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SMOKING CESSATION SEMINAR WORKING WITH PEOPLE RESISTANCE TO CHANGE JENNIFER PERCIVAL RCN TOBACCO POLICY ADVISOR
SMOKING CESSATION SEMINAR
WORKING WITH PEOPLERESISTANCE TO CHANGE
JENNIFER PERCIVALRCN TOBACCO POLICY ADVISOR
Tobacco is a public health prioritySource: WHO
In the year 20001 in every 6 deaths worldwidewas caused by smoking
By the year 20301 in every 3 deaths worldwidewill be due to smoking
70% of these deaths will be indeveloping countries.
Tobacco advertising has successfully encouraged more women to start smoking
Women and Tobacco
• In the UK lung cancer surpassed breast cancer as leading cause of cancer death in 1987
• Now more women die from lung cancer than breast, ovarian, cervical & endometrial cancers combined
The true picture is very different
His research has shown:
• Half of all regular smokers die prematurely:¼ in middle age (35-69)¼ in old age
• Stopping before 35 avoids most of the risks of premature death.
• Stopping smoking works.
WHO – ‘THE SILENT EPIDEMIC’
WORLD HEALTH ORGANISATIONEpidemiologist
Sir Richard Peto
“Tobacco use is increasing.Over 100 million deaths from tobacco
will occur during the next 20 years……. and if nothing changes
there will be ONE BILLION deaths this century.”
• A Chronic relapsing dependence syndrome
• Use of the addictive drug nicotine• Reinforced by sensory, behavioural and
social conditioning• Entrenched by powerful withdrawal
syndrome • Promoted commercially, exempt from
consumer protection legislation
What is smoking?What is smoking?
Why are cigarettes
so harmful?
Nicotine
4,000 chemicals
Tar
Carbon monoxide
ARE THESE PEOPLE RESISTANT TO CHANGE? OR HIGHLY NICOTINE DEPENDANT?
• Light-headedness• Sleep disturbance• Poor concentration• Craving • Irritability/aggression• Depression• Restlessness• Increased appetite
<48 hrs 10%
< 1 wk 25%
<2 wks 60%
> 2 wks 70%
< 4 wks 50%
< 4 wks 60%
< 4 wks 60%
> 10 wks 70%
Stopping Smoking Withdrawal effects: duration and frequencyStopping Smoking Withdrawal effects: duration and frequency
Reasons for NRT failure
• Unrealistic expectations• Incorrect use• Not used for long enough• Nicotine is often seen as the dangerous
element in cigarette smoke• Safety concerns can be a barrier to use
Helping people to Stop Smoking
The NHS Stop Smoking services were set up as
1) Smokers are suffering from a treatable medical disorder `nicotine dependence‘.
2) Treating nicotine dependence', is an extremely cost-effective way of prolonging life.
3) Brief advice backed up by a prescription for medication and where possible a referral for specialist support greatly increases a persons ability to stop smoking.
Standard Treatment Programme Pre Quit Assessment
• Assess current readiness and ability to quit
• Inform the client about your programme
• Assess current smoking
• Assess past quit attempts
• Explain how tobacco dependence develops
• Assess nicotine dependence
Pre Quit Assessment
• Explain and conduct carbon monoxide (CO) monitoring
• Explain the importance of abrupt cessation and the ‘not a puff’ rule
• Inform the client about withdrawal symptoms• Discuss stop smoking medication• Set the Quit Date• Prompt a commitment from the client• Discuss their preparations • Provide a summary
Standard Treatment Programme Quit Date
■ Confirm readiness and ability to quit
■ Confirm that the client has sufficient supply of medication and discuss expectations
■ Discuss withdrawal symptoms and cravings / urges to smoke and how to manage them
■ Advise on changing routine
■ Discuss how to address the issue of the client’s smoking contacts and how the client
can get support during their quit attempt
■ Address any potential high risk situations in the coming week
Quit Date continued
■ Conduct carbon monoxide (CO) monitoring
■ Confirm the importance of abrupt cessation
■ Prompt a commitment from the client – ‘not a single puff rule’.
■ Discuss plans and provide a summary
■ Boost motivation and self-efficacy
■ Build rapport
■ Use reflective listening
■ Provide reassurance
Core communication skills
• Boost the person’s motivation and self-efficacy
• Build rapport
• Use reflective listening
• Provide reassurance
Pre-quit assessment session
Assessing current readiness and ability to quit
Informing the client about the treatment programme
Assessing current smoking / Assessing past quit attempts
Assessing nicotine dependence
Explaining & conducting carbon monoxide (CO) monitoring
Explaining the importance of abrupt cessation and the “not a puff” rule
Informing the client about withdrawal symptoms
Discussing medication
Setting the quit date Prompting a commitment from the client
Discussing preparations and providing a summary
My observations from working in the
UK Stop Smoking services are that
direct persuasion is not enough to make people decide to stop smoking
People want the ‘benefits’ of being a non smoker …….
without recognising the often long process of ‘change’ they need to go through to acquire them.
DO YOU ALWAYS
FOLLOW GOOD ADVICE?
GOOD ADVICE
ADVICE
Reasons for Current
Behaviour
ADVICE
Reasons for Current
Behaviour
Current Behaviour
“I knew you could get cancer from smoking, but I’d planned to give up long before that happened to me”
Robert was diagnosed with cancer of his tonsils at age 36
THE CHANGE PROCESS
• No-one changes their behaviour without first changing their attitudes and beliefs.
• When a client argues with you it means you have made a wrong assumption.
• Long term behaviour change takes time to consolidate
FEAR
CONCERN FOR BABY
PEOPLE “NAGGING”
GUILT NICOTINE ADDICTION
STRESS RELIEF
HABIT
PARTNER SMOKES
NORMAL
A DIFFICULT TIME
Everyone has their own beliefs about safe behaviour
This child is strapped in and protected from the sun but....?
Hard Core Smokers?
• Yes…. there are definitely some people in the UK who have made a clear decision to continue to smoke regardless of the physical or social consequences to themselves.
• “It’s a lottery!”
• “I know many old smokers who are fine!”
• “Throw the fags in my coffin with me”
Principles of Motivational Interviewing
• Use a neutral manner to give clients information about the impact of their lifestyle on their health
• Help people interpret the health implications, risks and benefits of not changing.
• Assist people to explore for themselves the importance of making a specific change.
• Leave the responsibility for changing and the right to decide whether or not to change, with the client.
Helping people to stop smoking
• Avoid making pressure to change: this will create resistance. You can never win and, in the process, may lose the chance to help
• Roll with any resistance: do not argue with the patient if they say their action is not harmful. Instead, respectfully clarify their own thoughts or views
• Support the patient’s self-confidence: look for the positive aspects and build on them
HELPING PEOPLE TO STOP SMOKING WHAT WORKS?
• Find out what the tobacco user already knows about the risks and seek permission to provide further information.
• Link these facts to their current health status or medical condition.
• Explain the short and long term benefits of quitting and assess their understanding.
Try asking: What do you think might happen to you if you continue to smoke?
Unsure about change?
• Help them explore the perceived advantages and disadvantages of smoking
• Ask more about what brought them to see you and find out their concerns
• Describe any ambivalence you notice
• Plant a seed of change
PEOPLE NOT READY TO STOP
Respect their view
“It sounds like it would be hard for you to stop now”
“Are you planning to be a life long smoker”?
If they say NO
Ask: “What would need to change for you
to consider stopping smoking”?
Explain your medical / social concerns
Leave the subject open for future discussion
Asking questions can plant aseed of change
‘New thoughts’ often help people think differently about what they believe to be true.
Helping people to stop smoking
• Show empathy: even if you do not share a person’s viewpoint, find ways to show that you understand and respect them
• Identify discrepancies: there are often differences between how a person behaves and how they see themselves
Name these in a neutral way
eg.’Don’t want their kids to start smoking’
Core communication skills
• Boost motivation and self-efficacy
• Build rapport
• Use reflective listening• Provide reassurance
People making plans to quit
• Congratulate this decision
• Check their expectations of changing
Ask “What could get in your way?”
“What can you do to avoid that”?
• “What help will you need?”
• “Who can you ask?”
Helping people to changeAsk:-
• “What are you planning to do next”?
• “Who are you going to ask to support you?”
• “What quit date have you decided?
Can you commit to not having a single puff
of a cigarette from then onwards?”
• “What medication are you going to use?
RELAPSEWhy do smokers return to tobacco?
• Stopping under pressure from someone else
• Lack of personal motivation
• Attaching insufficient importance to stopping
• Withdrawal symptoms
• Poor timing
• A question of self-image
• “I thought `just one’ wouldn’t hurt”
Re- engaging people to make another quit attempt
Importance to them of stopping? Assess their expectation of the costs and benefits of quitting
Confidence in ability to quit?• Find out their belief in their ability to
stop smoking
Relapse preventionAsk:• What makes this a good time to stop?
If they have tried many times before:• What have you learnt from past attempts?• What will you do differently now to stay
stopped? • How would you feel if you had a cigarette
again?• Who is going to support you?
Respond to these statements
1. I’ve tried before, its not worth it, the damage is already done”
2.“My doctor’s told me to see you to quit smoking”
3 “I’ve really cut down since my heart attack.”
4 “I feel so low now I’ve stopped smoking and I crave a smoke all the time.”
5 “I do want to give up, but it’s hard because my partner smokes.”
In pairs work out some appropriate responses to the following client responses:
Statement 1 “I think smoking will help me have a smaller baby.”
Statement 2 “I’ve cut down on how much I smoke now I’m pregnant.”
Statement 3 “I’ve tried to stop in the past and it’s not easy.”
Statement 4 “I want to try NRT, but I’m worried it will harm my baby.”
Statement 5 “I have almost managed to quit, but I still smoke the odd
one with my partner.”
Statement 6 “I’ll smoke outside when the baby arrives”
Statement 7 “I don’t like to ask my in-laws not to smoke in the house.”
