Smoking Cessation Clinical Practice Guideline PDF

# CLINICAL INTERVENTIONS FOR TOBACCO USE DISORDER There are two types of clinical intervention depending on the intensity of intervention and level of service provided. They are: - Brief clinical intervention - Intensive clinical intervention ## Brief Clinical Intervention for Tobacco Use Disorder...

# CLINICAL INTERVENTIONS FOR TOBACCO USE DISORDER There are two types of clinical intervention depending on the intensity of intervention and level of service provided. They are: - Brief clinical intervention - Intensive clinical intervention ## Brief Clinical Intervention for Tobacco Use Disorder ### For All Smokers Brief clinical intervention by the physician increases quit rates effectively. It is vital to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified and offered treatment. The five major steps (5 A's) for intervention are described below and summarized in Table 1. The strategies are designed to be brief and minimal healthcare provider's time is required. These brief opportunistic advices typically involve asking patients about their current smoking, advising them to stop, offering assistance either by providing further advice, a referral to a specialist service or recommendation of or a prescription for pharmacotherapy or arranging a follow up wherever it is appropriate. The focus of this opportunistic advice is to increase smokers' motivation to quit in improving success rate of quitting. This brief intervention has been proven to increase overall tobacco abstinence rates regardless he or she is referred to an intensive intervention. The steps involved in the delivery of brief intervention include: #### Step 1: Ask about tobacco smoking **ALL patients should be asked about their smoking status and the findings should be documented in the patient's notes**. This should be delivered opportunistically during routine consultations to all smokers regardless whether they are seeking help to stop smoking. For people who smoke or have recently stopped smoking, the smoking status should be checked and updated at every visit to prevent relapse. Systems should be in place in all health care settings to ensure that smoking status is accurately documented at every visit. #### Step 2: Advice to quit Advice to quit should be given clearly to all patients found to be smoking. Studies have shown that advise by health care providers increases rates of abstinence. There is a strong dose-response relationship between the session length of person-to-person contact and successful treatment outcomes. Multiple efforts by health care providers can increase these rates further. Every tobacco user should be offered at least a brief intervention which consists of brief cessation advice from the health care providers. However, intensive interventions are more effective than brief interventions and should be used whenever possible as smokers' motivation, beliefs and feeling about smoking and quitting is always conflicting. Face to face treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, treatment providers should strive to meet four or more times with individuals quitting tobacco use. Health care workers should be provided with appropriate training to enable them to provide brief advice. This training should include providing the health care worker with information on available evidence-based smoking cessation treatments. #### Step 3: Assess willingness to make a quit attempt Health care providers involved with tobacco treatment should assess the willingness to begin treatment to quit. Though there is a lack of evidence for greater effectiveness of stage based approaches, stages of change model provides a useful framework to help health care providers to identify smokers and assist smokers in quitting. There is some evidence that the likelihood of success in an attempt to quit is unrelated to the smoker's expressed interest in quitting in the period leading up to the attempt - unplanned attempts to quit are as likely (or even more likely) to be as successful as planned attempts. Thus, there is benefit in encouraging all smokers to consider quitting whenever the opportunity arises. #### Step 4: Assist in quit attempt All patients should be assisted to quit. Brief advice as short as 30 seconds and self-help material have been shown to help. Brief advice (3-5 minutes) is effective and there is a dose response in treatment provision. Setting a quit date has been shown to be effective. Ideally the quit date should be within 2 weeks on assessment to quit. - Individual, group and telephone counselling approaches are effective and should be used in smoking cessation interventions. Smoking cessation interventions that are delivered in multiple approaches increase abstinence rates and should be encouraged. Studies have shown that individual counselling resulted in higher abstinence rates as compared to group or phone counselling and self-help. There are two forms of telephone counselling which is the 'proactive counselling' and 'reactive counselling. In proactive counselling, smokers receive calls from healthcare providers according to a pre-agreed schedule. In 'reactive counselling', smokers calls a helpline seeking help or advice. Proactive services, compared to reactive services, have been more widely evaluated as they can be more easily controlled. Studies have recommended that proactive telephone counselling as one of the formats for delivering behavioural counselling. For hospitalised patients, a study has shown that high intensive telephone follow-up (4 calls at 48 hours post discharge, 7, 21, 90 days) was more effective than low intensive follow-up (1 call at 48 hours post discharge) in addition to 30 minutes counselling. #### Step 5: Arrange follow up Health care providers wanting to do more intensive counselling will require further appropriate training. Health care providers who are not confident in providing counselling interventions can still assist patients wanting to quit by arranging referrals to services that can assist. Patients who are attempting to quit are at high risk of relapsing. Continuous abstinence is achieved when the patient has not smoked for at least 6 months. The highest risk of relapse is within the first 8 days of quitting. Hence the support has to be given the utmost importance in the first week of quitting cigarette smoking. Evidence has shown that abstinence of 12 months follow up is a good indicator for long term abstinence. The evidence suggests that multiple treatment sessions increase smoking abstinence rate and its effectiveness. More intensive interventions (more than eight sessions in six months) may produce enhanced abstinence rate. However, these interventions may have limited reach (affect fewer smokers) and may not be feasible in some primary care settings. The steps recommended by the NCSCT for evidence-based behaviour change techniques to assist health care providers in managing smokers who seek clinic help to quit smoking are.. ## Table 2: The "5 A's" for brief intervention - **Ask about tobacco use:** - Identify and document tobacco use status for every patient at every visit, including the adolescents. - Where appropriate, ask the caretaker of the patient about tobacco use or exposure to tobacco smoke. - **Advise to quit:** - In a clear, strong and personalized manner urge every tobacco user to quit. - Advice should be: - **Clear:** "I think it is important for you to quit smoking now and I can help you" "Cutting down while you are ill is not enough." - **Strong:** "As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you." - **Personalized:** Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household. - **Assess willingness to make a quit attempt:** - Is the tobacco user willing to make a quit attempt at this time? - If the patient is willing to make a quit attempt at this time, provide assistance. - If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention. - If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention built around the "5 R's": relevance, risks, rewards, roadblocks, and repetition. - If the patient is a member of a special population (e.g., adolescent, pregnant smoker), consider providing additional information. - **Assist in quit attempt:** - For the patient willing to make a quit attempt, use counselling with pharmacotherapy (when indicated) to help him or her quit. ### Preparations for quitting: (STAR) - Set a quit date. Ideally, the quit date should be within 2 weeks. Reduce the number of cigarettes gradually before the set date. - Tell family, friends, and co-workers about quitting and request understanding and support. Also, help patient obtain extra-treatment social support from self-help groups. Other smokers in the household. Patients should encourage household members to quit with them or not smoke in their presence to minimize risk of treatment failure and exposure to second-hand smoking. - Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. Discuss challenges/triggers and how patient will successfully overcoming them. Provide patients with problem solving/skills training. - Remove tobacco products from his or her environment. Prior to quitting, avoid smoking in places where a lot of patient's time is spent (e.g., work, home, car). - Provide a supportive healthcare environment while encouraging the patient in his or her quit attempt. - Abstinence. Total abstinence is essential. Not even a single puff after the quit date. - Past quit experience. Identify what helped and what hurt in previous quit attempts. - Alcohol. Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. - Recommend the use of approved pharmacotherapies, if indicated. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms. - Provide supplementary materials. - **Arrange follow-up:** - Schedule follow-up, preferably within the first week after the quit date. - Timing. Follow-up should occur soon after the quit date, preferably during the first week. Subsequent follow-ups are recommended weekly within the first month, and then every two weeks for the 2nd and 3rd month, and monthly after that up to 6 months. - For those who successfully quit, schedule follow-up, either in person or via telephone. Actions during follow-up: - Congratulate success - If tobacco use has occurred, review circumstances and elicit commitment to total abstinence. - Remind patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. - Assess pharmacotherapy use and problems. Consider using more intensive treatment, if not available, referral is indicated. ## 4.1.2 ABC for Smoking Cessation Alternatively, another approach is the ABC approach to help smokers to quit smoking. The steps are as follows: - **Ask** all people about their smoking status and document this. - **Provide Brief advice to stop smoking** to all people who smoke, regardless of their desire or motivation to quit. - **Make an offer of, and refer to or provide, evidence based Cessation treatment.** ## 5.0 FOR PATIENTS WHO ARE UNWILLING TO QUIT Motivational interviewing (MI) techniques may assist with smoking cessation when the health care providers are empathetic, promotes patient autonomy, and supports the patient's self-efficacy. Patients unwilling to make a quit attempt during a visit may be due to: - Lack of information about the harmful effects of tobacco. - May be demoralized because of previous relapse. - Lack the required financial resources - May have fears or concerns about quitting Such patients may respond to a motivational intervention built around the "5R's": Relevance, Risks, Rewards, Roadblocks and Repetition. ### Table 4: Strategy B1. Motivational interviewing strategies | | | |---|---| | **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."). - 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, and you are worried you might develop a serious disease."). - 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." - "It's great that you are going to quit when you get through this busy time at work." - Build and deepen commitment to change: - "There are effective treatments that will ease the pain of quitting, including counselling and many medication options." - "We would like to help you avoid a stroke like the one your father had." | | **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: - "So you were fairly successful the last time you tried to quit." - Offer options for achievable small steps toward change: - Read about quitting benefits and strategies. - Change smoking patterns (e.g., no smoking in the home). - Ask the patient to share his or her ideas about quitting strategies. | ### Table 5: Enhancing motivation to quit tobacco-the "5 R's" | | | |---|---| | **Relevance** | - Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. - Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g. having children in the home), health concerns, age, gender, and other important patient characteristics (e.g. prior quitting experience, personal barriers to cessation). | | **Risks** | -The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples of risks are: - **Acute risks:** Shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, and infertility. - **Long-term risks:** Heart attacks and strokes, lung and other cancers (e.g., larynx, oral cavity, pharynx, oesophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care. - **Environmental risks:** Increased risk of lung cancer and heart disease in spouse; increased risk for low birth-weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers.| | **Rewards** | - The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards follow: - Improved health - 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 and decreasing the likelihood that they will smoke - Having healthier babies and children - Feeling better physically - Performing better in physical activities - Improved appearance, including reduced wrinkling/aging of skin and whiter teeth | | **Roadblocks** | - The clinician should ask the patient to identify barriers or impediments to quitting and provide treatment (problem solving counselling, medication) that could address barriers. Typical barriers might include: - Withdrawal symptoms - Fear of failure - Weight gain - Lack of support - Depression - Enjoyment of tobacco - Being around other tobacco users - Limited knowledge of effective treatment options | | **Repetition** | - The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. | ## 6.1 Minimal Practice Relapse Prevention This is appropriate for most recent quitters and can be addressed briefly during a coincident clinic visit or a scheduled follow-up visit. Similarly, the "5 R's" strategy should be used to prevent relapse. Patients should be encouraged to report difficulties promptly (e.g. lapses, depression, medication side-effects) while continuing efforts to remain abstinent. The simple D.E.A.D. pointer technique can be applied to refrain oneself from smoking: - **Delay** - Deliberately delay the act of lighting up cigarette by doing something else - **Escape** - Escape any situation / environment that induce smoking - **Avoid** - Plan to avoid situation / environment that induce smoking - **Distract** - Distract the intention to smoke by doing relaxation techniques, housework, spending time with family, etc. ### Strategy: Intervening with the patient who has recently quit Former tobacco user should be congratulated on ANY success and strong encouragement to remain abstinent. When encountering a recent quitter, use open-ended questions relevant to the topics below to discover if the patient wishes to discuss issues related to quitting (e.g., How has stopping tobacco use helped you?): - The benefits, including potential health benefits, the patient may derive from cessation - Any success the patient has had in quitting (duration of abstinence, reduction in withdrawal, etc.) - The problems encountered or anticipated threats to maintaining abstinence (e.g. depression, weight gain, alcohol, other tobacco users in the household, significant stressors) - A medication check-in, including effectiveness and side effects if the patient is still taking medication This document describes the clinical interventions for tobacco use disorder. It includes detailed information on the types of interventions, the five major steps for intervention, and strategies for addressing patients who are unwilling to quit.