Counsellors' Manual for Commercial Tobacco Cessation Treatment
Counsellors' Manual for Commercial Tobacco Cessation Treatment
Counsellors' Manual for Commercial Tobacco Cessation Treatment
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IT’S TIME: INDIGINENOUS TOOLS & STRATEGIES ON<br />
TOBACCO INTERVENTIONS & MEDICINES<br />
Counsellors’ <strong>Manual</strong> <strong>for</strong><br />
<strong>Commercial</strong> <strong>Tobacco</strong><br />
<strong>Cessation</strong> <strong>Treatment</strong><br />
This is an optional, supplementary resource <strong>for</strong> counsellors, community<br />
workers and peer helpers who are able to provide counselling sessions<br />
to groups or individuals trying to quit commercial tobacco use.<br />
This manual uses a combination of motivational interviewing and<br />
cognitive behavioural therapy approaches, and can be offered to either<br />
groups or individuals. Note that the tools and materials in this resource<br />
may not be relevant or helpful to all people – this resource is one among<br />
many approaches to healing and recovery from commercial tobacco use.
NICOTINE DEPENDENCE CLINIC, CAMH<br />
© Centre <strong>for</strong> Addiction and Mental Health<br />
2011<br />
This resource may be freely reproduced, adapted and used by any helper or community in accordance with OCAP principles<br />
(Ownership, Control, Access and Possession).
Session<br />
1<br />
Screening and Assessment<br />
This session is designed to give people personalized feedback about their<br />
tobacco use and how it is affecting other areas of their lives. An emphasis is<br />
placed on ensuring that assessment in<strong>for</strong>mation is used clinically to enhance a<br />
person’s motivation and readiness to change.<br />
T<br />
obacco dependence can be a challenging topic to raise with people, particularly when they<br />
are seeking help <strong>for</strong> some other issue. Even opening a conversation about commercial<br />
tobacco use can be a challenge if the person has been accustomed to being “lectured” by<br />
health practitioners, family, friends and the media. Adopting a motivational stance is<br />
important in raising the issue in a non-confrontational, matter-of-fact way. This means:<br />
<br />
<br />
<br />
<br />
<br />
Avoiding arguing<br />
Expressing empathy<br />
Developing discrepancies between a person’s goals and their use of commercial tobacco<br />
Rolling with resistance<br />
Supporting self-efficacy (confidence that they can achieve their goals).<br />
For example, asking the person, “What is the most unusual thing you’ve ever done to make sure<br />
you’d have cigarettes <strong>for</strong> the next morning” can elicit responses that are very helpful in<br />
developing a discrepancy between how a person regards him- or herself, and his or her behaviour.<br />
Examples we have heard in our practice include ordering pizza in order to get cigarettes delivered,<br />
picking cigarettes off the ground, stealing and sifting through cigarette butts in an ashtray. The<br />
important thing is to give people an opportunity to explore and resolve their ambivalence around<br />
changing their use of commercial tobacco. Helpers should strive to avoid attempts to persuade or<br />
confront people about their tobacco use, as this can lead to resistance and disengagement.<br />
The tools in this section can be used in a variety of ways:<br />
<br />
Brief screening tools used in conjunction with other intake or assessment instruments in<br />
your program or service
As a standalone brief assessment of commercial tobacco use<br />
As a more structured follow-up to a short conversation about commercial tobacco use<br />
As the first session in a group or individual treatment program <strong>for</strong> commercial tobacco<br />
cessation.<br />
As a helper, you are the best one to decide – in partnership with your client – how to approach<br />
the topic of commercial tobacco use, what kinds of questions to ask, what kinds of structured<br />
tools to use, and how to build a trusting relationship. In the end, it is the relationship between<br />
helper and client that is the most vital. The tools in this section and throughout this manual are<br />
meant to support an exploration and journey towards healing and recovery, so use or adapt what<br />
is useful and leave the rest.<br />
Note that many of the tools and approaches discussed in this manual have been used with other<br />
kinds of substance use or behaviour change issues – most of them are not specific to commercial<br />
tobacco use (especially the tools in Sessions 2-6). There are some references at the end of this<br />
manual if you would like to access further readings or resources on motivational interviewing,<br />
cognitive behavioural therapy and health behaviour change.<br />
Session 1: Assessment<br />
Clinical Tools<br />
‣ Fagerstom Test <strong>for</strong> Nicotine Dependence<br />
‣ How does commercial tobacco affect you and others in your life (worksheet)<br />
‣ Brief <strong>Commercial</strong> <strong>Tobacco</strong> Use Assessment <strong>for</strong>m<br />
‣ Reasons to Quit Smoking <strong>for</strong>m and Why You Smoke <strong>Commercial</strong> <strong>Tobacco</strong> <strong>for</strong>m<br />
A NOTE ABOUT CALCULATING “PACK YEARS”:<br />
The simple <strong>for</strong>mula <strong>for</strong> calculating pack years is as follows:<br />
# of cigarettes / day X # of years smoked<br />
__________________________________<br />
20<br />
=<br />
___ pack years<br />
For example, a person who smokes 25 cigarettes per day <strong>for</strong> a total of 35 years would have a 43.75 pack year history (25 x 35 =<br />
875; 875 ÷ 20 = 43.75). An online pack year calculator, frequently asked questions and correlations between pack years and<br />
smoking related diseases can be found at: http://smokingpackyears.com/.<br />
One of the utilities of this tool is to help determine which people might be referred <strong>for</strong> spirometry screening which helps detect COPD<br />
(cardio-obstructive pulmonary disease). People with a pack year history of 15 or more, especially those over age 40, should be<br />
referred <strong>for</strong> this type of screening. (Tinkelman et al., 2007).<br />
Tinkelman, D.G., Price, D.B., Nordyke, R.J. and Halbert, R.J. (2007). COPD Screening ef<strong>for</strong>ts in primary care: What is the yield<br />
Primary care Respiratory Journal, 16 (1), 41-48.<br />
3
Fagerstrom Test <strong>for</strong> Nicotine Dependence<br />
Not only is it important to know whether or not your patients smoke, it’s also important to know<br />
how addicted to nicotine they actually are. Fagerstrom’s Test <strong>for</strong> Nicotine Dependence is an easy<br />
way to assess your patient’s addiction. Have your patients answer the questions; each answer gets<br />
a set amount of points. Add up the points and check out the score indicator below:<br />
Questions Answers Points<br />
1. How soon after you wake up do you smoke your<br />
first cigarette<br />
2. Do you find it difficult to refrain from smoking<br />
in places where it is <strong>for</strong>bidden such as church, the<br />
library, or movie theatres<br />
Within 5 minutes<br />
6 to 30 minutes<br />
31-60 minutes<br />
After 60 minutes<br />
Yes<br />
No<br />
3<br />
2<br />
1<br />
0<br />
1<br />
0<br />
3. Which cigarette would you hate most to give up The first one in the morning<br />
All others<br />
1<br />
0<br />
4. How many cigarettes do you smoke (20<br />
cigarettes are<br />
in a pack)<br />
5. Do you smoke more frequently during the first<br />
hours after waking than the rest of the day<br />
6. Do you smoke if you are so ill that you are in<br />
bed most of the day<br />
10 or less<br />
11-20<br />
21-30<br />
31 or more<br />
Yes<br />
No<br />
Yes<br />
No<br />
0<br />
1<br />
2<br />
3<br />
1<br />
0<br />
1<br />
0<br />
Score:<br />
0-2 Very Low Addiction<br />
3-4 Low Addiction<br />
5 Medium Addiction<br />
6-7 High Addiction<br />
8-10 Very High Addiction<br />
Usually, people who score 6 or greater need additional assistance in quitting smoking. This may<br />
mean Nicotine Replacement Therapy or one-on-one counseling to problem solve ways to<br />
overcome barriers and cope with withdrawal symptoms.<br />
This in<strong>for</strong>mation is provided by WHISC - Women’s Health: Interventions <strong>for</strong> Smoking <strong>Cessation</strong>. It is part of the Provider Tool Kit <strong>for</strong> Assisting<br />
Women to Quit Smoking. WHISC is a project funded by a grant from The Duke Endowment to Wake Forest University School of Medicine in<br />
partnership with the Northwest AHEC (North Carolina) Program. January 2001<br />
4
How does commercial tobacco affect you and<br />
others in your life<br />
PHYSICAL<br />
SPIRITUAL<br />
Example: I have a cough<br />
especially in the mornings<br />
Example: <strong>Tobacco</strong> is a gift from the<br />
Creator, and I want to honour that gift<br />
Example: Feeling bad because I want<br />
to set a good example <strong>for</strong> my kids<br />
Example: Thinking about how smoking<br />
cigarettes is hurting my body<br />
EMOTIONAL<br />
MENTAL<br />
5
BRIEF COMMERCIAL TOBACCO ASSESSMENT FORM<br />
I. CURRENT COMMERCIAL TOBACCO USE<br />
Number of<br />
Cigarettes/<br />
day<br />
Importance<br />
Fagerstrom<br />
Test <strong>for</strong><br />
Nicotine<br />
Dependence<br />
Confidence<br />
/10<br />
# of cigarettes / day X # of years smoked<br />
__________________________________<br />
20<br />
=<br />
___ pack years<br />
/10<br />
Readiness to<br />
Change<br />
/10<br />
Goals around <strong>Commercial</strong> <strong>Tobacco</strong> Use<br />
<strong>Cessation</strong> Reduction Undecided<br />
<strong>Commercial</strong> <strong>Tobacco</strong> Use History<br />
Age smoking started ________________ Number of past quit attempts______________<br />
Most recent quit attempt _________________ Longest quit (number of) ___________ months<br />
What led to relapse _____________________________________________________________<br />
Past quit smoking strategies ______________________________________________________<br />
II. COMMENTS<br />
III. SMOKING ENVIRONMENT<br />
Exposure to 2nd hand smoke on a regular basis______________<br />
OTHER COMMENTS ON ENVIROMENT (where you smoke, who you smoke with, etc)<br />
IV. CURRENT MENTAL HEALTH ISSUES AND CURRENT TREATMENT<br />
V. CURRENT MEDICAL CONCERNS AND CURRENT TREATMENT<br />
6
VI. PAST MEDICAL AND/OR MENTAL HEALTH ISSUES AND PREVIOUS<br />
TREATMENT<br />
VII. OTHER SUBSTANCE USE<br />
PRESENT USE<br />
PAST USE<br />
VIII. PSYCHOSOCIAL RELATIONSHIPS<br />
(Include in<strong>for</strong>mation on finances, employment, relationships/ support system, family, legal issues, current<br />
stressors)<br />
IX. TREATMENT PLAN<br />
Include in<strong>for</strong>mation on strengths and resources, traditional healing approaches, other helpers or resources<br />
in the community, and any referrals needed to other programs (if available).<br />
7
Why You Smoke <strong>Commercial</strong> <strong>Tobacco</strong><br />
This scale helps us identify some of the reasons or factor as to why you smoke. If you score higher in some<br />
categories, then these might be the areas that you really need to focus on when you are trying to quit or reduce<br />
your smoking. The higher the number in each category, the more likely that is an area is a factor <strong>for</strong> why you<br />
smoke.<br />
Stimulation _____ wake yourself up, give yourself some energy<br />
Handling _____ like the feel of cigarette in hand, ritual of lighting cig.<br />
Pleasure _____ your reward, smoke in pleasant moods or to celebrate<br />
Coping _____ to cope with negative emotions or stress or trauma<br />
Craving _____ experience physical craving or strong desire to smoke<br />
Habit _____ specific routines, i.e.: after meals, with coffee, in car<br />
Reasons To Quit<br />
This scale will help you identify some of the reasons that are motivating you to quit. It is divided into 3 broad<br />
categories: External (Others want you to quit, financial reasons), Self Image (worried about how cigarettes<br />
make you look and feel about yourself) and Health (worried about current and future health). Again the<br />
higher the score the more likely that is one of the reasons <strong>for</strong> why you would like to quit or reduce your<br />
smoking<br />
External Self Image Health<br />
Opinion of others<br />
Personal Appearance<br />
Images of Illness<br />
_________________<br />
Financial Reasons<br />
_________________<br />
Environmental Factors<br />
_________________<br />
_________________<br />
Responsibility<br />
_________________<br />
Self-Esteem<br />
_________________<br />
_________________<br />
Health deterioration<br />
_________________<br />
Health Improvement<br />
_________________<br />
8
2<br />
Strategize: What are my<br />
reasons <strong>for</strong> change<br />
Session 2 is designed to build on the momentum generated during the<br />
assessment. This session is focused on facilitating an exploring a person’s<br />
ambivalence about changing their use of commercial tobacco.<br />
W<br />
hy change This is a recurring question – and concern – <strong>for</strong> people considering any<br />
change. This session poses the question of why changing commercial tobacco use<br />
might be an important (and desirable) step towards accomplishing other life goals.<br />
For example, the person may want to improve overall health, set a good example <strong>for</strong><br />
their children, or save money. On the other hand, we also recognize that there are powerful<br />
reasons why a person might resist changing: concerns about weight gain, withdrawal symptoms,<br />
coping strategies and losing the enjoyment of smoking are all factors that make it difficult to quit<br />
commercial tobacco use. By using a combination of providing neutral in<strong>for</strong>mation/feedback and<br />
facilitating an exploration of ambivalence, this session helps build motivation.<br />
Providing in<strong>for</strong>mation in a motivational way can be a challenge. The temptation is to adopt a<br />
warning or lecturing posture in communicating health effects or reasons <strong>for</strong> change. The danger<br />
in this stance lies in the fact that it does not leave the person space to articulate his or her most<br />
compelling reasons <strong>for</strong> change. Here are some tips <strong>for</strong> providing in<strong>for</strong>mation more<br />
“motivationally”:<br />
1. Ask permission: Preface your comments with a statement such as, “I’d like to take the<br />
next few minutes to go over some of the myths and facts about smoking. How does that<br />
sound to you” This invites “conversational consent” from the person or group, and sets<br />
the stage <strong>for</strong> a more productive discussion. An alternative “permission question” could be<br />
something along the lines of, “Would it be helpful to briefly go over some of the longer<br />
term risks associated with smoking as few as 10 cigarettes per day” It is often the case<br />
that a person comes to counselling with a wealth of in<strong>for</strong>mation already. Asking<br />
permission respects the possibility that a person may already know what we are going to<br />
tell them!<br />
2. Provide the in<strong>for</strong>mation in a neutral, non-dramatic way: It is hard to overstate the<br />
risks of smoking cigarettes. However, by maintaining neutrality when we provide<br />
in<strong>for</strong>mation we acknowledge that people may choose to disregard our teachings…and in<br />
the end, a decision to change can only be made by the individual. It is always better <strong>for</strong><br />
the client to express surprise, concern or dismay than <strong>for</strong> the helper to do so.
3. Beware of overloading a person with too much in<strong>for</strong>mation: The handouts included<br />
in this section are designed to be read by the person, and discussed in the group or the<br />
individual counselling session. It is helpful to touch on key points or questions, and use<br />
these as “jumping off” points <strong>for</strong> discussion and reflection.<br />
4. When finished providing in<strong>for</strong>mation, ask “How does that fit <strong>for</strong> you” or “What<br />
do you make of that” These questions give a person the opportunity to reflect on how<br />
(or whether) the in<strong>for</strong>mation provided relates to his or her own life, experiences and<br />
goals.<br />
It can be also be useful to have a person reflect on their feelings and expectations about<br />
counselling. For example, many people who have never attended group counselling may be<br />
anxious about the amount or type of disclosures that are expected. An important task in building<br />
cohesion in group treatment contexts is to teach people how to be “good group members”,<br />
through modeling and feedback. Here are some sample questions to start a discussion of group<br />
process issues, as well as build group cohesion:<br />
<br />
<br />
<br />
<br />
<br />
“What was it like <strong>for</strong> you to sit in this circle”<br />
“What are some of the things you are wondering about this group”<br />
“What needs to happen here in order <strong>for</strong> you to feel like this is a really helpful<br />
experience <strong>for</strong> you”<br />
“What would be important <strong>for</strong> us to do to support each other”<br />
“What are some ground rules or guidelines we should adopt in this group in<br />
order <strong>for</strong> everyone to feel respected and safe”<br />
The above questions can also be modified <strong>for</strong> use in individual sessions, in order to build rapport<br />
and trust. Setting a supportive tone and fostering a psychologically safe climate are crucial in<br />
counselling. Encouraging group members to interact with one-another (as opposed to directing all<br />
communication through the helper), periodically pausing to reflect on group process (as opposed<br />
to a strict content focus), and being explicit about group norms, goals and patterns of interaction<br />
can all help foster cohesion and mutual support.<br />
A client and a helper can work together to develop a strategy that mobilizes existing support<br />
systems, coping strategies, and medicines (both traditional and non-traditional). Even be<strong>for</strong>e<br />
setting s quit date, a person should be encouraged to begin to implement such strategies as:<br />
• Keep track of when and how many cigarettes smoked, including thoughts and feelings –<br />
this helps identify risky situations and possible triggers.<br />
• Thinking about and talking about the costs and benefits of quitting versus continuing to<br />
smoke commercial tobacco.<br />
• Completing a Decisional Balance exercise and reflecting on the costs and benefits of<br />
quitting versus continuing to smoke.<br />
10
Session 2: Dealing with ambivalence<br />
Clinical Tools<br />
o Reasons <strong>for</strong> Change <strong>for</strong>m<br />
o Decisional Balance <strong>for</strong>m<br />
o Readiness Ruler<br />
o<br />
Traditional Alternative to Readiness Ruler: TOBACCO CESSATION MEDICINE WHEEL - AN ANISHNAWBEK<br />
APPROACH<br />
o Daily Diary – NOTE: You might find it helpful to make several copies of the Daily Diary, and encourage a<br />
person to complete this every week, <strong>for</strong> discussion during each counselling session.
Reasons <strong>for</strong> Change<br />
Making a commitment to meeting your goal is important to your success. Sometimes, it’s<br />
easy to <strong>for</strong>get why you’re making the change, so write down your reasons and use this as a<br />
reminder to yourself when things seem tough!<br />
The most important reasons that I want to change are:<br />
1. _______________________________________________________________<br />
_______________________________________________________________<br />
_______________________________________________________________<br />
2. _______________________________________________________________<br />
_______________________________________________________________<br />
_______________________________________________________________<br />
3. _______________________________________________________________<br />
_______________________________________________________________<br />
_______________________________________________________________<br />
12
Decisional Balance Sheet<br />
Try to fill out personal reasons <strong>for</strong> why you continue to smoke commercial tobacco or why you may want to quit.<br />
Benefits of:<br />
Continue Smoking<br />
o Reward<br />
o Helps getting started in the morning<br />
(routine)<br />
o Helps me deal with stress<br />
Quit Smoking<br />
o Feel better about myself<br />
o Set a good example <strong>for</strong> children and<br />
community<br />
o Save money<br />
Costs of:<br />
o Smells bad<br />
o Costs too much<br />
o Skin damage<br />
o Out of breath when I walk<br />
o It will be hard to quit<br />
o I will miss smoking<br />
o Other people might not support me<br />
wanting to quit<br />
13
Readiness Ruler<br />
Now that you have thought about some of your reasons <strong>for</strong> change, where would<br />
you rate the importance of actually making these changes How confident do<br />
you feel about whether you can make this change How ready are you to start<br />
the journey of change<br />
How important is it to change this behaviour<br />
How confident are you that you could make this change<br />
How ready are you to make this change<br />
14
TOBACCO CESSATION MEDICINE WHEEL<br />
AN ANISHNAWBEK APPROACH<br />
YOUR HEALTH & WELL-BEING - IT’S UP TO YOU!<br />
10<br />
MENTAL ASPECT<br />
OF QUITTING TOBACCO<br />
eg: poor judgment/decision making, difficulty<br />
concentrating, bipolar illnesses, depression, etc.<br />
How confident are you that you could make this change<br />
PHYSICAL ASPECT OF TOBACCO USE<br />
SPIRITUAL ASPECT OF QUITTING<br />
TOBACCO<br />
10 How has your tobacco use impacted you<br />
How has quitting in the past affected you<br />
0<br />
eg: confusion, loss of<br />
connectedness, and/or<br />
problems in the physical,<br />
emotional or mental aspects.<br />
10<br />
How ready are you to make this<br />
change<br />
EMOTIONAL ASPECT<br />
OF QUITTING TOBACCO<br />
eg: low self-esteem, loss of ability to<br />
cope, relationship difficulties, etc.<br />
How important is it to change this behaviour<br />
10<br />
Anishnawbek teachings maintain that a person contains the four directions which must be in balance to achieve health. This wheel is<br />
combination of these teachings and the work of the TEACH project and motivational interviewing.<br />
The numbers serve as a guide to help the person(s’) explore change and gives the helper an idea of the balance of the person(s)<br />
The Gifts of the Seven Grandfathers (which are interwoven into daily life) are given to the people to help them understand and attain health and<br />
well-being.<br />
15
Daily Diary<br />
Date<br />
Behaviour<br />
(How many<br />
cigarettes<br />
today)<br />
Describe the situation (eg. Were<br />
you alone or with others, at home in<br />
a social setting)<br />
Thoughts and Feelings (What<br />
were you thinking and feeling in<br />
this situation)<br />
Monday<br />
Tuesday<br />
Wednesday<br />
Thursday<br />
Friday<br />
Saturday<br />
Sunday<br />
16
3<br />
Strategize: Setting a Quit Date<br />
Session 3 is focused on working with people around making a decision to<br />
change. Although not everyone may be ready to set a quit date or make a clear<br />
decision, the session content can be adapted to continuing the work around<br />
addressing ambivalence (Session 2).<br />
M<br />
aking a decision to change can be an intimidating process, particularly when it involves<br />
giving up a long-term behaviour, such as smoking commercial tobacco. There<strong>for</strong>e, the<br />
emphasis on this session is to continue to build motivation by focusing on the tools<br />
and strategies that can be helpful in changing commercial tobacco use. For some<br />
people, the decision to change may involve cutting down (as opposed to quitting). For many<br />
people, this is the most realistic first step, and harm reduction is a step in the right direction. In all<br />
cases, the feasibility and reasonableness of a person’s goal should be addressed.<br />
For a person who is not yet ready to change their use of commercial tobacco, the focus on this<br />
session can remain on barriers to change, as well as possible strategies <strong>for</strong> overcoming those<br />
barriers. A goal statement <strong>for</strong> someone not ready to quit might focus on a goal to smoke outside<br />
to prevent other people and animals in the home from the effects of second-hand smoke. If<br />
smoking is a way to cope with stress, the person’s goal might be to first try one or two other<br />
useful strategies <strong>for</strong> stress management be<strong>for</strong>e having a cigarette, and noting how helpful these<br />
alternative strategies are.<br />
Nicotine replacement medications (such as the nicotine patch, gum, lozenge or inhaler) can also<br />
be discussed in this session, and can be introduced as an option <strong>for</strong> anyone who is interested,<br />
regardless of their willingness or perceived ability to set a change goal at this time.<br />
A person completes the Goal Statement and another Readiness Ruler in this session. Note that an<br />
interim goal (such as smoking outside or cutting down on the number of cigarettes smoked) may<br />
be set if the person is not ready or willing to set a quit date at this time.<br />
It is also helpful to explore traditional healing approaches: <strong>for</strong> example, healing circles, prayer,<br />
offerings to the creator, teachings from an Elder, fasts or sweats can be powerful ways to support<br />
and heal a person in his or her recovery.
Session 3: Making a Decision to Change<br />
Clinical Tools<br />
o Preparing <strong>for</strong> Quit Day handout<br />
o How Fast Will I Improve Handout<br />
o What withdrawal symptoms can I expect Handout<br />
o Quitting Cold Turkey versus Cutting Down (handout)<br />
o Myths and Facts of Nicotine Replacement Therapies Quiz<br />
o Goal Statement & Readiness Ruler<br />
Note that there are many handouts and tools in this<br />
section – talk to your client about which one(s) would be<br />
the most helpful.<br />
18
Preparing <strong>for</strong> Quit Day<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
A few weeks prior to quit day, limit your smoking to only one room in your home or<br />
completely make it smoke free. This room should be the least com<strong>for</strong>table room in<br />
your house.<br />
Clean out your car and clean / deodorize your home.<br />
Visit your dentist to get your teeth cleaned. With the tar and nicotine removed from<br />
your teeth you are literally starting with a fresh mouth.<br />
Monitor alcohol and caffeine consumption be<strong>for</strong>e and after quit date as these can been<br />
seen as triggers to use. Cut down on caffeine after you quit, because people who don’t<br />
smoke commercial tobacco are more sensitive to caffeine (<strong>for</strong> example, coffee will<br />
have a stronger effect after you quit smoking).<br />
Get lots of rest leading up to your quit day.<br />
Drink lots of fluids as this can help with cravings.<br />
Use healthy substitutes such as sugarless gum, carrot sticks, sunflower seeds, raisons<br />
etc. This will help keep your mouth stimulated.<br />
Repeat your reasons <strong>for</strong> quitting or post a list on your fridge where you will be<br />
constantly be reminded.<br />
Plan activities <strong>for</strong> your first week of being smoke free. Keeping yourself occupied is<br />
important as well as planning activities that do not place you in situations where you<br />
will be tempted to smoke.<br />
Occupy your hands with toothpicks, pencil, rubber bands, stress balls, etc…<br />
Be aware of cigarette advertisements or other triggers.<br />
Never allow yourself to think that one cigarette won’t hurt. Many smokers relapse<br />
when they believe they can control their smoking. This is harmful because even if you<br />
are able to control your cigarette consumption <strong>for</strong> awhile it generally ends up<br />
increasing to where it was be<strong>for</strong>e you quit.<br />
Use your support system and don’t be afraid to ask <strong>for</strong> help from community members,<br />
Elders, family etc.<br />
19
How fast will I improve after I stop using commercial tobacco<br />
Everyone improves after quitting smoking at varying rates. This may be dependent on amount smoked,<br />
years smoked, if you are exposed to second hand smoke (among other factors).<br />
Immediately<br />
The air around you and your family and friends is safer.<br />
Within 20 minutes of<br />
last cigarette<br />
After 8 hours<br />
Blood pressure drops<br />
Pulse rate drops to normal<br />
Body temperature of hands and feet increases to normal<br />
Carbon Monoxide level in blood drops<br />
After 24 hours<br />
Chance of heart attack decreases<br />
After 48 hours<br />
Nerve endings may re-grow<br />
Ability of smell and taste enhanced<br />
After 72 hours<br />
Bronchial tubes relax; if undamaged, will make breathing easier<br />
Lung capacity increases<br />
2 weeks to 3 months Circulation improves<br />
Walking becomes easier<br />
Lung functioning may increase up to 20%<br />
1 – 9 months Coughing, sinus congestion, fatigue, shortness of breath may decrease<br />
Potential <strong>for</strong> cilia in lungs to re-grow, increasing ability to handle mucus, clean<br />
the lungs and reduce infection<br />
1 year The risk of heart disease is reduced by half of someone who continues to smoke<br />
20
2 years Cervical cancer risk reduced compared to people who continue to smoke<br />
Bladder cancer risk halved compared to continuing smokers<br />
5 – 15 years Stroke risk is reduced to that of a nonsmoker!<br />
10 years Risk of cancer of the lung, mouth, throat, esophagus, kidneys and pancreas<br />
decreases<br />
Document prepared by CAMH Nicotine Dependence Clinic – adapted from:<br />
http://www.quittobacco.org/whyquit/physicalbenefits.html<br />
21
What Withdrawal Symptoms Can I Expect<br />
Each individual can experience very different withdrawal symptoms from quitting commercial tobacco. Most<br />
people will experience the worst physical withdrawal symptoms within the first 3 – 5 days. If a symptom<br />
persists or seems worse you should see a doctor or nurse practitioner. Here are some things you may<br />
experience when quitting commercial tobacco use (cigarettes or smokeless tobacco).<br />
‣ Occasional dizziness – This is caused by the fact that you are now absorbing more oxygen through<br />
your lungs. The dizziness may come upon you <strong>for</strong> a few days and usually lasts <strong>for</strong> only a few<br />
seconds.<br />
‣ Headache – One in four smokers reports a mild headache at some point during their quitting<br />
process.<br />
‣ Hunger – Almost all smokers notice this symptom. Nicotine is an appetite suppressant so you feel<br />
like eating more. The body’s absorption of food is improved too, so that you gain more nourishment<br />
even if you do not actually increase the amount you eat. It is important to note that not all people<br />
gain weight when they quit and healthy eating and exercise can help to curb this.<br />
‣ Constipation – Intestinal motility may decrease <strong>for</strong> a brief period when you quit cigarettes. This<br />
usually lasts <strong>for</strong> only 3 – 4 days. If you have further concerns about this please see a health<br />
practitioner.<br />
‣ Shakiness – You may notice your hands tremble slightly, perhaps <strong>for</strong> several weeks. The tremor<br />
usually subsides as your body gets used to its new non-smoking environment.<br />
‣ Sweating – This is another common reaction. Like the shakes, it will go away after a while. Hot baths<br />
or showers can dispel the perspiration.<br />
‣ Coughing more – As the cilia in your lungs rebuild, they start to clean the bronchial tubes and<br />
remove the phlegm, thus causing increase in coughing. This can last <strong>for</strong> a few weeks and results in<br />
the disappearance of the “smoker’s cough”.<br />
‣ Other symptoms you may experience include: decreased concentration, feeling fatigued,<br />
nervousness, irritability, anxious, or sadness. These are normal, and they are part of physical,<br />
emotional and spiritual healing from commercial tobacco.<br />
22
Cold-Turkey vs. Cutting Down<br />
We are often asked which strategy is the best way <strong>for</strong> quitting commercial tobacco use. Un<strong>for</strong>tunately there<br />
is no easy answer and this decision depends on each individual’s preferences, strengths and weaknesses.<br />
Consider the following in<strong>for</strong>mation be<strong>for</strong>e making your decision.<br />
Cold-Turkey<br />
When a person quits cold turkey this means that he/she has gone from smoking his/her normal amount of<br />
cigarettes to abruptly stopping completely. The amount of nicotine in blood stream quickly drops off. As a<br />
result, the body may experience some withdrawal symptoms (restless, irritable, appetite changes, sleep<br />
disturbances, headache, fatigue, coughing etc.). The benefit of quitting this way is that it is quick and your<br />
body begins to heal itself immediately.<br />
Cutting down or tapering<br />
Some people decide to cut down the number of cigarettes that they smoke and thereby reduce the amount<br />
of nicotine in the body. The benefit to this process is the potential reduction of withdrawal symptoms.<br />
However some people find that it is difficult <strong>for</strong> them to maintain a lower level of nicotine because the body<br />
begins to crave the original amount that the smoker was consuming. There<strong>for</strong>e they may find themselves<br />
going up and down with the amount that they smoke because the body may experience mini withdrawal<br />
symptoms. To prevent this from happening nicotine replacement therapies were developed. These<br />
products were designed to lower the amount of nicotine in the body gradually to minimize withdrawal.<br />
Whatever method of quitting you decide upon, it is important to be prepared. If you decide to go coldturkey,<br />
know what you are going to do on your quit date and have supports in place to help you through<br />
your chosen date. Alternatively, if you are going to taper down, there are many strategies that you can use to<br />
help you through this process.<br />
23
Myths and Facts about stop-smoking medications<br />
How much do you know about medications to help people quit smoking Take<br />
this True-or-False quiz and find out (answers are at the bottom).<br />
Myth or Fact<br />
1. Nicotine is one of the harmful substances in cigarettes.<br />
2. Nicotine addiction is equally likely whether the nicotine is obtained<br />
from cigarettes, nicotine patch, gum, lozenge or inhaler.<br />
3. Nicotine patches, gum, lozenge and inhalers carry significant health<br />
risks if used by people who smoke.<br />
4. Smoking while on the patch causes heart attacks.<br />
5. People with heart disease should not use nicotine replacement<br />
medications.<br />
6. Pregnant women should never use nicotine replacement<br />
medications.<br />
7. People under age 18 should never use nicotine replacement<br />
medications.<br />
8. Stop-smoking medications should not be used in combination with<br />
one-another.<br />
9. People using nicotine replacement medications should not exceed<br />
the dose recommended on the medication package.<br />
10. Stop-smoking medications are only appropriate <strong>for</strong> short-term use.<br />
11. Nicotine replacement medications should not be used by people<br />
who just want to cut down on the number of cigarettes they smoke.<br />
True or False<br />
Answers:<br />
1. False: The thousands of toxins in tobacco smoke are harmful. Nicotine is not associated with cancers or chronic respiratory conditions.<br />
2. False: Cigarettes are far more addictive than nicotine replacement, primarily because of how they deliver nicotine.<br />
3. False: Nicotine replacement therapy is safe <strong>for</strong> smokers.<br />
4. False: The use of nicotine replacement does not increase cardiovascular risk,<br />
5. False: It is more dangerous <strong>for</strong> people with heart disease to continue smoking than to use nicotine replacement, and many such patients are not able to<br />
quit on their own.<br />
6. False: nicotine replacement is safer <strong>for</strong> the fetus than smoking, and is appropriate <strong>for</strong> pregnant women who are unable to quit using behavioural<br />
interventions.<br />
7. False: Most daily smokers begin smoking be<strong>for</strong>e age 18, and are already getting nicotine from cigarettes. Nicotine replacement should be considered <strong>for</strong><br />
youth who are regular smokers who are unable or unwilling to quit using behavioural interventions.<br />
8. False: The nicotine patch/gum/lozenge/inhaler can be used at the same time and/or in combination with bupropion (Zyban).<br />
9. False: Smokers should be in control of how and how much they use nicotine replacement medications.<br />
10. False: Nicotine replacement should be used <strong>for</strong> as long as needed to maintain or prolong tobacco abstinence.<br />
11. False: Nicotine replacement can be used by people who are not ready to quit as a way to reduce their smoking, and progress towards a longer-term<br />
goal of abstinence.<br />
(adapted from Ontario Medical Association Position Paper: Rethinking stop-smoking medications: <strong>Treatment</strong> myths and medical<br />
realities, January, 2008).<br />
24
Goal Statement<br />
The behaviour I want to/need to change is:<br />
_____________________________________________________<br />
_____________________________________________________<br />
_____________________________________________________<br />
What is your goal now<br />
_____________________________________________________<br />
_____________________________________________________<br />
_____________________________________________________<br />
Start date: ______________________________<br />
Achievement date: _______________________<br />
Tip – If you are not ready to quit commercial tobacco, think about what a small goal<br />
might be. One example might be to not smoke in your car, to smoke outside, or to not<br />
smoke <strong>for</strong> a three hour period each day <strong>for</strong> a week. Any others<br />
25
Readiness Ruler<br />
Now that you have set a goal, where would you rate the importance of you goal<br />
How confident do you feel now in accomplishing your goal How ready are you<br />
to continue the journey of change After you have completed this sheet, go back<br />
and compare your responses with the one you completed in the last session.<br />
How important is it to change this behaviour<br />
How confident are you that you could make this change<br />
How ready are you to make this change<br />
26
4<br />
Take Action<br />
Session 4 builds on the person’s goal statements by asking him or<br />
her to identify what might stand in the way of accomplishing these<br />
goals. In Session 4 we are asking people to examine their major<br />
risk situations <strong>for</strong> commercial tobacco use. The work in this session<br />
sets the stage <strong>for</strong> the development of concrete plans <strong>for</strong> preventing<br />
relapse, covered in Session 5.<br />
I<br />
dentifying high-risk situations is an important step towards being able to develop<br />
a way to deal with triggers to use commercial tobacco. This session is focused on<br />
a detailed look at the person’s major areas of risk. It can be a challenge <strong>for</strong> a<br />
person who uses commercial tobacco in so many different settings and<br />
circumstances to come up with three major triggers…especially in the early days and<br />
weeks of quitting or cutting down tobacco use. However, the process of figuring out<br />
the states of mind, settings, times of day or other triggering events is key to coming up<br />
with an effective coping plan. Even opening the conversation gives a person some<br />
“food <strong>for</strong> thought” around beginning to anticipate – and plan <strong>for</strong> – the situations that<br />
will be especially difficult.<br />
Here are some suggestions of common risk situations to get the conversation started:<br />
First thing in the morning, or just be<strong>for</strong>e going to bed<br />
After meals<br />
While driving<br />
With a coffee<br />
While on the phone<br />
In a social setting<br />
With particular people (friends or family members)
When feeling upset, sad or angry.<br />
The discussion of triggers is complemented in this session by also focusing on possible<br />
coping strategies. Important messages to rein<strong>for</strong>ce are that change is possible, and even<br />
the most severe cravings will pass.<br />
For example:<br />
Changes in mood = what further support is needed<br />
Withdrawal symptoms = re-assess medicines or think about using nicotine<br />
replacement<br />
Low motivation = review Decisional Balance and Reasons <strong>for</strong> Change exercises<br />
Weight gain = recommend physical activity, healthy eating, additional support<br />
Lapses or slips = explore triggers and coping strategies; continue self-monitoring<br />
Perhaps most important of all, especially if the person has been experiencing some<br />
difficulties in meeting his or her goal, is to congratulate him or her <strong>for</strong> coming back to<br />
see you, and <strong>for</strong> the ef<strong>for</strong>t of trying. Remind the person that quitting smoking is not an<br />
event, it is a process!<br />
In this session, it is suggested that you complete with the person the Triggers and<br />
Consequences work sheet and/or the Change Plan Work Sheet.<br />
28
Session 4: Making a Decision to Change<br />
Clinical Tools<br />
o Triggers and Consequences Worksheets<br />
o Change Plan Worksheet<br />
o General Coping Strategies (handout)<br />
o Healing from <strong>Commercial</strong> <strong>Tobacco</strong> Use – Some Traditional Approaches (handout)<br />
Note that there are many handouts and tools in this section<br />
– talk to your client about which one(s) would be the most<br />
helpful.
Triggers and Coping Skills<br />
Sample Plan<br />
Triggers<br />
Coping Skills<br />
Smoke with friend every<br />
day at breaks<br />
Tell friend “I am quitting”<br />
After meals<br />
Chew gum after meals; get up<br />
from table right away<br />
Stress at work gets too<br />
much on some days<br />
Plan to take walks when<br />
stress is high<br />
Triggers<br />
Coping Skills<br />
30
Change Plan Worksheet<br />
The changes I want to make are:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
The most important reasons why I want to make these changes are:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
The steps I plan to take in changing are:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
The ways other people can help me are:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
I will know that my plan is working if:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
Some things that could interfere with my plan are:<br />
________________________________________________________________________<br />
________________________________________________________________________<br />
31
General Coping Strategies<br />
Things I can do Thoughts that can help Coping with feelings<br />
Visit an Elder or Knowledge<br />
Keeper and offer to be a helper<br />
Attend a sweat lodge ceremony<br />
Smudge<br />
Have a cedar bath<br />
Drink a cup of cedar tea<br />
Go in the bush<br />
Sit by the water<br />
Make a tobacco offering in<br />
gratitude <strong>for</strong> the day<br />
Avoid people or places that<br />
trigger problematic coping<br />
strategies (i.e. tobacco use,<br />
drinking, drug use, self-harm)<br />
Identify and avoid high-risk<br />
situations.<br />
Take a “buddy” when going to a<br />
risky place /situation.<br />
Leave risky situations, or limit<br />
how long you stay.<br />
Phone someone <strong>for</strong> support<br />
Go <strong>for</strong> a walk.<br />
Read a book.<br />
Exercise or do something<br />
physical.<br />
Stand tall and feel your body’s<br />
strength. Remind yourself that<br />
you are a strong person.<br />
Hold onto something to ground<br />
yourself (chair you are sitting in,<br />
key ring, picture etc.)<br />
Clean or do housework.<br />
Offer a daily prayer of gratitude<br />
Talk to an Elder or Knowledge<br />
Keeper about the Seven<br />
Grandfather teachings<br />
Think kind thoughts about yourself<br />
Remember the positive things<br />
about using healthy coping<br />
strategies.<br />
Remember the negative<br />
consequences of using<br />
problematic coping strategies.<br />
Tell yourself that feelings, even<br />
difficult feelings, are normal.<br />
Distract yourself by thinking about<br />
something else.<br />
Recognize when you are making<br />
self-defeating statements or<br />
rationalizations (i.e., I am such a<br />
loser).<br />
Plan ahead <strong>for</strong> any risky situations<br />
or “loopholes” to your plan.<br />
Imagine a stop sign when you are<br />
having intrusive thoughts or<br />
imagery.<br />
Think about your future goals and<br />
how to achieve them.<br />
Remind yourself that you only<br />
have to worry about what you have<br />
control over today.<br />
Remind yourself that you are in the<br />
present and the past cannot hurt<br />
you now.<br />
Make a commitment to yourself<br />
and remind yourself of it.<br />
Think that you are in charge of<br />
whatever decisions you make<br />
about your safety.<br />
☯ Talk to an Elder or<br />
Traditional Healer<br />
☯ Acknowledge your<br />
internalized oppression<br />
☯ Read inspiring literature on<br />
self-growth or recovery.<br />
☯ Ask yourself what you are<br />
feeling (go through a<br />
checklist of your common<br />
“feeling triggers” –am I<br />
lonely, sad, anxious,<br />
scared).<br />
☯ Give yourself permission to<br />
feel emotions (don’t judge<br />
your feelings).<br />
☯ Express your feelings (cry,<br />
smile, etc.,).<br />
☯ Ask <strong>for</strong> support.<br />
☯ Talk to someone about your<br />
feelings.<br />
☯ Find a creative outlet <strong>for</strong><br />
feelings (music, drawing,<br />
painting, poetry etc.,).<br />
☯ Get a journal and write to<br />
yourself.<br />
☯ Take time to soothe /<br />
nurture yourself.<br />
☯ Praise yourself <strong>for</strong> the<br />
progress you have made.<br />
☯ Use affirmations.<br />
☯ Light candles to help you to<br />
focus on your thoughts and<br />
feelings.<br />
☯ Write a letter to someone<br />
about how you are feeling (it<br />
32
Do volunteer work<br />
Try meditation, deep breathing,<br />
and relaxation tapes.<br />
Try new hobbies or leisure<br />
activities.<br />
Practice saying no with both<br />
your voice and body language.<br />
Stay in contact with supportive<br />
people.<br />
Take care of yourself if you are<br />
hungry, thirsty or tired.<br />
Keep a visual reminder of the<br />
negative consequences of your<br />
problematic coping strategies<br />
(i.e. court papers, photos)<br />
Keep visual reminders or<br />
written lists of the positive<br />
consequences of the changes<br />
you’ve made.<br />
Reward yourself <strong>for</strong> your<br />
ef<strong>for</strong>ts.<br />
Go to a support group.<br />
Listen to music. Sing. Dance.<br />
Cook and eat nutritious food.<br />
Practice being kind to yourself<br />
Tell yourself that you are doing<br />
well so far and don’t want to<br />
interfere with the progress.<br />
When feeling overwhelmed, make<br />
a pro / con list and limit your<br />
decisions until you feel less<br />
overwhelmed.<br />
Monitor your use and urges to use<br />
problematic coping strategies<br />
Think about the times in your life<br />
(even if few) where you have felt<br />
good about yourself. Try to get in<br />
touch with the feelings of strength<br />
and success that went along with<br />
those events.<br />
<br />
When a negative belief about<br />
yourself pops into your head, try to<br />
remember where it really came<br />
from—who originally planted those<br />
beliefs Think about challenging<br />
them with other in<strong>for</strong>mation that<br />
you know about yourself, which<br />
proves the beliefs to be false.<br />
Be aware of any tendency you<br />
have to make general statements<br />
about yourself. Being human<br />
means having good and bad days.<br />
Post a copy of the Seven<br />
Grandfather teachings where you<br />
can review it each day<br />
is better to not send the<br />
letter, keep it, burn it, bury it,<br />
flush it).<br />
☯ Get a punching bag, or hit a<br />
pillow or bed, scream into a<br />
pillow.<br />
☯ Throw rocks in the lake<br />
☯ Talk to a pet / spend time<br />
with animals.<br />
☯ Go to a spiritual place<br />
(anyplace you define as<br />
spiritual).<br />
☯ Create a safe or sacred<br />
place in your home.<br />
☯ Be kind to yourself.<br />
☯ If you are afraid of being<br />
overwhelmed by your<br />
emotions, imagine them<br />
coming through a tap where<br />
you are able to control the<br />
flow<br />
33
Healing from commercial tobacco use: some traditional approaches<br />
The following are ideas and suggestions and may not necessarily apply to all Nations. We recognize there are no<br />
universal or pan‐Aboriginal approaches to healing commercial tobacco use.<br />
A community member should always begin their traditional healing path by consulting with people s/he trusts to get<br />
referrals to respected and recognized Traditional Healers, Elders and Medicine People within his/her community or<br />
organization. An Elder in the community would be willing to help the community member who wants to quit by being<br />
available throughout the process of their journey toward becoming a non‐smoker. When you seek the help and advice<br />
of an Elder, Healer or Medicine Person, and give your offering of tobacco, they know that a request may be made as<br />
tobacco is so sacred.<br />
<strong>Tobacco</strong> is the first plant that the Creator gave to the peoples of Turtle Island. It is used as an offering <strong>for</strong> everything in<br />
every ceremony. “Always through tobacco,” the saying goes. Traditional tobacco was given to us so that we can<br />
communicate with the spirit world. It opens up the door to allow that communication to take place. When we make an<br />
offering of tobacco, we communicate our thoughts and feelings through the tobacco as we pray <strong>for</strong> ourselves, our<br />
family, relatives and others.<br />
<strong>Tobacco</strong> has a special relationship to other plants: it is said to be the main activator of all the plant spirits. It is like the<br />
key to the ignition of a car. When you use it, all things begin to happen. <strong>Tobacco</strong> is always offered be<strong>for</strong>e picking<br />
medicines. When you offer tobacco to a plant and explain why you are there, that plant will let all the plants in the area<br />
know why you are coming to pick them.<br />
We express our gratitude <strong>for</strong> the help the spirits give us through our offering of tobacco. It is put down as an offering of<br />
thanks to the First Family, the natural world after a fast. Traditional people make an offering of tobacco each day when<br />
the sun comes up.<br />
Traditional tobacco is still grown in some communities. For example, the Haudenosaunee people use a traditional<br />
tobacco that they grow themselves and that is very sacred to them. <strong>Tobacco</strong> along with sage, cedar and sweetgrass<br />
make up the Four Sacred Medicines.<br />
In addition to speaking to a traditional person and making offerings, a community member can also find healing through<br />
ceremony such as:<br />
- daily smudges with the sacred medicines and prayers<br />
- going on a fast<br />
- going to a sweat<br />
Many options are available <strong>for</strong> reconnecting with traditional activities, replacing unhealthy environments and activities<br />
with healing ones, or distracting ones hands from the habit of cigarette smoking, such as:<br />
- spending time in the bush<br />
- traditional, jingle, fancy shawl, grass, chicken, etc. dancing<br />
- beadwork and craft‐making<br />
- hunting, trapping, cooking traditional foods<br />
- singing<br />
- drumming<br />
(In part adapted from “The Four Sacred Medicines”. Anishnawbe Health Toronto, 2000, and through consultation with<br />
the Enaahtig Healing Lodge and Learning Centre.)<br />
34
5<br />
Optimize Your Plan<br />
In Session 4, the person was asked to identify some major triggers <strong>for</strong> commercial<br />
tobacco use, and to think about ways to cope. In this session, the person will examine<br />
what is working well and what needs further change to “optimize” the plan of action.<br />
This session and the last session (Session 6) are devoted to “fine-tuning” and testing<br />
out various coping strategies and supports.<br />
A<br />
sking <strong>for</strong> feedback from others is the primary focus of the fifth treatment session. Who are the<br />
most helpful supports to changing commercial tobacco use These can include Elders, family<br />
members, friends, colleagues or health professionals. The person is encouraged to ask <strong>for</strong><br />
feedback on his or her plan of action, identify what is missing or what he or she could try to do<br />
differently, and to watch <strong>for</strong> saboteurs (people who are not supportive of change).<br />
During this session, the helper could coach the person on ways to ask <strong>for</strong> specific feedback. This might<br />
include identifying a number of possible options <strong>for</strong> each trigger or risk situation, and asking <strong>for</strong> specific<br />
feedback on what might work best. The concept of “options” can be difficult to communicate to people.<br />
Here is a suggested way of framing this task:<br />
“In the past, commercial tobacco has been a way to cope with the trigger situations we talked about<br />
last week. But, if you think about it, people who don’t smoke also experience similar triggers… they<br />
just cope (or behave) in different ways. This week, we’re going to look at some of the other things<br />
you could do when you’re confronted with one of these triggers. The more options you come up<br />
with the better.”<br />
Providing some concrete examples can be helpful in clarifying the task. Some possibilities include:<br />
Trigger:<br />
Options:<br />
o Smoking while drinking coffee in the morning<br />
o Switching to tea or juice<br />
o Drinking coffee in a place that doesn’t allow smoking (like a coffee shop)
o Changing my morning routine<br />
o Quitting coffee completely<br />
o Continuing to have my morning coffee at home, but not smoking<br />
After the person has generated three or more options, they are asked to reflect on the likely consequences<br />
of each option – both short- and long-term, and positive and negative. Returning to the example above,<br />
here are some of the possible consequences <strong>for</strong> each of the options listed:<br />
Possible consequences to each option:<br />
1. Switching to tea or juice<br />
• Hard to give up my morning coffee<br />
• I would feel tired<br />
• It wouldn’t be the same<br />
• I would be tempted to make a coffee<br />
• I wouldn’t be as likely to crave a cigarette<br />
• Tea or juice is healthier.<br />
2. Drinking coffee in a place that doesn’t allow smoking (like a coffee shop)<br />
• I might not have time to stop at a coffee shop in the morning<br />
• More expensive<br />
• Would be relaxing and a change of pace<br />
• Gets me out of the house<br />
• Not as tempted to smoke, since it wouldn’t be an option<br />
3. Changing my morning routine<br />
• I’ve been trying to do this already<br />
• Helps with the cravings in the morning<br />
• Doesn’t take me any more time, and might save me time<br />
• Healthier<br />
36
4. Quitting coffee completely<br />
• Headaches<br />
• I love the taste of coffee<br />
• Not sure if I want to give it up – would feel even more deprived<br />
• Healthier if I gave it up<br />
5. Continuing to have my morning coffee at home, but not smoking<br />
• Would be hard to resist smoking<br />
• Wouldn’t have to make any more changes<br />
Examining the costs and benefits of each option helps people to complete the next part of the exercise:<br />
deciding on their best, and their second-best options. After looking at the pros and cons of each of the<br />
options in our example, the person decided that Option #3 was the best, and Option #2 was the second<br />
best.<br />
The final part of this exercise involves coming up with an Action Plan <strong>for</strong> her best option, and another<br />
plan <strong>for</strong> her second-best option. Here is a sample Action Plan <strong>for</strong> the option, “Changing my morning<br />
routine”:<br />
‣ Wake up 30 minutes earlier<br />
‣ Do some type of exercise either at home or at the Community Centre<br />
‣ Get out of the house first thing in the morning (got to work, go <strong>for</strong> walk, visit non-smoking<br />
family or friends)<br />
‣ Don’t linger at home with my coffee like I usually do.<br />
People often have some difficulty making their Action Plans concrete. It is important to look at each step<br />
in his or her plan, and ask the person: “Is this something you could do tomorrow” The key is to help the<br />
person come up with the specific steps they will take <strong>for</strong> each of their best options.<br />
“Homework” <strong>for</strong> the coming week involves trying out these options to see what works, and approaching<br />
others to ask <strong>for</strong> feedback and “troubleshooting.”<br />
Note that there are no specific “Clinical Tools” in this section – refer back to the plans and<br />
handouts discussed in the previous sessions and help the person reflect on what is working well and what<br />
further changes he or she can make.<br />
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6<br />
Prevent Relapse<br />
This final session is an opportunity to review the feedback from<br />
personal supports received during the previous week, determine<br />
strategies that are effective, and come up with alternative strategies<br />
and plans as needed. Clients are invited, during this session, to<br />
review what they have accomplished in counselling, and to reflect on<br />
their successes and accomplishments. This session also explores with<br />
people “what else is needed” with respect to continuing counselling,<br />
supports or other needs.<br />
W<br />
hat has been helpful What more is needed These are the key questions<br />
that guide this final counselling session. Ask the person to review the<br />
feedback he or she received from his or her support network, with a goal<br />
of identifying the steps and strategies that have worked well, along with<br />
those that need some additional “fine-tuning.” The goal throughout these sessions has<br />
been <strong>for</strong> the person to become his or her own teacher, through communicating a<br />
general problem-solving approach that can be applied to a variety of behaviour change<br />
goals. Ideally, at this point in counselling, the person has mastered the strategies of<br />
identifying risk situations, generating options, and developing concrete Action Plans.<br />
The person is also invited to review the Decisional Balance exercise that they<br />
completed at the beginning of the counselling journey (Session 2). This is important,<br />
since the Decisional Balance focused on hypothetical costs and benefits of change. It is<br />
often the case that the actual costs are not as significant as originally anticipated. The<br />
benefits to change may be greater than a person thought, or there may be other,<br />
unanticipated benefits.<br />
Finally, this session is an opportunity to identify and reflect on possible next steps.<br />
These might include attending an ongoing support group, attending a self-help group,<br />
reading self-help materials, or connecting with Elders or community supports or<br />
programs or other ways of healing. The notion of change and recovery as an ongoing<br />
process is useful. “Bumps in the path” are to be expected – the issue is how the person<br />
addresses these temporary setbacks. A person can also be provided with additional<br />
self-monitoring <strong>for</strong>ms, and encouraged to continue to track triggers, possible<br />
commercial tobacco use and coping strategies.
Session 6: Preventing Relapse<br />
Clinical Tools<br />
Decisional Balance exercise revisited<br />
“If I were to relapse…” exercise<br />
“I Can Quit” planning sheet<br />
“Current Motivation and Next Steps”
Decisional Balance Sheet<br />
Write down the good things (benefits) of quitting commercial tobacco use, as well as the less good<br />
things (costs) of quitting. Then compare your answers with the ones that you wrote in Session 2.<br />
Were there any differences For example, were there any benefits that you have experienced that<br />
you had not anticipated Have the costs of quitting been as hard as what you thought at the<br />
beginning of counselling<br />
Continue Smoking<br />
Benefits of: o Reward<br />
o Helps getting started in the<br />
morning (routine)<br />
o Helps me deal with stress<br />
Quit Smoking<br />
o Feel better about myself<br />
o Set a good example <strong>for</strong> children and<br />
community<br />
o Save money<br />
Costs of:<br />
o Smells bad<br />
o Costs too much<br />
o Skin damage<br />
o Out of breath when I walk<br />
o It will be hard to quit<br />
o I will miss smoking<br />
o Other people might not support me<br />
wanting to quit<br />
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I CAN QUIT PLANNING SHEET<br />
Prevent Relapse<br />
Optimize<br />
Strategize<br />
Take Action<br />
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If I were to relapse….<br />
…it would most likely be in the following situation:<br />
________________________________________________________<br />
________________________________________________________<br />
________________________________________________________<br />
________________________________________________________<br />
What coping strategies could I use to avoid this<br />
________________________________________________________<br />
________________________________________________________<br />
________________________________________________________<br />
________________________________________________________<br />
This worksheet demostrates <strong>for</strong>ward thinking. How would you feel if you<br />
relapsed<br />
This is another tool that can help prepare you to avoid relapse as it helps<br />
you anticipate high risk situations and plan alternate strategies<br />
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Current Motivation and Next Steps<br />
1. Where were you when you started this process, and where are you now<br />
2. What do you need to do to continue to make positive changes<br />
3. What is your next step<br />
Completing this worksheet allows you to gain perspective on quitting commercial<br />
tobacco use. Reflect on how this entire journey has gone from starting to think<br />
about behaviour change, to continuing these ef<strong>for</strong>ts, and write down the next<br />
step that you need to take moving <strong>for</strong>ward. This gives you the chance to feel<br />
proud about the progress you have made to date, gain confidence, and realize<br />
that even if you have not yet met your ultimate goal – you are still farther ahead<br />
than when you first started!<br />
Additional resources that can support me…<br />
Keep this list handy. It can have names, contact in<strong>for</strong>mation, websites, favourite<br />
quotes etc – whatever is meaningful to you.<br />
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Resources and Further Reading<br />
Key Resources <strong>for</strong> Continuing Professional<br />
Development in Motivational Interviewing<br />
Online Training & Resources<br />
Centre <strong>for</strong> Addiction and Mental Health<br />
online courses, including MI:<br />
http://www.camh.net/education/Online_co<br />
urses_webinars/index.html<br />
Clinical Training Institute: Online MI<br />
courses including MITI coding and<br />
Certificate Programs:<br />
http://www.motivationalinterviewing.info/<br />
Motivational Interviewing Home Page –<br />
International Introductory and Advanced<br />
Training In<strong>for</strong>mation:<br />
http://motivationalinterview.org/training/in<br />
dex.html<br />
Books<br />
Naar-King, S. and Suarez, M.<br />
(2011). Motivational<br />
Interviewing with Adolescents<br />
and Young Adults. New York:<br />
Guil<strong>for</strong>d.<br />
Rollnick, S., Miller, W.R. and<br />
Butler, C.C. (2008).<br />
Motivational Interviewing in<br />
Health Care. New York:<br />
Guil<strong>for</strong>d.<br />
Rosengren, D.B. (2009).<br />
Building Motivational<br />
Interviewing Skills: A<br />
Practitioner Workbook. New<br />
York: Guil<strong>for</strong>d.<br />
More resources are available at:<br />
www.teachproject.ca<br />
http://www.cancercare.on.ca/cms/one.aspxpageId=9322<br />
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