Reach ‘n Teach Supporting pre and postnatal women and their families who use tobacco.
1
Reach ‘n Teach: Supporting pre and postnatal women and their families who use tobacco was created in response to a request from KFL&A Public Health Staff in the Family Health Division for a comprehensive and concise reference guide on key messages regarding tobacco cessation in the prenatal and postnatal periods. It started as a student nursing project, and was developed by compiling information from health promotion materials, reports, position statements, literature, and guidelines related to smoking cessation. This is not an exhaustive list of resources and information. This resource is intended to act as a reference for service providers who have received training in tobacco cessation techniques appropriate for their scope of practice. Authors: Dawn Cole, RN, Kingston, Frontenac and Lennox & Addington Public Health, Emma D’Accord and Jane Morrison, 4th year BScN students Contributors: Marie-Josee Boulerice, Eastern Ontario Health Unit Design Credit: Jacqueline Venditti, Kingston, Frontenac and Lennox & Addington Public Health Reviewers: Members of the TCAN East Pre/Postnatal working group as follows: Carolyn Comerford, RN, Renfrew County and District Health Unit Colleen Kearns, RN, Ottawa Public Health Crystal Roach, RN, Hastings and Prince Edward Counties District Health Unit Diana Brooks, RN, Renfrew County and District Health Unit Kimberley Marshall, RN, Leeds, Grenville, and Lanark District Health Unit Nik Hotte, Eastern Ontario Health Unit Robyn Hurtubise, Eastern Ontario Health Unit Marie Brisson, Bilingual Health Promotion Consultant, Best Start Resource Centre, Toronto, ON Completed January 2014 Requests to adapt this resource can be made to TCAN East by contacting: Andrea Kruz, TCAN East Co-ordinator KFL&A Public Health 221 Portsmouth Avenue Kingston ON K7M 1V5
[email protected] 613-549-1232
Table of Contents Section I: Benefits of Quitting and Health Risks of Tobacco Use
4
Section II: The Process of Nicotine Addiction
14
Section III: Tobacco Use Methods
18
Section IV: Brief Intervention, the “5 A’s”
22
Section V: Intensive Intervention
26
Section VI: Use of Pharmacotherapy for Tobacco Cessation
32
Section VII: Supporting Smoke-Free Environments
40
Section VIII: Involving Partners in Tobacco Cessation
46
Section IX: Withdrawal and Coping Strategies
52
Section X: Understanding the Stages of Change
60
Section XI: Using Motivational Interviewing
66
Section XII: Carbon Monoxide Monitoring
70
Section XIII: Relapse Prevention
74
Section XIV: Resources for Clients and Staff
80
Section XV: Bibliography
88
1
Benefits of Quitting and Health Risks of Tobacco Use Many people who use tobacco grossly underestimate the health risks of tobacco use to themselves and of tobacco smoke exposure to others, because they are unaware of all the effects of tobacco use 14
4
Section I - Benefits of Quitting and Health Risks of Tobacco Use
5
1 Benefits of Quitting For long term success, a cessation approach should emphasize the benefits of quitting smoking not only for the health of the fetus, but also for the woman herself.1
Some of the Benefits of Quitting: •
More energy2,3,10
•
Easier breathing and better lung function2,3,10
•
Improved circulation, blood pressure, and heart rate2,3
•
Increased oxygen in the blood3
•
Save money4,10
•
Better smelling home environment10
•
Sense of taste and smell improves2,3,10
•
Satisfaction in reaching goal of quitting10
•
Carbon monoxide level drops2,3
•
Less likely to have heart disease or heart attack2-4,11
•
Less likely to get respiratory infections and disorders (e.g. Chronic Obstructive Pulmonary Disorder [COPD])3,11
6
•
Decreased cancer risk2-4,11
•
Increased life expectancy12
•
Fresh breath4
•
Fewer wrinkles4
•
Whiter teeth4
Section I - Benefits of Quitting and Health Risks of Tobacco Use
If Mom Quits During Pregnancy: Additional benefits for mom: •
Less likely to miscarry4
•
Will experience less complications during pregnancy4
Benefits for the fetus: •
Receives more oxygen, and is less likely to be born at a lower birth weight10
•
Less likely to be born too early10
Benefits for the newborn: •
Better lung function10
•
More likely to be born at a healthy weight4,10
•
Lower risk for Sudden Infant Death Syndrome (SIDS)10
Benefits for the child: •
Improved lung function
•
Improved growth
•
Less likely to become a smoker10
•
Fewer colds, coughs, and ear infections10
•
Fewer asthma or wheezing episodes4,10
Women who stop smoking before or during their first trimester of pregnancy reduce the risks to their baby to a level comparable to that of women who have never smoked.3
Section I - Benefits of Quitting and Health Risks of Tobacco Use
7
Health Risks of Tobacco Use Tobacco, used exactly as intended, kills about half of its users. If it were a new product introduced today, no government would allow it to be sold.13
Background on Tobacco Tobacco is a tall leafy plant that is grown throughout the world15. The tobacco plant naturally contains the toxic chemical nicotine. Nicotine is the main addictive component in tobacco; however it is all of the other chemicals found in tobacco and tobacco smoke that are responsible for the majority of tobacco-related disease17. Of the over 4,000 chemicals found in tobacco smoke15, many are known causes of cancer. Just a few of the harmful chemicals found in tobacco smoke are:15-16 •
Carbon monoxide
•
Arsenic
•
Ammonia
•
Acetone
•
Sulphur compounds
•
Lead
•
Formaldehyde
•
Butane
•
Cyanide
•
Tar
For information regarding how the chemicals in tobacco smoke are formed and how they impact human health, visit Health Canada’s “Tobacco: Behind the Smoke” at www.hc-sc.gc.ca/hc-ps/tobac-tabac/fact-fait/smoke-fumee1-eng.php
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Section I - Benefits of Quitting and Health Risks of Tobacco Use
Health Risks of Tobacco Use: •
Premature death2,3
•
Heart disease, heart attack, stroke1-4
•
High blood pressure3,18
•
High cholesterol3
•
Numerous types of cancers (e.g. lung, cervical, mouth)1-4
•
Respiratory disorders (e.g. COPD, Emphysema, etc.)1-3
•
Osteoporosis1-3
•
Type II diabetes 3
•
Infertility for men and women, unsuccessful fertility treatments1,2,4-7
•
Menstrual problems, irregularity, early menopause1,2,18
•
Gastrointestinal problems (e.g. peptic ulcers, chronic bowel disease)3
•
Tooth decay, gum disease3,4
•
Cataracts3,4
•
Respiratory illnesses (eg. influenza, common cold, pneumonia)3,4
Section I - Benefits of Quitting and Health Risks of Tobacco Use
9
If Mom Uses Tobacco During Pregnancy: Mom is more likely to experience: •
miscarriage,1-6,9,18
•
premature delivery,1,3-6,8,9,18
•
placental abnormalities,1-,6,9,18
•
birth complications,1,9 and
•
bleeding during pregnancy.3
The fetus is more likely to: •
develop growth restriction4, 5,18, as less oxygen and nutrients reach the baby,8
•
have a slower fetal heart rate,4 and
•
develop birth defects (e.g. cleft lip, cleft palate).2,4,18
The newborn is more likely to •
be born at a lower birth weight,1-8,18
•
have a smaller head circumference,5
•
be at risk for Sudden Infant Death Syndrome (SIDS),2-6,18 and
•
be admitted to Neonatal Intensive Care Unit (NICU) for health complications.5,6
As the child grows, it is more likely to: •
suffer from respiratory illnesses (e.g. asthma, pneumonia, croup, bronchitis),2,3,5,9,18
•
experience other childhood medical problems (e.g. ear infections),5,18
•
have difficulty learning and develop behavioural problems (e.g. Attention Deficit Hyperactivity Disorder (ADHD), short attention span, antisocial),4,5,7,18
10
•
become addicted to nicotine and use tobacco later on,9,18
•
experience childhood allergies,3
•
develop high blood pressure and obesity later on in life,3 and
•
be of shorter height.3
Section I - Benefits of Quitting and Health Risks of Tobacco Use
If Mom Uses Tobacco When Breastfeeding Breast milk is the natural food for newborns, and contains all the nutrients that babies need.19 It is best for breastfeeding mothers to quit or cut down on smoking.19 The chemicals from cigarettes pass to the baby through breast milk.3,9 Tobacco use can decrease breastfeeding initiation18, and may also interfere with milk production and lead to early weaning.3,5,18,19 If mom is unable to quit smoking, breastfeeding is still good for baby.19
Benefits of Breastfeeding: •
Decreases baby’s risk of ear, chest, and stomach infections19
•
Decreases baby’s risk of developing childhood obesity19
•
Decreases baby’s risk of Sudden Infant Death Syndrome (SIDS)19
•
Promotes healthy brain development19
•
Reduces mom’s risk of breast, uterine, and ovarian cancers19
•
Controls mom’s postpartum bleeding19
•
Helps mom return to a healthy body weight after birth19
For harm reduction strategies regarding tobacco use and breastfeeding, please refer to page 36 of Breastfeeding Matters, a resource developed by The Best Start Resource Centre, available for download at: www.beststart.org/resources/breastfeeding/pdf/BreastfeedingMatters_2013_low_rez_ reference.pdf
Section I - Benefits of Quitting and Health Risks of Tobacco Use
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References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
19.
12
British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Al-Sahab B, Saqib M, Hauser G, Tamim H. Prevalence of smoking during pregnancy and associated risk factors among Canadian women: a national survey. BMC Pregnancy and Childbirth. 2010;10(24):1471-2393. Action on Smoking and Health (ASH). ASH research report: secondhand smoke: the impact on children. London (UK): ASH; 2010. The Lung Association. Smoking and pregnancy. Toronto: The Lung Association; 2007. Canadian Cancer Society. Clear the air. Toronto: Canadian Cancer Society; 2007. KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. Health Canada. On the road to quitting: guide to becoming a non-smoker. Ottawa: Publications Health Canada; 2007. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto: CAMH TEACH Project; 2011. World Health Organization (WHO). WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package. [document on the internet] Retrieved December 14, 2012 from www.who.int/tobacco/mpower/gtcr_download/en/index.html WHO. WHO Report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. [document on the internet]. Retrieved December 14, 2012 from www.who.int/tobacco/global_report/2011/en/ Canadian Lung Association, Smoking & Tobacco, Facts about smoking, 2012. [document on the internet]. Retrieved November 2012 from www.lung.ca/protect-protegez/tobacco-tabagisme/facts-faits/what-que_e.php New York State Smoker’s helpline, Facts and Myths, 2012. [document on the internet]. Retrieved November 2012 from www.nysmokefree. com/Subpage.aspx?P=40&P1=4010 Ontario Medical Association Position Paper: Rethinking Stop Smoking Medications. 2008. [document on the internet]. Retrieved December 14, 2012 from https://www.oma.org/Resources/Documents/e2008RethinkingStop-SmokingMedications.pdf Best, D, the Committee on Environmental Health, the Committee on Native American Child Health, and the Committee on Adolescence. American Academy of Pediatrics. Technical report- Secondhand and prenatal tobacco smoke exposure. Pediatrics. 2009; 124(5):e1017e1044. The Best Start Resource Centre. Breastfeeding Matters: An important guide to breastfeeding for women and their families. Toronto: Health Nexus; 2013.
Section I - Benefits of Quitting and Health Risks of Tobacco Use
Section I - Benefits of Quitting and Health Risks of Tobacco Use
13
2
The Process of Nicotine Addiction Nicotine is addictive.1
14
Section II - The Process of Nicotine Addiction
15
2 The Process of Nicotine Addiction Nicotine is 1000 times more potent than alcohol, 10 to 100 times more potent than barbiturates, and 5 to 10 times more potent than cocaine or morphine.1
What is Nicotine? Nicotine is a highly addictive chemical present in tobacco2, 5, 6 It is a psychoactive drug that affects the central nervous system and alters brain function.3
Why is Nicotine Addictive? •
When nicotine is taken in by inhaling tobacco smoke, it reaches the brain within seconds.4, 6
•
In the brain, nicotine triggers the release of dopamine, a chemical associated with pleasure that makes the smoker feel good.3-5
•
Nicotine is addictive because it gradually increases the number of receptor sites in the brain and decreases sensitivity of receptors to nicotine.4, 5
•
The number of receptor sites is increased, so smokers need greater and greater amounts of nicotine to receive the same amount of pleasure.5, 6
•
Then, when nicotine leaves the system after smoking, the brain begins to crave it and withdrawal symptoms are experienced.2,4,5, 6
•
The uncomfortable nature of withdrawal symptoms makes it difficult for people to quit.4, 6
Overcoming Nicotine Addiction: •
Smokers will need to replace their smoking behaviours with other activities that stimulate the pleasure pathway and make them feel good in a natural way.4
•
When clients stop smoking, the extra receptor sites from nicotine gradually begin to disappear as the body begins to heal.4
16
Section II - The Process of Nicotine Addiction
References 1. 2. 3. 4. 5. 6.
Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. Health Canada. On the road to quitting: guide to becoming a non-smoker. Ottawa: Publications Health Canada; 2007. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. KFL&A Public Health. Invisible reality. Kingston: KFL&A Public Health; 2007. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Ontario Medical Association Position Paper: Rethinking Stop Smoking Medications. 2008. [document on the internet]. Retrieved December 14, 2012 from https://www.oma.org/Resources/Documents/e2008RethinkingStop-SmokingMedications.pdf
Section II - The Process of Nicotine Addiction
17
3
Tobacco Use Methods
18
Section III - Tobacco Use Methods
19
3 Tobacco Use Methods Cigarettes and Cigarette-like Products: The cigarette is a highly sophisticated delivery device that has been engineered to allow nicotine to peak in the body within seconds of inhalation1. In Canada, there are several brands and types of cigarettes and cigarette-like products sold on the market2-5. Chemical analysis and comparison of the smoke of different brands of cigarettes, mini-cigarettes, contraband cigarettes, cigars, and mini-cigars has shown very similar results. Health Canada considers that smoking any of these forms of tobacco has the same detrimental health effects. 2-5
Smokeless Tobacco Products: Smokeless tobacco products are made of tobacco, water, and added chemicals, and can be chewed, sucked, or inhaled through the nose6. They can appear in a variety of different forms, including plugs, shredded, or fine powder. These products can be advertised as “spit” or “spitless”.6 Chemical analysis of a variety of different forms found that they all contain nicotine, carcinogens, and other health hazards. 6
Waterpipe Smoking: Waterpipe, also known as hookah, shisha, and a variety of other names, has been used for centuries as a way to smoke tobacco.7 For more information on the rise of this smoking trend, please refer to the report Waterpipe Smoking: A Growing Health Concern by the Ontario Tobacco Research Unit, available at www.otru.org/ waterpipe-smoking-a-growing-health-concern-2/.
Electronic Cigarettes: Electronic cigarettes, or e-cigarettes, are found in Canada9. Health Canada permits e-cigarettes to be sold in Canada as long as they do not contain nicotine or make a health claim. Health Canada also states that the use of e-cigarettes may pose health risks to the user, and they have not been evaluated for safety, quality, and efficacy8,9. This is an evolving issue. Please consult with Health Canada for the most up to date information.8-10 You can also visit www.nsra-adnf.ca/cms/page2292.cfm, and refer to the references below.
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Section III - Tobacco Use Methods
Where to Turn for Tobacco Use Statistics: The following is a list of sources for tobacco use in Ontario and Canada: •
Tobacco Use Statistics available through Health Canada: o Canadian Tobacco Use Monitoring Survey (CTUMS) & the Youth Smoking Survey (YSS) o www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/index-eng.php
•
BORN (Better Outcomes Registry Network) Database: o Reports are available on smoking during pregnancy, and information is provided about accessing data for your region. o www.bornontario.ca
•
CAMH (Centre for Addiction and Mental Health) Monitor: o Collects statistics on addictions among adults aged 18 years and older in Ontario through ongoing surveys. o Up to date reports are available for download. o www.camh.ca/en/research/news_and_publications/Pages/camh_monitor.aspx
•
Ontario Tobacco Research Unit (OTRU): o www.otru.org
References 1.
Ontario Medical Association Position Paper: Rethinking Stop Smoking Medications. 2008. [document on the internet]. Retrieved December 14, 2012 from www.oma.org/Resources/Documents/e2008RethinkingStop-SmokingMedications.pdf 2. Health Canada. 2011. Little Cigars, big concerns. [document on the internet]. Retrieved December 13, 2012 from www.hc-sc.gc.ca/hc-ps/pubs/tobactabac/little-cig-petits/index-eng.php 3. Health Canada. 2011. Contraband cigarettes: Tobacco smoke analysis. [document on the internet]. Retrieved December 13, 2012 from www.hc-sc. gc.ca/hc-ps/pubs/tobac-tabac/contra-cig-contre/index-eng.php 4. Health Canada. 2011. Discount cigarettes.[document on the internet]. Retrieved December 13, 2012 from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/ discount-rabais/index-eng.php 5. Health Canada. 2011. Mini size cigarettes: Smoke emissions and toxicity analysis. [document on the internet]. Retrieved December 13, 2012 from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/mini-size-format-mini/index-eng.php 6. Health Canada. 2010. Smokeless tobacco products: A chemical and toxicity analysis. [document on the internet]. Retrieved May 16, 2013 from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/smokeless-sansfumee/index-eng.php 7. Ontario Tobacco Research Unit (OTRU). 2011. Waterpipe smoking: A Growing Health Concern. [document on the internet]. Retrieved May 16, 2013 from otru.org/waterpipe-smoking-a-growing-health-concern-2/ 8. Health Canada. 2009. Notice- identification number RA-110003348. Retrieved May 16, 2013 from www.healthycanadians.gc.ca/recall-alert-rappel-avis/ hc-sc/2009/13373a-eng.php 9. T-CAN East. 2012. E-Cigarette Prevalence in Eastern Ontario. Retrieved May 16, 2013 from www.smokefreeottawa.com/uploads/1/1/7/4/11742147/ ecigarette_prevalence_in_eastern_ontario_web.pdf 10. Non-Smokers’-Rights Association. March 2012. Buzz on E-Cigarettes. Retrieved May 16, 2013 from www.nsra-adnf.ca/cms/page2292.cfm
Section III - Tobacco Use Methods
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4
Brief Intervention, the “5 A’s” Quitting smoking at any point throughout pregnancy has benefits.1
22
Section IV - Brief Intervention, the “5 A’s”
23
4 Brief Intervention Brief advice from a health professional decreases the proportion of people smoking by about 2 percent per year.1 Providing a brief intervention (typically lasting 1 to 3 minutes) to all tobacco users at every appropriate opportunity can have a significant effect on smoking cessation rates.3
The “5 A’s” It is estimated that about 70% of all smokers are interested in quitting.2
ASK: • “Have you used tobacco in the past six months?”3 •
Determine whether she currently smokes and her current smoking patterns.4,5
•
Ask if she has made any changes in her smoking patterns since becoming pregnant.4
ADVISE: • “The most important advice I can give you is to quit smoking.”3
24
•
Make a clear statement about the benefits of quitting.4
•
Advise about the importance of quitting in a non-judgmental manner.3,5
Section IV - Brief Intervention, the “5 A’s”
ASSESS: • • •
Determine if she has considered quitting.4 Assess willingness to make a quit attempt.4,5 If time is available to provide a more intensive intervention, see Intensive Intervention section for more information.
ASSIST: •
Assist her with ways to quit according to her level of readiness and stage of change:3-5 o Provide information about reducing the impact of smoking. o Discuss use of Nicotine Replacement Therapy (NRT) and/or stop-smoking medications. o Offer support resources (e.g. self-help resources, group/individual counselling, community services, Smokers’ Helpline). o Refer to a healthcare provider. o See Resources for Clients and Staff section for more information.
ARRANGE: •
Arrange support and follow-up.4,5
•
Arrange referral to smoking cessation program.3
References 1. 2. 3. 4. 5.
CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto, Canada: CAMH TEACH Project; 2011.
Section IV - Brief Intervention, the “5 A’s”
25
5
Intensive Intervention Whenever possible, pregnant smokers should be offered one-on-one interventions that exceed minimal advice to quit.1
26
Section V - Intensive Intervention
27
5 Intensive Intervention It is estimated that 5-15% of women will quit smoking as soon as they become pregnant – but, with a counselling session and client education materials provided by a professional, cessation rates can increase to 15-20%.2
What is intensive intervention? Intensive intervention involves an extended interaction between the staff and the client, typically lasting longer than 10 minutes.3,4
Why is it important? Intensive intervention is appropriate for all smokers who are willing to participate. It is especially recommended to be offered to pregnant women.3 During pregnancy and breastfeeding, counselling is recommended as first-line treatment.1
28
Section V - Intensive Intervention
What can you do? •
Discuss strategies to quit and treatment options:3 o Set a quit date o Review quitting history o Review potential challenges or triggers o Encourage support of family and friends o Offer information about pharmacotherapy
•
Use tools to assess:3 o Reasons for smoking (WHY Test) o Nicotine dependence (Fagerstrom Test) o Decisional Balance o Readiness Ruler
•
Schedule follow-up.3
•
Support use of telephone counselling, or community/public health programs.3
•
Offer cessation interventions to family/friends/partner.1
Assessment Tools This section provides a brief list of some assessment tools that health care providers trained in their use may choose to use when supporting a client in a quit attempt. This is not an exhaustive list of assessment tools available, and they are presented in no particular order.
Fagerstrom Test for Nicotine Dependence: •
Most widely used tool for identifying a client’s level of nicotine addiction.
The WHY Test: •
Used to identify client’s reasons for smoking.
Decisional Balance: •
Allows clients to identify personal reasons for continued smoking vs. quitting.
•
See an example of this on page 12 of the Liberation! Helping Women Quit Smoking: A Brief Tobacco Intervention Guide, available from www.bccewh.bc.ca/publications-resources/
documents/Liberation-HelpingWomenQuitSmoking.pdf.
Section V - Intensive Intervention
29
Readiness Ruler: •
Helps clients identify importance, confidence, and readiness to change tobacco use.
•
See an example of this on pages 13-14 of the Liberation! Helping Women Quit Smoking: A Brief Tobacco Intervention Guide, available from www.bccewh.bc.ca/publications-
resources/documents/Liberation-HelpingWomenQuitSmoking.pdf.
Tips for Clients:3 •
Pick a quit date and stick to it.
•
Make a plan for coping with stressful situations.
•
Avoid visiting places where you usually smoke.
•
Don’t try “just one” cigarette.
•
Keep yourself busy (e.g. increase physical activity)
•
Think positively and congratulate yourself!
Cessation Approaches for Clients:5 •
To quit suddenly (“cold turkey”), clients should: o understand where and why they smoke, o be confident in their ability to break the patterns associated with their smoking, o be mentally prepared to cope with withdrawal, and o when ready, set a quit date and stop all at once.
•
To quit by cutting back gradually, clients should: o Reduce the amount of cigarettes gradually as they move closer to their quit date. o Strategies include:
smoking less of each cigarette,
rationing cigarettes by carrying only enough to get them through the day and refusing to buy more,
cutting out the cigarettes they may not need, and
waiting 5-10 minutes before acting on an urge to smoke.
o Cutting back gives the client a sense of what it will be like to quit permanently.
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Section V - Intensive Intervention
For more information about these and other assessment tools, please visit the following resources: Urquhart, C., Jasiura, F., Poole, N., Nathoo, T. & Greaves, L. (2012). Liberation! Helping Women Quit Smoking: A Brief Tobacco Intervention Guide. Vancouver, BC: British Columbia Centre of Excellence for Women’s Health. Available from www.bccewh.bc.ca/publicationsresources/documents/Liberation-HelpingWomenQuitSmoking.pdf Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Available from rnao.ca/bpg/guidelines/integrating-smoking-cessation-daily-nursing-practice
References 1. 2. 3. 4. 5.
CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto, Canada: CAMH TEACH Project; 2011. Health Canada. On the road to quitting: guide to becoming a non-smoker. Ottawa: Publications Health Canada; 2007.
Section V - Intensive Intervention
31
6
Use of Pharmacotherapy for Tobacco Cessation The use of pharmacotherapy can double long-term quit rates.1-4
If applicable, please ensure to follow your agency guidelines regarding pharmacotherapy for tobacco cessation.
32
Section VI - Use of Pharmacotherapy for Tobacco Cessation
33
6 Use of Pharmacotherapy for Tobacco Cessation Types of Pharmacotherapy: •
Nicotine Replacement Therapy (NRT): o NRT Gum o NRT Lozenge o NRT Inhaler o NRT Patch o NRT Mouth Spray
•
Stop-Smoking Medications: o Bupropion (Zyban/Wellbutrin) o Varenicline (Champix)
Factors to Assess When Considering Pharmacotherapy:1,4
34
•
Level of dependency
•
Length of addiction
•
Smoker’s goals
•
Compliance
•
Cost of medication
•
Ease of administration
•
Timing of quit attempt
•
Contraindications
•
Co-morbid conditions
•
Previous response to medications
Section VI - Use of Pharmacotherapy for Tobacco Cessation
Nicotine Replacement Therapy (NRT) It is not nicotine, but the thousands of other toxins present in cigarettes, that are responsible for the vast majority of tobacco-related disease.3
Key Facts About NRT: •
Provides the body with nicotine to minimize withdrawal symptoms, making it easier to avoid smoking.1-3
•
Supplies nicotine in a safe manner, without the toxins found in cigarettes.2-5
•
Can help clients who are not ready to quit reduce their smoking.3
•
NRT is most effective when used in combination with counselling.2
•
Different types of NRT (gum, patch, etc.) may be used together.4
•
Does not require a prescription.1-5
•
Can be expensive.1,5
•
May not be effective in clients who smoke <10 cigarettes/day.1,6
•
NRT has very little addictive potential compared to cigarettes.3
•
NRT use does not increase risk for heart attack, stroke or cardiovascular disease, even if used while still smoking.3
•
NRT dosages are only guidelines and should be individualized.3
•
NRT doses should be reduced over time.5
NRT in Pregnant and Breastfeeding Women: •
NRT should be considered a second-line option for pregnant and breastfeeding women who are unable to quit using counselling, or who are “heavy smokers”.3,5-9
•
NRT should be avoided in the first trimester of pregnancy.3,8,9
•
NRT can be used during pregnancy or while breastfeeding following a risk-benefit analysis – consider risks of continued smoking vs. use of NRT.2,5,8,9: o NRT is safer than smoking, which exposes the woman and her baby to many dangerous toxins and higher levels of nicotine.3,4 o Breastfeeding women are recommended to breastfeed prior to using NRT each time in order to minimize the infants’ exposure.9
Section VI - Use of Pharmacotherapy for Tobacco Cessation
35
•
Oral NRT (gum, inhaler, lozenge) is preferred to NRT patches during pregnancy.5,7-9
•
When using the patch, some researchers suggest that a pregnant women remove the patch before bed to reduce the fetus’ exposure to nicotine.9
•
Pregnant women should try to use the lowest NRT dose possible for the shortest time possible.5,7
•
A pregnant or breastfeeding woman should always check with her doctor before initiating NRT.4
NRT Gum: •
May be appropriate for patients who desire oral stimulation during cessation, identify boredom as a trigger for smoking, or are concerned about weight gain after quitting.7
•
Meant to be chewed and “parked” between your teeth and gums.2,4-6
•
Comes in different doses for light/heavy smokers.5
•
One piece provides the body with nicotine for 20-30 minutes.2,6
•
Gum can be used to respond to immediate cravings as it eases withdrawal.2,7
•
Gradually reduce dosage over time.6
NRT Lozenge: •
Works in a similar manner to NRT gum.5
•
Not meant to be chewed- slowly suck, rest between cheek and gum, wait 1 minute, and repeat.2,4-6
•
Takes around 30 minutes to consume one lozenge.2
•
Comes in different doses for light/heavy smokers.5
•
Gradually reduce dosage over time.6
NRT Inhaler: •
Delivers nicotine through a cartridge that is shaped like cigarette.5
•
The client “puffs” on the cartridge like a cigar and nicotine is absorbed in the mouth and throat.2,4,5
•
One cartridge is equal to 4-5 cigarettes, or 20 mins of puffing.2,4
•
Mimics the “hand-to-mouth” ritual of smoking and helps address cravings.2,4,5,7
•
Gradually decrease the number of cartridges per day.5,6
NRT Patch:
36
•
Skin patch that delivers a continuous dose of nicotine through the skin.2-6
•
Applied once per day to control cravings and ease withdrawal.5,7
•
Takes longer to feel the effects when using a patch compared to other forms of NRT.3,5
•
Comes in different doses for light/heavy smokers.5,7
•
Dosage is gradually reduced over time5,6
Section VI - Use of Pharmacotherapy for Tobacco Cessation
NRT Mouth Spray: Please be advised that this product contains alcohol. Evidence shows that no amount of alcohol is safe in pregnancy; abstinence from any amount of alcohol is the safest choice in pregnancy.10 •
Client sprays the product into the mouth (not the throat), avoiding the lips.11
•
May use up to 2 sprays at a time, up to 4 sprays per hour, and not more than 64 sprays every 24 hours.11
•
Gradually reduce the number of sprays per day over time as body adjusts to not smoking.11
For more information about NRT, including the use in specialty populations, please refer to the Clinical Practice Guidelines developed by the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-information Tobacco Treatment (CAN-ADAPTT), available online at: www.nicotinedependenceclinic.com/English/CANADAPTT/Guideline/Introduction.aspx
Stop-Smoking Medications: •
It is recommended that the use of NRT products are considered first before trying either bupropion hydrochloride (Zyban) or varenicline tartrate (Champix).12
•
Smokers can use prescription medications that are non-nicotine based, such as bupropion hydrochloride (Zyban) and varenicline tartrate (Champix).1,4
•
Clients will require a prescription from a physician, nurse practitioner, or dentist should they wish to use stop-smoking medications.2
•
Please consult product monographs for more information.
Stop-Smoking Medications in Pregnancy: •
There is no evidence of harm associated with use of bupropion (Zyban) during pregnancy.3,8
•
Bupriopion (Zyban) may be considered as an alternative to NRT.3,8
•
Varenicline (Champix) has not been studied in pregnancy.3
•
Varenicline (Champix) is not recommended for use during pregnancy.3
Section VI - Use of Pharmacotherapy for Tobacco Cessation
37
Bupropion Hydrochloride (Zyban): •
Reduces withdrawal symptoms and reduces desire for nicotine.4,7
•
How it works is unclear.7
•
Also an antidepressant – can be helpful if prone to depression while quitting.3,6
•
Can be used alone, or in combination with NRT.2-4
•
Shown to minimize weight gain.2
•
Side effects:5 o Dry mouth o Insomnia
•
Contraindications: 2,3 o Seizure history o Prior or current diagnosis of an eating disorder o MAO Inhibitors o Sensitivity to bupropion (Zyban) o Already using bupropion (Zyban) o Should not be used if undergoing abrupt discontinuation of alcohol or sedative use.
•
Dosing: o Start bupropion (Zyban) while the client is still smoking (about a week before the quit date).4,5 o Starting dose is 150 mg once daily for 3 days.2 o On day 4, increase to 150mg twice daily, waiting 8 hours between doses.2 o
Use twice a day for 8-12 weeks.5
o At the end of that period, the medication is stopped- not reduced over time.5
Varenicline Tartrate (Champix): Not to be used in pregnancy.
38
•
Reduces withdrawal and cravings.2,4
•
Prevents pleasurable effects of smoking by mimicking the action of nicotine.2,4,6
•
Not recommended to be used in combination with NRT.2,4,6
Section VI - Use of Pharmacotherapy for Tobacco Cessation
•
Side effects:2 o Gastrointestinal symptoms o Skin reactions o Aggression
•
Contraindications: o Pregnancy3,6 o Sensitivity to varenicline (Champix)6
•
Dosing: o Should be started while the client is still smoking (about a week before the quit date).4-6
For further information, please visit Motherisk at www.motherisk.org.
References 1. 2.
Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto, Canada: CAMH TEACH Project; 2011. 3. Ontario Medical Association. Rethinking stop-smoking medications: treatment myths and medical realities. Update 2008. Ont Med Rev. 2008 Jan; 75(1): 22-34. 4. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. 5. British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. 6. KFL&A Public Health. Nicotine replacement therapy: it may double your chance of quitting…but it is not a magic bullet! Kingston: KFL&A Public Health; 2011. 7. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. 8. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. 9. Greaves, L., Poole, N., Okoli, C. T. C., Hemsing, N., Qu, A., Bialystok, L., & O’Leary, R. (2011). Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and post-partum women (2nd ed.). Vancouver: British Columbia Centre of Excellence for Women’s Health. 10. Society of Obstetricians and Gynaecologists of Canada (SOGC). (2010). Alcohol use and pregnancy consensus clinical guidelines. JOGC [document on the internet]. 2010 Aug [cited 2013 Jul 15];32(8): S1-S36. 11. Quitnow. Quitting medications- Mouth spray. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/toolsand-resources/quitting-medications/mouth-spray.php 12. Health Canada. 2013. Notice- identification number RA-33623. [document on the internet]. Retrieved July 15, 2013 from www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2013/33623a-eng.php
Section VI - Use of Pharmacotherapy for Tobacco Cessation
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7
Supporting Smoke-Free Environments There is no risk-free level of exposure to second-hand smoke.1,2
40
Section VII - Supporting Smoke-Free Environments
41
7 Supporting Smoke-Free Environments Smoke from the burning end of a cigarette has more harmful chemicals in it than the smoke inhaled directly by a smoker through a filtered cigarette.3
What is Second-Hand Smoke? Second-hand smoke is the smoke that goes into the air from the end of a burning cigarette, pipe, or cigar. It also includes the smoke that is exhaled by a smoker. Second-hand smoke is also known as environmental tobacco smoke, or passive smoke.4-6
What is Third-Hand Smoke? Third-hand smoke refers to the toxins in smoke that linger after a smoker puts out a cigarette. Third-hand smoke gets trapped in hair, skin, walls, fabric, carpet, furniture, and toys. It also builds up over time.7
42
Section VII - Supporting Smoke-Free Environments
What are the risks? •
Babies and children breathe faster than adults, so they tend to inhale more air and more second-and third-hand smoke.7-9
•
Babies have a higher risk of pneumonia, bronchitis, SIDS, and low birth weight.3,8,10-12
•
Babies can swallow dust containing third-hand smoke when they crawl on the floor and put their hands into their mouths.7
•
Children are less able to complain about smoky air, their immune system is weaker, and they are less able to remove themselves from exposure.9
•
Children have a higher risk of asthma, ear infections, and acute respiratory problems, such as colds and coughs.3,6,9,10-13
•
Children of parents who smoke are more likely to start smoking as well.8
•
Adults have a higher risk of heart disease, cancers, and respiratory diseases.3,6,10
•
Exposure increases the risk of negative pregnancy outcomes.11,15
•
Continued exposure can lead to premature death and disease in children and adults who do not smoke.1
Strategies for a Smoke-Free Home or Apartment Unit: •
Smoke outside and make sure the smoke doesn’t drift back inside through windows or doorways.12,14
•
Find a caregiver to watch children while taking a smoke break.7,12
•
Set up a comfortable area, preferably outdoors, for smokers to use.4,5,12
•
Politely ask family members and friends to smoke outside.4,7,12,15
•
Ask children’s caregivers not to smoke around them.4
•
Remove all ashtrays from inside the home and keep only one for smoking outside.4,5,12
•
Clean ashtray after every use.4,5,12
•
Post a “Smoke-Free Home” magnet or sign in the home.5
•
Wash hands after smoking, and consider changing into clothing that doesn’t smell of smoke.
•
If living in a multi-unit apartment building where the ventilation system is shared: o identify where the smoke is entering the home,5 o install special seals for electrical outlets,4 o install door sweeps,4,5 o install window fans to help increase ventilation,5 o seal cracks around vents, pipes and windows with foam insulation,4,5 and o talk to neighbours about reducing the effects of smoking.4
Section VII - Supporting Smoke-Free Environments
43
Strategies for a Smoke-Free Vehicle •
Let all passengers know that the vehicle is smoke free4,5,12
•
Give the car a good cleaning4,5
•
Clean out the ashtray4,5
•
Leave work or home a few minutes earlier so time is available to smoke outside before getting into the car4
•
Pull off at rest areas for smoke breaks or schedule stops for smokers on long trips.14 If possible, wash hands after smoking.
•
Lock cigarettes in the trunk14
•
Post a “Smoke-Free” decal in the car window5
Remember: It is the law in Ontario that no one can smoke in a vehicle where a person under 16 years old is present.12
The STARSS (Start Thinking about Reducing Second-Hand Smoke) program was developed by AWARE (Action on Women’s Addictions-Research and Education) to provide strategies and resources for pregnant and parenting women smokers especially those who don’t want to, or aren’t ready to, quit smoking. For more information, visit: www.aware.on.ca/resources/
44
Section VII - Supporting Smoke-Free Environments
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. Physicians for a Smoke-Free Canada (PSC). Ventilation of second-hand smoke. Ottawa: PSC; 2001. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Canadian Cancer Society. Clear the air. Toronto: Canadian Cancer Society; 2007. Health Canada. Make your home and car smoke-free: a guide to protecting your family from second-hand smoke. Ottawa: Health Canada; 2008. Action on Smoking and Health (ASH). ASH research report: secondhand smoke: the impact on children. London (UK): ASH; 2010. Best Start Resource Centre. A smoke-free environment for your children. Toronto: Health Nexus; 2010. The Lung Association. Smoking and pregnancy. Toronto: The Lung Association; 2007. Physicians for a Smoke-Free Canada (PSC). Second hand smoke & children’s health. Ottawa: PSC; 1999. Physicians for a Smoke-Free Canada (PSC). Health effects of second-hand smoke. Ottawa: PSC; 2001. Oliffe JL, Bottorff JL, Sarbit G. The right time. The right reasons: Dads talk about reducing and quitting smoking. Kelowna: Institute for Health Living and Chronic Disease Prevention, University of British Columbia; 2010. KFL&A Public Health. Tips to keep your home and family smoke-free. Kingston: KFL&A Public Health; 2010. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. British Columbia Centre of Excellence for Women’s Health (BCCEWH). Couples and smoking: What you need to know when you are pregnant. Vancouver: BCCEWH; 2008. KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto: CAMH TEACH Project; 2011.
Section VII - Supporting Smoke-Free Environments
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8
Involving Partners in Tobacco Cessation
46
Section VIII - Involving Partners in Tobacco Cessation
47
8 Involving Partners in Tobacco Cessation
For a pregnant woman, cessation and relapse from tobacco use are often affected by whether or not her partner smokes, and what their views about smoking in pregnancy are.9
48
Section VIII - Involving Partners in Tobacco Cessation
Family & Partner Smoking: •
Partners, friends, and family members should be offered smoking cessation interventions.4, 8
•
It can be difficult to stop when someone else in the household smokes.5, 8
•
The client’s ability to stop smoking is influenced by the routines they have with their partner.5, 8
•
Couples who stop smoking together may be able to help each other stay smoke-free.5,7
•
If talking about smoking starts an argument, help the client develop strategies to deal with the situation (e.g. getting some space until everyone calms down).5
•
Strategies for Dads who smoke include:2 o Delay next smoke o Act now - Make a commitment o Drink a glass of water when craving a smoke o Something else to do - Get involved in being a Dad!
•
Advice for clients during a quit attempt: o Discuss smoking openly.9 o Tell other smokers in your home what you’re doing and why.3 o Help others understand the impact of smoking on health.9 o Rally support and encouragement from others.6 o Ask others to be patient with you during your quit attempt.6 o Have others help out around the house to ease the stress of quitting.5,6 o Ask your partner to help distract you from triggers.5 o Ask others not to smoke around you.5,6 o Ask others not to leave cigarettes or ashtrays around the house.5 o Be firm about your right to have a smoke-free home.1 o Reach out for help from others who have quit.6 o Recognize the efforts made by people who smoke.9
Here are some more resources for clients: “Couples and Smoking: What you need to know when you are pregnant”5 facet.ubc.ca/wpcontent/files/Couples-and-Smoking.pdf “The right time. The right reasons: Dads talk about reducing and quitting smoking”2 facet. ubc.ca/wp-content/files/Right-Times-Right-Reasons.pdf
Section VIII - Involving Partners in Tobacco Cessation
49
References 1. 2. 3. 4. 5.
6. 7. 8.
9.
50
Canadian Cancer Society. Clear the air. Toronto: Canadian Cancer Society; 2007. Oliffe JL, Bottorff JL, Sarbit G. The right time. The right reasons: Dads talk about reducing and quitting smoking. Kelowna: Institute for Health Living and Chronic Disease Prevention, University of British Columbia; 2010. KFL&A Public Health. Tips to keep your home and family smoke-free. Kingston: KFL&A Public Health; 2010. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Bottorff, J. L., Carey, J., Poole, N., Greaves, L. & Urquhart, C. (2008). Couples and Smoking: What you need to know when you are pregnant. Available from: www.facet.ubc.ca and www.hcip-bc.org. Jointly published by the British Columbia Centre of Excellence for Women’s Health, the Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, and NEXUS, University of British Columbia Vancouver. KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. Greaves, L., Poole, N., Okoli, C. T. C., Hemsing, N., Qu, A., Bialystok, L., & O’Leary, R. (2011). Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and post-partum women (2nd ed.). Vancouver: British Columbia Centre of Excellence for Women’s Health. Best Start Resource Centre. A smoke-free environment for your children. Toronto: Health Nexus; 2010.
Section VIII - Involving Partners in Tobacco Cessation
Section VIII - Involving Partners in Tobacco Cessation
51
9
Withdrawal & Coping Strategies Experiencing withdrawal symptoms usually means that your body is healing.1
52
Section IX - Withdrawal & Coping Strategies
53
9 Withdrawal & Coping Strategies
What is Withdrawal? Withdrawal is a normal part of quitting smoking.1 After quitting, the brain will continue to crave nicotine causing some symptoms of withdrawal.2 Not all people experience withdrawal symptoms, and very few experience all of them.3,9 On the following pages are some suggestions you can share with clients who are experiencing withdrawal symptoms.
54
Section IX - Withdrawal & Coping Strategies
The following list includes examples of withdrawal symptoms:
Withdrawal symptoms are no different for pregnant women than for other women.5
•
Feeling grumpy, irritable1-4,9, aggressive3,4
•
Restlessness1,2,4,9
•
Depression2-4,9
•
Anxiety3, 9
•
Dizziness, lightheadedness1,3,4,9
•
Headaches1,3,9
•
Trouble sleeping1-4,9
•
Fatigue3,9
•
Difficulty concentrating1-4,9
•
Constipation1,3,4,9
•
Hunger, weight gain1,3,4,9
•
Mouth ulcers3,4
•
Dry mouth3,9
•
Sore throat, gums, and tongue1,3
•
Urges to smoke3-5,9
•
Coughing1-3,9
Duration of Symptoms: •
Time for withdrawal symptoms varies from person to person, but usually the first couple of days are the most difficult.5,9
•
Urges to smoke rarely last more than a few minutes.2
•
Other symptoms usually lessen after 3-4 days, but may last 2-3 weeks.2,5
•
For some clients, psychological withdrawal symptoms may last more than a few weeks.5
•
Using Nicotine Replacement Therapy (NRT) can help to lessen withdrawal symptoms.3,4,9
Section IX - Withdrawal & Coping Strategies
55
Coping with Physical Withdrawal Symptoms: •
Dizziness/headaches: o Get fresh air.1 o Take a nap.1 o Change positions slowly and use caution.9 o Avoid caffeine.9
•
Coughing, sore throat, or dry mouth: o Use cough drops.1, 9 o Sip warm drinks.1, 9
Remember the 4 D’s: Delay Smoking Deep Breathe Do Something Else Drink Water.3,9
o Drink plenty of fluids.9 •
Hunger: o Follow Canada’s Food Guide to Healthy Eating.8 o Eat healthy snacks.1,2,6, 8, 9 o Drink lots of water.1, 9 o Be more active.9 o Leave table immediately after eating and brush your teeth.9
•
Constipation: o Add more fibre, whole grains, and fruit and vegetables to your diet.1, 2, 6, 9 o Drink lots of water.1, 9 o Exercise regularly.9
•
Weight gain: o Gaining weight during pregnancy is healthy and necessary. o Maintain a healthy weight by eating healthy and being physically active.6,8,10 o Speak to your health care provider for more information and tips on how to maintain a healthy weight.
•
Fatigue: o Take rest periods/naps.9 o Try to get a good amount of sleep.7 o Do not push yourself.9
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Section IX - Withdrawal & Coping Strategies
Coping with Psychological Withdrawal Symptoms: •
Difficulty concentrating: o Go for a walk.1,2,6,9 o Try to work in short bursts, instead of for long periods.1,9 o Get lots of sleep.1
•
Feeling grumpy/irritable: o Share with others how you are feeling.1,9 o Go for a walk.1,2,6
•
Restlessness: o Go for a walk.1,2,6 o Keep your hands and mouth busy.1 E.g. Knit, doodle, squeeze a ball, chew gum, sip water o Avoid caffeine.1
•
Difficulty sleeping: o Avoid caffeine.1 o Get more exercise.1,2,6 o Read or do something you enjoy until you feel sleepy.1,7 o Try relaxation techniques before bed.9
•
Urges to smoke: o Remind yourself why you quit.5 o Avoid trigger situations.5 o Have a plan for what you can do instead of smoking in trigger situations.5 o Think of each urge as a bridge you have to cross to reach the reward on the other side.2 o Go for a walk.1,2,6 o Call a friend.1,3 o Consider NRT.9
•
Anxiety: o Go for a walk.1,2,6 o Use positive self-talk.1 o Take a bath.1 o Call a friend.1,3
•
Depression: o Write down your feelings.1 o Go for a walk.1,2,6 o Talk to a friend.1,3 o Reward yourself.1,2 o Talk to your healthcare provider.
Section IX - Withdrawal & Coping Strategies
57
Coping with Stress: For a helpful guide on these and other coping strategies, refer to Coping with Stress available here www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5590155/k.3B4A/Heart_ disease__Coping_with_stress.htm •
Deep breathing7,11: o Can be done anytime, anywhere.7 o Inhale slowly through your nose and expand your abdomen. Reverse the process as you exhale. Repeat for 3-5 minutes when you feel tense.7
•
Physical activity7,11: o Helps to clear your mind, reduce tension, and increase energy.7
E.g. walking, team sports, aerobic classes, swimming2,7
For the PARmed-X for Pregnancy, a free health screening guideline that pregnant women can have their health care providers complete prior to participating in physical activity, visit www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf.
•
Get a good sleep7,11: o If you can’t sleep after 30 minutes, get out of bed and read a book, listen to quiet music, or play solitaire. This will help to relax you, even if you cannot fall asleep right away.1,7
•
Relaxation Exercises: o Set aside some time each day to unwind.2,7
E.g. listen to music, read a book, do yoga2
•
Eat a healthy diet.7,11
•
Talk it out.11
•
Spend time with supportive people.11
•
Use the 4As for preventing stress11: o Avoid the situation.
E.g. avoid stressful situations and people if possible, say “no” when you want to11
o Alter the situation.
E.g. ask others to change their behaviour, and be willing to change yours11
o Accept the situation.
If possible accept what you can’t change and move on. 11
Practice positive self-talk ie. “I made a mistake but I’ll survive”11
o Adapt to the situation
If you believe that you can’t cope without a cigarette, your stress will increase!11
Try stopping negative thoughts in their tracks, adopt a mantra like, “I can cope without a cigarette and I will!”11
To find out what mental health services are available in your community, contact The Mental Health Helpline at 1-866-531-2600.
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Section IX - Withdrawal & Coping Strategies
References 1. 2. 3.
KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. Health Canada. On the road to quitting: guide to becoming a non-smoker. Ottawa: Publications Health Canada; 2007. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. 4. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto: CAMH TEACH Project; 2011. 5. British Columbia Centre of Excellence for Women’s Health (BCCEWH). Couples and smoking: What you need to know when you are pregnant. Vancouver: BCCEWH; 2008. 6. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. 7. Heart & Stroke Foundation of Canada, Canadian Mental Health Association. Coping with stress. Ottawa: Canadian Mental Health Association, National Office; 2009. 8. Health Canada. Canada’s food guide: Maintaining healthy habits. [document on the internet]. 2007. [cited 2013 Jul 15]. Available from: www.hc-sc.gc.ca/fn-an/food-guide-aliment/maintain-adopt/index-eng.php 9. Quitnow. Common withdrawal symptoms & coping strategies. [document on the internet]. 2011. [cited 2013 Jul 15]. Available from: www.quitnow.ca/database/files/library/Common_Withdrawal_Syptoms_and_Coping_Strategies___Aug_30_11(1).pdf 10. Quitnow. Minimize weight gain. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/tools-and-resources/staying-quit-resources/weight.php 11. Quitnow. Manage stress, quit smoking. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/tools-andresources/resources-for-staying-quit/stress.php
Section IX - Withdrawal & Coping Strategies
59
10
Understanding the Stages of Change
60
Section X - Understanding the Stages of Change
61
10 Understanding the Stages of Change
The task for those who work with pregnant women is to help the women plan for long-term cessation rather than pregnancy-linked cessation.1
Stages of Change During Pregnancy: • “Readiness to quit” often has a different meaning during pregnancy.1 •
Women who are willing to quit may link quitting to the pregnancy and view returning to smoking as a reward after delivery.1,5
•
Pregnant women may move through the precontemplation and contemplation stages into preparation and action stages very quickly, which may be detrimental to their quit attempt and result in postpartum relapse.2,5
•
Although pregnant women may appear to be in the action stage, they may not be adequately prepared.5
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Section X - Understanding the Stages of Change
Stages of Change Smokers may not move through the stages linearly. Most smokers will cycle through the stages 3 to 4 times before quitting for life.2
1. Precontemplation: Description: •
Client is unwilling to change and may deny they have a problem.2,3
•
Client is not thinking of quitting in the next six months.2
Goal: •
Help the client begin to think seriously about quitting.2
Strategies: •
Stay low key and be very brief.3
•
Identify community supports and programs promoting benefits of quitting.4
•
Let the client know that you would be happy to help them if they are interested in quitting.3
2. Contemplation: Description: •
Client has identified that they have a problem.3
•
Client is ambivalent and has no commitment to take action.2,3
•
Client is thinking about quitting within six months.2
Goal: •
Help the client move towards a decision to stop smoking and feel more confident.2
Strategies: •
Offer cessation support.4
•
Politely give as much information as possible and elicit as much information as possible from the client.3
Section X - Understanding the Stages of Change
63
3. Preparation: Description: •
Client is getting ready to quit within the next 30 days.2
•
Client has set a quit date.2
•
Client has made a 24-hour quit attempt in the last 12 months.2
Goal: •
Help the client prepare for and positively anticipate a quit date.2
Strategies: •
Congratulate and reassure the client about the value of the decision to quit.3
•
Ask the client if they have any questions about cessation and what can be done to help them quit.3
•
Offer pharmacotherapy and support.4
•
Refer to cessation program.4
4. Action: Description: •
Client has started the process of quitting smoking within the past six months and is actively applying cessation skills.2,3
Goal: •
Help client stay off tobacco products and recover from relapse.2
Strategies: •
Provide follow-up, provide support, and answer questions.3
5. Maintenance: Description: •
Client is integrating smoke-free living into their routine.2
•
Client has quit for more than six months.2,3
Goal: •
Help the client remain smoke-free for a lifetime.2
Strategies: •
Congratulate the client, ask how quitting has benefited their life, and how they were successful.3,4
•
64
Identify fitness/wellness programs.4
Section X - Understanding the Stages of Change
References 1. 2. 3. 4. 5.
British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. Registered Nurses’ Association of Ontario (RNAO). Nursing best practice guideline: integrating smoking cessation into daily nursing practice. Toronto: RNAO; 2007. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. Greaves, L., Poole, N., Okoli, C. T. C., Hemsing, N., Qu, A., Bialystok, L., & O’Leary, R. (2011). Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and post-partum women (2nd ed.). Vancouver: British Columbia Centre of Excellence for Women’s Health.
Section X - Understanding the Stages of Change
65
11
Using Motivational Interviewing
Effective motivational interviewing should consist of 70% listening and 30% talking.1
66
Section XI - Using Motivational Interviewing
67
11 Using Motivational Interviewing It is the quality of the intervention, not the length of time, that is most important in motivational interviewing.1
What is Motivational Interviewing? Motivational interviewing is a counselling technique that explores the client’s own reasons for change and helps to address ambivalence.2
Five Counselling Techniques1-4: 1. Express Empathy 2. Avoid Arguments 3. Develop Discrepancy 4. Roll with Resistance 5. Support Self-Efficacy
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Section XI - Using Motivational Interviewing
General Skills of Motivational Interviewing: •
Provide client choices.3
•
Give personalized feedback.3,4
•
Ask open-ended questions.1-3
•
Use reflection.1,4
•
Provide affirmations.1,4
•
Summarize or reframe.1,4
•
Encourage self-motivational statements.4
•
Engage in decision balance.1,2
For more information or training on Motivational Interviewing, contact the Program Training and Consultation Centre or the TEACH project (See Resources for Clients and Staff section).
References 1. 2. 3. 4.
CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto: CAMH TEACH Project; 2011. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario.
Section XI - Using Motivational Interviewing
69
12
Carbon Monoxide Monitoring
70
Section XII - Carbon Monoxide Monitoring
71
12 Carbon Monoxide Monitoring What is Carbon Monoxide (CO)? Carbon monoxide is an odourless, colourless gas that is produced as a by-product of burning organic compounds, such as tobacco.1 Cigarette smoke is a significant source of CO.1-3
CO Monitoring: • “Some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense. This, in turn, makes it difficult to ensure they are offered appropriate support. A CO test is an immediate and non-invasive biochemical method for helping to assess whether or not someone smokes.”4 •
CO monitoring is considered easy to use in cessation interventions.2
•
The half-life of CO in the blood is approximately 2-5 hours.1
•
Monitoring the levels of CO in the breath can indicate abstinence from smoking, but should not be used as an indicator of recent cigarette use.1
72
Section XII - Carbon Monoxide Monitoring
References 1. 2. 3. 4.
Dolcini MM, Adler NE, Lee P, Bauman KE. An assessment of the validity of adolescent self-reported smoking using three biological indicators. Nicotine Tob Res. 2003 Aug; 5(4): 473-483. Javors MA, Hatch JP, Lamb RJ. Cut-off levels for breath carbon monoxide as a marker for cigarette smoking. Addiction. 2005 Feb; 100(2): 159-167. Hedblad B, Engstrom G, Janzon E, Berglund G, Janzon L. COHb% as a marker of cardiovascular risk in never smokers: Results from a population-based cohort study. Scand J Public Health. 2006; 34(6): 609-615. National Institute for Health and Clinical Excellence (NICE). 2010. NICE public health guidance 26: How to stop smoking in pregnancy and following childbirth. London, UK: NICE.
Section XII - Carbon Monoxide Monitoring
73
13
Relapse Prevention The more past attempts to stop smoking a person has made, the more likely they will be to successfully stop in the future.1
74
Section XIII - Relapse Prevention
75
13 Relapse Prevention 20 to 30% of women continue to use tobacco during pregnancy, and of those who quit, about 70% return to smoking after their babies are born.2 Most people make several quit attempts before they succeed—but most do succeed!2
What is a Relapse? A relapse means returning to smoking about as much or as often as before quitting.2 It is a common occurrence in the process of making a behavioural change.1 Relapsing calls for a new quit plan, and a different approach.2
What is a “Slip?” A “slip” means having a puff or two after quitting smoking. It is very common, and does not mean failure. A slip provides an opportunity to look at what went wrong and review reasons for quitting.2
76
Section XIII - Relapse Prevention
Factors Associated with Relapse: •
Lack of support1,3
•
Other smokers in household1, 8
•
Alcohol or recreational drug use1
•
Exposure to high-stress situations and individual triggers (ie. financial worries, change, return to work, etc.)1
•
Negative mood or depression1,3
•
Motivation centered around the baby3, 8
•
Negative self-talk1
•
Weight gain3
•
Dietary restrictions1
•
Strong or prolonged withdrawal symptoms1,3
•
Problems with pharmacotherapy (e.g. under-dosing, side effects, compliance, or premature discontinuation)1
Preventing Relapse: •
Be aware that relapse often occurs in the first two weeks to three months after quitting.1
•
Advise clients not to try “just one puff” after quitting.4
•
Help the client identify tempting situations and develop a plan to handle them.1
•
Review client’s reasons for quitting and develop strategies to cope with cravings.4,5
•
Encourage the client to ask for help from others.4
•
Encourage clients to report difficulties promptly (e.g. “slips”, depression, withdrawal symptoms1)
•
Always congratulate the client on changes made.1,5
•
Advise women to quit right after their period starts, as they are more likely to relapse during the premenstrual phase.6
Section XIII - Relapse Prevention
77
Moving Forward after Relapse: •
Never condemn a client for “slipping”.1
•
Encourage the client not to give up after a “slip” and get back to their quit plan right away.2,4
•
Reframe a “slip” as a learning opportunity – help the client learn to manage stress and balance their lifestyle so that triggers are not overwhelming.1
•
Following relapse, a new quit plan and a new quit date are needed.2
•
Look at what went wrong, what worked, and help the client plan how they can do better next time.2,5
•
Remind the client that all experiences learned in previous attempts are useful and can be built upon for a future successful quit attempt.1
•
Think of the prior quit attempt as “practice” and remind clients that practice makes perfect!2
Postpartum Relapse: •
Relapse is a significant problem for pregnant smokers who quit.8
•
20% of women relapse prior to delivery, and 70% relapse after giving birth.6,7
•
Make sure that the client is aware of the high risk of postpartum relapse.2
•
Helping to shift the woman’s motivation for quitting from improving the health of her fetus to improving her own health may help prevent postpartum relapse.8
Questions to identify those at greatest risk for postpartum relapse:2 o Which of the following best describes your personal goal with regard to smoking after delivery?
To stay off of cigarettes
To control when and where you smoke
To go back to smoking
Unsure
o How likely are you to smoke in the first six months after your baby is born? o Since your first prenatal visit, have you smoked a cigarette, even a puff?
78
Chapter XIII - Relapse Prevention
References 1. 2. 3. 4. 5. 6. 7. 8.
Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007. Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8. KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto: CAMH TEACH Project; 2011. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010. CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Greaves, L., Poole, N., Okoli, C. T. C., Hemsing, N., Qu, A., Bialystok, L., & O’Leary, R. (2011). Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and post-partum women (2nd ed.). Vancouver: British Columbia Centre of Excellence for Women’s Health.
Chapter XIII - Relapse Prevention
79
14
Resources for Clients and Staff Get to know your local resources and where to look for any additional resources for you and your clients.
80
Section XIV - Resources for Clients and Staff
81
14 Resources for Clients and Staff
Cessation Resources in Eastern Ontario Please refer to the pamphlet entitled “Quit Smoking Programs in Eastern Ontario” available in hard copy from your local Public Health Unit or online at smokefreeeast.blogspot.ca/p/quitting.html
82
Section XIV - Resources for Clients and Staff
Provincial Resources •
Smoker’s Helpline (Canadian Cancer Society) o Phone: 1-877-513-3333 o Website: www.smokershelpline.ca o Free confidential support available by phone 7 days a week. o Services available in English and French and translation service available in many other languages. o Online quit program and online community available 24/7 o Text messaging support. o Quit connection fax referral program quit.smokershelpline.ca/refer
Online Resources •
PREGNETS: www.pregnets.org o Information on smoking cessation practices for pregnant and postpartum women. o Toolkit for health care professionals. o Anonymous online discussion board.
•
Expecting to Quit: www.expectingtoquit.ca/resources/ o Videos and written cases of different women’s experiences in quitting smoking.
•
Health Canada: www.hc-sc.gc.ca/hc-ps/tobac-tabac/index-eng.php o Information available on tobacco control, legislation, second-hand smoke, effects of tobacco on the body, and other resources.
•
Registered Nurses Association of Ontario (RNAO): tobaccofreernao.ca o Offers client resources. o Video vignettes of implementing 5A’s in practice o Online web course on integrating smoking cessation into daily practice. o Community discussion board
Chapter XIV- Resources for Clients and Staff
83
Self-Help Resources for Clients •
Make Your Home and Car Smoke-Free: A guide to protecting your family from second-hand smoke. o www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/second-guide/index-eng.php o Developed by Health Canada.
•
On the Road to Quitting: Guide to becoming a non-smoker. o www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/road-voie-eng.php o Developed by Health Canada.
•
Quit 4 Life: A guide to becoming a non-smoker for youth. o www.hc-sc.gc.ca/hc-ps/tobac-tabac/youth-jeunes/life-vie/index-eng.php o Developed by Health Canada.
•
The Right Time...The Right Reasons...Dads talk about Reducing and Quitting Smoking: This booklet is for men who identify with the challenges around being an expectant or new dad who smokes. o facet.ubc.ca/wp-content/files/Right-Times-Right-Reasons.pdf o Developed by UBC, Institute for Healthy Living and Chronic Disease Prevention, and Families Controlling and Eliminating Tobacco (FACET).
•
Help a Smoker Quit: One step at a time: This booklet includes advice for family and friends on what to do, and what not to do, to help a smoker quit. o www.cancer.ca/~/media/cancer.ca/CW/publications/OSAAT%20help%20a%20smoker%20quit/OSAAT-Help-a-smoker-quit-2013-EN.pdf o Developed by Canadian Cancer Society
•
One Step at a Time: For Smokers Who Don’t Want to Quit: This booklet offers smokers who are not ready to quit some helpful information. o www.cancer.ca/~/media/cancer.ca/CW/publications/OSAAT%20for%20smokers%20 who%20dont%20want%20to%20quit/OSAAT-Smokers-who-dont-want-to-quit2013-EN.pdf o Developed by Canadian Cancer Society
•
One Step at a Time: For Smokers Who Want to Quit: This booklet is for smokers who have decided that they want to quit smoking. o www.cancer.ca/~/media/cancer.ca/CW/publications/OSAAT%20for%20smokers%20 who%20want%20to%20quit/OSAAT-Smokers-who-want-to-quit-2013-EN.pdf o Developed by Canadian Cancer Society.
•
Journey 2 Quit: This workbook is for smokers trying to quit. o www.on.lung.ca/journey o Developed by the Ontario Lung Association.
84
Chapter XIV - Resources for Clients and Staff
•
Coping with Stress: This booklet will help you understand and manage stress in your life. o www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5590155/k.3B4A/Heart_disease__Coping_with_stress.htm o Developed by Heart and Stroke Foundation and Canadian Mental Health Association.
•
Clear the Air: Protect yourself and your family from second-hand smoke. o www.cancer.ca/~/media/cancer.ca/CW/publications/Clear%20the%20air/Clear-the-air2011-EN.pdf o Developed by Canadian Cancer Society.
•
A Smoke-Free Environment for Your Children: Learn more about second-hand and thirdhand smoke. o www.beststart.org/resources/tobacco/pdf/tobacco_handout_eng_FINAL.pdf o Developed by The Best Start Resource Centre.
•
Smoke-Free Home Sticker o www.beststart.org/resources/tobacco o a 3”x3” opaque sticker for a door or window. o Developed by The Best Start Resource Centre
Additional Resources for Pregnant Women •
The STARSS (Start Thinking about Reducing Second Hand Smoke) Program: For pregnant smokers and women smokers with children who don’t want to, or aren’t ready to, quit smoking. Resources for both health care providers and women are available online to download. o www.aware.on.ca/starss o Developed by AWARE (Action on Women’s Addictions- Research & Education)
•
Couples and Smoking: What you need to know when you are pregnant: This is a self-help booklet for pregnant women who smoke. o facet.ubc.ca/wp-content/files/Couples-and-Smoking.pdf o Developed by Centre for Healthy Living and Chronic Disease Prevention, NEXUS – Researching the Social Contexts of Health Behaviour, and the British Columbia Centre of Excellence For Women’s Health.
•
Smoking and Pregnancy: Facts about smoking. o
lung.healthdiary.ca/Guest/Product.aspx?IDS=5BYQIAlELDKFjDXhcD%2fnxw%3d%3d
o Developed by The Lung Association. •
Motherisk: Provides evidence-based information on the safety and risks of exposure to drugs and other chemicals in pregnancy and while breastfeeding. o 1-877-327-4636 or www.motherisk.org
Section XIV - Resources for Clients and Staff
85
Aboriginal Resources •
My Journey with Tobacco: A facilitators guide and toolkit for creating a youth-focused group o nafc.ca/uploads/miscpdf/Tobacco_Cessation_Facilitators_Guide.pdf o Developed by the National Association of Friendship Centres.
•
The Best Start Resource Centre: o Sacred Tobacco, Sacred Children - A video, facilitator’s guide and parent handout for smoke-free spaces
There are also two pregnancy related resources that discuss tobacco use, one for service providers and one for clients.
www.beststart.org/resources/aboriginal_health.html
o Sacred Tobacco, Sacred Children – DVD
A video for Aboriginal parents and caregivers. It offers real stories from Aboriginal families who have smoke-free homes.
www.beststart.org/resources/aboriginal_health.html
o Sacred Tobacco, Sacred Children - Facilitator Guide
The guide offers suggestions for discussing smoke-free homes. It provides information about sacred use of traditional tobacco and about the effects of recreational use of commercial tobacco.
www.beststart.org/resources/tobacco/pdf/FACILITATOR%20GUIDE.pdf
o Beginning Journey: First Nations Pregnancy Resource
This prenatal book will help First Nations women to prepare for pregnancy, to have a healthy pregnancy, and to welcome a new life into their family.
www.beststart.org/resources/rep_health/E33A_Beginning_Journey.pdf
o Aboriginal Smoke-free Home Sticker
A 2.5”x3.2” re-positional sticker designed to be applied on a door or window, indicating that the environment is smoke-free.
•
www.beststart.org/resources/aboriginal_health.html
Aboriginal-focused Resources for Commercial Tobacco Cessation - An Environmental Scan of Resources, Programs and Tools: o www.nicotinedependenceclinic.com/English/teach/resources/Recommended%20 Readings/Aboriginal-focused%20Resources%20for%20Commercial%20 Tobacco%20Cessation.pdf o Developed by the TEACH Project and STOP Study, Centre for Addiction and Mental Health (CAMH).
86
Section XIV - Resources for Clients and Staff
Resources for Staff Please note the following is a list of additional resources that have no already been mentioned in this section. •
Liberation! Helping Women Quit Smoking: A Brief Tobacco Intervention Guide: A guide for practitioners to help women quit smoking and increase motivation. o www.bccewh.bc.ca/publications-resources/documents/LiberationHelpingWomenQuitSmoking.pdf o Developed by British Columbia Centre of Excellence for Women’s Health.
•
Helping Women Quit: A Guide for Non-Cessation Workers: A guide for those who work with women, but who don’t have a background in tobacco cessation. o ades.bc.ca/assets/pdf’s/Helping_Women_Quit_Guide.pdf o Developed by BC Health Authorities.
•
Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and post-partum women (2nd ed.): A best-practices review of smoking cessation interventions for pregnant and postpartum girls and women. o www.expectingtoquit.ca/about/order.php o Developed by British Columbia Centre of Excellence for Women’s Health.
•
Better Outcomes Registry & Network (BORN) Database: For statistics and information regarding prevalence of tobacco use in pregnancy in Ontario. o www.bornontario.ca
•
CAN-ADAPTT Canadian Smoking Cessation Clinical Practice Guideline: o www.nicotinedependenceclinic.com/English/CANADAPTT/Guideline/Introduction.aspx o Developed by CAN-ADAPTT.
•
RNAO Best Practice Guidelines: Integrating Smoking Cessation into Daily Nursing Practice. o rnao.ca/bpg/guidelines/integrating-smoking-cessation-daily-nursing-practice o Developed by Registered Nurses’ Association of Ontario. o A pocket guide for staff is also available.
•
TEACH Project (Training Enhancement in Applied Cessation Counselling and Health): The TEACH Project’s objective is to ensure that practitioners who serve people who use tobacco have the specialized knowledge and skills to deliver effective, evidence-based cessation intervention. o https://www.nicotinedependenceclinic.com/English/teach/Pages/Home.aspx o Developed by the CAMH (Centre for Addiction and Mental Health).
•
Program Training and Consultation Centre (PTCC): A resource centre for health care professionals as part of the Smoke-Free Ontario strategy. Provides training and technical assistance to health care providers in Ontario. Has a resource library for many tobacco control topics, including women and tobacco. o https://www.ptcc-cfc.on.ca/home
Section XIV - Resources for Clients and Staff
87
15
Bibliography
88
Section XV - Bibliography
89
15 Bibliography
The following is an alphabetical list of references for this document. Please refer to the section titled Resources for Clients & Staff for additional resources.
90
Section XV - Bibliography
A Action on Smoking and Health (ASH). ASH research report: secondhand smoke: the impact on children. London (UK): ASH; 2010. Action on Women’s Addictions- Research & Education (AWARE). Start Thinking About Reducing Second Hand Smoke (STARSS). [document on the internet]. 2007. [cited 2013 Jul 15]. Available from: www.aware.on.ca Al-Sahab B, Saqib M, Hauser G, Tamim H. Prevalence of smoking during pregnancy and associated risk factors among Canadian women: a national survey. BMC Pregnancy and Childbirth. 2010;10(24):14712393.
B Best, D, the Committee on Environmental Health, the Committee on Native American Child Health, and the Committee on Adolescence. American Academy of Pediatrics. Technical report- Secondhand and prenatal tobacco smoke exposure. Pediatrics. 2009; 124(5):e1017-e1044. Bottorff, J. L., Carey, J., Poole, N., Greaves, L. & Urquhart, C. (2008). Couples and Smoking: What you need to know when you are pregnant. Available from: www.facet.ubc.ca and www.hcip-bc.org. Jointly published by the British Columbia Centre of Excellence for Women’s Health, the Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, and NEXUS, University of British Columbia Vancouver. British Columbia Centre of Excellence for Women’s Health (BCCEWH). Couples and smoking: What you need to know when you are pregnant. Vancouver: BCCEWH; 2008. British Columbia Ministry of Health Services. Helping women quit: a guide for non-cessation workers. Victoria: British Columbia Ministry of Health Services; 2007.
C CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. Canadian Cancer Society. Clear the air. Toronto: Canadian Cancer Society; 2007. Canadian Lung Association, Smoking & Tobacco, Facts about smoking, 2012. [document on the internet]. [cited 2012 Nov]. Available from www.lung.ca/protect-protegez/tobacco-tabagisme/factsfaits/what-que_e.php Centre for Addiction and Mental Health (CAMH) Training Enhancement in Applied Cessation Counselling and Health. Fundamentals of tobacco interventions: participant manual. Toronto, Canada: CAMH TEACH Project; 2011.
Section XV - Bibliography
91
D Dolcini MM, Adler NE, Lee P, Bauman KE. An assessment of the validity of adolescent self-reported smoking using three biological indicators. Nicotine Tob Res. 2003 Aug; 5(4): 473-483.
E F G Greaves, L., Poole, N., Okoli, C. T. C., Hemsing, N., Qu, A., Bialystok, L., & O’Leary, R. (2011). Expecting to Quit: A best-practices review of smoking cessation interventions for pregnant and postpartum women (2nd ed.). Vancouver: British Columbia Centre of Excellence for Women’s Health.
H Health Canada. Canada’s food guide: Maintaining healthy habits. [document on the internet]. 2007. [cited 2013 Jul 15]. Available from: www.hc-sc.gc.ca/fn-an/food-guide-aliment/maintain-adopt/indexeng.php Health Canada. 2007. On the road to quitting: guide to becoming a non-smoker. Ottawa: Publications Health Canada. Health Canada. 2008. Make your home and car smoke-free: a guide to protecting your family from second-hand smoke. Ottawa: Publications Health Canada. Health Canada. 2009. Notice- identification number RA-110003348. [document on the internet]. [cited 2013 May 16]. Available from www.healthycanadians.gc.ca/recall-alert-rappel-avis/hcsc/2009/13373a-eng.php Health Canada. 2010. Smokeless tobacco products: A chemical and toxicity analysis. [document on the internet]. [cited 2013 May 16]. Available from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/ smokeless-sansfumee/index-eng.php Health Canada. 2011. Contraband cigarettes: Tobacco smoke analysis. [document on the internet]. [cited 2012 Dec 13]. Available from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/contra-cig-contre/ index-eng.php Health Canada. 2011. Discount cigarettes.[document on the internet]. [cited 2012 Dec 13]. Available from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/discount-rabais/index-eng.php Health Canada. 2011. Little Cigars, big concerns. [document on the internet]. [cited 2012 Dec 13]. Available from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/little-cig-petits/index-eng.php Health Canada. 2011. Mini size cigarettes: Smoke emissions and toxicity analysis. [document on the internet]. [cited 2012 Dec 13]. Available from www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/mini-sizeformat-mini/index-eng.php
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Section XV - Bibliography
Health Canada. 2013. Notice- identification number RA-33623. [document on the internet]. [cited 2013 Jul 15]. Availablefrom healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2013/33623a-eng. php Heart & Stroke Foundation of Canada, Canadian Mental Health Association. Coping with stress. Ottawa: Canadian Mental Health Association, National Office; 2009. Hedblad B, Engstrom G, Janzon E, Berglund G, Janzon L. COHb% as a marker of cardiovascular risk in never smokers: Results from a population-based cohort study. Scand J Public Health. 2006; 34(6): 609-615.
I J Javors MA, Hatch JP, Lamb RJ. Cut-off levels for breath carbon monoxide as a marker for cigarette smoking. Addiction. 2005 Feb; 100(2): 159-167.
K KFL&A Public Health. Need help putting out that cigarette? Kingston: KFL&A Public Health; 2001. KFL&A Public Health. Invisible reality. Kingston: KFL&A Public Health; 2007. KFL&A Public Health. Tips to keep your home and family smoke-free. Kingston: KFL&A Public Health; 2010. KFL&A Public Health. Nicotine replacement therapy: it may double your chance of quitting…but it is not a magic bullet! Kingston: KFL&A Public Health; 2011.
L The Lung Association. Smoking and pregnancy. Toronto: The Lung Association; 2007.
M Monson AL, Romas JA. A review of pharmacological and educational approaches for tobacco cessation. The Internet Journal of Allied Health Sciences and Practice. 2005; 3(3): 1-8.
N National Institute for Health and Clinical Excellence (NICE). 2010. NICE public health guidance 26: How to stop smoking in pregnancy and following childbirth. London, UK: NICE. Nevala J, Sears K, Steibelt E. Women and tobacco info pack. Toronto: Program Training and Consultation Centre; 2010.
Section XV - Bibliography
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New York State Smoker’s helpline, Facts and Myths, 2012. [document on the internet]. [cited 2012 Nov]. Available from www.nysmokefree.com/Subpage.aspx?P=40&P1=4010 Non-Smokers’-Rights Association. March 2012. Buzz on E-Cigarettes. [cited 2013 May 16]. Available from www.nsra-adnf.ca/cms/page2292.cfm
O Oliffe JL, Bottorff JL, Sarbit G. The right time. The right reasons: Dads talk about reducing and quitting smoking. Kelowna: Institute for Health Living and Chronic Disease Prevention, University of British Columbia; 2010. Ontario Medical Association Position Paper: Rethinking Stop Smoking Medications. 2008. [document on the internet]. [cited 2012 Dec 14]. Available from www.oma.org/Resources/Documents/ e2008RethinkingStop-SmokingMedications.pdf Ontario Tobacco Research Unit (OTRU). 2011. Waterpipe smoking: A Growing Health Concern. [document on the internet]. [cited 2013 May 16]. Available from otru.org/waterpipe-smoking-agrowing-health-concern-2/
P Physicians for a Smoke-Free Canada (PSC). Second hand smoke & children’s health. Ottawa: PSC; 1999. Physicians for a Smoke-Free Canada (PSC). Health effects of second-hand smoke. Ottawa: PSC; 2001. Physicians for a Smoke-Free Canada (PSC). Ventilation of second-hand smoke. Ottawa: PSC; 2001.
Q Quitnow. Common withdrawal symptoms & coping strategies. [document on the internet]. 2011. [cited 2013 Jul 15]. Available from: www.quitnow.ca/database/files/library/Common_Withdrawal_ Syptoms_and_Coping_Strategies___Aug_30_11(1).pdf Quitnow. Manage stress, quit smoking. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/tools-and-resources/resources-for-staying-quit/stress.php Quitnow. Minimize weight gain. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/tools-and-resources/staying-quit-resources/weight.php Quitnow. Quitting medications- Mouth spray. [document on the internet]. 2013. [cited 2013 Jul 15]. Available from: www.quitnow.ca/tools-and-resources/quitting-medications/mouth-spray.php
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Section XV - Bibliography
R Registered Nurses’ Association of Ontario (2007). Integrating Smoking Cessation into Daily Nursing Practice (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario.
S Society of Obstetricians and Gynaecologists of Canada (SOGC). (2010). Alcohol use and pregnancy consensus clinical guidelines. JOGC. 2010 Aug;32(8): S1-S36.
T T-CAN East. 2012. E-Cigarette Prevalence in Eastern Ontario. Retrieved May 16, 2013 from www. smokefreeottawa.com/uploads/1/1/7/4/11742147/ecigarette_prevalence_in_eastern_ontario_web. pdf The Best Start Resource Centre. Breastfeeding Matters: An important guide to breastfeeding for women and their families. Toronto: Ontario, Canada; 2013. The Best Start Resource Centre. A smoke-free environment for your children. Toronto: Ontario, Canada; 2010.
U Urquhart, C., Jasiura, F., Poole, N., Nathoo, T. & Greaves, L. (2012). Liberation! Helping Women Quit Smoking: A Brief Tobacco Intervention Guide. Vancouver, BC: British Columbia Centre of Excellence for Women’s Health.
V W World Health Organization (WHO). WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package. [document on the internet]. [cited 2012 Dec 14]. Available from www.who.int/ tobacco/mpower/gtcr_download/en/index.html WHO. WHO Report on the Global Tobacco Epidemic, 2011: warning about the dangers of tobacco. [document on the internet]. [cited 2012 Dec 14]. Available from www.who.int/tobacco/global_ report/2011/en/
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