SMOKING CESSATION SEMINAR WORKING WITH PEOPLE RESISTANCE TO CHANGE JENNIFER PERCIVAL

1. SMOKING CESSATION SEMINAR WORKING WITH PEOPLE RESISTANCE TO CHANGE JENNIFER PERCIVAL RCN TOBACCO POLICY ADVISOR

2. Tobacco is a public health priority Source: WHO 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.

3. Tobacco advertising has successfully encouraged more women to start smoking

7. 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

8. The true picture is very different

9. WHO – ‘THE SILENT EPIDEMIC’ WORLD HEALTH ORGANISATION Epidemiologist 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.” • 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.

10. What is smoking? • 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

11. Nicotine 4,000 chemicals Tar Carbon monoxide Why are cigarettes so harmful?

12. ARE THESE PEOPLE RESISTANT TO CHANGE? OR HIGHLY NICOTINE DEPENDANT?

13. 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 frequency

14. 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 Reasons for NRT failure

15. Helping people to Stop Smoking • The NHS Stop Smoking services were set up as • Smokers are suffering from a treatable medical disorder `nicotine dependence‘. • 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.

18. 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

19. 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

20. 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

21. 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

22. Core communication skills • Boost the person’s motivation and self-efficacy • Build rapport • Use reflective listening • Provide reassurance

23. 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

24. My observations from working in the UK Stop Smoking services are that direct persuasion is not enough to make people decide to stop smoking

25. 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.

27. DO YOU ALWAYS FOLLOW GOOD ADVICE?

28. GOOD ADVICE

31. Reasons for Current Behaviour ADVICE

32. Reasons for Current Behaviour ADVICE

34. Current Behaviour

35. “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

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

37. A DIFFICULT TIME

38. Everyone has their own beliefs about safe behaviour This child is strapped in and protected from the sun but....?

39. 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”

41. 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.

42. 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

44. 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?

45. 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

46. 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

47. Asking questions can plant aseed of change ‘New thoughts’ often help people think differently about what they believe to be true.

49. Helping people to stop smoking • Show empathy: even if you do not share a person’s viewpoint, find ways to show that youunderstand and respect them • Identify discrepancies: there are often differences between how a person behaves and how they see themselves Name these in aneutral way eg.’Don’t want their kids to start smoking’

50. Core communication skills • Boost motivation and self-efficacy • Build rapport • Use reflective listening • Provide reassurance