Smoking Cessation – CAN-ADAPTT Guideline 2012

Motivational Tasks Associated with Patient Stages of Change

1. Precontemplation – Not considering the possibility of change
   • Raise doubt.Help patient understand the benefits of the unhealthy behaviour, while at the same time highlighting the costs
2. Contemplation – Seriously thinking about change, but not ready to take action. The individual considers change and rejects it
   • Tip the balance in favor of change: Strengthen patient self-efficacy to change by drawing upon past successes
3. Preparation – Getting ready to change
   • Help the patient identify small, realistic behavioural steps towards change
4. Action – Actively engaged in a new healthier behaviour
   • Support new behaviours, empathize difficulty of change behaviour
5. Maintenance – Maintain new behaviour for several months
   • Help the individual use new skills to prevent relapse
6. Relapse – Return to old pattern of unhealthy behaviour
   • Help the patient avoid discouragement and demoralization

Couselling and psychosocial Approaches

The 5A’s tool – for pt willing to Quit

• ASK: Tobacco use status updated for all pt on a regular Basis
  • “Have you used any form of tobacco in the past 6mo?”
  • Smoked: cigarettes, cigarillos, cigars, blunts, pipe, shisha, hookah, electronic cigarette
  • Smokeless: chewing tobacco, dipping tobacco, dissolvable tobacco, snus, snuff
  • Identify prev quit attempts and results
• Advice: Clearly advise pt to quit.
  • make pt aware of withdrawal symptoms:
    1. low mood, insomnia, irritability, anxiety
    2. difficulty concentrating, restlessness
    3. decreased HR, increased appetite
• Assess: Assess the willingness of pt to begin Tx to achieve abstinence
• Assist: Offer assistance to every pt who expresses the willingness to begin Tx to quit
  1. Intensive interventions: dose-response relationship between the session length & successful Tx
  2. Provide resources / counselling: self-help, individual, group, helpline, web-based, motivational interviewing
  3. ≥ 4 counselling sessions >10min each with 6-12 months f/u yield better result 
  4. Combination counselling and smoking cessation medication is more effective than either alone.
  5. Provide practical counselling on problem solving skills + provide support as a part of Tx

• Arrange:
  • Regular f/u to assess response, provide support, and modify Tx
  • Refer pt to relevant resources

Aboriginal People

• Tobacco misuse status updated on a regular basis
• Offer assistance to pt who misuse tobacco with specific emphasis on culturally appropriate methods
• Familiar w/ available cessation support services
• Seek appropriate training in providing evidence-based smoking cessation support

Hospital-Based population

• All pt should be made aware of hospital smoke-free policies
• Elective pt should be directed to resources to assist them to quit prior to admission or surgery
• All hospital should have systems in place to
  • identify all smoker
  • Rx nicotine withdrawal during hospitalization
  • promote attempts toward long-term cessation
  • Provide pt with f/u support post-hospitalization
• Pharmacotherapy
  • to assist pt to manage nicotine withdrawal in hospital
  • for use in-hospital & post-hospitalization to promote long term cessation

Mental health +/- other addicitons

• Screen pt with mental illness / additions for tobacco use
• Offer counselling & pharmacotherapy Tx to persons who smoke & have a mental illness / addiction to other substances
• While reducing smoking or quiting, monitor pt’s psychiatric condition(s): mental health status, other addicitons. Medication dosage be monitored and adjusted as necessary

Pregnant and Breastfeeding women

• Smoking cessation encourage for all pregnant, breastfeeding, postpartum women
• Counselling is 1st line Tx in pregnancy and breastfeeding
• If counselling ineffective, intermittent dosing nicotine replacement (lozenges, gum) are preferred over continuous dosing of the patch (↑risk)
• Partners, friends, family should also be offered smoking cessation interventions.
• A smoke-free home environment encouraged for pregnant and breastfeeding women to avoid exposure to second-hand smoke

Youth

• Obtain info about tobacco use – cigarettes, cigarillos, waterpipe, etc on a regular basis
• Couselling that supports abstinence from tobacco / cessation
• Counsel parents about the potential harmful effects of 2nd-hand smoke on the health of their children

Reference

• http://www.strokebestpractices.ca/wp-content/uploads/2012/04/CAN-ADAPTT2.pdf
• TN2013