associated with smoking (drinking coffee) will act as triggers

The mere sight of a cup of coffee will cause you to reach for your cigarettes without any conscious thought

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Triggers Seeing friends

smoking cigarettes Watching movies

where actors smoke Smell of cigarette

smoke may trigger the psychological desire to smoke

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The Insular Researchers found smokers

with a damaged (due to stroke) insula, a region of the brain linked to emotion and feelings, quit smoking easily and immediately

Provides direct evidence that addiction to nicotine takes control of some of the neural circuits in the brain

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Ventral Tegmental Area

Brain’s reward circuit are located along the medial forebrain bundle (MFB)

Brain’s punishment circuit (the periventricular system, or PVS) enables us to cope with unpleasant situations

Two major systems of motivation in humans

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Ventral Tegmental Area Neurobiological foundations of addiction

traced to the VTA – “reward circuit” Reward system in the brain is activated when

a person performs an action necessary to survival, such as eating

Activation of the reward circuit provides pleasurable feelings, gives positive feedback

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Ventral Tegmental Area Most abused drugs stimulate the reward system Provide greater pleasure than normally the result of

natural stimulation The reward system underlies addiction to tobacco Many drugs cause physical addiction by affecting

the levels of neurotransmitters, specifically dopamine and glutamate, in the reward circuit of the VTA

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Epinephrine

Immediately after exposure to nicotine, there is a "kick" caused by stimulation of the adrenal glands and resulting discharge of epinephrine (adrenaline)

This stimulates the body causing a sudden release of glucose, and an increase in blood pressure, respiration, and heart rate

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Norepinephrine

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

Nicotine stimulates specific excitatory systems in the brain

These systems excite not only dopamine but a host of other brain chemicals, such as norepinephrine and serotonin

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Acetylcholine Every nerve in your brain and nervous system

communicates with other cells by sending out tiny neurotransmitters (chemical messengers)

These are received by the receptors of the other cell Nicotine acts on the receptors that are normally used by

a main neurotransmitter called acetylcholine Essentially tricking your body into thinking the nicotine

is extra acetylcholine

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AcetylcholineWhen you started smoking, your

body began responding to the nicotine thinking it was extra acetylcholine

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AcetylcholineAs you continued to smoke, your body

began to adapt to this "extra" acetylcholine

How? By growing extra acetylcholine receptors!

This is the way that nicotine physically alters your brain function

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Over the years, your body has become used to what it thinks is a normal level of acetylcholine

If you were to suddenly stop smoking, your body would react, thinking it was being deprived of this neurotransmitter

Seeking equilibrium, subconsciously your body tells you that you must get more acetylcholine

This is where the craving for nicotine comes from

Acetylcholine

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After a day or two of not smoking, cells begin adapting again by decreasing the amount of acetylcholine receptors

Nicotine cravings begin to subside In fact, the physical addiction to nicotine

can be broken in a matter of days

Acetylcholine

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So why is smoking considered so difficult to give up if nicotine addiction is gone in a few days?

Breaking the physical addiction to nicotine is actually half the battle

Acetylcholine

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Treatment

Once the foundations ofunderstanding addiction have

been laid, the next obviousquestion is how to treat it.

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1. Pre-contemplation: smoking isn't a problem

2. Contemplation: smoking has disadvantages, but I'm not yet ready to quit

3. Preparation: you want to quit and you prepare to quit

Seven Phases of Behavior Modification

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Seven Phases of Behavior Modification

4. Action: you stop smoking 5. Maintenance: you are more

comfortable as a non-smoker 6. Termination: you are a non-smoker 7. Relapse: Back to Phase 2

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B. F. Skinner

Behavior modification is based on the principles of operant conditioning

Developed by American behaviorist B. F. Skinner (1904-1990)

Formulated the concept of operant conditioning

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B. F. Skinner

Behavior shaped by reinforcement or lack of it

Considered his concept applicable to a wide range of both human and animal behaviors

Introduced operant conditioning to the general public in his 1938 book, The Behavior of Organisms

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Behavior Modification

Behavior modification is a treatment approach

Based on the principles of operant conditioning

Replaces undesirable behaviors with more desirable ones through positive or negative reinforcement

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Behavior Modification Positive incentives Negative incentives/Aversive techniques Self-monitoring-keeping a “smoking diary” Step-wise decreasing of agent (nicotine) Stimulus control Contingency management-drawing up contract Coping skills Peer pressure

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Successful Behavior Modification

The success of this approach/technique is dependent on the following environments:

PsychosocialEconomicalReligiousPolitical Educational

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Positive Reinforcement Encourages certain behaviors through system of

rewards Draw up a contract with the client establishing

terms of the reward system Small rewards or recognition programs (t-shirt, pin,

certificate) Providing nicotine replacement products at no cost Reducing insurance premium differentials between

smokers and non-smokers

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Additional Incentives Adding cash to a flexible spending account to

pay for enrolling in a tobacco cessation program

Joining program gets reward Anything economically and socially

acceptable Academic reward Different incentives at different stages

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Negative ReinforcementAnother behavior modification technique

is negative reinforcementMethod of training that uses a negative

reinforcer

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Negative ReinforcementCharging smokers higher insurance

premiumsNegative reinforcer is an event or

behavior whose reinforcing properties are associated with its removal

Example: terminating an existing electric shock after a rat presses a bar is a negative reinforcer.

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Aversive/Punishment Use of electric shock as a punishing stimulus as is

done in the Schick program to eliminate smoking behavior has had limited success

In satiation treatment, subjects are required to increase the number of cigarettes smoked and the rate at which they are smoked

Rapid smoking requires the subject inhale from a cigarette once every six seconds for the duration of the cigarette or until nauseated

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Punishment

In addition to rewarding desirable behavior, behavior modification can also discourage unwanted behavior through punishment

Punishment is the application of an aversive or unpleasant stimulus in reaction to a particular behavior

Penalties Financial fines Extreme -- +education

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Extinction

The removal of reinforcement altogether is called extinction

Extinction eliminates the incentive for unwanted behavior by withholding the expected response

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Thank YouThank You

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Day 2: How To Quit

Ata Ulhaq, MD, FACEP, MPH

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4 Key Factors

Making the decision to quit Setting a quit date and choosing a quit plan Dealing with withdrawal Staying quit (maintenance)

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How Do People Change?

Decision only individual can make

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Health Belief Model

More likely to stop if you:Believe you could get smoking related disease

and this worries youBelieve you can make an honest attemptBelieve the benefits of quitting outweigh the

benefits of continuingKnow someone who has had health problems

from smoking

American Cancer Society

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Stages of Change

Pre-contemplation Contemplation Preparation Action Maintenance

American Cancer Society

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Stages of ChangePrecontemplation

Contemplation

Preparation

Action

Maintenance TerminationRelapse

Don’t want to quit

Want to quit sometime

Will quit in next 30 days

Am quitting now

American Cancer Society

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Preparing to Quit

Pick a Quit Day, mark your calendar Plan for prescriptions (Zyban, Chantix) Tell friends and family about Quit Day

American Cancer Society

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Preparing to Quit

Rid home, car and work of all ashtrays and cigarettes

Stock up on oral substitutes (gum, carrot sticks, hard candy, toothpicks)

Decide on a plan Set up support system (group, class, family,

friend)

American Cancer Society

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On Quit Day

Do not smoke! Keep active Drink water, juices Nicotine replacement Attend class

Avoid situations that trigger urge to smoke

Reduce or avoid alcohol

Change your routine

American Cancer Society

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Realizations

Definition: mistaken thought that makes sense at the time, but is not based on reality I’ll just have one Today is not good, I’ll quit tomorrow It’s my only vice How bad is it, really? Air pollution is probably just as bad

American Cancer Society

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Avoid Temptation

Change your habits Alternatives: hard candy, coffee stirrer, etc. Activities: Exercise, needlework, woodworking Deep Breathing Delay: If you feel you are about to light up,

delay

American Cancer Society

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Get Through Tough Times

Review reasons for quitting Think of benefits: health, finances, family There is no such thing as just one cigarette or

just one puff Ride out the desire Avoid drinking alcohol Avoid weight gain by staying active

American Cancer Society

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Useful Tools

Beck’s Depression Inventory Family and Personal Development Rating

Scale (social history) These can help establish a percentage rating to

determine “State of Readiness”

Atwood and Clark Consultants

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Freedom From Smoking

Highly structured comprehensive behavior modification approach to smoking cessation in a group support setting

American Lung Association

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Freedom From Smoking

Based on premise that smoking is learned behavior

Seven session format provides tracking personal habits developing coping strategies supportive environment with others who are

experiencing the same feelings and challenges

American Lung Association

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Thinking About Quitting

Session 1: Three-Link Chain of Addition. Physical,

mental and social aspects of addiction Benefits of Quitting. Physiological rewards Registration. Time to decide if ready Triggers and Coping. Prompts and effective

ways to change behaviors Medications. Present medications

American Lung Association

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On the Road to Freedom

Session 2 Self-Management. Techniques to help

participants get past triggers Stress management. Discuss ways to

counteract harmful feeling of stress Assessing Nicotine Dependence. Learn about

personal nicotine addiction. Review medications that help smokers quit

American Lung Association

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Wanting to Quit

Session 3 Increasing Motivation. Reinforce “whys”

behind quitting Social Support. Build a buddy system from

within the group Making a Quit Plan. Design a plan to help

succeed Relapse Prevention. Identify high-risk

situations

American Lung Association

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Quit Day

Session 4 (Follow up with Session 5 within 48 hours) Panel of Ex-Smokers. Listen to other’s personal experiences with

quitting Quitting ceremony. A formal way to say goodbye to cigarettes Contracts and Rewards. Sign a 2-day contract not to smoke and

list rewards Recovery Symptoms. Explain the physical and psychological

symptoms of quitting smoking Overcoming Cravings. Special techniques to use when cravings

come

American Lung Association

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Winning Strategies Session 5

48-Hour Report. Assess short-term coping skills The Grief Cycle. Understand the physiological recovery from

nicotine addition Benefits of Quitting. Discuss medical/non-medical benefits Coping Strategies. Review strategies for dealing with physical,

mental and social aspects of quitting Refining the Quit Plan. Fine tune the original plan Stress Management. More exercises to improve relaxation

American Lung Association

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The New You

Session 6 Progress Review. Assess participants’ success to date. Lifestyle changes. Ways to encourage lifetime abstinence. Weight Management. Introduce ways to control weight. Staying Smoke-Free. Overview of program and tips on

long-term abstinence. Social Situations. Learn to handle risky social situations

carefully.

American Lung Association

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Staying Off

Session 7 Physical Activity. A realistic approach to

physical activity. Changing Your Self-Image. Become a non-

smoker. Assertive Communication. Learn to

communicate in ways that help to handle stress.

American Lung Association

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Celebration!

Session 8 Rewarding New Behaviors. Appreciate current

success. Relapse Prevention. Continue with techniques

that support not smoking. Challenge Your Thinking. Learn to think

differently. Completion Ceremony. Recognize and celebrate

completion of the program.

American Lung Association

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Ultimate Goal – Complete Abstinence

Even in instances when complete abstinence from smoking is not achieved, smoking cessation pharmacotherapies may benefit individual health - and ultimately the public’s health if the smoker reduces the number of cigarettes smoked.

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Ultimate Goal – Complete Abstinence

Relationship between cigarette smoking and lung cancer, and other smoking-associated malignancies, is strongly dose-dependent.

Individual smoker who is unable or not motivated to quit may benefit by using pharmacotherapies (or other means) to reduce the number of cigarettes smoked per day.

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Pharmacological Adjuncts

Bupropion HCl is a non-nicotine aid to smoking cessation.

Relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine, and does not inhibit monoamine oxidase.

Exact mechanism by which bupropion HCl enhances ability of patients to abstain from smoking is unknown.

Presumed that this action is mediated by noradrenergic or dopaminergic mechanisms.

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Theoretical Reasons Antidepressants Help

Two theoretical reasons to believe antidepressants might help in smoking cessation: Nicotine withdrawal may produce depressive symptoms or

precipitate a major depressive episode and antidepressants may relieve these.

Nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect.

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More on Antidepressants

Alternatively, some antidepressants may have a specific effect on neural pathways underlying nicotine addiction, (e.g. blocking nicotine receptors) independent of their antidepressant effects.

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Questions?

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How To Quit

Part 2

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Find reasons to quit that are important to you. Think of more than just health reasons. For example, think of: How much money you'll save by not buying cigarettes The time you'll have for yourself instead of taking

cigarette breaks, rushing out to buy a pack, or searching for a light

Not being short of breath or coughing as much Setting a better example for your children

Smokefree.gov

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Write Down Why You Want To Quit

List ways to fight the urge to smoke, too. (You will find tips for coping later in this guide.)

Keep your list where you'll see it often. Good places are: Where you keep your cigarettes In your wallet or purse In the kitchen In your car

Smokefree.gov

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Reasons for Quitting

1. I will feel healthier right away. I will have more energy and better focus. My senses of smell and taste will be better. I will have whiter teeth and fresher breath. I will cough less and breathe better.

Smokefree.gov

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Reasons for Quitting

2. I will be healthier the rest of my life. I will lower my risk for cancer, heart attacks, strokes,

early death, cataracts, and skin wrinkling.

3. I will make my partner, friends, family, kids, grandchildren, and coworkers proud of me.

4. My children will be healthier (fewer ear infections, coughs, and severe asthma attacks).

Smokefree.gov

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Reasons for Quitting

5. I will be proud of myself. I will feel more in control of my life. I will be a better role model for my children.

6. I will have more money to spend. 7. I won't have to worry: "When will I get to

smoke next?" or "What do I do when I'm in a smoke-free place?"

Smokefree.gov

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Overview of the Basic Steps

S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.

Smokefree.gov

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Set a Quit Date

Think about choosing a special day: Your birthday or wedding anniversary New Year's Day Independence Day World No Tobacco Day (May 31) The Great American Smokeout (the third

Thursday of each November)

Smokefree.gov

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Tell Others your Plan to Quit

Ask everyone to understand your change in mood Remind them that this won't last long (The worst

will be over within two weeks.) Tell them this: "The longer I go without cigarettes,

the sooner I'll be my old self." Does someone close to you smoke? Ask them to

quit with you, or at least not to smoke around you

Smokefree.gov

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Tell Others your Plan to Quit

Do you take any medicines? Tell your doctor and pharmacist you are quitting.

Nicotine changes how some drugs work. You may need to change your prescriptions after you quit.

Smokefree.gov

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Tell Others your Plan to Quit

Get support from other people. You can try talking with others one-on-one or in a group.

You can also get support on the phone. You can even try an Internet chat room. This

kind of support helps smokers quit. The more support you get, the better. But

even a little can help.

Smokefree.gov

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Benefits of a Quit-smoking Program

Quit-smoking programs help smokers spot and cope with problems

The programs teach problem-solving and other coping skills

Can help you quit for good by: Helping you better understand why you smoke Teaching you how to handle withdrawal and stress Teaching you tips to help resist the urge to smoke

Smokefree.gov

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Keep Busy

Keep very busy today. Go to a movie. Exercise. Take long walks. Go bike riding

Smokefree.gov

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Keep Busy

Spend as much free time as you can where smoking isn't allowed (malls, libraries, museums, theaters, department stores, and places of worship)

Do you miss having a cigarette in your hand? Hold something else (a pencil, paper clip, marble)

Smokefree.gov

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Stay Away from What Tempts You

Instead of smoking after meals, get up from the table.

Brush your teeth or go for a walk.

Smokefree.gov

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Stay Away from What Tempts You

If you always smoke while driving, try something new: Listen to a new radio station or your favorite music. Take a different route. Or take the train or bus for a while, if you can.

Stay away from things that you connect with smoking. Do it today and for the next few weeks. These may include:

Watching your favorite TV show

Smokefree.gov

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Stay Away from What Tempts You

Sitting in your favorite chair Having a drink before dinner Do things and go places where smoking is not

allowed. Keep this up until you're sure that you can stay smoke-free.

Remember, most people don't smoke. Try to be near nonsmokers if you must be somewhere you'll be tempted to smoke, for example at a party or in a bar.

Smokefree.gov

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Remember the Instant Rewards of Quitting

Your body begins to heal within 20 minutes after your last cigarette

The poison gas and nicotine start to leave your body

Your pulse rate goes back to normal The oxygen in your blood rises to a normal

level

Smokefree.gov

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Remember the Instant Rewards of Quitting

Within a few days you may notice other things: Your senses of taste and smell are better. You can breathe easier. Your "smoker's hack" starts to go away. (You

may keep coughing for a while, though.)

Smokefree.gov

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Remember the Instant Rewards of Quitting

The nicotine leaves your body within three days. Your body starts to repair itself. At first, you may feel worse instead of better. Withdrawal feelings can be hard. But they are a sign that your body is healing.

Smokefree.gov

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Long-term Rewards of Quitting

After you've quit, you've added healthy, full days to each year of your life

You've greatly lowered your risk of death from lung cancer and other diseases including: Heart disease Stroke Chronic bronchitis Emphysema At least 13 other kinds of cancer

Smokefree.gov

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No matter how much or how long you’ve smoked, when you quit smoking, your risk of heart disease and stroke starts to drop.

In time your risk will be about the same as if you’d never smoked!

American Heart Association

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Step One

List your reasons to quit and read them several times a day

Wrap your cigarette pack with paper and rubber bands

Each time you smoke, write down the time of day, how you feel, and how important that cigarette is to you on a scale of 1 to 5

Rewrap the pack

American Heart Association

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Step Two

Keep reading your list of reasons and add to it if you can

Don’t carry matches, and keep your cigarettes out of easy reach

Each day, try to smoke fewer cigarettes, and try not to smoke the ones that aren’t most important.

American Heart Association

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Step Three

Continue with Step Two Set a target date to quit Don’t buy a new pack until you

finish the one you’re smoking Try to stop for 48 hours at one time

American Heart Association

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Step Four

Quit smoking completely Throw out all cigarettes and matches.

Hide lighters and ashtrays Stay busy! Go to the movies, exercise,

take long walks, go bike riding. Avoid situations and “triggers” you relate

with smoking Find healthy substitutes for smoking

American Heart Association

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How Can Physical Activity Help?

Walking and other exercise releases stress and

calms you It can improve your mood It keeps your mind off cigarettes It can help control your appetite

American Heart Association

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How Can Physical Activity Help With the

Stress? It can help you lose weight if you’re

overweight, or stay at a normal weight. It can lower your blood pressure level It can increase your “good” blood lipid level It can help reduce your risk of developing

heart disease and stroke It can help control blood sugar by

improving how your body uses insulin

American Heart Association

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Questions?

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How To Quit

Part 3

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Nicotine Anonymous

12 Step Fellowship of men and women helping each other live nicotine-free lives

Welcomes all those seeking freedom from nicotine addiction, including those using cessation programs and nicotine withdrawal aids

Nicotine Anonymous

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Nicotine Anonymous

Primary purpose is to help all those who would like to cease using tobacco and nicotine products in any form

Offers group support and recovery using the 12 Steps as adapted from Alcoholics Anonymous to achieve abstinence from nicotine

Nicotine Anonymous

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Facing the Fatal Attraction

Smoking tobacco is the most common method of nicotine delivery

Worldwide 47.5% of men and 10.3% of women smoke a total of 6 trillion cigarettes a year (World Health Organization, 2008)

Nicotine Anonymous

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Facing the Fatal Attraction

In 2000, 70% of U.S. adult smokers wanted to quit 41% stopped smoking for at least one day during

the preceding year in an effort to quit (Centers for Disease Control and Prevention)

Since 1965, more than 49% of all adults who have ever smoked have quit

Nicotine Anonymous

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The Twelve Steps of Nicotine Anonymous

1. We admitted we were powerless over nicotine – that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

Nicotine Anonymous

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The Twelve Steps of Nicotine Anonymous

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

Nicotine Anonymous

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The Twelve Steps of Nicotine Anonymous

7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and

became willing to make amends to them all.9. Made direct amends to such people wherever

possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

Nicotine Anonymous

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The Twelve Steps of Nicotine Anonymous

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to nicotine users and to practice these principles in all our affairs.

Nicotine Anonymous

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Tips for Gaining Freedom

It's not as hard as you think Inform yourself about nicotine Understand that you do not need nicotine (it

is not nutritional)

Nicotine Anonymous

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Tips for Gaining Freedom

Understand that addiction is a chemically compelled behavior

Make an honest appraisal of your nicotine use

Don't delay action toward stopping your use of nicotine because you think there are too many pressures in your life

Nicotine Anonymous

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Treat yourself with love and respect rather then by placating yourself with rationalizations

Write down reasons why you want to be nicotine free rather than thinking about reasons why you "can't quit yet"

Nicotine Anonymous

Tips for Gaining Freedom

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Quit for yourself Look at quitting the use of nicotine as giving

yourself a precious gift Make things easier for yourself

Before quitting, plan your activities for the first few days of abstinence

Nicotine Anonymous

Tips for Gaining Freedom

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Consider quitting as a challenging adventure Imagine letting go of nicotine There is no perfect time to start preparing to

quit

Nicotine Anonymous

Tips for Gaining Freedom

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If you are not going to quit right away, try cutting down

Don't minimize the truth or deny the risks even if you are not quitting today

Set a quit date Look at quitting as an investment.

Nicotine Anonymous

Tips for Gaining Freedom

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Quit nicotine one day at time and think only about the part of the day you are in

If you could have just one, you wouldn't have had the thousands of cigarettes you have smoked A pack a day for ten years is 73,000 cigarettes!

Think about letting go of nicotine as a "choice" rather than something you are doing to deprive yourself

Pray instead of puff

Nicotine Anonymous

Tips for Gaining Freedom

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When you quit you may experience a sense of loss If you feel an urge to use nicotine think H.A.L.T.

Four basic triggers for using nicotine are when we are Hungry, Angry, Lonely and Tired

Feed your body with nutrition instead of nicotine Drink lots of liquids to help flush the poison out of

your system What and how much you eat is important when you

quit nicotine

Nicotine Anonymous

Tips for Gaining Freedom

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When you first stop, don't be surprised if you find yourself feeling cranky, grumpy, crabby or downright angry

Take a second look before you react There are better companions than cigarettes Avoid becoming too tired

Nicotine Anonymous

Tips for Gaining Freedom

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Sometimes all we need is a distraction to shift our focus from a craving

Surround yourself with supportive positive people Ask for help from family, friends, and co-workers Plan activities that do not permit tobacco use Keep something handy for your hands

Nicotine Anonymous

Tips for Gaining Freedom

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Boredom is a signal to get busy Suck, bite, or chew Change your routine

Nicotine Anonymous

Tips for Gaining Freedom

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Give yourself rewards, frequently Avoid the self-pity trap If you have a problem and then use nicotine,

you now have two problems Re-read all the Nicotine Anonymous

literature on a regular basis

Nicotine Anonymous

Tips for Gaining Freedom

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All you have to do is not have the "next one" and you will avoid smoking thousands

Frequently notice how you are improving Maintain what you have gained If you want to smoke, use all the tools of the

program instead, and Keep Showing Up

Nicotine Anonymous

Tips for Gaining Freedom

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hhs.gov

Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit

Effective treatments exist, however, that can significantly increase rates of long-term abstinence

It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting

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Tobacco dependence treatments are effective across a broad range of populations

Clinicians should encourage every patient willing to make a quit attempt to use the recommended counseling treatments and medications in the Guideline

hhs.gov

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Brief tobacco dependence treatment is effective

Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in the Guideline

hhs.gov

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Individual, group and telephone counseling are effective and their effectiveness increases with treatment intensity

Two components of counseling are especially effective and clinicians should use these when counseling patients making a quit attempt:

Practical counseling (problem-solving/skills training) Social support delivered as part of treatment

hhs.gov

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FDA Approved Medications

Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline

hhs.gov

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Counseling and medication are effective when used by themselves for treating tobacco dependence

The combination of counseling and medication is more effective than either alone

Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication

hhs.gov

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Telephone quitline counseling is effective with diverse populations and has broad reach

Clinicians and healthcare delivery systems should both ensure patient access to quitlines and promote quitline use

If a tobacco user is currently unwilling to make a quit attempt, clinicians should use the motivational treatments shown in the Guideline to be effective in increasing future quit attempts

hhs.gov

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Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders

Providing coverage for these treatments increases quit rates

Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in the Guideline as covered benefits

hhs.gov

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Questions?

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How To Quit

Part 4

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"5 A's" Model for Treating Tobacco Use and Dependence

1. Ask about tobacco usea) Identify and document tobacco use status of

every patient at every visit

2. Advise to quit a) In a clear, strong and personalized manner urge

every tobacco user to quit

Surgeon General

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"5 A's" Model

3. Assessa) For current tobacco user, is the tobacco user

willing to make a quit attempt at this time?b) For the ex-tobacco user, how recent did you

quit and are there any challenges to remaining abstinent?

Surgeon General

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"5 A's" Model

4. Assista) For the patient willing to make a quit attempt,

offer medication and provide or refer for counseling or additional behavioral treatment to help the patient quit

b) For patients unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts

c) For the recent quitter and any with remaining challenges, provide relapse prevention

Surgeon General

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"5 A's" Model

5. Arrangea) All those receiving the previous A's should

receive follow up

Surgeon General

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Advise—Strongly Urge All Tobacco Users to Quit

Action In a clear, strong, and personalized manner, urge

every tobacco user to quit Advice should be:

Clear—"I think it is important for you to quit smoking (or using chewing tobacco) now and I can help you."

"Cutting down while you are ill is not enough." “Occasional or light smoking is still dangerous.”

Surgeon General

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Advice Should Be

Strong—"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future.

The clinic staff and I will help you."

Surgeon General

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Advice Should Be

Personalized Tie tobacco use to current symptoms and health

concerns, and/or its social and economic costs. and/or the impact of tobacco use on children and

others in the household. “Continuing to smoke makes your asthma worse,

and quitting may dramatically improve your health.

Quitting smoking may reduce the number of ear infections your child has.”

Surgeon General

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Public Health Service (PHS) Guideline

Ensure that all smokers are offered effective tobacco-use treatment at all clinical encounters.

Increase access to and participation in effective tobacco-use counseling.

Public Health Service

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Public Health Service (PHS) Guideline

Increase access to and appropriate use of effective tobacco-treatment medications.

Reduce patient out-of-pocket costs for tobacco-use treatment.

Create a social and economic environment that promotes quitting

Public Health Service

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Community Preventive Services

Increase the unit price for tobacco products

Implement sustained mass media campaigns

Public Health Service

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Community Preventive Services

Implement provider reminder systems in health-care settings

Reduce patient out-of-pocket costs for tobacco-use treatment

Initiate multi-component interventions that include patient telephone

Public Health Service

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CDC Goals

Mobilize health insurers, employers, and others to foster evidence-based tobacco-dependence coverage for all covered lives.

Mobilize health systems to implement system-level changes to foster effective utilization of tobacco-dependence treatments.

CDC

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CDC Goals

Mobilize national quality assurance and accreditation organizations, clinicians, health systems, and others to establish and measure the treatment of tobacco dependence as part of the standard of care (www.cdc.gov/tobacco/ICHS).

CDC

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CDC Goals

Mobilize communities to ensure that policies and programs are in place to increase demand for services and to ensure access to such services, especially for underserved populations (Fiore et al., 2004).

CDC

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CDC Strategies

Health insurance that pays the full cost of smoking-cessation treatments can increase quit rates compared to benefit plans that only partially cover cessation treatment or that offer no cessation benefits

Programs to stop smoking delivered during hospitalization that include a 1-month follow-up are most effective

CDC

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CDC Strategies

Proactive telephone counseling can be effective compared to an intervention without personal contact

Successful interventions generally involve multiple contacts timed around a quit attempt

CDC

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CDC Strategies

All of the commercially available forms of nicotine replacement therapy (gum, transdermal patch, nasal spray, inhaler, and sublingual tablets/ lozenges) are effective as part of a strategy to promote smoking cessation

Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small

CDC

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Negative Incentives

Focus on the failure of an individual to adopt a desired behavior

Discipline the individual by withdrawing the reward

Believing this will encourage adoption of the desired behavior

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Negative Incentives

The 192 members of WHO unanimously adopted the Framework Convention on Tobacco Control (FCTC)

Aimed at curbing tobacco-related deaths and disease

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WHO Negative Incentives

requires countries to impose restrictions on: tobacco advertising sponsorship and promotion establish new labeling clean indoor air controls strengthen legislation to clamp down on tobacco

smuggling

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Negative Incentives

Taiwan doubled the surcharge on cigarettes to discourage smoking

US: on April 1, 2009, the tax on cigarettes rose from 39 cents to $1.01 per pack

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Negative Incentives

Chile bans smoking in schools, hospitals, government offices, shopping centers, supermarkets, pharmacies, airports, buses, subway networks and other indoor public places. Smoking in universities indoors is banned, however, smoking is allowed outdoors.

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Negative Incentives

Croatian Parliament passed legislation prohibiting smoking in public institutions such as hospitals, clinics, schools and universities with infractions punishable with up to 1000 kuna (140 euros).

A notable exception in the Act are psychiatric wards in Croatia's hospitals.

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On the Flip Side…

The Gong’an County government of Hubei province found itself at the center of public outrage

Demanded local officials to consume up to 23,000 packs of locally produced cigarettes annually, worth 4 million yuan, using public money

Each office under its jurisdiction received a quota and would face a fine if they failed to meet the target, or if found buying cigarettes produced by other provinces

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Of Interest…

www.stickK.com take out a

“commitment contract” By doing so, you

essentially put your money where your mouth is

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More on StickK.com

You commit yourself to quit smoking within a month

If at the end of the month, you’re still smoking, Stickk will keep the money you deposited

To make it even more interesting, whenever you fail, they have the option of giving your money away to a cause (or person) you really hate.

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Put Your Money Where Your Butt Is

CARES (Committed Action to Reduce and End Smoking) is a commitment savings program

Smokers who wish to quit smoking are encouraged to deposit an increasing percentage of the money they ordinarily spend on cigarettes into their CARES accounts for six months

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Put Your Money Where Your Butt Is

Deposits are collected every week by field staff who motivate clients to continue reducing smoking behavior

The client cannot withdraw any money during the deposit period

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Put Your Money Where Your Butt Is

The balance is what is at stake if the client should fail to quit

At the end of six months, the client submits to a urine test to confirm smoking cessation

Only by passing the test can s/he access the money in the CARES account

Otherwise, the account is closed and the money donated to a charity

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Positive Incentives

Providing smokers with financial incentives to stop smoking increases enrollment in smoking-cessation programs

Cessation efforts using monetary incentives have had yielded increased success in abstinence

Receive incentives or prizes for “good” behavior – in this case, not smoking

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Example of Positive Incentive Program

Individuals given chance to win prizes if their breath and urine samples test negative for cigarette smoking.

The number of draws from a prize bowl increases as long as the participant continues to test negative over the 24-week study

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Positive Incentive Program

The prize bowl contains about 500 cards, half of which are winning cards.

Prizes range from small toiletries, snacks, or coffee shop gift certificates, to tool kits, compact disc players, and prepaid telephone cards.

One card in the prize bowl offers a $100 prize such as a DVD player, a television, or a stereo.

The cards are replaced after each drawing so the probabilities remain constant.

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Questions?

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Day 3: Proposed Program

Ata Ulhaq, MD, FACEP, MPH

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3 Year Program

Phase 1: Year 1 University can become flag bearer/pioneer in

beginning a program for other universities, cities and the entire country

Program for students, faculty, contractors (anyone who is on property)

Positive reinforcement with help and rewards

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Phase 1: Year 1 Four week program open for 3 years and beyond Specific brochure/booklet for new students

advising them of smoke free plan Heavy promotion should be done

3 Year Program

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Government Involvement

Support encouraged by governmental organizations

Involvement in public awareness Radio ads TV ads Billboards Public service announcements

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University Involvement

Signs on campus College radio station Publication Full support of student body/student union Visible student involvement

Joining and supporting – not just talk Actively involved on an individual basis

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3 Year Program

Phase 1: Year 1 Funding from University, government, other agencies Support by faculty, student union/student body, all

involved in campus Step wise reduction/cessation Set up restricted smoking areas New students are advised that in three years, campus will

be totally smoke-free Smokers are strongly advised to join program

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3 Year Program

Phase 2: Year 2 Continue 1st year program Controlled, organized continuation of 4-week

program Mostly negative incentives Demand smoking to restricted smoking areas

only

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3 Year Program

Phase 2: Year 2 If found smoking in other than designated areas,

impose fines Monetary, temporary privileges

At the end of Phase 2, remove restricted areas Anonymous reporting system for non-

compliance comprised of student body (optional)

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3 Year Program

Phase 3: Year 3 Continuation of Phases 1 and 2 No smoking Increased negative incentives Increased penalties (monetary) Prospective students who are smokers must join

Program before enrolling in University Students are required to join program for non-

compliance

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Phase 3: Year 3 Expulsion/no admittance for smokers Anonymous reporting system for non-

compliance comprised of student body (optional) In class, student union, dormitories, etc.

If penalties are not paid, registration for next semester could be withheld

Once penalized, they must join 4-week program

3 Year Program

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Faculty follows same rules and regulations as student body

Separate session for faculty Faculty offered the 4-week program

3 Year Program

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Penalties vary Increased monetary value for faculty (double that

of students) Possibly more for repeat offense of non-

compliance Reporting of non-compliance by faculty and

students Once penalized, they must join 4-week program

3 Year Program

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Contractors Follows same regulations Worst penalty – they can lose their contract Can they join the program?

Separate session for contractors onlyContractors must pay fee to join programOnce penalized, they must join 4-week program

3 Year Program

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Year 1: Phase 1

Beginning program kickoff Supportive of individuals who want to quit

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Kickoff

Set day in advance and build up towards it Well publicized and well known When big day arrives, make it a big event! Celebration!

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Principle

“A Healthy Body Resides

a Healthy Mind”

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Before Beginning

Registration Screening to determine motivation

What made them come? Based on motivation, grade is given

+ 75% will succeed in quitting (if life value involvement is present/doing it for their

children) + - 50% possibility of quitting - 75% will not quit

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Who Gets + 75%?

Those who have life value involvement

Who gets + - 50%? Those you are not sure of

Who gets – 75%? Those who do not have life value involvement or

are doing it for someone other than themselves

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Life Value Involvement

Belief you could get smoking related disease and this worries you

Someone close who has had health problems from smoking; cancer

Loved one diedHeart attack (self or loved one)

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Life Value Involvement

Belief and motivation that is self-centered/tragic experience = more likely to quit

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Screening

Physical screening + - (optional) Determine underlying medical condition Individual who has coughed blood Other bleeding (hematuria, melena or

hematochezia, hematemesis) Weight loss/unable to gain weight – weakness These should be referred for further evaluation

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Depression

Depression is associated with an increased frequency of smoking

Addicted smokers are characterized by: preoccupation with smoking abnormal attachment to cigarettes anticipation of brain reward

Attempts to quit smoking often lead to a decreased level of pleasure and undesirable mood swings

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Created by Dr. Aaron T. Beck 21-question multiple-choice self-report

inventory One of the most widely used instruments for

measuring the severity of depression

Beck’s Depression Inventory

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Individuals with underlying or current depressive symptoms are more likely to experience mood disturbances when they attempt to quit

Smoking may mask an underlying depression in some smokers

Smoking, therefore, may be a way for depressed individuals to self-medicate depressive symptoms

Reason for Beck’s?

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Consequently, healthcare professionals who offer smoking cessation programs should offer depression screening

Should be prepared to address underlying mood disorders as part of a comprehensive smoking cessation program

Reason for Beck’s?

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Beck’s Depression Inventory

1. SADNESS (feeling or showing sorrow; unhappy; causing or characterized by sorrow or regret; unfortunate and regrettable)

0 I do not feel sad. 1 I feel sad much of the time. 2 I'm sad all the time. 3 I'm so sad and unhappy that I can't sand it.

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BDI

2. PESSIMISM0 I'm not discouraged about my future. 1 I feel more discouraged about my future than I

used to be. 2 I do not expect things to work out for me. 3 I feel my future is hopeless and will only get

worse.

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BDI

3. PAST FAILURE 0 I do not feel like a failure. 1 I have failed more than I should have. 2 As I look back, I see a lot of failures. 3 I feel I am a total failure as a person.

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BDI

4. LOSS OF PLEASURE 0 I get as much pleasure as I ever did from the

things I enjoy. 1 I don't enjoy things as much as I used to. 2 I get very little pleasure from the things I used

to enjoy it.3 I can't get any pleasure from the things I used

to enjoy.

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BDI

5. GUILTY FEELINGS 0 I don't feel particularly guilty. 1 I feel guilty over many things I have done or

should have done.2 I feel quite guilty most of the time. 3 I feel guilty all of the time.

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BDI

6. PUNISHMENT FEELINGS 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished.

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BDI

7. SELF-DISLIKE 0 I feel the same about myself as ever. 1 I have lost confidence in myself. 2 I am disappointed in myself. 3 I dislike myself.

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BDI

8. SELF-CRITICALNESS 0 I don't criticize or blame myself more than

usual. 1 I am more critical of myself than I used to be. 2 I criticize myself for all of my faults. 3 I blame myself for everything bad that

happens.

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BDI

9. SUICIDAL THOUGHTS OR WISHES 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would

not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance.

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BDI

10. CRYING 0 I don't cry anymore than I used to. 1 I cry more than I used to. 2 I cry over every little things. 3 I feel like crying, but I can't.

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BDI

11. AGITATION(a stirring up or arousing; disturbance of tranquility; disturbance of mind which shows itself by physical excitement)

0 I am no more restless or wound up than usual. 1 I feel more restless or wound up than usual. 2 I am so restless or agitated that it's hard to stay still. 3 I am so restless or agitated that I have to keep moving

or doing something.

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BDI

12. LOSS OF INTEREST 0 I have not lost interest in other people or

activities. 1 I am less interested in other people or things

than before. 2 I have lost most of my interest in other people

or things. 3 It's hard to get interested in anything.

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BDI

13. INDECISIVENESS(not having or showing the ability to make decisions quickly and effectively)

0 I make decisions about as well as ever. 1 I find it more difficult to make decisions than usual. 2 I have much greater difficulty making decisions than I

used to. 3 I have trouble making any decisions.

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BDI

14. WORTHLESSNESS(having no real value or use; having no good qualities; deserving contempt)

0 I do not feel I am worthless. 1 I don't consider myself as worthwhile and useful as I

used to. 2 I feel more worthless as compared to other people. 3 I feel utterly worthless.

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BDI

15. LOSS OF ENERGY 0 I have as much energy as ever. 1 I have less energy than I used to have. 2 I don't have enough energy to do very much. 3 I don't have enough energy to do anything.

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BDI

16. CHANGES IN SLEEPING PATTERN(Changes in either direction are important. Thus tick the appropriate answer either less or more do you sleep.)

0 I have not experienced any change in my sleeping pattern.

1 I sleep somewhat more OR less than usual. 2 I sleep a lot more OR less than usual.3 I sleep most the day. OR I wake up 1-2 hours early and

can't get back to sleep.

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BDI

17. IRRITABLITY(having or showing a tendency to be easily annoyed or made angry)

0 I am no more irritable than usual. 1 I am more irritable than usual.2 I am much more irritable than usual.3 I am irritable all the time.

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BDI

18. CHANGES IN APPETITE(Changes in either direction are important. Thus tick the appropriate answer either less or more do you eat.)

0 I have not experienced any change in my appetite. 1 My appetite is somewhat less than usual. OR My

appetite is somewhat greater than usual.2 My appetite is much less than usual. OR My appetite is

much greater than usual.3 I have no appetite at all. OR I crave food all the time.

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BDI

19. CONCENTRATION DIFFICULTY(the action or power of focusing one's attention or mental effort)

0 I can concentrate as well as ever. 1 I can't concentrate as well as usual. 2 It's hard to keep my mind on anything for long. 3 I find I can't concentrate on anything.

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BDI

20. TIREDNESS OR FATIGUE 0 I am no more tired or fatigued than usual. 1 I am more tired or fatigued more easily than

usual.2 I am too tired or fatigued to do a lot of things I

used to to do.3 I am too tired or fatigued to do most of the

things I used to to do.

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BDI

21. LOSS OF INTEREST IN RELATIONSHIPS

0 I have not noticed any recent change in my interest in relationships.

1 I am less interested in relationships than I used to be.

2 I am much less interested in relationships now.3 I have lost interest in relationships completely.

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Scoring of Beck’s Depression Inventory

Total score of 0-13 is considered minimal range

14-19 is mild 20-28 is moderate 29-63 is severe

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Treatment for Smoking Addiction and Depression

New medicine treatment for smoking addiction that is also an effective antidepressant Bupropion, (Zyban) is a safe and effective Non-nicotine treatment Lessens withdrawal symptoms Prevents weight gain Improves mood in most patients Before Zyban™ was approved for smoking cessation, it

was, and remains, an effective and commonly prescribed antidepressant sold under the trade name Wellbutrin™.

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Other Treatments

Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline

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Makes Sense

The Author notes that if no depression is present, it is reasonable to treat nicotine with nicotine Nicotine patch Gum Inhalant

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Proposed Program

Smokefree.gov American Heart Association American Lung Society

Organized 4-week program

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Overview of the Basic Steps

S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.

Smokefree.gov

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Products to Help

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Week 1

Facilitator will help by presenting ill effects of cigarette smoking

Program should run 2-3 hours for week 1 Have support group in place

Female support for females/male support for males

Write down list of reasons for quitting on an index card

Make several (you can even laminate)

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List of Reasons

Put these lists in places where you frequently smoke Car, purse, wallet, office, fridge Tuck one in your books as a bookmark Wrap one around your cigarette pack with a

rubber band

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Rewards

Reward yourself at the end of each nonsmoking week

Write reward on back of list of reasons to quit Doesn’t have to be expensive

Homemade meal Hot bath

When the urge comes, look at both sides of the card Isn’t it worth coping for 3 minutes?

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When the Urge to Smoke Arises

Remind yourself of why you quit by reading the list!

Place a sticker on the back for each time you resist

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Week 2

Set a quit day Talk to your doctor/obtain prescription Tell family, friends, co-workers Anticipate changes Remove cigarettes, ashtrays, etc.

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Week 2 Plans Have Alternate Plans in Case You are Tempted

Get away from dinner table

Go for a walk Exercise Call a friend Listen to music or talk

radio in the car

Wash the car Knit a scarf Garden Read a book Take up a new hobby Brush/floss your teeth

Anything to avoid smoking!

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Week 2 Plans

Be Prepared for Your Urges! In most cases, something triggers the craving

Certain feelings People Places

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Be Prepared for Your Urges! Divide a blank piece of paper into 2 columns On one side list “triggers”

Stuck in traffic Morning coffee Arguing with colleague

In column 2 write alternative course of action

Week 2 Plans

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Week 2 PlansAlternative Course of Action

Trigger Morning coffee

Heated argument

Action Read morning paper

Walk around the blockor

Write down everything you think about this person and then tear it up and throw it away(this works!)

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Triggers and Alternatives

If riding in the car, make your car an unfriendly place to smoke Clean it out Empty and scrub the ashtrays and the glove

compartment

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Triggers and Alternatives

Do you find yourself wanting a cigarette right after eating? Get busy immediately after your meal Get up and clear the table Do the dishes/pack up the leftovers

Often just getting through the first few minutes is all you need

Just delay that urge

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Week 2 Plans: Distract Yourself

With a quick task (5-10 minutes) Make a call Send a fax Pour yourself a cup of coffee Water a plant Anything! Hint: Find something that makes smoking

impossible

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Week 2 Plans:Remember…

S = Set a quit date.T = Tell family, friends, and coworkers that you plan to quit.A = Anticipate and plan for the challenges you'll face while quitting.R = Remove cigarettes and other tobacco products from your home, car, and work.T = Talk to your doctor about getting help to quit.

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Week 3 A

Quit day! Keep busy! Utilize support group already in place Remember coping mechanisms

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Week 3 A

Remember list, read and re-read Do things that make you happy Get involved in other activities Keep away from people, places, things that

remind you of smoking

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Author’s Note

Plan to quit at least one day before using any drugs or nicotine aids

Drugs or nicotine aids more effective when used in this manner

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Week 3 B

Two days after quit day: This is most difficult time Bring individual in again to reinforce Should be seen a total of 5 times See how they are tolerating things Check their list for dots indicating they resisted

the urge to smoke

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Week 4

Successfully complete one week smoke free Re-evaluate support group’s efforts Support group to involve facilitator

Female support for females/male support for males

Not more than 20 people for each facilitator

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Week 4

Compliment and encourage each other Group to be available 24/7 by phone Female support for females/male support for

males Meet weekly for two months

Once monthly thereafter Support as long as individuals desire Open for alumni as well

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Phase 2: Year 2

Ongoing 4-week program Restricted areas are now removed Fines are imposed on smokers

Monetary Other privileges temporarily withheld

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Phase 3: Year 3

Penalties/fines increase Program readily available Increased negative incentives Prospective students who are smokers must

join Program before enrolling in University Expulsion/no admittance for smokers

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Questions? Comments?

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Day 4: Open Forum

Participants will join for an open forum and discussion concerning modification of the proposed program or accepting it as such for the University.

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Day 5: Formulation of a Program for The University

Participants will unite to give their blessing to the accepted program for the University

University now becomes the flag bearer/pioneer in beginning a program for other universities, cities and the entire country

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Thank YouThank You


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