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Management of Tobacco Use Part 2
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
~ Barriers to Engagement
~ Screening
~ Preparing for Change
~ Practical Interventions
~ Relapse Prevention
~ Essential Education
~ Motivational Interviewing Techniques
~ Tips for Supporters

Barriers to Engagement
~ Lack knowledge about:
~ How to identify smokers quickly and easily
~ Which treatments are effective
~ How such treatments can be delivered
~ Relative effectiveness of different treatments.
~ Inadequate clinic or institutional support for routine assessment and treatment of tobacco use
~ Time constraints
~ Lack of insurance coverage for tobacco use treatment, or inadequate payment for treatment

Getting Started: Screening
~ 5 As
~ Ask about tobacco use
~ Advise quitting
~ Assess needs and readiness for change
~ Assist in quit attempt or employ a motivational intervention
~ Arrange
Helping Clients Get Ready: STAR
~ Set a quit date within 2 weeks.
~ Tell family, friends, and coworkers about quitting, and request understanding and support.
~ Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks.
~ Remove tobacco products from your environment.
~ TIP: Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car).
~ TIP: Make your home smoke-free

Practical Tools
~ Abstinence.
~ Past quit experience: Identify what helped and what hurt in previous quit attempts. Build on past success.
~ Quitline support (1-800-QUIT-NOW).
Practical Skills
~ Relapse Triggers and Traps (Baseline and chaining)
~ Negative affect (Boredom, depression, anger, anxiety)
~ Being around other tobacco users
~ Experiencing urges
~ Smoking cues and availability of cigarettes
~ Strengths Based Coping Skills
~ Anticipate and avoid temptation and trigger situations

Practical Skills cont
~ Accomplish lifestyle changes that reduce stress, improve quality of life, and reduce exposure to smoking cues. (Define a RML)
~ Learn cognitive and behavioral activities to cope with urges and improve mood
~ Activities, Contributions, Comparisons, Emotions, Pushing away, Thoughts, Sensations
~ Imagery, Meaning, Prayer, Relax, One at a time, Vacation, Encouragement
Practical Skills cont…
~ Create peaceful times in your everyday schedule.
~ Try relaxation techniques
~ Rehearse and visualize your relaxation plan.
~ When you quit smoking, drinking coffee or tea without smoking may make you feel sad. Focus on what you’ve gained by quitting.
~ Switch to decaffeinated coffee or tea for a while, particularly if you are irritable or nervous.
~ Avoid foods that increase your urge to smoke
Practical Skills cont…
~ Call a friend or take a walk as soon as you’ve finished eating.
~ Brush your teeth or use mouthwash right after meals or even chew on a toothpick
~ Wash the dishes by hand after eating—you can’t smoke with wet hands!
Emergency Options for Distress
~ Wait 15 minutes, and then ask yourself if you can wait another 15 minutes, etc.
~ Hold ice
~ Bite into a hot pepper or chew a piece of ginger root.
~ Rub liniment or Vicks Vapor Rub under your nose.
~ Take a cold bath/shower.
~ Scream or scream-sing your favorite song.
~ Stomp your feet…a lot. In heavy shoes (not heels…)
~ Flatten cans or boxes for recycling, as fast as possible
~ Rip an old newspaper or phone book apart.
~ Throw a tennis ball against a wall
~ Crank up the music and move.
~ Run up and down the stairs at work
~ Addictive nature of tobacco
~ Effects of E-Cigarettes
~ Relapse Prevention: Any smoking (even a single puff) increases the likelihood of a full relapse
~ Understanding Withdrawal: Symptoms typically peak within 1–2 weeks after quitting but may persist for months.
~ These symptoms include negative mood, urges to smoke, and difficulty concentrating.
~ How To Handle Withdrawal Symptoms and Triggers

Education cont…
~ Details about the harm-reduction approaches
~ Benefits of using NRT to reduce the harm from smoking
~ Types of NRT available
~ Myths about NRT Fact Sheet (PDF)
~ How to use NRT products effectively to manage the cravings, mood swings and other effects of nicotine dependency and to prevent relapse
~ Where NRT products can be purchased and who is able to supply or prescribe them
~ Where to Get Help
Toolkits and Resources
~ American Cancer Society
~ American Lung Association
~ Centers for Disease Control and Prevention
~ How to Quit
~ Nicotine Anonymous
~ Clear Horizons for smokers over 50 View/Print PDF
~ Forever Free for Baby and Me™ (2004) for pregnant smokers who have recently quit
~ Smokeless Tobacco: A Guide for Quitting

Engaging the Unwilling Client
~ Patients unwilling to make a quit attempt
~ May lack information about the harmful effects of tobacco use and the benefits of quitting
~ May lack the required financial resources
~ May have fears or concerns about quitting
~ May be demoralized because of previous relapse.
~ Focus on exploring a tobacco user’s feelings, beliefs, ideas, and values regarding tobacco use in an effort to identify ambivalence
Express Empathy
~ Use open-ended questions to explore:
~ The importance of addressing smoking or other tobacco use (e.g., “How important do you think it is for you to quit smoking?”)
~ Concerns and benefits of quitting (e.g., “What might happen if you quit?”)
~ Use reflective listening to seek shared understanding:
~ Reflect words or meaning (e.g., “So you think smoking helps you to maintain your weight.”).
Express Empathy
~ Summarize (e.g., “ What I have heard so far is that smoking is something you enjoy. On the other hand, your boyfriend hates your smoking.”)
~ Normalize feelings and concerns (e.g., “Many people worry about managing without cigarettes.”).
~ Support the patient’s autonomy and right to choose or reject change (e.g., “I hear you saying you are not ready to quit smoking right now. I’m here to help you when you are ready.”)

Develop Discrepancy
~ Highlight the discrepancy between the patient’s present behavior and expressed priorities, values, and goals (e.g., “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?”).
~ Reinforce and support “change talk” and “commitment” language: “So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids.”
~ Build and deepen commitment to change: “There are effective treatments that will ease the pain of quitting, including counseling and many medication options.”
Roll with Resistance
~ Back off and use reflection when the patient expresses resistance: “Sounds like you are feeling pressured about your smoking.”
~ Express empathy: “You are worried about how you would manage withdrawal symptoms.”
~ Ask permission to provide information: “Would you like to hear about some strategies that can help you address that concern when you quit?

Support Self Efficacy
~ Help the patient to identify and build on past successes
~ Offer options for achievable small steps
~ Call the quitline (1-800-QUIT-NOW)
~ Read about quitting benefits and strategies.
~ Change smoking patterns
~ Ask the patient to share ideas about quitting strategies

Increase Motivation with The 5 Rs
~ Relevance—Why is quitting relevant to you
~ Rewards
~ Improved health / Feeling better physically
~ Food will taste better
~ Improved sense of smell
~ Saving money
~ Feeling better about oneself
~ Home, car, clothing, breath will smell better
~ Setting a good example for children
~ Performing better in physical activities
~ Improved appearance, including skin and teeth

5 Rs cont.
~ Roadblocks
~ Withdrawal symptoms
~ Fear of failure
~ Weight gain
~ Lack of support
~ Depression
~ Enjoyment of tobacco
~ Being around other tobacco users
~ Limited knowledge of effective treatment option
5 Rs cont.
~ Relapse Risks—Acute and long term
~ Repetition: The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting.

Help for Supporters
~ Do respect that the quitter is in charge.
~ Do ask the person whether they want you to ask regularly how they’re doing. Ask how they’re feeling
~ Do let the person know that it’s OK to talk to you whenever they need to hear encouraging words.
~ Do help the quitter get what they need, such as hard candy to suck on, straws to chew on, and fresh veggies cut up and kept in the refrigerator.
~ Do spend time doing things with the quitter to keep their mind off smoking
Help cont…
~ Do try to see it from the smoker’s point of view
~ Do make your home smoke free, meaning that no one can smoke in any part of the house.
~ Do remove all lighters and ash trays from your home.
~ Do wash clothes that smell like smoke. Clean carpets and drapes. Use air fresheners
~ Do celebrate along the way. Quitting smoking is a BIG DEAL!
Help cont…
~ Don’t judge, nag, preach, tease, or scold.
~ Don’t take the quitter’s grumpiness personally during their nicotine withdrawal.
~ Don’t offer advice. Just ask how you can help.
~ If the ex-smoker “slips”
~ Don’t assume that they will start back smoking like before.
~ Do remind the quitter how long they abstained
~ Do help the quitter remember all the reasons they quit
~ Do continue to offer support and encouragement. Remind them they’re still a “quitter” – NOT a smoker.
~ Don’t scold, tease, nag, blame, or guilt the quitter
~ It is important to assess for nicotine use in a variety of settings
~ Screeners must have referral resources and educational information to use as needed
~ There are steps that can be used to enhance motivation
~ People need social support in order to quit, and supporters need information to be effective.
~ A variety of free resources, workbooks and self-help programs exist.