Counselling clients to quit smoking may be a part of your practice no matter what kind of therapy you do. While many clinicians may wish to refer clients to others for this work, learning the skills to handle smoking cessation may be a valuable addition to your work with clients in other areas and so is worth the time.
In Canada, about 1 in 5 individuals smoke (Statistics Canada, 2014) and this level has been going down, as it has in most western countries, for many years. Tobacco smoking often begins in the teen years (U.S. Department of Health and Human Services, 2012) with the Surgeon General noting that “vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.”
Smoking often affects the poor, mentally ill and other marginalized groups. (Passey & Bonevski, 2014) The mortality rate of both male and female smokers is three times higher than non-smokers and the rate of heart attack in middle aged men is four times higher. (CDC, n.d.)
Most individuals who attempt to quit smoking will require multiple attempts to quit, with sources citing between 5 and 30 (Chaiton, et. al., 2016).
Benefits of Quitting Smoking
The following list of health benefits comes from the World Health Organization (n.d.), and may help convince a smoker who believes that there is no point in quitting, to attempt to do so:
Within 20 minutes of your last cigarette, your heart rate and blood pressure drop.
Within 12 hours, the carbon monoxide level in your blood drops to normal.
2-12 weeks, your circulation improves and your lung function increases.
1-9 months, coughing and shortness of breath decrease.
1 year, your risk of coronary heart disease is about half that of a smoker’s.
5 years, your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.
10 years, your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.
15 years, the risk of coronary heart disease is that of a nonsmoker’s.
The benefits are clear! But that doesn’t mean quitting smoking is easy.
When a client stops their regular smoking, they begin to experience withdrawal symptoms within about 2 hours (Medline, 2015) as the nicotine begins to leave their bloodstream. The Mood and Physical Symptoms Scale (West & Hajek, 2004) is a tool for measuring withdrawal symptoms. These symptoms can include depression, anxiety, irritability, restlessness, hunger, inability to concentrate, poor sleep and more.
Assessment of Smoking Behaviours
The Fagerstrom Test for Nicotine Dependence is a common measure of smoking-related behaviour. It asks six questions:
- How soon after waking do you smoke your first cigarette?
- Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
- Which cigarette would you hate to give up?
- How many cigarettes in a day do you smoke?
- Do you smoke more frequently in the morning?
- Do you smoke even if you are sick in bed most of the time?
See my article on assessments for substance use disorders for more information on the Fagerstrom Test.
Interventions to Quit Smoking
Nicotine Replacement Therapy (NRT)
Nicotine replacement therapy (NRT) includes products like patches, gum, inhalers and lozenges. Use of nicotine replacement therapy nearly doubled a client’s ability to quit smoking in a Cochrane review (Silagy, et. al., 2012) NRT is contraindicated in the following groups (Department of Health, Western Australia, 2012):
- Lactating women
- Smokers under 12 years of age
As well, those:
- Between 13 and 18
- With severe heart problems
Should receive NRT under physician supervision. Additional recommendations (e.g. for people with diabetes, mental health issues or from specific cultural groups) are found in the Clinical Guidelines in the References. In general, clients should receive medical support from a GP who can properly monitor them when taking any medications, including NRT.
Motivational interviewing (MI) is a brief intervention that aims to highlight and amplify intrinsic motivation and intent to quit smoking that already exists in clients. (Rollnick & Allison, 2001) Some elements of motivational interviewing include (Sciacca, 2009):
- Change and sustain talk, messages from the client that indicate either a willingness to change or a desire to keep things the way they are
- Rolling with resistance, and recognizing a client’s desire not to change may be the result of the clinician’s approach, the client’s unreadiness or both
- Ensuring empathy to build a strong relationship
- Identifying discrepancies, for instance where a client’s values (“I want to be there for my children”) conflict with their behaviours (“My daughter had to wait in the rain so I could have a smoke”)
There is a large body of research (e.g. the metareview by Lundahl & Burke, 2009) supporting the effectiveness of motivational interviewing in helping clients to quit smoking or using other substances.
The 5 A’s of Quitting Smoking
The 5 A’s describe simple set of steps for a brief tobacco intervention, they come from MDQuit (2012).
- Ask – It’s important to ask the patient about their smoking. Do they smoke at all?
- Assess – If they do smoke, how much do they smoke. You may wish to use the Fagerstrom criteria for this (see above, Assessment for Substance Use Disorders)
- Assist – Help the client make an informed decision about their smoking behaviour if they wish to cut down.
- Advice – Provide information on the risks of continuing and the benefits of quitting.
- Arrange – Finally, arrange some form of followup if possible to check on their progress.
Quit Smoking Training
The Government of Western Australia has produced the Brief Tobacco Intervention Training Program designed to teach basic cessation skills to clinicians (nurses and doctors) in advising clients on how to quit smoking. It is available freely online and takes about 2 hours to complete.
The California Smokers Helpline provides a number of free courses and online webinars covering a variety of smoking cessation-related topics that may be eligible for Continuing Education (CE) credits.
In Canada, the Centre for Addiction and Mental Health provides the Training Enhancement in Applied Cessation Counselling and Health (TEACH) program, comprised of online and in-person workshops to teach clinicians skills in smoking cessation.
Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/
Chaiton, M., Diemert, L., Cohen, J., Bondy, S., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6(6), doi:10.1136/bmjopen-2016-011045
Department of Health, Western Australia. (2011) Clinical guidelines and procedures for the management of nicotine dependent inpatients. Perth: Smoke Free WA Health Working Party, Health Networks Branch, Department of Health, Western Australia; Retrieved on August 11, 2016 from http://www.health.wa.gov.au/smokefree/docs/Clinical_guidelines.pdf
Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal Of Clinical Psychology, 65(11), 1232-1245. doi:10.1002/jclp.20638
Medline. (2015). Martin, L.J. “Nicotine and tobacco” Retrieved on August 11, 2016 from https://medlineplus.gov/ency/article/000953.htm
MDQuit. (2012) “Brief Interventions & 5 A’s | MDQuit.org” Retrieved on August 11, 2016 from http://mdquit.org/cessation-programs/brief-interventions-5
Passey, M., & Bonevski, B. (2014). The importance of tobacco research focusing on marginalized groups. Addiction, 109(7), 1049-1051. doi:10.1111/add.12548
Motivational interviewing. In: International handbook of alcohol dependence and problems. New York, NY: Wiley; pp. 593-603.. (2001)
Sciacca, K. (2009) “MOTIVATIONAL INTERVIEWING –MI, GLOSSARY & FACT SHEET” Retrieved on August 11, 2016 from http://www.motivationalinterview.net/miglossary.pdf
Silagy, C., Lancaster, T., Stead, L., Mant, D. & Fowler, G. (2007) Nicotine replacement therapy for smoking cessation (Review). The Cochrane Library. (3)
Statistics Canada. (2014) “Smoking, 2014”, Retrieved on August 11, 2016 from http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14190-eng.htm
U.S. Department of Health and Human Services. (2012) Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Retrieved on August 11, 2016 from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf
West, R. & Hajek, P. (2004). Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal Psychopharmacology, 177, 195-199.