Tobacco Cessation Part 2

This episode was pre-recorded as part of
a live continuing education webinar. On demand CEUs are still available for this
presentation through ALLCEUs. Register at So welcome everybody to today’s
presentation. This is part two of management of tobacco use. So remember we
talked about how we’re breaking it up and today we’re really going to focus on
interventions and things that clinicians can do and paraprofessionals can do to
help people who are trying to stop using tobacco now some of this will apply to
people who are trying to stop using or help themselves as well but we’re gonna
talk about barriers to engagement screening preparing for change practical
interventions that we want to make sure that people are aware of relapse
prevention strategies to make sure that they are able to you know effectively
change essential education that we may need to pass on to people motivational
interviewing techniques to help people who are not motivated or when their
motivation starts to wane and tips that we for supporters that we can give the
loved ones and the family members and you know whatever of the person who’s
trying to quit so one of the biggest barriers of engagement of people with
tobacco issues is that we as clinicians often lack knowledge about how to
identify smokers quickly and easily or we may not know how to deal with it so
we’re like well I know you smoke but I don’t even have any idea what to do
about that so I’m just gonna leave it alone and you can talk to your doctor
about it or whatever that’s not the right response what we want to do is
make sure just like for co-occurring disorders is no wrong door wherever they
come in we’re assessing people and saying you know if you use nicotine
products and you want to stop there are options out there and I’m more than
happy to help you so we need to know how to identify those smokers and we’ll talk
about a screening measure which treatments are effective
now we’re not prescribing treatments for the most part unless you’re actually a
clinician but knowing which treatments are effective can help you have open a
discussion with people about nicotine replacement therapy and alternatives
like you propia and all those other things we want to know how treatments
can be delivered you know for example nicotine replacement therapy most people
know about the and a lot of people know about the patch
but did you know it comes in a nasal spray it also comes in a let’s see
lozenge gum patch nasal spray and hard candy lozenge so there are a lot of
different ways that you can get the nicotine replacement in your system and
we need to know about the relative effectiveness of different treatments
and you know we talked about that a little bit on the last presentation and
the fact that nicotine replacement therapy by itself is definitely very
very helpful for people who are trying to quit using nicotine replace
replacement product or nicotine products however when you combine nicotine
replacement products with either with additional in the katene replacement
product or with other things like p pro peon or other oral medications it can
significantly help the person especially the person who has been using for a
really long time and/or is a heavy heavy user so you know it’s important to
understand the different treatments out there so if you’re working with somebody
and you’re the person that screens them and maybe you’re the person that sees
them once a week or once a month and they’re starting to try to change and
they’re saying you know the doctor prescribed the gum for me and I’ve been
using that but it’s just not enough I can’t do it that’s okay you know that
that is not the only intervention and they’ve found that for a lot of people
Ally at least during the first couple of months they may need multiple combined
interventions and we talked about those in part one we can have inadequate
clinic or institutional support for routine assessment and treatment of
tobacco use not every place is going to treat tobacco use but human resources
departments for example should be able to have a clinic where people can do
voluntary assessments or whatever if they want to I’m not sure about all the
laws about whether a human resource personnel can actually ask about smoking
or not don’t know but you know there are a lot
of companies that have a health and wellness champion that works in their
human resources department who can provide information about the harms of
nicotine and smoking and methods for stopping and all that kind of stuff and
they can also provide referrals for anyone who wants to stop using and you
know you may be thinking well what’s the benefit to it you know trucking company
that to implement is kind of a program that’s going to be more money they’ve
got to spend well yeah but they the health benefits from helping people stop
nicotine products will come back to them in terms of lower health insurance
premiums reduce sick days you know maybe even potentially reduce turnover because
you don’t have people that are leaving because they are just incapacitated with
something like emphysema so there are a lot of health benefits to organizations
not even just in health care in health care situations whether it’s mental
health care or primary health care or even those emergency walk-in clinics
it’s always good to have a protocol – and we’re going to talk about the five
days in a minute to screen people that way maybe they have started thinking
about maybe wanting to quit but they don’t know who to ask or they don’t want
to make an appointment with their doctor or whatever it is if they’re already in
your office take advantage and say if you’re thinking about it I’m here or if
you’re thinking about it here are some options you can call the quit line there
there are some other things that you can do that won’t necessarily commit you to
anything or cost you any money but it can give you some information a lot of
times as clinicians you know whether you’re a nurse or a doctor or a mental
health clinician or even a teacher you’ve got time constraints you’ve got
18 other things that need to be done before the end of the day and you’re
like one more thing I’ve got to screen everybody for tobacco use I don’t know
how to do that well think about it a little bit more simply the screenings
that we do are often take less than five minutes so you know how could you do
that effectively with your the people that you see and you know you got to
figure out a way to work it in if you want to be able to screen and another
barrier for some people is lack of insurance coverage for tobacco use
treatment now under ACA policies there are a lot of insurance policies that
will cover a certain amount of tobacco cessation treatment nicotine replacement
products etc but it’s important to recognize that that’s not necessarily
immediately accessible for anyone because they may still have to meet
their deductible so even though ACA is out there and it says that insurance has
to cover it and some of the policies I think say they have to cover it
regardless of whether the person’s met their deductible which is great but
there are also people out there who don’t have insurance you know they had
to drop it because it was too expensive or for whatever reason and we need to be
able to figure out how can we serve that population talk with your local health
department because they probably have ideas or resources that they can tap
into to help people who don’t have insurance access nicotine replacement
therapy and intervention stuff so the screening I told you as Fast Five the
five days asked about tobacco or nicotine use and anymore we really need
to ask about nicotine because you’ve got vaping you’ve got dip you’ve got smoking
tobacco they’re pipe tobacco there’s a lot of different things so you don’t
want to just say cigarettes and you know you want to make sure that you’re
getting every type of nicotine administration so do you use any
nicotine products advise quitting you know you probably are well aware that
it’s you know really beneficial to quit using nicotine but you know I recognize
that it is a really hard thing to do assess
the person’s needs and readiness for change
you know if they look at you and they start you can see that they’re starting
to tune you out all right they’re not ready for change yet and you can at that
point say you know what if at any point you decide that you want to quit using
nicotine products I’m a great resource so just come to me and we will see about
what we need to do to get you set up with whatever tools you need if they’re
ready for change and even if they’re just saying well you know I thought
about it but great so let’s assist in the quit attempt and
start using some motivational interventions to help them identify all
the reasons they want to change deal with all their apprehensions and start
identifying resources that are out there you’re not going to do this in one
session I advise you and it can be done there are a lot of workbooks online that
people can use so you don’t have to walk people through this the whole way you
can go online or if you’re taking this as part of a class that all CEUs you can
go into your classroom and find a ton of different workbooks that will help
people get ready to change and the fifth a is a range a range for any referrals
you know make sure that they know what needs to happen so for a lot of people
it’s gonna go really fast because you’re gonna ask about tobacco use make your
statement about how it’s in you know it’s helpful to quit and then if they
are in pre contemplation and not identifying it as something they’re
ready to change letting them know that the doors open you’re there should they
try to decide they want to change if you keep pounding them with it and go even
further and start lecturing or whatever you’re gonna be tuned out there there’s
just no point in doing that and we’re going to talk about some motivational
interventions later but you know it’s important to make sure that the person
knows that when they’re ready if they come to you but they’re not going to be
henpecked into something that they’re not ready to do
so helping clients get ready the clients that are ready set a quit date within
two weeks and when I say clients again if you’re a
human resources manager or wellness coordinator or a nurse or whomever you
know whomever you work with those are your clients so encourage them to set a
quit date within two weeks doesn’t have to be tomorrow but we want to know that
it’s going to happen if you said it much further out than that then it can kind
of come and go and you know whatever two weeks is a good amount of planning time
encourage them to tell family friends and co-workers about quitting and
request understanding and support because quitting nicotine is one of the
hardest things to do so there may be some moments of irritability or a lot of
moments of irritability initially so it’s important to get support from other
people and let them know that you know what this is gonna be tough but it’s
something that I really want to do encourage them to anticipate challenges
to the upcoming quit attempt particularly during the first few weeks
and I say 12 weeks 12 weeks for most people the next first step is to remove
tobacco products and smells from your environment so have them avoid smoking
in places where they spend a lot of time like at work at home in their car make
the home smoke-free tobacco free nicotine free get rid of the smell
rent a carpet cleaner clean your carpet clean your upholstery if you have any
wash your drapes wipe down the walls you know there’s a lot that you can do and
and in order to help get rid of the nicotine smell change your air filters
that’s super important change the air filters in your house and in order to
start getting the nicotine smell out there which can be triggering and if you
use or if the person uses vaping products that are scented like
strawberry or or whatever it’s important to also pay attention to those sensory
triggers so the first practical tool for smoking
cessation is guess what cessation or abstinence so this is really where we
want to go not everybody is willing to go here right away and that’s okay
you know everybody’s recovery plan is a little bit different some people will
want to gradually taper how much they’re using they may want to switch to lower
nicotine products and then taper how much they’re using they may want to quit
cold-turkey and use nicotine replacement products you know you need to talk to
them about what they envision as being most helpful for them talk about a past
quit experiences and have them identify what’s helped and hurt in previous quit
attempts and build on past successes and a lot of this is covered in the
workbooks in the various workbooks out there that can help people quit make
sure that they know that they can call the 1-800 quit now in order to get quit
quit line support in order to get support when they’re having cravings
when their nicotine replacement therapy their NRT is not quite doing what they
need to do and they don’t know what the next step is they can always call this
line they don’t have to pay for it help them or make sure that they are
identifying all of their relapse triggers and traps and you do this with
baseline and chaining so or you can this is how I have a lot of my clients do it
going through the week identifying any time they felt triggered to use or they
wanted to use or had a craving they need to note that time and identify you know
what was triggering that urge to use did they smell it did they see somebody
smoking was it just that time of day you know identifying those triggers so we
get an idea about how frequently they’re triggered and what triggers them because
what we want to do is start addressing those triggers but also reducing the
frequency that they’re triggered so some things that can trigger urges and
cravings negative effect and that’s you know a big
garbage term that covers boredom depression anger anxiety guilt you know
anything that’s not what we call an unpleasant emotion okay so when you feel
that way what things help you feel better what things can you do to feel
better what things have worked in the past and they may have some great tools
they may be a little short on tools and that’s okay let’s see what they’re
working with and try to build on what’s already there if there’s um a trigger or
a trap being around other tobacco users figuring out how to handle that it
doesn’t always work you know sometimes you’re gonna have to be around tobacco
users it’s very very rare but every once in a while it does minimizing how often
you’re around people who are actively using nicotine products or who smell
like nicotine or you know again the flavored vaping stuff if that’s a
trigger for you avoid being around any sensory triggers is the first thing and
when you can’t one of the things that we’re going to talk about later that
helps some people is to put like vicks vapor rub or something under their nose
so they’re not smelling the nicotine product experiencing urges is a big
trigger you think I’ve got to have a cigarette or I’ve got to go out and vape
or whatever it is okay developing tools distress tolerance
skills to ride the wave get through that urge and come out the other end and
other smoking cues and the availability of cigarettes it’s important that people
learn strengths-based coping skills and that’s kind of what I was talking about
earlier identify ways that they have coped with distress or unpleasantness or
urges in the past that have been at least partially successful and build on
that anticipate and avoid temptation and trigger situations so if you’ve got
somebody who’s getting ready to quit smoking and you know they can’t
anticipate that they’re going to be around somebody else that smoke
you know what can they do how can they avoid the temptation if they know that
they are going to my Uncle Jack’s house yeah I talked about him last time he
smoked a pipe and whenever I went to his house it always smelled of his pipe
tobacco so if somebody’s going into that environment where they can smell smoke
they’re going over to our relatives or a friend’s house even if that person is
not smoking in front of them it can be a trigger so what can they do
again putting the liniment under their nose certain aromatherapy concoctions
can help not only with stress management but also just to kind of give you
something else to smell finding other things to do making sure you keep your
hands busy keeping other things in your mouth like straws toothpicks you know
ideally not your hands don’t bite your fingernails accomplish lifestyle changes
that reduce stress improve quality of life and reduce exposure to PO smoking
cues so use the miracle question or however you want to phrase it with the
with the client and say when you become a nonsmoker you know and what is gonna
be different what’s what’s life gonna look like or ideally you know you’re
quitting for a reason in order to improve your quality of life so tell me
in your rich and meaningful life in in your ideal life when you are a nonsmoker
what’s gonna be different and why is it important to you to quit using you know
maybe they want to be able to breathe better or you know stops coughing every
morning or whatever it is that they do learn cognitive and behavioral
activities to cope with urges and improve mood now I talked a little bit
about it last time but we’re going to go through them a little bit more now
dialectical behavior therapy has two acronyms excepts and improve and those
things can be used as prompts for people when they start feeling the urge to use
or they start feeling an unpleasant emotion they can distract this doesn’t
cope with it just helps them get through it
Wow that emotion or that urge feels overwhelming until they can think more
clearly about okay what’s the best way to handle this situation
so accepts stands for activities that means get up and do something don’t just
sit there and think about it contributions kind of relates to
activities volunteer contribute something so go help somebody else offer
to you know take out the trash whatever it is comparisons you know compare
yourself to you know maybe people who are smoking and you know what’s better
now that you’re not smoking emotions do the opposite so if you’re stressed out
you know the opposite of any of these dysphoric emotions is generally gonna be
happy so do something that makes you happy
listen to a comedian that you find particularly funny
whatever it is they can get you into a different emotional window push away
just imagine yourself pushing away the thought that you have to use the
nicotine product right now change your thoughts you know focus your thoughts on
recovery or focus your thoughts on something completely different
instead of focus focus on your thoughts on that urge and sensations that’s the
final and sometimes a really strong sensation will divert your attention if
you’ve ever had an injury and you’ve had to ice it you know when you’ve got ice
on yourself you are not thinking about much of anything else you’re thinking
about when you can get that daggum ice pack off or at least that’s me so ice is
one of those sensations you can use you want to use a strong sensation that will
focus your attention holding ice snapping a rubber band is one I don’t
like doing that one or suggesting that one because it can injure yourself loud
music cold shower even a hot shower just not so hot you scald yourself thinking
about different sensations that will direct your attention even going out and
running really really hard you know like
interval training now if you’re stopping smoking that might not be the best
suggestion works really well for people who are depressed but finding something
that is going to divert your attention from your urge the other acronym improve
imagery using guided imagery imagine yourself getting through this without
using or and I kind of combined this with vacation that we’re gonna get to in
a minute go on a mini mental vacation to your happy place and I know you may be
rolling your eyes now but encourage clients to really use all of their
senses to cognitively transport themselves to their ideal happy place
you know what does it smell like what do they hear what do they see and it’s not
just one thing you know if you walk into a room you don’t see just one thing you
see a lot of things when you walk outside you don’t you know hear just one
thing you hear a lot of things when I walk outside my office I hear the birds
I hear the traffic I hear the door shut behind me I hear the wind I hear so
encourage clients to really dig deep and write it down in a narrative if they
have difficulty with remembering this narrative they can when they’re having a
moment they can read this narrative that takes them to their happy place or they
can even record it I mean your mobile device has a voice recorder so have them
record it on their mobile device so they can listen to it and again they can kind
of transport themselves to that place meaning find meaning in whatever’s going
on you know what is the meaning what does why are you trying to quit what is
the meaning in that in order to encourage yourself prayer including the
serenity prayer relaxation a lot of times people use nicotine products
because they’re stressed out so if you can find a way to calm your stress
reactions it can help you for a lot of pee
that can be deep breathing because that slows your heart rate down and causes
your body to start sending out the relaxation neuro chemicals go on a walk
you know that’s another thing that you can do because sometimes if you’ve got a
lot of energy you just need to get it out you need to move around for a minute
some people will meditate some people will do yoga
some people will Journal encourage clients to really brainstorm what helps
them relax when they are feeling all tied up encourage them to focus on one
thing at a time you know you can start getting bombarded with things I need to
I really want to use and then focusing on why they shouldn’t use and this that
and the other just encourage them to kind of clear their head and identify
one thing in their environment that they can focus on yeah we’re not focusing
anything about smoking right now we’re focusing on one thing in the environment
for example right here I have a plastic yellow cup and you know I may focus on
that for a minute and read everything that’s printed on there and you know
think about why people why they chose to design it the way they did or whatever
it is but I’m gonna focus on this one thing in the moment that has nothing to
do with my urge to use or do whatever yeah we already talked about the mental
vacation and mental vacation can also mean just kind of checking out for a few
minutes and maybe going to YouTube and watching stupid cat videos or whatever
it is you do to check out an encouragement get encouragement provide
yourself encouragement be your best cheerleader but also reach out to other
people who can provide encouragement for you and help you get through a difficult
moment create peaceful times in your everyday
schedule whatever that means for you you know if a peaceful time is putting on
your headphones and turning on hailstorm you know more power to you you know
that’s what I do but if your peaceful time is sitting quietly and meditating
that’s fine too whatever it is that helps you kind of
get reground ‘add try different relaxation techniques rehearse and
visualize your relaxation plans so if you’re at work and you’re in a meeting
and you start to get really stressed out and have those cravings you know make
sure that clients know how to handle this you know what can you do when you
start you know you’re somewhere where you can’t just check out or whatever
what can they do one of the things that I used to do when I was in in graduate
school and I’d be stuck in a class and I don’t sit still for long very well at
all and I would start to get really antsy and one of the things I would do
to help myself relax while I was you know stuck there would be I would start
making lists of things you know grocery lists whatever if I needed to or you
know writing down different relaxation words or just sketching you know
sketching chickens and butterflies and what I can the few things that I can
draw so encourage clients to keep a list of things they can do to help them relax
even if they are stuck in a public place remind clients that when they quit
smoking drinking coffee or tea may make them feel sad if they used to smoke
while they did that you know they would wake up in the morning and drink their
coffee and have a cigarette or after dinner they have coffee and have a
cigarette those are things to recognize there’s going to be a grieving process
because smoking or using nicotine products had a benefit you know they did
it they liked it now they don’t want the added baggage that it brings along so
they’re trying to quit but there was something about using the nicotine
product that they really liked and so they’ve got to go through this grieving
process and when they recognize that it’s not something they’re choosing to
do anymore and come to acceptance of that and yes
we can say focus on what you’ve gained by quitting and that helps a little bit
but it’s also important to encourage clients to recognize that it’s a
grieving process to it you’re kind of losing a best friend so working through
that and figuring out how the next chapter stop starts without this you
know friend in it switch to decaffeinated coffee or tea for a while
particularly if smoking cessation or nicotine cessation is making you
irritable or nervous because caffeine is just gonna rev you up even more you know
I am a hundred percent decaf so a lot of well the whole reason I drink coffee
decaf coffee you know it’s pretty much just colored water is partly for the
taste but not so much but there is a cognitive component there’s just
something relaxing about drinking coffee I don’t know why but you know I can do
decaf avoid foods that increase your urge to smoke and you may be going huh
things like sandwiches you know it’s harder to smoke if you’re having to use
a knife and fork and all that kind of stuff but if you can hold a sandwich in
one hand and a cigarette in another then that particular food may trigger you to
smoke so if there are foods to the trigger you avoid them for right now you
can eventually add them back in as soon as you’ve finished eating call a friend
or take a walk or brush your teeth those things can help you not light up right
after eating which is something that a lot of nicotine users do other things
that you can do include chewing on a toothpick especially the cinnamon ones
those can be really helpful for satisfying that fixation to have
something in your mouth but not using a nicotine product wash the dishes by hand
after eating because you can’t smoke with wet hands now you know this doesn’t
work quite as well for people who who dip
you know it is harder to dip and wash hands or with wet hands because you’re
having to hold the jar and stuff but this is especially true for people who
smoke or who vape because you don’t want to be holding the the e-cigarette or
anything when your hands are wet emergency options for distress sometimes
you’re just gonna be like oh and because of whatever is going on that day so make
sure clients have a list of emergency options that work for them not all of
these are gonna sound appealing to them all of these sound appealing to me which
is why I included them on the list but basically we want people when they’re
feeling distressed to be able to get through 15 minutes they can get through
15 minutes then they can go alright I can do another 15 minutes instead of
going I’ve got to go you know I’m still abstinent and I can never smoke again
well that that’s a big big hurdle let’s just try to make it through 15 minutes
because 15 minute increments add up so have people start the step clock if you
will what can they do to help them get through that first 15 minutes or the
next 15 minutes they can hold ice or put their hand in ice water bite into a hot
pepper or chew a piece of ginger root yeah I mean that really gets your taste
buds kind of going funky which will ruin the taste of any sort of nicotine
product that you take in orally rub liniment or vicks vapor rub under your
nose so you’re having something else to smell peppermint also tends to excite certain neurotransmitters so you
may feel more relaxed take a cold bath or shower scream you know depending on
where you’re at this may or may not be helpful if you’re at work you may have
to you know excuse yourself go down to your car roll up the windows and you
know just have a pillow or something in the car and scream into it really loud
and then go back inside not that I’ve thought that through or
anything but you know you don’t want people to be calling 911 but sometimes
you just got to get it out and be like oh and then you can move on or you can
scream sing your favorite song so again go down to your car cuz your office
mates don’t want to hear you belting out redneck woman or something to the top of
your lungs but you can do it really loud and again that energizes your senses and
it gets you focused on something and it can help you actually start
de-escalating because you’re breathing deeper when you’re screaming or where
you’re scream singing which is going to help slow your heart rate smoke your
feet a lot and you can even do it in heavy shoes but I do recommend strongly
not doing it in heels number one cuz you’ll break your heels
number two because you could break your ankle and number three because you could
either dent a wood floor or crack a tile floor so you know heels not so much but
heavy shoes they’re great because it takes more effort to stomp with heavy
shoes and it’s louder flattened cans are boxes for recycling as fast as possible
you know sometimes when I’m having a bad moment I will just go out into the
garage and start flattening boxes and folding them up and everything so I can
take them out to my garden rip an old newspaper or phone book apart or if you
save up your bills or junk mail and then when you start having a bad moment
you’ve got something easy to shred throw a tennis ball against a wall now this
will mark your wall so you don’t want to do it inside probably but you can throw
it as hard as you want and just think about whatever you’re thinking about and
come to throw a temper tantrum and get it out crank up the music and move
you don’t have to dance you can just move but the loud music will help
distract you or if you’re somewhere like at work maybe you can just go into the
stairwell and run up and down this there’s a few times to get yourself and
say some parts racing for a reason not just because of anger so like I said
these are the ones that work for me I don’t know what works for you encourage
clients to brainstorm this is a fun group activity to do what can you do
when you’re feeling really stressed out that just helps right away we do need to
make sure that we are educated and we can provide simple education handouts
you know we don’t want to get into long hour long videos we want to provide
tidbits of information about the addictive nature of nicotine products
the effects of e-cigarettes relapse prevention strategies and the fact that
any smoking even a single puff or deeply inhaling secondhand smoke increases the
likelihood of a relapse we want to make sure that people clients as well as
their support of others understand withdrawal symptoms and the fact that
the symptoms peak usually within a week or two after quitting but will persist
likely on and off for months it gets better but you know it takes a while
because again your brain is resetting itself if you will there are also websites that people can
go to that will help them identify how to handle withdrawal symptoms and
triggers but providing again another handout that they can use that they can
have handy it is really helpful provide education about harm reduction
approaches what can they do if they’re if they’re smoking right now what’s less
harmful and the research kind of keeps changing on that a little bit
obviously cutting down smoking is going to help so going from three packs a day
to one pack is going to be better switching to lower nicotine based
products that can help and just talk with them about what they’re willing to
do discuss the benefits of using nicotine replacement products to reduce
harm from smoking and the types of nicotine replacement that are available
and you can get these fact sheets online pretty much all the time and I recommend
that annually you go out and you find the most current nicotine replacement
fact sheets because new things are coming out all the time that may work a
little bit better and make sure you provide information for people about
where to get help unless you’re the one providing the help where do they get
nicotine replacement products who do they go to to get the prescription for
this I mean obviously if we’re talking prescriptions probably a doctor but some
things you can get over-the-counter or through a pharmacist now so you know
where do they have to go what do they have to do so I keep talking about
toolkits and resources the American Cancer Society American Lung Association
CDC how to quit nicotine anonymous smoke-free gov clear horizons for
smokers over 50 is a workbook designed to help smokers over 50 quit forever
free baby and me is for pregnant smokers who have recently quit or who are
thinking about quick quitting and smokeless tobacco a guide for quitting
obviously applies to things other than cigarettes and pipes so we’ve been talking about the client
in large part who is at least considering change but sometimes you’re
going to have a client who is not interested in changing and the reasons
for that are are varied and if you look at Prochaska and D Clemente’s model on
motivation for change you’ll find that there are multiple different types of
pre contemplate errs which is basically what the unwilling client is so why are
some people unwilling to quit and each type of pre contemplate er is unwilling
to quit for a different reason some people lack the information about
the harmful effects they just don’t understand why it’s such a big deal some
people don’t have the required financial resources you know they’re afraid
they’re not going to be able to access what they need they may want to but they
don’t think they can do it for some reason they may have fears or concerns
about quitting maybe they tried before and they weren’t successful and they’re
afraid to try again maybe they’re demoralized because of a
previous relapse they were smoke-free for a year and then they relapsed so we
want to understand the reasons a person may be unwilling and help them dispel
some of those concerns we do want to focus on exploring the person’s feelings
beliefs ideas and values regarding nicotine use in an effort to identify
ambivalence because a lot of people are ambivalent it’s like yeah I smoke I know
it’s bad for me but da-da-da-da-da okay well you know it’s bad for you so
there’s the ambivalence you’re smoking you know it’s bad for you you know what
things in your life might make it worth quitting Express empathy by using
open-ended questions to explore the importance of addressing nicotine use in
this person’s life you know they may not think it’s a big deal they’re just like
whatever you know and help them explore their concerns about the benefits of
quitting what might happen if they quit use reflective listening to seek a
shared understanding you know so you you’re both on the same page
they may not share your point of view but you want to really understand their
point of view reflect their words or meaning so if they say you know right
now I’m a smoker I know it’s not the best for me but it really helps me
maintain my weight okay so you would reflect something like so you think
smoking helps you with maintaining your weight and they may say yes sir well
obviously they would summarize what you hear the clients saying for example what
I’ve heard so far is that smoking is something you really enjoy but you know
your boyfriend really does hate your smoking so that’s causing some conflict
you know that points out some discrepancies there normalize their
feelings and concerns about quitting and life without cigarettes and support
their autonomy and right to choose or reject change they don’t have to do it
you know you’re there if they want to do it but they don’t have to we’re just you
know talking here develop discrepancy by highlighting the difference between the
person’s present behavior and they’re expressed priorities values and goals
reinforce and support change talk and commitment language so if they start
saying you know yeah I’ve thought about change that’s awesome you know why did
you decide not to or you know what was different then start talking about those
change things and build and deepen their commitment to change by helping them
once they start going yeah you know maybe I’m ready to start again okay you
know let’s talk about options that might exist and what your concerns are so we
can make it as painless as possible you know it’s not going to be easy but you
know I want to help you be have the greatest chance of success
you can also roll with resistance by backing off you know if they’re saying
nope I’m not ready to use not gonna use can’t make me stop okay that’s fine so
use reflection for example saying something like it sounds like you’re
feeling pressured about your smoking or it sounds like you feel I’m lecturing
you so you know no problem Express empathy that you know maybe they’re
worried about how they would manage withdrawal symptoms if they say you know
what I’ve tried before and the withdrawal was just too bad the cravings
were too awful I just can’t do it so empathy would help them understand that
you are hearing how difficult it really was and before you start lecturing or
providing suggestions ask permission to provide information if somebody is not
ready for change if you start handing them stuff and going we’ll take this
anyway then that basically says I don’t care
what you think you need to think the way I do that’s not going to help you so you
want to ask permission you know would you mind or would it be okay if I gave
you this handout or another way you can do it is have handouts available in the
lobby or in your office and tell people that they are more than welcome to help
themselves to any of the handouts that are that are there you know they don’t
have to ask permission that empowers them to go over and look and see if
there’s anything they’re interested in support self efficacy by helping the
person identify and build on past successes offer options to achieve small
progress small steps such as calling the Quitline
reading about the benefits and strategies of change maybe starting to
change their smoking patterns cutting back a little bit that’s great you know
I’m not looking for everybody to go oh yeah okay I’m ready to quit I’m gonna
stop cold turkey tomorrow that doesn’t work for everybody not everybody’s
willing to even consider that okay what are you willing to do and ask the person
to share ideas about strategies for quitting what do you think might help
you and let’s see how we can make that helping increase motivation with the
five R’s help them I’ve identified the relevance to quitting why is it
important in helping you achieve the kind of life that you want brainstorm rewards such as improved
health feeling better physically food is gonna taste better there’s the sense of
smell is going to improve you know how when you have a cold you know if you
haven’t ever smoked you may not make the connection but like when you have a cold
you can’t taste much or things taste funky because your sense of smells off
and smell and taste are really connected so a lot of people who use nicotine
products don’t have a good sense of smell which means their sense of taste
is also off people who use chewing tobacco often have problems with their
sense of taste as well they’re gonna save money they may feel better about
themselves their home car clothing breath will smell better they’re setting
a good example for their kids they may perform better in physical activities
they may have improved in appearance including their skin and teeth and aging
and all that kind of stuff those are just some other obvious rewards to
quitting encourage people to think about you know other things obviously they’re
reducing their cancer risk reducing their risk of emphysema and you know
some of those other things as well encourage them to look at roadblocks
that might keep them from quitting such as their fear of withdrawal symptoms or
failure their fear of weight gain lack of support depression that accompanies
quitting the fact that they enjoy tobacco and they really don’t want to
give it up being around other tobacco users and limited knowledge of effective
options so a lot of these you can address with an effective relapse
prevention plan withdrawal symptoms can be mitigated with nicotine replacement
therapy and some of the other drugs that are out there to help stop smoking fear
of failure you know we want to look at what’s causing that fear of failure and
focus on successes you can help the client develop a plan to prevent weight
gain a lot of times when people quit smoking or using nicotine products one
of the ReWalk couple reasons they gain weight
number one they used to smoke to help relax and to help them feel less
unpleasant well when we eat especially when we eat high sugar or high-fat foods
our brain releases dopamine and other relaxation chemicals and when we eat it
triggers the rest and digest system to kick in which again floods our system
with more of those relaxation chemicals so eating can serve a similar purpose
now it doesn’t get rid of the stress and there are other ways to deal with the
stress but that’s one of the reasons that people turn to food so much when
they stop smoking or using nicotine products another reason that they may do
it is just the habit of hand to mouth they want something in their mouth so
wanting something in your mouth is like I said their alternatives such as toothpicks gum sugar-free candy you know
there are options that you’ve got out there a pencil if you’re really strapped
for options encourage them to get support before they even launch on this
so they’re not doing it all on their own have them figure out ways to address
their depression and include happy things in their routine but also address
any triggers for depression if they’re smoking to self-medicate depression or
you know if they’ve got some pre-existing depression they may need to
address that too relapse risks are another thing that
people have to look at acute and long-term what things might trigger a
relapse we already talked about those and repetition motivation is going to
wax and wane just kind of like the tides come in some days it’s going to be like
I got this and other days it’s going to be much more difficult so encouraging
people to regularly check in with themselves remind themselves of the
reasons they’re changing stick to their plan encourage them to include
motivational interventions in their recovery routine every single day for
supporters people can be really supportive and it’s important to have
support so we want to educate the family and the supporters and that includes us
you know as clinicians or whoever’s doing this assessment and intervention
respect the quitters in charge ask the person whether they want you to
regularly check in with how they’re doing and when you do check in with how
they’re doing ask how they’re feeling not so you still smoke-free
you know just how’s it going how you feeling you know check in to see how
they’re doing and if they want to share the other they will let the person know
that it’s okay to talk to you whenever they need to hear encouraging words
you’re not going to ridicule them if they’re having cravings or they think
they’re gonna slip or or whatever or even if they have slipped you know it’s
better to talk about it and address it now nip it in the bud so to speak help
the quitter get what they need such as hard candy to suck on straws to chew on
and fresh veggies that are cut cut up and kept in the refrigerator spend time
doing things with the quitter to keep their mind off smoking especially in
that first three-month period it’s important to stay busy because the brain
is rebalancing and everything and the cravings are going to be a lot stronger
try to see it from the smokers point of view or the quitters point of view
whatever you want to say so you understand how difficult it is make your
home smoke-free and meaning that nobody can smoke in any part of the house and
that includes like right out on the stoop because you can still smell it
remove all lighters and ashtrays from your home wash everything that smells
like smoke use air fresheners change your air filters and celebrate along the
way because quitting is a big deal you know celebrate the first day that
they’re smoke-free celebrate the first week they’re smoke-free celebrate the
first month they’re smoke-free yeah you see what I’m you know what I’m getting
at and I keep saying smoke free but I mean nicotine free so this applies to
people who use smokeless tobacco and other things
don’t judge nag preach tease or scold we don’t want people to do that when we
make a mistake or are struggling to make a change so don’t do it to somebody else
don’t take the quitters grumpiness personally during their nicotine
withdrawal and remember I said the first two weeks are generally the worst and
then it starts subsiding but it could last you know some of these symptoms
could and often do last for months they get less you know they’re not as intense
but they can last for months so it’s important to you know step back and go
alright is this a reaction to them not having access to nicotine and a lot of
times you know if you’re six months into it and all of the sudden the person gets
really irritable with you for some reason you may want to step back and go
was there some sort of relapse trigger that intensified this person’s cravings
they may not often or always recognize the relapsed trigger so you know that’s
where supportive people can be helpful if the quitter wants we can sometimes
see blind spots so we can sometimes see triggers that they missed but don’t
offer advice or point out these things unless you already have a pre agreed
arrangement that that’s okay if the ex-smoker slips don’t assume that
they’re going to start back smoking like before do remind them how long that they
were smoked some new katene free help them remember all the reasons they quit
continue to offer support and encouragement and remind them that
they’re still a quitter I don’t like that term but you know you can find a
different term that’s a little less pejorative there’s still someone who is
smoke-free not a smoker they just happen to pick up that one time don’t scold
tease nag blame or guilt them still so it’s important to assess for nicotine
use in a variety of settings from mental health the physical health and even in
jails it can be a great place to identify people who might be willing to
start quit quitting screeners must have referral resources and education
you know information to use as needed it doesn’t do any good to do a screening
and go Oh sounds like you want to quit well good luck you need to make sure
that whoever’s doing the screening has the resources to help the person get to
the next step there are steps that can be used to enhance motivation and people
who are not thinking about change or are not quite ready to take that big step
yet so motivational interviewing motivational enhancement therapy are
excellent add-on skills to just understanding tobacco cessation
procedures people need social support in order to quit and supporters need
information to be effective so we can’t just say you know you just got to be
there for them we need to help them understand the relapse process the
withdrawal process the brain chemistry in manageable chunks they don’t need to
know it on a graduate level but provide enough information that they can be
informed and helpful and make sure to have available a variety of resources
and there are many many free resources workbooks and self-help programs that
you can access online by just doing a simple internet search or you can call
the quit line and they can point you in the direction of some additional free
resources alright everybody thanks for being with me and we will be back on
Monday with the third and final part of this series counselor toolbox podcast is
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