JENNIFER PERCIVAL NURSE, MIDWIFE, HEALTH VISITOR

1. JENNIFER PERCIVALNURSE, MIDWIFE, HEALTH VISITOR HELPING PEOPLE TO STOP SMOKING

2. TOBACCO IS A SERIOUS PROBLEM In the year 2000 1 in every 6 deaths worldwide was caused by smoking By the year 2030 1 in every 3 deaths worldwide will be due to smoking 70% of these deaths will be in developing countries. Source: WHO

3. WHO Global statistics Five countries China, India, Indonesia, Russia and Bangladesh account for half of all the world’s smokers Smoking is a risk factor for six of the eight leading causes of deaths in the world. Smoking will kill at least a third of all current smokers many more develop serious illness because of tobacco.  People killed by tobacco lose on average 10 - 15 years of life. Almost half of the world's children breathe air polluted by tobacco smoke.

4. WHY IS TOBACCO USE INCREASING GLOBALLY?

5. Tobacco Industry constantly works to make cigarettes socially acceptable “You’re clearly someone who considers others. That’s why Superslim Capri is the choice for you…great tobacco flavor, but less smoke for those around you.”

6. Tobacco advertisers have no boundaries

7. China has been a success story for the tobacco industry

8. Adverts have long been targeting women

11. The truth aboutWomen and Tobacco • Lung cancer surpassed breast cancer as leading cause of cancer death in 1987 • More women die from lung cancer than breast, ovarian, cervical & endometrial cancers combined

12. The WHO Framework Conventionon Tobacco ControlMain Measures • Ban on tobacco advertising • Increase Taxation • Take effective measures on passive smoking • Put Labelling and warnings on tobacco • Provide Education campaigns • Cessation guidelines and services • Take Action on illicit trade • Control sales to minors

13. Sir Richard Peto WHO Epidemologist “Most of those who will be killed by to tobacco in the first half of this century have already begun to smoke. These tobacco deaths can be substantially reduced only by current smokers giving up the habit.”

14. What is smoking? • A chronic relapsing dependence syndrome • Use of the addictive drug nicotine delivered rapidly to the brain via the lungs and blood • A strong habit reinforced by sensory, behavioural and social conditioning • Entrenched by powerful withdrawal syndrome • Great harm is caused by toxins in the smoke

15. 4,000 chemicals Tar Carbon monoxide What’s in a cigarette?

16. 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% What happens when you try to stop? Withdrawal effects: duration and frequency

17. NZ Best Practice Ask about smoking Give Brief advice to quit Offer Cessation support

18. You may have already noticed that ‘professional persuasion’ does not always make people decide to stop smoking Miller WR et al. J Consult Clin Psychol 1993;61:455–61;Miller and Rollnick, 1991

19. GOOD ADVICE

21. CREATING RESISTANCE TO CHANGE? • It’s tempting to be ‘helpful’ by informing clients of the urgency of their medical problems and the advantages of stopping smoking • But these tactics can often increase client resistance and may even lessen the probability of change Miller WR et al. J Consult Clin Psychol 1993;61:455–61;Miller and Rollnick, 1991

22. Reasons for Current Behaviour ADVICE

23. Reasons for Current Behaviour ADVICE

24. PREGNANCY CAN BE A DIFFICULT TIME

26. Current Behaviour

27. ROBERT said “I knew you could get cancer from smoking.My Dad got lung cancer in his 60’s and I’d planned to give up long before that could happen to me. My last cigarette was to have been on my 40th birthday” Robert was diagnosed with cancer of the tonsils at age 36

28. 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. • It takes a long time to make a behaviour change.

30. STEPS TO CHANGE • Deciding • Preparing • Taking action • KEEPING UP THE CHANGE • Coping with setbacks

31. PEOPLE CHANGE WHEN THEY: • Want to change • Invest time and thought in the issue • Know what to expect • Have enough information and/or developed new coping strategies to manage the change • Have plans for difficult or unexpected situations • Have encouragement • Believe in the benefits of the change • Can see themselves acting/ behaving differently

32. HOW TO HELP - WHAT WORKS? • First elicit what the client already knows and theirinterest in receiving information about stopping smoking. • Provide information on their personal health status and the benefits of stopping in a neutral manner • Elicit the client’s interpretation of the discussion Ask: Do you think there would be any benefit in your stopping smoking?

33. MOTIVATIONAL INTERVIEWING (1) • Ambivalence is a normal state of mind • Express empathy and understanding of people’s past choices • Be realistic, rather than judgmental as demonstrating acceptance helps facilitate change • Reflective listening is essential to helping facilitatechange

34. MOTIVATIONAL INTERVIEWING (2) • Resistance is a signal to do something different • Emphasize the client’s choice and dilemma about making a change • Summarize the pros and cons of their decision to change • Help client to reflect on the whole situation by providing a summary

35. CLIENT - NOT READY! Respect this decision If they show resistance: do not argue, instead, respectfully clarify their expressed views Ask: What would need to be different for you to consider changing? • Explain your own concerns about their smoking • Leave the door open for future discussions

36. CLIENT - UNSURE ABOUT CHANGE? • Discuss their ambivalence. • Ask them about the pros and cons of them being a smoker • Explore any concerns now and for the future • Ask “What do you think could happen to you if you don’t stop smoking?

37. Client making plansto change? • Congratulate them and recommend they use a treatment product • Help them to set a quit date • Find out their expectations of stopping smoking and if they have tried before Ask “What could get in your way?” “What could you do to avoid this?” “Who could help/ support you?” “When would you like to see me again?”

38. 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”

39. Empowering people to change Support the persons decision and self-confidence to quit by asking: • “What are you actually planning to do next”? • “Who are you going to ask to support you?” • “What quit date have you set? • “Will you commit to not having a single puff of a cigarette from then onwards?” • “What medication are you going to use?” • “When would you like to see me again”?

40. INTERACTIVE WORKSHOPIN PAIRS ONE TO ONE COMMUNICATION SKILLS

41. Work out helpful responses to the following statements. • Statement 1 • “I was really upset when the specialist told me I had to stop smoking” • Statement 2 • “I’ve cut down on how much I smoke - isn’t that enough?” • Statement 3 • “I don’t want to get addicted to the NRT” • Statement 4 • “I know I should stop smoking now I’m pregnant - but its not easy” • Statement 5 • “I’m so afraid I will put on weight if I stop smoking” • Statement 6 • I want to give up -but it’s hard as my partner smokes at home

42. Nicotine Replacement Therapy, Zyban & Champix

43. NRT Reduces severity of withdrawal symptoms Reduces urges to smoke Delays weight gain Reduces relapse Doubles success rates of long-term abstinence (regardless of type of support used) Stead, L. F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. (2008) Nicotine replacement therapy for smoking cessation, Cochrane Database Syst Rev, CD000146.

44. Nicotine delivery Royal College of Physicians, Nicotine Addiction in Britain, 2000

45. Nicotine chewing gum 2mg and 4mg Recommend 10-15 pieces a day, hourly Recommend use for up to 3 months Start chewing slowly (chew-park-chew technique), takes a few days to get used to Each piece lasts 30 minutes (can be chewed longer) Acid drinks slow down absorption

46. Gum– things to tell your patients Chew it in the right way (its not like regular chewing gum) Chew until you get a hot peppery taste, then park it in the side of your mouth. After a few minutes chew it some more and repeat chew-park-chew It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it Use enough of it – once an hour

47. Lozenge Come in low and high strength 1mg vs. 2mg (Novartis) Higher dose for more dependent smokers Recommend 10-15 lozenges a day, hourly Recommend use for up to 3 months Roll around in the mouth until dissolved, takes a few days to get used to

48. Lozenge– things to tell your patients It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it Use enough of it – once an hour If it is taking a long time to dissolve – it can be discarded after 30-40 minutes as most of the nicotine will have been absorbed

49. Transdermal patch 24hr patch currently subsidised Smaller patches for weaning-off period (these are not essential) Recommend use for some 3 months 24 hr patches can cause nightmares (remove over night if problematic) In case of allergic skin reaction change product

50. Patches – things to tell your patients New patch each morning On upper arm, side of torso, hairless part of body Do not put on the same place, especially if still red Some redness of skin normal