Smoking Cessation:
Counseling and Resources
Catherine A. Powers, EdD, LSW
Boston University
School of Medicine
The 5 A’s
• Ask about tobacco use. Implement an office-wide
•
•
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system that ensures that, for EVERY patient at EVERY
clinic visit, tobacco-use status is queried and
documented.
Advise to quit. In a clear, strong, and personalized
manner, urge every tobacco user to quit.
Assess willingness to make a quit attempt. Ask every
tobacco user if he or she is willing to make a quit attempt
at the time (e.g., within the next 30 days).
Assist in quit attempt. Help the patient with a quit plan
Arrange follow up. Schedule follow-up contact, either in
person or via telephone.
Effective Counseling
and Behavioral Therapies
for Smokers
• Research found three types of counseling and
behavioral therapies to be especially effective, and all
patients attempting tobacco cessation should use them
-Provision of practical counseling
(problem solving/skills training)
-Provision of social support as part of treatment
• (intra-treatment social support)
-Help in securing social support outside of treatment
(extra-treatment social support)
(Treating tobacco use and dependence. A clinical practice guideline 2000)
Common Elements
of Practical Counseling
• Practical counseling (problem solving/skills training)
• Treatment component
• Teach patient to recognize danger situations—Identify
events, internal states, or activities that increase the risk
of smoking or relapse.
• Examples
• Negative affect.
• Being around other smokers.
• Drinking alcohol.
• Experiencing urges.
• Being under time pressure.
Coping Skills
• Develop coping skills—Identify and practice coping or
problem-solving skills.
• Typically, these skills are intended to cope with danger
situations.
• Examples
• Learning to anticipate and avoid temptation
• Learning cognitive strategies that will reduce negative
moods
• Accomplishing lifestyle changes that reduce stress,
improve quality of life, or produce pleasure.
• Learning cognitive and behavioral activities to cope with
smoking urges (e.g. distracting attention)
Provide basic information about smoking
and successful quitting
• Provide basic information—Provide basic information
about smoking and successful quitting
• Examples
• Any smoking (even a single puff) increases the likelihood
of full relapse
• Withdrawal typically peaks within 1-3 weeks after quitting
• Withdrawal symptoms include negative mood, urges to
smoke, and difficulty concentrating
• The addictive nature of smoking
Intra-treatment Supportive
Interventions
•
Elements of Intra-treatment Supportive Interventions
(within treatment setting)
•
Treatment provider offers encouragement and belief in user's ability to quit
•
Provider communicates caring and concern, is open to individual's
expression of fears of quitting and ambivalent feelings
•
Tobacco user is encouraged to talk about the quitting process (reasons to
quit, previous successes, difficulties encountered)
•
The use of intra-treatment social support yields a 14.4% abstinence rate
(Fiore et al., 2000)
Extra-treatment Supportive
Interventions
•
Elements of Extra-treatment Supportive Interventions (outside treatment
setting)
•
Tobacco user is offered skills training in soliciting support from others
(family, friends, co-workers), is helped in establishing a smoke-free home
•
Information on community resources (helplines) is provided
•
Tobacco user establishes a buddy system (letters, contracts, tip sheets)
(www.lungusa.org)
•
Extra-treatment social support shows a 16.2% abstinence rate (Fiore et
al., 2000)
Does Counseling Work?
• There is a strong doseresponse relationship between
the intensity of tobacco
dependence counseling and it
is effectiveness.
• Treatments involving personto-person contact (via
individual, group, or proactive
telephone counseling) are
consistently effective
• Effectiveness increases with
treatment intensity
(minutes of contact)
Telephone Counseling
•
•
•
•
Community Preventive Services
recommend multicomponent
cessation interventions that
include telephone support
Used to increase the motivation of
the smoker
Can include trained counselors,
healthcare providers or a taped
message in single or multiple
sessions
Usually combined with other
interventions
– Client education materials
– Individual or group cessation
counseling
– Nicotine replacement
therapies
Telephone Counseling in
Community Settings
• May provide access to
self-help materials
• List of local resources
(for example schedule of
group sessions)
• May provide counseling
and motivation cessations
Telephone Counseling in the
Clinical Setting
• Follow-up calls usually
support other clinical
cessation interventions
• Including:
• Provider counseling
• Group cessation
sessions
• Nicotine replacement and
other therapies
Smoking Cessation Groups
• There are two types of
smoking cessation groups
that are discussed in the
literature
• Support groups (also labeled
self-help) and group
counseling with a trained
facilitator
Support/Self-Help Groups
vs.
Group Counseling
• Support groups are more informal and require the client to be
motivated to attend the meetings on her own
• According to the Public Health Service Clinical Practice Guidelines,
Treating Tobacco Use and Dependence, self-help does not appear
to have a significant impact on reducing rates of smoking among
the general population
•
Group counseling may be done in a more structured environment,
or even in a prenatal care setting
• It is organized by a health care professional with knowledge of
evidence-based tobacco treatment approaches
• Facilitated group counseling improves people's ability to quit
• 14% abstinence rate versus 10.8% abstinence rate for no
intervention
Web-based Interventions
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Reaches a wide audience
Readily available
Inexpensive to operate
Easy to update and collect data
Limited number of health-based
web programs have been evaluated
• Limited empirical support for webbased smoking cessation
• Maybe used in conjunction with
counseling and other treatment
options
Don’t Miss Opportunities
to make a Difference
• Prenatal – up to
12 provider visits
• Post-partum –
follow-up visit
• Well baby visits
•
Patient may be
motivated by her
pregnancy
•
Motivated by
new baby
•
Motivated by
concern for
newborn
Pediatric Providers on the Frontline
• The American Academy of Pediatrics recommends a well
care visits at the following ages:
birth; 1 week; 1, 2, 4, 6, 9, 12, 15, and 18 months
Annual visits from age 2 and up.
• Visits to the pediatric provider that include counseling,
medication, and collaborative support can help parents
stop smoking
• Each well-child visit provides an
• opportunity for a brief tobacco counseling intervention
Intervention with Parents
• The American Academy of Pediatrics and the American
Academy of Family Physicians have policies supporting
parental smoking cessation in order to end children's
ETS exposure.
• Policies include counseling pregnant women, women
with infants, and other parents who smoke.
• Pediatric clinicians are well positioned to address
parental smoking because of interactions with parents
during health visits that occur frequently during a child's
early years.
• The evidence base regarding the positive effect of
clinicians counseling adults during their own health visits
is clear
• The evidence base regarding the effectiveness of
pediatric clinicians counseling parents during their child's
health visits is beginning to accumulate.
(National Conference on Tobacco or Health)
Parents Want Referrals
• In a survey of parents who smoke conducted at
Children's Hospital Boston, all believed that
pediatricians should offer parents the chance to
participate in a smoking cessation program
• 56% of parents enrolled in a smoking cessation
program when asked by a motivational
counselor.
(Jonathan Winickoff, MD, MPH Massachusetts General Hospital ,Center for Child and Adolescent Health Policy)
Teachable Moment
• "Harnessing the pediatric visit sets
up a teachable moment for
smoking parents, because they
are concerned about the health of
their child. Many physicians think
that parents would refuse smoking
cessation services, but we had 80
percent saying they wanted it,
which is similar to what we saw in
the hospitalization study.“
Jonathan Winickoff, MD, MPH Massachusetts General Hospital
Center for Child and Adolescent Health Policy 2003
The Role of the
Pediatric Providers
There are several steps
pediatric providers can
take
1. Communicating with the
parent's primary care
physician
2. Referring the patient to
phone counseling
3. Steering the parent
toward such community
resources as local health
plans, hospitals,
or smoking cessation support
groups
Take Home Message
for Your Students
• Provider Counseling is effective
• intra-treatment social support
yields a 14.4% abstinence rate
• Extra-treatment social support
shows a 16.2% abstinence rate
• Community and web-based
resources help patients stay
smoke-free
• Information on local and
national quit lines and
cessation groups are available
on the web