Tobacco Cessation
Interventions
Lunch and Learn Seminar
Series for Physicians,
Family Health Teams, and
other Health/Allied Health
Practitioners
Session 2:
Brief Tobacco
Screening and
Assessment
Faculty: Jennifer Mitton,
RN, PhD
Housekeeping
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2
Please sign-in
Please ensure you have completed Learning Assessment 1 (insert
link)
A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
If you haven’t already, please dial-in via audioconference
Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Jennifer Mitton, RN, PhD
Jennifer.mitton@hamilton.ca
Jennifer Mitton is a public health nurse with Hamilton Public
Health Services’ Tobacco Control Program. She is also an
Assistant Professor with McMaster University’s School of Nursing.
In 2008, Jennifer developed the Quit Smoking Clinic at Hamilton
Public Health Services where she continues to provide intensive
tobacco dependence treatment clients. She has also assisted in
the implementation of best practices at St. Joseph’s Healthcare
Hamilton and Hamilton Health Sciences, including the
development and implementation of hospital-wide staff continuing
education programs. Jennifer is a Registered Nurse and
graduated with her BScN and PhD degrees from McMaster
University. She obtained her Tobacco Treatment Specialist training
at University of Massachusetts Medical School and is a graduate
of the TEACH program.
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Disclosures
Jennifer Mitton
No Disclosures
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 2: Learning Objectives
1.
2.
3.
4.
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Identify evidence-based tobacco screening
tools
Assess various dimensions of tobacco use
and motivation for change in patients who
smoke
Implement tobacco assessment and
screening in a motivational way
Apply new knowledge and skills to your
practice with your patients
# 1 Chronic Disease?
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Prevalence of Tobacco Use
10

Tobacco is the second most commonly used
psychoactive drug in Canada, after alcohol,
with 18% of Canadians aged 15 and over
reported as current smokers

Tobacco kills 50% of people who do not quit
smoking
Impacts on Health - Tobacco
11

Smoking is responsible for 90% of all COPD
cases, and 30% of all cancers

There is no safe level of tobacco use, even
light smoking (1 – 5 cigarettes/day) has been
proven to increase a person’s risk of dying of
heart disease and other causes
Tobacco Interventions in
Pediatric Settings
12

A recently published study revealed that only half of
primary care physicians ask parents of pediatric
patients about their tobacco use

Less than 20% of physicians reported advising parents
about quitting or providing assistance in their quit
attempt

Physicians with tobacco-related CME are more likely to
offer assistance and discuss the effects of tobacco-use
with parents
Screening for Tobacco Use
•
•
•
•
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Screening for tobacco use is a critical component of
treating tobacco use
In a primary care setting treating tobacco use
through brief intervention necessitates the fulfillment
of the 4 A’s model similar to that used for unhealthy
alcohol use
CDC guidelines recommend expanding the vital
signs to include tobacco use, using tobacco stickers
on all patient charts, or indicating tobacco use status
either through the physician’s electronic medical
record or any other form of computerized reminder
system employed by the physician
Such a system would ensure systematic
identification of all tobacco users at every visit
“When written in Chinese, the
word "crisis“ is composed of
two characters.
One represents danger and the
other represents opportunity.”
John F. Kennedy
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Fagerstrom Test for Nicotine
Dependence
Questions
Answers
Points
Within 5 minutes
6 to 30 minutes
31 – 60 minutes
After 60 minutes
3
2
1
0
Yes
No
1
0
The first one in the morning
All other
1
0
10 or less
11-20
21-30
31 or more
0
1
2
3
5. Do you smoke more frequently during the first hours after
waking than the rest of the day?
Yes
No
1
0
6. Do you smoke if you are so ill that you are in bed most of
the day?
Yes
No
1
0
1. How soon after you wake up do you smoke your first
cigarette?
2. Do you find it difficult to refrain from smoking in places
where it is forbidden such as the library, or movie theatres?
3. Which cigarette would you hate most to give up?
4. How many cigarettes do you smoke? (20 in a pack)
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Fagerstrom Scoring
16
0-2
Very Low Addiction
3-4
Low Addiction
5
Medium Addiction
6-7
High Addiction
8-10
Very High Addiction
Calculate Pack History
# of cigarettes / day X # of years smoked
__________________________________
20
=
___ pack years
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Calculate Pack History
25 cigarettes / day X 30 years smoked
__________________________________
20
=
37.5 pack years
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Calculate Pack History
5 cigarettes / day X 15 years smoked
__________________________________
20
=
3.75 pack years
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Calculate Pack History
5 cigarettes / day X 30 years smoked
__________________________________
20
=
7.5 pack years
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www.smokingpackyears.com
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Why calculate pack year history?
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
One of the utilities of this tool is to help
determine which patients might be referred for
spirometry screening which helps detect COPD

Patients with a pack year history of 15 or more
are generally referred for this type of screening
Biochemical
Markers
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Carbon Monoxide Monitor
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Monitors level of
exposure to carbon
monoxide
Gives objective data of
very recent smoking (<
12 hours) or exposure to
smoking
Need to record last
cigarette smoked
What Your Carbon Monoxide
Levels Mean:
0-5ppm
20 ppm
35 ppm
50 ppm
60 ppm
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Non-smoker levels
Loss of oxygen to vital organs
Legal limit for 8hr workplace
exposure
Air pollution emergency
Headaches, nausea, nervous system
slows down, difficulty thinking
clearly, vision difficulties
Assessments
Seven Key Components
1.Level of nicotine dependence/ severity of withdrawal
2. Motivation
3. Past quit attempts and smoking history
4. Co-morbidities
5. Reasons for smoking, environment, triggers, reasons
for quitting
6. Social environment supports and barriers
7. Smokers’ preference
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Assessment Components
1. Level of nicotine dependence/ withdrawal
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Withdrawal symptoms, what happens when they
don’t smoke or are unable to smoke?
How much do they smoke presently?
Menu of tools (addressed in the next section)
Assessment Components
2. Motivation
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What brought this person in?
Urgent issues (i.e. pregnant, COPD, transplant
lists)
May need to modify assessment depending on
client’s situation
Reasons for wanting to quit (why now?)
–
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External or internally motivated
Assessment Components
3. Past quit attempts and smoking history

When did they start smoking, using tobacco
products? Daily smoking?
–
–
–
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How long? How much? How many quit attempts?
Longest quit attempt?
What have they tried? Review use of medications
and supports
Assessment Components
4. Co-morbidities
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Other substance use / mental health issues
–
–

Medical issues / medications
–
–
–
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Can have an impact on treatment planning
Do they see a connection between their other issues and
smoking?
Will these have an impact on quit attempts?
Sometimes small adjustments in medication can shift a client’s
attitude towards taking NRT
Are they motivators or stressors?
Assessment Components
5. Environment, triggers, reasons for
smoking
–
–
–
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Identify high-risk situations and triggers to smoking
What led to relapse?
What does their environment look like?
Helping to Define Triggers (5)
Asking the Client:
“ Can you identify 3 times in your daily routine
that you are 100% certain that you will smoke?”
1.
2.
3.
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________________________________
________________________________
________________________________
Assessment Components
7. Smoker’s Preference
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
What are the client’s goals around smoking?
Resources / coping skills
–
–
–
–
–
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Client’s perception of self-efficacy
Learnings from past quits
What are their preferences, expectations, timelines
around treatment?
What other stress management techniques do they
utilize?
What are the client’s strengths?
STAGES OF CHANGE
maintenance
MAINTENANCE
action
preparation
ACTION
PREPARATION
contemplation
precontemplation
CONTEMPLATION
PRECONTEMPLATION
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Copyright Dr. Selby, 2002
Readiness Ruler
Circle the number (from 0 to 10) on each of the rulers that best fits with how
you are feeling right now.
1. How important is it to quit or cut down your use of tobacco?
0
1
2
3
4
5
6
7
8
9
10
2. How confident are you in your ability to quit or cut down?
0
1
2
3
4
5
6
7
8
9
10
9
10
3. How ready are you to make this change?
0
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1
2
3
4
5
6
7
8
Brief Tobacco Interventions
•
•
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CDC guidelines recommend brief interventions to
assist patients with smoking cessation
The CDC guidelines demonstrate a dose-response
relationship between session length and abstinence
rates, an increase in abstinence rates with
increasing “total amount of contact time” up to a
maximum of 90 minutes, and a dose-response
relationship between number of session and
treatment effectiveness
Questions?
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Applying the Skills: Video
Jeanne: Session 1
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Discussion and Debrief
1.
2.
3.
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What aspects of Jeanne’s tobacco use were
assessed in the video?
How did the style of the assessment impact
Jeanne’s motivation for change?
What other questions would you want to ask?
For reflection/discussion…
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What will you take a away from this session?
How will your learning impact your clinical
practice?
What is one thing you will commit to trying with
patients in the coming week?
Resources
Primary Care and Quit lines
Q: Do cessation
supports enhance the
practice of Primary
Care physicians?
3 A’s + Fax Referral
to Quitline vs.
only 3 A’s
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Rothemich, S., Woolf S., et al. American Journal of Preventive
Medicine 2010, 38 (4) 367-374.
A: Yes: The combination of
In-office discussion
and Fax/Quitline referral
increased the frequency of
cessation support
for smokers
(difference of 12.5% between
Both groups)
The Canadian Cancer Society
Smokers’ Helpline
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How can I refer to SHL?
Health professionals are in a unique position to assist
tobacco users. Even a minimal contact intervention can
powerfully motivate clients to make a quit attempt.
You can refer patients/clients to SHL using either:
1. Quit Connection
2. Fax Referral Expanded Program
Both provide a seamless integration between cessation
services of SHL and health professionals’ cessation
interventions, through a fax referral.
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Practice Guidelines
•
•
•
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Among the most authoritative resources regarding
the treatment of tobacco use is the CDC Clinical
Practice Guidelines Treating Tobacco Use and
Dependence (2008, Fiore et. Al.).
This extensive document covers the assessment of
tobacco use, clinical interventions for tobacco use
and dependence, intensive interventions for tobacco
use and dependence, systems interventions,
evidence and recommendations, and specific
populations, as well as additional topics of interest.
Available at:
http://www.surgeongeneral.gov/tobacco/treating_tob
acco_use.pdf
CAN-ADAPTT
The Canadian Action Network for the Advancement, Dissemination and
Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) is a
Practice-Based Research Network (PBRN) committed to facilitating research
and knowledge exchange among those who are in positions to help smokers
make changes to their behaviour (e.g., practitioners, healthcare/service
providers) and researchers in the area of smoking cessation.
Members will receive:
 Updates on CAN-ADAPTT’s research and funding opportunities
 Access to CAN-ADAPTT’s Tobacco Control Guidelines
 Access to CAN-ADAPTT’s discussion board
 Notices of General Meetings
And may also benefit by:
 Networking/collaborating with other health care/service providers
 Exchanging knowledge and expertise of better smoking cessation practices
To become a member, simply visit www.can-adaptt.net
and click "register" to fill out the short registration form found on the home
page.
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Remember …
A link to the Online Course Evaluation will be
sent by e-mail.
 A link to Learning Assessment 2 will also be
sent by e-mail. This must be completed by
June 1st in order to receive your Letter of
Completion
 Next session: June 15th, 2011:
Brief Cessation Counselling: The Four-Point Plan
**Application period is now open**

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Announcement by Minister Best of funding for Family Health Teams to
provide free NRT to patients, January 19, 2011
(L-R) Dr. Catherine Zahn, President and CEO of CAMH, Dr. Anne DuVall, President of the
Ontario College of Family Physicians; The Honourable Margarett Best, Minister of Health
Promotion and Sport; and, Dr. Peter Selby, Clinical Director, Addictions Program and Head of
the CAMH Nicotine Dependence Clinic.
Thank
you!
References
Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical
Practice Guideline. Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service. 2008.
Fiore MC, et al. Smoking status as the new vital sign: effect on assessment
and intervention in patients who smoke. Mayo Clin Proc. 1995; 70(3):209213.
Hahn DL, et al. Implementation of a systematic health maintenance protocol in
a private practice. J Fam Pract. 1990;31(5):492-502
Kottke TE, et al. A contolled trial to integrate smoking cessation advice into
primary care practice: Doctors Helping Smokers, Round III. J Fam Pract.
1992;34(6):701-708
Maciosek MV, et al. Priorities among effective clinical preventive services:
results of a systematic review and analysis. Am J Prev Med. 2006;
31(1):52-61.
Miser WF, Critical Appraisal of the Literature, J AM Board Fam Pract, 12(4):
315-333, 1999.
Rothemich SF, et al. Effect on cessation counseling of documenting smoking
status as a routine vital sign: an ACORN study. Annals of Family Medicine.
2008;6(1):60-68.
Taylor MC, et al. Prevention of tobacco-caused diseases. In: Canadian Task
Force on the Periodic Health Examination. Canadian Guide to Clinical
Preventive Health Care. 1994: 500-11.
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Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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