For Day1

Train-the-Trainer Tobacco Dependence Treatment Workshop in Ghana
Yvonne Olando Clinical Psychologist
Introduction
Who are you ? Where are you from ? What do you want to get from this workshop?
02-05 September 2013
Train-the-Trainer: Ghana 2
Aim of training
To increase your knowledge, skills and confidence; to equip you to provide training on brief tobacco interventions, intensive counselling and nicotine replacement therapy (NRT).
Objectives
1. Describe prevalence and patterns of tobacco use in Ghana 2. Explain the role of tobacco dependence treatment within a comprehensive tobacco control strategy 3. Explain the health consequence of tobacco use and benefits of quitting 4. Explain the biological, psycho-behavioural and social causes of tobacco dependence 5. Identify evidence-based tobacco dependence treatments 6. Describe and deliver brief interventions as part of their routine practice according to a "5A's" Model and a "5R's" Model 7. Demonstrate effective counselling skills (motivational interviewing, practical counselling) 8. Conduct a brief assessment of nicotine dependence 9. Understand and appropriately prescribe Nicotine Replacement Therapy products 10. Describe strategies and coping skills that can reduce relapse risk 11. Describe and apply adult education skills to training
02-05 September 2013 Train-the-Trainer: Ghana 4
The role of tobacco dependence treatment within a comprehensive tobacco control strategy
Learning Objectives
At the end of the presentation the participants will be able to:
Recognize treatment of tobacco dependence as a key component of any comprehensive tobacco control initiative.
The Vision of WHO

Only a comprehensive tobacco control strategy can reverse the global tobacco epidemic Treatment for tobacco dependence should be a key component of this comprehensive tobacco control policy
Reflected in the WHO FCTC

The core technical package in WHO FCTC :
At the population level:
Price and tax measures to reduce the demand for tobacco (Article 6) and smuggling control (Article 15) Protection from exposure to tobacco smoke (Article 8) Packaging and labeling of tobacco products (Article 11,12) Ban of tobacco advertising, promotion and sponsorship (Article 13) Monitoring and evaluation (Articles 20, 21)
At the individual level:

Tobacco dependence treatment and cessation (Article 14)
Quitting has the potential to save lives in the short & medium-term
If adult consumption were to decrease by 50% by the year 2020, approximately 180 million tobacco-related deaths could be avoided.
Three types of treatment should be included in tobacco prevention

Tobacco cessation advice incorporated into primary health-care services (feasible, effective and efficient) Easily accessible and free quit lines Access to low-cost pharmacological therapy.
Treatment of tobacco dependence part of Global NCD Action Plan 2008-2013

Endorsed by 193 countries at WHO's World Health Assembly in May 2008
Global NCD Action Plan 2008-2013

1. 2. 3. 4. 5. 6. development agenda national policies risk reduction research partnership monitoring & evaluation
New Action Plan endorsed at the WHA this week
Global NCD Action Plan 2008-2013

Objective 3: To promote interventions to reduce the main shared modifiable risk factors for NCDs:
Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol
Treatment of tobacco dependence as part of Assessment and management of cardiovascular risk (PHC-level)
WHO/ISH Pocket guidelines for predicting 10-year risk of a fatal or non-fatal major heart attack and stroke risk based on: Age Sex Blood pressure Smoking status Blood cholesterol Presence or absence of diabetes Recommendations: Smoking cessation Dietary changes Physical activity Weight control Alcohol intake reduction Antihypertensive drugs Lipid-lowering drugs Antiplatelet drugs
Story 1-What happened after the UK smokefree legislation was introduced?

March 2006 July 2007 smoke-free legislation was introduced in Scotland, Wales, Northern Ireland and England, making virtually all enclosed public places and workplaces smoke-free. The new law has encouraged smokers to quit smoking. Local NHS Stop Smoking Services in England saw an increase in demand of around 20% in the months around the law change.
Story 2-What happened after the US raised tobacco tax in spring 2009?
The US raised federal tax in 2009. The impact of the tax increase on calls to US quitlines.
Question what do these two stories imply about treatment of tobacco dependence? Implementing population level tobacco control policies can motivate people to stop smoking and increase their demand for tobacco dependence treatment.
Story 3 The tax on tobacco products increased in Hong Kong

On 25 February 2009, the excise duty on tobacco products was immediately increased by 50% from 16 to HK$ 24 per pack. Sales of electronic cigarettes increased immediately after the tax increase. A news report on 3 March 2009 said suppliers of electronic cigarettes had run out of stock. Some smoker used it as an alternative to smoking tobacco cigarettes and some smokers used electronic cigarettes to quit tobacco use. However, electronic cigarette is not a proven product for cessation
Question what does this story imply about treatment of tobacco dependence?
It is important to provide tobacco users effective support as much as possible to assist in their behaviour change. Or else, they will use whatever they can find.
Summary
Treatment of tobacco dependence is a key component of any comprehensive tobacco control strategy. Providing support for tobacco users to quit can also help reduce smoker's resistance to the implementation of population-level tobacco control policies Health Professionals have a prominent role to play All health professionals in the everyday health-care setting need to address tobacco dependence as part of their standard of care practice!
The impact of tobacco use and benefits of quitting
Train-the-Trainer: Ghana
21
Learning objectives
Describe health, social and economic impact of tobacco use on tobacco users and others
Clarify common misconceptions held by tobacco users Explain the benefits of quitting tobacco use
22
Brainstorming
What is the impact of tobacco use on tobacco users and others?
23
Health impact
24
Tobacco use and second-hand smoke damage every part of the body
Source: WHO Report on the Global Tobacco Epidemic 2008.
25
A risk factor for six of eight leading causes of death in the world
26
Tobacco kills up to half of its users

The tobacco epidemic kills nearly 6 million people each year, of whom:
more than 5 million are users and ex users more than 600 000 are nonsmokers exposed to secondhand smoke
27
The dangers of smokeless tobacco
Cancer of the head and neck, esophagus and pancreas, as well as oral diseases Heart disease Low-birthweight babies
28
More than 4000 chemicals have been identified in tobacco smoke

At least 250 of which are known to be harmful More than 50 of which are known to cause cancer
29
Common misconceptions about health effects of tobacco held by tobacco users
Light, "ultra-light". "low tar" or "mild" cigarettes are less harmful? Are 'rollies' safe to smoke? Will cutting down the number of cigarettes I smoke reduce my health risks? Only old people get ill from smoking don't they? Does everyone who quits smoking put on weight?
Economic impact of tobacco use
31
Costs to the society

Cost* attributable to tobacco use (2007 or latest available data) The United States 167.00 billion Japan 62.39 billion Germany 23.75 billion Canada France 17.00 billion 15.30 billion
China 5.00 billion Egypt 1.25 billion *:Direct health care costs plus indirect costs, including productivity losses,
absenteeism and other socioeconomic costs.
Source: Tobacco Atlas online- Cost to economy
32
Costs to families and individuals

Tobacco products are expensive. The price of 20 Marlboro cigarettes could buy:
a dozen eggs in Panama one kilogram of fish in France four pairs of cotton socks in China 6 kilograms of rice in Bangladesh
Tobacco use is costly with 5-15% of tobacco user's disposable income is spent on tobacco
Source: WHO The tobacco atlas, first version
33
Brainstorming
What are the benefits of quitting tobacco use?
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Health benefits
Time since quitting Within 20 minutes 12 hours 2-12 weeks 1-9 months 1 year 5 years Beneficial health changes that take place Your heart rate and blood pressure drop. The carbon monoxide level in your blood drops to normal. Your circulation improves and your lung function increases. Coughing and shortness of breath decrease. Your added risk of coronary heart disease is about half that of a smoker's. Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting. 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.
10 years
15 years
The risk of coronary heart disease is that of a non-smoker's

Exercise: quit & save
How much money can you save if you quit?

Total money spent on tobacco per day $2 The amount of money spent per year $730 The amount of money spent in ten years $7300 You can buy many things with the money saved:
36
Why do people smoke but don't quit?
37
Learning objectives
Describe why people smoke and why they dont stop
38
Brainstorming
Why do people smoke?
39
Understanding why people smoke People smoke for many reasons

Addiction Social activity Stress relief Emotional support Boredom/filling in time Everyone does it Sharing of cigarettes Bonding/acceptance
Understanding smoking behaviour

Tobacco addiction is made up of three parts:
Chemical/physiological/physical dependence Emotional/psychological connection Behavioural and social connection
41
Chemical addiction
A major factor that maintains a smoking habit over time is addiction to nicotine Nicotine has been shown to have effects on brain dopamine systems similar to those of drugs such as heroin and cocaine.
- It gradually increase the number of nicotinic receptors in the brain
- Smokers need greater amounts of tobacco to achieve the same levels of satisfaction.
Chemical addiction
Source: Powerpoint presentation from Dr Hayden McRobbie
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Inhalation is the quickest way for nicotine to reach the brain

Nicotine Nicotine Lung Arterial bloodstream Skin Venous system
Left side of the heart
Right side of the heart Left side of the heart Brain

Brain 7 -10 seconds

Nicotine Withdrawal
Nicotine increases the number of nicotinic receptors in the brain When receptors are empty, they make you feel uncomfortable and increase your urge to smoke
Nicotine Withdrawal
Common withdrawal symptoms : Headaches Coughing Cravings Increased appetite or weight gain Mood changes (sadness, irritability, frustration, or anger) Restlessness Decreased heart rate Difficulty concentrating Flu-like symptoms Insomnia
Nicotine Withdrawal
Source: Powerpoint presentation from Dr Hayden McRobbie
47
Video from Mayo Clinic: Stop smoking: Why is it so hard
48
Emotional/psychological connection
Smokers link feelings with cigarettes via the process of withdrawal and operant conditioning
Some of the emotional connections that may be associated with smoking:
Stressed Happy Sad Angry craving craving craving craving cigarette cigarette cigarette cigarette
Your cognitions (i.e. thoughts and beliefs) have effect on smoking too.
Smoking Cognitions Some Pros

It helps me relax Its not really that harmful!
Its cool to smoke! Ill stop smoking next year
It keeps my weight down
50
Smoking Cognitions Some Cons

Serious health risks! Affects fitness
Costs a fortune! It smells bad!
It hurts those around me
51
Behavioural and social connection

Smokers link behavior with cigarettes via the process of operant conditioning. Some of the habits that may be associated with smoking:
Coffee The end of meal phone Watching TV craving craving craving craving cigarette cigarette cigarette cigarette
Smoking is also prone to social influences:

These processes start early! Children are more likely to start smoking if their parents smoke Later on in life we smoke with friends its a social thing to do.
Interactions between Factors

The physical, psychological and social influences are not independent of each other.
physical withdrawal seeking behavioural, social support to help stop smoking. psychological distress, beliefs and cognitions
All three types of factors influencing smoking need to be explored and referred to in stop smoking support programmes.
Group discussion
Participants to discuss with the person sitting next to them:
Two ways in which you should use the knowledge of tobacco addiction when delivering brief interventions
Participants to read out responses and comment on each others responses.
Brief tobacco intervention:

the purpose, impact and delivery models
56
Learning objectives
Give an overview of a Brief Intervention
57
Preparation
Ask group for their experiences of talking to patients about smoking
58
Pre-training role play

Two volunteers will be asked for role-play:
One will be a patient who enjoys smoking The other will be a doctor who attempts to address the patient's smoking
The group will be asked to share their comments and feedback
59
Definition: Advice to stop using tobacco, usually taking only a few minutes, given to all tobacco users, usually during the course of a routine consultation or interaction. Used interchangeably with brief advice. Purpose: The primary purpose is to help the patient: understand risk of tobacco use and the benefits of quitting motivate them to make a quit attempt
Can also be used to encourage those heavy tobacco users to seek or accept a referral to more intensive treatments within their community
Source: WHO FCTC Article 14 Guidelines
Brief intervention
60
The population impact

The success of a service is measured by its:
Reach (number of people who receive the service/intervention) Effectiveness (percentage of people who change their behavior as a result of the service/intervention) and Cost per person to deliver.
Brief tobacco interventions even small effect sizes can have significant population impact if they are delivered routinely and widely across a healthcare system:
Reach: In the developed world, 85% of the population visit a primary health care clinician at least once per year Effectiveness: 40% of case will make a quit attempt; quit rate of 2% Cost: very low (a few minutes opportunistic intervention as part of PHC providers' routine practice).
Effective delivery models

5A's for patients who are ready to
quit
5R's for patients not ready to quit
Ask - Ask all patients if they smoke

need to quit
Relevance - How is quitting most personally relevant to you?
Advise - Advise smokers that they Assess - Assess readiness to quit
Risks - What do you know about the risks of smoking in that

regard?
Assist - Assist the patient with a quit

plan or provide information on specialist support
Rewards - What would be the benefits of quitting in that regard?
Roadblocks - What would be difficult about quitting for you?

Repetition - Repeat assessment of readiness to quit if still not
ready to quit repeat intervention at a later date.
Arrange - Arrange follow up contacts or a

referral to specialist support
62
Overview of the 5A's model
Ask
We need to be asking ALL of our patients if they smokemaking it part of our routine. Only then do we start to make a real difference to the smoking rates around us. Smoking should be asked about in a friendly way its not an accusation!
Advise
Assess Assist Arrange
Ask
Advice should be clear and positive.
Advise Assess
Assist Arrange
It should also be tailored to the particular patients characteristics or circumstances
More on tailoring advice later!
Ask
After giving advice we need to assess the patients readiness to quit. This will be determined whether they want to be a non-smoker, and by if they think they have any chance of quitting successfully. More on the assess stage later!
Advise Assess
Assist Arrange
Ask
If the patient is ready to quit then theyll need some help from us. We need to assist tobacco users in developing a quit plan or to tell them about the specialist support if that is available. The support needs to be described positively but realistically. More on this later.
Advise Assess
Assist Arrange
Ask Advise Assess Assist
If the patient is willing to make a quit attempt we should arrange follow-up around 1 week after the quit attempt, or arrange referrals to the specialist support.
More on arranging later.
Arrange
Patients not Ready to Quit?

Often, the patient will not be ready to quit. They may not want to be a non-smoker, or be certain that they could not quit. In these cases we will deliver a brief motivational intervention before ending the consultation. The intervention is called the 5Rs This will occur after the Assess stage. Once completed we can re-assess readiness to quit and complete the 5As if appropriate)
68
Patients not Ready to Quit?
Ask Advise
Assess
Assist Arrange
Not Ready to Quit
Five Rs
Not Ready to Quit
Ready to Quit
End positively
69
Other models of Brief Interventions

If specialist support (quitlines, cessation clinics) is available, other models can be used 1.AAA
Ask
2.AAR
Advise
Advise Brief advise
Assess Assist Arrange ACT on patient's

response
build confidence, give information, refer, prescribe; succeed with local Stop Smoking Services
Ask
3.ABC
Refer
to quitlines and to local cessation programs
Ask
Cessation
Make referral to the Quit line or cessation services Provide cessation support and medication Arrange follow-up within a week 70
Summary
The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that a PHC provider can do to help a tobacco user within 3 to 5 minutes in PHC settings You can start and stop at any step as indicated in the diagram
Ask
Arrange
Quit plan and follow-up plan
Advise Assess
71
Assist
Summary
Brief interventions may be delivered anywhere in the hospital setting, in the out-patient clinic or in the community. Brief interventions take a few minutes but if done routinely they can significantly increase the numbers of people quitting and save lives!
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COFFEE BREAK
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Asking, Advising
-The Five As
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Learning objectives
Ask and Advise patients about their smoking in an appropriate way
75
Preparation
Ask group for their thoughts on advice giving. How does giving advice on clinical issues differ from giving advice on behaviour change
76
Ask
Ask about tobacco use at EVERY encounter. Keep it simple:
Do you use tobacco? Does anyone else in your home use tobacco?
For health facilities: to include tobacco use as a vital sign

Tobacco use (circle one): Current Former Never
Advise to Quit
Advise to quit in clear, strong and personalised manner!
ClearIt is important that you quit smoking (or using

chewing tobacco) now, and I can help you.
StrongAs your clinician, I need you to know that

quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.
PersonalizedTie tobacco use to demographics, health

concerns and social factors.
78
Examples of personalized Advice

Demographics: For example, women may be more likely to be interested in the effects of smoking on fertility than men. Health: Asthma sufferers may need to hear about the effect of smoking on respiratory function, while those with gum disease may be interested in the effects of smoking on oral health. Social Factors: People with young children may be motivated by information on the effects of second hand smoke, while a person struggling with money may want to consider the financial costs of smoking.
Evidence shows that providing tailored information on smoking is more effective than providing standardised information.
Source: Lancaster & Stead , 2005
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Tailoring Advice
In a brief intervention: There are a number of factors that a practitioner may think about when give personalized advice It would be impossible to tell patients about every possible effect of tobacco use because the effects of tobacco use are very wide ranging, including a variety of health effects When how to tailor advice for a particular patient is not obvious, a useful strategy may be to ask the patient: What do you not like about being a smoker? The patients answer to this question can be built upon by the practitioner with more detailed information on the issue raised
80
Tailoring Advice
Example: Doctor: What do you not like about being a smoker? Patient: I suppose I dont like the way it makes me cough Doctor: Yes. Smoking does effect lung function, and it will get worse over time if you continue to smoke. Example: Doctor: What do you not like about being a smoker? Patient: Well, I dont like how much I spend on tobacco. Doctor: Yes, it does build up. Lets work out how much you spend each month. Then we can think about what you could buy instead!
Role Plays
One trainee will volunteer to play the role of the practitioner. He or she will:
A) Ask about the patients smoking B) Give some tailored advice.
The facilitator will play the role of the three fictional smokers: Jack, Rhea and Thomas The facilitator will invite comments from the group
82
Assessing Readiness to Quit
-The Five As
83
Learning objectives
Assess patients readiness to quit smoking
84

Preparation:
Ask group for their thoughts on how we can tell if someone is ready to quit.
85
When is someone ready to quit?

To be ready to quit we need to: Believe "quitting is important" Feel confident that we could quit successfully (i.e. have high selfimportance efficacy in relation to quitting). Self-efficacy: Relates to confidence in ones own ability to succeed in something. Person's belief about his or her ability and capacity to accomplish a task or to deal with the challenges of life
02-05 September 2013 Train-the-Trainer: Ghana
readiness to quit
self-efficacy
86
When is someone ready to quit?

If a tobacco user believes "quitting is important" and has high level of confidence in their ability to quit, he or she is more likely to say: 1. I want to be a non- tobacco user (a desire
to be non-tobacco user)
2. I have a chance of quitting successfully

(high level of confidence in his or her ability to quit)
88

Method 1: asking two questions related to importance and self-efficacy:
1. 2. Would you like to be a non-user? Do you think you have a chance of quitting successfully?
In relation to the first question someone needs to be quite sure that they want to be a non-tobacco user. Only a Yes will do! In relation to the second question there is room for some doubt. It is OK to be unsure but a definite No indicates a problem.

Any answer in the shaded area indicates that the smoker is NOT ready to quit.
Would you like to be a non-tobacco user?
Do you think you have a chance of quitting successfully?
Yes
Unsure
No
Yes
Unsure
No
In these cases we should deliver the 5Rs intervention.


Method 2: asking just one question:
Would you like to quit tobacco within the next 30 days?
If the answer is "No" indciates that the tobacco user is NOT ready to quit and we should deliver the 5R's intervention.
91
Evaluation of Day 1
Provide a brief review of what has been learned and a preview of what is to come in the second day. Allow 5 minutes so that trainees may ask questions at the end.
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Thank you for your attention
93

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Train-the-Trainer Tobacco Dependence Treatment Workshop in Ghana

Yvonne Olando Clinical Psychologist

02-05 September 2013

02-05 September 2013

The Vision of WHO

Reflected in the WHO FCTC

At the individual level:

02-05 September 2013

Three types of treatment should be included in tobacco prevention

Treatment of tobacco dependence part of Global NCD Action Plan 2008-2013

02-05 September 2013

Global NCD Action Plan 2008-2013

New Action Plan endorsed at the WHA this week

Global NCD Action Plan 2008-2013

Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol

Story 1-What happened after the UK smokefree legislation was introduced?

Story 3 The tax on tobacco products increased in Hong Kong

The impact of tobacco use and benefits of quitting

02-05 September 2013

02-05 September 2013

02-05 September 2013

02-05 September 2013

Source: WHO Report on the Global Tobacco Epidemic 2008.

02-05 September 2013

Source: WHO Report on the Global Tobacco Epidemic 2008.

02-05 September 2013

Tobacco kills up to half of its users

02-05 September 2013

The dangers of smokeless tobacco

Source: WHO Report on the Global Tobacco Epidemic 2008.

More than 4000 chemicals have been identified in tobacco smoke

Source: WHO Report on the Global Tobacco Epidemic 2011.

02-05 September 2013

Common misconceptions about health effects of tobacco held by tobacco users

Economic impact of tobacco use

02-05 September 2013

Costs to the society

Source: Tobacco Atlas online- Cost to economy

02-05 September 2013

Costs to families and individuals

02-05 September 2013

02-05 September 2013

The risk of coronary heart disease is that of a non-smoker's

Exercise: quit & save

How much money can you save if you quit?

02-05 September 2013

Why do people smoke but don't quit?

02-05 September 2013

Describe why people smoke and why they dont stop

02-05 September 2013

02-05 September 2013

Understanding why people smoke People smoke for many reasons

Understanding smoking behaviour

02-05 September 2013

Source: Powerpoint presentation from Dr Hayden McRobbie

02-05 September 2013

Inhalation is the quickest way for nicotine to reach the brain

Left side of the heart

Right side of the heart Left side of the heart Brain

Brain 7 -10 seconds

02-05 September 2013

Source: Powerpoint presentation from Dr Hayden McRobbie

02-05 September 2013