Organising the support of the smoker in the cessation process

1. Organising the support of the smoker in the cessation process Smoking consultations • Organising a smoking consultation • Objectives of a smoking consultation • Material needed for a smoking consultation • Expired CO analyser • Stages of CO analysis • Carbon monoxide exposure level • Doctors for smoking consultation • Health professionals for smoking consultation • Training of the smoking consultation staff • Proposed timing for smoking consultation

2. 1. Objectives 2. Necessary material 3. Qualification 4. Health care workers qualification 5. Schedule 6. Questionnaires 7. Biological exams 8. Group dynamic 9. Individual consultation 10. Activity follow up Organising a smoking consultation

3. Take into account the most dependant smokers, Evaluate cessation methods for less dependent smokers, Define and assure the content and training provided for all health care workers. Objectives of a smoking consultation

4. A consultation room with : - blood pressure measurer, - stethoscope. An appointment management system. Questionnaires sufficient number. Information brochures for patients A meeting or conference room for 10 people, equipped with Barco. A CO analyser (non necessary but very useful) with disposable nozzle and money for maintenance. A recording system : notebooks, files or computer to ensure consultations follow up and make statistics Tubes to measure urinary or salivary cotinine (eventually). Necessary material for a smoking consultation

5. The measure of the expired CO level is related to CO in haemoglobin (HbCO = carboxyl haemoglobin) and CO related to muscles. The level of expired CO will reflect recent tobacco intoxication (of causes of intoxication by the CO: parking, fire, extreme pollution....). CO’s half life in body is of approximately of 6 hours Expired CO analyser

6. 1- Check Zero (30 seconds at room atmosphere ). The figure must read between -5 and + 5 (some devices have an automatic Zero) If the figure is out of this interval, the device has to checked by maintenance (or it has to checked for pollution). For figures at room atmosphere between -5 and + 5, it is necessary to subtract from the figure obtained after smoker’s measurement. (For example, if the CO level in the room is 2 ppm and the value measured is 14, the level of expired CO will be 14-2 = 12 ppm.) 2- Use a single use mouth piece. 3- Deep breath, then hold the breath for 15 seconds, then breath out in a normal way, for as long as possible (”emptying lungs completely"). The reading is made 30 seconds after the expiration. Measurement is made in particles per (ppm). (Some devises convert on request the equivalent in HbCO.) 4- After the measure, remove the mouth piece and shake the device slowly before taking a second measurement. (Even in this case, it is necessary to wait for Zero which takes around 2 minutes.) Steps in CO analysis

7. Carbon monoxide exposure level • Cigars • 60 cigarettes • 1 pack cig. • Second hand smoking • Normal limit • Non smoker • Neurological disease • VME Workplace France • Alert in underground car park • 1/3 VME = Quality workplace target • Limit of air pollution Europe2001 • Non smoker limit • Town pollution limit, USA • Town pollution limit, Europe 2005 • Above normal limit • Countryside Non-smoker • 80 ppm • 50 ppm • 35 ppm • 17 ppm • 14,5ppm • 10 ppm • 9 ppm • 8,5 ppm • 5 ppm • 0 ppm

8. Personnel for a smoking consultation Specific time must be allocated for administrative and medical workers for the purpose of smoking cessation consultations Specific training for smoking cessation must be provide for medical, nursing and other healthcare professionals

9. Smoking consultation personnel have an important welcoming role. They have to be motivated. They must know that they are part of a caring process. Their role is not purely administrative. The training (for example, one hour per week for one month) is about: - tobacco and its effects - steps towards cessation - cessation techniques and cessation difficulties - relapse prevention Training for smoking consultation personnel

10. D0 D7 D14 D28 D42 2months 3 months (optional) (optional) Proposed calendar for smoking consultations Prior to cessation, depression and alcohol are factors to take into account Consultation prior to cessation (optional) 6 months (optional) Preparation Cessation Follow up

11. Prior to cessation, depression and alcohol are factors to take into account. Consultation prior to cessation (optional) Propose and organise cessation plan for the most appropriate time. Hold a group 1 hour information session. While waiting, fill out Fagerström and HAD questionnaires. - welcome - Give a few reminders on tobacco effects. (Be original and do not repeat what smokers already know.) - Hold round table discussion to establish the dependence level of all people seated around the table. Exchange stories of previous cessation difficulties and the causes of relapse. - Discuss proposed cessation methods and the smoking cessation plan. D0 first day (eventually coupled) completely stop smoking substitution nicotine cessation advises Proposed calendar for smoking consultations (1)

12. D7 second consultation adaptation of nicotine doses check for an increase in weight motivation reinforcement D14 third consultation check for an increase in weight motivation reinforcement D28 fourth consultation = third D42 = sixth week = fifth consultation This consultation can be postponed for 2, 4 to 6 weeks if the patient still shows withdrawal symptoms. - Non-smokers (according to official definitions) are those who have stopped for over 28 days. - If there are no more withdrawal symptoms, start decreasing nicotine dosage, diminishing by 1/3 the dose (for example going from patch 30 to patch 20 cm²). Proposed calendar for smoking consultations (2)

13. 2 months - Verification that the decrease is normal and that there is no reappearance of the withdrawal symptoms. -If withdrawal symptoms reappear stop decreasing, if there is no withdrawal symptoms continue decreasing (for example going from patch 20 to patch 10 cm²). 3 months The subject has to stop patch 7 days before and it is the first consultation after complete nicotine cessation. After this consultation, consultations can be stopped or continued at the patient’s request on a monthly basis. Proposed calendar for smoking consultations(3)

14. 1. Fagerström (6 questions) 2. Simplified Fagerström (2 questions) 2. Motivation test 3. HAD test 4. Horn test Useful questionnaires for a smoking consultation

15. 1. In communities to get people to want to stop 2. At the beginning of the cessation to reinforce motivation 3. During cessation in order to help one another 4. After cessation ”Self-Help Support Group " Group dynamic for a smoking consultation

16. 1. Presentation of cessation process 2. Presentation of tobacco and its effects 3. Round table (to precisely gauge the stage of preparation of each participant and reinforce or progress towards cessation) Group smoking consultation

17. Each individual smoking consultation is different The smoking consultation is different for each smoker according to his/her cessation experience. Individual smoking consultation

18. Smoking counsellors/facilitators must follow up their activities : - average time between appointment request and first appointment - number of new patients per year - number consultations per patient - cessation results at 3 months and at 6 months Follow up activity of a smoking cessation counsellors/facilitators

19. Criteria 1 : A doctor is specially in charge of the smoking consultation (minimum 3 times a week). Criteria 2 : There is a nurse (available 1 hour every day, and completely available during consultations). Criteria 3 : There is a possibility to see a dietician or / and a psychologist. Criteria 4 : There is an information document on tobacco and cessation available for the patient or given during the consultation. Criteria 5 : Appointment average waiting time is less than 5 weeks. Criteria 6 : There is a welcoming procedure for ancient and new patients. Criteria 7 : Appointment time are respected. Criteria 8 : Waiting times at the smoking consultation are evaluated. Criteria 9 : Patient’s satisfaction is evaluated. Criteria 10 : At least 5 consultations are offered to the patient during the cessation process. Criteria 11 : During the first 15 days of cessation there is a phone number for the patient to call in case of a problem. Criteria 12 : Cessation level is evaluated and yearly statistics are made One European experience Self-evaluation of the quality of the smoking cessation consultations

20. Organising the support of the smoker in the cessation process Behavioural • Behavioural treatment • Appetite and weight gained after smoking cessation • Smoking and alcohol cessation • Relapse prevention • High risks situation for relapses • Behaviour modification

21. This treatment is part of the whole of educational and socio-psychological approaches . Behavioural therapies are less easy to evaluate on medical grounds than pharmacological methods. It is difficult to collect homogeneous data because of the variation in practice. Nevertheless some controlled studies are in favour of this method. Source : Conference of Consensus on smoking cessation Paris October 98 Behavioural Treatment

22. Appetite gain: remains frequent sweets - mainly nibbling chocolate +++ Weight gain : average + 2 to 3 KGs sometimes more --> dietetic ± physical exercise ± medications ? NRT reduces weight gain. Avoid alcohol, which can cause relapse and increased calories (1 glass of wine = 5 sugars) If weight gain is not unaccepted to the patient or very fast: refer to dietician. Appetite and weight gained after smoking cessation

23. It is possible to give smoking and alcohol together. Cessation of both should be placed in the same global approach. Simultaneous cessation (is difficult to implement, especially in general medicine). Alcohol cessation then tobacco cessation, but announce at the start that both will be linked. No study demonstrates a negative effect of smoking cessation with alcoholism relapse. Smoking and Alcohol cessation Conférence Consensus sur sevrage alcoolique Mars 1999

24. Relapse Prevention • Relapses are frequent : • 75-80% of relapses occur within the first six months of cessation. • 40-80 % of ex-smokers relapse within 1 year. • Relapses must be viewed as steps in the cessation process (postponing success). • Source : Pierce et al, 1989

25. have "just one cigarette" to see state of negative emotion such as anger, frustration, depression conflict amongst people, within the family or at work social pressure, directly by a person, or indirectly in a situation wherein there are smokers (as at an evening party) alcohol, nice meal relaxing at home, in the evening, in front of the television see weight gained on the scale High risks situations for relapses Ex-Smokers relapse in these high risk situations:

26. Behavioural techniques: Anticipate Delay Escape Avoid Distract Social support Cognitive Strategy: Remember how difficult it is to stop. Imagine either a negative image (smell of cold tobacco,…) or a positive image of life without smoking. Remember relapses and their causes. Remember self control methods. Behaviour Modification Source : Richmond ; Smokescreen program 1998

27. Acupuncture and homeopathy were evaluated, but the lack of methodology of several tests and contradictory results do not allow dependable conclusions to be drawn. For these four methods, it is very difficult to dissociate their emphatic role delivered to the patient from their specific effect. Other techniques: acupuncture, homeopathy, mesotherapy, hypnosis Source : Consensus conference on smoking cessation Paris October 98

28. It is usual to note a little weight gain (2kg) after smoking cessation. But this weight gain is not automatic. Why? Weight stability and gain Weight is the result of a balance between: - calories intake (food and drinks) - energy spent (daily physical activity, sport) Any change in one or the other will have consequences on this balance. Cigarettes act in two different ways : - as a hunger cut - as a slight activator of calories spending Therefore, when an individual smokes, his weight is slightly lower than it should be. Diet advice In order to limit the weight gain, it is better to: - increase energy expenditure by a regular physical activity, - not to increase one’s calorie intake. Keep in hand: - a fruit or a raw vegetable to munch - a drink: mineral water or not, milky drinks, vegetable broth, instant soups, fruit or vegetable juices (rich in vitamin C whose leve is often low due to smoking) - some chewing-gums Attention : do not eat liquorice in great quantities because liquorice contains a substance which raises blood pressure. If you are inclined to gain weight or if you have a tendency towards nibbling, prefer: - low calorie drinks: mineral water or not, fizzy or not, flavoured water, unsweetened herbal teas, vegetable broth, diet drinks - diet sweets Don’t forget to eat slowly, to chew well in order to rediscover the pleasure of smell and taste. Choose, as often as possible, a place where you are offered a pleasant and comfortable setting and atmosphere. Diet advice for smoking cessation Source : D Garelik